You can be iron deficient long before you are anaemic — and ferritin is what shows it.
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Iron deficiency is the commonest nutritional deficiency in the world, and one of the commonest causes of persistent tiredness in the UK.
Crucially, you can be significantly iron deficient before your haemoglobin drops — the body depletes its stores first. A normal full blood count therefore does not rule it out, which is why ferritin needs measuring separately.
Iron stores empty before haemoglobin falls. That single fact explains most of the confusion here — you can be substantially iron deficient with a completely normal full blood count.
"Your blood count was fine" does not mean your iron was checked. Ferritin is a separate test and is frequently omitted.
Most UK laboratories flag ferritin only below about 15. In practice symptoms commonly appear below 30, and for hair shedding and restless legs many clinicians treat towards above 50.
A ferritin of 18 can be reported as normal and be the explanation at the same time.
Ferritin rises with any infection, inflammation or liver problem. A reassuring ferritin alongside a raised CRP can conceal genuine deficiency.
Which is why inflammatory markers are requested alongside — ferritin read in isolation is a number that can lie. Transferrin saturation is useful where the picture is muddied, and below about 20% supports deficiency.
The panel establishes that you are deficient. The cause determines what happens next, and it matters far more than the number.
Ferritin with a full blood count gives the complete picture — stores and haemoglobin together. Inflammatory markers are worth measuring alongside, since inflammation falsely raises ferritin and can mask a real deficiency.
Treatment is iron replacement, and the practical detail matters: alternate-day dosing is better absorbed and better tolerated than daily dosing, taken with vitamin C and away from tea, coffee and calcium.
The cause matters more than the number. Iron deficiency in a man or a postmenopausal woman needs investigating for a gastrointestinal source — we will say so directly and arrange referral.
Seek urgent care for chest pain, severe breathlessness or fainting with anaemia.
Black tarry stools, visible blood in stool, or vomiting blood need same-day assessment.
Black stools are normal and harmless on iron — alarming if nobody warned you. Black tarry stools with a foul smell are different and need assessing.
Constipation is common and usually manageable with fibre, fluid and alternate-day dosing.
Longer than most people are told — at least three months after the haemoglobin has normalised.
The point is refilling the stores, not correcting the count. Stopping as soon as the blood test improves is the commonest reason deficiency returns.
Diet alone rarely corrects an established deficiency, though it maintains stores afterwards.
Haem iron from meat and fish absorbs far better than plant iron. With plant sources, vitamin C alongside makes a real difference — and a cup of tea with the meal undoes much of it.
Iron tablets cost a few pounds over the counter, and NHS investigation of the cause — which is the part that matters most — is free.
Iron tablets cost a few pounds over the counter, and your NHS GP will test and treat iron deficiency free.
The single most valuable thing on this page is that ferritin has to be asked for specifically. A normal full blood count does not exclude iron deficiency — stores fall long before the haemoglobin does, and iron deficiency without anaemia causes exhaustion, breathlessness, poor concentration and hair loss for months or years before anyone tests for it.
Where a private consultation genuinely earns its fee is arranging that test quickly, and interpreting it properly — ferritin rises with any inflammation, so a normal result alongside raised inflammatory markers can still mask deficiency.
The practical advice that costs nothing and changes outcomes: alternate-day dosing absorbs better than daily dosing, which is counterintuitive and now well supported; take iron with vitamin C; and keep it away from tea, coffee, calcium and indigestion remedies, all of which block absorption. Continue for three months after the haemoglobin normalises, to refill stores — stopping too early is why it recurs.
The point that matters most is not the iron, it is the cause. Unexplained iron deficiency in a man, or in a woman past the menopause, warrants bowel investigation — treating the deficiency without asking why is how bowel cancer gets missed.
NICE Clinical Knowledge Summary, Anaemia — iron deficiency, and NICE NG8 for chronic kidney disease anaemia, are the principal references. CKS recommends serum ferritin as the primary test for iron deficiency, noting it is an acute phase reactant and may be normal or raised despite deficiency where inflammation is present.
CKS recommends continuing oral iron for three months after haemoglobin normalises to replenish stores.
Evidence on alternate-day dosing, reflected in BSG and haematology guidance, shows improved fractional absorption compared with daily or twice-daily dosing, with fewer side effects.
BSG (British Society of Gastroenterology) guidelines on iron deficiency anaemia recommend gastrointestinal investigation in all men and postmenopausal women with confirmed iron deficiency anaemia.
NICE NG12 lists unexplained iron deficiency anaemia among the criteria for urgent suspected cancer referral.
Yes, and it is common. Stores empty first; haemoglobin falls later.
Ask specifically whether ferritin was measured — it usually is not part of a standard blood count.
Look at the actual number rather than the word. Symptoms commonly occur below 30, and hair shedding and restless legs often need it above 50.
Also check whether inflammatory markers were done — a normal-looking ferritin with a raised CRP can hide real deficiency.
Because in a man, or a woman past the menopause, iron deficiency is a red flag for bowel bleeding until proven otherwise.
Supplementing without investigating can mask a serious diagnosis for months. We will say so rather than simply hand over tablets.
Taking iron raises a hormone called hepcidin, which blocks absorption of the next dose for around 24 hours.
So alternate-day dosing absorbs more overall and causes fewer side effects — better results from less medication.
Expected and harmless on iron.
Black, tarry, foul-smelling stools are a different thing and need same-day assessment.
Test rather than assume. Plant iron absorbs less well, so deficiency is commoner — but supplementing blind is a bad idea in anyone who might have haemochromatosis.
Pair plant sources with vitamin C and keep tea away from meals, which makes a measurable difference.
Usually inflammation, alcohol or fatty liver rather than iron overload.
Persistently high levels warrant looking at, including for haemochromatosis — an inherited condition where taking iron is actively harmful.
They are the leading cause in menstruating women, and they are frequently normalised.
Periods that soak through protection hourly or contain large clots are not simply heavy — they are treatable, and treating them fixes the iron problem at source rather than topping it up indefinitely.
August 23, 2026
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