Summer is supposed to feel like a chance to exhale.

The schedules are different. The days are longer. There may be more time outside, more travel, more space to catch up, or at least the hope of a slower pace.

For some people, that change of rhythm really does feel restorative. For others, summer is not exactly restful. It can mean kids home from school, disrupted routines, more social plans, travel stress, later nights, and the feeling that you are still trying to recover from a busy year while managing a completely different kind of busy.

Either way, summer has a way of revealing something important.

Are you tired because life has been full?

Or are you tired because something deeper is going on?

Fatigue is one of the most common things I hear from patients. Sometimes people bring it up right away. More often, it comes out casually after we have been talking for a few minutes.

  • “I’m just tired all the time.”
  • “I wake up tired.”
  • “I can get through the day, but I don’t feel like myself.”
  • “I used to recover from workouts or busy weeks, and now I just don’t.”


That last one always gets my attention.

There is a normal kind of tired. A late night, a stressful deadline, a sick child, travel, a poor night of sleep. The body asks for rest, you give it rest, and eventually you bounce back.

But there is another kind of tired that does not make as much sense. You sleep, but you are not restored. You eat, but you still feel depleted. You push through, but your energy feels borrowed.

That kind of fatigue is not something I like to dismiss.

First, what kind of tired are we talking about?

When someone tells me they are tired, I want to understand what that actually means.

Fatigue can feel like:

  • Low motivation
  • Brain fog
  • Muscle weakness
  • A heavy body feeling
  • A mid-afternoon crash
  • Needing caffeine to function
  • Exercise intolerance
  • Feeling wired but exhausted
  • Waking up tired, even after enough sleep


Those are different clues.

I also want to know when it started. Did it begin after an illness? Pregnancy? Surgery? A stressful season? A medication change? Around perimenopause? 

Did it come on gradually, or did it feel like someone flipped a switch?

These details matter because fatigue can come from many places. A standard workup may miss low ferritin, early insulin resistance, thyroid changes, hormone shifts, sleep apnea, chronic inflammation, nutrient deficiencies, or cortisol rhythm issues.

Normal ranges are useful. They are not always the same thing as optimal health.

The labs I do not like to skip

One of the first things I think about with fatigue is iron, especially ferritin.

Ferritin reflects stored iron. You can have a normal hemoglobin and still have low ferritin, which means you may not be anemic, but you may still be iron deficient.

Low ferritin can feel like dragging yourself through the day. 

Patients may notice:

  • Low stamina
  • Shortness of breath with exercise
  • Hair shedding
  • Dizziness
  • Feeling cold
  • Heavier fatigue around their period


Heavy menstrual bleeding is a common reason. So are low intake of iron-rich foods, pregnancy history, gut issues, poor absorption, endurance exercise, and restrictive diets.

B12 and folate are also important. These nutrients support red blood cell production, nerve function, mood, and energy. Low B12 can look like fatigue, brain fog, weakness, tingling, numbness, low mood, or a vague sense that something is off.

People often think of B12 deficiency only in vegetarians or vegans, but I see it in other situations too. Gut issues, acid-blocking medications, metformin, autoimmune gastritis, and absorption problems can all play a role.

Then there is thyroid.

Thyroid hormone affects metabolism, temperature, digestion, mood, hair, skin, menstrual cycles, and energy. When thyroid function is low, people may feel sluggish, cold, constipated, puffy, foggy, depressed, or like their metabolism has slowed down.

A lot of thyroid screening starts with TSH. TSH is useful, but it does not always tell the whole story. Depending on the patient, I may also look at free T4, free T3, and thyroid antibodies.

Blood sugar can drain energy all day

Blood sugar issues can be subtle at first.

Some people do not have diabetes. They do not even have a very high A1c. But they may already be on the insulin resistance spectrum, and their energy is paying the price.

This can look like:

  • An afternoon crash
  • Sugar cravings
  • Needing caffeine to keep going
  • Feeling shaky if meals are delayed
  • Waking in the night
  • Feeling exhausted after eating


Fasting glucose and A1c are helpful, but fasting insulin can give us earlier information. In some patients, a continuous glucose monitor can also be useful because it shows the relationship between food, stress, sleep, exercise, and energy in real time.

