Integrative Women’s Health Lab Cheat Sheet
Lab Work is context-dependent. It doesn’t make sense to order all the same labs on every individual. But how do we choose at Integrative Women’s Health?
Standard Labs:
“Standard labs” are labs that are typically available at a conventional lab (such as Quest or Labcorp). These labs may or may not be covered by insurance (that is dependent on guidelines and your individual coverage).
Ultimately, standard labs are an ideal place to start with data collection. Below, you’ll find a list of labs by category, with a brief description of what the labs is looking at, and when it might be a helpful tool.
Hormones: Hormone labs can be helpful for a number of reasons. Sex hormones, stress hormones, and thyroid hormones regulate metabolism, mood, menstruation, fertility, and so many more processes.
Hormones are interesting, because it’s not just the absolute values of hormones that impact wellbeing, but it’s also the balance between different hormones that needs to be considered.
Estradiol
Estradiol is the primary estrogen in the body. It is also the primary estrogen used in menopausal hormone replacement therapy. In women still cycling, the range of estrogen can be as low as 12pg/mL around menstruation, and as high as 350 at ovulation. After menopause, it is typically more steady, and often below 35pg/mL.
Estrogen testing is helpful for menstrual irregularities (such as painful periods, PMS, and heavy bleeding) and fertility planning.
Estrogen testing is also helpful for hormone replacement therapy (HRT). In the perimenopausal stage, estrogen can swing wildly. Typically, it is assumed that estrogen replacement helps with perimenopausal symptoms, but in some cases it can cause symptoms to become worse if there is very high estrogen. Testing estrogen is also important after beginning hormone replacement therapy to confirm the level is safe for ongoing use.
Estrogen excess can manifest with PMS, heavy menstrual bleeding, uterine fibroids, acne, and irritability. Estrogen deficiency is correlated with infertility, increased cardiovascular risk, decreased bone density, and metabolic imbalances.
Progesterone
Progesterone is the hormone that rises after ovulation in cycling women. It is an important hormone that balances the effects of estrogen in the body.
Progesterone deficiency can manifest with anxiety, insomnia, PMS, and infertility.
Progesterone typically isn’t trended when on HRT, but gathering a baseline value and a value while on hormones can help confirm appropriate absorption for safe HRT
Free and Total Testosterone (and SHBG / sex hormone binding globulin) + DHEA-S
Testosterone is the most abundant sex hormone in the female body. When too high, it can result in PCOS and insulin resistance. When too low, it can result in slow metabolism, decreased muscle mass, and changes in libido.
DHEA-S, like testosterone, is an androgen mostly made in the adrenal glands. When too high or too low, it results in similar symptoms to excess or deficient testosterone.
If testosterone is found to be out of balance, I follow up with free testosterone and SHBG. Free testosterone testing measures bioavailable testosterone. SHBG measures the protein that binds free testosterone, inactivating it.
FSH & LH (follicle stimulating hormone and luteinizing hormone)
FSH and LH are hormones released from the pituitary gland that stimulate estrogen and testosterone production at the ovaries.
When estrogen and testosterone are high, there is typically negative feedback at the pituitary and therefore LH and FSH decrease (with one exception near ovulation). When estrogen and testosterone are low, LH and FSH are typically higher.
LH surges before ovulation
Sustained elevated FSH is a sign of perimenopause
The balance between LH & FSH is also important. If LH is significantly higher than FSH, this typically results in elevated testosterone, and can be a marker for PCOS diagnosis.
TSH (thyroid stimulating hormone), free T3 & free T4
Thyroid stimulating hormone is produced at the pituitary gland. It stimulates the thyroid to produce T4, which then gets converted to the more active T3.
Low thyroid function (low free t3 and t4, and high TSH) results in sluggish metabolism and fatigue. Overactive thyroid function results in agitation, racing heart, and other signs of overactive metabolism.
In an ideal world, all three of these tests are ordered for any patient when screening for thyroid imbalances. It is possible to have very normal TSH with abnormal free (active) thyroid hormones.
Cortisol
This is the main stress hormone in the body.
When elevated, it can result in resistant abdominal fat and decreased sex hormones.
When reduced, it can result in increased inflammation in the body (since cortisol is a natural anti-inflammatory).
Elevated cortisol can result from mental and emotional stress, but also physiologic stress. For this reason, anything increasing inflammation in the body can also result in persistently high cortisol.
Micronutrients: Micronutrients are great markers to understand if your body is getting the nutrition it needs to perform basic physiologic tasks. It also can elucidate if food changes, or gut healing, are especially important pathways to wellbeing. A full micronutrient panel is rarely covered by insurance, but below you can find a list of common nutrient markers, and when it might be good to order them. It is impossible to characterize every function of the micronutrients listed below, but you will find primary processes they support. If only one or two micronutrients are deficient, supplementing with individual nutrients is reasonable. If two or more are deficient, I typically recommend high-quality broad spectrum multivitamin supplementation such as options found on fullscript.com.
