Iron Deficient But Not Anemic? A Simple Solution for Fatigue

Struggling with an iron deficiency without anemia? The best way to see whether you have an iron deficiency is by measuring your level of ferritin, a protein found inside cells that stores iron so your body can use it later.

iron deficient

Anemia occurs when your blood can’t effectively carry oxygen to your cells. This develops when you have too few red blood cells or hemoglobin, the part of red blood cells that bind oxygen.

Even if you don’t have anemia, you could have an iron deficiency that’s sapping your energy. It’s entirely possible, especially if you’re a woman of reproductive age, to have borderline anemia without becoming fully anemic. When you’re iron deficient but not anemic, you can still suffer from lower vitality, decreased immune function, poorer mental health, and impaired ability to perform physically and mentally.[1]

Being iron deficient is one of hundreds of causes of anemia, the most common blood condition in the U.S. It affects about 3.5 million Americans. Anemia occurs when your blood can’t effectively carry oxygen to your cells. This develops when you have too few red blood cells or hemoglobin, the part of red blood cells that bind oxygen. When your cells can’t get the oxygen they need, you experience chronic fatigue symptoms such as weakness, lethargy, and feeling sleepy all the time.

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Iron Deficient: Your Doctor May Not Be Ordering This Best Test

A study indicates that doctors may not be ordering the right test—and patients with chronic fatigue symptoms may therefore not be getting the right treatment—when it comes to iron deficiency.

The amount of ferritin in your blood (serum ferritin level) is directly related to the amount of iron stored in your body. With a ferritin deficiency, even one within the “normal” range, the more likely it is that you do not have enough iron.

However, most doctors don’t order this test. Instead, they may order only what is known as a CBC, which stands for complete blood count, to check a patient’s red blood cell and hemoglobin levels. If the CBC, which is a simpler, less expensive test, comes back normal, the doctor may send the patient away without ordering a ferritin test and with no explanation for the patient’s fatigue.

Causes of Low Ferritin Research Findings

In a recent double-blind, placebo-controlled study, French and Swiss researchers decided to check low ferritin symptoms.[2] They wanted to see whether iron supplementation would help women with fatigue symptoms who had either low or “borderline” ferritin levels (<50 mcg/L) but were not anemic (meaning they had low iron, normal hemoglobin levels, >12 g/dL).

Interestingly, the “normal” reference range for ferritin in women is typically 18 to 160 mcg/L, but the researchers considered any level below 50 mcg/L to be borderline low.

The researchers randomly assigned 198 women with unexplained fatigue to take either 80 milligrams of iron a day (as sustained-release ferrous sulfate) or a placebo. Over 12 weeks, women on iron supplements noticed a significant improvement in their fatigue. On average, scores on a standard measure of fatigue fell by nearly half – from about 25 to 13, on a scale of zero to 40 – among women getting the extra iron.

Those in the placebo group also improved, but not as much as those in the iron group.[2] They concluded their study by stating that in “women with unexplained prolonged fatigue, iron deficient should be considered when ferritin values are below 50 µg/L, even when hemoglobin values are above 12.0 g/dL.”

Why You Should Test First: Too Much Iron Is Dangerous

Other studies have also shown that low ferritin treatment or treatment of iron deficiency with either supplementation or a high iron diet results in improved mental health, increased energy, and decreased fatigue among women of childbearing age.[1,3]

But please be aware that it would be a mistake for you to take iron supplements or multivitamins with iron–thinking it will help your fatigue–without knowing if you are iron deficient in the first place. Studies have shown that excessive iron increases Alzheimer’s risk and can lead to serious health problems such as liver and heart disease.[4]

Iron Supplements: Do They Make a Difference?

We discuss in much more detail the dangers of too much iron in Part Two of this article. The ferrous sulfate used in the study cited above is the most commonly prescribed form of iron supplementation by conventional healthcare practitioners.

However, naturopathic physicians and other integrative healthcare practitioners trained in nutritional supplementation will often recommend other forms of supplemental iron which are better absorbed and cause less side effects in order to achieve normal iron levels. To learn more about these supplements and additional alternative remedies to fight fatigue symptoms, read Part Two of this article.

Iron Deficient: Conclusion

The conclusion to draw from this important study is that iron deficiency should always be considered as a possible underlying cause of your fatigue symptoms. However, because many doctors check only for anemia but not for low iron, this condition is commonly missed. Since too much iron is toxic and leads to serious health problems, you’ll want to absolutely know if you have low iron by checking your serum ferritin level before taking any iron supplements.

If your serum ferritin level is less than 50 mcg/L, use the suggestions found in Part Two to get your iron levels–and your energyback to normal.

