Iron Deficiency Anemia in Women's Health: Prevention, Awareness & Management

Sections

• Introduction
• Causes of Iron Deficiency Anemia (IDA)
• Symptoms
• Iron Deficiency without Anemia
• Consequences in Women and Children
• Heavy Menstrual Bleeding
• Pregnancy
• Postpartum
• Perimenopause

Introduction

• Global anemia prevalence: 24.8% (~1.62 billion people); 41.8% are pregnant women, and 30.2% are nonpregnant women (WHO, 2025)
• IDA affects women across all life stages: adolescents, reproductive-aged, pregnant, and perimenopausal.
• In pregnancy, anemia is an independent risk factor for maternal and fetal morbidity/mortality (ACOG, 2021).
• Racial disparities in anemia rates (women <50):
• 3.3% of Caucasians
• 8.7% of Latinas
• 24.5% of Black Americans (Krule et al., 2022)
• IDA affects 12% of premenopausal women; prevalence rises to 19% in Black women (Krule et al., 2022)

Causes of IDA

• Nutritional deficiency: Low dietary intake or poor iron bioavailability (ODS, 2025)
• Blood loss:
• Heavy menstrual bleeding (CDC, 2024)
• Gastrointestinal bleeding in postmenopausal women (Kaunitz, 2019)
• Impaired absorption:

• IBD, gastric bypass, celiac disease, proton pump inhibitors, autoimmune gastritis (Shander et al., 2023)

• Pregnancy: Increased iron demand and fetal iron transfer often outpace maternal intake, especially in women with marginal status before pregnancy (ACOG, 2021; WHO, 2025).

Symptoms of IDA

• Fatigue, low stamina, reduced exercise tolerance (Wassef et al., 2019)
• Palpitations, shortness of breath
• Headaches, cold intolerance
• Mood changes, depression, “brain fog” (Wassef et al., 2019)
• Alopecia, glossitis, koilonychia
• Restless legs syndrome
• Pica, especially pagophagia (ice-chewing) — often misrecognized, delaying diagnosis (Wassef et al., 2019)

Iron Deficiency Without Anemia

• Low ferritin may cause symptoms even in absence of anemia (Van Remoortel et al., 2021).
• Fatigue
• Reduced work performance 
• Reduced quality of life
• Early treatment improves symptoms and may prevent progression to anemia (Govindappagari & Burwick, 2019).

Consequences in Women and Children

Consequences Linked to Iron Deficiency Anemia in Pregnancy

• Preterm birth, IUGR, postpartum hemorrhage, increased infection (ACOG, 2021)
• Small-for-gestational-age newborns
• Postpartum depression and impaired maternal-neonatal bonding (Wassef et al., 2019)

Fetal-Neonatal Complications Linked to Maternal Iron Deficiency/Anemia

• Increased Risk of Schizophrenia:

• Maternal hemoglobin levels ≤10.0 g/dL during pregnancy are associated with a nearly fourfold increased risk of schizophrenia spectrum disorders in offspring. Each 1 g/dL increase in maternal hemoglobin reduced schizophrenia risk by 27% (Insel et al., 2008). 

• Elevated Autism Spectrum Disorder (ASD) Risk:

• Mothers with low iron intake during pregnancy had a fivefold greater risk of having a child with ASD, especially among older mothers or those with metabolic conditions (Schmidt et al., 2014). 

• Cognitive and Behavioral Delays:

• Early-life iron deficiency is associated with long-lasting neurocognitive impacts, including deficits in learning, memory, and behavioral regulation (Beard & Connor., 2003). 

• Impaired Recognition Memory in Infants:

• Infants with fetal-neonatal iron deficiency exhibited altered recognition memory as early as 2 months of age Lukowski, et al., 2015).

• Association with Intellectual Disability and ADHD:

• Anemia diagnosed before 30 weeks’ gestation was linked with increased risks of autism, ADHD, and intellectual disability in offspring (Sundelin et al., 2019).

Heavy Menstrual Bleeding

• Menorrhagia: >80 mL or >7 days/cycle (CDC, 2024)
• Iron loss can be gradual and overlooked
• RDA: 18 mg iron/day (ODS, 2025)
• Fatigue is often misattributed or normalized (Kaunitz, 2019)
• Screening questions:
• How often do you saturate a pad or tampon?
• Does bleeding last more than 7 days?
• Do you bleed through clothes?
• Does it disrupt school or work?

