What Is Chronic Fatigue?

Chronic fatigue is one of the most common complaints physicians hear. In at least 20 percent of all medical visits, patients name fatigue as a significant symptom. Millions of people function below par, accepting chronic fatigue and tiredness as a way of life. They never seek medical care because they think fatigue is a burden that they simply must endure. In my practice, many of the women seeking help are so tired that they have difficulty carrying out their day-to-day functions. My patients often tell me that their lack of energy seriously affects their quality of life. Many women find it hard to get up and get going from the moment the alarm rings in the morning. For these women, doing their daily tasks at work or even interacting with friends and family may be difficult. Many of my patients also complain of losing steam and tiring in the afternoon. Once this fatigue sets in, it may pursue women until they drop into exhausted sleep at bedtime. When seeing a new patient, fatigue is one of the first complaints that I address, because sufficient energy is central to day-to-day functioning.

Fatigue has many causes; it is a component of many of the most common health problems affecting women. When a woman iden-tifies fatigue as a serious complaint, one or more of four body systems may be compromised:

  • The immune system fights foreign invaders in the body, such as
    bacteria, viruses, and cancer cells.

  • The endocrine or glandular system regulates reproductive and metabolic functions, such as menstruation and the efficient burning of food for energy. The endocrine glands communicate with one another by secreting into the bloodstream chemicals called hormones that carry chemical messages from one gland to another.
    The hematological system is responsible for forming red blood cells, which carry oxygen to all tissues of the body, and white blood cells, which fight infections and other invaders in the body.

  • The nervous system comprises the fibers that connect the brain, organs, and muscles by transmitting impulses that allow normal bodily sensation and movement, as well as the experience and expression of moods and feelings.

    The remainder of this chapter discusses problems that arise in these systems-problems in which fatigue is a significant symptom.

    The Immune System

    Chronic Fatigue Syndrome (CFS)

    One of the most publicized causes of fatigue today, chronic fatigue syndrome (CFS) has been diagnosed in 3 million Americans. It is thought that millions more are affected by this severe and dis-abling problem but are undiagnosed.

    Women predominate among persons affected with CFS: 70 per-cent of the cases are female. Fatigue is the most prevalent symp-tom, occurring in almost all the afflicted. The onset of fatigue is often sudden, and many women can pinpoint when it started. The fatigue is so severe that even minor exertion, such as a short walk or light housework, can be debilitating. The loss of physical stamina and endurance is pronounced in women with CFS. Many women with CFS curtail their activities and take naps during the

    day or sleep more hours at night. Interestingly, increased bed rest doesn’t improve the energy level of afflicted. CFS occurs with a whole range of other symptoms, including headaches, low-grade fever, swollen lymph nodes, sore throat, depression, poor ability to concentrate and decreased mental acuity, muscle and joint aches and pains, allergies, digestive complaints, weight loss, and skin rashes.

    For many women, mental and emotional symptoms seem to predominate. Short-term memory may be diminished. Women with CFS often have trouble remembering specific names or places, or doing complex mental work, such as bookkeeping, administra-tive tasks, or teaching. Thus, women with CFS may have great difficulty performing functions that demand intellectual skills.

    Medical researchers have found no causative agent for CFS. The most widely accepted hypothesis is that a virus or a group of viruses is involved, although this has not been definitely proven. Most of the attention has focused on the herpes family of viruses as the causative agents. These include the Epstein-Barr virus (EBV), herpes simplex viruses (genital and oral), and cytomegalo-virus (CMV). Some researchers have suggested that the causative agents may be Candida albicans, a retrovirus that is in the same family as the AIDS virus, or parasites. Some physicians even propose a mixed infectious cause, with several pathogens causing symptoms simultaneously. A wide variety of environmental and lifestyle factors may also contribute to CFS by stressing the immune system. Many of my CFS patients report extreme and prolonged emotional stress, anxiety, and depression, and a history of poor nutritional habits predating the onset of CFS. Environmen-tal pollutants and contaminants may also play a role in weakening the body and allowing CFS to develop.

