Sunday, February 16, 2014

Running with Anemia

Things are never so bad that they can't be made worse. ~Humphrey Bogart

I believe I first heard that quote while in the Air Force. It was probably in reference to a bad commander that I couldn't wait to see move on. The military tends to rotate commanders every 2-3 years so we would rejoice when a bad one left. I'm sure some crusty old Chief Master Sergeant saw us rejoicing and threw that quote our way. Inevitably, I learned from experience he was right when the bad commander was followed by someone much worse. I have held that quote in my brain for over 20 years not because I'm a pessimistic person, but because I am a realistic person who likes to be prepared.

I'm going to pick up where we left off because I want to chronicle this adventure for those of you who may find yourselves in a similar situation. I get a great amount of info from others' blog posts and articles I find on the web. What I have found so far is that the issues I am dealing with are estimated to affect up to 80% of women and athletes are not spared. However, there is very little information specific to athletes out there on these topics. I decided I would at least share what I am going through in hopes that others will do the same making more information available to female athletes (and their significant others) everywhere.      

Where we left off: Two weeks ago, I had dropped out of a half marathon race because I had an episode of blood loss the night before. I decided to contact my lady doc since I realized 4 weeks of continuous bleeding was no longer within a normal range of variability for me. She scheduled an ultrasound for me the Thursday of that week and my regular doc scheduled some blood tests for me. I was relieved to get the blood test results showing that I hadn't become anemic since my last blood tests in November.

Just when I thought things were pretty bad, they got much worse. On Friday, I had a meeting scheduled and came prepared in case I had a major flooding episode. Well, the flood gates opened during the meeting and I could not control it. I had to politely excuse myself and drive home. This was flooding of biblical proportion. I had a dinner date with a friend that night at her house and experienced another flooding episode that led to an embarrassing admission on my part and sitting on a towel for the rest of the evening. My friend was, as I of course expected, very gracious.

I went for two runs over that weekend. Seven miles on Saturday and 12 miles on Sunday. I was pleasantly surprised that I was able to pull this off and maintain a decent (7:30) pace. I was definitely tired, but I was never on the verge of passing out or anything extreme.

Last Monday at 2 a.m., I woke to heavy bleeding and decided I needed to take action. I immediately sent a message to my lady doc. It was returned immediately with an out of office message. Damn it! I was luckily able to make an appointment with my former lady doc for that morning.

During that visit, my doc started with my ultrasound results which showed I had fibroids growing somewhere in my uterus. One of them was a big daddy, protruding 7cm into the uterus. The doc explained this was the likely culprit causing my excessive bleeding. However, she said that the IUD I had in place should be spewing out hormones to counteract the bleeding. We decided to have her take a look inside the madness, do an endometrial biopsy to rule out super bad stuff and remove the IUD to see if maybe it was contributing to my problems.

When she started checking under the hood, she got a concerned look on her face. She told me she couldn't find the IUD. She then checked the ultrasound report which would certainly note a foreign object in my uterus had it been present. No notes. She said that she has seen this a couple of times in her long career, and it was always associated with heavy bleeding. So, it appears I am now a human pez dispenser of IUDs. It seems crazy to me that something that big could come shooting out of me and I would not have seen or felt it. She said it is rare, but it happens. When I told my mom about this her response was, "well, I always told you you were special".  

It was a convenient explanation for what was happening. At some point, I lost the IUD and the hormones it was pumping into my system. When that happened, everything went haywire. So, the temporary solution was to put me on a heavy dose of progesterone pills and see what happens. We also went over the options that may be available to me depending on the results of the biopsy. Surgery of some kind looks like a probable next step. She explained that she was happy I had the blood tests done the week before because anemia was the most immediate concern with this issue. Since I wasn't anemic, we had some time to experiment with different treatments.

Not so fast...I got the blood test results back that I had taken after my appointment with the doc on Monday evening. I had become anemic over the weekend. Since this mess started, way back in November, I had wondered how much blood loss I could sustain before becoming anemic. This made me even more impressed with the two runs I had been able to complete over that weekend. This wasn't like low ferritin making me lose a few seconds per mile in my workouts. This was full on anemia. Interestingly, I asked to have my ferritin checked and it was 28, which is the same as it was in December. So, the iron supplements were clearly maintaining my blood iron levels high enough to continue to store iron.  I thought this was particularly germane given my discussion in last week's post about hemoglobin and ferritin. I just didn't expect to become Exhibit A in my own experiment so quickly.  

