Anemia: An Overlooked Reason for Your Fatigue?

Fatigue: Beyond Just the Adrenals and Thyroid

So many women come to see me for fatigue that sometimes I think we're experiencing an exhaustion epidemic! There are many reasons for fatigue – our diets, poor sleep, stress, and yes, hypothyroidism is quite under-diagnosed and adrenal fatigue, though dismissed by the medical industry, is a very real phenomenon. But there's another important cause of fatigue that often gets overlooked in women: anemia.

Anemia is no joke – it can cause such substantial fatigue that I’ve had patients who can barely get out of bed. It can cause severe cognitive function problems – memory and concentration problems for example, and even confusion. It can cause you to become exercise intolerant, and it can also cause you to lose your appetite, experience restless leg syndrome, and feel irritable. Severe enough iron deficiency can cause the heart to become stressed, leading to irregular heart rhythms and in the most extreme cases, heart attack! Of note, the most common symptom of a heart attack in women, even women in their 40s, is fatigue – so this is another reason not to ignore or dismiss severe fatigue as “no big deal” or “just some adrenal fatigue.”

Common Causes of Anemia

Over a recent lunch a colleague confided that she was just diagnosed with Crohn’s disease. Her only symptom for months? Intense, debilitating fatigue.

Previously energetic, her fatigue was so bad that it finally brought her to the doctor’s office where a battery of routine tests revealed the cause of her fatigue – severe anemia. She was so anemic, in fact, that she required intravenous iron infusions to get her iron levels to normal, after which she said she felt like a million bucks. She didn't even realize how badly it had been affecting her mood, her exercise habits, and her ability to concentrate at work!

A good doctor knows that anemia, while most commonly caused by insufficient dietary iron intake, is also sometimes a symptom of a more serious condition. So unless there are obvious dietary reasons for anemia, a further investigation should be done. In my colleague’s case, this included a colonoscopy, which revealed the Crohn’s disease in her colon.

Here are 6 common conditions that can cause anemia:

  1. Celiac disease
  2. Ulcerative colitis
  3. Crohn’s disease
  4. Dietary insufficiency
  5. Rheumatoid arthritis
  6. Dysfunctional Uterine Bleeding or Menorrhagia (heavy periods)

This is not an exhaustive list; it is, however, a list of some of the most common reasons for anemia that integrative MD's see in our practices.

Celiac disease, Crohn’s disease, and ulcerative colitis (UC) all share common causes of anemia – chronic intestinal inflammation leading to regular, microscopic amounts of blood loss from the gut, sometimes also punctuated by frank intestinal blood loss that can be seen in the stool, especially with Crohn’s and UC.

Additionally, these conditions cause general malabsorption of nutrients, making it hard to extract certain vitamins and minerals from your diet, and finally, folks with these conditions who also have severe digestive system symptoms often start to skimp on meals because eating causes discomfort. True to this pattern, my friend did not eat anything during our lunch date as she had just begun to have digestive symptoms along with the now improving fatigue. The treatment in situations where gut inflammation is causing the anemia is to heal the gut and reduce inflammation with herbs and supplements including curcumin from turmeric, marshmallow root, licorice root, and L-glutamine, for example. Iron can be supplemented at the same time to improve overall energy.

Dietary iron insufficiency is super common especially these days as so many women are on restricted diets for health reasons, are skipping meals because they are on the run, or frankly, due to the rampant number of women with overt or even more often, subtle forms of eating disorders, which can also lead to restrictive eating patterns. While a vegetarian or vegan diet can be very healthy, it does take extra effort to get enough iron in your diet if you’re not getting it from meat sources. I treat so many vegans and vegetarians who are chronically tired, come in for an appointment with me thinking it’s their thyroid that’s causing the problem, only to discover it’s iron deficiency anemia. The good news is this is easily fixable!

Heavy periods and dysfunctional uterine bleeding (uterine bleeding for a variety of reasons – usually too much environmental estrogen exposure, but also from uterine fibroids and other gynecologic issues) leads to blood loss that can be heavy enough to cause anemia. In this case, it is important to get to the bottom of the underlying hormonal imbalance or problem, while also treating the anemia with increased dietary iron and iron supplementation if severe enough to be causing anemia symptoms.

The third type of anemia that would typically be seen with rheumatoid arthritis or other chronic autoimmune conditions including Crohn’s, UC, and celiac, is called anemia of chronic disease. In this situation, the body is actually taking a lot of the iron out of circulation and putting it into storage. This may potentially be a biological mechanism that protects the body from the oxidative damage that freely circulating iron can cause, but deprives the tissues of needed oxygen, which is carried by the iron in the red blood cells. The natural approach in cases of autoimmune disease is to reduce overall inflammation in the body with dietary changes and using herbs and supplements such as curcumin, quercetin (if the kidney function is normal), and with antioxidants and adaptogens, get to the root causes of the autoimmune condition, and bring the condition into remission. Iron can also be supplemented to improve overall energy. Of course, appropriate medical care should also be part of the plan when needed.

