What is the management plan for an 18-year-old female with a ferritin level of 83?

Management of Ferritin 83 ng/mL in an 18-Year-Old Female

This ferritin level of 83 ng/mL is within the normal range and does not require iron supplementation or further investigation in an asymptomatic patient. However, the clinical context—including hemoglobin level, symptoms, menstrual history, and dietary patterns—determines whether any intervention is needed.

Initial Assessment Required

Before making management decisions, you must obtain:

• Complete blood count to assess hemoglobin and mean corpuscular volume (MCV) 1
• Hemoglobin threshold for anemia: <12 g/dL in non-pregnant women 1, 2
• Menstrual history: quantify blood loss, as menorrhagia is responsible for iron deficiency in 5-10% of menstruating women 1
• Dietary assessment: vegetarian/vegan diets increase risk of iron deficiency due to reliance on nonheme iron with decreased bioavailability 3
• Symptom review: fatigue, exercise intolerance, or other symptoms suggesting functional iron deficiency 4

Interpretation of Ferritin 83 ng/mL

Normal Iron Stores

• The average serum ferritin for women in the United States is 43 µg/L 1
• A ferritin of 83 ng/mL indicates adequate iron stores and is well above diagnostic thresholds for iron deficiency 1
• Ferritin <15 ng/mL confirms iron deficiency in women with anemia 1
• Some evidence suggests physiologic cutoffs may be higher (30-50 ng/mL), but this remains debated 4, 5

Key Caveat

Ferritin is an acute-phase reactant and can be falsely elevated by infection, inflammation, or chronic disease 1, 6. If clinical suspicion for iron deficiency exists despite normal ferritin, check C-reactive protein to exclude inflammation 4.

Management Algorithm

If Hemoglobin is Normal (≥12 g/dL)

No intervention is needed 1. Preventative iron administration in the presence of normal stores is inefficient, has side effects, and may be harmful 4.

• Monitor only if high-risk features present: heavy menstruation, vegetarian diet, high-performance athletics, eating disorders 4, 3
• For at-risk patients, repeat hemoglobin and ferritin every 6-12 months 4

If Hemoglobin is Low (<12 g/dL) with Ferritin 83 ng/mL

This scenario suggests anemia from a cause other than iron deficiency 1.

• Investigate alternative causes: vitamin B12 deficiency, folate deficiency, hemoglobinopathies, chronic disease 2
• Do not give iron supplementation when ferritin is adequate, as this will not correct the anemia and may cause harm 4

If Symptomatic Despite Normal Labs

Some patients with ferritin in the 30-100 ng/mL range may have functional iron deficiency with symptoms (fatigue, restless legs, exercise intolerance) 4, 5.

• Consider a trial of oral iron if ferritin is 30-50 ng/mL with persistent symptoms after excluding other causes 4
• Use preparations with 28-50 mg elemental iron once daily in the morning to minimize gastrointestinal side effects 4, 3
• Reassess after 8-10 weeks; if no improvement, discontinue iron 4

Dietary Counseling for Prevention

For adolescent females at risk of future iron deficiency:

• Increase heme iron intake: red meat provides the most bioavailable iron 3
• Enhance nonheme iron absorption: consume with vitamin C-rich foods; avoid tea, coffee, and calcium supplements with iron-containing meals 1, 3
• Vegetarians/vegans require 1.8 times the recommended iron intake due to lower bioavailability of plant-based iron 3
• Avoid iron-fortified supplements when stores are normal 4

When to Investigate Further

Investigation for gastrointestinal blood loss is not indicated in premenopausal women with ferritin 83 ng/mL unless:

• Anemia persists despite adequate ferritin 1
• Upper gastrointestinal symptoms are present 1
• Strong family history of colorectal cancer (two first-degree relatives or one affected before age 50) 1
• Age ≥50 years 1

For women under 45 years with normal ferritin, menstrual loss and dietary factors are the presumed cause, and endoscopic evaluation is unnecessary 1.

Common Pitfalls to Avoid

• Do not supplement iron when ferritin is normal: this provides no benefit and risks side effects including gastrointestinal symptoms and potential iron overload 4
• Do not use ferritin alone if inflammation suspected: check CRP to avoid missing iron deficiency masked by elevated acute-phase ferritin 4, 6
• Do not assume all anemia in young women is iron deficiency: with ferritin 83 ng/mL, look for other causes 2