110. Why ‘Normal’ Lab Results Can Still Miss the Diagnosis

What if being told “your labs are normal” didn’t mean normal at all—but incomplete? In this episode of Cycle Wisdom, Dr. Monica Minjeur unpacks why conventional testing often misses the root causes of infertility, irregular cycles, and miscarriage. You’ll learn how cycle-informed, time-specific testing reveals the bigger picture and how a restorative approach uncovers answers others often miss.

Imagine if your labs gave you clarity of the whole picture, rather than just unanswered questions.

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Transcript

Speaker: 0:01

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if you were told that your labs were all normal, but it really meant we ran a few tests. And we didn't really look any deeper, but everything we saw looked normal. Today we're gonna be unpacking the lab strategy I use in restorative reproductive medicine, which is time specific cycle informed and looks at your whole body system of health. When we address these pieces in a systematic way, we're often able to uncover the underlying causes behind irregular cycles, ovulation dysfunction, recurrent miscarriages. And unexplained infertility. So let's dive in with a patient story about Julia and Mark. Now, Julia came to me at 33 years old and she and Mark had been trying to conceive for the past 18 months. They had been to her OB doctor and told her labs were normal. So her next step was to try intrauterine insemination. When I received her records that had been done at the OB office, it showed that she had had a. Few tests done. A TSH, which is a cursory test that looks for thyroid function. A CBC, which checks your blood counts A MH, which looks for ovarian reserve and can be a marker used in IVF and a random day. Estrogen level and prolactin. There was nothing that was time to their cycle and there was no male testing that had been done because Mark had been otherwise healthy. Julia came to us because she felt dismissed. She had heavy PMS. Had cycle spotting in the middle of her cycle, and her cycles ranged anywhere from 25 to 40 days. She was told this was still normal, but she knew that all of her symptoms combined may explain why they were having fertility concerns and they wanted answers. Before jumping into another procedure. So as always, we started Julia and Mark with some fertility awareness based charting. This is intended to help us with a specific workup so that we can time labs appropriately and make sure that we look at all of the pieces. Now, I'm going to go into depth as far as everything that we checked, but basically we found that there was lots of different pieces that were going on in their case. In particular, we found that Julia had very low progesterone levels when we timed it to her cycle. She also needed some additional thyroid and autoimmune support, and we also uncovered insulin resistance as well as some factors in the male fertility side that needed some optimization. And although the initial test. Thing that had been done at the OB office was indeed considered normal. The fact is that there wasn't enough evaluation done to really find the underlying clauses, especially when we knew that Julia was having specific symptoms. We understood that we need to be able to treat those symptoms as a sign that something else may be going on. And so even though the initial labs were normal. The follow-up lab testing that we did that was both in depth as well as time to recycle was just incomplete. And the results that we found led us to be able to treat Julia and Mark in a way that helped them to conceive in about eight months later. So let's look at the big picture here. Why does this even matter? And we hear this so often in our practice, we get calls all the time from people saying, I was told my labs were normal. There's nothing else they can do, and the reality here is that infertility is not just about a single lab or even four or five or six different lab tests. We need to look at the big picture and the patterns over time to say what's going on with your cycle? What's happening with your charting as the first step? Then we need to understand what are the different labs. That can help us to determine is that normal or not during a particular phase of your cycle. And so if you can get your labs drawn at any point in time, that's not going to give us much information. Even if you get labs done on cycle day 21, which is oftentimes the standard that women are told, this can miss the picture in many cases now, cycle day 21, testing. Assumes the fact that you have ovulated on cycle day 14, which is not the case for all women, and even in a normal cycle, can vary from cycle to cycle. And so it is so critical that we know the exact day that you are ovulating in order to be able to time our labs. Ideally one week after ovulation, because that's when, for example, your progesterone and estrogen levels should be at their highest point during that phase of your cycle. So this is why it makes all the difference in the world, because if, for example, you ovulated on day 18, cycle day 21 is only going to be three days after ovulation if you ovulated on day 12. Then cycle day 21 is going to be much farther than that one week afterwards. And in some cases, women don't ovulate until cycle day 24. And in those cases, their day 21 labs might show that they're not ovulating at all and lead you down a