Fatigue: Lose the Snooze Button
Most of my patients report NOT feeling refreshed when they wake up in the morning. I’m always pleasantly surprised when I ask, and a patient says yes, they feel refreshed. Fatigue or feeling tired all the time is not normal. This may be a sign that there’s something wrong, so it should never be ignored.
If you are not waking up feeling refreshed, there are several possible explanations. Here are some common reasons for chronic fatigue:
- Not enough sleep or poor quality sleep
- Low iron or iron deficiency anemia
- Low thyroid or hypothyroidism
- Underactive adrenal glands, adrenal fatigue or HPA axis dysfunction
- Allergies or food sensitivities
- Depression
- Pregnancy – especially in the first trimester
- Chronic pain
Not enough sleep
Studies show that the optimal amount of sleep is 7-7.5 hours of restful sleep. If you wake frequently at night or get up to go to the washroom, try having a bite or two of protein-rich food before you sleep. This stabilizes your blood sugar overnight. While you may be getting enough hours of sleep, if it is not deep, restful sleep, it may not be sufficient to prevent fatigue throughout the next day. There are herbs, vitamins, and minerals I can recommend to help you achieve deeper sleep.
Fatigue Testing: What Your Blood Work Should Actually Show
Most fatigue patients come to me having been told their blood work is “normal.” The problem isn’t the tests; it’s the interpretation or the lack of thorough testing for fatigue. Standard laboratory reference ranges are built around population averages, not optimal function. Here’s what I look for that other medical professionals likely didn’t.
Low iron (ferritin)
Ferritin is a blood test that we do to check your stored iron. Iron deficiencies can lead to fatigue, weakness, and exhaustion. An optimal ferritin level for menstruating women is above 60 mcg/L. Some labs consider anything above 12 mcg/L to be within the expected range. So, your doctor may have told you that your iron (ferritin) was normal, even though it was below ideal levels. Ferritin below 40 mcg/L can lead to low-energy symptoms (and hair loss). If you struggle to maintain your iron levels, you may have difficulty absorbing iron. I only recommend the best-absorbed form of iron, and I will address what may be preventing you from absorbing it.
Ferritin: The Most Overlooked Cause of Fatigue in Women
Iron deficiency is not the same as iron deficiency anemia. You can be significantly iron-depleted, with ferritin levels low enough to impair energy, hair growth, and neurotransmitter synthesis and have a completely normal hemoglobin. This is one of the most common things I see in fatigued women, and one of the most commonly missed.
The standard laboratory lower limit for ferritin is typically 30 µg/L. Symptoms of fatigue, hair shedding, poor exercise tolerance, and low mood begin appearing when ferritin drops below 50 µg/L. For optimal energy, cognitive function, and hair retention, ferritin should be between 60 and 100 µg/L.
Ferritin also acts as an acute-phase reactant, meaning it rises with inflammation, which can mask underlying depletion. This is another reason why looking at ferritin alongside inflammatory markers (see below) gives a more accurate picture than ferritin in isolation.
Common reasons ferritin is low in women include heavy periods, inadequate dietary iron intake, and poor iron absorption due to low stomach acid or gut inflammation.
Low thyroid
Your thyroid regulates your energy, body temperature, and metabolism. Sluggish thyroid function significantly affects your energy. Blood work for the thyroid is usually limited to testing TSH. This hormone should stimulate your thyroid to work harder if it is underactive. So, a lower TSH means that your thyroid is working well. A higher TSH means your thyroid is not working well. The normal range for TSH is 0.35-5.00 mU/L. This is a wide range! Once your TSH gets above 3.00, your thyroid is underactive.
What most patients don’t realize is that TSH alone tells only part of the story. A full thyroid panel includes Free T4 (the storage form of thyroid hormone), Free T3 (the active form your cells actually use), and thyroid antibodies (anti-TPO and anti-thyroglobulin). You can have a TSH of 2.8, technically “normal” on a standard lab report, and still have Free T3 in the bottom end of the reference range, which is enough to leave you exhausted, cold, and unable to lose weight.
The conversion of T4 to active T3 is impaired by chronic stress, iron deficiency, selenium deficiency, and inflammation. This is why treating TSH in isolation misses the full picture. As someone with a background in medical laboratory science, I look at the entire thyroid hormone picture, not just the TSH flag.
Some endocrinologists and fertility specialists medicate your thyroid if the TSH level is above 2.50. As with ferritin, you may be told your thyroid is “normal.” As a naturopath, I treat a patient’s thyroid if the TSH exceeds 3.00, and sooner if free T3 or free T4 are off. We restore normal thyroid function before it worsens.
