Iron Deficiency Anemia

A 32-year-old vegetarian school teacher presented with progressive fatigue, weakness and breathlessness on exertion for four months. She also reported occasional dizziness and palpitations, along with a one-year history of heavy menstrual bleeding lasting 7–8 days and associated with passage of clots. Clinical examination revealed pallor, mild koilonychia and angular cheilitis. Investigations confirmed microcytic hypochromic anaemia with depleted iron stores, consistent with iron deficiency anaemia secondary to chronic menstrual blood loss.

Patient Profile

• Age: 32 years
• Sex: Female
• Occupation: School teacher
• Diet: Vegetarian
• Chief complaints: Fatigue, weakness and exertional breathlessness for 4 months

History of Present Illness

The patient reported progressive tiredness, reduced exercise tolerance, occasional dizziness and palpitations for approximately four months.

She had experienced heavy menstrual bleeding for the preceding year, with menstruation lasting 7–8 days and passage of clots.

There was no history of melena, haematemesis, chronic diarrhoea, weight loss or previous blood transfusion.

Clinical Examination

On examination, the patient was haemodynamically stable but showed clinical features suggestive of anaemia.

• Pulse: 96/min
• Blood pressure: 108/68 mmHg
• Respiratory rate: 18/min
• Pallor: Present
• Icterus: Absent
• Koilonychia: Mild
• Oral examination: Mild angular cheilitis
• Cardiovascular examination: Flow systolic murmur
• Lymphadenopathy: Absent
• Hepatosplenomegaly: Absent

Diagnostic Assessment

Laboratory investigations were performed to characterise the anaemia and assess iron status.

The combination of low haemoglobin, microcytosis, hypochromia, increased RDW, markedly reduced ferritin, low serum iron, elevated TIBC and low transferrin saturation supported the diagnosis of iron deficiency.

Diagnosis

The patient was diagnosed with:

Iron deficiency anaemia secondary to chronic blood loss from heavy menstrual bleeding.

Other causes of microcytic anaemia, including thalassaemia and other nutritional or chronic disease-related causes, should be considered when clinically appropriate.

Management

1. Identify and Treat the Underlying Cause

Management focused not only on correcting the iron deficiency but also on identifying the source of chronic blood loss.

A gynaecological evaluation was recommended for the heavy menstrual bleeding. Depending on the clinical assessment, potential causes such as:

• Uterine fibroids
• Adenomyosis
• Endocrine causes
• Other causes of abnormal uterine bleeding

may require evaluation.

2. Iron Replacement

Oral iron was considered the first-line replacement option when tolerated.

The dose and frequency can be individualised according to the patient’s tolerance, severity of deficiency and clinical circumstances. Iron therapy should generally be continued after haemoglobin normalisation for sufficient time to replenish depleted iron stores.

Response to treatment should be monitored through symptoms and laboratory parameters.

3. Dietary Advice

As a vegetarian, the patient was advised to include a variety of iron-containing foods in her diet, including:

• Green leafy vegetables
• Legumes and dals
• Beans and chickpeas
• Sesame seeds
• Pumpkin seeds
• Fortified cereals
• Nuts and seeds

Vitamin-C-rich foods can be included with iron-containing meals to support iron absorption.

Tea and coffee should not be taken together with oral iron because they can reduce iron absorption. Calcium supplements and calcium-rich products may also interfere with iron absorption when taken at the same time as oral iron.

4. Intravenous Iron

Intravenous iron may be considered in selected circumstances, particularly when:

• Oral iron is not tolerated
• Iron absorption is inadequate
• Rapid iron repletion is required
• Oral treatment is ineffective
• Ongoing blood loss makes oral replacement insufficient

The choice between oral and intravenous iron should be based on the individual’s clinical condition and treatment response.

Follow-Up

Following initiation of treatment, the patient was monitored for improvement in symptoms and haemoglobin levels.

Follow-up may include:

• Assessment of fatigue, breathlessness and exercise tolerance
• Repeat complete blood count
• Repeat iron parameters when clinically appropriate
• Monitoring and treatment of heavy menstrual bleeding

If the haemoglobin response is inadequate, possible causes should be investigated. These may include poor adherence, continued blood loss, malabsorption, an incorrect diagnosis or another underlying cause of anaemia.

Expected Outcome

With appropriate iron replacement and effective management of the underlying heavy menstrual bleeding, haemoglobin levels and iron stores are expected to gradually improve.

As the anaemia is corrected, symptoms such as fatigue, dizziness, palpitations and reduced exercise tolerance should also improve.

Key Learning Points

• Iron deficiency is a common cause of anaemia worldwide.
• In menstruating women, heavy menstrual bleeding is an important potential source of chronic iron loss.
• Serum ferritin is an important marker of iron stores, although inflammation can affect its interpretation.
• Microcytosis should not automatically be attributed to iron deficiency. Thalassaemia and other causes should also be considered.
• Effective management requires both correction of the iron deficiency and treatment of the underlying source of blood loss.
• Monitoring the response to treatment helps identify persistent blood loss, poor absorption, inadequate adherence or alternative diagnoses.

Conclusion

This case highlights the importance of recognising iron deficiency anaemia associated with chronic heavy menstrual bleeding in a young woman presenting with persistent fatigue and reduced exercise tolerance. The laboratory pattern of microcytic hypochromic anaemia, low ferritin, low serum iron, elevated TIBC and low transferrin saturation supported the diagnosis.

Successful management requires a comprehensive approach that includes iron replacement, dietary optimisation and appropriate evaluation and treatment of the underlying cause of menstrual blood loss.

Contact Us to learn more about evaluation and management of anaemia at Shivaay Hospicare.

Medical Note: This case study is intended for educational purposes only. Diagnosis and treatment should be based on an individual clinical assessment by a qualified healthcare professional.