2 / Exhausted All the Time? Where to Start

In the first article, we established something important: fatigue is a symptom, not a diagnosis.

You may be sleepy because your sleep is fragmented. Physically depleted because your iron stores are low. Mentally exhausted from chronic stress. Struggling with metabolic dysfunction, thyroid disease or inadequate nutrition. Or several of these things may be happening at the same time.

That explains the fatigue. But it still leaves the practical question:

What do I do first?

The answer is not to overhaul your diet, start exercising six days a week, buy an energy supplement and somehow squeeze another hour of sleep into your life.

We need an order.

Step 1: Start with the pattern, not the solution

Before changing anything, spend a week paying attention to when and how your fatigue happens.

Do you wake exhausted despite spending enough time in bed? That immediately pushes sleep quality higher up the list.

Do you start reasonably well and crash after lunch?

Does your energy disappear after physical exertion?

Are you exhausted during your period or in the days following heavy bleeding?

Do you become shaky, hungry and irritable several hours after eating?

Does the fatigue fluctuate with your menstrual cycle?

Or is it constant from the moment you wake until you go back to bed?

Also ask yourself when it began. A gradual decline over several years tells us something different from suddenly becoming profoundly fatigued three months ago.

You don't need an elaborate tracking app. A few notes about sleep, meals, menstrual cycle, activity and when fatigue occurs can reveal patterns that are surprisingly easy to miss when every day simply feels exhausting.

Step 2: Make sure this isn't something that needs investigating now

Before treating fatigue as a lifestyle problem, we need to decide whether it deserves medical assessment.

If fatigue is new, persistent, severe, worsening or significantly affecting your ability to function, don't spend the next six months trying to biohack it.

The same applies when fatigue accompanies symptoms such as unexplained weight loss, unusual bleeding, persistent fever, significant breathlessness, chest pain, fainting, new neurological symptoms or another unexplained change in your health.

Heavy or prolonged perimenopausal bleeding deserves particular attention. It may be contributing to iron deficiency, but abnormal bleeding itself may also need investigation.

And if you have been tired for months despite apparently doing everything right, that is also a reason to look more closely.

Sometimes the correct first step isn't changing your lifestyle.

It is finding out what is wrong.

Step 3: Work out whether the real problem is sleep

If you wake exhausted, start here.

Ask yourself whether you are actually getting enough sleep, but don't stop there. Seven or eight hours in bed does not necessarily mean seven or eight hours of restorative sleep.

Are hot flushes waking you? Are you waking repeatedly to urinate? Is pain disturbing you? Are you lying awake with a racing mind? Do you wake at 3 am and struggle to fall asleep again?

If menopause symptoms are repeatedly disturbing your sleep, those symptoms need addressing rather than simply telling yourself to go to bed earlier.

But there is another question I want you to ask:

Do I snore?

Obstructive sleep apnoea is frequently overlooked in women. Snoring, waking gasping, witnessed pauses in breathing, morning headaches, dry mouth, frequent nighttime urination and excessive daytime sleepiness are important clues, but women can also present primarily with insomnia and fatigue.

If you consistently spend enough time asleep but wake feeling as though you've been hit by a bus, sleep quality deserves proper investigation.

No supplement can compensate for repeatedly disrupted breathing throughout the night.

Step 4: If your periods are heavy, move iron near the top of the list

This is one of the clearest examples of why we need an order.

Perimenopause can bring heavier or longer periods. Repeated blood loss can gradually deplete iron stores, and iron deficiency can exist before you become anaemic.

So if you have heavy periods alongside exhaustion, weakness, headaches, palpitations, hair shedding, breathlessness or reduced exercise tolerance, don't simply assume menopause is making you tired.

Ask for a full blood count and ferritin, with additional iron studies where appropriate.

And don't blindly take iron either.

Too much iron can be harmful, and if iron deficiency is confirmed, we also need to understand why it developed.

If heavy menstrual bleeding is responsible, replacing iron treats the consequence. The bleeding itself may still need investigation and treatment.

Step 5: Make sure you are actually feeding the body you are asking to perform

Now we look at food, but not through the lens of another menopause diet.

