Anaemia – why you are tired, and what is causing it
Anaemia is a finding, not a diagnosis. Treating the low iron without finding the reason for it is how a serious cause gets missed.
A symptom of something, not a condition on its own
Anaemia means too few healthy red blood cells to carry oxygen around the body. It causes tiredness, breathlessness on exertion, pallor, dizziness, palpitations, headaches, cold hands and feet, and sometimes odd cravings for ice or soil.
The important point is that anaemia is always caused by something, and the cause matters more than the anaemia. Handing out iron tablets without asking why iron is low is how a slowly bleeding bowel cancer gets missed for a year.
The common causes here
- Iron deficiency — the most common. From heavy periods, pregnancy, poor intake, or bleeding from the stomach or bowel.
- Blood loss from the gut: ulcers, long-term anti-inflammatory use, haemorrhoids, or a bowel tumour.
- Parasites — hookworm and bilharzia both cause chronic blood loss and are relevant in parts of South Africa.
- Chronic disease: kidney disease, HIV, TB, cancer, and long-standing inflammation.
- Vitamin B12 or folate deficiency.
- Inherited conditions affecting the red cells.
Treatment, and taking iron properly
Depending on the cause:
Ferrous Sulfate — FerroGrad, Ferrous Sulfate Lennon, Ferro-Gradumet, Fefol
Iron deficiency anaemia; iron supplementation in pregnancy
Folic Acid — Folic Acid Lennon, Folik
Neural tube defect prevention; megaloblastic anaemia; folate supplementation in pregnancy
Cyanocobalamin (Vitamin B12) — Betolvex, Neurobion (combination)
Vitamin B12 deficiency; pernicious anaemia; neuropathy due to B12 deficiency
- Take iron with something containing vitamin C — orange juice or fruit — which improves absorption considerably.
- Avoid tea, coffee, milk and calcium supplements within a couple of hours of the dose; tea with meals is a common and avoidable reason iron does not work.
- Expect black stools. That is normal and not bleeding.
- Constipation and nausea are common. Taking it with a little food, or every other day, often helps and may absorb just as well.
- Keep taking it for months after the blood count normalises, to refill the body's stores — stopping as soon as you feel better is why it recurs.
- Keep iron out of reach of children. Iron overdose is a leading cause of poisoning deaths in small children.
When it needs urgent attention
Common questions
- Can I just buy an iron supplement?
- It is better to be tested first. Taking iron without deficiency is unhelpful and can be harmful in some conditions, and it delays finding a cause that may need investigating.
- Why am I still anaemic despite taking iron?
- Common reasons: it is not being absorbed, it is being taken with tea, coffee or calcium, ongoing blood loss is outpacing it, or the anaemia is not from iron deficiency at all. Any of these is a reason to go back rather than to keep taking it.
- Does eating spinach fix anaemia?
- Plant iron is absorbed far less efficiently than iron from meat, fish and chicken, and spinach contains compounds that further reduce absorption. Diet helps maintain levels but rarely corrects an established deficiency on its own.
Sources
- Primary Healthcare Standard Treatment Guidelines and Essential Medicines ListNational Department of Health, South Africa
- Adult Primary Care guideNational Department of Health, South Africa
Last reviewed 4 August 2026.