As this patient with HHT grows older, her bleeding tendency will likely become progressively more difficult to manage. If she were premenopausal, oral contraceptives would be an option, but in this patient, she may respond instead to tamoxifen. She must also be carefully followed for any symptoms of arteriovenous malformations, which need to be immediately treated by catheter-directed embolization.

The management of this patient's iron deficiency will also become a significant problem. She should receive maximum oral iron therapy in combination with repeated doses of parenteral iron (see Chapter S). lf this regimen fails to correct her anemia, she will eventually require increasingly frequent red cell transfusions to maintain a stable hematocrit around 30%.