Episode #194: How “Normal Labs” Miss PCOS Dysfunction

Have you ever sat in your doctor’s office, described everything that you’ve been experiencing, and then been told, “Your labs look normal,” and then dismissed? Like, that was the end of it, and you walked out of that appointment holding two completely contradictory pieces of information: the paper that says everything is fine—your lab work—and your body that very clearly is telling you that something is off.

If this has happened to you, then today’s episode is going to be very validating, but also it’s going to help you see where this happens and what you can do to still find out what is going on with your body, even when your labs are normal. Now, you may have some abnormal labs. This episode is still going to be really helpful because it’s going to show you really what goes on beyond the labs.

So let’s dive into what your symptoms are telling your body, how they are actually real, valid communication and something that’s very meaningful and that we don’t want to brush off.

Welcome back to the PCOS Repair Podcast. Hi, I’m Ashley, and I’m so glad that you are here listening today. If you’re new to this podcast, this is where we talk about PCOS information that is grounded in science, but with a practical approach that isn’t an all-or-nothing, overly restrictive approach, but an actually doable, sustainable option that will get you real results.

In this episode, we’re talking about lab work, blood work, things that test your blood sugar, your inflammation levels, your stress levels, all of those things. The things that test your reproductive hormones, like testosterone, estrogen, progesterone, and what specifically is going on in that gap that can exist between what your labs are showing and what you are experiencing in your body.

Because I want to be really clear here before we dive into the meat of today’s episode: lab work is extremely valuable. It gives us data points. All of you that have been listening for a while know that I can nerd out on the data points of how we track things and keep track of what’s going on in our body to see the trend so we can see our progress over time.

But it’s also really important to understand that labs can’t tell us everything. Lab work has ranges of normal. And when it comes to hormones, the slightest change from our normal is really, really a big deal. And so we may be going up and down in the normal range and still be having a significant change for us, which is why, back to those data points, having some starting baselines is really beneficial. So I’m not anti-lab at all, but I think that it’s really important to know what it’s testing, what it’s showing us, and where there may be some gaps in the information that it can provide.

So here’s an experience that I hear in some form or another over and over consistently when talking to women with PCOS. You’ve been struggling for a while with things like fatigue that sleep doesn’t fix. With cravings that feel completely out of control. Irregular cycles or cycles that have disappeared entirely. Acne that’s returning in your 20s and 30s with deep cystic acne that just seems to never go away. It’s painful. It takes forever to heal.

It leaves marks behind. Weight changes that make no sense at all. You gain weight even when you’re eating well. You can’t lose weight even when you’re restricting calories. Inflammation that makes you feel heavy and uncomfortable in your own body.

If any of this sounds familiar, and then you’ve gone to your doctor, you describe all of these symptoms, and they seem really hopeful that, “Oh yes, I think we have an idea of what you have going on. Let’s run some tests and see what’s going on.” They order the blood draws, they take the blood draw, you hear that the results are back in, and you go and talk to your doctor, and then you get this call or this portal notification. Maybe you don’t even get to talk to your doctor anymore, and you get the lab results back and everything is normal.

In this moment, all of a sudden we start to feel two things. One, “Oh yeah, everything’s normal. I’m fine.” And then there’s this sinking feeling of, “But I’m not fine. And now we don’t know why.”

So we had this hope. We told all of our symptoms to somebody, we made this appointment, we got there, we went through all of the steps, we got the results. We did all the work to get the results for them, and then we get these results back and they don’t tell us anything useful.

And this is the moment when we generally don’t know what to do with this information because, on one hand, normal is great. It sounds like a relief. But on the other hand, normal does not match how we’re feeling every day. So this is one of the biggest ways I think that women with PCOS feel very dismissed because their symptoms are real. If you’ve had this happen to you, your symptoms are real. They’re your body trying to communicate with you, and we shouldn’t dismiss them.

We shouldn’t just be like, “Oh, everything’s normal.” We should say, “Oh, your labs are normal, so let’s go to our second layer of discovery.”

Because this dismissal, even if it’s not intentional, has real consequences. We stop advocating for ourselves. We internalize the message that maybe it’s all in our head, that maybe it’s not that bad, maybe we’re being dramatic, maybe we just need to try harder because we just don’t have enough self-control—that’s why we have cravings. We’re just lazy—that’s why we’re so tired—and it doesn’t seem to be because we’re not getting enough sleep.

This isn’t the case. Okay? That’s really important to understand.

So what I want you to understand, if the only thing you walk away from this episode with, is that normal labs and optimal physiology are not always the same thing. And symptoms often tell the story way before labs can catch up.

So what are the labs, and what are they able to tell us, and what are they not able to tell us?

First of all, we have to understand that labs, in the medical world, we use them as a tool. And I think as people who are non-medical, we think of them as this magic insight into our bodies. But let’s look and see what they really are. First of all, labs are a reference range that is largely built around average populations.

