At the American Infusion Center’s location on lower Broadway in Manhattan, La-Z-Boy recliners with laptop tables are positioned in front of windows overlooking the Hudson River. The majority of people sitting in those seats—click-clacking away on their computers with an IV dangling from one arm—are women, including me. And many, including me, are there to get an iron infusion—a treatment that, despite being well-informed about my health, I hadn’t even heard of until I was in dire need of it at 47.

My iron levels weren’t ever mentioned at doctor’s visits until I was pregnant with my daughter at 39. With another human growing inside me, the need for adequate nutrients had new urgency. Those levels were steady for the duration of my pregnancy, but after a whirlwind four years—living through a challenging postpartum period, perimenopause, and a global shutdown—they took a nosedive.

But the drop wasn’t something my doctors picked up on easily. It took a year of relentless symptoms (fatigue, hair-shedding, brain fog, restless legs, anxiety), monthly periods reminiscent of crime scenes, and two myomectomy surgeries (to remove clusters of uterine fibroids) before I was deemed anemic. Iron deficiency is the most common cause of anemia, a condition that occurs when your body doesn’t have enough healthy red blood cells. You can be iron deficient (meaning you have low stored iron, or ferritin) but not necessarily anemic, although untreated iron deficiency often leads to anemia.

Though my iron deficiency went largely unrecognized for a time, I’m certainly not alone in this journey, which—like so many diagnoses in women’s health—often follows a long and winding path. A 2024 report from JAMA Open Network found that 34% of women between the ages of 18 and 50 are iron deficient. Post-menopause it becomes less common, as women stop bleeding regularly, so there’s less iron loss; that’s also why iron deficiency is less common in men.

The reason so many women find themselves dealing with anemia, particularly in their 40s (I was 45 when I was diagnosed), is not so straightforward—which is why it comes as no surprise that many are searching for answers and sharing symptoms on TikTok. Ahead, we sort through the signs of iron deficiency, including fatigue, shortness of breath, dark circles, cracking skin, and what social media is calling “ferritin face.”

What do we need iron for anyway?

Iron is a building block for hemoglobin, a protein in your blood that is required for the production of the red blood cells that deliver oxygen throughout our bodies. It sounds vital because it is. It’s key for optimal skeletal and cardiac muscle function, for hair growth, and for making neurotransmitters in our brain (including the dopamine and serotonin that have such a profound effect on our moods), says Imo J. Akpan, MD, a hematologist at New York Presbyterian.

“[Iron] also plays a quieter but important role in supporting regular ovulation and a healthy uterine lining, both of which matter when someone is trying to conceive,” says Lora Shahine, MD, a reproductive endocrinologist and ob-gyn at Ivy Fertility in Seattle.

And iron is foundational to how our bodies produce energy. Explains Amanda Kahn, MD, an internist in New York, “When iron stores are low, women often feel it everywhere, from their energy levels to their mood to their hair.”

The face (and hair and body) of iron deficiency

Do you have heavy periods? Do you have brain fog? Do you get winded walking up stairs even when you’re in really good physical shape? These are some of the questions Jamie Rosen, a 40-something brand consultant in New York City, remembers being asked by her hematologist Rachel Kramer, MD, during her first visit. “I was like, ‘Yes, yes, yes, yes, yes,’ to everything she asked me,” says Rosen, who had a list of symptoms that she had long been brushing off.

Dr. Kramer has an office at American Infusion Center’s Upper East Side location and has worked as a hematologist for nearly 30 years. She says many of her young, female patients likely have an iron issue that they are chalking up to something else. “Lots of people are iron deficient in their 20s and 30s, and they don’t get to me until they’re in their 40s,” she explains. “They often just think they’re a tired person.”

The most common signs of iron deficiency are: fatigue, headache, shortness of breath, dizziness, chest pain, muscle cramping, pica (the compulsion to eat non-nutritional items such as ice, clay, chalk, or soap), difficulty concentrating, and depression. But this deficiency can also have more visible manifestations, such as hair loss and what the internet has dubbed “ferritin face” or “low-ferritin face.”

Macrene Alexiades, MD, a dermatologist in New York City, says that patients whose iron stores are low often have pale and sometimes dry, cracking, itchy skin. “I see it with some regularity, and when we look under the hood, we often find there’s some iron deficiency there,” says Dr. Alexiades. The washed-out pallor and undereye shadows that sometimes accompany iron deficiency have recently come to be called ferritin face.

