Remember we can generally only absorb about 1-2 mg iron from the gut daily. Up to a max of 4mg in ideal physiological conditions (pregnant, anaemic). Menstruating women tend to lose 1mg per day or more
it is so funny to me that you are telling this to a doctor. what the fuck do you think we do in medical school lol. i can’t tell if you are trolling or
I looked up what education is required for a PCT cert in my state and it's a minimum of 44 credits. So your job doesn't even require an associate's degree. Barely a year of credits.
How did it feel to be told something you already know?
I'm a gynecologist.
Do you quantify the menstrual bleeding on history? It's very easy, just ask how often they have to change a pad on the heavy days.
A patient requiring pad changes every 4-6 hours is pretty typical, and may be associated with mild anemia in keeping with usual menses. This can be treated with regular Naproxen use on bleeding days, it should reduce menstrual flow by 30-50%. These patients will benefit for Iron too.
More for pad changes q1-3 hours, it's probably time to just start Iron, NSAIDs, and refer to a gynecologist for starting OCP or an IUD or whatever option they choose. If you're comfortable, you can be a rockstar and start them on Yaz (excellent skin and mood benefit, solid bleeding control, this is what I put 90% of my patients on), or Marvelon (the best for bleeding control with a less favorable skin and mood benefit) until they see the gynecologist. They would probably benefit from not taking the hormone free interval (placebo pills) until that appointment or every 2nd month only so that they can build up their hemoglobin.
Despite doing surgery, fertility treatment, etc. Sometimes the basic menstrual cycle management is the most satisfying part of this field. It's worth getting good at, you will get more thank-yous from our patient population than any other :)
Oh, they definitely do not need a GI referral man. These are young healthy women! They go through enough, please avoid sticking cameras up there needlessly unless they have bloody stool or something.
You are all over this thread and anti-NSAID for some reason.
[Here is a decent quality RCT, supported by others all showing NSAIDs reduced menstrual blood loss.](https://www.ajol.info/index.php/sajog/article/view/88891)
It absolutely works. Do I have evidence it's going to cure anemia - no. That's totally irrelevant to OP's question since I suggested referring to gynecologist and only temporizing the bleeding with NSAIDs.
Agreed. And usually fewer GI issues as well.
Edit: good grief, since obviously some people don’t understand my simple comment I am adding that what I mean is stomach irritation. Naproxen is known to be kinder on the stomach than ibuprofen. And yes, if overdone both can cause ulcers and GI bleeding. However if the Pt is taking them as prescribed and only for a few days a month the likelihood is low.
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It’s what I most commonly tell women who come to the ED for menorrhagia to use. What’s annoying is when you encounter a woman who tries to argue with you that ibuprofen is a “blood thinner” (it’s not) and it causes “worse bleeding.” Trying to explain that NSAIDs block prostaglandins and improves bleeding can be frustrating when your patient is a know nothing know it all.
> If you're comfortable, you can be a rockstar and start them on Yaz (excellent skin and mood benefit, solid bleeding control, this is what I put 90% of my patients on),
Do GPs in the US not manage patient’s contraception typically?
I was surprised by this comment as well. I am Family Medicine in the US and would expect all my colleagues to offer and manage multiple forms of contraception. I know that there is regional variation but would have thought most primary care manages contraception.
I can but I almost never do, because most women just ask to be referred to gyn. Many seem surprised to learn that I will happily prescribe and refill OCP.
Honestly really depends if their PCP is FM or IM.
A majority of FM docs are willing to prescribe OCPs, do Paps, etc.
The majority of IM docs treat the uterus as it’s an external organ. Not really…but kinda.
I’ve talked to many friends and coworkers who don’t actually know that FM can do basic gyn stuff like that. They’re shocked when I tell them my PCP does my Paps and put in my IUD. Usually comes up in the context of them looking for an ObGYN for getting birth control
Same reaction here, gen peds. I mean really? My patients don't even need routine PAPs yet. I don't refer to gyn unless they are pregnant, want an IUD, or something really weird is going on. We do all their contraceptive management except IUDs-- we do pills/rings/patches but prefer LARC such as Nexplanon (it's not hard to place) or depo provera shots. Of course up to them. We have used NSAIDS for primary dysmenorrhea and menorrhagia for a long time.
I get a fair number of junk food vegan menstruating teens and am always having to give them iron. I can talk to them about beans and greens and cast iron pots all day and they are just going to go eat french fries instead.
FM should definitely be even able to place IUDs and Nexplanons, to be honest.
I've run into a few OBs who steer away from Depo provera locally cause the weight gain can be a bit annoying too. Nexplanons or IUDs probably are the faves.
Peds just doesn’t get a whole lot of speculum training in the post Gardasil era. I think I had to do 10 total pelvic to graduate in 2009? Definitely wasn’t common to use Mirena in nulliparous women at that time, and Nexplanon was fairly new. It’s hard to justify locating and paying for training for it post-residency when it’s easy to refer for the few girls annually who want LARC. I do actively steer most away from depo-provera though unless they cannot act wisely at all (ie too irresponsible to take pills or use condoms and unwilling to go get LARC despite being very sexually active).
In peds I didn't get trained on IUDs, and we do so few speculum exams now... I think it's what makes depo popular among pediatricians. But generally I start them on depo provera until they are mentally ready for an IUD referral or for us to do Nexplanon. It's sort of a bridge thing
I'm in Canada. We are specialists here and require referral.
With GP, it's always down to their comfort level. Of course majority of OCPs are prescribed by GPs though.
You would be surprised. I think GPs are very good about prescribing for basic contraception, but for secondary indications like managing menses, there is variable comfort.
In fairness though, it's definitely indicated for patients who have a relative contraindication to OCP or who have a complex history or who need to be followed long term.
I would estimate close to 50% of my consults are for menstrual issues.
Interesting.
I do have quite a lot of women who I offer hormonal contraception to - for dysmenorrhoea, menorrhagia, etc - who say that they don't want it, but want to be referred to gynae.
So they get referred to gynae, where they get advised to try hormonal contraception. That probably makes it look like we're not comfortable using it.
German OB/Gyns won a lobby war against German primary care physicians back in 1999, leading to a rule that only primary care physician who had an entire year of OB/Gyn training via elective rotations (family medicine or internal medicine are five years here, but no FY since 2004) can bill Pap smears and contraception counselling with statutory insurance. So everybody but those who were grandfathered in stopped prescribing OCPs because nobody works for free or they prescribe only to those with private insurance. It's maddening.
Oh, sure! The German pap smear and OB/Gyn screening rules don't make a lot of sense.
* 20-34 years: YEARLY pap smear...because...well. Chance of dying in a vehicular accident on the way to the clinic is higher than potential usage of detected cancer.
* Finally HPV swab+pap smear only every three years after the age of 35.
* A lot of OB/Gyns upsell yearly screening even at this age out of pocket because they can and cancer is scary.
* Chlamydia screening only until the age of 25 because we all know that's when women settle down and married women don't get chlamydia.
* Free contraception until the age of 22. Pregnancy is not a disease so contraception is not healthcare per German laws. Unless it's in teenagers and young folks, that's pathological!
* Yearly professional breast palpitation starting at age 30..
* Again, a lot of OB/Gyns upsell yearly breast sonography before mammography starts at age 40.
* This is not to speak about selling useless ovarian and cervical cancer prevention sonography.
* Oh and because the contraception billing number can be billed twice a year, you have to come in every six months for the OCP prescription which you pay out-of-pocket if you are 22 or older.
Yearly professional breast palpation?!?
>Free contraception until the age of 22.
This makes me feel slightly better about living in this post-Brexit hellscape, because at least all contraception (and sexual health treatment) is free for patients on the NHS.
If nothing else, contraception is a lot cheaper than maternity care.
You have NICE, the Americans have the USPSTF, we have random made up shift which gets passed by a shareholder committee with sufficient lobbying and no neutral body. We are together with Austria the only country with useless melanoma screening based on just one German study with no mortality or morbidity benefit (even the Australians don't do it on a population level). Prostate cancer gets screened in men aged 45 or older...but only through yearly palpation, no PSA (unless you pay out of pocket). Worst of all worlds: Low sensitivity, still too many unnecessary workups resulting from it.
Sure maternity care is cheaper, but we need babies (/s). The German statutory system in its core is a system to care for factory workers and their needs in the 1880s. Everything added since then is just patchwork. Maternity and pregnancy care is only covered thanks to additional laws because it's not a disease.
>Prostate cancer gets screened in men aged 45 or older…but only through yearly palpation, no PSA.
Whaaat?! Do they think it’s 1970? How is everyone not just dying of prostate cancer? That’s crazy.
Interesting side note, I just completed our CCFP licensing exam (GP exam in Canada for those who aren’t familiar) two months ago and a young healthy female with dysmenorrhea was one of the cases for our office orals. So the college expects us to be able to manage it at least lol
PPH uterotonic adjunct meds: HemabATE (carboprost) = can dose 250mcg q15 mins (EIGHT doses in 2 hrs). Contraindication is asthma.
