RHR: How to Recover from Long-Term Use of Birth Control Pills
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RHR: How to Recover from Long-Term Use of Birth Control Pills

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It's common for women to have issues when they stop taking birth control. Here are three ways you can recover your health.

Revolution Health Radio podcast, Chris Kresser

Note: The Paleologix supplements are no longer available. Please click here to view the products recommended as substitutes.

Some people who take birth control for years will be able to stop birth control, and just resume having a normal menstrual cycle with no problems. But I’ll tell you that from my experience, those people are in the minority. It could be that I just don’t see those people in my practice, because they have no reason to contact me. But just from my experience as a clinician, and hearing from people through the blog and podcast and other colleagues of mine, I think it’s pretty common for women who’ve been on birth control for a while to have issues when they stop.

In this episode, we cover:

1:47  What Chris ate for breakfast
9:14  Nutrient deficiencies
18:15  Gut issues related to contraceptive use
19:57  Body detoxification
25:28  Addressing adrenal fatigue

Links We Discuss

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Steve Wright: Good morning, good afternoon, and good evening. You are listening to the Revolution Health Radio show. This show is brought to you by ChrisKresser.com. I am your host, Steve Wright from SCDlifestyle.com. With me is integrative medical practitioner, healthy skeptic, and New York Times bestselling author, Chris Kresser. Chris, how are you doing?

Chris Kresser: I’m well, Steve. How are you?

Steve Wright: I’m doing very well. Thank you.

Chris Kresser: You can tell the weather has changed a little bit around here.

Steve Wright: Yeah. Apparently, you haven’t turned on the heat yet in the house.

Chris Kresser: Yeah, we’re doing a cold thermogenesis. Now, it actually looks like it’s going to be sunny and warm, but it’s definitely cooled off a bit. I’ve been enjoying the fall. It’s been abnormally hot for October. I’ve been surfing quite a bit, which is always really good for me. For the past couple of days, it’s definitely cooled off.

Steve Wright: Nice. It’s actually heating up here in Colorado. It’s going to be 80 today.

Chris Kresser: Pretty good.

Steve Wright: I’m bringing the shorts back out.

Chris Kresser: Yeah, that’s pretty much how it’s been here. September is usually like that. October, you never know, but we’ve had our September in October. I hear they’re predicting it’s going to be a stronger El Niño year this year. So it’s going to probably be pretty wet. But the benefits of that are the bigger swells, better waves, so I’m okay.

Steve Wright: Hey, there you go! So what did you have for breakfast this morning?

What Chris Ate for Breakfast

Chris Kresser: Elanne made a really amazing chicken soup. I mean, chicken soup is one of those things that can just be so bland and blah; like, Campbell’s chicken soup or the typical way. But it can be so tasty and amazing if it’s done well, with fresh ingredients and good seasonings and stuff. And on a colder morning, I really like to have that for breakfast. Then we had some leftover almond flour biscuits that came out of The Zenbelly Cookbook, which we’ve been enjoying a lot. I think I mentioned that on a previous show. So I had chicken and biscuits, basically, is what I’m trying to say.

Steve Wright: Sounds delish.

Chris Kresser: With a little bit of sauerkraut. Sylvie loved it too. So we have a great question again. Everyone, thank you so much for sending the questions. It’s really great to be able to answer questions that I know are relevant to you. We have so many good questions being submitted, so please keep them coming.

Before we do that, I just wanted to remind you that the 14Four is live. This show, we record a couple of weeks in advance. So by the time you’re hearing this, it’s been live for a couple of weeks. It’s a total mind-body reset in 14 days. You make four big changes in 14 days. You dial in your nutrition, your physical activity, your sleep, and your stress management. I consider those to be the four most important areas that determine our health. You know, there are a lot of Paleo-challenge programs out there; I have one myself. Diet, of course, is crucial. But all too often, we neglect the stress management, sleep, and physical activity parts of the equation. I just see that happen a lot in my practice and my work with people. So I wanted to put together a program that was a little bit shorter, a little bit more accessible, but one that included all four of the elements that I think are just super, super crucial. It’s a really great program. We’ve got video demos of exercises you can easily do at home or while you’re on the road, video and audio demos of stress management techniques, sleep tips to help you get a better sleep, and of course, meal plans and recipes. We’ve got a private Facebook group that’s staffed by my registered dietitians, Kelsey and Laura, to answer your questions. I’m really excited about it. I think it’s going to help a lot of people and give people a chance to really dive into this with a lot of support and handholding, in a way that hasn’t been possible yet.