Also, when it comes to PCOS, most women being diagnosed and treated with PCOS are 40 and under. Now, that doesn’t mean our PCOS goes away once we’re 40, but most people who are being diagnosed are under 40. Every once in a while, someone slips through the cracks—in fact, more often than they should—and they get to be older before we discover that they have PCOS.

But for the most part, we’re younger, which means that a lot of the labs that we are testing are not designed for us. Okay, so when we think about all of the blood sugar labs—hemoglobin A1c, insulin, fasting insulin, fasting glucose, your glucose tolerance test—a lot of these things are used for people who are approaching later middle age, to somewhere in their 50s to 60s and beyond. And they’re using these labs to diagnose type 2 diabetes.

But here’s the issue with PCOS.

A lot of our symptoms are because our body is more sensitive, and we’re being sensitive to and noticing that we have started down that path toward type 2 diabetes, and our body is reacting to it very strongly. However, we’re still young and our body’s able to compensate for it.

So we may have blood sugar that’s bouncing all over the place, but our body is able to compensate for it relatively well. So our insulin levels are high on average, if you think about the average circulating amount of insulin throughout the 24-hour period, but our hemoglobin A1c is fine. Our fasting insulin is probably fine. Our fasting glucose is probably fine.

Unless we did an insulin tolerance test, we probably wouldn’t pick up on anything. And even then, we probably wouldn’t be all that amazed by what was happening.

However, when our symptoms deal with that insulin spike, here’s what happens. We begin the sugar roller coaster.

We eat something that perks us up because we feel flat. So we eat something that perks us up. It perks us up because it spikes our blood sugar, but then the insulin comes crashing in and it plummets our blood sugar. We’re slowly developing some resistance here, but it’s not enough to show up on labs yet. And because of that, we’re getting more insulin than somebody who hasn’t started to develop that insulin resistance for the same amount of sugar that we ate.

That plummet makes us crave sugar again because we feel low, we feel depleted, we need that other boost. So this is the roller coaster where we go up and down, up and down, up and down, and we do it in short increments throughout the day. As we do this, we keep adding more insulin to our system. That insulin tells our ovaries to produce more testosterone.

Then the whole PCOS cascade just comes from there.

That is an example where very little of that is going to be very profound on laboratory results. So the takeaway here is that all of that is real. All of that is physiologically and scientifically based and happening in your body. However, it will not be picked up on labs.

It’s going to require further investigation. It’s going to require someone who can listen to your symptoms and has an inkling of what’s going on and can direct you in the right way.

Then the second piece that’s important to remember is that these labs are not created for optimal health. They are created to catch advanced disease or to catch the beginnings of advanced disease. They’re not geared to catching unoptimal health.

And that’s a big distinction when you think about someone who is in optimal health. They’re very fit, they’re very strong, they eat amazing nutrition. If you took their labs, everything would be normal, right? I mean, unless they had some other disorder going on, but most likely everything would be normal. For this example, everything is normal.

But at some point, if something was going on in their body, if they were developing something, if they weren’t eating perfectly, at some point things start to develop. These labs are not designed to catch them at the beginning of something developing. These labs and these reference ranges are designed to catch them later on in progression.

So this is where it’s important to recognize these labs were not designed for women with PCOS, which isn’t—I mean, we have to just kind of use the tools we have, and over time maybe we can start to develop protocols of where really these levels should be for someone who’s in their 30s, right? But these were typically labs that we would order on people after 40 and 50.

So that’s a really important part to recognize.

So as we think of the physiological changes that are going on, these gradual, natural physiological changes, hormone signaling does not shift overnight. The dysfunction did not suddenly appear, right? It develops slowly in response to accumulating environmental stress, metabolic load, inflammation, undernourishment, all of the things that are going on in our environment that contribute to our PCOS.

And during these gradual developments, our body does what it was brilliantly designed to do, and especially at this younger age of PCOS, it does it brilliantly, and that is to compensate.

It adapts. It works harder. It maintains the markers that are keeping you functioning. And this is really important because that’s what’s keeping your labs looking normal even though your body is under distress.

But while it is compensating, these symptoms are beginning to appear because your body’s energy is depleted. So your energy is dropping, the cravings are intensifying, the cycles are becoming irregular, your skin is reacting, your mood is shifting, because the body is doing its best to adapt to the environment that it’s living in, but it is struggling.

And this is why your symptoms are so important, because they are telling us something very important. They are raising their hand and saying, “Hey, I’m struggling over here. I need help.”

So when the environment has been asking too much of our hormone system for long enough, the compensation starts to show cracks, not necessarily in dramatic lab abnormalities, although they will eventually show up, but in lived experiences of your symptoms.

Stress physiology and inflammation may not always have as clear of a path as I demonstrated in the insulin situation, but they still have the same type of scenario going on under the surface. That body is experiencing chronic inflammation. Your body knows it, you feel it, and those symptoms produce real information.