Have you had your ferritin tested? Tell us about your experience in the comments section below.

For related reading, visit these posts:


Originally published in 2012, this post is regularly updated.

[1] Patterson AJ, Brown WJ, Roberts DC. Dietary and supplement treatment of iron deficiency results in improvements in general health and fatigue in Australian women of childbearing age. J Am Coll Nutr. 2001 Aug;20(4):337-42.

[2] Vaucher P, Druais PL, Waldvogel S, Favrat B. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial. CMAJ. 2012 Jul 9. [Epub ahead of print] PubMed PMID: 22777991.

[3] Verdon F, et al. Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial. BMJ. 2003 May 24;326(7399):1124.

[4] Castellani RJ, Moreira PI, Perry G, Zhu X. The role of iron as a mediator of oxidative stress in Alzheimer disease. Biofactors. 2012 Mar-Apr;38(2):133-8.

 

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Comments
  • Moriah M.

    I find plenty of good information on this website. Much thanks and hello from Germany!

  • This is exactly what happened to me. I had very low ferritin (below the reference range) and was told by my doctor that my fatigue couldn’t be because of iron since I didn’t have anemia and my saturation level was okay. He was wrong. I feel SO much better now that I’m supplementing.

  • Sharon H.

    My ferritin levels were tested and they were so far below the low average I was ready to cry….finally an answer to why I was so tired all of the time. I have restless legs as well and the sleep specialist I saw was the one who asked about my iron level. I told him I was never diagnosed as anemic but that’s when he said that isn’t the most accurate test for iron stores. I am now taking an iron supplement daily in an effort to raise my ferritin level to the normal range. Just had it tested after six months of daily supplements so I’m hoping for good things! I know it’s a slow process but if I see an increase, I’ll be very encouraged.

  • All well and good but I don’t want to be taking ferrous sulphate for the rest of my life I want to understand the cause of why my body is not storing iron… but the medical profession are not interested so what do I do now?

  • Yes! I have a platelet disorder and my ferritin is low often, but my hemoglobin is often normal. I’ve tested often enough to see the hemoglobin dip below a week later. Any time I’m seeing a new doctor I have to make them call my hematologist to confirm.

  • My mum was diagnosed with haemochromatosis so all of her children were tested, myself included. My brother ferritin levels were in the 400’s (mum’s in the 800’s) but my sister’s and mine were 30 and 25 retrospectively. We have not been diagnosed with anemia as they are just in the “normal” levels but a throw away comment was made that our levels were low but nothing to worry about. I have subsequently started to take iron supplements to bring my levels up and will receive annual checks for our ferritin levels.

  • Ngarita

    I have been diagnosed as being a chronic anaemic. I have had 2 blood transfusions and 1 Iron transfusion in the past 18 months. I’m about to have another Iron transfusion. It has been a process to get the last 2 treatments after ending up with breathlessness, fatigue, headaches etc in A & E and only being sent home because my hamagloblin came back normal. My breathlessness was a clear sign that something was wrong so I was gobsmacked I wasn’t initially going to receive any treatment. This time around I knew to say to check my Iron level and sure enough it came up low so I’ll be getting the needed transfusion. I know the signs and what to say so don’t let them ignore you if your hamaglobin levels are ok.

  • I am currently reading to see the hematologist. The doctor noted low ferritin a year ago and then also found and IGA deficiency that I had to be referred to a urologist for first. I am now just going to the hematologist because he had ferritin levels below, consistently between 6 and 9, and my iron is normal (66). My IBC & transferrin slightly high with 15% saturation. When I take iron supplements my iron is too high. I have so many blood tests and they’re quite consistent and so confusing! Has anyone else experienced this? I’m tired, my hairs been falling out for 2.5 years & now its so thin. I’m hoping for a simple answer soon!

  • I have had unbearable complete lethargy and exaustion all day every day. When i woke in the morning i felt truly like i was dying of terminal illness. It was unbearable. My ferretin is always low but at the very bottom of normal like 17 or recently 26. My irons usually normal though. Doctor told me to take iron. I started and i noticed an IMMEDIATE imptovement. I no longer wake up feeling like im going to die. It started helping within days. Now im wondering if my low fertetin has anything to do with my low neutrophils. They are always low. Sometimes within normal limits but always low % wise. Im wondering if by taking iron it’ll make them go up to normal again.

  • Emma P.

    My ferritin reserve score was 9, rather low I guess but my blood test score for iron was 11.5 . B12 was only 350 but my doctor didn’t think that was low. low levels cause neuropsychiatric problems like memory issues, lack of concentration, depression etc. which are becoming more frequent. Maybe it’s not due to my age, rather due to B12 and ferritin levels. Aren’t doctors supposed to know this stuff???

