Abstract
e-Iron is a telemedicine platform developed at our institution to facilitate the administration of intravenous iron (IVI) to appropriate candidates, without the requirement of a traditional face-to-face hematology visit. We have previously shown that e-Iron expedites effective management across a wide range of patients with iron deficiency anemia (IDA).
However, in the largest group treated—women with heavy menstrual bleeding (HMB)—IDA recurrence following e-Iron–facilitated therapy is unacceptably high. A prior analysis identified several factors: under-recognition of HMB as a cause of IDA, insufficient screening for HMB, and inconsistent gynecology follow-up after infusion.
In response, we developed and piloted a protocol modification: the Hematology-Gynecology Clinic (HGC) intervention, implemented as an add-on to the e-Iron platform. The HGC protocol introduces structured screening, education, and targeted follow-up.
Under the revised protocol, all non-pregnant women of reproductive age referred to e-Iron and approved for IVI are screened for HMB by trained nurse practitioners (NP) at the time of infusion. If HMB is identified, patients are categorized into three groups:
HMB under active management,
HMB unmanaged but with access to gynecologic care,
HMB unmanaged with no access to gynecologic care.
For group 3, we established a dedicated referral pathway in collaboration with gynecology, to provide expedited in-person consultations, avoiding a typical months-long wait associated with standard referral.
All women receive education on the role of HMB in the development of IDA, with emphasis on the need for gynecology follow-up to prevent recurrence. Women reporting HMB at the time of infusion are also scheduled for a 6-week follow-up with the same hematology NPs, to reassess HMB status, repeat labs (CBC and iron studies), and review HMB management.
We analyzed 144 eligible patients referred to e-Iron during the first 3 months of the revised protocol. Of those screened, 105 (72.9%) reported HMB, of which 16 (15.2%) indicated they were receiving no active management. In 82 patients who reported having access to gynecology care, at the 6-week follow-up 56 (68.3%) were noted to have had, or scheduled, a gynecology visit. In the 16 patients who reported no access, expedited appointments were set up in 12 (75%). In the 3-month period after infusion, in 98 patients for which data was available, a gynecology follow-up was documented in 68 (69.4%). An intervention—pharmacologic, IUD-based, or surgical—was documented in 35.1%.
This reflects a notable improvement over pre-HGC data, which showed that within three months of e-Iron–facilitated care, 37% of patients with likely HMB had no documented attempt to screen for or address their bleeding, and only 29.1% had a documented intervention.
Nonetheless, follow-up adherence was poor. 6-week hematology and expedited gynecology follow-up attendance were 57.5% and 41.7% respectively. Anecdotally, many patients cited symptom resolution after infusion as a reason for missing follow-up, possibly perceiving further care as unnecessary. Among women who did return, mean hemoglobin was increased by 2.9 g/dL, and ferritin by 119.2 ng/mL.
Failure to identify and manage HMB as a central contributor to IDA in reproductive-age women is widespread, with gaps spanning primary care, hematology, and gynecology. In telemedicine platforms where patients may never see a hematologist in person, this gap is especially pronounced. Yet this same setting offers a unique opportunity: by embedding structured HMB screening, education, and referral into the e-Iron program, we can close a critical care gap, and by targeting patient understanding of the HMB–IDA connection, empower women to engage more effectively in their own care.
Our pilot study has highlighted challenges in achieving this goal – most notably, poor adherence to recommendations regarding gynecology follow-up. To address this, a more robust collaboration with our gynecology colleagues is being developed, entailing proactive outreach to patients identified by e-Iron-HGC as being at risk, and facilitation of appointment scheduling. Patient education will also be reinforced, and enhanced via customized printed material.
Ultimately, the intervention's effectiveness will be measured by a decrease in IDA recurrence, which we aim to confirm with ongoing analysis of long-term data.
