Rethinking Iron Treatment for Women With Heavy Menstrual Bleeding

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A new study published in Blood Advances suggests that starting IV iron earlier may be a cost-effective and quality-of-life-improving option for women with heavy menstrual bleeding and iron deficiency anemia (IDA).

IDA affects nearly one in three women worldwide, and heavy menstrual bleeding is one of the most common reasons women of reproductive age develop it. IDA can cause fatigue, brain fog, shortness of breath and reduced quality of life, yet many patients face long delays before receiving effective treatment.

Even though oral iron pills are typically used first, they often cause stomach upset, constipation or nausea, and many women struggle to take them consistently or absorb enough iron to feel better.

“Oral iron is usually given as first-line treatment because on the surface, it appears less expensive and more convenient,” said lead investigator Daniel Wang, a fourth-year medical student at Yale School of Medicine and recipient of the American Society of Hematology Medical Student Physician-Scientist Award. “However, we found that the preferred first-line treatment for these patients is IV iron, as it delivers the highest value for cost and substantially improves quality of life.”

In this study, investigators looked beyond short-term symptom relief to ask a critical question: Which iron treatment makes the most sense over a woman’s entire reproductive lifespan, both for health outcomes and cost?

Using a long-term economic model that followed women from age 18 to 51, the team compared first-line oral iron (alternate-day doses of 325 milligrams oral ferrous sulfate) with three IV iron options: dextran (one-time dose of 1,000 milligrams), ferumoxytol (two doses of 510 milligrams) or sucrose (five doses of 200 milligrams). They measured not just total costs, but quality-adjusted life years (QALYs), a standard way to capture both length and quality of life.

The results showed that starting treatment with IV iron dextran was the most cost-effective strategy, even though it costs more up front. Women receiving IV iron dextran gained more QALYs than those starting on oral iron (19.26 versus 19.10 QALYs, respectively), reflecting better symptom control and fewer ongoing health burdens.

The additional cost worked out to about $28,600 per QALY gained, which falls well within commonly accepted thresholds for cost-effective medical care in the U.S. Importantly, other IV iron options were more expensive without providing additional benefit, making IV iron dextran the clear value leader among IV therapies.

In addition, IV iron dextran provided an additional net monetary benefit of $11,500 compared with oral ferrous sulfate, meaning it delivered greater health gains for the cost. IV iron dextran also remained the most cost-effective option even in women with moderate to very heavy menstrual blood loss (240 milliliters to 420 milliliters per month).

Investigators noted several limitations. It assumed that women experienced the same level of menstrual blood loss throughout their reproductive years. In addition, while multiple iron treatments were evaluated, the analysis did not include other single-dose IV iron formulations, such as ferric derisomaltose or ferric carboxymaltose, and it did not account for patients switching between different iron therapies over time.

For patients, the findings show that the cheapest option at the pharmacy counter isn’t always the most affordable choice in the long run. Delays, side effects, poor absorption and repeated treatment failures with oral iron can add up, both financially and physically.

The findings suggest that earlier access to IV iron, especially for women with heavy menstrual bleeding, could reduce years of ongoing symptoms, missed work and repeat health care visits while still being a smart use of health care dollars.

“One study at a time, we hope to decrease insurance barriers and enhance decision-making and quality of life across the spectrum of a woman’s reproductive life,” said study investigator George Goshua, M.D., M.Sc., FACP, assistant professor of medicine in the section of medical oncology and hematology at Yale School of Medicine and Yale Cancer Center. “This is a prevalent global issue, and we hope that others around the world can take this model, adapt it to their contexts and continue building upon it.”