Chlorosis is a special form of iron deficiency anemia in young girls and women of perimenopausal age caused by hormonal changes. The clinical picture includes general weakness, pallor of the skin with a greenish tinge, dystrophic changes in the appendages of the skin (hair and nails). Also, patients are often disturbed by dizziness, fainting, perversions of taste and olfactory sensations. The diagnosis is made on the basis of symptoms and laboratory data ‒ low hemoglobin and iron content in blood tests. Treatment is carried out with the help of iron preparations and diet therapy.
D50.8 Other iron deficiency anemia
Chlorosis (from the Greek “chloros” — pale green, blue. “pale dumbness”, anemia) is an outdated term that denoted iron deficiency anemia (IDA) in girls under 20 years of age and women during perimenopause, clinically somewhat different from normal anemia. Men do not suffer from this pathology. Chlorosis was first described in the XVI century by the Danish researcher Johann Lange as a “disease of virgins”. Currently, there are only isolated cases of chlorosis. In the modern nomenclature of diseases, the term is no longer used and only a few specialists recognize it as a separate form of IDA due to some pathogenetic features.
The immediate cause is considered to be iron deficiency due to hormonal restructuring of the female body during certain periods of life. These include a sharp increase in the concentration of estrogens at the onset of puberty with the appearance of the first menstruation (menarche), as well as jumps in female sex hormones with the extinction of the endocrine function of the ovaries during perimenopause (about 50 years).
The fact is that estrogens reduce the iron content in the blood by suppressing its absorption by the gastrointestinal tract (by reducing the formation of hydrochloric acid by the cells of the gastric mucosa) and inclusion in hemoglobin during bone marrow hematopoiesis. The menarche period is the most dangerous in terms of the development of chlorosis, since at this age the young body has an increased need for iron.
Predisposing factors for the occurrence of chlorosis:
- reduced acidity of gastric juice;
- diseases of the female genital organs (ovaries, endometrium), leading to copious and prolonged menstruation, and hence to increased loss of iron;
the nature of nutrition: people who do not have foods containing a large amount of iron in their diet (vegetarians, vegans), the probability of developing chlorosis is very high.
The main pathogenetic link of chlorosis is considered to be a low concentration in the blood of a vital element – iron. With its deficiency, tissue hypoxia (oxygen starvation) occurs throughout the body. All redox and metabolic processes slow down, the activity of various enzymes decreases. The functioning of all systems is deteriorating. The nervous, cardiovascular system and gastrointestinal tract are particularly affected.
A decrease in the hemoglobin content with a decrease in the size of red blood cells indicates a complete depletion of iron reserves (depot). With a prolonged course of chlorosis, dystrophic phenomena develop in the internal organs. Pathoanatomic examination reveals atrophic gastritis, glossitis, myocardiodystrophy, etc.
The main factor underlying the classification of the disease is the age of the patient. The following types of chlorosis are distinguished:
- Juvenile (early). Develops in girls some time after puberty (at 15-18 years).
- Late (essential iron deficiency anemia). It occurs in menopausal women (45-55 years old). The exact pathogenesis of this variety is not fully established. There were cases of late chlorosis in women aged 30-40 years.
The clinical picture is extremely diverse. The onset of the disease is always gradual. At first, there is general weakness, fatigue after habitual activity, increased sensitivity to cold (chilliness). Then signs of low blood pressure are added (dizziness, rapid heartbeat, flashing of flies in front of the eyes). Aching pains in the heart, shortness of breath of a mixed type may bother. The skin and mucous membranes acquire a pale color with a characteristic greenish tinge (hence the name of the disease – chlorosis).
However, in the diagnosis of late chlorosis, it is impossible to focus only on the color of the skin, since due to the expansion of the superficial vessels, typical for the menopausal period (hot flashes), a bright blush appears on the skin of the cheeks. Also, patients with late chlorosis develop dystrophic changes in the appendages of the skin much more often than with early chlorosis. The hair becomes dry, thinning, falling out heavily. Nails lose their shine, acquire a concave spoon-shaped shape (coilonychia).
Due to the atrophy of the digestive tract, appetite decreases or completely disappears, saturation occurs quickly. Swallowing is difficult. There are pulling pains in the epigastric region, nausea, constipation. Olfactory and gustatory sensations are perverted. Patients begin to eat inedible objects – chalk, plaster, clay and even earth. Such unusual taste preferences are called “pica chlorotica” (pica chlorotica). Some patients have signs of weakness of the muscle sphincters – urinary incontinence when coughing, sneezing.
