Why hormone testing matters in perimenopause

In perimenopause and menopause, it’s tempting to assume the answer is always HRT. And for many women, HRT can be life-changing. But there’s a big problem with the “HRT first, questions later” approach:

If you don’t test, you can end up treating the wrong driver — or using the right tool in the wrong way.

What I see again and again is that mood, cognition, sleep, energy, and resilience are not “just estrogen”. They are the output of a whole network: cortisol, thyroid hormones, oestrogen, progesterone, testosterone, insulin/metabolic health — all talking to each other, all capable of producing very similar symptoms.

So if we skip testing and assume “menopause = low oestrogen = HRT”, we risk staying stuck on a treatment that doesn’t fully fit the biology in front of us.

The “hormone–brain” connection is real (and it’s not one hormone)

The talk highlights an integrative psychiatry lens: mental health symptoms often rise and fall with hormonal transitions — PMS, postpartum, perimenopause, menopause — and symptoms can worsen when there’s an additional inflammatory load (autoimmunity, infections like Lyme/tick-borne illness, metabolic dysfunction).

That matters because

• Anxiety, low mood, poor sleep, brain fog, low motivation, panic, irritability, poor focus, memory changes — these can be hormonal.
• But they can be driven by different hormones (or by the way those hormones interact).
• If you don’t identify which system is off, you can keep “adding things” without addressing the root cause.

This is where testing stops being optional and becomes the compass.

The trifecta: cortisol, thyroid, and reproductive hormones

One of the most useful frameworks in the excerpt is the “trifecta” idea:

Thyroid, reproductive hormones, and cortisol often rise and fall together — and stress can knock the entire system off balance.

1) Cortisol and the HPA axis: the stress–mood amplifier

Cortisol isn’t just about stress. Chronically elevated or dysregulated cortisol can:

• suppress thyroid function
• worsen anxiety and depression symptoms
• disrupt circadian rhythm and sleep
• reduce serotonin synthesis and dopamine transmission (key neurotransmitter pathways)
• contribute to cognitive symptoms (brain fog, memory issues, executive functioning struggles)

Clinically, this is huge: the woman who feels “wired but tired”, wakes at 3 a.m., feels anxious, depleted, and emotionally reactive may not primarily need “more oestrogen” — she may need her HPA axis mapped and supported.

Testing helps you see whether cortisol is high, low, flipped, or flat (and therefore what type of intervention is actually appropriate).

2) Thyroid: the quiet driver behind “depression-like” symptoms

Thyroid function directly influences brain metabolism and neurotransmitter activity. Low thyroid activity can look like:

• low mood
• fatigue
• poor motivation
• cognitive slowing and brain fog
• weight changes
• low resilience and emotional flatness

And importantly, thyroid dysfunction can be missed when women are told their TSH is “fine” even though they feel anything but fine.

A functional approach typically considers a full thyroid panel (not only TSH), because conversion issues, reverse T3, and antibodies can matter — especially under stress or inflammation.

If we don’t test properly, a woman can be labelled “depressed” (or “just menopausal”), when the bigger issue is thyroid-driven brain metabolism.

3) Oestrogen, progesterone, testosterone: mood, immune balance, and brain function

Yes, oestrogen fluctuations can strongly affect serotonin signalling, mood, and cognition — and many women notice the biggest emotional and cognitive shifts during perimenopause when hormones become erratic.

But the excerpt also reminds us:

• progesterone and testosterone have important neuroprotective and anti-inflammatory roles
• hormone receptors exist throughout the body (including immune pathways)
• imbalance can feed into inflammatory patterns that worsen mood and symptoms

So if you only focus on oestrogen (or only prescribe one formula), you may miss a progesterone deficit pattern, androgen depletion, or an inflammatory pattern that’s undermining the whole picture.

Why “staying stuck on HRT” happens when you don’t test

Here are the most common patterns I see when hormone therapy is started without deeper assessment:

The symptoms improve… but plateau

HRT may soften hot flushes and sleep slightly, but mood, anxiety, brain fog, or motivation don’t fully return. Without testing, the next move is often: “increase the dose” or “try another patch”.

Sometimes that’s appropriate. Often, it’s not.

You treat oestrogen while cortisol is the real issue

If cortisol is dysregulated, it can suppress thyroid and disrupt neurotransmitters. HRT may help a little, but the system is still running on stress chemistry.

You treat menopause while thyroid autoimmunity is brewing

If Hashimoto’s (or another autoimmune pattern) is present, symptoms can worsen around hormonal transitions. If you don’t check antibodies and a full panel, you can miss the root driver.

You treat hormones while metabolic dysfunction is the hidden driver

Insulin resistance and blood sugar instability can mimic (and worsen) perimenopausal symptoms: fatigue, poor sleep, irritability, anxiety, weight changes, cravings, low mood.

You miss that “more isn’t better”

Sometimes symptoms aren’t from low hormones but from imbalance, poor clearance, inflammatory load, or incorrect ratios. In those cases, “more HRT” can worsen breast tenderness, headaches, mood swings, bloating, or irritability — and the woman loses confidence because she feels like her body is “failing” treatment.

Testing prevents this spiral.

What “testing” actually means in a functional menopause approach

Testing is not about chasing perfect numbers. It’s about matching the plan to the physiology you’re actually dealing with.

A robust approach often includes:

• Full thyroid assessment (not only TSH; consider free hormones and antibodies when clinically relevant)
• HPA axis / cortisol patterning (especially when sleep, anxiety, fatigue, and stress tolerance are central)
• Sex hormone patterns that reflect symptoms and stage (plus consideration of how hormones are being metabolised/cleared when relevant)
• Metabolic markers (glucose/insulin patterns, lipids, inflammation markers where appropriate)
• A wider look when indicated: inflammation, autoimmunity, nutrient status (e.g., key B vitamins that support neurotransmitter synthesis), and triggers such as chronic infections

And crucially: testing is only useful when it changes what you do next.

The payoff: personalised care, not guesswork

When women feel emotionally “not themselves”, they deserve better than trial-and-error.

Testing allows you to answer questions like:

• Is this primarily oestrogen fluctuation, progesterone depletion, testosterone decline — or a cortisol/thyroid pattern masquerading as menopause?
• Is inflammation or autoimmunity amplifying symptoms?
• Is the nervous system running on stress chemistry and breaking sleep and mood?
• Is blood sugar instability driving irritability, insomnia, and fatigue?
• If HRT is used, what dose, what balance, what delivery route, and what else must be addressed alongside it?

That’s how you avoid getting stuck — on HRT, on antidepressants, on “maybe it’s just stress” — while symptoms persist.

A better narrative for women: “You’re not broken — you’re unmeasured”

Perimenopause is a transition, not a diagnosis. And mood symptoms in this phase are not “all in your head”.

They’re often the predictable result of a shifting endocrine network interacting with stress load, immune function, thyroid physiology, and metabolic health.

HRT can be part of the solution — but testing is what makes it the right solution, for the right woman, at the right time, in the right way.

Call to Action:

If you are perimenopausal or menopausal and:

• have been offered HRT without a deeper assessment
• are already on HRT but still don’t feel like yourself
• feel stuck between “being told you’re fine” and knowing something isn’t right

then it may be time to step back and get clarity.

In my clinic, we begin with a full clinical history and use targeted testing where appropriate to understand what is actually driving your symptoms. From there, we create a plan that supports hormones, thyroid function, stress physiology and metabolic health — together, not in isolation.

If you would like to explore this approach, you can book an initial consultation to discuss whether testing would be helpful for you at this stage.

You don’t need to guess your way through this transition.

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