It was a Saturday and I had just finished running 10 miles training for a half marathon. After I got home, I couldn’t motivate to get off the couch. The day was far from over as I had plans to go to a 50th birthday party that night.
There was no possible way for me to physically get dressed and head out for the night. I let my friend know that I wasn’t feeling well. But I wasn’t sick, just bone tired.
Four months later I discovered I was anemic. The light bulbs started to go off as I made connections between my brain fog, lack of energy, and low iron.
I felt kind of embarrassed that as a dietitian I didn’t catch this sooner. But I started to put the pieces together and realized that my doctors should have caught this earlier. That is, if they did the test that I now know every woman needs: ferritin.
And because my way of coping is to (over) research, I learned a lot.
So, let’s start with a quick review before we dig into ferritin.
Red blood cell 101
Red blood cells account for 40 percent of blood volume and are continually made in the bone marrow. They contain hemoglobin, a protein that gives blood its red color.
Iron is the heme part of hemoglobin and its job is to carry oxygen. When we breathe in, blood passes through the lungs where oxygen attaches to hemoglobin. Red blood cells then transfer oxygen to the rest of the body’s cells and tissues.
After supplying oxygen, empty red blood cells attach to waste products like carbon dioxide, which are excreted when we exhale.
The most sensitive indicator of iron status is a protein in the blood called ferritin, which reflects iron stores in the body. When iron stores decline past a certain point, the delicate balance of red blood cells gets off-kilter.
By the time the body has worked through its iron stores and full-blown anemia occurs, cells and tissues aren’t getting the oxygen they need to function properly.
Watch the big four
When iron gets out of balance, it’s because intake doesn’t meet demand. And that’s because one more of the following factors are at play.
- Decreased iron intake: When a woman doesn’t meet her needs for iron, her stores become depleted. Honestly, breastfed infants are at the greatest risk for this but so are vegetarians and vegans who may eat less iron or less absorbable sources of iron.
- High demand: There are times the body needs more iron like during growth (infants/puberty), pregnancy, and intense exercise.
- Poor absorption: Iron absorption is compromised under a variety of circumstances like in gastric bypass patients, inflammatory bowel disease, use of antacids, and celiac disease.
- Increased loss: The body loses red blood cells during menstruation, when giving blood, and with any disease that causes internal bleeding. Active people also lose iron through the gastrointestinal (GI) system, urine, and sweat.
It’s all about Ferritin
Throughout my life all doctors ever checked was a complete blood count which included hemoglobin and hematocrit to check for anemia. For me, these have always been in the normal range.
When I got diagnosed with anemia, they followed it up with a complete iron panel that checks ferritin. Less than 30 is considered iron deficiency and mine was 10.
I dug deep into my medical file where I keep old blood work from my twenties and thirties. There was no ferritin to be found! I had no idea of what my baseline ferritin was before having kids when I had relentless energy.
Women should keep track of their ferritin levels because, due to biology, they are at risk for low iron. There’s a huge range of normal depending on the lab ferritin can range from 10-307mcg/L. According to the National Institutes of Health Office of Dietary Supplements:
Serum ferritin concentration, a measure of the body’s iron stores, is currently the most efficient and cost-effective test for diagnosing iron deficiency. Because serum ferritin decreases during the first stage of iron depletion, it can identify low iron status before the onset of Iron deficiency anemia (IDA). A serum ferritin concentration lower than 30 mcg/L suggests iron deficiency, and a value lower than 10 mcg/L suggests IDA. However, serum ferritin is subject to influence by inflammation (due, for example, to infectious disease), which elevates serum ferritin concentrations.
In short, anemia is the last and more severe stage of iron deficiency. Unable to get enough oxygen, the body increases heart and breathing rate and women may experience palpitations. The body slows down resulting in fatigue, weakness, and shortness of breath. A lack of oxygen to the brain results in brain fog, headaches and/or dizziness. Feet and hands get cold, hair may fall out, and spooning of the nails can occur. See the complete symptom chart list below.
Although it is assumed these symptoms only occur at the final stage of anemia, research suggests signs may appear much earlier in the process. If women can get clues before this happens, they can avoid the decreased quality of life and health risks that go along with it.
In one study, two groups of women with ferritin levels of less than 50mcg/L were given iron supplements or a placebo. The women given the iron reported a 48% decrease in fatigue, significantly more than the placebo group.
Women have more iron loss
It all starts in adolescence with the first period. A girl’s risk for iron deficiency increases because she now loses iron. In one study, 80% of girls had ferritin levels under 40. Adding to the toll for any female is heavy periods where as many as 90% of women have low ferritin.
In another study with 236 women with heavy menstrual bleeding 63 (27%) were anemic and 140 (60%) were severely iron deficient (ferritin <15 ng/ml). Out of the anemic women, only 8% were taking iron supplements. They were treated with either hysterectomy or an IUD which stopped or decreased bleeding significantly.
A year later they all felt better in terms of energy, social functioning, and physical functioning, and iron improved. The anemic women also had decreases in anxiety and depression. But it took 5 years for ferritin to get back to normal.
Yet some women are protected from this risk if they are on birth control that keeps their flow light or stops their periods entirely.
