Duration. Iron deficiency in the absence of anemia is asymptomatic, but there may be the non-hematological clinic of deficiency, symptoms and signs that are not very specific because they can be found in the absence of other elements (deficiency of Vitamins B12, Folic Acid, Vitamin B6 etc).
Iron deficiency anemia is a consequence in most cases of chronic (repeated) blood loss (secondary). Therefore, to treat it, a detailed examination is needed to find the possible cause.
The human body is designed not to lose blood normally in any place. The only physiological blood loss is in women in the reproductive period through a regular Menstrual Cycle in time and quantity. Any blood loss, even with the Menstrual Cycle more frequently and with a larger amount of blood, is pathological. The main cause of Fe loss is hemorrhage (not hemorrhage in large and rapid amounts, but loss in small amounts and over a relatively long time that are visible to the naked eye and not evaluated, or not seen but detected with certain qualitative tests or with a microscope). 1.0 ml of blood contains 0.5 mg iron.
a. Chronic blood loss from metrorrhagia and menometrorrhagia in females (½ l of blood contains about 250 mg/iron). Menstruations are the main cause of blood loss and the cause of anemia in females in the reproductive period. During the menstrual cycle, an average of 80 ml of blood is lost (40 mg iron). When the menstrual cycle is increased in quantity, longer than normally or the frequency is higher, the possibility of developing iron deficiency anemia increases. Normally, 35-80 ml of blood is lost for a CM (15 ml for some).
An increased blood flow is evaluated with these data; inability to control the blood flow only with tampons, using more than 4 tampons per day or 12 tampons for the whole cycle, presence of clots especially when they are more than 2 cm or persist even after the first day, if the CM lasts more than 7 days.
The CM affects the AF depending on the frequency (every 21, 28, 33 days), the number of days, the amount of blood. The more frequent (a 21-day cycle causes AF more than a 28-day CM), the longer and the larger the amount, the greater the possibility of occurrence and the sustaining treatment (after filling the stores) should be taken continuously to maintain an adequate amount of iron stores within the continuation of the "normal" CM.
As we said above, the Recommended Daily Dose (RDA, Physiological Daily Dose) in the USA is for adults 10 mg/male and 18 mg/female in the reproductive period. The usual daily American diet contains about 10 mg iron, from which only 1 mg will be absorbed under normal conditions (as much as is eliminated in one day under physiological conditions) in males and in females not in the reproductive period (i.e., without the Menstrual Cycle). In the latter, normally there should be monthly menstrual loss of 40 ml (equivalent to 16 mg iron), which can be compensated by dietary iron (mens includes blood loss and other tissue from the uterus in menstruation).
Thus, the human body is designed not to lose blood, because the Circulatory System has no direct communication with the external environment (blood only circulates in a closed system of tubes). The only physiological blood loss in humans is the loss with the Menstrual Cycle in females in the reproductive period (menorrhea, the physiological amount of blood lost during a menstrual, lunar cycle, every 28 days).
In some females who consider themselves healthy may have a "physiological" Menstrual Cycle (i.e., without a gynecological pathology evaluated by a specialist) 7 or more days long. They may lose up to 490 ml of blood in a month (about 200 mg iron – 28 days/cycle) or 7 mg iron/day (physiologically 1.5 – 2 mg iron/day). These females are predisposed to iron deficiency, iron deficiency anemia, and their recurrence, after cessation of treatment.
Any female in the reproductive period with a Menstrual Cycle that is more frequent than it should be (not 28 days but more often 21, 24 etc.), any menstrual cycle that is longer than it should be (3-4 days usually) and with more blood than it should be (more than 35 ml, maximum 80 ml, menorrhagia – abnormal blood loss during the Menstrual Cycle), without apparent gynecological pathology (always a consultation with the gynecologist is required in these cases) is predisposed to empty the iron stores (hypoferritinemia) and if this is not corrected (possibly even the cause removed) Iron Deficiency Anemia will be superimposed.
