Post #31

The Unusual Suspects: Anemia

Crone Intelligence Briefing · Filed under: Prime Mimics & Hormonal Imposters

The Unusual Suspects

In this series I’ll be investigating the common culprits that mimic peri/menopause. Unfortunately, these imposters make it hard to navigate hormonal changes and to even discover whether you’re actually in peri/menopause in the first place.

Third offender in the dock is…

ANEMIA

It sounds innocuous enough, doesn’t it? In fact, most of us have had it at some point in our lives and we don’t exactly see it as life-threatening. BUT it would be wise not to underestimate Anemia because like most unusual suspects, it’s wise not to turn your back on it. According to the Indian Journal of Ob Gyn, 1 in 4 individuals are anemic. Rising to 30% in nonpregnant women and 42% in pregnant women across the world. That’s a LOT of people so here we go.

What is Anemia?

Anemia occurs when your blood doesn’t have enough healthy red blood cells or hemoglobin - the protein which carries oxygen to the blood and tissues. Each hemoglobin protein (Hb) contains four tiny iron atoms (Fe). When we breathe in, the oxygen (O2) binds directly to the iron atoms in a reversible (easy to attach and detach from) process allowing the red blood cells to transport it through your bloodstream to then drop it off to your organs and muscles. After making the oxygen delivery, hemoglobin then attaches to carbon dioxide (CO2) the waste product made by your cells and sends it back to the lungs to be breathed out.

So when I said Anemia doesn’t seem life threatening? It isn’t really the fast burn but a slow fuse because iron is at the heart of this matter. Low iron = inadequate binding to hemoglobin and diminished delivery of oxygen to tissues.

What causes it?

Most commonly, iron deficiency which can happen due to blood loss from heavy periods, internal bleeding, or a diet which doesn’t supply essential nutrients. We get a lot of iron from our food which is absorbed in the intestines before being stored in the liver as the protein ferritin. Ferritin is then released whenever it’s needed to create new blood cells. If this iron stash gets used up faster than it gets made, this causes (ID) iron deficiency and (IDA) iron deficiency anemia.

Sometimes certain illnesses affect the body's inability to absorb iron properly. These include celiac disease, kidney disease, pregnancy, or genetic disorders where the body destroys red blood cells too quickly. These include Sickle Cell disease where hemoglobin is misshapen and twists red blood cells into crescent-shapes that rupture. Or Thalassemia where the body doesn’t produce enough hemoglobin, leading to unstable cells that the body quickly destroys.

Symptoms overlap

🩸 Anemia

Extreme fatigue - tissues lack oxygen
Brain fog & dizziness - low iron impairs oxygen delivery to the brain
Heart palpitations - the heart pumps harder to move oxygen
Heavy bleeding - causes anemia
Irregular periods - low iron causes progesterone drops
Thinning hair/hair loss - reduced oxygen to the follicles
Temperature regulation - low iron leads to feeling cold

🔥 Peri/menopause

Extreme fatigue - disrupted sleep and hormonal dips
Brain fog & dizziness - fluctuating estrogen affects cognitive function
Heart palpitations - hormonal shifts affect the nervous system
Heavy bleeding - due to erratic ovulation and hormonal dips
Irregular periods - due to erratic ovulation and hormonal dips
Thinning hair/hair loss - dip in estrogen, rise in testosterone
Temperature regulation - estrogen dip causes hot flashes

As you can see this is pretty damning evidence of an overlap that makes a perimenopause diagnosis difficult. I mean, our medical unprofessionals struggle as it is. There’s evidence that 40 – 55-year-old women (see articles) often experience low iron levels and their doctors are none the wiser, in fact they’re likely to talk about aging and stress! Not shocked about that.

What’s the relationship between hormones and iron?

You might have noticed that absolutely everything related to hormones involves a very delicate dance. In the case of iron, this ‘simple’ element is more influential than you think. Let’s look deeper.

How does low iron affect hormones?

It can disrupt ovulation because iron is essential for oxygenation and metabolic function. Low iron can affect normal follicular development and that leads to poor egg quality and a failure to ovulate (anovulation). That in turn affects the levels of progesterone because ovulation produces progesterone. This leads to irregular, painful or heavy periods due to estrogen dominance. Additionally, that extra fatigue from a lack of oxygen to the tissues increases stress, by boosting stress hormone cortisol. All of which leads to brain fog, mood swings which mimic perimenopause. Low iron levels lead to sluggish thyroid function (hypothyroidism). And as you know from the first Unusual Suspects: Thyroid issues, a poorly functioning thyroid interferes with estrogen and progesterone metabolism bringing us back to missed cycles and erratic or heavy bleeding. Finally, during hormonal transitions: postpartum, stopping birth control, or during perimenopause, estrogen levels naturally drop. This causes the liver to produce more hepcidin, which blocks your gut from absorbing iron.

What about how hormones affect iron?

Estrogen helps control hepcidin, which regulates how much iron your body absorbs and releases. When estrogen levels fall during perimenopause or hormonal shifts within the cycle, hepcidin levels can rise and block the body from effectively absorbing and utilizing iron, even if you eat foods rich in iron. Your body will still try to get hold of as much iron as it can by releasing iron stored in your cells into your blood. This process helps you naturally replace the iron you lose during periods. Basically, estrogen helps your body get and use more iron.

