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Welcome to The Modern Midlife Collective—where midlife isn’t a crisis, it’s a rebirth. Hosted by Dr. Ade Akindipe, DNP, and Dr. Jillian Woodruff, MD, this is the podcast for women ready to unapologetically own their power, thrive through the ups and downs of hormones, weight, and self-care, and show the world that thriving at 40 and beyond isn’t just possible—it’s your birthright.
Biweekly, we bring you science-backed insights on hormones, menopause, longevity, and sexual health—real tools to empower women in midlife and beyond. With a fearless blend of functional medicine, real-life wisdom, and no-nonsense empowerment, we’re here to challenge the norms, break through the barriers, and help you step into a life of vitality, confidence, and unstoppable strength.
Ready to rise? Let’s do this.
Jillian Woodruff MD (00:00)
Okay, today is the episode I've been waiting for. The messages we got after parts one and two, I just was not prepared for the response.
Ade Akindipe, DNP, APRN (00:09)
Yeah, women saying they finally felt seen, which I can only imagine women forwarding their episodes to their doctors, women crying on their way to work and just listening to this and finally feeling like somebody explained what's been happening in their body for years. And then almost every message ended the same way. Okay, now what do I do about this?
Jillian Woodruff MD (00:17)
I know.
Yes, and that's exactly what we promised. We told you part three was coming and here it is. This is the protocol episode. It is the complete fatigue protocol for midlife women. So today we're giving you the clinical picture, the labs that actually matter, the supplement stack that we recommend with the reasoning behind each one, and the language to use when you walk into a 15-minute appointment.
So you can walk out with something that's truly useful.
Ade Akindipe, DNP, APRN (00:59)
Yes, for anyone joining us for the first time, parts one and parts two are episodes 31 and 32. So make sure that you go back and listen, because these are the foundations, so you understand this part better. What you need to know right now is that chronic fatigue in midlife women almost never just has one cause. It is multi-systemic, so multiple things going on, so they start to dysregulate at the same time.
And for so long, many of us have been told that it's simply what it's like. You're just getting older and it's not.
Jillian Woodruff MD (01:33)
That's right, it is not. And we also built you something that you can hold on to. It's a free downloadable fatigue protocol that has everything that we're going to be talking about today. And it's organized and ready for you to bring into your provider. So grab it right now at modernmidlifecollective.com forward slash fatigue. And or you can find the link that's going to be posted in the show notes.
Pull it up while you listen to us or save it for after. Either way, just get it. Today's episode is pretty dense. It's going to be long, just like the other ones. That's how complicated fatigue is, so... Right? You're going to want that guide.
Ade Akindipe, DNP, APRN (02:07)
Hmm.
Sure is.
All right, let's do this.
Jillian Woodruff MD (02:14)
Before we get into the protocol, a quick note. Everything we share today is for educational purposes only. We are clinicians, but we're not your clinicians. And this is not medical advice. Nothing we discuss is a substitute for working with your own medical provider. So with that knowledge, with that being said, let's get into it.
Ade Akindipe, DNP, APRN (02:35)
Awesome, let's do
it. So the first thing is we want to be very upfront about something before we get specific into labs. What we're sharing today goes deeper than what a standard primary care appointment typically covers. And it's not that we're trying to criticize your doctor. It's just the reality of the healthcare system, right? So you have 15 minutes allocated for a wellness visit or maybe a sick visit and is not structured for this kind of comprehensive evaluation.
there are also some insurance considerations. When using insurance, every test you get has to have a diagnosis code. Otherwise, there's no way for your insurance to really cover it. And some of those diagnoses are not established until after a first visit. So that doesn't mean you cannot get what you need. It means we need to be very strategic and patient about how and when we ask for those extra testing.
Jillian Woodruff MD (03:54)
Yeah. And it's also worth knowing that there are cash pay alternatives. There's cash pay lab services that you can perhaps have significantly more flexibility. Many of the tests we're going to discuss today are available direct to consumer through different lab companies with or without a provider order and at a pretty reasonable cost. So that's an option. There's also some tests that we're going to talk about that may not
Ade Akindipe, DNP, APRN (04:16)
Yeah.
Jillian Woodruff MD (04:20)
be offered through conventional laboratories are able to be ordered by your provider in a conventional fashion. those may always have an out-of-pocket expense to it. So if you do find resistance in a conventional setting, that is an option worth exploring. So labs, this is how I approach it. In my practice, think in two tiers. I have tier one, those are the labs that I order.
you know, on anybody. So if you're coming in, you're saying, I am significantly fatigued and, you know, I, nothing I do works, then I have these high yield labs that reveal the most common drivers of fatigue efficiently. And then tier two, these are kind of add-ons, I would say, when something in tier one comes back abnormal, I would then maybe add on these additional labs to further dive into the abnormalities. So,
Let's say for example, someone has fatigue. I'm not going to do an extensive iron deficiency workup on a woman that I do not know has iron deficiency anemia, let's say. So if there are signs from the blood work that I may dive deeper and do some more specific, like comprehensive lab panel for anemia specifically. Dr. Day, what's your approach in this situation?
Ade Akindipe, DNP, APRN (05:38)
Yeah, very similar. know, because I work mostly with a lot of women who are dealing with some metabolic issues and they tend to be 35 plus. So like you said, you want to give women a realistic expectation when they walk into an appointment. So a lot of the labs that we draw, because we see the same patterns over and over again, we have kind of like similar to the tiers you're talking about, usually looking at metabolic function, looking at their
hormones, their thyroid, any nutrient deficiency that they might have. So you're not asking for everything at once, but typically when you're seeing it from their symptom checklist, there's a menopause rating scale that we look at. So if we're seeing those common symptoms over and over again, then we kind of know what labs to draw. So you're asking for a prioritized starting point, which is really great.
Jillian Woodruff MD (06:28)
Yeah, that's right. Well, to start for labs, I'm a gynecologist, so I do tend to start with hormones. And specifically the sex hormones. So let's start there. I would get an ⁓ estradiol or progesterone and testosterone. I would typically get both a free and a total testosterone level. So I know the testosterone amount that is available to your tissues as well as the total testosterone.
