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Anemia in Perimenopause

by | Jul 10, 2024 | Perimenopause

What are the symptoms of anemia in perimenopause?

Anemia in perimenopause can commonly present as fatigue, weakness, headaches, anxiety, difficulty concentrating, brain fog, and light-headedness. Other symptoms include increased heart rate, shortness of breath, restless leg syndrome, beeturia (red urine after eating beets), or getting sick regularly.

What is perimenopause?

Perimenopause is the transition time leading up to the last menstrual period. This transition can last between 2-12 years, with an average of 7 years. This time can begin in the mid-30s or as late as the early 50s. Most women begin the perimenopause time in their early-mid 40s. Perimenopause ends 12 months after the last menstrual period.

What are perimenopause symptoms?

There are 100s of symptoms associated with the complex hormonal changes of perimenopause. These are unrelated to the mere fact of “aging,” as they occur at different times for different women, but are all characterized by the unique hormonal shifts associated with this transition.

The most common symptoms of perimenopause include new onset heavy bleeding or scanty bleeding, irregular cycles, anxiety, insomnia, fatigue, hot flashes, night sweats, and vaginal dryness. Other common symptoms include bloating, digestive issues, brain fog, memory issues, heart palpitations, dizziness, dry skin, and increased urinary frequency.

25% of women have severe symptoms. Many women have mild symptoms, however, they are still in a critical window for long-term health factors like thyroid disease, heart disease, insulin resistance, and neurological conditions

What causes perimenopausal symptoms?

In perimenopause, the brain is recalibrating to new levels of hormones. Estrogen and progesterone influence other hormones like thyroid, insulin, and cortisol, as well as neurotransmitters like serotonin and dopamine.

Due to the gradually decreasing progesterone levels, women may experience worsening of [remenstrual syndrome symptoms such as insomnia, anxiety, crying easily, fatigue, headaches, and depression.

During perimenopause, women experience estrogen levels up to three times higher than ever before but also times of lower estrogen than ever before.  These wildly fluctuating estrogen levels may cause symptoms such as irritability, breast tenderness, insomnia, heavy periods, and hot flashes.

Eventually, a new normal baseline level of lower estrogen is established in menopause, which is essential for lifelong brain, bone, and cardiovascular health.

It’s interesting to note that women in various cultures have greatly differing experiences of the perimenopause transition.  For example,  some cultures report no associated symptoms other than the gradual cessation of periods. In some cultures, where elders are revered, menopause is seen as a lifting of the “veil of hormones.” In these cultures, menopause is a liberating and new phase of life and women are seen as sources of wisdom in their community. Many women report a newfound “zest” and energy for life during menopause.

What are the 4 phases of perimenopause?

The very early stage of perimenopause is characterized by slowly decreasing progesterone levels. Signs of this phase are worsening PMS symptoms like crying easily, fatigue, headaches, depression, insomnia, and anxiety. In this stage, cycles may still be regular but with fluctuating levels of hormones.  Heavier menstrual bleeding during this time can result in anemia in perimenopause.

Early perimenopause begins with the onset of irregular periods (greater than 7-day variation in the overall cycle length). This phase lasts approximately 2-5 years.

The late transition of perimenopause is characterized by the first cycle of greater than 60 days. For example, women often refer to this as a “skipped period.” This stage lasts approximately three years.

Late perimenopause is the 12-month time frame following the final period. If you go six months without a period, then have another period, the 12-month count would restart.

Menopause is the life phase beginning 1 year after the last period.

How to tell if I’m in perimenopause if I’ve had a hysterectomy?

If a woman had a partial hysterectomy (removal of the uterus) but retained ovaries, she would still go through the phases of natural perimenopause. This means she will experience years of hidden cycling, but with no bleeding to signal what’s going on. This may be confusing, however, with the use of the Creighton Model FertilityCare™ System, a woman can still monitor her cervical mucus changes to aid in understanding where she is in her cycle. This knowledge can be very beneficial for using cooperative bio-identical progesterone supplementation.

Is anemia in perimenopause common?

Up to 50% of women experience anemia in perimenopause often due to iron deficiency. Abnormal bleeding accounts for about 65% of gynecological office visits during perimenopause.

What causes anemia in perimenopausal women?

There are many possible underlying causes of anemia in perimenopause. The most common cause is iron deficiency but vitamin B12 and folate deficiency is also common. Interestingly, iron deficiency can be both a cause and effect of heavy menstrual bleeding.

Factors that should be evaluated for include hormone imbalance, gynecological problems (including fibroids, cervical cancer, endometrial cancer), hypothyroidism, gastrointestinal issues (such as stomach ulcers), insulin resistance, dietary deficiencies, and nutrient malabsorption (low stomach acid is a common cause).

Many medications can also cause low iron. These include antacids, blood pressure medications, NSAIDs like ibuprofen, and acetaminophen (like Tylenol).

What labs should I have done to tell if I’m anemic?

