Last year, at the age of 39, Philippa O’Brien went to the doctor in search of some answers. She was exhausted, dizzy, losing her hair, experiencing brain fog and memory issues, palpitations, insomnia and anxiety, amongst other symptoms. When the GP suggested she might be perimenopausal, she wasn’t surprised — because truthfully, she had suspected she was too. “Perimenopause is quite well known now, isn’t it?” she says. “It’s a bit of a hot topic of conversation”. As an employment lawyer, it was a term that had risen to prominence in recent years in her work, alongside greater menopause awareness-raising. And as she and her female friends crept towards 40 it had started to become the word (and worry) on everyone’s lips. But when the doctor suggested getting a coil or starting hormone replacement therapy (HRT), the combined pill or anti-depressants to treat the symptoms, something made her pause. She couldn’t silence a niggling doubt that the diagnosis wasn’t quite the right fit, because in reality, these symptoms had been following her round on and off for the best part of two decades.
She put this to her GP who decided to order a range of blood tests, just to cover all bases. What she found was that her serum ferritin level (which measures a person’s iron stores) was just five. According to NICE guidelines, a level under 30 signifies iron depletion. When Philippa started looking into it, she noticed a trend — her ferritin had been under 30 in previous tests, going back years. She also had low B12, which the doctor told her indicated pernicious anaemia – an autoimmune condition that causes B12 deficiency, and often comes hand in hand with iron deficiency. “It was just a bit of a shock, really,” she says.
Soon after that she received an iron infusion, as well as treatment for the pernicious anaemia, and since then, a lot of her symptoms have either vanished completely or are steadily improving. “I’m so glad we did those tests,” she says, the relief visible in every corner of her face. She will continue to have these under the guidance of her doctor.If you are a woman and over 30, then the word “perimenopause” has probably been hitting your radar a lot over the past few years. This is an expressly Good Thing; until recently this, and all aspects of the menopause, were often relegated to hushed chats between friends and female relations. Something to be tolerated in silence, and piled with shame. Today, efforts over the past five to 10 years to raise awareness and normalise the experience have borne fruit — with high-profile journalists like Davina McCall and Emma Barnett regularly speaking about it, and advice abounding on the internet. But while it is great that this information is reaching more women, there are worries that the omnipresence of menopause has perhaps made us all (including doctors) a little too primed to diagnose it when there may be other, perhaps more obvious, factors at play.Andrea, from Bath, was 43 when she started to notice she was struggling to function. She tells me she had “all the perimenopause symptoms” including hair loss, extreme fatigue and migraines, as well as irregular menstrual cycles. Before starting her on HRT, her GP first suggested they take her bloods, and found that her ferritin level was 16. “My very excellent doctor suggested tackling the iron first and then going from there, so I started taking iron tablets,” she tells me. They took a while to kick in, she says, but after about three months she felt completely different and, apart from slightly irregular periods, all the other symptoms she had put down to perimenopause had pretty much gone. “So glad I didn’t just jump straight to HRT!” she tells me.Iron deficiency affects almost one in three women in the UK, according to research published in the Lancet in 2025. With wide-ranging symptoms including (but not limited to) dizziness, extreme fatigue, brain fog, shortness of breath, palpitations, tongue sores and strange cravings, as well as memory issues — iron deficiency is chronically underdiagnosed (and undertreated) in the UK, according to Dr Sue Pavord, a consultant haematologist for the NHS and president of the British Society for Haematologists (BSH). As a result, she says that she often sees patients whose symptoms have previously been thought to indicate the onset of perimenopause, but later prove to be either improved or eliminated after any identified iron deficiency is treated. “Many of these symptoms can occur with both iron deficiency and menopause,” she tells me, adding that “there is a high prevalence of iron deficiency amongst young women, due to pregnancies and regular periods”. The good news is that prolonged iron deficiency won’t cause lasting damage that is not reversible, according to Pavord. “When corrected, the body cells will start working again”. But that doesn’t diminish the significant impact on the quality of life of patients in the meantime. By the time someone is diagnosed as deficient, it is very difficult to correct through simply diet alone, so a GP will often prescribe iron tablets or — for those who are unable to tolerate oral iron, which is common — can refer for an infusion.A diagnosis of iron deficiency doesn’t exclude the possibility of perimenopause, Pavord says. “But if iron deficiency has not been corrected, it will still be a problem when women go through the menopause, and will add to their menopausal symptoms.” In her view, even if perimenopause and iron deficiency are happening at the same time, it is important to address the latter first.
Dr Louise Newson, an NHS GP and hormone specialist who is credited with kickstarting the “menopause revolution”, agrees that it is possible to suffer from both issues at once, and actually it often happens. “Our hormones, especially estrogen and testosterone, affect iron absorption,” she says. “And so although we do give iron to people that need it, we also find that when we give hormones back, iron deficiency improves as well,.”Both Pavord and Newson are quick to remind me that even if iron deficiency is found and treated, that doesn’t necessarily mean that you aren’t also perimenopausal — but that either way information is power. A big part of the problem is that the NHS works in siloes, says Newson. “If you’re a cardiologist and you see a woman with palpitations, you’ll think about a heart problem – you may not even think to check their iron, for example, or consider hormones”. In such an environment, advocating for yourself is very important.One thing is certain, all the women I spoke to for this piece were relieved to have addressed their iron deficiency, regardless of whether or not they went on to be treated for perimenopause, and are glad they pushed to get more answers from the GP. “The thing is,” Andrea tells me, “it’s like we’re taught to accept feeling tired and terrible as women — maybe you aren’t in perimenopause after all, or maybe you are — but wouldn’t you rather know what’s really going on?”
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