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Dear Dr. Roach: I'm a 66-year-old female who's in good health. I was experiencing some dizziness and was prevented from donating blood due to a failed finger prick test. I asked my doctor to check my iron levels. All my blood work was excellent, except that my ferritin level was 19 ng/mL with an iron saturation of 18%.
When I researched my results online, there seemed to be great concern about the ferritin level since I'm postmenopausal, as some type of slow internal bleeding can occur. My doctor, however, wasn't at all concerned, saying that he wouldn't act on a ferritin level of 19 ng/mL with all my other labs (a complete blood count) resulting in very good levels.
I also read that the American Society of Hematology has recently changed the guidelines for what "normal" iron levels should be. I'll be taking an iron supplement (per my doctor's recommendation), but do I need to be concerned about the underlying cause of my ferritin level? -- Anon.
Answer: I'm sorry to disagree with your doctor, but a ferritin level this low does concern me, especially in a postmenopausal woman or a man. There are many causes, but some are very concerning.
The one that I was taught to consider first, as you cannot miss this diagnosis, is an advanced colon polyp or colon cancer. In my opinion, a low iron level alone, even without an anemia, should at least cause a clinician to consider this diagnosis. The new recommendations are that adults with a ferritin level less than 30 ng/mL should be considered to have iron deficiency.
Perhaps your doctor knows that you recently had a completely normal colonoscopy, so he wasn't as worried about colon cancer. (Unfortunately, even a colonoscopy occasionally misses some polyps that can bleed, as well as small cancers.) However, there are other conditions, such as ateriovenous malformations, celiac disease, and Crohn's disease, that can cause blood loss, prevent iron absorption, or do both.
It's also clear now that iron deficiency, even without an anemia, can cause symptoms, which is different from what I (and maybe your doctor) learned in medical school. Fatigue and dizziness are among the most-common symptoms. I agree with iron supplementation, but a careful consideration of other causes (and usually some additional testing) is warranted in my opinion.