The Basic Tests to Get if You’re Feeling Tired for No Reason

When my patients come in telling me they are just plain exhausted for no obvious reason, I ask deeply about symptoms to help me target in on the most likely causes, but I generally also order the following tests, which can be obtained from a convention lab or your primary doctor.

  • Thyroid Testing: TSH, Free T4, Free T3, reverse T3, and thyroid antibodies
  • Complete Blood Count: to include hemoglobin, hematocrit, white blood cell count
  • Iron Studies: Ferritin, serum iron, and total iron binding capacity (TIBC)
  • 24 Hour Urine Cortisol or Salivary Cortisol Testing
  • Epstein Barr Virus Panel to include: Viral capsid antigen (VCA)-IgM, VCA-IgG, D early antigen (EA-D), Epstein Barr nuclear antigen (EBNA)

I order the thyroid testing because it’s an incredibly common cause of fatigue; the iron studies and CBC specifically look at the status of your iron, and the white blood count rules out more dastardly causes of fatigue like leukemia (don’t get scared, I’m just saying that’s why I include it – I’m a doctor – I do these things!), and then the cortisol and EBV testing assess for adrenal problems that can cause fatigue, and acute (new onset) or chronic Epstein Barr, the virus that causes mono, and which is actually common in women in their 20s-50s, even if you’ve never had mono before.

Of note, if all of these tests come back normal, or there are other symptoms, I might do additional testing ranging from Lyme disease to a stress test to a sleep apnea test. But the above give you a great starting place, and most doctors would be happy to run these tests for you.

What to Do If Your Testing Shows that You’re Anemic

Based on your test results, your doctor will be able to help you with the detective work of sorting out whether you are anemic and if so, what type of anemia you have – for example, whether it’s due to a nutritional deficiency or a chronic disease, or a combination of both as often happens when the digestive system is inflamed.

Iron Deficiency Anemia

If it’s merely a nutritional issue, you can increase the iron in your diet with these iron-rich foods:

  • Lean red meats and dark meat poultry 2-3 times/week, or even a small daily portion of 3-4 oz. to boost your iron up
  • Red beans and lentils daily
  • Dark leafy greens like kale, collards, and spinach daily
  • Dried fruits, such as raisins, dried apricots, and prunes daily

Avoid combining dairy products with your iron sources as calcium can interfere with iron absorption.

If you are anemic, you may also need to supplement for a while to get up to normal, after which you can keep up your supply with your diet. I use a product called iron chelate, at 30 mg 1-2 times day depending on the severity of the anemia, along with improving dietary iron sources. This form of iron is easy to absorb and doesn’t cause nausea or constipation. Don’t take your iron supplement with dairy or calcium for the same reason. Accidental iron supplement overdose is a leading cause of fatal poisoning in children under 6, so iron-containing supplements should be kept out of reach of children.

If you do have a thyroid problem and are taking Levothyroxine (i.e., Synthroid, Tirosint), note that iron supplements can reduce the absorption of levothyroxine tablets and so levothyroxine shouldn't be taken within 4 hours of iron supplements.

I do admit that while I am an ardent supporter and promoter of plant-based diets, and was a vegetarian myself for 15 years, including through multiple pregnancies, many of my vegetarian patients with anemia who do start eating meat say they feel that someone finally turned their engine on – they didn’t realize they’d been going through life in such a fog of low energy. It’s a personal choice – but one to consider deeply if chronic iron deficiency anemia is keeping you from living your life energetically and effectively. It doesn’t take eating much meat to get enough to keep your iron up.

Anemia of Chronic Disease

Blood work can point your doctor in the direction of a diagnosis of “anemia of chronic disease,” which you'd see if there is high ferritin and a low TIBC. If you do have this type of anemia, you may need more of a medical work-up to get to the root cause of the problem and you can't fix the anemia just with diet and supplements. You have to treat the cause of the anemia.

Sometimes additional blood tests can identify a condition such as Rheumatoid arthritis, or if symptoms aren’t obvious for celiac, UC, or Crohn’s, a colonoscopy and intestinal biopsy might be recommended. Whether to pursue this more invasive testing immediately, versus trying natural approaches first, is a personal decision you will want to make with your medical doctor based on the severity of your symptoms and risks. Often a natural approach as a first response is appropriate, but on occasion, it is not.

If anemia is due to celiac disease you will need to go off of gluten permanently. Celiac disease can be tested for by testing gluten antibodies in the blood, getting an intestinal biopsy, or simply going off of gluten completely and strictly, including cross-reactive grains, for at least 3 months and tracking changes in your health. Gluten intolerance can also cause intestinal inflammation and nutritional malabsorption, and may lead to anemia, but it is much tougher to test for. It may also not require you to remain gluten-free permanently.

