Menopause Myth #16: Is It Menopause or Your Thyroid? Why Both Need Checking

“Is it my thyroid or is it menopause?”

A 49-year-old woman sits in front of me, exhausted beyond words. She’s been profoundly fatigued for over a year — not just tired, but bone-deep exhaustion that doesn’t improve no matter how much she rests. Her hair has been falling out in alarming amounts. She’s gained 15 kg despite eating the same as always. Her periods have become irregular. She has brain fog so severe she’s making mistakes at work. Her mood is low. She’s cold all the time, even in summer.

She went to her GP six months ago. “You’re perimenopausal,” her GP said. “These symptoms are normal for menopause. Here’s a prescription for HRT.”

She started HRT. Some symptoms improved — her hot flushes stopped (she’d been having mild ones), her sleep got slightly better. But the crushing fatigue, the hair loss, the weight gain, the feeling cold — all persisted.

“The HRT isn’t working,” she tells me. “Should we increase the dose? Try a different type?”

I review her history carefully. Then I ask: “Has anyone checked your thyroid function?”

She looks surprised. “No. My GP said it was menopause. Do you think it could be my thyroid?”

I order blood tests: TSH, free T4, free T3, thyroid antibodies.

Results come back: TSH 12.8 mU/L (very high — normal is 0.4-4.0), free T4 low, thyroid antibodies highly positive.

Clear hypothyroidism. Autoimmune thyroid disease (Hashimoto’s thyroiditis).

She has BOTH menopause AND a thyroid disorder — and no one had checked.

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The Problem: Overlapping Symptoms

Why are menopause and thyroid disorders so often confused?

Because many symptoms are identical.

Hypothyroidism (Underactive Thyroid) Symptoms:

• Profound fatigue, low energy
• Weight gain (despite no change in diet)
• Hair loss or thinning
• Dry skin
• Feeling cold (cold intolerance)
• Low mood, depression
• Anxiety
• Brain fog, difficulty concentrating, memory problems
• Muscle aches, joint pain
• Constipation
• Heavy or irregular periods
• Sleep disturbances

Perimenopause/Menopause Symptoms:

• Profound fatigue, low energy
• Weight gain
• Hair loss or thinning
• Dry skin
• Feeling cold (sometimes)
• Low mood, depression
• Anxiety
• Brain fog, difficulty concentrating, memory problems
• Muscle aches, joint pain
• Constipation
• Heavy or irregular periods
• Sleep disturbances

See the problem? The symptom lists are nearly identical.

It’s nearly impossible to distinguish clinically without blood tests.

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The Statistics: How Common Is This?

Thyroid disorders and menopause frequently coexist:

Prevalence:

• Up to 20% of perimenopausal women have thyroid dysfunction
• Women are 5-8 times more likely than men to have thyroid disorders
• Risk increases with age (peak incidence in 40s-60s — same age range as perimenopause)
• Autoimmune thyroid disease (Hashimoto’s thyroiditis, Graves’ disease) particularly common in women

This means: If you’re experiencing symptoms during perimenopause, there’s a 1 in 5 chance you also have a thyroid disorder.

Why the Overlap?

Several factors explain why thyroid issues and menopause often coincide:

Age:

• Both peak in 40s-60s
• Natural timing overlap

Autoimmune factors:

• Many thyroid disorders are autoimmune (body’s immune system attacks thyroid)
• Women more prone to autoimmune conditions generally
• Autoimmune conditions often emerge or worsen during hormonal transitions

Hormonal interactions:

• Oestrogen affects thyroid hormone binding proteins
• Thyroid hormones and sex hormones interact in complex ways
• Changes in one system can affect the other

Stress:

• Perimenopause is often high-stress life stage
• Chronic stress affects thyroid function
• Can trigger or worsen autoimmune thyroid conditions

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Types of Thyroid Disorders

Understanding the basics helps you advocate for appropriate testing:

Hypothyroidism (Underactive Thyroid)

What it is:

• Thyroid gland produces insufficient thyroid hormones (T4 and T3)
• Metabolism slows down
• Most common thyroid disorder

Causes:

• Hashimoto’s thyroiditis (autoimmune — most common cause in developed countries)
• Previous thyroid surgery or radioactive iodine treatment
• Certain medications (lithium, amiodarone)
• Iodine deficiency (rare in UK)
• Pituitary problems (rare)

