154. Why Am I So Tired?

Fatigue is one of the most common complaints women bring to their doctors — and one of the least thoroughly investigated. "You're doing too much" and "it's probably stress" are not diagnoses. And for the millions of women walking around exhausted despite sleeping enough, eating well, and exercising regularly, they are not answers either.

In this episode of Cycle Wisdom, Dr. Monica Minjeur breaks down the real hormonal, nutritional, and lifestyle drivers of fatigue that are actually worth looking for — and explains why the standard three-test workup misses most of them. Through Peyton's story, a 31-year-old nurse who had seen three doctors and been told her labs were normal before finally getting real answers, you will see what a thorough evaluation can find that conventional medicine almost always overlooks.

You will learn:

• Why normal labs do not mean nothing is wrong — and what a complete fatigue workup actually looks like for women
• How thyroid antibodies, low ferritin, short luteal phase, and adrenal dysfunction can each contribute to exhaustion independently — and how they frequently overlap
• What the functional reference ranges for key markers like ferritin and T3 actually are — and why the lab's normal range is often not good enough

If you have been told everything looks fine but you still feel exhausted — this episode will help you know exactly what to ask for next. Learn more or schedule a free discovery call at radiantclinic.com.

Transcript

Speaker 0:02

Fatigue is one of the most common complaints that women bring to their doctors, yet it is one of the least thoroughly investigated. You might get answers like, "You're doing too much," or, "It's probably stress." These are not diagnoses. Today, we're going to break down the real hormonal, nutritional, and lifestyle drivers of fatigue that are actually worth looking for, asking for, and connecting with a healthcare team who cares enough to dig a bit deeper. I'm Dr. Monica Minjeur, the host of Cycle Wisdom, where we help women and couples restore hormonal balance and reclaim their wellbeing through personalized healthcare grounded in clinical excellence. So let's start off today, as always, with a patient story, and we'll call her Peyton. Now, Peyton was 31 at the time she came to see me. She worked as a full-time nurse, frequently doing overnight shifts, and she was active, eating what she thought was a healthy diet, slept about seven or eight hours a night, but was still exhausted. Her weight was healthy, her cycles happened regularly, and she was incredibly frustrated because she felt like she should be able to push on through, but she was quietly afraid that something was seriously wrong. She had been to three other doctors before seeing me, and they all told her the same thing, "Stop working night shift. You're probably burned out. Everything looks fine with your labs." Peyton eventually was fed up when she fell asleep during her lunch break three nights in a row when she was at work, and she said, "I can't keep functioning this way." A friend sent her to see us, looking for some actual answers and to dig deeper beyond the cursory lab work that had already been done. Our comprehensive lab workup uncovered multiple overlapping contributors. First of all, her iron counts were incredibly low. Now, they were technically in range by lab standards, but well below the functional threshold for good energy. We also identified subclinical hypothyroidism or low thyroid. Now, her thyroid gland was working okay, but the thyroid hormone wasn't binding to her cellular level, and we also found positive thyroid antibodies, so she had a new diagnosis of Hashimoto's disease. This had never been previously tested. The past tests her doctors had done looked at a TSH. She was told everything was normal and move along. When we evaluated deeper what was going on with her cycles, we saw that although she was having cycles roughly every 28 to 30 days, she had an incredibly short luteal phase, typically running eight or nine days, and the average should be somewhere at least closer to 12. We identified and confirmed that the lab showed low progesterone, and this can also contribute to poor sleep quality and exhaustion, especially leading up to the menstrual cycle beginning. We also identified some dysfunction with her adrenal glands and upon looking deeper into her lifestyle habits, found that her caloric intake was significantly below what her activity level actually required. So lots of things going on here, and this was not just nothing or just change your job. We worked with Peyton to address all of these contributors simultaneously, fixing the thyroid, restoring the iron stores, improving the quality of the ovulatory period and the luteal phase to restore the progesterone levels, and most importantly, addressing those lifestyle factors that would help to make the longer term change. Over the course of the next two months, Peyton noticed noticeable and targeted changes that were exactly what her body needed. If somebody had just kept telling her, "Sleep more, stress less, change your job," that advice was never going to get her where she needed to be, and this is why it is so important that you are working with somebody who actually listens and is going to dig deeper to get to that root cause of what is causing your problem. Now, fatigue is a symptom. It's not a specific diagnosis, and in women, it almost always has an identifiable and treatable cause or multiple causes, as was the case for Peyton. Again, it just takes looking deeply enough. Now, many of our patients that come to see us when they