High hemoglobin levels treatment. High Hemoglobin Levels: Causes, Symptoms, and Treatment of Polycythemia
What are the causes of high hemoglobin levels. How is polycythemia diagnosed. What are the symptoms of polycythemia vera. What treatment options are available for high hemoglobin counts. How does polycythemia affect quality of life. What are the risks associated with untreated polycythemia. How can polycythemia be managed long-term.
Understanding High Hemoglobin Levels and Polycythemia
High hemoglobin levels, also known as polycythemia, occur when the body produces an excess of red blood cells. Hemoglobin is the protein in red blood cells responsible for carrying oxygen throughout the body. While some elevation in hemoglobin can be normal, significantly high levels may indicate an underlying condition that requires medical attention.
A high hemoglobin count is typically defined as more than 16.6 grams per deciliter (g/dL) of blood for men and 15 g/dL for women. However, the exact threshold can vary slightly between medical practices. In children, the definition depends on age and sex.
What factors can affect hemoglobin levels?
- Time of day
- Hydration status
- Altitude
- Smoking habits
- Underlying medical conditions
Common Causes of Elevated Hemoglobin
There are several reasons why a person might develop high hemoglobin levels. Understanding these causes can help in identifying potential risk factors and seeking appropriate medical care.
Are there lifestyle factors that can lead to high hemoglobin?
Yes, certain lifestyle factors can contribute to elevated hemoglobin levels:
- Smoking: Tobacco use can cause the body to produce more red blood cells to compensate for reduced oxygen levels.
- Living at high altitudes: The body naturally increases red blood cell production to adapt to lower oxygen levels at higher elevations.
Can medical conditions cause high hemoglobin counts?
Several medical conditions can result in increased hemoglobin levels:
- Chronic lung diseases (e.g., COPD, emphysema)
- Congenital heart defects
- Heart failure
- Kidney cancer
- Liver cancer
- Polycythemia vera (a rare blood disorder)
In some cases, high hemoglobin levels may be a compensatory mechanism for chronically low blood oxygen levels due to poor heart or lung function.
Polycythemia Vera: A Closer Look
Polycythemia vera (PV) is a rare blood disorder characterized by the overproduction of red blood cells in the bone marrow. This condition is part of a group of diseases called myeloproliferative neoplasms, which affect blood cell production.
What causes polycythemia vera?
Polycythemia vera is typically caused by a genetic mutation in the JAK2 gene. This mutation leads to uncontrolled production of red blood cells, white blood cells, and platelets. The exact reason for this genetic change is not fully understood, but it is not inherited from parents.
Who is at risk for developing polycythemia vera?
While polycythemia vera can affect anyone, certain factors may increase the risk:
- Age: It is more common in people over 60, although it can occur at any age.
- Sex: Men are slightly more likely to develop PV than women.
- Ethnicity: It is more common in people of European descent.
Recognizing Symptoms of Polycythemia
Identifying the symptoms of polycythemia is crucial for early diagnosis and treatment. While some individuals may be asymptomatic, others may experience a range of symptoms due to increased blood viscosity and circulation issues.
What are the common symptoms of polycythemia?
Polycythemia can manifest in various ways, including:
- Headaches
- Dizziness
- Fatigue
- Itching, especially after warm baths or showers
- Reddened skin, particularly on the face
- Shortness of breath
- Numbness or tingling in the extremities
- Chest pain
- Abdominal discomfort due to an enlarged spleen
These symptoms can vary in severity and may develop gradually over time. It’s important to consult a healthcare provider if you experience persistent or concerning symptoms.
Diagnosis of High Hemoglobin Levels and Polycythemia
Diagnosing high hemoglobin levels and polycythemia involves a combination of physical examinations, blood tests, and sometimes additional diagnostic procedures. Early detection is crucial for effective management and prevention of complications.
How is a high hemoglobin count initially detected?
A high hemoglobin count is typically discovered through routine blood tests or tests ordered for other medical conditions. If an elevated hemoglobin level is found, further testing is usually required to determine the underlying cause.
What specific tests are used to diagnose polycythemia vera?
The diagnosis of polycythemia vera may involve several tests:
- Complete blood count (CBC): This test measures the levels of red blood cells, white blood cells, and platelets in the blood.
- Blood smear: A sample of blood is examined under a microscope to check for abnormalities in blood cells.
- Erythropoietin level: This test measures the amount of erythropoietin, a hormone that stimulates red blood cell production.
- Genetic testing: Tests for mutations in the JAK2 gene, which are present in most cases of polycythemia vera.
- Bone marrow biopsy: This procedure involves taking a small sample of bone marrow to examine the production of blood cells.
These tests help differentiate polycythemia vera from other conditions that can cause high hemoglobin levels, such as secondary polycythemia due to lung or heart disease.
Treatment Options for High Hemoglobin Levels and Polycythemia
The treatment of high hemoglobin levels and polycythemia aims to reduce the risk of complications, manage symptoms, and improve quality of life. The specific approach depends on the underlying cause and the severity of the condition.
What are the primary treatment strategies for polycythemia vera?
Treatment for polycythemia vera typically involves a combination of the following approaches:
- Phlebotomy: Regular blood draws to reduce the number of red blood cells and lower blood viscosity.
- Low-dose aspirin: To reduce the risk of blood clots.
- Medications: Such as hydroxyurea or interferon-alpha to suppress bone marrow activity and reduce blood cell production.
- JAK inhibitors: For patients who don’t respond well to other treatments or have severe symptoms.
How is secondary polycythemia treated?
For secondary polycythemia caused by underlying conditions:
- Treating the underlying cause (e.g., managing lung or heart disease)
- Lifestyle changes, such as quitting smoking or moving to a lower altitude
- Phlebotomy in some cases
The treatment plan is tailored to each individual’s specific situation and may be adjusted over time based on response and any side effects.
Managing Complications and Long-term Outlook
While proper treatment can effectively manage polycythemia, it’s important to be aware of potential complications and the long-term outlook for individuals with this condition.
What are the potential complications of untreated polycythemia?
Untreated or poorly managed polycythemia can lead to serious complications:
- Blood clots (thrombosis)
- Stroke
- Heart attack
- Deep vein thrombosis
- Pulmonary embolism
- Enlarged spleen (splenomegaly)
- Gout
- Peptic ulcers
Regular medical follow-ups and adherence to treatment plans are crucial in preventing these complications.
