Dr. Karima Khamisa
Anna* was desperate; she had tried at least three types of antidepressants and remained exhausted. She was 30 years old, a single mother and could not work. She insisted her family physician run further blood tests; she was found to have severely low iron levels. She was prescribed iron tablets but found these harsh on her stomach. She was then prescribed intravenous iron infusions at her local hospital. Her mood and concentration improved dramatically with the iron infusions. She was able to return to work full time.
The story of Anna is not uncommon in my practice. As a hematologist, I have treated many patients with iron deficiency anemia. However, according to a recent study, this condition is overlooked by many clinicians(1, 2).
Symptoms of iron deficiency include fatigue, low mood, poor concentration, reduced exercise tolerance, hair loss, restless legs, and brittle nails. Iron deficiency anemia affects 18 – 30% of women in their childbearing years(2, 3). The World Health Organization has committed to reducing the level of iron deficiency in women by 50% in 2025 (4).
What is iron deficiency anemia?
Iron is a critical part of all cells in our body. In particular, iron is a key component of red cells that deliver oxygen to all the organs of the body. Anemia occurs when there are not enough red blood cells in the body. There are many causes of anemia, but iron deficiency is the most common cause worldwide(3). The diagnosis is straightforward, requiring a few simple blood tests.
What causes iron deficiency anemia?
The most common cause of iron deficiency anemia in women is due to heavy menstrual bleeding (HMB). Other reasons include poor absorption of nutrients, bowel bleeding and bowel cancer.
What can I do to prevent iron deficiency anemia?
If you are a young woman with HMB, it is important to talk to your doctor about this issue. Preventing excessive blood loss will help keep more iron in your body. The following Canadian website can help determine if you have HMB. A referral to a hematologist may be needed if you have other unusual types of bleeding or easy bruising.
How much iron should I consume?
Young women should ensure they consume at least 18mg a day of iron. However, despite a good diet rich in iron, many women remain iron deficient.
What should I do if I think I have iron deficiency anemia?
If you are struggling with fatigue, low mood, hair loss and/or poor exercise tolerance, you may be suffering from iron deficiency anemia. Regarding fatigue, many conditions cause this (see Table 1). Speak with your doctor to explore your specific symptoms. If your doctor orders blood work that identifies iron deficiency, you may be advised to take iron supplements. While iron supplements are available in Canada without a prescription, I would not advise taking these without a firm diagnosis of iron deficiency. This is because iron can accumulate in the body, and too much iron can be dangerous as well.
What happens when I take iron tablets?
You should take your iron tablet every day; if your anemia is mild, studies have shown taking an iron tablet every second day is also effective.
It is best to avoid other medications or dairy-containing foods at the same time as taking an iron tablet. This is because certain medications and dairy foods decrease the absorption of iron(5). If you are prone to constipation, it is important to drink plenty of water the days you take your iron. If you cannot tolerate your oral iron pill due to side effects, or you aren’t feeling any improvement after a month – you should contact your doctor again to re-check your blood count and switch to another type of oral iron supplement.
I can’t handle iron tablets and have tried many kinds – what do I do next?
30% of patients can’t tolerate oral iron at all. In that case, your physician may recommend an intravenous (IV) iron infusion. Iron infusions are usually given at a hospital and take one to two hours to complete. They are fairly safe but can be costly.
Some provinces have subsidies for IV iron, but greater access is needed to these medications. Studies have shown a women’s health and productivity increase once their iron levels are in the normal range(6).
Iron deficiency is a common condition affecting women, particularly those with heavy menstrual bleeding. Early Identification and treatment can vastly improve energy and quality of life in patients with this disorder.
Common Causes of Fatigue
|Extremes of activity|
|Night shift work|
|Sleep deprivation, poor sleep habits|
|Chronic liver and kidney disease|
|Chronic lung disease, hypoxemia|
|Hyperglycemia, uncontrolled diabetes mellitus|
|Medication side effects|
Table 1: Causes of Fatigue (American College of Physician Medical Knowledge Self-Assessment Program 18, Copyright 2018)
*Name changed to preserve anonymity
2Dugan C, MacLean B, Cabolis K, Abeysiri S, Khong A, Sajic M, Richards T; Women’s Health research Collaborative. The misogyny of iron deficiency. Anaesthesia. 2021 Apr;76 Suppl 4:56-62. doi: 10.1111/anae.15432. PMID: 33682094.
3Bayen S, Le Grand C, Bayen M, Richard F, Messaadi N. Anemia management in non-menopausal women in a primary care setting: A prospective evaluation of clinical practice. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-1086-5
4World Health Organization. (2014). Global nutrition targets 2025: anaemia policy brief. World Health Organization. https://apps.who.int/iris/handle/10665/148556
5Powers JM, Buchanan GR, Adix L, Zhang S, Gao A, McCavit TL. Effect of low-dose ferrous sulfate vs iron polysaccharide complex on hemoglobin concentration in young children with nutritional iron-deficiency anemia a randomized clinical trial. JAMA – J Am Med Assoc. 2017;317(22):2297-2304. doi:10.1001/jama.2017.6846
6Macher S, Herster C, Holter M, et al. The effect of parenteral or oral iron supplementation on fatigue, sleep, quality of life and restless legs syndrome in iron-deficient blood donors: A secondary analysis of the ironwoman rct. Nutrients. 2020;12(5). doi:10.3390/nu12051313