Back in 2014 I started feeling more tired than usual and was having difficulty concentrating. So, my doctor (ND) checked my iron and ferritin (storage form of iron) levels and ran a CBC (complete blood count). Lab reference ranges have a much wider “normal” range that varies between labs due to the patient population, differing criteria for selecting healthy populations, and your geographic location.  As you can imagine, what’s “normal” is not necessarily optimal! The normal reference range for ferritin from the lab that ran my test is between 12-263 ng/ml for a menstruating woman over 40 years of age. That’s a huge range! But the Functional Nutritionists and Functional Medicine practitioners I’ve spoken with say optimal ferritin levels are between 70-90 ng/ml. My ferritin was 9 ng/ml! But my doctor dismissed the results as a lab error because my CBC was “normal” as well as my iron. I later found out (three years later…well just now actually while researching for this blog post) that iron levels can be normal in the early stages of iron deficiency, while ferritin levels can be low. If you have high ferritin levels it may indicate of chronic inflammation.

Fast forward two years and my symptoms of being tired and lack of concentration have worsened. I’m seriously thinking something is wrong with me. I fear early onset Alzheimers. I know, a bit dramatic, but my mom started showing signs of early onset Alzheimers around age 50, so I worry about this stuff. Anyway, in mid-2016 I had an episode of extremely heavy menstrual bleeding. I was up all night bleeding through menstrual pads, I had never had such a heavy period! Later that month I went to a medical doctor, who ran a CBC, but did not order an iron/ferritin test. Many doctors don’t run the ferritin/iron test unless the CBC shows low hemoglobin. My CBC came back “normal”. My doctor wrote a dismissive note on the lab results, “I wanted to let you know that the tests we did were normal. No signs of anemia at this time. You couldn’t have lost too much blood. Good news!” Me: Oh, that’s great news doc, I must have imagined that I was up all frickin’ night bleeding through pads and tampons. I’ve had periods for 30 years, I know what excessive bleeding is! In fact, I wrote about heavy menstrual bleeding HERE.

Time goes on, I didn’t treat the low ferritin from 2014 because the first doctor said it was a lab error. And then in 2016, I didn’t treat it because the second doctor said my labs were “normal”. I did take some liquid iron now and then during my periods, but evidently not enough. By the way, there are many things can cause low iron other than heavy menstrual bleeding, some of the causes are quite serious.

My symptoms continued to get worse. I was having difficulty writing my blog and had to decline writing for someone I really admired. I was moving at a snail’s pace with developing my online course, yeah the course I announced a couple of years ago, is still in development! Then a few months back I was interviewed for a popular podcast and remember having difficulty thinking clearly during the interview and I misspoke a few times. I cringe thinking about it now! Then one day I thought I was going to pass out behind the wheel. So, I got my tired ass to a new naturopathic physician and she ordered the CBC, ferritin, and iron. This time around, I was full on anemic and my ferritin was 6 ng/ml and iron was 33 mcg/dL. No wonder I was so fatigued!

I’m now working on building up my iron stores again and will retest in a couple of weeks.

Lessons learned: I had non-anaemic iron deficiency years ago. Checking ferritin levels is important if you’re experiencing unexplained fatigue, even if anemia isn’t present and CBC is normal. See the PubMed articles below on non-anaemic iron deficiency.

Non-anaemic iron deficiency – a disease looking for recognition of diagnosis: a systematic review.

Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial.

Lesson #2 “The development of iron deficiency anemia is a gradual process. If your body is not taking in enough iron, your body first uses the iron that is stored in tissues (i.e., ferritin) and blood levels of ferritin will begin to decrease. If not corrected, the stored iron begins to be depleted as it is used in the production of red blood cells. In the early stages of iron-deficiency, blood levels of iron can be normal while stored iron, and therefore ferritin levels, will begin to decrease.” Source. I wish my doctor knew this back in 2014. I don’t expect doctors to know everything, they have a lot of ground to cover. But I do expect them to investigate or retest if things don’t make sense, or when in doubt refer out.

Lesson #3 Anemia can be caused by heavy menstrual bleeding and be the cause of heavy menstrual bleeding. As Dr. Jennifer Karon-Flores explained, “Basically, iron helps with platelet aggregation, so in absence of enough iron, platelets decrease and don’t work as well. Also, the arterioles in the endometrium get poor signaling in this environment, which further enhances the bleeding.” Here is a study that explains the mechanisms at play.  

Lesson #4 Normal is not optimal when it comes to lab results. I hear the frustration in my client’s voices when they say “the doctor says all tests are normal, so why do I feel like sh*t?” They start to question whether it’s all in their heads. It happens a lot!

Lesson #5 If your doctor is dismissive, get another doctor. Find a doctor who listens to you and works in partnership with you.

Lesson #6 Listen to your gut. Personally, I could have been more proactive much earlier. My wakeup call wasn’t until I felt like I was going to pass out while driving on the highway.  Looking back, my body was sending me signals for a long time.

A guide to diagnosis of iron deficiency and iron deficiency anemia in digestive diseases


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