What is the long-term outlook for individuals with polycythemia vera?
With proper management, many people with polycythemia vera can lead normal lives. However, it is a chronic condition that requires ongoing care. The long-term outlook depends on several factors:
- Age at diagnosis
- Overall health
- Response to treatment
- Development of complications
In some cases, polycythemia vera may progress to other blood disorders, such as myelofibrosis or acute leukemia. Regular monitoring and early intervention can help manage these risks.
Living with Polycythemia: Lifestyle Considerations
While medical treatment is essential, lifestyle modifications can play a significant role in managing polycythemia and improving overall quality of life.
What lifestyle changes can help manage polycythemia?
Individuals with polycythemia can benefit from the following lifestyle adjustments:
- Staying well-hydrated to maintain proper blood flow
- Avoiding extreme temperatures, especially heat, which can exacerbate symptoms
- Engaging in regular, moderate exercise to improve circulation
- Maintaining a healthy weight
- Quitting smoking
- Limiting alcohol consumption
- Managing stress through relaxation techniques
How can patients effectively monitor their condition?
Self-monitoring is an important aspect of managing polycythemia:
- Keeping track of symptoms and reporting changes to healthcare providers
- Adhering to scheduled blood tests and medical appointments
- Maintaining a health diary to track trends in symptoms and overall well-being
- Being aware of potential complications and seeking prompt medical attention when necessary
By actively participating in their care, patients can work effectively with their healthcare team to manage their condition and maintain a good quality of life.
High hemoglobin count – Drugs.com
- Mayo Clinic Symptom Guide
- High hemoglobin count
Medically reviewed by Drugs.com. Last updated on Dec 2, 2020.
Definition
A high hemoglobin count indicates an above-normal level of the iron-containing protein in red blood cells. Hemoglobin (often abbreviated as Hb or Hgb) is the oxygen-carrying component of red blood cells.
Hemoglobin, which gives red blood cells their color, helps carry oxygen from the lungs to the rest of the body and carbon dioxide back to the lungs to be exhaled.
The threshold for a high hemoglobin count differs slightly from one medical practice to another. It’s generally defined as more than 16.6 grams (g) of hemoglobin per deciliter (dL) of blood for men and 15 g/dL for women. In children, the definition of a high hemoglobin count varies with age and sex. Hemoglobin count may also vary due to time of day, how well-hydrated you are and altitude.
Causes
A high hemoglobin count occurs most commonly when your body requires an increased oxygen-carrying capacity, usually because:
- You smoke
- You live at a high altitude and your red blood cell production naturally increases to compensate for the lower oxygen supply there
High hemoglobin count occurs less commonly because:
- Your red blood cell production increases to make up for chronically low blood oxygen levels due to poor heart or lung function.
- Your bone marrow produces too many red blood cells.
- You’ve taken drugs or hormones, most commonly erythropoietin (EPO), that stimulate red blood cell production. You’re not likely to get a high hemoglobin count from EPO given to you for chronic kidney disease. But EPO doping — getting injections to enhance athletic performance — can cause a high hemoglobin count.
If you have a high hemoglobin count without other abnormalities, it’s unlikely to indicate a related serious condition. Conditions that can cause a high hemoglobin count include:
- Congenital heart disease in adults
- COPD (chronic obstructive pulmonary disease) exacerbation — worsening of symptoms
- Dehydration
- Emphysema
- Heart failure
- Kidney cancer
- Liver cancer
- Polycythemia vera
When to see a doctor
A high hemoglobin count is usually found from tests your doctor has ordered to diagnose another condition. Your doctor is likely to order other tests to help determine the cause of your high hemoglobin count.
© 1998-2019 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.
Terms of use.
Polycythemia Vera – NORD (National Organization for Rare Disorders)
TEXTBOOKS
Lichtman MA, Beutler E, Kipps TJ, Seligsohn U, et al. Eds. Williams Hematology. 7th ed. McGraw-Hill Companies. New York, NY; 2006:779-803.
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Berkow R., ed. The Merck Manual-Home Edition.2nd ed. Whitehouse Station, NJ: Merck Research Laboratories; 2003:102-1027.
JOURNAL ARTICLES
Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol. 2017;92:94-108.
Barbui T, Thiele J, Vannucchi AM, Tefferei A. Rationale for revision and proposed changes of the WHO diagnostic criteria for polycythemia vera, essential thrombocythemia and primary myelofibrosis. Blood Cancer J. 2015;5:e337.
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Scott LM, Tong W, Levine RL, et al. JAK2 Exon 12 mutations in polycythemia vera and essential thrombocythemia. N Engl J Med. 2007;356:459-468.
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Tefferi A. Classification, diagnosis and management of myeloproliferative disorders in the JAK2V617F era. Hematology Am Soc Hematol Educ Program.2006;240-5.
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INTERNET
Nagalla S and Besa EC, Polycythemia Vera. Medscape. Updated: Jun 01, 2018. Available at: http://www.emedicine.com/MED/topic1864.htm Accessed October 8, 2018.
Mayo Clinic for Medical Education and Research. Polycythemia Vera. Feb. 08, 2017. Available at: http://www.mayoclinic.com/health/polycythemia-vera/DS00919 Accessed October 8, 2018.
Leukemia & Lymphoma Society. Polycythemia Vera Facts. Revised April, 2015. Available at: https://www.lls.org/sites/default/files/file_assets/FS13_PolycythemiaVera_FactSheet_final5.1.15.pdf Accessed October 8, 2018.
Low Red Blood Cell Count Tips
Anemia is a decrease in the number of red blood cells (RBCs). Since chemotherapy destroys cells that grow at a fast rate, red blood cells are often affected. Patients receiving a combination of radiation therapy and chemotherapy are at greater risk for anemia. An important part of the RBC is hemoglobin, the part that carries oxygen throughout your body. Therefore, when your hemoglobin is low, oxygen levels are decreased and your body has to work harder in order to compensate. The end result is that your body will show signs of being very tired.
Normal hemoglobin levels for women are usually in the range of 11.8 to 15.5 gm/dL; for men, the normal level is from 13.5 to 17.5 gm/dL. While receiving chemotherapy/radiation therapy, your hemoglobin level may drop to lower than these normal levels, so your hemoglobin level will be checked periodically throughout the course of treatments. Any time that your hemoglobin level drops below 12.0 gm/dL, you are considered to be anemic.
