Sara Szal MD
She was 39, a managing partner in her law firm, when she came to see me for fatigue that multiple rounds of blood work elsewhere had failed to explain.
I looked over the labs. Her cortisol curve was flat from years of override. Her thyroid was within range but no one checked for anti-thyroid antibodies. Her anti-Müllerian hormone and follicle-stimulating hormone were well within the premenopausal normal range, and her progesterone confirmed ovulation.
What was more glaring was her calendar. She worked 60-hour weeks. She managed her children’s school schedules, her mother’s move to assisted living, and her household. She didn’t use the word “no” much.
She told me, “I’m not depressed or anxious. I’m just gone. I don’t know where I went.”
That statement got me thinking about what’s missing in the labs and what our culture is doing to women through the use of Faustian bargains. Her labs were clean. Her culture was not.
A Faustian bargain may seem reasonable in the moment. The high cost shows up later. I’m not talking about thoughts, I’m referring to patterns the nervous system runs automatically, sometimes for years, before the conscious mind catches up to what it’s been agreeing to.
Chronic accommodation looks like a chronic threat response. The body doesn’t distinguish between suppressing a need to keep a marriage intact and suppressing a need to survive genuine danger. Either way, the sympathetic nervous system stays engaged longer than it was built to.
Over months and years, that sustained activation shows up as reduced heart rate variability (HRV), a flat cortisol rhythm, and potential downstream disruption to the hormones that govern sleep, desire, immune function, and repair, including progesterone, testosterone, and DHEA.
This is the nervous system doing exactly what it was trained to do. By the time a woman feels the exhaustion, the body has usually been keeping the score for years.
What I was taught in medical training: fatigue this vague warrants a differential diagnosis, including iron-deficiency anemia, sleep apnea, hypothyroidism, and depression, among others. If labs return normal, it’s either an incomplete history or more likely to be depression.
What I now understand: sometimes the history is complete, and the diagnosis is a life that has been running on a bargain the labs were never built to reveal.
I believe the fatigue that brings most women into my office is downstream of a bargain far more often than it is downstream of a single hormone level.
A healthy partnership is a mutual exchange between two people who can ask for what they need. What I’m describing here is different: the exchange running in one direction for years until the body slows down and finally gets her attention.
The inventory and protocol below map where the bargain lives in the body and hot to begin removing your name from the deal.
You will find the biological signature of the 10 female bargains named in the essay last week, a renegotiation sequence for undoing one bargain at a time, and a five-minute way to check whether your nervous system is already behind on the score.
Bloodwork alone will now show you what you have traded away. It can confirm it, once you know what to look for.