“It’s not an established clinical term, but it reflects a real phenomenon that clinicians and patients are noticing,” says Jamie Schwartz, RD, LDN, a registered dietitian at Health Loft. And one that TikTokkers are chronicling in earnest. “I looked literally half dead,” one woman posted about the effect of her ferritin level on her face (with Mumford and Sons’ “White Blank Page” as a soundtrack). "Low iron is looking like this even after 10 hours of sleep and being asked if you're ok 24/7," wrote another, who chronicles her iron struggles online.

While skin pallor and dark circles can be a clue, they are not specific enough on their own to suggest iron deficiency, says Marisa Garshick, MD, a dermatologist based in New York and New Jersey. “Skin pallor is often only noticeable in individuals with lighter skin tones and is not always obvious or easy to detect, while dark circles can occur for many reasons, including genetics,” she points out. That said, “it’s changes in hair and nails that will most commonly prompt an iron work-up in my practice.”

Meanwhile, the connection between hair shedding and ferritin is well documented, with studies associating low ferritin levels with telogen effluvium, a form of temporary hair loss.

The testing (or lack of testing) is part of the problem

Screening for iron levels is not part of a standard checkup. Women are routinely screened only when they’re pregnant, and even then, testing is typically limited to how much iron we have moving in our blood (our serum iron level) and not how much ferritin our bodies are producing. Serum iron levels can go up or down in response to your diet, supplement regimen, or menstrual cycle, and they change quite significantly throughout the day. Ferritin, on the other hand, says Dr. Akpan, refers to our iron reserves and isn’t affected by your diet or periods, and isn’t likely to fluctuate from one day to the next. It’s a much more reliable marker of iron deficiency.

Dr. Akpan describes ferritin as our “iron savings account.” If you’re nearing overdraft, the low balance can have a ripple effect on your body—even if your serum iron level is within normal range. This is why it’s not uncommon for a woman who is noticing hair loss and feels exhausted to still be told by her doctor that her labs are “normal.” Few doctors will do a full iron panel, which includes serum iron and ferritin, as part of a routine visit, so patients often have to request it.

What is considered normal ferritin, though, can be subjective. (Like I said: long and winding.) “We do not have an agreed-upon threshold for diagnosing iron deficiency in women,” says Dr. Akpan. “The World Health Organization recommends using a ferritin cutoff of <15 ng/ml to diagnose iron deficiency in women, but several other medical societies suggest that this is too low and should be <30 ng/ml.” A 2025 Lancet Hematology Review proposed that any ferritin levels under 50 ng/ml should prompt a closer look, and Dr. Kahn, who works closely with a hematologist in her practice, often targets a ferritin level closer to 100 ng/ml.

A diagnosis may be further complicated because low iron can masquerade as something else or overlap with other issues. If a patient is not anemic—something measured by the hemoglobin test that is part of a routine checkup—doctors may not screen for iron deficiency at all. “A patient with fatigue who has a normal level of hemoglobin is more likely to have a thyroid test than an iron test,” says Dr. Akpan, “or someone who is depressed may be started on antidepressants but not have their iron levels checked.”

While the importance of iron is emphasized during pregnancy and postpartum, it is crucial across the entire reproductive lifespan, particularly in perimenopause, when menstrual cycles can become heavy and unpredictable. Uterine fibroids, adenomyosis, and conditions that cause heavy menstrual bleeding are, says Dr. Shahine, a major and underappreciated cause of iron deficiency in women.

“Paradoxically, the years leading up to menopause can be when iron deficiency is most likely, even though we tend to associate it with younger reproductive years,” says Dr. Shahine. “The fatigue and brain fog of this transition are sometimes attributed entirely to shifting estrogen when low iron may also be part of the picture.”

Women also tend to simply shrug off or accept some symptoms. If you’re working full-time and parenting and caring for aging parents while also trying to find time to shower every day, you might not think to question the fact that you feel exhausted. The number of post-menopausal women suffering from iron deficiency is lower, but the prevalence is not zero, says Dr. Akpan, and deficiency can still occur during this period due to gastrointestinal conditions or malabsorption.

How to close the iron gap

Once you’ve determined that you are, in fact, low in ferritin, your doctor will likely tell you to first look at your diet. But gastrointestinal absorption is a perpetual problem with iron, whether you’re trying to get enough through food or with the help of supplements. There are also a number of conditions that can further impact the body’s ability to absorb iron, like celiac disease, gut inflammation, and reduced stomach acid (common in anyone who uses proton pump inhibitors for acid reflux). Your genetics can also play a role in how you absorb iron, and research has shown that Hispanic and Black women are more prone to iron deficiency. Says Dr. Kahn, “Some women aren’t losing iron, they simply aren’t absorbing it well.”

