Women and Anemia

Women and Anemia

Anemia, a condition in which the blood is deficient in red blood cells, hemoglobin content, or total volume,1 is a major global health concern impacting both developing and developed nations. While there are numerous classifications and etiologies of anemia, the most significant contributor to the development of anemia is iron deficiency.2 Iron deficiency is the most prevalent nutritional disorder in the world and is the only nutrient deficiency that is also significantly widespread in industrialized countries.3


Women and children are impacted most by anemia, with approximately 818 million pregnant women, non-pregnant women, and young children suffering from the disease.4 Poor nutritional status, increased blood loss during menstruation, and increased blood-supply demands during pregnancy contribute to the increased prevalence of anemia in women.5

  • Anemia impacts more than 30% of the world population.3
  • The prevalence of anemia is higher in women than men.2
  • Anemia contributes to 20% of all maternal deaths.3

Types of Anemia

While there are numerous classifications of anemia in women, the most significant contributor to the development of anemia is iron deficiency.6 Iron deficiency is the most prevalent nutritional disorder in the world and is the only nutrient deficiency that is also significantly widespread in industrialized countries.7


Iron deficiency anemia is a common anemia (characterized by low red blood cell level) caused by insufficient dietary intake and absorption of iron and/or iron loss from bleeding, which can occur from a variety of sources, such as intestinal, uterine, or from the urinary tract.


  • 50% of all anemia cases are due to iron deficiency. But the proportion may vary among population groups and in different areas, depending on local conditions.8
  • A moderate degree of iron deficiency anemia affects 9% of the worldwide population and is more prevalent in women than men.8
  • World estimates of iron deficiency occurrence are somewhat vague, but the true number probably exceeds one billion people.8

Megaloblastic anemia is caused by incomplete formation of the red blood cell, resulting in large numbers of immature and incompletely developed cells. These red blood cells do not function like healthy red blood cells. They crowd out the healthy cells, causing anemia. Since these cells are underdeveloped, they also have a short life expectancy.9 Low levels of vitamin B12 or folate are the most common causes of this type of anemia.


  • Megaloblastic anemia is most common in the elderly, with 1 in 8000 being affected.10
  • This type of anemia can be seen in all races but is particularly common in Nordic people.10
  • There is an association with other autoimmune diseases, particularly thyroid disease, Addison’s disease, and vitiligo.10
  • Prevalence of this anemia in the U.S. is rather low, with fewer than 200,000 people affected.

Pernicious anemia (PA), a form of megaloblastic anemia, is a rare disorder in which the body does not absorb enough vitamin B12 from the digestive tract, resulting in an inadequate amount of red blood cells (RBCs) being produced. It is also referred to as vitamin B12-deficient anemia.



  • One in 680 people (0.15% of the population) in the U.S. have PA.
  • PA is estimated to affect 0.1% of the general population and 1.9% of those over 60, accounting for 20–50% of vitamin B12 deficiency in adults.11
  • A study of Americans over the age of 65 years found that the prevalence of low vitamin B12 detected in the blood was 15%. However, this is probably an underestimate, considering the increasing population of the elderly and the widespread use of drugs that reduce stomach acidity.
  • The adult form of PA is most prevalent among individuals of either Celtic (i.e., English, Irish, Scottish) or Scandinavian origin. In these groups, 10–20 cases per 100,000 people occur per year. Pernicious anemia is reported less commonly in people of other racial backgrounds.12
  • Although the disease was once believed to be rare in Native American people and uncommon in black people, its incidence in these groups now appears to be higher than previous estimates suggested.12
  • Adult PA usually occurs in people aged 40–70 years. Among white people, the mean age of onset is 60 years, whereas it occurs at a younger age in black people (mean age of 50 years).12
  • A female predominance has been reported in England, Scandinavia, and among persons of African descent (1.5:1). However, data in the United States show an equal sex distribution.12

Risk Factors

Two billion people—over 30% of the world’s population—are anemic, many due to iron deficiency. In resource-poor areas, anemia is frequently exacerbated by infectious diseases.14


Women and people with chronic diseases are at increased risk of anemia. Important factors to remember are:15

  • Certain forms of anemia are hereditary, and infants may be affected from the time of birth.
  • Women in the childbearing years are particularly susceptible to iron deficiency anemia because of blood loss from menstruation and increased blood-supply demands during pregnancy.
  • Older adults also may have a greater risk of developing anemia because of poor diet and other medical conditions.
  • Women whose menstrual cycles are heavy
  • Women who are pregnant or breastfeeding or those who have recently given birth
  • People who have undergone major surgery or physical trauma
  • People with gastrointestinal diseases, such as celiac disease, inflammatory bowel diseases such as ulcerative colitis, or Crohn’s disease
  • People with peptic ulcer disease
  • People who have undergone bariatric procedures, especially gastric bypass operations
  • Vegetarians, vegans, and other people whose diets do not include iron-rich foods (iron from vegetables, even those that are iron-rich, is not absorbed as well as iron from meat, poultry, and fish)
  • Children who drink more than 16–24 ounces a day of cow’s milk (cow’s milk not only contains little iron, but it can also decrease absorption of iron, and irritate the intestinal lining causing chronic blood loss)
  • Pregnant women in third-world countries, especially suffering from malaria, hookworms, or vitamin A deficiency
  • Women aged 50 and over who suffer from GI bleeding, duodenal or gastric ulcers, or GI cancer

