Danielle Francis says, "Reasons ferritin would be low, 15 nanograms per milliliter, when
hemochromatosis iron overload is present, very high transferrin saturation serum and
low unbound iron binding capacity.
When treating, I get overload by a blood loss in the past and ferritin continued to drop."
Danielle, I answered a very similar question in the last AMA from Chris Merrill.
I'll answer this, but I would encourage people who are interested in this question, you also
listen to the last AMA to get some extra details there.
Ferritin is your long-term iron storage.
Transferrin is your short-term iron storage.
The problem with hemochromatosis is that usually in a normal functioning system, there is a
hormonal regulatory system that prevents you from absorbing iron from food when you have
enough iron that when you have too much iron, shuttle the iron into ferritin which is protective
both against pathogens eating the iron to grow and against oxidative stress, which free
iron causes, which if you don't know the details about can be thought of as wear and tear on
your tissues over time.
In hemochromatosis, normally the way you judge how much iron you have is in the circulating
transferrin pool, which is your short-term storage.
How full is it?
The defect in hemochromatosis is that when the short-term storage, transferrin, starts
getting fuller than usual, you don't notice it, so you don't stop absorbing iron from
food that makes the transferrin saturation go up even further.
But you don't shuttle the iron into ferritin.
That makes ferritin lower.
What people get confused by is that historically, we have only paid attention to hemochromatosis
when it's too late, when the person has been suffering for it from 30 or 40 years and they
need organ transplants.
What happens at that point is that the ferritin is very, very high.
Why is the ferritin high?
Not because you had too much iron.
The person without hemochromatosis has the ferritin go up when they have too much iron.
The defect in hemochromatosis is that you do not stop absorbing from food when you have
enough, and you do not put the iron into ferritin when you have too much.
The reason that ferritin is high in someone who's had hemochromatosis for 30 or 40 years
is not because they have too much iron.
It is because they have oxidative stress and damage caused by that iron.
Oxidative stress and damage cause ferritin to go up no matter how much iron you have.
So does infection, no matter how much iron you have.
Essentially, what you have is ferritin is not the fireman that he should be to put out
the fire as it starts, and the smoke detectors go off.
Ferritin hemochromatosis is the cleanup crew who got to the fire after the house burned
down.
The question is why would ferritin be low in hemochromatosis iron overload when transferrin
saturation is very high?
The answer is because you haven't had hemochromatosis for 40 years.
If these are your results, then you are female.
I'm not sure of your age.
But in general, females, compared to males, are powerfully protected against iron overload
because of the blood loss that occurs during menstruation.
If these are female data, then you're like 20 or 30 years behind a man of the same age.
Even for a postmenopausal female who's 65, there's like 30 years, and I know there's
variation in blood loss through the degree of menstrual flow but still.
Just take the average female.
The average female at 70 years old is like if they have hemochromatosis, they're like
a man who's 30 with hemochromatosis.
That's barely the beginning of problems starting to arise because Danielle is 27 and the midwife
is concerned about her levels.
Danielle, like a man who's 27 who has hemochromatosis at genetics, would never be diagnosed with
hemochromatosis by the standard conventional historical criteria because it's just not
bad enough yet.
A woman who's 27, of course your ferritin is going to be low because you're looking
at this happening 40 years before you would see the blood markers that are expected.
I don't know who diagnosed you with hemochromatosis, but probably you're looking at the genetics
and you're looking at the blood markers that I recommend.
You're looking at it way before the fact.
Should you be concerned about the ferritin?
Well, look, first of all, I'm not a doctor and so you have to not take my answer as treatment
and pregnancy management advice.
But I'll answer this in the context of what I would do myself if I were in that situation.
If I were in that situation, knowing what I know about iron physiology, I would be assuming
that the low ferritin is not indicating that your total body iron storage is low.
It's indicating a problem with the feedback loop.
My suspicion is going to be that your thyroid is probably fine, which would not be fine
in iron deficiency, and that your hemoglobin and your red blood cell count is probably
fine, which it would not be an iron deficiency.
I would not be donating blood leading into the pregnancy.
I don't know what the recommendations around pregnancy are in this, but I imagine that
you would want to have the full capacity of your body at your disposal.
I wouldn't do anything, depleting anything leading into pregnancy unless it was strongly
warranted.
But would I be worried that my ferritin was low?
Not the ferritin, but I would probably look at my thyroid markers and I would look at
a complete blood count to make sure that I wasn't anemic and I wasn't hypothyroid.
But I wasn't anemic and I wasn't hypothyroid, I would conclude that the low ferritin was
not an issue.