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Welcome to The Modern Midlife Collective—where midlife isn’t a crisis, it’s a rebirth. Hosted by Dr. Ade Akindipe, DNP, and Dr. Jillian Woodruff, MD, this is the podcast for women ready to unapologetically own their power, thrive through the ups and downs of hormones, weight, and self-care, and show the world that thriving at 40 and beyond isn’t just possible—it’s your birthright.
Biweekly, we bring you science-backed insights on hormones, menopause, longevity, and sexual health—real tools to empower women in midlife and beyond. With a fearless blend of functional medicine, real-life wisdom, and no-nonsense empowerment, we’re here to challenge the norms, break through the barriers, and help you step into a life of vitality, confidence, and unstoppable strength.
Ready to rise? Let’s do this.
Dr. Ade Akindipe, DNP (00:00)
Okay, I want us to describe to you a woman who is in her late 40s. Think of a woman that's in the middle of a presentation at work and her thoughts suddenly disappear, right in the middle of her sentence. And later staring at her computer thinking why she can't concentrate. She's read the same few paragraphs the three, you know, three times. She's noticed that she's pulling more hair out of the shower drain and starting to get concerned.
Dr. Ade Akindipe, DNP (00:25)
And has been told that she may be going bald and maybe lying awake because her legs won't settle down. They are restless. Maybe they're she's having some tingling, and she has probably been told that everything on her labs is normal. Maybe her physical exam is normal, her hemoglobin is normal. Nothing in the lab is jumping out. Her results are in her portal. nothing is highlighted red. And because she's in midlife.
Dr. Ade Akindipe, DNP (00:49)
She listens to all of these podcasts such as this and she immediately thinks, here we go, menopause. Because there's another condition that can cause some really surprising similar symptoms. And many women just don't realize they can they can have it even if their labs are not telling that they're anemic. And yes, we're talking about iron deficiency today.
Jillian Woodruff, MD (01:10)
Right, and that's an important distinction because iron deficiency and anemia are not the same diagnosis. You can have depleted iron stores for quite some time before your hemoglobin drops enough for you to technically become anemic. So that's one of the reasons this topic is so timely because there's new 2026 guidance from the American Society of Hematology. They are now putting more emphasis on identifying iron deficiency.
Jillian Woodruff, MD (01:38)
earlier including in people who do not yet have anemia. So really leaning in more towards prevention. We do not want to get to that point of anemia. And when your iron stores start dropping, you have symptoms. And so we'll talk about some of those symptoms. symptoms going beyond fatigue. So brain fog, difficulty concentrating, hair loss, hair thinning, restless legs, reduced exercise tolerance. That's definitely one.
Jillian Woodruff, MD (02:03)
And also we'll talk about why the phrase, your labs are normal, and I'm using air quotes that may deserve a little more investigation.
Jillian Woodruff, MD (03:08)
So I want to get back to the woman we were discussing and well you described in that meeting. But before we go any further, we do have to define two terms. And that's because, like I said, people use iron deficiency and anemia interchangeably all the time, and they're not interchangeable. So iron deficiency, and you can if you even have a better way of you know describing this, jump in. But iron deficiency means your body does not have adequate.
Jillian Woodruff, MD (03:37)
iron available or stored to meet its needs. And iron's essential for many processes processes in the body. So most people do associate it with making hemoglobin and and of course that's very important, but iron's also involved in other cellular processes, cellular energy production, and we know that's important. Muscle function, enzymes, sending messages and normal neurologic
Jillian Woodruff, MD (04:04)
Function. So that's your normal brain function. Anemia, on the other hand, means the concentration of hemoglobin in your blood has fallen below the expected range. And hemoglobin is the protein inside red blood cells that carries oxygen. So I imagine that is pretty important to have hemoglobin carrying oxygen throughout your body. And here's the important part, or another important part. There are many causes of anemia. There's
Jillian Woodruff, MD (04:32)
Iron deficiency that we're talking about today is just one cause of anemia. And there's also a stage where someone has iron deficiency without having anemia. And that means the body's iron reserves have become depleted, but the hemoglobin hasn't dropped below the diagnostic threshold for anemia yet. So when someone tells me, no, I don't have anemia, everything was normal in my labs.
Jillian Woodruff, MD (04:58)
They probably don't even know if they've had iron checked. I want to slow down at this point because a normal hemoglobin does not automatically tell us that your iron stores are adequate.
Dr. Ade Akindipe, DNP (05:08)
Absolutely. I'm super happy that, you know, Society of Hematology is putting more emphasis on that because, you know, we're seeing, and I'm sure you're seeing it as well in clinic is sometimes those lab values are not necessarily, you know, translating to what we're seeing clinically in women and they're coming in with all of those symptoms. And I think that's part of that's going to surprise a lot of women because most of us grew up thinking, iron deficiency anemia means iron deficiency means anemia.
Dr. Ade Akindipe, DNP (05:33)
So you go to your doctor, they check your blood count, you're told you're not anemic. And mentally you cross iron off the list. But if you could actually be further upstream from anemia, right? Your reserves are getting low and your body may already be giving you clues, hence the reason why you're having all of those symptoms. But it's not translating to your hemoglobin dropping because you don't have
Dr. Ade Akindipe, DNP (05:59)
evidence that your maybe your blood volume is low and all those other things, but the symptoms is really what we should be paying attention to.
Jillian Woodruff, MD (06:06)
Right. I was trying to come up with a way to think about iron and ferritin. And so I was thinking about your checking account and your savings account. But you you know I'm not
Dr. Ade Akindipe, DNP (06:14)
That's a good analogy. Yeah.
Jillian Woodruff, MD (06:16)
the best with money management. So I could have it wrong, but
Dr. Ade Akindipe, DNP (06:22)
Ha ha.
