Iron Deficiency Day: Q&A with UPHS – Portage Hematologist & Oncologist Charles Goodwin, MD

November 26 is Iron Deficiency Day, aimed at raising awareness for people living with iron deficiency and iron deficiency anemia. To help further spread awareness and educate our community on symptoms, treatments and the important role a hematologist can play in managing blood disorders, we did a Q&A with UP Health System – Portage Hematologist and Oncologist Charles Goodwin, MD.

Q: Explain your role as a Hematologist:

A: Hematology is the clinical specialty focusing on the diagnosis and treatment of blood disorders, which includes conditions that could cause a person to have too few or too many of a particular blood cell type. For example, anemia is a condition in which a person has too few red blood cells, while polycythemia (or erythrocytosis) is a condition in which a person has too many red blood cells. Hematology also includes conditions that affect the clotting system, such as disorders where a person is unable to make clots effectively and therefore is at risk for bleeding, versus conditions where a person makes clots too easily and is at risk of developing painful and potentially dangerous clots in the veins in their lungs or legs. All of these abovementioned conditions are part of what is called “benign hematology” or “classical hematology.” There is also the field of “malignant hematology” which involves cancers of the blood systems, such as leukemias, lymphomas, and multiple myeloma. I treat both benign and malignant hematology conditions. Historically, oncology (treatment of cancers) and hematology have been paired together so that doctors interested in these specialties are often trained in the management of both and often practice in both areas.

Q: Why did you choose to pursue this specialty?

A: I originally became interested in blood disorders in graduate school while doing research on leukemia and stem cell biology. As I pursued my medical training, I found that I was just as interested in the clinical management of blood disorders as I was in the underlying science, so I decided to make it my area of specialization along with oncology.

Q: What are some common blood disorders you treat and what symptoms can the public be on the lookout for?

A: Anemia is probably the most common blood disorder I treat. Again, anemia is the condition of having low red blood cells, but clinically, we define anemia as the laboratory measurement of low hemoglobin. Hemoglobin is the iron-containing oxygen-carrying protein complex in red blood cells that allows red blood cells to do their job, which is to pick up oxygen from the lungs, where oxygen gets into the bloodstream, and to deliver it to all the tissues of the body.

The most common symptoms of severe anemia are fatigue and the feeling that you can’t seem to catch your breath. The fatigue of anemia is not really sleepiness or the feeling that you are about to fall asleep (i.e., not “yawning” fatigue). It is generally more of a lack of energy or stamina—for example, if you are trying to do something physical like mop your kitchen floor or mow your lawn, you have to take breaks to catch your breath and get your energy back. I should stress that anemia is not the only cause of fatigue, and many other potential causes should not be ignored. 

People who notice bleeding such as blood in their stool or black, tarry, sticky stools, or heavy menstrual bleeding (periods lasting longer than five to seven days or needing to change menstrual products very frequently, like every two hours) are at increased risk of anemia, especially anemia caused by low iron levels. Individuals with those concerns should see their primary care providers. “Appearing pale” is very subjective and I don’t think that is a helpful indicator of anemia. Finally, a classic (though not very specific) symptom of severe iron deficiency is the compulsive need or desire to chew on ice, which is called “pica.” Multiple other causes of anemia may have other particular symptoms as well.

Blood clots in the legs or lungs are also commonly seen in my clinic. The symptoms of lung clots would include chest pains and problems breathing while the symptoms of clots in the legs would include leg swelling and pain. Clots, particularly in the lungs, can be dangerous or even life-threatening, so any concerns for lung clots should be promptly evaluated in the emergency room with initiation of blood thinning medications if a clot is found.

Q: What causes anemia and how is it treated?

A: Anemia is the condition where there are too few red blood cells, but again we clinically define this as low hemoglobin levels, as described above. Anemia can be due either to decreased production of red blood cells or increased loss of red blood cells. Decreased production of red blood cells can be due to (1) deficiencies in the “ingredients” needed to make red blood cells such as B12 or iron; (2) decreased signal from the body telling it that it needs to make more red blood cells, usually as the result of severe kidney disease or severe inflammation; or (3) problems with the bone marrow itself where all red blood cells are made, which can be due to genetic conditions that interfere with normal red blood cell production, certain medications or toxins, or blood cancers or bone marrow failure conditions. Increased loss of red blood cells can be due to (1) bleeding or (2) destruction of the red blood cells caused either by the immune system attacking the red blood cells or genetic conditions that cause red blood cells to be inherently more fragile or delicate. 

The treatment of anemia depends on identifying the underlying cause (or causes) and treating it appropriately if possible.  If the cause of anemia is bleeding, then the treatment is stopping the bleeding. If the cause is a deficiency of B12 or iron, then it is replacing the B12 or iron. If the cause is immune-mediated destruction of red blood cells (or autoimmune hemolytic anemia), then it is suppressing the immune system with steroids and possibly other medications.  It is important to note that giving extra iron (or trying to eat more iron-rich foods) only improves anemia if the cause of anemia is due to iron deficiency and no other cause, just as putting more gas into the tank of a car with a dead battery isn’t going to get it running. 

