I am an avid napper, I always have cold hands and feet, and my hair can be found everywhere I’ve been, and I’ve been mostly-a-vegetarian for 15 years. I’ve also been iron deficient a number of times. Whilst iron deficiency doesn’t entirely explain all of this, it has helped me to learn more about my body’s needs and has helped me understand my complete lack of energy during my period.
What is iron deficiency?
Iron deficiency is the most common nutrient deficiency globally, affecting 25% of people (1). Iron deficiency can occur because of low iron intake, low iron absorption from food, low iron stores, and from an increased loss of iron whilst bleeding – particularly for those with heavy periods.
When iron deficiency occurs for a number of months, it impacts on the body’s ability to produce haemoglobin (the oxygen carrying part of a red blood cell), and this can progress to Iron Deficiency Anaemia (2). Anaemia occurs when the number of red blood cells, or the amount of haemoglobin within red blood cells isn’t sufficient to support the body’s needs. People who menstruate make up one third of anaemia cases globally (5), with iron deficiency contributing half of this number (3). In some countries like India, Iron Deficiency Anaemia is as high as 60% in adolescents (4).
Around 20-40% of people who menstruate experience heavy menstrual bleeding (6). Heavy menstrual bleeding can cause decreased iron and haemoglobin levels in the body, and can lead to anaemia in some cases. Having heavy periods doesn’t mean that you have Iron Deficiency Anaemia, but you are more likely to have iron deficiency than those with lighter periods (7, 8).
Being vegetarian (or vegan) whilst bleeding
I was a vegetarian for a long time, but I ate a lot of iron-rich foods, so I assumed my iron level was at least normal.
Despite vegetarian and vegan diets demonstrating similar iron content, people who menstruate and eat a vegetarian diet are more likely to have iron deficiency, and Iron Deficiency Anaemia than people on non-vegetarian diets (9, 10).
Plant foods that contain high amounts of iron include legumes, beans, whole grains, dark and leafy green vegetables. There is, however, a difference in the body’s ability to absorb the type of iron present in plant foods (non-heme iron) rather than meat (heme iron), called bioavailability. Meaning that a lower amount of iron is absorbed in vegetarians, even when the iron content of food is similar (10). Iron absorption from plant foods can also be inhibited by other factors found in plant foods, as well as in tea, coffee and red wine, (9, 10).
What does iron deficiency feel like?
Symptoms of iron deficiency and iron deficiency anaemia can be mild at first and include pale skin, weakness, fatigue, headache, lightheadedness, less energy for physical work or exercise, difficulty concentrating, brittle nails, hair loss, cold hands/feet and unusual cravings for non-food substances (6, 7). Iron Deficiency Anaemia has also been linked to menstrual related migraines (12).
If you experience the above symptoms, particularly around your period, see a doctor if you can. Self-diagnosing iron deficiency can be risky, since the overloading the body with iron can be dangerous to your liver. Iron deficiency and Iron Deficiency Anaemia are typically diagnosed with blood tests that evaluate your levels of red blood cells, haemoglobin and iron.
How is iron deficiency treated?
Iron supplementation is the most common method of treating iron deficiency and Iron Deficiency Anaemia, and has been shown to decrease anaemia, increase haemoglobin concentration, as well as improve exercise performance and reduce fatigue (10). It does have some side effects including constipation and nausea (10, 11), however, in studies that compared daily iron supplementation to iron supplementation a few times a week, similar benefits occur (1). Taking iron supplements a few times a week instead of daily, can reduce the side effects (1).
What about changing my diet?
If you are iron deficient, your doctor might also discuss with you increasing your iron intake and supporting iron absorption in your diet. The type of iron that you are consuming is important.
Products like meat, fish and poultry, contain heme iron which is more easily absorbed into the body (13, 14). To increase your intake of heme iron, you would increase your consumption of these products. If you consume a vegetarian diet, non-heme iron can be a little more complex.
The body’s ability to absorb non-heme iron is easily affected by other factors of your diet (like phytic acid, tannic acid and cholorgenic acid), as well as your intake of vitamin C levels. To support iron absorption, limiting foods with these acids, like seeds, tea and tomatoes whilst you’re consuming a meal (13, 15). You can also increase your intake of iron-rich foods like legumes, beans and dark and leafy vegetables, or add iron fortified foods to your diet if these are available to you to help increase your iron intake (14, 15). Inclusion of Vitamin C in your diet can, however, improve non-heme iron absorption (15).
