Should I seek further evaluation of my iron levels after they were dismissed as normal by my healthcare provider?

Should You Seek Further Evaluation of Your Iron Levels?

Yes, you should advocate for proper evaluation of your iron status if you have symptoms of iron deficiency or risk factors, even if your provider dismissed initial results as "fine." Many healthcare providers use inadequate thresholds for diagnosing iron deficiency, and "normal" hemoglobin does not exclude clinically significant iron deficiency.

Understanding What "Fine" May Actually Mean

Your provider may have only checked hemoglobin and declared it normal, but iron deficiency exists on a spectrum and can cause significant symptoms even before anemia develops 1. The key issue is that:

• Iron deficiency without anemia affects approximately 14% of US adults and can cause fatigue, difficulty concentrating, restless legs syndrome, pica, exercise intolerance, and depression 1
• Standard hemoglobin testing alone misses non-anemic iron deficiency entirely 1
• Ferritin levels below 30 ng/mL indicate iron deficiency in individuals without inflammatory conditions, yet many labs use lower cutoffs like 15 ng/mL 2, 1

Required Testing for Proper Diagnosis

You need specific iron studies, not just a complete blood count 2, 1. The essential tests are:

• Serum ferritin - the most efficient single test for iron deficiency, with <30 ng/mL indicating deficiency in non-inflammatory conditions 1, 3
• Transferrin saturation (TSAT) - calculated as (serum iron/total iron binding capacity) × 100, with <20% indicating iron deficiency 2, 1
• Hemoglobin and mean corpuscular volume (MCV) - to assess for anemia and microcytosis 2

A common diagnostic error is misinterpreting results in the presence of inflammation, where ferritin can be falsely elevated 2, 4. In inflammatory conditions, TSAT <20% becomes more reliable than ferritin alone 2.

When to Insist on Further Evaluation

You should pursue further assessment if you have any of the following 2, 1:

• Symptoms: Fatigue, exercise intolerance, difficulty concentrating, restless legs syndrome (affects 32-40% with iron deficiency), pica (40-50%), irritability, depression, dyspnea, or lightheadedness 1
• Risk factors: Heavy menstrual bleeding, pregnancy, gastrointestinal symptoms, use of NSAIDs, inflammatory bowel disease, chronic kidney disease, heart failure, cancer, previous bariatric surgery, or vegetarian/vegan diet 2, 1
• Abnormal indices: Low MCV (<80 fL), low hemoglobin, or any ferritin <30 ng/mL 2

Investigation of Underlying Causes

If iron deficiency is confirmed, the cause must be identified 2. The British Society of Gastroenterology guidelines are explicit:

• All patients with confirmed iron deficiency should undergo coeliac disease screening (tissue transglutaminase antibody) 2
• Men and postmenopausal women require gastrointestinal investigation with upper endoscopy and colonoscopy or CT colonography, as gastrointestinal malignancy is a critical concern 2, 5
• Premenopausal women aged ≥50 years should undergo GI investigation similar to men 2
• Younger premenopausal women should be investigated if they have GI symptoms, family history of colorectal cancer, or persistent iron deficiency despite treatment 2

Treatment Expectations

If you have iron deficiency, treatment should restore hemoglobin AND replenish iron stores 2. The guidelines specify:

• Oral iron therapy (ferrous sulfate 325 mg daily or alternate days) is first-line for most patients 1, 6
• Iron supplementation should continue for 3 months after hemoglobin normalizes to replenish stores 2
• Follow-up monitoring should occur every 3 months for the first year, then annually 2

Intravenous iron is indicated for oral intolerance, malabsorption (celiac disease, post-bariatric surgery), chronic inflammatory conditions (IBD, CKD, heart failure), ongoing blood loss, or pregnancy (second/third trimester) 2, 1.

Common Pitfalls to Avoid

Do not accept dismissal based on 2, 4:

• Hemoglobin alone being "normal" - this misses non-anemic iron deficiency
• Ferritin of 15-30 ng/mL being called "adequate" - this represents depleted stores
• Attribution to "just being a woman" without proper investigation
• Failure to investigate the underlying cause of confirmed deficiency

Your Next Steps

Request specific testing including ferritin and transferrin saturation if not already done 1, 3. If these confirm iron deficiency (ferritin <30 ng/mL or TSAT <20%), insist on appropriate investigation for the underlying cause based on your demographic and risk factors 2, 5. If your provider remains dismissive despite objective evidence of iron deficiency or concerning symptoms, seeking a second opinion is medically justified 2.