  • Carolyn

    My ferritin level was recently checked and was 6. I feel horrible, my heart is always racing, I’m exhausted, I can’t think straight, my head hurts and I get short of breath just getting up from a seated position. I’m a regular exerciser and this is the pits. I just want to cry. I started iron supplements 3 times a day a week ago and I don’t feel any better yet. Hoping to feel something next week… a small improvement would give me hope.

  • Julie

    I have had symptoms of light headedness, chills, extreme fatigue, and even chest pressure, pounding heart when climbimg stairs and depression. My ferritin levels are 9 and iron levels are normal. I had been feeling like this for years. After finding out I had low ferritin I started taking iron in liquid form. This was the only form that didn’t upset my stomach. Immidiately, I started feeling better. My energy level is so much better, no more lightheadedness and I feel really happy. I seems to imrpove depression too. I found that I had to eat things that help absorb the iron. Foods that have vitimin C and magnesium seem to help absorb the iron. I am so grateful that my doctor ordered the ferritin test. It was very helpful to read the other comments!

  • Susan H.

    I had been feeling terrible for some time. I went to the doctor two weeks ago. He suggested that I might not be getting enough exercise. The last thing I felt like doing was exercise, as I was so tired and fatigued. I asked him for blood tests. I actually said that I wanted everything tested, because I was feeling so terrible Fortunately, he had my iron level tested and it was found to be quite low. He said that I was either not absorbing iron properly anymore, or that I was not eating enough iron rich food. He suggested that I modify my diet and see if that works first. I am 65 years old and have never had this problem before. I am wondering whether it may be age related.

    E

  • Low B12 can cause iron stores to become depleted. Ask your doctor to test for low B12 by testing homocysteine (with levels less than 10 being desirable) and your methylmalonic acid (MMA) (should be less than 370 in the blood or less than 4 mcg in urine). The MMA test is the most specific test for B12 levels but most doctors only test the blood B12 levels and counts which is insufficient.

  • Melinda J.

    Please help me! After numerous years of going to my doctor, I was finally diagnosed with panic low ferritin. The level was 2.5. I was placed on ferrous sulfate then Vitron C. I’ve been hospitalized 3 times. Two years ago, months prior to diagnosis it was the neurologist believed I was having a stroke. Praise the Lord! No apparent after affects. After the 2.5 level it raised to 7 then 12 then 16. Now for some reason, it is dropping again. Drs thought it was because of a heavy menstrel cycle, so I had myriene put in. No period for almost 2 years. I need someone to help answer questions about Gene mutation and what to do to find out. My family history is important too.

  • Currently normal hemoglobin levels abnormally low ferritin level. Chronic fatigue, shortness of breath, difficulty concentrating. Several months ago hemoglobin level was below 13 Hematolgist agreed to four iron infusions. Hemoglobin level raised ferritin level remained below normal.
    Hematolgist’s stance is unless hemoglobin level drops below 13 ferritin level is ignored along with my complaints!!! Over the counter iron supplements causes me to have severe constipation. I don’t know where to turn. I’m so desperate I posted here knowing my email box will now be inundated with junk mail!

  • I am trying to determine if my ferritin level is low. My doctor didn’t mention anything to me. The test results show normal between 11. – 306.8. Mine was 30. Is this low?

  • Sophia A.

    I’ve suffered from iron deficiency for years because of heavy menstruation and my hemoglobin is usually on the very low end of normal and sometimes I fall below normal into anemia. Mostly my body does a good job to recover but what I have found is that when I’m on the lower range of normal, I’m still iron deficient when doctors do an iron study. Once my hemoglobin was 12.8 but my ferritin was a 3 and all other numbers were low. So I say demand a iron study if you fall on the low end of normal. Ranges can and should be questioned and every body is different. An IUD worked to reduce bleeding and I saw all my numbers go up and experienced improved energy along with supplementation. Had a endometrial biopsy which caused severe bleeding and I lost all my gains with lightheaded ness and extreme instability on my feet. I am having a hysterectomy in a couple days as the hormones in IUD do not agree with me and are causing stroke like symptoms and increase risk of breast cancer (hyperplasia now) and a very large fibroid on outside of my uterice. This is an extreme measure but one that needs to happen so I can begin to feel better. I agree with this study that doctors aren’t looking for iron deficiency and only hemoglobin but they should investigate a low normal hemoglobin with an iron study. FYI: Floradix is amazing and helped me tremendously. Easy to digest and on the stomach. Read reviews.

