Case 9: Anaemia

 

Case 9: Anaemia

CASE 9: ANAEMIA

History

A 39-year-old woman is referred from the haematologist, with anaemia. She had been complaining of increasing tiredness and shortness of breath for 3 months, with frequent headaches.

Her periods occur every 24 days and the first day is generally moderate but the second to

fourth days are very heavy. She uses tampons and sanitary towels together. She has no pain.

Her last smear test was normal 2 years ago. She has had no previous gynaecological problems

and takes no medication.

Examination

The woman is slim with pale conjunctivae. Abdominal, bimanual and speculum examination are unremarkable.

INVESTIGATIONS

Normal range

Haemoglobin 6.3 g/dL 11.7–15.7 g/dL

Mean cell volume 66 fL 80–99 fL

White cell count 9.1×109/L 3.5–11×109/L

Platelets 300×109/L 150–440×109/L

Ferritin 9 mg/L 6–81 mg/L

Iron 7 mmol/L 10–28 mmol/L

Total iron-binding capacity (TIBC) 80 mmol/L 45–72 mmol/L

Blood film: hypochromic microcytic red cells

Transvaginal ultrasound scan report (day 4): the uterus is normal size and retroverted. The

endometrium is smooth and thin measuring 3.1 mm. Both ovaries are normal.

Questions

• How do you interpret these findings?

• What is the likely underlying diagnosis?

• How would you manage this woman?100 Cases in Obstetrics and Gynaecology

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ANSWER 9

The blood count shows anaemia with reduced mean cell corpuscular volume and low mean

cell haemoglobin suggestive of a microcytic anaemia. Iron deficiency is the commonest cause

for this picture and is confirmed by the low ferritin and iron, with raised iron-binding capacity. The anaemia accounts for the breathlessness, tiredness and headaches.

Menorrhagia is the commonest cause of anaemia in women, and in this case is supported by

the history of excessive bleeding. The woman herself may not recognize that her periods are

particularly heavy if she has always experienced heavy periods or if she thinks it is normal for

her periods to become heavier as she gets older.

As no other cause of heavy bleeding is apparent from the history and the ultrasound is normal, then the underlying diagnosis is one of exclusion referred to as dysfunctional uterine

bleeding (DUB).

Dysfunctional uterine bleeding

Excessive heavy, prolonged or frequent bleeding that is not due to pregnancy or any recognizable pelvic or systemic disease.

Management

The anaemia should be treated with ferrous sulphate 200 mg twice daily until haemoglobin

and ferritin are normal. It may take 3–6 months for iron stores to be fully replenished.

Tranexamic acid (an antifibrinolytic) should be given during menstruation to reduce the

amount of bleeding. It is contraindicated with a history of thromboembolic disease.

The levonorgestrel-releasing intrauterine device is used for its action on the endometrium

to reduce menorrhagia, often causing amenorrhoea, though it is commonly associated with

irregular bleeding for the first 3 months. The combined oral contraceptive pill is effective for

menorrhagia in young women (below 35 years).

If these first-line management options are ineffective then endometrial ablation should be

considered, which destroys the endometrium down to the basal layer. It is successful in 80–85

per cent of women and they should have completed their family and use effective contraception. There are several approved minimally invasive endometrial ablation techniques with

broadly similar efficacy: these include use of radiofrequency waves, electrocautery, microwaves, heated saline, or a heated balloon. Amenorrhoea occurs in 30–60 per cent of women

with 70–90 per cent describing their satisfaction as good or excellent.

Hysterectomy is considered a ‘last resort’ for DUB, due to the associated morbidity.

KEY POINTS

• A woman’s perception of bleeding is not always proportionate to the actual volume

lost, so haemoglobin should be checked in any woman suspected of menorrhagia.

• DUB is a diagnosis of exclusion.

• A hierarchy of first-, second- and third-line treatment should be used in

management.