I had two children right before I turned 40, followed with regular, ample periods for 10 years, and I’m a runner. This combination of risk factors–of which no health professional asked about - led me to iron deficiency anemia right at 50. I thought my heart palpitations, swallowing problems, intermittent high heart, driving anxiety, periodic dizziness, and fragmented sleep were due to changing hormones. Nope, it was a lack of iron. Once I was anemic, my doctors then checked my iron stores (ferritin), which was 10 mcg/L. When I looked back at my labs over the years, I could not find one ferritin. Not one!

Research suggests that symptoms of fatigue can occur when ferritin dips below 50 mcg/L, much higher than the World Health Organization (WHO) cutoff of 15 mcg/L and the National Institute of Health cutoff of 30 mcg/L. Although current guidelines call for anemia screening, IDWA is three times more common. By the time doctors diagnose a woman with iron deficiency anemia, defined as a hemoglobin of less than 12 g/dL, she is in the third and final stage of iron depletion. Ferritin is the gold standard for diagnosing iron deficiency. It reveals the amount of stored iron which works like an iron savings account for your body–when it runs low, you’re in trouble.

The public health epidemic of IDWA occurs mostly in women due to iron loss during the menstrual cycle and those who become pregnant. According to recent findings, 40% of women have a ferritin of less than 25 mcg/L and 80% less than 50 mcg/L.

IDWA not only hurts women, it strains the healthcare system. A significant number of women (46.6%) receive psychotherapy, medical therapy (think heart tests for palpitations) and medications for symptoms later to discover iron deficiency caused them. Making matters worse is the longer a woman has been iron deficient, the harder it is to treat. 

Although best known for its function in making hemoglobin to transport oxygen, iron is part of 180 biochemical reactions. These include thyroid hormone synthesis, immune function, DNA synthesis, neurotransmitter synthesis and cellular respiration in the muscles, heart, and energy metabolism. The same way a declining savings account forces people to spend less, the body pulls back on these functions to conserve iron for oxygen transport.

In fact, many diseases linked to iron deficiency have a high female to male ratio including thyroid dysfunction (8:1), fibromyalgia (8-9:1), chronic fatigue (4:1), IBS (2-2.5:1), depression (2:1), restless legs (2:1), long covid (1.6:1) and allergies (1.4/1). In pregnant and reproducing women, iron deficiency increases the risk of overt and subclinical clinical hypothyroidism. Women with iron deficiency are 66% more likely to experience allergies and patients with restless legs, and a ferritin less than 75mcg/L, show improvement with iron supplementation. Then, we know iron deficiency has a known cost to both pregnancy and childhood health outcomes, including a higher risk of cognitive impairment and behavioral problems in children.

To build a healthcare system that supports women, as the White House Health Initiative for Women’s Health Research intends, universal ferritin screening must be implemented. In the summer of 2023, a group of researchers from Australia laid out what this could look like in the International Journal of Gynecology and Obstetrics:

·  Screen females every 5 years, starting three years after menstruation starts until menopause.

·  Start iron supplementation when ferritin falls <30mcg/L with 65mg elemental iron every day or every other day.

·  Three months after starting supplementation, individuals should aim for ferritin levels higher than 30 mcg/L and continue the supplementation until levels reach 50 mcg/L.

· If a patient fails to reach an initial ferritin level of 30mcg/L, the healthcare provider should consider IV iron.

The following additional points should be considered:

· Testing any woman who complains of fatigue, vertigo, heart palpitations, joint/body pain, hair loss, sleep issues and other iron deficiency symptoms with no other known cause.

·  Consider iron supplementation in women up to 100mcg/L who have iron deficiency symptoms, as ferritin can be falsely high because of inflammation.

·  Develop a research plan to determine optimal ferritin levels in women for health and well-being.

·  Educate medical school students and health professionals about IDWA so they understand that symptoms and problems occur well before anemia sets in.

Women - and their children - have suffered from IDWA far too long. Additionally, performing basic ferritin screenings will reduce healthcare costs by reducing disease burden and unnecessary tests. The White House Initiative on Women's Health Research is happening, making it the ideal time to address a major health concern for women.