The truth is that most women do not get nearly enough dietary iron. The recommended daily allowance for girls and women aged 9-50 is 18 mg; that number drops to 8 mg after menopause. To be clear, that can’t be 18 mg in one meal. For example, that steak you had for dinner is absorbed at only 25-30% (a lean cut will yield about 2.5 mg of iron), and that big spinach salad at only 2-10%. “More iron on the plate doesn’t mean more iron absorbed,” says Schwartz, who explains that the body has a ceiling on how much it can absorb at one time, regulated by hepcidin, a peptide hormone produced in the liver. “And how much you absorb shifts based on your current iron stores, inflammation levels, and the form of iron consumed.”

You also need to consider the type of iron-rich food you’re consuming: Heme iron is dietary iron found in foods of animal origin and is proven to be better absorbed; while non-heme iron is found in foods of plant origin and is less efficiently absorbed.

Pairing those iron-rich plant sources—like spinach, swiss chard, and broccoli—with vitamin C is helpful. One quick and easy hack is to squeeze lemon on them before consuming. Says Schwartz, “Eating iron-rich foods like lean red meat, liver, lentils, chickpeas, pumpkin seeds, and dark, leafy greens alongside vitamin C is foundational as it significantly boosts the absorption of non-heme iron.” She explains further that, though vitamin C will add to the iron you can absorb during the day, it won't raise the maximum amount your body can take in: “It's more a tool that helps you get closer to whatever your personal ceiling happens to be that day.”

Plant-based eaters need to be extra mindful about their iron. “A woman relying solely on plant sources would need to eat considerably more volume [almost twice as much] and variety to hit the same absorbed amount,” says Schwartz, adding that the body absorbs iron more efficiently from multiple smaller exposures than from one large intake. “Eating twice as much [of one protein source] doesn't give you twice as much absorbed iron—it gives you diminishing returns.”

When your dietary intake doesn’t match your iron needs, which is the case for many women, that’s when supplements should be considered. “Ferrous sulfate is the classic affordable option, but it’s notorious for causing constipation and nausea, which is why so many people quit,” says Schwartz, adding that one study reports that up to 40% of people stopped over a three-year period. She recommends other types of supplements, like iron bisglycinate or liposomal iron, which are better tolerated.

Wendi LeBrett, MD, a Los Angeles-based gastroenterologist, says that pairing your iron supplement with vitamin C improves uptake, and emerging evidence suggests that taking iron supplements every other day, versus daily, helps absorption and curbs GI side effects. You may also need to be mindful about supplement stacking. Because you know those calcium supplements your doctor said you need for your middle-aged bones? Well, they're inhibiting the absorption of dietary iron and supplements, says Dr. LeBrett. So are coffee, tea, and chocolate. She recommends consuming any of these things two to three hours apart from your chosen iron.

Did you get all that? Right, it’s a lot to consider. And that’s why some women—like me—have started getting IV iron, or iron infusions. (At the end of the story, we’ll tell you how to find a reputable clinic.) These infusions go directly into the bloodstream, which can help with absorption by bypassing the GI tract and bolster your iron levels more quickly, says Dr. Kahn. Common side effects of iron infusions include nausea, dizziness, and headaches. Rarer side effects could include anaphylaxis.

When I went in for my first infusion, my ferritin level was 13; three treatments later, it had increased fivefold. This was after years of taking oral iron supplements without much discernible change. Many hematologists believe infusions, which are most commonly offered in a hospital or outpatient-clinic setting, are still thought of as a last resort. “IV iron supplementation is still underused,” says Dr. Akpan, adding that many patients simply don’t try or can’t handle other supplementation. Adds Dr. Kramer, “You shouldn’t wait until your ferritin is [low] and your hair is falling out all over the place and you feel terrible.”

Dr. Akpan usually sees an improvement in her patients’ iron levels with one to three infusions, then will continue to recheck levels every four to six weeks to assess their iron stores. Says Dr. Garshick, depending on the degree of deficiency, many people begin to notice improvements within a few weeks of treatments, including improvements in their skin; hair recovery can take longer, she adds, often three to six months to see meaningful changes.

And, importantly, Dr. LeBrett cautions that taking any iron supplements without properly investigating the root issue can itself be an issue. “People shouldn’t ignore a problem just because it’s corrected with supplementation,” she says, noting that iron deficiency can be a side effect of celiac and inflammatory bowel disease. In fact, overdoing it on iron can be another issue entirely and lead to inflammatory conditions.

