Frequently Asked Questions

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Anemia Basics

What is anemia?

Anemia develops when there are not enough healthy red blood cells in the body. This condition can be detected when there is a below-normal level of hemoglobin in the blood. Hemoglobin is the iron-rich protein in red blood cells that carries oxygen from the lungs to all parts of the body. If you have anemia, your body doesn’t get enough oxygen-rich blood. As a result, you may feel tired or have other symptoms depending on the severity of anemia. People with severe anemia may feel tired, fatigued or experience shortness of breath which can cause problems carrying out routine activities. Anemia can be a temporary condition, a consequence of other health conditions, or it can be a chronic problem. Many mild types of anemia can be easily treated, however, certain types of anemia may be severe, long lasting, and life threatening if not diagnosed and treated.

Are some types of anemia inherited?

Yes, some types of anemia are due to inherited or genetic defects. Sickle cell anemia occurs most frequently in people of African, African-American, and Mediterranean descent. Thalassemia (or Cooley's anemia) is found in people of Mediterranean and Southeast Asian descent. These types of anemia are extremely common. Another inherited anemia is Fanconi anemia, but this is very rare.

Causes of Anemia

Which people are at the highest risk for anemia?

Groups of individuals who are at risk for developing anemia include:

• infants who may not have adequate iron intake
• children going through a rapid growth spurt, during which the iron available cannot keep up with the demands for a growing red cell mass
• women in childbearing years who have an excessive need for iron because of blood loss during menstruation
• pregnant women, in whom the growing fetus creates a high demand for iron.

People with ongoing gastrointestinal blood loss are at risk of developing iron deficiency, as are individuals with leukemia or cancer who must receive chemotherapy or radiation to treat their disease. The drugs or radiation used to treat these diseases frequently suppress the bone marrow's ability to make cells of all classes - red blood cells, white blood cells, and platelets.

In addition, many individuals with chronic inflammatory conditions, such as rheumatoid arthritis or chronic infections, may become anemic through a combination of an inadequate supply of iron for red blood cell production and bone marrow suppression. We now recognize that the increased anemia seen in the elderly may be a form of bone marrow suppression from chronic inflammation. Recognition and treatment of the anemia in the elderly has gained clinical interest because correcting the anemia may have beneficial effects on quality of life.

Can certain medications cause a person to become anemic?

Yes, medications can cause anemia for many different reasons. For example, chemotherapeutic agents often cause anemia because they the bone marrow's ability to manufacture red blood cells, hemoglobin is carried by RBC's, If there are not enough RBC's, the body does not get the right amount of oxygen. Other types of medication-induced anemia are usually unpredictable, and not well understood (such as drug induced aplastic anemia). Some patients react to drugs because of inherited susceptibility, such as patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. G-6-PD is an important enzyme that buffers the mature red cell against oxidative stress. In individuals who are deficient in G-6-PD, exposure to certain chemicals, drugs, or even some foods will result in the alteration of hemoglobin and breakdown of red blood cells.

Symptoms of Anemia

What are the symptoms of anemia?

The symptoms of anemia can include headache, fatigue, weakness, difficulty in thinking. With severe anemia, other symptoms, such as shortness of breath and rapid heartbeat, may be experienced.

Diagnosing Anemia

At what point are people considered anemic?

Anemia occurs when a patient has a lower than normal amount of red blood cells. Anemia is assessed by measuring the amount of hemoglobin, the substance in red blood cells that transports and delivers oxygen throughout your body. A doctor can determine if you are anemic by performing a routine blood test called a complete blood count (CBC) test, which provides levels for both hemoglobin and hematocrit (the percentage of red blood cells in a blood sample). The measurement of hemoglobin is the most common method for assessing anemia, although hematocrit values may also be used.¹ The normal value or range for these indicators varies with both gender and age.

Once a diagnosis of anemia is made by your doctor, more tests, such as iron status tests, are often required to determine the cause of the anemia and the best course of treatment. Anemia is further categorized as mild, moderate or severe depending how far a patient's hemoglobin level resides below the normal range. As important, anemia that develops over a short period of time, such as hours to days, will lead to more symptoms than a case of anemia that slowly develops over months to years.

What tests might my doctor perform to determine if I have anemia?

