Let’s Talk About Fatigue (part 1)

So many people come to me with ‘fatigue’ as a symptom, that I can no longer count how many.

Fatigue is one of those generic and vague symptoms that we experience when something is definitely not right, but that there are literally thousands of reasons why we might be fatigued.

So, let’s say you’re experiencing fatigue. Its either a recent development, or you’ve been living with it for some time. What do you do to fix it?

First, understand that fatigue is NEVER the actual problem. It is always a symptom. And it is NEVER just because “you’re getting old.” Age plays a role in some of the things I’m going to talk about, but its also never the underlying cause.

In my experience, the vast majority of fatigue (I would say in ~90% of patients I’ve worked with) is due to one of these three things (in no specific order):

  • Oxidative stress
  • Hormone imbalances
  • Nutrient deficiencies

And these three things can all be going on at the same time. And some of them can cause others. So, figuring out exactly what’s wrong can be a delicate process of elimination, testing, trial and error, retesting, and monitoring.

I’ve had patients that we nailed down the cause on the first go around, and others that it took 2 years to finally get to the root of what was going on.

I’m going to walk you through each of these three categories to hopefully provide some direction if you’re experiencing fatigue but do not know where to start.

This post will focus primarily on hormones, and there will be two others to follow focusing on oxidative stress and nutrient deficiencies.

How Do Hormones Affect Energy?

Before we dive in, this is going to be an extremely abbreviated post, and an over-simplification, in many ways. There is just no way to touch on all the minutiae and intricacies of reproductive hormones, energy, and metabolism in a blog post.

We have several different types of hormones we produce, but most of the time, when we talk about hormones, we’re talking about reproductive hormones, also called sex hormones. These include estrogen, progesterone, testosterone, and some intermediates of those, as well as the hormones released by our brain, FSH and LH, that stimulate production of our reproductive hormones.

When I say ‘energy,’ I’m broadly referring to our ability to perform tasks of daily living, exercise, and remain alert during the day, but also energy metabolism, which includes how we use the food we eat to build muscle, store fat, and fuel our cells.

Whether or not we feel we have the physical energy to do things depends on several factors, primarily calorie balance (do you eat enough calories from food?), but also how our body uses the calories we’ve eaten (is the body efficient at burning calories for fuel?).

In both women and men, energy in the form of calories comes from the breakdown of carbohydrates, fats, and to some extent, protein.

In women, a primary hormone that impacts how much energy we ‘feel’ is estrogen, because it exerts control over everything from our appetite and hunger, to our skeletal muscles and heart, to our immune function, our liver, and more [1].

Even if we’re eating enough calories, and certainly even when we eat too many calories, we can still feel physical fatigue, or low energy levels, if the energy from the food we ate is being used up by other systems, such as the liver or the immune system.

We can also feel low energy when we eat enough calories, but we do not have enough of the building blocks of our hormones to make enough hormones to keep metabolic energy production running.

In pre-menopausal women, estrogen and progesterone are the primary hormones that affect energy levels and blood sugar, outside of insulin.

When we go through prolonged periods of stress, or get sick, or have some other event that requires our body to fight, repair, or heal, the available building blocks for hormones like estrogen will be used up more in that process, rather than available to the body to make more hormones.

The same goes for testosterone and progesterone.

There is also a factor of available energy and nutrients being drained in order to help the body fight or heal, such as vitamins, minerals, and macronutrients (carbs, protein, and fat).

And, a large part of this concept that needs to be recognized is a phenomenon referred to as ‘pregnenolone steal.’ During times of stress, whether physical, emotional, or psychological, pregnenolone, which is the mother hormone to all other reproductive hormones, will be suppressed due to the body’s demands for more cortisol.

It is also important to note that not shown on this chart is cholesterol. Cholesterol is a precursor to pregnenolone, so I will usually assess a patient’s overall fat intake, especially from saturated fats, which are the primary dietary source of cholesterol, and which, when insufficient, can lead to a secondary insufficiency of hormones downstream.

Cholesterol is also a major carrier of fat-soluble toxic waste that needs to be carried to the liver, as well as a major structural element in our brain and nervous system. Its also the critical component of our cell membranes that keeps our cells in tact all day every day.

Pregnenolone can be made into progesterone or DHEA, which converts to either estrogen or testosterone, depending on the body’s needs.