Pregnancy increases demand
Another factor that increases the risk of low ferritin is pregnancy. Iron needs increase significantly during pregnancy to help meet the increased demands of the fetus and this accelerates the last trimester when the baby begins to store iron.
Anemia is very common during pregnancy ranging from 17% to 31% in Europe and North America, 44–53% in South East Asia, and 53–61% in Africa.
To examine the effects pregnancy has on a woman’s iron stores, researchers divided women into those who took iron supplements and those who didn’t. The ones that did not take iron (except for prenatal vitamin), had decreases in serum ferritin levels and by 28 weeks’ gestation and this was associated with erythrocyte microcytosis (smaller red blood cells) the last trimester. About 6 months after the pregnancy, ferritin levels were significantly lower than at the beginning of pregnancy.
Yet the women taking iron had no such changes and that includes a decrease in ferritin after pregnancy.
Not only does pregnancy decrease iron stores, but it also takes time to recover.
Women with back-to-back pregnancies may be at higher risk of low ferritin. And some may not recover from the decrease in ferritin especially if they start regular periods soon after pregnancy.
Other factors to consider
There are other risk factors for low iron such as being a vegan or vegetarian, frequently giving blood, and intense exercise.
Vegetarians are at increased risk because the iron in plant foods isn’t absorbed as well as animal sources. In a meta-analysis examining 13 studies, vegetarian women with low ferritin (<12mcg/l) ranged from 12% to 79%.
Another risk factor for low ferritin is regular intense exercise like running. Women involved in intense training may also have increased iron losses in sweat, urine, the GI tract. Also due to increased workload, their muscles and lungs require more oxygen.
According to an ACSM position stand:
Regardless of the etiology, a compromised iron status can negatively impact health, physical and mental performance, and warrants prompt medical intervention and monitoring. Iron requirements for all female athletes may be increased by up to 70% of the estimated average requirement. Athletes who are at greatest risk, such as distance runners, vegetarian athletes, or regular blood donors should be screened regularly and aim for an iron intake greater than their RDA (ie, >18 mg for women and >8 mg for men).
Iron supplementation in women of reproductive age has been found to aid exercise performance and lower heart rate.
Midlife is the perfect storm for iron deficiency
Using myself as an example, midlife was the perfect storm for depleted iron stores. Even though my intake of iron was adequate, having two pregnancies back-to-back followed by years of ample menstruation mixed with intense exercise meant the iron in my diet wasn’t enough to keep up with the demand and losses.
The loss of iron often accelerates at midlife. When women enter perimenopause they are likely to experience heavier and erratic cycles. According to one study of 1300 women aged 42-52, 25 percent said they had 1-3 occurrences in a 6-month period of 10 plus days of bleeding and 78 percent said they had three or more days of heavy flow during cycles. Many women had spotting and/or heavy bleeding in between irregular periods.
“This was me! My iron was so low, that my hair started to fall out,” said Irene, a midlife woman. “During a routine dentist appt (yes, the dentist) she advised to me ask for biotin, iron, and vitamin D and B12 test. I pushed for those and my dentist was right. My iron count was in the single digits.”
When women like Irene have symptoms of low iron, they may think it’s just symptoms of perimenopause and don’t seek help. Even worse, is that doctors usually only check for anemia and not ferritin levels. Or even worse than that, women get their ferritin checked and are told it’s normal even though it’s too low to function optimally.
When a normal ferritin still means low iron
As I was searching for answers I came across a very interesting paper by an internist at Eira Hospital in Helsinki Finland, Esa Soppi. He makes a convincing case for the problem of iron deficiency without anemia. He writes:
During my 30-year carrier as an internist with a special interest in thyroid diseases and hematology, I have met hundreds of patients, mainly menstruating females, who seek advice because of prolonged (1–25 years) fatigue, brain fog, muscle and joint pains, weight gain, headache, dyspnoea, palpitations, sometimes associated with sleep disturbances, arrhythmia, lump in the throat or difficulty in swallowing, and restless legs.
He goes on to explain how many of these women had different diagnoses like fibromyalgia, hypothyroidism, depression, and migraine because the symptoms are very similar, and they were told their ferritin was in the “normal” range.
Most surprising is that based on his experience, he believes that ferritin concentrations as high as 100mcg/L can still indicate low iron status. Dr. Soppi says as long as women have symptoms of iron deficiency, it’s worthwhile to supplement with iron. He puts it this way:
If symptoms are in accordance with iron deficiency, the patient should be considered iron deficient at least up to a serum ferritin concentration of 100 mcg/L, or even much higher, if the patient has an inflammatory condition, kidney disease or fatty liver. Iron deficiency irrespective of manifestation should always be treated. Patients with true iron deficiency anemia on the basis of negative bone marrow iron staining may have a serum ferritin concentration close to 50 mcg/L. Patients with restless leg syndrome should be considered iron-deficient when their ferritin concentration is <75 mcg/L.
Adding to the problem is iron deficiency can negatively impact the thyroid since it’s required for thyroid hormone production and the conversion of T4 to T3. That also means that thyroid problems can cause low iron making knowing your ferritin if you have thyroid problems especially important.
“I have found that low ferritin levels have been the missing link in some patients with hypothyroidism who just can’t seem to get their thyroid levels in balance,” writes Dr. Hedberg, D.C. a functional medicine doctor who specializes in thyroid issues. “If you have a thyroid problem, definitely have your ferritin levels checked to make sure your ferritin is not too high or too low.”
