Thyroid Patients: Is It Perimenopause or Menopause?

Perimenopause refers to the hormonal shifts that occur in the years prior to the last menstrual period..

Many women with thyroid conditions receive treatment, and yet continue to struggle with a variety of symptoms. One of the questions you need to ask is if the symptoms you are experiencing -- and attributing to your thyroid -- may actually be related to perimenopause.

Menopause can be a loaded word for some women, and you may be inclined to think "there's no way, because I'm still having menstrual periods," or "I'm only in my early forties." But it's important to understand that menopause is defined as the point at which you haven't had a menstrual period for a year.

The average age for American women is 51.

But perimenopause is defined as the period leading up to menopause, and the shifts in hormones can take place as long as ten years before you are officially "menopausal." That means that if you're a woman in your late thirties to early forties, you may be in early perimenopause, and most women are going through perimenopause in their forties.

What Happens in Perimenopause

When you are born, your ovaries contain follicles that contain as many as a million eggs. By puberty, you have around 75,000 to 300,000 eggs remaining. During your reproductive years, about 400 to 500 eggs mature and are released. The rest deteriorate over time.

What triggers perimenopause is that as we get older, our baseline levels of estrogen and progesterone can start to decline. At the same time, the supply of egg follicles drops, the follicles that remain are less sensitive to stimulation, and the eggs that remain are older.

Because there are fewer follicles, and they are less sensitive, the hypothalamus stimulates the pituitary to make more Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) in an attempt to stimulate the remaining follicles, cause them to mature and be released as normal. During perimenopause, then, the FSH levels tend to rise.

During some cycles, your follicle doesn't develop fully, and estrogen doesn't rise in response. In some cases, the egg is not released at all, and progesterone is not released. This is known as an "anovulatory" cycle. The drops in estrogen and progesterone signal your uterus to shed its endometrial lining early, so your period may come earlier than usual. A shorter menstrual cycle is one the most common symptoms of perimenopause.

In other cycles, the follicle will develop normally, and normal amounts of estrogen and progesterone are released, and your menstrual cycle may follow its typical schedule.

Over time, as your baseline levels of estrogen and progesterone decline or become more erratic, and egg supply dwindles, you may have more anovulatory cycles, and more frequent periods.

Cycles when follicles don't develop and progesterone doesn't rise may result in a reduction in common PMS symptoms (backaches, bloating, cramps, etc.). At the same time, drops in estrogen can cause new symptoms such as hot flashes and night sweats.

As hormone levels further drop, As menopause approaches, levels of circulating follicle stimulating hormone (FSH) rise dramatically, in an effort to stimulate the remaining follicles to ovulate. At the same time, the ovaries cut back on production of estrogen.

Eventually, the stock of viable eggs is depleted, and hormone levels cannot trigger ovulation, menstruation stops, and menopause occurs.

Signs and Symptoms of Perimenopause

Signs and Symptoms of perimenopause include:

  • Menstrual irregularities: including heavier menstrual flow, bleeding at shorter intervals than three weeks, continual spotting or flow every two weeks, clotting with cramping, light spotting after sex, and phantom periods (you have all the signs and symptoms of a menstrual period, without bleeding). Important Note: while some bleeding irregularities can be expected during perimenopause, any significant irregular bleeding should be evaluated to rule out pregnancy, fibroids, or cancer, and all postmenopausal bleeding must be evaluated promptly by a physician.
  • Fertility issues: reduced fertility, infertility
  • Breast issues: including swollen and tender (sometimes lumpy) breasts, shrinking, sagging, and reduced firmness in breasts.
  • Vaginal issues: increased vaginal mucous and a heavy pelvic feeling almost like cramps or swelling, dryness, and an irritated feeling in the vagina
  • Urinary issues: including more frequent urination, and a tendency toward urinary tract infections, stress incontinence
  • Sleep problems: including difficulty falling asleep, frequent waking, waking frequently to urinate, inability to go back to sleep after waking, waking early
  • Weight issues: including weight gain, difficulty losing weight, redistribution of weight from the lower body to the abdomen, waist, hips and thighs, and decrease in muscle mass
  • Mood changes: including irritability, tension, anger, rapid mood swings, inability to cope with stress, extreme emotionality, and anxiety.
  • Changes in sex drive: including low sex drive, or loss of sex drive
  • Hair loss: including thinning of hair from the head or body, loss of hair from the head or body, receding male-pattern style hair loss at the temples
  • Unwanted hair: on the chin, upper lip, chest and abdomen.
  • Skin issues, including thinner, drier skin, more prominent wrinkles, adult-onset acne, and formication (an itchy, tingly sensation under the skin)
  • Aches and pains: including shoulder stiffness
  • Heart-related problems: including rapid heartbeat, heart palpitations, and an irregular heartbeat

Other common perimenopausal symptoms include:

  • Hot flashes
  • Night sweats
  • Lower bone density
  • Elevated cholesterol levels
  • Fatigue
  • Lack of energy
  • Concentration and memory problems

Is it Your Thyroid or Perimenopause?

