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You’re tired, brain fogged, gaining weight, feeling overheated, and your periods are irregular. Your next step is usually “Dr. Google.” But an online search for these common symptoms is just as likely to suggest that you're in perimenopause or menopause as hypothyroidism.
While the symptoms often look very similar and the conditions can mimic each other, perimenopause/menopause and hypothyroidism are different and require different approaches for diagnosis and treatment. Let’s explore some key questions about overlapping symptoms of perimenopause/menopause and hypothyroidism and how to tell the difference.
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It’s important first to understand what sorts of changes are happening with female hormones during the perimenopausal and menopausal stages of the hormone life cycle. During a Paloma Speaker Series event on hypothyroidism and menopause, Dr. Anna Barbieri -- a physician and founder of Electra Health, a specialized platform for women in perimenopause and menopause, explained what happens to estrogen, progesterone, and testosterone during a woman’s life.
“These hormones do not function in a vacuum. All hormones function together. Thyroid hormone is like the conductor. It leads the hormones – estrogen, progesterone, testosterone – in their function. They’re really different members of the same orchestra, and hormones need to function together for us to feel optimal.
From the age of roughly our mid-twenties, testosterone tends to slope down very gently, but that transition is pretty smooth. When you look at estrogen and progesterone, they tend to stay relatively even. Of course, they change with every menstrual cycle. Estrogen goes up as we start our period, and it has another peak after ovulation, then drops.
Progesterone starts to go up after ovulation, stays elevated for about 10 to 14 days, then drops. And it’s really the drop of estrogen and progesterone that triggers a menstrual period.
Typically, in our early forties – but this can happen earlier –we enter perimenopause. As you can see from the chart, estrogen starts to go down, but pretty gently, then it goes through this very crazy transition when it’s up and down and up and down, and can change in every cycle.
But progesterone drops, and it drops earlier. So, early in perimenopause, we usually see shorter cycles in those first couple of years of change, and sometimes heavier bleeding, worsening premenstrual syndrome, and more thyroid dysfunction. These issues tend to be related not as much to low estrogen but to a drop in progesterone. Due to this imbalance between these two hormones, sleep disturbances and anxiety are very common during this time. And this is exactly what I felt at that time. And as we get closer to menopause, when we stop having our periods, the later stage of perimenopause is then characterized by this very swift drop in estrogen. And that’s when we start to skip cycles. We have hot flashes and night sweats, and vaginal dryness can start. And those symptoms are due to estrogen levels dropping.
When all of these hormones reach a stable level again, they are much lower than before.”
It’s often hard to determine if symptoms point to perimenopause, menopause, or hypothyroidism because they are the same. The following table shows the degree of overlap between the symptoms of hypothyroidism and menopause.
It’s also confusing because there’s a tendency to assume that everyone in perimenopause or menopause has hot flashes and night sweats, but the reality is often very different. Perimenopause and menopause symptoms aren’t stereotypical in some women. Dr. Barbieri spoke about this issue in the Paloma Speaker Series on hypothyroidism and menopause.
“Boy, was I surprised to discover that I was going through perimenopause a few years ago because, really, we were trained in medical school to look for the typical symptom profile of hot flashes and night sweats. All I had was just an impending sense of anxiety and self-doubt. I thought I was too stressed and doing too many things. It was actually very physical in nature. I did not even realize it at the time!”
Jill Chmielewski – a certified integrative nutrition health coach, applied functional medicine practitioner, women’s health educator, and registered nurse – explained the difference between perimenopause and menopause during the Paloma Speaker Series on hypothyroidism and menopause.
“Perimenopause refers to the time before menopause.
Perimenopause can last five years; it can last 10 years, and it can last longer than that. It’s not this short transition period of just one or two months.
A good portion of women will start to have what we call anovulatory cycles or cycles without ovulation around age 35 or maybe in the late thirties. And that kick off perimenopause. We only make progesterone when we ovulate. So, it makes sense that we start to see that steady decline in progesterone in our mid to late thirties or early forties. For most women, in the one to two years before menopause, you’ll see estrogen finally start making its downward descent.
Menopause is officially defined as the point at which you haven’t had a menstrual period for a full year.
The average age for menopause is 51. So that really means that about half of us are going to go through menopause before age 51. And about half of us after age 51.”
Whether you have symptoms that point to untreated hypothyroidism, suboptimal thyroid treatment, or the onset of perimenopause, a good starting point is to start with the thyroid gland, and evaluate your thyroid gland first. It’s easy to test your thyroid hormone levels at home with Paloma’s at-home thyroid test kit, and you can then work with your healthcare provider to determine if an underactive thyroid could be at the root of many of your symptoms.
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Ultimately, after thyroid function tests, it’s essential to see a healthcare provider for a formal diagnosis of hypothyroidism and a treatment plan.
To help diagnose whether a patient is experiencing symptoms of hypothyroidism, perimenopause, or menopause, Dr. Barbieri starts with a symptom profile.
“We take a really good look at the person in front of us and their history and their lifestyle, what’s going on in their life. We ask how long this has been going on. What’s going on with skin, hair, and weight? Has this been a problem since someone’s late twenties, or is it just starting now? Have there been other changes, such as major stressors in the last several months, or other medications and supplements that were added?
