According to research, iron deficiency affects one in two healthy women in South Africa, with endurance athletes being at particular risk…

Menstruating women and athletes have an increased risk of iron deficiency, but just what is it and what causes it?

“Iron deficiency occurs when iron reservoirs in the body become depleted,” explains Dr Jarrad van Zuydam, a sports medicine physician with a special interest in the medicine of cycling and other endurance sports.

“The most common cause is inadequate dietary intake of iron. Iron is a micronutrient needed for the synthesis of the protein haemoglobin in the body.  Haemoglobin in the blood carries oxygen from the lungs around the body, and cells use the oxygen delivered to them to generate the energy needed for cellular processes.”

If your iron levels are low, your cells receive less oxygen, leaving them less able to generate energy. When iron levels become so low that your body depletes its iron stores and the level of red blood cells is lower than normal, you have full-blown iron deficiency anaemia (IDA).

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“Women are particularly vulnerable, because when they menstruate they lose blood, and with it, red blood cells and iron,” says Dr van Zuydam.

Iron is a micronutrient needed for the synthesis of the protein haemoglobin in the body. Haemoglobin in the blood carries oxygen from the lungs around the body, and cells use the oxygen delivered to them to generate the energy needed for cellular processes… – Dr Jarrad van Zuydam

Why female athletes have a higher risk

Women who do sport are at additional risk. They have greater iron requirements than non-athletes – their dietary iron recommendations are 1,3 to 1,7 times higher, and meeting them is often difficult, notes the organisation Sports Dietitians Australia (SDA). And the idea that women athletes lose their menstrual cycle is a myth – heavy menstrual bleeding is common even in elite athletes.

In addition, iron can be lost through sweat, and repeated strenuous movement such as running can lead to red blood cell destruction or haemolysis and blood loss. Blood loss has also been reported from the digestive tract and through urine after extreme events like marathons.

Iron deficiency expert Professor Toby Richards, a consultant surgeon at University College, London, tested 257 women doing a half-marathon and found that 17% had an iron deficiency, although most were unaware of it.

SDA notes that recent evidence suggests that even early iron depletion or low levels can reduce oxygen uptake into cells, reducing sports performance capacity. Untreated, this can develop into iron deficiency anaemia, leaving you lethargic and incapable of any effort in training, prone to injury and loss of endurance, and at increased risk of infection.

Are you getting your daily dose of iron?

Exercise-induced anaemia

And it’s not just elite athletes who are at risk: a study in the British Journal of General Practice has noted that ‘exercise-induced anaemia is a forgotten cause of iron deficiency anaemia’, particularly in young women.

The study concludes that ‘exercise-induced anaemia must be considered in young female adults with unexplained IDA. A thorough history-taking is warranted in order to uncover this often forgotten cause of anaemia and may prevent unnecessary diagnostic invasive procedures’.

What are the signs and symptoms?

Signs of iron deficiency include:

  • fatigue and weakness
  • pallor
  • brittle nails
  • hair loss
  • progressing to chest pain
  • irregular or fast heartbeat
  • shortness of breath
  • headaches
  • lightheadedness
  • cold hands and feet
  • tingling legs
  • poor appetite
  • unusual cravings for things like ice or dirt as you develop anaemia

Get tested

If you have any of these signs, it’s important to have iron deficiency confirmed, says Dr van Zuydam.

You can now get tested with a new rapid self-screening test, Ferricheck®, available at all leading pharmacies. If it shows positive for iron deficiency, it’s important to consult your healthcare provider, who will recommend treatment.

“Medical care involves identifying the cause,” Dr van Zuydam says. “This will involve a thorough medical history and may encompass tests.”

Apart from a diet with iron-rich foods (red meat, and to a lesser extent, chicken, eggs, shellfish, beans, dark green leafy vegetables, and fortified cereals and breads), an iron treatment will often be prescribed.


  1. Phatlhana, D.V., Zemlin, A.E., Matsha, T.E., Hoffman, M., Naidoo, N., Hoffman, M., et al. The iron status of a healthy South African population. Clinica Chimica Acta 460 (2016) 240-245.
  2. Burden, R.J., Morton, K., Richards, T., Whyte, G.P., Pedlar, C.R. Is iron treatment beneficial in iron-deficient but non-anaemic (IDNA) endurance athletes? A meta-analysis. BJSM Online First published on October 31, 2014 as 10.1136/bjsports-2014-093624.
  3. Sports Dietitians Australia: Iron Depletion Fact Sheet.
  4. Women in Sport and Iron Deficiency Fact Sheet: (Women_In_Sport_IDA_090916_2 latest.pdf)
  5. Professor Tony Richards quoted in “Always tired? Why you could be struggling with iron deficiency”, 20 October 2016.
  6. Mayo Clinic:
  7. Wouthuyzen-Bakker, M., Van Assen, S.. Exercise-induced Anaemia. British Journal of General Practice 2015; 65: 268-269.

While All4Women endeavours to ensure health articles are based on scientific research, health articles should not be considered as a replacement for professional medical advice. Should you have concerns related to this content, it is advised that you discuss them with your personal healthcare provider.