Polycythemia vera (PV) is a form of myeloproliferative neoplasm (MPN) that causes your blood to become thick, with too many red blood cells to flow freely. Most people with PV have iron deficiency.

If you have PV, it’s important to realize that iron deficiency may worsen with repeated phlebotomies (blood draws) given to reduce your red blood cell count. Symptoms of iron deficiency can overlap with PV symptoms, which can make iron deficiency harder to recognize without testing.

In this article, we’ll discuss how low iron levels are defined, the causes of iron deficiency in PV, symptoms of iron deficiency, and what you can do to manage it.

🗳️ Have you discussed iron deficiency with your PV care team?

Yes, and we’ve taken steps to improve iron levels.

Yes, but we haven’t taken any steps to improve iron levels.

No, we haven’t discussed iron deficiency.

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Iron Levels and Iron Deficiency

A complete blood count is a blood test that can help your healthcare team check for anemia by measuring your hemoglobin level and red blood cell count. Separate blood tests can measure iron and ferritin levels to help assess your iron levels and iron stores.

Blood iron levels are measured in micromoles per liter. Most healthy adults have iron levels between 10 and 30 micromoles per liter.

If your iron levels are lower than 10 micromoles per liter, your iron level is considered low. Your healthcare team will look at this result along with other blood tests to determine whether you have iron deficiency anemia.

Ferritin levels are measured in micrograms per liter. Normal ferritin ranges differ between men and women.

According to the National Heart, Lung, and Blood Institute, the normal range is 40 to 300 micrograms per liter for men. For women, it is 20 to 200 micrograms per liter. A ferritin level below 10 micrograms per liter is considered low and can indicate iron deficiency.

Causes of Iron Deficiency in PV

In most healthy people, common causes of iron deficiency include blood loss, such as from gastrointestinal problems or menstrual periods, and malabsorption, when your body can’t absorb enough iron from food.

In people with PV, iron deficiency can result from increased red blood cell production and may be worsened by repeated therapeutic phlebotomy. Your healthcare team may recommend phlebotomy to reduce the number of red blood cells, ease PV symptoms, and lower the risk of blood clots.

Iron Deficiency Symptoms and PV

Symptoms of iron deficiency usually start mild but can get worse over time. The symptoms can also vary from person to person, so you may not have all of the symptoms listed.

Common Iron Deficiency Symptoms

Iron deficiency anemia can affect how you feel and even how clearly you think. Some of the most common symptoms of iron deficiency anemia are:

• A racing heart
• Pale skin
• Fatigue — Having low energy that doesn’t improve with rest
• Pica — A condition that causes you to want to eat odd substances like sand or ice
• Headaches
• Shortness of breath
• Muscle cramps
• Irritability
• Itchy skin

How Iron Deficiency Can Affect PV Symptoms

Repeated phlebotomies, even if they’re a part of your PV treatment plan, can make iron deficiency symptoms worse.

With regular blood draws, you might experience additional iron deficiency symptoms that affect your quality of life, such as restless legs syndrome or trouble with thinking and memory. You might have a hard time sleeping due to iron deficiency and PV symptoms.

Several symptoms of iron deficiency anemia overlap with symptoms of PV. Itchy skin, shortness of breath, and sounds in your ears (like ringing or whooshing) can all come from either PV or iron deficiency anemia. If you have both, the symptoms may be more noticeable or severe.

Safe Treatments for Iron Deficiency in PV

Most doctors don’t recommend iron supplements for treating iron deficiency in people with PV because they can increase the number of red blood cells. This makes it even harder for your blood to flow through your blood vessels.

Other PV treatments may help improve iron levels without directly adding iron.

Janus Kinase Inhibitors

Janus kinase (JAK) inhibitors like ruxolitinib (Jakafi) may help improve iron levels in people with PV. Ruxolitinib is approved for people with PV who don’t respond well to hydroxyurea or can’t tolerate it.

JAK inhibitors help treat PV by slowing the production of red blood cells, which can reduce the number of red blood cells circulating in your blood without a phlebotomy. However, since they cause changes in levels of blood cells, they can cause side effects like anemia, fever, and infections.

Always follow your doctor’s instructions closely while taking prescribed medications, and tell your doctor if your anemia symptoms seem to get worse.

Rusfertide

In August 2026, the U.S. Food and Drug Administration (FDA) approved rusfertide (Mimrylo) to treat erythrocytosis (too many red blood cells) in adults with PV. Rusfertide works by mimicking hepcidin, a hormone that regulates how the body uses iron.

Clinical trials found that rusfertide helped control hematocrit levels and reduce the need for phlebotomy. It also improved fatigue in people with PV.

Talk to Your Doctor

Iron deficiency and PV can cause some of the same symptoms, which can make it hard to tell what’s causing them. Always notify your doctor if you think you have signs of iron deficiency anemia. They can give you a blood test to check ferritin and iron levels.

Together, you and your healthcare team can decide on the best treatment options for PV and iron deficiency.