Steve Wright: Yeah. I think it’s so important to concentrate on all these factors at once, because I feel like we’re in a culture where we’re compartmentalizing everything these days. We get very focused in on diet and the super, best, -ist, everything maximized in diet. Then we totally forget about walking every day, or sleeping, or stress or something. So to have a program that really zooms back out to 15,000 feet and kind of really helps bring everything in line, I think that’s really important in today’s day and age. I’m looking forward to trying it myself.

Chris Kresser: As I said last time, I plan to do a 14Four once a quarter, just to kind of hit the reset button. These are things that I’ve been doing for a long time. Even for me, having done them for years and years, it’s still sometimes a challenge to keep them all a regular part of my daily life. Because let’s face it, there’s a lot going on for most of us, and it can be a struggle to keep these things in place. So the 14Four is, like I said, a total mind-body reset. I hope it works as well for you as it’s worked for me. You can check it out at 14Four.me. Now, we will move on to this question, which we’ve gotten in some form at several different times over the years. I think we’ve talked about it as well. But I wanted to take the opportunity to kind of summarize everything in one place. Here we go.

Faith: Hi, Chris. I’ve been on hormonal birth control pills for a few years now, and I’m beginning to think about starting a family. I wanted to see if you had any recommendations for women like me who’ve been on birth control for a period of time. Do you recommend stopping birth control for a length of time before trying to conceive? I proposed this to my doctor, and she just basically scoffed at the idea, but I think there must be some benefit in restoring a natural hormone balance before trying to conceive. If you do think this will be beneficial, what other things can I be doing to help aid the body in restoring that natural hormone balance? Thanks.

Chris Kresser: All right. Well, as is almost always the case, the answer to this question is it depends.

Steve Wright: It’s always simple, isn’t it?

Chris Kresser: It’s just always that simple—it depends. Maybe is another way of putting it. The thing is, some people who take birth control for years will be able to stop birth control, and just resume having a normal menstrual cycle with no problems. But I’ll tell you that from my experience, those people are in the minority. It could be that I just don’t see those people in my practice, because they have no reason to contact me. But just from my experience as a clinician, and hearing from people through the blog and podcast and other colleagues of mine, I think it’s pretty common for women who’ve been on birth control for a while to have issues when they stop.

There’s actually a term that’s used in the functional medicine world for this, which is post birth control syndrome. I’ve talked about that before on the podcast, and maybe even written about it a little bit on the blog. It basically describes the set of problems that women can experience when they get off oral contraception. You won’t find that term in the scientific literature, and you won’t find a lot written about that specifically, but you will find studies that indicate mechanisms which individually, when you put them together, could lead to this syndrome. Because syndrome is not a disease; it’s a collection of signs and symptoms. So other syndromes that we’ve talked about before would be adrenal fatigue syndrome. Adrenal fatigue is not a disease like diabetes. It’s a collection, a constellation of signs and symptoms. Premenstrual syndrome is another constellation of signs and symptoms. Post birth control syndrome would be this constellation of things that can happen after you use oral contraception for an extended period of time. And the extent to which somebody will develop post birth control syndrome is usually directly related to the length of time they’ve been taking the oral contraceptives, as well as their genetic and epigenetic sensitivity to the underlying mechanisms that can lead to that syndrome.

Nutrient Deficiencies

Let’s talk a little bit about what those mechanisms are. The first one would be nutrient deficiency. There are studies in the literature—we can include one of them that summarizes some of these issues in the show notes—that discuss the nutrients that can often be depleted by oral contraceptive use. There’s a fairly long list of them. I’m going to talk more specifically about the ones I see most often. But they include zinc; vitamin B6; B12; B2, which is riboflavin; magnesium; selenium; vitamin C; folate, which is B9. Folate is a super important one, which we’re going to talk a little bit more about later in the show. All of these nutrients have been shown to be depleted by oral contraceptive use. So if you have someone who’s been on contraceptives for a long time, these nutrients are depleted. They all play an important role in the menstrual cycle, but specifically folate, B12, B6, zinc, and magnesium are especially important. When a woman stops and she’s low on those nutrients, then she may not resume her menstrual cycle at all. That’s fairly common, just having total amenorrhea after stopping birth control. Or it may be a very irregular cycle, where the cycle length is alternating, a woman’s bleeding for a very short of period of time, there’s a shortened luteal phase, there’s no ovulation, or ovulation’s happening twice. We see all kinds of different presentations of this.

