Diseases & Conditions



Much of the iron in the body is contained in hemoglobin. Hemoglobin is the component of red blood cells that enables them to carry oxygen and deliver it to the body's tissues. Iron also is an important component of muscle cells. It is also necessary for the formation of many enzymes in the body.

The body recycles iron: When red blood cells die, the iron in them is returned to the bone marrow to be used again in new red blood cells. A small amount of iron is lost each day, mainly in cells shed from the lining of the intestine. This amount is usually replaced by the 1 to 2 milligrams of iron absorbed from food each day.

Food contains two types of iron: Heme iron: Animal products contain heme iron. It is absorbed much better than nonheme iron. Nonheme iron: Most foods and iron supplements contain nonheme iron. It accounts for more than 85% of iron in the average diet. However, less than 20% of nonheme iron that is consumed is absorbed into the body. Nonheme iron is absorbed better when it is consumed with animal protein and with vitamin C.

Iron Deficiency

Iron deficiency usually results from loss of blood in adults but, in children and pregnant women, may result from an inadequate diet. Anemia develops, making people appear pale and feel weak and tired. Doctors base the diagnosis on symptoms and blood test results. Doctors look for a source of bleeding, and if one is identified, they treat it. Iron supplements, usually taken by mouth, are often needed.

Iron deficiency is one of the most common mineral deficiencies in the world. It causes anemia in men, women, and children.

In adults, iron deficiency is most commonly caused by loss of blood. In premenopausal women, monthly menstrual bleeding may cause the deficiency. In men and postmenopausal women, iron deficiency usually indicates bleeding, most often in the digestive tract—for example, from a bleeding ulcer or a polyp in the colon. Chronic bleeding due to colon cancer is a serious cause in middle-aged and older people.

Iron deficiency may result from an inadequate diet, primarily in infants and small children, who need more iron because they are growing. Adolescent girls who do not eat meat are at risk of developing iron deficiency because they are growing and starting to menstruate. Pregnant women are at risk of this deficiency because the growing fetus requires large amounts of iron.


When iron reserves in the body are exhausted, anemia develops (see Anemia: Iron Deficiency Anemia ). Anemia causes paleness, weakness, and fatigue. People usually do not notice how pale they are because it happens so gradually. Concentration and learning ability may be impaired. When severe, anemia may cause shortness of breath, dizziness, and a rapid heart rate. Occasionally, severe anemia causes chest pain and heart failure. Menstrual periods may stop.

In addition to anemia, iron deficiency may cause pica (a craving for nonfoods such as ice, dirt, or pure starch), spoon nails (thin, concave fingernails), and leg cramps at night. Rarely, iron deficiency causes a thin membrane to grow across part of the esophagus, making swallowing difficult.


Iron deficiency is diagnosed based on symptoms and blood test results. Results include a low level of hemoglobin (which contains iron), a low hematocrit (the percentage of blood volume that is red blood cells), a low number of red blood cells, and the presence of abnormally small red blood cells. Blood tests also include the following: Transferrin: Transferrin is the protein that carries iron in blood when iron is not inside red blood cells. If the percentage of iron in transferrin is less than 10%, iron deficiency is likely. Ferritin: Ferritin is a protein that stores iron. Iron deficiency is confirmed if the ferritin level is low.

However, the ferritin level may be normal or high when iron deficiency is present if people have inflammation, an infection, cancer, or liver damage.

Occasionally, a bone marrow examination is needed to make the diagnosis. A sample of bone marrow cells is removed, usually from the hipbone, through a needle and examined under a microscope to determine the iron content.


Because the most common cause of iron deficiency in adults is excessive bleeding, doctors first look for a source of bleeding. If the source is excessive menstrual bleeding, drugs, such as oral contraceptives (birth control pills), may be needed to control it. Surgery may be needed to repair a bleeding ulcer or remove a polyp in the colon. A blood transfusion may be necessary if the anemia is severe.

Normal dietary intake of iron may not be sufficient to replace lost iron (because less than 20% of iron in a typical diet is absorbed into the body). Thus, most people with iron deficiency need to take iron supplements by mouth usually once or twice a day. Iron in supplements is absorbed best when taken on an empty stomach, 30 minutes before meals or 2 hours after meals, particularly if the meals include foods that reduce the absorption of iron (such as vegetable fibers, phytates, bran, coffee, and tea). However, taking iron supplements on an empty stomach can cause indigestion and constipation. So some people must take the supplements with meals. Antacids and calcium supplements can also reduce iron absorption. Consuming vitamin C in juices or taking it as a supplement enhances iron absorption, as does eating small amounts of meat, which contains the more easily absorbed form of iron (heme iron). Iron supplements almost always turn stools black—a harmless side effect.

