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Sara Szal MD<\/span> <\/span><\/p>\n 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.<\/p>\n 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-M\u00fcllerian hormone and follicle-stimulating hormone were well within the premenopausal normal range, and her progesterone confirmed ovulation.<\/p>\n What was more glaring was her calendar. She worked 60-hour weeks. She managed her children\u2019s school schedules, her mother\u2019s move to assisted living, and her household. She didn\u2019t use the word \u201cno\u201d much.<\/p>\n She told me, \u201cI\u2019m not depressed or anxious. I\u2019m just gone. I don\u2019t know where I went.\u201d<\/p>\n That statement got me thinking about what\u2019s 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.<\/p>\n A Faustian bargain may seem reasonable in the moment. The high cost shows up later. I\u2019m not talking about thoughts, I\u2019m referring to patterns the nervous system runs automatically, sometimes for years, before the conscious mind catches up to what it\u2019s been agreeing to.<\/p>\n Chronic accommodation looks like a chronic threat response. The body doesn\u2019t 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.<\/p>\n 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.<\/p>\n 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.<\/p>\n What I was taught in medical training: <\/strong><\/em>fatigue this vague warrants a differential diagnosis, including iron-deficiency anemia, sleep apnea, hypothyroidism, and depression, among others. If labs return normal, it\u2019s either an incomplete history or more likely to be depression.<\/span><\/p>\n What I now understand: <\/strong><\/em>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.<\/span><\/p>\n 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.<\/p>\n A healthy partnership is a mutual exchange between two people who can ask for what they need. What I\u2019m describing here is different: the exchange running in one direction for years until the body slows down and finally gets her attention.<\/p>\n