Allostatic Load and Women’s Health: The Physiological Cost of the Second Shift

What Virginia Woolf’s A Room of One’s Own can teach us about chronic stress, recovery, and the conditions necessary for women’s health.

Sadie Carlsen, NP

FunctNP Functional Medicine

A Room of One’s Own 97 years later.

On October 24, 1929, the British edition of Virginia Woolf’s A Room of One’s Own was published.

Woolf argued that women needed financial independence and a room of their own to write fiction. Her argument extended beyond the physical room itself. It challenged readers to consider how opportunity, resources, and social expectations influence a woman’s ability to create.

Ninety-seven years later, her work invites another question:

What do women need in order to be well?

For many women, the workday doesn’t end when they leave work.

It becomes dinner.

Laundry.

Appointments.

Childcare.

School schedules.

Groceries.

Cleaning.

Planning.

Remembering.

The responsibilities may be ordinary, but their cumulative demands deserve our attention.

Sociologist Arlie Hochschild popularized the term the second shift to describe the unpaid household and caregiving labor that often follows paid employment.

And while these responsibilities may be socially categorized as separate from professional work, the body’s physiological systems continue responding to demands throughout the day.

This is where the concept of allostatic load becomes relevant.

What Is Allostatic Load?

The human body is remarkably adaptable.

When we encounter a challenge, physiological systems coordinate to help us respond. Heart rate may increase, stress hormones may be released, attention may sharpen, and energy availability may change.

This adaptive process is called allostasis, often described as achieving stability through change.

Allostasis is not inherently harmful. It is essential to survival.

The difficulty arises when stress responses are activated repeatedly, remain elevated longer than necessary, or become poorly regulated.

Researchers use the term allostatic load to describe the cumulative physiological burden associated with these adaptations over time.

The concept was developed through the work of researchers including neuroscientist Bruce McEwen, whose research examined how stress mediators can be both protective and potentially damaging.

In other words, the problem isn’t that stress exists.

The concern is what happens when demands repeatedly exceed opportunities for recovery.

The Physiology of Chronic Stress

Stress is not simply an emotional experience. It involves communication among multiple physiological systems.

The HPA Axis

The hypothalamic-pituitary-adrenal (HPA) axis helps coordinate the hormonal response to stress.

Through a series of signals involving the hypothalamus, pituitary gland, and adrenal glands, the body regulates cortisol production.

Cortisol plays important roles in glucose regulation, immune activity, blood pressure, and normal circadian physiology.

It is not a hormone we should automatically seek to suppress.

However, prolonged stress exposure can be associated with changes in cortisol regulation, and these patterns vary considerably between individuals.

The Autonomic Nervous System

The autonomic nervous system regulates functions including heart rate, digestion, vascular tone, and aspects of the stress response.

Its sympathetic and parasympathetic divisions help the body respond to challenges and support recovery.

Repeated stress exposure, insufficient sleep, and other factors may influence autonomic regulation.

Heart rate variability (HRV) can provide information about aspects of autonomic function, but it is influenced by age, fitness, illness, medication, and measurement conditions. It is not a standalone diagnostic test for allostatic load.

Metabolic and Immune Health

Chronic stress can also interact with metabolic and inflammatory pathways.

Sleep disruption, altered eating patterns, reduced physical activity, and sustained physiological arousal may influence glucose regulation, blood pressure, and other cardiometabolic markers.

These relationships are complex and often bidirectional.

Importantly, no single laboratory test establishes that someone has excessive allostatic load. Research measures typically combine several biomarkers, and there is no universally accepted clinical diagnostic threshold.

Why This Conversation Matters for Women

Women’s experiences of stress are shaped not only by biology but also by their environments.

Employment demands, caregiving responsibilities, financial pressures, relationship dynamics, and unequal distributions of domestic labor can affect opportunities for rest and recovery.

A woman may complete her professional responsibilities only to begin several more hours of unpaid work.

Another may be caring for children, aging parents, or a family member with chronic illness.

Some women are navigating these responsibilities with limited financial resources, inadequate social support, or little control over their schedules.

These circumstances do not affect every woman equally, and they should not be treated as inevitable features of womanhood.

But they are relevant to health.

Research examining family caregivers has identified associations between caregiving burden, perceived stress, and higher measures of allostatic load.

