When Your Bloodwork is Normal but You Know Something Is Off

“​W​​ell, everything looks pretty normal.” This is exactly what you want your doctor to say, right?

For years before my cancer diagnosis, that’s what I was told. But I knew something was off: I was too tired for someone who ate well and exercised regularly. Eventually, I started paying out of pocket to see functional medicine doctors and naturopaths who ordered fancy, high-hassle hormone panels.

Those came back fine, too; my hormone levels were “normal for my age.” Low estrogen was just…expected. A number in range. Nothing to see here, folks. A naturopath sold me expensive supplements to boost my energy and estrogen, which I took dutifully. What else could I do?

Then I was diagnosed with breast cancer, and in the flurry of testing that followed, a different picture emerged: I had metabolic dysfunction, and I was highly inflamed.

The seven simple tests below showed that I had been suffering from low levels of chronic inflammation and oxidative stress for years. Oxidative stress is the wear and tear that builds up when your body produces more free radicals than its antioxidant defenses can neutralize, damaging your cells, proteins, and DNA. It’s essentially rust inside your cells, the same kind of oxidation that corrodes metal.

Oxidative damage to DNA is one of the ways healthy cells turn malignant; it’s a cause of cancer. I will never know for certain what caused my cancer, but I do know the years-long process quietly damaging my metabolism and inflaming my body would have been visible years earlier if I’d just been given the right blood tests.

As we age, or if we aren’t feeling well, it’s worth tracking how sensitive we are to insulin, and how inflamed we are. These two systems are linked to many of the chronic diseases that shorten and diminish the quality of our lives, like dementia, diabetes, and cancer. And, not coincidentally, estrogen loss quietly degrades both systems.

Disclaimer: I have a PhD, not an MD. I developed this list with my own primary care physician and with Jill Foley, MD, who is the Chair of the Women’s Health Service Line at Sutter Health.

System one: Metabolic Health

Hemoglobin A1c (HbA1c) and fasting insulin. HbA1c is a proxy for your average blood sugar over the past three months. It’s a late signal: it doesn’t budge until blood sugar has already started to climb. Fasting insulin is an earlier warning. Typical labs measure fasting glucose (your blood sugar on the day of your blood draw), which, like mine, can read as normal for years while your body quietly produces more and more insulin to keep it that way. In one landmark study, insulin sensitivity, estimated from fasting insulin, was already declining steeply over the five years before a diabetes diagnosis, but fasting glucose didn’t accelerate until the final three.

A full lipid panel, plus ApoB. A standard panel gives you LDL, an estimate of the “bad” cholesterol in your blood. ApoB counts the number of actual artery-clogging particles. When those two numbers disagree (in insulin-resistant people they often do), ApoB tells a truer story about cardiovascular risk, which is why cardiology guidelines increasingly recognize it. Most doctors won’t order this one unless you ask.

Liver enzymes: ALT, AST, GGT. These are probably already in your chart even if nobody has ever walked you through them. Mildly elevated ALT and AST are often the first sign of metabolic dysfunction associated with fatty liver disease, which is a consequence of insulin resistance. GGT is often dismissed as a marker of heavy drinking, but it can hint that your metabolism is struggling. And because it recycles your body’s master antioxidant, high GGT is also a flag for oxidative stress and inflammation.

System two: Inflammation

hs-CRP. A standard CRP will catch the roaring inflammation of an infection; the high-sensitivity version (the “hs” in hs-CRP) detects the low, smoldering background inflammation linked to cardiovascular disease and the general wear and tear of aging. In one large study of women, hs-CRP was a stronger predictor of cardiovascular events than LDL cholesterol.

ESR (erythrocyte sedimentation rate). Paired with hs-CRP, ESR helps distinguish a one-off blip of inflammation from a persistent pattern.

Oxidized LDL. This is cholesterol that’s been chemically damaged by oxidative stress. Free radicals chemically damage LDL cholesterol, creating oxidized LDL that is more likely to become plaque that sticks to blood vessel walls.

In addition to being a valuable marker for cardiovascular health, oxidized LDL is where metabolic health and inflammation systems meet. When our cells convert sugar (glucose) into energy, the process generates free radicals, much like an engine produces exhaust. When blood sugar is chronically high, our antioxidant defenses are overwhelmed by exhaust (free radicals). That’s oxidative stress. High levels of oxidized LDL are an indicator of oxidative stress.

Oxidative stress disrupts insulin signaling, weakening the “let glucose in” message that insulin sends to move glucose out of our blood and into our cells, where it is converted to energy. That’s the insulin resistance that causes diabetes.

Estrogen helps keep that “let glucose in” message strong, and it doubles as one of the body’s own antioxidants. So when estrogen levels fall, the signal weakens, and oxidative stress rises.

High glucose also feeds oxidative stress through a few side doors: excess sugar sticks to proteins and fats (a process called glycation, which is what HbA1c measures), and those sugar-damaged molecules (AGEs, or “advanced glycation end-products”) themselves generate more free radicals. So chronically high blood sugar hits from two directions at once: it produces a lot of free radicals, and it litters the system with sticky, reactive debris.

It’s a vicious cycle: oxidative stress worsens insulin resistance, which raises blood sugar, which in turn increases oxidative stress.

What to ask your doctor about

Here are measures your doctor probably already has on file (or can easily add):

• Full lipid panel (HDL, LDL, total cholesterol, triglycerides)
• HbA1c
• Liver enzymes (ALT, AST, GGT)

You may have to specifically request these:

• Fasting insulin (don’t confuse with fasting glucose)
• ApoB
• hs-CRP — specify high-sensitivity, not standard CRP (not all labs measure this)
• ESR
• Oxidized LDL (specialized; may not be covered by your insurance)

Use these to start a conversation with your doctor, not to hand them a shopping list. You can say: “I’d like to understand my insulin sensitivity and my inflammation, not just my cholesterol and glucose. What would you look at?” And be sure to review each of these markers with them when the results come in.

Insulin resistance and inflammation build quietly for years in the blind spots of a standard panel. But quiet isn’t the same as unstoppable. Caught early, these markers are among the things most responsive to how we eat, move, sleep, and manage stress. That’s the whole reason to look while it’s still quiet.

Mine weren’t being watched. Yours can be.