Where does anemia in women come from?

Mrs. Patrycja, a 37-year-old manager working for a corporation in Warsaw and a mother of two children, has been struggling with chronic fatigue, paleness, and heavy menstrual periods lasting up to 8-9 days for about 3 years since the birth of her last child. Initially, she did not seek medical attention for these symptoms, attributing everything to overwork. Later, for 2 years, she supplemented iron (her hemoglobin level had dropped to 9.5 g/dl), going to various doctors without success. It was only one of the gynecologists specializing in endometriosis who—after performing a transvaginal ultrasound—referred Mrs. Patrycja to a phlebologist at the Phlebology Clinic.

A phlebological consultation, including a full ultrasound evaluation with Doppler venous ultrasound, revealed pelvic venous insufficiency, which was later confirmed to be the main cause of her prolonged and heavy periods and the secondary anemia resulting from them.

This example is not isolated. According to the latest epidemiological data, iron deficiency anemia affects up to 30% of women of childbearing age in Poland, and heavy menstrual periods occur in 20-30% of women of reproductive age. Many of these patients suffer from pelvic venous insufficiency without even knowing it

What is pelvic venous insufficiency and why is its early diagnosis so important in the context of potential anemia?

Pelvic venous insufficiency is one of the more common gynecological diseases in women who have given birth. It occurs much more frequently in the population of women who have given birth than endometriosis. This condition is characterized by abnormal blood flow in the veins of the abdominal cavity (most often the ovarian veins) and the pelvic organs.

The main causes of pelvic venous insufficiency include:

– unfavourable anatomical conditions in the structure of the venous system
– hormonal factors - estrogens, especially during pregnancy and in the pre-menopausal period, contribute to increasing the elasticity of the vein walls

-pregnancies and childbirth: every pregnancy increases the risk of developing pelvic venous insufficiency. The growing uterus puts pressure on the main abdominal veins, and the increased volume of circulating blood strains the venous system.

– lifestyle: prolonged sitting, lack of physical activity, overuse of strength training exercises, and obesity are risk factors that particularly affect contemporary women

Heavy periods – when should they concern you?

Understanding the medical terminology for menstrual disorders is crucial for a proper assessment of your health. A heavy menstrual period (menorrhagia) is considered to be bleeding that:

• lasts longer than 7 days;
• is associated with a total blood loss of more than 80-100 ml during the entire cycle.
• requires changing a sanitary pad or tampon more frequently than every 2 hours
• contains bloody clots larger than 2.5 cm in diameter.

Here are the basic definitions and concepts (besides menorrhagia) related to menstrual bleeding that are worth mastering.

– eumenorrhoea – normal menstruation is a cycle lasting 21-35 days, with the bleeding itself lasting 3-5 days and a physiological blood loss of 30-80 ml.

– hypermenorrhoea – excessively heavy menstrual bleeding lasting longer than 7 days.

– metrorrhagia – – it is irregular bleeding outside of the menstrual cycle.

– oligomenorrhoea – rare menstruation (a cycle longer than 35 days)

– polymenorrhoea – – too frequent menstrual periods (a cycle shorter than 21 days).

What is important is that for these patients, the bleeding affects their daily functioning.
The story of Agnieszka, a 29-year-old teacher, perfectly illustrates this problem: "For years, I thought my periods were normal. It wasn't until a friend asked if it was normal for me to have to take time off work during the first few days of my period that I started to wonder. It turned out that my 'normal' period was a blood loss of over 120 ml per month.

If you recognize these symptoms in yourself or your daughter, don't ignore them. Early diagnosis at this stage of life can save you from years of suffering and serious complications in the future. Heavy menstrual periods can be a symptom of various conditions, but they often co-exist with pelvic venous insufficiency. The mechanism is complex: blood stasis in the veins, including the uterine veins, leads to endometrial hypertrophy, which in turn causes heavier bleeding. This is confirmed by research conducted for over 10 years by doctors at the Phlebology Clinic. Our observations show that over 60% of women with confirmed pelvic venous insufficiency complain of heavy menstrual periods..

The hidden connection between pelvic venous insufficiency and heavy menstrual periods.