  • I’m only 18, but when I was 17 I had a blood test done because of how weak & tired I had always been. The results came back with my ferritin being a 7 & everything else was sitting where it was meant to be. My doctor asked me if I had a history of bowel cancer in the family & I didn’t understand why that was the first thing asked of me. My menstrual cycle and diet has always stayed the same & I’ve never experienced low iron before hand. I’m not sure what caused such a dramatic drop in my iron levels, but have not been tested since.

  • Ive been with the same problem. Im not anemic but have eating cinnamon by the spoonful and feeling tired all the time .. I know my ferritin is low but on my next appointment I will demand a ferritin test .

  • Rebecca

    I just found out that my ferritin level has been at 5 for over 9 years. I am so frustrated because my doctors never told me anything about it. I have had fatigue, lightheadedness, and I was always wanting to sleep. I just found a good doctor who ordered an iron profile and found the ferritin low. I had six iron infusions and feeling much better. I can’t wait to have labs again so I can see how much the ferritin has come up. My advice to everyone, insist that your doctor check your ferritin level!

  • Marie s.

    I have read many of the women comments. Quite a few has hit home. My sister is having iron fusions (3). She is tired all the time and like me no reason for it. We both have very bad bones. I learned a lot from the comments .thank you.

  • Mary j.

    I’m always tired and I have body ache my ferritin level is only 2 my doctor told me that I have to take my iron vitamins and eat a lot of veggies.. I been doing this for five months eating veggies and iron vitamins but my ferritin still 2 I’m so worried is there anyone can help me what’s the best meds to take? Thank you

  • @Rebecca it is not always iron. I felt gravely ill, exhausted, weak, slept 10-12 hours, lightheaded etc. when i was low on vitamin D. I never tested it, but once i took few pills of 5600 iu and felt MUCH better for the first time in few months. Then i discovered i had low vitamin D. There is also magnesium, B vitamins, etc. that needs to be corrected

  • Melissa R.

    I have been in and out of the Dr’s for the last two years. Of course they have messed with my thyroid medication and now put me on several forms of HRT. Every Dr says the other one doesn’t know what they are doing. I heard about ferritin so I asked my Dr to test me. It came back at 30. She said my iron is fine because my Iron total is 136 mcg/dL, iron binding capacity is 349 mcg/dl and % saturation is 39. I am still suffering from fatigue, horrible hair loss, and my hair is so tangly and is a texture it has never been. Why are my ferritin levels low but my iron totals are normal?

  • I have been very very ill with colitis and bleeding from my rectum for over a year…my Hematacrit and Hemoglobin are always low normal but still normal…I was passing out, panic attacks., Heart racing and skipping and pounding……no one knows what is wrong ….I found on my chart that my IRON was LOW….no one ever told me about it…..so I started taking a PATCH IRON..vitamin patch…so it won’t upset my stomach…..it seems to be helping…I am getting a bit stronger…but the FACT that my DOCTOR NEVER TOLD ME …is what really ticks me off….knowing I was PASSING OUT…..they did CT SCANS, and Brain Scans, and LUNG scans, and HEART SCANS you name it……and all along it could be that I was IRON deficient from bleeding for over a year……I was always suprised when they would tell me YOU ARE NOT ANEMIC>….I sure felt like I was…….

  • I was having pain and weakness in legs, feet and joints along with fatigue. I had testing of both Ferritin and Serum Iron which were low. Hemoglobin and Hematocrit were within normal. Started iron supplements 2 months ago without much improvement in the way I was feeling. I’m thinking that I may have a B6 toxicity. Check you supplements to make sure that you are not getting too much B6 which I understand can interfere with iron storage. Have stopped the supplements that include B6 4 days ago and now feeling about 10%better. I’m hoping it continues in the right direction.

  • Elizabeth

    I have had unexplained fatigue for 16 months and I have been to a sleep specialist, a hematologist, a rheumatolgist, and pretty much everyone else you can think of! I could not find an answer and all my doctors were stumped! I finally went to a Nautropathic doctor and immediately she wanted to know about my ferritin and iron. After getting the blood results back my ferritin was at 4, my iron at 24, and my % saturation was less than 5%!! No one else even thought to test for it because my hemoglobin and RBCs were normal. I will soon be calling my doctor to see what the next course of action is and I am hoping I will be back to normal soon with more energy!!

  • I’ve been battling for years with ferritin – from an old blood test I naturally have levels of around 120 and I’ve been trying to function at 9. After supplements and now IVs my level got back up to 110 but has already dropped back down by 60% in 2 months. Has anyone else experienced this? Currently having the ‘scopies done to check for underlying issues.

