Treatment Approach for Iron Deficiency with Hair Loss and Voice Changes
Start oral iron supplementation immediately with ferrous sulfate 200 mg twice daily (providing 60-80 mg elemental iron per day) and continue for at least 3 months after hemoglobin normalizes to replenish iron stores. 1
Initial Iron Replacement Therapy
Your patient has confirmed iron deficiency (transferrin saturation 17%, below the normal threshold of 20%) with symptoms directly attributable to this deficiency—hair loss is a well-recognized manifestation of iron deficiency even without anemia. 2, 3
Specific oral iron regimen:
- Ferrous sulfate 200 mg twice daily 1, 4
- Take in the morning with vitamin C 250-500 mg to enhance absorption 1
- Continue for minimum 3 months after hemoglobin normalizes 1, 4
- Expected hemoglobin rise: approximately 2 g/dL after 3-4 weeks 1
The slightly elevated ESR (18) and high-normal albumin (5.2) suggest possible mild inflammation or hemoconcentration but do not contraindicate iron therapy. 4
Monitoring Response
Recheck labs at 1 month:
- Hemoglobin should rise ≥1.0 g/dL 4
- If no response, evaluate for: 1, 5
- Non-compliance with oral iron
- Ongoing occult blood loss
- Malabsorption (consider celiac screening with anti-tissue transglutaminase antibodies) 1
- Need for intravenous iron therapy
Investigation of Underlying Cause
The iron deficiency requires source identification: 4, 5
- In premenopausal women: menstrual blood loss is most common 2
- In men or postmenopausal women: gastrointestinal evaluation is mandatory (colonoscopy if >50 years) 5
- Consider Helicobacter pylori testing if iron deficiency persists after normal endoscopic evaluation 4
- Screen for celiac disease with serologic testing 1
The voice cracking may represent laryngeal changes from iron deficiency or could be unrelated; reassess after iron repletion.
Alternative Iron Therapy if Oral Fails
If oral iron is not tolerated or ineffective after 1 month: 1, 4
- Switch to intravenous iron preparations
- Options include iron sucrose (200 mg IV over 10 minutes) or ferric carboxymaltose (up to 1000 mg IV over 15 minutes) 4
- Total dose can be calculated using Ganzoni formula or empiric 1 gram total 4
Critical Pitfalls to Avoid
- Do not stop iron therapy prematurely—continue for 3 months after hemoglobin normalizes to replenish stores 1, 4
- Do not exceed 100 mg elemental iron daily as this increases side effects without improving absorption 1
- Do not take calcium supplements simultaneously with iron as calcium impairs iron absorption 1
- Do not rely solely on ferritin for monitoring—use hemoglobin and MCV as well 1
- Do not ignore the need to find the source of iron deficiency, especially in men or postmenopausal women where GI malignancy must be excluded 5
Addressing the Elevated B12
The B12 level of 1004 (slightly above normal range of 180-914) is not concerning and requires no intervention. Elevated B12 can occur with supplementation, liver disease, or myeloproliferative disorders, but in isolation with normal CBC and other labs, this is clinically insignificant. 4