Hormones and Thyroid Function Can Contribute to Anxiety and Why I Test for Them

Anxiety is often treated as if it only lives in the mind. While thoughts, trauma, stress, relationships, sleep, and coping patterns absolutely matter, the body also plays a major role in how safe or unsafe we feel. As a psychiatric provider with an integrative approach, I do not look at anxiety as “just anxiety.” I want to understand what the nervous system is responding to and whether there may be underlying physiologic stressors making symptoms worse.

Two areas I often consider are hormone balance and thyroid function. These systems influence mood, energy, sleep, metabolism, heart rate, temperature regulation, cognition, libido, motivation, and stress tolerance. When they are out of balance, anxiety can feel louder, more physical, and harder to manage with mindset strategies alone.

The thyroid and anxiety

The thyroid is a small gland in the neck, but it has a powerful effect on the entire body. Thyroid hormones help regulate metabolism, energy production, body temperature, heart rate, digestion, menstrual cycles, cognition, and mood.

When thyroid activity is too high, the body can feel like it is stuck in overdrive. A person may experience a racing heart, shakiness, sweating, heat intolerance, irritability, restlessness, insomnia, weight changes, frequent bowel movements, and anxiety. For some people, this can feel very similar to panic.

When thyroid activity is too low, anxiety can still show up, but it may look different. Low thyroid function is more often associated with fatigue, low motivation, depression, brain fog, constipation, cold intolerance, dry skin, hair changes, heavier periods, and slowed thinking. However, when the body feels exhausted, foggy, inflamed, or unable to function normally, anxiety can develop as a secondary response. Many people describe feeling “wired but tired,” overwhelmed by basic tasks, or emotionally less resilient.

This is one reason I do not like to assume that anxiety is purely psychological. If someone has new anxiety, worsening anxiety, panic-like symptoms, fatigue, brain fog, menstrual changes, weight changes, palpitations, poor sleep, or a sense that something feels “off,” I want to know what the thyroid is doing.

Why I do not only look at TSH

TSH is commonly used as a first-line thyroid screening test, but it does not always tell the whole story by itself. TSH reflects the brain’s signal to the thyroid, while free T4 and free T3 give more information about circulating thyroid hormones and how much hormone is available to the body.

Depending on the person’s symptoms and history, I may look at TSH, free T4, free T3, thyroid antibodies, and nutrients that support thyroid function. These may include iron/ferritin, vitamin D, B12, folate, selenium, zinc, and magnesium.

This does not mean every person needs every lab every time. It means testing should be guided by symptoms, history, risk factors, medications, menstrual patterns, pregnancy or postpartum status, family history, and the full clinical picture.

Sex hormones and anxiety

When we talk about hormones and anxiety, the conversation often focuses on women’s hormones, menstrual cycles, PMS, PMDD, postpartum changes, and perimenopause. Those are important, but they are not the whole story. Hormones affect all of us.

Estrogen, progesterone, testosterone, DHEA, cortisol, insulin, and thyroid hormones all interact with the nervous system. They influence neurotransmitters such as serotonin, dopamine, GABA, and glutamate, which help regulate mood, motivation, calm, sleep, focus, and emotional flexibility.

This is why some people notice anxiety that follows a pattern. Symptoms may worsen before a period, during times of poor sleep, after major stress, postpartum, during perimenopause, after stopping hormonal birth control, with weight changes, with overtraining or under-eating, or during periods of chronic illness or burnout.

The important point is that hormones do not always have to be severely “abnormal” on a lab test to affect mood. Sometimes symptoms are related to sensitivity to normal hormone fluctuations. Sometimes they are related to high or low hormone levels. Sometimes the issue is not one hormone, but the relationship between hormones, stress, sleep, metabolism, and inflammation.

Testosterone and anxiety

Testosterone is often associated with libido and muscle mass, but it also plays a role in energy, motivation, confidence, cognition, mood, sleep, and overall sense of well-being. Low testosterone does not always look like obvious depression or anxiety. Some men describe it as feeling flat, unmotivated, irritable, foggy, tired, less resilient, or less like themselves. Others notice lower libido, erectile changes, poor workout recovery, increased body fat, decreased muscle mass, poor sleep, or a drop in drive.

This matters because men are often socialized to push through symptoms or describe emotional distress in physical terms. Instead of saying, “I feel anxious,” they may say, “I cannot sleep,” “I have no motivation,” “I am more irritable,” “I feel off,” or “I just do not feel like myself.” Those concerns deserve the same curiosity and thorough evaluation.