Ade Akindipe, DNP, APRN (06:33)
Yes, I am.
Jillian Woodruff MD (06:55)
I would get an FSH, so the signal from your brain that tells your ovary to release estradiol. And then I may add a DHEAS and I may add an LH. The FSH and LH would kind of help me to figure out where they are in that perimenopause-menopause transition. And then I was putting sex hormone binding globulin in my tier two, but then I had to move that.
because I realize I do pretty much order that all the time. The sex hormone binding globulin may not be a common lab to order, but it tells me how much of her testosterone and estrogen is actually free and available to her cells and not bound like a straight jacket to sex hormone binding globulin. So I consider sex hormone binding globulin a first visit essential. And I...
Ade Akindipe, DNP, APRN (07:40)
Mm-hmm.
Jillian Woodruff MD (07:47)
There is a bit of a nuance because if a woman's on oral contraceptive pills, those medications directly manipulate her hormone levels. So if I'm checking hormone levels on that woman, I'm not going to be really checking what her body is doing. I'm checking to see how her body's responding to hormones. And oral contraceptive pills, for one, will increase that sex hormone binding globulin, which binds up our...
know, hormones, our estrogen and our testosterone typically results in lower levels. So, I sometimes will check some of these things, but some of them may be left off because they will not be, you know, useful information to know.
Ade Akindipe, DNP, APRN (08:26)
Yeah, so the way you put it right there just lets us know that it's not a one size fits all for hormone labs. It's just to reassure our listeners to hear that medicine is individualized. You might have two women that might come in with fatigue, but with very different root causes. And that's exactly how I approach hormones. And for thyroid, which, you know, it's very common.
common to see thyroid hormones that are not as optimal as they should. So I always include it on a first visit. And this is not just a TSH. I know some folks will do biometric screenings. Maybe you want to go to your doctor or maybe a company driven one. And it's usually the TSH, but it doesn't really give us the full picture. So you run the TSH, which is the thyroid stimulating hormone, a TSH, T3 rather, free T3.
and a free T4. Those together can tell us a whole lot of, you getting the actual hormone that will work at the cellular level? So the TSH tells me what the brain is requesting from the thyroid. Free T3 and free T4 tell me what the thyroid is actually doing at your cells for your metabolism, for your energy. And of course, you want to check your antibodies, the TPO.
⁓ on the first pass that lets us know if you might have symptoms or if you have Hashimoto's, which is one of the most common causes of thyroid dysfunction in women.
Jillian Woodruff MD (09:51)
Maybe you can share your opinion on whether to test Total T3, Free T3, or Total T4 in Free T4. I used to actually check all of them, and now I tend to only check Free T3 and Free T4 just to see what's bioavailable.
Ade Akindipe, DNP, APRN (10:03)
Yeah.
Yeah, I think that's a great, that's a good question. I also check TPO antibodies, thyroid peroxidase antibodies. They are the primary, like I mentioned before, they're the primary marker for Hashimoto's. But what I've also found too is it's not necessarily the T3 that's the issue. Sometimes I find women have issues with converting or maybe their TSH is normal, but at the cellular level, the T3 is not high enough or optimal.
So sometimes it just might be a matter of replacing some of the nutrients, nutraceuticals, for example, that women might need like selenium and zinc. Those are the essential nutrients your body needs to convert. So it's important to look at like the reverse T3, for example. If reverse T3 is high, then maybe you're not converting into T3, right? So it's not just, the TSH is in a normal range. If I do not check antibodies on the first visit, then of course you'll miss it.
You need to know if something is, you your immune system is attacking the thyroid, very important. And catching it very early changes how you manage, you know, the conversation. Are you experiencing fatigue because your thyroid isn't functioning? Then it also impacts your diet. Do you need to be on an anti-inflammatory diet? Maybe we need to remove gluten out of your diet because, or do we need to reduce stress? that, getting that whole panel,
I think is really important in how we support the thyroid function.
Jillian Woodruff MD (11:29)
Do you check the Reverse T3 on your Tier 1 primary panel or is that an addition? Okay, I agree.
Ade Akindipe, DNP, APRN (11:34)
Secondary secondary oftentimes, you
know, if you see the first labs and you're it's not optimal and you're trying to fix other things Especially lowering the stress fixing the day and you're not really seeing the movement in the thyroid in the right direction Then we can look at hey, are you actually converting? So so reverse t3 would be on the second tier
Jillian Woodruff MD (11:53)
I agree with that. And are you
checking total T3 versus free T3? That was my free... Okay. Okay. Same thing. Okay. Well, let's move on to metabolic assessment, which is your specialty. So why don't you start us off? This is one of our root causes for fatigue. Start us off with what you get in this situation to assess their metabolic health.
Ade Akindipe, DNP, APRN (11:58)
I'm checking free two three, free two three, yes.
Yeah, absolutely. this is, know, insulin resistance is so common now that we see this a lot, especially with women that are navigating perimenopause. So with insulin resistance, we want to check our fasting glucose. And usually that's tier one. So that'll come in your metabolic panel that you would get at your doctor's office. So the range, you know, between 60 and a hundred, then you want to check fasting insulin. Fasting insulin is usually what's missing from most labs. ⁓ Most doctors will check the
glucose, it's normal, well, you don't have pre-diabetes, but often if that insulin is high, then we know that there's something going on in your body that's doing a really good job at compensating, which our body is good at, it's very smart. You want to also check your hemoglobin A1C, this is also tier one. This looks at how your blood sugars have been doing over the last three months. The higher that number, the poorly controlled your blood sugars are. So that's why fasting glucose alone is not sufficient.
Fasting insulin is also the marker that catches insulin resistance years before glucose starts to move. So this is a compensatory thing. So fasting your insulin goes up because your blood sugars have been going up, which is exactly when the fatigue is already happening, but no diagnosis has been made yet. Hearing this, fatigue can be because your sugars are out of balance. There's also something called the HOMA IR score.
