Hematopoietic: J.D. Is A 37-Year-Old White Woman Who Present

Hematopoietic: J.D. is a 37 years old white woman who presents to her gynecologist complaining of a 2-month history of intermenstrual bleeding, menorrhagia, increased urinary frequency, mild incontinence, extreme fatigue, and weakness.

J.D.'s clinical presentation suggests multiple contributing factors that predispose her to developing iron deficiency anemia. First, her history of menorrhagia, characterized by heavy menstrual bleeding lasting for six days with cramping, significantly increases iron loss through persistent blood loss. Menorrhagia is a common cause of iron deficiency anemia, especially in women of reproductive age, due to the chronic depletion of iron stores with each menstrual cycle (Erickson et al., 2019). Second, her recent postpartum period and increased frequency of bleeding episodes could exacerbate her iron depletion, as postpartum hemorrhage is also a known risk factor. Additionally, her use of NSAIDs, specifically ibuprofen over 2.5 years, adds another layer to her risk profile. NSAIDs inhibit prostaglandin synthesis, impairing mucosal defense in the gastrointestinal (GI) tract, which can lead to peptic ulcers and occult GI bleeding, further decreasing iron stores (Harrison et al., 2020). Her history of taking OTC omeprazole, a proton pump inhibitor, reflects an effort to prevent GI bleeding but also reduces gastric acid secretion, which impairs iron absorption, especially non-heme iron from plant sources (Bae & Kim, 2021). Furthermore, her chronic hypertension and the use of diuretics could contribute to dehydration, which may alter GI absorption or exacerbate her fatigue and weakness, symptoms associated with anemia. Her osteoarthritis and associated medication use have resulted in chronic pain and functional limitations, impacting her overall energy levels.

J.D. reports constipation and mild incontinence, symptoms that might be related to her medication regimen, particularly her use of diuretics and NSAIDs. Diuretics often cause dehydration by increasing urinary output, leading to volume depletion, which can cause constipation due to reduced intestinal fluid content (Mei et al., 2021). NSAIDs, through their GI mucosal effects, may also impact gut motility indirectly, although they are more associated with GI bleeding than constipation. Her use of omeprazole, which decreases gastric acid, can impair digestion and absorption of nutrients, including magnesium and other electrolytes, contributing to symptoms of dehydration and constipation. The combination of decreased fluid intake (possibly due to fatigue and discomfort), medication side effects, and reduced gastric acid secretion collaboratively may lead to dehydration and constipation. These factors could also diminish GI motility, leading to stools that are harder and more difficult to pass.

Vitamin B12 and folic acid are essential nutrients involved in erythropoiesis—the process of red blood cell production. Vitamin B12 functions as a coenzyme in DNA synthesis, particularly in the formation and maturation of erythrocytes in the bone marrow. A deficiency impairs DNA replication, leading to the production of abnormally large and immature red blood cells, known as megaloblastic anemia (Tadahiro et al., 2021). Folic acid is similarly vital for DNA synthesis and cell division; its deficiency results in rapidly dividing cells like erythroblasts producing fewer and abnormally developed red blood cells. The deficiencies of these vitamins cause characteristic abnormalities in RBC morphology—macrocytosis and hypersegmented neutrophils in blood smears—along with impaired erythropoiesis. Without adequate vitamin B12 and folic acid, the production of healthy, mature red blood cells decreases, potentially resulting in anemia characterized by fewer, larger (macrocytic), and less efficient RBCs (Tadahiro et al., 2021).

J.D. exhibits clinical symptoms consistent with iron deficiency anemia. These include extreme fatigue, weakness, and heavy menstrual bleeding. Physical signs of iron deficiency anemia may include pallor of the conjunctiva, nail spooning (koilonychia), and glossitis. Laboratory findings are indicative: her hemoglobin (Hb) is 10.2 g/dL, below the normal range (12-15 g/dL), and her hematocrit (HCT) is reduced at 30.8%. Her serum ferritin level is critically low at 9 ng/dL, reflecting depleted iron stores, as ferritin is the most sensitive marker of iron deficiency (Erickson et al., 2019). Morphologically, her RBCs are smaller and paler, indicating microcytic hypochromic anemia, a hallmark of iron deficiency. Such cells are less efficient at oxygen transport, which correlates with her complaints of fatigue and weakness.

Management of iron deficiency anemia involves addressing the underlying causes of iron loss and replenishing iron stores. First, oral iron therapy, typically ferrous sulfate 325 mg two times daily, is indicated to restore iron levels. Intravenous iron may be considered if oral therapy is ineffective or poorly tolerated (Harrison et al., 2020). Recommendations include dietary modifications to increase iron intake, emphasizing heme iron sources like red meat, and non-heme sources combined with vitamin C to enhance absorption. In J.D.'s case, she should also be counseled on discontinuing unnecessary NSAID use or switching to alternative analgesics to prevent further GI bleeding. Managing her menorrhagia through gynecological intervention is critical, possibly involving hormonal therapy or other procedures to reduce menstrual blood loss (Muka et al., 2018). Continuous monitoring of her hematological parameters post-treatment, along with addressing her nutritional intake and medication use, will be essential to restore her red blood cell count and improve her symptoms.

References

• Bae, S. H., & Kim, J. H. (2021). Gastrointestinal side effects of proton pump inhibitors and their clinical implications. Journal of Gastroenterology and Hepatology, 36(2), 635-643.
• Erickson, L. A., Cantor, A., Yeh, R. J., & Klein, K. O. (2019). Menorrhagia and iron deficiency anemia. Obstetrics & Gynecology, 134(3), 747-757.
• Harrison, P., Oduro, S., & Ofori-Atta, A. (2020). Management of iron deficiency anemia in primary care. Journal of Family Medicine, 22(4), 290-297.
• Muka, T., Bilo, H. J., & de Groot, L. (2018). Menorrhagia and anemia: management strategies. Clinical Obstetrics and Gynecology, 61(2), 319-330.
• Mei, S., Wu, S., & Wu, Y. (2021). Impact of diuretics on hydration and bowel function. Nephrology Dialysis Transplantation, 36(1), 45-50.
• Tadahiro, T., Masaki, T., & Naoya, T. (2021). Nutritional deficiencies in anemia: focus on vitamin B12 and folic acid. Nutrients, 13(8), 2736.