Have you ever wondered why “spinster aunts” in books and movies are always portrayed as either napping, irritable or both? I think of Aunt May from Little Women- always critical, irritated, and nodding off. (By the way this sums up my daily mood in lockdown currently.) My theory is that these women had too many goddamned periods. And guess what? It’s likely that you do as well. The bottom line is that many women I see in my practice today are deficient in their iron stores, or ferritin. Many of us are losing too much iron through menstruation, and not absorbing iron optimally due to being too busy to slow down and eat properly. Most women menstruate monthly, but are not intending to get pregnant, so they don’t need to have periods. This is a challenging duality to correct, but it is essential for quality of life. Insomnia, anxiety, depression and fatigue are very commonly caused by low iron stores. It’s high time we screen all our female patients for their iron stores, and treat accordingly.
What is Ferritin?
Iron can be assessed in the bloodstream in a number of ways. If your doctor checks your iron levels, it typically will be an iron panel that looks at circulating iron, and the iron binding capacity, which is how much more iron can be transported. Most people will have normal levels of iron, and most doctors won’t even go so far as to order the iron panel if your CBC (red blood cells and white blood cells) looks normal. It takes a lot of iron deficiency for a CBC to look abnormal, so most iron deficiency is going undetected by medical professionals.
Ferritin is an iron storage protein that can also be tested with a simple blood draw. Ferritin releases iron when it is needed. This is a less common test that has been ignored and underutilized until recently. What I have found- and to be honest I still cannot determine the reason for this- is that FERRITIN correlates more closely with how people FEEL. This is especially true for women, who bleed and lose iron monthly through menstruation, unless pregnant, nursing or otherwise. You can have normal-appearing red blood cells, and a normal iron panel, but if your ferritin is low it is unlikely your energy, mood and sleep will be optimal.
Normal ferritin ranges vary per lab, but typically look like this: 12-230ng/mL. Look at how big this range is! This is an ABSURD normal range, and to me signals that this is a bloodstream marker that needs further research. Most women do not feel optimal until their ferritin gets up well above fifty, and preferably over 80. Many of us are walking around with iron stores well below this level. This is true for men, women and children alike. In fact, I first learned about this when my son was young and had terrible sleep issues. The sleep medicine department at Children’s Hospital checked his ferritin, and when we raised his levels with supplementation it was a game-changer for his sleep.
Do We Need Periods? And What About Hormonal Contraception?
We remain extremely primitive in our bodily functions. This means that while we live in a world with refrigerators, cars, and birth control, our bodies still operate on a daily basis as if we live in caves. For a woman who is still in her reproductive years (premenopausal), this means that we are designed to be making and feeding babies. This is the purpose of the menstrual cycle. When you are pregnant, you are not having a period. The blood that is shed with a period is the uterine lining, so if you are pregnant this builds up and is used to nourish a growing baby. When you are nursing, particularly during the months when you are nursing exclusively, you are typically not having a period. Think of life for women before contraception- when it was common to have more children during a lifetime, it was common to have fewer periods. (More time spent nursing or pregnant.) Fewer periods means a lot less iron lost through menstruation. Overall this would equate to improved iron stores. (Of course, nursing and pregnancy can also suck the iron right out of you, but over time with nursing I believe this to be less than through frank loss of blood due to monthly period.)
This is not an essay on how many kids you should or shouldn’t have. This is not an attempt to put all women on birth control. This is to help you understand why I see so many women who are iron-deficient, exhausted, and losing their nutrients every month with periods they don’t need. And I don’t have the perfect solution either. I can’t tolerate hormonal birth control because it makes me a crazy person. What is important is to assess whether or not you need to be having a period, what options you have, and to make sure you get your iron stores checked if you are bleeding each month.