The signs and symptoms of anemia include:
- weakness or fatigue
- dizziness
- headache
- shortness of breath or difficulty breathing
- chest pain or palpitations
- irritability
- a heavy feeling in your upper legs
- ringing in the ears
- feeling chilled
What Can I Do to Prevent Anemia?
Since red blood cells are destroyed as a side effect of chemotherapy/radiation therapy, there is nothing specifically that you can do to prevent anemia from occurring. Anemia usually causes you to feel weak and tired; therefore, it is very important that when you are anemic you try to prevent your body from becoming extremely tired. Failure to do so may result in your becoming ill. Specific actions to take include:
Rest as much as you can to save your energy.
- Get plenty of sleep.
- Avoid prolonged or strenuous activity.
- Pace yourself. Take rest periods during activities that make you feel tired. If necessary, take short naps throughout the day.
- Prioritize your activities so you will have enough energy for important activities or the activities that you enjoy the most.
- Ask friends and family to help you prepare meals or do chores when you are tired.
Be careful to avoid injury if you are experiencing dizziness.
- Change positions slowly especially when going from lying to standing.
- When getting out of bed, sit on the side of the bed for a few minutes before standing.
Eat a well-balanced diet.
- Eat foods high in iron, including green leafy vegetables, liver and cooked red meats.
- Drink plenty of fluids.
- Avoid caffeine and big meals late in the day if you’re having trouble sleeping at night.
- Take iron supplements only if your oncologist or nurse practitioner/physician assistant has told you to do so.
When Should I Call My Doctor?
Call your doctor immediately if you have any one or more of the following:
- dizziness
- shortness of breath or difficulty breathing
- excessive weakness or fatigue
- palpitations or chest pain
How is Anemia Treated?
Depending on the cause and severity of the anemia, there are several ways that anemia can be treated. Your doctor may instruct you to take over-the-counter iron pills on a daily basis or may order blood transfusions.
Your doctor may also choose to order injections of a “growth factor” (Aranesp or Procrit). These substances work by stimulating the body’s production of erythropoietin. An important growth factor used with cancer patients stimulates the growth of red blood cells. By increasing your body’s production of red blood cells, this growth factor may decrease your risk of becoming anemic, and may also decrease the number of blood transfusions that may be required during your treatment.
Blood Transfusions for Anemia in the Hospital
How much blood do you need?
Getting a blood transfusion in the hospital can save your life. You may need a lot of blood if you are bleeding heavily because of an injury or illness.
But anemia is usually not urgent. And usually you don’t need a lot of blood. You may only need one unit of blood while you are in the hospital. Or you may not need any blood at all. Here’s why:
What is anemia?
If you have anemia, your blood doesn’t have enough red blood cells, or they don’t work properly. Red blood cells carry hemoglobin. This is an iron-rich protein that helps bring oxygen to the body. Anemia is measured in hemoglobin levels.
There are a number of reasons you may become anemic while you are in the hospital, including:
- Bleeding
- Frequent blood draws
- Liver and kidney damage
- A chronic condition or disease
- Medications
- Kidney disease
- Chronic infections
- Cancer
Extra blood units are not helpful.
A normal hemoglobin level is 11 to 18 grams per deciliter (g/dL), depending on your age and gender. But 7 to 8 g/dL is a safe level. Your doctor should use just enough blood to get to this level. Often, one unit of blood is enough.
Some doctors believe that hospital patients who fall below 10 g/dL should get a blood transfusion. But recent research found that:
- Many patients with levels between 7 and 10 g/dL may not need a blood transfusion.
- One unit of blood is usually as good as two, and it may even be safer.
- Some patients in intensive care may do better when they receive less blood.
Using more blood units may increase risks.
In the U.S., the blood is generally very safe (see Advice column). The risks when you get blood are very small. They include:
- Cardiac overload—severe shortness of breath from overloading the heart with fluid
- Lung injury
- Infections
These problems can happen with any transfusion. But the risks are higher if you get more blood.
Blood transfusions can cost a lot.
A unit of blood usually costs about $200 to $300. There are added costs for storage and processing, as well as hospital and equipment fees. Costs can be much higher if the transfusion causes an infection or serious problem. Also, if you only use the blood you need, you are helping to keep a blood supply for other people.
Do patients ever need more than one unit?
Most patients do well with just one unit of blood, if the transfusion is not for an emergency. But some people may need more blood. Discuss this with your doctor.
You may need more than one unit if:
- You have bleeding that is not well controlled, such as bleeding that continues during surgery.
- You have severe anemia and unstable chest pain. (“Unstable” means that your symptoms keep changing.)
This report is for you to use when talking with your health-care provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
© 2018 Consumer Reports. Developed in cooperation with the American Society of Hematology.
4/2015
The Importance of Hemoglobin in Women’s Health : HemoCue America
Q: What is hemoglobin?
A: Hemoglobin is an iron-rich protein contained in red blood cells. In addition to giving blood its red color, hemoglobin makes it possible for red blood cells to transport oxygen from the lungs throughout the body. It also allows carbon dioxide to be transported from the body to the lungs, where it’s exhaled.2
To manufacture hemoglobin and its carriers, red blood cells, the body needs adequate amounts of iron, as well as folate, vitamin B-12 and other nutrients, the Mayo Clinic reports.2
Q: How is hemoglobin measured?
A: While a standard CBC is often used to measure hemoglobin levels, other tests are available that give accurate, specific readings on the spot — no venipuncture needed, and no waiting for lab results. The HemoCue® Hb 801 System, for example, includes point-of-care tests that gather blood samples via a fingerstick and microcuvette. The microcuvette is then inserted into the analyzer, which displays results in less than one second.
While ranges for normal hemoglobin levels can vary a bit according to specific labs or medical practices, the Mayo Clinic cites the following as general guidelines:3
• For nonpregnant women: 12. 0 – 15.5 g/dL
• For men: 13.5 – 17.5 g/dL
Q: Why is it important to test hemoglobin?
A: According to the U.S. National Library of Medicine at the National Institutes of Health, abnormal hemoglobin levels do not always indicate a medical problem, as high or low numbers can be caused by fairly innocuous factors, such as a patient’s activity level, diet, medications or menstrual cycle. Even living at a high altitude can cause abnormal levels.
