This appeared last week:
More awareness is vital to say the
least:
Gaslit, dismissed and treated as hypochondriacs: The
gender divide in iron deficiency
By Kate Aubusson
August 16,
2025
Iron-deficient
and anaemic women are being gaslit and denied effective treatment, while
pathology companies systematically report “normal” blood test results for
females who would be diagnosed with iron deficiency if they were male.
Among the
more than 2000 women who shared accounts of medical misogyny with this masthead were
more than 50 women with debilitating iron deficiency or anaemia who were
treated as hypochondriacs or had their symptoms dismissed by healthcare
professionals, including one woman whose haemoglobin count was that of a
traumatic car crash victim.
Other women
described their heavy menstrual bleeding being written off as a normal,
untreatable part of womanhood, and experiencing damaging delays in
investigating serious underlying causes of their low iron. Iron is an essential
mineral for organ function, from carrying oxygen in red blood cells, to immune
and brain health.
Some of
Australia’s biggest pathology providers have for years set a significantly
lower benchmark for what they consider “normal” iron stores in females compared
to males, leaving a huge proportion of iron-deficient women undiagnosed and
untreated.
“The fact
that there is a difference in what is considered iron-deficient between men and
women is insane,” Professor Nada Hamad, a Sydney haematologist and clinician
researcher, said.
“Can you
imagine how gaslit these women are when they are told that their iron level is
normal, when, by definition, a man with the same results would have been
diagnosed iron-deficient?” said obstetrician and gynaecologist Dr Talat Uppal,
a leading international expert in heavy menstrual bleeding.
This is a modal window.
Following
questions during this investigation, laboratory heads of pathology providers
convened an emergency meeting, and those still upholding the “sexist practice”
told this masthead that it would be overhauled.
Meanwhile,
women with chronically depleted iron stores are offered no alternative to
over-the-counter iron tablets, despite reporting brutal side effects, no
improvements and pleading for iron infusions.
“I’ve got
patients who have had untreated iron deficiency for years, then they wind up in
emergency departments severely anaemic,” specialist haematologist Dr Lisa
Clarke said.
“All because
there are people in the healthcare system who truly don’t believe iron
deficiency without anaemia in women is a problem.”
The women,
doctors and experts are speaking not to blame individual healthcare
professionals, but to expose entrenched, systemic gender bias in healthcare
systems that can be traced back centuries, long before iron deficiency
was believed to cause “hysteria” in women of the 16th century.
‘You have
the blood count of a shark attack victim’
Abigail
Rodwell had grown accustomed to being told by GPs not to worry about her
fatigue, headaches and gastrointestinal symptoms.
“I can’t tell
you how many times doctors have told me: you run a business, you’re studying
your master’s degree, your doctorate, and you have two little children. You’re
fine. Just rest,” Rodwell said.
Abigail
Rodwell had been iron deficient for years but was offered no alternative to
iron supplements with intolerable side effects.
“I’m pretty
confident that men who work and have kids don’t hear that. They hear: how can
we fix you?”
Rodwell got
on with life until one evening in 2016.
“I was
vomiting, I was struggling to breathe, and my whole body was cramping up,” she
said.
Rodwell
recalls screaming in pain as the paramedics carried her into the emergency
department.
“The head
nurse yelled at me, ‘I don’t know if you’re on drugs or something, but you will
stop screaming’,” she said.
The mother of
two was admitted for suspected influenza, but her blood test results showed her
haemoglobin was 56 grams per litre (g/L). Normal haemoglobin levels typically
range from 115 to 165 g/L. Rodwell was severely anaemic.
Iron is
essential to make haemoglobin – a protein in red blood cells that binds to
oxygen and transports it around the body. It is critical for tissue and organ
function. Without treatment, iron-deficiency anaemia can cause life-threatening
complications, including heart failure.
The attending
gastroenterologist assumed she had cancer, Rodwell said.
