Iron-dependent erythropoiesis in women with excessive menstrual blood losses and women with normal menses

Absolute and functional iron deficiency: Biomarkers, impact on immune system, and therapy

Iron is essential for numerous physiological processes and its deficiency often leads to anemia. Iron deficiency (ID) is a global problem, primarily affecting reproductive-age women and children, especially in developing countries. Diagnosis uses classical biomarkers like ferritin or transferrin saturation. Recent advancements include using soluble transferrin receptor (sTfR) or hepcidin for improved detection and classification of absolute and functional iron deficiencies, though mostly used in research. ID without anemia may present symptoms like asthenia and fatigue, even without relevant clinical consequences. ID impacts not only red-blood cells but also immune system cells, highlighting its importance in global health and immune-related comorbidities. Managing ID, requires addressing its cause and selecting appropriate iron supplementation. Various improved oral and intravenous products are available, but further research is needed to refine treatment strategies. This review updates on absolute and functional iron deficiencies, their relationships with the immune system and advancements in diagnosis and therapies.

Menstrual blood loss is an independent determinant of hemoglobin and ferritin levels in premenopausal blood donors

INTRODUCTION

To prevent blood donors from developing iron deficiency (ferritin <15 μg/L) and subsequent anemia (hemoglobin <120 g/L), blood services rely on information about known risk factors, including the donor's sex and age. For example, while Finnish women are able to donate whole blood with a minimum donation interval of 91 days, women in the 18 to 25-year-old age group are recommended to donate no more than once per year. Menstrual blood loss is not accounted for in blood donation interval recommendations, despite being a known risk factor of iron deficiency. We aim to investigate to what extent menstrual bleeding is associated with ferritin and hemoglobin levels in female blood donors, and quantify the association of other menstruation-related variables not currently accounted for by blood services (i.e., use of hormonal contraception, heavy menstrual bleeding) with iron deficiency or anemia.

MATERIAL AND METHODS

The study population consisted of 473 premenopausal and 491 postmenopausal Dutch whole blood donors. Exclusion criteria were current pregnancy, BMI ≥50, ferritin ≥200, pictorial blood assessment chart (PBAC) ≥400, and age <18 or ≥70 years. Menstrual blood loss was quantified using a PBAC, a semiquantitative method to evaluate the number of used menstrual products and the degree of staining. We identified predictors of log(ferritin)/hemoglobin and iron deficiency/anemia using Bayesian linear and logistic regression models and quantified the average percentage of variance in log(ferritin) and hemoglobin explained by the covariates.

RESULTS

Menstrual blood loss accounted for most of the explained variance in hemoglobin (8%) and second only to the number of days since last donation for ferritin (8%). Heavy menstrual bleeding (PBAC ≥150, OR = 3.56 [1.45-8.85], prevalence 13%) was associated with anemia, and use of levonorgestrel-releasing intrauterine device was negatively associated with iron deficiency (OR = 0.06 [0.01-0.44]). After statistical control for menstrual blood loss, age was not associated with iron status.

CONCLUSIONS

Menstrual blood loss and blood donation were the most important determinants of iron status in premenopausal women. Thus, results suggest that accounting for menstrual blood loss in donation interval guidelines may benefit blood donors.

Iron deficiency and supplementation in heart failure

Non-anaemic iron deficiency (NAID) is a strategic target in cardiovascular medicine because of its association with a range of adverse effects in various conditions. Endeavours to tackle NAID in heart failure have yielded mixed results, exposing knowledge gaps in how best to define 'iron deficiency' and the handling of iron therapies by the body. To address these gaps, we harness the latest understanding of the mechanisms of iron homeostasis outside the erythron and integrate clinical and preclinical lines of evidence. The emerging picture is that current definitions of iron deficiency do not assimilate the multiple influences at play in patients with heart failure and, consequently, fail to identify those with a truly unmet need for iron. Additionally, current iron supplementation therapies benefit only certain patients with heart failure, reflecting differences in the nature of the unmet need for iron and the modifying effects of anaemia and inflammation on the handling of iron therapies by the body. Building on these insights, we identify untapped opportunities in the management of NAID, including the refinement of current approaches and the development of novel strategies. Lessons learned from NAID in cardiovascular disease could ultimately translate into benefits for patients with other chronic conditions such as chronic kidney disease, chronic obstructive pulmonary disease and cancer.

The Menstrual Health Manager (MHM): A Resource to Reduce Discrepancies Between Science and Practice in Sport and Exercise

Inadequate research on female health and performance; the complexity of the research; low menstrual health literacy of athletes, coaches, and support staff; and ethical and cultural sensitivities are all recognized as barriers to effective health monitoring for females in sports. Frameworks have been developed for academics to follow to help improve the quality of female-specific research. However, a similar resource that enables correct terminology, and use of health monitoring techniques has not been provided for sporting organizations, coaches, support staff or athletes. Therefore, this critical commentary presents a new resource, the Menstrual Health Manager. This resource may be used to determine the level of menstrual health monitoring detail that may be used by organisations, coaches or athletes, and specifies what reproductive health details the data will provide. This resource aims to provide organizations and coaches with a means of understanding the data that inform their decisions for female athletes. Utilization of this resource may aid in the consistent use of terminology and methods for female-specific health monitoring in both sports and research.

