Is Your Period Draining Your Iron Stores? (Episode 633)

Full Transcript: Episode 633

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 633. In today’s episode, I will be diving into an important topic, iron deficiency in women. I’m going to be diving into a recent paper that looked at this phenomenon, what is associated with it, what some of the risk factors are, and some of the interesting points that were brought up in the paper.

For anybody who has struggled with low iron or if you have questions about iron or how it works, I feel like this episode is going to be really interesting and really helpful for you.

The paper that I will be delving into is called Diagnosis and Management of Iron Deficiency in Females. This is a review study — essentially an analysis of multiple studies that have looked at this topic, which provides us with a really great wealth of information.

The first point that I want to talk about is — I think a surprise to absolutely no one — what the researchers identified is that heavy menstrual bleeding is actually the primary driver of iron deficiency. How they define heavy bleeding I think is really important.

This isn’t exactly new information if you are familiar with my books, because I do think that when you look at how researchers define heavy periods — or what would be the cutoff for us to consider the volume of bleeding to be normal — I do think that for many women, it’s surprising how low that bar is, considering how significant of a range of bleeding there is when we’re looking at menstrual blood loss.

Anywhere between 18 to 50% of the women within the sample cohort met the criteria for heavy menstrual bleeding. And this does not surprise me at all. In The Fifth Vital Sign and in Real Food for Fertility, generally speaking, the range of what we consider to be normal for menstrual bleeding is somewhere between 25 and 80 milliliters of blood loss.

One of the things that I’ve written about in the past is that the researchers determined that 80 milliliters is kind of the top for what they would consider to be normal blood loss. Not because there aren’t many women who bleed more than that, but it’s because when women are bleeding more than 80 milliliters, they are typically at a greater risk for iron deficiency anemia.

This paper simply supports that same information. What the researchers say is that normal menstrual cycles deplete anywhere between 10 and 20 milligrams of iron, and cycles above 80 milliliters directly increase iron deficiency risk.

Their point is valid — they say that most women and many practitioners significantly underestimate what qualifies as heavy menstrual bleeding, because up to 50% of the women in this study actually did meet that criteria.

A quote from the paper: the researchers said, “Saturating two heavy pads” — and they’re saying that’s 100 milliliters of bleeding — “or three heavy tampons,” which they say is equivalent to 90 milliliters over a menstrual cycle, “immediately meets the criteria for heavy menstrual bleeding.”

So if during the course of your menstrual cycle you bleed through two heavy pads and saturate them, or three heavy tampons, then you are immediately meeting that criteria for heavy menstrual bleeding. It really doesn’t take much.

Over the years of working with a variety of clients, there are plenty of women who don’t bleed that much and have periods on the lighter end that fall into the normal range. But there is a significant percentage of women who bleed a lot more than that 80 milliliters — myself included.

It is really helpful to know that heavy bleeding is one of the most significant factors. If you consider your own cycles to be heavy, or if you bleed the equivalent of saturating two heavy pads or three heavy tampons over the course of your whole period, then you actually are losing quite a bit of iron when you have your period. It would be worthwhile to consider your regular intake of iron-rich foods, such as liver and red meat, so that you can ensure that you are not putting yourself at a greater risk for deficiency.

Another really interesting point that the researchers highlight is the reference range for iron in the form of ferritin — this is always one that’s up for discussion. For any of our practitioners who are listening, if you’re looking at these reference ranges, the reference range is typically enormous. Sometimes it’s anywhere from 15 to 200. That very large range is obviously not telling us what is optimal.

This paper confirmed that. The reference range, when it was initially developed, actually included people who were deficient. The old lower limit of 12 to 15 micrograms per liter, depending on the lab, was actually replaced in 2024 with 30 micrograms for adults and 20 micrograms per liter for children, at least within the Canadian system that they were studying.

It’s about time. It’s absolutely incredible that they had such a large range, but they identified that that range was initially determined using people who were actually deficient.

One of the important points that the researchers discuss is that even though they’ve set this limit at 30 micrograms per liter for adults, what the research actually shows is that if your ferritin level is below 50 micrograms per liter, your body is already showing abnormal biochemical markers of iron deficiency. At that stage, your body is already starting to compensate for the fact that it is deficient. The deficiency is not overt, and it hasn’t caused additional issues yet.