completely wrong path of evaluation. So this is why it is so critical to understand the exact day that you've ovulated and time the labs appropriately so that we get a clear picture of what's going on. The other big piece here is that it is. So important as to looking at all of the different systems that play a role when it comes to your reproductive health. So of course, hormones are a big part of that, but we also always look at an in-depth evaluation for thyroid inflammation, nutritional status, and particular vitamin levels, as well as insulin and glucose. In addition to this, when we evaluate fertility, we also are looking at male factor because male factor oftentimes goes unrecognized and there aren't often symptoms that correlate with poor sperm production or poor sperm quality. So there are absolutely things that we can do in order to optimize male fertility. And if you wanna hear more about that, go back to listen to episode number 85 where I talk all about male factor fertility. What we evaluate why and how we can make a difference on what happens as far as the male factor that goes into fertility. So our ultimate goal here when we do this in-depth lab work is to identify why there are issues that have arisen, whether that is symptoms that are going on in your cycle. Ovulation problems, implantation difficulty, or early pregnancy failures. All of those pieces are really important to understand the why we're having troubles, and that's what we're looking at, not just a particular functional range to know yes or no ovulation has occurred. Heard, but also to understand what is optimal. So I'm going to walk you through the labs that I evaluate from the female factor side of things today, and we're going to discuss a little bit about why each of these labs are important and the role that they play when it comes to looking at the big picture. Now, as I mentioned, we absolutely always consider male factor evaluation, and I discuss that with couples usually at our first or second visit, understanding that at. Different points that can be done and it does not have to be done timed along with these other labs. The other piece that we always pay attention to is if there is anything abnormal that's showing up on the charting. So for example, if you are someone who has irregular bleeding patterns or patterns that might, uh, indicate inflammation or something else going on. We're always wanting to look at those pieces. In addition, now there are certainly individual hormone factors that can play a role with that, but we always need to make sure that we're ruling out anything that is anatomic infectious or inflammatory that could be a cause of that irregular bleeding. So that absolutely goes without saying, but that's a little bit different from just the lab tests. So let's dig into the lab testing and what we look at as well as why. So the first test that we typically do is what we call our basic hormonal profile, and this is generally done early on in your cycle of bleeding, somewhere between cycle day three, four, or five if cycle day one is the first day of your menstrual bleed. Now, oftentimes this is going to include A C, B, C, which is a complete blood count. This is going to assess for your actual hemoglobin, the amount of blood that you have, both red blood cells, white blood cells, and platelet. And we especially utilize this if we are concerned about heavy bleeding or iron deficiency as a potential clause that may be happening with your cycles. I can also look at a metabolic panel which assesses different things like liver and kidney f dysfunction, as well as your electrolyte levels, a cholesterol panel, and sometimes a hemoglobin A1C, which is a three month average on blood sugar readings. Now, I also oftentimes, instead of the A1C. We'll order a glucose and insulin level or a glucose tolerance test. Now, I talked all about that glucose tolerance test and why insulin is so important in episode number 1 0 7, just a couple weeks ago, and so you can understand why that one is so important. Go back and listen to that episode, but it tells us a lot specifically as far as ovulation function. So the other things that we're looking at in that early part of your cycle, we start off with an FSH follicle stimulating hormone and LH luteinizing hormone. Now, these two hormones are responsible for helping to stimulate ovulation to happen, and so it's a message that goes from your brain to your ovaries and back again, that tells your body, this is the time we are supposed to start working on ovulation, on developing that follicle for this cycle that's going to release the egg. So again, we're looking for optimal levels, and ideally we want an FSH less than seven at this phase of the cycle to tell us that your body is stimulating the follicle and that it's not having to work too hard, which can sometimes be a sign of ovulation dysfunction. We also look at prolactin at this time of your cycle. Now, prolactin is important because if the level is. Too high, it can actually block ovulation from occurring. Prolactin is typically excreted in our bodies when we are pregnant or breastfeeding, and when that level gets high, it tells our body not to ovulate. And so if there are other reasons that the prolactin is elevating, whether it's inappropriate secretion from your pituitary gland, or in some cases a small benign mass, which we call a micro adenoma. That prolactin level can elevate and can