Look around you and it isn’t hard to find an exhausted woman. There she is, standing behind you in the queue at the post office or delivering your Amazon package. Here she is at the school gates, puffing after running from the car, coffee in hand, apologising for forgetting to pack a PE kit. Or trying to stop a yawn escaping during a long work meeting. Or eyes closed on a noisy commuter train, about to miss her stop.
Maybe this seems normal to you because, honestly, in today’s fast-paced culture, who isn’t exhausted? But take a closer look and you’ll see that this level of fatigue is often much more than something a simple nap could remedy. You’ll find these bone-tired women asking friends in WhatsApp groups why their hair is falling out, or complaining to their beautician that their nails are always breaking, or manically Googling symptoms, trying to work out why their brains are so foggy or why, despite having youth on their side, they sometimes forget how to form a sentence. Friends ask each other online whether everyone else is so overwhelmed with anxiety that they can’t sleep. Perhaps they’re taking antidepressants and wondering why their racing thoughts are not relenting. They may have asked their GP why day-to-day life leaves them feeling so drained and been told it’s “inevitable” with small children, or asked if they are getting enough exercise.
But what if the root of these experiences isn’t lack of exercise or overwork or a mysterious illness – or even mysterious at all. What if, in fact, their symptoms are very common signs of a condition that affects almost one in three women of reproductive age in the UK, and that in all likelihood much of the above could be explained by a simple blood test and treated fairly quickly after that?
Because they aren’t “just tired” at all. They are almost certainly iron deficient.
* * *
The Global Burden of Disease study, led by the Institute for Health Metrics and Evaluation at the University of Washington, puts iron deficiency anaemia as one of the top five causes of disability in women of reproductive age globally. Defined by the NHS as the most common cause of anaemia (when blood lacks the resources to deliver an adequate amount of oxygen to the tissues and organs), iron deficiency disproportionately affects women because – owing mostly to menstruation – they both need and lose more iron than men do. According to the NHS, women between 19 and 49 need to ingest almost double the amount of iron every day as men to stay healthy, making what we eat and how it is made a contributing factor – but this is only part of the story. A recent UK study by Randox Health, a blood-testing and diagnostics company, found almost one in three women attending its clinics had absolute iron deficiency (iron stores insufficient for an individual’s needs). And while treatment should be simple, it is so hard to come by that many of these women are just having to live with symptoms that can sometimes be life-ruining.
It’s something that Sam, a 38-year-old mother of two who lives in Bath, knows all too well. After her second baby was born in 2024 and she was struggling to cope with spells of dizziness and exhaustion, she went to her GP. “They suggested I was just tired and dehydrated,” she says. “They didn’t check my blood and told me to drink more water.” Despite expecting this to be the answer, her gut told her they were missing something.
Earlier this year, after starting a new contraceptive pill, she bled for a whole month and was advised by her GP to stop taking it. “That’s when the symptoms really ramped up,” she says. Her hair was falling out, she was often dizzy, extremely fatigued, got nausea in the evenings and struggled to shift illnesses her kids brought back from nursery. So she went back to the GP, who ordered some blood tests and an electrocardiogram (ECG, a test that records electrical activity in the heart). While it came back as normal, her level of serum ferritin (the protein that stores iron in the blood) was 10mcg, indicating iron deficiency. (Nice, an independent UK body that provides guidance to the NHS, defines this as anyone with a serum ferritin level under 30mcg a litre.)
Sam felt relief wash over her when she read the result. “There was an answer,” she says. “It could be treated!” But the doctor reviewing her bloods didn’t appear to be on the same page. “She told me I was ‘only just’ below the healthy range so it was unlikely to be causing my symptoms,” she says. “Iron tablets were suggested as I was at the low end of the scale, but she did not prescribe them.” Desperate to feel better, Sam bought over-the-counter iron pills and began taking them immediately.
