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The Hidden Struggles: Iron Deficiency and Anemia in Women
By Henry Xu, Ph.D, Joanne Tejeda, Ph.D
July 2, 2024
Iron is an essential mineral for your body, playing crucial roles in your immune and cardiovascular systems. It is mainly used to produce a protein called hemoglobin, which carries oxygen in red blood cells. When your body lacks sufficient iron, it can result in iron deficiency anemia, a common health issue affecting many women worldwide. Globally, more than 33% of women aged 15-49 suffer from anemia, with over 800 million cases due to iron deficiency – twice as many compared to men [1]. In Canada, an estimated 29% of women aged 19-50 experience iron deficiency anemia. [2]. These conditions can lead to various health complications, impacting overall quality of life and productivity.
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In this article, we explore how to identify iron deficiency anemia and manage iron levels. Catching symptoms of anemia early and taking steps to maintain healthy iron levels are crucial for women's health.
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What Causes Iron Deficiency Anemia in Women?
Iron deficiency is a condition where the body does not have enough iron to produce hemoglobin. When this condition worsens and there isn’t enough oxygen in red blood cells, it can result in iron deficiency anemia, potentially leading to tissue and organ damage. [3]. Several factors contribute to the increased prevalence of iron deficiency in women. Women of reproductive age are particularly susceptible to iron deficiency due to blood loss during menstruation [4].
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Abnormal uterine bleeding (AUB) – where bleeding from the uterus is abnormal – affects up to 25% of women of reproductive age. The most common subtype of AUB is heavy menstrual bleeding (menorrhagia), which significantly increases iron loss [5]. An ongoing comprehensive review by Dr. Michelle Zeller from McMaster University is examining the effectiveness of iron treatments for AUB [6]. This research aims to improve our understanding of how iron treatments can enhance health outcomes for women with iron deficiency due to AUB.
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Iron deficiency is also a common issue for expecting and postpartum mothers. The increased iron demands during pregnancy and lactation can lead to the rapid depletion of iron stores in the mother’s body, especially if the pregnancy is not supported with additional iron through nutrients or supplements.
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An unbalanced diet with limited consumption of iron-rich foods, such as red meat, poultry, and fish, is another common factor leading to iron deficiency. Vegetarian and vegan diets may also pose a risk if not carefully managed to include alternative iron sources. In addition, several gastrointestinal conditions, such as celiac disease, Crohn's disease, inflammatory bowel disease (IBS), and those who have undergone gastric bypass surgery, can decrease iron absorption, leading to iron deficiency.
Common Symptoms of Iron Deficiency Anemia
The symptoms of iron deficiency and iron deficiency anemia can vary in severity and may include [4, 7]:
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The Impact of Iron Deficiency Anemia on Women’s Health
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Adolescent Women
During these developmental years, bodies are rapidly changing and growing, making iron even more important. Without enough iron, adolescents can feel tired, weak, and have trouble concentrating, impacting their performance and daily activities. Additionally, as girls begin menstruating, they lose iron each month, increasing their risk of deficiency. Ensuring sufficient iron is essential for maintaining their energy levels, supporting growth, and promoting overall well-being [8].
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Adult Women
Iron is equally important for adult women. Without healthy levels of iron, they might feel tired, weak, or even dizzy, greatly impacting their work and social life. Women periodically lose iron during menstruation, making it even harder to meet the body’s iron needs. Heavy and prolonged athletic activities also increase iron loss through sweating [4].
Pregnant Women
Iron needs increase significantly to support fetal development and increased blood volume. Pregnant women are often advised to take prenatal vitamins that include iron to prevent deficiency. Monitoring iron levels throughout pregnancy is essential to ensure both maternal and fetal health. Iron-deficient mothers can encounter complications during pregnancy, including preterm delivery and low birth weight [4].
Perimenopausal Women
During perimenopause, women may experience irregular or increased menstrual volume. These changes can contribute to increased iron loss and result in iron deficiency anemia. Some symptoms of perimenopause, such as fatigue and headaches, might overlap with iron deficiency symptoms, making it important for perimenopausal women to regularly check their blood iron levels to avoid developing anemia [4].
Postmenopausal Women
Postmenopausal women generally have a lower risk of iron deficiency due to the cessation of menstrual blood loss. However, they can still be affected by insufficient dietary iron or gastrointestinal issues. Regular health check-ups and maintaining a balanced diet are important for preventing iron deficiency in this age group [4].
How is Iron Deficiency Anemia Diagnosed?
Diagnosing iron deficiency anemia involves a combination of clinical evaluation and laboratory tests [3], including:
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1. A Complete Blood Count (CBC), which is a comprehensive blood test used to evaluate overall health and detect a variety of disorders, including anemia, infection, and many other diseases. The CBC measures several components and features of your blood, such as Red Blood Cells (RBCs), White Blood Cells (WBC), Hemoglobin (Hgb), Hematocrit (Hct), and Platelets.
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2. A Serum Ferritin Test that measures the level of ferritin in your blood. Ferritin is a protein that stores iron in your body's cells, and the amount of ferritin in your blood reflects the amount of stored iron. This test helps to evaluate your body's iron levels and diagnose conditions related to iron deficiency or excess. Low ferritin levels indicate low iron stores, which can lead to iron deficiency anemia.​​​
Interpretation of Serum Ferritin Test Results
Table adapted from NIH National Heart, Lung, and Blood Institute [9, 10]
3. A Serum Iron and Total Iron-Binding Capacity (TIBC) test that measures the amount of circulating iron and the blood’s capacity to bind iron, respectively. Low serum iron and high TIBC levels are indicative of iron deficiency.
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4. The Transferrin Saturation Test used to evaluate how much iron is bound to transferrin, the protein that transports iron in the blood. Low transferrin saturation indicates insufficient iron supply.
