A Woman Presenting With Anemia Secondary to Heavy Periods - Case Study

History
A 30-year-old woman is referred from the hematologist, with anemia. She had been complaining of increasing tiredness and shortness of breath for 3 months, with frequent headaches.
Her periods occur every 24 days and the first day is generally moderate but the second to fourth days are very heavy. She uses tampons and sanitary towels together. She has no pain. Her last smear test was normal 2 years ago. She had no previous gynecological problems and takes no medication.

Examination
The woman is slim with pale conjunctiva. Abdominal, bimanual and speculum examination are unremarkable.

Investigations: 
Hemoglobin =  6.3 g/dL (Normal range = 11.7–15.7 g/dL)
Mean cell volume = 66 fL (normal = 80–99 fL)
Ferritin  = 9 μg/L (normal = 6–81 μg/L)
WBC count and platelets = within normal ranges
Total iron-binding capacity = (TIBC) 80 μmol/L (normal = 45–72 μmol/L)

Blood film: hypochromic microcytic red cells

Transvaginal ultrasound scan report (cycle day 4): the uterus is normal size and retroverted. The endometrium is smooth and thin measuring 3.1 mm. Both ovaries are normal.

Questions
• How do you interpret these findings?
• What is the likely underlying diagnosis?
• How would you manage this woman?

Answers And Discussion:


• How do you interpret these findings?
The blood count shows anemia with reduced mean cell corpuscular volume and low mean cell hemoglobin suggestive of a microcytic anemia. Iron deficiency is the commonest cause for this picture and is confirmed by the low ferritin and iron, with raised iron-binding capacity.
The anemia accounts for the breathlessness, tiredness and headaches.

• What is the likely underlying diagnosis?
Menorrhagia is the commonest cause of anemia in women, and in this case is supported by the history of excessive bleeding. The woman herself may not recognize that her periods are particularly heavy if she has always experienced heavy periods or if she thinks it is normal for periods to become heavier as she gets older.
As no other cause of heavy bleeding is apparent from the history and the ultrasound is normal, then the underlying diagnosis is one of exclusion referred to as dysfunctional uterine bleeding (DUB).

Dysfunctional uterine bleeding: is defined as "Excessive heavy, prolonged or frequent bleeding that is not due to pregnancy or any recognizable pelvic or systemic disease."

• How would you manage this woman?

The anaemia should be treated with ferrous sulphate 200 mg twice daily until hemoglobin and ferritin are normal. It may take 3–6 months for iron stores to be fully replenished.

Tranexamic acid (an antifibrinolytic) should be given during menstruation to reduce the amount of bleeding. It is contraindicated with a history of thromboembolic disease.

The levonorgestrel-releasing intrauterine device is used for its action on the endometrium to reduce menorrhagia, often causing amenorrhoea, though it is commonly associated with irregular bleeding for the first 3 months. 

The combined oral contraceptive pill is effective for menorrhagia in young women (below 35 years).

If these first-line management options are ineffective then endometrial ablation should be considered, which destroys the endometrium down to the basal layer. It is successful in 80–85 per cent of women and they should have completed their family and use effective contraception.

Hysterectomy is considered a ‘last resort’ for DUB, due to the associated morbidity.

Key Learning Points In This Case:

• A woman’s perception of bleeding is not always proportionate to the actual volume lost, so hemoglobin should be checked in any woman suspected of menorrhagia.

• DUB is a diagnosis of exclusion.

• A hierarchy of first-, second- and third-line treatment should be used in management.