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In high school biology, I remember learning that hemoglobin was the star of the show when it came to iron.

It’s how oxygen travels in your blood. It’s what gets measured in a routine complete blood count (CBC). And it’s the number doctors look at first when you say you’re tired.

So that’s what gets tested. And when it comes back “normal,” we’re told everything’s fine.

But hemoglobin is just the surface of the story.

You can have “normal” hemoglobin and still be iron deficient. Your body’s iron system is more complex than a single number can reveal.

In this issue, I’ll walk through the three-part system your body uses to store, transport, and use iron—and why current testing often misses what matters most.

How to Get a Full Picture of Your Iron Status

Iron isn’t just one number on a lab test. It’s a dynamic system.

Iron doesn’t just float freely in your bloodstream. It’s transported, stored, and used by your cells in a tightly regulated system.

The Three Pillars of Iron Testing

A full evaluation looks at each of these three stages:

Many routine blood panels only check hemoglobin or serum iron. But those are the last things to drop when you’re becoming iron deficient.

You can have very low ferritin and still have “normal” hemoglobin, especially early on.

And that means your symptoms are real, even if your labs look fine on paper.

A History of Oversight

Unfortunately, this isn’t new.

The WHO World Health Organization’s core recommendations for assessing and preventing iron deficiency anemia date back to the early 1990s. While the 2020 update made some progress, like pointing to ferritin to assess iron status, parts of the guidance still feel behind the times.

A major issue is that WHO continues to rely heavily on anemia as a proxy for iron deficiency, even though anemia can result from a range of causes that have nothing to do with iron.

Recent studies suggest that the thresholds WHO uses to define deficiency may be set too low, missing many people who could benefit from early treatment.

How Guidelines Compare—and What They Miss

The lack of clarity around iron testing isn't you. It’s baked into the guidelines.

Different medical bodies offer wildly different advice on when and how to screen for iron deficiency, especially in women:

🩺 FIGO (2023)

• Recommends universal screening for all women starting at menarche.

• Ferritin <30 µg/L = iron deficiency with serious consequences if left untreated.

• Prioritizes testing pre-pregnancy and in the second trimester.

🩸 European Hematology Association (2024)

• Emphasizes restoring iron stores before conception to support healthy pregnancies.

• Highlights the importance of treating iron deficiency during and after pregnancy.

🇺🇸 U.S. Preventive Services Task Force (2024)

• Still says evidence is “insufficient” to recommend routine screening, even in pregnant individuals.

🔬 Other Specialty Groups

• 🧫 AGA recommends ferritin <45 ng/mL for patients with anemia, plus additional markers like transferrin saturation.

• 🇬🇧 BSG and 🇨🇦 Canadian guidelines recommend CBC¹ + ferritin first, then deeper investigation when inflammation or chronic disease is involved.

Despite mixed guidance, some patterns are emerging:

• Universal screening for women of reproductive age is gaining support (see FIGO, EHA).

• Ferritin thresholds vary, but many experts argue the cutoffs we use today are still too low.

• In the U.S., preventive screening lags behind, with bodies like the USPSTF still unconvinced by the evidence.

Don’t wait for universal agreement. If you’ve been told “you’re fine,” but you don’t feel fine, ask for the few more tests you need.

💬 What’s been the most confusing part of navigating iron testing for you? Was it interpreting results, knowing what to ask for, or getting your concerns taken seriously?

1  Comprehensive blood count (CBC) tests measure the following: red blood cells, white blood cells, hemoglobin, hematocrit, and platelets.