“After an
endoscopy, the gastroenterologist just said, ‘You don’t have cancer’ and told
me to see my GP. That was it. Consultation over.”
At her GP,
she was scolded for not taking iron supplements, Rodwell recalled.
Rodwell had
tried taking various forms of supplements for years, but she couldn’t tolerate
the gastrointestinal side effects.
Over-the-counter
oral iron is the first-line treatment for iron deficiency and can be an
effective option. But 30 to 70 per cent of people can’t tolerate the gastrointestinal
side effects, including nausea, diarrhoea, constipation, and heartburn.
“[My GP] was
so curt and rude, I had to stop myself from crying,” Rodwell said.
Between 2018
and 2020, her health slowly deteriorated. She had a constant headache, extreme
fatigue, weakness, dizziness, pale skin, cold hands and feet, a slightly
swollen tongue and loss of appetite.
“I was
crunching ice all the time,” Rodwell said, unaware that craving ice is a
symptom of iron deficiency.
Medical
misogyny: a call for action
The Age
and The Sydney Morning Herald last year launched an investigation into
medical misogyny: ingrained, systemic sexism across Australia’s healthcare
system, medical research and practise.
More than
2000 women shared their experiences as part of our crowd-sourced investigative
series, which prompted a national outpouring of grief and frustration as women
described feeling gaslit, dismissed or being told their pain was “all in their
heads”.
We call on
the federal government to boost Medicare funding for GP appointments that last
more than 20 minutes to improve care for women and others with complex health
conditions.
The Albanese
government and the Coalition have promised to pour $8.5 billion into Medicare
to make GP visits more affordable and improve bulk billing rates, but longer
20-minute appointments will receive a smaller proportional funding
increase.
Doctors have
warned that these policies could further disadvantage women by continuing to
incentivise shorter consultations, which don’t give GPs enough time to address
menopause, pelvic pain and other women’s health issues.
“I was just
withering away, but I was still working. I would just take myself to the
doctor, and the doctor would look at me and she wouldn’t be worried.”
In mid-2020,
another blood test showed her haemoglobin was 53. Her GP sent her straight to
hospital, where staff had prepared the resuscitation room.
“They said,
‘Do you know you could die at any second? You have the blood count of a car
crash or shark victim’,” Rodwell recalled.
But she
hadn’t had traumatic blood loss. It was her iron that had drained away.
Clarke was
the haematologist assigned to Rodwell’s case. She said years of living with
undiagnosed food intolerances had likely damaged Rodwell’s gastrointestinal
tract, preventing her from absorbing iron from her food.
“Iron
deficiency is so insidious,” Clarke said. “Abby had become used to functioning
with low iron levels and subsequent anaemia until her haemoglobin finally
dropped to critical levels.”
Clarke
ordered a blood transfusion and two iron infusions.
“It was like
I walked into sunshine from a dark room,” Rodwell said. “Everything, in
hindsight, had been slower and more exhausting, both mentally and physically.”
The blood
test that erases iron-deficient women
A contentious
debate is playing out in clinics, laboratories and medical journals between
clinicians and researchers, raising the alarm about untreated iron deficiency
in women and their colleagues who don’t believe it’s an issue worth treating.
Editorial
Medical misogyny
Ignored
and dismissed, women raise voices against medical misogyny
The Herald's View
Editorial
“It’s
incredibly frustrating because iron is critical for multiple functions beyond
haemoglobin and red blood cells,” Clarke said.
But iron
deficiency alone can impair the body’s
cellular energy production.
“Iron is also
required for the production of our feel-good messaging in our brains –
serotonin and dopamine, which is how iron deficiency can be linked to depressed
mood,” Clarke said.
There is a
vagueness to some signs of iron deficiency (brain fog, fatigue) that medicine is not well-equipped to decipher.
Symptoms can
also include hair loss, headaches, easy bruising, restless leg syndrome, a
weakened immune system, and an eating or craving of dirt, paper, and ice.