When clinically appropriate, testosterone testing may include total testosterone, free testosterone, sex hormone-binding globulin, LH, FSH, prolactin, thyroid markers, vitamin D, B12, folate, iron/ferritin, and metabolic markers. In some cases, additional pituitary or adrenal evaluation may be considered depending on the full picture.

Testosterone should be interpreted carefully because levels can fluctuate with time of day, sleep quality, illness, calorie restriction, alcohol use, medications, stress, and body composition. For men, testosterone testing is typically most useful when drawn in the morning and interpreted alongside symptoms rather than treated as a single isolated number.

It is also important to say this clearly: testing testosterone does not mean automatically recommending testosterone therapy. The goal is not to turn hormones into a quick fix or reduce mental health to a lab value. The goal is to understand whether there is a physiologic contributor that may be making anxiety, fatigue, irritability, low mood, poor sleep, or low motivation harder to manage. Treating low testosterone is often about maintaining a healthy weight, avoiding synthetic estrogens, increasing muscle mass-specifically in the quads and glutes, getting good, quality sleep, detoxifying, and decreasing stress. I may prescribe a medication or supplements to help your body support natural testosterone production while we work on the factors you can control. Once those align we may be able to remove the medication and/or supplements.

Estradiol, testosterone, and body composition

Body composition can influence hormone balance across the lifespan. Adipose tissue is not just stored energy; it is metabolically active and contains aromatase, an enzyme that helps convert androgens, such as testosterone, into estrogens, including estradiol.

This matters because hormone balance is not only about whether one hormone is “high” or “low.” It is also about ratios, patterns, symptoms, and how the body is responding. In men, higher body fat may contribute to lower testosterone, relatively higher estradiol, or a shift in the testosterone-to-estradiol balance. Some men may notice fatigue, low motivation, irritability, low libido, erectile changes, poor sleep, increased body fat, decreased muscle mass, or mood changes.

In women, body fat can also influence estrogen activity, insulin signaling, inflammation, menstrual patterns, PCOS symptoms, perimenopausal symptoms, and mood. Some women may experience anxiety, irritability, cycle changes, heavier or irregular bleeding, low mood, brain fog, cravings, or sleep disruption when hormones and metabolic health are under stress.

This is one reason I do not look at testosterone, estradiol, thyroid markers, cortisol patterns, or metabolic labs in isolation. A lab value may be “normal,” but the overall pattern may still provide important clues. Hormones interact with sleep, blood sugar, inflammation, stress, nutrition, medications, alcohol use, movement, and nervous system regulation.

Hormone patterns in women

For women, hormone-related anxiety may show up around predictable reproductive transitions or cycle changes. Some people feel fairly stable for part of the month and then feel anxious, irritable, tearful, overwhelmed, or panicky in the week or two before their period. Others notice anxiety worsening postpartum, during perimenopause, after stopping hormonal birth control, or during times of major stress.

Hormones may be contributing to anxiety when symptoms worsen before a period, improve once bleeding starts, come with irritability or rage, increase around ovulation or the luteal phase, occur with breast tenderness or bloating, or show up alongside migraines, cravings, sleep changes, hot flashes, night sweats, low libido, vaginal dryness, heavier bleeding, irregular cycles, or brain fog.

In PMS and PMDD, symptoms may be related to sensitivity to normal hormonal fluctuations rather than a simple hormone deficiency or excess. That is why symptom tracking is so helpful. The pattern matters.

Perimenopause and anxiety

Perimenopause can be especially confusing because symptoms often begin before periods fully stop. Many women are told they are “too young” or that their labs are “normal,” even though they are experiencing sleep disruption, mood changes, increased anxiety, heavier or irregular cycles, night sweats, brain fog, and lower stress tolerance.

During this transition, estrogen and progesterone can fluctuate unpredictably. These changes can affect serotonin, sleep quality, temperature regulation, and nervous system stability. Poor sleep alone can make anxiety significantly worse. When sleep disruption, stress, hormone shifts, and life demands collide, many women feel like they suddenly cannot cope the way they used to. This is not a character flaw, rather it is physiology.

Cortisol, stress, and the hormone-anxiety connection

Cortisol is one of the body’s main stress hormones. It is part of the hypothalamic-pituitary-adrenal axis, often called the HPA axis. Cortisol is not “bad.” We need it to wake up, regulate blood sugar, respond to stress, reduce inflammation, and maintain energy. But when the stress response is chronically activated, the nervous system can begin to feel stuck in survival mode.

