Should a 36-year-old woman with a history of heavy menstrual bleeding who presents during menses with fatigue and dizziness be admitted for red blood cell transfusion?

Admission and Transfusion Decision for Acute Symptomatic Anemia from Heavy Menstrual Bleeding

Yes, this patient should be admitted for blood transfusion given her symptomatic presentation with fatigue and dizziness during active heavy menstrual bleeding. 1

Immediate Management Algorithm

Assess Hemodynamic Status and Severity

• Check hemoglobin level immediately - the presence of fatigue and dizziness during active bleeding indicates symptomatic anemia requiring urgent evaluation 2, 3
• Obtain orthostatic vital signs (blood pressure and pulse measurements) to assess hemodynamic stability, as orthostatic changes indicate significant volume depletion 3
• Evaluate for signs of severe anemia - symptoms of fatigue, dizziness, dyspnea, or altered mental status warrant aggressive intervention 4

Transfusion Criteria

Blood transfusion is recommended for symptomatic anemia regardless of the specific hemoglobin threshold. 1 The AAOS guidelines provide moderate-strength evidence supporting transfusion for patients with symptoms of fatigue and hypotension, even when hemoglobin levels are above 8 g/dL. 1

• For asymptomatic patients, a restrictive threshold of 8 g/dL is appropriate 1
• For symptomatic patients (like this case with fatigue and dizziness), transfusion should not be delayed waiting for hemoglobin to drop below 8 g/dL 1

Acute Bleeding Control During Admission

First-line medical management should be initiated immediately: 3

• Tranexamic acid (antifibrinolytic) in oral or intravenous form to stop active bleeding 5, 3
• High-dose hormonal therapy if hemodynamically stable - combined hormonal contraceptives given as monophasic pills (one pill three times daily for 7 days) can control acute bleeding 3
• Aminocaproic acid as an alternative antifibrinolytic agent 3

Critical Laboratory Evaluation During Admission

Obtain the following tests to guide ongoing management: 2, 3

• Complete blood count with hemoglobin/hematocrit
• Serum ferritin to assess iron stores (low ferritin predicts heavy menstrual bleeding) 2
• Pregnancy test in all reproductive-age women 5
• Coagulation screening if history suggests bleeding disorder - up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 5, 6
• Thyroid function tests to evaluate for ovulatory dysfunction 2

Post-Stabilization Management Plan

Maintenance Therapy After Acute Episode

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment for preventing recurrent heavy menstrual bleeding, reducing blood loss by 71-95% 5, 7

Alternative maintenance options include: 5, 3

• Combined hormonal contraceptives (oral or transvaginal) as second-line 5, 7
• Tranexamic acid for non-hormonal option 5
• Cyclic oral progestins (reduce bleeding by approximately 87%) 5

Hematology Referral Indications

Refer to hematology if: 2

• Flooding (pad/tampon changes more frequently than hourly) 2
• Prolonged menses (>7 days) 2
• Personal or family history of bleeding symptoms 2
• Clots ≥1 inch in diameter 8, 2

Common Pitfalls to Avoid

Do not discharge without addressing the underlying cause - this patient's case series literature shows that life-threatening anemia (hemoglobin <2.0 g/dL) can occur when patients repeatedly refuse treatment or lack disease awareness 4

Do not use short-course oral progestogens (≤14 days per cycle) as they provide less impressive reduction in menstrual blood loss compared to other options 7

Do not delay transfusion in symptomatic patients waiting for an arbitrary hemoglobin threshold - symptoms of fatigue and dizziness during active bleeding warrant immediate transfusion 1

Surgery should be reserved for patients who do not respond to medical therapy or are clinically unstable despite initial measures 3