Understanding Fatigue: Causes, FAQ, and Solutions covered by Dr. Sklar

Introduction to Fatigue and Conventional Medicine 0:00

Hi everyone, we are having a monthly April Instagram Live on the issue of fatigue and treating fatigue the Sklar Center way. I want to tell you about how I approached fatigue in the past when I was a conventional OB-GYN doctor.I remember now somebody coming in to me that they were fatigued and I didn't know much of anything to do about it. I mean, pretty much in conventional medicine, you check two things. One is thyroid function, okay? And we didn' have the criteria that I have now in functional medicine for really evaluating thyroid functions.

And then the other thing we would do is see if the person was anemic, which happens to women, especially if they have heavy menstrual periods. But most of the time people were not anemia or having low blood. And then after that, I didn't know what else to tell them. And what we often see, especially with women, because women are thought to be still hysterical and emotional more than men, is if a doctor can't figure out why you're fatigued, they'll recommend an antidepressant. I hear that very often in my practice that people say, well I'm not depressed, i'm tired.

Certainly one of the symptoms of depression can be like a lack of initiative and lack wanting to do things. But that's different from being tired or fatigued. So I wanna go through with you today some of the different causes of fatigue that we treat at the Sklar Center and also answer some questions that are common questions. And if you have any questions, put them in the chat and I will try to get to them also. So fatigue is the most common reason that people come to see us at the Sklar Center.

And I would say one of the common reasons for fatigue, is low hormone levels. Many of our hormone level decrease as we age. And a lot of aging is written off to, oh well, you know, that's how it goes and you're just gonna have to live with it. And what do you expect at your age? And really, I feel like people should be able to feel vibrant and resilient and have the initiative to do the things they love at any age. So one of the things we look at are hormones. Thyroid hormones are one them. And the conventional medical system usually only checks the following two hormones, levothyroxine, or rather T4, thiroxin,

Thyroid Function and Hidden Low Thyroid Symptoms 2:53

a levothyroxyne is a medication. They check your thyroxide level and they check you thyroid stimulating hormone level or TSH for short. And the TSH reference range is a huge wide range. Normal is anywhere from about .5 to 4.5. And what that means is that's where 95% of the population falls. It does not mean that where people are when they're feeling their best. Even the Endocrine Association in America has said 4.5 is too high because the higher your thyroid stimulating hormone, the lower your actual thyroid function.

So thyroid-stimulating hormone is a message that's sent from the pituitary gland in the brain to your thyroid gland and your neck to tell your Thyroid Gland how much thyroid to make. It's a messenger, like all hormones are messengers. And so if your brain thinks there is not enough active thyroid hormone in your circulation, it will send out more of these messages, more this thyroid stimulating hormone to try to get your thyroid gland to make more hormone. So the higher the TSH, the lower functioning your thyroid is.

We like TSH to be around one or two, which is what the Endocrine Association of America has as their goals also. By the time you're up around three or four, even if it's in the reference range, you probably don't have enough thyroid hormone and circulation to feel good. And I remember one particular patient years ago who was 18 years old, she was young, And she came to see me about her thyroid and she brought me her medical records. And there was a letter from her endocrinologist to her primary care doctor who had referred her and it was UCLA endocannologist.

So very well trained. The letter said so and so. thyroid function appears to be normal on blood testing, but she complains of, and I have to tell you that's the medical term for when you have symptoms or problems, medically it's called a complaint. So he said she complaints of fatigue, hair loss, coldness and constipation, But her thyroid tests are normal, so we're not going to change anything in her treatment. and she came to see me and first of all they hadn't checked her active thyroid hormone level which is free T3.

So T 3 is your active thyroid hormone and the T4 that normally gets measured on conventional testing has to convert into T three and if you're not a good converter your T-3 level is low and so why might you not be a converter? If you're really stressed, you don't convert as much, or you actually convert some of that T4 into something called reverse T3, which actually blocks your active T-3 hormone from doing its job. If your low in certain nutrients like selenium, zinc or iodine, You will not be able to convert T 4 into T 3. So this young woman had quote, normal lab levels, but almost every symptom of low thyroid function possible.