Safety monitoring of oral iron supplements in pregnant women with anemia: a multi-center observational clinical study

Aims

To investigate the safety of oral iron therapy in pregnant women with iron-deficiency anemia (IDA) in the real world.

Methods

A retrospective analysis was performed on 1792 pregnant patients with IDA who received oral iron supplements from 12 hospitals in Shandong Province from 1 April to 31 June 2021; follow-up and adverse reactions were recorded. They were divided into six groups according to the treatment drugs.

Results

The overall adverse reaction rate was 15.4%, and the main adverse reaction site was the digestive system. The incidence of all kinds of oral iron adverse reactions from high to low in order: compound ferrous sulfate and folic acid tablets (21.88%); iron proteinsuccinylate oral solution (20.90%); ferrous succinate tablets (19.76%); ferrous succinate sustained-release tablets (18.00%); iron polysaccharide complex capsule (12.06%); and iron dextran oral solution (6.94%). It was found that there was a significant difference in the incidence of adverse reactions among the six drugs (p < 0.05). Pairwise comparison showed that the incidence of adverse reactions was higher in the iron proteinsuccinylate oral solution than that in the iron polysaccharide complex capsule (p < 0.05). There was no significant difference in the incidence of adverse reactions in different ages (p > 0.05), but there was a significant difference in the incidence of adverse reactions in different gestational ages (p < 0.05). In Adverse Drug Reaction (ADR) patients, the adverse reaction result of most patients is recovery or improvement, and there was no serious adverse reaction outcome such as sequela and death.

Conclusion

All the adverse reactions of oral iron were mainly gastrointestinal adverse reactions, and no heavy adverse reactions were found. Iron proteinsuccinylate oral solution has a higher incidence of adverse reactions than iron polysaccharide complex capsule. The results showed that oral iron was safer for anemia patients during pregnancy.

Oral contraceptive use and menstrual cycle influence acute cerebrovascular response to standing

PURPOSE

To determine if the menstrual cycle and oral contraceptives (OC) influence responses to acute orthostatic stress and if these factors are clinically relevant to the diagnosis of initial orthostatic hypotension (iOH).

METHODS

Young, healthy women were recruited, including OC users (n = 12) and non-users (NOC; n = 9). Women were tested during the low hormone (LH; placebo pills; days 2-5 natural cycle) and high hormone (HH; active dose; days 18-24 natural cycle) menstrual phases. Changes in mean arterial pressure, cardiac output, heart rate, the 30:15 heart rate ratio and cerebrovascular resistance indices within 30 s of standing were examined.

RESULTS

There were no effects of OC or menstrual cycle on hemodynamic responses during standing (all p>0.05). In the LH phase, OC users had a greater fall in mean middle cerebral artery blood velocity (MCA_V) compared to NOC (p<0.05). However, this was reversed in the HH phase, where OC users had a reduced fall in mean MCA_V (p<0.05). Interestingly, 8 women (OC and NOC) had drops in systolic/diastolic blood pressure meeting the criteria for iOH, and 7 of those 8 women displayed this drop in a single phase of the menstrual cycle.

CONCLUSION

Our results indicate that chronic versus acute OC use (i.e., long-term use observed via LH phase versus short-term use observed via HH phase) have opposing effects on cerebral blood velocity during standing. Further, our results highlight that multiple assessments across the cycle may be necessary to accurately diagnose iOH, as most women met the diagnostic criteria during a single menstrual phase.

Chronic Fatigue Syndrome in Patients with Deteriorated Iron Metabolism

Fatigue is a common, non-specific symptom that often impairs patients’ quality of life. Even though fatigue may be the first symptom of many serious diseases, it is often underestimated due to its non-specific nature. Iron metabolism disorders are a prominent example of conditions where fatigue is a leading symptom. Whether it is an iron deficiency or overload, tiredness is one of the most common features. Despite significant progress in diagnosing and treating iron pathologies, the approach to chronic fatigue syndrome in such patients is not precisely determined. Our study aims to present the current state of knowledge on fatigue in patients with deteriorated iron metabolism.

A contemporary understanding of iron metabolism in active premenopausal females

Iron metabolism research in the past decade has identified menstrual blood loss as a key contributor to the prevalence of iron deficiency in premenopausal females. The reproductive hormones estrogen and progesterone influence iron regulation and contribute to variations in iron parameters throughout the menstrual cycle. Despite the high prevalence of iron deficiency in premenopausal females, scant research has investigated female-specific causes and treatments for iron deficiency. In this review, we provide a comprehensive discussion of factors that influence iron status in active premenopausal females, with a focus on the menstrual cycle. We also outline several practical guidelines for monitoring, diagnosing, and treating iron deficiency in premenopausal females. Finally, we highlight several areas for further research to enhance the understanding of iron metabolism in this at-risk population.

