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The Relationship between Heavy Menstrual Bleeding, Iron Deficiency, and Iron Deficiency Anemia

  • M.G. Munro
    Correspondence
    Corresponding Author: Malcolm G. Munro MD,
    Affiliations
    Clinical Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles

    Chair, Women’s Health Research Collaborative; Chair, SEUD Abnormal Uterine Bleeding Task Force; Immediate Past Chair, FIGO Menstrual Disorders Committee; Section Head, Faculty Opinions and Faculty Member for Menstrual Disorders and Abnormal Uterine Bleeding
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  • A.E. Mast
    Affiliations
    Senior Investigator, Medical Director of the Medical Sciences Institute, and Walter A. Schroeder Endowed Chair for Blood Research at Versiti Blood Research Institute, Milwaukee Wisconsin
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  • J.M. Powers
    Affiliations
    Assistant Professor of Pediatrics at Baylor College of Medicine, Houston, Texas

    Associate Chief of Hematology and Director of the Iron Disorders and Nutritional Anemias Program within the Section of Hematology/Oncology at Texas Children’s Cancer and Hematology Center; directs the Iron Disorders and Nutritional Anemias Program and Young Women’s Bleeding Disorders Clinic
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  • P.A. Kouides
    Affiliations
    Medical and Research director of the Mary M. Gooley Hemophilia Center; Clinical Professor of Medicine at the University of Rochester School of Medicine, Rochester, New York

    Section co-chair of the American Society of Hematology (ASH) Self-Assessment Program chapter on Women with Hemostasis and Thrombosis issues; President, Thrombosis and Hemostasis Societies, North America
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  • S.H. O’Brien
    Affiliations
    Pediatric hematologist, Nationwide Children’s Hospital Hemostasis and Thrombosis Center; Investigator, Center for Health Equity and Outcomes Research, Nationwide Children’s Research Institute; Associate Professor of Pediatrics, The Ohio State University College of Medicine; Director of Experimental Therapeutics, Division of Pediatric Hematology/Oncology/BMT; leads a multi-disciplinary hematology and adolescent gynecology clinic, Nationwide Children’s Hospital
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  • T. Richards
    Affiliations
    Lawrence-Brown Professor, Vascular Surgery, University of Western Australia and Faculty of Health and Medical Sciences, Head, Division of Surgery and Director of the Clinical Trials Unit. Honorary Professor of anaesthesia, Monash University and Honorary Professor, the UCL institute of clinical trials and methodology
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  • M. Lavin
    Affiliations
    Consultant Haematologist, National Coagulation Centre, St. James’ Hospital, Dublin

    Clinical Lead, Haemostasis Research, Irish Centre for Vascular Biology, Royal College of Surgeons, Ireland

    Co-Chair of the International Society on Thrombosis and Haemostasis (ISTH) VWF Scientific Subcommittee (SSC), European Association of Haemophilia and Allied Disorder (EAHAD) Women’s Health Committee
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  • B.S. Levy
    Affiliations
    Clinical Professor, Department of Obstetrics and Gynecology, University of California, San Diego

    Clinical Professor, Department of Obstetrics and Gynecology, George Washington University, Washington DC

    Former Vice President, Health Policy, American College of Obstetricians and Gynecologists, Washington DC
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Published:January 24, 2023DOI:https://doi.org/10.1016/j.ajog.2023.01.017
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      ABSTRACT

      For reproductive-aged women, the symptom of heavy menstrual bleeding is highly prevalent and a major contributor to iron deficiency and its most severe manifestation, iron deficiency anemia. It is recognized that these two clinical entities are not only highly prevalent, but their interrelationship is poorly appreciated and frequently normalized by society, healthcare providers, and affected girls and women themselves. Both heavy menstrual bleeding and iron deficiency, with or without anemia, adversely impact the quality of life – heavy menstrual bleeding during the episodes of bleeding and iron deficiency on a daily basis. These combined issues adversely affect the lives of reproductive-aged girls and women of all ages, from menarche to menopause, while their often-insidious nature frequently leads to normalization. The effects on cognitive function, as well as the related work and school absenteeism and presenteeism, can undermine the efforts and function of women in all walks of life, be they students, educators, employers, or employees. There is also an increasing body of evidence that suggests that iron deficiency, even in early pregnancy, may adversely impact fetal neurodevelopment with enduring effects on a spectrum of cognitive and psychological disorders, critically important evidence that begs the normalization of iron stores in reproductive-aged women. The authors seek to raise individual, societal, and professional awareness of this underappreciated situation in a fashion that leads to meaningful and evidence-based changes in clinical guidance and healthcare policy directed at preventing, screening, diagnosing, and appropriately managing both disorders. This manuscript provides evidence supporting the need for action and describes the elements necessary to address this pervasive set of conditions that not only affect reproductive-aged girls and women but also the lives of children everywhere.

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