Have you found yourself struggling with persistent exhaustion? Telling yourself to” dig deeper”, “keep showing up”, but despite your efforts to keep trying harder or rest more, you still feel deeply fatigued?
Or, do you have other long-standing symptoms like body pain, depression, and low energy without a full picture of what’s causing them?What if there's more to the story?
I see many people in my practice who find out too late they’ve been struggling with undetected iron deficiency: a condition that is often overlooked, underestimated, and under-treated and can be a silent culprit behind not just fatigue, but many seemingly complex and prolonged symptoms.
Symptoms of Iron Deficiency
Exhaustion, fatigue
Inability to exercise; exercise intolerance
Low mood, depression, anxiety
Shortness of breath
Racing heart
Easy bruising
Tingling, crawling feelings in feet and hands
Restless legs syndrome
Food cravings (especially cravings to crunch ice or other mineral tastes like paper, clay, chocolate, wine, or mineral water)
Hair loss
Poor wound healing
Dry, rough skin and brittle nails
Brain fog
Headaches (especially frontal and vertex headache pain)
Iron deficiency occurs on a spectrum that ranges from a mild deficiency (poor iron stores), to insufficient iron (which is a precursor to anemia), to full anemia. Many people with deficiencies are not aware they have them: A 2023 JAMA study found that a staggering number—almost 40%—of 12- to 21-year-old non-pregnant U.S. females are iron deficient, and 6% have iron deficiency anemia (Weyand, 2023). Other data suggests of the prevalence of absent iron reserves ranges between 20 to 65% of menstruating women in the US (Cook, 1986).
Insufficient Testing
Standard screening for anemia typically involves a Complete Blood Count to review Hematocrit and Hemoglobin levels. But the reality is that our bodies start experiencing symptoms well before these tests are impacted.
In addition, iron deficiency is common among menstruating women. Often, women’s symptoms are diminished, discounted, or normalized rather than rigorously challenged and treated. So, if you’ve been feeling any of the signs above, specifically tell your doctor that you want to look deeper into your symptoms and request that a “Full Iron Panel with Ferritin” be added to your regular lab draw.
Prolonged Iron Deficiency Can Cause Severe Symptoms
It’s important to understand the impact of iron on our health because it has such a profound impact on many symptom areas including: mood and depression, attention span, physical and immune resiliency, thyroid status, and regular menses.
In addition, mildly low iron stores can be quickly depleted during episodes of heavy menses, excess exertion, early pregnancy, post surgery, or as a result of the compromised digestion that occurs during periods of high stress.
And, if left undiagnosed or untreated, the body may present with deeper symptoms of iron deficiency such as:
Deeper, more severe fatigue.
Heavier menstrual cycles.
Otherwise unexplained dull, aching, or nervy body pain.
Cognitive issues such as poor attention/concentration and diminished executive dysfunction (such as in ADHD).
Susceptibility to increased absorption of heavy metals via the intestine such as lead and cadmium.
Hearing loss.
In severe conditions, prolonged iron deficiency anemia can stress the cardiovascular system, vasculature, and contribute to irregular heartbeats.
Replete Iron Stores Impact Many Body Functions
Appropriate levels of iron support the healthy functioning of many systems throughout the body.
Mood: Low iron can cause or worsen mental health symptoms such as anxiety and depression. This is because you need iron to make the neurotransmitters serotonin, dopamine, and noradrenaline.
Tissue Repair: Iron is involved in the synthesis of collagen, a key component of connective tissue. Collagen is crucial for wound healing and tissue repair, providing structural support to the newly formed tissue such as muscles, tendons, ligaments, and connective tissue. Iron deficiency can compromise collagen synthesis, leading to impaired wound healing. Women athletes with suboptimal iron status may be at risk for increased incidence of injury, susceptibility to tendonitis and muscle strains, and slower healing and recovery times.
Thyroid Function: Healthy levels of iron are needed for the thyroid gland to produce thyroid hormone and chronic iron deficiency anemia can worsen hypothyroidism (Soliman, 2017).
Tissue Oxygenation: Iron transports oxygen throughout the body via the red blood cells, so inadequate iron stores can cause causing shortness of breath or weakened performance during exertion.
Immune Function: Iron is also essential for proper immune function. Iron deficiency can weaken the immune response and delay the resolution of inflammation, hindering the overall healing process. (Side note: there are other more complicated ways that iron participates in the inflammatory immune process, so It’s important to have a doctor interpret your lab results with you to get a full picture.)
Are You at an Increased Risk of Iron Deficiency + Iron Deficiency Anemia?
Iron deficiency anemia is more common among certain groups of people and specific health profiles. You may need to keep better track of your iron levels if you happen to fall into any of the categories below:
Female athletes within reproductive years.
Athletes at-risk of overtraining.
Those with heavy menstrual cycles. If you have heavy periods (e.g. you lose more than a total of five tablespoons over the entirety of the period), you are likely to be iron deficient, even if your blood test says you're not anemic.
Active people on plant-centered, vegetarian, or vegan diets.
Women with eating disorders or restrictive diets.
Reproductive-age women with health conditions impacting their nutrient absorption, such as: chronic digestive issues (e.g. chronic gastritis, IBS, Crohn’s disease, ulcerative colitis, Celiac / gluten sensitivity, post gastric-bypass). Also, stress-related changes in gut health and appetite can lead to reduce iron intake and absorption.
