Frequently Asked Questions

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Anemia Basics

What is anemia?

Anemia develops when there are not enough healthy red blood cells in the body. This condition can be detected when there is a below-normal level of hemoglobin in the blood. Hemoglobin is the iron-rich protein in red blood cells that carries oxygen from the lungs to all parts of the body. If you have anemia, your body doesn’t get enough oxygen-rich blood. As a result, you may feel tired or have other symptoms depending on the severity of anemia. People with severe anemia may feel tired, fatigued or experience shortness of breath which can cause problems carrying out routine activities. Anemia can be a temporary condition, a consequence of other health conditions, or it can be a chronic problem. Many mild types of anemia can be easily treated, however, certain types of anemia may be severe, long lasting, and life threatening if not diagnosed and treated.

Are some types of anemia inherited?

Yes, some types of anemia are due to inherited or genetic defects. Sickle cell anemia occurs most frequently in people of African, African-American, and Mediterranean descent. Thalassemia (or Cooley's anemia) is found in people of Mediterranean and Southeast Asian descent. These types of anemia are extremely common. Another inherited anemia is Fanconi anemia, but this is very rare.

Causes of Anemia

Which people are at the highest risk for anemia?

Groups of individuals who are at risk for developing anemia include:

• infants who may not have adequate iron intake
• children going through a rapid growth spurt, during which the iron available cannot keep up with the demands for a growing red cell mass
• women in childbearing years who have an excessive need for iron because of blood loss during menstruation
• pregnant women, in whom the growing fetus creates a high demand for iron.

People with ongoing gastrointestinal blood loss are at risk of developing iron deficiency, as are individuals with leukemia or cancer who must receive chemotherapy or radiation to treat their disease. The drugs or radiation used to treat these diseases frequently suppress the bone marrow's ability to make cells of all classes-red blood cells, white blood cells, and platelets.

In addition, many individuals with chronic inflammatory conditions, such as rheumatoid arthritis or chronic infections, may become anemic through a combination of an inadequate supply of iron for red blood cell production and bone marrow suppression. We now recognize that the increased anemia seen in the elderly may be a form of bone marrow suppression from chronic inflammation. Recognition and treatment of the anemia in the elderly has gained clinical interest because correcting the anemia may have beneficial effects on quality of life.

Can certain medications cause a person to become anemic?

Yes, medications can cause anemia for many different reasons. For example, chemotherapeutic agents often cause anemia because they the bone marrow's ability to manufacture red blood cells, hemoglobin is carried by RBC's, If there are not enough RBC's, the body does not get the right amount of oxygen. Other types of medication-induced anemia are usually unpredictable, and not well understood (such as drug induced aplastic anemia). Some patients react to drugs because of inherited susceptibility, such as patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. G-6-PD is an important enzyme that buffers the mature red cell against oxidative stress. In individuals who are deficient in G-6-PD, exposure to certain chemicals, drugs, or even some foods will result in the alteration of hemoglobin and breakdown of red blood cells.

Symptoms of Anemia

What are the symptoms of anemia?

The symptoms of anemia can include headache, fatigue, weakness, difficulty in thinking. With severe anemia, other symptoms, such as shortness of breath and rapid heartbeat, may be experienced.

Diagnosing Anemia

At what point are people considered anemic?

Anemia occurs when a patient has a lower than normal amount of red blood cells. Anemia is assessed by measuring the amount of hemoglobin, the substance in red blood cells that transports and delivers oxygen throughout your body. A doctor can determine if you are anemic by performing a routine blood test called a complete blood count (CBC) test, which provides levels for both hemoglobin and hematocrit (the percentage of red blood cells in a blood sample). The measurement of hemoglobin is the most common method for assessing anemia, although hematocrit values may also be used.¹ The normal value or range for these indicators varies with both gender and age.

Once a diagnosis of anemia is made by your doctor, more tests, such as iron status tests, are often required to determine the cause of the anemia and the best course of treatment. Anemia is further categorized as mild, moderate or severe depending how far a patient's hemoglobin level resides below the normal range. As important, anemia that develops over a short period of time, such as hours to days, will lead to more symptoms than a case of anemia that slowly develops over months to years.

What tests might my doctor perform to determine if I have anemia?

If your hemoglobin and hematocrit tests (as described above) indicate that you may have anemia, your doctor may take additional steps to determine the cause, severity and appropriate treatment for your condition. Some of those additional steps may include the following examinations.

Physical Examination: The first step in any diagnosis is a physical examination to determine if you have symptoms of anemia and any complications. Your doctor may also ask you some of the following questions to determine if you have any conditions that may be causing your anemia:

• Have you or anyone in your family suffered from anemia?
• Do you experience heavy menstrual bleeding? (women)
• Have you ever had blood in your stool or any other signs of bleeding?
• What is your usual diet?
• Have you ever had an ulcer?
• Do you regularly take aspirin or anti-inflammatory drugs?