High stress can affect sleep, blood sugar, thyroid function, sex hormone production, inflammation, digestion, and emotional regulation. It can also change how other hormones behave in the body. This is one reason I pay attention to the bigger pattern rather than looking at one lab value by itself.

Research has explored how sex hormones and adrenal hormones, including testosterone, estradiol, DHEA, and cortisol, may relate to anxiety and depression symptoms. These relationships are complex and do not prove simple cause and effect, but they support the importance of considering hormone patterns when evaluating mood, anxiety, sleep, energy, irritability, and motivation.

Why I test

I test because I do not want to miss treatable contributors to anxiety. Therapy, nervous system regulation, nutrition, movement, medication, sleep support, and stress reduction can all be helpful. But if the thyroid is overactive, underactive, inflamed, or unsupported nutritionally, the person may continue to feel anxious despite doing “all the right things.”

We must put out the fire before we can rebuild the house.

I also test because patients often know something feels off before their symptoms fit neatly into a diagnosis. They may say:

• “I do not feel like myself.”

• “My anxiety feels physical.”

• “My heart races for no reason.”

• “I am exhausted but cannot relax.”

• “My symptoms are worse before my period.”

• “I wake up anxious at 3 a.m.”

• “I feel flat and unmotivated.”

• “I am more irritable than usual.”

• “My labs were normal, but I still feel terrible.”

Those statements matter and they tell us to look deeper. Testing does not replace a mental health assessment. It adds context. Anxiety can be influenced by many factors, including trauma, chronic stress, genetics, blood sugar changes, nutrient deficiencies, medications, substance use, sleep disorders, inflammation, thyroid dysfunction, hormone changes, and life circumstances. A good evaluation should make room for all of that.

What I want patients to know

If you struggle with anxiety, it does not mean your body is broken, and it does not mean it is “all in your head.” Anxiety is a signal. Sometimes it is signaling emotional stress. Sometimes it is signaling nervous system overload. Sometimes it is signaling a medical, hormonal, metabolic, or nutritional contributor. Often, it is a combination.

My goal is not to chase labs or blame everything on hormones. My goal is to understand your body as a whole so we can create a plan that actually fits you. When we identify thyroid dysfunction, hormone patterns, nutrient deficiencies, blood sugar instability, poor sleep, chronic stress physiology, or inflammation, we have more options. We can support the body while also supporting the mind.

That is the heart of integrative psychiatry: looking beyond the diagnosis and asking, “Why is this happening for this person, in this body, at this time?”

Every person deserves that level of curiosity.

Work with me

If you recognize yourself in this pattern, there is a different way to approach it.

In my practice, we look at:

• your genetic predisposition

• how your body processes hormones

• your nervous system

• and how your system has been adapting over time

From there, we build a plan that supports your body.

If you’re ready to feel more stable and understand what’s driving your symptoms, reach out to schedule a consultation.

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References

American College of Obstetricians and Gynecologists. (2023). Management of premenstrual disorders: ACOG clinical practice guideline. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/12/management-of-premenstrual-disorders

American Thyroid Association. (n.d.). Thyroid function tests. https://www.thyroid.org/thyroid-function-tests/

American Urological Association. (2018). Testosterone deficiency guideline. https://www.auanet.org/guidelines-and-quality/guidelines/testosterone-deficiency-guideline

Bhasin, S., Brito, J. P., Cunningham, G. R., Hayes, F. J., Hodis, H. N., Matsumoto, A. M., Snyder, P. J., Swerdloff, R. S., Wu, F. C. W., & Yialamas, M. A. (2018). Testosterone therapy in men with hypogonadism: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 103(5), 1715–1744. https://doi.org/10.1210/jc.2018-00229

Chronister, B. N. C., Gonzalez, E., Lopez-Paredes, D., Suarez-Torres, J., Gahagan, S., Martinez, D., Barros, J., Jacobs, D. R., Jr., Checkoway, H., & Suarez-Lopez, J. R. (2021). Testosterone, estradiol, DHEA and cortisol in relation to anxiety and depression scores in adolescents. Journal of Affective Disorders, 294, 838–846. https://doi.org/10.1016/j.jad.2021.07.026

Endocrine Society. (2022). Menopause. https://www.endocrine.org/patient-engagement/endocrine-library/menopause

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Disclaimer: This content is for educational purposes only and is not a substitute for personalized medical or psychiatric care. Individual needs vary. Please consult with a qualified healthcare provider before making changes to your treatment.