This is a calculated score from glucose and insulin together. This tells us a, it gives us a measure of how significant your insulin resistance is. So it's, non-negotiable, but I mean, I don't always check this on the first visit, ⁓ especially when, you know, the, insulin isn't that high. This is something I would probably check on the secondary on a tier two. I would add that a fasting lipid panel rounds out the metabolic picture.
Especially when I'm seeing things like high visceral fat. We do a body composition on every woman. So you come in, you have high visceral fat, high percent total body fat. When I see it climbing into the 30s and 40s and 50s, we want to look at your lipid panel, maybe even going further into the size, the particles of the cholesterol that you get to see if you are developing cholesterol or plaque in your arteries.
We also check your elevated triglycerides. This is the one that is stored around the belly, around the liver. So the higher those numbers, you know, we start to worry about metabolic dysfunction. That combined with your low HDL, which is your good cholesterol, these are early signs of insulin resistance and is often already on file from a routine blood draw. So, which makes it usable and useful starting the conversation about, we need to start doing something about your metabolic health.
Jillian Woodruff MD (15:01)
You know, I'm always surprised with the amount of women I see that have known high cholesterol. They may not be on any sort of medication, but they also have no more information except that they have a high LDL or high triglycerides. They've never been sent for any advanced testing, no particle sizes, no APO A1, no lipoprotein A, no APO B. Like it just seems so wild that
Ade Akindipe, DNP, APRN (15:25)
Yeah.
Jillian Woodruff MD (15:27)
They'd have no idea like how much of a risk this issue is for them or is there a genetic component. I think that you'd want to know this, right?
Ade Akindipe, DNP, APRN (15:34)
Or yeah,
especially if you're starting, if you already have a family history of it, your father or your grandfather, yeah, absolutely, should be, definitely getting that done is important.
Jillian Woodruff MD (15:40)
of cardiovascular disease, yeah.
So maybe not part of this, you know, fatigue, this topic is just about fatigue and our labs are about that. However, that may be a future episode is getting more into that. yeah, absolutely. Well, I guess the only thing I would add is like a comprehensive metabolic panel. I'm sure you get that on everybody. Just basic, assessing kidney function, liver enzymes, electrolytes.
Ade Akindipe, DNP, APRN (15:51)
Yeah.
Sure, it's worth mentioning too, right? ⁓ All right.
Jillian Woodruff MD (16:14)
You know, very basic but important, so I don't skip it.
Ade Akindipe, DNP, APRN (16:17)
Absolutely. Okay, next one is nutrient deficiencies. And we kind of touched on it a little bit for nutrients. I check ferritin specifically. like you mentioned before, cash-based labs, which I absolutely recommend if you are trying to avoid all the issues with insurance. Sometimes they're more flexible, they're more cost effective. We throw an iron panel on there, not just a CBC or a complete blood count.
Sometimes if your ferritin is depleted, this is where your iron is stored. So iron depletion shows up before full anemia develops. So we want to check that. We also want to check 25 hydroxy vitamin D. That's what it looks like, your vitamin D level on your labs. And then your B12 levels. These are the most common nutrient deficiencies I find in women. And every single one is correctable.
with vitamin Ds, oral supplements, or even injectables, once a week injections.
Jillian Woodruff MD (17:12)
I agree. I agree. With these, I think that also there is a sort of idea that these are just vitamins and they're not very important. know, people are, they come and they're feeling, they may be feeling bad and you see that they have very low, abnormally low levels of vitamin D and usually they have a little bit of B12 and it, but it's still at the lower end.
and you'll say, okay, I think we need to do this supplement or replete this and, you know, replete that. And they're like, okay, but what, you know, what else, you know, or what medication will help me? And sometimes it isn't really. There's no magic medicine.
Ade Akindipe, DNP, APRN (17:48)
Yes, you are so right about that. Yes, it's these simple
ones that we need to start with. Yeah, absolutely agree.
Jillian Woodruff MD (17:56)
Yeah, yeah.
So with the, I think we already mentioned, like not all of these we're going to get all at the same time. There are certainly, you know, panels out there where you can get these things. There's different organizations and groups that give you a whole list of, know, they take all your blood and do all the things. I love it. I love data. That's so fun. But when you come into the office, you know, that's typically not.
what we do, we're just trying to hone in on specifics of how you're feeling and get you feeling your best self. And we're going to be doing things that we're able to follow up and take control over, like guiding you and helping you to feel your best self. So, I may not do that full anemia panel first time around, but if you're coming in with heavy bleeding and periods that have been going on for a while and you are feeling fatigued.
due to this, then yes, I mean, right out of the gate, I'm gonna be checking deep into those ferritin levels. Ferritin's pretty much a standard, but there's other, like the binding capacity and the carrier proteins and all of that part I would go deeper on the second time around. And then finally, one of my favorite labs to check falls under our root cause number six, was inflammation, chronic inflammation.
And this lab is called High Sensitivity CRP, or High Sensitivity C Reactive Protein. And it's an inflammation marker, and it gives me a single number representing systemic inflammatory burden, and tells me how aggressively to address anti-inflammatory pillars. So, this is one of my tier one panel labs that I get, because inflammation is almost always a part of a chronic fatigue syndrome.
And interestingly, today I had a patient that I was talking to her about, her inflammatory marker and how it was elevated, and she said, well, what is inflammation? She just, you know, she didn't understand. And I started to think, what is inflammation? Like, how do you explain it? And so I started to think about like, each of our organs is like a separate neighborhood. We have all these neighborhoods are close together. We're in a city, a large city.
and you have a fire in one of our organ systems. There's a fire, so then what happens? You have inflammatory proteins. Those are like the immune system, right? The immune system comes out to fight. So we have firefighters, we have police officers that are blocking the street. We have our city water supply. Everybody's coming to fight this one fire, but the fire in this one neighborhood is really close to another neighborhood, right? So then in this other neighborhood, there's smoke.
So they're having smoke inhalation over here. They're worried. They're looking like, is the fire going to come across the street here? What's going to happen, right? And so then there's like little electrical fires in different places. So the fire people, the firemen, they never get to go away. They're always there. They're always present, looking for danger. And like, what happens? Don't they have to sleep? know, like you can't always have them present and ready and fresh.
