Anemia Case Study

Ms. A. presents with increased dyspnea, decreased energy, as well as an episode of lightheadedness while on the golf course today. Past medical history is positive for menorrhagia and dysmenorrhea for the last 10-12 years. She takes aspirin 1,000 mg every 3-4 hours during her menstrual cycles. She also takes additional aspirin when playing golf due to arthritis. Vital signs reveal tachycardia and tachypnea as well as hypotension and patient reports significant migraines. Laboratory findings show anemia with a red blood cell count of 3.1 x 10/mm, hemoglobin of 8 g/dL, hematocrit 32%, RBC smear shows microcytosis and hypochromic cells. Ms. A’s most likely diagnosis is iron deficiency anemia secondary to menstrual blood loss.

Anemia is defined as a decreased number of red blood cells. Red blood cells (RBCs) normally function in the exchange of oxygen and carbon dioxide. The RBCs bring oxygen from the lungs to the tissues in exchange for carbon dioxide (Maakaron, 2018). 

Iron deficiency anemia is the most common cause of anemia in the world. The most common cause of iron deficiency anemia is a substantial loss of blood. In a menstruating female, menstrual bleeding is the most common cause (Schrier & Auerbach, 2018). Ms. A. presents with menorrhagia which is defined as heavy or prolonged menstrual bleeding (Kaunitz, 2018). In female patients post-menopausal or male patients, gastrointestinal bleeding is the most common (Schrier & Auerbach, 2018). Due to the result of bleeding, iron levels decrease. This stimulates the bone marrow to start producing increased hemoglobin. With prolonged blood loss, hemoglobin levels become depleted. The bone marrow can no longer produce enough hemoglobin and thus produces immature red blood cells, resulting in small and pale RBCs (Harper, 2018). This is seen in Ms. A.’s blood work with microcytic hypochromic red blood cells. Ms. A. has a long history of menorrhagia however her significant aspirin use is also contributing to her bleeding especially given her recent golfing as she reports she takes more aspirin due to arthritis when golfing.

Symptoms of anemia are secondary to the decrease in RBCs resulting in decreased oxygen delivery. The severity of the anemia determines when symptoms occur and to what severity. Initially, with mild anemia, the body is able to compensate however with progressive anemia, symptoms develop including shortness of breath, fatigue, weakness, and dizziness (Maakaron, 2018). In acute blood loss, there is a decrease in intravascular volume which results in hypotension. This triggers the sympathetic nervous system resulting in tachycardia. The decrease in oxygen-carrying capacity also results in tachypnea. On physical exam, the presence of pallor of the skin and mucous membranes may be present depending on the severity of the anemia (Harper, 2018). Ms. A. had a recent episode of lightheadedness while on the golf course which is likely secondary to her anemia as well as low blood pressures. 

Diagnosis is made with laboratory findings in a combination of history and physical exams. A complete blood count (CBC) will show decreased RBCs, hemoglobin, and hematocrit as well as microcytic hypochromic cells on peripheral smear. Iron panels will reveal low iron level and low ferritin (storage form of iron) levels. Reticulocyte level will be low due to decreased iron levels and the inability of the bone marrow to produce RBCs. (Harper, 2018).   

The treatment of iron deficiency anemia involves treating the cause of the anemia as well as iron supplementation in the form of oral ferrous sulfate. Blood transfusions are not often done unless the anemia is severe (Harper, 2018). Given Ms. A’s significant menorrhagia, she should be referred to her gynecologist for treatment of the cause of her bleeding. In patients of menorrhagia, different medications can be used to decrease dysmenorrhea as well as menorrhagia such as oral contraceptives (Kaunitz, 2018). Her aspirin should also be stopped to decrease her bleeding risk. She should use Tylenol for discomfort as this does not increase bleeding risk. Given her young age and gradually progressive symptoms, it is unlikely that she needs a blood transfusion as dietary changes such as following the DASH diet can help.. 

Iron deficiency anemia is the most common anemia in the world. In menstruating females, menstrual blood loss is the most common cause. Given Ms. A’s long history of menorrhagia as well as aspirin use and worsening of symptoms around her menstrual periods, care should be taken to not only treat her anemia but also the cause of her anemia.

References

Harper, J. L. (2018). Iron deficiency anemia. Emedicine. Retrieved from https://emedicine.medscape.com/article/202333-overview

Kaunitz, A. M. (2018). Patient education: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics). Up to Date. Retrieved from https://www.uptodate.com/contents/heavy-or-prolonged-menstrual-bleeding-menorrhagia-beyond-the-basics

Maakaron, J. E. (2018). Anemia. Emedicine. Retrieved from https://emedicine.medscape.com/article/198475-overview

Schrier, S. L. & Auerbach, M. (2018). Causes and diagnosis of iron deficiency and iron deficiency anemia in adults. Up to Date. Retrieved from https://www.uptodate.com/contents/causes-and-diagnosis-of-iron-deficiency-and-iron-deficiency-anemia-in-adults