What is hypochromia

Hypochromia means that the red blood cells have less color than normal when examined under a microscope. Hypochromia usually occurs when there is not enough of the pigment that carries oxygen (hemoglobin) in the red blood cells. Hypochromia is defined as low mean corpuscular hemoglobin concentration (MCHC) in the setting of normal hemoglobin (Hb) in the red blood cells ¹. The cause of hypochromia should be evaluated by your health care provider.

Hypochromia causes

The most common cause of hypochromia in the United States is not enough iron in the body (iron deficiency). If it is not treated, this can lead to a disorder called iron deficiency anemia.

Hypochromia and microcytosis

Microcytic anemia is defined as the presence of small, often hypochromic, red blood cells in a peripheral blood smear and is usually characterized by a low mean corpuscular volume (MCV) (less than 83 micron) ². Iron deficiency is the most common cause of microcytic anemia.

Iron deficiency anemia is a common type of anemia — a condition in which blood lacks adequate healthy red blood cells. Red blood cells carry oxygen to the body’s tissues.

As the name implies, iron deficiency anemia is due to insufficient iron. Without enough iron, your body can’t produce enough of a substance in red blood cells that enables them to carry oxygen (hemoglobin). As a result, iron deficiency anemia may leave you tired and short of breath.

You can usually correct iron deficiency anemia with iron supplementation. Sometimes additional tests or treatments for iron deficiency anemia are necessary, especially if your doctor suspects that you’re bleeding internally.

Iron deficiency anemia signs and symptoms

Initially, iron deficiency anemia can be so mild that it goes unnoticed. But as the body becomes more deficient in iron and anemia worsens, the signs and symptoms intensify.

Iron deficiency anemia signs and symptoms may include:

• Extreme fatigue
• Weakness
• Pale skin
• Chest pain, fast heartbeat or shortness of breath
• Headache, dizziness or lightheadedness
• Cold hands and feet
• Inflammation or soreness of your tongue
• Brittle nails
• Unusual cravings for non-nutritive substances, such as ice, dirt or starch
• Poor appetite, especially in infants and children with iron deficiency anemia

Iron deficiency anemia causes

Iron deficiency anemia occurs when your body doesn’t have enough iron to produce hemoglobin. Hemoglobin is the part of red blood cells that gives blood its red color and enables the red blood cells to carry oxygenated blood throughout your body.

If you aren’t consuming enough iron, or if you’re losing too much iron, your body can’t produce enough hemoglobin, and iron deficiency anemia will eventually develop.

Causes of iron deficiency anemia include:

• Blood loss. Blood contains iron within red blood cells. So if you lose blood, you lose some iron. Women with heavy periods are at risk of iron deficiency anemia because they lose blood during menstruation. Slow, chronic blood loss within the body — such as from a peptic ulcer, a hiatal hernia, a colon polyp or colorectal cancer — can cause iron deficiency anemia. Gastrointestinal bleeding can result from regular use of some over-the-counter pain relievers, especially aspirin.
• A lack of iron in your diet. Your body regularly gets iron from the foods you eat. If you consume too little iron, over time your body can become iron deficient. Examples of iron-rich foods include meat, eggs, leafy green vegetables and iron-fortified foods. For proper growth and development, infants and children need iron from their diets, too.
• An inability to absorb iron. Iron from food is absorbed into your bloodstream in your small intestine. An intestinal disorder, such as celiac disease, which affects your intestine’s ability to absorb nutrients from digested food, can lead to iron deficiency anemia. If part of your small intestine has been bypassed or removed surgically, that may affect your ability to absorb iron and other nutrients.
• Pregnancy. Without iron supplementation, iron deficiency anemia occurs in many pregnant women because their iron stores need to serve their own increased blood volume as well as be a source of hemoglobin for the growing fetus.

Risk factors for iron deficiency anemia

These groups of people may have an increased risk of iron deficiency anemia:

• Women. Because women lose blood during menstruation, women in general are at greater risk of iron deficiency anemia.
• Infants and children. Infants, especially those who were low birth weight or born prematurely, who don’t get enough iron from breast milk or formula may be at risk of iron deficiency. Children need extra iron during growth spurts. If your child isn’t eating a healthy, varied diet, he or she may be at risk of anemia.
• Vegetarians. People who don’t eat meat may have a greater risk of iron deficiency anemia if they don’t eat other iron-rich foods.
• Frequent blood donors. People who routinely donate blood may have an increased risk of iron deficiency anemia since blood donation can deplete iron stores. Low hemoglobin related to blood donation may be a temporary problem remedied by eating more iron-rich foods. If you’re told that you can’t donate blood because of low hemoglobin, ask your doctor whether you should be concerned.