The progesterone started working within the first two days to reduce the bleeding but then, Wednesday morning, I woke to mind-blowingly painful abdominal cramps. I complained a bit to the Genius before he left for work, but told him I'd be fine. Then, I wasn't fine. I tried to stand and started seeing stars. I became clammy and sweaty. I looked in the mirror and was pale as a ghost. My fingertips were ghostly white. The pain was unbearable and NSAIDs were doing nothing to curb it. I called the Genius and asked him to shuttle me to the ER. He raced me there as fast as he could while I lay moaning in the seat next to him. I pleaded with him to run a red light when we seemed to be stopped there for hours.

As per usual, the ER was an adventure, but not as great as the one I had there that time I left with a full leg, bi-valve cast. I was lucky to have a good ER doc this time who has actually been following up with me via email. He gave me an IV to help hydrate me and a big dose of ibuprofen to help with the cramps. It wasn't until I got the narcotics that the pain finally went away. They also ran more blood tests and the results came back showing I had become more anemic in the last 36 hours with a hemoglobin level of 9.6. The doc discharged me, declaring this heavy menstrual cramps and told me to keep up with the iron supplements. I will admit I felt like a bit of an idiot having gone to the ER for "menstrual cramps". I should return if the bleeding came back full force or if I pass out though he reassured me that I could still lose a lot more blood before it would be dangerous enough for them to transfuse. Comforting.

I had follow up blood work taken on Friday, and it came back showing no improvement over Wednesday's results but at least it wasn't worse. My results for the past few blood tests are shown below for reference:
And that's what a week of blood loss will do to you.
This weekend, the mad scientist came out in me, and I decided this was a great opportunity to see how much the anemia affects my running. I first asked the ER doc if it was safe to exercise and he said that I could exercise to tolerance but to try not to pass out. Doctor Mom did not agree with these  medical instructions and ordered me not to run. Sorry Mom.

I ran Thursday, the day after the ER visit and it was slower than the runs over the weekend, but I didn't pass out. Yesterday I decided to run a workout. It was the workout I was supposed to have done earlier in the week. After deciding to push my next marathon to the summer or fall, Jack put me back on short repetition training similar to what I had been doing last winter.

I must admit that I was a little afraid about how my body might respond to high levels of exertion, so I brought my iPhone with me just in case. I also used the livetrack feature on my new Garmin 620 so that the Genius and my mom could track me during the run. I ran to the practice track at Sac State and had to climb over the fence to gain access. I realized that I must be pretty determined to get this workout done if I was willing to climb the fence to get to the track.

After huffing and puffing through a few strides, I started my workout:

4 x (200m Rep pace/200m jog + 200m Rep pace/200m jog + 400m Rep pace/400m jog)

The first split was 37 and I felt it. I jogged the next 200m and decided I would try to slow the rest of these down. The 400s were tough. I got heavy-legged in the last 100m like I had done 10 or 12 400s before the first one. I walked a bit of the 400m recovery lap and then slowly jogged to the start line to start again. I was shocked at how well this workout went. I ran within a few seconds of my prescribed (non-anemic) paces with the 200s averaging around 39 and with every 400 in exactly 82 seconds. I was tired for sure, but I wasn't passing out. I did notice the anemia during the recovery jogs which became recovery walks for the first few meters between reps. That didn't compromise the workout at all given that the purpose of a repetition workout is to improve running economy by running fast with good form and without strain. This means taking full recovery in between each repeat even if it means taking a little longer to start the next rep.

I jogged back to my car feeling really proud of myself. It wasn't so much about having run a great workout despite my condition. I was happy to have overcome the fear of the unknown. I have felt tired from low iron stores before, but this was serious stuff that had me staring down the barrel of a potential blood transfusion. How would my body respond to the effort? Would I pass out at some point? Would the effort trigger more blood loss? These were the fears I started the workout with and effectively slayed.