Ferritin (and other iron labs)
Ferritin helps the body move iron, and therefore oxygen, throughout the body, which is essential for metabolism. Low ferritin results in anemia, fatigue, and many other conditions.
Vitamin D
Vitamin D is important for the immune system, neurotransmitter production, and hormonal balance. It is commonly deficient since we are spending more and more time inside . Ideal vitamin D levels are 50-100 ng/mL.
Magnesium
Magnesium is important for detoxification, musculoskeletal comfort, neurotransmitter production, and hormone balance.
Zinc
Zinc is important for immune function and wound healing
Iodine
Iodine is necessary for thyroid hormone production. In rare cases in the US, it can be the underlying cause for thyroid dysfunction- ironically this is more likely in more health-conscious patients who choose natural himalayan salt over iodized salt, for example, and avoid processed foods that otherwise also have iodized salt
Homocysteine (a B12/folate marker)
Homocysteine is a sensitive marker for B12 and folate deficiency. When elevated, it means the body needs more of these B vitamins. It is important for energy production, metabolism, normal nervous system function, and detoxification.
Inflammatory and autoimmune markers: Inflammatory markers are helpful to understand how much physiologic dysfunction might be related to inflammation. Not everyone with inflammation has the same positive inflammatory markers. Inflammatory markers are helpful because when pursuing a functional medicine plan, one primary goal is to reduce the levels of inflammation in the body, and these labs provide a quantitative measurement of inflammation.
CRP (C-reactive protein)
This is a common go-to initial inflammatory spot check because it is typically (but not always) one of the first measurable signs of inflammation in the body. HS-CRP (highly sensitive CRP) is a more sensitive marker for inflammation than a standard CRP order.
ESR (erythrocyte sedimentation rate)
ESR is another common inflammatory marker. It can be helpful to trend if there is strong suspicion of inflammation that didn’t show up on CRP testing.
RF (rheumatoid factor)
RF is an inflammatory marker more specific to rheumatoid arthritis. Ideally it is ordered for any patient with joint aching as well as suspected high inflammation, to rule out autoimmune arthritis
TPO (thyroid peroxidase antibodies), thyroglobulin antibodies, reverse t3
TPO and thyroglobulin antibodies are inflammatory causes of thyroid dysfunction. If they are positive, focusing on reducing inflammation is an essential part of the thyroid recovery plan.
Reverse t3 is a marker of how much inflammation in the body is impairing the thyroid hormones from doing their job
ANA (antinuclear antibody)
This is the most common marker for autoimmune disease. If this is positive, I often recommend patients work with rheumatology in addition to our functional approach.
Metabolic markers and other standard labs: These are labs important for understanding metabolism, cardiovascular risk, and diabetes risk.
Comprehensive metabolic panel (CMP)
A CMP includes markers for kidney and liver health, electrolytes, and pH balance. When looked at with a keen eye, it can also elucidate chronic dehydration and protein malnutrition.
Complete blood count (CBC)
A CBC measures red blood cells, white blood cells, platelets, and markers of anemia and normal blood production. It can give clues about nutrition status, inflammation in the body, and microbial imbalances in the body.
Hemoglobin A1c
A1c is a 3-month blood sugar average. It is a helpful marker for general blood sugar balance.
Fasting Insulin
Insulin is released when the body consumes carbohydrates. However, this is also a low level baseline insulin secretion. If the body is accustomed to a lot of refined carbohydrates, insulin resistance can develop, and then the baseline insulin levels are elevated.
Fasting insulin is a measurement of insulin resistance that changes more rapidly than a1c, so can be a great marker for more recent dietary changes.
Lipid Panel
The lipid panel looks at good and bad cholesterol. It is helpful for evaluating metabolic dysfunction and cardiovascular risk..
Ordering standard labs, and getting them covered by insurance is an art. Not all labs can be ordered at once, and not all labs make sense for every patient. It’s important to understand why your provider is ordering certain labs, and don’t be afraid to ask for additional information. A great provider will take the time to help you understand why certain labs may or may not make sense for your health goals at any given time. If you don’t have good insurance coverage for standard labs, please know that there are companies that offer cheaper cash rates if you are willing to pay ahead of time. Lab data is often expensive, and financial conversations with ordering providers are important.
Functional Labs:
Functional labs are not covered by insurance for the most part. However, they are robust panels that peer into the body through an entirely different lens. Here is an incomplete list of functional labs available, including the ones typically ordered at Integrative Women’s Health (please note, not every patient needs functional labs, so if they are cost-prohibitive, know a lot of excellent information can be gleaned from standard labs and your health history alone if necessary).
