Oh, there are so many things women navigating perimenopause have to complain about.
Night sweats that wake us from a perfectly good sleep.
Those What did I come into this room for? moments.
Changes in our bodies that seem to happen overnight.
But the one thing I suspect many of us have in common? Being so dang tired!
And fatigue is tricky. How are we supposed to know whether we’re tired because of changing hormones, disrupted sleep, stress, or simply because we’re women in midlife trying to do about 47 things in a single day?
Even when we’ve gotten wiser about rest, setting boundaries, and taking care of ourselves, life doesn’t necessarily become less demanding.
For me, fatigue tends to show up around two or three in the afternoon. Even after a decent night’s sleep, I can reach a point where I genuinely feel like I could lie down on the floor and fall asleep. And sometimes, if life allows, I do.
I’ve wondered whether this degree of fatigue is something I should simply accept as part of midlife.
The truth is, there is no one simple explanation for perimenopausal fatigue. But there is one potential contributor, and that is what I’m focusing on today… iron levels.
Of course, not all perimenopausal fatigue is related to low iron. But for women who are still menstruating, particularly those experiencing heavier periods or who exercise regularly, iron deficiency is one possibility worth investigating.
Over the past few years, I’ve been paying closer attention to my own iron levels, and they tend to run on the lower side, despite my efforts to improve them through food and supplements.
In addition to this, recent clinical guidance has raised some interesting questions about what we consider low iron in the first place.
Changes in guidelines
In 2026, the American Society of Hematology (ASH) released new guidelines for diagnosing iron deficiency, recommending a ferritin threshold of 30 ng/mL rather than the historically used 15. For menstruating women with symptoms or additional risk factors, a threshold of 50 ng/mL may be appropriate.
A little context…
Iron is essential for making hemoglobin, the protein in red blood cells that carries oxygen throughout the body. It’s also involved in energy production, brain function, and muscle health.
Ferritin is a protein that stores iron, giving us an estimate of the body’s iron reserves. Think of it as your iron savings account.
Here’s why the updated guidelines matter: Iron deficiency can occur long before anemia develops.
You can have normal hemoglobin and still experience symptoms such as fatigue, difficulty concentrating, or reduced exercise tolerance.
The tricky part is that ferritin isn’t routinely included in many standard annual laboratory panels. Unless there’s a reason to investigate iron status, your physician may not order it.
And even when iron testing is ordered, ferritin is only one piece of the picture. Other markers, including hemoglobin and transferrin saturation, can help provide a more complete assessment. Ferritin can also increase with inflammation, potentially masking low iron stores.
So, What About My Ferritin of 37?
My ferritin has hovered in the 20s and 30s for years, most recently measuring 37 ng/mL.
While that’s above the new general cutoff, research suggests that some women with fatigue and ferritin below 50 may benefit from iron treatment, even without anemia.
Could improving my iron stores make a difference in how I feel?
Food, supplements, and the challenge of rebuilding iron stores
As a dietitian, my first instinct was naturally to increase my intake of iron-rich foods. Iron rich foods include: meat, poultry, fish, shellfish, beans, lentils, tofu, pumpkin seeds, and fortified cereals.
For those who eat a plant-based diet, absorption matters, too. Iron from plant foods is generally less readily absorbed than the heme iron found in animal foods, but pairing plant-based iron sources with vitamin C-rich foods can help.
I’ve worked with many clients over the years to improve iron intake through food, and I absolutely think it’s worthwhile.
But I also think we need realistic expectations.
When iron stores are depleted, food alone may not be enough to restore them efficiently, especially when someone continues to lose iron through menstruation or has difficulty absorbing it.
Dietary changes and iron supplementation can work together. One helps support ongoing iron intake, while the other can provide a more concentrated dose to help replenish stores when treatment is needed.
Iron supplements come with their own challenges, too. For starters, remembering to actually take them! ;)
Ferrous sulfate is one of the most widely studied and commonly recommended forms of iron. It’s inexpensive and effective, but it can also cause constipation, nausea, and abdominal discomfort.
And I know first hand that those side effects can make consistency difficult!
Other formulations, including iron bisglycinate, sometimes marketed as gentle iron, may be better tolerated by some people.
