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title: "Iron Deficiency Anemia: The Risks in Heavy Menstrual Bleeding and Its Impact on Energy, Exercise, and Overall Health"
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Iron Deficiency Anemia

Heavy menstrual bleeding affects many women and often leads to iron deficiency (ID), which can progress to iron deficiency anemia (IDA) when left untreated. When you experience heavy periods month after month, your body loses significant amounts of iron that isn't easily replaced through diet alone.

Iron deficiency anemia from heavy menstrual bleeding can seriously impact your quality of life. Some of the symptoms can include:

- fatigue/weakness
- dizziness
- light headedness
- pale skin
- cold intolerance
- hair loss or thinning
- cognitive issues/brain fog
- shortness of breath on exercise (e.g. going up the stairs and feeling winded easily) 
- Decreased immune system (e.g. getting colds easily)

Iron plays a crucial role in your body in creating hemoglobin . It is very important for numerous physiological functions and cellular processes. Hemoglobin, the protein in red blood cells, requires iron to bind and transport oxygen from your lungs to tissues throughout your body. When your doctor does a blood test called a "complete blood count (CBC)" this includes the measurement of hemoglobin levels.

Also important to note is that you can have iron deficiency without anemia - meaning your iron stores (the blood test we use is called ferritin ) are depleted but haven't yet affected your red blood cell count enough to be classified as anemia. This occurs when on a blood test one's hemoglobin levels are within normal range but their iron stores (ferritin) is below optimal. This means low iron is very often under diagnosed.

This connection between heavy periods and iron problems is frequently overlooked in healthcare settings. Many women suffer silently with exhaustion and other symptoms without realizing that heavy menstrual bleeding globally is the most common cause of iron deficiency in women of reproductive age -from adolescence, to pregnancy, to postpartum and in the perimenopausal and menopausal years.

"Anemia is a serious global public health problem that particularly affects young children, menstruating adolescent girls and women, and pregnant and postpartum women. WHO estimates that 40% of children 6–59 months of age, 37% of pregnant women, and 30% of women 15–49 years of age worldwide are anaemic."

(World Health Organization, 2025)

Recognizing symptoms early and seeking appropriate treatment can prevent the progression from heavy bleeding to iron deficiency to full-blown anemia. Both conditions - the heavy bleeding itself and the resulting iron deficiency - adversely impact your quality of life in ways you might not expect.

## Iron Deficiency Anemia (IDA) what are the implications for health?

Iron deficiency anemia occurs when your body lacks sufficient iron to produce enough healthy red blood cells. This condition develops gradually as your body depletes its iron stores, affecting your ability to transport oxygen throughout your body.

Iron deficiency most commonly results from blood loss, with heavy menstrual bleeding being a leading cause in women of reproductive age. Up to one-third of women experience heavy menstrual bleeding, which can significantly deplete iron reserves.

Poor iron absorption due to gastrointestinal conditions such as:

- Celiac disease
- Inflammatory bowel disease (e.g. Crohn's, Ulcerative Colitis, etc.)
- Pregnancy (increased blood volume and fetal needs)
- Blood donation (too frequent)
- Internal bleeding (ulcers, polyps, or cancers)
- undergone gastric bypass surgery

One's risk of IDA increases if there is inadequate iron in the diet such as in some restrictive diets as it can limit your body's ability to absorb adequate iron from food sources.

## Heavy Menstrual Bleeding (HMB) and the causes

Heavy menstrual bleeding, medically known as menorrhagia , affects many women and can significantly impact quality of life. This condition goes beyond normal period flow and creates risks for iron deficiency that should not be ignored.

HMB  is characterized by excessive or prolonged menstrual bleeding. You may have menorrhagia if your period lasts more than 7 days or if you lose more than 80 ml of blood per cycle. Recently however, I simply ask my female perimenopausal women patients the following questions:

"Does our bleeding interfere with your physical, social, or emotional quality of life?"
"Do you avoid going to the office because you are worried you may leak at your desk?"
"Do you have to avoid going to the gym in case your pads/tampons don't hold the flow?"
"Do you need to rearrange your life to accommodate your bleeding?"
"Are you changing feminine hygiene pads/tampons/cups more than every 1-2 hours or does your period lasts longer than a week?"

If the answer is yes to these questions, then you have HMB.

## Heavy menstrual bleeding signs and symptoms:

- Needing to change pads/tampons every hour or more frequently
- Passing large blood clots (quarter-sized or larger)
- Bleeding that soaks through your clothes or bedding
- Needing to use double sanitary protection
- Restricting daily activities due to heavy flow

Research shows that excessive fatigue is common in women with menorrhagia, severely affecting daily activities. Without treatment, iron deficiency can become chronic and increasingly difficult to correct.

There are several common conditions that can cause HMB for women in perimenopause such as with the acronym: PALM-COEIN. PALM is related to s tructural causes of HMB and COEIN are n on-structural causes. You can read my [previous blog](/blog/heavy-menstrual-bleeding-relating-to-perimenopause-causes-and-management-options)where I discussed each of these.