If your hemoglobin and hematocrit tests (as described above) indicate that you may have anemia, your doctor may take additional steps to determine the cause, severity and appropriate treatment for your condition. Some of those additional steps may include the following examinations.

Physical Examination: The first step in any diagnosis is a physical examination to determine if you have symptoms of anemia and any complications. Your doctor may also ask you some of the following questions to determine if you have any conditions that may be causing your anemia:

• Have you or anyone in your family suffered from anemia?
• Do you experience heavy menstrual bleeding? (women)
• Have you ever had blood in your stool or any other signs of bleeding?
• What is your usual diet?
• Have you ever had an ulcer?
• Do you regularly take aspirin or anti-inflammatory drugs?

Bleeding: Loss of blood, or bleeding is a common cause of anemia. This bleeding may go unrecognized until you begin to suffer from the anemia. If your doctor suspects a source of bleeding within your body, several tests may be used to discover the source of the bleeding. One of the first tests ordered is the fecal occult blood test. This test checks the stool for signs of blood and can detect even small amounts of blood. This simple, noninvasive test is done by placing a small sample of stool on a chemically treated card. Then a chemical solution is put on top of the sample. If the card turns blue, there is blood in the sample.

Vitamin Deficiencies: Your doctor may check the amount of folate, vitamin B-12 and vitamin C in your blood to determine if your anemia is due to a vitamin deficiency.

Iron Deficiency: Since iron deficiency is the most common cause of anemia, your doctor may conduct some blood tests to check the level of iron in your blood. Some common iron status tests are:

• Serum ferritin - Ferritin is a protein that helps store iron in the body. Results of this test give doctors a good idea of how much of the body's stored iron has been used up.
• Transferrin level or total iron-binding capacity - Transferrin is a protein that carries iron in the blood. Total iron-binding capacity measures how much of the transferrin in the blood is not carrying iron. People with iron-deficiency anemia have a high level of transferrin that is not carrying iron.

Chronic Illness: Because anemia may be the first symptom of a serious illness, determining its cause is very important. This may be difficult, particularly in the elderly, malnourished, or people with chronic diseases, whose anemia may be caused by one or more factors.

Treatment: Your doctor will use these and other tests to help determine the best course of treatment for you.⁴

Treating Anemia

Is it normal to get an upset stomach, become constipated, or both after taking iron supplements?

Many people who take iron supplements experience side effects that make it difficult to follow the recommended dosing. It has been estimated that up to 25% of patients who take iron supplements will experience side effects in their digestive tract – most commonly an upset stomach, constipation, or both.

Iron supplements are absorbed better if taken one hour before meals. However your doctor may tell you to take your iron with food to reduce an upset stomach. Also, starting with half the recommended dose and gradually increasing to the full dose may help minimize these side effects. If iron makes you constipated, consider taking a stool softener such as docusate sodium along with your iron.

I have been taking the iron supplements my doctor recommended, so why haven’t my symptoms gone away?

In order to correct anemia, your body must manufacture new red blood cells to replace those that were lost. It takes about 5-7 days to start developing red blood cells which should increase hemoglobin levels within 2-3 weeks of starting iron supplementation. Therapeutic doses of iron (50-60 mg of oral elemental iron twice daily) should increase hemoglobin levels by 0.7-1.0 g/dL per week.⁵ You may need to continue to take an iron supplement for several months in order to build up iron stored in your body and prevent anemia from returning. Therefore, it is important to take pills for as long as your doctor recommends, even if your symptoms have lessened or disappeared.

The most common reason iron therapy fails is because doses are not fully taken or they are not taken properly.⁶ The amount of iron absorbed decreases as you take larger doses of iron. For this reason, it is recommended that most people take their iron supplements in two or three equally spaced doses.⁷ In order to decrease side effects, iron supplements are often taken with food – but it is important to note this may decrease iron absorption by as much as 40-66%.⁶ Since you are receiving less iron this way, you may need to take your supplement for a longer period of time for it to have the same effect.

Blood Donation

I tried to donate blood, but was denied because my blood count (hematocrit value) was too low. What hematocrit value is required to donate blood? What should I do about my low hematocrit value?

Hematocrit is a measure of the percentage of red blood cells in a blood sample. To donate blood, a person's hematocrit value must be above the threshold of 38%, a level which is established by the U.S. Food and Drug Administration (FDA). If you are found to have a low hematocrit value, you will not be able to donate blood on that particular day. Having a low hematocrit is the most frequent reason for not being able to donate blood. It is normal for hematocrit values to vary from day to day or even hour to hour and values can be influenced by such things as diet, hydration and health issues.