    The length of the illness varies. One-third of CFS patients recover fairly quickly, regaining their health within a few months. Another third of CFS patients take two years to recover, while the other third remain ill after two years. I have seen patients in my practice for whom CFS has been a long-term and extremely debilitating condition. These women had tried many drugs and natural treatment regimens. In treating women with CFS, I have had wonderful success with a variety of supportive techniques, primarily in the self help or lifestyle area. I describe these techniques fully in the following chapters.

    Candida Infections

    Although commonly referred to as a yeast, Candida albicans is actually a parasitic fungus that only resembles a yeast. Found most commonly in the large intestine and esophagus, candida is a normal inhabitant of the digestive tract and usually lives in bal-ance with friendly bacteria that help the digestive system function optimally. When the balance between the bacteria and the fungi is upset, candida may proliferate, infecting tissues of the digestive tract, vagina, and mouth. The toxins released by the fungi weaken the immune system, allowing candida to penetrate throughout the body and spread to other systems, such as the bladder and respiratory system.

    Women with candida infections in the vagina (candida vagini-tis) often have a thick vaginal discharge, redness, itching, and burning. Women with digestive symptoms of candida may have heartburn, bloating, gas, abdominal pain, constipation, and diarrhea. Candida infection of the mouth is called thrush and most commonly afflicts infants and children. Thrush presents with white lesions inside the mouth and on the tongue. In the most severe cases, candida can travel through the bloodstream to invade every organ system in the body. This type of blood poisoning is called candida septicemia and is usually seen only in seriously ill patients, such as people with AIDS or terminal cancer.

    The weakening of the immune system caused by the over-growth of candida has been linked to many symptoms other than those of active infection. These include chronic fatigue, lethargy, poor ability to concentrate, depression, visual changes, pain and swelling in joints, nasal congestion, sore throats, and muscle weakness. Candida infections are more common in diabetics and have been linked to the prolonged use of antibiotics, cortisone, or birth control pills. Diets that include large amounts of bread, alcoholic drinks, candy, cookies, fruit juice, and other foods with high sugar or yeast content promote the growth of candida.

    Because candida is present in most people, a candida infection is difficult to diagnose. Women with candida vaginitis may be diagnosed by identifying the organisms on a slide. However, for women who may have candida in other organ systems and tissues, the most definitive diagnostic test may be their response to a sugar- and yeast-free diet, as well as their response to the appropri-ate medication. See the self help section of this book for more infor-mation on effective medical and self help treatment for candida.


    Allergies occur when the body’s immune system overreacts to harmless substances. Normally, the immune system is on the alert for invaders such as viruses, bacteria, and other organisms that cause disease. The immune system’s job is to identify these invaders and destroy them before they cause illness. In allergic people, this system begins to react to other substances-typically pollens, molds, or foods such as milk or wheat (called allergens). Sometimes allergic reactions are easily diagnosed, because the symptoms occur immediately after the encounter with the allergen. Immediate allergic symptoms include wheezing, itching and tearing of the eyes, nasal congestion, and hives. Some allergic reactions are delayed; they may occur hours or days after expo-sure to the allergen. Delayed symptoms include joint aches and pains, eczema, and fatigue and depression. The person affected may be unaware that an allergy is causing her symptoms. Fatigue is a very common symptom of an allergic reaction; it can accom-pany an allergy to foods or to chemical or environmental triggers.

    Allergies are very common; approximately 24 million Ameri-cans (10 percent of the population) suffer from allergies. As much as $1 billion is spent each year in the medical treatment of aller-gies, while an additional $1 billion is lost in time away from work and allergy-related disability compensation.

    Several tests are available for diagnosing allergies; they are not always accurate and can be expensive. Physicians don’t agree on the usefulness or accuracy of the different types of tests. The most traditional type has been skin testing: A minute amount of allergen is placed on or within the skin, and the physician then observes whether an allergic reaction takes place (commonly a red swelling or itching and tenderness). Any reactions take place within a day or two. Traditional allergists consider blood tests, such as the RAST test (radio allergosorbent test) and the FICA (food immune complex assay), to be more controversial. These tests detect rises in the specific IgE antibodies; a rise reflects the body’s immune response to different allergens. My experience with RAST testing finds that it may be inaccurate or not correlate well with actual clinical symptoms. It is also less sensitive than skin testing.