It’s important to note that ferritin levels can increase when there’s an infection or inflammation, which happens about 10% of the time. Additionally, some people absorb too much iron because they have hemochromatosis or other health condition. This is why it’s important to have an entire iron panel done and consult with a doctor. Especially looking at transferrin saturation. Anything less than 20% is linked to iron deficiency and when it’s great than 45%, iron overload.
How much to take?
Faced with a ferritin of 10 and anemia, I couldn’t believe my doctor recommended a multivitamin with iron (now ex-doctor). Research shows iron in a multi is not as effective in bringing up iron as iron alone.
As for goals for my ferritin level, without a baseline level, I went with the advice from Dr. Soppi and watched my symptoms.
Although it’s still common for doctors to prescribe high levels of 100-200mg of elemental iron throughout the day, high doses often result in GI disturbances like constipation and nausea. And research shows less iron (60-80mg elemental) taken every other day may be tolerated better.
That’s because when the body gets flooded with iron it releases more of the hormone hepcidin, which suppresses iron absorption. In one study women were getting iron every day or every other day for 14 days. The total absorption in the everyday iron group was 131mg versus 175mg in the alternate-day group. Serum hepcidin was higher in the everyday group.
I took 65mg every day and eventually switched to every other day. My levels went up fast and I have found that ferritin of at least 50mcg/L keeps my symptoms away. Other research points to that 50 cut-off too. To maintain that, I take iron once a week and a couple of times during my cycles.
In one study, weekly iron for 16 weeks of 60mg elemental iron (check labels) was enough to raise ferritin from 27.97 to 45.45 in adolescent girls.
When possible, take iron one to two hours before or after a meal and avoid taking it with milk, caffeine, calcium, or antacids. Taking it with 250mg vitamin C will help it absorb better. See this article for information on iron infusions.
Remember that iron supplements usually come as ferrous sulfate. You want to check the amount of elemental iron. For example, 325mg ferrous sulfate contains 65mg elemental iron. Keep iron pills away from children.
What about diet?
The RDA for iron for women under 50 is 18mg and that drops to 8mg after 50. When it comes to iron deficiency with or without anemia, this amount is not enough to raise levels. I eat well-rounded meals with iron sources of both plant and animal origin and plenty of vitamin C.
A 2015 study in The Journal of Nutrition found that absorption rates of iron may not be as high as we think. Researchers found a 15% absorption rate, lower than the 18% typically cited. Absorption from plant foods is about 5-7% and animal foods 25%. The researchers write:
Despite global efforts to improve iron nutrition in at-risk populations, iron deficiency anemia remains a challenge. In the United States, the prevalence of iron deficiency is high even at the present in certain populations, even when the diet is high in heme iron and most foods are fortified with iron. One possible explanation for this persistent deficiency is that the bioavailability of iron in the diet of Americans has been overestimated.
If you want to increase iron, adding animal foods makes sense but women at midlife may find this isn’t an ideal health goal. Additionally, healthy plant-based foods contain iron inhibitors such as polyphenols, oxalates, and phytates. Foods and supplements rich in calcium and eggs are inhibitors as well.
Yet supplementing can easily help fill the gaps and it’s easier to take iron without food and additional vitamin C. I’ve learned the hard way that a little extra iron goes a long way.
Know your ferritin
This whole experience just made me upset as so many girls and women suffer needlessly. Shouldn’t we all be educated about the importance of ferritin at some point in our lives?
It’s true that as women stop menstruating their risk of iron deficiency decreases. Yet according to the aforementioned study, it can take ferritin five years to return to normal without taking iron. Also, one of the big four could still cause low ferritin although it’s less likely.
I hope there’s a day where we will know our ferritin just like we know our cholesterol. Then, just maybe, we can get control of the world’s leading nutrition deficiency.
Do you know your ferritin?
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This was so helpful! I’m a dietitian but I don’t look at ferritin either. This post caught my eye because I’m fatigued lately, so I looked it up and my ferritin is 22. My lab says above 20 is normal, but I wonder if an iron supplement would help. I give blood a lot. Anyhow, interesting! Thanks for sharing.
Most cut-offs I’ve seen for iron deficiency are 30 or less. Studies show that 50 or less can cause symptoms and when iron and bone marrow decreases. So considering you give blood and you are tired with a level of 20, taking iron every other day can be helpful. I’ve found a level of 50 is the amount needed to keep my symptoms away.
My annual physical labs showed the Ferritin Iron level at 43. I felt that low, when the range is 11-307. I am age 65, post menopaused around age 50.
Some upper ranges are 150. If you don’t have any symptoms like feeling tired etc it’s probably fine. Do you know what your iron saturation is?
wow really interesting read, my ferritin has been up and down over the years,highest being 23 and recently 11, I took it was pre menopause all my symptoms but now thinking could be my low levels?
Yep that was me. Correcting iron eliminated my symptoms. Are you taking iron now?
I have a daughter who just started her period and will be 12 in July. She plays sports 2-4 days a week. She constantly complains of fatigue despite other changes (limiting screen time before bed, etc). It would be a struggle to get her to have blood drawn to check her ferritin. I’d like to try her on some iron – what would you recommend? You mentioned the 60 mg elemental weekly for adolescent girls. Would that be a good starting place?
