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The Essential Guide to Iron Deficiency for Women: Fertility, Pregnancy, and Postpartum Health

Writer's picture: Andrea PicardoAndrea Picardo

Updated: Sep 14, 2024


A woman struggling with fatigue from iron deficiency.

Iron is a vital nutrient that plays a crucial role in various aspects of health, particularly for women who are planning to conceive, are pregnant, or are in the postpartum period. In light of the recent changes to Ontario's new iron deficiency guidelines, I thought we would unpack iron deficiency in each of these areas (1).


40% of females of reproductive age in Ontario are estimated to be iron deficient (1).

Some causes of low iron include:

  • Not regularly eating meat, poultry, and fish (2)

  • If you are a regular blood donor (donating every 8 weeks), about 25%–35% of regular blood donors develop iron deficiency (3)

  • Struggling with chronic conditions, such as Crohn's, celiac, cystic fibrosis, chronic pancreatitis (4)

  • History of gastric bypass (5)

  • Athletes (6)

  • Blood loss through menses, ulcers, hemorrhoids, polyps, colon cancer, surgery (7)

  • Postpartum


There are 3 stages of low iron:

Stage of iron deficiency

What's happening

Tests

Stage 1: Depletion of iron stores (mild iron deficiency)

Iron might be lower due to blood loss and/or low iron intake through nutrition

Low ferritin

Stage 2: iron-deficiency erythropoiesis

The body may have to draw from zinc stores to make red blood cells, which are on the smaller side and may have lower hemoglobin that are still within the normal range.

Low ferritin Low transferrin saturation Normal hemoglobin

Stage 3: iron deficiency anemia (IDA)

The red blood cells produced are now small and have low colour saturation. There may also not be enough red blood cells and low oxygen carrying capacity.

Low hematocrit Low hemoglobin (105-111) Low MCV (<80) Potentially low RBC's


As you can see, you can have low iron levels and symptoms without anemia, which are abnormal red blood cells.


Anemia is a late-stage manifestation of iron deficiency

Symptoms of iron deficiency can include:

  • weakness and fatigue

  • brain fog and poor memory

  • feeling cold all the time and cold hands/feet

  • heart palpitations and potentially low blood pressure

  • headaches

  • dizziness and pale skin

  • brittle hair and nails, or hair loss

  • pica - an abnormal craving to eat nonfood substances (eg, ice, dirt, paint, starch, ashes)


A person with low iron may also struggle with heavy periods as their clotting pathways are compromised - this is a vicious cycle.


Understanding and managing iron levels can make a significant difference in fertility, pregnancy outcomes, and recovery after childbirth. Here’s a comprehensive guide to iron levels across these important stages and why they matter.


1. Fertility: Testing and Optimal Levels

Before trying to conceive, it’s important to ensure your iron levels are optimal. Ferritin, a protein that stores iron in your body, should be measured to assess your iron status. Optimally, we are aiming for ferritin levels of 80-100 ng/L to support fertility effectively and be at a level adequate enough to be carried through pregnancy. At the very least, your iron should be above 30ng/L (8). Ideally, this is with low inflammatory markers (like ESR and CRP) as ferritin can be falsely elevated when there is infection or inflammation in the body.


Deficient iron can lead to disrupted ovulation, thyroid imbalances, and increased risk of pregnancy complications like low birth weight, preterm birth, and pre-eclampsia. Therefore, a pre-conception check-up that includes iron testing is a proactive step for women planning to get pregnant.


2. Pregnancy: Managing Iron During Gestation

Iron needs increase significantly during pregnancy - 40% of pregnancies globally present with iron deficiency or anemia. This is partly due to hemodilution—the process where blood volume increases more rapidly than red blood cells, causing a dilution effect. According to studies, iron levels typically drop during the second trimester, which can sometimes lead to anemia.


Low iron levels during pregnancy are linked to various risks.

  • increased risk of low birthweight, premature birth, low iron stores, and impaired cognitive and behavioral development (9,10).