This is certainly a case for an optimal range versus the typical reference range, or a functional range for iron — especially in menstruating women and women of reproductive age. This quickly becomes an issue for women who are trying to conceive, who get pregnant, because our requirement for iron significantly increases with pregnancy and lactation and multiple pregnancies.

Another point that the researchers brought up is the difference between non-anemic iron deficiency and iron deficiency anemia. They were calling out the tendency to assume that if there’s no anemia, the iron deficiency isn’t really a big issue.

What they actually found was a connection between absolute iron deficiency and mortality risk. Women who had iron deficiency, even if it wasn’t iron deficiency anemia, had a higher mortality rate, and the finding was significant. Absolute iron deficiency was independently associated with all-cause mortality, even after adjusting for other risk factors.

Even when it’s not officially called anemia, non-anemic iron deficiency is still associated with a variety of symptoms — fatigue, brain fog, hair loss, even restless leg syndrome, not recovering well from exercise, various types of cognitive impairment, and even anxiety and depression.

What this paper is highlighting — putting it in my own words — is a need to really acknowledge that there’s a functional range. Even if you’re not in the most overt category, it’s still causing problems, even at the level where it’s not officially considered anemia.

The researchers also identified iron deficiency in pregnancy as a significant issue — we could even say a borderline crisis problem. Based on the studies they looked at, 53% of pregnant outpatients in Ontario were iron deficient. Over half of the pregnant women were deficient in iron. This is a significant problem.

When you look at the research on iron deficiency anemia in pregnancy, it is linked to preterm labor, postpartum hemorrhage, peripartum death, postpartum depression, and even intellectual disability. Women who are iron deficient to the point of anemia have significantly higher risks of these conditions, including autism spectrum disorder and ADHD.

There was something really interesting that the researchers said — a quote from the study: “Given that 1,000 milligrams of iron is equivalent to 177 large steaks, it is impossible to eat your way out of iron deficiency in pregnancy.”

What they were saying is that over half of these women going into pregnancy are deficient in iron. In order for them to correct that deficiency, pregnancy requires approximately a thousand milligrams of iron to support fetal growth and placental development, to accommodate the expanded blood volume, and also postpartum losses. So they made that comparison to say it would be impossible for these women to consume 177 steaks in order to make that up. You can’t make up that deficiency with food alone.

The average diet that the average woman is eating is leading half of these women to not have sufficient iron stores in pregnancy. In Real Food for Fertility, Lily and I go into a lot of depth about the importance of consuming sufficient iron and also the importance of a preconception nutrition phase — where before you’re even pregnant, you’re spending a minimum of three to six months actively building up your stores.

While there is an argument to be made that it would be difficult for a woman to consume a correct amount when she’s already pregnant, I find that interesting. Even if you look at 177 steaks over the course of a year, it’s like three steaks a week or so over the course of a year.

The takeaway that I have from this information is that it is a well-established issue that women are going into pregnancy deficient in iron. I’ve actually worked with a number of clients who were previously vegetarian, who literally during their pregnancy start eating steak. For practitioners, when you’re working with women in the preconception stage, it is essential to bring to their attention the importance of iron and proper preconception nutrition practices that will lead them to really start to build their iron stores.

What I always say is: when you’re not pregnant, when you’re in the preconception stage, there is not really a limit as to how much liver you can consume. We don’t really have to worry about teratogenic metabolites when you are not pregnant yet. It’s a great opportunity during that three to six months or more leading up to pregnancy to really focus on upping your liver consumption, upping your red meat consumption, increasing your consumption of fish and seafood — oysters and shellfish and a variety of different foods that are high in many of these key nutrients in general, but also particularly iron, vitamin A, and zinc.

I feel like this study really solidifies the importance of nutrition. I would argue that it might be difficult for women who are already deficient to rectify this issue with only food. Although I have found that women who are actively consuming liver or red meat — but particularly liver — do see that liver is extremely effective at increasing iron stores above and beyond the potential for supplementation.

The researchers acknowledge this in the paper. Their solution to the problem of women going into pregnancy heavily deficient — and their own stated issue that it would be impossible for these women to eat enough iron-rich food to offset this — is interesting. They don’t mention liver anywhere in this paper whatsoever, even though it’s one of the richest sources, if not the richest source, of iron.