However, high or low levels can also indicate more serious medical conditions, including liver or heart disease, cancer or, as mentioned above, anemia.4
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Uses, Side Effects, Procedure, Results
A hemoglobin test measures the amount of hemoglobin (Hb or Hgb) in your blood. This protein in your red blood cells (RBCs) carries oxygen and carbon dioxide between the lungs and the rest of the body. An altered hemoglobin level is often a sign of disease. Without the right amount, your body may not have enough energy to function optimally.
A blood test that measures hemoglobin is part of a routine check-up. Your doctors might also order a hemoglobin test for you if they are concerned about your health.
Verywell / JR Bee
Purpose of Test
A hemoglobin level is part of a standard complete blood count (CBC), so you may have your level measured when you have your routine yearly physical—even if you don’t have symptoms. A hemoglobin test is also part of the standard comprehensive newborn screening.
But there are times when doctors may order this test for a more specific reason.
If you have symptoms consistent with altered hemoglobin, you may have this test to help determine the cause of your symptoms. These may include:
- Fatigue, low energy
- Dizziness
- Generalized weakness
- Weight loss or malnutrition
- Jaundice (yellow skin and/or eyes)
- Blood in the urine or stool
- Bruising
- Severe trauma
- Excessive vomiting
You may also periodically need this test to monitor a known medical illness that affects your hemoglobin.
Risks and Contraindications
You will have your blood collected for your hemoglobin test.
There very few risks to this procedure. If you’ve had a reaction when having a blood test before, you can expect the same with this test (e.g., puncture site soreness). If you tend to get squeamish around blood or needles, you may feel dizzy or lightheaded.
While it’s rare, there is a slight risk of infection, especially if the area of needle insertion becomes exposed or gets dirty before the skin heals.
Bleeding
You may have some bruising or swelling around the area where the needle is inserted, especially if you have a bleeding disorder like hemophilia or if you take a blood thinner such as aspirin or Coumadin (warfarin).
Before having your blood collected, let the nurse or phlebotomist who is drawing your blood know if you have these risk factors. You may need a pressure bandage afterward to stop the bleeding and/or they may ask you to stay until they have confirmed that your bleeding has stopped.
Before the Test
You don’t need to do anything in advance to prepare for your hemoglobin level test.
It’s unlikely that your doctor will tell you to stop taking your blood thinner, especially if you take it to prevent a heart attack or stroke. But you may be advised to avoid using nonsteroidal anti-inflammatories (NSAIDs) for pain relief the day before your test if you have a bleeding tendency.
Timing
The process of taking a sample of your blood normally takes less than five minutes. However, you need to allot at least an hour for the test.
You will have to register, wait your turn, and wait for the phlebotomist to make sure that your puncture site is not bleeding before you can leave.
Location
You might have your test done in your doctor’s office, a phlebotomy lab (on-site or off-site), or at the hospital.
What to Wear
You don’t need to wear anything special for a hemoglobin test. Avoid tight shirt sleeves since you’ll need to roll up your sleeve to have your blood collected.
Food and Drink
If you are just getting a hemoglobin test, you don’t need to make any adjustments in your diet ahead of time.
If you are also going to be having other blood tests at the same time (such as blood glucose), then your doctor may advise you to fast for around eight hours before the test.
Cost and Health Insurance
Generally, the cost of a hemoglobin test or a CBC is covered (partially or in full) by insurance and Medicare or Medicaid. If you aren’t sure if your test will be covered, you can contact your health insurer or the location/lab where you will have your test done to confirm. Check if you will be required to pay a co-pay or a deductible.
If you are paying for your test out of pocket, you can expect the cost of a hemoglobin test to range between $5 to $30, and the cost of a CBC to range between $10 and $35.
What to Bring
Make sure you bring a form of identification, your insurance information, and a form of payment in case you are paying the whole cost of your test or some of the cost.
During the Test
Your blood will be drawn by a nurse or a phlebotomist. The sample is then sent to a lab for processing.
Pre-Test
You may need to fill out forms when you check-in for your test to authorize billing and to release your test results to your physician(s).
Throughout the Test
Your nurse or phlebotomist will ask you to sit down and choose the arm you’d prefer to use. (Many choose their non-dominant arm in case soreness results.) They will find a vein from which to collect blood, possibly inside the crease of your elbow.
You will have a tourniquet tied above the vein. After the area is cleaned, a small needle will be inserted into your vein and your blood will be collected in a tube. You may feel a small poke, possibly with mild discomfort and/or pain.
If you have a tendency to feel lightheaded or dizzy around needles or blood, it’s helpful to look away during the procedure. Tell your nurse if you feel like you’re going to faint and/or if you have fainted before during a similar procedure.
Your nurse or phlebotomist will take off the tourniquet before removing the needle from your arm. Then they will press gauze over the puncture site to stop bleeding and apply a bandage.
Finger-Prick Alternative
If your baby is the one having this test, usually their heel will be pricked for a blood sample. There are also finger-prick tests available for measuring hemoglobin in adults. These tests are used in certain circumstances, such as when a nearby lab isn’t available or when you are having a pre-test before donating blood.
If you’re having a finger prick, your finder tip will be cleansed and quickly pricked with a tiny needle. You may feel a sharp poke, but it only lasts for a second.
Post-Test
If you feel fine, you’ll be free to go as long as the bleeding has stopped. If you are lightheaded or dizzy, you may need a little time to recover before you can leave.
After the Test
Once you’re done with the test, you can go about your normal activities. On the first day after your blood is collected, it’s a good idea to avoid lifting very heavy items with the arm that was used for your blood collection.
If your arm is sore, you should take it easy and you can place an ice pack on it.
Managing Side Effects
You may experience some bruising, swelling, or slight pain in the area the needle was, but this should be minor and last no more than a few days. If it persists or is getting worse, call your doctor.
Also call your doctor if you develop a fever or if the area where blood was drawn becomes warm, very painful or swollen, or oozes blood or pus.
Interpreting Results
If a finger-prick test was performed, the blood may be placed in a digital machine that provides results within minutes of the sample being drawn. Results of a typical blood draw for a hemoglobin test will be ready within a day or two.
Your doctor will consider your medical history, physical examination, and other diagnostic tests when interpreting your hemoglobin test results.
In most cases, your doctor will interpret the results of your hemoglobin level test along with results of other blood tests. If your hemoglobin is being measured as part of a CBC, your RBC count and hematocrit level will be available as well.
