A 38-year-old woman from rural India presents with fatigue, dyspnea on exertion, and angular cheilitis. She reports heavy menstrual bleeding for the past 18 months. Hemoglobin is 7.2 g/dL, MCV 62 fL, serum ferritin 8 ng/mL, and serum iron 35 µg/dL. Peripheral blood smear shows microcytic hypochromic RBCs with target cells. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** In iron deficiency anemia with clear etiology (menorrhagia) and no alarm features, iron replacement is the first-line management step. **High-Yield:** The diagnosis of iron deficiency is confirmed by: - Low serum ferritin (<15 ng/mL indicates depleted iron stores) - Low serum iron - Microcytic hypochromic indices (MCV <70 fL) - Microcytic RBCs on peripheral smear ## Management Algorithm ```mermaid flowchart TD A[Confirmed IDA] --> B{Etiology identified?} B -->|Yes: Menorrhagia| C[Start oral iron] B -->|No or alarm features| D[GI workup] C --> E[Ferrous sulfate 200 mg OD] E --> F[Recheck Hb in 2-4 weeks] F --> G{Hb rise ≥1 g/dL?} G -->|Yes| H[Continue 3-6 months] G -->|No| I[Assess compliance/absorption] ``` **Clinical Pearl:** Menorrhagia in reproductive-age women is the most common cause of IDA in India; GI workup is reserved for: - IDA in postmenopausal women - IDA in men (any age) - Alarm symptoms (dysphagia, weight loss, melena) - Failure to respond to iron therapy ## Iron Replacement Dosing | Parameter | Details | |-----------|----------| | **First-line agent** | Ferrous sulfate 200 mg OD (or BD if tolerated) | | **Alternative** | Ferrous gluconate, ferrous fumarate | | **Absorption** | Best on empty stomach; take with vitamin C | | **Expected response** | Hb rise 1–2 g/dL per 2–4 weeks | | **Duration** | Continue 3–6 months after Hb normalizes to replete iron stores | **Warning:** Do NOT transfuse unless Hb <5 g/dL or symptomatic with cardiac compromise; transfusion delays diagnosis of ongoing bleeding and increases iron overload risk.