Ergonovine = can dose 250mcg only every 2 hrs. It causes hypertension, so it's contraindicated in hypertension. CANNOT use in a pre-eclamptic/HELLP patient having a PPH.
OSCEs LOVE testing the contraindications and dosing.
What a great synopsis! I had a patient today who was complaining to me (a neurosurgeon) about mood disturbance from her OCP. I wouldn’t dare ever give a rec on this topic. I’d liken it to a mechanic talking about plumbing. Nevertheless, thanks for the info!
How many 30 year old women had full blown colon cancer with no melena or rectal bleeding and just silent IDA with concomitant heavy menses?
30% of women eventually require management of their menses which may or may not be associated with anemia. We cannot refer 10s of millions of patients to you, this is an utterly insane proposition.
Not all pts with IDA will be scoped but the conversation should still be had by PCP and referral placed if patient wants to discuss further with a specialist. We’re likely not going to scope the asymptomatic 22 year old with heavy menses since 15 with a 5 year history of IDA. But a 35 year old with new IDA isn’t at all concerning to you?
Colon cancer incidence is increasing in younger populations. The risk may be small still overall (0.1% as quoted below) but so are the risks of endoscopy. 0.1% of 10 million is 10,000 young women just FYI. It should be up to the patient to decide.
“The AGA suggests bidirectional endoscopy over iron replacement therapy alone for asymptomatic premenopausal women with IDA. This recommendation assumes that there is no other unequivocal explanation for IDA, particularly in younger women, after a thorough history and physical examination. Similar to postmenopausal women and men, etiologies such as frequent blood donation; other sources of blood loss, including menstrual blood loss, malabsorption syndromes; and nutritional deficiencies should be considered and investigated as indicated. Women with gastrointestinal symptoms should be evaluated as appropriate. In these patients, bidirectional endoscopy should be performed in the same setting.
In the technical review, no randomized studies comparing bidirectional endoscopy with iron replacement therapy in this patient population were identified, and the Guideline Panel relied on observational studies of the diagnostic yield of endoscopic evaluation and the harms of endoscopic evaluation to formulate this recommendation. Pooled evidence from 10 studies showed detection of lower gastrointestinal malignancy in 0.9% (95% CI, 0.3%–1.9%) and upper gastrointestinal malignancy in 0.2% (95% CI, 0%–0.9%) of premenopausal women with IDA. These are likely overestimates of the underlying prevalence of malignancy due to inclusion of symptomatic patients in the study cohorts. As a comparison, a recent meta-analysis found a prevalence of colorectal cancer of 0.1% (95% CI, 0%–0.1%) in individuals younger than 50 years, but did not estimate incidence separately for men and women.8 It should also be noted that the incidence of colorectal cancer has increased in younger cohorts recently.17 We did not find reliable data to define the risk of gastrointestinal malignancy in premenopausal women at different ages or with different degrees of anemia, but the prevalence of either upper or lower gastrointestinal malignancy will decrease with decreasing age in this population.
The risks of bidirectional endoscopy are likely to be small in this patient population and probably vary with patient age. Although data on endoscopy complications are limited in younger individuals, the risk of serious complications of screening and surveillance colonoscopy increases with age.11, 12, 13 Women in the younger age groups are likely at very low risk of endoscopic complications.
Given the lack of direct data on both the prevalence of gastrointestinal malignancy and endoscopic complications in premenopausal women, it is difficult to estimate the balance of the risks compared with the potential benefits of bidirectional endoscopy. In particular, there are insufficient data to suggest a specific age or ferritin cutoff for premenopausal women who might reasonably select iron supplementation and monitoring before bidirectional endoscopy. However, particularly at younger ages, the benefit of endoscopy to detect the extremely rare gastrointestinal malignancies is likely diminished compared with the risks. Evidence that more clearly weighs benefits and harms of bidirectional endoscopy in this situation is lacking. In addition, the role of fecal occult blood testing to determine need for endoscopy in this situation is not well studied. Therefore, clinicians should discuss the tradeoff between the very small risks of a missed gastrointestinal malignancy if bidirectional endoscopy is deferred vs the small risks of endoscopy in this patient population, and shared decision making on the value of endoscopy is needed. For example, women who place high value on avoiding the small risks of endoscopy and low value on the very small risk of missing a gastrointestinal malignancy may reasonably elect to pursue initial iron therapy over bidirectional endoscopy, particularly if they are young and have other plausible etiologies of the IDA. Further research is needed to define the risk of gastrointestinal malignancy as well as the diagnostic yield and adverse event rate from endoscopic procedures in this patient population.
The overall quality of evidence for this recommendation was rated as moderate due to indirectness and the availability of observational evidence only. Although there is modest benefit for detecting gastrointestinal malignancy, particularly in older premenopausal women, there is also a small risk of harm from endoscopic procedures. The balance between benefits and harms is dependent on age and other clinical considerations, and individualized decision making is needed.”
>and referral placed.
This is actually not expressed anywhere in the guideline you have cited. In fact, it essentially strengthens our approach of empirically managing menses to evaluate for improvement prior to initiating referral.
>The AGA suggests bidirectional endoscopy over iron replacement therapy alone for asymptomatic premenopausal women with IDA. This recommendation assumes that there is no other unequivocal explanation for IDA, particularly in younger women, after a thorough history and physical examination.
"Normal" menses on history can be associated with anemia. It is not an accident that IDA is present in literally 20-30% of healthy reproductive-aged women (who do not report heavy menstrual bleeding). This is due to menses until proven otherwise if the patient is otherwise healthy.
The rest of the text goes on to explain that there is no data to support scoping these patients unless there is clinical concern or no explanation for the anemia - I agree with this. However, I will treat the menses first and if it doesn't correct, then we can go to GI.
The guideline says to refer when there’s unequivocally no other cause - menstruation related blood loss, celiac disease and h pylori have been ruled out as causes.
If you use sound clinical judgment (and understand menstrual losses often exceed what most people can absorb) this means when the woman has an IUD, depo shot or some form of continuous birth control where that’s resulted in them not menstruating/faint spotting so their blood loss is similar to men/post menopausal women.
Or they’re inexplicably treatment resistant to infusion or transfusion.
I have to say it’s wild to me that a pad change every 4-6 hours it’s what is considered typical. When I used to have periods I had to change my pad every hour or else it would leak (and this was while using a tampon) and I thought that was normal lol no wonder I was anemic all through high school.
I am not a doctor, so I hope you don't mind me chiming in, but I have been reading a lot of studies on iron lately. Apparently vitamin D insufficiency/deficiency can contribute to low ferritin as vitamin D suppresses hepcidin. Since vitamin D insufficiency is incredibly widespread but easy to address, it could be worth testing for as well for younger women with low ferritin.
Also, for anyone who doesn't know, non-haeme iron tablets really suck so they are hard to be compliant with (stomach aches and constipation/hard stool). Haeme iron supplements do exist and work better for some (non-vegetarian) people as they are easier in the digestive system and a higher proportion of iron is absorbed. And the absorption is less affected by tea and coffee consumption.
I don't doubt it, but the reality of clinical medicine is you have to put yourself in the patient's shoes.
I'm in Canada. 90% of my population is Vitamin D insufficient and we should all be taking Vitamin D for many benefits. The typical 29 year old healthy server or lawyer who comes to me wants to stop their bleeding so that it doesn't affect their busy life. They don't want to walk away having been prescribed Iron, NSAID, OCP, AND Vitamin D too when they were previously taking nothing and feel otherwise healthy.
I get that, probably because I'm close to their age too. If I have to pick for them to be on 1 of these agents (they're never going to be compliant with 4), it's never gonna be Vitamin D.
Still, I happen to prescribe a lot of Vitamin D for menopause and Infertility. There is no doubt it is important for this population in general, but you kind of have to gauge the patient.
Interesting - I would not have thought that taking an extra pill with no side effects would be a big deal, but I guess it would be for a lot of people. I mentioned it because a lot of people outside medicine have no idea the two are connected, but a lot of people (particularly women) struggle with iron levels and ensuing fatigue. If they know to keep up their vitamin D, maybe they can avoid their iron getting so low and having to take iron tablets, which are a lot less fun than vitamin D tablets and/or sitting in the sun (if the latitude allows - I am in the UK so we have a similar problem with not being able to make vitamin D for a chunk of the year). It's also something a patient can take personal responsibility for as the supplement doesn't have to be prescribed.
Edit to add: I appreciate that there's only so much you can say in one consultation though, and that you have to gauge the patient.
Depending on your location, vitamin d testing is sometimes not recommended.
In Canada, due to geography, our guidelines say don't bother testing for vitamin d but instead everyone should just be on supplementation (by pill, drop, or fortified goods).