Pregnancy

• Up to 40% of women start pregnancy with depleted iron stores (Shander et al., 2023).
• Physiologic anemia expected (Hgb 10–11 g/dL)
• A comprehensive analysis of 272 studies found that maternal Hgb levels below 11 g/dL are associated with increased risks of low birth weight, preterm birth, small-for-gestational-age infants, stillbirth, and perinatal and neonatal mortality (Rahman et al., 2016).
• Contributing factors:

• ↑40–50% plasma volume, ↑20–30% RBC mass, fetal iron transfer

• WHO (2024): Recommends 30–60 mg elemental iron + 0.4 mg folic acid daily to reduce anemia, low birth weight, and sepsisg
• ACOG (2021) recommend: IV iron after 1st trimester if oral iron fails or is intolerable
• Blood loss at delivery increases need.

IV Iron in Pregnancy

• IV iron is more effective than oral iron for increasing hemoglobin and replenishing iron stores (Govindappagari & Burwick, 2019).
• A 2024 Cochrane review found that IV iron improves anemia and hemoglobin levels without increasing adverse maternal or neonatal outcomes (Cochrane Review, 2024).
• A meta-analysis of 34 studies showed fewer adverse events with IV iron compared to oral iron (Nature Scientific Reports, 2023).
• A large 2025 multicenter study found a single dose of IV iron in the second trimester was safe and effective (SMFM, 2025).
• IV iron isomaltoside was not associated with increased maternal or fetal complications; side effects were mild and infrequent (Qassim et al., 2020).
• ACOG (2021): Recommends IV iron after the first trimester if oral iron is not tolerated or is ineffective.

Postpartum

• Hgb <10 g/dL = clinically significant anemia (ACOG, 2021)
• Hemoglobin typically lowest ~48 hours after birth
• Ferritin unreliable postpartum due to inflammation; reassess after 6 weeks if needed (Wassef et al., 2019)
• Risk factors:

• Multiparity, obesity, adolescent mothers, low socioeconomic status

• WIC study (n=60,000):
• 27% postpartum anemia overall
• 40% Hispanic; 48% Black women (Wassef et al., 2019)
• Postpartum Depression:
• 8/10 studies found higher PPD risk with IDA
• 4/5 studies showed reduced risk with iron therapy (Wassef et al., 2019)

Perimenopause

• Perimenopause is the transitional stage before menopause when estrogen and progesterone levels begin to fluctuate.
• These hormonal changes lead to irregular ovulation, which can cause unpredictable or heavy menstrual bleeding.
• Heavy bleeding during this stage can result in significant iron loss and contribute to iron deficiency or anemia, especially if untreated.
• Signs of concern: Saturating pads/tampons every 2 hours, bleeding >8 days (CDC, 2024)
• Symptoms of iron deficiency in perimenopause:
• Fatigue, low energy, brain fog, poor concentration
• Decreased work productivity, reduced quality of life
• Mood changes, low self-esteem, difficulty coping with stress
• Mental health impact:
• Depression affects 4 in 10 perimenopausal women, often linked to both hormonal shifts and iron deficiency (Wassef et al., 2019)
• These challenges can persist for years and are often underrecognized
• Iron requirements:
• Recommended intake: 18 mg/day (Office of Dietary Supplements, 2025)
• Many women may be unaware of iron depletion unless screened
• Treatment and management options:
• Iron-rich diet (e.g., lean red meat, leafy greens, fortified grains)
• Oral iron supplementation (first-line)
• IV iron infusion if oral iron is not tolerated or ineffective
• Menstrual bleeding control strategies:
• Hormonal contraception (e.g., oral contraceptives)
• Intrauterine devices (IUDs)
• Tranexamic acid (TXA) to reduce blood loss
• Endometrial ablation in refractory cases
• Clinical considerations:
• Symptoms are often dismissed or minimized by providers
• Regular OB/GYN visits can help address both bleeding and mood symptoms
• Mental health referrals may be appropriate for persistent depression or anxiety

References

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