Iron deficiency anemia prevention

You can reduce your risk of iron deficiency anemia by choosing iron-rich foods.

Choose iron-rich foods

Foods rich in iron include:

• Red meat, pork and poultry
• Seafood
• Beans
• Dark green leafy vegetables, such as spinach
• Dried fruit, such as raisins and apricots
• Iron-fortified cereals, breads and pastas
• Peas

Your body absorbs more iron from meat than it does from other sources. If you choose to not eat meat, you may need to increase your intake of iron-rich, plant-based foods to absorb the same amount of iron as does someone who eats meat.

Choose foods containing vitamin C to enhance iron absorption

You can enhance your body’s absorption of iron by drinking citrus juice or eating other foods rich in vitamin C at the same time that you eat high-iron foods. Vitamin C in citrus juices, like orange juice, helps your body to better absorb dietary iron.

Vitamin C is also found in:

• Broccoli
• Grapefruit
• Kiwi
• Leafy greens
• Melons
• Oranges
• Peppers
• Strawberries
• Tangerines
• Tomatoes

Preventing iron deficiency anemia in infants

To prevent iron deficiency anemia in infants, feed your baby breast milk or iron-fortified formula for the first year. Cow’s milk isn’t a good source of iron for babies and isn’t recommended for infants under 1 year. After age 6 months, start feeding your baby iron-fortified cereals or pureed meats at least twice a day to boost iron intake. After one year, be sure children don’t drink more than 20 ounces (591 milliliters) of milk a day. Too much milk often takes the place of other foods, including those that are rich in iron.

Iron deficiency anemia complications

Mild iron deficiency anemia usually doesn’t cause complications. However, left untreated, iron deficiency anemia can become severe and lead to health problems, including the following:

• Heart problems. Iron deficiency anemia may lead to a rapid or irregular heartbeat. Your heart must pump more blood to compensate for the lack of oxygen carried in your blood when you’re anemic. This can lead to an enlarged heart or heart failure.
• Problems during pregnancy. In pregnant women, severe iron deficiency anemia has been linked to premature births and low birth weight babies. But the condition is preventable in pregnant women who receive iron supplements as part of their prenatal care.
• Growth problems. In infants and children, severe iron deficiency can lead to anemia as well as delayed growth and development. Additionally, iron deficiency anemia is associated with an increased susceptibility to infections.

Iron deficiency anemia diagnosis

To diagnose iron deficiency anemia, your doctor may run tests to look for:

• Red blood cell size and color. With iron deficiency anemia, red blood cells are smaller (microcytes) and paler in color than normal (hypochromia).
• Hematocrit. This is the percentage of your blood volume made up by red blood cells. Normal levels are generally between 34.9 and 44.5 percent for adult women and 38.8 to 50 percent for adult men. These values may change depending on your age.
• Hemoglobin. Lower than normal hemoglobin levels indicate anemia. The normal hemoglobin range is generally defined as 13.5 to 17.5 grams (g) of hemoglobin per deciliter (dL) of blood for men and 12.0 to 15.5 g/dL for women. The normal ranges for children vary depending on the child’s age and sex.
• Ferritin. This protein helps store iron in your body, and a low level of ferritin usually indicates a low level of stored iron.

Additional diagnostic tests

If your bloodwork indicates iron deficiency anemia, your doctor may order additional tests to identify an underlying cause, such as:

• Endoscopy. Doctors often check for bleeding from a hiatal hernia, an ulcer or the stomach with the aid of endoscopy. In this procedure, a thin, lighted tube equipped with a video camera is passed down your throat to your stomach. This allows your doctor to view the tube that runs from your mouth to your stomach (esophagus) and your stomach to look for sources of bleeding.
• Colonoscopy. To rule out lower intestinal sources of bleeding, your doctor may recommend a procedure called a colonoscopy. A thin, flexible tube equipped with a video camera is inserted into the rectum and guided to your colon. You’re usually sedated during this test. A colonoscopy allows your doctor to view inside some or all of your colon and rectum to look for internal bleeding.
• Ultrasound. Women may also have a pelvic ultrasound to look for the cause of excess menstrual bleeding, such as uterine fibroids.

Your doctor may order these or other tests after a trial period of treatment with iron supplementation.

Iron deficiency anemia treatment

To treat iron deficiency anemia, your doctor may recommend that you take iron supplements. Your doctor will also treat the underlying cause of your iron deficiency, if necessary.

