A 38-year-old woman from rural India presents with fatigue and dyspnea on exertion. On examination, she has pallor and mild glossitis. Her hemoglobin is 7.2 g/dL with microcytic hypochromic indices. Serum ferritin is low and TIBC is elevated. What is the most common cause of iron deficiency anemia in women of reproductive age in India?

Explanation

## Most Common Cause of Iron Deficiency Anemia in Reproductive-Age Women **Key Point:** Menorrhagia (heavy menstrual bleeding) is the single most common cause of iron deficiency anemia in non-pregnant women of reproductive age, both globally and in India. **High-Yield:** The mechanism is straightforward — each menstrual cycle normally results in loss of 30–40 mL of blood (15–20 mg iron); menorrhagia increases this to >80 mL per cycle, overwhelming dietary iron replacement and depleting body stores over months to years. ### Epidemiology in India In the Indian context, while hookworm and other parasitic infections are endemic and contribute significantly to anemia in certain populations, menorrhagia remains the leading cause in reproductive-age women across socioeconomic strata. The patient's glossitis and low ferritin confirm iron deficiency; the gender and age group make menorrhagia the most likely culprit. ### Differential Causes by Frequency | Cause | Frequency in Reproductive Women | Notes | |-------|----------------------------------|-------| | Menorrhagia | Most common (40–50%) | Heavy or prolonged menses; often due to fibroids, adenomyosis, or dysfunctional uterine bleeding | | GI blood loss | Common (20–30%) | Peptic ulcer, gastritis, angiodysplasia; more common in older women and men | | Hookworm | Common in endemic areas | More prevalent in rural/tribal populations; contributes to population-level anemia | | Malabsorption (celiac, etc.) | Less common (5–10%) | Requires small bowel pathology; less frequent than menorrhagia | **Clinical Pearl:** Always ask reproductive-age women about menstrual history (duration, frequency, clot size, impact on quality of life). Menorrhagia is often underreported due to cultural factors in India. **Mnemonic — Iron Loss Sites in Women: "MAGE"** - **M**enorrhagia - **A**limentary (GI) loss - **G**enitourinary (rare) - **E**ndoscopic findings (peptic ulcer, angiodysplasia) [cite:Harrison 21e Ch 417]