You get up, you do the day, you fall into bed, and you wake up tired again. If you are a woman in your late thirties through your fifties, you may also be the person who remembers everyone else's schedule. If that sounds like you, whether you live in Raleigh, Durham, Chapel Hill or Cary, you are not lazy and you are not imagining it.
There is rarely one cause. This guide walks through the ones that come up most often in women, what to ask for at a doctor's visit, and where daily habits fit in. It is a companion to the main fatigue and low energy guide, with a focus on women.
Why are women more often tired?
The health sources cited here do not give a single number for how much more often women feel tired than men. They do show that several causes of fatigue are more common in women, or look different in women.
Here are the pieces that stand out:
- Sleep. The Office on Women's Health says women are more likely than men to have insomnia and other sleep problems, and that changing hormones during the menstrual cycle, pregnancy and menopause can affect how well a woman sleeps.1
- Iron. Teen girls and women with heavy periods are among the groups more likely to have trouble getting enough iron.2
- Thyroid. Women are much more likely than men to develop an underactive thyroid.5
- Mood. Depression is more likely to affect women than men.1
- ME/CFS. Among adults with myalgic encephalomyelitis/chronic fatigue syndrome, women are affected more often than men.14
Because causes overlap, a long list is not a checklist. A doctor can work through the possibilities with you.
Could it be iron or heavy periods?
Possibly. ACOG says blood loss from heavy periods can lead to iron-deficiency anemia.3 The NIH Office of Dietary Supplements lists weakness, tiredness, lack of energy and problems with concentration and memory among the symptoms of iron-deficiency anemia.2
How do you know if your periods count as heavy? ACOG lists any of these as signs of heavy menstrual bleeding:3
- Bleeding that lasts more than 7 days
- Soaking through one or more tampons or pads every hour for several hours in a row
- Needing to wear more than one pad at a time
- Needing to change pads or tampons during the night
- Blood clots as big as a quarter or larger
ACOG also says heavy menstrual bleeding is not normal and may be a sign of an underlying health problem, so tell your ob-gyn.3
Iron works like a savings account. The body draws on stored iron first, and the Office of Dietary Supplements says that when stored iron gets low, iron-deficiency anemia sets in.2 A ferritin blood test shows how much iron you have stored, and MedlinePlus says it may be used to check for low iron before symptoms develop in people at high risk, including those with heavy menstrual bleeding.4
One caution. Do not start iron on your own. The Office of Dietary Supplements says too much iron can be harmful, and high doses can cause stomach upset, constipation, nausea and vomiting.2 Ask your doctor or pharmacist before you take any supplement, especially if you take medicines.
Could it be your thyroid?
It could. The thyroid is a small gland in your neck that makes hormones controlling how your body uses energy.6 NIDDK lists fatigue among the common symptoms of an underactive thyroid, along with heavy or irregular periods, and notes that women are much more likely than men to develop it.5
Two things are worth knowing:
- Fatigue alone does not prove a thyroid problem. NIDDK says fatigue and weight gain do not necessarily mean you have one, and that symptoms alone are not enough to confirm it.5
- A thyroid problem can build slowly. MedlinePlus says many people do not notice symptoms of an underactive thyroid for months or even years.6
A TSH blood test measures thyroid-stimulating hormone and shows how well your thyroid is working. It cannot show what is causing a problem.6 If you have symptoms, ask your doctor whether a thyroid test fits your case.
Could perimenopause be part of it?
It can be. Perimenopause is the run of years before menopause, and ACOG says the ovaries' estrogen production begins to fluctuate in your 30s and 40s.7 The NIA adds that most women begin the menopausal transition between ages 45 and 55.8
Tiredness can come in several ways. ACOG says hot flashes at night, called night sweats, can wake you and leave you tired and sluggish the next day. It lists insomnia and waking up long before your usual time as other common signs.7 The NIA includes trouble sleeping, moodiness and irritability, forgetfulness and difficulty concentrating among the symptoms some women have.8 The Menopause Society says hot flashes and night sweats are the most commonly reported symptoms of the transition, and that one large US study found up to 80% of women have them at some point during the transition.9
A change in your menstrual cycle is a common sign of perimenopause. Cycles may become shorter or longer, and flow may turn lighter or heavier.7 ACOG says changes in bleeding are normal in perimenopause, but you should still report them to your health care professional, because abnormal bleeding may be a sign of a problem.7
These can overlap. ACOG says flow may turn heavier in perimenopause, and heavy periods can lead to iron-deficiency anemia, while night sweats can leave you tired the next day.37 So more than one cause can be at work at once. For a deeper look, see perimenopause fatigue and our naturopathic guide to perimenopause symptoms.
