For Healthcare Professionals: Tired All The Time: The Impact Of Heavy Periods And Low Iron On Perimenopausal Women

Introduction

Heavy menstrual bleeding during the menopause transition is a leading cause of low iron in women across the developed and developing world.¹

According to the World Health Organisation (WHO), almost 30% of women of reproductive age – equivalent to over half a billion women aged 15-49 years – are anaemic.² The goal of this white paper is to highlight common symptoms linked with low iron levels, the impact it has on women’s health and wellbeing, particularly during perimenopause, and recommendations for minimising the associated health outcomes.

Iron deficiency has a variety of consequences and can cause:

• Tiredness, chronic fatigue and lack of energy
• Dizziness
• Difficulty concentrating
• Being prone to illness. ³

A 2024 survey by Active Iron demonstrates the physical, emotional and societal impact of heavy periods and resulting low iron, with 74% of the 1500 women surveyed reporting exhaustion or tiredness.⁴ Low iron puts all organ systems under stress as they work harder to respond and make up for the deficit. The effects of low iron on quality of life during the menopause transition and beyond are increasingly apparent. In current clinical care, more recognition of these features is needed so healthcare providers and patients can be informed and motivated to act on iron levels as early as possible.

Promoting optimal levels of iron in women has far reaching benefits for health, day to day performance and overall wellbeing.

Background

Menopause is a retrospective diagnosis. Natural (non-surgical and non-chemical) menopause is defined as no menstrual bleeding for one full year. This occurs when ovaries have no remaining follicles and a woman’s primary source of oestrogen production is gone.⁵

Perimenopause includes both the transition to menopause and the first year following a woman’s final menstrual period. The menopause transition is a time of hormonal fluctuations that can result in irregular menstrual periods and a myriad of physiological and psychological symptoms. The average age of menopause in the UK and Ireland is 51 years old, though this can be 4-6 years earlier in some ethnicities.⁶

The length of time from the transition to the final menstrual period varies greatly, sometimes lasting over 10 years.

Menopause is not something that only affects older women, we need to be mindful of early menopause (which affects women under the age of 45) and POI too (Primary Ovarian Insufficiency, where a woman’s ovaries stop working normally under the age of 40). No matter when it occurs, it’s often at a time when women are juggling demanding jobs, school age children and elderly parents.

Every woman experiences the menopause transition differently, with up to 80% of women undergoing physical and/or emotional symptoms. These symptoms vary greatly and include hot flushes and sweats, tiredness and sleep disturbance, joint and muscle aches, heart palpitations, mood swings, anxiety and depression, forgetfulness, lack of concentration, genitourinary conditions, dyspareunia, low libido and increased urinary frequency or urgency.⁷

Symptoms can have a significant impact on health and wellbeing, personal and social relationships, as well as work and careers. According to Active Iron’s survey, 64% of women reported changes in mood as the most common symptom of perimenopause, with tiredness and fatigue being the second most common (63%). In addition, 44% of women find their methods to manage fatigue ineffective, with 80% reporting feeling tired all the time.⁴

There are a number of ways that hormonal changes during perimenopause can influence iron regulation:

Menorrhagia

Menorrhagia or heavy periods is a common side effect of fluctuating levels of hormones - often due to unopposed oestrogen building up in the uterine lining - and frequently coexists alongside anovulatory cycles and irregular menstrual bleeding. Prolonged or heavy bleeding (flooding) can lead to iron loss, potentially resulting in low iron over time.⁸

Decreased iron absorption

Oestrogen plays a role in promoting the absorption of iron in the intestines. As oestrogen levels decline during perimenopause, the body may become less efficient at absorbing iron from the diet.⁹

This can lead to reduced iron levels in the body, increasing the risk of iron deficiency.

Reduced iron storage

Oestrogen influences the production of ferritin, which stores iron in tissues. Declining oestrogen levels can lower ferritin levels, reducing the body’s iron reserves.⁹ This in addition to insufficient dietary intake of iron to compensate, can contribute to reduced overall iron levels.