And she wanted to go to dental school, But she didn't have like the brain power and the energy to figure out how she was going to get through it. When I actually saw how low her free T3 is, I could see why she had all of those symptoms, classic symptoms of Low Thyroid Function. sluggish brain function, fatigue, constipation, feeling cold all the time, dry hair, dried skin, she had them all. And when we provided the T3 that she needed, it was like she woke up and she got her energy back. She went on to dental school.

So I'm giving this to you as an example of how the conventional medical system approaches thyroid and really fails in truly evaluating it properly and treating it and so that is probably one of the most common reasons for fatigue that we see and this young woman was 18 years old so, that wasn't even an age-related issue although thyroid function seems to go down as we get older. There are some other hormones that are really important for energy. One of them is DHEA dehydroepiandosterone, it's a really long name.

And a lot of you may be familiar with DHEA. It's, uh, a supplement. You can get it over the counter and levels of D HEA are probably the best when we are between age 25 and 30, when were at our really hormonal optimal, we should be, and it goes down through life.

Hormones, Menopause, and Energy Decline 8:07

So by the time you're in your mid forties, It was, it is half of what it was between age 25 and 30. By the time you're in your sixties, It's a quarter of it had been. Now, DHEA is a really important energy, vitality, resilience, immunity, blood sugar regulation hormone. And when we replace it and see levels come up into the young adult healthy range, people's energy starts getting better. Some other hormonal reasons for fatigue are in perimenopausal and menopause of women who are getting hot flashes and night sweats that disrupt their sleep.

And, you know, people always make jokes about menopposal women are always fanning themselves and they think it's funny, but you what hotflashes are not funny and. They are disruptive of sleep, they can be disruptive your daytime function. And with lack of sleep and sleep interruption, fatigue can occur the following day. So, um, and that lack. Lack of estrogen, which causes the hot flashes and night sweats happens with the perimenopause and menopausal. We also lose progesterone when we become men oposal and progesterone is very brain calming.

So progesterone helps your sleep, it helps you get into deep sleep and it help your brain stay sedated during the night. And we lose progesterone with menopause and we loose that calming effect. I hear about that a lot from women that come to see us who not only are having sleep issues, but notice that they're having more anxiety. Or if they had anxiety previously with menopause, now they are having full blown panic attacks. And part of that is due to this loss of progesterone, which is very brain calming.

So you can see there are a lot of hormonal reasons why people can feel fatigued. Restoring those hormones helps most of those people. So what are some of the other issues that we see that cause fatigue that are not hormonal? For one thing, autoimmunity is associated with fatigue. And so undiagnosed autoimmune disorders can cause a number of symptoms, joint pain, rashes, and fatigue can be one of them. So a dry mouth, dry eyes, these are all various symptoms of auto immunity. other causes for fatigue are toxins from the environment.

And so one of the questions I got is what's happening in our body when we experience fatigue. I'll go ahead and answer it now because it's a natural segue.

Autoimmunity, Toxins, and Cellular Energy 11:11

When we're experiencing fatigue, our biochemical processes are not happening at the rate in which they normally should happen. That includes the manufacture of energy. And the energy in our cells is made in a little area of the cell called the mitochondria. And, the Mitochondria are actually a leftover from prehistoric and before remnants of a virus, actually. Mitechonria have a Little Energy Factory in it. The Energy factory turns glucose or other sugars into energy. There are a number of steps in that process and they require a lot of different cofactors.

So, magnesium is one of the cofactors, coenzyme Q10 is a co-factor. Carnitine is a cofactor. So if you're low in any of these components, your little factory that's supposed to be spewing out what's called ATP, adenosine triphosphate, which is energy, the factory's not working. And why might somebody be low? There are a whole variety of reasons. Statin medications,which are used to lower cholesterol, prevent you from making cholesterol, so it'll lower your blood test, but the same enzyme that you block when you're on a statin medication also helps your body make coenzyme Q10.

And so many people on statins medications are low in CoQ10 and it can come out in various symptoms. Fatigue is one of them. Muscle pains and aches and weakness are very common with statin medications. And I actually just had a friend tell me that he was having terrible muscle fatigue and feeling awful on his staten medication and his doctor had switched him around. all different kinds and put him on the one that was the least likely to do it and he couldn't tolerate it, and so he was off of it. He's somebody who really needs to be on it for a variety of reasons.