One of the most common patterns I see in midlife is a woman who has gained weight, becomes frightened of gaining more and responds by progressively eating less.

She skips breakfast. Eats a tiny lunch. Avoids carbohydrates. Extends fasting windows. Drinks coffee to keep going and then wonders why she is exhausted and ravenous by late afternoon.

If this sounds familiar, the first intervention is not greater restriction.

Start by establishing regular, nutritionally substantial meals.

Each meal should provide a meaningful source of protein, plants and fibre, appropriate whole-food carbohydrates and healthy fats. The exact proportions will differ according to your metabolic health, activity, appetite and goals.

Protein becomes particularly important in midlife because maintaining muscle requires adequate amino acids alongside resistance exercise.

Carbohydrates are not inherently energy-draining or fattening. Their quality, quantity and metabolic context matter. Lentils, oats, beans, fruit or potatoes do not behave in the body exactly like biscuits and sweetened drinks.

And if you are physically active, chronically under-eating carbohydrate while training hard can leave you feeling considerably worse.

Before asking what you should remove, ask:

Am I giving my body enough of what it needs?

Step 6: Stop using caffeine to hide the problem

Coffee can temporarily make an exhausted person feel more alert because caffeine blocks adenosine receptors in the brain.

That is useful.

But alertness and restored energy are not the same thing.

If you need caffeine from morning until late afternoon simply to function, it may be masking how tired you actually are. Later caffeine can also interfere with sleep in susceptible people, potentially creating a cycle of poor sleep, more caffeine and greater fatigue.

You don't necessarily need to give up coffee.

Start by looking at how much you need and when you need it.

If you cannot function without several coffees, energy drinks or pre-workout stimulants, I am more interested in why your baseline energy is so poor than in finding a better stimulant.

And if sleep is already fragile, move caffeine earlier in the day and see whether sleep quality changes.

Step 7: Look at what happens after you eat

If fatigue consistently appears after meals, don't immediately diagnose yourself with insulin resistance. A large meal naturally shifts physiology toward digestion, and circadian alertness also tends to dip during the afternoon.

But if post-meal fatigue occurs alongside increasing abdominal fat, strong carbohydrate cravings, frequent hunger, elevated triglycerides, high blood pressure, a history of gestational diabetes or a family history of type 2 diabetes, I want to look more closely at glucose regulation.

The first practical intervention is surprisingly simple.

Build meals around protein and fibre, reduce large amounts of refined carbohydrate and added sugar, and move after eating.

Even a short walk after a meal helps skeletal muscle take up glucose and can reduce the postprandial glucose excursion.

Then assess the metabolic picture rather than trying to eliminate carbohydrates completely.

We will go considerably deeper into energy metabolism in Article 3.

Step 8: Check whether alcohol is borrowing tomorrow's energy

Alcohol can feel relaxing in the evening and may make you fall asleep faster.

That doesn't mean it improves sleep.

As alcohol is metabolised, sleep can become more fragmented later in the night. It can worsen snoring and sleep-disordered breathing in susceptible people and may aggravate night sweats or hot flushes in some women.

So if you regularly have wine in the evening and wake tired, don't assume alcohol isn't relevant because you fall asleep easily. Try a genuine experiment.

Reduce or remove it for several weeks and observe sleep continuity, morning energy, night sweats and daytime fatigue.

This costs nothing and gives you information about your own physiology rather than somebody else's rules about alcohol.

Step 9: Don't prescribe yourself harder exercise because you're tired

Movement can absolutely improve energy. But the dose matters.

If you are sedentary and deconditioned, regular walking and gradually increasing physical activity can improve fitness, metabolic health, sleep and eventually energy.

If you are already training intensely while sleeping badly, eating inadequately and feeling increasingly exhausted, adding more exercise may simply add another stressor.

This is where I want you to distinguish movement from punishment.

On very depleted days, your starting point may be walking outdoors rather than doing a punishing HIIT session.

As energy and recovery improve, resistance training becomes increasingly important because muscle supports glucose disposal, physical function and metabolic health. Cardiovascular exercise helps build aerobic capacity and mitochondrial adaptations.

