Rule Out What's Treatable First — When It Looks Like a Relationship Problem but It's Physiology
Day 5 of the 30-day Relationships Series.
One of the most important sentences I say to couples in my practice is this: sometimes the relationship is fine, and the chemistry is not.
Before you decide the marriage is broken, before you decide you are with the wrong person, before you decide you are yourself defective — please rule out the biological drivers that dress up in a relationship costume. Because there are more of them than most people realize, and they are more treatable than most people realize.
This is the psychiatric lane. This is where I live. And this is where I have watched a lot of marriages get their second chance.
Conditions That Wear a Relationship Costume
Untreated depression in either partner. Flatness, low libido, irritability, withdrawal, and the vague sense that nothing is fun anymore are not signs of the wrong marriage. They are often signs of untreated depression.
Untreated anxiety. A partner who reacts to small things as if they are catastrophes, or who cannot receive reassurance, is often anxious — not cruel, not controlling, just under-regulated.
Untreated ADHD, especially in women who were missed as girls. Chronic tardiness, forgetting important dates, half-finished household projects, and a partner who feels chronically unimportant are all common ADHD relational fallout. Treat the ADHD, and the marriage often heals along with it.
Perimenopause and menopause. See the entire 30-day series before this one. Estrogen and progesterone swings can dismantle a marriage in a matter of months if nobody names them.
Male testosterone decline. Real, common after 40, associated with irritability, low libido, low motivation, and a partner who feels shut out.
Sleep apnea. Under-diagnosed. Devastating for mood, libido, and the general tolerance for being another human being's spouse.
Thyroid disease. Fatigue, weight gain, low mood, irritability. Cheap to test, life-changing to treat.
Chronic pain. If one of you is in daily pain, the marriage is running on a tax you may not have named.
Alcohol use disorder or heavy drinking. Even at levels culturally considered normal, alcohol devastates sleep, mood, sex, and repair capacity.
Medication side effects — especially SSRIs, birth control pills, beta blockers, and some blood pressure medications. Ask your prescriber. Options exist.
Postpartum, perinatal, or premenstrual mood disorders. These can shape a marriage for years if nobody catches them.
This is a partial list. It could easily be longer.
Why This Matters So Much
Because thirty days of connection exercises — no matter how well-taught — cannot outrun untreated physiology. A partner running on four hours of sleep, unmedicated ADHD, and a glass of wine every night at 9 PM will not become a warmer partner because they are trying harder. They need a workup, not a workshop.
The relational work still matters. Everything in this series still applies. But it applies on top of settled biology, not instead of it.
The Order of Operations
In my clinical work, I run couples through this order when they show up saying their marriage is in trouble.
Safety first. Is anyone being physically, sexually, or coercively controlled or harmed? If yes, the plan is different from anything in this series. Reach out to a licensed clinician or the National Domestic Violence Hotline at 1-800-799-7233 (or text START to 88788).
Rule out the biology. Full workup for both partners — thyroid, testosterone, estradiol, sleep study when indicated, honest inventory of alcohol and medications, screening for depression, anxiety, ADHD, and trauma. Treat what is treatable.
Then, and only then, do the relational work in this series — presence, curiosity, repair, and rekindling.
That order matters. Skipping the middle step is the reason a lot of couples counseling stalls.
A Word to the Person Reading This Alone
You may be the one whose biology is in the way. Or you may be the partner of the one whose biology is in the way. Both count. Both are common. Neither is a moral failing.
The most helpful thing you can do, before you conclude anything about your marriage, is to have this conversation with a clinician who takes both the relational and the biological lanes seriously. That is not always your primary care provider. It may need to be a specialist.
Whole-Person Steps
Ask honestly — what has changed physiologically in the last few years for either of you? Sleep? Weight? Alcohol? Menses? Medications? New diagnoses?
Get the labs. Both of you. Thyroid panel, testosterone, estradiol/progesterone if perimenopausal, B12, vitamin D, ferritin, A1c, and a comprehensive metabolic panel at minimum.
Screen for depression and anxiety honestly. Untreated mental illness is one of the most under-named relationship dividers.
Consider a sleep study if either of you snores, wakes tired, or wakes irritable.
Do not skip this step. The relational tools work far better on a body that is well.
If You Are in Utah
At Integrative Mind Body Psychiatry, I take the whole picture seriously — the biology, the mental health, and the relationships that shape both. Telehealth for adults, adolescents, and women in hormonal transitions across Utah. Insurance accepted through Headway (headway.co/providers/beth-makar).
Tomorrow: Day 6 — Communication Is Not the Real Problem. What actually is.
This post is educational and is not a substitute for individualized medical, mental-health, or couples-therapy care.
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