A blood test
for ferritin – a protein that stores iron, mainly in the liver – is the most
sensitive indicator of a person’s iron stores.
National
guidelines by the Royal College of Pathologists Australia were updated in 2021
to define iron deficiency as a ferritin level below 30 micrograms per litre
(μg/L) for adults, eliminating a long-standing sex bias that meant women needed
to have significantly lower ferritin levels than males to be diagnosed. Some
pathology services, including Laverty, 4cyte and NSW Health Pathology use the
same.
But other
pathology providers, as well as the Australian Red Cross LifeBlood, still define
iron deficiency as below 15μg/L for women. The variation means that for women
whose ferritin level falls in the no man’s land between 15 and 30μg/L, getting
diagnosed (and having a chance of treating it) can depend on which pathology
service draws her blood. It’s a global problem.
Estimates
suggest between 25 and 50 per cent of iron-deficient women are missed using
15 μg/L as a cut-off.
“I am seeing
woman after woman who tell me that their iron results are always normal,” said
Uppal, Australia’s appointee to the International Federation of Gynaecology and
Obstetrics Committee on Menstrual Disorders and Related Health Impacts.
“I say, ‘No,
your ferritin is 18. You have been iron-deficient for years’.
“Using lower,
inconsistent cut-offs for women only perpetuates gender-based inequity and
delays care for a condition that is both common and treatable,” Uppal said. “It
is one of the reasons women with heavy menstrual bleeding can suffer and not
get timely medical care.”
Setting reference
ranges is not an exact science. But pathology sector insiders said the decision
to set a lower floor for women comes down to the concern that too many women
would be diagnosed as iron-deficient.
Up to 34 per
cent of Australian women of reproductive age are iron-deficient – almost
tenfold the proportion of iron-deficient men (3.5 per cent), according to an
analysis of ABS data.
“It’s sexist.
There’s no way around it,” said one pathology service employee not authorised
to speak publicly.
Hamad said,
“people will say, well, the World Health Organisation used 15 μg/L as the lower
threshold. But WHO uses 15 [μg/L] for all adults and has to cater for
services operating in some very limited-resource countries, so why are
pathology services cherry-picking 15 for women and 30 for men?”
Chief medical
officer for major pathology provider Douglass Hanly Moir, Adjunct Professor
Annabelle Farnsworth told this masthead that after months of discussion, its
laboratories will stop using 15μg/L as the cut-off for females, and instead use
30μg/L for all adults from September.
“It is
completely the right thing to do,” Farnsworth said.
A
spokesperson for SydPath, which also uses the lower floor for females, said its
ferritin range was under review and its ranges would be updated to align with
the RCPA’s.
Lifeblood’s
medical director of pathology services Dr James Daly said the service was in
the planning stages of changing the lower ferritin threshold for female donors
to 30μg/L.
Research analysing other markers of iron deficiency suggests that
even 30μg/L is too low.
The gold
standard (but invasive) test that involves using a blue stain to visualise iron stores in bone marrow indicates 50 to 100 μg/L is the “sweet spot”, Hamad said.
‘Is this
just in my head?’
It would take
almost two years, countless doctors’ appointments, and the intervention of her
father before Kate Burns was diagnosed with the condition for which she had all
the hallmarks. Iron deficiency was just the precursor.
Burns was a
21-year-old with a deep trust in healthcare professionals when she started to
believe that she might be a hypochondriac.
She had
intense, almost constant headaches, waves of fatigue and extreme dizziness.
“My reflux
was so severe I couldn’t lie flat. I had to prop up one end of my bed with
chunks of wood,” Burns said.
The talented
lacrosse player who had travelled solo overseas could no longer stay awake for
the train ride to her university, walk upstairs without feeling dizzy and
breathless, or keep up with her coursework. She was in almost constant pain and
had lost an alarming amount of weight from her already slight frame.
