Q. Can there be no menses when anemic?

Answered by
Dr. Prakash H Muddegowda
and medically reviewed by Dr. Sneha Kannan
This is a premium question & answer published on Feb 26, 2016 and last reviewed on: May 20, 2019

Hi doctor,

I am a 40 year old woman. I had hysterectomy 4 years back.  Now, I have no periods or blood loss of any measure. I am having balanced diet with plenty of meat and kale chips. Since 3 months, I have started taking raw food and prenatal vitamins because of cracks in mouth that would not heal and it seemed like hair was falling out. After over a year of severe insomnia, exhaustion, mouth sores, constant itchiness and RLS issues that made my husband wonder, I went to my doctor last week wondering if it could be hypothyroid. As I have not had periods since 4 years, I did not suspect any anemia. Doctor has done two CBC's. The second one had even lower hemoglobin and hemotocrit levels. My last CBC that was taken 4 years back showed a hb of 14.4 but vitamin B12 results were within normal range. I am attaching all my reports for your reference. Please guide.

Dr. Prakash H Muddegowda

Geriatrics Hematology Pathology


Welcome to icliniq.com.

Based on your query and reports (attachments removed to protect patient identity), my opinion is as follows:The low hemoglobin at present is not due to blood loss, it is nutritional. If you look at the iron studies, the iron levels are very low, indicating inadequate iron in body. They can be possibly secondary to reduced intake and may be a cause of malabsorption.

As the other vitamin levels are normal, it is more likely reduced iron intake or absorption. The reticulocyte count would increase in case of anemia, if the nutrition too improved. It is staying within the normal range. If you start iron supplements along with vitamin C (for better absorption of iron), you will find your reticulocyte count increasing within 2 weeks.

There is no hemolysis or hemorrhage, as in both conditions, if nutrition was adequate, the reticulocyte count would have also increased. At present, all studies including red blood cell volume distribution (RDW), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) are iron studies that are pointing towards iron deficiency. Good to know your thyroid profile is good.

Insomnia and exhaustion can be easily explained by anemia. Also improve the hydration (take at least 5-6 liters of water per day). Avoid coffee or tea along with food, as it inhibits iron absorption. Adding citrus fruits or vitamin C rich diet during food intake improves iron absorption.

At present, nothing to worry except iron deficiency. Supplements of iron with iron fortified food and iron-rich diet should help. Also, take vitamin B-complex supplements, as early changes like ovalocytes are also seen in blood. Both iron and vitamin B-complex supplements to be taken, and within two months, you will return to your normal self.

Investigations to be done:

Repeat the reticulocyte count after 15 days to check if it is increasing.

Treatment plan:

1. Both iron and vitamin B-complex supplements to be taken.
2. Most importantly iron-rich foods to be taken along with vitamin C supplements.

Preventive measures:

1. Iron-rich diet, iron fortified foods.
2. Balanced diet and good hydration.

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