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Treatment and Prevention
The primary goals in treating iron deficiency anemia are to replenish iron stores and address any underlying causes [3,4]. Dietary changes are usually a fundamental step in treatment and prevention. Heme iron, found in animal products, is more readily absorbed by the body compared to non-heme iron in plant-based foods. Including vitamin C-rich foods in meals can enhance non-heme iron absorption.
​For women with dietary restrictions or needing additional iron, ferrous sulfate and other oral supplements are commonly used to treat iron deficiency. While effective, these supplements can cause gastrointestinal side effects like constipation and nausea, which can be mitigated by taking them with meals and consuming fiber. For those who cannot tolerate oral iron or have severe deficiencies, intravenous iron infusions may be necessary, especially in cases of absorption issues. Always consult your doctor to determine which supplement option is best for you.
If you're persistently tired or noticing other symptoms, consult a healthcare professional about iron deficiency anemia. Proactive steps like eating a balanced diet and getting regular check-ups can help maintain healthy iron levels and ensure your well-being.
New Update: September 2024 Iron Deficiency Guidelines for Ontario
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New guidelines introduced in Ontario on September 9, 2024, have raised the thresholds for diagnosing iron deficiency, allowing for earlier detection and improved treatment. Previously, ferritin levels below 10 to 15 micrograms per litre were flagged as abnormal, but many patients with symptoms of iron deficiency went undiagnosed due to these low thresholds. The updated standards now raise the baseline to 30 micrograms per litre for adults and 20 for children, aligning with global research and evidence dating back to 1992. This change is expected to significantly improve patient care, especially for women, marginalized communities, and those at higher risk due to conditions like heavy menstrual bleeding.
Below is the updated table reflecting the new serum ferritin level thresholds:
Interpretation of Serum Ferritin Test Results ( Per New Ontario Guidelines)
These guidelines are a major step forward in addressing health equity and improving outcomes for those who have long suffered from undiagnosed iron deficiency.
Don’t Miss Out – Access the Video Recording Now!
On July 24th, 2024, Healthyher.Life had the privilege of hosting Dr. Michelle Zeller, a clinical hematologist and Associate Professor at McMaster University, for an insightful Women Talking™ Wednesday event: "Iron is Essential for Your Health and Vitality – Are You Getting Enough?"
If you’re wondering whether you have unmet iron needs or how iron plays a critical role in your health, this is your chance to get informed. Dr. Zeller’s expert insights on the importance of iron and how to ensure you’re getting enough could make a real difference in your well-being.
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References:
[1] GBD 2021 Anaemia Collaborators. “Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990-2021: findings from the Global Burden of Disease Study 2021.” The Lancet. Haematology vol. 10,9 (2023): e713-e734. doi:10.1016/S2352-3026(23)00160-6
[2] Cooper, M., Bertinato, J., Ennis, J. K., Sadeghpour, A., Weiler, H. A., Dorais, V.. “Population Iron Status in Canada: Results from the Canadian Health Measures Survey 2012-2019.” The Journal of Nutrition, Mar 2023, Volume 153:5, pp1534-1543. doi:10.1016/j.tjnut.2023.03.012
[3] Kumar, A., Sharma, E., Marley, A., Samaan, M. A., & Brookes, M. J., “Iron deficiency anaemia: pathophysiology, assessment, practical management.” BMJ open gastroenterology, 2022, Volume 9:1:e00759, doi: 10.1136/bmjgast-2021-000759
[4] Percy, L., Mansour, D., Fraser, I. “Iron deficiency and iron deficiency anaemia in women.” Best Practice & Research Clinical Obstetrics & Gynaecology, 2017, Volume 40, pp 55-67, doi: 10.1016/j.bpobgyn.2016.09.007
[5] Whitaker, Lucy, and Hilary O D Critchley. “Abnormal uterine bleeding.” Best practice & research. Clinical obstetrics & gynaecology vol. 34 (2016): 54-65. doi:10.1016/j.bpobgyn.2015.11.012
[6] Nazaryan, H., Watson, M., Ellingham, D., Thakar, S., Wang, A., Pai, M., Liu, Y., Rochwerg, B., Gabarin, N., Arnold, D., Sirotich, E., Zeller, M. P. “Impact of iron supplementation on patient outcomes for women with abnormal uterine bleeding: a protocol for a systematic review and meta-analysis.” Systematic reviews, Jul 2023, Volume 12:1, pp 121, doi: 10.1186/s13643-023-02222-4
[7] “Iron-Deficiency Anemia.” Office on Women's Health, U.S. Department of Health and Human Services, Feb. 2022, www.womenshealth.gov/a-z-topics/iron-deficiency-anemia.
[8] Aksu, Tekin, and Åžule Ünal. “Iron Deficiency Anemia in Infancy, Childhood, and Adolescence.” Turkish archives of pediatrics vol. 58,4 (2023): 358-362. doi:10.5152/TurkArchPediatr.2023.23049
[9] “Iron-Deficiency Anemia.” National Heart Lung and Blood Institute, U.S. Department of Health and Human Services, 24 Mar. 2022, www.nhlbi.nih.gov/health/anemia/iron-deficiency-anemia.
[10] Mei, Zuguo et al. “Physiologically based serum ferritin thresholds for iron deficiency in children and non-pregnant women: a US National Health and Nutrition Examination Surveys (NHANES) serial cross-sectional study.” The Lancet. Haematology vol. 8,8 (2021): e572-e582. doi:10.1016/S2352-3026(21)00168-X
[11] Harrison, L. (2024, September 9). Ontario's new iron deficiency guidelines may change lives: Doctors. CBC News. www.cbc.ca/news/canada/toronto/iron-deficiency-bloodwork-testing-ontario-1.7314795