The importance of Iron Physiologyance

The role of iron in humans is critical and multifaceted to an extent that is often unappreciated by healthcare practitioners, including gynecologists and gynecologic surgeons. Whereas iron is important for the construct of hemoglobin needed for oxygen transport, it is also a trace mineral essential for mitochondrial energy metabolism as well enzymatic processes in many tissue sites such as the immune system,  myocardial and skeletal muscle, and the nervous system where it is involved in the production of neurotransmitters (19). While iron metabolism is tightly regulated by the body, there is no mechanism for active iron excretion. Consequently, ID most commonly occurs either via insufficient iron intake because of diet or poor iron absorption; or iron loss in excess of nutritional intake secondary to clinical problems such as heavy menstrual bleeding (HMB) or chronic gastrointestinal blood loss.

When ID occurs, an initial physiological response is mobilization of its stored form, ferritin, located predominantly in the liver.  As the ID worsens, iron also is taken from iron‐enzymes and iron‐proteins to maintain erythropoiesis(24). Consequently, this diversion of the body’s iron resources to the maintenance of heme comes at the expense those body functions dependent on iron, well before the appearance of anemia. As a result, it is important to understand that IDA the final stage, not the initial manifestation of ID(19). In fact, ID without IDA is associated with a multitude of symptoms that affect both mental and physical health (25)(26, 27). Treatment of ID in non-anemic women has been shown to improve both skeletal muscle function and physical function (28). Our current understanding of the prevalence of ID and IDA in the female population is largely obtained by studies of adolescent girls and women presenting for blood donation. The US based CHILL study of adolescent girls presenting for blood donation demonstrated a prevalence of absent iron stores of 18% (<12 ng/mL) and iron deficiency of 50% (here defined as <26 ng/mL), approximately twice that of adult women(37). These data are similar to those reported from the REDS study in the US(38), Canada(39) and Australia, (40).

Against this background, women with leiomyomas frequently have the symptom of HMB, a circumstance that amplifies the manifestations of ID, while placing them at increased risk should surgical intervention be required. Available evidence suggests that the global risks of morbidity and mortality are substantially increased when women undergo major surgery when anemic (<11 g/dL), an outcome that doesn’t appear to be mitigated by blood transfusion. Furthermore, the costs and other morbidity associated with blood transfusion demand a different approach to restoration of iron stores in women being scheduled for surgery; one that includes appropriate iron administration combined with reduction or elimination of HMB. 

Evaluation for ID and IDAance