Be careful if a pregnant woman has anemia in the early months, to ask about the Menstrual Cycle (or other causes of iron loss or consumption) before pregnancy and for pathological blood loss in the early weeks of pregnancy. Every woman planning to become pregnant to do ferritinemia and correct it if it is low (because often in the first months of pregnancy there are nausea and vomiting, which limit the intake of the best supplements for compensating iron deficiency, which themselves often provoke irritation of the mucosa of the GI Tract with nausea, vomiting, diarrhea).
And other tests should be done to detect blood loss and if there is none, surely there is no Menstrual Cycle, then the current iron deficiency comes from pregnancy (a person needs 10-14 mg dietary iron daily, while a pregnant woman with filled iron stores needs twice as much, as are the usual supplements given to pregnant women, e.g., prenatal). If a pregnant woman has iron deficiency (hypoferritinemia), then correction is not done with supplements, but with the therapeutic dose of correcting iron deficiency and its consequence (iron deficiency anemia) 180 – 200 mg elemental iron/day for at least 3 consecutive months.
b. Chronic blood loss from the Gastrointestinal Tract (causes are various: esophageal varices, hiatal hernia, gastritis and duodenal and stomach ulcers, atrophic gastritis, various tumors, malabsorption, stomach resection, anal fissures and hemorrhoids etc). Anemia from stomach operations (total gastrectomy, partial or vagotomy with gastroenterostomy or with gastric bypass surgery in obese patients) will develop after a period from 7 months to 8 years after the operation and is also accompanied by Vitamin B12 deficiency.
Decreasing stomach acidity is only one of the causes. Other causes are iron losses due to accompanying hemorrhages (gastric ulcer or acute gastritis) or from the increased elimination of enterocytes, or from the rapid passage of food (the reserved function that the stomach has for food is lost) to the more active iron absorption sites which are located in the upper intestine (more in the duodenum) will cause a decrease in absorption. Angiodysplasia, intestinal diverticula, hereditary telangiectasia (Morbus Osler) are among the causes of chronic GI blood losses.
c. Melena, refers to black, "tarry" feces, after an upper GI hemorrhage. The cause of the black color is the oxidation of iron (Fe3+) of hemoglobin during passage through the ileum and colon. Blood needs about 14 hours to pass through the intestine and colon. If the passage of blood is more than 14 hours, the patient will have melena. If the passage is less than 14 hours, there will be hematochezia (bright red blood).
There is a rule that; melena will occur if the hemorrhage is above the ligament of Treitz. It may also come from lower paths if the mass displacement is slow enough for iron oxidation to occur. But when the amount of blood is large and from the upper GI paths, the blood comes out quickly and bright red. Rectal bleeding is the discharge of bright red blood, from damage to the lower paths of the GI Tract.
Be careful when taking the history and the patient refers to defecating darkly. This may also come from taking iron-containing preparations, iron-rich foods, nasal hemorrhage, the back part that passes into the continuation of the GI Tract.
Preparations that can cause GI hemorrhage (NSAIDs-Aspirin and other preparations, Glucocorticoids, anticoagulants, stanozolol) can cause iron deficiency. Aspirin is the main culprit. People (70% of them) who use aspirin at a dose of 2-6 gr/day have an average blood loss of 5 ml/day. After 7 days of treatment with 2 aspirin tablets (2x500 mg) or other preparations containing salicylates will lose an additional amount of blood from 1-4.5 ml/day.
In another study, it was seen that using aspirin 4 times a week will cause hemorrhage. Aspirin (salicylates in general) cause erosive gastritis and may participate in the pathology of gastric ulcers. Aspirin inhibits the synthesis of prostaglandins by eliminating their protective role through maintaining the integrity of the mucosa. In the acidic pH of the stomach, the preparation is not ionized and in this way will penetrate the cell membrane and destroy the apico-lateral bonds of the cells.
On the other hand, being an acid (salicylic acid) aspirin will affect the increase of stomach acidity. In this way, hydrochloric acid of the gastric fluid will reach the blood vessels and will directly contact the gastric mucosal cells that normally are protected by the integrity of the mucosa and bicarbonates. Switch aspirin with paracetamol (acetaminophen) which does not cause gastric hemorrhage.
