A Man's Guide to Blood Work
Thinking of becoming even more autistic and neurotic about your health? Here's where to start.
Originally published in Man's World Edition 7 and reprinted with kind permission from Raw Egg Nationalist. You can read it on page 343 here, along with fantastic pieces from many other great authors.
Chad wheeled himself onto a packed 5.30pm train after a brutal leg day at the gym. He didn’t need a wheelchair, but optimised his gains by avoiding cardio, such as walking or using his legs to drive home. As he took a carton of farm-fresh eggs from his bag for a satisfying post-workout slonk, he was bumped by a dysgenic freak.
Emaciated appendages, impossibly tight jeans, an ill-fitting polo stretched across a bloated abdomen. A neurotically manicured beard – designed to look messy – was splayed across a pale moon face wearing thick-rimmed glasses, with a rainbow lanyard hanging limply beneath. There was a hint of sweat gleaming off the forehead, but thankfully the remainder of the face was covered with a mask bearing the Reddit symbol.
This was the ugliest image Chad had ever seen. A demonic horror of human development gone wrong. Chad wondered; how does one get this sick? What must be wrong with him? Chad resolved to get some bloodwork done to make sure that he never became such a repulsive, skinnyfat abomination.
This guide will tell you where to start. You will have an idea of the fundamentals for basic blood test interpretation, which can help you develop a “blood work passport”. This serves as a yardstick so that should anything go wrong in the future, you will have objective data to understand what the cause may be, and which systems may be impacted.
You should not take this to mean that anything unusual or outside of normal limits is necessarily bad. If you go searching for problems, you’ll probably find them, and you shouldn’t sweat it over one aberrant result, which may well be transient or harmless. For most of the markers we’ll be looking at, changes are more important than absolute values.
Blood testing is broken up into systems, or “axes”, which account for several interdependent hormones each. Where one is high, the other should be low; where this relationship is disturbed, you have an idea of which part of the axis is poorly functional. Given that these tests are usually ordered as part of a singular package, we will consider them as a group.
Androgen Studies
Testosterone
SHBG
Free testosterone
DHEA-S
Testosterone is the major endogenous androgen produced by Leydig cells in the testes. Low testosterone has major impact on a man’s quality of life: low energy, less masculine features, and difficulty gaining muscle size and strength are well-understood impacts which readers would be keen to avoid.
It is important to understand that testosterone “normal” reference ranges are constructed such as that 95% of non-obese males between 20-40 years of age would be considered “normal”. As the last sane man in the medical profession, I consider the “normal” 20–40-year-old male far from healthy; the “normal” man is a beta cuckold. Measurement is complicated by the fact that normal testosterone levels – given they are calculated from an increasingly unhealthy population – have been in decline for decades. As such, men can present with symptoms of low testosterone despite “normal” serum testosterone.
SHBG (sexual hormone binding globulin) determines how much free testosterone is available for the body to use. High testosterone is useless if the free testosterone – the active testosterone, which can bind receptors – is low. This should be around 2-3% of the total testosterone value. If your normal levels of testosterone are towards the lower end, you can be physiologically well if your free testosterone is higher to compensate.
DHEA-S is a metabolite of the weak androgen DHEA, which serves as a precursor to many hormones including more potent androgens and estrogens. Given DHEA is weak androgen, has lower impact on overall androgenic activity, testing this once for simple screening is sufficient. DHEA-S concentrations dramatically increase during puberty until age 20, after which it slowly declines. Regular exercise and fasting can increase its concentration.
Hormone Studies
LH
Estradiol
Prolactin
Estradiol, despite generally considered a “female” hormone, is a very important hormonal marker for men. Estradiol is critical for general metabolism, including bone and skin health, and erectile and sexual function. When high, estradiol indicates physiological stress and can lead towards more feminine fat distribution including gynaecomastia (“gyno”) and have psychological impacts like depression and anxiety in severe cases. Estradiol level should be towards the lower end of normal, but not beyond it.
I remind the reader that hormones must be considered in relation to other hormones in their axis. While generally not reported on laboratory results, the ratio between testosterone and estradiol is important and should ideally be over 40:1.
Luteinising hormone (LH) is produced in the pituitary and is what drives the Leydig cells of your testes to produce testosterone. If you record both low testosterone and LH, it is likely that your balls are fine, but they are not being driven hard enough by the pituitary gland. Low testosterone levels should drive LH production, and it’s very difficult to fix this without grey market Chinese pharmaceuticals.
Prolactin is also produced in the pituitary and can have inhibitory effects on testosterone production. Interestingly, it is implicated (along with estradiol) in gynaecomastia and partly responsible for feelings of tiredness after ejaculation. Coomers holding yet another L.
While outside the scope of this article, many others have crafted strategies to maximise your natural testosterone levels and become hormonally optimised. This guide is to assist with understanding your baseline.
Biochemistry
Vitamin D
Fasting Glucose
HbA1c
Fasting insulin
Vitamin D is critical for many metabolic processes including sex hormone synthesis and calcium metabolism. While the main source of vitamin D is sunlight exposure (hence the exhortations to sun your balls), there is a small dietary component. This is critically important: it’s very difficult to have too much Vitamin D, and if you’re an indoors wagecuck, easy to have too little.
