Not Just in Your Head: How Hormones Drive Anxiety, Fatigue, and Brain Fog

In my clinical practice, a question I hear almost daily is: "Is this anxiety... or is it my hormones?" For many women, especially those in their 30s through 50s, the answer is: both. Our hormonal landscape shifts dramatically across our lifespan—and those shifts are intimately tied to how we think, sleep, digest, and emotionally regulate. It's time we unpack the science and connect the dots.

Feeling overwhelmed, foggy, or just off lately?

Hormone shifts, stress, and nutritional deficiencies can all impact your mood and focus. You're not alone—and you're not broken. Let's get to the root cause.

Inflammation, Adipose Tissue & Mental Health

Adipose (fat) tissue isn’t just an inert storage depot—it’s an active endocrine organ that secretes inflammatory cytokines. In fact, increased visceral fat, especially post-menopause, correlates with elevated inflammation and higher rates of anxiety and depression [1]. As fat stores increase, so too does the conversion of hormones like testosterone into estradiol via aromatase—throwing the body into imbalance and affecting mood, energy, and cognition.

Site-specific regulation of adipose tissue by estrogen

Front. Endocrinol., 25 May 2022, Sec. Obesity, Volume 13 - 2022 | https://doi.org/10.3389/fendo.2022.889923

The Perimenopause Timeline: What Goes First?

Perimenopause can last 4 to 12 years. Progesterone is typically the first hormone to decline, often as early as a woman's mid-30s. Estrogen and testosterone drop more abruptly in the late 40s to early 50s.

Symptoms of early hormonal shifts include:

• Poor sleep

• Rising anxiety or irritability

• Brain fog

• Heavier or irregular periods

• Increased PMS

Newer research from the North American Menopause Society (NAMS) and The British Menopause Society highlights the importance of early treatment with hormone therapy—including estriol, estradiol (E2), testosterone, and DHEA—not only to improve symptoms but to reduce long-term risks like osteoporosis and cardiovascular disease [2][3].

Sex Hormone Pathways

The Cortisol Connection: Stress, Progesterone & Mood

High stress levels elevate cortisol production. Cortisol and progesterone share the same precursor hormone: pregnenolone. When cortisol demand rises, the body "steals" pregnenolone, reducing the amount available to make progesterone—worsening anxiety, fatigue, and belly fat. This is called the pregnenolone steal.

In women, lower progesterone impairs GABA receptor function (our calming neurotransmitter), directly contributing to anxiety and insomnia.

The DUTCH Test vs Routine Blood Labs

Most conventional providers won’t assess hormones unless a woman is postmenopausal—and even then, tests like serum estradiol or FSH offer limited insight. Blood levels fluctuate wildly during perimenopause, making it difficult to capture the full picture with a single draw.

At Starry Brook, we offer both insurance-covered routine labs and DUTCH testing because each provides unique insights.

• Serum testing is the gold standard for assessing testosterone levels, which helps us fine-tune dosing for symptoms like brain fog, low libido, and fatigue.

• DUTCH Complete Test adds essential information by:

  • Measuring cortisol levels throughout the day (diurnal rhythm)

  • Assessing estrogen metabolism pathways, including markers that relate to cancer risk

  • Showing how DHEA is being converted into testosterone, estrogen, or neither

Using both testing approaches allows us to correlate symptoms with lab data and individualize hormone therapy more precisely. For example, if serum testosterone is low but DHEA is high, we may need to address conversion issues—not just replace hormones.

This dual testing strategy ensures you're not just chasing numbers—we’re treating you.

What Each Hormone Does (and What Happens When It’s Off)

Progesterone

Normal: Calms the nervous system, supports sleep, balances estrogen

Low: Anxiety, insomnia, short luteal phase, heavy periods

Estrogen (E2 and E3)Normal: Mood, memory, bladder health, tissue elasticity

Low: Vaginal dryness, UTIs, mood swings, hot flashes

Excess (unopposed): Breast tenderness, anxiety, weight gain

Testosterone

Normal: Focus, libido, muscle tone, motivation

Low: Brain fog, low libido, fatigue, poor muscle tone

Hormone Therapy Isn’t One-Size-Fits-All

Websites like RO or HERS promise easy fixes, but they often fall short. For example, HERS cannot prescribe testosterone—a critical hormone for energy, memory, and sexual function. Instead, they offer over-the-counter DHEA, hoping your body will convert it.

But not all bodies do. Some women preferentially convert DHEA into estrogen rather than testosterone—making symptoms worse.

Additionally:

• Topical estrogen may work better for some than oral.

• Vaginal estradiol is often covered by insurance and helps with UTIs, vaginal microbiome balance, and comfortable sex.

• Sublingual hormone options avoid first-pass liver metabolism and may stabilize mood better in some women.

  
  

Final Thoughts: Your Hormones Are Not Too Complex to Understand

Mainstream medicine often dismisses women's hormonal concerns or chalks them up to “mood” or “stress.” But hormones are not mysterious—they follow patterns. They respond to lifestyle, stress, aging, and inflammation. And yes, they affect everything from your anxiety to your pelvic floor.

Your body is giving you clues. The right provider doesn’t just offer a pill—they help you interpret the message.

Let’s get you balanced. Schedule a hormone consult today.

References:[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9217881/[2] https://www.menopause.org/docs/default-source/professional/nams-2022-hormone-therapy-position-statement.pdf[3] https://www.thebms.org.uk/publications/tools-for-clinicians/testosterone-replacement-in-menopause/