Session transcript

Your Blood Test Results Are Normal. So Why Do You Still Feel Awful? How to Tie Persistent Exhaustion, Brain Fog, and Midlife Symptoms to Your Results

with Toki Birch · Day 5 · The Polite One

A lot of women arrive at the GP's already rehearsing how to prove that they feel unwell. Then the results come back in range, and somehow that becomes the end of the conversation, at least for a while anyway, until the symptoms become worse again.

Many of us have learned to be the easy patient. We nod, say thank you, and then leave with questions still unasked, because we don't want to be labelled as difficult or take up more time. Your test results are important, yes. But so is the fact that you're always exhausted, losing words halfway through a sentence, crashing in the afternoons, and feeling very unlike yourself because your mood is all over the place.

For the next 15 minutes, I want to help you understand your results and prepare clearer questions for your next appointment. Remember, this is general education, so please do speak to your GP or your physician about your own symptoms and what assessment or support would be appropriate.

Here's what we're going to cover. First, what a normal result can tell you, and where it stops being helpful. Then, why one symptom can have several contributors, and why your history matters so much. After that, we'll turn your symptoms into a clear pattern, and I'll finish with words you can borrow for your next appointment.

Your test results can show that everything is within "normal" limits, but your lived experience feels more difficult, and that feels completely different. You may be sleeping and still waking up tired, or waking up multiple times in the night. Perhaps you lose your words or forget your train of thought in the middle of a conversation, or reach the afternoon and feel like someone has pulled the plug.

While a normal test result can be reassuring, it doesn't erase the symptoms you're experiencing, and it doesn't tell us that every possible angle or explanation has been considered. A test result can answer the numbers question. Your history gives an idea of what's going on and which questions should be asked. Perimenopause can bring about sleep problems, mood changes, brain fog, joint pain, and a myriad of other symptoms, and those symptoms can also overlap with other health concerns. So we need enough curiosity to consider whether anything else is going on at the same time.

I know how this feels personally, because about 15 years ago, I could be in bed for 12 hours a day, waking almost every hour on the hour, and waking up in the morning feeling like I'd run a marathon and then been hit by a truck. I was so tired in those days that I used to have to prop my head up with my hand just to eat, and I needed to use both hands to hold my toothbrush while brushing my teeth, because I was tired and weak as all get out.

My blood test results came back normal, and I was told I was fine, but perhaps a little bit depressed. One afternoon I was so tired I just crashed at work. I left early, and I was so desperate that I drove to my GP surgery without an appointment. When I got there, they were closed, and I just sat on the ground in the car park, leaning against my car, and I sobbed. I was a practising orthodontist with three years of medical training under my belt. I was supposed to have answers as well, and I had nothing. Nada. So today is about making sure that you walk into your next appointment with more than I had that day.

A normal test result usually means that the particular value that was measured fell within the lab's reference range. It doesn't mean that every possible cause has been excluded. So a normal result isn't the same as asking whether the result explains what's happening to you.

The next question really should be: do these results make sense alongside the symptoms you experience and your medical history? Your medications, sleep, nutritional status, and your social lifestyle as well. How do they compare with your usual baseline, if previous results are available? Because sometimes a result may need follow-up. Other times, the right next step isn't necessarily another test. You may be better served by a more comprehensive history, a medication review, or a conversation about your sleep, nutritional status, or other social and lifestyle factors.

Now, I'm not saying that you should distrust every normal test. That's not what I'm saying. But it's important not to treat a reference range as the end of your story when your day-to-day function has clearly changed.

During perimenopause, hormone production doesn't decline in a smooth, predictable manner like we'd expect. Estrogen can fluctuate, and ovulation and progesterone production become less consistent. Even testosterone production can be affected. A blood, urine, or saliva test can measure what was present during its collection window, or during the 30 seconds the needle is in your arm. A comprehensive dried urine test can provide more data, yes. But what it can't do on its own is confirm that perimenopause caused a particular symptom, or even rule it out because the result happened to be in range in that particular collection or test.

That's why NICE recommends identifying perimenopause clinically, without lab tests, in otherwise healthy women aged over 45 with recently started hot flushes or night sweats and changes in the menstrual cycle. Assessment can differ for those under 45, though. A clinician may consider FSH (follicle stimulating hormone) testing between ages 40 and 45, or investigate suspected menopause in those under 40 if symptoms match. A precise measurement of an ever-changing system can't always give reliable clinical answers. So symptoms, cycle changes, medical history, and the effect on your daily life still need to be borne in mind, rather than relying on tests which don't tell us a lot.

