Burnout happens when you’re overwhelmed, emotionally drained, and unable to keep up with life’s continuous demands.
A Functional Medicine approach to burnout not only focuses on your physical and mental health but also underlying factors that got you to the point of burnout in the first place.
Below is a great example.
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CC: Fatigue, Anxiety, Irregular Menstrual Cycle, and Hypothyroidism
Sarah* was a 37-year-old female with significant fatigue, anxiety, and mood swings. She had a previous history of postpartum hypothyroidism when she was 33, which was successfully managed with levothyroxine for a year until it stabilized.
Two years ago, she accepted a position managing a company with multiple locations across the US, which came with frequent travel and long hours. In this timeframe, she started experiencing trouble sleeping, bloating and stomach discomfort for the first time in her life, and irregular menstrual cycles ranging from 23-38 days.
She felt that her level of fatigue and lack of energy and motivation were now far worse than when she was a brand new mom, and she “hadn’t felt rested in 2 years.” Additionally, she mentioned that when she tried to fall asleep recently, it felt like her “brain was on fire,” and the only way to shut it off was if she could sleep.
Her recent lab work at the time showed slightly elevated TSH, low total and free T3, and low vitamin D. While her general physician did not seem concerned, Sarah was worried because she “knew something wasn’t right.”
She had never felt the physical fatigue she was currently experiencing, and the new appearance of gut symptoms and menstrual cycle changes concerned her.
Additional History
While Sarah had support at home to help with childcare while she traveled, this was the first time she was gone for at least a week each month during motherhood, and she admitted this caused her stress and feelings of guilt and worry.
She enjoyed cooking and meal prepping at home but didn’t have the time with her new job and travel in the past two years. The stress of a pandemic added to her plate, and she felt she was grabbing more cookies and sweets when she felt overwhelmed. Her travel diet consisted of takeout food, grocery store shelf-stable protein shakes or skipping meals in order to work.
While Sarah used to sleep 6-7 hours per night, her sleep had changed since having her daughter. Before she accepted her new job, she would typically sleep in two 3-4 hour blocks, often waking up around 2 AM for an hour or so. With her new job came additional trouble falling asleep, and she was now only getting approximately 3-4 hours of sleep a night in the past year or two, with minimal exceptions.
She had started drinking more coffee now to get through her day and was up to 4 cups per day. She is exercising still, fitting in 20-30 minute HIIT classes in addition to long runs on the weekend when she’s home.
Functional Medicine Initial Lab Work
Comprehensive Stool Test Results
- Pancreatic elastase LOW
- Beneficial SCFA’s LOW
- Secondary bile acids LOW
- Lactobacillus LOW
- Bifidobacterium LOW
- Zonulin Family Peptide HIGH
Other Relevant Lab Findings
- +/+ COMT Chromosome 22.11q V158M (down regulation)
Lab Work Overview
Sarah’s lab work points to a few core issues that are contributing to her fatigue, anxiety, and newer complaints of menstrual cycle irregularities and bloating:
Cortisol
- Her cortisol labs are irregular, with low values throughout the morning and day and rising at night. Ideally, cortisol increases in the morning and lowers throughout the afternoon and evening. In Sarah’s case, her cortisol doesn’t rise until the evening, contributing to her low energy and sleep disturbances.
Thyroid
- Slightly irregular thyroid labs: Sarah’s TSH is elevated, while her free T3 is low. An additional antibody panel would have been helpful to rule out thyroid autoimmunity contributing to this pattern. However, the combination of high TSH and low free T3 explains her fatigue and lack of energy. Hypothyroidism can also be linked to irregular menstrual cycles, so this pattern is potentially contributing to that newer symptom as well. Low RBC selenium and magnesium also indicate she may be missing essential micronutrients in her diet needed for proper thyroid hormone production and conversion of T4 to T3.
Hormones
- Depressed progesterone, DHEA, and testosterone: Sarah’s fatigue and anxiety can be impacted by low levels of hormones such as testosterone and progesterone. Healthy testosterone levels in women are associated with greater energy and a better sense of well-being. At the same time, progesterone plays a critical anxiolytic role and contributes to a regular menstrual cycle length.
Digestive Health
- There is evidence of decreased digestive enzyme function and absorption and low growth of beneficial gut bacteria such as Lactobacillus and Bifidobacterium.