are tired, when they are fatigued, they get really excited when we find something going on with their thyroid, but that is not the whole story. Yes, thyroid alone can cause significant problems with fatigue, but it is oftentimes so much deeper than that and multifaceted. The standard workup that most conventional medicine doctors will perform if you come in complaining with fatigue is to do a lab test checking for your blood counts, a basic or a complete metabolic panel checking liver function, kidney function, electrolytes, and a TSH, which is a screening test for thyroid. However, this misses a significant amount of the findings that matter most for women throughout their reproductive years and beyond. Fatigue is one of the most common presenting symptoms of hormone imbalance, nutrition deficiency, adrenal dysfunction, and thyroid disease, all of which are entirely treatable and all of which frequently have an overlap with multiple different systems. This is why addressing only one thing while missing the others explains why many women oftentimes will feel somewhat better, but never fully back to themselves. We also see frequently that women are told, "Oh, your iron is a bit low. Take an iron supplement." And although that can be helpful, if it is not the whole picture, if it's not addressing looking at the whole individual and all of the other components that play a role with that, it is really challenging to get back to complete health So I wanna address a few myths before we move along here, and the first is if your labs are normal, there's nothing wrong. We hear this all the time. Every day when we see new patients in our clinic, they tell us, "My labs have all been checked. I was told everything was normal." There's two issues with this. The first is it only can be normal if you are looking for the right things. If you only check for three tests, but those three tests are normal and it was something else, then we have missed the boat. The other is that reference ranges that are set by the labs are incredibly arbitrary, typically based on population averages. More importantly, depending upon the lab, some of those reference ranges are not even based on data performed on research of women's numbers. And so this is why it's incredibly important to understand what is normal for you as a woman, whether you are menstruating, whether you're in menopause, whether you're a teenager. What should that normal reference range be? So although the lab paper may say that it's normal, it doesn't necessarily mean that that's the whole picture. So I just really wanna make sure we focus on that because, again, it is one of the most common things we hear, 'My labs were normal. I was told everything was normal. Why do I still feel like garbage?' Another common myth we hear is you just need to sleep more, or you just need to stress less, or maybe you should stop XYZ. Sleep alone doesn't always fix fatigue. Now, we absolutely want to make sure that we're getting good quality sleep. We can't just treat all the other things and still have poor sleep quality. But if sleep alone doesn't fix the fatigue, the cause is not just sleep more, stress less. There is likely something else going on that is physiologic that can be identified and treated. So let's break down a few of the common reasons we see for fatigue, and many of these I've already talked about in previous episodes. So I'm happy to help point you in the right direction if you wanna hear more about any particular things. Now, the first one, and of course, we cannot skip addressing this, is actual sleep. Now, I'm not talking about just getting enough hours of sleep, I'm also talking about sleep quality and why this makes such a difference. Now, I've talked about sleep a lot on this show in the past. Episodes number 55 and 98 both focus specifically on sleep, why it matters, how it impacts our hormones. But fatigue, despite having normal sleep hours, almost always signals poor sleep quality, not necessarily always just not getting enough sleep. And why this matters is that progesterone supports receptors that help us to make sure that we have good quality sleep. Our cortisol is supposed to help relax overnight. The cortisol is supposed to decrease. But if we have a spike of cortisol prior to going to bed, we've got too much light coming into our eyes from screen time, we've got too much exercise, too much activity, something else that's keeping us awake and stressed later into the evening hours, it can cause that cortisol level to spike right before bedtime, which can delay the onset of our deep sleep, of our REM sleep, and that can oftentimes change and adjust what happens with our hormones overnight for that evening Blood sugar instability is also a common thing that can disrupt sleep. So if you are undereating or if you are overeating or if you have a high-sugar diet, this can oftentimes cause cortisol to be released around that 2:00 to 3:00 AM timeframe, producing an early wake and fatigue. And sometimes people have a hard time getting back to sleep during that timeframe. So it's important that we talk about sleep. We, again, are always going to screen for what are the total number of hours that you're sleeping, but also what is the quality of that sleep that is happening? Another important factor that we always wanna address when it comes to lifestyle is looking at your activity level, so your exercise or how busy is your job, what does day-to-day life look like for you, as well as balancing what am I taking in as far as nutrition? Even if you have unintentional or moderate calorie restriction, this can be a significant and