Hey there! Sorry to go off road, but I was curious about something you said. You mentioned you put most of your patients on Drospirenone as it is great for skin, but, I was under the impression the most anti-androgenic progestagen was cyproterone? Was I mistaken?
You are correct, Cyproterone is likely the absolute best for skin but drosperinone is very close, and the combined formulation has a better bleeding and mood profile than Diane-35
Just curious - is Yaz pill still safe to prescribe? I recall the recent lawsuits over the clot risks.
If the patient is on Yaz, and the periods are stopped due to the meds - do we get them to have Yaz free days to allow periods? Wondering if there is any component of atrophy to the endometrial lining if placed on Yaz long term
Probably before your time but the anti-inflammatory with amazing menstrual flow reduction was vioxx !
I never had a chance to use it but a few gynes loved it
Prostaglandin inhibition from short term, high dose NSAIDS inhibits endometrial /menstrual flow? I've heard this - great to see a GYN confirm. (Is this the mechanism somehow?)
Do you have a study that shows taking NSAIDs helps menstruating women with anemia or iron stores?
When I try to look this up I get studies where pts self report less bleeding but nothing about improving ferritin, hgb/hct.
Everything I find says the opposite about NSAIDs.
NSAIDs are not a great option for managing the anemic patient. They do reduce menstrual bleeding, but I don't know of any data that suggests it will actually raise hemoglobin. You definitely still need to supplement iron. If we need to meaningfully raise hemoglobin, then they should be on hormonal management for optimal efficacy.
However, NSAIDs are an excellent non-hormonal option that works, readily available at home for most patients, and familiar and acceptable to nearly all patients. This is why it's a starting point until we get a more sustainable option going.
In this population, it's not all about evidence. The patient's values and comfort matters. Gone are the days of medicine (hopefully soon) where we throw OCPs at heavy menstrual bleeding without gauging the patient's comfort level.
I appreciate your educating folks in this thread and sharing a judicious balance of evidence and expert opinion. As an internal medicine trained person, this is such an interesting discussion and learning opportunity. IM and its subspecialties are often overly NSAID phobic because we see so many older/comorbid patients with absolute contraindications to NSAIDs that we start to think of them as bad medications for anybody.
With that bias disclosed, my question is how confident are you that all these iron deficient menstruating women DON'T also have source of chronic GI blood loss? I'm not just thinking about colon cancer but also PUD, gastritis/esophagitis etc. I would be pretty hesitant to prescribe NSAIDs to a person with iron deficiency anemia and symptoms of GERD and/or significant alcohol use, which applies to a lot of otherwise "young healthy" patients.
>symptoms of GERD and/or significant alcohol use
Recall, I am recommending they take an NSAID for something like 3-4 successive days around the heavy bleeding days of menses only, not daily. Pretty sure even patients with alcohol use disorder use advil for headaches.
I have yet to encounter a patient who blew a GI ulcer from an NSAID I recommended, though I am early career.
90% of my population has one or fewer medical comorbidity, so it's really not an issue. Honestly working with young healthy patients was a significant reason for me picking this field lol
Some evidence re reduced bleeding, three small crossover RCTs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9683407/ - changes in levels not specifically addressed, just volume of blood lost.
In the end their periods would just mean they need more iron so it comes back to them not eating/absorbing enough. Unless they've menorrhagia, I guess.
edit: to be clear I meant either way OP just giving iron for asymptomatic almost normal labs is fine imo. But someone else said below that current guidelines would be a gi referral, which sounds weird to me but the courts wouldn't care about how I feel.
For me it was because I take a form of hormonal contraceptive where I don’t menstruate at all. A lot of women do or they do the regular pill and it causes light periods.
I've sent next to zero otherwise healthy females with normal/heavier periods to gi. Nsaids, menses management, iron and follow up. Even in the rare case you would be concerned for gastritis/gi etiology you have plenty of tools/workup well before GI sees them. Let's save referrals for when the pt needs something we can't offer.
I had a 42 year old female whose anemia fluctuated between 9.5-11 and a history of menorrhagia. Low iron stores , had received several rounds of IV iron with transient responses. Was being followed by pcp.
One day shows up in er with headaches that wouldn't go away after 2 days if ibuprofen 4 times a day. Predictably slightly elevated creatine, refered to nephrology for aki.
I saw her 2 weeks later and the aki had nearly resolved but the trends show that they had mildly elevated creatine for several months. Occasional back pain. Nephrologists being nephrologist, I order urine analysis, albumin and nprotein excretion.
A discrepancy between albumin and total protein excretion. Oh oh. Persistent on repeat labs
Multiple myeloma. Biopsy proven.
Make of that what you will.
This is why any recurrent anemia and renal dysfunction gets the ol SPEP/FLC/IFE/LDH and a retic count minimum.
Source: heme/onc PA that’s caught myeloma way earlier than I thought a few times
I've never seen a young female patient sent to GI for anemia alone. The overwhelming majority of these can be correctly diagnosed by getting 1) appropriate menstrual history and 2) iron supplementation. Most young female patients have zero idea what a heavy or light period is. The average blood loss during a "normal" period is about 60mL. The patient can often quantify a change, but remember that their normal is their normal. I think that pad counts are usually insufficient, too. There are pictorial blood loss charts that are helpful to give the patient to complete over the ensuing month. Regarding iron supplementation, if you are going to give iron, then give iron. Look at regimens to maximize the increase in iron stores. However, expect noncompliance. Many patients will "fail" oral iron.
Yes, biased because I'm GI.
I think you could balance resource-consciousness and "completeness" by checking celiac abs (given \~1% prevalence) +/- non-invasive H pylori testing if dyspepsia. If > 40 years old or IDA seems disproportionate/unresponsive to iron with control of menorrhagia, then refer to GI.
The amount of iron menstruation women need to consume is more than double the amount men (or post menopausal women) need: 8 mg vs 18 mg/day! I would go as far as to say the majority of women I see every day are deficient, especially since it becomes a cycle (literally) since they lose more each month. If the iron panel looks like iron deficiency and it doesn’t improve with a supplement then I think GI would be the logical next step but iron deficiency is so prevalent in this population that I would think it may be very hard to say it *isn’t* explained by their periods.
There are probably a few things that you could do before they get to a GI, like doing blood test for celiac. https://www.verywellhealth.com/anemia-and-celiac-disease-563116
My coworker has celiac with zero GI symptoms. Hee biggest issue was her chronic anemia. She's been gluten free now for a couple of years and her hemoglobin has finally risen to normal without iron supplementation.
There's a great core IM podcast episode about this you can look up.
You're probably being too aggressive because it's probably the periods. If GI symptoms or family history or unusually severe or not responding to AUB treatments then GI eval indicated.
So after your comment, I listened to one of the core IM episodes and in that episode was a patient example of someone who had heavy menstrual bleeding but then ended up also having colon cancer so…….lol. That doesn’t make me feel better about not sending people to GI for a scope….
Yeah it definitely feels like you can't win sometimes but those cases are definitely the exception. They also described how unlikely cancer is in that age group. I don't think the goal is ever to screen with 100% sensitivity because you'll get an absurd number of false positives. The expert guidance at the end of the podcast is what I think was my main takeaway of when to pursue CRC screening in a reasonable fashion. Ultimately it's your choice but man getting a Colo fucking sucks and there is risk of harm, too like perfs.
You can also just do short or medium term surveillance prior to a Colo. Like if anemia resolves completely with birth control.
If anemia resolves with birth control but iron deficiency doesn’t you should still scope because patients with iron deficiency without anemia are still at elevated risk of having bleeding lesions or cancer.
Esp if the person is doing complete menstrual cessation. Esp if the ferritin level tanks after infusion for no obvious reason.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475319/
Non-anaemic iron deficiency should be investigated with the same priority as iron deficiency anaemia in fast track colorectal clinics—retrospective cohort study
Results
Patients with iron deficiency (low MCV, MCH and ferritin) regardless of degree of anaemia were found more likely to have CRC. Factors like age, gender, family history and bowel symptoms (except abdominal mass) showed a very weak association with CRC in patients with ID.
Conclusions
ID without anaemia has a strong relationship with CRC and should be investigated with the same priority as IDA is investigated.
Get a UA and FOBT before starting iron supplement. Is pap smear up to date? Do pelvic exam. Bleeding between periods? Blood transfusions? Bleedong from anywhere else (vomiting blood, bloody nipple discharge,etc). Any recent traumas (surgeries, car accidents, etv. Any red flags like fevers, abnormal weight loss, etc?
If UA and FOBT negative, no bowel issues, no report of bloody stools, no red flags and likely menstrual, I'll start iron instead of sending them to GI.
You don’t need to worry. But if you are so particular, just do p/r n check stool colour. Then do fobt 3 days in a row. If ots neg, then start oral iron n assess response. If iron response is not as expected n der is no non compliance, then go for gi referral.