They are saying you can’t eat enough. They’re saying that when you consume prenatal vitamins with iron or when you take a lot of iron pills, it can also cause stomach upset and decreased bowel motility — basically constipation. A quote from their paper: “Oral iron supplementation is unlikely to meaningfully increase ferritin levels during pregnancy because pregnancy is a time of iron utilization, not storage.” So they’re actually saying that women should have intravenous iron during this time because they’re not going to be able to get enough from food and the supplements aren’t going to be as effective.

I find this all very interesting. Oral supplementation can prevent the most severe forms of deficiency, but it doesn’t always result in optimal levels. The absorption isn’t as great. But if you have a woman who starts eating liver or taking liver capsules and does that for a period of six months to a year, her ferritin levels and her iron stores will be significantly improved beyond what I’ve seen to be possible with supplements.

That’s just a little side note. I thought it was really interesting that they’re identifying this really big problem, but the most obvious and efficient and effective solution of changing your diet and eating liver is not mentioned once, even though this paper is about iron and that would potentially make the biggest difference for these women.

One last point — and this just builds on what I’ve been talking about. The researchers identified iron deficiency as a health issue, but they also found a disparity between the iron deficiency of Caucasian women and Black women. What they reported was that Black females have four to seven times higher iron deficiency anemia prevalence compared to white females.

The paper itself didn’t talk about why this is happening, but when we look at the general data that is available, Black women are at a higher risk of fibroids, and fibroids are known to be associated with heavier bleeding. There are also known differences in maternal mortality rates, access to care, and a variety of other factors that may lead Black women to consistently have this higher level of iron deficiency anemia.

According to the paper: “Black females were five times more likely to die from postpartum hemorrhage than females of other races and ethnicities.”

The final point I wanted to identify from this paper was that there was also a racial difference with respect to iron deficiency. As a Black female — as an N of one — I can’t really speak to this on a broader level, but I do know that personally, fibroids were a significant factor in my family, to the point that I requested early diagnosis. I proactively went to my doctor in my 20s and requested an ultrasound because I wanted to verify if I had fibroids, and it did come back positive. Even in my 20s, that was identified. I’ve always had very heavy cycles, and I would assume that it’s related to the existence of fibroids, which fortunately have not increased in size and haven’t grown to cause more of an issue than they already have.

I do think it’s worthwhile — whether you are a practitioner working with a variety of different women, or whether you are listening for yourself — to be aware that Black women, according to this study, are much more likely to be experiencing iron deficiency anemia. It would be worthwhile to keep that in mind when you’re working with a variety of different populations.

For all women, it is helpful to learn about what is considered to be normal in terms of blood loss, because women who bleed heavy — that’s just their normal. I remember when I started working with clients and I learned about the normal ranges of bleeding, and I would have clients who would be at the lower range of what’s considered normal. That was astounding to me — that there were women who for the course of their whole period might fill one menstrual cup. The lower end of normal. And to me that was astounding, being that I’m typically filling that menstrual cup within a few hours on the first day of my cycle.

I do think it’s helpful for all women to learn more about what is considered to be normal, to understand what that looks like. One of the activities we do with our practitioners and that I’ve always done with clients is demonstrate what that normal blood loss looks like. Grab a menstrual cup — it’s typically about an ounce — and you can actually use that to demo what the normal range is.

If you think to yourself, “I think my bleeding is pretty normal,” or “I think my bleeding is pretty heavy,” it could be a worthwhile experiment to track how many cups you fill if you use menstrual cups, or track how many pads you use if you use pads. Pay attention to whether you’re saturating the pad or not, whether it’s a super or heavy pad. Pop it into an AI tool like ChatGPT and ask it to estimate how much blood you’re losing. Even just by doing something like that, you’ll all of a sudden have a better idea of how much blood loss you have. It’s not perfect when we’re going based on pads and tampons, but you can still get a general estimate and compare it to what the normal parameters are.

With that said, I hope you enjoyed today’s episode. If you can think of somebody who would benefit from hearing it, feel free to share. The share links are available in your favorite podcast player, and you can also head over to fertilityfriday.com and look for today’s episode. You will find in the show notes the links to the paper that we talked about, and any other relevant links that we add to this episode.

I hope that you have a wonderful week — whenever you are tuning into today’s episode. And as always, until next time, be well and happy charting.