Iron deficiency and iron deficiency anaemia in women

doi:10.1016/j.bpobgyn.2016.09.007

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 40, April 2017, Pages 55-67

https://doi.org/10.1016/j.bpobgyn.2016.09.007 Get rights and content

Highlights

•
Iron deficiency (ID) is the most common micronutrient deficiency worldwide with >20% of women experiencing it during their reproductive lives.
•
Oral preparations vary in their iron content and can result in gastrointestinal side effects. Parenteral iron is indicated when there are compliance/tolerance issues with oral iron, comorbidities, which may affect absorption or ongoing iron losses that exceed absorptive capacity.
•
As gynaecologists, we focus on managing women's heavy menstrual bleeding (HMB) and assume that primary care clinicians are treating the associated ID/IDA. We now need to take the lead in diagnosing, managing and initiating treatment for ID/IDA and treating HMB simultaneously.
•
In this study, we will summarise the importance of iron in cellular functioning, describe how to diagnose ID/IDA and help clinicians choose between the available treatment options.

Iron deficiency (ID) is the most common micronutrient deficiency worldwide with >20% of women experiencing it during their reproductive lives. Hepcidin, a peptide hormone mostly produced by the liver, controls the absorption and regulation of iron. Understanding iron metabolism is pivotal in the successful management of ID and iron deficiency anaemia (IDA) using oral preparations, parenteral iron or blood transfusion.

Oral preparations vary in their iron content and can result in gastrointestinal side effects. Parenteral iron is indicated when there are compliance/tolerance issues with oral iron, comorbidities which may affect absorption or ongoing iron losses that exceed absorptive capacity. It may also be the preferred option when rapid iron repletion is required to prevent physiological decompensation or given preoperatively for non-deferrable surgery.

As gynaecologists, we focus on managing women's heavy menstrual bleeding (HMB) and assume that primary care clinicians are treating the associated ID/IDA. We now need to take the lead in diagnosing, managing and initiating treatment for ID/IDA and treating HMB simultaneously. This dual management will significantly improve their quality of life.

In this chapter we will summarise the importance of iron in cellular functioning, describe how to diagnose ID/IDA and help clinicians choose between the available treatment options.

Introduction

Iron deficiency (ID) is the commonest micronutrient deficiency worldwide and is defined as a reduction of total body iron ∗[1], ∗[2] As a result, there may be impairment of oxygen transportation and enzyme reactions involved in nearly all major metabolic pathways. ID may occur with or without anaemia defined as a decreased quantity of erythrocytes or level of haemoglobin associated with morphological changes in erythrocytes ∗[3], ∗[4]. Anaemia has been wrongly considered as an indicator of ID. However, it is only with progressive iron depletion and its associated functional impairment that anaemia finally develops [5]. Furthermore, haemoglobin concentration has a low sensitivity and specificity for ID [6].

Iron-restricted erythropoiesis and functional ID occur in those with chronic inflammation, cancer or renal disease. This is because inflammatory processes impair the delivery of iron to red cell precursors, irrespective of iron stores, with mobilisation of iron from stores insufficient to meet metabolic demands. This can also be observed following treatment with erythropoiesis-stimulating agents [1].

Section snippets

Incidence and prevalence of ID/IDA

Anaemia is a global health problem affecting both low- and high-income countries with social and economic consequences for all [7]. Anaemia impairs the health and well-being of women and increases the risk of adverse maternal and neonatal outcomes [8]. Worldwide anaemia accounted for 68.4 million years of life lived with a disability in 2010, an increase from 65.5 million years of life in 1990 [3]. However, during this time frame, the prevalence of anaemia decreased from 40.2% to 32.9% [3]. The

Iron metabolism and its role in the body's physiological processes

Iron is crucial for cellular functions including respiration, oxygen transport, DNA synthesis, energy production and cell proliferation [1]. It mediates electron transfer with iron acting as an electron donor in the ferrous state and an acceptor in the ferric state. However, excess iron is toxic. To ensure iron requirements are met but toxicity is prevented, a tightly regulated homeostatic system operates to maintain levels within normal ranges. The controller of this system is the peptide

Clinical presentation

ID/IDA are chronic conditions that may be asymptomatic. Symptoms can include weakness, fatigue, irritability, hair loss, poor concentration and poor work performance, resulting from reduced enzyme activity and oxygen delivery to tissues [1]. Many of these symptoms are also associated with HMB [13].

