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Dear Dr. Roach: My daughter’s iron level has been dangerously low for several years. One measurement was as low as 5, but mostly it is between 9 and 15. She took iron pills, which affected her in many other ways.

She was given one iron injection, which affected her negatively. She refused the second one. She has been on an antidepressant and an antipsychotic med for bipolar disorder for 10 years. She is 45. They can’t figure out why her iron stores are so low. She had an endometrial ablation two years ago, and her menstruation stopped. Her iron stores are still low. She is taking iron pills to keep her functioning. What causes a person to NOT store iron?

M.S.

Dear M.S.: I don’t think the issue is her being unable to store iron; rather, the issue probably is she isn’t absorbing it. Whatever endometrial problem she had that required ablation probably caused her to bleed, and the bleeding caused her to cut her iron stores. Over time, her bone marrow and liver ran out of iron almost completely. (The blood levels of 5-15 indicate very little blood iron. A low ferritin level would confirm low iron stores.)

Iron by injection is an effective way of replacing iron. There are several formulations available, some of them quite new (with fewer side effects than older preparations), so it may be worth trying a different preparation from the one she did not react well to.

If she is not replenishing her iron stores despite adequate oral iron, then either she is not absorbing it or she is losing it elsewhere. Both are possible. Common causes of poor iron absorption include celiac disease, inflammatory bowel disease, pernicious anemia and tropical sprue. Many people simply do not take oral iron because it can cause stomach upset, constipation and other problems, so it is critical to make sure people are actually taking it.

Ongoing blood loss can confuse the issue. Hidden inflammatory bowel disease, such as Crohn’s, may produce blood loss with no symptoms.

Given how long your daughter’s problem has been going on, it’s time for a fresh evaluation and rethinking of her issue.

Dear Dr. Roach: Why do I get lightheaded just before I have a bowel movement? This happens day or evening.

R.E.

Dear R.E.: This is due to stimulation of the vagus nerve, which provides the nerves to your gut but which also can slow down the heart. Yours is an exaggeration of a normal reflex. It can be extreme, with some people fainting when going to the bathroom. Making sure you have adequate fluid and avoiding straining are the first steps in treatment.

Email questions to ToYourGoodHealth@med.cornell.edu.

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