Case Study: 21-Year-Old Female with Severe Fatigue Due to Symptomatic Iron Deficiency without Anemia

Case at a Glance

A 21-year-old female with a history of menorrhagia presented with a sudden onset of debilitating fatigue and exertional tachycardia. Laboratory tests revealed a normal hemoglobin level but profoundly low ferritin, confirming iron deficiency without anemia. This case highlights the clinical challenge of managing severe, symptomatic iron deficiency when hemoglobin levels have not yet fallen into the anemic range, and the discrepancy between patient-reported symptom severity and conservative treatment approaches.

Patient's Story

A 21-year-old female presented with a two-week history of a sudden and dramatic decrease in exercise tolerance. She reported being an active gym-goer who was now unable to walk short distances without experiencing significant fatigue and a racing heart. The patient noted a personal history of anemia and believed she had poor iron absorption despite an iron-rich diet. A key factor in her history was menorrhagia, with heavy menstrual periods lasting up to 10 days. She expressed frustration, as her primary care physician had informed her she was 'not anemic' based on her blood work, which did not align with her debilitating symptoms.

Initial Assessment

On presentation, the patient appeared fatigued but was in no acute distress. Her vital signs were stable at rest. Given her classic symptoms of fatigue and palpitations, coupled with a significant history of menorrhagia, suspicion was high for an iron-deficient state. The patient had recent lab work done and was also curious if a CBC from three months prior might have shown early signs of her deteriorating condition.

The Diagnostic Journey

Review of the patient's recent laboratory results showed a hemoglobin level within the normal range. However, the iron panel was highly revealing: serum ferritin was critically low at 17 ng/mL, confirming depleted iron stores. Her serum iron was 65 ug/dL. The physician's diagnosis was Iron Deficiency without Anemia. This created confusion for the patient, who equated her symptoms with anemia. It was explained that iron deficiency exists on a spectrum; her body's iron stores were exhausted, leading to significant symptoms, even though she was still able to produce enough hemoglobin to avoid the technical definition of anemia. Dissatisfied with the recommendation for oral supplements due to the severity of her symptoms, the patient inquired about intravenous (IV) iron infusions for a more rapid recovery. Her request was denied by her physician, who stated that IV iron was reserved for patients with frank anemia and that oral supplements would be just as effective over time.

Final Diagnosis

Iron Deficiency without Anemia, secondary to menorrhagia.

Treatment Plan

The initial treating physician prescribed standard oral iron supplementation. However, considering the patient's severe symptoms, ongoing blood loss from menorrhagia, and the potential for poor adherence or absorption with oral supplements, an alternative plan was considered. An appropriate course of action would include a referral to a hematologist to evaluate her for IV iron infusion, a reasonable option for rapid repletion in highly symptomatic patients. Concurrently, a referral to a gynecologist is essential to investigate and manage the underlying menorrhagia, which is crucial for preventing recurrence of iron deficiency.

Outcome and Follow-up

The patient was left at a crossroads, feeling her symptoms were not being adequately addressed and was considering seeking a second opinion. This case underscores the clinical principle of treating the patient's symptoms, not just the laboratory values. Long-term management requires a two-pronged approach: replenishing iron stores and addressing the root cause of the blood loss. Follow-up would involve monitoring her symptomatic improvement and repeating her CBC and iron panel to ensure an adequate response to therapy. The gynecological evaluation and management of her menorrhagia remain the cornerstone of preventing future episodes.