But when her
CT scan came back clear, her doctor intimated that she was exaggerating her
symptoms, Burns recalled.
She told two
GPs that the medication they had prescribed for reflux wasn’t working after
several weeks of persisting.
The first
doctor told her that she was overreacting, the second diagnosed her with anxiety and suggested she take
antianxiety medication.
“I just burst
into tears,” Burns said. “I went away questioning my sense of reality.”
When her
blood test results showed her ferritin level was 6μg/L, indicating iron
deficiency, her doctor told her to take iron tablets, but they exacerbated her
reflux and nausea, and caused severe gut pain, Burns said.
“I’d been so
unwell for a year now, and no one was listening to me,” Burns said.
“I was this
shell of a human being … I would describe how drastically my life had changed
to doctors, and it didn’t make any difference.”
Research
analysing the use of iron supplements shows that by the time clinicians tell
women to take them it’s often too late.
“We know it’s
poorly absorbed, so we advise them to take it on an empty stomach and every
day. That just increases gastrointestinal side effects, reduces compliance and
sets it up for failure,” Clarke said.
Meanwhile,
some iron supplements marketed as causing fewer side effects don’t contain
enough absorbable iron to be effective, Hamad said.
“This annoys
me because it’s a waste of money, generally for women, and a form of financial
toxicity,” she said.
Kate Burns’
father, Mark, recalls her asking: “Dad, is this just in my head?”
“I would say,
‘What are you talking about, Kate? No, you’re unwell, look at you’,” he said.
“Seeing her
world crumble … as a father, it tore me to pieces.”
He described
coming home one evening to find his daughter deeply distraught and in pain.
“I said,
‘That’s it. I’m coming with you to the doctor’,” he said. “We saw a new GP and
I insisted on some blood tests.”
Her ferritin
was again 6μg/L. Further tests confirmed coeliac disease – a common cause of
iron deficiency. Her body was not absorbing iron, calcium and other essential
nutrients from her food.
Burns’ GP
told her to stop eating gluten, take iron tablets, and directed her to a
coeliac disease information website.
She
discovered on her own that she needed an endoscopy to confirm the coeliac
diagnosis and a bone density scan to assess the damage.
It took Burns
two years to convince a doctor to prescribe an iron infusion – the most
effective treatment for replenishing iron stores.
“They would
just push the iron supplements” that only exacerbated her symptoms, she said.
Mark Burns
can’t help but wonder whether Kate could have been spared the ongoing anguish
of multiple autoimmune conditions triggered by her untreated coeliac disease if
her doctors had intervened earlier.
“She has lost
so much in her life,” he said.
From iron
flood to a pregnant pause
Heavy
menstrual bleeding (HMB) is considered the leading cause of iron deficiency.
Defined as excessive menstrual blood loss which interferes with the woman’s
physical, emotional, social and/or material quality of life, occurring alone or
with other symptoms, it affects about one in four women of reproductive age.
Every month,
these women lose a flood of blood (and iron) that seeps through their clothes
or multiple forms of sanitary products, and pass clots larger than a 50-cent
coin.
Studies
suggest up to 60 per cent of women with HMB have severe iron
deficiency, and half have not seen a doctor about it. No underlying cause (such
as polyps, fibroids, adenomyosis, uterine or blood disorders) is found in about
half of the cases investigated.
“These are
staggering statistics,” said Uppal, who is also co-vice president of the Bleed Better initiative
that helps co-ordinate the International Heavy Menstrual Bleeding Day (May 11).
It aims to destigmatise HMB and raise awareness about available treatments.
“This is
clearly a huge unmet clinical need and a public health issue,” Uppal said of
the underdiagnosed condition.
Iron infusion
is recognised as the most effective treatment for replenishing iron. But using
iron infusion to treat pregnant women without anaemia is a contentious issue
among obstetricians and gynaecologists. A lack of robust research underpins
this.