Any women experiencing signs of anemia or of abnormal bleeding (including heavy bleeding – changing a pad or tampon more than every two hours; periods lasting longer than 7 days; or new onset premenstrual spotting lasting more than 3 days), should first have a blood testing done to evaluate for hormonal causes.  Basic bloodwork should include complete blood count, serum iron, and ferritin. Thyroid, prolactin, and insulin testing would also be warranted to evaluate if these factors are involved in the heavy bleeding. A pregnancy test is appropriate to rule out pregnancy. If a woman is charting with the Creighton Model FertilityCare™ system, she would be able to have progesterone and estrogen lab tests done at the appropriate time in her cycle.

If hormonal causes have been evaluated/treated, but a woman is still experiencing abnormal or heavy bleeding, she should have a pelvic exam to rule out vaginal or cervical causes and uterine fibroids. If the pelvic exam finds a uterine mass, a transvaginal ultrasound should be done to rule out endometrial polyps, endometrial hyperplasia cancer, and fibroids.

Should women take iron supplements in perimenopause?

If a woman is very low in iron, supplementation may be necessary. Iron is best absorbed when taken every other day. The maximum supplementation dose is 80mg/day. It is best to take iron supplements under the guidance of a physician, as taking more than you need is dangerous. Iron levels, just like everything else in the body, need to be at an optimal level (not too high, not too low). While excessive amounts of some water-soluble nutrients can be excreted as urine by the body if levels are too high, excessive iron supplementation is stored in the body and can build up, causing harmful side effects.

The preferred form of iron supplementation is iron bisglycinate, which is most readily absorbed by the body and least likely to cause side effects. Side effects of other types of iron, like ferrous sulfate, include abdominal pain and constipation.

Liquid iron forms can be very helpful as they are most easily absorbed. Floradix is a great, natural, plant-based liquid form of iron that includes fruit-based forms of vitamin C that improve iron absorption.

Iron Tonic by Vitanica is a tincture using botanical medicines (like nettle and yellow dock) that are both naturally rich in iron and aid in iron absorption. This would be an excellent addition to have before eating your iron-rich meals.

Check out Dr. Whelan’s Fullscript Medicinal for these supplement options.

How to improve iron levels in perimenopause? What foods are high in iron?

The best way to improve iron is to emphasize iron-rich foods, including red meat (beef, lamb, venison), pork, organ meats (like beef liver), egg yolks, dark molasses, dark leafy vegetables (like spinach, kale, swiss chard, collards), dried dark fruit (raisins), and nettle tea.

Improving stomach acid helps to absorb iron. Both vitamin C-rich foods and vinegar can improve stomach acid. So eating iron-rich foods alongside vinegar dressings, citrus fruits, or high-vitamin C veggies (like broccoli, cabbage, bell peppers, tomatoes) is ideal.

What foods to avoid if you are anemic?

Calcium competes for iron absorption. So plan to eat iron-rich foods at a different time than calcium-rich foods like dairy products, or even antacid medications.

Tannins also block iron absorption. It’s best to avoid/limit black tea and coffee if you are very iron-deficient.

Take away:

Up to 50% of women experience iron-deficiency anemia in perimenopause. Iron deficiency can be both a cause and effect of heavy menstrual bleeding. It is important to have other causes evaluated – such as fibroids, thyroid issues, insulin resistance, gastrointestinal bleeds, and endometrial cancer.

Iron deficiency can mimic other symptoms of perimenopause, including anxiety, insomnia, fatigue, and heart palpitations.

Food supplementation is ideal by emphasizing red meat, dark leafy greens, and egg yolks. Vitamin C, vinegar, bitters, and having adequate stomach acid ensure optimal iron absorption. Avoid eating dairy products or using antacids alongside iron-rich foods, as this can block iron absorption.

Some women require iron supplementation but this should be done under the guidance of a doctor to ensure safe levels. The best forms of iron supplementation are iron bis-glycinate, plant-based liquid formulas, and formulations containing iron-rich herbs such as nettle.

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The practice of Dr Jessica Whelan offers in-person visits in northeast Vermont, conveniently located near St Albans, Colchester, Georgia, Fairfax, Fairfield, Burlington, Essex, Williston, Montgomery, Enosburg, Sheldon, Berkshire, Underhill, Jericho, Jeffersonville, Cambridge, Shelburne, Milton, Swanton, Highgate, Richford, Stowe, Waterbury, and more.   Virtual visits via telehealth are also available.

About Dr. Jessica Whelan

Dr. Whelan is a highly regarded licensed naturopathic doctor (N.D.) based in Vermont. She is renowned for her expertise in treating women’s reproductive hormone disorders. Her practice specializes in lifestyle medicine, nutritional counseling, botanical medicine, and bioidentical hormone replacement therapy, taking a holistic approach to optimize hormonal health and fertility.

Dr. Whelan’s main focus addresses hormone imbalances related to conditions such as PCOS, Hashimoto’s, heavy menstrual bleeding, PMS, perimenopause symptoms – (including insomnia, brain fog, fatigue, anxiety, depression, digestive issues), insulin resistance, adrenal dysfunction, fertility issues, irregular menstrual cycles, endometriosis.

She earned her Doctor of Naturopathic Medicine (ND) degree from the National University of Natural Medicine. She completed her undergraduate studies at Salisbury University Maryland.

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