Your doctor may use blood tests, ultrasound, or other tests such as biopsy, to determine the cause. Identifying the underlying condition is crucial for effective treatment and preventing complications like iron deficiency anemia or iron deficiency.

## Heavy Menstrual bleeding: Implications for Women's Health

The health impacts of heavy bleeding extend far beyond the menstrual period itself. Iron deficiency negatively affects your well-being even before anemia develops.

Proper diagnosis and timely treatment are essential for managing both heavy menstrual bleeding and the associated iron deficiency anemia. Several effective approaches exist, ranging from simple blood tests to medication and surgical interventions.

"Heavy menstrual bleeding was reported by large minorities of women of reproductive age, and the proportion increased with age. Many women experience symptoms that have a substantial impact on their physical and mental health-related quality of life." (Wilson, et al, 2025)

# Assessing Menstrual Blood Loss

Diagnosing heavy menstrual bleeding starts with your description of symptoms. Your primary care provider may ask you to track your period using a menstrual chart or specialized apps to document flow intensity and duration.

## Menstrual Product Options for Heavy Flow

Selecting appropriate menstrual products is crucial when you experience heavy menstrual bleeding. High-absorbency pads and tampons provide better protection during heavy flow days.

- Ultra or super-absorbent pads with wings
- High-capacity tampons (change every 4-6 hours)
- Menstrual cups (can hold more fluid than tampons, typically 20 to 30 mg per cup depending on the brand)
- Period underwear

Track your usage of pads and tampons to help measure blood loss. (Remember, needing to change products more than every 1-2 hours suggests heavy bleeding that warrants medical attention.) 

Products with moisture-wicking technology can improve comfort during your menstrual cycle. Consider overnight protection designed specifically for heavy flow to prevent leakage during sleep.

## Blood tests in Perimenopause to rule out iron deficiency with or without anemia

- Complete blood count (CBC)
- Ferritin levels (the most sensitive test for iron deficiency)
- Total iron binding capacity (TIBC)
- TSH (Thyroid stimulating hormone)
- Transferrin Saturation (especially helpful test to distinguish if a women has iron deficiency with suspected other underlying inflammatory condition)
- Coagulation tests (INR, platelets)

If a bleeding disorder is suspected, your doctor may test for von Willebrand disease, which affects up to 20% of women with heavy periods, or other coagulation disorders like hemophilia. If you bruise easily or it takes a long time for cuts to heal or you get frequent nose bleeds, discuss this with your primary care provider.

## Treatment for heavy menstrual bleeding (HMB) in Perimenopause

Several medications can effectively manage heavy menstrual bleeding and associated iron deficiency by reducing bleeding and blood loss. The treatment depends on the cause of the bleeding.

# Hormonal options:

Combined hormonal contraceptives or "the birth control pill" (pills, patches, rings)

Progestin-only pills

Hormonal IUDs (e.g. Mirena)

# Non-hormonal medications:

Tranexamic acid (TXA)

Nonsteroidal anti-inflammatory drugs (NSAIDs) e.g. Advil, Motrin, Naproxen

Surgical options need to be considered in some women who have severe bleeding and there is no resolution of symptoms with other treatment. It is important to speak to your primary care provider to decide on the best treatment(s) for you.

## Taking iron for iron deficiency and iron deficiency anemia

- Oral iron supplementation (ferrous sulfate, ferrous gluconate - these are widely available supplements available in most pharmacies and are higher doses of elemental iron around 100-150 mg per capsules) e.g. Ferramax, Euro-Fer, Palafer, etc.
- IV iron (for severe deficiency)
- Other forms that are lower dose but have shown better absorption are typically iron glycinate or iron citrate. The dosing is anywhere from 25-30mg of elemental iron. However some women who experience side effects from the higher iron doses such as constipation, do better with these lower dose supplements. E.g. Ferrosom Forte, Bio-ferra, etc.

## Diet modifications can help boost iron levels:

- Avoid taking iron close to any medication especially things like thyroid medication (e.g. synthroid)
- Consume iron-rich foods (lean red meat, beans, fortified cereals)
- Include vitamin C with meals to enhance iron absorption
- Avoid coffee, tea, fibre and calcium supplements with iron-rich meals
- Taking iron supplements between meals rather than with food improves absorption.
- Starting with lower doses and gradually increasing can reduce stomach upset.
- If constipation occurs speak to your primary care provider to change dosing strategies such as using a lower iron dosage or taking it every other day instead of every day.

## Treatment for ongoing heavy bleeding, a woman often needs combination therapy

- Hormonal treatments such as an IUD (e.g. Mirena) or birth control pills to reduce bleeding or if bleeding is excessive more advanced interventions such as myomectomy or ablation or even surgery may be recommended 
- Iron supplements to correct deficiency
- Management of any underlying bleeding disorders
- Consider Ginger (Zingiber officinale) and Frankincense (Boswellia serrata, oleoresin) as a supportive treatment used in the cycle prior to the period to help with bleeding. Ginger & Boswellia is an anti-inflammatory. 

