Iron Deficiency & Anemia
In Brief
Dr. Sanika Kshirsagar at Soma Naturopathic in Kirkland, WA runs a full iron panel rather than a bare haemoglobin, treats iron deficiency before it becomes anaemia, uses better-tolerated dosing schedules, and — importantly — investigates why iron is low, because heavy periods, coeliac disease, low stomach acid and GI blood loss all need different answers.
Iron deficiency is the most common nutritional deficiency in the world and it falls overwhelmingly on menstruating women. Iron is lost with every period, and when intake or absorption fails to keep pace, stores draw down over months to years. Crucially, symptoms begin long before haemoglobin drops: ferritin — the storage form — can be low enough to cause profound fatigue, hair shedding, breathlessness and poor concentration while a standard complete blood count still reads as entirely normal. Many women are told they are not anaemic and are therefore fine, when in fact they are iron deficient without anaemia.
Symptoms
- •Fatigue that rest does not resolve, and reduced exercise tolerance
- •Breathlessness on stairs or mild exertion, and heart palpitations
- •Hair shedding, often diffuse, several months after stores fall
- •Pale skin, pale inner eyelids, brittle or spoon-shaped nails
- •Poor concentration, brain fog, low mood and irritability
- •Restless legs at night, headaches, and unusual cold intolerance
- •Pica — craving ice, dirt or starch — which is fairly specific to iron deficiency
Causes & Risk Factors
- •Heavy or prolonged menstrual bleeding, the leading cause in premenopausal women
- •Inadequate dietary iron, especially on vegetarian and vegan diets without planning
- •Impaired absorption from coeliac disease, gastritis, H. pylori or low stomach acid
- •Long-term proton pump inhibitor use reducing the acid needed for iron absorption
- •Pregnancy, breastfeeding and closely spaced pregnancies raising requirements
- •Gastrointestinal blood loss from ulcers, polyps or colorectal pathology
- •Chronic inflammation raising hepcidin and blocking iron absorption and release
Naturopathic Approach
The first principle is to measure properly. A complete blood count alone is insufficient, because haemoglobin is the last marker to fall; Dr. Sanika orders ferritin alongside serum iron, transferrin saturation, total iron-binding capacity and often CRP, since ferritin is an acute-phase reactant and can read falsely reassuring when inflammation is present. The second principle is to find the cause rather than simply refilling the tank. In a menstruating woman the usual answer is menstrual blood loss, and heavy bleeding is then treated in its own right; in others the workup looks for coeliac disease, H. pylori, gastritis, or medication effects, and refers for gastrointestinal evaluation where blood loss is suspected — particularly in a post-menopausal woman, where unexplained iron deficiency warrants investigation rather than supplementation alone. Repletion is then done in a way people can actually tolerate: gentler forms such as bisglycinate, alternate-day rather than daily dosing, which evidence suggests improves absorption by avoiding a hepcidin spike, taken with vitamin C and away from calcium, coffee and tea. Clinical nutrition addresses food sources and the absorption inhibitors and enhancers that surround them. Repeat testing at around three months confirms that stores are genuinely rebuilding, and treatment continues well past symptom resolution because ferritin needs to be restored, not merely nudged over the laboratory cut-off.
Related Modalities
Iron Deficiency & Anemia Care by City
Frequently Asked Questions
My blood test was normal but I am exhausted. Could it still be iron?
Yes, and this is one of the most common misses in women’s health. A complete blood count checks haemoglobin, which stays normal until iron stores are nearly exhausted. Ferritin — your stored iron — can be very low while haemoglobin is still fine, and that state causes fatigue, hair shedding, breathlessness and poor concentration. Many laboratories flag ferritin as abnormal only below about 15 ng/mL, but symptoms commonly appear well above that. Asking specifically for a ferritin level is worthwhile.
Iron supplements make me constipated and nauseous. What are my options?
Usually the form and the schedule are the problem rather than iron itself. Ferrous sulphate is poorly tolerated by many people; gentler forms such as iron bisglycinate cause considerably less GI upset. Alternate-day dosing is often better absorbed than daily dosing because daily dosing raises hepcidin, which then blocks the next dose, and it halves the GI exposure. Taking iron with vitamin C and away from calcium, coffee and tea also improves absorption so that lower doses work.
How long does it take to feel better?
Energy often improves within three to six weeks, but rebuilding ferritin takes considerably longer — typically three to six months of consistent supplementation, sometimes more if losses are ongoing. Hair regrowth lags furthest behind, often six months or more, because the hair cycle is slow. Stopping as soon as you feel better is the usual reason people end up deficient again within the year.
Do I need iron if I am vegetarian or vegan?
Not necessarily, but your risk is higher and it is worth testing rather than assuming. Plant iron is non-haem iron, which is absorbed less efficiently, and phytates in grains and legumes further reduce absorption. A well-planned plant-based diet can maintain iron status by pairing iron-rich foods with vitamin C, soaking or sprouting legumes and grains, and avoiding tea and coffee with meals — but if you are also menstruating heavily, diet alone often will not keep up.
References
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Dr. Sanika Kshirsagar, ND
Doctorate of Naturopathic Medicine (ND)
Bastyr University, Kenmore, WA
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