I'd like to end with a look back at why my experience is relevant to you, my readers. Many of you will never have to run with full blown anemia, but if you do, at least you'll have my experience to draw from. I will be continuing to post about my progress in recovering from the anemic state I am in and how it affects my activities. There is a ton of information about running with sports anemia (low iron stores) and pseudo anemia (relatively low concentration of red blood cells due to higher blood volume in athletes), but I found zero about running with clinical anemia. If it's out there, I'd love to know about it and post a link.

And, for you lucky ladies heading into your 40s, there is a good chance (maybe as high as 80%) that you either have or will have fibroids. Many women never know they have them and get along fine. For others, they can cause crazy problems like the ones I am experiencing (assuming it's the fibroids doing this to me) but might even present as a sports-related injury like this Aussie triathlete describes in this interview (be sure to click on "show" next to the word "transcript" on the page to read the interview). Her fibroid was pressing on nerves in her spine giving her severe leg pain that wouldn't resolve and made her stop running altogether. It's a great story of courage and the power of pushing back on those in the medical profession.

I will continue to use my body as a laboratory of sorts and post the information. I am most interested in follow up blood work and how my running and racing times and perceived exertion levels change along with my CBC readings. I am of course curious to see how long it takes to dig myself out of this anemic state as well. I have read predictions of 1-2 months all the way up to a year. I imagine this is an individual thing, but I will at least share my experience.                                        

Thanks to everyone who has wished me well through this journey. I wish it were nearing conclusion but I have a feeling it has just begun.

Until later,

Anemia girl, signing off.


Tuesday, February 4, 2014

This one's for the ladies

My title is intended to serve as fair warning to readers of the male species and any women who are uncomfortable with girlie talk that this sh*t's about to get real. Fast. I really, really don't like talking about this stuff, even with close friends, so writing about it is not fun either. This blog has never been about comfortable writing for me, though. So, I'll just do what I normally do when I feel uncomfortable and picture you all naked, reading my blog, eating cheetos on your couches. There. That's better.

I dropped out of my half marathon race on Sunday. Not a proud moment for me, but a necessary one. With all of the hard work I had put in, it was a great disappointment to not be able to test my fitness in a race. Again. Conditions were pretty abysmal, as all of the rain California was missing for these past few months blew in and dumped on the race course that morning. Seriously. I saw waterfalls in Golden Gate Park draining the burgeoning drainageways into lower lying areas. Given that and the fact that my Garmin completely fritzed out, I'm not sure it would have been a great test anyway. I still have no idea how fast I ran the 8 miles of the race that I did run before walking off the course. What ultimately stopped me was a health issue that has been developing for months.

I know. I just got through an injury that sidelined me for months and now this. It sucks.

My health problem is no doubt related to being in my mid-40s and likely some wackadoodle hormonal changes associated with my age. I've blogged about that before. However, this time, I am not talking about feeling a little tired or taking a day longer to recover. Here I am talking about, to be indelicate, bleeding like a stuck pig. I can't begin to quantify the amount of blood I have lost over the past few months, but it is a triumphant amount.

Of course, with the loss of blood comes anemia, and that's what is limiting me right now. I am supplementing as much as I think I can safely (liquid ferrous sulfate in OJ, 2x per day) and doing everything right in terms of not eating calcium rich foods, no tea or coffee with it, etc.  I just think supplements are no match for my archenemy or, as I like to call her: She Who Must Not Be Named (SWMNBN).

I have tested my ferritin levels (iron stores) regularly since last June and have seen a gradual decrease in those values over time: 70+ng/ml (June), 38 (Sep), 38 (Oct), 25 (Dec). So, clearly my body is losing iron stores despite the supplementation. That last downward jump, between October and November happened after my first encounter with SWMNBN. It lasted for 5 hours straight and, being my first episode, I was so afraid, I had the Genius on standby to take me to the emergency room if it didn't stop.

I started really feeling the effects in my training about 3-4 weeks ago. My legs started getting that heavy feeling, and it seemed to take more effort than necessary to hit paces. I especially felt the effects after a big episode. I've now had 4 of these with a lot of "normal" ones in between. I would need to take 1-2 days off from running right after the major events and felt like I needed tons of sleep to recover.