You could try that or 27mg elemental iron twice a week. Also, be sure to give it to her when she’s on her period at least once as more is absorbed. Monitor her symptoms and see if it helps.
Thanks! Ironically I just had mine tested and my Ferritin is 7! My doctor (I see a naturopath) is recommending iron infusions, 3-5 of them every 1-2 weeks and then start oral iron. She said that it could take 6-12 months for my Ferritin to get above 50 with oral supplements alone. What are your thoughts on that?
From what I’ve read it’s better to start with oral iron therapy first and if that doesn’t bring it up go with the infusion. My ferritin was 10 and went up pretty quickly with oral iron.
I recently received my ferritin levels and they are at 8; what oral iron would you recommend to bring levels up quickly?
I would take 65mg elemental iron with 250mg vitamins C two hours before or after eating. What did your doctor recommend?
Very helpful read! My college daughter had a lot of health issues her second semester of college and had to drop out of a lot of things due to headaches, fatigue, tachycardia when standing, cold hands, chest pains, brain fog, dizziness, etc. Recently a doctor started treating her for POTS, which has a big overlap of symptoms with iron deficiency. She finally got her blood work tests back. Her ferritin level is 25, and in her portal where she can see see the results, her cardiologist said to start “Ferrous Glyconite + Vitamin C & B12 (OTC) 1 tablet daily or a Flintstones Multivitamin with iron.”
I was quite surprised by the Flintstone Multivitamin suggestion, but evidently that is somewhat common for POTS patients to increase their iron. She already takes a women’s multivitamin.
We did get the Flintstone vitamin, but I am thinking about switching her to getting the separate vitamins. the doctor has her on Pepcid to try to help with POTS, and my daughter has been taking that the same time as her multivitamins, one in the morning and evening. I’m guessing she’s not really getting the iron she needs this way? If she doesn’t get an increase in energy, there is no way she will be able to return to college.
I’m not sure about what is recommended for POTS. But I would also check her folate and B12. Maybe talk to her doctor about holding hold off on the pepcid until you see her iron go up? I would think if you do everything at once you may not know what is working. Plus, pepcid will likely decrease iron absorption. Also, I would take the iron separately from the multivitamin. Good luck!
This article is very interesting. https://www.healthrising.org/blog/2016/11/19/iron-man-pots-chronic-fatigue-syndrome-recovery-ferritin/
This is great info. I have been going to the doctor for years complaining of tiredness, shortness of breath, achy muscles, headaches , etc. – not once were my iron levels checked, I am 43 for context. Finally in March of this year a doctor thought to check them- I was at 7! I have been taking iron supplements since the end of April and now a month later I’m at 18. Still low but definitely much better. I also noticed I am not getting many of the symptoms noted above anymore, with the exception of tiredness. I agree that this needs to be checked for women on a regular basis, and I can’t believe it took so long for a doctor to check this.
I’m so glad you got the test and are feeling better! This really needs to automatically be checked in all women!
Such a great read. Thank you! Question in less than a year my levels went from 95 to under 50. I’m starting to have symptoms. Can you share brands of ferritin, vitamin c and dosage recommendations?
Thank you:)
Thanks! Generally taking 65mg elemental iron in the form of ferrous sulfate every other day (I use Nature Made brand). Take 250mg vitamin C 1-2 hours after/before eating. Check your ferritin and symptoms and once they get back to normal you can probably get by with a weekly dose of the iron perhaps taking it every other day during your menstrual cycle. Let me know if that makes sense.
Very interesting! Ironically, my dr. recently suggested an iron supplement for me because she said my iron is low. I have struggled with chronic fatigue, brain fog, lack of concentration, memory and anxiety for as long as I can remember without ever finding a real cause. My ferritin is 50 though. Is it still safe/suggested to supplement to see if that helps symptoms? I know you said 50 was your magic number to relieve symptoms, but is it safe to aim for higher? How much do you suggest I take? Thank you!
The upper level for ferritin is 150 so it can’t hurt and the study I mention says anyone with 100 or less with symptoms should try iron. I would also screen for B12 and folate as they can cause symptoms as well. I hope you figure it out!
After years of fatigue, hair loss, brain fog, I went to my compounding pharmacist who was an expert at analyzing thyroid labs. I took labs that was previously done by my doctor but the pharmacist recommended I get a ferritin and insulin test. My ferritin was 15 and normal lab range was 16 – 288. No insulin problem. My thyroid wasn’t making enough T3 and not using B12. He recommended iron bis glycinate. It is recommended I take with meals. Not on empty stomach. Is this ok?
I think that form is better absorbed so it doesn’t matter so much. The key is to check your levels to see if it’s working. Glad you figured things out!
Thank you so much for this article. I don’t understand how doctors don’t take this more serious. It’s something that can be improved easily but its being ignored. For years my ferritin levels have been below 15, yet 3 different doctors told me that I don’t need supplemental iron. The first my ex-primary to whom I went for symptoms of dizziness, fatigue, anxiety and heart palpitations. She said its all in my head and i need to get my anxiety under control. I did not pick up the Lexapro prescription she gave me. Next was my gyn who told me its probably perimenopause causing all the symptoms. New primary is also a cardiologist and also said ferritin of 14 is normal ! He said that its dangerous to take iron when its not needed. Nevertheless I would like to try taking iron supplements but have a very sensitive stomach, which makes me a little nervous about taking iron on an empty stomach. Any suggestions which kind or brand to take? Thanks.
