Private Medicine · Women’s Health
Persistently Tired and Exhausted — Causes and Work-Up
When the tiredness doesn’t go away: which causes are actually plausible, which blood values make sense — and which are unnecessary. A structured medical assessment, instead of self-diagnosis online.
Knowledge Base · Fatigue
Not Every Fatigue Is Iron Deficiency
Fatigue is one of the most common complaints — and one of the least specific. It can be harmless and simply come down to sleep. But it can also point to iron deficiency, the thyroid, a vitamin deficiency, or hormonal change. This overview shows which causes are worth considering, how a sensible work-up proceeds — and why more lab values don’t automatically mean more clarity.
Fatigue is a symptom, not a diagnosis
Many people come to me saying: “I’m tired all the time and I don’t know why.” I won’t promise you a quick fix or an infusion that fixes everything. What I offer is the opposite of guessing: a structured work-up that either identifies a cause for the symptom — or gives a well-founded reason why no identifiable physical cause is present.
Here’s the honest starting point: the most common reasons for persistent fatigue are lack of sleep, stress, and emotional strain — not some exotic nutrient deficiency. At the same time, there are physical causes that shouldn’t be overlooked. Telling the two apart cleanly is the actual medical task.
The most common physical causes
A rough map — none of these can be confirmed from behind a screen, but it shows what’s worth thinking about.
Iron deficiency
The classic cause, especially in women with heavier periods. Iron is needed to carry oxygen in the blood; when it’s low, this often shows up as fatigue, poor concentration, and paleness — sometimes even before anemia develops.
Marker: Ferritin (iron stores) and blood count. Ferritin can be falsely normal during inflammation.
Thyroid
An underactive thyroid — often caused by Hashimoto’s thyroiditis — slows metabolism: fatigue, feeling cold, weight gain, dry skin. An overactive thyroid can also be exhausting.
Marker: TSH as a screening test; if abnormal, fT3/fT4 and antibodies.
Vitamin B12 and folate
Both are needed for blood formation and nerve function. A deficiency mainly affects people on a vegan or vegetarian diet, older age groups, and those taking certain medications (such as metformin or acid-reducing drugs).
Marker: Vitamin B12 (possibly Holo-transcobalamin), folate, blood count.
Vitamin D
A deficiency is common in our latitudes, especially in winter. The role of vitamin D in fatigue isn’t fully settled scientifically — what’s established is its importance for bone and muscle function. The value is taken into account, but not overweighted as a sole explanation.
Marker: 25-OH vitamin D.
Menopause and hormones
In perimenopause, often starting in the mid-40s, hormones shift. Sleep disturbances, night sweats, mood swings, and exhaustion are part of this — and are often not connected to it.
Marker: Assessed mainly clinically; hormone values are only of limited use here.
Sleep, stress, and mental health
By far the most common group — and the most underestimated. Lack of sleep, disrupted sleep (for example from nighttime breathing pauses), chronic stress, and low mood very often first show up as physical exhaustion.
Marker: Assessed through conversation; targeted further diagnostics if indicated.
When fatigue needs prompt medical attention
Certain accompanying signs shouldn’t be waited out: unintended weight loss, fever or night sweats without explanation, shortness of breath, chest pain, markedly enlarged lymph nodes, bloody stools, or exhaustion that clearly worsens within a few weeks. In these cases, work-up takes priority — please see a doctor promptly, your primary care physician or an emergency department if in doubt.
How a sensible work-up proceeds
Good diagnostics don’t start in the lab — they start with listening. Only the conversation determines which values are actually worth checking.
History-taking
Since when, how severe, in what context? Sleep, diet, cycle, medications, life situation. This is where the first well-founded suspicions take shape.
Physical examination
Paleness, thyroid, heart, lungs, lymph nodes — simple findings that point the way.
Targeted lab diagnostics
Not everything at once, but the values that match your history. For women with heavy periods, for example, ferritin and blood count come first — not a blanket sweep of twenty parameters.
Interpretation in context
A lab value is only meaningful in context. A borderline value with matching symptoms means something different than the same value without symptoms.
Plan
From this comes a concrete, understandable next step: targeted treatment, monitoring over time, lifestyle changes — or a well-founded all-clear.
Not every fatigue needs twenty lab values. Untargeted testing mainly produces borderline findings that create uncertainty without helping. More values don’t mean more clarity — the right selection means more clarity.
Checklist: Preparing for Your Consultation
The more precisely you describe your symptoms, the more targeted the work-up can be. Check what applies to you — this creates a short note you can bring to your consultation (with me, or with your primary care doctor).
Fatigue and general
Cycle and menopause
Diet and lifestyle
Pre-existing conditions
BMI (optional)
This value is only for context in the consultation — no assessment is made here.
This checklist is not a diagnosis and does not replace a medical examination. It only helps you prepare for the conversation. No data is transmitted to the practice — everything stays in your browser.
Orientation Calculators
For an initial sense of things — not a diagnosis, but a way to better understand your values and needs:
Get your exhaustion checked
If you’d like to get to the bottom of this in a structured way, I offer a thorough work-up: history-taking, examination, targeted lab diagnostics, and a clear explanation of your results — with a defined next step.
This extended work-up is a self-pay service and does not replace necessary primary or specialist care. For acute or severe symptoms, regular medical care comes first.
This article is for general information and to help you prepare for a medical consultation. It does not replace individual advice, an examination, a diagnosis, or treatment by a physician. Which work-up makes sense in your case can only be judged after history-taking and examination. Medical disclosure under German law (§630e BGB) takes place exclusively in a personal consultation.
Dr. med. Thomas Ackermann
Specialist in Anesthesiology · Harmonie der Ästhetik, Herzogenaurach. Focused on sober, evidence-based medicine — evidence, not promises.
Methodological basis: among others, the S3 guideline “Fatigue” of the German College of General Practitioners and Family Physicians (DEGAM, AWMF register 053-002) as well as EFSA and DGE assessments of nutrients. Information provided without claim to completeness.
Next step
Questions about this topic?
What applies to you is best discussed in person — with your results, without time pressure. Herzogenaurach, twelve minutes by car from Erlangen.
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