actually impair ovulation function. So this is another one that's really important to make sure that the levels are within normal range, not just that they're normal per lab standards, because even a suboptimal level on this can cause some ovulation dysfunction. We also check a cortisol level. Now, cortisol is really tricky in order to pin down, and part of that is because our cortisol levels change drastically throughout the day. But primarily what I'm looking for here is to make sure that your cortisol level is not too low. If it is too low, then oftentimes we see that can be a sign of chronic stress. Our body is suppressing the cortisol levels and we're not making enough cortisol in order to be able to get through our daily functions. In some cases, we see that cortisol is very elevated, and that can be a sign of acute stress at the time that your lab was drawn and can oftentimes be seen in women who are currently taking oral birth control, who are on other types of medications that can increase the stress levels. Or if you are currently fighting off an active infection or going through something else that's stressful, either emotionally, physically, so again, cortisol is just a snapshot in time, but it is a part of this bigger picture that we want to check to make sure we don't have adrenal insufficiency or adrenal burnout. The next set of labs we look at. Focus a lot on androgen hormones, so total testosterone, andro, Stine, Dion, free testosterone. All of these pieces are really important to determine what other symptoms might be impacted by that. So for example, in women that have very high testosterone levels, we oftentimes will see an increase in acne or facial hair growth. In women with really low testosterone levels, I oftentimes see symptoms of decreased libido, fatigue and energy troubles, and sometimes problems with exercise tolerance. So checking testosterone is not just about male factor here. We absolutely need testosterone as females, but again, it is a sweet spot of finding that balance. We also look for something called DHEA sulfate. Now, D-H-E-A-I explain is kind of like the Legos or the building blocks in our body. And what I mean by that is, is that DHEA goes on to create many other hormones that are in our body like testosterone, estradiol, and progesterone. And if we don't have enough of that, DHEA. We don't have enough of those Legos to build together all of the hormones that our body needs. Now, interestingly, DHEA and cortisol are related in that if you are needing extra cortisol in order to keep up with stressful situations or stressful demand from an infection or an illness that you're fighting off, your body will divert its energy towards producing more cortisol in order to keep bodily functions going. In these cases, we oftentimes see that that DHEA level is. Decreased, which then will downstream lead to decrease on your other hormone levels. And so in many cases where we find DHEA deficiency, we see that there are subsequent changes that happen with the hormones, especially if this has been going on long term. So understanding where your stores of DHEA are makes a big difference as to knowing. Why you are getting those low hormone levels, and also gives us an idea of how we need to treat that to improve your levels. We also do at least a one-time screen for something called 17 hydroxy progesterone. Now this is typically associated with a congenital abnormality that can cause problems with your adrenal gland. Which are responsible for hormone production. Now, it's not incredibly common to find issues here, but again, we want to be making sure that we're doing a deep dive so that we exhaust all avenues and make sure that we aren't missing something else that may be causing a bigger problem. The next set of labs that we look at is a full thyroid panel. Now I dig into this in episode number 28, so if you have thyroid concerns or questions, you can go back and listen to that episode. But at a minimum, for me, a full thyroid panel includes a thyroid stimulating hormone free T four, which is a marker of how much thyroid hormone our thyroid gland is actually producing, as well as the breakdown of free and total T three, which is the version of thyroid hormone that actually binds to our cells. And reverse T three, which is the version that helps stimulate ourselves to produce more T three. Now we also look at the thyroid ratio, the total T three, compared to the reverse T three, and it is incredibly common for me to find in these labs that your thyroid gland can be working okay. But your body may be struggling to convert that thyroid hormone from the thyroid gland to the active form of thyroid hormone that can actually bind to your cells. And this can still create significant problems when it comes to how you feel, energy levels, fertility, ovulation, all of those pieces. And so it's. So important that we do more than just a TSH when it comes to thyroid function, as well as to explaining the other symptoms you might be having. We also always are checking for thyroid antibodies because you can have completely normal thyroid labs, but have thyroid antibodies present, and in those cases we want to make sure that we're monitoring more frequently to see if your thyroid changes over time. The last section that we check during this cycle, day 3, 4, 5 test is going to be vitamin levels. So in particular we check for vitamin D, B12 and ferritin, or your iron stores. Now