I’m so sorry to hear that. I really hope more doctors become aware as this is such a common issue. Thorne has an iron bisglycinate which is supposed to be tolerated better and I think you can take with food (and don’t need as much). You can take it every other day too.
https://www.thorne.com/products/dp/iron-bisglycinate?gclid=CjwKCAjwt8uGBhBAEiwAayu_9QEL8c9fzOJBNjJlt9G0VPY75OmNUJAAnerK2njuCFXaCx5-HtKNjxoCEUwQAvD_BwE
Hi Maryann,
Thank you for providing such a thorough write up about Ferritin. I am a 35 year old woman, who is training for a 100 mile ultramarathon. I have done several long ultras in the past couple of years. My Ferritin was in the 20s, then got up to about 45 with taking supplements daily. A few months ago, it dropped down to 35. My new primary is not concerned, but I get the fatigue and “sucking wind” feeling more than I should while running. I have been pescatarian for about 12 years, which I know is not as ideal for iron intake. Would you recommend switching to taking supplements EOD instead of once a day? I am a little confused about that part of the article.
Thank you!
Becky
Yes taking every other day ends up with higher absorption. How much are you taking?
Hi,
Currently pregnant and my ferritin has been steadily dropping (104 in June, 61 in July, 24 now). However, my iron serum level is 154 which is above the normal range. Is there a way to only increase ferritin levels? I’m concerned about taking additional iron when my iron serum levels are already above normal. Obviously, I’m also asking my OB about this as well.
Did you get an entire iron panel done? Do you know your iron saturation? With your doc aid look at all your numbers on the iron panel.
I’m 42 and had my levels checked in July. My iron came back normal but my ferritin levels were abnormally low. Doctor said take an iron supplement year round. How long until I see improvement? I did call & will go this week for blood work again. I don’t feel any difference. I’m desperate for relief. Showering, walking up stairs, any simple activity makes me feel exhausted & needing to sleep. It’s impacting my life as I’m not able to work when I should. I literally have to force myself to do anything. I have hair loss, GI upset, my heart beats so fast etc. should I be asking for blood work to check my hormonal levels since I’m 42?
Yes, you should get your ferritin checked to see if it’s working.
Hi Maryann, This was so interesting to read because about 20 years ago my iron level was 6 and I had all those symptoms. They put me on iron and this past May I felt the same way again after being on iron for approximatelIy 20 years. (They immediately made me stop the iron supplements) I went to the Dr. and explained my symptoms and she ordered a Ferritin test right away. They had never done one before this. My ferritin level came back at 972. They have tested me 5 times since May and it went down to 907, then 824 and then 817 and this past week up again to 1,018. They tested me for Hemochromotosis and they have checked all blood test you can think of and everything is normal. My iron is even normal and they just tested my C-reactive protein and it was fine and my Sed Rate and it was fine. If you have any ideas of where to get better information about high ferritin please let me know. I have looked at just about everything. And yes, please ladies, make sure they keep checking your ferritin levels. May was the first time they had ever checked mine. Thank you, Mikki
A family member of mine had high ferritin so I’ve looked into this. I’m not sure if your testing for hemochromatosis included genetic screening or if they just checked your iron saturation. If you didn’t consider getting the genetic testing, as there is something called Ferroportin disease that can cause high ferritin but normal iron saturation. Another factor that can cause high ferritin is alcohol consumption. I read that if you stop drinking for two weeks that may decrease it considerably (that is if it is due to alcohol). Also, I would also look into Nonalcoholic fatty liver disease (NAFLD). Those are the factors I found in my research. Good luck!!
I had high ferritin for no apparent reason and then I had my breast implants removed, and guess what my ferritin went back to normal (extremely low, but no longer high). I read an article that stated, infection and inflammation can both cause high ferritin levels. I know the implants were causing a lot of health issues, including inflammation.
Yes, inflammation can cause ferritin to increase. Glad you got it taken care of!
Thank you!
Hi!
My 18 year old daughter seems to have unusual iron panel results. She went to her doctor with fatigue, anxiety, lack of concentration, etc. Her iron panel results are:
IRON, TOTAL 192 (HIGH)
IRON BINDING CAPACITY 363
% SATURATION 53 (HIGH)
FERRITIN 16
All CBC, CMP, CRP, and TSH were in the normal range. She showed slightly low Vit. D (25) and low-normal B12 (311), normal Folate. Her ANA IFA screen and Celiac were negative.
(A couple of years ago, her ferritin level was at a 6 but it was brought up by taking iron supplements for a few months.)
Recently she had been taking a Women’s Multiple vitamin that has iron in it, a few times a week. We’re wondering how to help her bring up her current Ferritin levels (16). Her doctor says NOT to take any iron products because of her high iron levels. Any thoughts?
Thank you!
I’m sorry I took so long to reply. Those results are puzzling because usually when %sat is high so is ferritin. I would ask to repeat the test and be sure it’s fasting. If you get the same results, you may want to ask for a referral to a hematologist. Has she had a peripheral blood smear?