Sample Hemoglobin Level Reference Ranges | |
---|---|
For | Approximate Range |
Women | 12. 0 to 15.5 gm/dl |
Men | 13.5 to 17.5 gm/dl |
Children | 11 to 16 g/dl |
Pregnant Women | 11 to 12 g/dl |
Consult your lab or physician for appropriate reference ranges for your results.
Low Hemoglobin
Low hemoglobin levels may be reflective of the body’s reduced production of hemoglobin, decreased production of RBCs, or the destruction or loss of RBCs.
Low hemoglobin levels are associated with:
Diseases like sickle cell disease, thalassemia, and glucose-6 phosphate dehydrogenase (G6PD) deficiency may cause low hemoglobin levels when RBCs become severely low during a crisis.
Your hemoglobin level may also be low after you donate blood. In this case, you should expect it to normalize after a few weeks.
High Hemoglobin
Elevated hemoglobin levels can mean that the body is making too many RBCs or that the body is low in fluid volume, such as with dehydration.
Keep in mind that elevated hemoglobin, even when it is the result of the body compensating for disease (such as lung or heart disease), is a sign of poor health.
Elevated hemoglobin levels are associated with:
- Polycythemia vera, a rare condition that causes your bone marrow to produce too many red blood cells
- Smoking
- Kidney cancer
- Chronic lung disease
- Heart failure
- Living at high altitude
- Dehydration
Follow-Up
You may need additional testing and/or treatment if you have an abnormal hemoglobin level.
For instance, if your doctor is concerned about a bleeding ulcer or kidney disease, you may need additional tests to identify the cause of your altered hemoglobin level.
And if your low hemoglobin is caused by iron deficiency due to inflammatory bowel disease (IBD), treatment for both issues can help restore your hemoglobin to a normal level.
A Word From Verywell
Hemoglobin levels are a helpful indicator of a number of medical issues. Since you are unlikely to have a hemoglobin level without other blood tests too, an assessment of the combination of test results will be helpful as your medical team evaluates your overall health.
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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Parker M, Han Z, Abu-haydar E, et al. An evaluation of hemoglobin measurement tools and their accuracy and reliability when screening for child anemia in Rwanda: A randomized study. PLoS ONE. 2018;13(1):e0187663.doi:10.1371/journal.pone.0187663
Blood Tests. National Heart Lung and Blood Institute.
Peerschke EI, Pessin MS, Maslak P. Using the hemoglobin content of reticulocytes (RET-He) to evaluate anemia in patients with cancer. Am J Clin Pathol. 2014;142(4):506-12.doi:10.1309/AJCPCVZ5B0BOYJGN
Ziegler AK, Grand J, Stangerup I, et al. Time course for the recovery of physical performance, blood hemoglobin, and ferritin content after blood donation. Transfusion. 2015;55(4):898-905.doi:10.1111/trf.12926
High Hemoglobin Count. Cleveland Clinic. May 2, 2018.
Kaitha S, Bashir M, Ali T. Iron deficiency anemia in inflammatory bowel disease. World J Gastrointest Pathophysiol. 2015;6(3):62-72. doi:10.4291/wjgp.v6.i3.62
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90,000 Increased hemoglobin – causes of appearance, in what diseases it occurs, diagnostics and methods of treatment
IMPORTANT!
The information in this section cannot be used for self-diagnosis and self-medication. In case of pain or other exacerbation of the disease, diagnostic tests should be prescribed only by the attending physician. For a diagnosis and correct treatment prescription, you should contact your doctor.
Increased hemoglobin, or erythrocytosis: causes of appearance, in what diseases it occurs, diagnosis and treatment methods.
Definition
Erythrocytosis – an increase in the content of red cells per unit volume of blood, accompanied by an increase in the level of hemoglobin. The main symptoms of these changes are headaches, muscle pains, dizziness, nosebleeds, fatigue, more specific symptoms depend on the corresponding disease.
Varieties of erythrocytosis
Erythrocytosis can be primary and secondary.
Primary erythrocytosis is considered as an independent disease of the hematopoietic system and has a genetic nature.In medicine, it is known as congenital polycythemia, or Vakez disease. This pathology provokes an increase in bone marrow volume and an increased production of red blood cells and hemoglobin.
Secondary erythrocytosis is not considered a separate disease, but only a symptom of acute or chronic diseases and conditions.
Relative erythrocytosis is the result of dehydration caused by profuse diarrhea or vomiting.
Also, an increase in hemoglobin levels can be the result of drug overdose, smoking, alcohol abuse and exposure to chemicals (nitrites).
Absolute erythrocytosis is the result of increased erythropoiesis, the formation of red blood cells in the bone marrow. This form of pathology is always associated with diseases of internal organs or systems.
Possible reasons for the increase in hemoglobin
I. Hereditary:
- Changes in the structure of the Jak2 V617F gene, which is responsible for the production of red blood cells.
- Inability of blood to bind and transport oxygen to tissues.
- Decreased oxygen supply to the kidney tissues (this leads to the fact that they begin to intensively produce the hormone responsible for the formation of red blood cells (erythropoietin)).
- Deficiency of enzymes responsible for the production of red blood cells and their function of transporting oxygen to tissues.
II. Acquired:
- Kidney disease (hydronephrosis, polycystic kidney disease, cancer and renal artery stenosis).
- Lung diseases (chronic obstructive bronchitis, bronchial asthma, diseases affecting the lung tissue, sometimes of unknown cause).
- Heart diseases (congenital and acquired heart defects).
- Liver diseases (liver tumors).
- Diseases of the brain (in particular, cerebellar tumor).
- Diseases of the female reproductive system (oncological diseases of the ovaries).
- Diseases of the endocrine system, affecting the adrenal glands and contributing to an increase in blood pressure, in which the main drugs used in hypertension (Itsenko-Cushing’s disease, pheochromocytoma) are usually ineffective, as well as diseases of the thyroid gland.
- Carbon monoxide poisoning.
- Stay at high altitudes.
- Obstructive sleep apnea syndrome, characterized by temporary cessation of breathing during sleep.
Which doctor should i contact if hemoglobin is elevated
If an increase in the number of erythrocytes, hematocrit, hemoglobin is detected, first of all, it is necessary to consult a hematologist as soon as possible.
To clarify the diagnosis, a sternal puncture or trepanobiopsy of the bone marrow may be required.
