Women's Issues
Fatigue
by Carolyn Ross, MD

We've all felt it. That feeling of not being able to do or even think another thing, a feeling down to the bones: fatigue.

Fatigue is a normal response after a marathon (or, for amateurs, a 10K run), a night of sleeplessness due to worry or a sick child, or a stressful day at work. Generally, though, a good night's sleep banishes this kind of fatigue. Abnormal fatigue is waking up tired, feeling exhausted walking up the stairs or vacuuming, not being able to make it through a normal day, or feeling tired for weeks on end despite getting enough rest. Fatigue can be associated with increased stress, mood swings, or it can be a sign of physical illness. When fatigue is chronic it is a symptom that something is wrong and should not be ignored.

These days fatigue seems to be a way of life for many Americans. One recent study showed that 28 percent of women who visited their doctors complained about fatigue being a "major problem" for a month or more. The root cause of fatigue can be difficult to determine since physical, psychological and lifestyle factors can all contribute to the problem. We'll examine each area to help you do your own personal detective work.

Your Physician or Nurse Practitioner

Your doctor or nurse practitioner will take a health history to identify possible causes for fatigue, followed by a complete physical examination including blood tests. This will be done to distinguish between short-term, explainable fatigue and chronic fatigue lasting longer than six months. One common cause of fatigue is anemia. As many as 80 percent of exercising women and 39 percent of premenopausal women in general are iron deficient. Symptoms of iron deficiency such as tiredness and irritability can occur even before the onset of anemia. Other common causes include thyroid disease (which is more common in women and runs in families), and viral or bacterial infections.

Following are other conditions which need to be ruled out:

1. Rheumatological diseases (such as lupus and rheumatoid arthritis).
2. Diseases such as diabetes, cancer, muscle diseases such as polymyalgia rheumatica, or AIDS.
3. Hormonal irregularities during perimenopause and menopause.
4. Chronic fatigue and immunodeficiency syndrome (CFIDS) is a diagnosis of exclusion--that is, we consider it when all other conditions are ruled out. It may then be diagnosed in women reporting fatigue for greater than six months, usually occurring after a flu-like illness, surgery or extended treatment with antibiotics. CFIDS is associated with muscle and joint pain, flu-like symptoms, depression and cognitive difficulties.
5. Sleep disorders, which include snoring, restless legs and sleep apnea (stopping breathing while asleep), can cause fatigue even with adequate time in bed. Symptoms include not feeling well rested in the morning, feeling sleepy during the day, and having trouble concentrating.
6. Fatigue is often a presenting complaint of depression, which is more common in women. Other symptoms include disturbances in appetite and sleep patterns, persistent sadness without apparent cause, or difficulty concentrating and making decisions.
Any primary illness or disease for which fatigue is a symptom will be treated appropriately.

Here are some do's and don'ts to help you get better sleep:

• Do go to bed and get up at the same time each day.
• Do adjust your total sleeping time to fit your needs--may be as little as 4 or as much as 10 hours.
• Do keep your bedroom dark, quiet and at a comfortable temperature.
• Do sleep in the same room consistently and use your bed only for sleep and sex.
• Do plan regular daily exercise.
• Do take medicines only as directed.
• Avoid exercising or engaging in stimulating activity (exciting TV or novels) just before going to bed.
• Avoid routine daytime naps.
• Avoid large dinners and excessive snacking or alcohol after dinner.
• Avoid caffeine (coffee, tea, cola drinks, cocoa, chocolate) within 8 hours of bedtime.
• Avoid using sleep medications and bedtime alcohol.
• Avoid lying in bed sleepless for more than half an hour--instead get up, do some quiet activity, then return to bed when you are sleepy.

Psychological Counseling

The fact that fatigue can have psychological origins does not in any way lessen its importance or the need to treat it. Modern environmental psychologists find that problems can arise from both overstimulation and understimulation. Feelings of helplessness, loss of control, or 'broken spirit' can contribute greatly to feelings of fatigue. Fatigue may also mask depression or unresolved past losses such as grief, wounds of a past relationship or the move away from home.

A psychologist or psychotherapist may evaluate your situation through a face-to-face interview about your present life, past events and family/social supports. These will help your mental health professional to recommend a course of treatment customized to fit your needs. For example, fatigue relating to interpersonal problems may indicate the need for assertiveness training or couple/family counseling. If fatigue is masking depression, you may benefit from cognitive therapy. If indicated, trauma recovery may include supportive and grief counseling.

Women tend to have two interpersonal difficulties that can result in their becoming fatigued:

• Not being able to say "no" and
• Role overload due to not delegating.

Saying "No, I'm not able to" without giving reasons or explanations can be very effective when said in a clear, calm and firm way. Practice saying "no" to the safest people first before you say it to the more difficult people. To delegate tasks and increase cooperation from others, ask: "I'd like to know if you'd be willing to __(state what you want)__."

To manage fatigue related to worrying about others, take people breaks. Take a walk and instead of thinking or talking about others while you're walking, notice the sights, sounds and smells of nature.

Traditional Chinese Medicine (TCM)

A TCM practitioner identifies two kinds of fatigue: overuse and disease. Overusing energy is generally a short-term problem due to lack of sleep or other modifiable cause and does not require treatment. Fatigue due to illness or disease in the Chinese view is a deficiency of Qi (energy) in the blood, Yin or Yang, involving the spleen and stomach networks. Treatment would include tonifying or strengthening the energy and blood through herbal medicines and a course of acupuncture lasting four to six weeks.

