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If you’re hypothyroid and going through perimenopause or menopause, you may wonder if it is safe to take (HRT) hormone replacement therapy while taking your thyroid hormone replacement medication. Or, you may have had surgery that has put you into premature menopause and could benefit from HRT. If you need to take HRT while on thyroid medication, this article explores some of the possible outcomes of combining these medications.

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Perimenopause and menopause bring about a range of common symptoms due to hormonal fluctuations. In perimenopause, which typically begins in a woman’s 40s but can start earlier, irregular periods, hot flashes, night sweats, mood swings, changes in libido, vaginal dryness, and difficulty sleeping are common. As menopause progresses, periods cease entirely, and symptoms like hot flashes, night sweats, mood swings, vaginal dryness, thinning hair, and cognitive changes may persist or intensify. Additionally, women may experience bone density loss, leading to an increased risk of osteoporosis. Each woman’s experience with perimenopause and menopause can vary in severity and duration.

Hormone replacement therapy (HRT) encompasses the hormonal medications prescribed to help minimize the symptoms and side effects of perimenopause and menopause. HRT works by replacing the declining or low levels of ovarian hormones -- namely estrogen and progesterone that are the root cause of symptoms. 

What are the different types of HRT? Like other medications, HRT comes in multiple routes for administration. These forms include pills, vaginal rings, creams, gels, injections, implants, skin patches, and even nasal sprays, featuring various forms of estrogen and/or progesterone in bioidentical or conjugated forms. 

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HRT is predominantly used by women who are going through natural or surgical perimenopause or menopause. By replacing the missing estrogen and progesterone, the body can fully function as if those hormones are still in place. Women who typically experience menopause symptoms range between the ages of 45-55. Age ranges for menopausal women can vary due to gynecological surgeries or medications that can initiate menopause or similar symptoms at an earlier age.

HRT is also used by some cancer patients who are undergoing treatment for breast or ovarian cancer. Reports indicate, however, that oncologists are reluctant to use HRT in these patients due to the possibility that the treatment may promote a cancer recurrence.

Male-to-female transgender people also commonly receive HRT while they are transitioning. The hypothalamus and pituitary glands regulate the hormones throughout the body, controlling everything from mood to bone density to sex drive. While these two glands essentially work together, a person receiving gender-based hormonal therapy may experience an imbalance, which could lead to hypothyroidism.

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HRT has both advantages and downsides. Having to live with symptoms like mood swings, hot flashes, insomnia, low sex drive, and mood swings can be exhausting and debilitating. HRT can make those symptoms tolerable, providing relief, in some cases, as quickly as several weeks. In addition to relief from menopausal symptoms, HRT can:

• help women prevent osteoporosis and reduce the risk of bone fractures by maintaining bone density
• potentially protect heart health and reduce the risk of heart disease
• maintain sexual function and libido, and reduce vaginal dryness and discomfort
• improved mood and mental well-being
• potentially reduce the risk of colorectal cancer and Alzheimer’s disease in specific populations

Hormone replacement therapy (HRT) can pose risks, mainly when used over an extended period of time. Some potential risks include:

1. Cardiovascular Risks: Studies have suggested that estrogen replacement therapy, particularly in older women or those with existing cardiovascular issues, might slightly increase the risk of heart attack, stroke, or blood clots.
2. Breast Cancer: There’s a slight increase in the risk of breast cancer associated with long-term use of combined hormone therapy (estrogen and progestin). However, this risk decreases after stopping HRT.
3. Endometrial Cancer: For women who have not had a hysterectomy and are taking estrogen-only therapy, there’s an increased risk of endometrial cancer.
4. Ovarian Cancer: Some studies have suggested a slightly increased risk of ovarian cancer with long-term use of estrogen-only therapy.
5. Gallbladder Disease: Estrogen therapy might increase the risk of gallbladder disease, particularly in menopausal women.
6. Blood Clots: There’s an increased risk of blood clots, particularly deep vein thrombosis and pulmonary embolism, associated with hormone therapy, especially in the first year of use.
7. Other Side Effects: Other potential side effects include bloating, breast tenderness, nausea, headaches, mood changes, and vaginal bleeding.

It’s important to note that not all women will experience these risks, and for some, the benefits of HRT may outweigh the risks, especially for managing severe menopausal symptoms. However, it’s crucial to discuss the risks and benefits with a healthcare provider before starting hormone replacement therapy. Additionally, the type of hormone therapy, dosage, and duration of use can all influence the associated risks. Regular monitoring and adjustments by a healthcare provider can help minimize these risks.

In general, it’s recommended that HRT is taken for at least three months to notice results. If you continue to have side effects after three months, your health provider should be notified.

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HRT is not suitable for everyone. People who should avoid or be cautious with HRT include:

1. History of Breast Cancer: If you have had breast cancer or are at high risk for breast cancer, HRT may not be recommended due to its potential to increase the risk of breast cancer recurrence or development.
2. History of Blood Clots: Individuals with a history of blood clots, such as deep vein thrombosis or pulmonary embolism, or conditions like atrial fibrillation, should avoid estrogen-based HRT as it can increase the risk of blood clots.
3. History of Stroke or Heart Disease: If you have a history of stroke or heart disease, especially if it’s related to blood vessel disease, HRT may not be recommended as it could potentially increase the risk of cardiovascular events.
4. Liver Disease: Liver disease can affect the way hormones are metabolized in the body, so HRT may not be suitable for individuals with severe liver dysfunction.
5. Unexplained Vaginal Bleeding: If you experience unexplained vaginal bleeding, it’s essential to see a healthcare provider to determine the cause before starting HRT.
6. Pregnancy or Breastfeeding: HRT is not appropriate during pregnancy or breastfeeding.
7. Severe Migraine Headaches: Women with a history of severe migraine headaches, especially those with aura, may be advised against using estrogen-containing HRT as it can potentially worsen migraines.