She was in fact displaying many of the hallmark symptoms of iron deficiency. Others include aching joints, breathlessness, a metallic taste in the mouth, hair loss, depression, anxiety, brain fog, weakness and pallor, says Dr Kayathry John (Dr Kai online), a Manchester-based GP and co-host of the Talking Longevity podcast. She says although awareness of the extent of iron deficiency and its impact is growing in the UK medical community, whether it is spotted depends on your own doctor’s experience. “Once you qualify as a GP, you’re on your own and expected to do your own research,” she says. “We get updates and emails for new findings and medications, but that’s in every field of every topic.” She says this may explain why Sam’s GP didn’t connect the dots between her ferritin level and her symptoms.
One of the most common causes of iron deficiency is heavy periods, which affect one in three women, according to Prof Toby Richards, a global expert in iron deficiency and founder of the Iron Clinic in London. “Heavy periods can be categorised as those that require you to change your tampon or pad every one to two hours (or use both at once), to get up at night to change, to bleed for more than seven days, or to worry about leaving the house for fear of accidents or passing clots.” This, he says, can lead to blood loss above what the NHS considers the normal range: 20ml-90ml a month.
The Randox study found that women of menstruating age are the most common group to have a ferritin level below 30 (85% of women with absolute iron deficiency fell within this category), with 47.5% reporting heavy periods. As for other risk factors, “the prevalence of iron deficiency among different ethnic groups in the UK at present is unknown,” Richards says, before highlighting a research group at the University of East London that he is part of called Shine Project, which he hopes will shed light on this issue.
Sam found the iron tablets made her feel even worse – an experience that is not uncommon: according to Richards, one in four people do not tolerate them, experiencing side-effects that predominantly affect the gut, such as constipation or nausea. Still, Sam took the pills as often as she could tolerate. “After around seven to 10 days on iron, my period came and the symptoms all returned,” she says. So she went back to her GP practice, this time seeing a different doctor who apologised for her colleague and said Sam’s symptoms were clearly caused by iron deficiency. She prescribed a different form of oral iron, with a review in a few weeks. “It was very validating for me,” Sam says.
But the new tablets didn’t help and she felt desperate. “The way I was feeling affected my whole life,” she says. “I struggled to concentrate at work, to play with my kids, cook meals, spend time with my partner in the evening, go for a short walk … It changed who I am. I just can’t enjoy my life in the way I would usually.”
Sam’s case is far from rare. Richards says almost one in five women in the UK are unknowingly living with iron deficiency, and diagnosis and treatment take on average eight years. Why are women expected to tolerate these symptoms? “Medical misogyny,” he says.
When you consider the raw data, which shows just 3% of men have iron deficiency anaemia in the UK compared with 8% of women, it’s hard not to believe him. I later visit the Iron Clinic and ask the clinician in charge, Asela Dharmadasa, the same question. He is pretty direct: “Put it this way, if this was an issue that mainly affected men, the pathways for diagnosis and treatment would have been cleared long ago.”
* * *
This is certainly what Hannah, a 33-year-old mother of two, believes. Lying back on a leather chair at the clinic while a drip delivers synthetic iron directly into her bloodstream, it is clear she has had enough. As she describes a day over the summer when she went to A&E with symptoms of what she thought was a heart attack – strong palpitations, sweating, pain – it is clear she feels embarrassed at “making a fuss”. Especially because the doctor she saw ordered an ECG and quickly reassured her that her heart was OK. “One thing he did say, though, is that the blood samples they took showed my ferritin level was 15mcg a litre.” He then told her all her symptoms were consistent with iron deficiency – so bringing up her level would make her feel better.
“But I already knew this,” she says. Her ferritin level had been low for years, and she had been back and forth multiple times to her GP looking for answers to the extreme fatigue, frequent headaches, anxiety, dizziness and breathlessness she experienced on a daily basis. Each time she was sent away with oral iron tablets, which she had told several doctors made her feel worse.