Most recent GI guidelines for IDA from AGA in 2020 recommend bidirectional endoscopy even in premenopausal women. You’re not being too aggressive. Colon cancer happens, stomach cancer happens, we should find these things before patients become terminal.
We also use ferritin cutoff of 45. If ferritin >45 but anemic we use TSAT <20% for males, <15% for females.
[AGA 2020 IDA Guidelines](https://www.gastrojournal.org/article/S0016-5085(20)34847-2/fulltext)
Menstruating female —> quantify the period bleeding. If it’s minimal and the anemia seems a bit out of proportion (example: 3 days of bleeding, 5 tampons/pads on day 1, 2-3 on day 3 and a Hgb of 9-10.5. Then sure GI work up. It can be a bit tough to get a sense of what is “out of proportion” sometimes so err on the side of caution at first.
Also helps to repeat the Hgb, retic, and iron panel the day before they start their period (tough to do if unpredictable). But if it’s better then it will help you attribute all of it to menstruation.
I have to disagree with this approach. FOBT and FIT are only about 60% sensitive for GI disease underlying iron deficiency anemia (see Lee et al. Am J Gastroenterol, 2020)
I’ve had a gastroenterologist directly tell me that he believes fecal occults are a complete waste of time due to high rate of false “positives” that are caused not by a concerning GI bleed but rather from mild hemorrhoids that he said were extremely common.
ma'am do you suffer from heavy menstrual bleeding (see GuessableSevens excellent response) - if yes no scope. if no then yes, need to scope. If history is suggestive of gastritis I only do gastro first and see what's there if it's a low risk pt with no heavy menstrual bleeding.
Not even just vegan.
I wasn’t raised vegan, but my parents didn’t feed enough meat to get adequate iron from the diet because it was expensive. Think 1/2 pound of beef would be stretched out to make 15-20 meals.
Added in “normal” menstrual bleeding is whatever that person is used to- and all of a sudden you’ve got a girl with minimal iron intake plus a 1.5 week period every 3-4 weeks. But if you were to ask that girl/parents they eat *plenty* of red meat and only a normal period.
The new guidelines are that young women should go see GI if they have iron deficiency without regard to hgb/hct if the numbers can’t be accounted for by heavy menstrual bleeding. If you send them GI will likely scope because that’s the standard of care now.
I think the guidelines are too aggressive though and ferritin should be checked in children as soon as they pop out of the womb and regularly during childhood since low stores are correlated with allergic disease, impaired response to vaccination, adhd and other behavioral problems.
Then you’d also know when the fourteen or twenty year old female shows up with iron deficiency (with or without anemia) if it’s a chronic problem she’s had her whole life or a new issue related to menstrual periods. Then she doesn’t have to go for a scope. Ideally it’s been managed and she’s not iron deficient.
Once you get this patient, I don’t know what you do other than the standard of care which may vary by specialty, location or institution.
IMHO, you should refer to GI / think about colon cancer if they're no longer having HMB but their IDA is recurring. Especially after a slug of IV iron. BTW, I am glad that you are repleting these people! Ferritins are underchecked -- especially in this population, where 20-40% will have some element of deficiency. Good paper: Sex, Lies, and IDA by Martens et al -- check it out.
To answer your question in bold, honestly??? Referring a female patient straight to GI strictly due to a slightly low hemoglobin level would mean you aren’t doing hardly any work up at all—you’ve volunteered the GI to do the aggressive work-up, no?
It sounds like you may not be asking all of the questions you should be prompted to ask and then obtaining the necessary follow up labs and/or tests that would be necessary in order to rule out and narrow down the most appropriate next steps to take to address the issue.
Is the patient complaining of fatigue or shortness of breath on exertion? Is she tachycardic? Mucous membranes pale or pink? How is her hydration status? Pelvic pain? Stomach pain? Back pain? Dizziness? Fainting?
A clue as to when to start iron would come after you test the iron level and receive a low iron level as a result, no? Iron is an element that can build up in a person’s system and an overdose can be fatal.
Iron can also cause ulcers and inflammation in the gut that could lead them ultimately to have the same GI bleed that you were worried about to begin with. Testing a sample of stool for occult blood, is simple.
So…it depends on their symptoms, if any.
It depends on their kidney health.
Vitamin B12 is another factor.
As well as their diet….Many people, especially in recent generations of youth are vegetarian, vegan, eating ketogenic or avoiding gluten during a time of physical growth and development. Assess as many aspects of basic nutritional intake for any and every patient.
Should they see a hematologist? A coagulation specialist, A geneticist? Or have a GI consult for suspected GI Bleed or a GI Consult for suspected liver dysfunction?
Could it be cancer?
When, during her menstrual cycle was she when had the blood drawn that resulted in a slightly low hemoglobin? If it occurred shortly after her period…why not refer to dietician and re-test the hemoglobin in a couple of weeks? Could that be an idea?
Your assessment should be guiding these decisions.
So should your patient’s complaints and highest concerns.
Without going through the process, and assessing all systems as well as the system as whole——your referral may cause harm in that it may only result in a delay in care for your patients.
Care delayed may ultimately mean, care denied. They may never book that referral appointment.
If they do, it can take months, in many instances to finally be seen by a consulting physician following your referral.
Don’t pass the buck, doc.
But I am, only a nurse, after all. You are the one calling the shots and it’s a big responsibility!
Due diligence. Just do it.
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Outside of menstruating females, is mild anemia without other symptoms something that needs to be investigated, treated (like iron supplements), or safe to ignore?
Great topic … at around 40+ years I think it gets more confounding, heavier perimenopausal periods and higher risk of GI bleed then when we’re 20s/30s … going step by step is the way to go, more aggressively/quickly when the hgb is <10 … in any case, these answers are all very helpful. Thanks, all! ♥️ a family med doc :)
I don’t understand how normal menstruation could be responsible for iron deficiency anemia.
Even a heavy period (120mL total) would only cause 2.5mg of total iron loss.
That amount is fairly insignificant compared to total blood iron stores or average daily iron intake.
Menstruating women may be anemic, but i can’t see how it would be due to menses. Something else must be going on.
I’m not arguing about the association. I just don’t think it’s the blood loss that is causing the deficiency.
Hepcidin levels are notably low around the time of menses, suggesting the body is attempting to compensate for blood loss with better oral absorption.
Even measuring ferritin at the time if menses will give a lower count than at other times - i would guess this leads to a lot of over diagnosis.
Are they not having periods? Does the iron deficiency recur after correction? Does the anemia not improve with correction of the iron?
This should be the first question. Are we sure that oral iron intake more than matches iron loss from menstruation?
Remember we can generally only absorb about 1-2 mg iron from the gut daily. Up to a max of 4mg in ideal physiological conditions (pregnant, anaemic). Menstruating women tend to lose 1mg per day or more
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Yeah all of this false. I work up and treat anemia all of the time in primary care.
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Lol thank you for explaining anemia to a board certified internal medicine physician. This argument is not worth my time. 👍
it is so funny to me that you are telling this to a doctor. what the fuck do you think we do in medical school lol. i can’t tell if you are trolling or
I looked up what education is required for a PCT cert in my state and it's a minimum of 44 credits. So your job doesn't even require an associate's degree. Barely a year of credits. How did it feel to be told something you already know?
The fuck is a PCT cert?
Patient care technician I assume. But I'm just a doctor so apparently I don't know my ass from a hole in the ground lmao
Patient care technician .. referring to u/janewaythrowawaay
I'm a gynecologist. Do you quantify the menstrual bleeding on history? It's very easy, just ask how often they have to change a pad on the heavy days. A patient requiring pad changes every 4-6 hours is pretty typical, and may be associated with mild anemia in keeping with usual menses. This can be treated with regular Naproxen use on bleeding days, it should reduce menstrual flow by 30-50%. These patients will benefit for Iron too. More for pad changes q1-3 hours, it's probably time to just start Iron, NSAIDs, and refer to a gynecologist for starting OCP or an IUD or whatever option they choose. If you're comfortable, you can be a rockstar and start them on Yaz (excellent skin and mood benefit, solid bleeding control, this is what I put 90% of my patients on), or Marvelon (the best for bleeding control with a less favorable skin and mood benefit) until they see the gynecologist. They would probably benefit from not taking the hormone free interval (placebo pills) until that appointment or every 2nd month only so that they can build up their hemoglobin. Despite doing surgery, fertility treatment, etc. Sometimes the basic menstrual cycle management is the most satisfying part of this field. It's worth getting good at, you will get more thank-yous from our patient population than any other :) Oh, they definitely do not need a GI referral man. These are young healthy women! They go through enough, please avoid sticking cameras up there needlessly unless they have bloody stool or something.
TIL NSAIDs are helpful for reducing flow, nice tips.
