Treatment of Anemia and Heavy Menstrual Bleeding

Immediate Iron Replacement Therapy

The American Gastroenterological Association recommends initiating oral iron supplementation with ferrous sulfate 200 mg three times daily to correct anemia and replenish iron stores in reproductive-age women with heavy menstrual bleeding and anemia 1
Iron supplementation should be continued for three months after correction of anemia to replenish body iron stores, with an expected hemoglobin rise of 2 g/dL after 3-4 weeks of treatment 1
The addition of ascorbic acid (vitamin C) can enhance iron absorption, particularly when response is poor 1

The American College of Obstetricians and Gynecologists recommends the levonorgestrel-releasing intrauterine system (LNG-IUS) as the most effective medical treatment for heavy menstrual bleeding and as first-line therapy 2
LNG-IUS provides a dual benefit of bleeding control and contraception for women who need both, with efficacy comparable to endometrial ablation or hysterectomy while preserving the uterus 3

Antifibrinolytics, such as tranexamic acid, are the second most effective first-line treatment after LNG-IUS, reducing menstrual blood loss by 20-60% and serving as a non-hormonal alternative 3
Combined hormonal contraceptives (CHCs) are effective for regulating menstrual cycles and reducing bleeding, particularly appropriate for younger women who also desire contraception 2
Nonsteroidal anti-inflammatory drugs (NSAIDs) provide a modest reduction in menstrual blood loss and can be used as adjunctive therapy 4

Patients should be reassessed at 3-6 months to evaluate treatment response, menstrual pattern normalization, hemoglobin levels, and patient satisfaction, with hemoglobin concentration checked and monitored at three-monthly intervals for one year, then annually 1

Delaying iron supplementation while waiting for bleeding control can worsen anemia, and iron therapy should not be stopped when hemoglobin normalizes 1
Aspirin should not be used for bleeding control as it may increase menstrual blood loss, and heavy menstrual bleeding should not be normalized as it significantly impairs quality of life and cognitive function 4