Dr Andrew Klein, who runs an iron clinic in Cambridge, says one in three people can’t absorb oral iron, making treatment less straightforward. Even for those who can, it is still a slow process. Intravenous (IV) iron takes just over an hour from start to finish and, depending on the reason for deficiency, can restock a patient’s iron stores indefinitely. Serious side-effects are rare, though many patients report feeling a little fluey for a couple of days, and the results can be transformational. But it is more expensive than pills – it costs the NHS about £600 a patient (including the costs of the drug, the facility, nursing staff, disposable supplies, admin and blood tests). Part of the problem, Klein says, is that a lack of good quality research into treatment means a dearth of effective cheaper options. The only clinical randomised trial he is aware of showed significant benefit from IV compared with oral iron. “If I were to develop a cheaper alternative, I would be the richest person in the world,” Klein adds, pointing out that close to a billion women worldwide have iron deficiency.
Hannah asked her GP for a referral for an iron infusion after reading online that it would make her feel better. But, despite Nice guidelines suggesting referral for those in Hannah’s boat, she was told she was unlikely to qualify. “Access is dependent on several factors,” Dr Kai explains. “Severity of the deficiency is priority, as are comorbidities, particularly conditions that can be worsened by a deficiency. Symptoms are taken into account, but as most people will have tiredness as a symptom, those will take precedence.”
Richards says another issue is that, with GPs often stretched too thin, there is a common misunderstanding that often precludes correct diagnosis and treatment. “Many don’t know that iron deficiency can occur without anaemia,” he says, “so only check for that by looking at haemoglobin, a protein in red blood cells that transports oxygen to tissue and organs, and anaemic people lack, when ferritin requires a separate test.”
So looking at haemoglobin levels in isolation can be a red herring. “Iron is one of the ingredients that makes haemoglobin,” Richards explains. “If your iron stores – ferritin – run low, your body steals iron from elsewhere.” Iron is a core component in our mitochondria – the nuclear powerhouse of the cell that makes energy. “So if you have low iron in your muscles, you feel tired. You have trouble walking upstairs, with shortness of breath, chest pain or palpitations. You can feel dizzy. And if this iron is taken from the brain, then women describe brain fog, forgetfulness or an inability to think clearly.”
“I was so tired of the GP not taking me seriously,” Hannah says, the emotional exhaustion evident even in her body language. I ask whether she thinks her gender played a part in her experience: “100%.” Despite going back to her regular doctor after her A&E visit and directly asking for an IV, she says she was told point blank that her symptoms weren’t due to her low iron.
“Ultimately, the NHS is struggling,” Richards says. “GPs have their hands tied as there is little access for women to get IV iron in many hospitals.” GPs can only do so much in a system under strain. “When oral iron fails or is not tolerated,” says GP Dr Mike Banna, “the pathways through which GPs can refer for IV iron are often clunky and subject to the same pressures and waiting times that have become so commonplace post-Covid.” Using resources as cost-effectively as possible is part of a GP’s job. “This does not necessarily mean withholding treatments or only offering cheap options, but it does involve using an established pathway that may be more economical – and less invasive for the patient – before progressing to more costly and invasive options if necessary.”
As we know, though, saving money in one area can often impact another and when you start to add up the other costs to the economy of iron deficiency – absence from work or education, referrals to psychologists or doctors, unnecessary prescriptions, expensive tests and visits to A&E (57,000 emergency admissions to UK hospitals each year are due to iron deficiency anaemia, according to Nice) – providing access to IVs starts to look like the cheaper option by some way.
Societal shifts in eating habits may be a contributing factor to iron deficiency. Nichola Ludlam-Raine, a nutritionist, says, “There are two different types of iron. Heme iron is from animal sources such as red meat, chicken and fish, and is much more readily absorbed by the body. Non-heme iron, found in plant sources such as beans, lentils or fortified breakfast cereals, is less efficiently absorbed and requires vitamin C to enhance this process.” So while switching to a vegan or vegetarian diet is not in itself an issue, doing so without knowing about this might be.
Caffeine can also inhibit the absorption of non-heme iron, Dr Kai says: “But try telling an exhausted woman she can’t drink coffee! Instead I recommend leaving a two-hour window before or after a coffee or tea when eating iron-rich food or taking tablets, to aid absorption.”
Another issue is the rise of ultra-processed foods which, while not bad for our iron levels per se, Ludlam-Raine says, will often crowd out our diets with calorie-dense foods high in fat, salt and sugar. That leaves less space for the nutrient-rich food our bodies need to function properly. She is also quick to clarify that diet can only do so much. “If someone’s already got iron deficiency anemia, it’s really hard, or even impossible, to correct through food,” she says.