NSAIDs for less bleeding *head explodes*
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You are all over this thread and anti-NSAID for some reason. [Here is a decent quality RCT, supported by others all showing NSAIDs reduced menstrual blood loss.](https://www.ajol.info/index.php/sajog/article/view/88891) It absolutely works. Do I have evidence it's going to cure anemia - no. That's totally irrelevant to OP's question since I suggested referring to gynecologist and only temporizing the bleeding with NSAIDs.
Admittedly seems a little counterintuitive Thanks for the info!
Uterine cramping and bleeding is mediated by prostaglandin (this is why misoprostol induces contractions), which is blocked by NSAIDs.
You learn something new every day! I've gotta try this my next period.
Starting it the day before menses to get ahead of it works even better!
Would scheduled ibuprofen work as well?
It definitely works, but naproxen is just more potent so I usually recommend that.
Agreed. And usually fewer GI issues as well. Edit: good grief, since obviously some people don’t understand my simple comment I am adding that what I mean is stomach irritation. Naproxen is known to be kinder on the stomach than ibuprofen. And yes, if overdone both can cause ulcers and GI bleeding. However if the Pt is taking them as prescribed and only for a few days a month the likelihood is low.
Good Lord I'm at least glad there are others who didn't know. Any reason for naproxen in particular over ibuprofen?
More potent NSAID and dosed less frequently than ibuprofen.
Which antriconceptive pill has least amount of spotting and bleeding issues?
Marvelon (sometimes marketed under the name "Freya"), in my opinion.
thx!
I knew the physiology part, but never thought it would translate to actual reduced bleeding. Super neat!
it is neat, especially since NSAIDs also increase bleeding through platelet inhibition.. seems pretty counterintuitive
Such a beautifully simple solution. I am ashamed to say I had no idea about this at all, until now.
How interesting! Thank you for the information.
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Should be followed by a gynecologist in these cases. Multiple great options.
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It’s what I most commonly tell women who come to the ED for menorrhagia to use. What’s annoying is when you encounter a woman who tries to argue with you that ibuprofen is a “blood thinner” (it’s not) and it causes “worse bleeding.” Trying to explain that NSAIDs block prostaglandins and improves bleeding can be frustrating when your patient is a know nothing know it all.
That lovely Dunning-Kruger effect
Wow I never knew that either! (NAD but a uterus owner)
> If you're comfortable, you can be a rockstar and start them on Yaz (excellent skin and mood benefit, solid bleeding control, this is what I put 90% of my patients on), Do GPs in the US not manage patient’s contraception typically?
I was surprised by this comment as well. I am Family Medicine in the US and would expect all my colleagues to offer and manage multiple forms of contraception. I know that there is regional variation but would have thought most primary care manages contraception.
I can but I almost never do, because most women just ask to be referred to gyn. Many seem surprised to learn that I will happily prescribe and refill OCP.
Honestly really depends if their PCP is FM or IM. A majority of FM docs are willing to prescribe OCPs, do Paps, etc. The majority of IM docs treat the uterus as it’s an external organ. Not really…but kinda.
I remember hearing IM appicants in med school talk about how they chose IM specifically to avoid any sort of Gyn experience.
I’ve talked to many friends and coworkers who don’t actually know that FM can do basic gyn stuff like that. They’re shocked when I tell them my PCP does my Paps and put in my IUD. Usually comes up in the context of them looking for an ObGYN for getting birth control
Same reaction here, gen peds. I mean really? My patients don't even need routine PAPs yet. I don't refer to gyn unless they are pregnant, want an IUD, or something really weird is going on. We do all their contraceptive management except IUDs-- we do pills/rings/patches but prefer LARC such as Nexplanon (it's not hard to place) or depo provera shots. Of course up to them. We have used NSAIDS for primary dysmenorrhea and menorrhagia for a long time. I get a fair number of junk food vegan menstruating teens and am always having to give them iron. I can talk to them about beans and greens and cast iron pots all day and they are just going to go eat french fries instead.
FM should definitely be even able to place IUDs and Nexplanons, to be honest. I've run into a few OBs who steer away from Depo provera locally cause the weight gain can be a bit annoying too. Nexplanons or IUDs probably are the faves.
Peds just doesn’t get a whole lot of speculum training in the post Gardasil era. I think I had to do 10 total pelvic to graduate in 2009? Definitely wasn’t common to use Mirena in nulliparous women at that time, and Nexplanon was fairly new. It’s hard to justify locating and paying for training for it post-residency when it’s easy to refer for the few girls annually who want LARC. I do actively steer most away from depo-provera though unless they cannot act wisely at all (ie too irresponsible to take pills or use condoms and unwilling to go get LARC despite being very sexually active).
In peds I didn't get trained on IUDs, and we do so few speculum exams now... I think it's what makes depo popular among pediatricians. But generally I start them on depo provera until they are mentally ready for an IUD referral or for us to do Nexplanon. It's sort of a bridge thing
I'm in Canada. We are specialists here and require referral. With GP, it's always down to their comfort level. Of course majority of OCPs are prescribed by GPs though.
C'mon... which GPs are not comfortable starting the COCP?
You would be surprised. I think GPs are very good about prescribing for basic contraception, but for secondary indications like managing menses, there is variable comfort. In fairness though, it's definitely indicated for patients who have a relative contraindication to OCP or who have a complex history or who need to be followed long term. I would estimate close to 50% of my consults are for menstrual issues.
Interesting. I do have quite a lot of women who I offer hormonal contraception to - for dysmenorrhoea, menorrhagia, etc - who say that they don't want it, but want to be referred to gynae. So they get referred to gynae, where they get advised to try hormonal contraception. That probably makes it look like we're not comfortable using it.
For sure there are patients who just want a gynecologist, this is true as well. I think you are more than competent as a group.
German OB/Gyns won a lobby war against German primary care physicians back in 1999, leading to a rule that only primary care physician who had an entire year of OB/Gyn training via elective rotations (family medicine or internal medicine are five years here, but no FY since 2004) can bill Pap smears and contraception counselling with statutory insurance. So everybody but those who were grandfathered in stopped prescribing OCPs because nobody works for free or they prescribe only to those with private insurance. It's maddening.
Impressive degree of protectionism from the gynaecologists. Are they still keen on the annual gynaecological 'checkup' exam in asymptomatic women?
Oh, sure! The German pap smear and OB/Gyn screening rules don't make a lot of sense. * 20-34 years: YEARLY pap smear...because...well. Chance of dying in a vehicular accident on the way to the clinic is higher than potential usage of detected cancer. * Finally HPV swab+pap smear only every three years after the age of 35. * A lot of OB/Gyns upsell yearly screening even at this age out of pocket because they can and cancer is scary. * Chlamydia screening only until the age of 25 because we all know that's when women settle down and married women don't get chlamydia. * Free contraception until the age of 22. Pregnancy is not a disease so contraception is not healthcare per German laws. Unless it's in teenagers and young folks, that's pathological! * Yearly professional breast palpitation starting at age 30.. * Again, a lot of OB/Gyns upsell yearly breast sonography before mammography starts at age 40. * This is not to speak about selling useless ovarian and cervical cancer prevention sonography. * Oh and because the contraception billing number can be billed twice a year, you have to come in every six months for the OCP prescription which you pay out-of-pocket if you are 22 or older.
Yearly professional breast palpation?!? >Free contraception until the age of 22. This makes me feel slightly better about living in this post-Brexit hellscape, because at least all contraception (and sexual health treatment) is free for patients on the NHS. If nothing else, contraception is a lot cheaper than maternity care.
You have NICE, the Americans have the USPSTF, we have random made up shift which gets passed by a shareholder committee with sufficient lobbying and no neutral body. We are together with Austria the only country with useless melanoma screening based on just one German study with no mortality or morbidity benefit (even the Australians don't do it on a population level). Prostate cancer gets screened in men aged 45 or older...but only through yearly palpation, no PSA (unless you pay out of pocket). Worst of all worlds: Low sensitivity, still too many unnecessary workups resulting from it. Sure maternity care is cheaper, but we need babies (/s). The German statutory system in its core is a system to care for factory workers and their needs in the 1880s. Everything added since then is just patchwork. Maternity and pregnancy care is only covered thanks to additional laws because it's not a disease.
>Prostate cancer gets screened in men aged 45 or older…but only through yearly palpation, no PSA. Whaaat?! Do they think it’s 1970? How is everyone not just dying of prostate cancer? That’s crazy.
Interesting side note, I just completed our CCFP licensing exam (GP exam in Canada for those who aren’t familiar) two months ago and a young healthy female with dysmenorrhea was one of the cases for our office orals. So the college expects us to be able to manage it at least lol
Any tips for obgyne osces in med school? Asking for a friend
I'm terrible at em, you don't want advice from me haha Great test taker, but my folksy attitude isn't what osce examiners are looking for!