Reduced thyroid function

Thyroid hormones are essential for regulating iron utilisation. If thyroid function is disrupted during perimenopause, it can affect the body’s ability to metabolise and absorb iron efficiently, potentially leading to iron deficiency.¹⁰

CONSEQUENCES OF LOW IRON

Along with low energy and fatigue, the consequences of low iron levels can extend to dizziness, difficulty concentrating and an increased risk of reduced immune function.³

It’s not hard to see how these symptoms might impact a women’s quality of life, making daily activities such as work, relationships and exercise increasingly difficult. Iron deficiency may also exacerbate a number of perimenopause symptoms, including fatigue and cognitive changes. An added complication to identifying iron deficiency during perimenopause is that symptoms often overlap those attributed to hormonal changes.

PROPOSED SOLUTION

Talking with a healthcare provider is a likely first step in managing low iron caused by heavy periods, however, a societal aversion to discussing menstruation means many women report not feeling comfortable doing so. 48% of women surveyed said they’d rather talk to friends and family than a medical professional, and 1 in 4 had never sought support or advice for the symptoms of their heavy periods.⁴

For those who do take action, supplementation is a key consideration. However, traditional iron supplements have their challenges and are often shunned or short-lived due to the long list of side effects, such as nausea, constipation and gastro intestinal discomfort. This may cause people to be poorly compliant with the treatment, thus reducing the likelihood of improving iron stores.

There have been some alternative formulations developed in recent years that aim to increase iron levels without the negative side effects often associated with oral iron. One such solution is Active Iron, as it is clinically proven to increase iron levels by 94% while avoiding troublesome side effects such as nausea and constipation.¹¹

Active Iron is also clinically proven to increase energy levels and can be used as a tool to support menstrual fatigue.¹¹ The clinical studies completed by Active Iron target women with an unmet need for iron; the latest study was carried out in women of childbearing age with periods (including perimenopausal women).¹¹

Conclusion

Iron deficiency anaemia is a common clinical presentation with a prevalence in women, but often goes undetected. There is a strong association between heavy periods and low iron in perimenopausal women. Unfortunately, there doesn’t seem to be enough awareness that iron deficiency can be a problem in women in this demographic, as symptoms can be non specific in nature and often overlap or mimic those of perimenopause itself. Greater awareness of heavy menstrual bleeding and its relationship with low iron is needed in this population, as well as tighter diagnostic and management guidelines. Supplementation with products carefully formulated to support the needs of women, such as Active Iron, can be a valuable tool in helping to avoid low iron in women with periods in this lifestage. Active Iron is clinically proven to be effective in increasing iron and energy levels with minimal gastrointestinal side effects¹¹, allowing women a better quality of life, workplace performance, and physical, social and cognitive function.

References

1. Palacios S. The management of iron deficiency in menometrorrhagia. Gynecol Endocrinol. 2011; 27(Suppl 1): 1126-1130.
2. https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_ children
3. NHS: Iron deficiency anaemia https://www.nhs.uk/conditions/iron-deficiencyanaemia/
4. Active Iron Survey 2024. n =1500 women. Data on File.
5. BRITISH MENOPAUSE SOCIETY Tool for clinicians. https://thebms.org. uk/wp-content/uploads/2023/08/17-BMS-TfC-What-is-the-menopauseAUGUST2023-A.pdf
6. https://www.swanstudy.org/ NHS inform: Signs and symptoms of menopause.
7. https://www.nhsinform. scot/healthy-living/womens-health/later-years-around-50-years-and-over/ menopause-and-post-menopause-health/signs-and-symptoms-of-menopause/
8. Petraglia et al. Iron deficiency anemia: Impact on women’s reproductive health. Fertil Steril. 2022; DOI: 10.1016/j.fertnstert.2022.08.850
9. Qian et al. Estrogen contributes to regulating iron metabolism through governing ferroportin signaling via an estrogen response element. Cell Signal. 2015; DOI: 10.1016/j.cellsig.2015.01.017
10. Garofalo et al. Relationship between Iron Deficiency and Thyroid Function: A Systematic Review and Meta-Analysis. Nutrients. 2023; DOI: 10.3390/ nu15224790
11. Ledwidge. et al. PRECISION Study. Int J Clin Pharm. 2023; https://doi. org/10.1007/s11096-023-01640-7