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Review
. 2021 Jan;38(1):201-225.
doi: 10.1007/s12325-020-01564-y. Epub 2020 Nov 27.

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

Diana Mansour  1 , Axel Hofmann  2   3 , Kristina Gemzell-Danielsson  4
Affiliations
Review

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

Diana Mansour et al. Adv Ther. 2021 Jan.

Abstract

Introduction: Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA).

Aim: To review 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.

Methods: The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies.

Results: Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA.

Conclusion: Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients.

Keywords: Anemia; Clinical guidelines; Gynecology; Heavy menstrual bleeding; Iron deficiency; Iron treatment; Iron-deficiency anemia; Patient blood management; Women’s health.

Plain language summary

Women who bleed heavily during menstruation are at risk of iron deficiency and anemia. This can have a negative effect on the well-being of women and can cause serious complications after surgery. Iron is an important part of the hemoglobin in red blood cells that carries oxygen around the body. Bleeding causes iron to be lost from the body. If there is heavy blood loss, iron stores in the body can become low, leading to iron deficiency. If the iron deficiency is severe enough to impair red blood cell production, iron-deficiency anemia can develop. We reviewed the current guidelines for the care of women with heavy menstrual bleeding, focusing on the detection and treatment of iron deficiency and anemia. Most guidelines include routine testing for anemia. Fewer guidelines consider measuring iron levels. 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. A lack of clear guidance on detecting and treating iron deficiency and anemia caused by heavy menstrual bleeding puts women at risk of being undiagnosed and untreated. To address these concerns, the authors recommend the development of consensus guidelines. These should contain comprehensive recommendations on all aspects of the diagnosis and management of iron deficiency and anemia in women with heavy menstrual bleeding.

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Figures

Fig. 1
Fig. 1
Geographic distribution of guidelines. Most of the guidelines on the management of iron deficiency and iron-deficiency anemia in women with heavy menstrual bleeding originate from Europe and North America
Fig. 2
Fig. 2
Guideline recommendations for iron screening. There is high heterogeneity among the guidelines with recommendations for screening iron levels in women with HMB, varying from those that recommend it routinely, those that specifically advise against this practice, and those that recommend iron testing as a second-line investigation. HMB heavy menstrual bleeding, ID iron deficiency. Guidelines referred to: red circle [51, 55, 59], blue circle [5, 52, 56, 57, 60, 62], turquoise circle [4, 50, 56, 57]
Fig. 3
Fig. 3
Patient populations in which iron replacement therapy is recommended by guidelines. Oral iron administration is the preferred route of treatment if permitted by the patient’s health and circumstances, both for patients with confirmed ID/IDA and patients classified at risk of developing ID/IDA. IV iron therapy is most commonly recommended in patients who do not respond, cannot tolerate, or do not comply with oral iron administration, before and after surgery and in patients with severe anemia. ID iron deficiency, IDA iron-deficiency anemia. Guidelines referred to: (1) [51, 57], (2) [5, 62, 63], (3) [5, 57], (4) [57, 62, 63], (5) [62], (6) [57], (7) [5, 57, 62], (8) [51, 57, 62], (9) [5, 57, 62, 63]
Fig. 4
Fig. 4
Summary of guideline coverage for the diagnosis and management of ID/IDA in women with HMB. There are many gaps in the current guidelines regarding the diagnosis and management of ID and IDA in patients with HMB. HMB heavy menstrual bleeding, ID iron deficiency, IDA iron-deficiency anemia, IV intravenous
Fig. 5
Fig. 5
How treatment of ID/IDA in women with HMB could fit within the “3 pillars” principles of patient blood management. Recommendations to correct ID/IDA in patients with HMB align with pillar 1 of PBM recommendations in surgical settings, which advocates treatment of preoperative anemia and optimization of red blood cell mass prior to surgery. The care of women with HMB could also incorporate pillar 2 of PBM, which aims to minimize blood loss. In HMB, this would involve treatment of the underlying cause of the excessive bleeding. HMB heavy menstrual bleeding, ID iron deficiency, IDA iron-deficiency anemia, IV intravenous, PBM patient blood management, RBC red blood cell
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References

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