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This complex process means that conditions affecting the stomach or intestines can significantly impair B12 absorption, including pernicious anaemia, atrophic gastritis, previous gastric surgery, coeliac disease, Crohn's disease, and long-term use of certain medications (such as metformin, proton pump inhibitors, and H2 antagonists)

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The differential diagnosis should include other melanotic lesions, such as malignant melanoma, pigmented meningioma, and medulloblastoma [ 5 ]

Employer-Based and Individual Plan Differences Some insurance plans, particularly individual marketplace or employer-sponsored plans , may have exclusions or strict limitations on hormone therapy