    Some holistic physicians test for food allergies by doing sub-lingual provocative tests. In this test, a food extract is placed under the tongue to see whether it elicits a reaction. Neutralizing antidotes are then administered to the patient to reduce or eliminate symptoms. This test is not used by traditional allergists, who consider it to be ineffective. Another way to test for food sensitivities is simply to eliminate suspected food allergens. First, the patient fasts, taking only distilled water for several days. Then she reintroduces foods one at a time. If the patient is allergic to a specific food, a reaction will occur after she adds that food to her diet.

    Treatment for allergy usually includes avoiding the offending substance, if possible, or using over-the-counter and prescription medication and desensitization shots. Managing stress and following a low-stress elimination diet may also be very helpful in treating and preventing allergies. It is also important to rotate foods and choose from a wide variety of high-nutrient food.

    The dietary principles discussed in this book are very helpful for women with allergies.

    Endocrine or Glandular System

    Premenstrual Syndrome

    Premenstrual syndrome (PMS) is one of the most common problems affecting women during their reproductive years (from the teens to the early fifties). PMS affects between one-third and one half of all American women between the ages of 20 and 50- in other words, as many as 10 to 14 million women. There is no single cause of PMS; medical researchers now believe that various hormonal and chemical imbalances can trigger PMS symptoms. The symptoms usually begin 10 to 14 days before the onset of the menstrual period and become progressively worse until the onset of menstruation or, for some women, several days after the onset. This means that millions of women spend half of each month of their adult lives feeling sick.

    The symptoms of PMS are numerous and involve almost every system in the body. More than 150 symptoms have been docu-mented: emotionally based symptoms such as anxiety, irritability, mood swings, depression, and fatigue, and physical symptoms such as headaches, bloating, breast tenderness, weight gain, sugar craving, and acne. For many women, the emotional symptoms and fatigue are the most severe, adversely affecting their family relationships and their ability to work.

    A woman may have as many as 10 or 12 of these symptoms. Many PMS patients describe severe personality changes-much like Dr. Jekyll and Mr. Hyde. They say they are irritable, witchy, and mean-that they yell at their children, pick fights with their spouses, and snap at friends and co-workers. They often spend the rest of the month repairing the emotional damage done to their relationships during this time.

    Many factors increase the risk of PMS in susceptible women. It occurs most frequently in women over 30. (The most severe symptoms occur in women in their thirties and forties.) Women are at high risk when they are under significant emotional stress or if they have poor nutritional habits and don’t exercise. Women who are unable to tolerate birth control pills seem to be more likely to suffer PMS, as are women who have had a pregnancy complicated by toxemia. Also, the more children a woman has, the more severe her PMS symptoms.

    PMS rarely goes away spontaneously without treatment. My experience is that it gets worse with age. Some of my most uncom-fortable patients are women in their middle to late forties, who are also approaching menopause. These women often feel they have the worst of both life phases as they pass from their active repro-ductive years into menopause. Often, PMS symptoms coexist with bleeding irregularities and hot flashes. Once the PMSis treated, the accompanying fatigue and mood symptoms clear up. Ther-apies for PMS are discussed in the self help section of this book.

    No single hormonal or chemical imbalance has been linked to PMS. Instead, nearly two dozen hormonal, chemical, and nutritional imbalances may contribute to causing the symptoms. Even more confusing for patients and physicians alike is that the underlying causes may differ from one woman to another. As a result, no single wonder drug cures PMS, although many drugs have been tested, including hormones, tranquilizers, antidepres-sants, and diuretics. Luckily, PMS seems to respond very well to healthful lifestyle changes. In my practice, I have found PMS to be a very treatable problem. It does require, however, that women participate actively in their own program, adopt better nutritional habits, and deal with stress more effectively.


    Menopause, the end of all menstrual bleeding, occurs for most women between the ages of 48 and 52. However, some women cease menstruating as young as their late thirties or early forties, while others continue to menstruate into their mid-fifties. Fatigue often accompanies this process as women go through the hor-monal changes that lead to the cessation of menstruation.