Bleeding: Loss of blood, or bleeding is a common cause of anemia. This bleeding may go unrecognized until you begin to suffer from the anemia. If your doctor suspects a source of bleeding within your body, several tests may be used to discover the source of the bleeding. One of the first tests ordered is the fecal occult blood test. This test checks the stool for signs of blood and can detect even small amounts of blood. This simple, noninvasive test is done by placing a small sample of stool on a chemically treated card. Then a chemical solution is put on top of the sample. If the card turns blue, there is blood in the sample.

Vitamin Deficiencies: Your doctor may check the amount of folate, vitamin B-12 and vitamin C in your blood to determine if your anemia is due to a vitamin deficiency.

Iron Deficiency: Since iron deficiency is the most common cause of anemia, your doctor may conduct some blood tests to check the level of iron in your blood. Some common iron status tests are:

• Serum ferritin - Ferritin is a protein that helps store iron in the body. Results of this test give doctors a good idea of how much of the body's stored iron has been used up.
• Transferrin level or total iron-binding capacity - Transferrin is a protein that carries iron in the blood. Total iron-binding capacity measures how much of the transferrin in the blood is not carrying iron. People with iron-deficiency anemia have a high level of transferrin that is not carrying iron.

Chronic Illness: Because anemia may be the first symptom of a serious illness, determining its cause is very important. This may be difficult, particularly in the elderly, malnourished, or people with chronic diseases, whose anemia may be caused by one or more factors.

Treatment: Your doctor will use these and other tests to help determine the best course of treatment for you.⁴

Blood Donation

I tried to donate blood, but was denied because my blood count (hematocrit value) was too low. What hematocrit value is required to donate blood? What should I do about my low hematocrit value?

Hematocrit is a measure of the percentage of red blood cells in a blood sample. To donate blood, a person's hematocrit value must be above the threshold of 38%, a level which is established by the U.S. Food and Drug Administration (FDA). If you are found to have a low hematocrit value, you will not be able to donate blood on that particular day. Having a low hematocrit is the most frequent reason for not being able to donate blood. It is normal for hematocrit values to vary from day to day or even hour to hour and values can be influenced by such things as diet, hydration and health issues.

Being deferred from donation due to a low hematocrit does not always mean that you have anemia or a medical problem. However, if you have been denied from donating blood because of a low hematocrit value it is possible that you have anemia. Decreased hematocrit often indicates anemia caused by an iron or vitamin deficiency. Further testing may be necessary to determine if you are anemic and if so, the cause of the anemia. If you find your hematocrit value is low or think you might be anemic, you should schedule an appointment with your doctor.

Blood Transfusion

Are blood transfusions commonly used to correct anemia, and are they dangerous?

Blood transfusions are used to treat anemia as a last resort. The physican first identifies the cause of the anemia and corrects the cause, if possible. With concern over the safety of the blood supply, more attention is being given to anemia management. Most blood transfusions are given because of excessive bleeding at the time of surgery, with trauma, or because of bone marrow suppression, in patients with cancer or leukemia on chemotherapy. Blood transfusions are much safer than ever before but we also know that blood transfusions affect the immune system and may increase certain risks. There is also a concern for human error, which in 1/16,000 transfusions results in a patient receiving a transfusion of blood that is not matched with his/ her blood type.

Iron Deficiency

What is iron deficiency anemia and can I correct it by changing my diet?

Iron is an essential part of hemoglobin, and without enough hemoglobin, anemia develops and the body does not get the right amount of oxygen. Iron deficiency anemia develops after the body has had a low level of iron for a long time, either because of iron loss or inadequate iron intake over a long period of time. It can be caused by blood loss, not taking in or absorbing enough iron, increased demands for iron (like pregenancy or rapid growth). In each case, iron supplementation may be necessary, in order to correct the iron deficiency. In the case of poor absorption, supplemental iron may have to be given intravenously or vitamin C may be given because it assists with absorbing iron.

I have been diagnosed with iron deficiency anemia and my doctor prescribed iron supplements. How long will it take for my blood to become normal?

It depends on the degree of anemia at the beginning of treatment. Most people with mild to moderate iron deficiency anemia will correct the anemia over a period of 2 to 3 months. However, the anemia is corrected, the iron stored by the body is still low. Physicians often recommend an additional 6 months of oral iron therapy once the anemia has been reversed, in order to replenish iron stores. This will help prevent the iron deficiency anemia from recurring quickly.

Surgery

My hemoglobin level is low and I am scheduled for surgery. Should I postpone the surgery?

If you have a low hemoglobin (Hb) level, you should discuss this with your doctor as soon as possible. No treatment may be necessary if minimal blood loss is expected during a minor procedure. If a greater blood loss is expected for more extensive procedures, you should ask your doctor about being treated with erythropoietin and iron to raise your hemoglobin to a normal level before surgery. An anemic patient who undergoes high-blood-loss surgery has a greater risk of surgical complications and need for a blood transfusion, which also carries some risk.