In 15% of patients with esophageal hiatal hernia (especially in the paraesophageal form, where the hernia is larger) will develop anemia from iron deficiency. Anemia can also develop when dyspeptic symptoms are absent. The daily amount of blood lost from an EHH can reach up to 15 ml/day. The cause of hemorrhage is the damage to the gastric mucosa at the neck of the hernia sac or from gastric reflux will develop esophagitis.
Increased Fe needs: childhood, adolescence, pregnancy, lactation etc.
a. Iron deficiency in children. Iron deficiency and Iron Deficiency Anemia often develop in children in the first year of life if the breastfeeding mother has iron deficiency in her body. The causes of iron deficiency in children are various: Decrease in the overall body iron at birth. At birth, the amount of iron in the child's body is about 78 ml/kg (65-90 ml/kg), of which 60 ml/kg is in the composition of Hb. A linear relationship exists between body weight and total iron amount.
Children born at the upper limits of weight have 80% more iron than children born at the lower limits of it. In premature children, the total amount of iron is even smaller. In one study, it was seen that 26.5% of premature children develop iron deficiency anemia with Hb < 9 gr/dl and from the use of supplemental iron foods only 6.4% of these children will develop iron deficiency anemia.
Iron deficiency is greater in twins, because they tend to have a lower weight and on the other hand, there is blood transfer from one placenta to the other. The timing of the umbilical cord clamping matters. If the cord is clamped quickly after birth, up to 100 ml/fetal blood may remain in the placenta. If the umbilical cord is clamped 3 minutes after birth, then the TRCV will increase up to 58%. Although the child does not have a direct need for erythrocytes, the iron they contain can be used later for growth needs.
The decrease in iron reserves in a pregnant mother has little or no effect on the total iron reserves in the child's body. There is no difference in the Hb value of children born from anemic mothers at birth, from those born from non-anemic mothers (at birth or later). Iron supplementation during pregnancy has no effect on iron deficiency anemia that may develop in the child after birth. The iron reserves in the mother have no relation to the iron reserves in the fetus.
Fetomaternal transfusion. The transplacental passage of fetal RBCs into the mother's blood is a physiological process. In 50% of pregnant women, a small amount of fetal blood (0.4 ml) may pass into circulation between weeks 21 and 42 of pregnancy. In the process of birth in 50% of cases (pregnant women), a quantity of fetal blood passes to the mother and this can range from 0.5 -40 ml and in 1% of cases in large amounts up to 80 ml. (which can cause anemia in the newborn).
In some cases from a large amount of fetomaternal transfusion especially near birth may cause hemorrhagic anemia, shock, and fetal hydrops. Small amounts of blood can reduce the child's iron reserves and may favor the later development of anemia in these children.
b. Growth. In the absence of any disease, the needs for iron in an adult male are generally small (0.5-1 mg/day). In childhood up to adolescence due to rapid tissue growth, the needs for iron are greater. These needs are much increased in the first year of life. Body weight and blood mass triple, while the concentration of circulating Hb doubles.
Even greater are the needs in premature children and those born at the lower limits of the norm. A premature child weighing 1.5 kg, at the end of the first year has sextupled the weight and blood mass, while the concentration of circulating Hb triples. A full-term child needs 135-200 mg iron during the first year, while a premature child needs up to 350 mg iron. After the age of 1 year (up to the age of 12) the needs for iron are smaller and the growth rate is not as high as in the first year of life.
To ensure a positive iron balance, 0.2-0.3 mg/day is needed. From the age of 11-14 years, a larger amount of iron is needed to ensure a positive balance of it (0.5 mg/day in females and 0.6 mg/day in males). By the end of this period in females, menstruations begin and the needs for iron increase to be equaled with those of males. In the newborn, the reserve iron is 75 mg/kg (from the mother), at 6 months it is 50 mg/kg (from mother's milk and foods), then 30 mg/kg.