I said, well, did your cardiologist talk to you about CoQ10? He said no. Cardiologists don't seem to understand the biochemical step. that causes statin side effects. So you know it now and so you that if you need to be on a staten medication and you should be COQ10 along with it. What other things can cause fatigue? toxins in the environment. So toxins, heavy metals, pesticides, organic pollutants that off gas from our new cars and carpets and paint get into our system and gum up the works and prevent that factory, that ATP energy producing factory from working optimally.

So toxins are an issue as far as fatigue goes. And one of the questions I got are, are fatigue and sleepiness the same thing? And I would say no. Sleepiness is kind of like more like you want to fall asleep and your, your brain isn't moving fast enough and fatigue is more of an energy issue. So something needs to be done about either one of them if they're an issue for you. Other problems that can cause fatigue are problems with sleep.

Sleep Problems, Insomnia, and Snoring 15:13

And so we see a lot of people with insomnia and there are a whole lot reasons for insomniac. I mentioned one before. And that is lack of progesterone, other reasons for insomnia, anxiety. And there was one expert that says there's no insomniac, there is only anxiety, so we know that meditation, and there have been hundreds of studies that show that mediation improves sleep and it reduces anxiety calms your brain and calmed your cortisol levels. The other thing about sleep is you want to have what we call good sleep hygiene.

So you do not want be looking at bright screens on your computer or your TV within an hour or two of bedtime. You want a dim the lighting. It's hard for a car to go from a hundred miles an hours to a full stop. Its hard to you to from 100 miles per hour during your day to full stops all of a sudden at night. Having a wind down period. where the lights are dim, where you do something relaxing. You might meditate, you might read, might listen to music. If you have to be at a screen, use blue blocking glasses, which are kind of like fit over.

Well, if you wear glasses like I do, they're fit overs or not of a yellow glass that blocks out the blue light that comes from our screens that inhibits our pineal glands manufacture of melatonin, and melatons are sleep hormones. The other things that insomnia can be involved with is lack of adequate oxygen at night. So if you are somebody who snores, there is a pretty high likelihood that you may not be oxygenating well at. And for women, this is especially important because it's like many things harder to pick up on than lack of oxygenation and sleep for men.

So the classic person with sleep apnea we think of as a man with a short fat neck and as soon as he lies back all those tissues press on astrakia and block air coming in. And so that's easy to You know, just to evaluate. Women, however, have other sleep problems, and one of them is called upper airway resistance syndrome, where women who look like me with a long skinny face and a skinny neck have a thin trachea. And when we lie back, that trachea may narrow to just like a sixteenth of an inch, like not enough for enough air to get through.

It's usually worse when people lie on their backs. So a lot of people think that they happen to like sleeping on one side or the other or their stomach. But in fact, it may be your body telling you this is the best way that you can get oxygen without you even really being aware of it. It's a natural thing that your body does to get you more oxygen. So if you're a snorer and you are fatigued, it's really important to go to sleep study. The other thing I found out is women who have this upper airway resistance syndrome have a lot of symptoms that overlap with menopause.

Hot flashes and night sweats, mood problems, and like I said, fatigue. It's important to get a sleep evaluation if you're fatigued and you are snoring. Another question we got is, I feel fatigue shortly after I eat, what could be happening? And we usually see this with high carbohydrate meals. It is an indication of insulin resistance. So, Insulin is a hormone that our bodies produce when we eat and it is used to get the breakdown products of our food, which is glucose, into the cells. And if we are insulin resistant, it's like you have a creaky gate on a fence.

It's really hard to push the gate if it rusted.

Blood Sugar, Insulin Resistance, and Adrenal Fatigue 19:38

And it takes more insulin to open that gate and let the glucose into your cell. And that will end up giving you a feeling of fatigue after eating. The other thing that I want to mention that is really important is the issue of adrenal fatigue. What is that? Well, our adrenal glands are glands that govern a lot of different things. We usually think of them as our, you know, red light emergency glands. So we have evolved to be able to respond to an emergency like a predatory animal is wants to eat us and so we have to think fast, act fast and have the muscle power to get the heck out of there right so that we don't get eaten by the predator.