Iron supplements

Your doctor may recommend over-the-counter iron tablets to replenish the iron stores in your body. Your doctor will let you know the correct dose for you. Iron is also available in liquid form for infants and children. To improve the chances that your body will absorb the iron in the tablets, you may be instructed to:

• Take iron tablets on an empty stomach. If possible, take your iron tablets when your stomach is empty. However, because iron tablets can upset your stomach, you may need to take your iron tablets with meals.
• Don’t take iron with antacids. Medications that immediately relieve heartburn symptoms can interfere with the absorption of iron. Take iron two hours before or four hours after you take antacids.
• Take iron tablets with vitamin C. Vitamin C improves the absorption of iron. Your doctor might recommend taking your iron tablets with a glass of orange juice or with a vitamin C supplement.

Iron supplements can cause constipation, so your doctor may also recommend a stool softener. Iron may turn your stools black, which is a harmless side effect.

Iron deficiency can’t be corrected overnight. You may need to take iron supplements for several months or longer to replenish your iron reserves. Generally, you’ll start to feel better after a week or so of treatment. Ask your doctor when to have your blood rechecked to measure your iron levels. To be sure that your iron reserves are replenished, you may need to take iron supplements for a year or more.

Treating underlying causes of iron deficiency

If iron supplements don’t increase your blood-iron levels, it’s likely the anemia is due to a source of bleeding or an iron-absorption problem that your doctor will need to investigate and treat. Depending on the cause, iron deficiency anemia treatment may involve:

• Medications, such as oral contraceptives to lighten heavy menstrual flow
• Antibiotics and other medications to treat peptic ulcers
• Surgery to remove a bleeding polyp, a tumor or a fibroid

If iron deficiency anemia is severe, you may need iron given intravenously or you may need blood transfusions to help replace iron and hemoglobin quickly.

Hypochromia symptoms

At first anemia can be so mild that it goes unnoticed. But symptoms worsen as anemia worsens.

Anemia signs and symptoms vary depending on the cause of your anemia. They may include:

• Fatigue
• Weakness
• Pale or yellowish skin
• Irregular heartbeats
• Shortness of breath
• Dizziness or lightheadedness
• Chest pain
• Cold hands and feet
• Headache

Hypochromia treatment

Anemia treatment depends on the cause.

• Iron deficiency anemia. Treatment for this form of anemia usually involves taking iron supplements and making changes to your diet. If the underlying cause of iron deficiency is loss of blood — other than from menstruation — the source of the bleeding must be located and stopped. This may involve surgery.
• Vitamin deficiency anemias. Treatment for folic acid and B-12 deficiency involves dietary supplements and increasing these nutrients in your diet. If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots. At first, you may receive the shots every other day. Eventually, you’ll need shots just once a month, which may continue for life, depending on your situation.
• Anemia of chronic disease. There’s no specific treatment for this type of anemia. Doctors focus on treating the underlying disease. If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin, a hormone normally produced by your kidneys, may help stimulate red blood cell production and ease fatigue.
• Aplastic anemia. Treatment for this anemia may include blood transfusions to boost levels of red blood cells. You may need a bone marrow transplant if your bone marrow is diseased and can’t make healthy blood cells.
• Anemias associated with bone marrow disease. Treatment of these various diseases can include medication, chemotherapy or bone marrow transplantation.
• Hemolytic anemias. Managing hemolytic anemias includes avoiding suspect medications, treating related infections and taking drugs that suppress your immune system, which may be attacking your red blood cells. Depending on the severity of your anemia, a blood transfusion or plasmapheresis may be necessary. Plasmapheresis is a type of blood-filtering procedure. In certain cases, removal of the spleen can be helpful.
• Sickle cell anemia. Treatment for this anemia may include the administration of oxygen, pain-relieving drugs, and oral and intravenous fluids to reduce pain and prevent complications. Doctors also may recommend blood transfusions, folic acid supplements and antibiotics. A bone marrow transplant may be an effective treatment in some circumstances. A cancer drug called hydroxyurea (Droxia, Hydrea) also is used to treat sickle cell anemia.
• Thalassemia. This anemia may be treated with blood transfusions, folic acid supplements, medication, removal of the spleen (splenectomy), or a blood and bone marrow stem cell transplant.

1. Hammadah M, Brennan ML, Wu Y, Hazen SL, Tang WH. Usefulness of Relative Hypochromia in Risk Stratification for Nonanemic Patients With Chronic Heart Failure. Am J Cardiol. 2016;117(8):1299-304. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811711[↩]
2. Microcytic anemia. Differential diagnosis and management of iron deficiency anemia. https://www.ncbi.nlm.nih.gov/pubmed/1578956/ https://www.ncbi.nlm.nih.gov/pubmed/1578956/[↩]