Effectiveness of Dietary Interventions to Treat Iron-Deficiency Anemia in Women: A Systematic Review of Randomized Controlled Trials

Iron-deficiency anemia is the most frequent nutritional deficiency, with women of reproductive age being particularly at risk of its development. The aim of the systematic review was to assess the effectiveness of dietary interventions to treat iron-deficiency anemia in women based on the randomized controlled trials. The systematic review was conducted according to the PRISMA guidelines and registered in the PROSPERO database (CRD42021261235). The searching procedure was based on PubMed and Web of Science databases, while it covered records published until June 2021. It included all randomized controlled trials assessing effectiveness of various dietary interventions on treatment of iron-deficiency anemia in women of childbearing age. The total number of 7825 records were screened, while 14 of them were finally included in the systematic review. The studies were screened, included, and reported, and the risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials by two independent researchers. The included studies compared the effectiveness of various dietary interventions with supplementation, placebo, control, or any other dietary intervention, while the assessed dietary interventions were based either on increasing iron supply and/or on increasing its absorption (by increasing vitamin C or vitamin D or decreasing phytate intake). The duration of applied intervention was diversified from 3 months or less, through 4 or 5 months, to half of a year or more. Among the assessed biochemical measures, the following were analyzed in majority of studies: hemoglobin, ferritin, transferrin receptor, hematocrit, and transferrin. The majority of included studies supported the influence of dietary interventions on the treatment of iron-deficiency anemia, as the applied dietary intervention was not effective in only three studies. The majority of included studies were assessed as characterized by medium risk of bias, while the overall risk was high for only four studies, which resulted from the randomization process, deviations from the intended interventions, and selection of the reported result. The majority of included studies were conducted for increasing iron supply and/or increasing vitamin C supply; however, only for the interventions including increasing iron supply and simultaneously increasing its absorption by vitamin C supply were all results confirmed effective. Vitamin D also seems to be an effective dietary treatment, but further studies are necessary to confirm the observations. Considering this fact, dietary interventions recommended for anemic female patients should include increased intake of iron and vitamin C.

Nutrition and hair

Healthy hair results from a combination of good generalized health and mindful health care practices. Many nutritional deficiencies lead to poor hair health and include changes to hair structure, texture, and viability. Although the mechanisms by which individual nutrients contribute to hair growth and maintenance have yet to be fully resolved, there are a variety of risk factors that predispose an individual to a nutritional deficiency; age, malnutrition, malabsorption, and medication use are among the most common. A thorough history should be taken in a patient with a hair disturbance to identify risk factors for a nutritional deficiency, which will then guide directed laboratory testing and treatment.

The need to screen for anemia in exercising women

ABSTRACT

Anemia is common, affecting 1 in 3 women in their lifetime. Despite high prevalence rates, awareness is poor. This is relevant for women undertaking sport as anemia can lead to reduced physical performance. There is no current screening program for testing of anemia for exercising women. Therefore, the objective of the present study was to assess a simple screening tool to predict anemia in exercising women.Cross sectional survey study.National fitness festival.Three hundred exercising women.Screening methodology (Female Health Questionnaire and a haemoglobin concentration measurement).The Female Health Questionnaire inquired about; previous iron status, menstrual blood loss, diet, and motherhood. Participants were asked to self-report any symptoms of iron deficiency, including; brain fog, palpitations, shortness of breath, restless legs, hair loss, and pica. Results were compared to fingerprick haemoglobin levels with anemia defined as [Hb] < 120 g/L.Average age was 31.21years (s.d.7.72), average [Hb] was 131.76 g/L (s.d.11.5) and 36 (12%) had anemia. A history of iron deficiency was reported by 127 (43.49%), 127 (43.49%) reported heavy menstrual bleeding (HMB), 75 were vegetarian (18%) or vegan (8%) and 33 were mothers (11%). In total 80 reported taking time off work (total 1612 days). Women with anemia more commonly reported HMB (58.33% vs. 41.57%, P = .04), and those with HMB were more likely to report days off (39.37% vs. 18.18%, P < .001).Anemia was common in exercising women, particularly those with HMB. A simple screening tool for HMB and finger prick haemoglobin testing for anemia is recommended in women undertaking exercise.

Oral high-dose sucrosomial iron vs intravenous iron in sideropenic anemia patients intolerant/refractory to iron sulfate: a multicentric randomized study

Iron deficiency anemia is among the most frequent causes of disability. Intravenous iron is the quickest way to correct iron deficiency, bypassing the bottleneck of iron intestinal absorption, the only true mechanism of iron balance regulation in human body. Intravenous iron administration is suggested in patients who are refractory/intolerant to oral iron sulfate. However, the intravenous way of iron administration requires several precautions; as the in-hospital administration requires a resuscitation service, as imposed in Europe by the European Medicine Agency, it is very expensive and negatively affects patient's perceived quality of life. A new oral iron formulation, Sucrosomial iron, bypassing the normal way of absorption, seems to be cost-effective in correcting iron deficiency anemia at doses higher than those usually effective with other oral iron formulations. In this multicentric randomized study, we analyze the cost-effectiveness of intravenous sodium ferrigluconate vs oral Sucrosomial iron in patients with iron deficiency anemia refractory/intolerant to oral iron sulfate without other interfering factors on iron absorption.

