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Ferritin in Serum

The most sensitive marker of iron storage and also an indicator of inflammation.
Roche method sheet
Also known as:
S-ferritin.
Do not confuse with serum Iron (Fe).

Ferritin ranges for

Interpret your result
Normal reference range: 22–500 µg/L for males
22
500
According to Peter Attia, Ferritin should be between 30 and 400 µg/L:
30
400
According to OptimalDX, Ferritin should be between 45 and 79 µg/L:
45
79
According to American Gastroenterological Association, Ferritin should be above 45 µg/L:
45
Unexplained fatigue and weakness was associated with Ferritin below 50 µg/L:
50
Hair loss was associated with Ferritin below 40 µg/L:
40
70
Restless Legs Syndrome was associated with Ferritin below 75 µg/L:
75
Increased all cause mortality was associated with Ferritin above 194 µg/L in males:
194
Optimal range
Optimal range for Ferritin appears to be between 60 and 100 µg/L:
0
40
60
100
180
600
Why this optimal range?

Both observational and interventional data suggest that ferritin levels below 60 µg/L may be associated with symptoms.

Longitudinal studies indicate that both high and low ferritin levels are linked to increased all-cause mortality. But GWAS studies suggest that lower ferritin levels are preferable, so I am inclined to keep ferritin levels relatively low, yet above the level associated with symptoms.

What a low value may mean:

Common reasons for low Ferritin:

  • Dietary iron deficiency
    Iron deficiency is one of the most prevalent nutritional deficiencies according to the WHO. In both the developed and developing countries.
    77.5% of young females are considered iron deficient when using a 50-μg/L cutoff
    Adult vegetarians have significantly lower serum ferritin levels (-29.71 µg/L) than their non-vegetarian controls. (meta analysis of 27 cross-sectional studies)
  • Impaired iron absorption
    GI diseases, such as celiac disease, IBD, H. pylori, atrophic or autoimmune gastritis, Crohn's disease...
    Tea consumption with a meal inhibits iron absorption by 37%. Waiting one hour after the meal reduces this inhibition to only 18%.
    Coffee inhibits iron absorption from a supplement by 54%.
    Calcium supplementation (1200 mg/day) significantly reduces daily non-heme iron absorption from 15.8% to 4.7%.
  • Blood loss,
    Heavy menstrual bleeding, blood donations, accidents, or surgery.
  • Drugs that decrease iron absorption or cause gastrointestinal bleeding,,
    Proton Pump Inhibitors, Antacids and H2-Receptor Antagonists, Aspirin and Other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Certain Antimicrobials like tetracycline and ciprofloxacin ...
  • Hypothyroidism,
    Serum ferritin levels appear to increase when even subclinical hypothyroidism is treated. However, a combination of levothyroxine and iron salts is more effective than using either one alone.
  • Colon cancer in older adults,
    Up to 60% of patients with colon cancer have iron deficiency at diagnosis, often due to chronic blood loss. Peter Attia emphasizes investigating unexplained low ferritin in adults over 50 to rule out colon cancer.
  • Running - footstrike hemolysis
    Athletes such as marathoners with high training volumes would be particularly at high risk.

Possible consequences from low Ferritin:

  • Unexplained fatigue and weakness
    Both intravenous and oral iron supplementation have improved fatigue in iron-deficient, non-anemic women of childbearing age.,
    In a case-control study of 46 women with fibromyalgia and 46 healthy women, ferritin <50 ng/mL was associated with 6.5-fold higher odds of fibromyalgia.
  • Hair loss
    A meta-analysis of 36 observational studies found lower average ferritin levels in women with nonscarring hair loss than in healthy controls.
    In a smaller study involving 210 patients with hair loss and 210 healthy controls, females with hair loss had an average ferritin level of 49.27 µg/L, while healthy women had an average of 77.89 µg/L. Additionally, 22.7% of males with hair loss had a serum ferritin level lower than 70 µg/L, compared to healthy males, where non of them had ferritin levels below 70 µg/L.
    In a small prospective comparative study of 60 women, the intermittent iron group had a 16% improvement in hair density over six months, compared with 9% in the 2% minoxidil group. Random allocation was not reported.
  • Restless Legs Syndrome
    A meta-analysis found that lower ferritin was associated with RLS augmentation (worsening of symptoms during dopaminergic treatment). This association does not establish that iron supplementation prevents augmentation.
    Mayo clinic: RLS patients with serum ferritin concentration of 75 µg/L or less and transferrin saturation below 45% should receive a trial of oral iron therapy.
  • Being pale or having yellow "sallow" skin
    Shortness of breath or chest pain, especially with activity
    Unexplained generalized weakness
    Rapid heartbeat
    Pounding or "whooshing" in the ears
    Headache, especially with activity
    Craving for ice or clay - "picophagia"
    Brittle nails