Ade Akindipe, DNP, APRN (20:50)
Mm-hmm.
Jillian Woodruff MD (20:57)
And then that's when you start having little breakdowns. The streets start kind of having needing repair. You think of the streets as like the blood vessels that go from one organ to another. Everything just starts breaking down a little bit, little pain here, little pain there, and then, you know, not getting out of bed.
Ade Akindipe, DNP, APRN (21:15)
That's right. It's so similar to it's funny because it's very similar to how I describe it. It's like that constant fire that just we're trying to put it out, but it's just there all the time. Chronic inflammation. Very great job explaining that. That's exactly how you do it. So when do we go deeper? So tier two is pretty much what we're talking about here is what we add when something
Jillian Woodruff MD (21:19)
breakfast like that.
I can't finish. Yes!
Yes.
Ade Akindipe, DNP, APRN (21:42)
points us there. So if your thyroid antibodies are elevated, we can add reverse T3 to complete the autoimmune and conversion picture. So we want to know that you are converting your inactive form to your active form. your cells can actually get the T3 that it needs to function to give you the energy that you need. And antithyroglobulin antibodies, if there is still some suspicion,
about Hashimoto's or after your thyroid peroxide oxidase comes back, like it's elevated again, and we start to look at further. If insulin resistance is present, I always recommend a continuous glucose monitor or a CGM. There's different types of that out there. Just as a trial, and usually they're good for two weeks, you can really see in real time what's happening to your energy. Maybe you start off
the beginning of the day with a cup of coffee, nothing in your stomach, and maybe you do get a cortisol spike, right? But then you crash in the afternoon if you haven't really gotten a good source of protein. You can see this actually on ⁓ your graph. And you can immediately connect it to all of the lifestyle habits that you have. So highly recommend that. The moment you recognize this, it's a very powerful tool to start to get your energy back. Real-time data is very powerful.
If you don't want to do that, jotting down your habits of eating is very important, even though you don't have the blood sugars there, but you can kind of pattern and say, okay, well, I had this meal after I finished eating this, this is when I noticed that my blood sugar or my energy started to crash. So these are just different ways you can work on that.
Jillian Woodruff MD (23:20)
They have so many tools to help you with that too, like taking pictures of your food and right, so many things. So then I know one of our favorites to talk about is that tired but wired feeling. And so that has to do with our hypothalamic pituitary axis. And these people have difficulty winding down their energy spikes in the evening at 10 p.m. when it should be declining. I know you're looking at me.
Ade Akindipe, DNP, APRN (23:23)
Yeah.
Jillian Woodruff MD (23:46)
I feel like that's me. I'm feeling a little guilty because this certainly happens. I could be so tired that I'm like, yay, I'm awake. I am, I am. yeah, so I tried many, many years to become a morning person and it just doesn't happen for me. So, but I can recognize healthy habits and not healthy habits. So.
Ade Akindipe, DNP, APRN (23:47)
I was not. Are you feeling guilty?
You're a night owl. I don't know how you do it.
Jillian Woodruff MD (24:12)
This one is not the easiest thing to check out to find out what your pattern is of how your cortisol is spiking or elevating or going down. So I would add to those who have an issue with this, who we've identified as the four point salivary cortisol testing. And so you're going to get your level at morning, noon, evening and bedtime. It's not, there's no blood draw really you can do. That's why when people ask for cortisol,
they probably encounter a no more times than a yes because the information that they gain is just not that useful. Now I will do some, know, randomly sometimes, I know it's not tier one at all, but sometimes I'll do like an early morning cortisol if they're doing other early morning testing just to see, you know, do they have the spike? And sometimes I find that, you know, they don't. So it could be that they didn't get any, you know, sunlight or they're not used to getting sunlight within.
you know, 30 minutes or so of waking, or they're just in a dysfunctional pattern. So, this is usually a specialty lab. You have to get this at a specialty lab and then... and then they send you results. Mm-hmm. Do you do any testing like this?
Ade Akindipe, DNP, APRN (25:14)
Absolutely. ⁓
Yeah, and like you said, this is more detailed testing and there's lots of labs that do it. The four-point salivary gland testing is really great at seeing your trend because if you just look at one cortisol test early in the morning, it doesn't really give the full picture of how, if you're having that tired, wired, usually you'll see that cortisol rise in the evening time, like you said. So yeah, it's one of the ones that I would recommend if we're not sure, if we're not getting somewhere with the energy levels.
And magnesium is another one, the RBC, red blood cell magnesium, when the clinical picture suggests depletion. So women who are struggling with a lot of stress, they're not sleeping well. Some women might even have symptoms of restless leg or muscle cramps at nighttime, anxiety. Serum magnesium is nearly useless because only 1 % of the body's magnesium is in the blood.
The serum would read normal even when you are significantly depleted at the tissue level.
Jillian Woodruff MD (26:20)
A few extras that guess I get as second line are folate. I think that kind of goes along with my B12 and the anemia profile too. It's kind of all in there. If I'm getting a comprehensive profile or looking further into nutrient deficiencies, I would get a folate. And then selenium and zinc are also a tier two for me, but they're important for our thyroid.
Ade Akindipe, DNP, APRN (26:26)
Mm-hmm.
12.
Jillian Woodruff MD (26:46)
So they also can help. You had just talked about the T4 to T3 conversion, and we know selenium can help to augment that conversion from T4 to T3. Another thing, though, that's so useful, I think we'll talk about it, is stress management, because chronic stress inhibits that conversion from T4 to T3, and it increases reverse T3. So you're doing all this work to convert, and it just goes right back to T4.
The reason why this is important is because T3, that's our active thyroid hormone. That's what's doing the work. That's what's managing. Yeah. Stress. Yeah.
Ade Akindipe, DNP, APRN (27:18)
Can you say that louder for the women? Louder, stress, stress.
We're killing ourselves with stress. Our
thyroid is just shot because we are so stressed. Imagine that.
Jillian Woodruff MD (27:32)
Yes, no matter how loud we say it, it's hard
to internalize that. It's hard to take that in, you know? Because it's not recognized as something that's really important for us to manage or that. I mean, it's serious, you know, and it's kind of made fun of, you know, when people are worried about their mental health, you know, they're like, it's just mental health. It's not just. It's so important. It's so important. And it affects every organ system.
