Anemia? Low RBC, Normal Ferritin

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  • #53496
    Melanie Hunter

    On the topic of anemia–I have had lifelong issues with low hemoglobin/hematocrit/RBC, but my ferritin levels are typically around normal. (I remember being told I was anemic and given iron pills when I was little kid. Tip: Do not chew these. Even if you are a 5-year old.)

    I’m now in my late 40’s and have been extremely active and borderline anemic, with bouts of unusual fatigue, my entire life. My latest blood work I had hemoglobin of 11.5, ferritin of 54 ng/ml, but still a slightly low red blood cell count of 3.74 (with a reference range of 3.77-5.28 x10E6/uL).

    I am posting because I have never gotten a satisfactory answer as to 1. whether this is a concern and 2. what, if anything I should do about it. (As noted in other posts in this forum, I have found that including red meat in my diet is effective to raise hemoglobin and hematocrit where supplementation had no effect.)

    Does anyone have any experience with/insight into this pattern?

  • Moderator
    Thomas Summer, MD on #53506

    Hi Melanie!

    Was there ever any additional blood work done? MCV, MCH, Vit B12, Folic acid, CRP…

    As hemoglobin is measured in g/dl it is also depending on plasma volume. So the more water the more “dilution” which means relatively less red blood cells per dl. So there are things like hydration status to consider. And especially, that with lots of endurance training you increase your total blood volume. But your body increases the plasma volume more than the red blood cells. So this means that the blood gets relatively more “diluted”. That’s not a bad thing, but actually good. If you are doing a lot of endurance training that could be the case for you, as your hemoglobin is only slightly below normal values.
    There are many reasons for “unusual fatigue”. Maybe it’s even not so “unusual” when you are “extremely active”!?

    hope that helps?

    and better chew some red meat than the iron pills;-)


    Melanie Hunter on #53510

    Hello Thomas–

    Thanks for taking the time to respond! MCV and MCH are always normal (93fL and 30.7 pg, respectively, for this last round of testing), and my CRP is always in the 1.5 mg/L ballpark. I’ve not had B12 and folic acid tested recently, but those were normal at last check, too.

    Your explanation regarding the increased plasma volume associated with endurance training is really helpful. So–is it reasonable to assume that my usually very good hydration status could also be a contributing factor to slightly low RBC?

    Years ago I was an Army pilot and anemia can be a career-ender; I’ve been through many, many tests, but I’ve never understood whether I truly had an issue or not. They made such a big (unpleasant) deal of it, though, that I started worrying that any time I was tired, that was the reason.

    Thanks again!

    LindsayTroy on #53537

    Hey Melanie-

    What I’ve learned from my two-month long journey through the world of iron deficiency (w/o anemia) is that you treat the patient not the numbers. So if you’re feeling symptoms, the recommendation is to treat it, but if you are feeling ok then its best(?) or at least ok-est not to treat.

    You didn’t ask this, but I’ll say it anyways. I had a call with a dietician to help get my dietary iron up and the recommendations were: cast iron pans, 3 daily sources of food iron (dark leafy greens, fortified cereal, or tofu/other fortified protein since I’m veg) with a serving of vitamin C. My sister in law who is a dietician recommended an iron fish so I’ve also been using that (although not while on iron pills)

    Good luck!

    Thomas Summer, MD on #53550

    Hey Melanie!

    A Ferritin of 54ng/ml is pretty sure not the cause of anemia. But it’s possible that it causes symptoms. But as I wrote: there are many other causes for fatigue.
    How was your Ferritin in the past? Did you feel better with higher numbers?

    Dilution can be a contributing factor. That’s why it is best to take the blood in a fasted state in the morning.


    russes011 on #53613

    Hi Melanie,

    Recurrent fatigue is a tough one to figure out. As Thomas mentions, it can be associated with a variety of different conditions, some pathologic, most not. For example, it could very likely be unrelated to your mild anemia–perhaps this anemia has even distracted some medical professionals in the past from exploring other more subtle causes.