These findings do not establish that every caregiver will develop disease. They do, however, reinforce the importance of considering the environments in which health and illness develop.

Not Every Symptom Is Cortisol

Fatigue, disrupted sleep, difficulty concentrating, and changes in energy are common concerns in clinical practice.

They are also nonspecific.

A woman experiencing persistent fatigue may have iron deficiency, thyroid dysfunction, sleep apnea, depression, medication-related effects, inadequate nutrition, or another medical condition.

She may also be experiencing prolonged psychosocial stress.

Sometimes several factors coexist.

This is why thoughtful evaluation matters.

Not every symptom is a cortisol problem, and not every tired woman needs an adrenal support supplement.

The goal should be to investigate symptoms appropriately rather than attributing them automatically to stress.

Allostatic load is a useful framework for understanding cumulative physiological demands. It should not replace an evidence-based medical assessment.

A Functional Approach to Women’s Health

Functional medicine, at its best, should examine the relationship between physiology, environment, behavior, and lived experience.

Depending on a patient’s history, symptoms, and clinical findings, evaluation may include assessment of:

• Thyroid function and iron status

• Sleep quality and possible sleep disorders

• Nutritional adequacy and relevant deficiencies

• Cardiometabolic health

• Reproductive or menopausal concerns

• Mental health, medications, and other contributors to symptoms

Testing should be guided by clinical indications rather than an assumption that every woman needs an extensive hormone panel.

And treatment should be equally individualized.

Sometimes the intervention is medical.

Sometimes it’s nutritional.

Sometimes it’s movement, improved sleep, or treatment of an underlying condition.

Sometimes appropriate supplementation has a role.

And sometimes a meaningful part of the treatment plan is identifying ways to create more capacity for recovery.

Recovery Is More Than Self-Care

We frequently encourage women to manage stress through meditation, exercise, journaling, or better sleep habits.

These strategies can be valuable.

But they have limitations when the underlying demands remain unchanged.

A woman cannot always meditate her way out of financial insecurity.

A more consistent bedtime may be difficult when caregiving responsibilities extend through the night.

An exercise recommendation may be unrealistic without childcare, transportation, or adequate time.

This is why discussions about stress should include both individual health behaviors and the conditions that make those behaviors possible.

Recovery may involve protecting sleep, sharing domestic responsibilities, accessing community support, addressing financial or occupational pressures, or setting boundaries where it is safe and feasible to do so.

These are not always simple changes.

And the responsibility for making them possible should not fall entirely on women already carrying disproportionate demands.

Good medicine should recognize that recovery requires more than another task on an already overwhelming to-do list.

Making Room for Health

Nearly a century ago, Virginia Woolf challenged readers to consider the material conditions necessary for women’s intellectual freedom.

Her argument was not that women simply needed to try harder.

It was that creativity required opportunity, resources, and space.

Perhaps healthcare should be willing to ask a similarly expansive question.

We can investigate thyroid function, iron status, metabolic health, sleep, and other contributors to symptoms while recognizing that laboratory results exist within a human life.

We can treat illness without assuming every difficulty is a medical disorder.

We can recommend meaningful lifestyle interventions while acknowledging that access to recovery is not distributed equally.

And we can recognize that the goal is not necessarily to help women tolerate increasingly unsustainable demands.

Sometimes the demands themselves need to change.

Functional medicine should not medicalize an unsustainable life.

It should help us understand the relationship between physiology, environment, and lived experience — and identify where meaningful intervention is possible.

Virginia Woolf asked what women required to create.

Ninety-seven years later, perhaps healthcare should also be asking:

Does she have enough room in her life to recover?

Sadie Carlsen, FNP-C
FunctNP Functional Medicine
Next-generation functional medicine for women.

References and Further Reading

1. Woolf V. A Room of One’s Own. Hogarth Press; 1929.

2. Hochschild AR, Machung A. The Second Shift: Working Families and the Revolution at Home. Viking; 1989.

3. McEwen BS. Protective and damaging effects of stress mediators. New England Journal of Medicine. 1998;338:171–179. doi:10.1056/NEJM199801153380307.

4. McEwen BS. Stress, adaptation, and disease: allostasis and allostatic load. Annals of the New York Academy of Sciences. 1998;840:33–44. doi:10.1111/j.1749-6632.1998.tb09546.x.

