Iron Deficiency and Fatigue in Adolescent Females with Heavy Menstrual Bleeding,
Authors: Wang Wenting , Bourgeois Tran , Klima Jennifer , Berlan Elise D. , Fischer Anastasia N. , O'Brien Sarah H. 
Published: October 2019

Abstract
Abstract 4215

Introduction
Adolescent females are one of two pediatric populations at greatest risk for iron deficiency. An important risk factor for iron deficiency in adolescent females is excessive menstrual blood loss. Due in part to changes in circadian rhythms and poor sleep hygiene, fatigue is also a pervasive problem in adolescence, and may be exacerbated by iron deficiency secondary to menorrhagia. Clinical trials have shown that non-anemic adult women with low serum ferritin (≤15„30 ng/ml) and unexplained fatigue demonstrate improvement in fatigue with iron supplementation. Similar studies have not been performed in women <18 years of age. Our primary objective was to define baseline ferritin values and fatigue symptoms in a population of young females with a history of heavy menstrual bleeding.

Methods
The study population included 11,Ÿ17 year old females presenting to an Adolescent Gynecology Clinic or Menorrhagia Clinic for initial evaluation or follow-up of heavy menstrual bleeding. To mirror our clinical practice, the study population included patients who did and did not take iron supplements, as well as those who did and did not use hormonal contraception. To evaluate the degree and effects of menstrual blood loss, we utilized the Ruta Menorraghia Scale (RMS), a subjective measurement of menstrual blood loss and health-related quality of life. Possible responses to each multiple choice question were assigned ordinal scores to produce a total menorrhagia severity score (MSS). We investigated symptoms of fatigue using the Fatigue Severity Scale (FSS), a Likert scale measurement of fatigue's effects, symptoms, and severity (possible responses range from 1 to 7). Hemoglobin and ferritin levels were obtained by venipuncture after the completion of survey instruments. A control population of 12,Ÿ17 year old menstruating females was recruited from a Sports Medicine clinic. These patients completed the RMS and FSS instruments but did not undergo venipuncture. We compared FSS and MSS between the two populations using the Kruskal Wallis test. We evaluated possible predictors of ferritin level (age, body mass index, fatigue scores, and MSS) using generalized linear models.

Results
A total of 31 adolescents diagnosed with heavy menstrual bleeding and 37 healthy adolescents completed the study. Mean MSS was 39.3 (±17.4) in those with a history of heavy menstrual bleeding, compared to 17.9 (±10.0) in controls (p<.0001). When completing the menorrhagia scale, over two-thirds (71%) of adolescents with heavy menstrual bleeding reported that menses mildly to moderately affected their ability to participate in physical education class or sports, compared to 27% of controls. Thirteen (41.9%) of those with heavy bleeding reported missing at least one day of school with each menses, compared to 8.1% of controls. Mean fatigue score was 4.2 (±1.5) in patients with heavy menstrual bleeding, similar to values reported in adults with sleep-wake disorders. In contrast, the mean fatigue score was 2.98 (±1.1, p=.001) in the control population, similar to values reported in normal healthy adults. Twenty-five of 31 (80.6%) adolescents with heavy menstrual bleeding had ferritin levels ≤30 ng/ml, and ten (32.2%) had ferritin levels ≤15 ng/ml. Our generalized linear models did not identify any significant univariate relationships between ferritin levels and patient age, body mass index, fatigue score, or menorrhagia score. This finding may be due to our small sample size, or the narrow range of ferritin levels in our study population (87% had a ferritin level <40 ng/ml).

Discussion
Iron deficiency and symptoms of fatigue were common findings in a small population of young women with heavy menstrual bleeding. Fatigue severity scores were significantly higher in our study population as compared to healthy controls. Larger studies are needed to delineate the relationship between menstrual blood loss, fatigue, and ferritin values in adolescents, in order to plan for future intervention trials of iron supplementation. We also identified a high frequency of physical activity limitations and school absence in young women with heavy menstrual bleeding, highlighting the importance of including these types of patient-reported outcomes in the design of clinical trials for this patient population.

Disclosures:
No relevant conflicts of interest to declare.