What are the potential causes and treatments of fatigue in adult males?

Fatigue in Adult Males: Causes and Management

For adult men presenting with fatigue, begin with systematic screening using a 0-10 numeric scale, then evaluate for treatable medical causes (anemia, hypothyroidism, cardiac dysfunction) and contributing factors (depression, sleep disturbance, pain), followed by implementation of physical activity and cognitive behavioral therapy as first-line interventions. 1

Initial Screening and Assessment

• Screen fatigue severity at every clinical encounter using a 0-10 numeric rating scale 1, 2
• Scores 0-3 require no immediate intervention; rescreen at regular intervals 1
• Scores ≥4 mandate comprehensive evaluation including focused history on onset timing, daily patterns, duration, alleviating/aggravating factors, and functional impact 1, 2
• Document physical, cognitive, and emotional dimensions of fatigue 1, 2

Comprehensive Evaluation for Moderate-to-Severe Fatigue (Score ≥4)

Laboratory Testing

• Complete blood count with differential to assess for anemia (compare current hemoglobin/hematocrit with baseline values) 1, 2
• Comprehensive metabolic panel for electrolytes, hepatic and renal function 1, 2
• Thyroid-stimulating hormone (TSH) and free thyroxine 1, 2
• Consider morning cortisol and ACTH if endocrine dysfunction suspected 1

Clinical Evaluation

• Review all medications, including over-the-counter drugs and supplements, for fatigue-inducing effects 1
• Assess for alcohol/substance abuse 1
• Evaluate cardiac function (especially if history of cardiotoxic exposures) 1
• Screen for depression and anxiety using validated instruments 1
• Assess sleep quality and duration 1, 2
• Evaluate pain levels 1, 2
• Document nutritional status and recent weight changes 1

Risk Factors Specific to Men

• Older age (≥75 years) significantly increases fatigue risk (adjusted OR 3.88) 3
• Single marital status increases risk (OR 1.94) 3
• Unemployment status increases risk (OR 1.68) 3
• Multiple chronic diseases (≥2) substantially increase risk (OR 2.83) 3
• Hospitalization within the past year increases risk (OR 1.61) 3
• Men with fatigue particularly show associations with handicaps and severe chronic complaints 4

Treatment Algorithm

Step 1: Address Treatable Contributing Factors (Priority)

• Treat anemia with iron supplementation or erythropoietin as clinically indicated 1, 2, 5
• Correct hypothyroidism with thyroid hormone replacement 1, 2
• Manage cardiac dysfunction with appropriate cardiology referral 1
• Initiate antidepressants (SSRIs such as fluoxetine, paroxetine, or sertraline) if depression is present—this is a Category 1 recommendation 1, 2, 5
• Implement cognitive behavioral therapy for insomnia if sleep disturbance identified 1, 2, 5
• Optimize pain management through appropriate analgesics and non-pharmacologic approaches 1, 2
• Address nutritional deficiencies with supplementation and dietitian referral 1, 2

Step 2: First-Line Non-Pharmacologic Interventions

Physical Activity (Category 1 Recommendation)

• Prescribe 150 minutes of moderate aerobic exercise weekly (such as brisk walking, cycling, swimming) plus 2-3 strength training sessions 1
• Walking programs are generally safe and can begin after physician consultation without formal exercise testing 1
• Start at low intensity and gradually increase based on tolerance 2, 5
• Regular exercise decreases anxiety and depression, improves body image, and increases physical activity tolerance 1
• Exercise has the best evidence among all non-pharmacologic approaches for managing fatigue 1
• Consider gentler alternatives: tai chi, qigong, or yoga, which show significant improvements in physical functioning, quality of life, and fatigue 1, 5

Caution: Men with significant deconditioning, cardiopulmonary limitations, or neuropathy should be referred to physical therapy or exercise specialists before initiating programs 1

Cognitive Behavioral Therapy (Category 1 Recommendation)

• CBT delivered by trained providers demonstrates moderate improvements in fatigue, distress, cognitive symptoms, and mental health functioning 1, 5
• Web-based versions of effective in-person programs also show benefit and may be more accessible 1
• Focus on thoughts, feelings, and behaviors related to fatigue 5

Mindfulness-Based Interventions

• Mindfulness-based programs show moderate effect sizes for enhancing quality of life 1, 5
• Mindfulness-based stress reduction may effectively reduce fatigue 5

Step 3: Complementary Interventions

• Acupressure may be recommended for persistent post-treatment fatigue (based on rigorous single trial) 1
• Manual acupuncture can be considered: 20-30 minute sessions three times weekly for 2-3 weeks, then twice weekly for 2 weeks, then weekly for 6 weeks 5
• Psychoeducational interventions providing information about fatigue and adaptive coping strategies in supportive environments 1

Step 4: Pharmacologic Considerations

May Consider

• Bupropion may be considered based on favorable open-label trial results and its potential to target neurotransmitter pathways involved in fatigue 1, 6, 5
• Vitamin B12 intramuscular injection if deficiency documented (essential for hematopoiesis and myelin synthesis; deficiency allowed to progress >3 months produces permanent spinal cord damage) 7

Do NOT Routinely Use

• Wakefulness agents, psychostimulants (including methylphenidate), and antidepressants specifically for fatigue reduction are NOT effective and should not be routinely recommended 1, 5
• Do not use corticosteroids, antivirals, or antibiotics (no demonstrated benefit) 5
• Do not use opioids, NSAIDs for chronic pain, or sedative-hypnotic drugs routinely 5

Important caveat: Current pharmacotherapies have likely not directly targeted the underlying biological mechanisms of fatigue (neurotransmitter disruptions, neuroendocrine dysregulation, immune/inflammatory dysregulation, gut microbiome alterations), which explains their limited effectiveness 1, 6

Ongoing Monitoring

• Reassess fatigue levels at every visit using the same 0-10 numeric scale to track response 2, 5
• Modify management strategies based on response and changes in clinical status 2, 5
• Schedule regular follow-up visits rather than sporadic urgent appointments for effective long-term management 8
• Refer to appropriate specialists (cardiologist, endocrinologist, mental health professional) if fatigue persists despite comprehensive management 1, 2, 5

Common Pitfalls to Avoid

• Do not ignore fatigue complaints—adopting a patient-centered communication style provides a more complete picture 4
• Do not perform extensive repeat laboratory testing if initial results are normal; laboratory studies affect management in only 5% of patients 8
• Do not recommend exercise for patients with fever, significant anemia, neutropenia, or thrombocytopenia until these conditions resolve 1
• Do not assume fatigue is purely psychological—fatigue involves complex biopsychosocial mechanisms including inflammatory processes, HPA axis dysfunction, circadian rhythm disruption, and monoamine pathway disturbances 1, 6
• Men and women experience different contributing factors: men's fatigue relates particularly to handicaps and severe chronic complaints, while employment status and childcare are less relevant factors in men compared to women 4