90,000 Why is an excess of “iron” terrible for the body? – Rossiyskaya Gazeta
An adult’s body should contain approximately 4-5 g of iron.
But today there are less and less people who have this element in the norm. Especially in townspeople, an increased concentration of iron is increasingly observed. Is this good or bad?
We will not rust
Everyone knows that “low iron levels are bad.” And only recently they started talking that there is nothing good in the increased content of this element. Indeed, in addition to transferring oxygen, iron regulates the immune system, takes part in the thyroid gland, helps to eliminate toxins from the body, participates in regeneration processes, improves the condition of the skin, the structure of hair and nails … In a word, most of the processes in our cells take place with the participation of iron. … But with its excess, reactions similar to the formation of rust occur: iron molecules are oxidized and damage living tissues.
Where does the surplus come from?
Most of the iron in our body is part of hemoglobin, which is responsible for carrying oxygen in the body.That is why, when a person does not have enough oxygen, the body tries to compensate for this by increasing the concentration of hemoglobin. This is the case with climbers in the mountains. And for residents of cities where the air is saturated with exhaust gases. But climbers descend from the mountains. And the townspeople are constantly experiencing oxygen starvation. Sometimes excess iron in the blood is a sign of liver disease. And then there are people (almost every seventh inhabitant of the planet) who are carriers of a special gene that causes the accumulation of iron.Fortunately, this gene is mostly dormant, so few suffer from hemochromatosis (the so-called excess iron content). This “defective” gene is also called the “Celtic gene”. It is more common in Scandinavians. Excess iron is more typical for men, because of the physiological loss of blood in women, this trouble affects less often, but after menopause, they begin to “catch up” with men.
Symptoms
Symptoms of excess iron are similar to signs of hepatitis – icteric staining of the skin, sclera, as well as palate and tongue, itching, enlarged liver.
In addition, the heart rhythm is disturbed, people look pale, lose weight. Pigmentation is also possible in those places where it should not be by definition, for example, on the palms, in the armpits, in the places of old scars. But in order to make an accurate diagnosis, a biochemical blood test is required
Most of all iron accumulates in the liver, pancreas, heart muscle, which ultimately becomes the cause of changes in the organ itself: hepatitis, liver cirrhosis, diabetes mellitus, diseases of the joints, nervous system, heart pathologies, up to sudden cardiac arrest.
An excess of iron complicates the course of Parkinson’s and Alzheimer’s diseases, can provoke cancer of the intestines, liver, and lungs. Rheumatoid arthritis also often occurs with excess iron.
What to do
People with highly elevated hemoglobin need a special approach. They should not even be prescribed a seemingly harmless ascorbic acid, because this vitamin tends to enhance the absorption of iron.
An excess of iron is even more difficult to eliminate than a deficiency.Perhaps only the old grandfather’s method – bloodletting (phlebotomy) – allows you to achieve the desired results and sometimes even avoid medications during treatment.
Abroad, for example, people over 40-50 years old are even recommended donation – for the prevention of coronary heart disease. So a person “overflowing” with iron can safely join the ranks of blood donors.
Well, the most traditional, but also the surest way to regulate the level of iron in the blood is proper nutrition.
important to know
Iron in red meat is believed to be better absorbed than iron from plants. It is not always so. For example, regular consumption of celery can restore the balance of this element in the body in a few weeks. Iron from plant foods is better absorbed when combined with animal products.
Vitamin C and B vitamins contribute to better absorption of iron. So, for example, it is useful to eat an apple in addition to meat in case of anemia, but in case of high hemoglobin it is better to abstain.If there is a lot of calcium and sugar in food, iron is poorly absorbed. Buckwheat, boiled in water (without milk), is much more useful with low hemoglobin.
It is best to cook food in a Russian stove, but it can be replaced by an aerogrill, which cooks according to the same principle. The dish warms up evenly from all sides, while – without excess water and oil, which allows you to better preserve the useful properties of the products. All this makes food tasty and healthy, it is well absorbed by the body, supplying the maximum of necessary elements.Not only vegetables, but also meat cooked in the airfryer meets the recommendations of nutritionists and helps to normalize hemoglobin.
Good hemoglobin is not yet an indicator
Are you tired out of the blue? Your body may be lacking iron.
Doctors say that many Belarusians experience iron deficiency, but they don’t even know about it.
“There are concepts of iron deficiency anemia and latent iron deficiency,” she told 1prof.by Head of the Consulting Department of the Minsk Clinical Consultative and Diagnostic Center Tatiana Rachkova .
– Anemia is indicated by a low level of hemoglobin, but a latent state is when the level of hemoglobin is still normal, and iron stores are already depleted. One hundred percent confirmation of this condition is low ferritin levels. The development of iron deficiency can be caused by diseases of the gastrointestinal tract, and in women – gynecological problems. As practice shows, 30% of Belarusian women of reproductive age suffer from a latent form of iron deficiency, iron deficiency anemia occurs in 10%.This is a fairly large percentage, considering that I do not take into account pregnant and lactating women.
– What symptoms should make a person check the blood for ferritin and why is it about him?
– The level of ferritin always reflects the real picture of affairs, while serum iron is a rather subjective indicator, it can change for various reasons. As for the symptoms, it is better not to wait for them: any of us should have a routine blood test at least once a year. CBC and ferritin levels should be done overtime if you begin to feel unusual weakness during normal physical activity. Other common symptoms include: shortness of breath, a feeling of lack of air in a poorly ventilated room (although you previously tolerated such an environment quite calmly), light-headedness, brittle and depleted nails, hair loss, taste perversion: people want to eat dry buckwheat or chalk. To determine the cause of iron deficiency, it is necessary to undergo available examinations.For women, first of all, an examination by a gynecologist is shown, since even heavy menstruation can gradually deplete iron stores. The second step is, as the people say, “swallow the probe”. The fact is that a biopsy performed during this procedure will help determine the problem that interferes with the absorption capacity of the stomach. If it is reduced, then, of course, a person will receive less of many useful substances, including iron.
– It turns out that people who eat meat with meat can have anemia?
– Of course. If the absorption capacity of the gastrointestinal tract changes, no matter how much beef or by-products we eat, the body will receive less than it needs.
– Let’s say the root cause has been eliminated. Can you replenish your iron stores with food alone?
