A patient hands me a single sheet of paper from her primary care visit six weeks ago. Three numbers: TSH 2.8, total testosterone 28, estradiol 42. Her doctor told her everything was "in the normal range" and that her symptoms — exhaustion, midsection weight gain, anxiety that appeared out of nowhere at 47, sleep that fragments at 3 a.m. four nights a week — were probably stress.
That sheet of paper is not a hormone workup. It is a screening for overt disease, and screening for overt disease is not the same thing as evaluating a symptomatic mid-life patient for hormonal optimization. The labs that would have answered her question were not ordered. This conversation happens in my office every week, with patients from Columbus, Warner Robins, the Fort Benning community, and across middle Georgia.
A comprehensive hormone panel is what tells us what is actually happening at the signaling level. The point of doing it correctly is that you cannot reason about treatment from a panel that is missing the markers that drive the picture.
Why a TSH and a total testosterone is not a workup
Hormones are signaling molecules, and the signal a tissue actually receives depends on more than the bulk concentration of the hormone in the bloodstream. It depends on free (unbound) hormone, on receptor sensitivity, on conversion to the active form, on the binding-protein system that controls bioavailability, and on the rhythm of when the hormone is released versus measured.
A total testosterone of 28 in a 47-year-old woman tells me almost nothing without SHBG, free testosterone, and DHEA-S in the same draw. A TSH of 2.8 tells me almost nothing about thyroid function without free T3, free T4, and reverse T3 — because the patient with elevated reverse T3 has functional hypothyroidism at the tissue level even when the TSH and the T4 look reasonable. An estradiol of 42 in isolation, without progesterone, without knowing where she is in her cycle (or whether she still has cycles), and without context of her symptom timeline, is a number floating in space.
This is what I mean when I say the workup that primary care typically does is screening, not evaluation. It is meant to catch overt disease — frank hypothyroidism, hyperthyroidism, established hypogonadism. It is not meant to evaluate the in-between state where the patient is symptomatic, the system is failing, but no single marker has crossed a textbook threshold.
The patients I see in mid-life are usually living in that in-between state. The panel has to be built for it.
The panel I order on a first hormone visit
Here is the actual order set I run when I evaluate a new patient for hormonal symptoms, with my reason for each marker.
Sex hormones
- Estradiol (sensitive assay). Tracked alongside symptoms and cycle position when applicable. The standard estradiol assay is fine for most patients; the sensitive assay matters in postmenopausal women and in men where estradiol levels are low.
- Progesterone. Drawn in luteal phase if the patient still cycles, otherwise as a baseline. Progesterone deficiency is the earliest perimenopausal change and the most under-recognized.
- Total testosterone. A starting point, not an endpoint.
- Free testosterone. What the tissue is actually receiving. A normal total with high SHBG and low free testosterone is a clinical syndrome, not a normal lab.
- SHBG (sex hormone binding globulin). Elevated SHBG (commonly seen with high cortisol, hyperthyroidism, oral estrogen, or aging) suppresses free testosterone. Suppressed SHBG (commonly seen with insulin resistance) raises free testosterone but is itself a metabolic warning sign.
- DHEA-S. Adrenal contribution to androgen pool. Often low in chronically stressed patients and in older women — affects energy, libido, and lean mass.
- FSH and LH. Pituitary signaling. Elevated FSH in a perimenopausal woman tells me the ovaries are working harder for less output. Useful for staging.
- Prolactin. A small but meaningful prolactinoma rate hides in the differential of fatigue, libido loss, and menstrual irregularity. I screen because the cost of missing one is high.
Thyroid — full panel, not just TSH
- TSH. Pituitary signaling, useful but insufficient on its own.
- Free T4. Storage form output.
- Free T3. Active form. This is what the tissues actually use.
- Reverse T3. Produced when the body is shunting T4 away from active T3 — a chronic-stress signature. High reverse T3 with low-normal free T3 is functional hypothyroidism that a TSH-only panel will miss every time.
- TPO and thyroglobulin antibodies. Hashimoto's prevalence in mid-life women is far higher than most patients realize. Antibody-positive autoimmune thyroiditis often precedes overt thyroid failure by years and changes the treatment plan.
Metabolic markers
- Fasting insulin and HOMA-IR. The single most under-ordered marker in primary care. Fasting insulin tells me whether the pancreas is compensating for insulin resistance years before the glucose or the HbA1c moves. Optimal fasting insulin is under 7 mIU/L; over 10 in the context of normal glucose is insulin resistance.
- HbA1c and fasting glucose. Late-stage markers, but still part of the picture.
- Lipid panel including triglyceride-to-HDL ratio. A ratio over 2.0 is a clean clinical proxy for insulin resistance. ApoB if I can get it.
Inflammatory and nutritional markers
- hs-CRP. Systemic inflammation. Drives many of the symptoms patients attribute to "aging" and modifiable in most patients.
- Ferritin. Iron stores. Low ferritin (under 50) is a frequent driver of fatigue, hair loss, and exercise intolerance, particularly in still-cycling women.