Fasting glucose, HbA1c and fasting insulin are all measures of your insulin sensitivity, which is perhaps the most important overall marker of long-term metabolic health. Fasting glucose and insulin are good measures at a point in time – ideally both are on the lower end of the normal scale. HbA1c is a more long-term indicator, reflecting weeks and months of blood glucose concentration; it represents something called ‘glycated haemoglobin’. The more chronically elevated your blood glucose, the more damage (or ‘glycation’) is done to haemoglobin on your red blood cells. Aim for this to be as low as possible.
Lipid studies
Total cholesterol
HDL cholesterol
LDL cholesterol
Non-HDL cholesterol
Triglyceride
Clinicians obsess over blood lipids for their ability to predict and monitor cardiovascular disease risk. The raw numbers are less useful than you are led to believe. An example: LDL cholesterol levels, even if high, are irrelevant if HDL levels are also high.
Doctors will usually be most concerned over your triglycerides, total cholesterol, and LDL cholesterol; if high, they’ll worry that you’ll have a heart attack or stroke and sue them – which is why they prescribe statins, which are usually unnecessary and come with a huge list of side effects.
As an aside, statins are useless drugs whose sole purpose is to pad the wallets of big pharma stockholders. Studies consistently show that if 1000 low-risk people were treated for 5 years, these miracle drugs would prevent a grand total of around…. 6 adverse cardiovascular events, while also increasing risk of type II diabetes. What a game changer!
The most important marker for cardiovascular health is the ratio of triglycerides to HDL. This ratio should be as low as possible – mine is 0.3, which is basically as good as it gets. If your ratio is under 1, you’re doing well.
Maintaining a healthy, lean body composition, and eating a clean diet with healthy fats is sufficient to improve your blood lipids and bring them to healthy levels. I have 70-year-olds with blood tests indistinguishable from my own, purely through diet and exercise.
Iron Studies and Full Blood Count
While most men will be aware of the consequences of anaemia from low iron, general functioning can also be disturbed by high levels of iron. There are strong associations between high levels of iron (which is stored as ‘ferritin’ in the body) and chronic inflammatory states such as obesity, diabetes, and metabolic syndrome. The following markers are required for full assessment of blood iron:
Haemoglobin
RBC
Iron
Transferrin
Ferritin
Red blood cells and haemoglobin are simple screening tools for anaemia. It’s good to get a baseline, but don’t worry if it’s normal.
Males are adapted for combat above all else. This means that we are designed with a series of compromises that prioritise short-term survival over chronic disease burden. One such combat adaptation is extra blood volume and retaining as much iron as possible. So, when Grug finds you abducting war brides from his cave and sticks you with a dirty wooden spear, you’re less likely to bleed out. But those same adaptations put you at higher risk of disease in spreadsheet and codemonkey world.
Ferritin is a measure of the body’s ‘cold storage’ of iron. Remember: iron oxidises things, and oxidisation means damage. Ferritin, while necessary, is like having a tiny melted-down Chernobyl inside of every cell.
Our goal with optimisation is to keep ferritin as low as possible without becoming anaemic. A typical laboratory’s normal range can go as high as 500ug/L, but you should aim for this to be under 150ug/L. The best way to lower your ferritin is to lose blood. If you’re not regularly picking up cuts, scrapes, and bruises, you should give blood. Bloodletting is based. Don’t let modern doctors tell you otherwise.
Transferrin has nothing to do with gender dysphoria and is a measure of the bioavailable ferritin floating around in your bloodstream. If your body needs more iron, it’ll mobilise ferritin by turning it into transferrin.
You should take some care with interpreting the iron (Fe) result – it is an “acute phase reactant” and can be elevated with infection or inflammation. Only get the bloods taken if you’ve been healthy and well for at least a week.
A Word on Thyroid Function Tests
No analysis would be complete without assessment of thyroid function, which as a master regulator of metabolism will impact all the tests discussed earlier. Unfortunately, Ray Peat forum users have threated to kidnap and shoot me should I misrepresent thyroid physiology. But, I must pay them their due; thyroid function test are crude measures and lack some conceptual validity. However, as I have not been able to make it through the 15,000 relevant threads on the Ray Peat forum prior to publication, I will only give a very basic rundown.
Free T3
TSH
Free T4
I repeat: if you are feeling symptoms of hypo- or hyperthyroidism, blood test results will not rule out thyroid pathology. Blood tests only help confirm a clinical (based on history and examination) diagnosis.
T3 is the most active thyroid hormone and can be somewhat accurately measured from a blood test using a radioimmunoassay. If possible, check that this is the technique your lab uses. This assay approximates the metabolic rate, and therefore overall thyroid health, but it is an indirect measure rather than a direct one. There are many causes for deranged T3, and each cause should be addressed at root, rather than by gross replacement of thyroid hormone.
Conclusion
Getting a baseline on your bloods is an excellent tool for understanding how your lifestyle affects your body’s physiology. That said, it is still imperfect, and you should take what you are experiencing (good or bad) and correlate this to your bloods, rather than taking the lab as gospel. What you measure, you can manage – to see your testosterone, lipid profile, or HbA1c improve is a great confirmation that the changes you SEE and FEEL are reflections of improvements in your body’s functioning.
With thanks to Dominated by Dig Dug and other friends
A Man's Guide to Blood Work
Hilarious subtitle!
Any recommendations for increasing T levels? Apart from eating healthy and exercising? Thank you