Thyroid health and the menopause

How hormonal imbalances can affect your thyroid

• Thyroid conditions cause similar symptoms to the perimenopause and menopause
• A blood test can help determine if your symptoms are thyroid related
• You can still take HRT with a thyroid condition

The thyroid is a butterfly-shaped gland that’s located in your neck in front of your windpipe, below your Adam’s apple, and is part of your endocrine system. It’s a vital hormone gland, so it’s not surprising that perimenopause and menopause – with their accompanying hormonal disruptions – can cause thyroid issues. ­

Your thyroid gland has two main functions: firstly, to control metabolism, or the rate at which the cells in your body work; and secondly, to control growth in early life. It also helps to regulate various body functions by releasing thyroid hormones into your bloodstream, helping absorption of vitamins and regulating vitamin D processing.

Several different hormones are produced by your thyroid. The main ones are tri-iodothyronine (T3), an active hormone that regulates your body’s metabolism, and thyroxine (T4), an inactive hormone that becomes active once it is converted to T3. T4 is converted by enzymes, mostly in your liver, into T3. Your thyroid also produces very small amounts of T1 and T2, although little is known about their roles, and calcitonin, which is involved in calcium and bone metabolism.

Who suffers from thyroid issues?

Thyroid problems often run in families and can happen at any age. However, thyroid diseases predominantly affect women; their incidence is 5-20 times higher in women than in men [1]. They also increase with age. Thyroid conditions include Hashimoto’s, Grave’s, hypothyroidism, hyperthyroidism, nodular goitre, and cancer all of which occur often in postmenopausal and elderly women [2].

An overactive thyroid (known as hyperthyroidism) occurs if your thyroid gland makes too many thyroid hormones. An underactive thyroid (hypothyroidism) is where the gland doesn’t make enough thyroid hormones.

Your thyroid gland may grow in response to poor function, which, when significantly enlarged becomes known as a goitre. Sometimes individual lumps called nodules grow in your thyroid gland known as nodular goitre, and sometimes lumps in the thyroid can be cancerous.

Many symptoms of thyroid diseases – such as anxiety, heart palpitations, sweating, gaining weight and insomnia – can be tricky to diagnose in menopausal women as they are common for both thyroid problems and menopause [3]. 

What are the symptoms and causes?

Underactive thyroid (hypothyroidism)

This is found in at least 2% of the UK population – one in 20 people – and in more than 5% of those over 60. Women are 5 to 10 times more likely to be affected than men [4]. 

Most cases of an underactive thyroid are caused by your immune system, which usually fights infection, “attacking” your thyroid gland and damaging it so that it can’t make enough of the hormone thyroxine. A condition called Hashimoto’s disease is the most common type of autoimmune reaction that causes an underactive thyroid. 

Typical symptoms of hypothyroidism may include tiredness, feeling cold, weight gain, poor concentration, constipation and depression.

Overactive thyroid (hyperthyroidism)

This is a less common thyroid condition, although it is about 10 times more common in women than men, and typically happens between 20 and 40 years of age [5].

There are several conditions that can cause your thyroid to become overactive, with Graves’ disease being the most common (about four in every five people with an overactive thyroid gland have it) [6]. There is a genetic disposition to Graves’ and it mostly occurs in women aged 30-60 [7].

Your thyroid can also become overactive if nodules develop on it as these can contain thyroid tissue, which results in the production of excess thyroid hormones. Thyroid nodules are usually non-cancerous and usually affect people over 60 years of age.

Common symptoms of hyperthyroidism include weight loss, heat intolerance, fatigue, anxiety, difficulty sleeping and palpitations.

How does menopause affect the thyroid?

According to the British Thyroid Foundation, it is common for perimenopausal and menopausal women to also have an underactive thyroid [8]. Because thyroid and menopause-related symptoms are common, non-specific and can overlap, it is important to see your doctor to identify the cause. The only accurate way of finding out whether you have a thyroid problem is to have a thyroid function test, where a sample of blood is tested to measure your hormone levels.

If you’ve already been diagnosed with hypothyroidism and are taking daily thyroid hormone replacement tablets, called levothyroxine, to raise your thyroxine levels, your dose may need to be adjusted during perimenopause and menopause. This is because changing oestrogen levels are thought to affect thyroid function.