    For most women, the transition to menopause occurs gradually, triggered by a slowdown in the function of their ovaries. The pro-cess begins four to six years before the last menstrual period and continues for several years after. During this period of transition, estrogen production from the ovaries decreases, finally dropping to such low levels that menstruation becomes irregular and finally ceases entirely. For some women this transition to a new, lower level of hormonal equilibrium is easy and uneventful. For many women, however, the transition is difficult and fraught with many uncomfortable symptoms, such as irregular bleeding, hot flashes, mood swings, and fatigue. As many as 80 percent of all women going through menopause experience some of these symptoms.

    Many women approaching menopause experience heavy, irreg-ular bleeding. The increased blood loss in these women can trig-ger a loss of energy as well as decreased stamina and endurance. Though most cases of heavy, irregular bleeding in transitional women are due to fluctuating hormonal levels, other medical problems can cause bleeding, too. These include fibroid tumors (an overgrowth in the muscular tissue of the uterus), polyps, uter-ine cancer, and cervical cancer.

    The hormonal deficiency that develops during this period may also trigger other physical and emotional symptoms. One of the most uncomfortable symptoms is hot flashes-sudden and intense sensations of heat that occur unexpectedly. A woman suddenly notices that she feels warm, and often experiences heavy sweat-ing. As the sweating cools her skin temperature, she begins to shiver. In response to this uncomfortable fluctuation in tempera-ture, many women alternately shed and add clothes. Hot flashes frequently begin on the chest, neck, or face, and radiate to other parts of the body.

    Eighty percent of women in menopause experience hot flashes, with 40 percent of these women having symptoms severe enough to seek medical care. Hot flashes may occur during both day and night. When they occur at night, they can interrupt a woman’s sleep pattern, leaving her exhausted and fatigued during the day from sleep deprivation. Though most flashes appear to occur without any specific environmental trigger, coffee and alcohol intake may spark a flash. The frequency, intensity, and duration of hot flashes vary greatly. For most women they last two or three minutes, but they can last longer, even up to an hour in some cases. In most women, the symptoms begin to subside within four to six years after the last menstrual period.

    The tissues of the vagina and urethra undergo a number of changes as the hormonal levels diminish. The vaginal and urethral linings become thinner, drier, and inelastic. Blood supply to the vaginal and urethral area decreases. The cervix secretes much less mucous than in a woman’s fertile years. The vagina actually shrinks, becoming much shorter and narrower at the opening.

    As a result, sexual intercourse often becomes painful or uncom-fortable. Sexual arousal no longer produces the same level of lubrication, and the capacity for vaginal expansion in response to sexual arousal may decrease. Vaginal infections may become more frequent because the tissues are easily traumatized. The changes that occur in the urethral tissues may increase the frequency of urination. Women find that they have to get up at night to void, which-like hot flashes-can interrupt sleep and worsen fatigue. Even more frustrating for some women is the tendency to leak urine when they laugh, sneeze, or cough.

    Besides the physical changes, many women may note mild to marked changes in their moods during menopause. These symptoms include insomnia (often associated with hot flashes), irritability, anxiety, depression, and fatigue. Both estrogen and progesterone have been studied for their effects on mood: If estro-gen predominates, women tend to feel anxious; if progesterone predominates, women may feel depressed and tired. With a decrease in both hormones, symptoms can run the gamut from irritability to fatigue and depression. The severity of the symp-toms probably depends on the woman’s individual biochemistry, as well as social factors. Women have worse symptoms if they are under severe emotional stress or have aggravating dietary habits, such as excessive caffeine, sugar, or alcohol intake.

    Many effective treatments, such as hormonal replacement ther-apy and the use of vitamin, herbal, and mineral supplements, help support menopausal women’s reproductive and glandular systems. Stress management techniques and regular exercise may also help to restore energy and vitality and stabilize mood. These are discussed in the self help section of this book.


    Hypothyroidism-an underactive thyroid-is far more common in females than in males. In fact, 90 percent of diagnosed cases are women. Low thyroid condition is a common cause of chronic fatigue and tends to worsen with age. The thyroid affects our energy level because it controls our metabolism (the rate at which our cells burn fuel and oxygen). Women with a slow metabolism caused by an underactive thyroid can suffer from a variety of symptoms. Besides fatigue, hypothyroid women often complain of a hoarse voice, constipation, intolerance to cold, thickening and scaling of skin, facial puffiness, delay of deep tendon reflexes, and slowness of speech, thought, and movement. They also tend to gain weight easily and find it hard to lose weight on a conven-tional diet. They may suffer from low blood pressure as well as low blood sugar and may crave carbohydrates. Clinical diagnosis of hypothyroidism in older women may be difficult because many women do not have the typical symptoms mentioned above. In many older women, debilitation and apathy may be the only signs of low thyroid function. Medical studies suggest that thyroid screening by simple blood tests of thyroid hormones should be a routine part of the physical examination for older patients.

