What could be causing my symptoms of feeling cold with increased sweating, considering potential conditions such as hypothyroidism, anemia, or anxiety?

Feeling Cold with Increased Sweating: Differential Diagnosis and Evaluation

The combination of feeling cold with increased sweating most commonly suggests hypothyroidism, but requires systematic evaluation to exclude hyperthyroidism, medication effects, anxiety, anemia, or rare autonomic disorders.

Primary Diagnostic Considerations

Hypothyroidism (Most Likely)

Hypothyroidism should be your first consideration, as it characteristically causes cold intolerance alongside paradoxical sweating in some patients. 1

Key clinical features to assess:

• Fatigue, lethargy, and weight gain are cardinal symptoms 1
• Bradycardia (slow heart rate) and mild diastolic hypertension with narrowed pulse pressure 1
• Coarse skin, periorbital puffiness, and delayed ankle reflex on physical examination 2, 1
• Cold skin, slow movement, and hoarseness 2
• Muscle weakness, muscle cramps, and constipation 1
• Depression, intellectual slowness, and somnolence 1

Order thyroid-stimulating hormone (TSH) and free thyroxine (T4) immediately - elevated TSH with low or normal free T4 confirms the diagnosis 1

Hyperthyroidism (Important to Exclude)

Despite feeling cold being atypical, hyperthyroidism causes prominent sweating and must be ruled out. 2

Distinguishing features include:

• Excessive sweating with heat intolerance (not cold intolerance) 2
• Tremors, nervousness, insomnia, and tachycardia 2
• Hypertension and goiter on examination 2
• Warm, moist skin and fine tremor of outstretched hands 2
• Lid lag or retraction in Graves' disease 2

The same TSH and free T4 panel will show suppressed TSH with elevated free T4 if hyperthyroidism is present 2

Medication-Induced Sweating

Check all medications, as sympathomimetics, stimulants, and certain antidepressants commonly cause excessive sweating. 3

Culprit medications include:

• Decongestants, caffeine, nicotine, and cocaine/amphetamines 2
• NSAIDs, oral contraceptives, and cyclosporine 2
• Antidepressants (though typically without cold sensation) 3
• Fine tremor, tachycardia, and sweating suggest sympathomimetic use 2

Consider urinary drug screen if illicit drug use is suspected 2

Secondary Considerations

Anxiety Disorders

Anxiety can present with sweating and subjective cold sensations, but this is a diagnosis of exclusion. 4

Critically, anxiety-like symptoms may actually represent undiagnosed hypothyroidism - one case series documented a 10-month misdiagnosis of generalized anxiety disorder in a patient who actually had hypothyroidism 4. This emphasizes why thyroid testing must precede an anxiety diagnosis in patients with these symptoms.

Anemia

While anemia causes cold intolerance, it does not typically cause increased sweating and would be an unusual presentation for this symptom combination.

Rare Autonomic Disorders

Cold-Induced Sweating Syndrome (CISS) is an extremely rare genetic condition where cold exposure paradoxically triggers profuse sweating, but this typically presents in childhood with distinctive dysmorphic features. 5, 6, 7

Features include:

• Profuse sweating from back and chest when exposed to temperatures of 7-18°C 5
• High arched palate, inability to fully extend elbows, and scoliosis 5, 6
• Facial and bulbar weakness in infancy 6
• Abolished by atropine, indicating peripheral mechanism 5

This diagnosis is only relevant if symptoms began in childhood with characteristic features 6, 7

Recommended Diagnostic Algorithm

1. Measure TSH and free T4 immediately - this single test distinguishes hypothyroidism (elevated TSH, low T4) from hyperthyroidism (suppressed TSH, elevated T4) 1

2. Review all medications and supplements for sympathomimetics, stimulants, or other causative agents 3

3. Perform focused physical examination looking for:

   • Thyroid examination for goiter 2
   • Skin texture (coarse vs. warm/moist) 2, 1
   • Ankle reflex timing 2, 1
   • Tremor quality (fine vs. coarse) 2
   • Heart rate and blood pressure 1

4. Consider complete blood count if anemia is suspected based on other symptoms

5. Assess for anxiety only after excluding organic causes, particularly hypothyroidism 4

Critical Pitfall to Avoid

Never diagnose anxiety or prescribe anxiolytics without first checking thyroid function, as hypothyroidism commonly presents with anxiety-like symptoms and can be misdiagnosed for months, leading to unnecessary treatment and delayed appropriate care 4. The American College of Physicians specifically recommends checking thyroid function and reviewing medications to rule out secondary causes before attributing sweating to primary disorders 3.