Rarely, iron is given by injection. Injections are necessary for people who cannot tolerate tablets or for a few people who cannot absorb enough iron from the digestive tract.

Correcting iron deficiency anemia usually takes 3 to 6 weeks, even after the bleeding has stopped. After the anemia is corrected, an iron supplement should be taken for 6 months to replenish the body's reserves. Blood tests are usually done periodically to determine whether people are receiving enough iron and to check for continued bleeding.

Women who are not menstruating and men should not take iron supplements or multiple vitamins with iron unless they are specifically instructed to do so by a doctor. Taking such supplements can make diagnosing bleeding from the intestine difficult. Such bleeding may be due to serious disorders, including colon cancer.

Because a developing fetus requires iron, iron supplements are recommended for most pregnant women. Most babies, particularly those who are premature or who have a low birth weight, need an iron supplement. It is given as an iron-fortified formula or, to breastfed babies, as a separate liquid supplement.

Iron Excess

Excess iron can accumulate in the body. Causes include the following: Repeated blood transfusions Iron therapy given in excessive amounts or for too long Chronic alcoholism An overdose of iron A hereditary disorder called hemochromatosis

Excess iron consumed all at once causes vomiting, diarrhea, and damage to the intestine and other organs. Excess iron consumed over a period of time may damage coronary arteries.

Often, deferoxamine Some Trade Names DESFERAL is given intravenously. This drug binds with iron and carries it out of the body in urine. Hemachromatosis is treated with bloodletting (phlebotomy).


In hemochromatosis, a hereditary disorder, too much iron is absorbed, resulting in the accumulation of iron in the body.

In the United States, over 1 million people have hemochromatosis. The disorder is potentially fatal but usually treatable. The gene associated with hemochromatosis has been identified. Iron can accumulate and damage any part of the body. People may develop symptoms of cirrhosis or diabetes or simply feel tired. Blood tests identify people who require genetic testing, which can confirm the disorder. Bloodletting, done periodically, can prevent further damage.


Usually, symptoms develop gradually, often not appearing until middle age or later. In women, symptoms usually start after menopause because the loss of iron during menstrual bleeding and the increased requirement for iron during pregnancy compensate to some degree.

Symptoms vary because iron accumulation can damage any part of the body, including the brain, liver, pancreas, lungs, or heart. The first symptoms, particularly in men, may be those of cirrhosis (due to liver damage) or those of diabetes (due to pancreas damage). Or, the first symptoms, particularly in women, may be vague and affect the whole body. Fatigue is an example. Liver dysfunction is the most common problem. The following problems can also occur: Bronze-colored skin Heart failure (occasionally) Joint pains Increased risk of liver cancer Infertility An underactive thyroid gland (hypothyroidism) Chronic fatigue

In many men, levels of male hormones decrease. Erectile dysfunction (impotence) may occur. Hemochromatosis can worsen neurologic disorders that are already present.


Identifying hemochromatosis based on symptoms may be difficult. However, blood tests to measure the levels of iron and two other substances can identify people who should be further evaluated. These substances are ferritin, a protein that stores iron, and the iron in transferrin, the protein that carries iron in blood when iron is not inside red blood cells. If the ferritin level and percentage of iron in transferrin are high, genetic testing is usually done to confirm the diagnosis. A liver biopsy may be necessary to determine whether the liver has been damaged.

Genetic testing is recommended for people with hemochromatosis and all of their first-degree relatives (siblings, parents, and children).


Usually, bloodletting (phlebotomy) is the best treatment. It prevents additional organ damage but does not reverse existing damage. Bloodletting is done once or sometimes twice a week. Each time, about 500 milliliters (1 pint) of blood is removed until the iron level and percentage of iron in transferrin are normal. Bloodletting is then done periodically to keep these substances at normal levels.

With early diagnosis and treatment of hemochromatosis, a long, healthy life is possible.

Last full review/revision August 2008 by Larry E. Johnson, MD, PhD

Source: The Merck Manual Home Edition