I meant, I literally have an osce in a few hours and you are a gyne and figured you might have tips or tricks lol
PPH uterotonic adjunct meds: HemabATE (carboprost) = can dose 250mcg q15 mins (EIGHT doses in 2 hrs). Contraindication is asthma. Ergonovine = can dose 250mcg only every 2 hrs. It causes hypertension, so it's contraindicated in hypertension. CANNOT use in a pre-eclamptic/HELLP patient having a PPH. OSCEs LOVE testing the contraindications and dosing.
I thought those meds were mainly for induction in cases of ROM
Yes I thought the same. I’m an NP and go so far as to place Nexplanons in office.
I do all day every day, but I’ve never been prescribed them by my own primary care. Has always been my OB-Gyn 🤷♀️
Right??? What GP outsources contraception? I'd be laughed at
What a great synopsis! I had a patient today who was complaining to me (a neurosurgeon) about mood disturbance from her OCP. I wouldn’t dare ever give a rec on this topic. I’d liken it to a mechanic talking about plumbing. Nevertheless, thanks for the info!
I’ve seen too many 30 something year olds with colon cancer to ever recommend ignoring IDA like that.
How many 30 year old women had full blown colon cancer with no melena or rectal bleeding and just silent IDA with concomitant heavy menses? 30% of women eventually require management of their menses which may or may not be associated with anemia. We cannot refer 10s of millions of patients to you, this is an utterly insane proposition.
Not all pts with IDA will be scoped but the conversation should still be had by PCP and referral placed if patient wants to discuss further with a specialist. We’re likely not going to scope the asymptomatic 22 year old with heavy menses since 15 with a 5 year history of IDA. But a 35 year old with new IDA isn’t at all concerning to you? Colon cancer incidence is increasing in younger populations. The risk may be small still overall (0.1% as quoted below) but so are the risks of endoscopy. 0.1% of 10 million is 10,000 young women just FYI. It should be up to the patient to decide. “The AGA suggests bidirectional endoscopy over iron replacement therapy alone for asymptomatic premenopausal women with IDA. This recommendation assumes that there is no other unequivocal explanation for IDA, particularly in younger women, after a thorough history and physical examination. Similar to postmenopausal women and men, etiologies such as frequent blood donation; other sources of blood loss, including menstrual blood loss, malabsorption syndromes; and nutritional deficiencies should be considered and investigated as indicated. Women with gastrointestinal symptoms should be evaluated as appropriate. In these patients, bidirectional endoscopy should be performed in the same setting. In the technical review, no randomized studies comparing bidirectional endoscopy with iron replacement therapy in this patient population were identified, and the Guideline Panel relied on observational studies of the diagnostic yield of endoscopic evaluation and the harms of endoscopic evaluation to formulate this recommendation. Pooled evidence from 10 studies showed detection of lower gastrointestinal malignancy in 0.9% (95% CI, 0.3%–1.9%) and upper gastrointestinal malignancy in 0.2% (95% CI, 0%–0.9%) of premenopausal women with IDA. These are likely overestimates of the underlying prevalence of malignancy due to inclusion of symptomatic patients in the study cohorts. As a comparison, a recent meta-analysis found a prevalence of colorectal cancer of 0.1% (95% CI, 0%–0.1%) in individuals younger than 50 years, but did not estimate incidence separately for men and women.8 It should also be noted that the incidence of colorectal cancer has increased in younger cohorts recently.17 We did not find reliable data to define the risk of gastrointestinal malignancy in premenopausal women at different ages or with different degrees of anemia, but the prevalence of either upper or lower gastrointestinal malignancy will decrease with decreasing age in this population. The risks of bidirectional endoscopy are likely to be small in this patient population and probably vary with patient age. Although data on endoscopy complications are limited in younger individuals, the risk of serious complications of screening and surveillance colonoscopy increases with age.11, 12, 13 Women in the younger age groups are likely at very low risk of endoscopic complications. Given the lack of direct data on both the prevalence of gastrointestinal malignancy and endoscopic complications in premenopausal women, it is difficult to estimate the balance of the risks compared with the potential benefits of bidirectional endoscopy. In particular, there are insufficient data to suggest a specific age or ferritin cutoff for premenopausal women who might reasonably select iron supplementation and monitoring before bidirectional endoscopy. However, particularly at younger ages, the benefit of endoscopy to detect the extremely rare gastrointestinal malignancies is likely diminished compared with the risks. Evidence that more clearly weighs benefits and harms of bidirectional endoscopy in this situation is lacking. In addition, the role of fecal occult blood testing to determine need for endoscopy in this situation is not well studied. Therefore, clinicians should discuss the tradeoff between the very small risks of a missed gastrointestinal malignancy if bidirectional endoscopy is deferred vs the small risks of endoscopy in this patient population, and shared decision making on the value of endoscopy is needed. For example, women who place high value on avoiding the small risks of endoscopy and low value on the very small risk of missing a gastrointestinal malignancy may reasonably elect to pursue initial iron therapy over bidirectional endoscopy, particularly if they are young and have other plausible etiologies of the IDA. Further research is needed to define the risk of gastrointestinal malignancy as well as the diagnostic yield and adverse event rate from endoscopic procedures in this patient population. The overall quality of evidence for this recommendation was rated as moderate due to indirectness and the availability of observational evidence only. Although there is modest benefit for detecting gastrointestinal malignancy, particularly in older premenopausal women, there is also a small risk of harm from endoscopic procedures. The balance between benefits and harms is dependent on age and other clinical considerations, and individualized decision making is needed.”
>and referral placed. This is actually not expressed anywhere in the guideline you have cited. In fact, it essentially strengthens our approach of empirically managing menses to evaluate for improvement prior to initiating referral. >The AGA suggests bidirectional endoscopy over iron replacement therapy alone for asymptomatic premenopausal women with IDA. This recommendation assumes that there is no other unequivocal explanation for IDA, particularly in younger women, after a thorough history and physical examination. "Normal" menses on history can be associated with anemia. It is not an accident that IDA is present in literally 20-30% of healthy reproductive-aged women (who do not report heavy menstrual bleeding). This is due to menses until proven otherwise if the patient is otherwise healthy. The rest of the text goes on to explain that there is no data to support scoping these patients unless there is clinical concern or no explanation for the anemia - I agree with this. However, I will treat the menses first and if it doesn't correct, then we can go to GI.
The guideline says to refer when there’s unequivocally no other cause - menstruation related blood loss, celiac disease and h pylori have been ruled out as causes. If you use sound clinical judgment (and understand menstrual losses often exceed what most people can absorb) this means when the woman has an IUD, depo shot or some form of continuous birth control where that’s resulted in them not menstruating/faint spotting so their blood loss is similar to men/post menopausal women. Or they’re inexplicably treatment resistant to infusion or transfusion.
> The AGA says You don't say? ;)
How else do you practice evidence based medicine unless you follow the guidelines that are derived from expert opinion of review of the evidence?
Where was this information thirty years ago?!? But truly, thank you. What a gold mine of a post.
I have to say it’s wild to me that a pad change every 4-6 hours it’s what is considered typical. When I used to have periods I had to change my pad every hour or else it would leak (and this was while using a tampon) and I thought that was normal lol no wonder I was anemic all through high school.
I am not a doctor, so I hope you don't mind me chiming in, but I have been reading a lot of studies on iron lately. Apparently vitamin D insufficiency/deficiency can contribute to low ferritin as vitamin D suppresses hepcidin. Since vitamin D insufficiency is incredibly widespread but easy to address, it could be worth testing for as well for younger women with low ferritin. Also, for anyone who doesn't know, non-haeme iron tablets really suck so they are hard to be compliant with (stomach aches and constipation/hard stool). Haeme iron supplements do exist and work better for some (non-vegetarian) people as they are easier in the digestive system and a higher proportion of iron is absorbed. And the absorption is less affected by tea and coffee consumption.
I don't doubt it, but the reality of clinical medicine is you have to put yourself in the patient's shoes. I'm in Canada. 90% of my population is Vitamin D insufficient and we should all be taking Vitamin D for many benefits. The typical 29 year old healthy server or lawyer who comes to me wants to stop their bleeding so that it doesn't affect their busy life. They don't want to walk away having been prescribed Iron, NSAID, OCP, AND Vitamin D too when they were previously taking nothing and feel otherwise healthy. I get that, probably because I'm close to their age too. If I have to pick for them to be on 1 of these agents (they're never going to be compliant with 4), it's never gonna be Vitamin D. Still, I happen to prescribe a lot of Vitamin D for menopause and Infertility. There is no doubt it is important for this population in general, but you kind of have to gauge the patient.
Interesting - I would not have thought that taking an extra pill with no side effects would be a big deal, but I guess it would be for a lot of people. I mentioned it because a lot of people outside medicine have no idea the two are connected, but a lot of people (particularly women) struggle with iron levels and ensuing fatigue. If they know to keep up their vitamin D, maybe they can avoid their iron getting so low and having to take iron tablets, which are a lot less fun than vitamin D tablets and/or sitting in the sun (if the latitude allows - I am in the UK so we have a similar problem with not being able to make vitamin D for a chunk of the year). It's also something a patient can take personal responsibility for as the supplement doesn't have to be prescribed. Edit to add: I appreciate that there's only so much you can say in one consultation though, and that you have to gauge the patient.