– Not a single anemia can be treated solely by diet, since there is not enough iron in foods for the therapeutic effect. It requires taking special medications. When taken orally (pills), there will be no overdose: the body will remove the excess itself.An excess of iron, which is also dangerous to health, can cause intramuscular and intravenous injections. Therefore, you cannot self-medicate, injections must be done strictly according to the appointment and under the supervision of a doctor.
– Are there any peculiarities of the development of iron deficiency in children?
– Yes. For example, babies whose mothers experienced a lack of an element during pregnancy are at risk. It should also be borne in mind that children of the first year of life grow very quickly and they need more iron than adults. That is why pediatricians advise to introduce complementary foods from the age of six months: oddly enough, but breast milk today contains less iron than special milk formulas. Another deficiency can provoke frequent infectious diseases (they require more iron intake). That is, if a child is healthy and is on an adequate, balanced diet, then, most likely, he is not threatened with iron deficiency. But in any case, a blood test is required once a year for babies.
– You mentioned “adequate” nutrition. Is vegetarianism a risk factor or is it the norm?
– I will answer this way. Iron is absorbed more intensively by our body in a bivalent (heme) form. Animal products contain just such iron, as well as essential amino acids and protein, which is necessary for the iron to be incorporated exactly where it needs to be. Plant food contains only ferric iron, that is, it is obviously absorbed much worse.If a vegetarian also has some concomitant health problems, we will definitely go to iron deficiency. I cannot dictate to a person his diet. But as a doctor, I am obliged to warn about such a development of events. It is clear that you do not need to overuse protein, but a complete rejection of it is also bad. Constantly replenishing iron with synthetic drugs is not an option. Iron in the form of tablets and vitamins is in a sense alien to the body. In fact, it is a corrosive chemical element that can cause micro-erosion during absorption.It is one thing when it is prescribed for medicinal purposes, and quite another when a person himself decided to make fun of the body, replacing food with a drug.
– Nowadays, doctors often prescribe a general blood test with an expanded leukocyte count. What it is?
– The general analysis includes only indicators of hemoglobin, platelets, leukocytes and erythrocytes. And they can be quite normal due to the adaptive capabilities of the body. And in the leukocyte formula, the percentage of various types of leukocytes is determined, which makes it possible to suspect even the prerequisites for a problem or a disease in the initial stage. Therefore, I insist on just such a detailed analysis.
– We spoke with you about low hemoglobin. And what does the increased indicator indicate?
– About the fact that you need to draw attention to yourself. Many rejoice seeing in the analyzes a very high level and in vain. This condition is called symptomatic erythrocytosis. First of all, smokers are susceptible to it (due to the constant lack of oxygen in the tissues), people with high blood pressure. In addition, high hemoglobin is associated with the risk of dangerous thrombotic situations.Therefore, even with a high level of hemoglobin, it is necessary to consult a specialist. It is also necessary to mention such an important indicator as platelets, I note that earlier this indicator was not included in a regular blood test. Now such research is required. And this is very good. For example, a low level of platelets (above 50 thousand) in ordinary life does not manifest itself in any way. But this is the first indicator of the risk of bleeding, which can only reveal itself during surgery. Therefore, I repeat once again: do not neglect preventive tests and take care of yourself.
Interviewed by Elena ORLOVA
Source: https://1prof.by/news/society/khoroshii_gemoglobin__eshche_ne_pokazatel_.html © 1prof.by
90,000 St Petersburg University expert: high ferritin levels may indicate a severe course of COVID-19
As noted by the world renowned specialist in the study, treatment and prevention of autoimmune diseases Yehuda Schönfeld, the team of scientists studied hyperferritinemia syndrome for a long time.“We have already published our findings on this condition,” says the professor. – It is characterized by the fact that in 50% of cases, patients die. This situation is similar to the one we are seeing today with the new coronavirus infection. ”
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In the body, ferritin acts as an iron depot. Protein binds free ions of a trace element, neutralizing its toxic properties and increasing solubility. In this state, the body is able to consume iron if necessary, in particular, to regulate oxygen exchange in cells with its help.Low ferritin levels lead to a decrease in iron concentration and the occurrence of iron deficiency anemia. A high level, or hyperferritinemia, is a marker for the entry of viruses and bacteria into the body. Hyperferritinemia can also be caused by a genetic mutation. In this case, it leads to neurological impairment and vision problems.
Recent studies by Italian scientists have shown that ferritin is also able to activate macrophages – cells of nonspecific immunity, which are among the first to begin the fight against foreign agents.
This is evidenced by hyperferritinemia in patients in a state of septic shock, catastrophic antiphospholipid syndrome and other situations with high macrophage activity. Similar observations have also been published in studies by scientists from China and the United States.
“When activated, macrophages begin to release cytokines. These are special signaling molecules for transferring information from one cell to another. In small amounts, they are safe for the body and help protect it from viruses and bacteria.But if too many of them are formed, a so-called cytokine storm develops, which in half of patients, especially in old age, can lead to death, says Yehuda Schoenfeld. – Thus, hyperferritinemia is a diagnostic parameter for a severe course of infections, including in COVID-19. Our task is to find a way to deal with it. ”
Read more about Professor Schoenfeld’s research in the COVID-19 scientific article in Autoimmunity Reviews.
The scientist has identified another important marker, which also indicates a high activity of macrophages and a high probability of complications.This is the cytokine CD163. In the laboratory of the mosaic of autoimmunity of St. Petersburg State University, along with the search for a way to reduce ferritin in the blood, the researchers are studying possible methods of blocking the synthesis of CD163, as well as other signaling molecules of macrophages, using antibodies. Similar work is now underway all over the world.
In addition, Yehuda Schoenfeld is working with colleagues to develop a vaccine against the new coronavirus infection. Researchers are developing a method to use virus particles, viral proteins, as the main components of the drug.These fragments are not found in the human body, which means they are not able to create an unwanted immune response, which makes them promising vaccine agents.
Treatment of iron deficiency anemia in women after childbirth
Anemia is a condition when the hemoglobin content in the blood is less than normal (low hemoglobin), which is reflected in blood tests. Hemoglobin is a molecule in red blood cells and requires iron to carry oxygen. Insufficient iron intake / absorption and iron loss (eg, through bleeding) can lead to iron deficiency anemia. Symptoms of anemia include tiredness / fatigue, shortness of breath, and dizziness. Women can lose a lot of blood during childbirth, and many pregnant women already have anemia, which can progress as a result of bleeding. Severe anemia can be associated with maternal mortality. Postpartum iron deficiency anemia is more common in low-income countries.