Relaxation Techniques and Massage Therapy

Unrelieved stress is a common cause of fatigue. Taking the time to engage in mindfully relaxing activities can help to manage that stress-related fatigue. A regular program of relaxing massage performed by a qualified massage therapist can be a vital part of your fatigue-fighting program.
Strategies to re-focus and re-energize include special breathing techniques. Form your mouth into an "O" and take long, slow breaths in and out. Focus inwardly: notice the air moving in and out, notice the movement of your chest as it rises and falls, notice how deep your inhalation goes as it causes your stomach to push out. Take those deep breaths and hold them for as long as you can, then slowly release. Focus on relaxation on the out breath.
(For more information, see Help Yourself . . . Stress/Burnout).

Exercise

Interestingly, both too little and too much exercise can contribute to fatigue. If you're an athlete or in training and begin to experience unusual fatigue or change in sleeping patterns, you are showing signs of overtraining. Rest is the cure. However, most busy women suffer from 'hypokinetic disorder', or low levels of physical activity. Women with extremely low levels of cardiovascular fitness may be taxed simply by walking through a parking lot with a load of groceries. Regular aerobic exercise increases your endurance, improving your physical condition by increasing delivery to and utilization of oxygen by your muscles. Physical activity also stimulates a feeling of wellbeing and helps your body to better handle the everyday physical and emotional stress of life.

Here are some tips for using exercise to fight fatigue:

1. For improved health and fitness, try to accumulate 30 minutes of physical activity most days of the week. Start with short, comfortable bouts of 5 to 10 minutes if you've been inactive.
2. To shake off the "blahs" in the morning or during the day, try a 10-minute brisk walk.
3. If you're beginning to suffer from tense, tight muscles at your desk, take a 5-minute break to stretch back, neck, shoulder and forearm muscles.
4. Avoid intense exercise if you are extremely stressed. Instead, try a more calming activity such as stretching or consciously relaxing your muscles.

Nutrition

Poor eating habits can cause fatigue in two ways: by creating vitamin and mineral deficiencies in the long term, and energy fluctuations on a daily basis. Shortages of iron and other minerals as well as the B vitamins and vitamin C appear to have the most significant effects on energy levels. You can improve your intake of other minerals and B and C vitamins by increasing your consumption of fruits, vegetables, whole grains, legumes, nonfat dairy products and lean proteins. A good general vitamin and mineral supplement complements but does not replace healthy foods. To
avoid iron deficiency and anemia, premenopausal women should consume 15 to 18 mg daily, while postmenopausal women require 10 mg per day. A moderate dose supplement of 18 mg per day should improve iron status and energy levels within three weeks. Higher doses for severe iron deficiency should be taken only under your physician's supervision.

Here are some tips for improving your iron status:

1. Iron-rich foods in order of iron content per serving include: oysters, beef liver, tofu, kidney beans, swiss chard, black beans, lean beef, acorn squash.
2. Eat vitamin-C-rich and iron-rich foods together since the vitamin C enhances absorption of iron.
3. Avoid drinking tea and coffee with meals since they can inhibit iron absorption by 80 percent.
4. Take iron supplements on an empty stomach and avoid taking zinc or calcium at the same time.

Caffeine, sugar and alcohol can also rob you of energy. While a small amount of caffeine can be a pick-me-up, greater than three servings per day can create a vicious cycle leading to fatigue-causing dehydration by day and poor sleep quality by night. Highly sugared snacks such as sodas, candy, and baked goods (low or high fat) cause blood sugar to rise rapidly. This triggers an often exaggerated insulin response, returning blood sugar to lower levels than before the snack and accompanied by sagging energy levels. Finally, alcohol interferes with sound sleep, dehydrates the body's cells and suppresses the nervous system, causing inability to concentrate and fatigue.

Here are some tips to avoid those daily energy fluctuations:

1. Avoid very low calorie diets or diet plans that require you to eat only a few specific kinds of food.
2. Eat high-quality breakfasts daily and replace sugary snacks with slow-release foods such as fruits or vegetables combined with protein or whole grains. Try to limit sugar intake to fewer than 10 percent of your daily calories (sugar-sensitive women may do well to eliminate it entirely).
3. Eliminate caffeine or limit yourself to three servings per day.
4. To improve your concentration and avoid a mid-afternoon slump, try eating more protein and reducing carbos at lunch. An ideal blend would be 3 to 4 ounces of lean protein with salad or veges, nonfat milk and no more than one small serving of bread or starch.
5. Drink plenty of water or fluids to avoid mild dehydration-induced fatigue. Eight to ten glasses per day is the rule of thumb.
6. Avoid alcohol or limit your consumption to not more than five servings per week.

Create Your Own Fatigue Profile

To help identify your own personal sources of fatigue, try keeping a journal. Record the times of day that you are the most and least energized and in the best and worst moods. Next, look at the activity or situation that preceded your highs and lows. Include diet, stress, sleep, exercise or other activities. You may see a pattern begin to emerge that you can use to find ways to combat those periods of low energy and/or mood.