The Low-Iron Maiden

This is what it looks like to feel your iron being low... not so smiley now! Photo Cred: @KissPix on instagram

On August 20, 2014, I got blood work because I was feeling run down. Having dealt with low iron for almost 10 years at that point, I was fairly certain I knew the culprit. With just under 6 weeks left until Twin Cities 2014, I found out that my ferritin was 17 and my iron saturation was 17%. But of course, the doctor who called in the blood work left a message on my phone telling me that “everything is normal!”

So while I upped my iron supplements, we took it easy for a week before Terry tested me with a 4x 3mi workout that went really well just 4 weeks out from the 2014 US Marathon Championships. Then I was back on track.



That story ended with one of the best moments in my career, and that’s why I’m telling it now. Ever since 2014, I’ve been working to figure out why my ferritin won’t get over 50 to save my life and typically hangs around 30. The highest Ferritin I’ve measured in the last 3 years was 47 just after 2 weeks off from running. So yes, I know that quitting running will solve my iron problem, but while I’m still a professional athlete, I am looking for solutions that involve staying in the sport.

Just yesterday I received word that my ferritin is back down to 21 – a level that is historically workable for me, but I still feel all the initial symptoms of low iron that I typically experience. And after now 12 years of taking note of the telltale signs I recognize in myself, this is the list I’ve come up with:

  • foggy brain
  • way more reliant on coffee and naps
  • generally sluggish and less peppy in everyday life
  • quad soreness
  • increasing poop stops during runs and especially hard efforts (this explains the one during TCM 2014, too)
  • my ability to gauge sustainable efforts is definitely off
  • long intervals get much harder than usual as the workout goes on
  • hills are harder than usual
Yeah, that's definitely more of a grimace than a smile this time. Low iron and humidity will do that. Photo Cred: Bob Smyth

Yeah, that’s definitely more of a grimace than a smile this time. Low iron and humidity will do that. Photo Cred: Bob Smyth

But here’s the weird part, and this is my call to all sports science, iron disorder, and hematology gurus out there: In the very same test (not fasting but well-hydrated), I got these indicators of low iron:

  • Hemoglobin 12.3
  • Hematocrit 36.6
  • Ferritin 21

I also got these indicators of high iron:

  • Iron Serum 173
  • Total Iron Binding Capacity 310
  • Iron Saturation 56%

I did take iron supplements on the day of the test, so that might account for some of the elevated levels, but I have often taken iron supplements on the day of a blood test and never seen those indicators so high – especially while also seeing my HGB, Hct and Ferritin so low! I have searched the internet through and through and I cannot find any information about the combination of high iron serum and saturation with low ferritin and HGB.

The only differences since my last test on June 20th, 7 weeks ago, is that I have gradually increased my training and in the past couple days, I have increased my iron supplementation again. I have tried cutting out coffee, but haven’t seen much of an impact. I have noticed that the summers have been historically bad for my iron – going all the way back to August 2005 when we first discovered the issue with a ferritin of 7 and HGB of 10.



It seems clear that while my body is absorbing iron through diet and supplements, it is not storing it, and somehow it’s not making the transition to usable iron forms. I have also seen that hepcidin has been found to correlate with iron levels and possibly impact them, and maybe Vitamin D has an effect on hepcidin? But I highly doubt that I am low on Vitamin D because I have gotten more sun this year than ever before in my life, thanks to moving to South Carolina.

After 12 years of struggling to manage my low ferritin while maintaining a high level of consistency and improvement in the sport, I’m sick of it and would love to know if anyone can give me answers. I’ve taken more iron supplements than you can imagine and that has done very little to elevate my ferritin above 30 while in heavy training (80-110 miles per week at sea level, typically with one workout and one long run).

I know I’ll be fine and I can bounce back from this just like I did in 2014, especially since I caught it earlier this time, but any insight would be greatly appreciated!