- Additionally, a high level of zonulin family peptide was found in her stool test. Increased zonulin family peptide has been associated with inflammation, dysbiosis, and increased intestinal permeability, resulting in a higher risk of developing autoimmunity and other inflammatory conditions. Altogether, these markers help piece together the new onset of digestive-related symptoms like bloating. Paired with a low Omega-3 index and a shift in her nutritional habits, there’s evidence that Sarah is dealing with systemic inflammation that can be impacting her health.
Functional Medicine Approach to Burnout: Interventions
- While Sarah was initially hesitant to take medication for her thyroid, we co-managed her case with her endocrinologist, who suggested a trial period of levothyroxine to improve her symptoms while working on her underlying health concerns.
- We added a few supplements to support her gut health, including Repairvite by Apex Energetics, MegaSpore probiotic, Enzymix-Pro digestive enzymes before meals, and a targeted elimination diet with the removal of foods that came back in her food sensitivity panel.
- We started planning her “travel nutrition” before each trip, which included pre-ordering groceries and finding local meal prep services with healthier, whole-food-based options.
- I encouraged her to focus on chewing her food and taking a break to eat her meals rather than eating at her desk or on the go.
- We also focused on adding in foods that reduce inflammation, such as salmon, berries, ginger, turmeric, leafy greens.
- Started Apex Energetics Adaptocrine, which contains ashwagandha (helps with T4-T3 conversion) and several other adaptogenic herbs to help with the body’s stress response.
- Encouraged her to switch from coffee to matcha green tea to help both her gut health (coffee was a “problem” food) and her hormone function.
- Started a fish oil supplement, 2-4g per day, to help reduce inflammation.
- Started Vitamin D, 5000 IU per day.
- We planned out 2-3 days of strength training when she was home, with bodyweight workouts on the road. Her cardio became walking and 1 HIIT workout during the week to take some of the strain off her system.
- Last, I encouraged Sarah to start a breathwork practice to help her with nervous system regulation and stress management. She found this a convenient practice that she could do when she traveled.
Follow-Up Labs 3 Months Later
When we re-ran labs and intake at 3 months, we saw several things trending in the right direction. By this point, Sarah was feeling significant improvement in her digestive symptoms, and her sleep was much more regular.
She still felt low energy levels, but she was making good strides with her nutrition and exercise and wasn’t as “dead tired” as she had been.
We also ruled out autoimmune thyroid activity as a cause of her abnormal thyroid labs. Sarah was not happy with her thyroid medication and struggled to figure out when to take it and decided to take herself off it two weeks prior to our three-month check-in. We discussed this with her endocrinologist, who recommended the Thyraxis-PT to focus more on brain-thyroid signaling.
Follow Up Labs 6 Months Later
At Sarah’s 6-month lab recheck, she had improved tremendously. She felt her energy was much better, especially noticeable earlier in the day, and her menstrual cycles were averaging 27-29 days with markedly less anxiety.
She was able to identify some patterns that “spiked” her anxiety, including sugar and wine, and had been working to reduce those as well.
Her labs were all normal or close to it at this point, and while some were still borderline low (such as free T3), the trends were enough that we continued with her protocol.
Sarah’s sleep had continued to improve, with her reporting she was only waking up 2-3 nights in a month now, usually the few days leading up to her period.
Her caffeine intake had remained steady at one cup of matcha tea in the morning, though she was adding in a coffee here and there on weekends because “she missed it.”
Sarahs’ gut symptoms, like the bloating and stomach discomfort, had resolved. She found that as long as she primarily focused on whole foods and limited the fast food and sugar, she had no issues with those previous symptoms.
A few times, she had a busy day while traveling and resorted to fast food and convenience foods, and she noted that she didn’t have a bowel movement the day after eating that way, which reinforced her newer habits.
At the point of her six-month visit, Sarah was interested in starting to look at wearables like an Oura ring or Whoop to continue seeing how her sleep and energy responded to different things.
Summary
This case highlights the complexity of burnout cases on multiple systems in the body. Approaching each hormonal system individually was not effective; we had to address the brain signaling pathways to help Sarah start feeling better.
This case shows the importance of nutrition and lifestyle on various hormone systems like the thyroid and adrenals. It also shows that co-management of cases can be in the patient’s best interest for a truly integrative approach.
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