Chronic sources of internal bleeding such as digestive ulceration or hemorrhoids.
Why Am I So Tired Before My Period?: The Relationship Between Iron Status + Menstruation
Also, it’s important to remember that unlike other vitamins and minerals, iron accumulates in the body, so it’s essential not to self-prescribe iron supplementation without lab testing and consultation with your doctor. Excess accumulated iron—e.g. supplementing without knowing your levels— can have adverse effects and may be unsafe for those without an actual deficiency, so please work with your provider to develop a plan that’s right for you.
This is why iron deficiency is more common in reproductive-age women with a monthly draw on their iron stores through their menstrual cycle. You probably know that heavy periods can cause iron deficiency, but did you know that iron deficiency can also make periods heavier? It’s true. This positive feedback loop can be a part of a vicious cycle that is important to treat as soon as possible to help get your body back into balance. (There are many therapies available to help return the menstrual cycle to balance. Look for support from a naturopathic doctor to gain help with hormone balance.)
A Comprehensive Holistic Approach to Symptoms
All of the reasons above illustrate why it’s important to have a full iron panel with ferritin levels included in your labwork if you are experiencing some of the symptoms above.
If your iron levels are off in some way, it may be due to anemia or it could be due to other more complex causes such as an underlying infectious process, an inflammatory process, an autoimmune condition, genetic issues. In rare circumstances, there may be an underlying blood disorder that needs specialist review or attention. So, it’s a good idea to review your lab tests with your doctor for interpretation so that your treatment takes the appropriate direction.
If your numbers are off, you may need to set a specific treatment plan as well as a plan to complete follow up testing to check in on your numbers normalizing.
Treating Anemia: New Research on Optimal Supplementation + Iron Rich Foods
Under normal circumstances, we assimilate all the iron that we need from a healthy, balanced diet.
But, if you are iron deficient or have anemia, the good news is that in many cases it can be well-treated with iron supplementation and intentional dietary changes.
New studies on bioavailability in women show that iron levels are best corrected with every-other day dosing. Interestingly, every-other-day dosing has been found to provide faster iron level corrections with less tissue inflammation than daily supplementation (Pasupathy, 2023). Iron absorption is improved when taken together with vitamin C in the morning with food.
In my practice, I like to recommend iron bisglycinate because it is often less stressful on the digestive tract than other forms of supplemental iron (e.g. causes less nausea and constipation).
In some cases of severe anemia, prolonged heavy bleeding or pronounced symptoms, there may be a need for urgent blood cell or iron transfusions to catch up. Of course, treating the underlying cause of anemia should be a part of the picture.
As far as nourishment, take an inventory of the iron-rich foods in your regular weekly intake and stock up on iron-rich foods that suit your lifeways. Iron rich foods include meats, proteins, leafy greens such as spinach, and legumes, especially white beans and kidney beans. Oysters, dark chocolate, and tofu are also all major iron sources. Check out sources of iron rich foods per serving size here.
Some women should increase their vitamin B12 or folate intake to combat other forms of anemia.
REFERENCES
Cook JD, Skikne BS, Lynch SR, Reusser ME. Estimates of iron sufficiency in the US population. Blood. 1986 Sep;68(3):726-31. PMID: 3742051.
https://lpi.oregonstate.edu/mic/minerals/iron#food-sources
Pasupathy E, Kandasamy R, Thomas K, Basheer A. Alternate day versus daily oral iron for treatment of iron deficiency anemia: a randomized controlled trial. Sci Rep. 2023 Feb 1;13(1):1818. doi: 10.1038/s41598-023-29034-9. Erratum in: Sci Rep. 2023 Jul 3;13(1):10711. PMID: 36725875; PMCID: PMC9892593.
Rawee P, Kremer D, Nolte IM, Leuvenink HGD, Touw DJ, De Borst MH, Bakker SJL, Hanudel MR, Eisenga MF. Iron Deficiency and Nephrotoxic Heavy Metals: A Dangerous Interplay? Int J Mol Sci. 2023 Mar 10;24(6):5315. doi: 10.3390/ijms24065315. PMID: 36982393; PMCID: PMC10049453.
Stoffel NU, von Siebenthal HK, Moretti D, Zimmermann MB. Oral iron supplementation in iron-deficient women: How much and how often? Mol Aspects Med. 2020 Oct;75:100865. doi: 10.1016/j.mam.2020.100865. Epub 2020 Jul 7. PMID: 32650997.
Soliman AT, De Sanctis V, Yassin M, Wagdy M, Soliman N. Chronic anemia and thyroid function. Acta Biomed. 2017 Apr 28;88(1):119-127. doi: 10.23750/abm.v88i1.6048. PMID: 28467346; PMCID: PMC6166193.
Weyand AC, Chaitoff A, Freed GL, Sholzberg M, Choi SW, McGann PT. Prevalence of Iron Deficiency and Iron-Deficiency Anemia in US Females Aged 12-21 Years, 2003-2020. JAMA. 2023 Jun 27;329(24):2191-2193. doi: 10.1001/jama.2023.8020. PMID: 37367984; PMCID: PMC10300696.