How to increase Ferritin:

  • Rule out serious diseases via Bidirectional endoscopy
    AGA recommendations for iron-deficiency anemia (ferritin <45 ng/mL):

    - Adult men and postmenopausal women: Strongly recommends bidirectional endoscopy for asymptomatic patients with iron-deficiency anemia.
    - Premenopausal women: Conditionally recommends bidirectional endoscopy, with shared decision making.
    - Non-invasive testing for H. pylori and celiac disease is also part of the evaluation.
  • Iron supplementation
    Calculate your Iron Stores and personalized supplementation plan.
    Read the American Society of Hematology guideline for Management of iron deficiency
    In trials of pregnant women, ferrous bisglycinate ("gentle iron") for 4-20 weeks resulted in higher hemoglobin concentrations and fewer reported GI adverse events than other iron supplements. Evidence in other populations was more limited.
    In a small study of 12 healthy volunteers, taking 500 mg of vitamin C together with 6 mg of iron as ferric ammonium citrate increased iron absorption from about 15% to 34%.
    Liquid iron might not be the best first option, as it can stain the teeth.
    Lab check ferritin at least twice a year, since high values are dangerous.
    "Slow-release" or "enteric-coated" Iron supplements are ineffective. Iron absorption primarily occurs in the duodenum, meaning there is only a limited window for efficient uptake.

What a high value may mean:

Common reasons for high Ferritin:

  • Acute or chronic inflammation, independent of iron levels,
    In these cases, a high ferritin level does not accurately reflect iron stores: Inflammation, infection, liver disease (particularly non-alcoholic steatohepatitis (NASH)/fatty liver), renal disease, alcohol excess, metabolic syndrome or malignancy.
    hsCRP can help identify an inflammatory contribution to elevated ferritin; a normal result does not exclude every non-iron cause of high ferritin.
    High ferritin with low transferrin saturation typically suggests inflammation rather than iron overload.
  • Excess dietary iron intake
    Transferrin saturation above 45% warrants further assessment for iron overload.
  • Hyperthyroidism / Grave's disease
    All patients in the study experienced a decrease in serum ferritin levels with antithyroid drug therapy.
  • Genetic disorders like hemochromatosis and ferroportin disease
    Check your genetic report for iron panel or specifically these genes: MtF, L-ferritin, HFE, SLC11A3, FTL.

Possible consequences from high Ferritin:

  • Symptomatic hemochromatosis
    Iron overload from hemochromatosis can cause the following symptoms; ferritin alone does not establish a threshold for symptom onset:
    Unexplained fatigue and weakness
    Joint pain
    Darkening of the skin / skin pigmentation
    Abdominal pain typically from the liver
    Cardiac arrhythmias
    Weight loss
    Diabetes due to iron accumulation in the pancreas
    Loss of libido and impotence

How to lower Ferritin:

  • It's important to determine the cause of elevated ferritin levels. The interventions outlined below are only for addressing iron overload:
  • Reduce dietary iron intake
    Check the labels of your supplements to ensure they do not contain iron (Fe).
    Alcohol enhances the absorption of iron
    Clams, beef liver and red meat are all high in heme iron
    Cast iron cookware significantly contributes to dietary iron intake
  • Phlebotomy (bloodletting)
    Consider blood donation. Depending on the country, you should not donate blood if your ferritin is above 400 µg/L.
    A blood donor loses about 250 mg of iron with each whole blood donation of 500 mL.
  • Chelation Therapy
    Iron-chelating medications are used for some forms of secondary iron overload, including iron overload associated with ineffective erythropoiesis or chronic hemolytic anemia. Treatment depends on the cause of iron overload.

Images:

Ferritin was associated with all cause mortality

Ferritin was associated with all cause mortality

Model 5 is the fully adjusted model. Significant results in bold
5,471 participants
Community dwellers aged ≥52 years from England.
Dataset: English Longitudinal Study of Ageing
Longitudinal study
High ferritin was associated with moderate rise in mortality

High ferritin was associated with moderate rise in mortality

Plasma ferritin cannot be reliably converted to serum ferritin.
8,988 participants
Randomly selected Danish population 20 to 80 years old followed up for 23 years.
Dataset: The Copenhagen City Heart Study
Longitudinal study
High ferritin was associated with moderate rise in mortality

High ferritin was associated with moderate rise in mortality

257,953 participants
European-ancestry cohorts; mortality analyses used the Norwegian HUNT cohort
Dataset: HUNT, MGI, SardiNIA, deCODE, INTERVAL and DBDS
GWAS Mendelian randomization study
Ferritin was not associated with all-cause mortality

Ferritin was not associated with all-cause mortality

However, all-cause mortality was inversely associated with transferrin saturation (%) in men.
5,695 participants
50 years or older men and postmenopausal women.
Dataset: NHANES III linked to mortality data
Longitudinal study

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