How do stress and caregiving play in?
Long stretches of caring for others can leave little room to look after yourself. The CDC says caregiving can be rewarding, but also demanding, and may make it hard for caregivers to take care of themselves.10
The CDC data on dementia caregivers is a sharp example. Approximately two-thirds of dementia caregivers are women, and about one-quarter are "sandwich generation" caregivers, meaning they care for both an aging parent and at least one child under 18. The CDC also says caregivers of people with Alzheimer's and related dementias are at greater risk for anxiety, depression and a poorer quality of life than other caregivers.10 Not everyone is caring for a person with dementia, but many women carry something similar: kids, a parent, a job and a house.
Then there is mood. NIMH says depression is different from ordinary sadness: it can cause severe symptoms that affect how you feel, think and handle daily activities such as sleeping, eating or working.11 Mayo Clinic says fatigue can be linked to depression and to anxiety disorders.12 If you feel flat, hopeless, or you have lost interest in things you used to enjoy, please tell your doctor. It is not a failing.
In the language of the garden, this is where Roots (stress) and Circle (the people around you) show up. I look at who is helping you and where you carry the most alone. Starting with one small change, such as one night a week that someone else handles, can be a good first step.
What should you bring and ask at your visit?
Bring a short log and a few specific questions. A visit goes better when your doctor can see a pattern, and two weeks of notes is enough to start.
What to bring
- A period calendar. ACOG suggests using a calendar or period-tracking app, with the dates your period started, how long bleeding lasted and how heavy the flow was.3
- A sleep diary. The Office on Women's Health suggests keeping one for one or two weeks before you see your doctor, noting when you go to sleep, wake up and nap.1 The CDC says a sleep diary helps a provider understand what is going on.15
- Every medicine and supplement you take. Mayo Clinic lists medicines such as ones for allergies or coughs, pain medicines, heart medicines and antidepressants among the causes of fatigue.12
What to ask
- "Could my periods be heavy enough to lower my iron? Is a ferritin test right for me, along with a blood count?"34
- "Should we check my thyroid?"56
- "Could this be perimenopause?"7
- "Could I have sleep apnea?" If you snore or gasp for air during sleep, NHLBI says to talk to your provider, who may order a sleep study.13 The Office on Women's Health says sleep apnea may be underdiagnosed in women, who tend to report more general symptoms such as insomnia, anxiety and nightmares.1
- "Could my mood or a medicine be part of this?"1112
If you hear "your labs are normal," that is not the end of the conversation. Read tired but labs normal for what routine tests do and do not show.
When should you see your own doctor?
See your own doctor if resting, reducing stress, eating well and drinking plenty of fluids for two or more weeks has not helped your fatigue.12 Book a visit sooner if tiredness comes with any of these:
- Very heavy periods. Bleeding that lasts more than 7 days or soaks through pads or tampons every hour for several hours in a row.3
- Loud snoring, gasping, or someone telling you your breathing stops during sleep.1
- A change in your bleeding pattern. ACOG says to report changes, because abnormal bleeding may be a sign of a problem.7
- Low mood that does not lift and gets in the way of sleeping, eating or working.11
- Fatigue that is severe, not improved by rest, and gets worse after any physical or mental effort, which is a feature of ME/CFS.14
- Tiredness you think a medicine may be adding to. Mayo Clinic lists medicines among the causes of fatigue.12
- Weight loss you did not plan, tiredness that came on suddenly, or tiredness with no clear reason. Cleveland Clinic lists these among reasons to call your provider.16
Call 911 if fatigue comes with chest pain, shortness of breath, an irregular or fast heartbeat, a feeling that you might pass out, severe stomach, pelvic or back pain, unusual bleeding or a severe headache.12 Cleveland Clinic also lists pain in the arm or upper back, an unusually slow heartbeat, vision problems and muscle weakness with fatigue as reasons for immediate medical attention.16
Call or text 988 if low mood comes with thoughts of harming yourself or suicide.12
What can you do about daily habits while you sort it out?
Pick one habit and give it two weeks. The CDC says adults aged 18 to 60 need seven or more hours of sleep, and that quality counts too.15 A steady bedtime and wake time, a cool quiet bedroom, and less caffeine in the afternoon are a reasonable first step.15 None of this replaces a medical check. It works beside it.
The three-minute Garden Check-in can help you choose. It asks about food, stress, sleep and energy, time outside and the people around you, and shows which part to start with. Dr. Werness works alongside your own doctor, and a free 20-minute call is there if you want to talk through your results.