Just as menopause can affect thyroid function, a thyroid condition can impact on your menopause. Uncontrolled hyperthyroidism can cause stress across your hormone system – studies have shown it decreases levels of progesterone, which can increase perimenopausal symptoms [9].

Can I take HRT if I have thyroid problems?

If you have hypothyroidism, you can take oestrogen through the skin by gel, spray or patch. Starting or increasing oestradiol can affect the thyroid function and you may need a dose adjustment of your thyroid medication. Progesterone in HRT is also not thought to significantly impact thyroid replacement doses. Testosterone also does not interfere with thyroxine.

However, the British Thyroid Foundation advises that if you wish to take oral combined HRT, you may need to increase your thyroxine dose. Oral oestrogen changes the amount of thyroxine bound to proteins in your blood and can result in there being less thyroid hormone freely available to do its job.  It advises that thyroid function tests should be re-checked after starting tablet-combined HRT.

Many women find that taking HRT actually improves their thyroid function.

Thyroid testing and diagnosis

The only current way to test for thyroid conditions is through blood testing alongside symptom history. 

To get a full check of your thyroid you need to have the following tests taken: TSH (thyroid stimulating hormone), free T4 and free T3 along with thyroid peroxidase and thyroglobulin antibodies. Free T3 is essential in this testing because it is one of the best thyroid lab measures as it reflects the actual available thyroid hormone in your body.

Alongside testing of your thyroid hormones, it is also useful to look at the most common vitamin levels that are adversely affected by poor thyroid function. These are vitamin B12, vitamin D, folate, and ferritin.

Testing your female sex hormones is useful. If your HRT is optimised, levels are adequate on a blood test and yet symptoms persist, alternative causes need to be considered.

If you have a goitre or nodules, your practitioner may request an ultrasound scan of your thyroid.

Diagnosis is made on a combination of the tests as above and symptoms.

Treatment

Hypothyroidism

Treatment for hypothyroidism is aimed at replacing your thyroid hormones.  The most common medication used is levothyroxine, although there are other hormonal forms available.

Most cases of hypothyroidism are caused by an autoimmune disorder where our own antibodies attack the thyroid.

Hyperthyroidism

Initial treatment for hyperthyroidism is aimed at lowering the levels of your thyroid hormones and managing the symptoms caused by excess thyroid hormone. The most common medical treatment is a drug called carbimazole, which reduces the amount of thyroid hormones produced by your thyroid gland. Propylthiouracil is a similar medication.

To manage symptoms such as palpitations and shakes, you might be prescribed a short-term course of a beta blocker such as propranolol. In the long term, if you continue to be hyperthyroid then more permanent treatment may be recommended to stop thyroid function altogether. This may be in the form of total thyroid removal or by radioactive iodine, which destroys the thyroid tissue. This will then leave you hypothyroid which will then require medication to be taken daily.

The good news is that thyroid conditions have been effectively controlled for many years, and there are several well-tolerated, excellent treatment options available. Given that the thyroid function is also regulated by hormones, it’s logical to consider thyroid function in relation to other hormones.

Resources

British Thyroid Foundation: Thyroid and menopause

The North American Menopause Society Is it menopause or a thyroid problem?

References

1-3. Gietka-Czernel M. (2017), ‘The thyroid gland in postmenopausal women: physiology and diseases’, Prz Menopauzalny,16(2):33-37. doi: 10.5114/pm.2017.68588

4, 7. NICE guidance: thyroid disease assessment and management

5-6. NHS: overactive thyroid hyperthyroidism

8. British Thyroid Foundation: thyroid and the menopause

9. Khinteel Jabbar N, Al-Abady Z.N., Jasib Thaaban Almzail A, Al-Athary RAH. (2022), ‘Relationship between Menopause and Complications of Hyperthyroidism in Female Patients in Iraq’, Arch Razi Inst. Aug 31;77(4):1481-1489. doi: 10.22092/ARI.2022.357618.2071

Written by:

Dr Louise Newson is a GP and menopause specialist. She’s the founder of the balance website and free app, Newson Health Research and Education, the Dr Louise Newson podcast and is the bestselling author of The Definitive Guide to the Perimenopause and Menopause.

Dr Georgina Conway is a GP with a special interest in thyroid disorders, hormones and women’s health. She has Hashimoto’s herself so understands the frustration of living with a thyroid condition. Her clinic, The Thyroid Clinic, has a patient-centred approach.

Dr Penny Ward is a GP and menopause specialist. She leads clinician education at Newson Health.