Steve Wright: I’m just going to break it up here for a second. This nutrient depletion, this is everything, or this is specifically caused by the contraceptive that is being taken?

Chris Kresser: This can be specifically caused by contraceptive use. This isn’t just nutrient—I mean, nutrient deficiency is common in the general population. I talked about that in my book.

Steve Wright: Right.

Chris Kresser: Almost 50% of the US population is deficient in these kinds of nutrients that we’re talking about now. But I’m specifically talking about studies that show that oral contraceptive use depletes these particular nutrients.

Steve Wright: Okay.

Chris Kresser: So that’s a different thing. But I’m glad you brought that up, because when you add those together, it’s a big problem. That’s because a lot of people are going into taking contraceptives already deficient in these nutrients. Then you add the contraceptives, and it exacerbates that deficiency.

Let’s talk a little bit about how to resolve these things. We always recommend food whenever possible. In some cases, that’s relatively straightforward. In other cases, especially when the deficiencies are fairly severe, supplementation may be necessary to get back to a normal level. For zinc, the main dietary sources would be shellfish, red meat, and pumpkin seeds. But if that’s not doing the trick, you can supplement with 15 to 30, or even 50 mg of zinc per day. I wouldn’t stay at a 50 mg per day dose of zinc for an extended period of time, but you can use that dose therapeutically for maybe two to three months. You want to test your zinc and copper levels, and make sure they’re in a fairly close relationship. So ideally, like a 1:1 ratio, or zinc even a little bit more than copper. If copper is a lot higher than zinc, it indicates a copper-zinc imbalance, which can cause menstrual problems and many other problems as well. Magnesium I talked about at length on the blog and in the book. Our soils are increasingly depleted of magnesium. Magnesium deficiency is one of the most common deficiencies in US adults in terms of nutrients. Supplementing is often helpful, anywhere from 100 to 400 mg a day, depending on what your dietary intake is like. The chelated forms like glycinate and malate are typically better.

Vitamin B6 is also lowered by contraceptive use. And this is relatively—well, it’s in a fair amount of foods, but one of the better sources of B6 is grains, which folks on Paleo diet aren’t eating. If you’re not eating organ meats and grains, and if you have SIBO or other issues that interfere with B-vitamin absorption, which a lot of people do—we run tests in our clinic. When we test people for SIBO, we also test them for their B-vitamin status using an organic acids panel. We see, almost without exception, people with SIBO have B-vitamin deficiency. So supplementing with maybe 25 mg of P5P, which is the active form of B6, or you can take 50 to 100 mg of just straight vitamin B6, that can be helpful.

Then the other nutrients that are affected, as I mentioned before, would be folate, which we’re going to talk more about when we talk about detox; riboflavin, which is B2; B12; vitamin C; vitamin E; and selenium. In my book, I mention where to get most of these nutrients from food sources, and if you can’t eat those foods or enough of those foods to meet your needs, you may want to consider supplementing with those as well.

One thing that can be helpful, if you have access to a functional medicine practitioner, is to have them run an ION (Individual Optimal Nutrition) Profile or a NutrEval, which are kind of comprehensive nutrient status tests that are offered by Genova Diagnostics. I think the ION used to be the Metametrix Panel, but Genova bought Metametrix. So now you can get the ION or the NutrEval. I think the ION is a little bit more—has a few markers that the NutrEval doesn’t have. But they’re both pretty extensive, and they have a lot of different markers that can indicate nutrient deficiency. So if you’re not able to figure it out on your own, you’re having difficulty, you can try to work with a functional medicine practitioner to get one of those panels, and they can give you some insight into what’s happening.

Steve Wright: How about the SpectraCell panels?