  • Just found out my Ferritin is at 5. Hoping that the Ferrasorb my Dr has prescribed will help quickly. I’ve been feeling, tired, depressed, bad hair and nails and the weirdest has been the obsession with eating ice constantly (Pica?). I guess my body was trying to tell me something.

  • stephanie b.

    My husband has suffered for two years with “anemia”. Iron infusions, RX iron,vitamins, blood products and to boot was misdiagnosed with Crohns. Folks, don’t take anemia lightly, my hubby has an enlarged spleen we didn’t know he had ,(dics didn’t inform us) also he will be having a bone marrow biopsy in 2 days because he has other atypical cells indicative of Myelofibrosis. This all stared with mild anemia counts of 10/29 …9/29 then trickle trickle and boom! Now, 2 years later all blood counts off…all…. Ferritin and iron levels were ambiguous and all over the board. Being tested for bone marrow cancer after a full evaluation from Vanderbilt 2 weeks ago . Don’t just treat the anemia,…ask why? And don’t stop asking until you rally have a logically answer. Have a smear done of
    Your blood…look at morphology. Stoop for blood, irons for blood ….FIND the reason.

  • Barbara M.

    2016 ferritin = 3, hemoglobin 5.2, RBC 2.77,hematocrit 20. 2017 = ferritin 7, 2018 = ferritin 15, hemoglobin 13.1, RBC 4.1, hematocrit 39.9. 2019 = ferritin 16, hemoglobin 12.7, RBC 4.16, hematocrit 38.7 (2019 iton glycinate with vit c supplements 3 months)

  • Alet L.

    I am suffering from low ferritin levels for many years, and adjusted my diet and having more iron enriched food and also went to see a haematologist who has put me in hospital one day to receive a ferritin drip! I am borderline just 11 and feel so fatique, ears ringing constantly, heart palpitations, very pale and doctors has prescibed so many supplements in the past and nothing help! What must I do? There is no blood loss either as that was tested too!

  • Michael j.

    My ferritin level keeps dropping I had iron infusions and they tell me I have a bleed and losing blood. I had two colonoscopies I had to end us copies and also had the capsule camera they found nothing. After the iron infusion it went up to 250 within two weeks it’s back down to 50 I am taking no medicines that will affect my ferritin level according to the doctor. What tests should I specify because the hematologist and the Endo chronologist do not know what to do they are just guessing at this point. My hemoglobin is back up to a 14 but it was at a sex they did not give me blood They just gave me iron infusions. I feel very weak I don’t know what to do. I’m afraid my hemoglobin is going to go down again

  • Lauren S.

    After years of tiredness and just being told to eat healthy and exercise I had a ferritin test In early pregnancy. My ferritin level was 6 and since then I have taken supplements. Having invested in a regular private test I have never managed to get my level above 34 but have just this week been told to stop the supplements as I now have iron overload. This is very frustrating as my GP is not interested in further discussion or testing as the current ferritin level (34) is normal. Still tired and struggle with concentration, headaches etc, but as I make a real effort to run, do yoga and eat well my doctor doesn’t seem to be concerned. It’s very frustrating as I could just give up, gain weight and tell my GP that I’m really struggling with my mood and then they would just look at antidepressant last rather than any underlying causes.

  • Like everyone else here i have suffered with fatigued, hair loss etc. I just had my ferritin checked and its under 10 again. Ive previously tried multiple things and been to a haemotologist. Ive had a colonoscopy, endoscopy, iron infusion, high protein diet, iron tablets the list goes on. My iron levels are normal, my blood analysis (haemoglobin etc) is perfect. I am not anaemic, i just don’t store it and noone can tell me why. My haemotologist said to me “its just you”, which isnt very helpful in providing an answer. The things ive tried to help elevate it work for a couple months but then im back in the low numbers again. Its frustrating not having an answer

  • Hi
    I discovered I had very very low B12 and low iron and low transferrin saturation. everything else is ok. I have B12 shots which changed my life!! B12 shots now regularly every month which manages to keep B12 in ok level. However, my doctor doesnt care that my iron is 0.51 and coefficient saturation 14. Is this correct not to worry. ? PS I am now 65 Thanks for your help!

  • Brandi O.

    I have had low ferritin levels for over a year. I presented to the doctor originally with fatigue, shortness of breath upon exertion, dizziness, and memory loss. All my other tests continue to come back normal so my doctor keeps telling me I’m fine. I am only 42 and I know I should not feel like this. I used to exercise daily and now cannot seem to muster up the energy to do so. When I take my grandson for a walk I feel like I need a nap after. I’m frustrated and things are getting worse. My ferritin levels have gone from 11 ng to 7ng and I am currently on supplements.

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