If you are not intending to make a baby, I would argue that periods are not necessary. I have so many young, female patients who I see already taking birth control for contraception but insisting they need to have a period each month because it’s healthy. My argument would be that this is a dated approach, and that periods are only necessary if you want to get pregnant. Think back to our history of pregnancy and nursing. These things suppress ovulation, which in turn means that you have fewer periods. Birth control that is hormonal will also suppress ovulation. (The exception to this is a type of IUD, which I will discuss later.) Almost all hormonal birth control includes a “blank” week of pills that contain no hormone, so that you experience a slight hormone withdrawal and have a period. This period is just a placeholder, however, as you still are not actually ovulating or cycling. For most women, hormonal birth control can be taken continuously- this means that you skip your blank weeks, begin a new pill pack, and if all goes smoothly within a few months you basically do not have a period.
Some women need to bleed every 3-6 months so that they do not experience spotting with this method. You will know this if you experience breakthrough bleeding (this means bleeding outside of the intended time). Like everything else in medicine, this can require some troubleshooting. Some women need a slightly higher dose pill in order to suppress the cycle. You can work with your doctor on determining the best method for this. Remember that hormonal contraception can be delivered in a pill, patch, or vaginal ring. If there are a lot of side effects from the pill taken orally, consider one of the other two delivery mechanisms.
Another great option is the IUD. Particularly the Mirena, Skyla and progestin-containing IUDs- these are designed to provide a very low dose of progesterone to the uterine lining, to prevent buildup of the uterine lining each month. No lining to build up means no lining to shed. This means that most women on these birth control methods bleed little if at all. They will still experience hormonal shifts from a cycle, but will not have as much of a period. Again, if the end game is to reduce bleeding, this is also a lovely option.
Not everyone tolerates hormonal birth control. I am one of those people, and so I focus on maintaining healthy iron stores and balanced cycles. There are so many approaches to this, and as I stated above the most important foundation is to assess your iron stores, and replenish if necessary.
But Aren’t You a Naturopath? How Can You Recommend Hormonal Contraception?
I joke that I am The Disappointing Naturopath. People come to me with the expectation that I am going to only use herbs and nutrients and magic to make them feel better immediately. Human physiology is so complicated, and so set in it’s ways. I can’t change your genetics or your unique physical fingerprint. So we look at what can be improved upon, what needs to change, and we use all the tools in the toolbox. In my opinion, after a handful of years practicing Women’s Health, if contraception is well-tolerated, there can be many benefits for the modern woman (who does not want to have children back to back). Naturopathic Medicine means that we use all the tools in the toolbox. As Dr. Bastyr famously stated, it is WHATEVER IT TAKES.
What About Absorption?
As I explained in one of my previous posts, making adequate stomach acid is essential for nutrient absorption. This is especially true for iron!! If you supplement with iron and it makes you constipated, this is a sign that it is staying in your gut, and not getting into your bloodstream where it can work it’s magic. I nearly always have my patients take a capsule of Betaine HCL with pepsin with every iron capsule. This supports stomach acid presence when you add iron. It can help improve absorption and reduce constipation.
Healthy stomach acid production is a rarity in our busy world. If you are not in a relaxed state when you eat, you cannot produce adequate acid to optimize absorption of your nutrients. Acid helps break the bonds that hold nutrients in our food. For people who do not like to take supplements, I always encourage slowing down when you sit before a meal. It sounds a little corny but saying a small prayer of thanks, taking five slow, deep breaths before a meal- these things actually help to put your body into a parasympathetic (relaxed) state. This relaxed state is the one in which we make optimal acid.
Again, we are still cave people in our physical bodies. If you are feeling threatened because a saber-toothed tiger is pacing outside your cave, and your body is on alert, then your body is shunting blood to your heart and your muscles and away from your digestive system. If your boss yells at you, your stress reaction looks the same. When we are stressed we are not getting into the parasympathetic state required to begin all the beautiful processes of digestion- salivating, making stomach acid, producing pancreatic enzymes, peristalsis (the movement of our intestines), etc. We need relaxation to optimize these processes. Is it any wonder that our absorption is somewhat compromised? We are all eating on the go, in front of our computers, between meetings and after-school activities and crammed schedules. You can optimize this process by intentionally slowing down when you are approaching your meals. A little deep breathing goes a long way.
The design of our bodies is ancient, but the way we live our lives is incredibly fast-paced. Let’s treat our bodies accordingly. If you are wondering if some of these concepts apply to you, contact your physician and get those iron levels checked!