Jillian Woodruff, MD (06:23)
I'm gonna try anyway. So I'm thinking about like hemoglobin is closer to your your checking account, your cash, the cash you're actually using. and ferritin.
Jillian Woodruff, MD (06:34)
gives us more information about your stored iron, so your savings account account. And so you kind of need both to be in a good financial state. You need a checking and a savings to be adequate, but you don't have to completely overdraw your checking before you realize your savings account is running low. Right. So if you have like no savings, that's can be financial ruin as well, even if you have some money
Jillian Woodruff, MD (07:01)
in your checking account to do the daily things right now. At some point you're going to get to a point where you can't sustain. Right, right. So that's why ferritin matters. The savings account matters.
Dr. Ade Akindipe, DNP (07:14)
I love that. So we need to
Jillian Woodruff, MD (07:14)
Thank you.
Dr. Ade Akindipe, DNP (07:15)
get our savings account up.
Jillian Woodruff, MD (07:17)
Yes, we do. Yes.
Dr. Ade Akindipe, DNP (07:18)
So that
Dr. Ade Akindipe, DNP (07:18)
explains a whole lot, you know, which you know explains why someone can say I was checked for anemia and they said I was fine, which even though her iron stores, like we you know, which is explained, your savings, your iron savings may not be have been evaluated. So your doctor may not be checking for ferritin. So a complete blood count or what's called CBC gives us information.
Dr. Ade Akindipe, DNP (07:42)
like your hemoglobin and your red cell indices, but a C B C alone doesn't check your savings account, right? For how how much stores you have in evaluating. So the ferrity may be missing.
Dr. Ade Akindipe, DNP (07:55)
Yeah. So that question, what was your ferritin, is really the reason why we're recording this episode, because that's very important.
Jillian Woodruff, MD (08:02)
Right, so like I mentioned, the American Society of Hematology recent and those are the people who study blood diseases, recently released updated guidance and actually very recent, so this month, September 2026. and this guidance specifically addresses iron deficiency both with and without anemia. And the headline is that ferritin level that we use to diagnose
Jillian Woodruff, MD (08:28)
Iron deficiency, that level threshold went up significantly. So we'll walk through the exact numbers in a minute. But the clinical threshold we use to identify iron deficiency is not the same thing as the laboratory's traditional statistical normal range. And that's why we want women to know the actual number rather than simply asking whether the result was marked low or high.
Dr. Ade Akindipe, DNP (08:51)
Yeah, yeah, and that changes the question you take into your appointment, right? So instead of asking, Am I anemic? You might ask, what was my ferritin level? could I be iron deficient even though my hemoglobin is normal? And then if it's low, why am I iron deficient? Because it's not just because you're iron deficient and we just put you on iron pills, it's figuring out what's causing it, identifying low iron is only part of the job.
Dr. Ade Akindipe, DNP (09:17)
You need to know what's going on there. So the more more more information so that we can prevent that from happening.
Jillian Woodruff, MD (09:23)
Yes, and historically many labs and guidelines used a ferritin cutoff of around 15 to diagnose iron deficiency in adults. And the range was so wide, 15 to hundreds, right? So that's such a wide range. Somebody with a ferritin level of 15 is not going to feel the same way as somebody with a ferritin level of 100 or 120 or more. And
Jillian Woodruff, MD (09:48)
So now the Society of Humatology recommends a ferritin up 30, at least 30. And so if your level is 30 or lower, you're considered to be iron deficient. And this level, even the threshold raises if you have different risk factors. So for an adult with a risk factor, let's say of heavy periods, heavy menstrual bleeding, the threshold can be 50. So
Jillian Woodruff, MD (10:13)
50 or lower is a diagnosis of iron deficiency in people that have this significant risk factor where they're losing blood.
Dr. Ade Akindipe, DNP (10:21)
I'm glad that that there's a distinction there because that that makes a lot of sense. You want to hire storage. So the fifty, the fact that there is a fifty, obviously clinicians, we still have to look at your symptoms, not just the number. So having the symptoms married with that number and saying at least you should be having at least this number is going to really help and and get that attention for our listeners. So you can bring that to your provider.
Jillian Woodruff, MD (10:43)
Yes, it should. You know, especially because heavy bleeding can be a major source of iron loss. And
Dr. Ade Akindipe, DNP (10:50)
Yeah.
Jillian Woodruff, MD (10:50)
e there's an actually a different approach when inflammation is present. And we know with our patients that we see we're seeing a lot of inflammation and that's increasing at midlife. And it increases because of our American diet and in many other
Dr. Ade Akindipe, DNP (11:06)
Yeah.
Jillian Woodruff, MD (11:06)
things, right? And so they say in adults with inflammation.
Jillian Woodruff, MD (11:11)
That a ferritin of one hundred or below is diagnostic of iron deficiency. That's a huge change from previous guidelines.
Dr. Ade Akindipe, DNP (11:20)
Yeah, so this is not one magic number for every woman in every situation, right? So the context of how we're looking at the labs really matter. So when your ferritin can rise during inflammation, doesn't necessarily mean that that's a good thing, you know, so a number that looks reassuring at first glance can be harder to interpret if the patient has some sort of inflammatory condition.
Jillian Woodruff, MD (11:43)
Yes, that's exactly right. Like we can't just look at that number. We have to
Dr. Ade Akindipe, DNP (11:47)
Yeah.
Jillian Woodruff, MD (11:47)
know about the context. You're exactly right. laboratory reference ranges, we say this all the time, right? Normal is not always normal. Common
Dr. Ade Akindipe, DNP (11:54)
Yeah. Always.
Jillian Woodruff, MD (11:56)
does not mean normal. So I we just have to keep saying it so everybody hears it.