* * *
Julie, a 51-year-old equine nutritionist from the north-east, went, in a matter of months, from being able to undertake the very physical work involved in looking after her horses – riding, walking them, mucking out – to barely being able to stand up, finding it hard to form sentences because her brain was so foggy and being unable to function at anywhere near the level she needed in order to keep her business afloat. She went to the GP, where a blood test showed she was severely iron deficient, with a serum ferritin level of 3mcg a litre – dangerously low. Her doctor, however, was dismissive: “He said that, given I was perfusing [blood was still being carried between her organs; she didn’t look pale], I couldn’t be that unwell.” She was sent home with iron tablets, even though she had already told him they made her feel worse. Over a period of months, she kept ringing the surgery for help, but was never even able to get an appointment and started to lose hope of getting better. As her symptoms continued to worsen, she even feared she was dying: “I got to the point where I felt I wouldn’t survive more than a few weeks if it kept going on.”
A month ago, desperate to feel better, Julie forked out £800 for a private iron infusion. The impact was almost immediate. “Like chalk and cheese,” she says. “My ability to concentrate is better and whereas before I struggled to climb the stairs, now I can run up them.” Best of all, she is able to be back outside with her horses.
For all the government’s focus on the gender health gap over the past few years, little attention is paid to women’s exhaustion. But, if the numbers are anything to go by, it is widespread and a huge cause of ill health (and therefore absences from work) in the UK. Part of the issue is being exhausted has become so common, we barely register it. “A lot of women accept tiredness as a norm,” Dr Kai says. “We think it’s because we are running the house, or looking after children while working, or because we’ve just given birth.” There’s always an excuse to be tired and, because of that, we often don’t seek medical help. “Life is tiring, and because life is tiring the organic cause is often ignored.”
Dr Banna says recognising the line between normal tiredness and medical exhaustion can be tough for a doctor, too. “Fatigue is an incredibly nonspecific symptom which can represent anything from normal life-related tiredness to serious illness,” he says.
An effective GP investigation will involve questions about other symptoms, lifestyle, mood, sleep, etc, as well as most likely a host of blood tests which can effectively rule out (or in) many of the most common medical causes of fatigue, Banna says. Dr Kai goes further and says whenever any woman presents with a mental health issue, she will have iron deficiency in mind. “As a doctor, when someone comes in complaining of depression, low mood or anxiety, one of the first things I do is screen their blood because deficiencies in iron, vitamin D and B12 can all cause mental strain.”
This reminds me of something Richards told me after I visited the clinic that I’ve been thinking about ever since: many of the women he has treated – more than 3,000 to date – are able to come off medication they have previously been prescribed for anxiety and depression as a direct result of their iron infusion. It makes me wonder how many women with poor mental health are simply in need of some iron.
I wondered whether the most obvious solution would be for those of us who suspect we are iron deficient to take supplements preventively, if we are able to tolerate them. Richards says this isn’t the answer, though, because too much iron can also be detrimental to our health. “Women should be screened regularly,” he tells me. He points out that in Australia, where iron deficiency has been prioritised within the health service and all women are screened regularly, women experience half the rates of anaemia seen in the UK.
All the experts I spoke to agree if you are experiencing symptoms it’s worth seeing a doctor and pushing for a ferritin test, taking oral iron if the number is below 30mcg a litre and – if that doesn’t agree with you or a blood test three months later shows it isn’t working – requesting an infusion. Because even if exhaustion is common, that doesn’t mean we have to live with it.
Julie has been advised she will need a further two infusions, six months apart. Even considering the high price, it is a cost she is willing to pay. “I am suddenly capable of being ‘in life’ again,” she says. “Everything before felt like it was ceasing and now there is hope.”
Sam recently received a phone call to arrange an iron infusion via the NHS after 10 months of feeling awful. Her relief when we speak is palpable. “These are the most precious years of my children’s lives,” she says. “I just want to be awake for them.”