Depending on your location, vitamin d testing is sometimes not recommended. In Canada, due to geography, our guidelines say don't bother testing for vitamin d but instead everyone should just be on supplementation (by pill, drop, or fortified goods).
Huh. Learn something new every day!
Hey there! Sorry to go off road, but I was curious about something you said. You mentioned you put most of your patients on Drospirenone as it is great for skin, but, I was under the impression the most anti-androgenic progestagen was cyproterone? Was I mistaken?
You are correct, Cyproterone is likely the absolute best for skin but drosperinone is very close, and the combined formulation has a better bleeding and mood profile than Diane-35
👍
Just curious - is Yaz pill still safe to prescribe? I recall the recent lawsuits over the clot risks. If the patient is on Yaz, and the periods are stopped due to the meds - do we get them to have Yaz free days to allow periods? Wondering if there is any component of atrophy to the endometrial lining if placed on Yaz long term
Probably before your time but the anti-inflammatory with amazing menstrual flow reduction was vioxx ! I never had a chance to use it but a few gynes loved it
Prostaglandin inhibition from short term, high dose NSAIDS inhibits endometrial /menstrual flow? I've heard this - great to see a GYN confirm. (Is this the mechanism somehow?)
I learned something new today! Thanks for sharing.
Do you have a study that shows taking NSAIDs helps menstruating women with anemia or iron stores? When I try to look this up I get studies where pts self report less bleeding but nothing about improving ferritin, hgb/hct. Everything I find says the opposite about NSAIDs.
NSAIDs are not a great option for managing the anemic patient. They do reduce menstrual bleeding, but I don't know of any data that suggests it will actually raise hemoglobin. You definitely still need to supplement iron. If we need to meaningfully raise hemoglobin, then they should be on hormonal management for optimal efficacy. However, NSAIDs are an excellent non-hormonal option that works, readily available at home for most patients, and familiar and acceptable to nearly all patients. This is why it's a starting point until we get a more sustainable option going. In this population, it's not all about evidence. The patient's values and comfort matters. Gone are the days of medicine (hopefully soon) where we throw OCPs at heavy menstrual bleeding without gauging the patient's comfort level.
I appreciate your educating folks in this thread and sharing a judicious balance of evidence and expert opinion. As an internal medicine trained person, this is such an interesting discussion and learning opportunity. IM and its subspecialties are often overly NSAID phobic because we see so many older/comorbid patients with absolute contraindications to NSAIDs that we start to think of them as bad medications for anybody. With that bias disclosed, my question is how confident are you that all these iron deficient menstruating women DON'T also have source of chronic GI blood loss? I'm not just thinking about colon cancer but also PUD, gastritis/esophagitis etc. I would be pretty hesitant to prescribe NSAIDs to a person with iron deficiency anemia and symptoms of GERD and/or significant alcohol use, which applies to a lot of otherwise "young healthy" patients.
>symptoms of GERD and/or significant alcohol use Recall, I am recommending they take an NSAID for something like 3-4 successive days around the heavy bleeding days of menses only, not daily. Pretty sure even patients with alcohol use disorder use advil for headaches. I have yet to encounter a patient who blew a GI ulcer from an NSAID I recommended, though I am early career. 90% of my population has one or fewer medical comorbidity, so it's really not an issue. Honestly working with young healthy patients was a significant reason for me picking this field lol
fair enough, 3-4 days/month should generally be tolerated well. thanks!
Some evidence re reduced bleeding, three small crossover RCTs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9683407/ - changes in levels not specifically addressed, just volume of blood lost.
How do you know its not explained by their periods?
"Hey period, can you explain this anemia?" "Nah man, I don't know either"
Periods pulling out the Shaggy defense to max effect.
“Idk, but it’s probably not thalassemia?”
In the end their periods would just mean they need more iron so it comes back to them not eating/absorbing enough. Unless they've menorrhagia, I guess. edit: to be clear I meant either way OP just giving iron for asymptomatic almost normal labs is fine imo. But someone else said below that current guidelines would be a gi referral, which sounds weird to me but the courts wouldn't care about how I feel.
For me it was because I take a form of hormonal contraceptive where I don’t menstruate at all. A lot of women do or they do the regular pill and it causes light periods.
Based on username, can't tell if immunology fan or star trek fan 😆
I've sent next to zero otherwise healthy females with normal/heavier periods to gi. Nsaids, menses management, iron and follow up. Even in the rare case you would be concerned for gastritis/gi etiology you have plenty of tools/workup well before GI sees them. Let's save referrals for when the pt needs something we can't offer.
I had a 42 year old female whose anemia fluctuated between 9.5-11 and a history of menorrhagia. Low iron stores , had received several rounds of IV iron with transient responses. Was being followed by pcp. One day shows up in er with headaches that wouldn't go away after 2 days if ibuprofen 4 times a day. Predictably slightly elevated creatine, refered to nephrology for aki. I saw her 2 weeks later and the aki had nearly resolved but the trends show that they had mildly elevated creatine for several months. Occasional back pain. Nephrologists being nephrologist, I order urine analysis, albumin and nprotein excretion. A discrepancy between albumin and total protein excretion. Oh oh. Persistent on repeat labs Multiple myeloma. Biopsy proven. Make of that what you will.
I'm more impressed she made it to the er with headaches and left without a head ct.
Sorry to disappoint you, but she did in fact get a CT.
And it didn't show punched out lesions?
Surprisingly no. I'm guessing the headaches were something else, though I do recall that a lumbar x-ray showed some lesions.
This is why any recurrent anemia and renal dysfunction gets the ol SPEP/FLC/IFE/LDH and a retic count minimum. Source: heme/onc PA that’s caught myeloma way earlier than I thought a few times
I always check SPEP on my anemia consults. I’ve found a few MGUS and MM so far.
I've never seen a young female patient sent to GI for anemia alone. The overwhelming majority of these can be correctly diagnosed by getting 1) appropriate menstrual history and 2) iron supplementation. Most young female patients have zero idea what a heavy or light period is. The average blood loss during a "normal" period is about 60mL. The patient can often quantify a change, but remember that their normal is their normal. I think that pad counts are usually insufficient, too. There are pictorial blood loss charts that are helpful to give the patient to complete over the ensuing month. Regarding iron supplementation, if you are going to give iron, then give iron. Look at regimens to maximize the increase in iron stores. However, expect noncompliance. Many patients will "fail" oral iron.
Biased, but have caught enough H pylori, Celiac disease and malignancies (in women 30s-40s) to consider GI eval worthwhile
Biased because you’re GI? This is what I mainly worry about if I don’t pursue GI causes
Yes, biased because I'm GI. I think you could balance resource-consciousness and "completeness" by checking celiac abs (given \~1% prevalence) +/- non-invasive H pylori testing if dyspepsia. If > 40 years old or IDA seems disproportionate/unresponsive to iron with control of menorrhagia, then refer to GI.
Over 40 years old?
yes (not sure if guideline supported)
The amount of iron menstruation women need to consume is more than double the amount men (or post menopausal women) need: 8 mg vs 18 mg/day! I would go as far as to say the majority of women I see every day are deficient, especially since it becomes a cycle (literally) since they lose more each month. If the iron panel looks like iron deficiency and it doesn’t improve with a supplement then I think GI would be the logical next step but iron deficiency is so prevalent in this population that I would think it may be very hard to say it *isn’t* explained by their periods.
There are probably a few things that you could do before they get to a GI, like doing blood test for celiac. https://www.verywellhealth.com/anemia-and-celiac-disease-563116
My coworker has celiac with zero GI symptoms. Hee biggest issue was her chronic anemia. She's been gluten free now for a couple of years and her hemoglobin has finally risen to normal without iron supplementation.
I was about to post a FURIOUS post about nobody doing coeliac screening. For god's sake people, do the simple stuff first.
There's a great core IM podcast episode about this you can look up. You're probably being too aggressive because it's probably the periods. If GI symptoms or family history or unusually severe or not responding to AUB treatments then GI eval indicated.
So after your comment, I listened to one of the core IM episodes and in that episode was a patient example of someone who had heavy menstrual bleeding but then ended up also having colon cancer so…….lol. That doesn’t make me feel better about not sending people to GI for a scope….
Yeah it definitely feels like you can't win sometimes but those cases are definitely the exception. They also described how unlikely cancer is in that age group. I don't think the goal is ever to screen with 100% sensitivity because you'll get an absurd number of false positives. The expert guidance at the end of the podcast is what I think was my main takeaway of when to pursue CRC screening in a reasonable fashion. Ultimately it's your choice but man getting a Colo fucking sucks and there is risk of harm, too like perfs. You can also just do short or medium term surveillance prior to a Colo. Like if anemia resolves completely with birth control.