Some physicians advocate measuring a patient's hemoglobin 30 days before surgical procedures. This allows time to identify and treat the anemia and its cause.⁵ There is a general consensus among surgeons, anesthesiologists, and internists to postpone surgery if a patient has severe anemia (Hb ≤ 8 g/dL).⁶

While many healthy adults are able to handle anemia before surgery ⁷ without any problem, elderly adults may not tolerate it as well. A recent study of elderly patients undergoing major non-heart surgery found that even mild anemia increased the risk of heart trouble or death after surgery.⁸ The treatment of anemia before surgery with iron, erythropoietin, or red blood cell products and their substitutes is possible for most major elective surgeries and can help prevent adverse outcomes, especially in elderly patients.

Women's Health

I heard that heavy menstrual periods can cause anemia. Is there anything I can do to prevent the anemia?

Heavy menstrual bleeding, also known as menorrhagia, is one common cause of iron deficiency anemia for women. Heavy menstrual bleeding has been reported in approximately 10-15% of all women at some point during their life. Among these women, as many as 20% will go on to develop iron deficiency anemia.⁹ You can begin to replace the iron lost from blood loss by eating more iron-rich foods, but supplemental oral iron medications may be required. Discuss your concerns with your doctor or gynecologist. To learn more, read our feature article Women and Anemia – Heavy Menstrual Bleeding and Fibroids.

What is the relationship between uterine fibroid tumors and anemia in women?

Anemia in women can be caused by the increased menstrual blood loss associated with uterine fibroid tumors. Uterine fibroids are noncancerous growths in the uterus that often appear during childbearing years. They almost never lead to cancer, and are not linked to any increased risk of cancer.¹⁰ Along with a healthy diet, iron supplementation may be required to prevent iron deficiency anemia from developing. To learn more about fibroid tumors, read our feature article Women and Anemia – Heavy Menstrual Bleeding and Fibroids.

What causes anemia during pregnancy?

Pregnancy places major demands on the body because the mother must meet the needs of both her body and her growing baby. The mother’s body needs enough iron and folate to make the right amount of red blood cells.¹¹ Most anemia during pregnancy results from this increased need for iron. It is estimated that women will need approximately 50% more iron during pregnancy, increasing from 18 to 27 milligrams (mg) per day.¹² Even a well-balanced diet can only provide about 12-14 mg of iron per day, well short of the iron a pregnant woman requires.

In order to prevent iron deficiency anemia during pregnancy, it is often necessary for pregnant women to take iron supplements. The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women should take a daily supplement of 30mg of elemental iron. The expectant mother should also stay in close contact with her doctor and gynecologist, and be sure to eat a diet that includes foods rich in iron and folate, like liver and dark green leafy vegetables. Read our feature articles to learn more about anemia caused during pregnancy, from vitamin deficiencies or from iron deficiency.

Can childbirth cause anemia? What is postpartum anemia?

Approximately 10% of women will suffer from anemia within the first six months after delivering their baby¹³ and 4% of women will have anemia lasting up to twelve months.¹⁴ Anemia experienced by mothers during this time following childbirth is called postpartum anemia and is usually caused by iron deficiency. Mothers suffering from postpartum anemia most likely lost a large amount of blood during childbirth, had twins or other multiple births, or were anemic during the third trimester of pregnancy.¹⁵ In any case, losing large amounts of blood or having low iron levels leaves the mother at risk for developing anemia.

Following childbirth, the mother’s body needs to start making new red blood cells. To do so, she will need enough iron to make hemoglobin, the part of the red blood cell that carries oxygen throughout the body. If she has anemia and there is not enough stored iron, her body will be unable to raise hemoglobin levels and reverse the anemia. Low iron levels before and after childbirth may require treatment. Close communication with your doctor and gynecologist will help him or her provide the best care to prevent anemia prior to child birth and treat postpartum anemia. To learn more about postpartum anemia, read our feature article Women & Anemia – Childbirth and Postpartum Anemia.

References

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9. Vercellini P, Vendola N, Ragni G, Trespidi L, Oldani S, Crosignani PG. Abnormal Uterine Bleeding Associated with Iron-Deficiency Anemia. J Reprod Med. 1993 July;38(7):502-4.
10. Healthwise, Incorporated. BC Health Guide: Uterine Fibroids. Link.
11. National Institute of Health. Office of Dietary Supplents. Dietary Supplement Fact Sheet: Folate. Link.
12. Milman N, Bergholt T, Byg KE, Eriksen L, Graudal N. Iron status and iron balance during pregnancy. A critical reappraisal of iron supplementation. Acta Obstet Gynecol Scand. 1999 Oct;78(9):749-57.
13. Bodnar LM, Cogswell ME, Scanlon KS. Low income postpartum women are at risk of iron deficiency. J Nutr. 2002 Aug;132(8):2298-302.
14. Bodnar LM, Scanlon KS, Freedman DS, Siega-Riz AM, Cogswell ME. High prevalence of postpartum anemia among low-income women in the United States. Am J Obstet Gynecol. 2001 Aug;185(2):438-43.
15. Centers for Disease Control and Prevention. Recommendations to Prevent and Control Iron Deficiency in the United States. MWR 1998; 47(No. RR-3):25.

Last Updated: November 14, 2008