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Iron Insufficiency Is Often Overlooked in Female Athletes

Ok, so judging by the title, this article is geared toward women. But guys, don’t bail yet because this is important info you can share with any female athletes you know. I’m passionate about this particular issue because I’ve seen so many women in clinic who present with fatigue, yet have not had the appropriate iron

I’m passionate about this particular issue because I’ve seen so many women in clinic who present with fatigue, yet have not had the appropriate iron lab tests done, if any at all.

Some background first about iron. Iron is the mineral we need to form the protein hemoglobin. Hemoglobin resides in our red blood cells and is responsible for carrying oxygen molecules, which we deliver throughout the body for energy production.

Inadequate iron can lead to small, shrunken red blood cells (and less hemoglobin). This is iron-deficiency anemia. (There are other forms of anemia but beyond our scope here).

Anemia equals fatigue, shortness of breath, pale skin, bruising, insomnia, anxiety and poor performance and recovery.

It’s really a no-brainer that women of reproductive age (WRA) need iron. Why? Because WRA menstruate and lose blood (and iron) - guys clearly don’t lose blood on a regular basis and rarely wind up with anemia.

Here’s the deal though. IF these women were lucky, they had a test which shows the size and shape of the red blood cells (CBC). If they’re small in size and number, it’s usually easy to diagnose iron-deficiency anemia.

However, what’s missing is the tests looking at iron stores. A simple iron panel can show low iron stores. But, even more important is the test for a protein called Ferritin.

You can think of ferritin as a storage form of iron.

And here’s where it gets interesting. Several studies (1,2,3,4) show that despite having a normal CBC, a low-ranging ferritin (below 50 μg/L) can make a women feel as if she’s anemic.

Keep in mind the bottom of the range for what’s considered normal is 20 μg/L. So, you could still be in the ‘normal’ range, have symptoms and be told that there’s nothing wrong with you.

Your ferritin should be above 50, probably around 70 is ideal if you’re an athlete.

A low ranging ferritin could explain symptoms like poor recovery, poor performance, shortness of breath. Stuff like that. Clearly, none of these symptoms are going to allow you to feel/perform at your best.

So, the take home is that all women of reproductive age should have a ferritin test done along with an iron panel and CBC.

It’s important because the standard line in conventional medicine is that despite symptoms of anemia, women who present this way (fatigue, shortness of breath, pale skin, poor performance, etc) are rarely treated, if at all. Usually they’re told to go home, rest and quit exercising so much. !!

Why is this? Part of the reason lies in test-centered and “evidence-based” medicine which leaves no room for functional medical interventions and dictates that patients are treated only if they have a strictly defined diagnosis.

I’ve treated many women who’ve presented with symptoms of anemia and a normal CBC and iron panel, but low ferritin with a course of iron and voila they're feeling much like themselves in short order.

But before you go supplementing with iron, there’s a few things you should know:

  1. These studies looked at women only. As I mentioned, it’s much more rare for guys to be iron deficient. If you are, time to go looking for the cause - don’t just take iron!

  2. Iron is dangerous stuff. Too much can lead to iron overload and that’s bad. Iron is also a leading cause of death in toddlers. So if you have iron supplements at home, keep them away from the little people.

  3. Testing for iron-deficiency is different than testing for anemia. If you’re suspicious that you may be iron deficient, you need a full iron panel AND a ferritin. It’s the ferritin test, in combination with the iron panel that will show if you’re iron-deficient, rather than anemic. Don’t let your doctor blow you off; this is how we can catch small things on labs that make a world of difference in performance!

  4. If you are iron deficient and or anemic, the cause needs to be ruled out. Sometimes it’s a combination of diet and heavy menses. Other times bleeding in the GI tract may cause it. So be prepared to undergo more testing if you are found to be anemic.

  5. Again, careful with iron supplementation. Too much can prolong infections (bacteria like to feed on it) and cause a ton of other problems. So don’t supplement unless you have a demonstrated need for it! If you do need iron, select a gentle one that won't cause stomach upset.

Lastly, if you’re not iron deficient, do incorporate iron-rich foods in order to keep iron stores up. The path out of anemia can take 6-8 weeks - it’s far easier to prevent it than recover from it.

The iron found in animal products (referred to as heme iron) is better absorbed than the iron found in plants (non-heme iron). Good plant sources of iron include dark green leafies, olives, beans, nuts and seeds. Vitamin C improves absorption of iron, so keep that in mind if you supplement or eat iron-rich foods.

Please share with the female athletes you know.

Questions about this blog?

Send me an email.


Feel free to schedule a complimentary 30 minute consultation if you’d like to learn more about how we can optimize your health and performance!

In Health, Fitness and Endurance,

Dr. Jason Barker


  1. Vaucher, P, et al. CMAJ 2012 Aug 7;184(11):1247-54. Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial.

  2. Pasricha, SR, et al. Journal of Nutrition, 2014 Apr 9. Iron Supplementation Benefits Physical Performance in Women of Reproductive Age: A Systematic Review and Meta-Analysis.

  3. Reinke S, et al. Int J Cardiol. 2012 Apr 19;156(2):186-91. Absolute and functional iron deficiency in professional athletes during training and recovery.

  4. Dellavalle DM, et al. Med Sci Sports Exerc. 2012 Aug;44(8):1552-9. Iron status is associated with endurance performance and training in female rowers.

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