Iron Deficiency Without Anemia

Iron Deficiency Without Anemia

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Disclaimer: The information contained within this blog post does not constitute medical advice and is for informational purposes only. While I have a Ph.D., I am not a licensed medical professional. Any questions you have regarding your health should be discussed with your treating physician.




Iron deficiency with or without anemia is a serious and under-recognized global health problem. Statistics report that 10-20% of menstruating women are iron deficient and 3-5% of them are anemic. This figure is likely much higher, as many women go undiagnosed or are misdiagnosed with another illness (e.g., subclinical hypothyroidism, chronic fatigue syndrome, fibromyalgia, chronic Lyme disease, burnout, and overtraining, etc.). Although this deficiency is very easy and cheap (<$100 cost to the insurance company) to screen for, it is often referred to as a clinical challenge. In my opinion, the clinical challenge is doctor bias and dismissal. Oftentimes when women visit their doctor for vague symptoms like fatigue, exhaustion, heavy periods, mood problems, cognitive issues, etc., they are told it’s part of their anxiety, depression, stress, or even worse, ‘in their heads.’ Within the past few years, research on this topic has gained some traction. While the findings are not mainstream yet, I suspect that as more people discuss this problem with their doctors and we raise awareness, that more people will be properly diagnosed and treated more quickly.


With or Without Anemia?


Anemia is when you lack enough healthy red blood cells to carry adequate oxygen to your body’s tissues. There are many types of anemia, one of which can be caused by iron deficiency. Without anemia means that you do have enough red blood cells which makes the condition easier to miss as most doctors don’t check ferritin on the first round of testing. If you ask to have your iron checked, most doctors will order a CBC, iron, and maybe TIBC. They generally don’t order ferritin, unless you explicitly ask for it. If you have iron deficiency with anemia, this will be picked up from those three tests. If you have iron deficiency without anemia however, it will be missed unless you ask for your ferritin to also be checked. Some doctors are not receptive to patient input, so it’s worthwhile to find a doctor that’s willing to listen to your concerns and take your suggestions seriously.


What is ferritin?


To distinguish between iron and ferritin, I like to think of iron as the cash in your wallet and ferritin as the cash kept in a bank account. When you go to the store to buy groceries, you can use the cash on hand. If you run out, then you can write a check or use your debit card to use the cash you have saved at the bank.


Iron and ferritin operate in a similar way in the body. There’s the iron that is circulating in your bloodstream, readily available for use (i.e., like cash in your wallet) and then ferritin, which is a protein that stores iron (i.e., like cash in the bank).


When your body needs more iron, the ferritin will release it. Ferritin usually lives in your cells, especially in the cells of your liver and your immune system.


It’s important to not only have normal iron levels, but your iron stores (ferritin) also need to be normal. Your body will deplete the iron stored in ferritin first before you hit anemia [1]. So you want a good level of ferritin, with optimal levels being cited as ~100 [2].




According to the scientific literature [3], there are many symptoms, most of which are non-specific:

  • Fatigue
  • Reduced mental awareness
  • Poor concentration
  • Headache
  • Hair loss
  • Shortness of breath or dyspnea
  • Weight gain
  • Loss of initiative
  • Memory lapses
  • Difficulties finding words
  • Vertigo
  • Heartburn
  • Cold hands and feet
  • Restless legs
  • Anxiety
  • Depression
  • Abnormal menstruation
  • Easy bruising
  • Dry skin and pruritis
  • Poor heat tolerance
  • Irritability and anger tantrums


A more comprehensive list of symptoms can be found in Table 2 of [3]. Looking back, I had complained about a lot of these symptoms to several different doctors across many specialties. Unfortunately for me, not one of them suggested checking this out. I had to put the pieces of the puzzle together myself.


If you suspect iron deficiency without anemia, print off Table 2 and circle the symptoms that you have. If you have a majority of them, it’s worth discussing with your doctor. Be sure to bring the table with you, so that you don’t forget any important symptoms.


How Does Iron Deficiency Develop?


I like to think of ferritin using an analogy. Imagine a kitchen sink that has both a drain and a faucet. The drain represents the loss of iron and the faucet represents the addition of iron. The rate of iron loss or addition can be controlled. The drain, or iron loss, can occur from surgeries, injuries, pregnancy, medical conditions (i.e., ulcers), and menstruation. The faucet, or iron addition, includes food, supplements, iron infusions. So to increase your iron stores, or have water building up in the sink, you need to have more coming in through the faucet than you have leaving through the drain. If you don’t, you end up with iron deficiency or worse, iron deficiency with anemia.


To balance the equation in your favor, you need to restrict losses through the drain and increase the addition through the faucet. As an example, let’s take someone who menstruates whose iron deficiency is caused by heavy and frequent menstrual cycles. In this case, the loss of iron could be restricted by getting a hysterectomy, an ablation, or taking birth control pills. To add iron, the slowest route is through food, the next through iron pills, and the fastest is through iron infusions. It’s important to talk to your doctor to find the best route for you. Keep in mind that with birth control pills, the situation can get much worse. Oftentimes it takes women many trials to find the right one. And if you are frequently switching birth control pills and going through withdrawal bleeds, that could make the situation worse.


How Long is Treatment?


It varies.


With pills, it will be a few years (yes, you read that correctly). And depending on the rate of blood loss, pills might be insufficient.