Iron overload in the HCT patient: a review

Iron overload (IO) is common in hematologic malignancies and hemoglobinopathies, largely due to red cell transfusion burden. End-organ damage from IO occurs via reactive oxygen species-mediated pathways. The impact of pretransplant IO on hematopoietic cell transplant (HCT) morbidity and mortality remains contentious; studies have shown mixed results, possibly due to variability in study population and design, as well as markers of IO. Ferritin has served as a traditional circulating marker of total body IO, but liver iron content by MRI appears to be a better marker of end-organ involvement. Novel surrogate markers including hepcidin, marrow Prussian blue staining, and labile plasma iron levels may prove to be more specific for HCT complications. Posttransplant phlebotomy, chelation, or both in combination remains the mainstays of treatment, though may ultimately be supplanted by pretransplant or peri-transplant use of bone marrow maturation agents or targeted chelation at time of highest IO risk. This review discusses the pathophysiology of IO in hematologic disease, the evidence supporting and refuting its negative impact on HCT outcomes, as well as current and future therapies.

A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding

Introduction

Up to one-third of women of reproductive age experience heavy menstrual bleeding (HMB). HMB can give rise to iron deficiency (ID) and, in severe cases, iron-deficiency anemia (IDA).

Aim

To review current guidelines for the management of HMB, with regards to screening for anemia, measuring iron levels, and treating ID/IDA with iron replacement therapy and non-iron-based treatments.

Methods

The literature was searched for English-language guidelines relating to HMB published between 2010 and 2020, using the PubMed database, web searching, and retrieval of clinical guidelines from professional societies.

Results

Overall, 55 guidelines mostly originating from North America and Europe were identified and screened. Twenty-two were included in this review, with the majority (16/22) focusing on guidance to screen women with HMB for anemia. The guidance varied with respect to identifying symptoms, the criteria for testing, and diagnostic hemoglobin levels for ID/IDA. There was inconsistency concerning screening for ID, with 11/22 guidelines providing no recommendations for measurement of iron levels and four contrasting guidelines explicitly advising against initial assessment of iron levels. In terms of treatment, 8/22 guidelines provided guidance on iron therapy, with oral iron administration generally recommended as first-line treatment for ID and/or IDA. Four guidelines recommended intravenous iron administration for severe anemia, in non-responders, or before surgery. Three guidelines provided hemoglobin thresholds for choosing between oral or intravenous iron treatment. Four guidelines discussed the use of transfusion for severe IDA.

Conclusion

Many of the guidelines for managing HMB recognize the importance of treating anemia, but there is a lack of consensus in relation to screening for ID and use of iron therapy. Consequently, ID/IDA associated with HMB is likely to be underdiagnosed and undertreated. A consensus guidance, covering all aspects of screening and management of ID/IDA in women with HMB, is needed to optimize health outcomes in these patients.

Women who bleed heavily during menstruation are at risk of iron deficiency and anemia. This can have a negative effect on the well-being of women and can cause serious complications after surgery. Iron is an important part of the hemoglobin in red blood cells that carries oxygen around the body. Bleeding causes iron to be lost from the body. If there is heavy blood loss, iron stores in the body can become low, leading to iron deficiency. If the iron deficiency is severe enough to impair red blood cell production, iron-deficiency anemia can develop. We reviewed the current guidelines for the care of women with heavy menstrual bleeding, focusing on the detection and treatment of iron deficiency and anemia. Most guidelines include routine testing for anemia. Fewer guidelines consider measuring iron levels. Not all the guidelines include advice on the best way to treat iron deficiency and anemia. For those that do, the recommendations vary and sometimes offer conflicting advice. There is little agreement on when to give iron therapy, and whether this should be given by mouth or by infusion. A lack of clear guidance on detecting and treating iron deficiency and anemia caused by heavy menstrual bleeding puts women at risk of being undiagnosed and untreated. To address these concerns, the authors recommend the development of consensus guidelines. These should contain comprehensive recommendations on all aspects of the diagnosis and management of iron deficiency and anemia in women with heavy menstrual bleeding.

Iron Therapeutics in Women's Health: Past, Present, and Future

Iron plays a unique physiological role in the maintenance of homeostasis and the pathological outcomes of the female reproductive tract. The dual nature of elemental iron has created an evolutionary need to tightly regulate its biological concentration. The female reproductive tract is particularly unique due to the constant cycle of endometrial growth and shedding, in addition to the potential need for iron transfer to a developing fetus. Here, iron regulation is explored in a number of physiologic states including the endometrial lining and placenta. While iron dysregulation is a common characteristic in many women's health pathologies there is currently a lack of targeted therapeutic options. Traditional iron therapies, including iron replacement and chelation, are common treatment options for gynecological diseases but pose long term negative health consequences; therefore, more targeted interventions directed towards iron regulation have been proposed. Recent findings show potential benefits in a therapeutic focus on ferritin-hepcidin regulation, modulation of reactive oxygen species (ROS), and iron mediated cell death (ferroptosis). These novel therapeutics are the direct result of previous research in iron's complex signaling pathway and show promise for improved therapy, diagnosis, and prognosis in women's health.

Elagolix Treatment for Up to 12 Months in Women With Heavy Menstrual Bleeding and Uterine Leiomyomas

Up to 12 months of elagolix with add-back therapy provided sustained reduction in menstrual blood loss with an acceptable safety profile in women with uterine leiomyomas.

To investigate the safety and efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy for up to 12 months in women with heavy menstrual bleeding associated with uterine leiomyomas.