As you can see, there are many symptoms -- fatigue, weight changes, and hair loss, for example -- that are common to both thyroid irregularities and perimenopause. How can you tell what is triggering your symptoms?

First, you need to make sure that your thyroid treatment is optimized. That means that your TSH, Free T4, and Free T3 are at appropriate levels that safely offer maximum relief from symptoms. (This may mean that treatment with T3 or natural thyroid becomes part of your regimen.)

Second, it's helpful to keep track of your menstrual cycle, characteristics, and symptoms for several months, to show your physician. Keep a calendar of chart that tracks your menstrual periods, including PMS symptoms, heaviness of flow, and other characteristics (like clots and color.)

If you have significant signs of perimenopause, or symptoms that are not relieved by optimal thyroid treatment, and you're over 40, it's time to want to work with your physician to evaluate your hormonal status. A review of your schedule, symptoms, an FSH test, evaluation of sex hormones (i.e., estrogen and progesterone), a pelvic examination, and a thorough family and personal medical history, may help your doctor determine if you are experiencing perimenopause.

Finally, if there are significant imbalances in your sex hormones that are causing symptoms, your doctor or practitioner may suggest supplements, medications or lifestyle changes to help restore balance and relieve symptoms. Certified Menopause Practitioners (they can be medical doctors, naturopaths, osteopathic physicians, nurse practitioners or physician's assistants), gynecologists, or practitioners who specialize in bioidentical hormones and hormone balance can recommend an treatment approaches that incorporate supplements, dietary and lifestyle changes, and even prescription medications to address your symptoms.

Thyroid Disease and Menopause The onset of thyroid disease is more common in women during perimenopause and menopause, in women over 40.

It's important to understand that the sex hormones and the thyroid -- both part of the endocrine system -- can get out of balance during the perimenopausal and menopausal period.

Thyroid Stimulating Hormone (TSH) Levels and Menopause

An important study was published in the medical journal Clinical Endocrinology, looking at the relationship between thyroid stimulating hormone levels - known as TSH -- and menopause. The study was based on an evaluation of results that came from the Study of Women's Health Across the Nation (SWAN).

They looked at menopausal symptoms, menstrual cycle bleeding characteristics and hormone levels -- as related to TSH levels -- in women aged 42 to 52 years from five different ethnic groups: African American, Caucasian, Chinese, Hispanic and Japanese.

The women had TSH, estradiol, testosterone, follicle stimulating hormone (FSH) and sex hormone binding globulin (SHBG) evaluated. The researchers were looking for a correlation between TSH levels, and other hormone levels during menopause, as well as menopausal symptoms.

There evaluation discovered that 6.2 percent of the women studied had a TSH above 5.0. This is a level that is above the top end of the reference range, and is considered indicative of hypothyroidism, an underactive thyroid.

A total of 3.2 percent of the women had a TSH below 0.5, which is indicative of potential hyperthyroidism, an overactive thyroid.

Of the various menopause symptoms evaluated, only a sense of fearfulness was associated with having a TSH value above 5.0 or below .5. Women with TSH values outside the .5 to 5.0 range also were more likely to report shorter or longer menstrual periods. There were no apparent linkages between TSH levels and the other hormones evaluated.

Implication for Patients: Perhaps most interesting in this study is the fact that almost 10 percent of women in the 42 to 52 year old age range had an undiagnosed thyroid condition. This is a higher prevalence rate than common estimates of thyroid disease for women in this age range.

Thyroid Problems in Menopause

Another study published in the journal Gynecologic Endocrinology found that the prevalence of high TSH levels increased with age, particularly in women after menopause. (Menopause is defined as the absence of a menstrual period for a year.)

In the postmenopausal population of women studied, they found 2.4 percent had clinical thyroid disease, and 23.2 percent had subclinical or borderline thyroid disease. Aong that group, almost 74 percent were hypothyroid, and 26 percent were hyperthyroid.

Implications for Patients: These researchers recommended routine thyroid screening in women during menopause.

Learn More About The Link Between Thyroid Disease and Menopause

Women over the age of 40 with thyroid disease should learn more about the impact of fluctuating sex hormones on thyroid function. Read Thyroid Patients: Could It Be Perimenopause?.

To learn more about how to differentiate between thyroid and menopause symptoms, and how thyroid patients can manage manage menopause, learn more about The Menopause Thyroid Solution.


North American Menopause Society,

Schindler, A."Thyroid function and postmenopause."Gynecol Endocrinol. 2003 Feb;17(1):79-85. Abstract.

Shomon, Mary. "Menopause Thyroid Solution," HarperCollins. 2009.

Sowers, Mary. "Thyroid stimulating hormone (TSH) concentrations and menopausal status in women at the mid-life: SWAN." Clinical Endocrinology. (2003) 58, 340–347. Full text.

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