And that all happens because of the release of cortisol as well as adrenaline and adrenaline of course gets your heart racing get your blood pressure increased, that pumps your around more quickly so your muscles can function better because in prehistoric times when this whole system developed, our main threat was from predators and our mean action was a physical action to run away. These days we get stressed Our bodies actually have the same physiologic responses when we're out in the jungle running away from predators, but we don't run anywhere.

Like you sit in traffic, stewing about traffic getting the rise in cortisol that you would get if you had an animal about to eat you. But what are you doing? You're sitting there stuck in travel. You get no physical release and change in your hormone levels that kind of recovery in modern times. And so what we see is with stress in our lives, we release a lot of cortisol. Cortisol does a number of things. It is a fat storage hormone, it is wake-up hormone. One of the problems we've seen is stress.

Sometimes the evening cortisol levels, which should be the lowest of day to allow us to fall asleep are really high. And when your cortisol levels are high, it's like you're tired but wired. You cannot let go and fall asleep. We have ways of diagnosing that with doing cortisol tests throughout the day. Our favorite test right now is a urine cortisol which is done on a small filter paper at four different times during the day. And your cortisol level normally should be the highest between about four and six in the morning.

That is what starts to wake you up from your sleep. Then it goes down at noontime and there's a little blip up after you have lunch. And then it goes down further at about like five in the evening and then you eat dinner. There's a little blip up. And, then, it's its lowest between ten and midnight. That's what allows you to finally fall asleep. If you're somebody who has been stressed over a period of time, you may have an inverted curve. Instead of having high in morning and lower through the day, You may be low in the morning and go up during the day, so that by 10 to 10 o'clock to midnight, your cortisol levels are high.

And you can't fall asleep if your core is all levels or high, you need a sledgehammer to knock you out if you're cortisol, levels, or higher. You're trying to go to sleep. So evaluating adrenal function, which is the gland that produces cortisol. turns out to be very revealing in terms of fatigue. And after somebody has gone through a high stress period where they're producing a lot of cortisol and might have that nighttime surge, and that's a classic actual pattern that we see where someone will say, I get really tired in the afternoon and then all of a sudden, when I should be going to sleep at around 10 or 11 o'clock at night, and finally have the energy to do something.

So then they're busy trying to everything they couldn't do during the day and now going to sleep at midnight or one in the morning, which is too late if you need to get up the next morning. What we need do is to try to reverse that inverted cortisol level of hormones and we have a number of ways of doing it. We have supplement that we really like at the Sklar Center called serifos, and it is phosphatidylserine. And it helps to blunt that high cortisol response. So it's something that use in people who have high cortisone at night, while we're trying to work on, you know, their stress issues and getting that cortisol, the root cause of that cortisol to come down.

If somebody has had high cortisol levels for a really long time, after a while there's a disconnect between the pituitary gland, which again, governs your adrenal glands. It govern all your glands, so your thyroid we talked about, now we're talking about your adrenal gland. And there can be a disconnected between pitutary and the adrenal gland so that the adrenal gland no longer produces enough cortisol. You go from a high-cortisol state to a low cortisol state. We call this adrenal exhaustion and the people who have this are tired even if they wake up from what they think is a really good night's sleep and they get more tired as the day goes on.

So regardless of how they sleep, even it seems good, They're tired on awakening and it just gets worse as the day proceeds. So very difficult situation to live with. And we have lots of things that we do for that. We actually have adrenal glandular. so similar to what we might give for thyroid replacement if somebody needs it is a pig derived thyroid gland product. we Have cow derived adrenal land products that help your body recover. not just a replacement, but actually recover from adrenal exhaustion and adrenal fatigue.

We sometimes even use a pharmaceutical called hydroxy cortisone, hydro cortison rather, that is like the cortisol that your body makes but it's not making enough of. And we use it short term, maybe three to six months to help your while it is recovering. And I would say Dr. James Wilson wrote a book called Adrenal Fatigue, The 21st Century Illness. And in fact, it is because we are so stressed and that was even before the pandemic, which has caused even more stress.

