Her heavy bleeding required approximately two boxes of tampons for every month of her menstrual cycle. She has experienced unusually heavy periods of bleeding for 12 months prior to her presentation to our medical facility. Our first patient is a 36-year-old Caucasian woman with dysfunctional uterine bleeding. Each patient fully meets the criteria for pica from Diagnostic and Statistical Manual of Mental Disorders and suffered from severe iron deficiency anemia. We believe that this was due to advances in technology and changing cultural customs. Here we present three patients who demonstrated subtle changes in pica associated with iron deficiency. We have also noted that although the ingestion of excessive amounts of ice (pagophagia) is an unusual symptom, its presence has invariably been associated with documented cases of iron deficiency anemia. Over a period of 30 years, our group has evaluated a monthly average of one to two patients with iron deficiency. Surprisingly, we found that the majority of primary care physicians are unaware of pica symptoms. When associated with iron deficiency, most physicians believe that pica is an effect rather than a cause. The exact etiology of pica remains unclear, but it is significantly associated with iron deficiency anemia. These patients are susceptible to electrolyte and metabolic disorders, lead and mercury poisoning, hypokalemia (from resinphagia), parasitic infections, tooth wear, intestinal obstruction, and various problems of the gastrointestinal tract. Pica poses significant health risks that often require medical interventions. A small percentage of patients have iron deficiency anemia. Worldwide, 25% to 33% of all pica cases involve small children, 20% are pregnant women, and 10% to 15% are individuals with learning disabilities. Although pica is most prominent in individuals with developmental disabilities, it has been observed in men and women of all ages and ethnicity, but is more prevalent among the lower socioeconomic classes. Since then, many cases of pica have been reported where patients have acknowledged ingesting ice cubes (pagophagia), clay (geophagia), dried pasta (amylophagia), chalk, starch, paste, Kayexalate resin (resinphagia), tomatoes, lemons, cigarette butts, hair, lead, and laundry starch (for example, Argo out of the box). One of the first cases of pica was noted in 6th century AD and was observed in a pregnant woman. The condition has been described in medical journals for centuries. Pica is an unusual craving for and ingestion of either edible or inedible substances. We believe pica is an important sign of iron deficiency that should never be ignored, and the craving for any unusual substance should compel clinicians to search for occult blood loss with secondary iron deficiency. Pica symptoms abated in one of our patients upon iron supplementation, while the other two are currently under treatment as of this writing. None of our patients we describe here, as well as their primary care physicians, were aware of the importance of their pica related symptoms. We have noticed that the younger community of academic and community physicians are not aware of the importance of complaints related to pica. Pica has been practiced for centuries without a clear etiology. All three patients presented with hematological parameters diagnostic for iron deficiency anemia. Lastly, the third patient, a 37-year-old Hispanic woman, presented with dysfunctional uterine bleeding and habitually chewed rubber bands. The second patient is a 62-year-old Caucasian man who presented with bleeding from colonic polyps associated with drinking partially frozen bottled water. The first patient is a 36-year-old Caucasian woman who had dysfunctional uterine bleeding associated with daily ingestion of two super-sized cups of ice as iced tea. We describe three patients who presented with symptoms of pica. We report three patients with pica, two of them showing evolutionary changes associated with pica and the third demonstrating a peculiar nature of pica, which has yet to be reported. Pica is an unusual condition where patients develop cravings for non-nutritive substances that can cause significant health risks.
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