Break the cycle: Making iron deficiency screening standard for women

Brought to you by CSL ViforAs an OB/GYN, Dr. Ally Murji sees all too often how treatable conditions in women can be normalized or underprioritized, leading to negative outcomes not just for female patients, but across generations. One such example? Iron deficiency anemia (IDA). “It's essentially a cycle that starts when women start first having their period,” says Dr. Murji, Professor & Division Head of Minimally Invasive Gynecologic Surgery at University of Toronto and Program Chief & Medical Director of Women's & Children's Health at Trillium Health Partners. Dr. Murji explains young women frequently develop iron deficiency (ID) or IDA, often through heavy periods where their body loses more iron than they consume. This can be compounded when women become pregnant, as the body needs more iron to support both mother and fetus. “When moms are iron deficient, their neonates end up being iron deficient when they're born, and that perpetuates this whole cycle,” he shares. IDA’s widespread impact before, during and after pregnancyLeft untreated, IDA comes with a slew of health risks, from impacted cognition, increased heart rate and difficulty sleeping, to increased risk of pregnancy complications, including abnormal fetal development. Possible complications during and after pregnancy make IDA an issue not only for individual women’s health, but an intergenerational concern.In fact, the International Federation of Gynecology and Obstetrics (FIGO), where Dr. Murji is the Chair of the Committee on Menstrual Disorders & Related Health Impacts, states anemia impacts more than 2 billion people worldwide, predominantly women and children, but is often underrecognized and undertreated.1Effects on surgery and pregnancyFIGO recommends women undergoing major gynecologic surgery be screened for anemia preoperatively. Dr. Murji explains “We know anemia, particularly iron deficiency anemia, has increased risks. You have to correct the anemia prior to surgery.”Pregnancy is one common cause of IDA, but another is heavy menstrual bleeding (HMB), a widely normalized issue impacting women at staggering rates. Dr. Murji notes, “Almost 50% of women will have heavy menstrual bleeding in their reproductive lives, and then 50% of them at least will have iron deficiency or iron deficiency anemia. When these women get pregnant, the situation is exacerbated, and this leads to adverse pregnancy outcomes.”An astounding 90% of patients are iron deficient in pregnancy2, which puts them at risk for numerous complications from placental abruption, pre-eclampsia and eclampsia, preterm labour, low birth weight, postpartum hemorrhage, and increased maternal, perinatal, and neonatal morbidity and mortality.3IDA in pregnancy can also impact children’s neurodevelopment. Dr. Murji shares, “There is really good data on abnormal neurodevelopmental sequelae of iron deficiency,” citing one cohort study of 532,232 nonadoptive Swedish children of 299,768 mothers, where anemia diagnosed during the first 30 weeks of pregnancy was associated with increased risk of diagnosis of Autism Spectrum Disorder, ADHD, and ID in offspring.4Support across the spectrum of careIdentifying IDA in patients is the first step to addressing it. Dr. Murji notes healthcare providers across the care spectrum should screen and treat IDA. “Providers, and doesn't matter what kind of providers, should be thinking about it, screening for it, evaluating it and treating it,” he says.He continues, “We should be focusing on iron status in patients who want to get pregnant. There should be screening in pregnancy, there should be screening postpartum. A lot of these patients will go into pregnancy with lower iron status, and pregnancy will make it worse. Screening on a population level can allow us to intervene so we can break the cycle.”An iron equilibriumTo help patients get back to healthy iron levels, achieving an equilibrium of iron intake is critical, since absorbing iron through diet is extremely challenging. Dr. Murji explains, “The amount of iron you actually take in is very little. So, even if you have a huge steak of 20 grams of iron, you are only going to absorb 1-2 grams of iron.”In pregnancy, the amount of iron needed by the body increases due to an increase in red blood cell production and resulting expansion in plasma volume and red cell mass.5 In Canada, there are now more treatment options than before, with more IV iron options coming into market. The FIGO guidelines on ID and anemia in women and girls states "intravenous (IV) iron should be considered, particularly since it has now been shown that, compared to oral iron, IV is more likely to result in normalised neonatal [iron stores]",6 and a paper co-authored by Dr. Murji observes parenteral iron achieves target hemoglobin with few adverse effects, and should be considered after the first trimester for patients with intolerance to oral therapy.7Dr. Murji notes treatment, starting with screening, should be the responsibility of all care providers. “Iron deficiency anemia touches primary practice, OB/GYN, gastroenterology, hematology, and more. When there's a condition that touches various specialists, especially when it comes to IV iron, who should be prescribing it? It's really everybody's responsibility.”

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