Did you know…

Iron deficiency without anaemia is more common than iron deficiency anaemia in menstruating women, and it is one of the most systematically missed nutritional diagnoses in modern medicine. Its symptoms (fatigue, palpitations, hair thinning, brain fog, restless legs) are routinely attributed to almost anything else.

The claim, in the words of a leading haematologist

Michael Auerbach directs Auerbach Hematology Oncology in Baltimore and has treated tens of thousands of patients with intravenous iron across the arc of the field’s evolution. He has argued for two decades that the symptomatic threshold for iron deficiency sits well above the WHO cutoff. In American Journal of Hematology, with James L. Adamson, he wrote:

“Iron deficiency without anaemia is the most common, and most commonly missed, nutritional deficiency in the industrialised world. Its symptoms are attributed to almost anything else.”

— Michael Auerbach & James L. Adamson, American Journal of Hematology, 2016

He has been more direct in clinical editorials:

“The dogma that a normal haemoglobin excludes clinically relevant iron deficiency has caused more diagnostic delay in my practice than any other single misconception.”

— Michael Auerbach

What the woman receives instead

The typical clinical trajectory of a menstruating woman with symptomatic iron deficiency without anaemia is well-mapped. She receives sleep-hygiene advice for the fatigue. She receives an SSRI for what is characterized as functional fatigue in a young mother. She receives a beta-blocker for palpitations. She receives reassurance that her haemoglobin is normal. She does not receive a ferritin measurement. If she does, her ferritin at 24 μg/L is flagged as normal against a reference range that begins at 10 or 15.

The reference range is calibrated on a depleted population

Reference ranges reflect the statistical distribution of the sampled population. In a population where the majority of menstruating women are iron-depleted, the range does not measure adequacy: it measures the average shape of the deficit. The patient told she is “normal” learns, in that moment, only that she resembles her equally depleted neighbours.

This entry is a companion to Right to Adequate Iron Status and to Ferritin 24: A Model Case.