Iron Supplementation in Women Over 65 Years
Iron supplementation in women over 65 should not be given routinely and requires full gastrointestinal investigation to identify the underlying cause before treatment, as iron deficiency anemia in this population is uncommon and typically indicates serious pathology such as gastrointestinal bleeding from ulcers or malignancy. 1, 2
When Investigation is Required
Women over 65 with iron deficiency anemia require comprehensive evaluation before supplementation:
- Full bidirectional endoscopy (upper endoscopy and colonoscopy) is strongly recommended for all postmenopausal women with iron deficiency anemia, as the risk of gastrointestinal malignancy increases significantly with age 1, 2
- Screen for celiac disease with tissue transglutaminase antibodies in all patients regardless of symptoms, as this affects up to 4% of cases 1, 2
- Test for H. pylori non-invasively before endoscopy 1
- Iron deficiency anemia is present in only 2% of women aged ≥50 years, and when present, 62% have gastrointestinal bleeding from lesions, while two-thirds have chronic disease or inflammatory conditions as the primary cause 1
Diagnostic Criteria
- Hemoglobin <12 g/dL in non-pregnant women 1
- Ferritin <45 ng/mL is the most powerful diagnostic threshold 1, 2
- Ferritin must be interpreted in context of inflammatory conditions, as it is an acute phase reactant 1
Iron Supplementation Dosing
Once serious pathology is excluded or identified and managed, iron replacement follows this protocol:
Oral Iron Therapy (First-Line)
- Start with ferrous sulfate 200 mg once daily (containing 65 mg elemental iron) taken in the morning on an empty stomach 2, 3
- Add vitamin C 500 mg with each iron dose to enhance absorption 1, 2
- Alternate-day dosing may optimize absorption in iron-deficient women, as daily doses ≥60 mg stimulate hepcidin elevation that persists 24 hours and blocks subsequent absorption 4, 5
- Low-dose therapy (15-50 mg elemental iron daily) is effective in octogenarians and significantly reduces gastrointestinal side effects compared to higher doses (150 mg), with similar hemoglobin response over 60 days 6
- Avoid excessive doses >200 mg elemental iron daily, as this paradoxically reduces absorption due to hepcidin elevation and increases side effects 2, 4
Duration and Monitoring
- Hemoglobin should rise by 2 g/dL after 3-4 weeks of treatment 2
- Continue oral iron for 3 months after hemoglobin normalizes to replenish iron stores 1, 2
- Monitor hemoglobin at 3-month intervals for 1 year, then annually, then only if symptoms recur 1
- Target ferritin >100 ng/mL to confirm adequate store repletion 1, 2
Intravenous Iron Therapy
Consider IV iron when:
- Intolerance to at least two different oral iron preparations 2, 7
- Contraindication to oral iron 2, 7
- Ineffective oral iron therapy (no hemoglobin rise after 4 weeks of compliant use) 1, 2
Ferric carboxymaltose 750 mg IV in two doses separated by at least 7 days (total 1,500 mg per course) for patients ≥50 kg 7
- Modern formulations allow 1-2 infusions rather than multiple doses 2
- Monitor for hypersensitivity reactions for at least 30 minutes post-infusion 7
- Check serum phosphate levels in patients requiring repeat courses within 3 months, as hypophosphatemia is a recognized complication 7
Critical Cautions for Elderly Patients
- Use low-dose oral iron therapy in vulnerable elderly to minimize side effects 1, 6
- Monitor iron status to avoid iron overload 1
- Avoid iron supplementation in anemia not attributed to iron deficiency, as this provides no benefit and risks toxicity 1
- Gastrointestinal side effects (constipation, nausea, abdominal discomfort) are dose-dependent and significantly more common with doses >50 mg elemental iron daily in octogenarians 6
- Never assume dietary deficiency as the cause in postmenopausal women—chronic disease and gastrointestinal pathology are far more common etiologies 1