Why do I have low iron?

[Yuluml]

I'm stumped as to why I have low iron and the doctors don't seem interested in finding the root cause. My GP did some blood tests recently as I've been having some gut issues - ongoing constipation and a bit of low level pain, pretty sure they only did the tests to placate me. I've done two FIT tests and a calprotectin test and they were normal. I've been tested for coeliac's and I don't have it. Nothing came up except for low ferritin, which is 17, but apparently I'm not anaemic because my haemoglobin is normal (135). My MCH and MCV are both low normal. GP isn't bothered about me having iron tablets, I didn't even realise 17 counted as iron deficient because it is still within normal NHS ranges, but according to NICE guidelines anything under 30 is iron deficient, whether you're anaemic or not. My B12 is quite low too (353) but still in NHS "normal" ranges so nothing doing about that either.

As my FIT stool test is normal and I have no rectal bleeding or other red flag symptoms my GP will not refer me to a gastroenterologist for any further testing. They tell me the most common reason for low iron in premenopausal women is heavy periods. But I do not have heavy periods. They only last four days, I don't have any clots or leaking or heavy bleeding. I did have a miscarriage at ten weeks back in late March, so not sure if that would be a factor. I also have a history of overuse of NSAIDs (neurofen) due to migraines.

Everything I've read says that low ferritin is the first step towards anaemia, so surely I should be having investigations into why it is low? Has anyone else had this and not had either heavy periods or coeliac's? In the states it seems to be the case that everyone with iron deficiency is advised to have a colonoscopy/endoscopy. Doesn't seem to be the case here.

Poor diet?

My diet is excellent. Varied, plenty of fruit and veg, wholegrains, and I eat red meat.

I had a hysterectomy due to heavy periods.
My ferritin is lower now that it was pre hysterectomy! They aren’t interested in finding out why it’s low at all. I have taken to buying supplements and have got it up to 23. I wish I knew the cause, I will be watching with interest to see if there are any suggestions because I still feel awful.

I don't even feel awful, I have 0 symptoms of low ferritin - I've seen people online with way higher ferritin than mine describing hair loss, debillitating fatigue, brain fog etc....hand on heart, I don't have any of that.

Ibuprofen depletes iron and folate so that could be why.
If your FIT and Calpro were normal it indicates that you don't have inflammation of the bowel and no blood detected in the faeces. So you wouldn't be referred.
It's very common for women to become iron deficient if they are still menstruating. You could stop the ibuprofen, take a course of iron tablets and then have a blood test after a couple of months, and then retest again a couple of months later to see if your levels are stable. I hope that helps.

I understood that's heavy periods, though - mine aren't remotely heavy.

I've not taken ibuprofen since I found out about the low iron but it's going to be really tricky when my next migraine hits as paracetamol does diddly squat, and they last for days (I've had them my whole life, this is not a new thing).

Should they not be checking me for bleeding in the stomach, for instance? Like an ulcer? Gastritis? As understand that's also linked to long term ibuprofen use.

I’ve had low ferritin (and sometimes B12) for almost 20 years, I think some people just don’t absorb things as well as they should 🤷🏻‍♀️

The NHS won’t be interested in finding out why!

Investigations seem so much more thorough in other countries!

Do you take any other medication for migraine? Sumatriptan may be worth looking into for you.
If you had bleeding in the stomach, it would be detected in the FIT test as it detects human haemoglobin that isn't broken down by stomach acid.
You could continue with the ibuprofen as long as you don't have any heartburn or stomach pain?.
Supplementing iron and folate and then retesting would be what I would do.

I tried Sumatriptan a few years back and it didn't help at all (nor did amitriptalyne - sorry for rubbish spelling!). Codeine helps but I can't take that regularly.

They don’t investigate because premenopausal women being anemic or close to anemic is really common and in 99% of cases it can be resolved through diet and iron supplements.

Have you tried nasal sumatriptan or the injections?
I have horrendous migraines and cluster headaches and the sumatriptan tablets are useless. Ibruprofen would be useless for mine too tbh.

How much red meat, how many times a week?

Have you explored other explanations for your pain & constipation? Do you get lots of exercise and drink 2-4 litres of fluids every day?

Steak/mince/liver - at least 4 times a week, never with dairy. According to google it's rare for iron deficiency to be from diet unless you are a very strict vegan.

I get plenty of exercise and drink plenty of water. The constipation is a new thing, it started about 3 months ago, hence the GP visits and testing.

I've tried both.

Ibuprofen is the only thing that takes the edge off somewhat - that and codeine.

When you say plenty of exercise..do you run? Running can cause some issue with iron due to feet striking the floor, can't remember what but Google it.
I had a low iron issue few years back after a very heavy miscarriage. I thought my diet was great too but when I looked at the amounts I wasn't always hitting the mark(despite eating healthily) as I don't eat crappy fortified bread or cereal.
I think it was s combination of all of these things that had mine so low

I don't want to worry you, but my mum had an iron deficiency and gut issues for years, and the GP kept prescribing her iron tablets. They told her that her gut problems were due to the iron tablets and they told her to improve her diet.

They were wrong. She had bowel cancer, and by the time they found out it was too late.

Please go back to your GP and pester them endlessly until they refer you for more investigations. It could save your life.

I'm sorry about your mum but there's no point me pestering them endlessly, my trust will categorically not give colonoscopies to low risk under 40s unless they have a positive FIT test, I've already been told that they just automatically reject all referrals without a postive FIT. Apparently if your test is negative your risk of bowel cancer is 0.7%. It is more accurate than the previous test they used apparently, which might have been what your mum had, if she did a stool sample.

And apparently iron deficiency without anemia is apparently not higher risk for malignancy, as iron deficiency anemia would be.

Given my age, lack of family history, negative FIT test and lack of red flag symptoms I can see why they aren't offering me a colonoscopy, and my constipation has got significantly better since I was put on laxatives which presumably it wouldn't if there was a blockage. I also had an abdominal X Ray in A&E a few weeks back which showed backed up stool.

I don't run, I walk, swim and do pilates and yoga.

@Yuluml I do hope you are soon feeling much better and can get your iron levels sorted out. My mum died in the early 90's so the tests would have been different then I guess.

It's really hard to hit the RDA for iron unless you eat either beans/lentils with every meal, or two big portions of meat/fish a day. I've been entering my diet into Cronometer for 6 months and that is what I have found.

Unless you have foods thar are fortified with iron too.

I'm absolutely amazed at 17 they haven't said take tablet. Mine was 26 and they gave me iron tablets.

Could too much red meat be the cause of your constipation and gut pain, 4+ times a week is significantly higher than guidelines. You could try more plant sources of iron if you are not already, spinich, peas etc.

Do you have any physical symptoms of iron deficiency? Some people just have naturally lower levels of some vitamins and minerals.

Low ferritin/ iron can also be the cause of migraines and improving ferritin levels may reduce your frequency of migraines too.

I don't know which test for coeliac disease that you had, but I had a blood test which came back as negative.

I was deficient in a few things, ferretin was low, vitamin d was low, to give a couple of examples but not significantly to the point where they suggested that I be prescribed anything.

I was also having problems with my thyroid, so was advised (not by a Dr) to give up gluten to see if it made a difference. Within 6 weeks my thyroid hormones came back in the normal range. I also became pregnant in that time and when I had my 12 week bloods, I was waiting to be told that I was anaemic (this was the case in my first pregnancy) turns out that all my iron levels- ferretin, hb, etc were all excellent, just over the middle of the normal range.

The only thing that I had done differently was cut out gluten.

Have you tried a gluten free diet to see if this makes any difference?