Association between Anemia and Stroke in Females: A Nationwide, Population-Based Cohort Study in Taiwan

Optimal stroke prevention strategies for women should take into account specific sex-related stroke risk factors. Anemia is a common medical condition in females, particularly in women of reproductive age. This study investigated whether anemia is an independent risk factor for stroke in females in a population-based cohort study. We investigated newly diagnosed anemic female patients with no history of central nervous system disease, psychiatric disorders, traumatic brain injury, major operations or hemorrhagic diseases identified from the Taiwan National Health Insurance Research Database. Non-anemic matched controls (1:1) were selected based on a propensity score estimated using a logistic regression model that included demographic characteristics and comorbidities. A competing risk analysis was applied to estimate the stroke risk in anemic patients compared to that of their matched controls. In our study, the adjusted sub-distribution hazard ratios (aSHRs) of overall, hemorrhagic and ischemic stroke in anemic female patients aged <50 years were 1.35 (95% confidence interval (CI): 1.19-1.52, p < 0.001), 1.31 (95% CI, 1.09-1.56, p < 0.003), and 1.35 (95% CI, 1.15-1.58, p < 0.001), respectively, compared to non-anemic female controls. However, a positive association between anemia and stroke was not found for those aged ≥50 years. Similar results were observed when the follow-up age was limited to 50 years to reduce the potential effects of menopause on stroke. In conclusion, the present population-based cohort study found that anemia is a potential risk factor for overall, hemorrhagic and ischemic stroke in females of reproductive age.

[Congenital factor Ⅶ deficiency: a retrospective analysis of 43 cases]

Objective: To explore the pathogenesis, clinical characteristics, laboratory findings, diagnosis, treatment, and prognosis of congenital factor Ⅶ (FⅦ) deficiency. Methods: Clinical data of 43 patients with congenital FⅦ deficiency diagnosed from April 1999 to September 2019 were retrospectively analyzed. Results: There were 27 females and 16 males. Median age was 16 (1-70) years. Family history was found in 6 cases. There were 29 (67.4%) cases with bleeding symptoms, most common of which were mucocutaneous bleeding (13 cases, 30.2%) , oral bleeding (13 cases, 30.2%) , and epistaxis (9 cases, 20.9%) . Menorrhagia occurred in 11 cases (47.6% of female patients who were in fertile age) . Laboratory findings were characterized by significantly prolonged prothrombin time (PT) , normal partial thromboplastin time (APTT) , and decreased FⅦ activity (FⅦ∶C) . Ten cases received gene mutation analysis and 3 new mutations were found. Fourteen cases (32.6%) were treated with prothrombin complex concentrates (PCC) , 12 (27.9%) with fresh frozen plasma (FFP) , and 3 (7.0%) with human recombinant activated FⅦ (rFⅦa) . Twenty cases (46.5%) with no or mild bleeding symptoms did not receive any replacement therapy. Previous bleeding symptoms recurred in 5 patients (11.6%) , 8 females still had heavy menstrual bleeding, and 9 patients (20.9%) were lost to follow-up. Conclusion: Most patients with congenital FⅦ deficiency have mild or no bleeding symptoms, but have a tendency to excessive bleeding after surgery or trauma. There is no significant correlation between FⅦ∶C and severity of bleeding symptoms. Prophylaxis should be applied in patients with severe bleeding symptoms and rFⅦa is the first choice. Gene mutation test is significant for screening, diagnosis, and prognosis prediction of the disease.

Iron Deficiency and Iron Deficiency Anemia: Implications and Impact in Pregnancy, Fetal Development, and Early Childhood Parameters

A normal pregnancy consumes 500-800 mg of iron from the mother. Premenopausal women have a high incidence of marginal iron stores or iron deficiency (ID), with or without anemia, particularly in the less developed world. Although pregnancy is associated with a "physiologic" anemia largely related to maternal volume expansion; it is paradoxically associated with an increase in erythrocyte production and erythrocyte mass/kg. ID is a limiting factor for this erythrocyte mass expansion and can contribute to adverse pregnancy outcomes. This review summarizes erythrocyte and iron balance observed in pregnancy; its implications and impact on mother and child; and provides an overview of approaches to the recognition of ID in pregnancy and its management, including clinically relevant questions for further investigation.

Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids

BACKGROUND

Uterine fibroids are hormone-responsive neoplasms that are associated with heavy menstrual bleeding. Elagolix, an oral gonadotropin-releasing hormone antagonist resulting in rapid, reversible suppression of ovarian sex hormones, may reduce fibroid-associated bleeding.

METHODS

We conducted two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids 1 and 2 [UF-1 and UF-2]) to evaluate the efficacy and safety of elagolix at a dose of 300 mg twice daily with hormonal "add-back" therapy (to replace reduced levels of endogenous hormones; in this case, estradiol, 1 mg, and norethindrone acetate, 0.5 mg, once daily) in women with fibroid-associated bleeding. An elagolix-alone group was included to assess the impact of add-back therapy on the hypoestrogenic effects of elagolix. The primary end point was menstrual blood loss of less than 80 ml during the final month of treatment and at least a 50% reduction in menstrual blood loss from baseline to the final month; missing data were imputed with the use of multiple imputation.

