What’s the most common nutritional deficiency in the world? Iron deficiency anemia (IDA) affects about 30% of the world’s population, with higher rates in menstruating women than any other demographic. Symptoms can vary and often include generalized fatigue, weakness, dizziness, headaches, heartbeat irregularities, pale skin, and cold hands or feet, though mild iron deficiency anemia may be asymptomatic. IDA occurs when there’s not enough iron in the body to produce hemoglobin, an important protein in red blood cells that carries oxygen throughout the body. It may occur due to the lack of adequate intake of iron through the diet, poor absorption of nutrients, blood loss, and other reasons. 

[signup]

CC: Fatigue, Dizziness, Headaches, PMS/Heavy Periods

Jill* was a 33-year-old female who presented with ongoing fatigue, dizziness (especially when moving from lying down or sitting to standing), headaches, and PMS symptoms. She had recently seen her primary care physician, who ran labs and found “everything was normal,” and the recommendation given to Jill was to go on an oral contraceptive for her periods and headaches. Jill decided she wanted to investigate further, as she had been experiencing the PMS symptoms and heavy periods for years and had been dealing with the fatigue for the better part of the last 18 months.  

Jill felt her fatigue initially came on in the afternoons and early evenings, which she had attributed to having a demanding job in corporate and having two kids who were involved in after-school activities and sports, so she was often busy and on the go. Over time, the fatigue became more constant, and now she felt tired from the moment she woke up and never really got an energy rise. This had her depending on coffee to get through her work days, and she found the caffeine also helped when she was experiencing headaches. Jill had headaches about 3-4 times per week and described them as a dull ache around her whole head. She had been experiencing headaches and dizziness more often over the past six months. Jill said she noticed the dizziness if she bent over or stood up quickly from sitting or lying down and noted that her weekly yoga class definitely aggravated those symptoms. 

Despite the heavy bleeding and PMS symptoms such as bloating, breast tenderness, cramping and pain, and mood swings, Jill’s cycle was typically 28-29 days in length and always predictable. She had tried Midol in the past, which helped a little, but she felt like she “lost a week” every month due to her symptoms. Additionally, in a review of systems, Jill also shared that while she felt her digestion was “normal,” she often had loose stools bordering on diarrhea.

From a nutrition perspective, Jill had been following a vegetarian diet for the past 5 years and relied on a lot of meat substitutes for her protein sources, along with fruits and vegetables. She also loved pasta and grain bowls. Jill drank plenty of water in addition to 3-4 cups of coffee daily. She walked daily, took a yoga class once per week, and tried to make it to at least 3 fitness bootcamp workouts before work during the week. Jill took a multivitamin she picked up at the drugstore and occasionally took melatonin to sleep; otherwise, she was not on any medications or supplements.  

Lab Work Results

The following specialty labs were run:

Comprehensive Stool Test

A Comprehensive Stool Test (the GI-MAP by Diagnostic Solutions) showed the following results: 

• Pancreatic elastase was low
• Fecal fat was high
• Elevated beta-glucuronidase
• Low commensal bacterial spp.
• Elevated opportunistic bacterial spp.

DUTCH Complete Hormone Testing

The DUTCH Complete showed the following results:

• Elevated estrogen metabolites 16-OH E1 and 4-OH-E1 and elevated estradiol and estriol
• Low progesterone metabolites
• Low cortisol throughout the day without ever getting a “rise” typical of the morning patterns

Additional Lab Results

Lab Analysis 

Jill’s lab work points to a few different problems that are contributing to her symptoms.