Dr. Ade Akindipe, DNP (12:01)
That's right. So if it wasn't read on your chart, it's not the same thing as we interpret this result in the context of my symptoms and risk factors. So.
Jillian Woodruff, MD (12:09)
Exactly. Okay, now we've separated anemia from iron deficiency. So let's get into the part I think will make a lot of midlife women stop and say, wait a minute, that's me. Because we're deliberately not making this episode another conversation about fatigue. I think people are fatigued out. We talked about fatigue a lot because that's a huge issue. And
Dr. Ade Akindipe, DNP (12:29)
Yes, it is.
Jillian Woodruff, MD (12:31)
right, many people know fatigue can accompany iron deficiency. Yes. However, we want to talk about
Jillian Woodruff, MD (12:38)
other symptoms that maybe you don't immediately think about when and or you don't immediately consider iron deficiency as being a cause. So let's start with a big one for midlife women, brain fog.
Dr. Ade Akindipe, DNP (12:51)
Mm, brain fog. See this one, there there can be a tendency in midlife to almost pre-diagnose ourselves, right? So we constantly talk about brain fog, it's part of menopause, it's on social media. In fact, they're like means of, you know, me going through perimenopause and all of that. So the moment it shows up, we always think, well, I guess this is just my new brain, or this is just part of what happens. But instead of asking, what's wrong with us, right? We should be asking a better question, like, what could be
Dr. Ade Akindipe, DNP (13:18)
causing this. I mean, we're not saying you should be diagnosing yourself, but I think it's important for us to stop and think and track when is this happening? What are the patterns? Is it happening around your periods? Right? It could be hormones. It could be sleep. It could be your iron. It could be several things happening at the same time. And that last piece is important because women don't come into our office and they everything's all neatly. I mean people will write down lists and they will put things together. Some people are really good at that, but
Dr. Ade Akindipe, DNP (13:46)
yes, iron deficiency can also be associated with difficulty concentrating, right? Impaired memory. If you if you have low iron stores or if you're if you are anemic because of the iron that's really low, yes, it'll impact your brain as well. So I just don't feel as sharp as I used to, might be something that women will say. And that's where we need to really become detectives and rather than just assigning this as perimenopause, we really need to look at the full picture.
Jillian Woodruff, MD (14:12)
Right. Menopause can be part of it. Sleep also can be part of it. Stress, depression, anxiety, thyroid disease. I don't know if we specifically talked about
Dr. Ade Akindipe, DNP (14:22)
Yeah.
Jillian Woodruff, MD (14:23)
thyroid as part of that, you know, triangle where everything affects the other, right? Thyroid, hormones, sleep, iron, absolutely. They all affect each other. The list can get pretty
Dr. Ade Akindipe, DNP (14:33)
Yeah.
Jillian Woodruff, MD (14:34)
long, and that's the point. We shouldn't, we should not.
Jillian Woodruff, MD (14:38)
Diagnose iron deficiency from brain fog, but we also should not just say, just minute pause because you
Dr. Ade Akindipe, DNP (14:45)
Yes.
Jillian Woodruff, MD (14:46)
have brain fog or because you're 48 and so you're thinking this is the time, right? A good midlife, good midlife medicine or a good hormone specialist will ask a better question, what else could be contributing to these symptoms?
Dr. Ade Akindipe, DNP (14:59)
Absolutely. A good life medicine definitely needs to be looking at the full picture, not just looking at a number. We need to get you up to this number and that's it. You know, sometimes things get missed. so the next thing we should really talk about is a symptom that make people click on this episode. Hair, hair loss and hair shedding.
Jillian Woodruff, MD (15:17)
You know, our hair is important for
Dr. Ade Akindipe, DNP (15:19)
Yes.
Jillian Woodruff, MD (15:20)
women and for men, for just humans in general. We like hair, and hair and nail changes can occur with iron deficiency, with or without anemia. When our hair starts changing, we notice when there's more hair in the brush or down the drain or the ponytail, you pull your hair together and it's just like thinner, you know, feels smaller. Iron deficiency is one of the things I evaluate when hair shedding.
Jillian Woodruff, MD (15:43)
Becomes a problem. And the research connecting the two is still evolving. We know it's a contributing factor. Is it the be all end-all of hair loss? No, there's so many contributing factors. So this is where social media, social media medicine can get us into trouble or TikTok medicine, right? There are so many different forms of hair loss, and there's many potential contributors. There's hormone changes, there's thyroid disease, there's genetics.
Jillian Woodruff, MD (16:10)
And that's a big one. there's major stress, physiologic stress could be illness, recent illness, it could be mental illness, certain medications. And we know we're seeing a lot more hair loss with the use of GLPs, right? GLP1 medications. there's nutritional deficiencies, autoimmune disease, even weight loss. We're always like, just lose a little weight. Yeah, you can lose some hair too. We have to think about that. So iron.
Jillian Woodruff, MD (16:37)
I we're saying it just should be part of that evaluation because it is a major contributor to it. but hair loss does not equal iron deficiency though.
Dr. Ade Akindipe, DNP (16:45)
Yeah. All of the things you just said. I mean, I can just think of all of the nutritional deficiencies. I think it's one that jumps right out out at me when they're on GLP ones, eating less protein. so yeah, a lot of different things can cause that. And so if your ponytail is thinner, the takeaway here is not to go buy iron pills. It you know, the takeaway is that this is worth evaluating. hair shedding is a symptom and our body's always trying to give us clues. It is a clue.
Dr. Ade Akindipe, DNP (17:11)
It's not necessarily a diagnosis. some people want to go straight for you know, this new medicine that well, it's not new, monoxidil and all the other things to try to mask what's happening, but the the real truth, what we're trying to get at is this is one of the many things I can cause it. And that's where I I really want us to protect our listeners from the natural next move. So, okay, brain fog, hair shedding. I need to order iron supplements tonight. No.
