Fatigue, weakness and shortness of breath are three common iron deficiency symptoms. Because they are nonspecific (symptoms of many different problems), individuals often attribute them to an existing medical condition such as heart failure, or to a medication they are taking. This mistake can delay diagnosis and treatment. Over time, symptoms multiply and worsen, adversely impacting quality of life. Unless iron levels are repleted, iron deficiency anemia can develop.
Iron Deficiency vs. Iron-Deficiency Anemia
Iron deficiency and iron-deficiency anemia are not synonymous.
“You can become iron deficient and not become anemic right away, but if you have enough iron deficiency, you will eventually become anemic,” says Cleveland Clinic hematologist Alan Lichtin, MD. “Anemia simply means you do not have enough red blood cells to carry oxygen throughout your body. Iron-deficiency anemia means you are both iron deficient and anemic.”
What Causes Iron Deficiency?
Iron, along with vitamin B 12 and folic acid, is needed to make blood. Iron’s job is to make hemoglobin, the protein in red blood cells that carries oxygen throughout the body.
Most of us get all the iron we need and more through our diet. Some of this iron goes into our bloodstream, while extra iron is squirreled away for later use.
Iron deficiency results when stored iron is depleted faster than it is replaced, or iron is not well absorbed. The most common causes of iron deficiency are:
- Blood loss, through heavy menstrual periods or chronic gastrointestinal bleeding
- Pregnancy
- Heart failure with reduced ejection fraction
- Bariatric surgery
- Inflammatory bowel disease, celiac disease or other condition that interferes with iron absorption
What Are the 3 Stages of Iron-Deficiency Anemia?
Medical experts have identified three stages of iron-deficiency anemia:
- In the first stage, iron stores decrease, but not enough to affect the red blood cells.
- In the second stage, the bone marrow responds to low iron levels by making red blood cells without enough hemoglobin.
- In stage three, hemoglobin levels drop below normal, and symptoms of iron deficiency anemia appear.
“It is important to understand that iron deficiency is only one path to anemia. If you are anemic, it’s important to investigate why,” Dr. Lichtin advises.
Iron Deficiency Symptoms and Signs
In the early stages of iron deficiency, symptoms may be mild or nonexistent. If the deficiency is not corrected, symptoms will multiply and gradually worsen.
In addition to fatigue, weakness and shortness of breath, individuals with iron deficiency, as well as iron-deficiency anemia, commonly experience:
- Feeling cold
- Pale skin and gums
- Dizziness and lightheadedness
- Brittle nails
- Headaches
- Heaviness in the legs
There are also some weird signs of iron deficiency:
- Pica: A craving to eat things like ice, soap, dirt or rubber bands
- Restless legs syndrome: The inability to keep legs still when lying down
- Plummer-Vinson syndrome: The development of webs in the esophagus that make it hard to swallow food
- Koilonychia (“spoon nails”): Nails lose their convex shape and become concave
- Cheilosis: The skin at the corners of the mouth breaks down, causing chronic sores
- Flattened tongue papillae: Normal bumps on the tongue disappear, making the tongue smooth
Diagnosing Iron Deficiency
A set of four blood tests known as an iron panel is used to diagnose iron deficiency:
- Serum iron level, which measures the amount of iron freely circulating in the blood
- Total iron binding capacity (TIBC), which measures the blood’s ability to attach to iron and carry it throughout the body
- Percent saturation (serum iron level divided by the TIBC)
- Ferritin level, the amount of iron stored in the body
“You have to take all numbers together to know whether someone is iron deficient,” says Dr. Lichtin.
Looking at blood cells under a microscope can be a shortcut to the diagnosis, because red cells shrink in someone who is iron deficient. But the presence of small red cells does not necessarily indicate iron deficiency.
“Small red cells are also characteristic of an inherited condition known as thalassemia, sometimes called Mediterranean anemia. If you see small red cells, it is important to look at the patient’s history to see if their red cells were always small, or if this is a new development,” Dr. Lichtin says.
Treating Iron Deficiency
Iron deficiency is treated by replenishing iron stores, using iron supplements or intravenous (IV) iron. The choice depends on the extent of the deficiency, the individual’s overall health and physician preference based on experience.
Oral iron supplements have side effects that can include constipation, upset stomach and tarry stools, but the supplements are convenient and inexpensive. “If the person can tolerate pills, I give pills,” says Dr. Lichtin.
IV iron is easier to tolerate, but it carries a risk of anaphylaxis. IV iron is the choice of Cleveland Clinic heart failure cardiologists because it has been shown to be more effective than oral iron at improving the heart’s contractility and functional capacity.
While your diet serves as your primary source of iron, increasing your consumption of iron-rich foods may help, but doing so will probably not be sufficient to restore iron levels to normal.
The good news is that the symptoms of iron deficiency disappear as soon as iron levels return to normal.