Symptoms:

• Fatigue, sluggishness
• Weight gain
• Cold intolerance
• Dry skin, brittle hair, hair loss
• Constipation
• Depression, low mood
• Brain fog, memory problems
• Heavy periods
• Muscle aches, joint pain
• Slow heart rate

Diagnosis:

• Blood tests: Elevated TSH, low free T4
• If autoimmune suspected: thyroid antibodies positive

Treatment:

• Levothyroxine (synthetic T4) — daily tablet
• Dose adjusted based on blood tests
• Lifelong treatment in most cases

Hyperthyroidism (Overactive Thyroid)

What it is:

• Thyroid produces excessive thyroid hormones
• Metabolism speeds up
• Less common than hypothyroidism

Causes:

• Graves’ disease (autoimmune — most common cause)
• Toxic nodular goiter
• Thyroiditis (temporary inflammation)
• Excessive iodine intake
• Certain medications

Symptoms:

• Anxiety, nervousness, irritability
• Rapid heart rate, palpitations
• Weight loss (despite increased appetite)
• Heat intolerance, sweating
• Tremor (shaking hands)
• Insomnia
• Frequent bowel movements
• Light or absent periods
• Fatigue (despite hyperactivity)
• Eye problems (in Graves’ disease — bulging eyes)

Diagnosis:

• Blood tests: Low or suppressed TSH, elevated free T4 and/or T3
• Thyroid antibodies (if autoimmune)
• Sometimes thyroid scan

Treatment:

• Antithyroid medications (carbimazole, propylthiouracil)
• Radioactive iodine (destroys overactive thyroid tissue)
• Surgery (thyroidectomy)
• Beta-blockers (for symptom control)

Subclinical Thyroid Dysfunction

What it is:

• TSH slightly abnormal but T4/T3 normal
• Mild thyroid dysfunction
• May or may not require treatment

Subclinical hypothyroidism:

• TSH elevated (>4.0) but free T4 normal
• May have mild symptoms or no symptoms
• Treatment debated — usually treated if TSH >10, or if symptomatic, or if antibodies positive

Subclinical hyperthyroidism:

• TSH suppressed (<0.4) but T4/T3 normal
• Often requires monitoring, sometimes treatment

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Why Both Conditions Are Often Missed

Menopause Symptoms Mask Thyroid Issues:

GPs attribute all symptoms to menopause:

• Woman in her 40s-50s with fatigue, weight gain, mood changes, irregular periods
• “You’re perimenopausal. That explains everything.”
• Thyroid never checked

HRT is started:

• Some symptoms improve (those truly due to menopause)
• Others persist (those due to thyroid)
• Woman told “give it more time” or “try different HRT”
• Underlying thyroid disorder still untreated

Thyroid Is Checked But Menopause Is Missed:

Conversely:

• Woman has symptoms, thyroid is checked and found abnormal
• Thyroid is treated
• Some symptoms improve but others persist
• Hot flushes, night sweats, vaginal dryness don’t improve with thyroid treatment alone
• Because she also has menopause symptoms

Testing Is Incomplete:

TSH checked but not comprehensive thyroid panel:

• Many GPs order only TSH
• Can miss some thyroid problems (particularly if pituitary involved, or if TSH “normal” but T4/T3 abnormal)
• Antibodies not checked (misses autoimmune cause)

Blood tests done but results misinterpreted:

• TSH 4.5 (slightly elevated) dismissed as “normal” (lab range often up to 4.5-5.0, but many endocrinologists consider >3.0 as potentially problematic if symptomatic)
• Subclinical hypothyroidism not treated despite symptoms

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How to Tell the Difference (Or Identify Both)

Given the overlapping symptoms, how do you know which is causing what?

The answer: You can’t tell without blood tests.