Dr. Ade Akindipe, DNP (17:36)
This episode is meant to make you more curious. Be curious about your body, when things are happening, not to prescribe for yourself, because too much iron also isn't good. Right. We need to know whether you're actually deficient. And if if you are, then why is that happening?
Jillian Woodruff, MD (17:52)
Exactly. And it's fine to treat, you know, and have
Dr. Ade Akindipe, DNP (17:54)
Mm-hmm.
Jillian Woodruff, MD (17:55)
medications that can help stimulate growth. But if the problem continues, just like if you're having heavy bleeding and you continue losing blood, but you're bumping up your iron because it is deficient, you're not fixing the problem. So we have to
Dr. Ade Akindipe, DNP (18:07)
Mm-hmm. Exactly.
Jillian Woodruff, MD (18:09)
get to the root of the problem, right? And I know that's your specialty, right? Getting to the root of the problem and then you start there. Takes a while. It's not easy.
Dr. Ade Akindipe, DNP (18:14)
Let's get to the root. It takes a bit.
Dr. Ade Akindipe, DNP (18:20)
It takes a bit. It can be frustrating.
Jillian Woodruff, MD (18:21)
Yeah, yeah.
Dr. Ade Akindipe, DNP (18:24)
so the symptom I think women may not connect to iron at all might be restless legs. they may describe it as this uncomfortable sensation, like crawling or pulling feelings.
Dr. Ade Akindipe, DNP (18:36)
and an urge to move their legs at night. It's a it actually can get worse at night or when you're sitting down or lying down. And it becomes a a domino effect almost. Y your legs keep up, keep you up, you you sleep bad. the next day your concentration is worse, your moose is your mood is worse and your brain fog is even worse.
Jillian Woodruff, MD (18:54)
Exactly. Now I've not experienced this, but this it does not seem pleasant. And so
Dr. Ade Akindipe, DNP (18:59)
Yeah.
Jillian Woodruff, MD (19:00)
when you think about well perimenopause affects sleep, this is true, but it may not be the only explanation. So we're not trying to like take symptoms away from menopause, but we're trying to stop menopause from becoming a diagnostic drunk junk drawer. And actually I don't even know that restless legs is really even in that junk drawer right now because
Jillian Woodruff, MD (19:21)
When people, by the time they come to me, they're already on medications for restless leg and they've been seeing somebody for quite some time and they didn't even connect it to perimenopause. So, and then way down the road is iron deficiency. And probably they did have their iron and ferritin checked, but it was in those probably low normal ranges where you can still have these symptoms. So
Jillian Woodruff, MD (19:44)
Don't just show throw everything into the diagnostic junk drawer for menopause simply because you're over forty. Keep digging.
Dr. Ade Akindipe, DNP (19:51)
That's right. I absolutely agree. And here's the other thing that some women may not know. The American Academy of Sleep Medicines 2024 guideline actually recommends considering iron therapy for restless legs when ferritin is 75 or lower and up to 100 for IV iron. So that is well above where many labs flag your ferritin as low.
Dr. Ade Akindipe, DNP (20:18)
So a ferritin that looks normal on paper may still matter if your legs will not settle down at night. That is very, very reassuring that that's there because then now we have a reason to say, okay, maybe my my patient can go and get some iron, maybe even get iron infusion.
Jillian Woodruff, MD (20:34)
I love iron infusions. People feel so good after they get them. And I just feel like it's so hard to get them for people, right? Or especially
Dr. Ade Akindipe, DNP (20:43)
Yes.
Jillian Woodruff, MD (20:44)
if they're wanting to use insurance to pay for this. And so when you brought that up, it just makes me think we kind of have to play this little game when you're trying to get things approved because you may say that the person has, you know, you're you're legitimately talking about their symptoms. Like, okay, this person is having.
Jillian Woodruff, MD (21:03)
brain fog or fatigue or shortness of breath and we want to get them iron infusions, but their iron level may be 51. So that may be considered normal and they're not having
Dr. Ade Akindipe, DNP (21:13)
Yeah.
Jillian Woodruff, MD (21:14)
heavy bleeding and they're not having inflammation. And so they may not be approved. But if we know about this study, perhaps this person may have restless legs, but they may not have discussed it with me because they didn't think it was part of a gynecology visit, let's say.
Dr. Ade Akindipe, DNP (21:28)
Yeah.
Jillian Woodruff, MD (21:29)
Right. But if I know and I know these guidelines, then perhaps if I just use those words, okay, this person is having interrupted sleep from restless legs, and then we could have gotten the iron approved. It shouldn't be that difficult to take care of people. It's frustrating.
Dr. Ade Akindipe, DNP (21:43)
It shouldn't. It really shouldn't. And I wonder these
Dr. Ade Akindipe, DNP (21:46)
guidelines now, I wonder what that would look like is in terms of getting that approved. I mean, it's not like you can say diagnose restless leg treatment, iron infusion, right? Because it's it sounds like it's not FDA approved for that, right? But this is something that they're they're recommending so that it just hasn't caught up probably for approval yet.
Jillian Woodruff, MD (22:07)
Right, and maybe it'll change, maybe 'cause this is twenty twenty four. So maybe in twenty twenty six those thresholds will will raise. So yeah.
Dr. Ade Akindipe, DNP (22:15)
I hope so. This will
Dr. Ade Akindipe, DNP (22:16)
be great. here's another one for our women who are walking, hiking, lifting, doing all the things, trying to stay strong in midlife. You know, what if your usual workout suddenly feels harder than it used to? this one definitely resonate with me. It's it's better now, but man, I did I did feel it. It takes longer to recover, poor exercise tolerance can occur.