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  1. 1

    Honestly I would look other places for issues. Ferritin is hard to prove as a source of energy. After all it’s stored. Not active. Personally in the past I have felt the best I ever have with a ferritin of 4. Are you taking a birth control? Any other supplements? That all matters. Interesting birth control effects on our body from head to toe.

    • 2

      Not on birth control because of the negative effects I experienced in college. I’ve had great success when I was taking Vitamin D and iron with Vitamin C and that’s it. I’m cutting out the multi I’ve been taking and adding back in just Vitamin D to see where that gets me. Also, I’m going to finally succumb to the gluten free calling and see if that does anything. And yes, I’m looking elsewhere, but nothing else seems to be off… Thanks for the thoughts!

  2. 3

    A hematologist or exercise physiologist experienced with the finer details of running performance could give more explanation. Consider also the MCV, MCH and MCHC. I’m not great with lab interpretation but most primary care providers know very little about running physiology. So I wouldn’t expect too much help from your PCP. I was just at my doctor’s office as well for these issues. MCV is your blood volume which is likely to be high due to normal adaptation to training.

  3. 5

    It sounds like something more hormonal than iron especially dangerously high iron saturation rates. Anything over 30% is too high. Look into magnesium deficiency which is often the link between iron disorders.

    In addition your adrenals sound very taxed from your description of how you feel day to day (less pep in your step and increasing reliance on coffee). I would have adrenals tested ( 4 Pt salvia test). Micro nutrient deficiencies like magnesium can severely impact adrenal health.

    Be wishes! I have always enjoyed reading about your running journey.

    • 6

      Awesome! That’s super helpful. So more magnesium and less iron or take a break from iron supplements for the moment? Maybe I should test again from a fasting state and without taking iron prior to the test…

  4. 8

    Pernicious anemia? VB12 deficiency or folic acid deficiency? Lack of intrinsic factor? Undiagnosed autoimmune disorder? Crohn’s disease, colitis, or IBS?

  5. 9

    Sounds like celiac disease. All your friends eliminating gluten and with improvements could well also all have celiac disease. Affects 1/100. Over nutrients won’t necessarily be low, but of course running knocks iron by itself. Get tested if you haven’t been! (Though now your on the gluten free diet you might not come back positive.)

  6. 10

    Hi Esther,

    Thank you for posting about your experience and possible solutions! I finally ran another marathon after over 2 years of struggling. My doctors thought it was asthma and allergies. Like your blood work, mine all looked normal! I finally had more blood work done showing low levels in February. At that point I had already started taking a liquid iron supplement and was feeling better. I have been able to breathe and finish my long runs but I still drink my coffee and need my daily nap. Have you tried the magnesium supplement that someone mentioned earlier? I also began taking liquid B12 along with my 10 ml of iron twice per day. What have you been taking? I am also prescribed anxiety and depression meds but I wonder if this could all be stemming from vitamin and mineral deficiency! Can anyone recommend the best type of doctor to go to that can address these issues? I feel like most just want to mask the symptoms instead of dealing with the cause! Thanks!

    • 11

      I love it! It sounds like your approach is really similar to my current approach. I haven’t had much luck with liquid iron, but ferrous sulphate worked well enough for me for a long time, and then when I got frustrated with dropping levels, I tried ferrous bisglycenate (chelated iron), and that has also worked well, especially since a lot of the supplements are paired with VitC, B12, and folate, which all aid in absorption.

      I’ve loved working with my Oriental Medicine doctor so far, and had a really good experience with an integrative endocrinologist in NJ. I feel like medical professionals who are more open to all methods of treatment are also better equipped to figure out exactly what will work. Whereas a lot of specialists are trained to stay focused on one small area and don’t necessarily know as much about the area of medicine that might be causing the problem.

      Based on my own experience with progestin-based birth control along with true iron deficiency anemia (in 2005 when my Hgb was under 10 and ferritin was 7), I totally believe that anxiety and depression can be closely tied to hormonal imbalances and vitamin deficiencies. Fatigue can often feel a lot like depression, especially for people who have always been highly motivated in general and all of a sudden “literally can’t even.” ;-P

  7. 13

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