Management of Recurrent Iron Deficiency Anemia in Young Woman with Menorrhagia
Case at a Glance
A 24-year-old woman with a 10-year history of recurrent iron deficiency anemia secondary to heavy menstrual bleeding presents with worsening fatigue and dyspnea. Recent laboratory results show hemoglobin 106 g/L and ferritin 5 μg/L, representing her lowest recorded values despite previous periods of successful treatment.
Patient's Story
The patient reports a decade-long struggle with intermittent anemia, with symptoms including severe exhaustion, shortness of breath, and fatigue that have recently worsened. She has a history of heavy menstrual periods and weighs 53kg with a height of 5'4". Three years prior, she achieved normal iron levels (hemoglobin 117 g/L, ferritin 28 μg/L) following treatment. She has attempted multiple therapies for menorrhagia including tranexamic acid, mefenamic acid, hormonal contraceptives (progesterone-only pill, combined oral contraceptive pill, and contraceptive patch), all without success. Notably, hormonal contraception caused prolonged bleeding for four months. Family history is significant for maternal menorrhagia requiring uterine ablation.
Initial Assessment
Physical examination revealed a young woman appearing fatigued but otherwise stable. Vital signs were within normal limits. The patient appeared pale but was not in acute distress. Weight: 53kg, Height: 164cm (5'4"). Recent laboratory investigations showed hemoglobin 106 g/L (normal 120-150 g/L for women) and ferritin 5 μg/L (normal 15-150 μg/L), representing significant iron depletion. Thyroid-stimulating hormone was within normal range.
The Diagnostic Journey
Historical laboratory data spanning several years demonstrated fluctuating iron status with previous successful treatment achieving normal levels. The current presentation represents the most severe iron deficiency documented for this patient. Given the clear pattern of heavy menstrual bleeding as the underlying cause, further investigation focused on optimizing iron replacement therapy rather than extensive additional workup.
Final Diagnosis
Iron deficiency anemia secondary to chronic menstrual blood loss (menorrhagia). The patient has documented intolerance to multiple hormonal therapies aimed at reducing menstrual flow.
Treatment Plan
Initiated oral iron supplementation with ferrous sulfate 200mg daily, following current evidence-based guidelines that suggest lower, less frequent dosing may improve absorption while reducing gastrointestinal side effects. Patient counseled to take iron with vitamin C-rich beverages to enhance absorption and avoid dairy products within 2 hours of dosing. Treatment duration planned for several months with follow-up laboratory monitoring.
Outcome and Follow-up
Patient education provided regarding modern iron supplementation protocols, which favor lower doses based on recent research showing improved absorption and reduced side effects compared to traditional high-dose regimens. The patient expressed initial concern about the lower dosage compared to previous treatments but was reassured about the evidence-based approach. Gynecologic consultation may be considered for alternative menorrhagia management options, though previous therapeutic failures limit options while preserving fertility.