There is a higher prevalence of constant tiredness in young and middle-aged women with ID (67% and 63%, respectively) compared with those without ID (45% and 48%, respectively) [14]. In a recent

Aetiology of ID/IDA

RDI of iron for women of reproductive age is 18 mg, although the median is 12 mg to combat loss due to menstruation. ID/IDA occurs when loss or requirements exceed absorption. The causes of ID/IDA are often multifactorial [12]. In general, there are four broad causative categories: increased loss of iron, decreased intake of iron in the diet, decreased absorption of iron from the gut and an increased iron requirement [15] (see Table 2). Blood loss is an important cause of ID/IDA, as there is

Diagnosis, assessment and investigation of ID and IDA

The WHO defines anaemia as a haemoglobin concentration of <130 g/L in men, 120 g/L in non-pregnant women and 110 g/L in pregnant women [10] (see Table 3). Pavord et al. (2012) recommended that in pregnancy, anaemia is diagnosed when haemoglobin is <110 g/L in the first trimester, <105 g/L in the second and third trimesters and <100 g/L during the postpartum period [2] (Table 3).

As the normal range for haemoglobin varies in different populations, a pragmatic approach is to define anaemia as a

Management of ID/IDA

The presence ID/IDA requires further investigation in all individuals to ensure that pathology is not missed. A comprehensive history should be taken and additional investigations ordered, depending on the key findings [17]. It is recommended that urinalysis is also undertaken for all patients diagnosed with ID as 1% of these patients will have an underlying renal tract malignancy [17].

Simply increasing dietary iron intake is insufficient to treat IDA. Replacement therapy is intended to correct

Conclusion

Iron plays a pivotal role in the metabolic pathways of the body. Worldwide ID and IDA are highly prevalent with the increased iron need associated with normal menstrual loss largely unmet. Women with HMB are at a higher risk of ID and IDA; therefore, we need to carefully evaluate and investigate our patients for the possibility of these conditions and where appropriate commence iron therapy. Furthermore, it is important that both the underlying cause and anaemia are managed effectively. Simply

Disclosure of interest

Dr Percy has received financial support to undertake training from Bayer.

Dr Mansour has received financial support to attend pharmaceutical advisory board meetings, undertake research studies and speak in educational meetings and conferences together with travel grants from Aspen, Astellas, Bayer, Consilient Healthcare, HRA Pharma, Mithra, Merck, Pfizer and Vifor Pharma.

Professor Fraser has received financial support to attend pharmaceutical advisory board meetings, undertake research studies

Author contribution

Laura Percy conducted the research and wrote the first draft. Diana Mansour revised the initial plan and edited the article. Ian Fraser instigated the article, wrote the initial plan and undertook the final edit. All authors have approved the final version.

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4Iron deficiency and iron deficiency anaemia in women

Highlights

Introduction

Section snippets

Incidence and prevalence of ID/IDA

Iron metabolism and its role in the body's physiological processes

Clinical presentation

Aetiology of ID/IDA

Diagnosis, assessment and investigation of ID and IDA

Management of ID/IDA

Conclusion

Disclosure of interest

Author contribution

Blood

Lancet

Value Health

Am J Med

Int J Gynaecol Obstet

Int J Gynaecol Obstet

Blood

Best Prac Res Clin Obstet Gynaecol

Iron-deficiency anemia

New Eng J Med

UK guidelines on the management of iron deficiency in pregnancy

Br J Haematol

Diagnosis and management of iron deficiency anaemia in the 21st century