Out of the Ordinary: The Overlap of Common and Critical in a Young Female with Anemia

We present a case of iron deficiency anemia in a premenopausal woman. The combination of her premenopausal status and self-reported menorrhagia could have led clinicians toward anchoring bias, potentially overlooking alternative etiologies. The proportion of colorectal cancer cases has increased from 11% in 1995 to 20% in 2019 among patients younger than 55 years of age (Ref. 1), underscoring the importance of investigating gastrointestinal malignancy as a potential cause of iron deficiency anemia (IDA) in younger patients. Specifically, premenopausal women present a unique diagnostic challenge because menorrhagia is often assumed to be the source of IDA. IDA in young women is frequently considered normal (Ref. 2) and ma not immediately trigger concern for alternative diagnoses. There have been studies exploring the relationship between IDA and gastrointestinal lesions. GI evaluation may be warranted in premenopausal IDA, beginning first with upper endoscopy. There is agreement that postmenopausal females deserve GI workup in the presence of iron deficiency anemia. Workup for premenopausal women with IDA remains controversial. Current American Gastroenterological Association (AGA) guidelines recommend bidirectional endoscopy rather than empiric iron therapy alone for premenopausal patients presenting with iron deficiency anemia, but leaves room for individualization, especially with progressively younger age. The workup should also consider evaluation for helicobacter pylori and celiac disease. If the initial workup including bidirectional endoscopy does not find a source of bleeding, the AGA recommends iron supplementation and watchful waiting before pursuing investigation of rare small bowel disease bleeding sources. This case underscores the necessity of considering alternative and serious causes of anemia, including gastrointestinal malignancy, in premenopausal women with additional risk factors.