Chris Kresser: I prefer the ION and the NutrEval. It’s difficult to test for nutrient status, because each nutrient resides in a different place, like different tissues or is represented differently in the body. For example, magnesium, less than one-half of 1% of magnesium is in the serum. So when you test serum magnesium, you’re getting a level—you’re only testing for 0.5% of the total body storage of magnesium. There is some correlation between serum magnesium and total body magnesium, but it’s certainly possible to have normal serum magnesium and have low body stores. It may even be possible to have low serum magnesium and normal body stores, although I think that’s less likely. With each nutrient there are certain things to be aware of, in terms of how it’s best tested. I’m not sure that the SpectraCell really takes that into account. I prefer the NutrEval because they’re often using organic acids or amino acids where—there are cycles in the body that require enzymes to complete. Each of those enzymes requires certain nutrients to function properly. So if you see a build-up of a certain organic acid, that indicates that that cycle wasn’t able to complete, which means that the enzyme needed in that cycle didn’t have the cofactors that it requires to make the conversion. Then you can kind of put all that together, and you can get information about nutrient deficiency. That way, that might be more accurate, because it’s reflecting actual usage of that nutrient in the body. The other thing is that method of testing often tests for the most active form of the nutrient that’s used in those enzymatic reactions, rather than the precursor forms of the nutrient. For example, urinary methylmalonic acid (MMA) is the best way to test for adenosylcobalamin or methylcobalamin deficiency, which are the active forms of B12, whereas serum B12 actually measures all of the total cobalamins, including the less active forms of B12, like cyanocobalamin. So you’re getting different information, depending on the different ways that you test.

Steve Wright: Interesting.

Gut Issues Related to Contraceptive Use

Chris Kresser: The next problem that we see a lot with women who’ve been on birth control for a while is gut issues. There’s not a lot in the literature about this. I assume there will be in the near future, now that there’s so much more interest in the gut microbiota. But there’s some evidence that oral contraceptives may alter gut microbiota. I see this anecdotally in the clinic. Women who’ve been on birth control for a significant period of time tend to have altered gut flora. You know, there’s a chicken-and-egg question—did the gut flora lead to issues hormonally that led to them taking birth control in the first place, if they were on birth control to regulate their cycle, rather than to prevent conception? There’s more research that needs to be done here. But I think it’s plausible that oral contraceptives would affect the gut microbiota. Once the gut microbiota is affected, it will, in turn, alter hormone regulation and detoxification. That’s not controversial. We know that the gut microbiota have an effect on hormone regulation. They affect the whole HPA axis. And we know that the status of the gut certainly affects detoxification capability. We’ve talked at length about gut health and how to improve gut health, so I’m not going to go into a lot of detail here. I’ll just refer you to my book, and also to the free eBook that we have at www.ChrisKresser.com on gut health. You can go to my.ChrisKresser.com/ebooks and find it there. Then there’s a lot of information on other podcasts and blog articles as well. So that’s the number two area.

Body Detoxification

The number three area would be detoxification. The body eliminates excess hormones via detoxification; phase I, phase II detoxification. If hormones accumulate from taking oral contraceptives for a long period of time and your detox capacity is impaired, that can be bad news, because you get a build-up of those excess hormones. One of the most important processes that controls our detoxification and determines whether it will work properly is methylation. I think we just did a show on methylation six weeks ago or something like that, Steve?

Steve Wright: Yeah.

Chris Kresser: Check that out for a primer on methylation, if you’re not familiar with it. In short, impaired methylation is fairly common. That’s because a relatively high percentage of the population, 45% of the population, is heterozygous for an MTHFR mutation, which, in layperson’s terms, means almost half the population has a genetic mutation that reduces the activity of the MTHFR enzyme up to between 20% and 40%. That alone doesn’t mean that the enzyme won’t function well. I want to emphasize that. I see a trend out there that really disturbs me, which is that people are getting genetic tests, and then taking supplements only on the basis of their genetic results. I think there’s really nothing in the research literature to support that. Genes load the gun and environment pulls the trigger, as I’ve said before. Genes can tell you what kind of methylation issues you’re predisposed to having, your specific genetic profile. But it can’t tell you how you’re actually methylating or whether you need methylation support. I just want to emphasize that, because I’ve been seeing that there are these companies now where you can run your genetic profile through them, and they spit back a list of supplement recommendations. I have a big problem with that. It’s a huge pet peeve of mine right now. I see a lot of people doing potential damage to themselves by just following those recommendations based only on the results of their gene profile.

Anyways, I digress. Methylation though can be impaired by environmental factors, and I would say diet and lifestyle have a far greater impact on your methylation capacity than your genes do. That’s because everything from your diet to the method of birth—whether you were born vaginally or via C-section—or whether you actually had a strong bond with your mother in the early years, makes a big difference in terms of methylation and gene expression. There’s a lot of research on that. Exposure to environmental toxins, exercise, sleep, stress management… you know, all the things that we’re always talking about directly affect methylation. And they affect it, like I said, in a way that’s probably more significant than genes.

