Mid-40 female presents with acute onset pain in both feet and hands. Questioning reveals that she has experienced episodic numbness in her feet over the past 2 years. Patient suspects gout but blood urate levels are normal and patient’s diet and lifestyle not ‘typical’ of the gout sufferer (high alcohol and meat intake, central adiposity etc.)
Further review of pathology organised by her doctor reveals severe anaemia (Hb 65!!, MCV 65, Ferritin not detectable), severely depressed serum calcium levels (suggesting marked magnesium deficiency) and elevated phosphate (calcium deficiency or bone mobilisation of other causes). Collectively these potentially explain her pain, altered neurological sensations and her general unwellness.
When questioned about the current ‘sudden onset’ anaemia, she reports that she had been experiencing shortness of breath but because she had only recently given up smoking, she had attributed this to her respiratory health. When asked about the usual risk factors for anaemia (e.g. low meat intake, high dairy consumption, endurance sports, PPI use, menorrhagia and non-hormone secreting IUD use) she reports extreme acyclic menstrual flooding since stopping the OCP 6 months ago.
She had accepted this as being ‘peri-menopausal’ and was prepared to ‘ride it out’. Immediate referral for pelvic US reveals 6cm fibroids, further investigation reveals severe cholestasis and gall bladder inflammation. A marked oestrogen excess picture is emerging and will need quickly remedying, to help control the bleeding and reduce her risk of CVD (and oestrogen dependent cancer risks) which are already high given her age, history of smoking, marked family history and nutritional deficiencies.