5. McEwen BS, Seeman T. Protective and damaging effects of mediators of stress: elaborating and testing the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences. 1999;896:30–47. doi:10.1111/j.1749-6632.1999.tb08103.x.

Educational information only. This article does not replace individualized medical evaluation or treatment.

Sadie Carlsen Sadie Carlsen Sadie Carlsen

Functional Medicine Meridian Functional Medicine Meridian

Insurance based Functional Medicine Meridian Idaho

Ferritin: The Iron Marker That Deserves More Attention

by Sadie Carlsen NP

Founder, FunctNP Functional Medicine
Meridian, Idaho

Ferritin is one of the most useful—and often overlooked—markers when evaluating fatigue, hair loss, exercise intolerance, brain fog, and even certain blood sugar patterns.

Ferritin reflects your body’s stored iron. While a standard CBC can tell us whether someone is anemic, ferritin can become low before anemia develops. That means a person can have a “normal” hemoglobin and still have depleted iron stores.

Low ferritin may be associated with symptoms such as fatigue, weakness, shortness of breath with exertion, headaches, restless legs, hair shedding, poor exercise recovery, difficulty concentrating, and feeling cold.

For women, low ferritin is especially common because of menstrual blood loss, pregnancy, postpartum changes, dietary intake, gastrointestinal issues, and difficulty absorbing iron.

Another reason ferritin matters is that iron status can sometimes influence how we interpret other laboratory markers.

One example is A1C.

A1C estimates average blood glucose by measuring glucose attached to hemoglobin inside red blood cells. Because the test depends partly on red blood cell lifespan and turnover, iron deficiency can sometimes make A1C appear higher than the overall glucose picture would suggest.

That does not mean every elevated A1C is caused by low ferritin. It means context matters.

When A1C seems inconsistent with fasting glucose, continuous glucose monitor data, or symptoms, it may be helpful to look at the bigger picture, including:

• Ferritin

• CBC

• Serum iron and iron saturation

• TIBC or transferrin

• Fasting glucose

• Fasting insulin

• Fructosamine

• Continuous glucose monitoring when appropriate

Functional medicine is not about chasing one isolated laboratory number. It is about asking whether the numbers make sense together.

If your ferritin is low, your A1C is borderline, or you have symptoms that have not been fully explained, a more comprehensive evaluation may help uncover what is actually going on.

Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen Sadie Carlsen

How FunctNP Has Evolved: From Women’s Functional Medicine to Whole-Person Primary Care

When I first started FunctNP, I envisioned a practice centered largely around women’s health, hormones, metabolic care, and functional medicine.

That foundation is still very much part of the practice today.

But as FunctNP has grown, so has the type of care I provide.

I’m Sadie Carlsen, FNP-C, founder of FunctNP Functional Medicine in Meridian, Idaho. Over time, my patient population has expanded beyond women seeking help with hormones, fatigue, thyroid concerns, and weight management. I now care for a much broader range of patients, including men, adolescents, and families looking for thoughtful, relationship-based primary care.

That evolution happened organically.

Patients began referring spouses, children, siblings, and friends. Follow-up visits turned into longer-term primary care relationships. What began as a functional medicine practice increasingly became a place where patients could bring more of their healthcare needs into one setting.

Functional Medicine Is Still Part of the Foundation

Functional medicine remains an important part of how I approach care.

I still look at patterns, contributing factors, lifestyle, nutrition, sleep, metabolic health, hormones, nutrient status, medications, family history, and the broader clinical picture.

But functional medicine is not the only tool I use.

Sometimes the right answer is lifestyle change. Sometimes it is medication. Sometimes it is additional testing. Sometimes it is watchful waiting. Sometimes a patient needs referral to a specialist.

My goal is not to practice one specific “type” of medicine.

My goal is to practice good medicine.

The Practice Has Become More Comprehensive

Today, FunctNP includes care for a much wider range of concerns, including:

• preventive and primary care

• women’s health

• men’s health

• adolescent care

• thyroid disorders

• metabolic health and insulin resistance

• weight management

• hormone concerns

• fatigue

• nutrient deficiencies

• cardiovascular risk

• gastrointestinal concerns

• mental health screening

• medication management

• acute concerns

• chronic disease follow-up

One of the biggest changes has been realizing how much patients value continuity.

They do not necessarily want another isolated consultation.