    I believe the episodic nature of the fatigue you describe may be the key to figuring it out over time. This sounds like a pain in the butt, but keeping a journal of your diet, fatigue, sleep, stress, thoughts, and training levels may allow you to associate certain training volumes, intensities, foods, stressors, seasons, etc. with when these episodes of fatigue occur. Then you could hone down on possible associations and explore them with the appropriate professional (like a dietitian if you think it may be diet related, or a coach if it’s training related). And when one lead doesn’t pan out, try a different one. You may have already done all of the above, or some of it in part.

    It appears that you have monitored all your blood tests and there doesn’t seem to be any significant deficits. As Thomas alluded to there can be mild, non-pathological changes to some blood tests with heavy training, including thyroid function. I’m not sure if you’re in America, but if you are, the medical system is unfortunately not really set up for such a holistic, activity-related evaluation that you may be looking for. There are probably some healthcare professionals that do this, but they may be hard to find.

    I understand I haven’t given much concrete advice, but I do wish you well in figuring out what can be quite a perplexing issue. At least it seems it hasn’t prevented you from being very active during your life thus far. And thank you for your military service. I always wanted to be military pilot when I was young but got rejected, in part, because I had a color deficiency in red.

    — Steve

    Melanie Hunter on #53620

    Hi Steve,

    Ah yes! Those red/green vision test cards are tricky even when you do have good color vision. And thank you for your kind words. It was a valuable experience on many levels.

    I appreciate your reply; you say you did not offer concrete advice, but you offered an astute read of my situation and validated my inclination to keep trying. I’ve been through a great deal in trying to get to the bottom of this, not least of which is wondering why I sometimes don’t seem to recover normally (a friend of mine once said to me “you’re like Wonder Woman most of the time but then you just DIE for a while). Back before everyone had iPhones and laptops I used to draw myself spreadsheets on notebook paper to track blood work, diet, sleep, training. I’m to the point now that I can almost guess what my blood work will look like based on how I feel, (Thomas–it’s not that I feel better at the higher numbers but more that I feel bad when they drop) but this low hemoglobin and occasional deep fatigue continue to confound me. Name a non-invasive approach to address this, I’ve tried it.

    Gosh, yes, the American health care system is certainly not set up to help someone parse this type of issue; as for the U.S. Army medical system…my experience as a young woman trying to retain my flight status dealing with Army doctors was very hard.

    But to focus on the positive, your response helped me decide to at least set up a consult with Rebecca Dent. I’ve listened to the podcast with her as well as hearing her on the female uphill athlete group calls and she knows her stuff!

    Lindsay, thank you for responding! Unfortunately, none of those approaches you mentioned ever moved the needle for me–only red meat has ever made a difference in both my blood work and how I feel–but, as you note, everyone is an individual.


    Thomas Summer, MD on #53633

    Hi Melanie!

    A consult with Rebecca is a very good idea.
    Have you ever worked with a coach? For us very driven athletes, it is sometimes very helpful to have someone to hold us back (trust me, I know what I’m talking about;-))


    LindsayTroy on #53657

    Lindsay, thank you for responding! Unfortunately, none of those approaches you mentioned ever moved the needle for me–only red meat has ever made a difference in both my blood work and how I feel–but, as you note, everyone is an individual.

    Melanie- I’ve heard this a lot as I’ve talked with other female athletes about it and as a long time vegetarian I’m really REALLY hoping this isn’t the case for me. (I have 2 more months to my first follow up bloodwork).

    Best of luck!

    Thomas Summer, MD on #53667

    The big question is: why would someone restrict their diet? I know many athletes who are too rigid with their diet. And for most of them, it causes problems. Even up to severe eating disorders. I think it is important to be aware of this problem…

    felixallenrunner on #67804

    Hi Melanie

    Did you get anywhere with the above situation? A few years ago I had become anemic by suspected foot strike hemolysis. It was when my 10k time went down by 6 minutes that I decided to get a blood test and found out. I had an iron infusion and was a changed man very quickly.

    But now I find myself in a situation where my feritin levels are ok but my red blood cell count is way below expected range. An infusion isn’t the answer this time and I don’t now what is.

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