More women are experiencing iron deficiency in midlife

“Whenever I would go to the infusion center in Long Island for my weekly iron IVs, I was always running into mom friends,” says Jennifer Conlon Pavelchak, a New York City-based publicist in her 40s. She was prescribed a five-dose course of iron infusions spaced a few weeks apart after hair loss, brain fog, and joint injuries prompted her doctors to test her ferritin (her level was 26). “I would say 80% of the people getting iron infusions with me every visit were women.”

Dr. Akpan and Dr. Kramer both report that more women in midlife are coming to their offices with iron issues than they were a decade ago. Parsley Health—a membership-based, functional health practice—has found the same to be true. Robin Berzin, MD, the company’s founder, has some ideas why: “We’re seeing more midlife women eating plant-forward diets and more of them on GLP-1 medications, both of which can decrease iron intake. GLP-1 medications reduce appetite and overall food volume. They can dampen the appetite for red meat, specifically, which is the most absorbable iron source, and cause slow gastric emptying, which may affect absorption.” If you do the math, eating less simply means less opportunity to reach the recommended daily iron intake.

But Dr. Kahn thinks the reason we are seeing more women with dipping iron levels goes beyond diet and exercise trends: “Part of it is increased awareness, but there’s also an intersection of multiple factors like perimenopausal bleeding changes, chronic inflammation, gut dysfunction, and women pushing themselves harder than ever professionally and personally.”

It’s that last point that really hits home. This innate need to constantly power through pain and exhaustion feels like the girl-bossification of health. The correlation between hard work and low iron may not be causal, but someone who is under chronic stress may eat poorly, skip meals, or form habits that contribute to poor iron absorption because of poor diet. “Women just feel like they should keep pushing,” says Dr. Kramer—and more awareness about iron being a possible culprit for many common symptoms is prompting us to take the reins and look into it.

Within a few weeks after Pavelchak’s course of five iron infusions, her hair stopped snapping off and grew back thicker; she no longer experiences daily mid-afternoon energy crashes; and her ability to heal following a series of knee injuries improved dramatically (she’s even running again). Now she gets her ferritin checked every three months to make sure it remains steady.

Rosen, who was switched to IV infusions after many months of supplementing, made no discernible difference, had an initial course of four spaced over six weeks; she still gets one every few months, along with regular lab work. She has noticed a marked change in her energy level and brain fog.

My own iron journey has been more of a marathon than a sprint: I’ve adopted an iron-rich diet, with plenty of tofu, eggs, red meat, sardines, and leafy greens; and been supplementing (I’m taking Pure Encapsulations Iron-C, which pairs iron glycinate with vitamin C for optimal absorption) and infusing (once a month) since January. I’m almost at the number where my doctor thinks I should feel my best (last ferritin count: 74!). My hair has stopped shedding excessively, my restless legs have chilled out, and my energy holds fairly steady on the days when I get enough sleep (an entirely different struggle). According to my mother, I also have “my color” back. I consider that progress.

FAQs

What is iron deficiency? How does it differ from anemia?

Iron deficiency occurs when your total iron stores or reserves are depleted. Anemia occurs when you don’t have enough healthy red blood cells to deliver oxygen throughout the body. You can be iron deficient but not anemic.

What are the most common symptoms?

Some of the most common symptoms are what doctors would call nonspecific and can include fatigue, shortness of breath, pale skin, dizziness, brain fog, muscle cramping, pica (eating non-nutritional items such as ice, clay, chalk, soap), and depression.

What is ferritin?

Ferritin is the storage form of iron, or what doctors think of as your “reserves.” Those so-called reserves are what the body dips into in order to make more red blood cells when needed.

What tests should you ask your doctor for?

A full iron panel measures your serum iron level (the amount in your blood right now), ferritin (your iron reserves, or stores), and often your TIBIC (your total iron-binding capacity, or how much iron your blood can carry).

What should you look for in a supplement?

Iron bisglycinate is considered to be the most tolerated and best absorbed form of oral iron supplementation. Studies confirm that it has a gentler side-effect profile than the more widely available ferrous sulfate form.

How do you find a reputable infusion center?

IV iron infusions should only be used after a referral from a doctor. They are often administered in a hospital or outpatient-clinic setting. Says Dr. Akpan, “My recommendation is to research physicians and advanced-practice providers who have clear expertise in the management of iron deficiency and have demonstrated that they usually manage patients in need of an iron infusion.”

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