direct cause of fatigue. I talked about this really recently in episode 150, where even if I'm eating a healthy diet, if it is not enough, it can be a significant cause for hormone disruption, and that can lead to fatigue. In women, especially those who are active, low energy can significantly drive your fatigue levels. It is telling your body, "Please rest. I need you to chill out a little bit because I don't have enough reserve to keep functioning." Oftentimes this is going to lead to feelings of fatigue, but also decreased hormone production, which can add to some of the other causes of lab findings that we'll talk about next Signs that undereating is happening or over-training or over-exercise is a part is if your fatigue worsens after workouts rather than improving. Oftentimes people will talk about a runner's high or feeling great after exercise. If you notice that you're actually more exhausted after exercise, I want you to pay attention to what is my caloric intake? What is my activity level? There are lots of different calculators that you can run online if you search for basal metabolic rate calculator, basal metabolic rate calculator or BMR calculator. What that does is it allows you to plug in your current vital statistics, your height, your weight, your age, your gender, and then it also will have you plug in what is my activity level. And it will tell you step by step what should my daily calorie intake be as well as what should the breakdown of macronutrients be. How much protein do I need? How much carbs do I need in order to make sure that my body is well-fueled? And again, a common misconception here is that calories are bad, cholesterol is bad, fat is bad, and that is incredibly, incredibly toxic thinking, especially when it comes to hormones. If we don't eat enough, if we don't fuel enough, and again, with healthy foods, we are going to be fatigued. We are going to have problems with keeping up with our hormone production. So what are some of the lab findings that we might find? Now a lot of these we found in Peyton, and again, are very common things we find in practice. First category is going to be hormone causes. So this can be anything from thyroid to progesterone and all of the other hormones that play a role from day-to-day basis, estrogen, testosterone. Thyroid dysfunction, let's start with that. Even if you have a normal TSH or if you have a normal free T4, these can cause measurable fatigue if you've got T3 dysfunction or thyroid antibodies. And this is why we talk about over and again why it is so important to get that complete thyroid picture. Thyroid dysfunction is eight times more common in women than it is in men, but it is not screened any more frequently. And more disturbing, many, many women are running around with T3 dysfunction or thyroid antibodies that have never been checked. Now T3, if you're not familiar with this, T3 is the active form of thyroid hormone that your body has to convert from the thyroid gland. T4 needs to convert to T3, and the T3 is what binds to your cells. So even if your thyroid hormone itself is producing adequate levels of T4, if your TSH level is fine, if your body is unable to or does not have the nutrients it needs to convert T4 to T3, you can still have all of the same thyroid dysfunction symptoms if you don't have enough T3 binding to your cellular level. So this is why it's so incredibly important to check for that full panel. Thyroid antibody dysfunction is again another really important player here. I talked a lot about thyroid antibodies in episode 133, and typically most people have heard of this as Hashimoto's disease or Graves' disease, and basically what it is is when your body develops antibodies against your thyroid or against thyroid hormone. This oftentimes can be detected for many years before you would even start to see a shift in your TSH or your other thyroid labs, and it can also cause significant problems with fatigue, brain fog, cold intolerance, weight gain. All of these can be early symptoms, and again, an important reason to check and make sure that we rule out any of these other causes that are not a part of the conventional medicine workup. And then finally in this category with hormones, low progesterone and/or estrogen imbalance. Now estrogen is interesting because you can have exhaustion and fatigue if you have too much estrogen or too low estrogen. So it's really important to make sure that we understand what is causing it, where is your estrogen level in response to where you're at in your cycle or based on your age in order to make sure that we have the estrogen levels in the correct range. Low progesterone can also cause problems in that it leads to sleep disruption. Progesterone itself is a very calming hormone, and so if we don't have enough progesterone firing in our system, especially during your luteal phase or right before your period starts, it can add to PMS symptoms, sleep disturbances, night sweats, fatigue, all sorts of these troubles that can add to your fatigue for the long run Next category I wanna talk a little bit about is vitamin deficiency. And again, the most common ones we find are going to be iron or ferritin. Now, ferritin is the stored form of iron, and this is a commonly missed cause that we find. Oftentimes women will have a complete blood count done and she's told, "You know what? Your hemoglobin or your blood counts are totally normal." However, it is incredibly important that we look at ferritin because the total blood counts are made up of lots of different pieces besides just your iron. You can have a completely normal blood count and still