Thank you so much for your response! I, too, find the results puzzling. Her doctor thinks it’s all okay.
I will have her ask to repeat the test. She hasn’t had a peripheral blood smear but will have her look into that as well. And if her primary doctor doesn’t help her, I’ll have her see a hematologist.
Thanks again!
Your welcome and good luck. Often, we have to fight for answers!
Thank you for this wonderful article! I have 2 questions:
1) Does levothyroxine affect iron absorption? I’ve been doing a trial test of the medication. I have normal thyroid labs, but many symptoms of hypothyroidism, so my doctor thought it was worthwhile to try a low dose for a few months. It’s been 6 months and my Free T4 is too high now, so I’m weaning off the medication. The only symptom I saw improvement with was restless legs, which made me think of iron. After starting the medication, the restless legs decreased from nearly every night to now only just around my period. My ferritin test before starting the medication was 42, but I haven’t had an updated test yet. (Quite a few years ago, I had a ferritin test and it was 20.) I’m wondering if my symptoms are due to an iron deficiency and not a thyroid problem.
2) I have a very heavy period. Is there a best time during your cycle to get an iron panel done?
Thank you!!
I’m not sure about levothyroxine and iron absorption, but low iron can negatively affect thyroid health. So can iodine, selenium, and vitamin A. While you should talk to a doctor, from what I’ve read levels of ferritin >75 may be needed for RLS to be resolved. I would get blood drawn at around the same time in your cycle. I think about 2 weeks after your period is good but as long as you do it at the same time, you should be fine.
https://www.frontiersin.org/articles/10.3389/fneur.2020.00298/full
Thank you! Is it important to be fasting when you have an iron panel done? What about just ferritin? I noticed that the study by Esa Soppi mentions fasting. I have difficulty with that though (I live out in the country far away from the hospital and am mildly hypoglycemic — by the time I’m at the lab for a blood draw, I’m jittery and extremely fatigued.) Is it possible to get a good reading on ferritin if you’re not fasting? The two ferritin tests I’ve had in my life were non-fasting. Does that mean that the results aren’t as true as they could be?
I looked it up because I forgot to fast before iron tests and it doesn’t matter for ferritin but it does for hemoglobin and hematocrit. I think the key is to do the same thing you’ve always done to keep things consistent.
Thank you!
Hi Maryann,
Thank you for your helpful article, and for your responses to everyone’s questions!
I have had three iron panels in the past year.
My serum iron ranges from 208, 181, and 187 (range: 40-190 mcg/dL), with % saturation of 60%, 49%, and 57% (range: 16-45%). The ferritin results were 22, 18 and 27 (range: 16-232 ng/mL).
Do you have any ideas how I might raise ferritin? Does it matter if my ferritin is low when serum iron is high?
I’ve been tested for iron throughout my life (I’m a vegetarian) and every doctor was surprised how high my iron was. Of course, they had never tested ferritin until a few years ago!
Hi Maria. Typically iron overload (hemochromatosis) is suspected when iron Sat >45 And ferritin >300. I’m not sure what having high iron sat and serum iron but low ferritin means. Basically your blood iron is high but storage iron is low. I’m not sure if taking more iron will help increase ferritin or just make serum iron high. Personally, I would ask for a referral to a hematologist to get clear on this and rule out any iron condition before working on your ferritin. Good luck!
Thank you! I will ask for a referral to a hematologist.
Thank you so much for this article! I have had difficulty swallowing for 4 years now and the past year it has gotten much worse. I can only have smoothies. I cannot eat solid foods. I had many tests (GI Doctor) done last December and the doctors could not figure it out. I’m pretty healthy except I cannot swallow. I have had low ferritin for years now due to heavy periods, do you think this could be what is causing my dysphasia?? I have been praying for an answer. The last time I had bloodwork was is March 2021 and since then I feel like it’s become even worse. Maybe it’s the 20 vials of blood they took when I was already deficient?? My iron results from that test were as follows:
IRON, TOTAL 52
IRON BINDING CAPACITY 340
% SATURATION 15 L
FERRITIN 8 L
Is this considered iron deficient or am I actually anemic? And I’m assuming that my levels are even lower after this test considering they took 20 vials of blood… would that probably be accurate? I also have off and on fatigue and restless leg syndrome that has started just this year. Your thoughts would be greatly appreciated! Thank you!
Did your doctor recommend iron supplementation? Based on those numbers with low %sat and ferritin under 10, you probably were anemic. I think swallowing can be affected by low iron and getting your numbers better should help. Find a better doctor!
There was not a huge concern over my iron status, nor did they mention iron deficiency or anemic. Thanks so much!
Hi,
Thank you for this article. I am not a doctor or dietitian, but it was the exact thing I wanted to write after recently finally having my ferritin and vitamin D tested and they were both low (10 and 21), but my iron is normal. I was told to take iron supplements and try to add iron to my diet and a vitamin D supplement. How long after supplementation did you start to feel better? Particularly with fatigue and brain fog, fatigue, and difficulty concentrating? I am a marathon runner and have been struggling to under why I get so tired and can’t maintain my former paces.
Every woman needs this information and it is an easy test to check.
