You might recognize this story: you go to the doctor and describe months of exhaustion sleep doesn’t touch, a short fuse you don’t recognize in yourself, and a body that feels restless and midnight and leaden at nine in the morning. The doctor draws blood. And then, it always ends the same way. A week later, a message arrives that everything looks normal.
For Derrick Pickering, a family nurse practitioner and certified nurse midwife who founded Sunrise Women’s Health in Mapleton, Utah, that message is where the conversation should begin rather than end. A large share of his practice involves hormone care that starts with symptoms. Patients frequently come to his office holding a folder of unremarkable results and a life that has quietly narrowed.
Nothing in that scenario means the testing was wrong or that the previous doctor was careless. But it does mean that the question being asked of the lab was narrower than the question the patient came in with.
Understanding the difference between the two is what turns a frustrating visit into a useful one.
What a Reference Range Actually Describes
A reference range is basically a statistical summary, mostly built by testing a large group of people assumed to be healthy, then marking the boundaries that contain the middle of the group, like the central ninety-five percent. If a marker shows up inside those lines, it’s flagged as normal. Everything outside is flagged for review.
The design does what it was built to do: catch disease. But it wasn never built to describe exactly how a particular person feels at a certain point in her life.
There’s two consequences to this. The first is that a result can sit just inside the boundary and still represent a meaningful change for that individual. The second is that the reference population itself is broad. It mixes ages, life stages, and body types. For some hormone tests, it mixes people who were themselves symptomatic but undiagnosed at the time of collection.
This is why some patients say their test results and their experience disagree. The lab still answered the question it was asked, but something is missing.
The remaining work is clinical: comparing a result against a woman’s own history, her prior values where they exist, and the pattern of what she is actually experiencing.
Thyroid Testing: Why One Number Rarely Settles It
Thyroid screening usually begins and often ends with TSH, a pituitary signal that rises when the body senses it needs more thyroid hormone. It’s a reasonable first look for any doctor and it can catch a great deal of problems before they become grave.
But it’s also indirect because it only measures the request being sent rather than the hormone being delivered and used.
The thyroid mostly produces T4, a storage form that has to be converted into T3, the form that does the work inside cells. That conversion happens in the liver, the gut, and other tissues, and it can be slowed by illness, by significant caloric restriction, by chronic stress, and by nutrient shortfalls. A woman can potentially have a TSH sitting comfortably in range while free T4 and free T3 tell a more textured story, particularly if thyroid antibodies are present.
That is why patients with fatigue, cold intolerance, hair changes, constipation, or a stubborn shift in weight often benefit from a fuller panel rather than a single value. When patients ask Derrick Pickering why anyone would order more than the standard screen, the answer is not that the screen is unreliable.
It’s that a single number cannot distinguish between a thyroid that is not producing enough and a body that is not converting well, and those two situations do not respond to the same plan.
Adrenal Rhythm and the “Tired but Wired” Pattern
Many people can understand the drag that is being exhausted all day and alert at night. Cortisol follows a daily rhythm, and if it’s working well, it should rise sharply in the first hour after waking, provide energy through the morning, and taper toward its lowest point at night so sleep can begin.
When that curve flattens or shifts, the timing of symptoms changes even though the total daily output may look unremarkable. A single morning cortisol drawn at an arbitrary hour can miss this entirely. Tests only capture one point on a curve rather than the shape of the curve itself. Ongoing stress, disrupted sleep, shift work, and a caregiving load that never lets up all influence that rhythm, and none of them show up as a diagnosis code.
It’s worth being careful with language here. “Adrenal fatigue” is not a recognized medical diagnosis, and genuine adrenal disease such as Addison’s or Cushing’s is uncommon and requires specific testing.
What is real, though, and deserving of attention, is that stress physiology, sleep, and hormone signaling are connected. Treating that connection seriously means asking when symptoms occur, not only whether a number cleared a threshold.
Progesterone, Cycles, and the Timing Problem
Progesterone is the clearest example of why timing changes everything. It stays low through the first half of a cycle and rises after ovulation. Drawn on the wrong day, a low result is not evidence of a deficiency. It is evidence that the sample was collected before the rise.
Even correctly timed, one draw is a snapshot of a moving system. During the years leading up to menopause, cycles shorten and lengthen, ovulation becomes less predictable, and estrogen can swing while progesterone declines. That combination produces the symptoms women most often report as mood related: irritability in the second half of the cycle, disrupted sleep, heightened anxiety, and heavier or erratic bleeding.
Tracking symptoms across the whole cycle for two or three months frequently reveals more than any single result, because it shows the pattern the blood draw could only sample.
Looking at the Whole Person, Not Just the Paper
The clinical approach Derrick Pickering describes is deliberately unglamorous. Listen first. Establish what the patient came in hoping to change. Interpret testing against her history and her stage of life rather than against a boundary alone. Then decide together what to do, which may mean further evaluation, may mean addressing sleep, iron status, nutrition, thyroid function, or perimenopausal changes, and sometimes means confirming that the results really are reassuring and looking elsewhere for the cause.
That last outcome matters. A whole-person approach is not a promise that a hormone explains every symptom. Fatigue and low mood have many origins, including anemia, sleep apnea, depression, and thyroid disease, and a careful evaluation is designed to separate them rather than fold them all into one explanation.
His path shaped that instinct. He spent nearly five years in pediatrics before completing midwifery training, and his own family navigated infertility, pregnancy complications, and the loss of prematurely born twins.
Those experiences tend to make a clinician slower to dismiss what a patient reports and more willing to sit with an incomplete picture until it comes into focus.
What to Bring to the Next Appointment
Derrick Pickering encourages patients to arrive with specifics. A well-prepared visit gets further than a well-ordered panel. You should note when symptoms are worst during the day and where they fall in the cycle. Bring prior lab results rather than a summary of them, since a trend across years carries information a single value does not. Ask which tests were run, which were not, and why, then ask what the plan is if the next round also returns in range.
Normal results are genuinely good news about disease. They are not, on their own, an explanation for how a person feels. The difference between those two statements is where most of this work happens.
About Derrick Pickering
Sunrise Women’s Health opened in Mapleton, Utah, in March 2021 as a practice built around caring for women at every stage, from primary care and contraception through infertility, midwifery, hormone replacement therapy, and menopause. The clinic’s stated aim is straightforward: listen to a patient’s concerns, clarify what she wants from the visit, and reach decisions together.
Derrick Pickering, FNP-C, CNM, is dual board-certified as a family nurse practitioner and a certified nurse midwife. He earned a Master of Science as a Family Nurse Practitioner from Brigham Young University-Provo in 2014 and a post-graduate certificate in nurse midwifery from Frontier Nursing University in 2022, and he founded Sunrise Women’s Health in Mapleton, Utah, where he cares for women across primary care, gynecology, infertility, midwifery, and hormone health.