Being deferred from donation due to a low hematocrit does not always mean that you have anemia or a medical problem. However, if you have been denied from donating blood because of a low hematocrit value it is possible that you have anemia. Decreased hematocrit often indicates anemia caused by an iron or vitamin deficiency. Further testing may be necessary to determine if you are anemic and if so, the cause of the anemia. If you find your hematocrit value is low or think you might be anemic, you should schedule an appointment with your doctor.

Blood Transfusion

Are blood transfusions commonly used to correct anemia, and are they dangerous?

Blood transfusions are used to treat anemia as a last resort. The physican first identifies the cause of the anemia and corrects the cause, if possible. With concern over the safety of the blood supply, more attention is being given to anemia management. Most blood transfusions are given because of excessive bleeding at the time of surgery, with trauma, or because of bone marrow suppression, in patients with cancer or leukemia on chemotherapy. Blood transfusions are much safer than ever before but we also know that blood transfusions affect the immune system and may increase certain risks. There is also a concern for human error, which in 1/16,000 transfusions results in a patient receiving a transfusion of blood that is not matched with his/her blood type.

Diabetes

What causes anemia in people with diabetes?

Long-standing diabetes can affect your kidneys (known as diabetic nephropathy) and your nerves (known as diabetic neuropathy).^8,9 When diabetes affects your kidneys, they may not be able to produce enough erythropoietin, a hormone that controls production of red blood cells.⁸ When diabetes affects your nerves, your body many not be able to properly signal the kidneys to produce more erythropoietin in response to anemia.⁹ Both diabetic nephropathy and neuropathy may contribute to the development of anemia.

Some medications used to treat diabetes, hypertension and other related conditions may add to the risk of anemia. Diabetes medications called thiazolidinediones (Avandia and Actos) as well as metformin (Glucophage) can increase the risk of developing anemia.¹⁰

What are the benefits of treating anemia in people with diabetes?

Correction of anemia can reduce your symptoms related to anemia, which may include fatigue, weakness, pale skin, chest pain, dizziness, irritability, numbness or coldness in your hands and feet, trouble breathing, a fast heartbeat, and headache. Studies have shown that treating anemia in diabetics may decrease hospital admissions⁸ and may also slow down the development of some of the complications of diabetes, including damage to the nerves, the eyes and the kidneys.¹¹

Iron Deficiency

What is iron deficiency anemia and can I correct it by changing my diet?

Iron builds muscle proteins, healthy bones, and most importantly, it helps blood cells carry the oxygen the body needs for energy. Iron deficiency anemia develops when the body has had a low level of iron for a long time. It can be caused by blood loss, not eating or absorbing enough iron, or by an increased demand for iron (like pregnancy or rapid growth).

For people with anemia, getting enough iron in their diet is an easy, natural way to begin improving their well-being. But, iron supplementation may be necessary in order to raise the low iron levels which are causing iron deficiency anemia. In the case of poor absorption, supplemental iron may need to be given intravenously (through an IV) or vitamin C intake may be increased to help the body absorb the iron from food.

Additional feature articles: Patient’s Oral Iron Guide | Nutrition: The Importance of Iron
Information handout: Iron Deficiency Anemia

What is the difference between iron deficiency and iron deficiency anemia?

Iron deficiency occurs when the body is low in stored iron. Iron deficiency may not cause any symptoms and is often not recognized. When it is detected, it can be treated with iron supplementation. If the low iron level or its cause is not corrected, it can lead to muscle weakness and eventually lead to iron deficiency anemia.

Iron deficiency anemia is a condition that develops when a low iron level persists and prevents the body from making enough healthy red blood cells. The body can make red blood cells, even when it has an iron deficiency, but eventually the shortage of stored iron can slow that process and cause anemia.

Iron deficiency anemia often leads to symptoms of fatigue, which may lead sufferers to seek medical attention. When iron deficiency anemia is diagnosed it is almost always treated, since untreated anemia can cause damage to the heart and other organs.

I have been diagnosed with iron deficiency anemia and my doctor prescribed iron supplements. How long will it take for my blood to become normal?

