Women's health.

A Red Flag for Women of Childbearing Age with Bleeding Disorders

This population faces a greater risk of iron deficiency, with or without anemia.
Author: Lisa Fields

Why are women, girls, and people with the potential to menstruate (WGPPM) who have hemophilia, von Willebrand disease, or other bleeding disorders more likely than men to develop iron deficiency?

Heavy, prolonged menstrual periods increase their risk. Pregnancy also contributes to iron deficiency: Mothers transfer iron to their babies in utero, and blood is lost at the time of delivery.

“Women, girls, and people with the potential to menstruate can bleed in every way that other people can,” says Bethany Samuelson Bannow, M.D., a hematologist at Oregon Health & Science University’s Center for Women’s Health in Portland. “When you add menstruation and pregnancy on top of it, that’s why this population is at higher risk for iron deficiency.”

When iron deficiency arises, a person’s iron stores are lower than they should be, and people may notice that they don’t feel well.

“[It] can manifest in symptoms ranging from fatigue, lightheadedness, and brain fog to hair loss and nail changes,” says Angela Christine Weyand, M.D., a pediatric hematologist at the Hematology Oncology Clinic at C.S. Mott Children’s Hospital in Ann Arbor, Michigan.

Doctors can look for iron deficiency by checking someone’s levels of ferritin, a blood protein that contains iron. People with more severe iron deficiency may also develop anemia, when they have low levels of hemoglobin, a protein in red blood cells.

“Anyone who menstruates should get their ferritin checked at least once a year,” Samuelson Bannow says. “Ask for that ferritin number, not just complete blood count and hemoglobin [for] anemia.”

New Testing Criteria

For years, many labs have used different parameters when measuring ferritin and hemoglobin levels in women and men, with lower numbers deemed “normal” for women.

“Their ‘normal’ range is not giving us the full picture,” says Samuelson Bannow, who notes that labs settle on their numbers by looking at ferritin and hemoglobin levels in a healthy population, but because iron deficiency is prevalent among WPPM, lower levels may seem to be the norm. There’s no reason to think that people who menstruate need fewer red blood cells or fewer iron stores than people who don’t menstruate, she says.

Some labs have started to update their parameters for WGPPM, but this varies by location, Samuelson Bannow says.

Treatments for iron deficiency are available for WPPM with inheritable blood and bleeding disorders. Among them are dietary changes, oral supplements, and intravenous iron. “It is important to replace the deficit and correct the underlying issue,” Weyand says.

Hormonal birth control and tranexamic acid may be prescribed to help control heavy or prolonged menstrual bleeding.

“If you don’t slow menstrual losses, the iron deficiency is going to recur, and you’re going to need IV iron again and again,” Samuelson Bannow says.