Ovulation and cycles, they are some of the first things to show that the body is struggling because our bodies know, “Hey, if I’m struggling, the first thing I need to just take off the table is fertility.”

Again, though, here labs like progesterone, estrogen, testosterone, they are so sensitive that the slightest shift even within the normal range can feel drastic to you. So that’s something that makes it really important to see over time and the trend of it over time.

And so it’s really important to have someone get those lab markers, whether or not you feel like everything else is normal. Why would those be different? It’s good to get the baseline of what they are, and even if they were normal, it’s good to retest them in three months, six months, especially if you’re doing things to help regulate them.

So here, let’s shift a little bit and talk about what your symptoms are actually telling you and how they are really empowering change. Because I think a lot of women’s symptoms feel like a source of shame, frustration. They can feel like this negative thing.

And I think if we can reframe our body symptoms as a negative and change them into a positive—”I’m so glad you let me know that information”—then we can begin to be curious, to learn and understand the physiology that’s changing under the surface. And then it’s how we can start to address our PCOS.

When we understand that our fatigue is telling us something about our cortisol rhythm, about our adrenal load, about our inflammation, and it’s not trying to say, “Hey, you’re lazy. You’re just not putting in the discipline and the effort that you need to be,” I think we can really make better progress.

When we get hungry, we don’t think, “Oh, my body’s broken. I shouldn’t feel this.” We think, “Oh, I’m going to need to get some food soon.” And that’s the type of feedback that our body’s trying to give us. And so if we can shift from it being like a good or a bad thing and just, “Hey, it’s just feedback,” then we can start to really see and understand and listen to our bodies.

When we understand that our intense cravings are telling us something about our blood sugar stability, about our insulin sensitivity, they stop being evidence of poor willpower and become feedback worth listening to.

When we can understand that our irregular cycle is trying to tell us something about our overall physiological safety and how our body perceives our stress levels and our safety, it stops being this random malfunction, “We’re broken,” and becomes one of the most sensitive vital signs that we have available to us inside of our body, even better than our pulse. I mean, that’s probably an urgent one, but it’s way better than some of these other things like our blood pressure. And it really tells us how our overall health is doing. It gives us a window into what’s happening inside of our body.

Symptoms provide meaningful feedback, so pay attention to them even when the labs are normal. You’re not a hypochondriac. You’re not being overly dramatic. This is called physiological literacy. You’re learning to be literate in your own physiology, and it’s one of the most empowering things that we can develop as women with PCOS.

It allows us to have context and to not just be dismissed, but to see it as an invitation to dive a little deeper to see what’s going on.

I want to close out this conversation today with something that is really important to me. Everything to me is about balance—balancing hormones, balancing our lifestyle. And I’m not here to tell you that labs don’t work and don’t matter. They absolutely do. They’re wonderful.

I love labs. Labs are valuable. They’re important and often an essential tool. And to get a comprehensive workup, oftentimes I’m advocating for women to get all of the labs, even though they may or may not be super beneficial in the moment, they’re still very beneficial to get done.

Whether or not they tell us information has less to do with whether it was good to see if they told us information, if that makes sense. A comprehensive and thoughtful lab panel, including markers like fasting insulin alongside a fasting glucose, inflammatory markers, a full thyroid panel, checking your vitamin D levels, and all of the reproductive hormones, can provide all of us genuinely meaningful information.

And I recommend that you get the majority of those tested every year. And if you’re making changes to improve some of them, maybe every three to six months for a little bit of an increment there until you kind of get things where you want them to be.

What I’m trying to say here is that labs are a tool, one of many, and they are most useful when interpreted alongside your symptoms and not in isolation.

When we look at your symptoms, your family history, your personal medical history, and your physiological context—not one of those in isolation, but all of those together—that’s when we get beautiful information. We start to understand patterns.

It creates a path forward for us.

When we understand this gradual nature of hormone change, when we can understand that it’s compensating, that it can be sort of making it work even in a dysfunctional state, it shows clearly on some labs, not on others. And you can understand that your symptoms are meaningful data points in their own right.

And so it’s not one or the other. It’s the two of them in combination.

And that’s the shift from being a passive recipient of a lab result to an active, informed, physiologically literate participant in your own health. And it’s just one of the most powerful things that we can start to be a part of on our PCOS health journey.

So I hope you found today’s episode helpful, not just from a standpoint of learning the limitations and the value of labs, but also from learning how important it is in all of these pieces to not just take one answer as, “Oh, I guess that’s just the way it is.”

But if you’re struggling with something, advocate for yourself. Understand that your symptoms matter, that they mean something.

And if you found this episode helpful, I hope you hit that subscribe button so that you get notified each and every week when a new episode of PCOS Health becomes available. I also hope you share this episode with anyone that you think may benefit from hearing more about how PCOS and the physiology and the lab work and all the information would be helpful for them.

So with that, I hope you found this episode helpful, and until next time, bye for now.