The recovery time depends on the degree of anemia at the beginning of treatment, the absorption of iron from the stomach and the kind of iron pills one is taking. Most people with mild to moderate iron deficiency anemia will correct the anemia over a period of 2-3 months. However, even when the anemia is corrected, the iron stored by the body is still low. Physicians often recommend an additional 6 months of oral iron therapy once the anemia has been reversed in order to reach a normal level of stored iron. This will help prevent iron deficiency anemia from recurring quickly.

Restless Leg Syndrome

What is Restless Leg Syndrome (RLS)?

Restless legs syndrome (RLS) is a condition in which your legs feel extremely uncomfortable while you're sitting or lying down. It makes you feel like getting up and moving around. When you do so, the unpleasant feelings temporarily goes away. People suffering from RLS describe the sensations as burning, creeping, tugging, or like insects crawling inside the legs. The sensations can be uncomfortable, irritating, or possibly even painful. These symptoms become worse during the early evening or later at night and can disrupt sleep, leading to insomnia and daytime drowsiness.¹² It has been estimated that approximately 10% of adults in North America and Europe experience RLS symptoms.¹³ RLS is not a dangerous or life threatening condition, but it can be painful and disrupt everyday life.

What causes RLS and is it related to anemia?

There is no known definitive cause for restless leg syndrome but one area of interest is its connection with iron deficiency and iron deficiency anemia. Iron deficiency and iron deficiency anemia are the most common medical conditions associated with RLS and are present in more than 20% of all cases.¹⁴ Two other major factors related to RLS include renal disease and pregnancy, which are frequently accompanied by iron deficiency anemia.¹⁵ More recent studies have shown that decreased levels of stored iron in the body can make RLS symptoms worse.^16,17 Additionally, researchers have found that not enough iron was getting to the brain cells of people who suffer from the symptoms of restless legs.¹⁸

Can treatment relieve my RLS symptoms?

Increasing the body’s stored iron can provide relief of symptoms in some RLS patients, especially those with iron deficiency.¹⁸ While oral iron supplements have shown benefit in these patients, IV iron may be needed in order to replenish low iron levels in the brain. A recent study showed that treatment with IV iron led to almost complete relief of the RLS symptoms in a small group of patients.¹⁵ Close communication with your doctor will help him or her provide the treatment that is best for you.

Surgery

My hemoglobin level is low and I am scheduled for surgery. Should I postpone the surgery?

If you have a low hemoglobin (Hb) level, you should discuss this with your doctor as soon as possible. No treatment may be necessary if minimal blood loss is expected during a minor procedure. If a greater blood loss is expected for more extensive procedures, you should ask your doctor about being treated with erythropoietin and iron to raise your hemoglobin to a normal level before surgery. An anemic patient who undergoes high-blood-loss surgery has a greater risk of surgical complications and need for a blood transfusion, which also carries some risk.

Some physicians advocate measuring a patient's hemoglobin 30 days before surgical procedures. This allows time to identify and treat the anemia and its cause.¹⁹ There is a general consensus among surgeons, anesthesiologists, and internists to postpone surgery if a patient has severe anemia (Hb ≤ 8 g/dL).²⁰

While many healthy adults are able to handle anemia before surgery ²¹ without any problem, elderly adults may not tolerate it as well. A recent study of elderly patients undergoing major non-heart surgery found that even mild anemia increased the risk of heart trouble or death after surgery.²² The treatment of anemia before surgery with iron, erythropoietin, or red blood cell products and their substitutes is possible for most major elective surgeries and can help prevent adverse outcomes, especially in elderly patients.

How long could it take for my hemoglobin level to return to its pre-surgical range if I did or did not receive a transfusion?

A blood transfusion replaces the red blood cells and hemoglobin (Hb) lost during surgery and may immediately return your hemoglobin level to its pre-surgical range. The symptoms of anemia (if present) may be relieved quickly, but the increase in hemoglobin level may only be temporary.²⁴ This is because the red blood cells in a blood transfusion do not last as long as the red blood cells your own body will make after surgery. If you receive a blood transfusion, your hemoglobin level will initially increase, but it could still take your body several weeks to regularly produce enough healthy red blood cells to sustain the pre-surgical hemoglobin level.