Dr. Ade Akindipe, DNP (22:37)
in non-anemic iron deficiency. And if iron deficiency anemia becomes more significant, people may develop shortness of breath, dizziness, lightheadedness, or even chest pain. So those are symptoms that deserve medical assessment, not, I guess I'm just getting old. You need to get that checked out or not just I'm out of shape, right?
Jillian Woodruff, MD (22:57)
Correct, correct. If something that was previously well tolerated has suddenly changed, that's more data to use. I think
Dr. Ade Akindipe, DNP (23:04)
Yeah.
Jillian Woodruff, MD (23:05)
another thing, because you are thinking maybe I'm out of shape, but as in midlife we know testosterone levels decline. And when that declines, you also have poor exercise tolerance or you're not seeing the results. And even more than that, it's how testosterone works on your brain. So you have lower motivation to
Dr. Ade Akindipe, DNP (23:23)
Yes.
Jillian Woodruff, MD (23:24)
do things. See everything is interconnected.
Dr. Ade Akindipe, DNP (23:26)
Absolutely.
Jillian Woodruff, MD (23:27)
You know?
Jillian Woodruff, MD (23:27)
Mood, that's another overlap zone. And iron deficiency can be associated with irritability. And we know that happens in perimenopause. We know that happens when testosterone levels are lower. So, but iron deficiency is a big one. And abnormal mood. But again, those symptoms are non-specific. we can't diagnose iron deficiency from irritability alone. If we could, every household with teenagers would have.
Jillian Woodruff, MD (23:53)
Iron deficiency.
Dr. Ade Akindipe, DNP (23:55)
This is probably why iron deficiency can hide in plain sight. Every individual symptom can really look like something else. So
Jillian Woodruff, MD (24:02)
Exactly.
Dr. Ade Akindipe, DNP (24:03)
yeah. And then we have this really strange one that I haven't personally, you know, done myself. I haven't experienced that, but pika, which is craving or eating non-food substances.
Dr. Ade Akindipe, DNP (24:16)
And it can be associated with iron deficiency. Ice chewing is a classic example that we you might see. So if someone tells you, I just have this strange craving for chewing ice, that definitely belongs in their medical history.
Jillian Woodruff, MD (24:29)
Absolutely. I've seen this in family members. The the chewing the ice. Also, eating flour. I don't know what
Dr. Ade Akindipe, DNP (24:36)
Ooh.
Jillian Woodruff, MD (24:37)
deficiency that is. Do you know?
Dr. Ade Akindipe, DNP (24:39)
No, I have not like flour? Like flour? Like the plant or baking flo? huh. Interesting.
Jillian Woodruff, MD (24:40)
But that's like baking baking flour. Mm-hmm.
Dr. Ade Akindipe, DNP (24:48)
No.
Jillian Woodruff, MD (24:48)
May seem like a quirky habit, but it probably is clinically relevant.
Dr. Ade Akindipe, DNP (24:53)
my goodness. Wow. Okay.
Jillian Woodruff, MD (24:55)
Mm.
Dr. Ade Akindipe, DNP (24:55)
Well, so our non-fatigue symptom list is, let's see, brain fog, difficulty concentrating, hair loss, brittle nail changes, restless leg, poor exercise tolerance, poor recovery from exercise, mood changes, and pikeups.
Jillian Woodruff, MD (25:13)
Yeah, so none of these symptoms prove iron deficiency, but prove you should have an evaluation. So together with the right history, with knowing the risk factors, they may be reasonable to evaluate iron status more carefully.
Dr. Ade Akindipe, DNP (25:26)
Yes, I agree with that. And now let's connect this directly to our midlife listeners. Why is iron deficiency such an important perimenopause conversation?
Jillian Woodruff, MD (25:36)
Well, I think in my opinion, a huge reason is menstrual blood loss, heavy menstrual bleeding. It's an important risk factor for iron deficiency. It's a cause, right? You're losing your blood. And one, and also not just iron deficiency, but iron deficiency anemia. And we talked about how there are two different diagnoses. But you can have both of those together. So one of the things that surprises women about perimenopause is that periods don't always just get light.
Jillian Woodruff, MD (26:03)
lighter and politely disappear. No. Gosh, for some women, the transition includes irregular bleeding and episodes of very heavy menstrual bleeding, with or without clots. They could have fibroids that are growing during this time because of the huge fluctuation of estrogen up and down, up and down. Adenomyosis, which is similar to endometriosis, where the inner glands inside the uterus spread into the muscle of the uterus, can have
Jillian Woodruff, MD (26:30)
ovulation dysfunction and other gynecologic causes can contribute to heavy and or irregular bleeding. And so this deserves an appropriate workup with the gynecologist. But we have to think about the consequences of that blood loss. So even if you're like, I can handle it, you know, I it's not too bad. No. If you're losing more blood month to month, you're also losing iron.
Jillian Woodruff, MD (26:56)
And then it causes a whole host of other symptoms.
Dr. Ade Akindipe, DNP (26:59)
Yeah, absolutely. I mean, I bet you see this a lot, especially with women who I'm assuming if they have conditions like fibroids, that can get aggravated during perimenopause, right? So you see a lot more heavy, heavy, heavy bleeding and of course I don't know how you function with hormone loss, and then you have blood loss on top of that. So that can be exhausting for for women.
Jillian Woodruff, MD (27:23)
Yeah.
Dr. Ade Akindipe, DNP (27:24)
And women normalize an extraordinary amount of bleeding. They've you know, they're changing pads every hour, doubling up, they're waking up at night because they've bled through everything. They're planning travel around their periods, they're carrying a lot of change of clothes and somehow, you know, it's just like, well I'm in perimenopause.