But you earn progression through recovery.

You don't force recovery by training harder.

Step 10: Look at your stress load differently

If you're chronically exhausted, being told to "reduce stress" can be infuriating.

You may not be able to remove your job, financial responsibilities, ageing parents, family problems or whatever else is happening.

So don't start with eliminating stress. Look for recovery opportunities.

Are there any periods in your day when your brain isn't processing information, answering messages, solving problems or anticipating the next demand?

Can you walk for twenty minutes without your phone? Sit outside after lunch? Read? Garden? Spend time with somebody who doesn't drain you? Go to bed rather than scrolling for another hour?

This is not fluffy wellness advice.

The autonomic nervous system continually adjusts between states supporting mobilisation and states supporting rest, digestion and recovery. Chronic psychological stress can also interact with sleep, mood, eating behaviour and metabolic regulation.

You do not need to "switch off cortisol."

You need periods when your physiology isn't being asked to respond to another demand.

Step 11: Then start rebuilding capacity

Once the obvious drains are being addressed, we move from stopping the energy leaks to increasing capacity.

This is where strength training, cardiovascular fitness, adequate protein, appropriate carbohydrate intake, circadian rhythm, daylight exposure, metabolic flexibility and mitochondrial adaptation become increasingly interesting.

A stronger, better-conditioned body can perform the same physical task at a lower relative effort than an unconditioned one.

That matters.

If climbing stairs requires a large proportion of your available physical capacity, it feels exhausting. Improve strength and aerobic fitness and the stairs haven't changed.

You have.

But this comes after we've addressed the woman who is sleeping five hours, losing iron every month and surviving on coffee.

First stabilise.

Then build.

What if you do all of this and you are still exhausted all the time?

Then we stop trying to lifestyle our way out of something that may need investigation.

Persistent fatigue can be associated with thyroid disease, anaemia or iron deficiency, diabetes, sleep disorders, medication effects, nutritional deficiencies, chronic inflammatory or infectious conditions, cardiovascular or respiratory disease, depression and many other conditions.

This is why I don't want you spending a year accumulating supplements because somebody told you fatigue after 45 is normal.

Sometimes all the foundations are good and something still isn't right.

That is useful information.

Take it seriously.

Your first energy plan

If this article feels like another long list of things to do, don't turn it into one.

Start with four questions.

Do I wake refreshed?

Am I eating enough nutritious food to support what I ask my body to do?

Is there an obvious drain such as heavy bleeding, poor sleep, excessive alcohol, overtraining or chronic stress?

Is my fatigue persistent or significant enough that it needs investigating?

Then address the biggest problem first.

If sleep is broken, work on sleep. If you're bleeding heavily and exhausted, investigate iron and the bleeding. If you're barely eating, nourish yourself before adding more exercise. If your lifestyle is reasonably solid and you remain profoundly tired, investigate.

That is a far more useful strategy than trying seventeen energy hacks simultaneously.

Which biomarkers I recommend checking

If fatigue is persistent, significant or unexplained, testing should be guided by your symptoms and history rather than ordering everything available.

Depending on the individual, I commonly consider full blood count and ferritin, with fuller iron studies where indicated; TSH and free T4; fasting glucose and HbA1c, with fasting insulin where it adds useful metabolic information; and vitamin B12, folate and vitamin D when symptoms or risk factors warrant assessment.

Renal function, liver function and electrolytes can also be appropriate in persistent unexplained fatigue, with additional testing determined by the clinical picture.

And if your story sounds like a sleep disorder, remember that another blood test isn't the answer.

You may need a sleep assessment.

Your next step

Once the biggest energy drains have been identified and addressed, we can move beyond simply trying to feel less tired.

We can start building energy capacity.

In the next article, we'll go deeper into what your cells actually need to produce energy, how mitochondria adapt, why muscle and metabolic flexibility matter, how thyroid and nutrient status influence energy production and what you can realistically do to become more resilient.

Next: How to Rebuild Your Energy After 45

You can also explore more articles, free and paid resources, my book and programmes in the Energy & Fatigue section of Feel Good Menopause.