Abstract
Background:
Heavy menstrual bleeding (HMB) is a common cause for iron deficiency amongst menstruating patients, yet it is often not discussed as a potential cause of iron deficiency by both patients and providers. This objective of this study is to evaluate documentation and workup of heavy menstrual bleeding in patients with known iron deficiency.
Methods:
This was a retrospective chart review of female patients (age, 18-50 years) with a ferritin value of less than 50 μg/L between February 1, 2024, and May 1, 2024 and visited a primary care clinic in our academic medical center. The visit was evaluated for documented discussion of menstruation and additional laboratory or imaging workup within a month of ferritin lab result.
Results:
Among 383 participants, the mean age (SD) was 36.3 (8.6) years, mean BMI was 28.7 (8.7). Our population comprised of 63% non-Hispanic white (NHW), 11% Hispanic, 9% Black, 14% Asian, 3% Native Hawaiian/Pacific Islander. Discussion of menstruation was documented in 46% of NHW participants versus 59% of non-white patients (P = .015). There was no significant difference in workup ordered. Male providers documented menstruation discussions in 42% of cases. Female providers documented it in 55% (P = .014).
Conclusions:
Non-white patients were more likely to be asked about HMB than NHW patients. Only about half of patients are asked about menstruation at the time of diagnosis for iron deficiency. Male providers are significantly less likely to ask about menstruation than female providers. The findings of this study highlight the infrequency of thorough discussion of menses in patients with ID, as this may improve diagnostic clarity, guide further workup, and thus reduce costs for unnecessary tests.
Introduction
Iron deficiency (ID), the most common nutrient deficiency, affects nearly 1 in 3 women in the United States and is associated with fatigue, headaches, and decreased exercise tolerance.1,2 Heavy menstrual bleeding (HMB) is a common cause of ID and is observed more frequently in lower income populations and minoritized groups, often leading to fatigue, headache, and decreased exercise tolerance. The objective of this study is to determine prevalence of heavy menstrual bleeding evaluation in the form of history taking and ordering of tests for menstruating individuals between the ages of 18 to 50 diagnosed with iron deficiency (defined as having ferritin less than 50 µg/L) in white versus not white racial groups in the primary care setting.
Methods
We performed a retrospective cohort study of female patients (age, 18-50 years) with a measured ferritin value of less than 50 μg/L, the lower limit of normal,3,4 between February 1 and August 1, 2024, who visited a primary care provider, either in Internal Medicine or Family Medicine, in our academic center within 6 months of the result. Participants were excluded if no race was documented. We collected age, self-reported race and ethnicity, and ferritin values. We reviewed the medical record for documented discussion of menstruation, including details of their menstrual cycle such if they used 2 different types of menstrual products (pads, tampons, and diva cups) simultaneously and how frequent they changed these products, and additional laboratory, imaging, and procedural evaluations for ID and/or HMB. We reviewed referrals to gynecology and/or hematology as well as orders placed for intravenous iron therapy. Chi-squared tests were used to analyze differences in evaluation between non-Hispanic white (NHW) and non-white and/or Hispanic patients. P < .05 was considered statistically significant. The Institutional Review Board approved the study (STUDY00027854) as a minimal risk research study.
Results
Among 383 participants, the mean age (SD) was 36.3 (8.6) years, mean BMI was 28.7 (8.7), 28% were ages 18 to 29, 29% were ages 30 to 39, and 43% were ages 40 to 50 (Table 1). Our population comprised of 63% NHW, 11% Hispanic, 9% Black, 14% Asian, 3% Native Hawaiian/Pacific Islander. Discussion of menstruation was documented in 46% of NHW participants versus 59% of non-white patients (P = .015; Table 2). There was no significant difference in workup ordered, referrals to gynecology and hematology, and number of IV iron orders placed. Most common additional workup ordered was CBC (76%) and iron panel (29%), Pelvic ultrasounds were ordered in 21% of patients with additional workup, and EGD and/or colonoscopies were ordered 22%. Discussion of menstruation was documented in 49% of participants aged 18 to 29 versus 50% aged 30 to 39, and 52% aged 40 to 50, and additional workup was ordered in 47% versus 47%, and 51% . Male providers documented menstruation discussions in 42% of cases. Female providers documented it in 55% (P = .014). Compared to 44% of patients with normal BMI range 18.6 to 24.9, menstruation was documented in 64% of participants with BMI <18.5 (P = .149) versus 60% BMI 25 to 29.9 (P = .022) versus 41% BMI 30 to 39.9 (P = .674) versus 67% BMI >40 (P = .012; Table 3).
Patient Demographics.
Documented History, Testing, and Referrals in Patients with ID based on Race.
Discussion of Menstruation based on Age and BMI.
Statistically significant relative to BMI 18.6 to 24.9.
Statistically significant.
Discussion
Only about half of patients are asked about menstruation at the time of diagnosis for iron deficiency, and fewer are asked about duration, frequency, or other details. Male primary care providers are significantly less likely to ask about menstruation than female providers, which may be due to discomfort or unfamiliarity with menstruation relative to female providers. Though reassuringly there was no statistical difference in additional workup and treatment for iron deficiency, discussion of menstruation may prompt a change management such as referrals to gynecology or pelvic ultrasounds. This may also allow for prevention of recurrence for iron deficiency. Though NHW women were significantly less likely to be asked about menstruation than non-white women, it is possible that iron deficiency was misattributed to menstruation in NHW with limited additional evaluation, as only a quarter of patients received a pelvic ultrasound. Patients with BMI in the normal range similarly were asked less about HMB than patients with BMI between 25 to 29.9 and greater than 40, where there may have been misattribution of irregular menstruation due to weight.
A limitation of this study is that it focuses on documentation of menstruation, which may not encompass the overall discussion a provider may have had with the patient. Another limitation is that the study population disproportionately has a higher number of white participants than the general population, and the study may not stratify to the general population, and the participants were limited to a single institution.
The findings of this study highlight the infrequency of thorough discussion of menses in patients with ID, as this may improve diagnostic clarity and guide further workup. The most common cause of iron deficiency in Western countries is bleeding, 2 so it is appropriate to assess for HMB in menstruating patients prior to doing further invasive measures such as endoscopies. Proper assessment could additionally reduce costs for these invasive measures. Assessing HMB can be challenging, and using a HMB questionnaire during annual wellness visits and in patients with known iron deficiency may prompt additional investigation5-7 and guide referrals to gynecology and hematology.
Footnotes
Acknowledgements
None.
Ethical Considerations
Oregon Health and Science University Institutional Review Board approved the study (STUDY00027854) as a minimal risk research study.
Consent to Participate
The requirement for informed consent was waived by the Institutional Review Board because it was declared as a minimal risk study.
Author Contributions
Dr. Nidhi Patel was responsible for the conception, methodology, investigation, data curation and analysis, writing the original draft, and reviewing and editing the manuscript. Dr. Bethany Samuelson Bannow was responsible for supervision and reviewing and editing the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data cannot be shared openly to protect study participants and are available on reasonable request from the corresponding author*.