- Fernández‐Gaxiola AC, De‐Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women. Cochrane Database of Systematic Reviews. 2019(1). https://doi.org/10.1002/14651858.CD009218.pub3
- Low MS, Speedy J, Styles CE, De‐Regil LM, Pasricha SR. Daily iron supplementation for improving anaemia, iron status and health in menstruating women. Cochrane Database of Systematic Reviews. 2016(4). https://doi.org/10.1002/14651858.CD009747.pub2
- Miller JL. Iron deficiency anemia: a common and curable disease. Cold Spring Harbor perspectives in medicine. 2013 Jul 1;3(7):a011866. https://doi.org/10.1101/cshperspect.a011866
- Reka P, Vasantha Devi K P, Thahira Banu, A. Prevalence of Anemia and problems during menstruation among adolescent girls, Indian Journal of Research in Food Science and Nutrition. 2015 2(1): 17-20. https://doi.org/10.15613/fijrfn/2015/v2i1/80074
- WHO. The global prevalence of anaemia in 2011. Geneva: World Health Organization. 2015.
- Kocaoz S, Cirpan R, Degirmencioglu AZ. The prevalence and impacts heavy menstrual bleeding on anemia, fatigue and quality of life in women of reproductive age. Pakistan journal of medical sciences. 2019 Mar;35(2):365. https://doi.org/10.12669/pjms.35.2.644
- Fernandez-Jimenez MC, Moreno G, Wright I, Shih PC, Vaquero MP, Remacha AF. Iron Deficiency in Menstruating Adult Women: Much More than Anemia. Women’s Health Reports. 2020 Jan 1;1(1):26-35. https://doi.org/10.1089/whr.2019.0011
- Toxqui L, Pérez-Granados AM, Blanco-Rojo R, Wright I, Vaquero MP. A simple and feasible questionnaire to estimate menstrual blood loss: relationship with hematological and gynecological parameters in young women. BMC women’s health. 2014 Dec 1;14(1):71. https://doi.org/10.1186/1472-6874-14-71
- Haider LM, Schwingshackl L, Hoffmann G, Ekmekcioglu C. The effect of vegetarian diets on iron status in adults: A systematic review and meta-analysis. Critical reviews in food science and nutrition. 2018 May 24;58(8):1359-74. https://doi.org/10.1080/10408398.2016.1259210
- Lönnerdal B. Soybean ferritin: implications for iron status of vegetarians. The American journal of clinical nutrition. 2009 May 1;89(5):1680S-5S. https://doi.org/10.3945/ajcn.2009.26736W
- Solmaz S. An Overlooked Side Effect Of Iron Treatment: Changes In Menstruation. International Journal of Hematology Research. 2016 Mar 8;2(1):120-3. https://10.17554/j.issn.2409-3548.2016.02.26
- Gür-Özmen S, Karahan-Özcan R. Iron deficiency anemia is associated with menstrual migraine: A case–control study. Pain Medicine. 2016 Mar 1;17(3):596-605. https://doi.org/10.1093/pm/pnv029
- Dinu M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian, vegan diets and multiple health outcomes: a systematic review with meta-analysis of observational studies. Critical reviews in food science and nutrition. 2017 Nov 22;57(17):3640-9. https://doi.org/10.1080/10408398.2016.1138447
- Prentice AM, Mendoza YA, Pereira D, Cerami C, Wegmuller R, Constable A, Spieldenner J. Dietary strategies for improving iron status: balancing safety and efficacy. Nutrition reviews. 2017 Jan 1;75(1):49-60. https://doi.org/10.1093/nutrit/nuw055
- Rammohan A, Awofeso N, Robitaille MC. Addressing female iron-deficiency anaemia in india: is vegetarianism the major obstacle? ISRN Public Health. 2012;2012. https://doi.org/10.5402/2012/765476
- Cooke AG, McCavit TL, Buchanan GR, Powers JM. Iron deficiency anemia in adolescents who present with heavy menstrual bleeding. Journal of pediatric and adolescent gynecology. 2017 Apr 1;30(2):247-50. https://doi.org/10.1016/j.jpag.2016.10.010
- Swanson CA. Iron intake and regulation: implications for iron deficiency and iron overload. Alcohol. 2003 Jun 1;30(2):99-102. https://doi.org/10.1016/S0741-8329(03)00103-4