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Iron Deficiency without Anemia: A Common Yet Under-Recognized Diagnosis in Young Women with Heavy Menstrual Bleeding
Stephen Johnson1, Abigail Lang2, Mollie Sturm3
1Internal Medicine-Pediatrics Residency Program, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio.
Insights
Screening for iron deficiency in young women with heavy menstrual bleeding using only hemoglobin or complete blood count (CBC) is insufficient. Over half of iron deficiency cases are missed, highlighting the need for ferritin level testing in at-risk individuals.
Area of Science:
- Hematology
- Pediatric Medicine
- Women's Health
Background:
- Heavy menstrual bleeding is a common complaint in adolescent females.
- Iron deficiency is a frequent complication of heavy menstrual bleeding.
- Standard screening tests may not adequately detect iron deficiency in this population.
Purpose of the Study:
- To determine the proportion of iron deficiency missed by screening with hemoglobin or complete blood count (CBC) alone in young women experiencing heavy menstrual bleeding.
- To evaluate the diagnostic accuracy of hemoglobin and CBC for detecting iron deficiency in this demographic.
Main Methods:
- Retrospective review of electronic medical records from Nationwide Children's Hospital.
- Inclusion of 114 young women (aged 9-19 years) referred to a young women's hematology clinic for heavy menstrual bleeding.
- Analysis of ferritin levels, hemoglobin, and CBC results.
Main Results:
- Over half (50.9%) of the participants had iron deficiency (ferritin <20 ng/mL).
- Hemoglobin and CBC alone detected iron deficiency in only 41.4% and 46.3% of cases, respectively.
- Overweight or obese patients had significantly higher odds (OR, 2.81) of iron deficiency.
Conclusions:
- Screening with hemoglobin or CBC alone is inadequate for detecting iron deficiency in adolescents with heavy menstrual bleeding.
- Measuring ferritin levels is crucial for early identification and management of iron deficiency in at-risk young women.
- Earlier iron therapy, guided by ferritin levels, can potentially improve symptoms associated with iron deficiency.
Study Objective:
To assess the proportion of iron deficiency that is not detected with a screening hemoglobin or complete blood count (CBC) alone in young women with heavy menstrual bleeding.
Design:
Retrospective review of electronic medical records.
Setting:
Nationwide Children's Hospital in Columbus, Ohio.
Participants, Interventions, And Main Outcome Measures:
One hundred fourteen young women aged 9-19 years consecutively referred to a young women's hematology clinic with a complaint of heavy menstrual bleeding.
Results:
Fifty-eight (50.9%) of all patients had ferritin <20 ng/mL indicating iron deficiency. Of the 58 patients with iron deficiency, only 24 (41.4%) were anemic and 25 (46.3%) were microcytic. The sensitivity of hemoglobin alone and CBC alone for identifying women with ferritin <20 ng/mL was 41.4% (95% confidence interval [CI], 28.7-54.1) and 46.3% (95% CI, 33.0-59.6), respectively. Both tests had reasonable specificity at 91.1% (95% CI, 83.6-98.5) for hemoglobin and 83.9% for CBC (95% CI, 74.3-93.6). Patients had significantly higher odds of having iron deficiency if they were overweight or obese (odds ratio, 2.81; 95% CI, 1.25-6.29) compared with patients with normal body mass index. Age at presentation for heavy menstrual bleeding, presence of an underlying bleeding disorder, and median household income were not significantly associated with iron deficiency.
Conclusion:
In adolescents with heavy menstrual bleeding, fewer than half of iron deficiency cases are detected when screening is performed with hemoglobin or blood count alone. Measuring ferritin levels in at-risk patients might allow for earlier implementation of iron therapy and improvement in symptoms.
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