Dysbiosis and Malabsorption

Jill’s stool test showed low pancreatic elastase and high fecal fat, indicating low digestive enzyme function and likely malabsorption. This can lead to not absorbing nutrients optimally from her diet and may cause bloating and digestive issues such as constipation or diarrhea.  If she can’t absorb nutrients like iron from her food well - especially being plant-based, since non-heme sources of iron aren’t absorbed as well as heme sources - it’s likely she isn’t getting enough micronutrients to meet her needs.  Her results also showed elevated opportunistic spp., with low commensal bacteria, indicating dysbiosis was present. A dysbiotic microbiome can cause inflammation, impaired detoxification ability, and even hormone imbalances and has been linked to some cases of iron-deficiency anemia in menstruating women.  Last, Jill had elevated levels of beta-glucuronidase, an enzyme that can become elevated in some cases of dysbiosis, which can interfere with estrogen metabolism and cause estrogen to be reabsorbed, contributing to estrogen dominance symptoms.   

Iron-Deficiency Anemia

Jill had the classic lab results typical of iron-deficiency anemia: low iron markers and iron stores, depressed hemoglobin, hematocrit, and RBC, and depressed MCV, MCH, and MCHC, with high total iron-binding capacity.  Symptoms of iron-deficiency anemia often include many of Jill’s symptoms, including fatigue, dizziness, and headaches. 

Hormone Imbalances

Jill’s testing showed elevated estrogen and elevation of the more inflammatory estrogen metabolites, 4-OH-E1 and 16-OH-E1. She also had low progesterone and low free T3.  Estrogen dominance can lead to heavy bleeding, a common root cause of iron-deficiency anemia in menstruating women, as well as many of the other PMS-related symptoms Jill described, such as painful cramping, bloating, and breast tenderness.  

Additionally, Jill had low levels of free T3, the active form of thyroid hormone, despite having TSH and T4 levels that were in range. This can suggest a conversion issue affecting the conversion of T4 to T3, a process that is partially dependent on adequate iron levels to take place.  Low T3 levels can also contribute to fatigue and low energy overall. Jill’s DUTCH Complete test also showed depressed cortisol throughout the day, which could be adding to her fatigue as well.  

Other Micronutrient Depletions

Jill had several vitamin and mineral depletions apparent on her micronutrient testing, including zinc, iron, magnesium, B6, B12, and selenium levels. Many of these micronutrient deficiencies have a higher likelihood to occur with vegetarian diets and paired with her gut testing results, it’s likely that a combination of nutrient and absorption problems are contributing to her low mineral levels.  

Interventions

Jill wanted to focus on nutritional and lifestyle interventions as much as possible. 

Supplementation

• Started magnesium glycinate, 400mg at night
• Started B complex once daily (Thorne)
• Started iron bisglycinate 60mg every other day 
• Started comprehensive digestive enzyme and betaine HCL to help support food breakdown and nutrient absorption. Reduced stomach acid and digestive enzymes are associated with reduced absorption of iron, so adding this support while healing Jill’s gut was essential to helping improve her iron levels.  
• Started having digestive bitters prior to meals to help stimulate stomach acid and digestive enzyme production.
• For 30 days, added in 1 scoop of Repair-Vite SE by Apex energetics (zinc carnosine to aid in supporting gut health and mucosal health).
• For 6 weeks, we added in Gi-MicrobX, an antimicrobial blend to help eradicate opportunistic microbes in the gut; we followed this up with probiotic rotations, including S. Boulardii and Lactobacillus/Bifidobacterium spp. In addition to prebiotic and probiotic foods in the diet.
• Started calcium-d-Glucurate to help reduce beta-glucuronidase levels and address high estrogen

Nutritional Changes

Nutritionally, we emphasized an anti-inflammatory, whole food, nutrient-dense diet rich in fruits, vegetables, healthy fats, and protein. Jill was willing to incorporate some quality animal proteins to try to better support her health, so we eased her into that as well.  