    Hypothyroidism is generally treated by thyroid replacement therapy. Older patients may require a much lower maintenance dose of thyroxine than younger women. Self help aspects of treatment and prevention include taking iodine either in the diet or in supplementary form. According to some evidence, adequate intake of vitamin A, vitamin E, and iodine may be necessary to maintain thyroid health and integrity. Once the underlying thy-roid deficiency is treated, many fatigued women notice a rapid improvement in their energy level and vitality.

    Women with low thyroid function often have exhaustion in other endocrine glands. The adrenal glands are particularly affected by poor thyroid function, as well as any other physical and emotional stress. The adrenals are two almond-sized glands that secrete several dozen hormones. Cortisol is an important hormone produced by the adrenal glands that helps regulate our response to stress. Stress can be a response to strong emotional feelings, such as anxiety or depression, or to physical triggers, such as an allergic reaction, infectious disease, burns, surgery, or an accident. Whatever the source of stress, cortisol lessens its injurious effects on the body, reducing pain, swelling, and fever.

    When stress has been recurrent and of long duration, the adrenal glands can become exhausted, mustering less and less ability to buffer the negative effects of physical and emotional stress. As a result of adrenal exhaustion, the individual may experience an increase in fatigue and tiredness. Much rest, stress management, and nutritional support are required to restore the adrenals and rebuild the physiological “cushion” to deal with stress. Many helpful techniques listed in the self help section of this book help to restore the glandular system.

    Hematological (Blood-Forming) System


    Anemia is one of the most common health problems affecting women of all ages. As many as 20 percent of all American women suffer from anemia. Women who are anemic have a reduced num-ber of red cells circulating in their blood or a reduced amount of hemoglobin (the oxygen-carrying protein in the red blood cells).

    Anemia reduces the amount of oxygen available to all the cells of the body, so the cells for the body’s normal chemical functioning have less available energy. Important processes, such as muscular activity and cell building and repair, slow down and become less efficient. Greater than 95 percent of the body’s chemical reactions depend on optimal oxygen levels in the cells and tissues. As a result, the symptoms of anemia can be very debilitating.

    Because the lack of oxygen impairs the body’s ability to carry out its numerous chemical reactions, many women with anemia feel extremely tired and fatigued. Because muscular activity is inhibited, they lack endurance and physical stamina. I have had many physically active patients who had to stop pursuing vigor-ous aerobic exercise programs when they developed anemia, because they lacked the physical energy to continue an active exercise regimen.

    When the brain cells lack oxygen, dizziness may result and mental faculties are less sharp. Women who are anemic tend to be pale with poor skin color and tone. They often appear “washed out” and seem listless. They lack the glowing skin color that we tend to associate with good health and vitality. Women with ane-mia may also suffer from hair loss and brittle, ridged fingernails.

    Digestive symptoms include loss of appetite, sore tongue, abdominal pain, heartburn, and diarrhea. In more severe cases, women can suffer from symptoms as varied as headaches, heart palpitations, tingling in the fingers and feet, loss of coordination, and a yellowing of the skin. As you can see, a woman can become quite ill from the physical and mental effects of anemia if her physician does not diagnose her condition properly.

    Many cases of anemia are caused by nutritional deficiencies. Without sufficient nutritional factors, the red blood cells cannot grow and mature normally. The most common cause of anemia is iron deficiency. In fact, as many as one-third to one-half of young American women have low or depleted iron stores. The main reason for these low reserves is that women simply don’t eat enough iron-rich foods.

    Children, adolescents, and women during their reproductive years are at particular risk of iron deficiency anemia. Children and teenage girls need this iron to support growth and development; grown women need it to replace the iron lost in the monthly men-strual period. This increased need for iron persists until meno-pause, when the monthly blood loss finally ceases. Elderly women are still susceptible to developing anemia because they tend to eat less and have a nutrient-poor diet, especially if they live alone or have a limited income.