Ade Akindipe, DNP, APRN (27:38)
Yeah. Yeah.
Mm-hmm.
Seriously.
super important. Yeah.
Jillian Woodruff MD (28:01)
you know, I don't actually check this one a lot. It's IGF-1. So I don't know if you check that, but I think it does correlate with fatigue and reduced muscle mass and poor recovery. So I don't know how often you check that and in who specifically.
Ade Akindipe, DNP, APRN (28:13)
Absolutely. Yeah.
I don't check it very often. Yeah,
I think for women who, you know, fatigue, especially if you're looking at a body composition and you're not seeing a really good muscle mass, ⁓ or maybe they've been on GLPs, for example, and they're losing a lot of muscle, I will check an IGF-1. If they're thinking on maybe just doing a little, you know, alternative things outside the box to improve muscle mass, like if they're going to be on peptides and things like that.
I will check it. So this is not tier one. This will definitely be tier two, just to look into how we can improve their muscle mass and recovery and energy.
Jillian Woodruff MD (28:52)
Okay, that's a good point, especially there are a lot of people on GLP-1, so I can see that necessity or usefulness for that lab. Okay, well, don't forget that all of these lab considerations that we are discussing today are in our free Fatigue Protocol Guide, so the comprehensive or complete fatigue protocol that you can find on our website at modernmidlifecollective.com forward slash fatigue.
Ade Akindipe, DNP, APRN (28:58)
Yeah.
Jillian Woodruff MD (29:20)
and we will link it in the show notes below as well. So you can see everything in a structured way and I'll have to remember all of these things we're discussing today.
Ade Akindipe, DNP, APRN (29:28)
All right, now we're going to move on to how to advocate for yourself in a 15 minute appointment. So let's talk about the appointment itself because I think this is where so many women lose the thread. It did happen today. I saw a patient who said, I'm here because I've been dealing with this issue for so long and I don't have the answers. I have these labs. I don't even know what they mean. And they were with a doctor who drew these labs. So it's not that the doctor has a problem. They know something is wrong.
they've done their own research sometimes maybe through ChatGPT. And they walk in and they're already frustrated because they're not getting the answers that they think that they should get. And somehow you walk out without the answers. So it can be frustrating.
Jillian Woodruff MD (30:09)
Yeah, or you walk out after being told just lose weight and it will be okay. ⁓ my goodness that every single day there's somebody that tells me that their weight is the cause of everything. Every ailment they have it's just lose weight and it's really frustrating for me to hear that like it because it just sounds like a dismissal to me and I don't know if it's that the person is meaning to do that. I think they're probably just repeating things that they've heard over the years over and over and over.
Ade Akindipe, DNP, APRN (30:22)
Yeah.
Yeah.
Yeah, absolutely. So the first thing you need to do is bring your symptom list. And it can't be vague. ⁓ I've been tired, right? ⁓ It's really important to look at the pattern. So a specific patterned account. for the past months, for the past four months, for example, I have been waking up at between two and 4am. My afternoon energy crashes around 2pm every day.
I have gained eight pounds without changing anything about my diet. I noticed when I started eating a certain way or I started certain medications, my weight has been creeping up. My periods have been heavier for six months. So this is not a complaint. This is you're giving data. And this is why I think if you're not sure if metabolically you're healthy,
A CGM, a continuous glucose monitor, is a great thing to bring to the doctor and say, this is what this looks like. That gives your provider a lot more data to work with,
Jillian Woodruff MD (31:33)
Yeah, and I would also say just to be specific about what you're asking for. So don't just go in saying you want to have your hormones checked. Now you have this guide, right? And so you can bring your guide and say, I want to have my estradiol, my progesterone, my free and total testosterone, my DHEAS. You know, don't ask just for a thyroid test because most likely they will do just that TSH. So they're just going to do...
Ade Akindipe, DNP, APRN (31:42)
Now part.
Jillian Woodruff MD (32:00)
the signal from your brain that tells your thyroid to release hormone and you're not going to have any idea what your thyroid is actually producing. So you're going to say, would like a full thyroid panel, my TSH and let's include my thyroid hormones in that panel, my free T3, my free T4, my TPO antibodies. And so this guide has the language written for you and you can literally bring it and ask for those things. And then ask...
Also, you know, there may be a reason why they do not want to order it for you at that time. It could be because you've had this test within a, you know, a close period of time. It could be that perhaps you're on, you want it because you want to see what your body's doing, but you're on a medication that will manipulate the results. So perhaps they want you to go off of certain medications or birth control and then check it at that point. So.
I want to say something that I do feel genuinely strong about is that you should come with your questions and your requests and your advocacy language, but you also want to allow space for your provider's expertise to guide you as well. know, Dr. Adeya and I share what we know from our clinical experience, but in good medicine is collaborative. I'm never afraid to...
collaborate with other medical providers in my community and beyond. We're lifelong students of this work and your goal with your provider should be a collaboration, not a confrontation. And there are certainly things that people know that I do not know, right? So I'm sharing my expertise with you, but there may be, you know, there's somebody that has another, you know, they have a...
a nuanced way of caring for your thyroid, let's say. And so you do want to allow room for that, or you wouldn't need them, right? You could order these things yourself. So if you're there, you do want to allow space for hearing their expertise too.
Ade Akindipe, DNP, APRN (33:56)
That is so true. And I think it makes it even more important that we talk about this because there's so much information out there. We've got AI, we've got social media, and sometimes you want to take all that information and you want to go to your doctor and say, well, doctor such and such said this on social media. The point is you should never feel dismissed for wanting to understand your own body.
Jillian Woodruff MD (34:12)
Yeah. They're like, who's that?
Ade Akindipe, DNP, APRN (34:22)
And if you receive your lab results and they're called normal, you're allowed to ask. But it's also good to come in a way where you're collecting your data. You're not just saying, well, I want you to do this. It's important for the doctor to know where, because they need to assess you. They need to make sure that the symptoms that you're talking about, not because you're doing it because somebody on social media said to do it.