But certain patterns provide clues:

Suggests Thyroid More Likely Primary Problem:

Profound, unrelenting fatigue:

• Beyond menopause tiredness
• Can barely function despite adequate sleep
• Most disabling symptom
• This level of fatigue more typical of hypothyroidism than menopause alone

Significant unexplained weight gain:

• 10+ kg gained over months despite no change in diet/exercise
• More typical of hypothyroidism
• Menopause causes weight gain but usually more gradual and responsive to lifestyle

Feeling cold all the time:

• Cold intolerance (need extra layers even in warm weather, can’t get warm)
• More specific to hypothyroidism
• Menopause more commonly causes heat intolerance (hot flushes)

Dramatic hair loss:

• Losing handfuls of hair, alarming thinning
• Hair loss occurs in both, but severe hair loss more concerning for thyroid

Severe constipation:

• Bowel movements every 3-5+ days despite adequate fiber/fluid
• More typical of hypothyroidism

Very slow heart rate:

• Resting heart rate <60 bpm (if not athletic)
• Hypothyroidism slows heart rate
• Menopause doesn’t typically affect heart rate (though palpitations can occur)

No hot flushes or night sweats:

• If you have profound fatigue, weight gain, mood changes but NO vasomotor symptoms (hot flushes/night sweats)
• Less likely to be menopause alone
• More likely thyroid (or other cause)

Suggests Menopause More Likely Primary Problem:

Hot flushes and night sweats:

• Very specific to menopause
• Not caused by thyroid disorders
• If these are prominent, menopause definitely involved

Vaginal dryness, painful sex:

• Specific to oestrogen deficiency
• Not caused by thyroid issues

Clear menstrual pattern changes:

• Periods becoming irregular, erratic timing
• Very common in perimenopause
• Hypothyroidism can cause heavy periods but doesn’t typically cause the erratic pattern of perimenopause

Sleep disruption specifically from night sweats:

• Waking drenched, needing to change clothing/sheets
• Specific to menopause

Often Both Are Present:

If you have:

• Fatigue, weight gain, hair loss, mood changes, brain fog (could be either)
• PLUS hot flushes, night sweats, vaginal dryness (definitely menopause)
• PLUS feeling extremely cold, severe constipation, dramatic hair loss (suggests thyroid as well)

You may well have both.

The only way to know: Blood tests.

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What Tests Should Be Done

If you’re experiencing symptoms, what thyroid tests should be requested?

Comprehensive Thyroid Panel:

1. TSH (Thyroid Stimulating Hormone):

• Most important screening test
• Produced by pituitary gland
• Tells thyroid how much hormone to produce
• High TSH = hypothyroidism (pituitary calling for more thyroid hormone because thyroid isn’t producing enough)
• Low/suppressed TSH = hyperthyroidism (pituitary telling thyroid to stop because too much thyroid hormone circulating)

Normal range: Typically 0.4-4.0 or 0.5-5.0 mU/L (varies by lab)

Important: “Normal” doesn’t mean optimal. Many people feel best with TSH <2.5. If TSH is 3.5-4.5 and you’re symptomatic, may still be worth treating.

2. Free T4 (Free Thyroxine):

• Main hormone produced by thyroid
• “Free” means the amount available to cells (not bound to proteins)
• Low in hypothyroidism, high in hyperthyroidism

Normal range: Typically 10-20 pmol/L (varies by lab)

3. Free T3 (Free Triiodothyronine):

• Active thyroid hormone (T4 converts to T3 in body)
• Most metabolically active
• Can be low even when T4 normal (conversion problem)

Normal range: Typically 3.5-6.5 pmol/L (varies by lab)

4. Thyroid Antibodies:

TPO antibodies (Thyroid Peroxidase):

• Positive in Hashimoto’s thyroiditis (autoimmune hypothyroidism)
• Can be elevated years before TSH becomes abnormal
• Important for diagnosis and prognosis

Thyroglobulin antibodies:

• Also elevated in Hashimoto’s
• Less commonly checked but useful

TSH receptor antibodies (TRAb):

• Positive in Graves’ disease (autoimmune hyperthyroidism)
• Usually checked if hyperthyroidism suspected

When to Test:

Screen for thyroid dysfunction if:

• You’re experiencing symptoms suggestive of thyroid disorder (fatigue, weight changes, hair loss, mood changes, etc.)
• You’re perimenopausal (given 20% prevalence of thyroid issues in this group)
• You have other autoimmune conditions (increases risk)
• Family history of thyroid disease
• Starting HRT and want baseline thyroid function
• On HRT but persistent symptoms despite treatment

Routine screening even without symptoms:

• Some guidelines recommend screening all women over 40-50 (though not universal)
• Definitely screen if high-risk (family history, autoimmune conditions, previous thyroid problems)

Interpreting Results:

Ask for actual numbers, not just “normal”:

• “Normal” can mean anywhere in the range
• TSH 4.5 is “normal” but may be suboptimal if symptomatic

If TSH elevated but T4 normal (subclinical hypothyroidism):

• Discuss treatment, especially if:
  • TSH >10
  • You’re symptomatic
  • Antibodies are positive (will likely progress)
  • Trying to conceive or pregnant

If all tests “normal” but still symptomatic:

• Consider asking for full panel if only TSH was done
• Consider other causes (menopause, B12 deficiency, iron deficiency, etc.)
• Consider retesting in 3-6 months (thyroid function can change)

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Treatment: What Happens If Both Are Present

If you have BOTH menopause AND thyroid disorder, how are they treated?

The Approach:

Treat both conditions:

• Thyroid disorder requires thyroid medication (levothyroxine for hypothyroid, antithyroid medication for hyperthyroid)
• Menopause requires HRT if appropriate
• Both can be treated simultaneously

Thyroid treatment:

• Usually started first or concurrently with HRT
• Levothyroxine typically started at low dose (25-50 mcg) and increased gradually
• Blood tests repeated 6-8 weeks after each dose change
• Target TSH usually 0.5-2.5 (though varies by individual and guidelines)
• Can take 3-6 months to optimize dose

HRT:

• Can be started at same time as thyroid treatment or shortly after
• No interaction between thyroid medication and HRT
• Both can be taken safely together

Monitoring:

• Regular blood tests for thyroid function (every 6-12 months once stable)
• Clinical assessment for menopause symptoms
• Both may need dose adjustments over time

Which Symptoms Improve With Which Treatment:

Thyroid treatment will improve:

• Fatigue (often dramatically)
• Weight (easier to manage, may lose some weight gained)
• Hair loss (usually stops, regrowth may occur)
• Feeling cold (improves)
• Constipation (improves)
• Brain fog, concentration, memory (often improve significantly)
• Mood (often improves)
• Muscle aches (may improve)

HRT will improve:

• Hot flushes, night sweats (often dramatically)
• Sleep quality (if disrupted by night sweats or hormonal changes)
• Vaginal dryness, painful sex
• Some mood symptoms (if hormonally driven)
• Some cognitive symptoms (if hormonally driven)
• Joint pain (may improve — common menopause symptom)

Lifestyle interventions help both:

• Adequate sleep
• Regular exercise (particularly strength training)
• Stress management
• Adequate protein
• Anti-inflammatory nutrition

Timeline:

Thyroid medication:

• May feel improvement within 2-4 weeks
• Full effect takes 6-12 weeks at stable dose
• Dose adjustments common over first 3-6 months

HRT:

• Hot flushes often improve within days-weeks
• Sleep may improve quickly
• Mood, energy, cognitive symptoms take longer (6-12 weeks typically)
• Full effect 3-6 months

If both treated:

• Some symptoms improve quickly (hot flushes with HRT, some fatigue with thyroid medication)
• Other symptoms take longer
• By 3-6 months should see significant improvement if both diagnoses correct and both treated appropriately

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What You Should Do

If You’re Experiencing Symptoms:

Step 1: Request Comprehensive Thyroid Testing

Don’t accept “we don’t need to check your thyroid”:

Say to your GP: “I’m experiencing [list main symptoms: fatigue, weight gain, hair loss, etc.]. I understand that thyroid disorders are common in perimenopausal women — up to 20% prevalence. I’d like comprehensive thyroid testing including TSH, free T4, free T3, and thyroid antibodies.”

Being specific about what tests you want:

• Increases likelihood of getting comprehensive panel (not just TSH)
• Shows you’re informed
• Makes it harder for GP to dismiss

Step 2: Get Actual Numbers

Don’t accept “your thyroid is normal”:

Ask: “What were the actual numbers? Can I have a copy of my results?”

You have a right to your medical records including blood test results.

Review results:

• Is TSH truly optimal (<2.5) or just “within range”?
• Are T4 and T3 actually measured or just TSH?
• Were antibodies checked?

