Why You’re Exhausted in Midlife—and What to Do About It

A step-by-step plan to tackle midlife fatigue

Photo by Toa Heftiba on Unsplash

It’s amazing how I used to put up with fatigue. When my kids were little, after getting through the day, I was spent. No. More. Energy.

Honestly, I didn’t notice how bad it was until I found solutions and to this day, if I get fatigued, it’s usually because I’m getting sick.

Fatigue is not a normal part of aging or the menopause transition; it’s a sign your body needs something. And it’s our job to figure it out.

It’s pretty darn common. In a study by Evernow with 100,000 women, 85% of midlife women complained of fatigue and low energy, which was the top menopause-related symptom in women.

Let’s figure out what’s causing fatigue, step by step. But first, let’s start by defining it.

What is fatigue?

Turns out, there’s no single definition of fatigue that everyone agrees on, even after researchers looked into it.

Although healthy people also experience fatigue, it is more prevalent among those with acute and chronic medical conditions.

This is why fatigue can be a pre-disease state, which makes digging into its cause important. Doctors define chronic fatigue syndrome as fatigue lasting six months and including at least four of the following symptoms:

· Increased feeling of tiredness after activity

· Sleep problems

· Muscle and join pain

· Head and neck pain

· Orthostatic disturbances

· Cognitive issues

There are physical, cognitive, and mental dimensions to fatigue. This definition from the Mayo Clinic sums it up nicely:

Fatigue reduces energy, the ability to do things, and the ability to focus. Ongoing fatigue affects quality of life and state of mind.

Step 1: Check your iron status

There are certain ingredients our bodies need to feel energetic. First is oxygen, which helps make energy (ATP) in the mitochondria by accepting electrons at the end of the electron transport chain.

But cells and tissues can’t get oxygen if its transportation is limited, which is where iron comes in. Iron is the heme part of hemoglobin, and its job is to carry oxygen to cells and tissues. But it’s also a cofactor for 180 biochemical reactions in the body.

So, when iron stores dip, the brain tells the body to slow down to conserve iron, and this shows up as fatigue.

It’s estimated that 80% of menstruating women have iron levels that produce fatigue.

[This was me for years; you can read my story here.]

Research links a ferritin level below 50mcg/L, a sensitive marker of iron deficiency, to unexplained fatigue in women. Many doctors will say this is normal, so know your numbers!!

Ferritin gradually rises after menopause and the risk of iron deficiency will decline. Yet functional iron deficiency can occur, which is when the body has enough iron stored but can’t access it.

My FREE Biomarker Guide has the details on what type of testing to look for and ask for.

Step 2: Focus on folate and vitamin B12

We need folate and vitamin B12 to form of red blood cells. When one or both are low, it can be a source of fatigue.

Declining B12 is usually because of changes in absorption with aging and decreases in stomach acid. A study revealed that 36% of post-menopausal women had a stomach pH level higher than the required 1-2 pH level to break down B12 from food.

Folate may decline with a low intake of grains, legumes, and citrus fruits. This can easily happen when following certain diets like keto or carnivore, reducing carbs, and not taking a multivitamin.

READ: The Essential Vitamin Every Midlife Woman Needs to Monitor

If your iron status is optimal and you’re still fatigued, ask your health care provider to check your folate and B12 levels.

Step 3: Nitric oxide blockers (and boosters)

Dr. John Stamler, professor of medicine at the Case Western Reserve University School of Medicine and President Harrington Discovery Institute, has proposed that we have a three-gas system that involves not just oxygen and carbon dioxide but also nitric oxide.

His 2015 study found that nitric oxide helps dilate blood vessels in mice, allowing oxygen into tissues. Later studies confirmed this in humans as well. Stamler said this when interviewed about the study:

The simplified textbook view of two gases carried by hemoglobin is missing an essential element—nitric oxide—because blood flow to tissues is actually more important in most circumstances than how much oxygen is carried by hemoglobin. So the respiratory cycle is actually a three-gas system.

READ: Nitric Oxide: The magic midlife molecule

Think of it like a food delivery driver stuck in traffic: the food is there, but it’s not reaching you in time. Poor circulation can slow everything down, and nitric oxide helps keep blood vessels open and everything moving smoothly.

As I explain in the One Health Principle, inflammation and oxidative stress lower nitric oxide levels.

Look for sneaky nitric oxide blockers like reduced thyroid function, high homocysteine and elevated uric acid, which I discuss further in my post: The Essential Question Every Midlife Woman Should Ask When Health Takes a Turn.

Estrogen and progesterone naturally boost nitric oxide, so hormone therapy is a tool women should investigate. Especially when symptoms like hot flashes cause poor sleep.