And this is why trying to match one symptom to one cause can become so frustrating. Persistent exhaustion, poor sleep, and brain fog can be experienced during perimenopause, but there may be other factors contributing to you having those same symptoms. Iron deficiency is one example, particularly if your periods have become heavier or more frequent. Thyroid problems can also create overlapping symptoms with perimenopause and menopause. Sleep disorders, medicines you take, low mood, anxiety, and other health conditions may need consideration here as well.

This doesn't mean that all these things need to be tested. I've just added them here as a reminder that different things may cause similar symptoms in different women. So individualised perimenopause and menopause care is needed, and this is one reason why a good history is so important to have.

If you're told that your results are normal, it's reasonable to ask what was checked and to request a copy of your test results. You're not challenging the clinician. You're trying to understand what has already been done.

If bleeding has become heavier, longer, or more frequent, mention that, because it changes the context for tiredness and helps consider possible iron deficiency. Ask whether iron status was considered and what the results showed. If thyroid function was checked, ask what was included and whether the result fits with the symptoms you have. Thyroid problems, perimenopause, and menopause, like I said earlier, can have overlapping symptoms.

There are other tests too, including B12 or other markers, which may or may not be appropriate, and your history will help your clinician decide what would be most useful for you. You can also ask why a particular test would or wouldn't be useful in your situation. I don't want you thinking that there's one magical marker that can be requested and will confirm perimenopause. What I want you to be aware of is that sometimes there are other tests which can be helpful in providing further information about the symptoms you're experiencing, although sometimes the next step is a different kind of assessment rather than further testing.

I've got here a few notes that can help you remember what you want to say during your appointment. Start with the symptom affecting your life the most, and then you can use these four questions to describe it.

When did it start? An approximate month is fine.

When does it happen? You might notice a particular time of day, maybe after meals, around your period, or if it's there most of the time.

What else have you noticed happening around the same time?

And what is it stopping you from doing?

For example: "For about three months, I've felt exhausted by 3 p.m. at least twice a week. My sleep is more broken, and I've struggled to finish my work." That gives us four details. It started about three months ago. It happens around 3 p.m. at least twice a week. Broken sleep is also present. And the impact is struggling to finish your work. These details can help you explain what has changed, but the cause still needs assessment.

So if you'd like, you can pause the video and try these four questions with one symptom of your own. Use what you remember, and you can add to your notes later. Choose the three symptoms affecting your life the most to start the conversation, and then take a written note of the others too, so you have them with you if you need them. You don't need to remember all of this for now. I'll be sharing a free checklist at the end, and I'll walk you through it.

You can take a photograph of this slide or write the words down. I've deliberately written them this way to make them specific: "My results are in range, but my symptoms are continuing and affecting my daily life. Could we look at them together, including whether perimenopause is part of the reason and whether anything else needs ruling out?"

By doing this, you're acknowledging the result and explaining that your symptoms are continuing. You're then naming the effect on your daily life and asking for the results and the symptoms to be considered together.

If speaking up feels difficult, give the clinician your written list at the start and say, "While I have a lot of symptoms, these are the three things affecting me the most." You can also ask for a copy of your results and what the next step will be.

If your symptoms continue, asking for follow-up doesn't make you difficult. If there's still no plan, it's reasonable to ask whether a referral or second opinion can be considered. If the symptoms are affecting your work, caring, or family life, asking for support or an accommodation is part of describing the real impact on your life.

If you feel brushed off, you might say, "I understand that these results are reassuring. However, I still need help with the symptoms. What would you suggest we do next?"

You can ask for help even if you lose your words or haven't managed to write everything down. Your notes are there to support you. Being listened to shouldn't depend on having a perfectly prepared explanation for how you're feeling. You shouldn't have to make yourself smaller to keep the appointment comfortable. You are allowed to explain what's happening and ask what the next step will be.

Before I let you go, here are three things to remember. A normal result answers the lab's question, and your symptoms still need to be considered as part of that conversation. Your symptom story, with its timing and its impact on your life, belongs in the same conversation as your test results. And asking what happens next, like I said, is a perfectly reasonable thing to do. You can be the polite one and still ask for a next step.

If you're fed up to the back teeth of hearing the phrase "everything looks fine, everything looks normal," I have made you a short checklist called But I Still Feel Awful. It helps you record five symptom patterns, note when they happen, and decide which three things are affecting your life the most. You can take that to your next appointment and then use the script on the final page if your mind tends to go blank once you're in the room with your GP or your physician. The link for the free checklist is on the slide and beside the session.

If you remember one thing from today, let it be this: a test result that's within the normal reference range and a life that's becoming hard and unrecognisable aren't competing stories. Your results, symptoms, and history need to be considered and discussed in the same conversation. You can be the polite one and still ask for a next step. Remember that.

Thank you for listening.