They want someone who knows their history.

Someone who remembers what was tried six months ago.

Someone who can look at a new symptom in the context of everything else that has been happening.

That is increasingly what FunctNP has become.

From a Niche Practice to a Family Practice

One of the most unexpected parts of growth has been seeing entire families begin to come through the practice.

I may first meet a mother for hormone or metabolic concerns, and later see one of her children for a wellness visit or fatigue, or another family member for a completely different concern.

That has changed the way I think about the practice.

FunctNP is still highly individualized and functional-medicine informed, but it is becoming less of a niche clinic and more of a modern, whole-person primary care practice.

Why the Evolution Makes Sense

My own clinical background has always been broad.

Before opening FunctNP, my experience included emergency care, telemetry, inpatient rehabilitation, home health, utilization management, neurology, and primary care.

So in many ways, the practice is simply growing into the type of clinician I have always been.

I enjoy complex cases.

I enjoy connecting pieces across different body systems.

But I also enjoy ordinary primary care—wellness visits, follow-ups, medication management, preventive care, and getting to know patients over time.

Those things do not compete with functional medicine.

They complement it.

Where FunctNP Is Going

I still care deeply about women’s health, hormones, metabolic care, thyroid health, and the conditions that initially shaped the identity of FunctNP.

But the practice is no longer limited by that original frame.

Today, FunctNP serves individuals and families seeking thoughtful, personalized care that combines conventional primary care with a functional and whole-person perspective.

And I think that evolution is exactly what was supposed to happen.

The practice grew because patients trusted me with more of their care.

That is something I do not take lightly.

About Sadie Carlsen, FNP-C

Sadie Carlsen, FNP-C, is the founder of FunctNP Functional Medicine in Meridian, Idaho. She provides primary care and functional medicine services for adults, adolescents, and families, with particular expertise in metabolic health, hormones, thyroid concerns, and complex symptom evaluation.

FunctNP serves patients throughout the Treasure Valley and across Idaho through telehealth when appropriate.

PMOS vs. NCCAH: Same Symptoms, Different Cause

Now that we’re all primed for PMOS, it’s time to go a little deeper into the medical rabbit hole.

Let’s talk about NCCAH — non-classic congenital adrenal hyperplasia — a condition that can look very similar to PMOS.

Both can show up with androgen-related symptoms. Both can involve irregular cycles, acne, unwanted hair growth, fertility concerns, and elevated androgens.

But the source can be different.

What is NCCAH?

NCCAH is an inherited adrenal condition that affects the way the body makes certain hormones.

The adrenal glands sit above the kidneys and play a major role in hormone production. In NCCAH, an enzyme pathway does not work as efficiently as expected. This can shift hormone production toward higher androgen levels.

That androgen excess can create a pattern that looks very similar to PMOS.

Why does NCCAH get mistaken for PMOS?

Because the symptoms can overlap.

Someone may have irregular cycles, acne, hair growth, elevated androgens, or fertility concerns and assume the answer is PMOS. Sometimes that is correct. But sometimes the signal is coming from somewhere else.

That matters because symptoms are not the diagnosis.

A pattern can point us in a direction, but the workup helps clarify the source.

PMOS vs. NCCAH: what is the difference?

PMOS is often connected to ovarian dysfunction, metabolic signaling, insulin resistance, and androgen excess.

NCCAH begins in the adrenal hormone pathway.

That difference changes the clinical conversation.

It can change which labs matter, which medications may be appropriate, whether specialty referral is needed, and what should be considered for fertility planning or long-term care.

Why medical evaluation matters

This is where medical care matters.

A wellness protocol may recognize that hormones are “off,” but a true medical workup asks a deeper question:

Where is the signal coming from?

Is it ovarian? Adrenal? Thyroid? Pituitary? Medication-related? Metabolic? Something else?

The goal is not to label the pattern and hand someone a supplement stack.

The goal is to understand the cause, build an appropriate treatment plan, and refer out when needed.

The takeaway

Not everything that looks like PMOS is PMOS.

PMOS and NCCAH can have similar symptoms, but they do not always come from the same source.

Same symptoms. Different cause. Different workup.

At FunctNP Functional Medicine, we help women move beyond assumptions and toward answers.

Sadie Nicole Carlsen, FNP

Provider & Founder

FunctNP Functional Medicine