Most people who come about iron have already started the tablets. A pharmacy conversation, a relative, a result from a wellness company. The fatigue is a bit better, or it is not. The question they think they are asking is which bottle to buy next. The question they are actually asking is why the number fell in the first place.
Iron deficiency is a finding. It is not a diagnosis. Tablets treat a number. They do not explain the leak. If haemoglobin keeps sliding, the next move is finding the loss, not another month of the same box.
Chest pain, signs of a stroke, severe breathlessness, heavy bleeding, a severe allergic reaction or symptoms of sepsis need 999 or A&E immediately. Chest pain on top of severe anaemia is 999 as well, not a repeat of the tablets.
Why iron deficiency is a finding and not a plan
The short version is this. Iron can be low because you are not taking enough in, because you are not absorbing what you take, or because you are losing it. Diet is real, and it is rarely the whole story once the anaemia is more than mild. Loss is the chapter people skip, because it is less polite. Periods. Stomach. Bowel. Pregnancy. Repeated blood donation. A hospital stay. Sometimes more than one of those at once.
Here is the longer version. Ferritin is a store. Haemoglobin is the oxygen carrying protein. You can have a low ferritin and a haemoglobin that has not dropped yet. You can have a haemoglobin that has dropped and a ferritin that still looks “in range” if there is inflammation sitting around it. The pattern matters more than the single reading. I want the full blood count, the film if the laboratory comments on it, ferritin, and often B12 and folate sitting next to them, because replacing one and missing the others is how people stay tired.
NICE is clear that iron deficiency anaemia in men, and in women after the menopause, should make us think about the stomach and the bowel, including cancer pathways, until someone has looked. That is not a way of frightening you. It is a way of not spending 6 months on tablets while a bleeding point sits there. In younger women with heavy periods and no other warning features, periods may be the whole explanation, and we still ask about bowel change, because “just periods” has missed things I would rather not miss.
It is worth saying plainly. I will start iron when it is safe and indicated. I will not let the tablet become the entire plan. And I will not promise that the number will be normal in 6 weeks. Absorption is messy. Compliance is messy. The leak, if we have not found it, is still there.
What I look at when the iron is low
What I look at in clinic is the story of the energy, then the story of the blood. When the tiredness started. Whether there is breathlessness on stairs, restless legs, ice craving, a sore tongue, hair thinning you have actually noticed, palpitations. Whether there is chest pain. If there is chest pain and you look anaemic, we are in a different building.
Then the loss questions, asked without apology. Periods: how many days, how many changes, whether there are clots, whether it has changed. Bowel: looser, thinner, darker, mucus, a new urgency, a pain, a family history of bowel cancer or coeliac disease. Stomach: indigestion, reflux, medicines from the pharmacy that irritate a stomach lining, a previous ulcer. Diet: what you actually eat in a week, not what you believe a good diet looks like. Blood donation. Pregnancy. A recent operation. Nosebleeds that nobody counts as bleeding. Blood in the urine.
Then I examine you. Colour of the conjunctiva. Pulse. Blood pressure, lying and standing if fainting is in the story. Abdomen. A rectal examination if the history points at the bowel and it will change what we do. I am looking for a mass, for tenderness, for the things the blood form cannot show. I am also looking at the person: how they walk in, whether they are breathless in the room, whether they look like the number on last week’s printout.
If we do not already have a proper set of bloods, we draw them. A blood draw is £20 plus the test. I want more than an isolated ferritin. Isolated ferritin without a full blood count is how wellness panels manufacture a shopping list. If the film comments on small red cells, that supports iron. If it comments on mixed sizes, we think about B12, folate, and mixed deficiency. If the white cells or platelets are doing something odd, iron is no longer the only character.
When this comes up in consultation, the second layer is often years of being told it is fine. Fine periods. Fine tiredness. Fine because you have children. Fine because you are vegetarian. Some of that is true. Some of it is a way of not looking. Women wait longer. Men with a new iron deficiency sometimes wait too, because tiredness feels like work. Neither wait is a plan.
If the picture points at the bowel, the next step is a referral, and a stool test for hidden blood can help decide tempo in some people. It does not replace looking inside when looking inside is indicated. If we are deciding how urgently the bowel needs to be seen, Dr Morawala and I will sometimes talk that through, because a surgical view changes the tempo. That is a conversation, not a promise of a date.
Coeliac disease belongs on the list when absorption is the story, or when there is bowel change, or when the iron keeps falling despite tablets and a diet that should be enough. A simple blood test starts that. It is not a personality. It is a cause.
I also look at the rest of the fatigue. Thyroid. Sleep. Mood. A ferritin of 18 does not explain everything, and it does not explain nothing. Treating the iron and ignoring the depression, or treating the mood and ignoring the iron, are how people bounce between rooms. We can do both in the same hour if both are sitting there.
If I do not know yet, I say so. Start iron, repeat the blood count in 4 weeks, and if it has not moved we stop pretending the leak is theoretical: that is a plan. Another box without a repeat is not.
When to come in sooner
Some of this is 999. Some of it is today. Some of it is this week.
- Chest pain, severe breathlessness, signs of a stroke, heavy bleeding, a severe allergic reaction, or symptoms of sepsis: 999.
- Black stools, vomiting blood, fainting, or bleeding that you cannot slow.
- A haemoglobin you already know is very low, or a rapidly worsening pallor.
- New bowel change with weight loss, or iron deficiency if you are a man, or a woman after the menopause.
- You have been on iron more than once and nobody has asked why it keeps falling.
- You are pregnant, or you might be, and you are more breathless than you expect.
If you are tired, your periods are heavy, and you have never had this looked at properly, book an ordinary slot and bring every old result. Do not start a fourth bottle while you wait and call that a plan.
How we investigate this here
You are seen face to face at Clinique Alpa in Palmers Green. A 30 minute appointment is £100. Blood draw £20 plus the specific test. If a specialist is the next step, a referral letter is £50 after the assessment. If you cannot get to clinic, a home visit is £250 in the day and £450 at night, up to an hour.
We agree the tests before we draw them. We book the results conversation rather than leaving you with a flagged ferritin at midnight. Read the fees page if you want the numbers first. If the result you already hold needs a same day look because the haemoglobin is the problem, say that when you ring.
With your consent we copy the plan to your NHS GP. Iron that is being replaced privately and investigated on the NHS, or the other way round, needs one story, not two half stories.
I will tell you what I think the cause is, what I do not know yet, and which test or referral would change that. I will not tell you the tablets have solved it until the number, and the reason, say so.
Be seen if the iron has been low more than once. Read our fees page, or call 020 8882 8088. 30 minutes £100. Blood draw £20 plus the test. Home visits £250 in the day, £450 at night, published in full. In an emergency call 999. Subject to availability.
Written by Dr Mitesh Parmar, MBBS MRCGP, GP and founder of Clinique Alpa, 466 Green Lanes, Palmers Green, London N13 5PA. This article is general information, not personal medical advice. In an emergency call 999. For NHS advice call 111 or visit nhs.uk.