Hashimoto’s disease is a common cause of low thyroid function. It is an autoimmune thyroid problem, and most doctors don’t test for it. Blood tests for Hashimoto’s can be abnormal even when your TSH is “normal.“
Vitamin B12: Deficiency Hides in Plain Sight
The standard serum B12 reference range flags deficiency at levels below approximately 150–200 pmol/L, depending on the lab. Clinical symptoms of B12 deficiency include fatigue, brain fog, peripheral tingling, and mood changes. B12 deficiency symptoms can occur at levels within the “normal” range, sometimes up to 300–400 pmol/L, particularly in patients with liver damage, such as fatty liver. Damaged liver cells leak vitamin B12 into the blood, falsely elevating the blood level.
Serum B12 also measures both active and inactive forms of the vitamin. Holotranscobalamin (active B12) is a more sensitive marker but isn’t available through standard Ontario laboratories. When I suspect functional B12 deficiency, I look at the full picture: serum B12, homocysteine, and methylmalonic acid, along with MTHFR status, if available.
Vegans and vegetarians, patients on long-term metformin or proton pump inhibitors, and anyone over 50 with reduced gastric acid production are at elevated risk and often only marginally deficient on standard testing.
Adrenal Fatigue or HPA Axis dysfunction
If all else above has been ruled out, chronic snooze-button use is likely due to adrenal gland underactivity. These are your stress glands. They sit on top of your kidneys and regulate various bodily functions. These include regulating blood pressure, blood sugar, the nervous system, libido, energy, drive, motivation, stress response, inflammation, and hormone balance.
Signs of low adrenal function include:
- NOT feeling refreshed after at least 7 hours of sleep
- hypoglycemia
- PMS
- anxiety
- fatigue
- depression
- feeling dizzy or light-headed on standing up quickly
- low libido
- inflammatory conditions such as allergies, asthma, eczema, arthritis, and inflammatory bowel disease.
Your HPA axis needs specific vitamins and minerals to work well. Chronic overwork or personal stress, poor diet, and modern agriculture mean that you aren’t able to take in enough of these vitamins and minerals, leading to HPA axis dysfunction. As a naturopath, I would target the specific vitamins and minerals your adrenals need to work at their best.
Cortisol Rhythm: It’s Not Just About Your Total Cortisol
A single morning cortisol measurement, which is what most practitioners order if they order anything at all, tells you very little about how your stress hormone system is actually functioning throughout the day. Cortisol follows a diurnal rhythm: it should peak sharply within 30–45 minutes of waking (the cortisol awakening response or CAR), remain moderately elevated through the morning to sustain energy and focus, and decline progressively through the afternoon and evening to allow for relaxation and sleep.
I will often begin with that single morning cortisol measurement. If there is no other explanation for fatigue, we may want to assess the pattern rather than a single number. A 4-point salivary cortisol test, collected at waking, midday, afternoon, and evening, can reveal:
- High cortisol throughout the day: Consistent with chronic psychological stress, blood sugar dysregulation, or early-stage HPA activation
- Inverted or flat cortisol curve: Associated with burnout, persistent fatigue, poor morning energy, and disrupted sleep architecture
- Low waking cortisol with normal afternoon levels: Suggests a blunted cortisol awakening response, often seen in people who wake unrefreshed regardless of how long they sleep
- High evening cortisol: A common pattern in people who feel wired at night but exhausted in the morning
Standard serum cortisol ordered through OHIP will not reveal any of this. A flat-line or inverted pattern on a 4-point test is meaningful clinical data; a single morning serum value within range may not be enough.
DHEAs: The Marker Most Fatigue Workups Skip Entirely
DHEAs (dehydroepiandrosterone sulphate) is produced by the adrenal cortex and is the most abundant circulating steroid hormone in the body. It declines with age and declines more steeply under chronic stress. It functions as a counter-regulatory hormone to cortisol; when DHEAs is low relative to cortisol, the physiological effects of cortisol are amplified and less well-buffered.
Low DHEAs is associated with fatigue, reduced stress resilience, low libido, muscle loss, and poor immune function. It is rarely included in standard fatigue blood work panels, but it is straightforward to measure with a simple blood draw.
Optimal DHEAs levels in premenopausal women generally fall in the upper third of the age-adjusted reference range. Levels in the lower end of the range, while technically “normal,” are often clinically relevant in the context of fatigue and burnout.
Inflammatory Markers: When Your Immune System Is Draining Your Energy
Chronic low-grade inflammation is one of the most underappreciated drivers of persistent fatigue. The mechanism is direct: pro-inflammatory cytokines (particularly IL-1β, IL-6, and TNF-α) act on the central nervous system to induce what researchers call “sickness behaviour” – fatigue, cognitive slowing, social withdrawal, and hypersomnia. This is the same mechanism that makes you feel wiped out during an infection, operating at a lower amplitude but chronically.