Anyone in these groups must consult with a doctor before beginning HRT. If you are under 60 years of age with menopausal symptoms and no history or minimal risks of the conditions mentioned above, the benefits of taking HRT may outweigh the risks.

Your Guide To The Genetics Of Thyroid Function

Knowing your risk for thyroid disease can help you stay in front of complications. Learn in this guide how genes impact your risk for hypothyroidism.

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The symptoms experienced during menopause and with an underactive thyroid are similar and can include dry skin, weight gain, increased fatigue, mood swings, decrease in sexual libido, constipation, intolerance to cold temperatures, and joint pain, among others. Menopause and hypothyroidism are very closely related, so optimal testing beyond TSH levels is required. Without in-depth testing, it could be easy to mistake the signs and symptoms of hypothyroidism for menopause -- and vice versa -- or misdiagnose these symptoms as another unrelated condition. Ultimately, however, a subset of women with an underactive thyroid -- with some estimates at roughly 5% of postmenopausal women on average -- are prescribed HRT while being treated for hypothyroidism.

There are several important things you need to know if you’re one of the women who is prescribed HRT while taking thyroid hormone replacement medication to treat an underactive thyroid gland.

Interaction with medications

First, it is essential to consider how thyroid hormone replacement medication and HRT may interact with each other. Oral forms of estrogen therapy can increase the body’s need for thyroid hormone replacement. Oral estrogen has a first-pass effect that causes the thyroxine-binding globulin to be absorbed by the hepatic system faster. This lowers the fraction of T4 (thyroxine) that moves through the circulatory system, resulting in the need for a higher dosage of thyroid medication. A healthcare provider should closely monitor hormone levels and symptoms to ensure that both medications work effectively.

An important note: Estrogen therapy also comes in transdermal forms, including a skin patch, gels, and creams. Transdermal estrogen does not affect T4 levels like the oral route. Transdermal application is recommended for those being treated for hypothyroidism and receiving HRT on a long-term basis.

Cardiovascular health

Both thyroid hormone replacement medication and HRT can impact cardiovascular health. Estrogen therapy, in particular, has been associated with an increased risk of blood clots and cardiovascular events. Women on both medications should be monitored for signs of cardiovascular issues, such as high blood pressure and heart palpitations.

Interaction between medications: It is essential to consider how thyroid hormone replacement medication and HRT may interact with each other. Some studies suggest that estrogen therapy can increase the body’s need for thyroid hormone replacement, which may require dosage adjustments. A healthcare provider should closely monitor hormone levels and symptoms to ensure that both medications work effectively.

Bone health

Thyroid hormone replacement medication has been linked to a higher risk of osteoporosis, while HRT can have a protective effect on bone density. Women on both medications should have their bone health assessed regularly to prevent fractures and other complications.

Mood and mental health

Thyroid hormone levels can have a significant impact on mood and mental health, and adding HRT to the mix may further complicate things. Women on both medications should be monitored for symptoms of depression, anxiety, and other mood disorders to ensure their mental well-being.

Most doctors recommend that a woman start HRT only when symptoms are debilitating enough to warrant treatment. It’s usually recommended that a woman continue HRT through the early fifties, on average. Keep in mind that you cannot take HRT and the contraceptive (or combination pill) together, as they both contain estrogen. There is another contraceptive pill, which is called a “mini-pill.” This mini pill only contains forms of estrogen, making it appropriate to take along with HRT when necessary.

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What if you don’t want additional prescription medications and prefer the natural or holistic route? Maybe your doctor has determined you are not a good candidate for HRT. Is it possible to implement changes in your lifestyle to avoid the use of such medications? Several options can be considered, including: 

• Stop smoking, as this increases the frequency of hot flashes.
• Avoid caffeine, spicy dishes, and alcohol consumption since they can also ignite hot flashes.
• Keep the temperature cool and use layers in bedding while you sleep to minimize night sweats.
• Refrain from wearing tight or form-fitting clothing, which can increase body temperature and exacerbate hot flashes.
• Maintain a healthy weight
• Eat a well-balanced diet.

In taking a more holistic approach, various herbal remedies have also been reported to improve menopausal symptoms, including: 

• Maca
• Black cohosh
• St. John’s wort
• Red clover
• Evening primrose oil
• Ginseng

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Overall, women who are considering adding hormone replacement therapy to their thyroid hormone replacement medication should consult with their healthcare provider to discuss the potential risks and benefits. Regular monitoring and close communication with a healthcare team can help ensure that both medications are used safely and effectively to improve your overall quality of life.

Remember that when a woman receiving thyroid hormone treatment for a thyroid condition is also prescribed HRT, the dosage of thyroid hormone replacement medication dosing may need to be adjusted or given in higher doses. Your doctor will likely recommend a regular testing schedule and bloodwork for thyroid levels, as well as estrogen and progesterone levels. Following that schedule is essential to ensure the safe and effective use of hormonal therapies.  

Before determining if HRT is an appropriate course of action or to manage your perimenopause and menopause along with hypothyroidism, consider becoming a Paloma member. You’ll have access to knowledgeable hormonal health experts and thyroid specialists who are always ready to help you better manage your thyroid and menopausal symptoms. If you are already on HRT and believe you may have symptoms related to hypothyroidism, use Paloma Health’s at-home testing kit to conveniently measure your thyroid hormone levels and help you and your healthcare provider determine how best to optimize your health.

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