Pediatrics Journal Article and Summary

A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding

Citation: Mansour D, Hofmann A, Gemzell-Danielsson K. A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding. Adv Ther. 2021;38(1):201-225. doi:10.1007/s12325-020-01564-y

  • Up to one-third of women of reproductive age experience heavy menstrual bleeding which can give rise to iron deficiency (ID) and, in severe cases, iron deficiency anemia (IDA).
  • This systematic review focuses on current guidelines for the management of HMB with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non- iron-based treatments.
  • 55 guidelines total identified and screened, 22 included in this review
  • Most guidelines include routine screening for anemia; fever consider measuring iron levels
  • Heavy menstrual bleeding (HMB) can be defined objectively as a total blood loss per menstrual cycle that regularly exceeds 80 mL
  • Iron plays a key role in many physiological processes, including energy production, respiration, DNA synthesis and repair, myocyte function, and cell division. More than two-thirds of the body’s iron is bound as hemoglobin (Hb) within erythroid precursors and mature red blood cells (RBCs). Severe ID can therefore lead to a fall in Hb levels, impairing RBC production, which in turn gives rise to normocytic or microcytic hypochromic anemia
  • IDA can significantly impair quality of life for women, and can lead to reduced cognitive ability and reduced productivity at work , as well as increased utilization of healthcare resources. Notably, isolated ID has also been shown to impair cognitive and physical performance in women, and exacerbate fatigue, with the impairments reversed by iron therapy

Management of IDA: Iron therapy

  • Oral Iron therapy for non-severe anemia
  • IV if Hg<9g/dL; imminent surgery or following bariatric surgery

Non-Iron Based Management:

  • Blood transfusion (depending on symptoms and hemodynamic instability)

< 6g/dL in Sx

< 5g/dL in aSx

  • Boosting Iron intake with food as an add on to iron therapy: clams, oysters, shrimp, sardines, liver, red meat and reducing consumption of foodstuffs that can block iron absorption, including tea and coffee

Treatments to Decrease Blood Loss from Heavy MB:

  • Hormonal Tx: 52 mg levonorgestrel-releasing intrauterine system (LNG- IUS) was the most consistently recommended hormonal treatment approach
  • Other progestogen-only methods, such as depot medroxyprogesterone acetate, and combined oral contraceptive pills (estrogens plus progestogen), can also markedly reduce HMB, including in adolescents
  • Non-hormonal Tx: if hormonal Tx are not appropriate/desirable (planning to get pregnant) or as a second line option if hormonal Tx are ineffective (NSAIDs, tranexamic acid)


  • Not all the guidelines include advice on the best way to treat iron deficiency and anemia. For those that do, the recommendations vary and sometimes offer conflicting advice.
  • There is little agreement on when to give iron therapy, and whether this should be given by mouth or by infusion.
  • Due to inconsistency in recommendations on screening for iron deficiency and use of iron therapy, ID/IDA due to HMB is likely to be underdiagnosed and undertreated
  • The paucity of recommendations to test for iron levels in women with HMB may reflect a lack of understanding regarding the benefits of treating ID in the absence of anemia.
  • One of the challenges to managing women with HMB is the involvement of multiple healthcare practitioners without clear guidance for those ultimately responsible for identifying and treating the resultant ID/IDA. There needs to be a consensus HMB guidance to cover all aspects of care, to improve health outcomes in these patients.

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