Does a woman with hair loss, ferritin approximately 14 ng/mL, borderline hemoglobin around 12 g/dL, and a history of oral iron supplementation require intravenous iron therapy?

Does This Patient Need Intravenous Iron Treatment?

No, this patient does not require intravenous iron at this time—she should start with oral ferrous sulfate 200 mg once daily plus vitamin C 500 mg, and reserve IV iron only if she fails to respond after 4 weeks or cannot tolerate at least two different oral formulations. 1, 2

Rationale for Starting with Oral Iron

Your patient has clear iron deficiency anemia:

• Ferritin 14 ng/mL has 99% specificity for absolute iron deficiency 1
• Hemoglobin ~12 g/dL meets WHO criteria for anemia in women 1
• Borderline hemoglobin with profound iron depletion warrants immediate treatment 1

Oral iron is first-line therapy because she has no absolute contraindications to oral supplementation. 1, 2 The fact that she has tried oral iron previously does not automatically mandate IV therapy—the key question is whether she tried an adequate regimen with proper dosing and adjuncts. 1

Specific Oral Iron Protocol

Prescribe ferrous sulfate 200 mg (65 mg elemental iron) once daily on an empty stomach. 1, 2 This is the most cost-effective formulation with efficacy equal to all other oral iron salts. 1

Add vitamin C 500 mg with each iron dose to enhance absorption, especially critical given her severely low iron saturation. 1, 2 This combination addresses the absorption barrier that may have caused her previous oral iron failure. 1

Once-daily dosing is superior to multiple daily doses because hepcidin remains elevated for ~48 hours after iron intake, blocking subsequent absorption and increasing gastrointestinal side effects without improving efficacy. 1, 2

If ferrous sulfate causes intolerable side effects, switch to ferrous fumarate or ferrous gluconate—these are equally effective alternatives. 1, 2

Expected Response and Monitoring

Check hemoglobin at 4 weeks—expect a rise of approximately 2 g/dL. 1, 2 Failure to achieve at least a 1 g/dL rise indicates treatment failure and warrants switching to IV iron. 1, 2

Continue oral iron for 3 months after hemoglobin normalizes to fully replenish iron stores; total treatment duration is typically 6–7 months. 1, 2

Absolute Indications for IV Iron (None Currently Present)

Switch to intravenous iron only if:

• Intolerance to at least two different oral iron preparations (ferrous sulfate, fumarate, and gluconate) 1, 2
• Ferritin fails to improve after 4 weeks of compliant oral therapy 1, 2
• Active inflammatory bowel disease with hemoglobin <10 g/dL 1, 2
• Post-bariatric surgery with disrupted duodenal absorption 1, 2
• Celiac disease with inadequate response despite strict gluten-free diet 1, 2
• Ongoing gastrointestinal blood loss exceeding oral replacement capacity 1, 2

Your patient meets none of these criteria. 1, 2 Her hemoglobin is borderline (~12 g/dL), not severely low, and there is no documented evidence of malabsorption or active inflammation. 1, 2

Investigation of Underlying Cause

In premenopausal women with hair loss and iron deficiency, assess menstrual blood loss first—menorrhagia, pregnancy, and breastfeeding account for iron deficiency in 5–10% of menstruating women. 1, 2

Screen for celiac disease with tissue transglutaminase IgA antibodies, as celiac disease is present in 3–5% of iron-deficiency cases and can cause treatment failure if missed. 1, 2

Gastrointestinal endoscopy is not indicated in women under 45 years without upper GI symptoms, alarm features, or family history of colon cancer. 1, 2

Hair Loss and Iron Deficiency: The Evidence Gap

The relationship between iron deficiency and hair loss remains controversial. 3, 4

Studies on iron and alopecia areata show conflicting results:

• Only 2 of 8 studies found an association between low ferritin and alopecia areata 3
• The largest study (n=52) found no differences in serum ferritin or iron between AA patients and controls 3
• Studies supporting an association were conducted exclusively in female subjects 3

There is insufficient evidence to recommend universal screening for iron deficiency in hair loss patients. 4 However, some experts suggest that ferritin levels ≥60 ng/mL (corresponding to hemoglobin ≥13.0 g/dL) may be optimal for hair growth, higher than the threshold for anemia. 5

No placebo-controlled trials have assessed iron supplementation specifically for treatment of alopecia areata. 3 The decision to treat iron deficiency in hair loss patients should be based on treating the iron deficiency itself, not the expectation of hair regrowth. 4

Critical Pitfalls to Avoid

Do not prescribe multiple daily doses of oral iron—this increases side effects without improving efficacy due to hepcidin-mediated absorption blockade. 1, 2

Do not stop iron therapy when hemoglobin normalizes—continue for an additional 3 months to replenish stores. 1, 2

Do not overlook vitamin C supplementation when oral iron response is suboptimal. 1, 2

Do not jump to IV iron without first trying an optimized oral regimen (once-daily dosing with vitamin C) and documenting failure after 4 weeks. 1, 2

Do not attribute hair loss solely to iron deficiency—investigate other causes including thyroid disease, autoimmune conditions, and psychological stress. 5

If Oral Iron Fails: IV Iron Protocol

If she meets criteria for IV iron after 4 weeks, choose ferric carboxymaltose 750 mg IV over 15 minutes, repeated ≥7 days later for a total of 1,500 mg. 1, 2, 6 This formulation allows complete repletion in 1–2 infusions with the lowest anaphylaxis risk (~0.1%). 1, 2, 6

Avoid iron dextran as first-line due to higher anaphylaxis risk (0.6–0.7%) and mandatory test-dose requirement. 1, 2, 6