    Pregnancy and the postpartum period are also vulnerable times for women because fetuses and breast-feeding infants take iron from the mother. Women athletes also have an increased need for iron during training because of the metabolic demands of heavy exercise.

    Some women develop iron deficiency anemia because their bodies are unable to absorb and assimilate iron properly. Iron absorption may be decreased by chronic diarrhea, laxative abuse, or malabsorption diseases such as celiac disease and sprue, as well as by nutritional deficiencies of vitamins and minerals needed for the health of the digestive tract.

    Another common reason for the development of iron deficiency anemia is excessive blood loss. This is commonly seen in women who suffer from menorrhagia (heavy or prolonged menstrual bleeding) caused by hormonal imbalances, fibroid tumors, or uterine cancer. Women who use intrauterine devices for contra-ception are also at higher risk of blood loss, as are women who overuse anti-inflammatory medications such as aspirin or ibuprofen, which can cause blood loss through irritation of the digestive tract.

    Besides iron, other nutrients are needed for healthy red blood cell growth and maturation. Deficiencies of vitamin B12, folic acid, and vitamin B6 are also common causes of anemia. Vitamin E is important for red blood cell survival. Medical research done on subjects deficient in vitamin E has shown that this nutrient helps prolong the life span of red blood cells.

    For many American women, anemia can complicate a pre-exist-ing health-care condition. For example, anemia often accompanies thyroid disease, rheumatoid arthritis, and chronic kidney disease, as well as recurring or chronic infections. Anemia contributes to the fatigue and lack of energy that affect people suffering from these health problems. Anemia can also be caused by drugs that destroy or interfere with the utilization of the nutrients necessary for the health and maturation of the red blood cells. These drugs include oral contraceptives, alcohol, and anticonvulsive agents such as Dilantin.

    In any case, the underlying causes of anemia must be reversed and corrected in order to re-establish healthy, normal red blood cells capable of carrying sufficient oxygen. When the anemia is corrected, the accompanying fatigue and lethargy will also be corrected.

    The Nervous System


    Depression is characterized as feeling so down or “blue” that these feelings interfere with daily life. One person in five in this country experiences symptoms of depression at some time. Thirty million people can expect to suffer from depression during their lifetimes, and 1.5 million people are currently undergoing treatment for this condition. Depression is twice as common in women as in men.

    Depressed people suffer from a variety of symptoms that cause them to feel lethargic, fatigued, and unable to cope with other people and normal life activities. These symptoms include difficulty in concentrating and making decisions, and lack of self-esteem and self-confidence. Depressed women may suffer from a feeling of worthlessness and self-pity and may want to isolate themselves from other people to avoid social contact. Women with depression also display anxiety and irritability. They often suffer from eating problems (either overeating or undereating), insomnia, fatigue, digestive complaints, loss of sex drive, headaches, and backaches. Most dangerous to the women affected is that severe depression can lead to suicide attempts. Any threat of suicide in a depressed woman should be taken seriously and immediate medical care begun.

    Many stressful life events can lead to depression, including death of a loved one, divorce, loss of a job, or even aging. Women who are experiencing low thyroid conditions, PMS, menopause, or the postpartum period are at higher risk of depression. Poor nutritional habits or the use of drugs and hormones (such as birth control pills and estrogen replacement therapy) can add to depression. Some women with depression are sensitive to the change of seasons. The shortness of the days and decreased light during the winter can trigger depression because the endocrine or glandular system may need more daylight to function optimally.

    Women with depression may need a combination of antidepressive medication along with psychotherapy to combat the condition. Self help techniques such as exercise, proper nutrition, and stress management can also be very helpful.

    In summary, fatigue is an important symptom in many common health problems of women, including chronic fatigue syndrome, candida infections, allergies, PMS, menopause, hypothyroidism, anemia, and depression. Chapter 2 contains a workbook that will help you pinpoint any underlying physical problems that may be compounding your fatigue. It will also help you evaluate how your lifestyle habits may be contributing to increased tiredness.

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    Written by Susan M. Lark MD

    Explore Wellness in 2021