In non-pregnant women of reproductive age, iron deficiency anaemia more than doubled, while iron deficiency remained consistently high.
The prevalence of anaemia and iron deficiency anaemia among reproductive-aged women in the US has risen sharply over the past two decades, according to a large analysis of national health survey data.
Researchers analysed data from 8200 non-pregnant women aged 20-45 years who participated in the National Health and Nutrition Examination Survey (NHANES) between 1999-2000 and 2021-2023.
The prevalence of anaemia increased from 8.0% in 1999-2000 to 14.2% in 2021-2023, while iron deficiency anaemia (IDA) more than doubled from 4.3% to 9.1% over the same period. In contrast, the prevalence of iron deficiency remained persistently high, rising only modestly from 17.9% to 18.8%.
Overall, 9.8% of women had anaemia, 17.3% had iron deficiency and 6.2% had IDA, representing approximately 3.3 million, 5.7 million and 2 million US women respectively.
The authors said the increase could not be explained by changes in the characteristics of the study population alone, such as adjusting for demographic and socioeconomic factors.
Anaemia was defined as a haemoglobin concentration below 12.0g/dL, while iron deficiency was defined as a serum ferritin level below 15μg/L (as per World Health Organization criteria). IDA was defined as meeting both criteria.
The study excluded women who were pregnant, had evidence of inflammation, infection or liver disease, or had severe iron overload (per WHO criteria).
Women aged 40-44 years had significantly higher odds of anaemia, iron deficiency, and IDA than women aged 20-34 years. The highest prevalence was also seen among women with lower educational attainment, lower incomes, obesity, poorer self-rated health, and among non-Hispanic Black women.
The authors said the findings had important implications for screening. Current US Centers for Disease Control and Prevention guidance, published in 1998, recommends screening for iron deficiency every five to 10 years, or annually for people with risk factors such as heavy menstrual bleeding or low iron intake.
However, there are no updated national US guidelines specifically addressing iron deficiency with or without anaemia.
Australia similarly has no recommendation for routine population screening of non-pregnant women for iron deficiency or anaemia.
Instead, guidance recommends testing people with symptoms or recognised risk factors, including heavy menstrual bleeding, dietary insufficiency, gastrointestinal disease, or other causes of chronic blood loss.
Pregnancy is an exception, with consensus guidance recommending routine ferritin screening during antenatal care.
The researchers said future studies should examine adherence to existing screening recommendations and determine whether more frequent screening could enable earlier diagnosis and treatment of iron deficiency and anaemia in women of reproductive age.
The University of Western Sydney addressed iron deficiency management at its recent seminar ‘Your Health, Your Voice: Breaking the Silence on Women’s Health’.
The seminar described the “silent barrier” of iron deficiency in working-age women; the fatigue, hair shedding, increased susceptibility to infection, reduced mental clarity, impacted concentration and memory, depression and anxiety, and restless leg syndrome that often are associated with iron deficiency or anaemia.
Associate Professor Talat Uppal, a Sydney-based gynaecologist, director of Women’s Health Road, and founder of Australia’s first abnormal menstrual bleeding management hub, described iron deficiency as a massive but highly treatable public health issue.
“As a clinician, I want to just highlight… how relatively easy it is to support women in their journeys, and that it’s a matter of screening, of looking, of treating, of offering options, and following up,” she said.
“One thing that I feel sometimes might be compounding the reason why this condition is so under recognised is that it is a quality-of-life diagnosis.”
It’s a priority to identify and treat the underlying causes of iron deficiency, she explained, with heavy menstrual bleeding being one of the most common contributors in women of reproductive age.
“We know that at least globally a quarter of reproductive age women suffer from heavy menstrual bleeding, so it is really down to what is a woman’s perception of her blood loss, but then compounding this problem is the normalisation of heavy periods,” she said.
She explained that as the condition often occurred in families, children learning about their periods were often taught coping mechanisms for what’s considered normal and it may never be flagged as an issue with that child’s healthcare provider.
“Sometimes clinicians are not always asking, and then if you’re not asking and then the patient is not volunteering, we’re still, you know, remaining in that cycle,” she said.
“[Heavy menstrual bleeding] is not always identified with the robustness, the rigor, the respect that we should give a condition that causes so much loss of quality of life for women.
“So, it’s all very well to say, look, it’s a quality-of-life issue, but at the end of the day, we need to have some clues or some hints that this patient is actually having heavy periods, and for the community also to process that this is not normal.
“We should ask, you know, are you using two forms of sanitary protection products, are you changing your pads or tampons more than two-hourly, and are the periods lasting longer than eight days? Are you finding that you’re unable to carry out your normal activities? Are you flooding through your clothes? Are you waking up at night to change sanitary products?
“We know statistically that less than half of women [with heavy menstrual bleeding] are seeking care… and one in 44 women with heavy bleeding actually have an underlying precancer or cancer.”
She shared data from her practice, highlighting a case of a woman with a ferritin of less than six and a haemoglobin of 83. Within a month of getting a Mirena IUD and iron infusion therapy, her ferritin went up to almost 100, and her haemoglobin increased to 120.
“This is the power that clinicians and, you know, health services hold – that we can honestly change trajectories for women,” she said.
“It is very sad to see ongoing suffering when this is a space that there is so much support and help.”
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Professor Uppal previously participated in research that included a survey of 5000 women, with a notable finding that 92% of participants said they wanted more conversations around treating heavy periods.
“Unfortunately, iron deficiency remains a space where it’s everyone’s job, and sometimes it’s no one’s job,” she said.
“So, the gynaecologist thinks the GP will do it, the GP sometimes thinks the haematologist will do it, and so then you know we’re fractionating care, whereas I firmly believe that heavy menstrual bleeding treatment and management must centre the ferritin screening, and also offering women options of treatment.”
As part of the seminar, Hayley Caratti, a third-year student doctor at UWA Medical School, shared some startling population-level impacts of iron deficiency.
“Nearly half of women with iron deficiency are initially misdiagnosed, and that mistake can cost them up to nine months of proper treatment,” she said.
“In the workplace, lost productivity and absenteeism can lead to a 4% reduction in wages per shift for anaemic women. That’s like losing a full day of work every month, and 2.6 days per year of iron deficiency associated sick leave.”
Professor Uppal explained the importance of making her community appreciate that this is a space where (generally speaking) treatment is reasonably straightforward.
“It is very high ROI, in my opinion, to support women’s quality of life,” she said.