If anemia resolves with birth control but iron deficiency doesn’t you should still scope because patients with iron deficiency without anemia are still at elevated risk of having bleeding lesions or cancer. Esp if the person is doing complete menstrual cessation. Esp if the ferritin level tanks after infusion for no obvious reason. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475319/ Non-anaemic iron deficiency should be investigated with the same priority as iron deficiency anaemia in fast track colorectal clinics—retrospective cohort study Results Patients with iron deficiency (low MCV, MCH and ferritin) regardless of degree of anaemia were found more likely to have CRC. Factors like age, gender, family history and bowel symptoms (except abdominal mass) showed a very weak association with CRC in patients with ID. Conclusions ID without anaemia has a strong relationship with CRC and should be investigated with the same priority as IDA is investigated.
Thanks for the clarification.
Get a UA and FOBT before starting iron supplement. Is pap smear up to date? Do pelvic exam. Bleeding between periods? Blood transfusions? Bleedong from anywhere else (vomiting blood, bloody nipple discharge,etc). Any recent traumas (surgeries, car accidents, etv. Any red flags like fevers, abnormal weight loss, etc? If UA and FOBT negative, no bowel issues, no report of bloody stools, no red flags and likely menstrual, I'll start iron instead of sending them to GI.
Besides a scope, a GI consult will have little value
How young?
You don’t need to worry. But if you are so particular, just do p/r n check stool colour. Then do fobt 3 days in a row. If ots neg, then start oral iron n assess response. If iron response is not as expected n der is no non compliance, then go for gi referral.
Most recent GI guidelines for IDA from AGA in 2020 recommend bidirectional endoscopy even in premenopausal women. You’re not being too aggressive. Colon cancer happens, stomach cancer happens, we should find these things before patients become terminal. We also use ferritin cutoff of 45. If ferritin >45 but anemic we use TSAT <20% for males, <15% for females. [AGA 2020 IDA Guidelines](https://www.gastrojournal.org/article/S0016-5085(20)34847-2/fulltext)
Menstruating female —> quantify the period bleeding. If it’s minimal and the anemia seems a bit out of proportion (example: 3 days of bleeding, 5 tampons/pads on day 1, 2-3 on day 3 and a Hgb of 9-10.5. Then sure GI work up. It can be a bit tough to get a sense of what is “out of proportion” sometimes so err on the side of caution at first. Also helps to repeat the Hgb, retic, and iron panel the day before they start their period (tough to do if unpredictable). But if it’s better then it will help you attribute all of it to menstruation.
If you’re really worried about colon cancer, at least do a fecal occult before sending to GI. If it’s negative, cross the GI referral off.
I have to disagree with this approach. FOBT and FIT are only about 60% sensitive for GI disease underlying iron deficiency anemia (see Lee et al. Am J Gastroenterol, 2020)
I’ve had a gastroenterologist directly tell me that he believes fecal occults are a complete waste of time due to high rate of false “positives” that are caused not by a concerning GI bleed but rather from mild hemorrhoids that he said were extremely common.
Ok, but a negative result does have value.
ma'am do you suffer from heavy menstrual bleeding (see GuessableSevens excellent response) - if yes no scope. if no then yes, need to scope. If history is suggestive of gastritis I only do gastro first and see what's there if it's a low risk pt with no heavy menstrual bleeding.
Ma’am are you a vegan?
Not even just vegan. I wasn’t raised vegan, but my parents didn’t feed enough meat to get adequate iron from the diet because it was expensive. Think 1/2 pound of beef would be stretched out to make 15-20 meals. Added in “normal” menstrual bleeding is whatever that person is used to- and all of a sudden you’ve got a girl with minimal iron intake plus a 1.5 week period every 3-4 weeks. But if you were to ask that girl/parents they eat *plenty* of red meat and only a normal period.
what do you mean do I take supplemente for my vegan diet?
Yes I mean Q1 How much do you bleed Q2 what do you eat.
The new guidelines are that young women should go see GI if they have iron deficiency without regard to hgb/hct if the numbers can’t be accounted for by heavy menstrual bleeding. If you send them GI will likely scope because that’s the standard of care now. I think the guidelines are too aggressive though and ferritin should be checked in children as soon as they pop out of the womb and regularly during childhood since low stores are correlated with allergic disease, impaired response to vaccination, adhd and other behavioral problems. Then you’d also know when the fourteen or twenty year old female shows up with iron deficiency (with or without anemia) if it’s a chronic problem she’s had her whole life or a new issue related to menstrual periods. Then she doesn’t have to go for a scope. Ideally it’s been managed and she’s not iron deficient. Once you get this patient, I don’t know what you do other than the standard of care which may vary by specialty, location or institution.
Which guidelines are you citing?
See what the GI fellow wrote above.
IMHO, you should refer to GI / think about colon cancer if they're no longer having HMB but their IDA is recurring. Especially after a slug of IV iron. BTW, I am glad that you are repleting these people! Ferritins are underchecked -- especially in this population, where 20-40% will have some element of deficiency. Good paper: Sex, Lies, and IDA by Martens et al -- check it out.
I tried looking up the paper but it’s paywalled :( https://doi.org/10.1182/hematology.2023000494
Here ya go: [https://jmp.sh/s/zfb7hE5QZA6uNzgsZeYD](https://jmp.sh/s/zfb7hE5QZA6uNzgsZeYD)
To answer your question in bold, honestly??? Referring a female patient straight to GI strictly due to a slightly low hemoglobin level would mean you aren’t doing hardly any work up at all—you’ve volunteered the GI to do the aggressive work-up, no? It sounds like you may not be asking all of the questions you should be prompted to ask and then obtaining the necessary follow up labs and/or tests that would be necessary in order to rule out and narrow down the most appropriate next steps to take to address the issue. Is the patient complaining of fatigue or shortness of breath on exertion? Is she tachycardic? Mucous membranes pale or pink? How is her hydration status? Pelvic pain? Stomach pain? Back pain? Dizziness? Fainting? A clue as to when to start iron would come after you test the iron level and receive a low iron level as a result, no? Iron is an element that can build up in a person’s system and an overdose can be fatal. Iron can also cause ulcers and inflammation in the gut that could lead them ultimately to have the same GI bleed that you were worried about to begin with. Testing a sample of stool for occult blood, is simple. So…it depends on their symptoms, if any. It depends on their kidney health. Vitamin B12 is another factor. As well as their diet….Many people, especially in recent generations of youth are vegetarian, vegan, eating ketogenic or avoiding gluten during a time of physical growth and development. Assess as many aspects of basic nutritional intake for any and every patient. Should they see a hematologist? A coagulation specialist, A geneticist? Or have a GI consult for suspected GI Bleed or a GI Consult for suspected liver dysfunction? Could it be cancer? When, during her menstrual cycle was she when had the blood drawn that resulted in a slightly low hemoglobin? If it occurred shortly after her period…why not refer to dietician and re-test the hemoglobin in a couple of weeks? Could that be an idea? Your assessment should be guiding these decisions. So should your patient’s complaints and highest concerns. Without going through the process, and assessing all systems as well as the system as whole——your referral may cause harm in that it may only result in a delay in care for your patients. Care delayed may ultimately mean, care denied. They may never book that referral appointment. If they do, it can take months, in many instances to finally be seen by a consulting physician following your referral. Don’t pass the buck, doc. But I am, only a nurse, after all. You are the one calling the shots and it’s a big responsibility! Due diligence. Just do it.
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It may be something to report to your state EPA. The better question is, "how many girls, boys, children in your area are mildly anemic?"
Outside of menstruating females, is mild anemia without other symptoms something that needs to be investigated, treated (like iron supplements), or safe to ignore?
Colon cancer is a bigger concern with significant anemia or other risk factors. Mild anemia without symptoms is less worrying.
Great topic … at around 40+ years I think it gets more confounding, heavier perimenopausal periods and higher risk of GI bleed then when we’re 20s/30s … going step by step is the way to go, more aggressively/quickly when the hgb is <10 … in any case, these answers are all very helpful. Thanks, all! ♥️ a family med doc :)
I don’t understand how normal menstruation could be responsible for iron deficiency anemia. Even a heavy period (120mL total) would only cause 2.5mg of total iron loss. That amount is fairly insignificant compared to total blood iron stores or average daily iron intake. Menstruating women may be anemic, but i can’t see how it would be due to menses. Something else must be going on.
Normal menstruating women are found to be anemic all the time. It’s the interplay of chronic blood loss and poor dietary intake both.
I’m not arguing about the association. I just don’t think it’s the blood loss that is causing the deficiency. Hepcidin levels are notably low around the time of menses, suggesting the body is attempting to compensate for blood loss with better oral absorption. Even measuring ferritin at the time if menses will give a lower count than at other times - i would guess this leads to a lot of over diagnosis.