Dehydration, Infections, and Other Causes of Fatigue 26:48

Let's see some other questions. Somebody asked, is it normal to experience a midday slump and what can you do about it? It is part of our natural decrease in cortisol levels. Like I said, between noon and five cortisol, levels go down. And so that besides people who have adrenal problems, that can be part a normal diurnal variation in energy. What you should not do is use caffeine, which of course a lot of us do to help us get through. And it's understandable because caffeine gives you a short jolt of energy and it actually is what's called a nootropic, it helps your brain work better short term.

But if you use that as your only method and don't start looking at the underlying causes, you can end up in even worse shape because you're kind of driving your body to keep going when it needs something else. It either needs rest, adrenal glandulars, it needs phosphatidylserine. It needs a good night's sleep. So if you're somebody who's having that midday slump, if your able to, with your job or whatever your schedule arrangement is, to get up and move around and go for a little walk, especially if can get outside, that is a really good way to boost your energy without driving your body beyond its capabilities.

Somebody asked about whether fatigue can be due to dehydration. And I think we overlook this a lot, but your cells cannot work right if you don't have adequate hydration. You are making everything in your body function in a sluggish fashion if your not drinking adequate fluids. And of course our favorite fluid is water or herbal tea or water with a little lemon in it. There are a variety of things you can do. Some people put electrolytes in their water. But you really need to be drinking a couple of quarts of water a day for your system to function optimally.

We have a question of, does fatigue come with brain fog, blurry vision, dizziness or chills? I would say that's not typical of the fatigue that we see at the Sklar Center. And if somebody has that constellation of symptoms, we certainly want to look into viral illnesses, tick-borne illnesses, there is tick borne relapsing fever and other tick born illnesses that will give you episodic fevers along with fatigue and chills. So that would be a more complicated situation, but certainly reactivated viral illnesses and Lyme and co-infections are really significant causes of fatigue that we see.

And the reactivity viruses, the main one that see is Epstein-Barr, An Epstein-Barr virus is almost ubiquitous in our society. By the time we're in the 20s, 90% of us have been exposed to the Epsteine-Bar virus. It's also called EBV. E for Epstine, B for Bar and V for Virus. And the Epstein-Barr virus, in your 20s, you might have had mononucleosis, or you may not have any illness at all. And what typically happens after we've been exposed to a viral illness is our white blood cells, which is a fighting army for viruses and bacteria, will expand to fight the epstein bar virus.

That will keep the virus from multiplying in our bodies and causing us to feel sick. After that initial infection, that big army of white blood cells is not maintained and it shrinks back to a little group of cells that is at the ready if we should get exposed again. And what can happen later in life is because our immunity is decreased due to stress, due illness, to toxins, our immune goes down and we no longer have that little smaller shrunk down army, the army expands and it means that we are now fighting the virus again.

So the viruses has been kept in check and now is multiplying and proliferating and making us feel bad. And it is a fairly common cause of fatigue that see in our patients. We have good luck treating it, we prefer not to use pharmaceuticals and doesn't seem like it's been necessary for Epstein-Barr. We use a derivative of coconut oil, which has very few side effects and seems to be really effective, but it's not an instant treatment. It goes on for three to six to nine months and sometimes requires a maintenance dose of it.

And the supplement we like to use is called loracetin. Lime and co-infections turns out to be a lot more common than anyone has thought over the last 30 or 40 years.

Closing Thoughts on Fatigue and Aging 31:58

So we're seeing a lots of lime and even without the fever and chills people can have lime or one of the infections that ticks carry. along with carrying Lyme. Lymen, its co-infections, are hard to diagnose. They're what's called intracellular, so they go and hide, and they don't travel around your bloodstream as readily as other infections. And so on a blood test can be hard, to actually see a positive test. So we go through a number of layers of testing for Lyne. We'll start with Quest and LabCorp, since a lot of people's insurances cover it.

And then we go on and do some specialized lab testing to look for these various organisms that can have, you know, tremendous and drastic effects on our health. Let's see, other questions that we have. I'm going to do one more question and that is, is experiencing fatigue normal. And like I said at the beginning, I don't write anybody off because of their age. I think you should be feeling good at any age and there may be some age-related decline, but you shouldn't end up sleeping all day just because you're getting older.

So we found that hormones in particular for older people have done a lot to help their energy. And I don't see any questions here. Let's see. I'm going to wrap up and I want to thank all of you who are on listening and send waves and hope to see you next time. Take care.