Updating the diagnosis and management of iron deficiency in the era of routine ferritin testing of blood donors by Australian Red Cross Lifeblood

To the Editor: We write regarding the recent article by Zhang and colleagues.1 We note that the Australian Red Cross Lifeblood's new practice and the accompanying guidance have the potential to improve the diagnosis and treatment of iron deficiency and iron deficiency anaemia. However, given that one in four women experience heavy menstrual bleeding, and half of these women will develop iron deficiency,1,2 we have concerns that the specific management of this group is absent from the article.

The article asserts that gastrointestinal blood loss accounts for most cases of iron deficiency; however, menstrual blood loss is the most common cause of iron deficiency in premenopausal women.2 The recommendation of routine bidirectional endoscopic examination for all adults with iron deficiency will lead to the over‐investigation of premenopausal women who have low risk of gastrointestinal pathology.3 The article acknowledges the contribution of menstrual blood loss to iron deficiency. However, without specifically addressing the assessment of heavy menstrual bleeding, and simple medical management options when appropriate, the recommendations may lead to inappropriate gastrointestinal investigation.

Assessment should include a thorough menstrual history and, when heavy menstrual bleeding is present, the International Federation of Gynecology and Obstetrics (FIGO) classification system should be used to systematically consider underlying causes.4 Management may include non‐hormonal options such as tranexamic acid and non‐steroidal anti‐inflammatory drugs (NSAIDs). Hormonal options include the 52 mg levonorgestrel‐releasing intrauterine device, currently the most effective hormonal therapy for heavy menstrual bleeding.5

Primary care providers are perfectly positioned to undertake this assessment and management, usually without referral to specialists — gynaecologists or gastroenterologists — for more invasive testing or treatment. Incorporation of this approach into the recommendations will result in less costly, less invasive and more effective care for many blood donors.

The Australian Commission on Safety and Quality in Health Care has released the revised Heavy menstrual bleeding clinical care standard (2024),6 which guides clinicians and health care services providing care for women with heavy menstrual bleeding. Supporting resources are also available, including a consumer fact sheet with information on potential treatment options.7