Treatment for iron deficiency anemia includes tablets containing iron or a solution that is injected into a vein (intravenously). Another treatment option is to restore red blood cells with a donor transfusion or stimulate red blood cell formation with erythropoietin. It is important to investigate which method is best in reducing the symptoms of anemia, and whether these treatment options are safe.
We included 22 randomized controlled trials with 2858 women and made 13 comparisons, many of which were based on only a small number of studies involving a small number of women. Overall, the quality of the evidence was low. Most of the clinical trials have been conducted in high-income countries.
Ten studies involving 1553 women compared intravenous iron with oral iron. Only one study has shown a temporary beneficial effect on fatigue / fatigue with intravenous iron. No other symptoms of anemia were reported. One woman died of heart complications in the intravenous iron group.Only two studies reported maternal deaths. Allergic reactions occurred in three women, and heart complications were in two women in the intravenous iron group. Gastrointestinal symptoms were frequent in the oral iron (oral) group and led to withdrawal from treatment in some participants.
in one study compared red blood cell transfusion with no transfusion. Some (but not all) indicators of fatigue / fatigue improved temporarily in the group of women with blood transfusions.Maternal mortality was not reported.
No symptoms of anemia were reported when comparing oral iron to placebo (three studies). It remains unknown whether the benefits of oral iron supplementation outweigh the known gastrointestinal harm (adverse effects).
Other studies that compared other treatment options did not investigate fatigue / fatigue.
Very few studies have reported a reduction in symptoms of anemia, although this is perhaps the most important treatment goal.
Existing evidence does not allow us to fully assess the effectiveness of treatment for iron deficiency anemia after childbirth, and further research is needed.
Anemia in pregnancy – iron arguments and dispelling myths
Anemia is one of the most common complications during pregnancy. In Russia, this diagnosis is made for every third pregnant woman. However, not everyone, faced with this diagnosis, understands what is at stake and what needs to be done to make the treatment as effective as possible.
Anemia is a disease in which the level of hemoglobin in the blood decreases, often with a simultaneous decrease in the number of red blood cells. The main reason for the development of anemia is the discrepancy between the intake of iron in the body and its costs.
During pregnancy, the costs of the growing fetus lead to a significant increase in the need for iron. In addition, an inadequate intake of folate or vitamin B12 can be a rarer but possible cause of anemia.
Risk factors for the development of iron deficiency anemia during pregnancy include:
- history of heavy menstruation;
- diseases of the gastrointestinal tract;
- infectious and inflammatory diseases;
- short interval between pregnancies, including conception during lactation;
- multiple pregnancies.
90,034 anemia in the past;
Since the main task of hemoglobin is to deliver oxygen – a vital element – to all tissues and cells of a woman and a fetus, it is not difficult to imagine the harm caused by its decrease during pregnancy.However, even after childbirth, the question cannot be considered closed. It has been proven that a low level of hemoglobin is associated with a decrease in lactation, as well as with the development of anemia in a child.
Iron deficiency anemia is manifested by weakness, dizziness, pathological fatigue, perverted perception of tastes and odors, palpitations, shortness of breath, headache, fainting. The skin becomes dry and pale, and the hair and nails become brittle.
The diagnosis of anemia is made based on the assessment of the hemoglobin level in the general blood test.The lower limit of the norm of hemoglobin during pregnancy is 110 g / l. However, before hemoglobin decreases, iron stores are depleted, which is manifested by a decrease in serum ferritin levels. This condition is called latent iron deficiency and also requires correction.
Treatment of anemia and latent iron deficiency is carried out with iron preparations, which are most often prescribed in the form of tablets or oral solution, but sometimes solutions for intravenous administration are used. This need arises when the level of hemoglobin is very low or in case of impaired absorption of iron from the gastrointestinal tract.
It is also important to remember the potential of a protein diet in correcting iron deficiency. Since hemoglobin is a bond between two subunits – the metal-containing gem and the protein globin, there is nothing to connect with even an adequate amount of iron in the body with insufficient protein intake.
When diagnosing anemia, it is important for the patient to remember that the consumption of foods high in iron will only help maintain the existing level of hemoglobin, but will not be able to increase its level and saturate iron stores sufficiently.
Separately, I would like to dwell on which products have a really high iron content. A common misconception is that with anemia, you need to eat apples, beets and pomegranates, as well as drink pomegranate juice. 100 grams of apples contain 0.5-2.2 mg of iron; 100 grams of beets – 1. 0 – 1.4 mg of iron; 100 grams of pomegranates – 0.78 mg of iron. Cucumbers, strawberries, pumpkin and other fruits and vegetables contain about the same amount of iron. For comparison, buckwheat contains 8 mg of iron per 100 g of product, dried fruits (dried apricots, prunes, dried apples) – from 12 to 15 mg of iron.Pork liver is the leader in iron content. In addition, the content of this trace element is high in beef liver, cocoa, lentils, egg yolk, heart.
Prevention of iron deficiency anemia in pregnant women is a study of iron stores and hemoglobin levels at the stage of pregnancy planning, and if abnormalities are detected, their timely correction, consumption of foods with a high iron content, intake of vitamin-mineral complexes containing preventive doses of iron.
Obstetrician-gynecologist
antenatal clinic №14
Khivrich Ye.B.
90,000 Treatment of low hemoglobin levels in women in women
Low blood hemoglobin level in women
Low hemoglobin in women is detected much more often than in men. This is due to the physiological characteristics of the female body. This problem is a symptom of more than a dozen different diseases, some of them have serious consequences and can even threaten the patient’s health and life.
Signs of low hemoglobin in women
Sometimes women do not immediately pay attention to deteriorating health, blaming everything on fatigue or other reasons. What are the signs that can determine the onset of anemia?
- general weakness;
- drowsiness;
- increased fatigue, fatigue;
- Frequent dizziness, up to fainting;
- pallor of the skin;
- swelling of the face and lower extremities;
- heart palpitations;
- interruptions in the work of the heart;
- pain in the region of the heart;
- perversion of taste;
- decreased exercise tolerance, muscle weakness;
- violation of the menstrual cycle.
90,034 brittle nails, hair loss;
90,034 shortness of breath, feeling short of breath;
90,034 tinnitus;