Jillian Woodruff, MD (27:42)
Exactly. Perimenopause may explain why bleeding patterns are changing, but that doesn't mean the bleeding should be ignored. And with the new guidelines, the hematology
Dr. Ade Akindipe, DNP (27:51)
Okay.
Jillian Woodruff, MD (27:51)
diagnostic guidance specifically identifies heavy menstrual bleeding as a high risk situation. So if a woman tells me she has very heavy periods, she's also complaining about probably brain fog or the hair changes or the restless legs, all the things, right? We have to bring all of that into the conversation and
Jillian Woodruff, MD (28:10)
evaluate the iron status.
Dr. Ade Akindipe, DNP (28:12)
Yeah. I mean this is like off topic, but well not really off topic. When you have women like that who are having heavy periods, low iron, you know, when do you start having that conversation about the different choices? I mean, sometimes it's a hysterectomy, but you know, what what has been your experience when it comes to this?
Jillian Woodruff, MD (28:29)
Yeah, if I hear this, they may be coming to me because they may be coming because they've been referred to talk about hormones and not about the bleeding. And
Dr. Ade Akindipe, DNP (28:37)
Yeah.
Jillian Woodruff, MD (28:38)
when we hear about the bleeding and they've accepted it as part of this transition, we talk about that because that affects the hormones and how they work. You know, when you have low iron, that affects your thyroid. Your thyroid isn't going to be functioning as well. It affects your hormone levels, right? It affects your oxygenation status. So I
Jillian Woodruff, MD (28:57)
actually change our conversation when we have to talk about let's stop the bleeding first and then we go into optimizing the hormones. It's extremely important part of that conversation. And you can
Dr. Ade Akindipe, DNP (29:10)
Yeah.
Jillian Woodruff, MD (29:10)
do simultaneously, but sometimes what we do with our hormones can negatively affect the bleeding. So that's why I feel like we have to work with the bleeding first.
Dr. Ade Akindipe, DNP (29:20)
Yeah.
Dr. Ade Akindipe, DNP (29:20)
Makes perfect sense. Yeah, absolutely. So this is where Dr. Jill's world and my world really overlap because whether we're talking conventional medicine or functional medicine, we eventually come to the same question, which is why? Right? She's talking about looking at all the other root causes, right? We the bleeding, we gotta figure out what's going on with the bleeding and and stop it so that everything else can work. So if the iron is low, why is it low? Maybe the woman is losing blood through heavy periods, maybe there's inadequate
Dr. Ade Akindipe, DNP (29:47)
Intake nutritionally, is there impaired absorption? You know, are you losing blood from the gut? maybe she's donating blood frequently. That's another one, right? Maybe there's more than one contributor. Replacing iron without understanding why it's disappearing can be like repeatedly filling a bucket without checking whether there's a hole in it, right? So it it's we have to make sure that we're looking at the whole thing.
Jillian Woodruff, MD (30:11)
Exactly. That's an analogy I like. I didn't think about that. Yeah.
Dr. Ade Akindipe, DNP (30:14)
Ha ha ha.
Jillian Woodruff, MD (30:16)
Diagnosing iron deficiency tells you the water in the bucket is low, but it doesn't necessarily
Dr. Ade Akindipe, DNP (30:21)
Yeah.
Jillian Woodruff, MD (30:22)
tell you where the iron went and why.
Dr. Ade Akindipe, DNP (30:24)
Yes.
Dr. Ade Akindipe, DNP (30:25)
Yes. Okay, Doctor Jill, let's flip this situation a bit. what if a woman is postmenopausal now with no periods, an iron deficiency or iron deficiency anemia shows up, so she can't automatically blame menstrual cycles anymore, right? She's not having them anymore.
Jillian Woodruff, MD (30:44)
Then the Y is still particularly important. Iron deficiency
Dr. Ade Akindipe, DNP (30:47)
Mm-hmm.
Jillian Woodruff, MD (30:48)
can result from other sources of blood loss, like gastrointestinal blood loss, also from malabsorption conditions. So you're not absorbing iron that you get from food or from supplements, such as celiac disease. I have a great number of people that have celiac. there's also
Jillian Woodruff, MD (31:07)
Medication related blood loss that can occur, dietary issues, inflammatory bowel disease, that's a big one, right? And that's a cause of inflammation as well. prior bariatric surgery, because that really can impair nutrient absorption.
Dr. Ade Akindipe, DNP (31:22)
Mm-hmm.
Jillian Woodruff, MD (31:23)
And yeah, there's other causes, but we have to find the one or two or three or whatever.
Dr. Ade Akindipe, DNP (31:28)
Yeah, all of those definitely stand out. I can think of different people in my head, like, yes, this is the you know, this problem it may potentially be the root cause. In other words, do not just refill the tank without, you know, looking for the leak like we just talked about.
Jillian Woodruff, MD (31:40)
Right. Yeah. And some people need blood transfusions. They can get to a point of anemia that's severe and they need blood transfusions. And so we're not saying don't get your blood transfusion. Absolutely. You have to, you have to do that. You need blood. But it is not going to be the most beneficial to you if you continue to let that leak happen. So you
Dr. Ade Akindipe, DNP (32:00)
Correct.
Jillian Woodruff, MD (32:00)
also have to be finding the leak and plugging it up. Right. So for
Jillian Woodruff, MD (32:06)
Postmenopausal women with iron deficiency anemia, looking at the GI system is important. The American Gastroenterological
Jillian Woodruff, MD (32:14)
GI, the GI Association. They recommend, why do we have to use all of these big words? Okay.
Dr. Ade Akindipe, DNP (32:19)
I don't know.