How and when we iron must also be considered.
Iron supplements and strenuous exercise can both temporarily increase hepcidin, a hormone that reduces iron absorption. Taking iron every other day may improve absorption efficiency and reduce digestive side effects for some people.
For active women, taking iron before exercise or away from the hours following a strenuous workout may also help. Coffee, tea, and calcium can interfere with absorption, so separating them from iron supplements is worth considering.
I experimented with different supplements, timing, and strategies to improve absorption, but my iron stores barely budged. And I know I’m not alone in finding this process frustrating!
When the usual approaches aren’t working.
At that point, I brought the conversation back to my physicians.
My primary care physician didn’t feel my ferritin was low enough to warrant further intervention, while my gynecologist was open to exploring an iron infusion.
Both perspectives were understandable, given my normal hemoglobin, ferritin of 37, and the many possible explanations for fatigue.
Ultimately, my gynecologist recommended an iron infusion, and I was grateful to feel heard and have my concerns taken seriously.
Not knowing much about iron infusions, I reached out to Kristen Sanfilippo, MD, MPHS, a hematologist and WashU Medicine physician, to get her perspective on IV iron, including when it should be considered, its potential risks, and how long the benefits might last.
Dr. Sanfilippo emphasized that oral iron remains an effective, less expensive first-line treatment for most people. However, when supplements aren’t well tolerated or iron stores fail to improve despite treatment, an infusion may be worth considering.
Intravenous iron delivers iron directly into the bloodstream, bypassing the digestive tract. It can replenish iron stores more quickly, but it also comes with additional costs, time commitments, and potential adverse effects.
An iron infusion isn’t necessarily better because it’s more intensive, but it can be a reasonable option depending on the individual. After more than a year of trying oral iron without much improvement, my gynecologist and I decided it was worth trying.
Would restoring my iron stores improve my fatigue?
I didn’t know…but I was curious to find out!
What was the infusion like?
The infusion itself was surprisingly uneventful.
I arrived around eight in the morning, was hooked up to the IV by nine, and spent the next two hours sitting in a chair getting some work done. Afterward, they kept me for another half hour to monitor for any reactions.
IV iron can cause side effects, including headache, nausea, itching, and infusion-related reactions. Serious allergic reactions are uncommon, but they’re one reason treatment is administered in a monitored setting.
Dr. Sanfilippo emphasized that risks vary by formulation, making it important to discuss the specific product being used. Cost and time are also worth considering.
Fortunately, I tolerated mine very well. No itching. No hives. No strange taste. The only unexpected development was rust-colored urine later that day.
My treatment plan includes a second infusion, scheduled for next week.
And then? We wait.
One question I had for Dr. Sanfilippo was how long the benefits of an infusion typically last?
Her answer was that it depends largely on why someone became iron deficient in the first place.
Someone with ongoing heavy menstrual bleeding, for example, may need additional treatment sooner than someone whose iron deficiency resulted from a one-time event.
In her practice, she typically reassesses iron levels four to six weeks after an infusion and then periodically monitors them to see whether stores are declining again.
An infusion can replenish iron, but it doesn’t necessarily address whatever caused those stores to become depleted.
I’ll have my levels reassessed, and I’ll pay attention to whether anything changes in how I feel.
What I’m taking away from all of this.
Something this experience reminded me of is that symptoms don’t have to be debilitating to deserve our attention.
I see this all the time in my nutrition practice. Clients live with persistent bloating, diarrhea, or other digestive discomfort for years because they’ve learned to tolerate it. The same can be true of fatigue, night sweats, and so many other symptoms we quietly accept as part of getting older.
We may still be working, exercising, raising families, and doing everything we need to do. But that doesn’t mean these symptoms aren’t quietly taking something away from our quality of life.
Just because we can live with something doesn’t mean we have to.
Menu for the Week of October 26-30th
This week I focused on recipes that are RICH in iron!
Monday
Lentil Bowls with Lemon Tahini Dressing
Tuesday
Wednesday
Pan Fried Sesame Tofu with Broccoli
Thursday
Friday
Dark Chocolate Bark with Apricots
Happy Fueling, Friends!