And then, of course, there’s the diagnostic aspect because often it is still really confusing. She may have polycystic ovarian syndrome. She may have hypothyroidism. She may be in perimenopause. That’s when we come to diagnostics. So usually, I will start with some lab work, a thyroid profile. We can do a hormonal profile. For patients with weight gain, I also like to look at insulin resistance and test for diabetes. I also look at nutrient profiles important for hormonal health, especially vitamin B levels, vitamin D levels, and magnesium levels. There are other ways of testing, including saliva and urine testing, that are a little more comprehensive, but I usually start out with a regular blood test that we can do right in the office.”
Jill Chmielewski also recommends that patients consider requesting the Dutch test for a comprehensive look at sex hormones and adrenal function. DUTCH stands for Dried Urine Test for Comprehensive Hormones.
“The Dutch test essentially checks 35 different hormones, including all three estrogens -- estrone, estradiol, and estriol – as well as progesterone, testosterone, DHT, cortisol, and melatonin.
One of the things that I really love about it is that it contains information about hormone metabolites. Metabolites are the results of the breakdown of hormones in the body. These metabolites have unique biological effects. When we look at metabolites, we can see the way that estrogen and testosterone are actually being broken down in the body as well. And we can actually do something about it if estrogen is going down a pathway we don’t love, or testosterone is leaning towards a path that we don’t love, or it’s imbalanced.”
When you have an underactive thyroid, the treatment of hypothyroidism starts with thyroid hormone replacement medication. The goal is to achieve optimal thyroid levels with the safest dose of the the best medication for you. You can learn more about optimal thyroid levels and how to achieve them here at the Paloma blog.
If you are perimenopausal or menopausal and experiencing symptoms of menopause, there are several options, as explained by Dr. Barbieri.
“Everything starts with nutrition. Eating whole foods, colorful foods, and enough healthy fats in our diet because fat, specifically cholesterol, is the backbone of hormonal production. So really, taking stock of our nutrition is super important.
It’s also important to decrease stress. Getting adequate sleep and meditation actually help with estrogen levels in the brain; our brain responds better – as if exposed to more estrogen.
There are, of course, herbs and supplements. Soy extract and soy isoflavones are phytoestrogens, meaning estrogenic plant compounds. They are not as powerful and immediate as taking estrogen, but they can be helpful. Black cohosh is another one.
And there are others that actually can help with symptoms of low estrogen but won’t act like estrogen. For example, one of them is a Swedish flower pollen supplement called, Relizen. It’s even safe for women with hormonally dependent breast cancer to use.
And, of course, hormone therapy is an option. We know that 20 years ago, the Women’s Health Initiative study reversed the trend of HRT – literally overnight. Women and doctors became afraid of HRT. It’s been 20 years, and amazingly, there are still people that apply the conclusions of that study to today’s practice, even though many of its conclusions have been disproven over time. For most healthy women – especially women around the age of menopause – hormone therapy will provide them with more benefit than harm.
Of course, like everything, HRT may carry some risk. So, the decision to really start hormone therapy needs to be very individualized and done with well-educated patients and practitioners who know what they are doing. The science is pretty clear now that hormones that are identical to the form that our body produces are likely safest. So, when I write for hormone replacement therapy for my patients, it is typically going to be with a transdermal form – a cream, patch, gel, or estrogen that is bioidentical. Meaning the form of it is exactly the same as what our body makes. And usually with oral progesterone, and that’s called micronized progesterone.“
A note about soy: Adding soy foods to the diet and taking soy and supplements are popular remedies for menopausal symptoms. According to Jill Chmielewski, if soy foods or supplements are going to be used, “I always recommend using fermented soy, and soy that’s non-GMO, not genetically modified.”
Dr. Barbieri is hesitant to recommend soy to her Hashimoto’s patients because those patients are more likely to be reactive to soy. “When I recommend a really solid anti-inflammatory diet, I will ask my patients to avoid soy at least for a while, and we test how they do with soy later on as we start adding things back in.”
Appropriate testing and good medical care are crucial when diagnosing and managing perimenopause, menopause, and hypothyroidism. Because it can be a very confusing time, and the conditions mimic each other, it’s essential to work with a knowledgeable healthcare practitioner to guide you.
One convenient way to get your thyroid hormone levels tested is with the Paloma Complete Thyroid Blood Test kit. The affordable and convenient at-home thyroid test kit from Paloma comes with everything you need to test Thyroid Stimulating Hormone (TSH), Free Thyroxine (Free T4), Free Triiodothyronine (Free T3), and Thyroid Peroxidase Antibodies (TPO). You also have the option to add on tests for Reverse T3 (RT3) and vitamin D.
Also, consider adding a practitioner to your team with expertise in hypothyroidism diagnosis and treatment. You can get high-quality hypothyroidism care from Paloma’s thyroid doctors. Paloma’s thyroid-savvy health care providers offer comprehensive diagnosis and optimal management of your levels of thyroid hormone, all from the convenience of your home. They have successfully worked with many hypothyroid patients in perimenopause and menopause, helping them resolve persistent symptoms of hormonal imbalance.