Microbiome and other Gut testing:
GI Map or GI Effects +/- zonulin: $250-400. These are microbiome and gut integrity stool tests to evaluate any patient with persistent IBS symptoms, or patients with persistent imbalances manifesting with skin rashes or acne, hormonal imbalances, elevated inflammation, or micronutrient deficiencies.
Food Sensitivity Testing: $220-500. Food sensitivity testing is helpful to evaluate what foods, in the short term, can be eliminated to support gut healing and reduced systemic inflammation. Please note, food sensitivity testing WILL INCLUDE false positives. If the gut is very inflamed, there will be more false positives. The best way to use a food sensitivity test is to create a targeted elimination diet based on the results. After that period of time, where the gut was allowed to heal, methodical reintroduction of foods while tracking symptoms helps you understand which results were true positives, and which were temporary positives because of overall gut dysfunction.
SIBO Breath testing: $200-300. Often this is best ordered by PCP or GI specialist in order to have it performed in-office, and therefore be covered by insurance. However, if this is not an option, it can be performed through functional lab companies as well. In this case, SIBO testing can be done by mail-in functional labs. SIBO can also sometimes be inferred by GI Map or GI Effects microbiome testing, but breath testing is a very sensitive marker for how active certain microbes are in actually producing the gas that is causing discomfort in SIBO.
Functional hormone testing:
Salivary or Urinary Cortisol testing: $115-250. This is a much more comprehensive way to view cortisol than can logistically be collected at a standard lab. Cortisol fluctuates throughout the day, ideally at it’s highest shortly after waking, and declining throughout the day. The at-home functional tests provide readings for 4 or 6 times throughout the day, to better understand if your body is producing optimal levels in a more holistic sense.
DUTCH testing: $300-500. This is a comprehensive urine sex and stress hormone panel. The DUTCH test can be a great tool if it is important to understand cortisol levels throughout the day. It can also be helpful if you want to understand how well your body detoxifies specific metabolites (breakdown products) of hormones, which becomes even more important if there is a family history of breast cancers or an inflammatory estrogen condition (such as endometriosis).
Genetics testing:
3x4 Genetic Testing: $300. My favorite part about genetics testing is that the results are valid for a lifetime. As testing evolves, more comprehensive genetics testing will become available. For the moment, my favorite test is the 3x4 genetics because it is a nutrigenomics company. This means that they give you actionable diet, lifestyle, and supplement recommendations to help your genes behave as best they can. I find genetics testing helps guide us on what sort of support your body may need in general for longevity and disease prevention. It clusters SNPs (single nucleotide polymorphisms) into categories such as detoxification, inflammation, mood, metabolism, etc… to help us identify key genetic patterns that your body may require additional support for.
Occult inflammation probing: Occult inflammation is not a primary specialty at Integrative Women’s Health, but when other labs don’t quite make sense, it can be helpful to start investigating possible sources of physiologic imbalances.
Organic Acid Testing (OAT): $250-500. This is a good test if you want a broad perspective of many systems in the body when there are chronic conditions and inflammation from an unknown source. It includes general markers for bacterial and yeast growth in the body (with specific markers for clostridia species), oxalate intolerance markers, neurotransmitter breakdown products, mitochondrial dysfunction markers, some micronutrients, and a few additional items. This test often leads to more targeted testing of the gut, neurotransmitters, toxins, or genetics.
Heavy Metal Testing: $80-250. Urine and hair heavy metal testing is robust and cost effective. It is also a reasonable and cost-effective surrogate marker for how much support the body needs with detoxification.
Mold Toxin & Environmental Toxin Testing: $350-800 mold and environmental toxin testing can be considered if the OAT test shows suspicion for toxins, if there has been potential exposure to these toxins, or if there is a chronic inflammatory condition that warrants further investigation. If these labs return positive, a genetics test might be helpful to understand if the body generally needs support with detoxification.
Lyme Testing: $600-2000+ Lyme and tick borne diseases can result in distressing ongoing symptoms, often characterized by fatigue and multisystem imbalances. The functional Lyme tests are very expensive from a functional perspective, so I often refer out if I feel it is absolutely necessary to get a second opinion above standard Lyme testing.
Hopefully this Lab guide has provided you with information that empowers you to feel confident when you have in-depth conversations with your providers regarding lab ordering and symptom investigation!
Sincerely,
Jessica Kolahi
Please note that some of these labs overlap with what a primary care provider might be ordering. While Integrative Women’s Healths strives to support whole-body healing, especially for women with hormonal imbalances, women struggling with fertility, and women in perimenopause (and beyond), it is required that all patients have a PCP. That way, we can focus on health optimization, while your PCP can make sure you are up to date on screening tests, and be certain you are medically safe.
Copyright Integrative Women’s Health SF 2024
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