have critically low iron stores, and this is why we want to make sure that we are checking and not accepting a normal r- reference range just based on your lab. Functional ferritin or iron stores are typically closer to the 50 to 70 range, but many women are told that they're fine even if they're as low as 10 or 15, because most labs will flag that as normal. Now, especially for women who are still having menstrual cycles, if you have heavier or prolonged periods, this is going to increase your risk for iron depletion. There are also other important factors that we pay attention to with iron dysfunction. Do you have a problem with absorption of iron, for example? Do you have a genetic disposition that predisposes you to not being able to absorb iron well? Might you be bleeding somewhere else that we are missing out on, rather than just the menstrual cycle? This is why it's so important that we're not only looking for and correcting this underlying source of iron dysfunction and depletion, but we also wanna be looking at what is the long-term reason why. If your periods are too heavy, let's talk about it. Let's get the bleeding slowed down a bit. If you are not absorbing enough, what's going on with your gut? Are you not getting enough in your diet? It is not enough to just throw a bunch of iron at you. We want to reverse that underlying cause so it doesn't continue to be a problem long-term And then the final thing I'll talk just briefly about, 'cause we just talked about it a couple weeks ago on this podcast, is your adrenal glands and stress. So back in episode 152, I talked about the importance of the adrenal glands and its regulation for cortisol and your other stress hormones. When your cortisol rhythm is disrupted, whether that's from chronic stress, s- shift work, poor sleep, prolonged over-exercise, undereating, something else going on either emotionally, physically, or recurrent illness, this exhaustion can continue despite having adequate sleep. Cortisol dysregulation can also significantly throw off thyroid conversion and all of your other hormones. This is why we say cortisol is so important. It's kind of the king of everything else. If cortisol is funky, everything else is gonna go sideways. So this is why we are going to always be looking not just at that cortisol level, because sometimes that can still look normal, but why it's so important that we're looking at all of the other factors that play a role when it comes to your adrenal glands, and looking at the lifestyle factors that play a role So couple of quick questions before we wrap up here. We are oftentimes told, I was told my blood counts were normal, my thyroid was normal. Could there still be something that's missing? And again, as I mentioned, it is so incredibly important that we're looking at the big picture here. Even though your blood counts are normal, we need to make sure that we're checking your ferritin, your iron stores, and sometimes this can be depleted oftentimes years before we see any changes on those blood counts. So always ask specifically for a ferritin level or your iron stores. Ask what the number is, not just whether it's in range. And again, for most individuals, somewhere at least in the 30 to 50 plus range is going to be where we want to aim for optimal health. Same with your thyroid. TSH or T4 alone does not capture the full picture. We need to know is your body converting that thyroid hormone over to T3, which is what binds to your cells. Do you have thyroid antibodies present? Many times thyroid antibodies and subtle T3 dysfunctions can create measurable symptoms, including fatigue, for years before we finally see a shift in that TSH. So asking for the full thyroid lab panel, including antibodies, is an appropriate screening. And finally, what do I do and how do I even know where to start if I think multiple things might be contributing? This is where we say it is so incredibly important to work with an healthcare professional who is looking at the big picture. Work with somebody who is going to evaluate what are all of the factors playing a role, especially if you are still having menstrual cycles. It is incredibly important that we are looking at a full hormone assessment at different times during your cycle, full thyroid panel, ferritin, cortisol, adrenal glands, and taking a look at what's going on overall from a nutritional status, exercise, and sleep. Finding what is actually going on and getting you an actual diagnosis rather than just chronic fatigue is the first next step. Imagine if your fatigue was never again dismissed as just the cost of being a busy woman, but instead treated as the signal that it actually is. Fatigue is a sign that something in the body's hormonal, nutritional, and/or physiologic system deserves attention. The appropriate medical response to exhaustion should be a thorough evaluation, not just a suggestion to sleep more or stress less. Imagine if women were given the specific answers their body is trying to signal and were able to find the energy they thought they had lost was recoverable all along. That is what it looks like to investigate fatigue the right way, and to use that investigation to improve your overall health for the long run

Speaker 2 21:49

If you're ready to work with our elite team of healthcare professionals, go to our website radiantclinic.com to schedule a free discovery call and learn more about our package-based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa clinic or can arrange for a telehealth visit if you live in many different states across the US. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom