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Health Protocols

Chronic Fatigue Syndrome


There is no specific diagnostic test for CFS, and it may be difficult to distinguish CFS from fatigue secondary to other health conditions. A diagnosis of CFS requires that other potential causes of fatigue be ruled out. Examples of such causes include:

  • obstructive sleep apnea (Norman 2008; Lieberman 2009)
  • depression (Skapinakis 2004)
  • hypothyroidism (Yancey 2012)
  • toxin exposures (Ziem 1999; Curtis 2004)
  • autoimmune diseases such as lupus or multiple sclerosis (Yancey 2012)
  • cancer (Yancey 2012)
  • traumatic brain injury (Mott 2012)
  • heart failure (King 2012)
  • anemia (Guralnik 2005; Jones 2011)
  • irritable bowel syndrome (Frissora 2005)
  • diabetes (Yancey 2012)
  • chronic or sub-acute infection (Jones 2011)
  • ongoing adverse reactions to medications (Jones 2011)

There are several diagnostic guidelines for CFS. A commonly used definition for CFS was developed at the US Centers for Disease Control and Prevention (CDC). These criteria include subjects who have experienced chronic, unexplained fatigue for at least six months, which is of new onset (ie, not a lifelong problem), is not the result of ongoing exertion, is not substantially relieved by rest, and hinders occupational, social, or personal activities. In addition, at least four of the following symptoms must be present 50% of the time for at least six months (Fukuda 1994; Jones 2011; Ferri 2014):

1) Unrefreshing sleep

5) Aching or stiff muscles

2) Impaired memory or concentration

6) Multi-joint pain

3) Sore throat

7) Headache of new type, pattern, or severity

4) Tender lymph nodes in neck or armpit areas

8) Post-exercise malaise or illness feeling which lasts more than 24 hours

Although there is no single diagnostic test for CFS, the following tests are used to help rule out other common causes of fatigue (Yancey 2012; Ferri 2014; Sawchuck 2013; Jones 2011):

  • basic blood chemistries and complete blood count (to check for anemia and other conditions)
  • thyroid hormone levels (to check for hypothyroidism)
  • blood sugar levels (to check for diabetes)
  • urinalysis (to check for kidney disease)
  • serum vitamin B12; serum and urinary methylmalonic acid (to check for vitamin B12 deficiency and insufficiency)

CFS is considered by some researchers to be the result of a chronic infection; however, testing for EBV, HHV-6, and Borrelia burgdorferi, which causes Lyme disease, are not routinely recommended. These tests can be considered on a case-by-case basis, depending on the patient's clinical presentation and history (Eymard 1993; Jones 2011). Other infections may be mistaken for CFS, so tests for tuberculosis; hepatitis A, B, and C; and HIV/AIDS should also be considered. Testing blood levels of 25-hydroxyvitamin D may be helpful as well, since vitamin D deficiency symptoms (ie, weakness, muscle pain) may sometimes overlap with CFS symptoms (Kennel 2010; Jones 2011). Psychological conditions, such as depression and substance abuse, should be ruled out as well (Jones 2011; Eymard 1993).

Sleep studies have been suggested for all CFS patients with symptoms suggestive of sleep disorders, as chronic sleep problems such as sleep apnea or insomnia can cause fatigue and be mistaken for CFS (Buchwald 1994; Neu 2014; Mariman 2013). A comprehensive discussion of several sleep disorders and methods of treating them is available in the Insomnia protocol.

Some researchers have suggested that sex hormone imbalances may contribute to CFS, especially in women, although the evidence is inconsistent (Harlow 1998; Boneva 2011). A full evaluation of hormonal status may be useful in understanding individual cases of CFS, with blood tests measuring levels of hormones such as DHEA-S, pregnenolone, estrogen, and testosterone. If levels are low, bioidentical hormone replacement may be a useful treatment or adjunct therapy. For more specific information on bioidentical hormone replacement and hormone testing, see the Female Hormone Restoration and Male Hormone Restoration protocols.​