Refractory iron deficiency anemia. A rise of only 0.4 g/dL over 3 months with a
ferritin of 8 ng/mL confirms failure of oral therapy and severe, unreplenished iron stores (the direct driver of hair loss/telogen effluvium).
Causes: Ongoing blood loss (most commonly heavy periods in a 28-year-old female), impaired gut absorption (celiac disease, H. pylori, or taking pills with tea/coffee/
calcium), or a co-existing condition (such as thalassemia trait or
B12 deficiency).
Immediate Next Steps
Investigation to do: Check CBC with RBC indices (MCV/MCH), peripheral smear, serum
Vitamin B12/folate, anti-tTG IgA (to rule out celiac), and hemoglobin HPLC (to rule out thalassemia trait).
Treatment Shift: Standard practice strongly favors switching to Intravenous (IV) Iron (such as Ferric Carboxymaltose). IV iron bypasses absorption issues, rapidly restores marrow stores, and halts further hair shedding far more reliably than continuing oral pills.