RESULTS

A total of 412 women in UF-1 and 378 women in UF-2 underwent randomization, received elagolix or placebo, and were included in the analyses. Criteria for the primary end point were met in 68.5% of 206 women in UF-1 and in 76.5% of 189 women in UF-2 who received elagolix plus add-back therapy, as compared with 8.7% of 102 women and 10% of 94 women, respectively, who received placebo (P<0.001 for both trials). Among the women who received elagolix alone, the primary end point was met in 84.1% of 104 women in UF-1 and in 77% of 95 women in UF-2. Hot flushes (in both trials) and metrorrhagia (in UF-1) occurred significantly more commonly with elagolix plus add-back therapy than with placebo. Hypoestrogenic effects of elagolix, especially decreases in bone mineral density, were attenuated with add-back therapy.

CONCLUSIONS

Elagolix with add-back therapy was effective in reducing heavy menstrual bleeding in women with uterine fibroids. (Funded by AbbVie; Elaris UF-1 and Elaris UF-2 ClinicalTrials.gov numbers, NCT02654054 and NCT02691494.).

Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the hematologist's view

In the childbearing years, hormonal therapy or hormonal changes in the menstrual cycle or the puerperium may be complicated by bleeding or thrombosis; however, among women with congenital disorders of hemostasis and thrombosis, the risk of bleeding or thrombosis may be increased. In women with congenital bleeding disorders, heavy menstrual bleeding is the most common bleeding symptom, and postpartum hemorrhage occurs despite treatment. Given the limitations of current therapy and the associated medical and psychological burden in women with bleeding disorders, better treatment approaches are needed to improve health outcomes and quality of life. In women with congenital thrombotic disorders, thromboembolism may complicate exogenous hormonal therapy and endogenous hormonal change during pregnancy and procedures, but risk differs by type of thrombophilia, procedure, time at risk, and thrombosis risk factors, all of which affect management. In this article, I shall consider a case-based discussion of current issues in women with congenital bleeding and clotting disorders, including heavy menstrual bleeding in a woman with VWD, postpartum hemorrhage risk in VWD, and thrombosis risk with oocyte retrieval in a woman with factor V Leiden and past thromboembolism. The goals are to review bleeding or thrombosis risk in these cases, current data, limitations of current treatment guidelines, and areas for future study.

Perspectives of women experiencing Menorrhagia: A descriptive qualitative study

OBJECTIVE

To describe the perspectives and support needs of women experiencing menorrhagia in Singapore.

BACKGROUND

Women with menorrhagia lack awareness regarding the severity of menorrhagia. There is a dearth of literature understanding the support needs of women with menorrhagia.

DESIGN

A descriptive qualitative study design was adopted. The Consolidated crieteria for Reportig Qualitative Research (COREQ) was used to report the findings of this study.

METHODS

The study was conducted at a tertiary public hospital in Singapore from July 2017-October 2017. Semi-structured interviews were used to collect data from 16 women who were diagnosed with menorrhagia. The total number of interviews was concluded based on data saturation. The interviews were transcribed verbatim, and thematic analysis was used to analyse the interview transcripts. The COREQ was used to report the findings of this study.

RESULTS

Participants reported that they were unaware about menorrhagia and its severity. Various internal and external factors influenced the participants' awareness and understanding of menorrhagia. Although the participants received support to cope with menorrhagia, the support was deemed insufficient. The women shared that menorrhagia had affected their lives physically, emotionally, socially and financially. They used both external and internal coping mechanisms to cope with their conditions and looked for information through close contacts and the Internet. They longed to learn more about their conditions.

CONCLUSION

Multiethnic Singaporean women with menorrhagia lacked awareness about their conditions and the severity, which affected their lives negatively. There should be greater efforts to raise the public's awareness of menorrhagia so that women can seek medical help early and minimise its negative influence on their lives.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to pay greater attention to menorrhagia in order to provide more holistic care and support for those experiencing this condition. Healthcare professionals should understand their patients' experiences with menorrhagia and evaluate their current support resources in order to create a strong support system.

A systematic review of methods to measure menstrual blood loss

Background

Since the publication over 50 years ago of the alkaline hematin method for quantifying menstrual blood loss (MBL) many new approaches have been developed to assess MBL. The aim of this systematic review is to determine for methods of measuring MBL: ability to distinguish between normal and heavy menstrual bleeding (HMB); practicalities and limitations in the research setting; and suitability for diagnosing HMB in routine clinical practice.

Methods

Embase®™, MEDLINE®, and ClinicalTrials.gov were screened for studies on the development/validation of MBL assessment methods in women with self-perceived HMB, actual HMB or uterine fibroids, or patients undergoing treatment for HMB. Studies using simulated menstrual fluid and those that included women with normal MBL as controls were also eligible for inclusion. Extracted data included study population, results of validation, and advantages/disadvantages of the technique.

Results

Seventy-one studies fulfilled the inclusion criteria. The sensitivity and/or specificity of diagnosing HMB were calculated in 16 studies of methods involving self-perception of MBL (11 pictorial), and in one analysis of the menstrual-fluid-loss (MFL) method; in 13 of these studies the comparator was the gold standard alkaline hematin technique. Sensitivity and specificity values by method were, respectively: MFL model, 89, 98%; pictorial blood loss assessment chart (PBAC), 58–99%, 7.5–89%; menstrual pictogram, 82–96%, 88–94%; models/questionnaires, 59–87%, 62–86%, and complaint of HMB, 74, 74%. The power of methods to identify HMB was also assessed using other analyses such as comparison of average measurements: statistical significance was reported for the PBAC, MFL, subjective complaint, and six questionnaires. In addition, PBAC scores, menstrual pictogram volumes, MFL, pad/tampon count, iron loss, and output from three questionnaires correlated significantly with values from a reference method in at least one study. In general, pictorial methods have been more comprehensively validated than questionnaires and models.