Without mentioning SWMNBN, I ran my fatigue and lower ferritin levels by my coach and said I thought that was contributing to my lower energy levels. He explained that a given ferritin value isn't really that useful. What is useful and important is the trend in values. He explained that hemoglobin levels were also very important in evaluating whether low iron stores were having an impact on sports performance. This all made sense to me when I read a bit more about how ferritin and hemoglobin interact to form red blood cells in this link.

Jack explained that a ferritin value of 20 ng/ml may be "good" if it was, say, 15 a month before. That indicates the body is storing iron and that iron can be used by hemoglobin to make red blood cells. If the value was 30 a month before, then there's a problem, because iron stores are being depleted and that will affect hemoglobin and hence RBC levels. He also mentioned that ideally I would want a hemoglobin level close to 14.0. He said the difference between a 13.0 and 14.0 hemoglobin level is about 40 seconds in a 5k.

I didn't have my hemoglobin levels tested every time I had my ferritin tested, but I did have a value from right after the first major incident (when my ferritin was 38 and normal), and sure enough, my hemoglobin was the lowest reading I've ever recorded: 12.4. So, even though my ferritin level appeared normal (for me), it was on a downward trend (from blood loss + high intensity training), leaving me with less and less available iron for my hemoglobin to turn into RBCs. As a comparison, my hemoglobin level was 13.9 when my ferritin levels were 70+ ng/ml. Without sufficient hemoglobin, I'm not producing enough red blood cells and performance eventually suffers, in a big way.

I should note that a hemoglobin level of 12.4 is not considered low for non-athletes, just like a ferritin value of 25 or even 15 isn't generally considered low. However, most coaches and athletes who have dealt with "sports anemia" know that there is a real impact on performance for athletes when their levels drop below a certain point. That point may be different for each athlete, but performance is affected well before a clinical diagnosis of anemia would be made based on the ranges most doctors use. There is also a lot of discussion on the internets about "pseudo" anemia which is actually a dilution of hemoglobin in the blood due to athletes having a higher blood volume. Some have hypothesized that the normal range of 13-14 that Jack gave me are high for fit athletes. If true, then my hemoglobin levels are normal for a fit athlete. The link I posted above discusses this. Bottom line: there's a lot to be learned about all of this stuff and we don't quite understand cause and effect yet. The best we can do in the mean time is track our own stats and performance values to try to come up with our own normal ranges.

Once Jack pointed out the hemoglobin/ferritin trend link, a lot of the conflicting research results I had read in the past regarding ferritin and performance started to make sense to me. If you look at just the ferritin value and not the trend then, there likely isn't a strong correlation with sports performance. However, speaking to the trend effect, in studies where women with low levels of ferritin have been given iron supplements and experienced an improvement in iron stores (ferritin values), they generally show an improvement in fatigue levels and performance.

One of the biggest challenges I have faced and I know other athletes face, is getting a doctor to give you tests often enough to see whether there is a trend. I have gotten around that issue by ordering (and paying out-of-pocket for) my own tests through It's $39 for a ferritin test and I get the results in 2-3 days. I will now be ordering hemoglobin tests too!    

So, Saturday night before the race, SWMNBN paid me a major visit (even though she had been taking up residence for the past 9 days already). She swooped in with particular force, and I knew that didn't bode well. I still felt like I needed to see what would happen on race day, allthewhile knowing the odds were against me. I started the race and it felt hard to run. I'm pretty sure I wasn't going that fast. I wanted to at least make it to the point on the course where it hits the ocean because there's a nice, long downhill section where I thought I might be able to get my stride. Nope. We hit the ocean and ran into a major headwind for another 3 miles. I gave it a mile more before I dropped.

Over the next few weeks, I'll be trying to find the cause of this troublesome issue. I have decided to abandon my plans for a spring marathon in favor of keeping myself healthy. Along with low iron levels often comes injury, or at least that has happened for me a couple of times. I will be even more vigilant these next few months as I **fingers crossed** kick SWMNBN out the door and fight tooth and nail to store some iron in my muggle bones.