But bring in the data, any good provider should have an open, be open-minded, be collaborative and want to work with you. Because there is meaningful clinical difference between, yeah, you have fatigue or someone said, can help my hair grow back. So it has to make sense. So just, you
Just FYI, there's a lot of information out there. It may not necessarily be right for you.
Jillian Woodruff MD (35:12)
Right, it's just like research when you're looking at research findings that you can't generalize the findings to all audiences, right? So it's the same with this. This is a general guide for fatigue. It is not for every single woman. We are all so individual and different. And so you want somebody that recognizes that and doesn't treat you like just all women, know?
Ade Akindipe, DNP, APRN (35:16)
Yeah.
Absolutely. And
if you're consistently not getting the answers you need, then a second opinion from a provider who focuses more on what you're dealing with, whether it's hormones or metabolic health is a good step. Either way, you deserve someone who takes your full picture seriously.
Jillian Woodruff MD (35:52)
Right? And I would say in range is not the same as optimal. You you could be within a reference range. That does not mean that that's the best place for you to be here where you will feel your best. So if you think about ferritin, your storage form of iron, there is a very large reference range. So a ferritin of 14 is still considered normal. I think that's terrible, but it's still considered normal at some labs.
Ade Akindipe, DNP, APRN (35:56)
Mm-hmm.
Yeah.
Jillian Woodruff MD (36:17)
And a ferritin of 95 is considered normal. So in range is optimal. Optimal should be what we're going for, not just I want to be average in range, you know? Because I bet you a person at 13 for ferritin level is going to feel very different than somebody who's at a level of 95.
Ade Akindipe, DNP, APRN (36:35)
Yeah, absolutely. And one other thing too, it's important to bring someone with you. I actually had a, well, I think this was for transitory purposes, but it also helped paint the picture because she was trying to communicate something, but her husband was able to give more scenario to what was happening and say, well, at this time of the day, this is what she does. And she's more moody around this time of day, which was really helpful.
It wasn't in a combative way. was like, what do we do when this happens? So it allowed me to paint the picture and say, yeah, this is probably because your blood sugars are crashing or whatever. So it's just great to have somebody that might be able to tell the story, especially if you're having trouble doing that.
Jillian Woodruff MD (37:18)
Yeah, some things you may not recognize in yourself that your partner may recognize or your friend may recognize. So, yeah, I agree. Well, now we have our labs. So where do we go from here? And I'm going to start with supplements. But before we say something about the supplements that support our system, that's what I really want to talk about is that supplements are they supplement the things that we're doing. We're getting from our food we are getting from
Ade Akindipe, DNP, APRN (37:20)
Yeah.
Jillian Woodruff MD (37:45)
Hopefully, can, there's processes that happen when we reduce stress, when we exercise and move our bodies. So these are, in addition to those very important things, supplements are one layer of our protocol, an important layer, but just one layer. And I think sleep is the foundation of anything we do. It's non-negotiable. Nothing else in the protocol will function without proper sleep.
Ade Akindipe, DNP, APRN (38:01)
us.
Jillian Woodruff MD (38:11)
⁓ And so if sleep is broken, we have to figure out what the driver is. And sometimes it's not just one thing. In the sex hormone world, a lot of times it's progesterone. And so many times starting by identical progesterone can restore sleep architecture. not just help you fall asleep, which when you're thinking about like medications like zolpidem and things that people take for sleep, there are medications that either that kind of...
paralyze the body a little bit, you know, or give you a feeling of sleeping because you're not waking up, but your body may not actually be rested in the morning. You may not have achieved deep sleep. So it's important to recognize that sleep is important, not just sleep, but appropriate sleep, deep sleep, restorative sleep.
Ade Akindipe, DNP, APRN (38:49)
Yeah.
Yeah,
restored asleep. That's the key word right there. Sleeping deep enough that your body can repair itself. And magnesium is the other one that I keep talking about and getting my patients on because it's important. It needs to be everywhere. I take it. It helps me as well just to kind of calm the nervous system. It's required for energy production, ATP, right? So the actual cellular energy production process.
It's also essential for deep sleep. It helps regulate the nervous system. So it supports so many functions, over 300 reactions in the body. And chronic stress depletes magnesium. Again, stress, women, we need to reduce our stress, depletes magnesium at rate most women have no idea. ⁓ But also the way you replete it is important.
So magnesium oxide, which is what you would find in most drug stores, is poorly absorbed and largely ends up causing stomach issues, digestive issues, without delivering the benefits that you're looking for. So the two forms we clinically are recommending are your magnesium glycinate, which binds magnesium to the amino acid glycine, making it very widely available and very effective for sleep, works very quickly.
for your nervous system, reduces anxiety, and magnesium malate, which binds magnesium to malic acid. This is a compound involved directly, again, in cellular energy production. So it's very good for daytime energy and muscle function. So we use both glycinate at night and malate during the day. Some actually come together if you're ⁓ trying to use it for sleep.
works great. I think it's a complex of magnesium. So very great choices if you're looking to ⁓ supplement that.
Jillian Woodruff MD (40:45)
Mm-hmm. I know you love your magnesium and so you'll appreciate the story. had a patient last year. She was in her early 40s, high functioning, she ran a business, two kids. She came to me just completely convinced she had early onset, insert something very serious here, but she was just exhausted. She was exhausted at night, but couldn't fall asleep very quickly because her head was just, you know,
busy, you know, figuring out all the things she had to do, right? And then she would finally fall asleep and then wake up at 3 a.m. and it wasn't the kids waking her up. She's just waking up. She's really restless. She had restless legs and she's like, why am I having these cramps? So we did a full panel on her and her ferretin was normal at 18.
and her magnesium was depleted. So I said, yes, I said, we're going to address both of those. know. And I think actually she had already had that part done or fair to done before she came. And so she was sitting on that level because she was told it was normal. And so we replaced her iron, we replaced her magnesium. She was sleeping better. And six weeks later, she messaged me to say,
Ade Akindipe, DNP, APRN (41:34)
18.
Mm-hmm.