If you do not receive a transfusion following surgery, it may take several weeks to sometimes two months to raise your hemoglobin level to its pre-surgical range. This is because your body must make new red blood cells to replace those that were lost during the surgical procedure. It normally takes about five to seven days to make a healthy red blood cell, but the normal course of healing and inflammation from the surgery can slow down the production of red blood cells.^25,26

Several studies have shown that without treatment, anemia is almost never corrected within one week after surgery. With appropriate therapy, about one-third of patients will have their anemia corrected two to four weeks after surgery and two-thirds within six weeks after surgery.²⁷ Patients with more severe anemia, and those who suffer from anemia of chronic disease before their surgery may take longer than six weeks to recover.²⁷ Your doctor may recommend an oral iron supplement to shorten the time it takes to recover.

In some circumstances, a blood transfusion may be necessary, but concerns about the risks involved have restricted their use. Blood transfusion has many known adverse effects including potential transmission of infectious diseases, allergic reactions, and decreased immune function.^28,29 Additionally, treatment with erythropoiesis-stimulating agents (ESAs) and iron have been shown to increase the rate of red blood cell production and may also help hemoglobin levels return to normal in surgery patients.^30-32

Women's Health

I heard that heavy menstrual periods can cause anemia. Is there anything I can do to prevent the anemia?

Heavy menstrual bleeding, also known as menorrhagia, is one common cause of iron deficiency anemia for women. Heavy menstrual bleeding has been reported in approximately 10-15% of all women at some point during their life. Among these women, as many as 20% will go on to develop iron deficiency anemia.³³ You can begin to replace the iron lost from blood loss by eating more iron-rich foods, but supplemental oral iron medications may be required. Discuss your concerns with your doctor or gynecologist. To learn more, read our feature article Women and Anemia – Heavy Menstrual Bleeding and Fibroids.

What is the relationship between uterine fibroid tumors and anemia in women?

Anemia in women can be caused by the increased menstrual blood loss associated with uterine fibroid tumors. Uterine fibroids are noncancerous growths in the uterus that often appear during childbearing years. They almost never lead to cancer, and are not linked to any increased risk of cancer.³⁴ Along with a healthy diet, iron supplementation may be required to prevent iron deficiency anemia from developing. To learn more about fibroid tumors, read our feature article Women and Anemia – Heavy Menstrual Bleeding and Fibroids.

What causes anemia during pregnancy?

Pregnancy places major demands on the body because the mother must meet the needs of both her body and her growing baby. The mother’s body needs enough iron and folate to make the right amount of red blood cells.³⁵ Most anemia during pregnancy results from this increased need for iron. It is estimated that women will need approximately 50% more iron during pregnancy, increasing from 18 to 27 milligrams (mg) per day.³⁶ Even a well-balanced diet can only provide about 12-14 mg of iron per day, well short of the iron a pregnant woman requires.

In order to prevent iron deficiency anemia during pregnancy, it is often necessary for pregnant women to take iron supplements. The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women should take a daily supplement of 30mg of elemental iron. The expectant mother should also stay in close contact with her doctor and gynecologist, and be sure to eat a diet that includes foods rich in iron and folate, like liver and dark green leafy vegetables. Read our feature articles to learn more about anemia caused during pregnancy, from vitamin deficiencies or from iron deficiency.

Can childbirth cause anemia? What is postpartum anemia?

Approximately 10% of women will suffer from anemia within the first six months after delivering their baby³⁷ and 4% of women will have anemia lasting up to twelve months.³⁸ Anemia experienced by mothers during this time following childbirth is called postpartum anemia and is usually caused by iron deficiency. Mothers suffering from postpartum anemia most likely lost a large amount of blood during childbirth, had twins or other multiple births, or were anemic during the third trimester of pregnancy.⁷ In any case, losing large amounts of blood or having low iron levels leaves the mother at risk for developing anemia.

Following childbirth, the mother’s body needs to start making new red blood cells. To do so, she will need enough iron to make hemoglobin, the part of the red blood cell that carries oxygen throughout the body. If she has anemia and there is not enough stored iron, her body will be unable to raise hemoglobin levels and reverse the anemia. Low iron levels before and after childbirth may require treatment. Close communication with your doctor and gynecologist will help him or her provide the best care to prevent anemia prior to child birth and treat postpartum anemia. To learn more about postpartum anemia, read our feature article Women & Anemia – Childbirth and Postpartum Anemia.

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Last Updated: April 8, 2009