Estimates
suggest as many as 70 per cent of pregnant women in their third trimester are
iron-deficient. Pregnant women need an additional 1 gram of iron throughout
their pregnancy.
“You have
some obstetricians who underplay the role of iron deficiency and are only
interested once the woman becomes anaemic, and screening for iron deficiency is
not uniform,” Clarke said.
The
reluctance to use iron infusions is “a historic hangover”, Hamad said, “from
decades ago, when there were problems with preparations, including allergic
reactions, and the culture carried through to today”.
Dr Nisha
Khot, president-elect of the Royal Australian and New Zealand College of
Obstetricians and Gynaecologists, said the vast majority of obstetricians and
gynaecologists recognise iron deficiency and will treat it.
“[But] it’s
very hard to tease out whether they are caused by iron deficiency or if they
are feeling this way because they are pregnant,” Khot said.
The scarcity
of access to infusions and the common side effects of oral iron supplements
(particularly for pregnant women) make managing iron deficiency very
challenging, she said.
“It’s an
issue of rationing,” Khot said. “We can’t provide everyone with an iron
infusion as and when they need it.
“Within
public hospitals, you can often say: ‘yes, this pregnant person needs an iron
infusion’, but there just isn’t the capacity to give them [one] in a timely
manner in all cases.”
Clarke, Hamad
and Uppal were involved in the development
of an unendorsed consensus statement to address the issue of untreated iron
deficiency in pregnancy.
The
statement recommends:
- All pregnant women should be offered
a blood test to check their iron and a full blood count in early pregnancy
and again at 24 to 28 weeks.
- Women with ferritin levels below
30μg/L should first be offered oral iron supplements.
- Women in the second and third
trimester who are low in iron, can’t tolerate oral iron or have tried
without improving, should be offered an iron infusion.
Khot said
most obstetricians would feel uncomfortable giving pregnant women an iron
infusion after only four to six weeks of taking supplements.
Iron
infusions come with a risk – though very rare – of anaphylactic reaction, she
said, as well as skin staining (a brown iron mark if the cannula is incorrectly
inserted).
“What we want
is some clear guidance on how to diagnose and manage iron deficiency,” Khot
said.
It all
adds up
Iron
infusions can also be prohibitively expensive. There is no Medicare subsidy.
Patients pay $200 to $700 per treatment if they can’t get a referral to the
limited public hospital infusion services.
At Dr Rebekah
Hoffman’s general practice in Sydney, about 90 per cent of iron infusion
patients are females, from teenagers through to pregnant and perimenopausal
women.
“Most of our
patients have heavy menstrual bleeding. They literally bleed out their iron
every single month, so much so that their bodies are just not able to keep up,”
said Hoffman, who is the NSW and ACT chair of the Royal Australian College of
General Practitioners (RACGP).
Hoffman’s
patients pay $200 to $300 out of pocket for an infusion every two to three
years.
“That adds
up,” she said. “There needs to be improved funding to cover iron infusions,
whether that be for GPs, for hospitals, for outpatient care or for private
hospitals.”
The RACGP has
been lobbying the federal government to introduce a $200 rebate for iron
infusions.
In response
to questions from this masthead, Federal Health Minister Mark Butler said he
had asked the Medical Services Advisory Committee to look at a Medicare item
for iron infusions in general practice.
“The Albanese
government is tackling sex and gender bias in the health system and
improving health outcomes, particularly for women at greater risk of poor
health,” Butler said in a statement.
“Women have
asked government to take their healthcare seriously, and we have listened,” he
said.
Here is the link:
https://www.theage.com.au/national/gaslit-dismissed-and-treated-as-hypochondriacs-the-gender-divide-in-iron-deficiency-20250729-p5mioa.html
It is amazing this is ever missed
given the suffering it can cause and how easy it is to correct!
My advice, If a women looks even a
little pale or lacks good exercise tolerance just check here Hb!
You can be a hero!
David.