Jillian Woodruff MD (41:59)
like she couldn't believe how she just suffered with something that was so easy to treat and thought she was literally like having something, you know, a really serious medical problem. Now needing iron, it is serious. That's a serious problem. You need red blood cells with iron to carry oxygen to your organ system. So it is serious, you know, but it, you know, you would think something serious is difficult to treat and it was not.
Ade Akindipe, DNP, APRN (42:03)
Yeah, look at that.
Yeah.
Jillian Woodruff MD (42:24)
Another thing we need CoQ10, specifically in the ubiquinol form because it's easier to absorb this form more so than ubiquinone. But CoQ10 is an electron carrier in mitochondrial and the mitochondrial energy chain. So you think about your powerhouses of the cells and your mitochondria needs to complete the ATP production process, your energy production process.
So this ubiquinol or CoQ10 is important, especially to people who are taking statins for high cholesterol. If you're on a statin medication, it blocks the same biochemical pathway that produces CoQ10 along with cholesterol. So it's getting rid of what they think is bad, being the cholesterol, but also the CoQ10. And then you're going to have an energy deficit problem.
The depletion is real, the fatigue is real. You may need some CoQ Tin.
Ade Akindipe, DNP, APRN (43:21)
Yeah, absolutely agree with that one. And then we have ⁓ for insulin resistance and blood sugar support. This one I always recommend for women that may suffer from significant metabolic dysfunction, especially in women who may have PCOS. Berberine has become one of my most favorite ones because it works very similar to metformin.
But it's found in a natural compounded plants like Barbary and golden seal and it works through multiple pathways at the same time it improves insulin sensitivity at the receptor level which is key for Women really feeling well. I mean picture women who have high blood sugars high insulin Their cells are not able to use glucose for energy. So that's why they're so exhausted So getting sugar, you know
glucose energy into the cells, very important. But when they're having high blood sugars like that, it's just wreaking havoc on their blood sugar, their immune system, thyroid, et cetera. So I also want to say something about blood sugar. I tell every patient, it's important, especially if you know that your blood sugars are running high, it's important not to run on just cortisol in the morning. So most of the time we want to pick up our cup of coffee.
and run through the door and we're done. Probably we won't eat till about 2 p.m. And unfortunately, that's just what can wreak havoc on your energy, your thyroid, and et cetera. So high protein as much as you can. If you don't have a lot of time, grab something that you can take with you. My go-to is a protein shake in the morning or a boiled egg. Just something to at least get your metabolism going.
so that you don't crash later and it stabilizes your blood sugar more. So at least the goal is about 30 grams minimum. If you're having trouble reaching that, you have to take a look at what's really going on there. But I know a lot of women don't like to eat breakfast in the morning, even drinking water, putting some electrolytes in there, something to get your blood flow. And then maybe when your stomach starts to feel more settled, maybe then you can eat something then.
This is the most single way our daily habit that I know for sure
Jillian Woodruff MD (45:30)
This is the most simple way or thing to comment that I know.
Ade Akindipe, DNP, APRN (45:34)
can stabilize your cortisol, support your thyroid hormone conversion, prevent the mid-morning crash that leads to afternoon coma. So don't start your day with coffee as much as you can. Do not start your day on an empty stomach. Your cortisol loading is what's already stressing out your system and then making you tired later on.
Jillian Woodruff MD (45:52)
That's right. Okay, HPA axis support. So supporting that stress response that we have, that elevated evening cortisol, a nervous system that can't down-regulate. I think of using adaptogens before a medication like a pharmaceutical. an adaptogen is usually, it's a term used loosely sometimes, but it's supposed to be.
a compound that helps normalize the body's response to stress by modulating the hypothalamic-pituitary axis. So these are what's releasing all the stimulating hormones and releasing hormones. So the hypothalamus releases a hormone that stimulates the pituitary gland, that releases a hormone that stimulates an organ system. And so the way these things are released really can be modulated negatively, actually, by stress.
adaptogens can help normalize it. So when you're thinking about cortisol stimulation and cortisol release, adaptogens can help just restore the natural rhythm. I think some of the supplements I recommend, I may say, it brings down your cortisol level at night or during the day, but really it's just helping to restore natural cortisol rhythms. We don't want to, you know, falsely manipulate things, but we want to get them back to typical patterns.
So, some of the adaptogens with the strongest evidence are ashwagandha. There's multiple randomized controlled trials to significantly... that shows that it significantly reduces salivary cortisol levels and improves stress resilience. And then there's rhodiola, which is really useful for cognitive fatigue.
that brain fog that people experience and it also accompanies the HPA dysregulation. And then there's phosphatidylserine. It's a phospholipid that blunts the evening cortisol elevation. And I think this is something that we found in the American lifestyle that your cortisol levels are supposed to be declining through the day. But in the American lifestyle, we see when we come home in the evenings, there's another spike.
but that's not a natural spike, and so that really affects our sleep. So, some of these adaptors are just going to help to really just bring us back to a path that we like, that's necessary for us. I know you have your own approach to adrenal support, so what do you reach for?
Ade Akindipe, DNP, APRN (48:13)
It's very similar. It's very
similar honestly because I love that you you really have a strong opinion because I really because I was like that I remember those days, you know when I was you know going getting your doctorate and all these things you're Thinking about all the things that you need to do and it can be so exhausting When you're not able to sleep so for my patients that have that wired but tired
Addressing the evening cortisol is important. So sleep improves your next day's cortisol rhythm, right? So if you have the same cycle repeating itself and it's hard. So those adaptogens that you mentioned, ashwagandha, rhodial are also what I reach for. They work really well. don't, they can help relax you, but they don't necessarily make you sleepy. So you can take them during the day, which is great.
⁓ Ashwagandha is my protocol consistently. And then I also like to layer in magnesium glycinate that helps me sleep at night as well. so they work really well together to calm the nervous system, allow the body to want wind down, allow the brain, allow the brain to just stop in that continuous, ⁓ thinking so you can finally fall asleep.