- Vitamin D 25-OH. Affects sex hormone production, immune regulation, and mood. Optimal 50-80 ng/mL.
- B12 and folate. Methylation, energy, neurological function.
- Magnesium (RBC magnesium when possible). Sleep, muscle, cardiovascular function.
Adrenal context, when indicated
- Morning serum cortisol or four-point salivary cortisol. When the symptom pattern suggests HPA dysregulation — wired-and-tired pattern, sleep onset insomnia, salt craving, blood pressure swings — I add this. Not every patient needs it, but the patients who need it cannot be evaluated without it.
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Other
- CBC, comprehensive metabolic panel. Baseline organ function.
- PSA in men over 40. Required before initiating testosterone therapy.
Drawn together at one fasting morning blood draw, this panel gives me the picture I need to actually reason about your physiology.
How to think about reference ranges
The single most common mistake I see in interpreting hormone labs is conflating "in the reference range" with "optimal." Reference ranges are statistical descriptions of the population the lab tested — they include healthy people and unhealthy people, optimized people and undertreated people, twenty-year-olds and eighty-year-olds. Falling inside the range does not mean the value is good for you. It means the value is not aberrant for the population.
A free T3 at the bottom of the reference range in a symptomatic 50-year-old is not "normal." A free testosterone at the bottom of the reference range in a 45-year-old man with loss of morning erections, midsection weight gain, and brain fog is not "normal." A fasting insulin of 14 in a patient with a normal glucose is "in range" and clinically resistant.
The clinical question is not "is this in range." The clinical question is "is this value appropriate for this patient's age, symptoms, and goals." Reasoning that way requires the full panel, the symptom timeline, and a clinician who is willing to treat the patient rather than the report.
What I look for when I read your labs
When I sit down with a patient at the lab review visit, I run through a sequence.
First, internal consistency. Does the picture hang together? A patient with high SHBG, low free testosterone, suppressed free T3, elevated reverse T3, and low DHEA-S has a coherent stress-and-aging picture. A patient with one outlier and an otherwise unremarkable panel needs me to think about why that single value is different.
Second, correlation with the symptom timeline. A progesterone deficiency with two years of 3 a.m. wakings and increasing anxiety is a treatable picture. A normal-looking panel with severe symptoms means I am missing a marker or the symptoms have a non-hormonal driver — either is important to know.
Third, the modifiable drivers behind the lab pattern. Is the high SHBG being driven by hyperthyroidism that needs to be addressed first? Is the low free testosterone being driven by insulin resistance that needs the metabolic program? Treating downstream of a modifiable driver without addressing the driver is how patients end up on therapy that "stops working" at six months.
Fourth, ranking what to address first. We rarely fix everything at once. The plan addresses the highest-leverage change first, with the next intervention sequenced based on the response.
How treatment follows the labs
Once the picture is clear, the plan writes itself in most cases. Hormone optimization for women is individualized — estradiol delivered transdermally or by Biote pellet therapy depending on the patient's preference and the clinical fit, progesterone as oral micronized progesterone for sleep and uterine protection, testosterone as a low-dose subcutaneous injection or pellet when the labs and symptoms support it. Men's testosterone replacement is similarly individualized — injection schedule, pellet, or topical depending on the patient's lifestyle and response, with hCG when fertility preservation matters and an aromatase inhibitor only when the labs show it is needed (which is less often than most prescribers assume).
Initial dosing is conservative. Recheck labs at 8 to 12 weeks. Adjust from data, not from guessing. Then six-month and annual reassessments after stabilization. The patients who do best are the ones who understand that hormone optimization is a clinical relationship over time, not a single prescription.
The concrete next step
If your symptoms have been brushed off because a three-marker panel came back "normal," and you are still feeling the way you were feeling when you raised the concern, the right next step is the actual workup.
Run the hormone health assessment, then book a consultation at the Columbus location or the Warner Robins location — the protocol is identical at both, and Travis Woodley sees patients at both clinics on a rotating schedule. Bring the labs you already have, even if a previous provider called them normal — they are still data. Bring a complete medication and supplement list. Bring a one-paragraph timeline of when each symptom started and how it has changed.
We will pull the comprehensive lab work that is missing, sit down with the data together at the second visit, and build the plan from what the numbers actually show. Most patients have a clear picture and an active treatment plan within three weeks of the first appointment. That is the right pace for a system that took years to drift and that responds to the right plan rather than to another round of "your labs are normal."
Medical disclaimer: This article is for educational purposes only and does not constitute medical advice. Individual clinical decisions should be made in consultation with a qualified healthcare provider following appropriate evaluation. References to specific treatments, dosing, or protocols are informational.
Travis spent 17+ years in high-acuity clinical medicine — emergency, cardiac ICU, and cath lab — before founding Revitalize. He is a Certified Platinum Biote hormone therapy provider, the published author of You're Not Broken — You're Unbalanced, and the founder of the Rebuild Metabolic Health Institute. His clinical writing reflects the same precision he brought to critical care: specific, honest, and built around what actually works.
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