If you experience significant enough stressors for a sufficiently long time, you will prioritize your pregnenolone to make cortisol instead of sex hormones. Your sex hormones will start to fall gradually as less pregnenolone is available, because the resources to make it are being redirected elsewhere (to make more cortisol) [2].

Over time, this can present as a gradual weight gain, water retention, loss of libido, depression, skin breakouts, brain fog, and, yes, fatigue.

Many people use the term ‘adrenal fatigue’ here, which is incorrect. Adrenal fatigue doesn’t exist as a medically defined condition, but is really the result of an internet trend that attributed low energy levels to cortisol abnormalities (either too low or too high cortisol).

The problem is not cortisol, as cortisol is actually your body’s defense mechanism against fatigue in many ways. The problem is being unable to balance cortisol with sufficient sex hormones, and manage stress and how you respond to it.

You can also experience low thyroid hormone levels, or hypothyroidism, which can reduce available sex hormones.

Now, cortisol itself, when unchecked, and especially when blood sugar levels are elevated, can feedback to the pituitary gland and suppress production of hormones that signal the production and release of sex hormones, so its important to keep in mind that none of these hormones exist in a vacuum. They are part of a greater system.

Both pregnenolone steal and thyroid disorders fall into the category of HPA Axis disorders. The HPA (hypothalamic-pituitary-adrenal) axis is a feedback loop between the brain and the adrenal glands, as well as sex hormones, that affects everything from energy, to stress levels, heart rate, digestion, sleep, mood, focus, growth, reproduction, and more.

How Can You Tell if Hormones Are The Problem?

Well, you need to have them tested. Because we’re starting with such a vague symptom, like fatigue, its incredibly hard to know if hormones are the only cause, or if they are simply suppressed or low due to something else.

When I look for hormonal abnormalities in a patient, I will request a pretty standard hormone panel that consists of:

  • Estradiol
  • FSH
  • DHEA-S
  • LH
  • SHBG
  • Cortisol
  • Total Testosterone
  • Free Testosterone
  • Progesterone
  • Parathyroid Hormone
  • Prolactin
  • Dihydrotestosterone
  • Pregnenolone
  • TSH
  • T3
  • T4
  • Free T3
  • Free T4
  • anti-TPO
  • anti-TG

In my experience, most of my patients that request this from their primary care doc will only get them to draw about half of these markers, which only gives you about half the picture.

When I am ordering the labs instead, I will usually also have a liver function panel added, as well as other tests I feel are necessary to assess someone’s baseline hormone status, based on symptoms they present with and medical history.

The more data you can get to start with, the better you can narrow down where a problem may be.

So back to the question: how can you tell if hormones are the root problem?

Once I have this data at a minimum, I am looking at patterns. All laboratories report your measured values in the context of a reference range.

A reference range is simply the lab saying that 95% of the general population tends to fall within these two numbers (the upper and low cutoff). Anything outside that 95% (confidence interval) is considered abnormal.

Now, while this is useful to determine where ‘most’ people will fall, its not useful to determine what is normal and certainly not what is optimal for you.

What I look at is where your values fall in relation to the reference range. Are one or more of your hormones trending high? Or are they trending low? Do you have too much of one in relation to another?

But most importantly, I’m considering this in the context of the patient’s symptoms. How they feel absolutely is a valid piece of data, even if its subjective, it is still that patient’s reality and is still very valuable to me, the clinician, in determining where they’ve come from and where they’re headed.

A common example I find in many women is their estrogen and progesterone are both in range (not too high or too low by the lab’s standards), but they are both near the bottom of the reference range based on where they are in their cycle or in relation to menopausal status.

This tells me they have just enough sex hormones to do some basic biological functions, and probably still have a mostly normal menstrual cycle of around 28-30 days, but they may not feel their best and probably have low libido, coupled with some stubborn metabolism.

I also commonly see women taking oral contraceptives with normal or even high estrogen, but low progesterone, which can leave them feeling tired and depressed, as well.

What Do You Do About Low Hormones and Energy?

This is where I fear I will actually just create more questions than answers for you, but I’ll try to give some direction.

First, remember that I said at the beginning of this post that you can have low hormone levels independent of anything else (maybe its just stress or birth control), or you can have low hormone levels because of oxidative stress or diet-related problems.

I do a full medical workup of a patient to assess what is most likely here. If I see risk factors like infections (viruses, tickborne diseases, gut pathogens), digestive problems, toxic exposures (mold, environmental pollutants, food poisoning, etc), I will be really blunt and let you know that your hormone problem is really not the root of your fatigue and you have something more serious going on.