Jillian Woodruff, MD (32:21)
They recommend that you have bidirectional endoscopy. So that's an upper endoscopy. So looking from the mouth down.
Jillian Woodruff, MD (32:27)
And then a colonoscopy looking from your you know anus up. So this is for a woman that's maybe asymptomatic, she's postmenopausal, she has iron deficiency anemia. So this is not a here's some iron see you next year. This is we need to understand or find the cause.
Dr. Ade Akindipe, DNP (32:43)
Yes. So iron deficiency may be the diagnosis, but it may also be a clue to another diagnosis, right? Okay. now let's go back to let's go back to the woman who is inspired by the title of this episode, My Doctor Says, My Labs or Normal. What should she actually ask?
Jillian Woodruff, MD (33:02)
First, was ferritin actually checked? So not just iron, but the ferritin, the storage form of iron. So a CBC may have been ordered, so you know what your hemoglobin is. That may be normal. Also, I would look, is it low normal? Because that's not optimal, right? And then we don't want the patient walking away from having a normal CBC thinking iron deficiency was ruled out. So we need to specifically evaluate iron stores. What's the ferritin part of that?
Dr. Ade Akindipe, DNP (33:28)
Yeah, absolutely. And then what was the actual ferritin value, not just whether it fell inside the lab reference range? Remember, we talked about how different people function at different levels. And then third, how should that result be interpreted in the context of your symptoms, your menstrual history and medical conditions, because there isn't one just one isolated number that's good for everybody and tells you every story for every patient, right?
Jillian Woodruff, MD (33:57)
Right. And I just want to expand on inflammation a bit. We talked about it, we touched on it, I would say. But ferritin is useful because it reflects stored iron. But ferritin is also what we call an acute phase reactant. So that means ferritin can rise in response to inflammation. So if you have an inflammatory condition, your ferritin actually may look higher than expected, even though the amount of iron
Jillian Woodruff, MD (34:23)
That actually is available to your tissues isn't adequate. So that's why in some clinical situations we look at ferritin together with some of these other measures, such as transferrin saturation. That's one of them. So there is a whole host of things. I do, like I, my lab calls it an anemia panel, where we look at more than one thing. We don't just look at iron or ferritin, but we look at like percent saturation, transferrin.
Jillian Woodruff, MD (34:50)
total iron binding capacity and that sort of thing. So I don't want people to think my ferritin is X, therefore I have a Y, because there's so much more. This is also why I have a problem. I don't actually have a problem, but you know how you can order your own labs now? Like you can go to, I think you can just go to Lab Core and just order things.
Dr. Ade Akindipe, DNP (35:07)
Yeah. You
Dr. Ade Akindipe, DNP (35:09)
you can order your own pal. You don't need an order. A a doctor's order. Yeah.
Jillian Woodruff, MD (35:11)
Yes. So
Jillian Woodruff, MD (35:13)
people come in now with their piano. And like on one hand, I'm like, good for you for advocating for yourself and wanting to have answers because some people, you know, there's some like clinicians that are like, I don't think you need to order that, right? So good for you for advocating, but I caught they I get things back that have like one thing because obviously that you know they don't know if you're not specializing in these sort sorts of things.
Jillian Woodruff, MD (35:38)
That one number, for example, they may just do an iron level. What does that really tell you? Just right? Nothing.
Dr. Ade Akindipe, DNP (35:45)
Not not much. Not much. Yeah.
Jillian Woodruff, MD (35:48)
But they're thinking they're doing something because do you have iron deficiency? Let me just do this, but not knowing why there's so many things that work together and they need to be done at the same time. So it's not like you can just go back and do the other parts. You need them at the same time. Just like I'm gonna do.
Jillian Woodruff, MD (36:04)
you know, they may have heard from us a free T3 looks at active thyroid hormone. And so they may get that. You need that with the T4, free T4, with the TSH, right? They have to be done in a in a group. So
Dr. Ade Akindipe, DNP (36:16)
Yeah. Yeah.
Jillian Woodruff, MD (36:17)
I wish they could, you know, take these symptoms to a person that has, you know, spent their life studying these things and then have that clinician be more responsive so that they can order the, you know, the things that
Jillian Woodruff, MD (36:30)
should be ordered because people have a right to know.
Dr. Ade Akindipe, DNP (36:33)
Yeah. I mean they're the they're getting it, you know, there's more technology, there's AI. And so I've seen some people actually get AI interpretation of those results. again, this is AI. You can't that cannot replace someone who spent years and is still learning every year. You know, and and then evidence changes all the time. So you can't go by just what the technology is telling you. It's very helpful in at least getting some insights, but I
Dr. Ade Akindipe, DNP (36:59)
100% agree. You know, there's a real good distinction between knowing your numbers and treating yourself according to those numbers. Like we just talked about, there are so many different things that could be causing your symptoms. It may not necessarily be iron, it could be that and other things. So we're encouraging women to know your numbers, but we're not saying that you need to become your own hematologist and your own gynecologist and your own everything. It's just, but I it's great that we're in a place where we are in.
Dr. Ade Akindipe, DNP (37:27)
empowered and empowerment is great but you still need definitely to talk to someone who's more experienced.
Jillian Woodruff, MD (37:32)
Exactly. Exactly. So
Dr. Ade Akindipe, DNP (37:34)
All right.
Jillian Woodruff, MD (37:35)
depending on the history in the exam, you'll order these labs and then the clinical context
Dr. Ade Akindipe, DNP (37:41)
Mm-hmm.
Jillian Woodruff, MD (37:42)
determines really which labs that you would you would order.
Dr. Ade Akindipe, DNP (37:46)
Yeah, absolutely. So let's make this practical for us. If someone is having these symptoms, what might her clinician consider?
