Iron Deficiency Anemia: Understanding Root Causes and Effective Treatment Strategies

Imagine two patients walking into a hematology clinic with similar symptoms—dizziness, fatigue, palpitations, and noticeable paleness. One is a 35-year-old female high school teacher named Ms. Xu; the other, Mr. Zhang, a 69-year-old retired factory worker. Despite their different ages and backgrounds, both were brought in by concerned family members who noticed their unusually pale complexions. Upon physical examination, no significant abnormalities were found beyond pallor. A complete blood count (CBC) revealed moderate microcytic hypochromic anemia in both cases—classic indicators pointing toward iron deficiency anemia.

Diagnosis Through Comprehensive Evaluation

To confirm the diagnosis, I ordered further testing known as the "iron panel"—measuring serum iron, ferritin levels, and total iron-binding capacity. For Mr. Zhang, given his age and gender, I also requested three fecal occult blood tests and referred him to gastroenterology for a thorough evaluation of possible gastrointestinal sources. Meanwhile, Ms. Xu was advised to consult gynecology to rule out menstrual-related blood loss or uterine conditions.

A few days later, both patients returned with updated results. The iron studies confirmed iron deficiency anemia in each case. Further investigations revealed that Ms. Xu had been suffering from uterine fibroids requiring surgical intervention, while Mr. Zhang was diagnosed with colon cancer—a finding that necessitated immediate oncological planning. These underlying causes explained the chronic blood loss leading to their anemia.

The Prevalence and Importance of Identifying Underlying Causes

This scenario plays out frequently in clinical practice. Iron deficiency anemia is the most common form of anemia worldwide, accounting for approximately 50% to 80% of all anemia cases. It affects individuals across all age groups but is particularly prevalent among children and women of reproductive age due to increased physiological demands and potential blood loss.

Why Treating the Cause Matters More Than Just Supplementing Iron

While oral iron supplementation can correct low hemoglobin levels, long-term recovery depends on identifying and resolving the root cause. Without addressing the source of iron loss, recurrence is almost inevitable. This makes etiological treatment not just important—but essential.

Primary Causes of Iron Deficiency Anemia

1. Increased Demand vs. Inadequate Intake
This imbalance commonly occurs during periods of rapid growth such as infancy, adolescence, pregnancy, and lactation. During these stages, the body's need for iron rises significantly, and dietary intake may fail to keep up, especially if nutrition is suboptimal.

2. Chronic Blood Loss – The Most Common Culprit
Persistent bleeding depletes iron stores over time. Key contributors include:

• Heavy menstrual bleeding (menorrhagia), often linked to fibroids or hormonal imbalances
• Gastrointestinal bleeding from ulcers, gastritis, hemorrhoids, or malignancies
• Frequent nosebleeds (epistaxis)
• Regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), which can damage the gastric lining

3. Impaired Iron Absorption
Even with sufficient dietary iron, absorption issues can lead to deficiency. Conditions affecting the small intestine or stomach interfere with iron uptake. Examples include:

• Chronic atrophic gastritis
• Prior gastric bypass or partial gastrectomy
• Celiac disease or inflammatory bowel disease (IBD)
• Excessive consumption of tannin-rich beverages like strong tea or coffee, which inhibit iron absorption

Rare But Important: Hemolytic Contributions

In rare instances, chronic intravascular hemolysis—such as in paroxysmal nocturnal hemoglobinuria (PNH)—can result in urinary loss of iron-bound proteins like haptoglobin and hemosiderin. Over time, this continuous excretion leads to depleted iron reserves and subsequent anemia.

Effective Treatment: Beyond Iron Pills

Once diagnosed, treatment typically begins with oral iron therapy. Ferrous sulfate (e.g., Slow Fe or Ferro-Gradumet) at 300 mg once or twice daily is standard. Patients usually experience a rise in reticulocyte count within 5–10 days, peaking at 7–12 days. Hemoglobin levels begin increasing after about two weeks, with full normalization expected within two months in responsive cases.

Crucially, supplementation should continue for 3–6 months after hemoglobin returns to normal to replenish bone marrow iron stores. Stopping too early risks relapse, especially when the underlying cause persists.

When Oral Iron Isn't Enough

In some cases—such as severe malabsorption, ongoing blood loss, or intolerance to oral iron—intravenous iron therapy may be necessary. Options like ferric carboxymaltose or iron sucrose offer rapid repletion and are increasingly used in clinical settings.

Conclusion: Cure Lies in Cause Elimination

Treating iron deficiency anemia goes far beyond prescribing supplements. True resolution requires uncovering and managing the underlying pathology—whether it's a benign condition like fibroids or a life-threatening illness like colon cancer. For younger women, gynecological evaluation is key. For older adults, gastrointestinal investigation is non-negotiable. Only by combining targeted medical therapy with definitive cause removal can we ensure lasting recovery and prevent future complications.