• Jill started to bring in chicken thighs, whole eggs, grass-fed bison, and beef into her weekly diet while starting to reduce some of her refined carbohydrate intake.  These are all nutrient-dense sources of iron and other vitamins and minerals, and we also emphasized plant-based sources, including pumpkin seeds, leafy greens, and cashews. Non-heme, plant-based sources of iron were always paired with a source of vitamin C (like citrus) to help with absorption.  
• We also had Jill get in a Brazil nut daily to help her low Selenium levels.
• Foods high in glucuronic acid, like apples, Brussels sprouts, cooked cruciferous vegetables, and oranges, were included to help reduce the high levels of beta-glucuronidase and support estrogen metabolism.
• Additionally, we included functional fibers to help support the growth of beneficial gut bacteria, including sources of inulin, beta-glucan, and fructo-oligosaccharides.  
• Emphasis was on having quality protein, fat (such as avocado, olive oil, and flaxseed), and fiber with each meal to keep her energy up while limiting sugar, refined carbohydrates, and fast food. 
• We had Jill focus on hydration and increasing her water intake while starting to switch to half-caff coffee to wean off her high caffeine intake 
• We also focused on eating hygiene to support the new protein sources Jill was adding in: chewing food well, slowing down and stepping away from work while eating, and taking a few slow breaths before starting a meal.

Lifestyle Recommendations 

• We had Jill really start to focus on managing stress and nervous system regulation, including breathwork and making the time to go hang out with friends and family more.
• We switched up her exercise routine to more walking, her weekly yoga class, and swapped her hour-long bootcamp classes for strength training.
• We had Jill do an audit of her personal care products and cleaning products to switch to lower-tox or non-tox options to cut down on xenoestrogen exposure.

Follow-Up Labs 5 Months Later

GI-MAP and Micronutrient Testing Follow-Up Results: All Within Normal Range

Jill’s micronutrient re-test came with all results within normal limits, demonstrating that her plan was helping restore her vitamin and mineral levels.

Additionally, her GI-MAP results improved to normal ranges:

• Pancreatic elastase was normal (initially low)
• Fecal fat was normal (initially high)
• Beta-glucuronidase was low (initially high)
• Normal commensal bacterial spp. growth (initially low)

Follow-Up Interpretations and Continued Interventions

Over the course of five months, Jill implemented every recommendation we made with regular check-ins and guidance. She started feeling better energy levels within the first few weeks of making nutritional changes and the lifestyle changes and felt she wasn’t so tired since she wasn’t doing the intense bootcamp-style cardio classes in the mornings.  

All of Jill’s lab markers returned to normal ranges, and by 3 months into her program, Jill was having more of a normal menstrual bleed with minimal pain and discomfort around menstruation.  She also lost about 8 pounds, and she felt she was sleeping really well. 

Jill’s diarrhea had disappeared after about 8 weeks, and she was having consistent, regular bowel movements daily now.

By 4 months in, Jill’s headaches had gone away, and as of five months, she had gone an entire month without a headache. Additionally, her dizziness had gone away, and she could do her regular yoga class without any issues.  

Moving forward from the 5-month lab re-check, Jill planned to continue her nutritional and supplemental approach as she felt it was simple to maintain and fit her lifestyle well, though we stopped her iron supplementation after seeing her normal lab ranges. We felt confident that between the regulation of her menstrual cycle and the introduction of more iron-rich foods into her diet, she could maintain her levels better moving forward.

[signup]

Summary

This case highlights the multifactorial nature of PCOS, as symptoms vary widely from person to person, and the pathogenesis often involves systems in the body besides the reproductive organs. In Nia’s case, her gut health and HPA dysfunction played a role in her symptom development and were not addressed by simply introducing an oral contraceptive pill. Nia had to make a lot of changes in her lifestyle in order to get the results she wanted, and it was not always a linear path; however, with consistency and guidance, she was able to start cycling regularly again and address her metabolic and gut health along the way.

This case highlights a common picture of iron-deficiency anemia in women of reproductive years.  Heavy bleeding can lead to iron loss, and paired with malabsorption/gut issues and poor dietary intake of iron, can turn into anemia leading to fatigue, dizziness, headaches, pale skin, and other symptoms.  In Jill’s case, optimizing her iron intake while supporting gut healing and regulation of her heavy periods was key to getting her the best results.