Crohn’s disease and Ulcerative colitis are more complex and require separate blogs to address adequately. An experienced functional or integrative MD, integrative gastroenterologist, or naturopathic doctor specializing in gut issues can help you to heal your gut, sometimes well enough to avoid flares and offset the need for immunosuppressive medications, as I have done with a number of patients.

Bonus: Herbal Iron Tonic Syrup Recipe

If you would like to use herbal support to boost your iron stores and status, here’s one that I’ve used for decades in my practice, and took myself during my pregnancies and after my babies were born. It’s very easy to digest and absorb, and it is plant-based, though admittedly, it’s an acquired taste. Note that it is made with molasses, which is rich in iron, but is also high in sugar, so if you are diabetic or on a low glycemic diet, check with your nutritionist or doctor, or monitor your other sugar intake yourself.

Here's the recipe:

  • 1/2 ounce dried dandelion root
  • 1/2 ounce dried yellow dock root
  • 1/2 cup blackstrap molasses

Put the roots in a quart jar and cover with boiling water. Let sit 4-8 hours or so. Strain into a pot and simmer off until you're left with 1 cup of liquid infusion. Add to this the blackstrap molasses while still heating, then remove from heat. Store in the refrigerator. Dose is 1-2 TBS. daily. Take it with 250 mg Vitamin C for best absorption. This preparation will keep refrigerated for at least several weeks.

You can purchase the dried herbs from Mountain Rose Herbs.

I'm confident that if anemia is an underlying cause of your fatigue, like my friend, you too will once again feel like a million bucks when you get to the bottom of it and get that iron boosted up! I look forward to hearing how this goes for you – let me know in the comments section below!


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Very informative post! Thank you. I had know idea that EBV can be a chronic issue, I always thought the bloodwork simply showed that you had it in the past... I'm interested to learn more as my tests were very high. Also, cumercin for healing the gut... Are normal supplemental doses OK during breastfeeding a one year old? I'm not anemic, but chronic fatigue is an issue! Thanks again.


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Ellah Ray

Thank you for this another great blog post! My question is, in the case of iron deficiency anemia, how often and which tests to repeat to see if what you're doing is working (increase dietary sources, supplement, etc)? Or can energy level be the indicator? Thanks again, Ellah


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Thank you This came at the perfect time as I'm dealing with low iron symptoms. Hair loss, fatigue, increased heart rate at night, pale skin, joint aches, insomnia. Interesting because I'm also Hypothyroid so the symptoms mimic thyroid. I've been going in to my clinic since January to have thyroid levels checked. I've had lots of blood draws and wondering if this could have contributed to my low iron. I always have ferretin around 24 and now it's 17. Frustrating because my current Dr said your fine 17 is in range 12-150. Well I don't feel fine and I remember in 2005 this happened to me and a wonderful endocrinologist at the mayo clinic listened to me and said my ferretin was 28 and on the low end gave me iron supplements. In a matter of weeks I felt great. I really think more awareness should be focussed on low iron. Thank you for your wonderful info.


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Angela G.

Hi Aviva!, I feel like you are reading my mind with the articles you write! I am 47 and have been hypothyroid since 30. I am overweight and exhausted! Thank you for all this wonderful information to make my life better. I feel I've missed out on a lot because of fatigue and I will definitely be working on getting my iron up my ferritin has been low for quite a while. Thank you again for all of this knowledge, all my best! Angela


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Aviva, I love the Dandelion-Yellow Dock-Molasses recipe you gave! I also like to include Nettles into the daily diet. Very thorough post!


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I've used that iron tonic with incredible results! I was exhausted towards the end of my 4th pregnancy and just thought it was life with small children and everything I had on my plate. But I made the tonic and felt like a totally new person! Thank you!


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Thanks for this article! It is my biggest struggle during pregnancies and in between. I would like to try your iron tonic, but wanted to first confirm that it is okay to take while nursing-- specifically those herbs. Also, if I cannot find both herbs locally, is it sufficient to make a tonic using only one of them? I know the dandelion root is at our local co-op, but the yellow dock is not. It costs more to ship the herb than it costs for the actual herb when purchased online.


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    Megan Liebmann

    Hi Leah, Yes! Totally safe while breastfeeding. Warmly, Megan- Aviva Romm’s Executive Assistant and Online Nutrition Expert


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Hi Aviva! I'm so glad I found this post. After giving birth to three babies in quick succession, I have a ferritin level of 18. I have been taking your tonic for a month and am happy to report improvement in my energy levels, but as you might imagine, with three little kids, I'm impatient to feel normal again (and for my hair to quit falling out!). Is there any sense in taking MORE than two tablespoons a day?


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    Aviva Romm

    Hi Ashley, That's terrific! If you're referring to the yellow dock and molasses tonic, you can take up to 2TBS /day. Just be aware that molasses, though high in minerals, is also sugar.... Adding high iron -foods can also really help! :)


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Nam Rice

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