“I’m exhausted all the time.”
It is something I hear regularly from women in clinic. Sometimes it is put down to a busy life, poor sleep, stress, work or simply having too much going on.
And sometimes those things are contributing.
But persistent tiredness, low energy or feeling unusually breathless can also be signs that your iron levels are low.
Iron deficiency is extremely common, particularly in women, and one of the things I think is important is not to simply accept symptoms such as fatigue as something you have to put up with. There is often a reason why your iron levels have fallen, and finding that reason is an important part of treatment.
Why do we need iron?
Iron is essential for making haemoglobin, the protein in our red blood cells that carries oxygen around the body.
When your iron stores become low, your body has less available iron to make healthy red blood cells. If the deficiency becomes significant, this can eventually lead to iron deficiency anaemia.
But importantly, you do not necessarily have to be anaemic to feel the effects of low iron.
Iron stores can become depleted before your haemoglobin falls outside the normal range, which means some women can experience symptoms even though they have been told that their blood count is “normal”.
Why is iron deficiency so common in women?
There are several reasons, but in my experience, one of the first things worth considering is menstrual blood loss.
Heavy periods
Every month that you have a period, you lose some blood – and therefore some iron.
If your periods are particularly heavy or prolonged, those losses can gradually add up. Over time, your body’s iron stores can become depleted.
Heavy menstrual bleeding can be associated with conditions such as:
- fibroids
- adenomyosis
- endometriosis
- hormonal changes
- some types of contraception.
One thing I would really encourage women not to do is assume that heavy periods are simply something they have to live with.
If your periods are affecting your energy, your ability to work, exercise or enjoy everyday life, they are worth discussing. Heavy bleeding can affect much more than just your menstrual cycle.
Pregnancy
Pregnancy places considerably greater demands on your body’s iron stores.
You need additional iron to support your growing baby and placenta, as well as the increase in your own blood volume.
If your iron stores were already low before pregnancy, they can become depleted more quickly.
This is one reason why iron levels are an important part of looking after your health during pregnancy and when planning a family.
Diet
Diet can also play a role.
There are plenty of good sources of iron in both animal-based and plant-based diets. These include:
- red meat
- poultry
- fish and seafood
- eggs
- beans and lentils
- chickpeas
- tofu and other soya products
- dark green leafy vegetables such as spinach
- nuts and seeds
- wholegrains
- iron-fortified breakfast cereals.
If you are vegetarian or vegan, you can absolutely get enough iron from a well-planned diet. However, the type of iron found in plant foods is absorbed differently from the iron found in meat and fish, so paying attention to the combination of foods you eat can be helpful.
Vitamin C can improve the absorption of iron from plant foods, so try combining iron-rich foods such as beans, lentils, tofu or leafy greens with foods such as peppers, tomatoes, citrus fruits, berries or broccoli.
There are also some foods and drinks that can reduce iron absorption when consumed around the same time as an iron-rich meal, including tea and coffee.
If you follow a vegetarian or vegan diet and are concerned about your iron levels, it does not automatically mean that your diet is inadequate. It may simply be worth reviewing what you are eating and, if you have symptoms or a history of iron deficiency, checking your iron levels.
Sometimes it isn’t your diet or your periods
Iron deficiency isn’t always explained by menstrual blood loss or diet.
Conditions affecting the digestive system, including coeliac disease and inflammatory bowel disease, can affect how well your body absorbs iron. Other gastrointestinal conditions can also cause blood loss.
If iron deficiency keeps coming back despite treatment, it is particularly important to look at why.
Sometimes iron deficiency is the first clue that something else needs investigating.
What does iron deficiency actually feel like?
Iron deficiency can develop gradually, which makes it surprisingly easy to overlook.
You might notice:
- feeling tired or lacking energy
- becoming more breathless than usual
- dizziness or light-headedness
- headaches
- difficulty concentrating or “brain fog”
- looking paler than usual
- heart palpitations
- brittle nails
- hair thinning or increased hair shedding
- restless legs, particularly at night.
These symptoms can have many possible causes. Women may understandably attribute them to stress, poor sleep, menopause, a busy lifestyle or simply getting older.
But if something doesn’t feel right, it is worth investigating rather than assuming you just need to slow down or get more sleep.
Can you be iron deficient without being anaemic?
Yes – and this is an important distinction.
Iron deficiency and iron deficiency anaemia are not exactly the same thing.
Your body’s iron stores, which can be assessed using a blood test called ferritin, can become depleted before your haemoglobin falls enough to meet the criteria for anaemia.
This means you may have symptoms associated with low iron even if your full blood count has been described as “normal”.
If iron deficiency is suspected, your clinician may therefore look at more than just your haemoglobin.
How do we check your iron levels?
Iron deficiency is usually investigated with blood tests.
Depending on your symptoms and circumstances, your clinician may request:
- a full blood count (FBC)
- ferritin, which gives an indication of your body’s iron stores
- additional iron studies where appropriate.
The blood test is important, but so is understanding why your iron levels are low.
If you have heavy periods, for example, simply replacing the iron without addressing the heavy bleeding may mean the problem keeps coming back.
How is iron deficiency treated?
Treatment depends on the cause and how significant the deficiency is.
It may involve:
- improving dietary iron intake
- oral iron supplements
- intravenous (IV) iron in selected circumstances
- treating heavy menstrual bleeding
- investigating and treating an underlying medical condition.
Some women begin to feel more energetic within a few weeks of treatment, but restoring your body’s iron stores can take considerably longer.
It is therefore important to follow the treatment plan recommended for you rather than stopping treatment as soon as you start to feel better.
When should you speak to someone?
I’d recommend speaking to a healthcare professional if you are experiencing:
- persistent or unexplained tiredness
- heavy or prolonged periods
- increasing breathlessness
- dizziness or light-headedness
- recurrent iron deficiency
- hair loss or significant hair shedding
- symptoms that are beginning to interfere with your everyday life.
And particularly if you have been treated for iron deficiency before and it keeps returning, it is worth asking whether there may be an underlying reason.
The bottom line
Iron deficiency is common in women, but that doesn’t mean it should be considered normal.
For women with heavy periods, the monthly loss of blood can gradually deplete iron stores without it necessarily being obvious at first. Pregnancy, dietary intake and conditions affecting absorption or causing blood loss can also play a role.
The good news is that iron deficiency is usually straightforward to investigate with blood tests, and there are effective treatments available.
If you’re constantly tired, struggling with your energy or finding that your periods are particularly heavy, don’t simply assume it is part of being busy or part of getting older.
Sometimes a simple blood test can provide an important piece of the puzzle – but the real goal is not just to replace the iron. It is to understand why you became deficient in the first place.