Nitrates in the diet and beet-root supplements are another way to boost nitric oxide, decrease inflammation, and increase energy.

Step 4: Check your breathing

When James Nestor was researching his book Breath: The New Science of a Lost Art, he let Stanford researchers block his nostrils and breathed through his mouth for 10 days. His blood pressure shot up 13 points. He snored loudly, developed sleep apnea, and his oxygen levels dipped.

“We knew it wasn’t going to be good, because there’s a very firm scientific foundation showing all the deleterious effects of mouth breathing, from periodontal disease to metabolic disorders,” Nestor said in this CNN interview.

Quality sleep is important to avoid fatigue. If you are making sleep a priority and still don’t feel rested, you’ll want to check how you are breathing during sleep.

People over 40 are six times more likely to breathe through their mouth during sleep. Signs include waking with a dry mouth, morning headache, and not feeling refreshed after sleep.

Midlife women are also at increased risk for sleep disordered breathing, ranging from a restricted airway to period blockages (sleep apnea).

This is important because it means oxygen levels decline during sleep, increasing inflammation, and reducing the quality of sleep. And because the nasal sinuses are a rich source of nitric oxide, breathing through our mouth decreases NO.

Step 5: Chronic stress and the overactive nervous system

I can always tell when stress has entered the danger zone because it’s starts affecting my sleep. That’s when I take notice.

There’s a lot of talk about cortisol rising at midlife and, yes, studies show it increases with age.

But if we take a step back, we can see that it mostly comes down to changes to our nervous system with more fight or flight sympathetic activity.

Our ability to handle stress changes with age and it forces us to act or deal with the negative consequences.

But even if we don’t have a lot of stress, our nervous system changes with Aging Pause. It always pays to work in ways to stimulate our vagus nerve to get it more balanced.

Besides developing a breathing practice, try getting out in nature, connecting with friends, listening to music, or practicing a hobby that calms you.

READ: Meet Your Post-40 Nervous System

Step 6: Check alcohol consumption

Alcohol is a funny thing because low-to-moderate intake can boost nitric oxide while overconsumption has the opposite effect.

Also, alcohol can disrupt sleep, causing a lower quality of sleep, especially when consumed close to bed.

It always pays to investigate your alcohol habits.

Maybe you cut it out for a time and monitor your sleep to see if it helps. Using tools like the Mindful Drinking app can help decrease intake.

Don’t miss my post where I detail the pros and cons of drinking and smart tips for those who choose to drink.

Step 7: Evaluate your exercise routine

A meta-with analysis with 172 studies reveals that moderate intensity exercise improves fatigue, vitality, and energy. A combination of resistance and aerobic exercise yielded the best results.

I love starting my day with exercise because it gives me a jolt of energy. I personally find aerobic exercise, especially energy lifting.

Of course, under or over-training could be affecting your energy. Experiment with exercise by trying something new.

Sheila recently started a jujitsu class, and it’s been challenging and fun but also creates the best sleep on those days.

If you mostly do weight training and walking, try a higher intensity exercise class. If only do aerobic exercise, consider trying strength training.

Often, as we get older, we tend to stop challenging ourselves physically.

Also, play around with workout times. I find that a 20-minute peloton ride gives me a boost in the afternoon.

If you have medical conditions, check with your doctor.

Step 8: Check your smartphone use

Think about how much technology has changed in 10 years. In 2011, only 35% of Americans said they owned a smartphone. That number more than doubled to 85% in 2021.

Whether it’s using your phone during the day either to check social media, the news, email or even research topics (I’m guilty) or your upcoming vacation, cellphone use sure can sneak up on you.

Before you know it, your motivation to work or do the dishes or workout is nonexistent. The culprit could be too much smartphone use.

There’s a certain fatigue induced by too much cell phone use called mental fatigue which “is characterized by an increase in subjective feelings of ‘tiredness’ and ‘lack of energy,’ associated with a decrease in cognitive performance or an increase in the effort required to maintain performance,” according to a 2023 study.

Research has shown that mental fatigue impairs sports performance, technical skills, and endurance. But is it the same for smartphone use?

To see how smartphones affect people, researchers had two groups of 40 adults either use their phones or watch a documentary for 45 minutes. Afterward, they all received a task.

Both groups showed mental fatigue and drowsiness, but the smartphone group also showed a decrease in performance during the task.

I personally will be working on this one during the summer.

Fatigue is not normal

Midlife fatigue is coming from somewhere and if we take the time to figure it out, we can conquer it.

Sometimes it’s one thing that’s obvious, but often it’s several smaller things that add up. The nice thing about these 8 steps is they are good for us to monitor regardless of if we feel fatigue or not.

I would love to hear from you. Have you been dealing with fatigue?