Life-threatening complications in chlorosis develop extremely rarely. Due to iron deficiency, the formation of secretory immunoglobulin A is suppressed, which leads to frequent upper respiratory tract infections (ARVI). As a result of atrophic gastritis, the absorption of vitamin B12 decreases (megaloblastic anemia). Patients with chlorosis often have impaired function of the genital glands, which can lead to infertility. Due to low blood pressure, patients often lose consciousness and get a traumatic brain injury or a limb fracture when falling. Myocardiodystrophy worsens existing cardiovascular diseases (CHD, CHF).
Patients with chlorosis are supervised by hematologists or therapists. During the survey of young girls, the doctor clarifies details about the onset of menstruation, their duration and volume. During a general examination, attention is drawn to the well-developed subcutaneous fat in combination with the pale green color of the skin. During auscultation, a systolic murmur is heard at the apex of the heart. Additional examination includes:
- Blood test. In the blood test, there is a decrease in the level of hemoglobin, color index (hypochromia), a decrease in the size of red blood cells (microcytosis) and the content of hemoglobin in them. Sometimes there is poikilocytosis (a change in the shape of red blood cells). The biochemical analysis reveals low concentrations of serum iron, ferritin, and an increase in the iron-binding ability of serum.
- Instrumental research. When complaining of abdominal pain, fibroesophagogastroduodenoscopy (FEGDS) is prescribed. Signs of atrophy are often found – areas of thinning of the mucous membrane, intestinal metaplasia. When performing intragastric pH-metry, some patients have low acidity of gastric juice.
The differential diagnosis of chlorosis is mainly carried out with other types of anemia:
It is also necessary to distinguish this type of anemia from chronic lead poisoning, porphyrin metabolism disorders, hemoglobinopathies (thalassemia). With pronounced taste perversions, it may be necessary to exclude psychiatric diseases.
Most often, patients can be treated on an outpatient basis. But in some cases, in a serious condition, when constant monitoring of the patient is necessary, hospitalization in a therapeutic or hematology department may be necessary. Only conservative methods are used to combat the disease. The main directions of treatment of chlorosis include:
- The appointment of iron preparations. This is the main direction of pathogenetic therapy. Oral forms of the drug (iron sulfate, fumarate) are preferred. Funds with divalent iron are absorbed more efficiently than with trivalent iron. For better absorption, ascorbic acid is additionally used. With severe anemia, parenteral solutions are resorted to. However, when they are used, the risk of developing hemosiderosis is very high.
- Food. A diet is prescribed, including foods rich in iron (eggs, mushrooms, apples). The diet must contain products containing heme iron (meat, liver, fish). At the time of taking iron preparations, it is worth stopping the use of coffee, cocoa, chocolate, as they reduce the absorption of trace elements in the gastrointestinal tract.
- Correction of gastric juice acidity. Since many patients with chlorosis have low acidity, they are entitled to frequent fractional nutrition, drinking mineral waters with a high concentration of sulfates, chlorides and calcium, as well as the use of medications with digestive enzymes (acidin-pepsin, natural gastric juice).
Prognosis and prevention
Chlorosis is a benign disease that responds very well to treatment. After about a month of using iron preparations, the symptoms regress. The most severe adverse effects are associated with the aggravation of already existing chronic cardiac pathologies (CHF, CHD). No deaths, the direct cause of which was chlorosis, have been registered. Primary prevention consists in a balanced diet, including iron-rich foods, as well as in determining the level of serum iron during puberty and perimenopause.
- Fighting Iron-Deficiency Anemia: Innovations in Food Fortificants and Biofortification Strategies. Liberal Â, Pinela J, Vívar-Quintana AM, Ferreira ICFR, Barros L. Foods. 2020 Dec 15;9(12):1871. link
- Iron replacement therapy: entering the new era without misconceptions, but more research is needed. Girelli D, Marchi G, Busti F. Blood Transfus. 2017 Sep;15(5):379-381. link
- Recent advances in hemochromatosis: a 2015 update : a summary of proceedings of the 2014 conference held under the auspices of Hemochromatosis Australia. Ekanayake D, Roddick C, Powell LW. Hepatol Int. 2015 Apr;9(2):174-82. link
- Mechanistic and regulatory aspects of intestinal iron absorption. Gulec S, Anderson GJ, Collins JF. Am J Physiol Gastrointest Liver Physiol. 2014 Aug 15;307(4):G397-409. link
- Review on iron and its importance for human health. Abbaspour N, Hurrell R, Kelishadi R. J Res Med Sci. 2014 Feb;19(2):164-74.link