With infusions, relief is usually on the order of a few months.


With either treatment method, it’s critical to identify the cause of the low ferritin. If the cause is not corrected, no matter how you treat it, the ferritin will drop again.


To clearly illustrate the differences in length of treatment, I’d like to briefly discuss two beautiful case studies that were published [2]. Both case studies show a treatment timeline showing the ferritin response to both iron pills and iron infusions for two patients.


Case Study 1


  • 55-year-old post-menopausal female
  • Treatment: 150 mg of ferrous sulfate daily
  • Starting point = 27 micrograms/L


You can see that for a post-menopausal female with no blood loss through menstruation or other health conditions, it took nearly 2.5 years on iron pills for symptoms to remit. This is a really long time to suffer from the symptoms in Table 2.


A graph showing the increase in ferritin levels with time for a patient who only took oral iron pills.


Case Study 2


  • 40-year-old female
  • Heavy menstruation, otherwise healthy
  • Two pregnancies, anemic for both
  • Oral iron for a year with increasing dosage, then switched over to iron infusions
  • Starting point = 5.4 micrograms/L


In this case study, you can see that the patient’s ferritin flat-lined between 10-14 months. If we think back to the sink analogy, this is likely the equilibrium point of her body. Meaning, that the rate of iron coming in through the faucet (via oral supplementation) exactly balances the loss of iron through the drain (via menstruation in this case). To break through this barrier, you either have to increase the rate of iron coming in via iron infusions or slow down the loss rate via birth control pills, hysterectomy, or endometrial ablation.


What’s also interesting, is the difference in the rates of uptake between the two patients. In Case Study 1, the rate of increase is about 17.5 micrograms/L per month, and for Case 2 it’s 4.5 micrograms/L per month. That’s a HUGE difference, likely due to the heavy menstruation in Case Study #2.


A graph showing the increase in ferritin levels with time for a patient who both took iron pills and who later received iron infusions.




There’s a simple solution. Everyone, including men, should have a CBC, iron, TIBC, and ferritin tests run at their annual physical. For women who visit their gynecologists annually, these tests can be ordered from their gynecologist. The cost to insurance companies for the tests is substantially cheaper than treating the complications of iron deficiency with or without anemia in the longer term. Not to mention, saving the patient from potential harm if they are misdiagnosed with other health conditions and put on other medications to manage those conditions. Some of those medications can be difficult to come off of, and cause other changes, that are best avoided in the first place if possible. So there is no reason to not perform this test on an annual basis. This, in turn, would reduce demand on healthcare resources and people would be healthier overall, as iron is a critical metal in the body.


Thank you for reading through this post, and I hope you found it helpful! If you have been diagnosed with iron deficiency with or without anemia, and are looking for support, there are some excellent support groups on Facebook that I will link to below. I will also post some additional resources that I have found helpful in learning about my condition.


Additional Resources



All scientific papers cited are available to the public FREE of charge. These papers can be helpful in guiding discussions with your doctor.

[1] Iron Deficiency Without Anemia

[2] Soppi, E. T. (2018). Iron deficiency without anemia–a clinical challenge. Clinical case reports, 6(6), 1082.

[3] Soppi, E. Iron Deficiency Without Anemia–Common, Important, Neglected.

5 thoughts on “Iron Deficiency Without Anemia”

  • One of the best articles I have ever read on this topic. Spot on with your analysis and recommendations. Sadly, I have this very issue and glad to say I am slowly recovering with iron supplements.

  • Thank you for this article. My doctors keep telling me that low ferritin is not causing my symptoms (resting HR of 110, hair loss, palpitations, toe cramps, restless leg, SOB). All the usual labs come back normal – I’m the picture of health, they say. But I can’t sleep at night because of the racing heat – which they say is “not that high”. I insisted on a serous ferritin test and it came back at 6. Which, again, they said is not concerning. But my symptoms are extremely bothersome and affects my quality of life and activities of daily living. My doctors just won’t listen. I’ve asked for a referral to hematology. Any other suggestions?

    • My only suggestion is to print off the papers directly and bring them in. The best reference I have found so far, is the paper titled: “Threshold ferritin and hepcidin concentrations indicating early iron deficiency in young women based on upregulation of iron absorption.” It is open access, so you can access it for free and print it off. It clearly shows in the paper (see Figure 5) that for any ferritin less than 50, the body upregulates iron absorption. If you have any questions, come find me on Twitter and we can discuss further.

  • I am stunned!! I can’t believe this. Have been struggling deeply for years. I thought I had cfs and had no where to turn. I have all the symptoms. I dreamed of the day that I would find an answer and see a list with ALL of my symptoms. So problem is…my doctor doesn’t believe that having low ferritin (12) and normal hemoglobin is an issue. He had the nerve to say it’s all in my head (this was deeply traumatizing for me). How much iron am I suppose to supplement? Is it ok to take a high dosage with normal hb? It won’t bring my hb too high?

    • Hi Chantel! Unfortunately I am not able to give out medical advice. I would however encourage you to seek out support from numerous facebook groups on this topic. What dosage is right for people, form etc, varies by person. That is an extremely low ferritin and I know when I was that low, I had difficulty getting out of bed and even sitting upright. I also made a YouTube video with a detailed discussion of all of my symptoms that you might also want to check out. Wishing you success on your health journey!

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