The co-occurrence of pelvic venous insufficiency and heavy menstrual periods creates a vicious cycle that often escapes the attention of both patients and doctors. The mechanism behind this phenomenon is both fascinating and quite simple. When the veins in the pelvis don't effectively drain blood, it leads to blood stasis in the area of the uterus and ovaries. This results in increased vascular permeability and tissue swelling. A chronically congested uterus responds by remodeling the uterine lining—the endometrium becomes thicker and more vascular. Additionally, venous stasis affects hormone production. Impaired blood supply to the ovaries can lead to irregular production of estrogens and progesterone, which further intensifies the heaviness of menstrual bleeding

It's estimated that in women with pelvic venous insufficiency, the average blood loss during menstruation can be as high as 125-135 ml, whereas in healthy women, it's only up to 45-62 ml.

Anemia in women - an underappreciated problem of modern women

Anemia in women, also known as iron deficiency, is a condition in which the hemoglobin concentration drops below 12 g/dL, which leads to insufficient oxygenation of the body's tissues. This may be accompanied by a decreased number of red blood cells (erythrocytes) and a reduced hematocrit. The normal level of hemoglobin in the blood for women is 12-15.5 g/dl. However, even at values below 12.5-13 g/dL, the first symptoms of anemia can appear. The problem is that anemia develops gradually, and the body adapts to the lowered hemoglobin level. In women of reproductive age, the most common cause of anemia is blood loss during menstruation, especially when it is long and heavy (known as menorrhagia).
In physiological conditions, during menstruation, there is an average loss of 30-60 ml of blood containing 15-30 mg of iron. The daily iron requirement for an adult woman is approximately 2 mg, and during menstruation, it increases to 18 mg for women of childbearing age (compared to 8-11 mg for men).

What do the typical symptoms of anemia look like in women?

Anemia in women can cause many alarming symptoms. The most common ones include:

Fatigue and weakness – women often attribute this to an intense lifestyle;
Pale skin and mucous membranes – especially visible on the conjunctiva and under the nails;
Dizziness and fainting sensation – especially with a sudden change in body position, for example, from crouching to standing;
Heart palpitations and shortness of breath – it's a mechanism to compensate for the body's lack of oxygen due to a drop in blood hemoglobin levels
Lack of concentration and memory impairment – chronic hypoxia in the course of anemia affects the cognitive functions of the brain.
Weakened nails and hair loss – iron deficiency affects all tissues.

In the context of pelvic venous insufficiency and the persistence of heavy menstrual periods, anemia can be chronic and progressive. In women, there is a constant drop in hemoglobin levels and a gradual exhaustion of the body.

Diagnosis and recognition - a comprehensive approach to the problem

Proper diagnosis of anemia resulting from pelvic venous insufficiency relies on appropriate associations and correlations between clinical symptoms and the results of imaging studies, such as: Doppler ultrasound of the veins, CT venography, or MR venography. The diagnostic process should always be comprehensive. In the differential diagnosis, we should consider many pathologies from the abdominal and pelvic areas.

A gynecological examination it is usually the first line of diagnosis. Hence, the role of a gynecologist who performs a transvaginal ultrasound is so important. The gynecologist assesses the menstrual period in terms of its duration, heaviness, and painfulness.
A reliable ultrasound examination allows for the assessment of endometrial thickness, and the exclusion of uterine fibroids, endometrial polyps, and external or internal adenomyosis, all of which can also cause heavy bleeding.

Laboratory tests include a complete blood count with a differential (evaluation of hemoglobin levels, hematocrit, red blood cell count), and measurement of the concentration of iron, ferritin, total iron-binding capacity, and vitamin B12 and folic acid. These tests allow for the determination of the type of anemia and sometimes its cause.

Phlebological diagnostics is a key element often overlooked in standard gynecological care. In our phlebological practice, we use: a comprehensive Doppler ultrasound examination of the veins of the abdomen, pelvis, and lower limbs, performed in both lying and standing positions.

CT venography komputerowej or Magnetic resonance (MR)– allow for a detailed visualization of the pelvic venous system, the detection of organ changes, and, most importantly, they make it possible to plan a corrective procedure (e.g., venous embolization)

Digital phlebography is an imaging examination that directly visualizes the venous system. It involves the selective administration of a contrast agent into a specific segment of a vein to verify its patency and efficiency.

Did you know?

Patients often come to our facility after standard gynecological diagnostics, referred by colleagues due to heavy and prolonged menstrual bleeding. This is precisely the moment when it's worthwhile to consider vascular causes and refer the patient to a phlebologist.

PhD Cezary Szary

Equally important in the overall diagnosis of patients with anemia is a detailed medical history regarding lifestyle, physical activities, the number of pregnancies and deliveries, and the occurrence of varicose veins in the lower limbs or intimate areas, which often accompany pelvic venous insufficiency.