Sleep is not just hours in bed

A lot of patients tell me, “I sleep enough.” Then we talk more.

They wake up at 3 a.m. They snore. They grind their teeth. They wake with headaches. They have dry mouth in the morning. They sleep eight hours but wake up exhausted.

That is not restorative sleep. Sleep apnea is one of the most missed causes of fatigue. It does not only happen in older men or people in larger bodies. I have seen sleep-disordered breathing in patients who do not fit the stereotype at all.

Deep sleep is when the body repairs. Sleep affects blood sugar, hormones, immune function, memory, mood, inflammation, and recovery.

Sleep hygiene still matters:

  • Get outdoor light early in the day
  • Keep the room cool and dark
  • Limit caffeine later in the day
  • Reduce blue light before bed
  • Avoid large meals close to bedtime
  • Keep a consistent rhythm when possible


But if someone has an actual sleep disorder, that is when we need to test.

Stress, cortisol, and hormones

I never want patients to hear “stress” and think I am dismissing them.

Stress is biochemical and not just emotjional. 

Cortisol is supposed to rise in the morning and gradually come down throughout the day. Chronic stress can disrupt that rhythm. Some people feel exhausted in the morning and wired at night. Some run on adrenaline all day and crash after dinner. 

Stress affects blood sugar, digestion, thyroid function, inflammation, immune health, hormones, and sleep. If the nervous system has been in survival mode for months or years, energy production can suffer.

Hormones can also change the whole energy picture, especially in midlife.

For women, perimenopause can begin long before periods become irregular. Sometimes the first sign is sleep disruption. Women start waking at 3 or 4 a.m. They feel more anxious, more inflamed, less resilient, or less able to recover from workouts.

Estrogen and progesterone affect sleep, mood, body temperature, body composition, and stress tolerance. When they fluctuate, energy often fluctuates too.

Testosterone matters for both men and women. Low testosterone can affect motivation, muscle mass, mood, libido, exercise tolerance, and overall vitality.

This does not mean every tired person needs hormone therapy. Many people need sleep support, blood sugar stability, nutrient repletion, strength training, thyroid care, or stress reduction first. But when the story fits, hormone testing can be very helpful.

What I usually want to understand

The exact workup depends on the person, their symptoms, and their history. But when fatigue is persistent, I often consider a deeper look at:

  • CBC
  • Comprehensive metabolic panel
  • Iron and ferritin
  • B12 and folate
  • Vitamin D
  • Thyroid markers, including TSH, free T4, free T3, and sometimes thyroid antibodies
  • Fasting glucose, fasting insulin, and hemoglobin A1c
  • Inflammation markers such as hs-CRP
  • Hormones when appropriate, including estradiol, progesterone, free and total testosterone
  • Cortisol testing in select cases


Sometimes we need a sleep study. Sometimes we need autoimmune markers, viral testing, stool testing, or a closer look at gut health.

The point is to stop guessing.

Where to start while you are looking for answers

Testing helps personalize the plan, but the foundations still matter.

Start with food. A whole-foods diet gives your body the raw materials it needs to make energy. 

I often encourage patients to eat the rainbow and aim for variety across the week. A helpful goal is around 30 different plant foods, herbs, and spices. Different colors bring different phytonutrients, minerals, and antioxidants. That variety also supports the gut microbiome.

Hydration matters too. A general guideline is about half your body weight in ounces of water per day, adjusted for sweating, heat, exercise, and caffeine. If you are sweating a lot, using a sauna, exercising intensely, or spending time in hot weather, electrolytes may help. Fruits and vegetables also provide natural electrolytes, which is another reason food quality matters.

Movement helps, but if you are exhausted, more intensity is not always the answer.

Start low and build. The goal is to increase capacity, not drain the energy you have left.

A final thought on fatigue

Fatigue is not always laziness, aging, stress, or being busy. It is information.

Sometimes the body needs rest. Sometimes it needs iron, B12, thyroid support, better sleep, blood sugar stability, hormone evaluation, nervous system regulation, or a deeper look at inflammation or infection.

If you are tired all the time, you do not have to accept that as your normal.

Your body may be asking for something specific.

Learn to listen to your body when it whispers so it does not have to yell.