If, however, I see someone who is simply struggling with diet, exercise, sleep, stress, and feels so fatigued he or she cannot quite get moving in the right direction, but there really aren’t any major red flags that they’re fighting off something else, then there’s a pretty good chance that this is purely hormonal and stress-related.

If that person has no digestive symptoms, no elevated liver enzymes, no abnormal red blood cell or white blood cell markers, no history of major illness or other symptoms that would cause me to consider additional root triggers of this fatigue, I would address this a couple different ways.

Option 1: Work With a Knowledgeable Healthcare Provider for Hormone Replacement

Hormone replacement isn’t just for post-menopausal women anymore. Medicine has come a long way to providing viable solutions for people of all ages who need some extra help with low hormones.

These generally require a prescription and can be in the form of shots/injections, troches, skin creams, and subdermal pellets.

If you go this route, look at several different options for clinics in your area and if anything seems off or unusual, don’t be afraid to find someone else. There are some fantastic providers in the anti-aging and hormone world, but there are some who aren’t that fantastic, too.

Ask questions, be sure the doctor or provider is listening to your concerns, and you also need to handle your stress. No amount of hormone replacement will solve chronic stress. You need to take the initiative to reduce your stress.

Also, hormones themselves won’t make you lose body fat. Not like you think, anyway. So, your diet and exercise will be critical to whether you lose body fat, if that is a goal.

Hormone replacement can sometimes take months to get you back to feeling ‘normal,’ so be patient. Not everyone feels great overnight. You’re undoing potentially years of stress and metabolic fatigue, so give yourself a break and let your body heal.

Option 2: Go slow and try herbals and supplements

Which herbals and supplements are right for someone depends heavily on what their hormones look like. If they are really out of range, or there is thyroid abnormality, this likely isn’t the route for you. You need to see a doctor.

But, let’s say you’re just trying to take the edge off, you’re willing to put in the work with diet and exercise, and just need something to boost you back up temporarily until you can get whatever stress is going on under control.

(as with all supplements or nutraceuticals, you should consult with a knowledgeable healthcare provider before taking anything; some of the supplements listed below can produce dangerous side effects when used improperly or in individuals with certain health problems or taking certain medications)

Here are some common options:

Direct hormone supplementation

You can buy supplemental forms of these from supplement companies. Doses vary widely depending on gender, age, lab testing, individual response, medical history, use of other prescription and non-prescription products, and more.

  • DHEA
  • Pregnenolone
  • over-the-counter creams for estrogen and progesterone*

*these are made from botanicals such as wild yam and phytoestrogens from plants. They are not bioidentical hormones, and in some people they produce undesirable side effects, while in others, they work great

Indirect supplementation/Adaptogens

Some of my favorites include:

  • Chaste tree/Vitex
  • DIM
  • Black cohosh
  • Saw palmetto
  • Dong quai
  • Ashwaghanda
  • Maca

I personally use herbs, but also use direct supplementation. I like both, and may combine these for a patient when appropriate. Or not at all. Herbs are pretty powerfully effective under the right conditions.

Not all herbs are right for all people, though. I have had many patients with almost identical hormone patterns on lab testing who cannot take the same type, form, or dose of the same herb.

Herbs are also very potent when used properly, and can cause serious side effects when they’re not. Its important to work with a knowledgeable healthcare provider before taking any of these.

Also, many herbs have medication interactions, which can increase or decrease the amount you absorb or retain of a medication you are taking. Talk to your doctor before adding any of these supplements if you are taking any medication, prescription or over-the-counter.

Ok, so what if you suspect that a purely stress-related hormone imbalance is not really the whole picture and you think you may have something else going on?

That’s going to be Part 2….so subscribe or follow me and you’ll get that delivered as soon as its posted.

For more information about working with me on your hormones or anything else, check out my Work With Me page 🙂

References and further reading:

  1. Mauvais-Jarvis, F., Clegg, D. J., & Hevener, A. L. (2013). The role of estrogens in control of energy balance and glucose homeostasis. Endocrine reviews, 34(3), 309–338. doi:10.1210/er.2012-1055
  2. Encyclopedia Britannica. Hormones of the Reproductive System. https://www.britannica.com/science/hormone/Hormones-of-the-reproductive-system


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