Q: What can someone with anemia or low iron/ferritin levels do to increase levels and improve their health?

A: The first step to treating iron deficiency anemia is to confirm that the patient actually has anemia and, if so, that the cause of the anemia is due to iron deficiency and not some other cause. We clinically define iron deficiency anemia as (1) anemia (namely, low hemoglobin); (2) the presence of small red blood cells or “microcytosis” (The size of red blood cell is measured by MCV or mean corpuscular volume, so a low MCV would indicate small red blood cells.); and (3) evidence of low iron levels, such as low ferritin and low transferrin saturation (or Tsat). It is not unusual for individuals, particularly healthy individuals to have an isolated “low” ferritin without microcytic anemia (or anemia with small red blood cells), which might indicate at most mild iron deficiency but is really of no clinical significance. In common clinical practice, I worry that far too much emphasis is placed on ferritin levels without interpreting it in the appropriate clinical context. A low hemoglobin might explain a patient’s fatigue symptoms, while an isolated “low” ferritin does not. Patients with fatigue and “low” ferritin and normal hemoglobin and normal MCV probably do not have significant iron deficiency and their fatigue almost certainly has other causes, and interventions like iron infusions are unlikely to make them feel better.

On the other hand, patients who have true iron deficiency anemia associated with fatigue would benefit from iron replacement and/or supplementation. For patients with moderate to severe iron deficiency anemia, iron infusions can be very helpful, and oral iron supplementation with a standard over-the-counter iron tablet (325 mg, or 65 mg elemental iron), which is ideally taken one tablet every other day or a Monday-Wednesday-Friday schedule, which improves absorption and tolerance. Any more than that will not be better absorbed and will likely cause unwanted side effects like constipation or upset stomach.

A final point about true iron deficiency anemia is that in almost all cases, iron deficiency is caused by bleeding. Thus, an important part of the management of iron deficiency anemia should include identification and treatment of the source of bleeding, which could be obvious, such as heavy menstrual bleeding, or not at all obvious, such as an occult gastrointestinal bleed that should prompt evaluation with upper endoscopy and/or colonoscopy as appropriate. I tell patients with iron deficiency that they are like a bathtub with a leak, and that rather than just dumping more water in the tub, it would be much more effective to plug the leak. 

Q: Do genetics play a role in blood disorders?

A: Most blood disorders have no known genetic or inherited causes, but there are inherited causes of anemia, including thalassemia, sickle cell anemia, and hereditary spherocytosis. There are inherited conditions that increase the risk of clotting (such as Factor V Leiden and Protein S deficiency) as well as inherited conditions that increase the risk of bleeding (such as hemophilia and Von Willebrand’s Disease).  There are also blood conditions that are caused by acquired genetic alterations or mutations such as polythemia vera which results in excessive red blood cell production and essential thrombocytosis which results in excessive platelet production, both of which can be caused by acquired (i.e., not inherited) mutations in a gene called JAK2; testing positive for this mutation is part of making the diagnosis. 

Q: What are some of the biggest challenges of your role as a Hematologist and Oncologist?

A: The biggest challenge in hematology and oncology is helping patients navigate the ever-increasing costs of treatments and the increasing complexity of our broken healthcare system; I wish I had a fix for it and a better understanding of it myself sometimes.

Specifically, regarding anemia, the biggest challenge is helping patients (and providers) understand common misconceptions and myths about anemia, particularly when it comes to iron deficiency and how this all relates to fatigue. Fatigue is very common and there are dozens of causes for fatigue other than iron deficiency anemia.  Part of this is due to the over-emphasis on ferritin testing, which is only meaningful in the setting of microcytic anemia (and documented or suspected bleeding concerns). For a patient with fatigue and an isolated low ferritin (without a low hemoglobin), I would advise exploring other possible causes of fatigue, as it is unlikely that simply giving iron is going to make the person feel better. Unfortunately, just giving iron infusions (or B12 shots) to everyone is not going to be the fountain of youth that will make them feel better. Common causes of fatigue that are often overlooked and unaddressed include depression, obstructive sleep apnea, and lifestyle. Particular lifestyle issues that can be addressed to improve energy include regular exercise, good diet (low in fats and processed foods), and good sleep hygiene (regular sleep and wake times, avoiding screens at least an hour before bed, etc.). 

Q: What's the most rewarding part of your job?

A: I enjoy educating patients on their conditions. I believe that by helping patients understand the mechanisms of, for example, red blood cell production and iron metabolism, they can better understand a condition like iron deficiency anemia, its causes, and the rationale for the best treatments. I believe there is a therapeutic benefit when a patient can understand his or her condition.

Q: Anything else you'd like to share with our community about Hematology?

A: We are available and happy to help address any concerns about a patient’s blood system, so if they have any concerns in that regard, they should request a referral to our office from their primary care provider.