Fluctuating or high levels of estrogen can cause thickening of the uterine lining causing heavier periods, leading to iron loss through bleeding.

A previous study using National Health and Nutrition Examination Survey (NHANES) III data on the general US population showed that iron levels changed between hormonal state and age. They were fairly low until after a woman’s fourth decade of life. Then rose sharply and continued to do so until 60 – 69. Not a coincidence, no bleeding = no uterine shedding and iron loss.

You’re at risk of low estrogen and iron if you have…

Heavy or prolonged periods
Uterine fibroids, endometriosis, or thyroid conditions
Are a vegetarian or vegan eating no iron-rich meat
A restrictive diet
Use a copper IUD causing heavier, longer, and more painful periods
Impending menopause and irregular cycles or spotting
Digestive issues like celiac disease, IBS, low stomach acid which affect absorption

How do you know if it’s Anemia or peri/menopause?

By now you know what I’m going to say… testing.

Iron tests that uncover the early signs of Anemia

Serum ferritin: This is the most telling. It measures the body's total iron store. In perimenopause, a woman might have a normal red blood cell count but low ferritin stores due to heavy bleeding, below 30 ng/mL = iron deficiency
Complete blood count (CBC): Checks hemoglobin (Hb) and hematocrit (Hct) to see if full anemia is occurring. It also looks at mean corpuscular volume (MCV) or red blood cell size. Low MCV = microcytosis = iron deficiency
Total iron-binding capacity (TIBC) and transferrin saturation: TIBC measures how well transferrin (protein) attaches to iron to transport it. When iron stores are low, TIBC levels rise because the body needs more transport vehicles for what little iron is available. Transferrin saturation is below 20%

Hormone tests to see perimenopausal transition is happening

Follicle stimulating hormone (FSH): the pituitary gland releases FSH to stimulate the ovaries. As ovarian reserve drops during perimenopause, the pituitary gland pumps out more FSH to get a response. High FSH levels around >30 IU/L, but fluctuating suggests perimenopause or menopause
Estradiol (estrogen): during perimenopause, estradiol levels spike and crash rather than remaining steady, contributing to hot flashes and mood swings
Thyroid stimulating hormone (TSH): Because thyroid issues mimic both anemia and perimenopause a TSH test rules out hypothyroidism

Treating iron deficiency?

Tackle your diet by eating iron rich foods like meat, fish, poultry, leafy greens, legumes, and iron-enriched cereals. Adding vitamin C rich foods like citrus fruits increases iron absorption. Often vegetarian / vegan diets get blamed for iron deficiency but this only true due to the iron source. Plant-based iron (non-heme) isn’t absorbed as easily (rate of 2-20%) as animal-based iron (heme) which has a 15-35% absorption rate and goes directly into cells while plant-based iron has to be chemically converted from its ferric form to its ferrous form in the gut before absorption. On top of this, compounds in plants like phytates and polyphenols bind easily to plant-based iron in the gut blocking your body from using it.

Taking iron supplements can help, as can intravenous iron therapy where iron is introduced via a vein. If you’re having heavy bleeding (soaking pads or tampons every two hours) or having periods longer than a week, birth control might be recommended or drugs like tranexamic acid for blood loss. Sometimes surgery is the answer especially if there are fibroids (myectomy), or the uterine lining is removed (endometrial ablation) or the uterus and/or ovaries are excised (hysterectomy).

The misdiagnosis nightmare

Anemia is notoriously difficult to diagnose in perimenopausal women because it mimics perimenopause too well. The symptoms of iron deficiency and perimenopause are nearly identical. When you tell your doctor, they’re likely to blame symptoms on fluctuating estrogen or progesterone.

Then there’s the blood tests and an issue with ranges. Often “well within range” is spouted to patients. A standard complete blood count only checks for anemia by looking at red blood cells and hemoglobin levels. But you can be severely iron-deficient long before it turns into full-blown anemia on a CBC test. Standard lab reference ranges for ferritin aren’t much better since many commercial labs list a "normal" ferritin cutoff as low as 15 ng/mL when in reality symptoms can appear when ferritin drops below 30 to 50 ng/mL. But because labs read as "normal," the doctor might dismiss iron as the problem.

Lastly because perimenopause is a well-known life transition, you are ‘of that age’ and you have irregular or heavy periods, your doctor might treat this symptom but ‘forget’ high blood loss = low iron reserves! Being within perimenopause age doesn’t mean every woman is in it. Just as most women of that age are low in iron.

Can HRT help anemia?

In short? Yes. It helps iron deficiency anemia by reducing heavy period blood loss and lowering hepcidin levels to improve iron absorption. But note HRT doesn’t contain iron, meaning you’ll still need to make dietary changes or take supplements to replenish empty iron reserves. The combination pill, patch, or ring which contain both estrogen and a progestin can suppress ovulation and thin the uterine lining. This means reduced blood loss.

So now you have the evidence, we deliberate for a second…

THE CRONE'S VERDICT UNUSUAL SUSPECT #3:
GUILTY AS CHARGED!