I have heard too often now, "my doctor says my labs are normal, but I feel like something's missing."
Sometimes bloodwork can only take us so far in figuring out root causes. However, there is so much more beyond the typical annual lab panel that can give us better insight into where to go next, perhaps with more speciality testing, or with simply understanding how to support you better through nutrition, lifestyle and natural medicines.
Maybe you are familiar with having your CBC, CMP, hemoglobin A1c, cholesterol and TSH checked every year, and they always come back relatively fine.
Firstly, there's "fine" and then there's optimal. So we'll chat about that. But also, if the testing stops there - SO much was missed.
THE GUIDE TO HOLISTIC ANNUAL LABS:
Let's start with the CBC or Complete Blood Count which should really begin the conversation of your nutritional health and immune system balance. The CBC shows the spectrum of red and white blood cell activity in the body. Clinically, it can tell us about certain types of anemia and red blood cell issues, as well as how well your immune system is working when it comes to white blood cell health. By the way, if your white blood cell count is consistently in the 3s or 4s (which is SO common that it is basically considered normal), we absolutely need to look deeper at your immune health.
What complements the CBC that is not routinely done but gives us so much more information?
Ferritin (the iron storage marker) - a common deficiency (with or without anemia present). Your CBC can be completely normal and you can STILL BE iron deficient, which significantly impacts energy and stamina. Ladies, iron deficiency can make our periods heavy and peri-menopause a bear - this HAS to be checked. For men, who more commonly have iron OVERLOAD, this is also useful to check because elevated iron levels are quite inflammatory. Look for an ideal level greater than 50, less than 150.
Vitamin B12 - a common deficiency which can impact energy levels. This may show up on the CBC as larger red blood cells, but most often does not. Look for a level of at least 600-800.
Vitamin D - a common deficiency which can impact immune function/inflammation. If your white blood cell count (WBC) is low, this is one of the things that needs to be evaluated as part of an investigation into why the immune system is suppressed. Look for level of 50-80.
Homocysteine - a marker of methylation status and potential B12 deficiency. If you have never heard of the MTHFR gene variations or methylation, I will have you head over Dr. Ben Lynch's website and read the book "Dirty Genes." It's a BIG conversation and one for another time! Look for a level of less than 10.
Next up, that CMP or comprehensive metabolic panel. This test is done to assess liver, gallbladder, kidneys, electrolytes, and fasting blood sugar. While this is a useful screen for major metabolic issues, and disease within the mentioned organs, it may not show us the trouble that is brewing. Hemoglobin A1c (a marker of your average blood sugars) and the cholesterol panel are annual labs that can shed additional light on the health of the metabolism, but more is so needed!
What complements the CMP, A1c and cholesterol panel that is not routinely done but give us so much more information?
Fasting Insulin level - to assess insulin resistance which commonly elevates prior to blood sugar issues. Look for a level of less than 7. If you insulin is up, your blood sugar will follow even if it is normal right now. By the way, I have heard from many clients that they were not informed that their hemoglobin A1c level was in the prediabetic range of 5.7-6.4. If this is you, reversal is key and can be done now with lifestyle and dietary changes.
Advanced Cholesterol/lipid panel - an advanced panel can check the size and shape of your lipid particles. If you have been told you have high cholesterol, or have a family history of heart disease, this helps us stratify risk MUCH better. Cholesterol is not the enemy, but there are healthy metrics and riskier ones.
CRP (C-reactive protein) - an inflammatory marker that can be utilized as a general screen for inflammation in the body. Ideally this should be less an 1, although normal is less than 5. If your CRP level is up, we need to look at your sleep quality, stress levels, nutrition, and exercise as foundational contributing factors. I will often assess GI health here, as sometimes the CRP is elevated due to GI inflammation or "leaky gut" - a topic for another post!
Lastly, when it comes to hormonal health, a TSH or thyroid stimulating hormone, is a sad investigation on its own. Very often I see a "normal" TSH in clients who have classic hypothyroid symptoms, only to find that when we do a FULL thyroid panel, some other metric is off. Also, know that the normal range for TSH goes up to 4 or even 5 depending on the lab, but an optimal level is 1-2.
What complements the TSH that is not routinely done but give us so much more information?
Free and total T4 - shows us the amount of inactive hormone your body is producing from the thyroid gland. Enough T4 means you have plenty of reserves from which to make the active form of the hormone, T3. Look for mid-range levels.
Free and total T3, and reverse T3 - shows us what is up with the active, available form of thyroid hormone. If you have enough T4 but not enough T3, we likely need to work on conversion which depends on certain nutrients, healthy stress management, regular physical activity, and a happy gut. A free T3 needs to be at least 3.
Thyroid peroxidase (TPO) antibodies and thyroglobulin (TG) antibodies - these are present in Hashimoto's thyroiditis (the most common cause of hypothyroidism). Measuring antibody activity ensures we are addressing thyroid health through the lens of the immune system. If your doc says there is no point testing these, let's talk. There are EVIDENCE based strategies to LOWER your Hashimoto's antibodies which may improve thyroid function and most importantly, make you feel better.
Sex hormone health: This is nuanced, but a sex hormone panel can be useful in certain circumstances for fertility purposes, menstrual cycle health, libido, fatigue, etc. For men: LH, estrogen, testosterone (free, and total), sex hormone binding globulin, and DHEAS at any time of the month. For women: LH, FSH, estrogen, progesterone, testosterone (free, and total), sex hormone binding globulin, and DHEAS - collected in the mid-luteal phase of the menstrual cycle (day 21 of a 28 day cycle), or anytime for post-menopausal women (note: post-menopause, the LH, FSH, estradiol, and progesterone are not useful unless planning for hormone replacement therapy).
*A note about labs... Many providers are not comfortable ordering labs that they are not familiar with interpreting. This means that even if you have a provider agree to this list, they may not be able to guide you through the results in a helpful way. Best to work with a naturopathic or functional medicine doctor who runs these routinely.
Lab List At A Glance:
Complete blood count (CBC) - to assess red and white blood cell health and immune function.
Ferritin (iron storage) - a common deficiency (with or without anemia present).
Vitamin D - a common deficiency which can impact immune function/inflammation.
Vitamin B12 - a common deficiency which can impact energy levels.
Homocysteine - a marker of methylation status and potential B12 deficiency.
Comprehensive metabolic panel (CMP) - to assess liver, kidneys, electrolytes, fasting blood sugar.
Hemoglobin A1C - to assess your average blood sugar.
Insulin - to assess insulin resistance (can elevate prior to blood sugar issues).
Cholesterol/lipid panel - to assess basic cholesterol health.
Advanced lipid panel or lipid fractionation testing (such as the Cardio IQ from Quest) - to assess the size and shape of the lipid particles, LDL particle number, and other independent risk factors for heart disease.
High sensitivity CRP (hsCRP) - an inflammatory marker that can be utilized as a general screen for inflammation.
Thyroid: Thyroid peroxidase (TPO) antibodies, thyroglobulin antibodies, TSH, Free and total T4, Free and total T3, and reverse T3
Hormones: LH, FSH, estrogen, progesterone, testosterone (free, and total), sex hormone binding globulin, and DHEAS.
I hope this is helpful guidance as a resource. Don't allow normal annual bloodwork to make you feel crazy for having symptoms that aren't showing up on paper. Either the right tests weren't done, or the right conversation about your history, symptoms or lifestyle was not had.