Thanks,
Angi
It took 2-3 weeks after I started supplementing to feel a difference. That’s how low my ferritin was too. I hope you feel better soon. I agree that it’s just ludicrous women suffer needlessly.
wow! this article was very helpful and so informative. I too was having symptoms such as rapid heart beat, palptations, headaches, anxiety, head fog, muscle and joint pain,irritability, sleep disturbances and hair loss that are all still happening.(pretty much every symptom you can have) I informed my doctor of this which triggered him to do bunch of labs and guess what?? My labs showed low ferritin of 9!! (I’m 47 years of age)just got over Covid-19 about 3 months ago and thought some of these symptoms were related to that ,I’m what they call one of the long haulers. but after checking my ferritin I’m now thinking otherwise, what are your thoughts? by the way these are the rest of my labs below….
iron is 42mcg
total iron binding 389mcg
% iron saturation 11%
unsaturated Iron binding 347ug/dl
I was prescribed 325mg of ferrous sulfate 2 X a day, taking it with 500 mg of vitamin C for better absorption. I started these on November 19th,2021 when should I get retested? I know it takes a while for these levels to go up. I heard 3 months! Ugh!!? I’ve also added more iron to my diet such as spinach,nuts,cereals high in iron.
I’m hoping my levels climb up quickly as my hair is falling out making me me more anxious. Help with any advice.
I’m glad you got tested! You’re numbers show you need iron. I’m sure covid decreased your iron and is a big part of your symptoms. It’s up to doctors and the earliest they check is 6 weeks. Doctors still give high levels but recent research shows taking once a day and even every other day may increase absorption. If you have GI problems or get constipated then you can lessen the dose.
thank you so much for your fast response! I cant wait to feel better and yes I thought the COVID was related to my symptoms. so far no GI issues, weird because I suffer from constipation and it hasn’t affected me. could be because I’m also adding some fiber and lots of water to my diet.. I just cant wait to be able to sleep without interruptions, I feel so exhausted! looking forward to many more of your articles. Ill come back an update you on my progress;) thanks again.
Hi,
Thanks for the article. About four months back my hemoglobin came back as 9.4 and ferritin 1. After oral iron supplementation..my hgb increased to 15 and ferritin 25 within a month or two. But after that, it just wasn’t increasing. So my hematologist suggests I get iron infusions to boost it to a level of 100 atleast. My question- why am I not able to increase ferritin via the oral route above 30 even though I had initial success?
I used to have moderate periods lasting 6 days every month. But it became lighter over the last year or two. I have no idea why. And not sure if this is the cause of my low ferritin. And I am a vegetarian, have mild chronic gastritis and on PPI since a year. Not sure if it is a combination of factors.
My main symptoms seem to be lightheadedness, fatigue and hair loss. I hope once I get the infusions, these symptoms will get better. Mainly, I wanted to check with you about lightheadedness and whether it is a symptom of low ferritin. My heart, brain, BP, glucose, thyroid, CMP, CBC all checked and they are fine. No other health issues except GERD and gastritis.
Manesa – PPIs can affect the absorption of iron because it changes the PH of the stomach so my guess is that is playing a role. Have you looked into other ways to handle your gastritis? PPIs are not meant to be taken long-term. Perhaps see a dietitian who specializes in GI disorders. Sometimes it’s a lack of stomach acid and finding ways to increase acid can be helpful. It could eventually affect the absorption of vitamin B12, zinc, and other nutrients so it’s worth looking more into.
This is from Linus Pauling
“Vitamin A deficiency often coexists with iron deficiency and may exacerbate iron-deficiency anemia by altering iron metabolism (15). Vitamin A supplementation has been shown to have beneficial effects on iron-deficiency anemia and improve iron nutritional status among children and pregnant women (15, 16). The combination of vitamin A and iron seems to reduce anemia more effectively than either supplemental iron or vitamin A alone (17). Vitamin A may facilitate the mobilization of iron from storage sites to developing red blood cells for incorporation into hemoglobin.”
I am a 45 year old female. I got a hysterectomy in 2018 because my periods were so bad that my ferritin level dropped to 7. I got iron infusions and unfortunately they did not help so I opted for the surgery.
So a month ago 1/22 I went to see my Dr. because I have been experiencing tiredness, weakness, low libido, brain fog. Lab work reported ferritin was high at 290. I did some digging into my medical record and saw that it was also high in 2017 at 492, but it was never discussed with me and it dropped to low a couple of months later, maybe after my period. I found out that my fraternal grandmother had iron overload and died of liver cancer. Should I be concerned?
Hi Vicky. Having heavy periods can mask hemochromatosis (iron overload) because you are losing blood. I would follow up with your doctor. I believe having a ferritin over 300 and iron saturation that is above 45% mean you could have hemochromatosis. They usually do genetic testing to make a final diagnosis. Good luck!
And since you have a family history you might want to have the genetic testing done regardless
I was diagnosed with a ferritin level of only 11 a month ago. I had symptoms earlier on, chronic fatigue especially during my period, hypersomnia. Constantly tired despite sleeping over 12 hours, nails breaking in the same spot. I knew something was up, but I just thought it was because I was getting older. Fast forward to a month ago, when I stopped being abled to sleep. If I did sleep it was fragmented and unsatisfying. I’ve been on 65mg vitron c for about 3 weeks now. I got desperate for sleep and upped it to twice a day, but I think I will lower it again. I now can at least sleep normally every other day, but it’s still very much torture the days I cannot. It seems insomnia is a rare symptom, but it’s the one that got me to take this more seriously. I hope I can sleep again, because this is really impacting my life negatively.
