What should I do about my mild anemia?

What to Do About Hemoglobin of 12 g/dL

Your hemoglobin of 12 g/dL represents mild anemia that requires investigation to identify the underlying cause before initiating treatment—you should not simply start iron supplementation without proper diagnostic workup. 1, 2

Initial Assessment and Classification

Your hemoglobin level falls into the mild anemia category (defined as Hb ≤11.9 g/dL and ≥10 g/dL), though the specific threshold varies by sex and age. 1 For women, anemia is defined as Hb <12.0 g/dL, while for men it's <13.0 g/dL. 3

The critical first step is determining whether your anemia is microcytic, normocytic, or macrocytic through complete blood count (CBC) with red cell indices. 2, 4

Diagnostic Workup Required

You need the following laboratory evaluation before any treatment:

• Complete blood count with peripheral smear and red cell indices (MCV, RDW) 2, 4
• Serum ferritin (most specific test for iron deficiency; <15 μg/L indicates absent iron stores, <30 μg/L indicates low stores, though 45 μg/L provides optimal sensitivity/specificity) 2
• Transferrin saturation (more sensitive than hemoglobin alone for detecting iron deficiency) 2
• Reticulocyte count (screens for hemolysis or blood loss) 1, 4
• Iron studies including serum iron 1
• Vitamin B12 and folate levels 1
• C-reactive protein (to assess for chronic inflammation) 1

If your MCV is low with RDW >14.0%, this suggests iron deficiency anemia; if MCV is low with RDW ≤14.0%, consider thalassemia minor. 2

Treatment Algorithm Based on Cause

If Iron Deficiency Anemia is Confirmed:

First-line treatment is oral ferrous sulfate 200 mg (containing 65 mg elemental iron) three times daily for at least three months after hemoglobin correction to replenish iron stores. 2, 5

• Take iron between meals to maximize absorption 1
• Add ascorbic acid (vitamin C) to enhance iron absorption 2
• Alternative formulations include ferrous gluconate or ferrous fumarate if ferrous sulfate causes intolerable side effects 2
• A good response is defined as hemoglobin rise ≥10 g/L (≥1 g/dL) within 2-4 weeks, which confirms iron deficiency 1, 2

If Oral Iron Fails or Is Not Tolerated:

Consider intravenous iron if there is malabsorption, intolerance to oral iron, or failure to respond after 4 weeks of compliant therapy. 2 Expected hemoglobin increase should be at least 2 g/dL within 4 weeks of IV iron. 2

If Not Iron Deficiency:

• Vitamin B12/folate deficiency: Supplement accordingly 1
• Anemia of chronic disease: Treat underlying inflammatory condition 1, 3
• Genetic disorders of iron metabolism or heme synthesis: May require specialized treatment including erythropoietin, transfusions, or even stem cell transplantation 1, 2

Monitoring and Follow-Up

• Recheck hemoglobin in 4 weeks after starting iron therapy 1
• If confirmed iron deficiency, continue iron for 2 additional months after hemoglobin normalizes, then recheck 1
• Monitor hemoglobin and red cell indices at 3-month intervals for one year, then annually 2
• Reassess approximately 6 months after successful treatment completion 1

Critical Pitfalls to Avoid

Do not start empiric iron therapy without confirming iron deficiency through ferritin and transferrin saturation testing. 2 Many causes of anemia will not respond to iron and require different treatments. 1, 6

Do not overlook combined deficiencies—iron deficiency can coexist with B12 or folate deficiency. 2

If anemia fails to respond to appropriate iron therapy despite compliance and absence of acute illness, perform additional evaluation including MCV, RDW, and serum ferritin to identify alternative causes such as genetic disorders of iron metabolism, thalassemia, or chronic disease. 1, 2

For unexplained anemia with iron deficiency in adults, consider gastrointestinal evaluation (bidirectional endoscopy) to rule out occult bleeding or malabsorption disorders like celiac disease. 7