  • Levels below 75 ng/L can contribute to symptoms such as restless leg syndrome and leg cramps, which can contribute to insomnia, depression, and other adverse outcomes (11).


Further to the point of ferritin being falsely elevated in the presence of infection or inflammation, Bowers 2016 found increased risk of Gestational Diabetes with ferritin levels >141ng/L. Checking levels early in pregnancy, dosing accordingly and providing ongoing monitoring can help mitigate a lot of these challenges.


3. Postpartum: Recovery and Ongoing Monitoring

The postpartum period is another critical time for managing iron levels. Blood loss during labor and delivery can significantly impact iron stores. If you are not menstruating postpartum, you may have an opportunity to replenish iron levels more effectively. However, many women resume menstruation sooner than expected, and some experience heavier periods, which can exacerbate iron deficiency.


Having adequate iron levels prior to "the fourth trimester" or postpartum can also reduce the risk of developing perinatal mood disorders like postpartum anxiety and postpartum depression.


The tests that can be valuable to run...

CBC with differential

This panel looks at your white blood cells (immune system health) and red blood cells (screening for anemia)

Ferritin

Measure of iron stores

Iron panel

A more complete iron panel looks at iron levels in the blood. This value is not as important as it can be so variable. However, it also looks other aspects of iron transport and use that can help us rule in and out other conditions like iron overload.

ESR, hsCRP

Inflammatory markers that tell us if there is inflammation present in the body or the blood vessels that can be falsely raising


Conclusion

Iron is a crucial nutrient throughout the stages of fertility, pregnancy, and postpartum recovery. Monitoring and maintaining optimal iron levels can help prevent complications and support overall health. For women planning to conceive, pregnant, or recently postpartum, staying informed and proactive about iron levels is essential for a healthy and vibrant journey through motherhood (this can be done in addition to other tests as well!)


Want to take a deeper look at your health? Book a discovery call today!




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REFERENCES

  1. https://www.cbc.ca/news/canada/toronto/iron-deficiency-bloodwork-testing-ontario-1.7314795

  2. Pawlak R, Berger J, Hines I. Iron status of vegetarian adults: a review of literatureAm J Lifestyle Med. 2016;12(6):486–498. doi:10.1177/1559827616682933

  3. Kiss JE, Brambilla D, Glynn SA, Mast AE, Spencer BR, Stone M, et al. Oral iron supplementation after blood donation: a randomized clinical trial. JAMA 2015;313:575-83.

  4. Saboor M, Zehra A, Qamar K, Moinuddin. Disorders associated with malabsorption of iron: A critical review. Pak J Med Sci. 2015 Nov-Dec;31(6):1549-53. doi:10.12669/pjms.316.8125

  5. Camaschella C. Iron deficiency: new insights into diagnosis and treatment. Hematology Am Soc Hematol Educ Program. 2015;2015:8-13. doi:10.1182/asheducation-2015.1.8

  6. Alaunyte I, Stojceska V, Plunkett A. Iron and the female athlete: a review of dietary treatment methods for improving iron status and exercise performanceJ Int Soc Sports Nutr. 2015;12:38. doi:10.1186/s12970-015-0099-2

  7. Camaschella C. Iron deficiency: new insights into diagnosis and treatment. Hematology Am Soc Hematol Educ Program. 2015;2015:8-13. doi:10.1182/asheducation-2015.1.8

  8. Holzer et al. Iron status in women with infertility and controls: a case-control study. Front Endocrinol (Lausanne). 2023; 14: 1173100.

  9. https://ods.od.nih.gov/factsheets/iron-HealthProfessional/

  10. Georgieff , M. Iron deficiency in pregnancy. Am J Obstet Gynecol.2020 Oct;223(4):516-524.

  11. Kondori et al. Management of Restless Legs Syndrome in Pregnancy and Lactation. J Prim Care Community Health. 2020 Jan-Dec

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© 2023 by Dr. Andrea Picardo, ND

MEDICAL DISCLAIMER | All material on this website is provided for information and educational purposes only. It is not intended as a substitute for the advice provided by your  healthcare professional or physician.

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