So sorry to hear that! For maximal absorption perhaps take two every other day. A hormone called hepcidin increases the day after you take over 60mg iron lowering absorption. Hang in there!
Thank you so much for this article! I’m a 33 year old woman who has struggled with fatigue for most of my adult life. Recently the fatigue has gotten so extreme that I have to lie down in bed multiple times a day. I just went to the doctor and got my blood tested, and my ferritin levels came back as 5. Last year when I was tested they were 7.9, which my doctor, when asked, said was a “bit low” so it would be ok if I took OTC supplements. I’ve been taking supplements for a year and apparently they haven’t even been able to maintain my levels, let alone raise them! My hemoglobin levels are on the lower side of normal, which is maybe why my last doctor didn’t pay attention to the ferritin. I also struggle with chronic gastrointestinal issues and take antacids daily, which may be why my body is having a hard time absorbing the supplements. Do you have any advice for when I speak to my doctor about these results to help actually get the care I need? It sounds like it would be really great if I could at least start with an iron transfusion, just to get my levels to a less dangerous place, especially since my stomach is already so sensitive, but I’m not sure if a PCP will be able to do transfusions, or if my insurance will cover it since my hemoglobin levels aren’t low.
IV iron is much safer than before with ferric carboxymaltose. With your levels I believe they have to do something. <10 is the same as anemia. You can send his this review https://ashpublications.org/hematology/article/2016/1/57/21060/Single-dose-intravenous-iron-for-iron-deficiency-a
Let me know how it goes. Where did you leave it with your doctor?
Hello, I appreciate the article as well. I’m a 45 year old woman with moderate periods that always last 5 days. I was vegetarian for a few years & that was not good for my health & I’ve been paleo since ‘15 & eat grassfed beef daily. I also tend to do high intensity exercise. My anemia work up consists of only iron which has been between 68 up to 147 depending on the time of the month I guess & my ferritin has consistently been around 35 give or take a few points over the last few years. HGB is always around 14.5 to 15.2. I’ve suffered on & off with severe bouts of dizziness/vertigo, fatigue (yet I can workout hard at the gym), & anxiety.
I’m seeing an NP now & we did a hair mineral analysis that says I have low iron levels so she recommended I take an iron supplement til we retest in 3 months. I ordered the Thorne iron bisglycinate & will try every other day.
If it were you, would you do the iron saturation test before taking the iron to be sure I need it or is the 35 ferritin & low concentration in the hair analysis enough to confirm the need for supplementation? I also have low hair concentrations of copper, manganese & a couple other minerals so I’m taking Thorne bisglycinate versions of those. Apparently, low copper makes you unable to utilize iron. So it’s possible addressing copper & other mineral deficiencies will at the same time address low iron
utilization.
I’ve noticed in the short time that I’ve taken the minerals including the iron that I feel stronger at the gym, but strangely I find it harder to get out of bed first thing in the morning.
Thanks again!
According to Esa Soppi paper mentioned in the article, anyone with a ferritin below 100 and symptoms of iron deficiency should try iron. Since you are checking in 3 months you can then look at your levels. I would also do a complete iron panel to get a better picture, maybe next time. Your hemoglobin is on the higher end of normal which is shows it hasn’t depleted but I’d be curious what it is next time you test.
I just read the book ‘Dumping iron’ by PD Mangan and now I am so confused again. He says that for women the healthiest iron range is 20-40 (mcg/l I think) and that the higher the ferritin is above that, the greater the health risks+damage. Because as ferritin rises, free iron rises as well which causes a lot of oxidative stress etc. He says that as long as your hemoglobin is high enough, you’re good. I don’t get anyway why you say that you can get symptoms when your ferritin is low(ish) if you’re hemoglobin is still good? That’s what it’s all about right? Ferritin is just iron in storage, it’s not doing anything for our health as long as it’s in storage?
I can’t speak for the book but I would simply check what research is being used to support 20-40 ferritin levels are ideal. In people without blood disorders like hemochromatosis, the body is tightly regulates blood iron. It binds to transferrin so it can’t do damage as free iron.
The way to think of ferritin and storage of iron is having money in your savings. Some months, you may need to access your savings. When you have good savings, you feel comfortable spending and doing things you want to do. But if your savings gets too low, you will cut back. This is what your body does with iron. Iron is not just about hemoglobin and transferring oxygen although that is its most important function. It’s involved in over 180 biological reactions in your body including the brain (neurotransmitters), thyroid, the heart and muscle. When iron goes low, it will always prioritize hemoglobin first which is why anemia is the final stage of iron deficiency. Please click through the research I cite to check for yourself, including the articles by Esa Soppi.
A high ferritin is not good for people either but it usually occurs because of inflammation, hemochromatosis (or other blood-regulating disorder), metabolic issues etc. But that is when it is higher than normal levels. It’s possible to be low in available iron and have a normal or high ferritin if you have inflammation.
I hope that explains where I’m coming from.