First identifying any methylation issues and then addressing them can really help with detoxification. If you’re working with a functional medicine practitioner, they can run panels, like the Health Diagnostics and Research Institute (HDRI) Methylation Pathway Panel. It’s a great panel, with nitrotyrosine, catalase, and some other markers added to it. To get a functional assessment of methylation, there are other urine panels that can help give information about methylation, particularly with COMT. So you see how you’re converting certain metabolites of estrogen into others. That can give you information about methylation. You can look at serum histamine, blood histamine levels, and see—because histamine breakdown requires methylation. If you have high histamine levels, it’s fairly likely your methylation is impaired. So there are lots of different ways you can get that information, working with a practitioner who knows what they’re doing.

If you’re working on this on your own, I can give you a couple of basic recommendations. One would be a supplement called Liveer Nutrients from Seeking Health. We can talk about this as a detox product, and it is, but what it really is, is a methylation support product in addition. Because, of course, one of the main ways to support detoxification is by improving methylation. There are many of the nutrients that support detox and methylation in there, like trimethylglycine, and N-acetyl cysteine.

Then there’s glutathione, the master antioxidant, our old friend that we’ve talked about a lot. I prefer the liposomal form of glutathione. You can also get that in my store. Epsom salt baths are a pretty good option for general detox support. You can add three cups of Epsom salt to hot water, and soak in that for 20, 25 minutes a night. That can be really helpful as well.

Steve Wright: You might want to work up to the three cups though.

Addressing Adrenal Fatigue

Chris Kresser: Yeah, that’s right! Depending on your status, that can be a little bit too much. The next thing we’re going to talk about is not really specifically related to oral contraceptives per se, in that I haven’t seen research that contraceptives can affect or impair adrenal status. But it’s true that a lot of women who have hormone issues have adrenal fatigue syndrome. That’s at the root of the hormone issues often. So you definitely want to address any adrenal fatigue issues that are present. That’s going to be an important part of recovering your cycle to a normal cycle and optimizing your fertility. And part of addressing adrenal issues is making sure that your blood sugar is properly regulated. This is where all of the basic recommendations that we make in my book, and now in the 14Four, come into play. You have to nail down the basics first before you do anything else. You’ve got to get your diet in line, your stress management, your sleep, and your physical activity. Then once you have those dialed in, you can start working on some of these more advanced issues that we’re talking about. I hope that was helpful. I know it’s a big question, and there’s a lot that we covered. There are a lot of areas where you’re still going to need to kind of go and get more information. But I wanted to just provide at least an overview of all the different elements that can be involved in this, and to point you in the right direction for each of them. Again, I hope it was helpful. Thanks, everyone, for listening. See you next week.

Steve Wright: Thanks, everyone. In-between shows, if you want to catch up with Chris, see what he’s doing, see what he’s researching—I know he dives down these rabbit holes and he’s created programs like 14Four, which you should check out at 14Four.me. But in-between there, when he’s trying to figure out how to bring you new and great information, he’s going to be posting studies on Facebook and Twitter. So go to Facebook.com/ChrisKresserLAc and Twitter.com/ChrisKresser to catch up on all that stuff that doesn’t quite make it to the blog yet, or maybe you’ll see it in six months on the blog. Thanks for listening.

  1. I just stopped BCP usage after 15 years. Reading some of these comments from other women with long term usage is making me nervous as far as what I’m going to expect. I started when I was 15, and on advice from others, I decided to stop and let me body return to its natural state. I’ve had GI problems for a long time, but they have decreased in severity since I started eating organic whole foods and increasing my exercise. I was on Sprintec for years until about four months ago, when I was having mid month bleeding. They switched me over to another type of oral because they thought I was ovulating at the wrong time, or something close to that. I had no idea that there were side effects like this to coming off of birth control or that BCP could increase vitamin deficiency. I work in oncology/public health, and I still didn’t know this was something fairly common.

  2. Hi Chris – a client of mine (vegetarian, BCP 20 years/off them 10 years) experiences anger and irritation when taking methyl B12. I’ve read people’s comments regarding this reaction to B12 and other B’s but could you please explain why this happens to some people? thank you !