"Ginger and frankincense are effective complementary treatments for heavy menstrual bleeding, reducing duration and improving quality of life in women of reproductive age." (Eschaghian, et al, 2019)

Regular follow-up appointments are important to monitor your iron levels and adjust treatment. The goal is to establish normal hemoglobin levels and reduce menstrual blood loss to improve your quality of life.

# Nutritional and Iron Supplement Guidance

Iron-rich foods should be a key part of your daily diet. Often women need a combination of improved diet as well as an iron supplement to improve their iron levels faster.

# Top Iron-Rich Foods:

- Red meat (especially liver)
- chicken and poultry
- seafood and fish
- Dark leafy greens (spinach, kale)
- Lentils and beans
- Fortified breakfast cereals or grains
- Dried fruits (apricots, raisins)

Iron supplements may be necessary if your diet alone can't meet your needs. Take supplements with vitamin C to improve absorption, but avoid taking them with calcium-rich foods, coffee, or tea.

Start with a lower dose and gradually increase to reduce digestive side effects. Many women find taking supplements with meals helps minimize stomach upset.

# Other dietary changes

Dietary changes can significantly improve your iron status. Focus on iron-rich foods like lean red meat, dark leafy greens, beans, and fortified cereals, paired with vitamin C to enhance absorption.

Vitamin B complex, especially Vitamin B12 and Folic acid (Vitamin B9), works alongside iron to produce healthy red blood cells. These vitamins don't directly reduce bleeding but support your body's ability to recover from blood loss. It can sometimes be helpful to also test your Vitamin B12 levels to ensure it is not low.

Vitamin C enhances iron absorption from both food and supplements. Including vitamin C-rich foods like citrus fruits, bell peppers, and strawberries with iron-containing meals can improve your iron status over time.

# Conclusion

Addressing the underlying cause of heavy bleeding is crucial for long-term management. Hormonal therapies, anti-inflammatory medications, or surgical interventions may be recommended based on your specific situation.

Iron deficiency anemia impacts your energy levels, physical performance, and cognitive function. You might notice decreased productivity at work, reduced exercise capacity, and difficulty with concentration or memory. It is important to identify and treat the cause as well as to relieve the symptoms of IDA and IA.

Would you like to book a discovery call, if so you can book [here](http://www.dramytung.janeapp.com).

Wishing you the best health,

Dr. Amy J. Tung, ND

Naturopathic Doctor

# References:

https://www.who.int/health-topics/anaemia#tab=tab_1

Baldwin, M. (2023). Iron deficiency and anemia in patients with heavy menstrual bleeding: Mechanisms and management. OBG Management. https://doi.org/10.12788/obgm.0268.

Bernardi, L.A., Ghant, M.S., Andrade, C. et al. The association between subjective assessment of menstrual bleeding and measures of iron deficiency anemia in premenopausal African-American women: a cross-sectional study. BMC Women's Health 16, 50 (2016). https://doi.org/10.1186/s12905-016-0329-z

Eshaghian, R., Mazaheri, M., Ghanadian, M., Rouholamin, S., Feizi, A., & Babaeian, M. (2019). The effect of frankincense (Boswellia serrata, oleoresin) and ginger (Zingiber officinale, rhizoma) on heavy menstrual bleeding: A randomized, placebo-controlled, clinical trial.. Complementary therapies in medicine, 42, 42-47 . https://doi.org/10.1016/j.ctim.2018.09.022.

Johnson, S., Lang, A., Sturm, M., & O’Brien, S. (2016). Iron Deficiency without Anemia: A Common Yet Under-Recognized Diagnosis in Young Women with Heavy Menstrual Bleeding.. Journal of pediatric and adolescent gynecology, 29 6, 628-631 . https://doi.org/10.1016/j.jpag.2016.05.009.

Mansour, D., Hofmann, A., & Gemzell‐Danielsson, K. (2020). A Review of Clinical Guidelines on the Management of Iron Deficiency and Iron-Deficiency Anemia in Women with Heavy Menstrual Bleeding. Advances in Therapy, 38, 201 - 225. https://doi.org/10.1007/s12325-020-01564-y.

Munro, M. (2023). Heavy menstrual bleeding, iron deficiency, and iron deficiency anemia: Framing the issue.. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 162 Suppl 2, 7-13 . https://doi.org/10.1002/ijgo.14943.

Wilson, L., Copp, T., Hickey, M., Jenkinson, B., Jordan, S., Thompson, R., Mishra, G., & Doust, J. (2025). Women who experience heavy menstrual bleeding: prevalence and characteristics from young adulthood to midlife, Australia, 2000-2021: a longitudinal cohort survey study.. The Medical journal of Australia. https://doi.org/10.5694/mja2.52596.

# Disclaimer:

The information in this blog is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your doctor or other qualified health professional with any questions regarding a medical condition or treatment. Never disregard professional medical advice or delay seeking treatment because of something you have read in this blog.

Individual results may vary, and the strategies discussed here are not guaranteed to work for everyone. This content does not create a patient-client relationship and should not be used as a replacement for personalized medical care.

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