If TSH 3.0-5.0 and you’re symptomatic:

• Consider discussing treatment even though “within range”
• Seek endocrinology opinion if GP won’t treat

Step 3: If Thyroid Abnormal, Start Treatment

Hypothyroidism:

• Levothyroxine (synthetic T4)
• Taken daily, on empty stomach, 30-60 minutes before breakfast
• Dose adjusted based on blood tests every 6-8 weeks initially
• Most people settle on 50-150 mcg daily (varies widely)

Hyperthyroidism:

• Referred to endocrinologist (specialist treatment)
• Antithyroid medication, radioactive iodine, or surgery
• More complex treatment

Important:

• Thyroid medication doesn’t interact with HRT
• Can take both safely
• Thyroid medication is usually lifelong (for hypothyroidism)

Step 4: Also Address Menopause If Appropriate

If you have thyroid disorder AND symptoms suggestive of menopause:

• Treat both
• HRT can be started alongside thyroid treatment
• Don’t assume all symptoms will resolve with thyroid treatment alone

If you have hot flushes, night sweats, vaginal dryness:

• These are menopause symptoms (not thyroid)
• Will only improve with HRT, not thyroid medication

Step 5: Monitor and Adjust

Thyroid:

• Blood tests 6-8 weeks after starting medication
• Then 6-8 weeks after any dose change
• Once stable: every 6-12 months
• If symptoms recur: recheck (dose may need adjusting)

Menopause:

• Review symptoms after 3-6 months on HRT
• Adjust if needed (dose, type, formulation)
• Annual review minimum

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Special Situations

If You’re Already on HRT But Symptoms Persist:

Common scenario:

• Started HRT for menopause symptoms
• Some symptoms improved (hot flushes, sleep) but others persist (fatigue, weight, hair loss, feeling cold)
• Consider thyroid testing if not already done

Persistent symptoms despite HRT should prompt investigation:

• Thyroid function
• B12, ferritin (iron stores), vitamin D
• Blood sugar (HbA1c)
• Medication review
• Other health issues

If You’re Already on Thyroid Medication But Symptoms Persist:

Common scenario:

• Diagnosed with hypothyroidism, started levothyroxine
• Some symptoms improved (fatigue better, weight more manageable) but others persist (hot flushes, sleep disruption, mood)
• Consider whether menopause also contributing

If you have:

• Hot flushes, night sweats
• Vaginal dryness
• Age 40s-50s
• Irregular periods

Discuss HRT with your GP — menopause symptoms won’t improve with thyroid medication alone.

Thyroid Medication and HRT: Any Interactions?

Good news: No significant interactions.

You can safely take:

• Levothyroxine (thyroid medication) and HRT
• No dose adjustments needed for either
• No timing restrictions (though levothyroxine should be taken on empty stomach, 30-60 min before breakfast; HRT timing doesn’t matter)

Both can be continued together long-term.

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The Bottom Line

Menopause and thyroid disorders frequently coexist — up to 20% of perimenopausal women have thyroid dysfunction.

The symptoms are nearly identical:

• Fatigue, weight gain, hair loss, mood changes, brain fog, muscle aches, sleep disturbances
• Impossible to distinguish clinically without blood tests

Why it matters:

• If thyroid disorder is missed → symptoms persist despite HRT
• If menopause is missed → symptoms persist despite thyroid treatment
• Many women have BOTH → need both treated for optimal outcomes

What you should do:

• Request comprehensive thyroid testing (TSH, free T4, free T3, antibodies) if experiencing symptoms
• Get actual numbers (don’t accept “normal” without seeing results)
• If thyroid abnormal: start appropriate treatment
• If also perimenopausal: consider HRT as well
• Monitor both conditions, adjust treatments as needed

Thyroid medication and HRT can be safely taken together — no interactions, both can be continued long-term.

Don’t assume all symptoms are menopause — check thyroid. Don’t assume all symptoms are thyroid — consider menopause.

Comprehensive assessment considering all potential factors = best care.

You deserve to have all contributing causes identified and treated.

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Need Support?

If you’re struggling with symptoms and unsure whether menopause, thyroid, or both are involved, I can help.

As a registered nurse and prescriber specializing in menopause care, I provide comprehensive assessment including appropriate investigations and treatment for both menopause and thyroid disorders.

Book a consultation for thorough evaluation and personalised treatment plan.