So a patient who described laying awake for two hours and they're scrolling on their social media or they're writing things in their brain, I tell women, write those things down. Sometimes if you take them off of your brain and you write it down, it feels like, okay, at least it's there. I know what I'm going to do with it versus just kind of repeating everything in your brain. So that with those ⁓ adaptogens really help very well.
So once we started that combination of ashwagandha, rhodiola, and magnesium, and she also added some micronized progesterone as well at nighttime, helped tremendously to help sleep and stay asleep. yeah, methylated B complex is foundational also. It's critical for women, like we talked about before, if you've been on oral contraceptives, PPIs, like anything that's going to be for stomach acidity, metformin.
All of this depletes your B vitamins significantly. So methylated B is essential because it's a meaningful portion of the population have what you call MTHFR gene variant. And that implies that they don't have the ability to convert your standard B vitamins. So when they do the methylated B vitamins, that helps them. So they'll do methylcobalamin versus cyanocobalamin.
Very important distinction, this is something that you've been diagnosed with, you want the methylated B vitamin instead.
Jillian Woodruff MD (50:44)
That's right. And I know a favorite or a standard for both of us is vitamin D, especially living in Alaska. People in the Pacific Northwest, they typically have much lower levels of vitamin D than our Floridians, or Texans, right? They get a lot more sunlight. So vitamin D, we've mentioned it before, it's a steroid hormone as well as a vitamin. And it binds to receptors in virtually every tissue.
and regulates thousands of genes. So low levels absolutely correlate with fatigue and a low mood and muscle weakness and so many other things, impaired immune system. And we want to pair vitamin D. So we want to do our vitamin D3. We want to pair it with K2. Vitamin D also increases calcium absorption significantly. Great. But K2...
directs that calcium to boat rather than to soft tissues like depositing it into your blood vessel walls, your arterial walls. That is not where we want calcium to lie, stuck to the side of our blood vessels, right? So, but in our bones, yes. So K2 would be quite important to take.
Ade Akindipe, DNP, APRN (51:56)
Absolutely. We also have omega-3 fatty acids, EPA and DHA, from high quality third-party tested fish oil. They modulate the inflammatory process at the biochemical level by competing with arachidonic acid for the same enzymatic pathways that produce pro-inflammatory cytokines. So basically, they kind of help with
inflammation, they help reduce inflammation. So same cytokines that rise when your estrogen declines during perimenopause and create that persistent drag on your energy and your brain function. So about two to four grams of combined EPA and DHEA daily is clinically supported. That's the clinically supported range. Strength training. this part I love. Strength training deserve a place in this segment because it is as important as any supplement. So
If you're doing about three sessions per week of progressive strength training, I literally prescribe this to every woman that's tired. It can really help boost your energy. I tend to do this in the morning and I can tell the difference in my energy levels throughout the day. It also improves insulin sensitivity. So if you tend to have higher blood sugars, this is your prescription. It stimulates mitochondrial biogenesis, the production of new healthy mitochondria, the powerhouse of your cell.
like I said, improves insulin sensitivity at the muscle level. It supports sleep. You sleep better. It reduces your stress levels over time. So even if you're doing about 20 minutes, which I only have time for about 30 minutes, about three times a week. And in between that, if you're moving, you're walking after meals, it's a great way to keep your energies up. So 20 minutes of resistance training about three times a week can definitely help.
Jillian Woodruff MD (53:34)
Exactly, and I see you working out. and it does, it gives you, you you kind of have a feeling, a high feeling, you know, just like the runner's high. It's great. Well, there's also a dietary foundation. There's whole foods are important, colorful produce, so colorful fruits and vegetables, proteins at every meal, fiber for your gut microbiome, and a meaningful reduction in ultra processed foods.
and refined seed oils like canola oil, grape seed oil, else is it? Soybean, soybean oil, corn oil. Those are probably maybe the most common ones. So we want to decrease, you know, eliminate whole foods. Your gut is actively regulating your immune system every day and what you eat directly affects your inflammatory burden and therefore your energy. So...
Ade Akindipe, DNP, APRN (54:07)
I
Jillian Woodruff MD (54:25)
All of these, what does this mean for you? You don't have to do all of these things at once, but you're gonna start with sleep. That's the big one. And so it may not just be as easy as I'm gonna sleep, right? But your sleep hygiene is important and then figuring out what is preventing you from getting the proper sleep architecture, your deep sleep. You're gonna stabilize your blood sugar. You're gonna get your labs done. Know your hormone status. Build from there small targeted changes.
compound into
I think we've talked a lot today about, in the last three episodes, this is our third episode on fatigue. So that's how big it is. Are you tired of talking about fatigue? I'm fatigued too. Well, every time we record together, I remember why this works. Why our work, why what we're doing matters so much. It's because women deserve real answers.
Ade Akindipe, DNP, APRN (55:02)
Well, it's a big topic. ⁓ Fatigue, talking about fatigue.
Jillian Woodruff MD (55:21)
⁓ Not just this is aging or not try, just try yoga, not just lose weight or this is normal in quotations, but they deserve clinical answers and they deserve answers delivered with respect and the answers exist.
Ade Akindipe, DNP, APRN (55:29)
Yeah.
Absolutely.
Absolutely. So every woman who listened to all three of these and you recognize yourself, we see you not as a patient with a complaint, but as a woman whose body has been working incredibly hard. You work so hard under real biological pressure. So if you've been told to just push through, you know that you deserve real answers and you deserve real solutions.
Jillian Woodruff MD (56:01)
Right? If this series has helped you, please share it. All three parts. Tell everyone. Share it with women in your life, those who you care about, especially the woman you keep saying that she's tired and laughs it off thinking it's fine. This is just what my life is like. It doesn't have to be. She's not fine. She's just used to it. I think sometimes we just get so used to feeling
how we feel, feeling not optimal. You don't even know what it feels like to feel your best self, right? So you guys deserve better, she deserves better.
Ade Akindipe, DNP, APRN (56:29)
Absolutely.
Yeah, please leave us a review if this series helped you. It means the world and it helps other women find the show. Thank you so much for listening and we'll see you next time on the Modern Midlife Collective. Goodbye.
Jillian Woodruff MD (56:46)
Bye.