Conclusions

Every method to assess MBL has limitations. Pictorial methods strike a good balance between ease of use and validated accuracy of MBL determination, and could complement assessment of HMB using quality of life (QoL) in the clinical and research setting.

Trial registration

PRISMA registration number: CRD42016032956.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0627-8) contains supplementary material, which is available to authorized users.

Do pregnancies reduce iron overload in HFE hemochromatosis women? results from an observational prospective study

Background

HFE hemochromatosis is an inborn error of iron metabolism linked to a defect in the regulation of hepcidin synthesis. This autosomal recessive disease typically manifests later in women than men. Although it is commonly stated that pregnancy is, with menses, one of the factors that offsets iron accumulation in women, no epidemiological study has yet supported this hypothesis. The aim of our study was to evaluate the influence of pregnancy on expression of the predominant HFE p.[Cys282Tyr];[Cys282Tyr] genotype.

Methods

One hundred and forty p.Cys282Tyr homozygous women enrolled in a phlebotomy program between 2004 and 2011 at a blood centre in western Brittany (France) were included in the study. After checking whether the disease expression was delayed in women than in men in our study, the association between pregnancy and iron overload was assessed using multivariable regression analysis.

Results

Our study confirms that women with HFE hemochromatosis were diagnosed later than men cared for during the same period (52.6 vs. 47.4 y., P < 0.001). Compared to no pregnancy, having at least one pregnancy was not associated with lower iron markers. In contrast, the amount of iron removed by phlebotomies appeared significantly higher in women who had at least one pregnancy (e^β = 1.50, P = 0.047). This relationship disappeared after adjustment for confounding factors (e^β = 1.35, P = 0.088).

Conclusions

Our study shows that pregnancy status has no impact on iron markers level, and is not in favour of pregnancy being a protective factor in progressive iron accumulation. Our results are consistent with recent experimental data suggesting that the difference in disease expression observed between men and women may be explained by other factors such as hormones.

Iron balance and iron supplementation for the female athlete: A practical approach

Maintaining a positive iron balance is essential for female athletes to avoid the effects of iron deficiency and anaemia and to maintain or improve performance. A major function of iron is in the production of the oxygen and carbon dioxide carrying molecule, haemoglobin, via erythropoiesis. Iron balance is under the control of a number of factors including the peptide hormone hepcidin, dietary iron intake and absorption, environmental stressors (e.g. altitude), exercise, menstrual blood loss and genetics. Menstruating females, particularly those with heavy menstrual bleeding are at an elevated risk of iron deficiency. Haemoglobin concentration [Hb] and serum ferritin (sFer) are traditionally used to identify iron deficiency, however, in isolation these may have limited value in athletes due to: (1) the effects of fluctuations in plasma volume in response to training or the environment on [Hb], (2) the influence of inflammation on sFer and (3) the absence of sport, gender and individually specific normative data. A more detailed and longitudinal examination of haematology, menstrual cycle pattern, biochemistry, exercise physiology, environmental factors and training load can offer a superior characterisation of iron status and help to direct appropriate interventions that will avoid iron deficiency or iron overload. Supplementation is often required in iron deficiency; however, nutritional strategies to increase iron intake, rest and descent from altitude can also be effective and will help to prevent future iron deficient episodes. In severe cases or where there is a time-critical need, such as major championships, iron injections may be appropriate.

Factor VII Deficiency: Clinical Phenotype, Genotype and Therapy

Factor VII deficiency is the most common among rare inherited autosomal recessive bleeding disorders, and is a chameleon disease due to the lack of a direct correlation between plasma levels of coagulation Factor VII and bleeding manifestations. Clinical phenotypes range from asymptomatic condition—even in homozygous subjects—to severe life-threatening bleedings (central nervous system, gastrointestinal bleeding). Prediction of bleeding risk is thus based on multiple parameters that challenge disease management. Spontaneous or surgical bleedings require accurate treatment schedules, and patients at high risk of severe hemorrhages may need prophylaxis from childhood onwards. The aim of the current review is to depict an updated summary of clinical phenotype, laboratory diagnosis, and treatment of inherited Factor VII deficiency.

[Diagnostic approach to iron deficiency anemia]

Anemia affects a fourth of the global population, with iron deficiency remaining the primary cause. It is associated with diminished work capacity, fatigue, impaired cognitive function, and can negatively impact the course of diseases like chronic heart failure or chronic kidney disease. Treatment options include oral and intravenous iron; however, conditions such as inflammatory bowel disease, celiac disease, or autoimmune gastritis can diminish the efficacy of oral iron. Timely recognition of iron deficiency anemia and administration of appropriate therapy not only improves quality of life, but also reduces the need for blood transfusions. Proper selection of iron-deficient patients for whom further diagnostic testing is necessary facilitates identification of underlying diseases that require specific treatment, and avoids unnecessary invasive testing.