The markers I assess for inflammation include:
High-sensitivity CRP (hs-CRP):
More sensitive than standard CRP for detecting low-grade inflammation. Optimal is below 1.0 mg/L. Values between 1–3 mg/L indicate moderate systemic inflammation even if no diagnosis has been made.
Homocysteine:
Elevated homocysteine reflects impaired methylation (often linked to low B12, folate, or B6 and MTHFR variants), increases cardiovascular and neurological risk, and independently correlates with fatigue and cognitive symptoms.
Fasting insulin and fasting glucose:
Chronic blood sugar dysregulation is profoundly fatiguing. Even without a diabetes diagnosis, fasting insulin in the upper-normal range indicates insulin resistance, which impairs cellular energy utilization. A fasting insulin above 60 pmol/L in the context of fatigue and carbohydrate cravings is clinically meaningful.
25-OH Vitamin D:
Vitamin D receptors are present on virtually every cell in the body, including immune cells and neurons. Deficiency (below 75 nmol/L) is common in Canada and is independently associated with fatigue, low mood, immune dysregulation, hormone imbalance, and musculoskeletal pain. Optimal levels for energy and immune function are 100–150 nmol/L.
Putting It Together: What a Complete Fatigue Blood Workup Looks Like
- Full thyroid panel: TSH, Free T4, Free T3, reverse T3, anti-TPO, anti-thyroglobulin
- CBC with differential (to assess for anemia and immune activity)
- Ferritin (with a target of 60–100 µg/L, not just “within range”)
- Serum B12 and homocysteine
- 25-OH Vitamin D
- Fasting glucose and fasting insulin
- hs-CRP
- DHEAs
- 4-point salivary cortisol (not available through OHIP, ordered as a private test)
- Estrogen, progesterone, and testosterone where clinically indicated
Allergies
Allergies often leave people feeling exhausted a good deal of the time because their immune system is working double time. Environmental allergies, food allergies, or food sensitivities all overwork the immune system, leaving you feeling tired. As a naturopath, I help people calm their allergies to improve their energy.
Depression
Excessive stress, under-functioning thyroid or adrenals, vitamin or mineral deficiencies, and hormone imbalance all lead to signs of depression. Symptoms of depression include difficulty getting out of bed or feeling motivated to do anything and a lack of joie de vivre. Depression isn’t just a psychological problem. Sometimes it is physiological, meaning that metabolic imbalances are at the core of the issue. These can be corrected through appropriate diet, lifestyle, herbal medicine, and other supplementation.
Pregnancy
Women often feel fatigued during the first trimester of pregnancy. The hormonal shift that accompanies pregnancy is usually the cause. However, sometimes there is a shift in thyroid function or low iron during pregnancy. I can optimize both.
Chronic Pain
Chronic low back pain, body aches, muscle pain, fibromyalgia, arthritis, or any other ongoing pain often leaves people feeling tired. Coping with chronic pain is tiring. Chronic pain also often leads to poor sleep or insomnia and, therefore, fatigue. I help with chronic pain through an anti-inflammatory diet, reducing stress, supporting the HPA axis, improving sleep quality and quantity, and acupuncture.
As a naturopathic doctor, I have many safe, natural treatment options for all of the above conditions.
For help with this or any other health problem, book an appointment here or call the office for more information at 416-481-0222.
Authored by Dr. Pamela Frank, BSc(Hons), ND
Dr. Pamela Frank has been in practice as a naturopathic doctor for over 26 years. Since 1999, she has earned acclaim as a leading naturopath in Toronto, amassing multiple awards.
Dr. Pamela has a special interest in addressing hormone-related complexities, including but not limited to PCOS, endometriosis, acne, hair loss, weight management, thyroid issues, and fertility.
Residing in Toronto with her family and loyal companion, Dolly the rescue dog, Dr. Pamela seamlessly combines her professional commitment with a diverse range of interests.
Beyond her clinical endeavours, she actively engages in kickboxing, leadership roles within Scout Groups, yoga practice, podcasting, and outdoor pursuits such as backcountry camping.
Dr. Pamela’s comprehensive approach reflects not only her dedication to optimal health but also her passion for continual personal and professional growth.
DISCLAIMER: The information provided here may not apply precisely to your individual situation. Diagnostic and therapeutic choices must always be tailored to the individual patient’s circumstances, and consultation with a licensed naturopathic physician should be undertaken before following any of the treatment strategies suggested in this website.