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This is CME on ReachMD. I’m Dr. Arjeme Cavens from Northwestern University, and I’m here today with Dr. Malcolm Munro from UCLA, who’s an expert on abnormal uterine bleeding and the causes of iron deficiency and iron deficiency anemia. So today we’re going to explore those causes in reproductive-aged girls and women, so let’s get into it.
Malcolm, what are the causes of iron deficiency and iron deficiency anemia?
In reproductive-aged women, who aren’t pregnant, it seems clear that the most common cause is the menstrual loss that they’re experiencing, typically on a cyclical basis. So we call that heavy menstrual bleeding. Now it’s true that nutrition has a lot of a part to play in the pathogenesis of iron deficiency, and that might be especially true in specific cultures and in young women, perimenarchally. But overall, the issue of heavy menstrual bleeding really seems to be the major problem, and although we seem to think that that’s a relatively uncommon entity – 3%, 5%, 10% – when we actually connect with women directly via screening studies, it appears that up to 50% have the symptom of heavy menstrual bleeding. And it’s not in a lot of these databases, because that heavy menstrual bleeding has been normalized by their family, by their friends, even by healthcare providers, who then don’t enter those data into the electronic record or other systems. So this really is the major contributor to iron deficiency in this age group, which appears to be extremely common.
So let me ask, do you have any guidance on how we as clinicians can better elicit histories and that information to lead to more diagnosis?
Sure. Well, I guess to start with the less common approach, if you do see an individual who is anemic or who is iron deficient, even without anemia, in this age group, think that they have heavy menstrual bleeding. I think that’s the first thing, and so be proactive in trying to find out what their bleeding experience is. Beyond that, it’s important to actually be proactive even in routine care. If you say to an individual, “Are your periods normal?” and they’ve been told that their heavy bleeding is normal, they’re going to say, “It’s normal.” So you have to go beyond that and talk to them about how abnormal bleeding or how their menstrual periods affect their life. Do they cause them to adjust their life in a social way, in a work way? Do they have to stay home from work or school? Are they worried about staining the upholstery in their house, or somebody else’s house, or the upholstery of their car? Do they have to wear extra protection? Do they have to wear black, baggy pants because they’ve got a Depends pad on to capture the blood that spills over? Ask them those questions and it doesn’t take very long, but often you’ll find that that normal period for them actually isn’t normal.
So as you’re alluding to, I think how we ask these questions and how we elicit a menstrual history is really key. There’s certainly some patients that present specifically to address what they recognize as heavy bleeding or abnormal bleeding, but then there’s some that’ll be much more hesitant to discuss their menses in general and especially any concerns they might have. And I think a combination of age, personal factors, family experiences, cultural factors, they all play a role in how comfortable or how forthcoming someone may be. But it’s really important as clinicians that we do normalize these conversations, we normalize descriptions of menstrual patterns, and that we also take the opportunity to educate patients and preventatively counsel patients on what’s normal versus not normal. What are concerning features that do need more of a workup? Really encourage them to seek evaluation when concerning changes occur. I think that I really find using a combination of open-ended questions, but these more specific follow-up questions that you mentioned is really the most helpful, and at the end of a visit, summarizing, again, what are those call-back symptoms? What are those signs I want you on the lookout for that will warrant a little more workup?
Absolutely, and not to forget the really vulnerable individual who is in her teen years. Sometimes your female patients, if you ask those questions, then they’ll go home and talk to their teenager about it as well, so often they are particularly vulnerable, and not only because they’re growing, because they have increased iron needs, but also nutritionally with their body image issues that they often have, there’s a panoply of micronutrient deficiencies including iron deficiency that they may be experiencing. So all of this is really important for them to set the stage for the rest of their life.
That’s a really, really excellent point.
Well, this has been a great micro discussion, but unfortunately our time is up. Thank you for listening.
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