  3. I have worn an estrodial hormone patch for over 10 years since a total hysterectomy. I started with 1.0 mg dose and in the past few years I tried to wean myself off the patch. I got down to point .6 and have insomnia and anxiety. Iam stuck!!!

  4. I was on permanent birth control for 4 years by getting my tubes tied. After some research work, we decided to choose tubal reversal procedure. And now we are happily trying to conceive for a baby.

  5. Hi Chris. Would that be possible to get the links of some studies that conclude that the pill affect nutrient status in the body ?
    Thanks for this great podcast.

  6. I had a terrible experience coming of BCP after 20 years of use. I was not adequately supported through the process and it completely turned my life upside down. I believe I was an extreme case because of my genetics and further complicated by the duration of BCP use. It was a perfect storm that took several years to sort out, because a lack of awareness in the health community.

  7. After taking BCP for 10 years ( I am 30), I decided to stop taking them when I adopted a Paleo lifestyle two years ago. I did not get my period for a year, and now my cycle is between 45-60 days long. When I experienced ovulation symptoms a few months ago I thought I was pregnant because I had not experienced that for 10 years! However, the most intense side effect has been TREMENDOUS anxiety around ovulation. It lasts for a week in which I am constantly talking myself down from a near panic attack. It sucks, for lack of a better term. Recently I have been adding supplements (like zinc, magnesium, and copper) to see if they alleviate these symptoms. So, I agree: BCP is scary stuff.

  8. It can take a while to recover from longterm use of birth control pills even when nutrition is optimal. It’s not uncommon to take several months to a year or longer. Low body weight and/or very low total cholesterol can also play a role in delaying a return of periods.

  9. Regarding use of organic acids testing and results of metabolic pathways to infer nutritional status, results could also be due to some degree of loss-of-function genetics at each point on a pathway. At that point it becomes an open question as to whether the use of a nutrient, and how much of that nutrient, could help or not.

  10. I was prescribed BCP for a few years to help regulate heavy, painful menstrual periods. I took them for a few years in my 20s (in my 40s now). I can’t remember specifically what made me decide to stop taking them (against my doctor’s advice), but I’m so glad I stopped. Years later I realized that BCP made my cholesterol quite high. Pretty much the whole time I was taking BCPs, the doctor who prescribed them told me my cholesterol was too high and I needed to cut way back on eating meat and fatty foods. After stopping BCP my cholesterol returned to normal without any changes in my diet. I look back now and call them the “ugly” pills. While taking them I experienced weight gain, melasma, change in body shape, dry/coarse hair. This all returned to normal not too long after stopping the BCPs.

  11. Do all/any of the issues related to oral contraceptives also apply to the Nuvaring or other non-pill forms of birth control, such as IUDs?

    • Yes, this is what I would like to know specifically as well. I can see it having the samw hormonal balance issues, but possibly not having as extreme effect on gut flora and fauna because the hormone inst being injested and take through the G.I. tract. Good question, I hope Chris answers you!

  12. I was on birth control for a short time in my early 20s and then I was on a hormonal regulating pill for adult acne for years. Both kept my cramping and bloating PMS symptoms pretty mild. I am several years off both pills and have had terrible cramps during my periods where I felt immobile. I recently went to a Paleo-style diet and my bloating and cramping during my period has almost disappeared! Diet is so important in regulating our hormones!

  13. Two questions: Does this issue apply to someone taking estrogen replacement therapy?

    And two, how do you get a doctor to order tests for zinc-copper, etc. if these issues aren’t even on their radar? Or are these tests for the micronutrients something an individual could get done?

  14. After being on birth control for 8 years I actually experienced some significant mental conflicts, like chronic anxiety and paranoia. It was really scary and I considered going back on the pill to alleviate the symptoms. I stuck with it though and slowly (after 2-3 months) my body made it’s way back into a sense of homeostasis. Powerful stuff, that pill!!

    http://www.songofourheritage.blogspot.com

  15. Just an FYI – the Spectracell test is not a serum test in the way that you describe serum tests. It does rely on a blood draw, but what the lab does it to isolate lymphocytes (average lifespan 4-6 months), and then place them into varying “ideal growth” solutions that are each missing a different micronutrient. The lab then compares growth rates of those cells against benchmarks, which allows one to see if the cells have enough of a particular micronutrient stored and available (intracellularly) to grow without it being present in the solution. This process necessarily measures the active form of the micronutrient, because it relies on what’s actually contained inside the cell.

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