there are certainly lots of other vitamins that we can check for, but these are the primary ones that we see play a role when it comes to fertility hormones as well as optimal pregnancy health. So we're doing a screen at this time. The next time that we check labs is going to be, again, seven days after ovulation. Now, this set of lab tests is much more concise because there's not as much that we need to grab at this time. So generally, we're going to always be checking a progesterone level. And an estradiol level, and oftentimes we'll recheck a prolactin or anything else that might have been abnormal from that first set of lab tests. And so really a much more limited and focused scope there. But again, so critical with this one to make sure that we are getting labs drawn at the appropriate time in order to get the data that we. To make good decisions. Now, one other thing that you'll notice I did not mention here is A MH or that anti-Mullerian hormone. Now, A MH is something that we do test in some of our patients, but again, for me it is not typically the end all be all when it comes to testing for fertility. It can be useful to look at it as a trend of the ovarian reserve. But it is not your fertility destiny. In fact, there have been many cases where we see pregnancy result, even with an A MH as low as 0.03. Now worldwide, I have colleagues that have seen lower numbers even than that, but even a very low number on a MH can still have a successful pregnancy. And again, if we think back to what we're looking at with this A MH, we're evaluating for how much ovarian reserve do I have? If I would need to try and hyperstimulate an IVF cycle, and that's what A MH was designed to do. And in our case, that's not what we need. We're looking just to see, do we have enough to have one egg that is released every month? And in many cases, that's the issue. So when we come back to interpreting all of these labs, what I tell my patients is I don't interpret any lab results. In a void one by themselves. We're looking at a pattern over time. Are your hormones rising and falling as they should and when they should? Are we correlating that with your charting and your symptoms? For example, oftentimes if patients come in that have PMS symptoms, I suspect that there's low progesterone, but I always want to correlate that and see, do the labs actually confirm that before I move forward with treatment? And then most importantly. When we decide on a treatment plan, we want to always make sure that we are reassessing over time, not just an improvement of symptoms, but also an improvement in the labs to make sure that we are on target, that we're not over-treating or under-treating, to make sure that it's actually making a difference in what we're seeing with the labs, with your charting, and most importantly with your symptoms. So I just wanna give you a few practical takeaways from this. So if you are not currently seeing a restorative reproductive medicine physician, I would absolutely advocate for that first. But it's also important to understand even before that point in time, what is being checked, why and when. So, I recommend that before you get your labs or testing done, don't accept the fact that this is the complete list. Ask for timing. What day of my cycle should my labs be drawn? Understand that just because a lab range might list your result as normal, depending upon where you're at in your cycle, it may be considered normal but suboptimal. Or in some cases it may not be normal at all, even if the lab reference range says it's normal. Again, include your partner. Early male testing oftentimes can be at least a part of the equation, if not the whole picture here. So just because your labs are normal. Doesn't mean that there's not something else going on. And again, make sure that you are confirming change. If you have any sort of treatment that is initiated, make sure that you have a follow-up lab test to verify improvement. And this is especially relevant when it comes to. Any sort of ovulation medications. So when you are on any sort of ovulation medication, you should absolutely be getting tested on a regular basis to make sure that the changes are actually making a difference for you. And again, I discussed this much more in detail in episode 94, where I took all about ovulation stimulation medications, and then finally. Please, please, please be aware of at home untimed panels. There is so much out there right now that you can order online kits and tests to do at home, and they say it doesn't matter when you check'em in your cycle, but a random hormone number does not equal a diagnosis. And again, episode number 1 0 2, I talk all about online fertility testing, and I just want people to be aware that that is not the story that's gonna give you the answers that you need. Imagine if seeing your hormones in context meant that you got the right labs, drawn on the right days, and had a complete and full picture of what was going on, not just from a standpoint of your fertility, but also your symptoms and your cycles. Imagine moving from uncertainty to clarity. Because your evaluation honored your cycle, your story, your symptoms, and the whole picture of who you are this way forward is possible. It is a part of what we do every single day at our clinic is help people to find answers. If this sounds like the kind of care you would like to receive, we can't wait to work with you soon.