What do elevated iron stores, low vitamin B12 (Vitamin B12), low transferrin saturation, and normal hemoglobin (Hgb) indicate in a 40-year-old female with surgical menopause?

Laboratory Findings Indicate Functional Iron Deficiency Despite Adequate Iron Stores

This laboratory pattern—elevated ferritin (313 ng/mL), low transferrin saturation (15%), and normal hemoglobin (13.1 g/dL)—indicates functional iron deficiency or an inflammatory state masking true iron status, rather than absolute iron deficiency, in this 40-year-old woman with surgical menopause.

Interpretation of Individual Parameters

Serum Ferritin (313 ng/mL)

• This ferritin level is well above the threshold for iron deficiency and suggests adequate or even elevated iron stores 1.
• In women without inflammation, ferritin <30 μg/L indicates depleted iron stores, while ferritin <15 μg/L confirms absent iron stores 1.
• The ESPEN guideline establishes reference intervals of 20-200 mg/L for women, placing this patient's value above the normal range 1.
• Ferritin is an acute-phase reactant, meaning chronic infection, inflammation, or tissue damage (hepatitis, cirrhosis, neoplasia, arthritis) can elevate it independent of actual iron status 1.

Transferrin Saturation (15%)

• This low transferrin saturation (<20%) indicates insufficient iron delivery to the bone marrow for erythropoiesis 1.
• Transferrin saturation reflects iron readily available for red blood cell production, and values <20% suggest either absolute or functional iron deficiency 1.
• In the absence of inflammation, transferrin saturation <20% combined with ferritin <100 μg/L would indicate absolute iron deficiency 1.
• However, when ferritin is elevated (>100 μg/L) with low transferrin saturation, this pattern suggests functional iron deficiency or inflammatory iron sequestration 1.

Hemoglobin (13.1 g/dL)

• This hemoglobin level is within the normal range for women (≥12 g/dL per WHO criteria) 1.
• The patient has non-anemic iron deficiency (NAID) if true iron deficiency exists, though the elevated ferritin argues against this 1.
• Normal hemoglobin with abnormal iron parameters indicates the body is currently maintaining adequate red blood cell production despite suboptimal iron availability 1.

Low Vitamin B12 (LVP 59)

• Assuming "lvp" refers to vitamin B12 level of 59 pg/mL, this is significantly below normal ranges (typically >200 pg/mL) 2.
• Vitamin B12 deficiency can coexist with iron abnormalities and may complicate the hematologic picture 2.
• This requires confirmation with methylmalonic acid and homocysteine levels, as these metabolites are more specific for B12 deficiency 2.

Clinical Significance in Surgical Menopause Context

Post-Menopausal Iron Status Changes

• Postmenopausal women typically have higher ferritin levels than premenopausal women (median 71 μg/L vs 37 μg/L) due to cessation of menstrual blood loss 3.
• After surgical menopause, the frequency of depleted iron stores drops dramatically (3.3% vs 17.7% in premenopausal women) 3.
• This patient's elevated ferritin is consistent with postmenopausal physiology, though the level is higher than typical 3, 4.

Most Likely Diagnoses

Primary Consideration: Inflammatory State or Chronic Disease

The combination of elevated ferritin with low transferrin saturation most strongly suggests an inflammatory condition causing iron sequestration 1:

• Inflammatory processes increase hepcidin production, which blocks iron release from stores 1.
• This creates "anemia of chronic disease" physiology even without overt anemia 1.
• Check C-reactive protein (CRP) to assess for inflammation—if CRP is elevated, the ferritin level is unreliable for assessing true iron stores 1.

Secondary Consideration: Combined Deficiency State

• The low B12 level requires urgent attention and may contribute to the overall clinical picture 2.
• Vitamin B12 deficiency can mask or coexist with iron deficiency, creating complex hematologic patterns 2, 5.

Recommended Diagnostic Approach

To clarify the iron status in this patient with conflicting parameters:

1. Measure inflammatory markers (CRP, ESR) to determine if inflammation is elevating ferritin 1.

2. If CRP is elevated, consider measuring soluble transferrin receptor or hepcidin, which are less affected by inflammation and more accurately reflect true iron deficiency 1.

3. Confirm B12 deficiency with methylmalonic acid and homocysteine levels, and initiate B12 replacement if confirmed 2.

4. In the presence of inflammation with ferritin 30-100 μg/L, a combination of true iron deficiency and anemia of chronic disease is likely; however, at ferritin 313 μg/L, true iron deficiency is unlikely 1.

Management Implications

Iron supplementation is NOT recommended when ferritin is normal or elevated (>100 μg/L), as this is potentially harmful 1:

• The elevated ferritin indicates adequate iron stores despite low transferrin saturation 1.
• Focus should be on identifying and treating any underlying inflammatory condition rather than iron supplementation 1.
• Address the B12 deficiency with appropriate replacement therapy 2.

Common Pitfall to Avoid

Do not reflexively treat with iron based solely on low transferrin saturation—the elevated ferritin indicates this is not simple iron deficiency 1. Giving iron when stores are already adequate risks iron overload complications 1.