Megaloblastic anemia is usually caused by a deficiency of folic acid or vitamin B12. Other less-common causes are:

  • Alcohol abuse
  • Certain inherited disorders
  • Drugs that affect DNA, such as chemotherapy drugs
  • Leukemia
  • Myelodysplastic syndrome
  • Myelofibrosis
  • The anticonvulsant drug phenytoin (Dilantin)

Pernicious anemia is more common in people of Northern European and African descent than in other ethnic groups. Older people also are at higher risk for the condition. This is mainly due to a lack of stomach acid and intrinsic factor, which prevents the small intestine from absorbing vitamin B12. As people grow older, they tend to make less stomach acid.


Pernicious anemia also can occur in younger people and other populations. People at risk for pernicious anemia include those who:

  • Have a family history of the condition
  • Have had part or all of the stomach surgically removed. The stomach makes intrinsic factor. This protein helps the body absorb vitamin B12.
  • Have an autoimmune disorder that involves the endocrine glands, such as Addison's disease, type 1 diabetes, Graves' disease, or vitiligo. Research suggests a link may exist between these autoimmune disorders and pernicious anemia that is caused by an autoimmune response.
  • Have had part or all of the small intestine surgically removed. The small intestine is where vitamin B12 is absorbed.
  • Have certain intestinal diseases or other disorders that may prevent the body from properly absorbing vitamin B12. Examples include Crohn's disease, intestinal infections, and HIV.
  • Take medicines that prevent the body from properly absorbing vitamin B12. Examples of such medicines include antibiotics and certain seizure medicines.
  • Do note eat any animal or dairy products and do not take a vitamin B12 supplement, or those who eat poorly overall.


Most of the time, anemia symptoms are mild at first and develop slowly. General symptoms may include:19

  • Feeling weak or tired more often than usual, or with exercise
  • Headaches
  • Problems concentrating or thinking


As the anemia gets worse, symptoms may include:

  • Blue color to the whites of the eyes
  • Brittle nails
  • Light-headedness when you stand up
  • Pale skin color
  • Shortness of breath
  • Sore tongue

Because iron deficiency tends to develop slowly, adaptation occurs and the disease often goes unrecognized for some time, even years; patients often adapt to the systemic effects that anemia causes. In severe cases, dyspnea (trouble breathing) can occur.20


  • Other symptoms and signs of iron deficiency anemia include:20
  • Anxiety often resulting in OCD-type compulsions and obsessions
  • Irritability or a low feeling
  • Angina
  • Constipation
  • Tinnitus (ringing in the ears)
  • Mouth ulcers
  • Palpitations
  • Hair loss
  • Fainting or feeling faint
  • Depression
  • Breathlessness
  • Twitching muscles
  • Pale yellow skin
  • Tingling, numbness, or burning sensations
  • Missed menstrual cycle
  • Glossitis (inflammation or infection of the tongue)
  • Koilonychia (spoon-shaped nails) or nails that are weak or brittle
  • Poor appetite
  • Pruritus (itchiness)

Symptoms of megaloblastic anemia can vary among individuals, but common symptoms include:21

  • Fatigue
  • Muscle weakness
  • Loss of appetite/weight loss
  • Diarrhea
  • Nausea
  • Fast heartbeat
  • Smooth or tender tongue
  • Tingling in hands and feet
  • Numbness in extremities

PA presents insidiously, and many of the signs and symptoms are due to anemia itself, where anemia is present. Untreated pernicious anemia can lead to neurological complications, and in serious cases, death. Common symptoms include:22

  • Fatigue
  • Depression
  • Low-grade fever
  • Nausea
  • Gastrointestinal symptoms
  • Weight loss
  • Neuropathic pain
  • Jaundice
  • Glossitis (inflammation or infection of the tongue)
  • Brittle nails
  • Thinning and early graying of the hair


Because PA may affect the nervous system, symptoms may also include:22

  • Difficulty with movement and orientation
  • Memory changes
  • Mild cognitive impairment
  • Impaired urination
  • Loss of sensation in the feet
  • Muscle weakness


Reducing the burden of anemic disorders in women includes:

  • Understanding risk factors
  • Making rapid, accurate diagnoses when symptoms occur
  • Implementing appropriate therapies
  • Monitoring treatment


Since anemia is usually found during routine blood tests, laboratory diagnostic testing plays an integral role in caring for women throughout the continuum of anemia treatment.


Throughout a woman’s lifetime, there are a number of conditions and diseases that affect her differently, or to a greater extent, than men. Many of these conditions and diseases are interconnected, where the onset of one leads to a greater risk of developing another. With an enhanced understanding and focus on the unique healthcare needs of women, healthcare providers across the continuum of care can be better equipped to prevent, detect, and treat the most threatening diseases affecting their female patients throughout all stages of their lives.


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RBC Folate






Soluble Transferrin Receptor (sTfR)






Total Iron-binding Capacity (TIBC)





Vitamin B12