Women with congenital factor VII deficiency: clinical phenotype and treatment options from two international studies

INTRODUCTION

A paucity of data exists on the incidence, diagnosis and treatment of bleeding in women with inherited factor VII (FVII) deficiency.

AIM

Here we report results of a comprehensive analysis from two international registries of patients with inherited FVII deficiency, depicting the clinical picture of this disorder in women and describing any gender-related differences.

METHODS

A comprehensive analysis of two fully compatible, international registries of patients with inherited FVII deficiency (International Registry of Factor VII deficiency, IRF7; Seven Treatment Evaluation Registry, STER) was performed.

RESULTS

In our cohort (N = 449; 215 male, 234 female), the higher prevalence of mucocutaneous bleeds in females strongly predicted ensuing gynaecological bleeding (hazard ratio = 12.8, 95% CI 1.68-97.6, P = 0.014). Menorrhagia was the most prevalent type of bleeding (46.4% of patients), and was the presentation symptom in 12% of cases. Replacement therapies administered were also analysed. For surgical procedures (n = 50), a receiver operator characteristic analysis showed that the minimal first dose of rFVIIa to avoid postsurgical bleeding during the first 24 hours was 22 μg kg(-1) , and no less than two administrations. Prophylaxis was reported in 25 women with excellent or effective outcomes when performed with a total weekly rFVIIa dose of 90 μg kg(-1) (divided as three doses).

CONCLUSION

Women with FVII deficiency have a bleeding disorder mainly characterized by mucocutaneous bleeds, which predicts an increased risk of ensuing gynaecological bleeding. Systematic replacement therapy or long-term prophylaxis with rFVIIa may reduce the impact of menorrhagia on the reproductive system, iron loss and may avoid unnecessary hysterectomies.

Severe anemia from heavy menstrual bleeding requires heightened attention

OBJECTIVE

The objective of the study was to analyze the behaviors of women that resulted in menstrually related severe anemia (hemoglobin <5 g/dL) from a single public hospital serving indigent women.

STUDY DESIGN

This was a retrospective cohort study of all women identified as having been treated at Harbor-UCLA Medical Center for excessive menstruation (International Classification of Diseases, ninth revision, codes 285.9, 6256.2) and hemoglobin values less than 5 g/dL in the 6 years from 2008 to 2013.

RESULTS

Approvals were obtained from the Human Subjects and Research Committees. This search identified 271 women with those 2 diagnoses; 122 were excluded because their severe anemia had nonmenstrual causes. The remaining 149 women had 168 episodes with hemoglobin levels below 5 g/dL attributed to chronic excessive menstrual bleeding. Mean age was 41 years (range, 19-55 years). Mean body mass index was 28.9 kg/m(2) (range, 18-57 kg/m(2)); 58.2% were actively bleeding at presentation, and 90.4% reported chronic excessive blood loss. Two thirds recognized heavy bleeding that had persisted for more than 6 months without seeking help. However, 7.8% described their bleeding as normal, and 40.5% had received at least 1 previous transfusion. Mean nadir hemoglobin was 4.15 g/dL (range, 1.6-4.9 g/dL). Mean corpuscular volume was 62.2 fL (range, 47.7-99.8 fL) and mean corpuscular hemoglobin concentration was 29.2 g/dL (range, 25.7-33.6 g/dL). Nearly a quarter had reactive thrombocytosis, which might have created a hypercoagulable state. Bleeding was ultimately attributed to leiomyoma in 47.9%; cancer was detected in 4.8%. A total of 33.9% were discharged without being offered any therapy to prevent subsequent bleeding; 3.0% declined any medical therapy; 35.1% were lost to follow-up prior to receiving effective therapy; and 26.8% had multiple subsequent transfusions before seeking/receiving definitive treatments.

CONCLUSION

Even when faced with potentially life-threatening anemia because of chronic, excessive menstrual blood loss, some women are not impressed with the serious nature of their problem. Women will benefit from recognizing the health consequences of chronic excessive blood loss. Chronic excessive blood loss should be treated as both an urgent and potentially recurrent problem; physicians should address this clinical concern proactively.

Comparison of dienogest versus triptorelin acetate in premenopausal women with adenomyosis: a prospective clinical trial

PURPOSE

To compare the efficacy of the oral dienogest versus triptorelin acetate injection for treatment of premenopausal menorrhagia and pelvic pains in women with uterine adenomyosis.

METHODS

A total of 41 patients with adenomyosis suffering from pelvic pains and menorrhagia were recruited. First group was managed with oral dienogest (2 mg/day, orally) while the second group received triptorelin acetate (3.75 mg/4 weeks, subcutaneous injection) for 16 weeks. Outpatient follow-up was undertaken after 8 weeks but mean values were calculated at baseline and after 16 weeks (end of treatment).

RESULTS

A total of 41 women were allocated to treatment with dienogest (n = 22) or triptorelin acetate (n = 19); 19 (86.4 %) and 18 (94.7 %) % of the respective groups completed the trial. Significant reductions in pelvic pains after 16 weeks treatment were obtained in both groups demonstrating the equivalence of dienogest relative to triptorelin acetate. Triptorelin acetate was more effective in controlling of menorrhagia and reduction of uterine volume.

CONCLUSIONS

Dienogest may be a valuable alternative to depot triptorelin acetate for treatment of premenopausal pelvic pains in women with uterine adenomyosis.