Jillian Woodruff, MD (37:54)
I think that's just that's it. Yeah. History,
Dr. Ade Akindipe, DNP (37:56)
Right. Yeah.
Jillian Woodruff, MD (37:58)
maybe an examination. depending on what the history is, right? What determines the kind of exam. Like are we, is your history suggesting something where we should be looking for bruising, let's say, you know, or or bleeding. And then that would determine the exam, where is the bleeding coming from? and then the labs, and then the that's the the the specific labs.
Jillian Woodruff, MD (38:21)
Also depends on the history and the clinical context.
Dr. Ade Akindipe, DNP (38:23)
Yeah,
Dr. Ade Akindipe, DNP (38:24)
I agree. So why not just take an iron supplement if iron deficiency is common? I'm sure there are
Jillian Woodruff, MD (38:30)
Right.
Dr. Ade Akindipe, DNP (38:31)
folks that are thinking like, well, why why can't I just go to Costco and just g get myself a good multivitamin with really good
Jillian Woodruff, MD (38:35)
Yes, no.
Dr. Ade Akindipe, DNP (38:35)
iron in it?
Jillian Woodruff, MD (38:36)
A good multivitamin, sure. But do not start a high-dose iron supplement
Dr. Ade Akindipe, DNP (38:40)
Yeah.
Jillian Woodruff, MD (38:42)
simply because you heard us in this episode, because more is not always better. Iron supplementation
Dr. Ade Akindipe, DNP (38:46)
Not yeah.
Jillian Woodruff, MD (38:48)
should be based on an appropriate diagnosis and treatment plan. Iron can cause some significant GI side effects. Constipation is one of them. So there are some supplements that are less likely to do that than others. people may have.
Jillian Woodruff, MD (39:01)
conditions, GI conditions specifically, where they shouldn't be taking oral iron. Or certain things need to be looked at first. Or if they're not absorbing, if they have a malabsorption problem, then you're just taking something that you're not absorbing. And then also how you take iron with what you take the iron makes a difference too in helping
Dr. Ade Akindipe, DNP (39:19)
Yeah.
Jillian Woodruff, MD (39:20)
the absorption or that prevents absorption. So it's certain certainly something to to talk about in more detail.
Dr. Ade Akindipe, DNP (39:26)
Absolutely.
Dr. Ade Akindipe, DNP (39:27)
Yeah. And the new Society of Hematology guidelines we're discussing today are specifically diagnostic guidelines. You know, they're probably gonna be releasing more treatment guidelines next year, twenty twenty seven. So a new ferritin threshold does not mean every person below that threshold should receive the same product dose or route of iron.
Jillian Woodruff, MD (39:48)
And that's exactly why this conversation belongs with you, between you and your clinician. Not in your online shopping cart.
Dr. Ade Akindipe, DNP (39:54)
Yes. No, not in shopping cart. Yeah,
Dr. Ade Akindipe, DNP (39:58)
I think I really think this episode is really about something bigger than iron, right? So midlife women were experiencing a lot of changes, constantly handed explanation for symptoms, both on social media, maybe certain doctors, maybe certain books you're reading. So, but it's really important that we are telling you what the the latest evidence is and what you need to do with that information.
Jillian Woodruff, MD (40:20)
Yes. Sometimes that information you read is very correct and sometimes it's incomplete and sometimes it just does not pertain to you.
Dr. Ade Akindipe, DNP (40:29)
Yeah, yeah. Menopause can be real and iron no, menopause is real.
Jillian Woodruff, MD (40:34)
Yeah, it's definitely real.
Dr. Ade Akindipe, DNP (40:36)
And iron deficiency can be real too. So sleep issues you know, it's a it's a huge part of what, you know, that that transition. And thyroid disease is also an issue. So more than one thing can coexist is what we're trying to say in the same woman.
Jillian Woodruff, MD (40:51)
Yeah, and our job as clinicians is not to choose our favorite diagnosis, it's to stay curious and evaluate the person in front of us.
Dr. Ade Akindipe, DNP (40:59)
Yeah, so if your brain is feeling foggy, your hair seems different, your legs won't settle down, or your workouts don't feel as great, or your periods are becoming more heavier, don't just assume and simply try to treat it. Definitely reach out. you know, you don't want to assume and s you know, s simply suppose to tolerate it if you know, just because you're in midlife.
Jillian Woodruff, MD (41:18)
And do not diagnose yourself from a podcast, even really good ones like I don't know, the Modern Midlife Collective.
Dr. Ade Akindipe, DNP (41:25)
Yeah.
Jillian Woodruff, MD (41:27)
But use this information to ask better questions, to know your numbers, work with your healthcare professional to understand what those numbers mean for you in your specific situation.
Dr. Ade Akindipe, DNP (41:38)
Yes. Because normal on a patient portal is not the goal, right? Understanding your health is the goal.
Jillian Woodruff, MD (41:43)
And sometimes all it takes is a better question. Okay, before we go, thank you, thank you for spending time with us. We know there are a million things competing for your attention, and we never take it for granted that you choose to spend part of your week with the Modern Midlife Collective. If this episode made you think of a woman who's been told your labs are normal, even though she knows she doesn't feel like herself, please send this episode to her. That one share.
Jillian Woodruff, MD (42:12)
will give her the language she needs to start a better conversation with her healthcare professional.
Dr. Ade Akindipe, DNP (42:17)
Yes, and if you're enjoying these conversations, make sure you're following the Modern Midlife Collective so you don't miss an episode. leaving us a review also helps more midlife women find this show and visit our website for episode resources, links, and more from the collective at www.modernmidlife collective.com.
Jillian Woodruff, MD (42:36)
Thank you for being part of this community. We will see you next time. Goodbye.