Is It Perimenopause or Hashimoto’s?

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If you’re in your late 30s or 40s and constantly fighting exhaustion, brain fog, stubborn weight gain, mood swings, and erratic periods, you might chalk it up to perimenopause—the rollercoaster ride leading to menopause.

But what if there’s more to the story? What if an undiagnosed thyroid condition, like Hashimoto’s thyroiditis, is secretly amplifying your symptoms and making you feel even worse?

Many women experience symptom overlap between perimenopause and Hashimoto’s, leading to misdiagnosis or delayed treatment. Since both conditions affect metabolism, mood, and energy levels and often strike at the same time of life, it’s crucial to understand the differences. Identifying whether your symptoms stem from hormonal fluctuations, an autoimmune thyroid disorder, or both can help you get the right medical care and start genuinely feeling better.

Let’s break down the key distinctions, how to identify which condition you might have, and what steps you can take next to smooth out the ride and feel well!

Perimenopause is the transitional phase before menopause when you’re still menstruating, even if periods are erratic. (Menopause is the point when it’s been a whole year since your last menstrual period.)

The perimenopausal period typically begins in your 40s, but it can start as early as your mid-30s or as late as your mid-50s. Perimenopause can last anywhere from a few months to over a decade, with an average duration of about 4 to 8 years. Factors such as genetics, smoking, medical conditions like hypothyroidism, or surgeries like hysterectomy can influence when perimenopause starts and how it progresses.

Perimenopause usually occurs naturally as the ovaries gradually reduce hormone production, and estrogen and progesterone levels fluctuate unpredictably and decline over time. The result is irregular ovulation and erratic menstrual cycles, as well as symptoms of both PMS and menopause.

Common symptoms of perimenopause

Perimenopause affects nearly every system in the body. While many women are familiar with menopausal symptoms, you may not realize that they are also perimenopausal symptoms. Here’s a closer look at the most common symptoms:

• Irregular periods: Menstrual cycles may become shorter or longer than usual. Some women experience heavier or lighter periods. It is also common to skip a period entirely for some months.
• Hot flashes and night sweats: Many women experience sudden heat surges that start in the chest and spread to the face and arms, known as hot flashes, and sometimes hot flushes. Night sweats are also common and can significantly disrupt sleep. These symptoms are often triggered by stress, caffeine, alcohol, or warm environments.
• Mood swings and anxiety: Fluctuating estrogen levels can lead to increased irritability, anxiety, depression, and feelings of sadness. Some women experience panic attacks or heightened stress responses, even if they have never struggled with anxiety before.
• Fatigue and brain fog: Many women feel exhausted even after a full night’s sleep. Some struggle with difficulty concentrating, forgetfulness, or mental fogginess, often referred to as “perimenopausal brain fog.”
• Weight gain and metabolism changes: Many women notice unexplained weight gain, particularly around the abdomen. Increased insulin resistance makes it harder to regulate blood sugar, and loss of muscle mass slows down metabolism.
• Sleep disturbances: Falling asleep may become more difficult, and many women wake up multiple times during the night. Early morning awakenings, where you wake up too early and cannot fall back asleep, are also common. These disturbances are often linked to declining progesterone levels, which generally help with relaxation and sleep.
• Changes in hair, skin, and joints: Some women experience dry skin, thinning hair, and brittle nails. Others notice increased joint pain or stiffness, which is sometimes mistaken for early arthritis. Loss of skin elasticity may lead to more noticeable wrinkles.
• Decreased libido: A reduced sex drive is common during perimenopause.
• Fertility decline: Although fertility declines during perimenopause, pregnancy is still possible until menopause is reached.

How perimenopause is diagnosed

Healthcare providers typically diagnose perimenopause based on physical symptoms and changes in menstrual cycles. Some may check hormone levels, including follicle-stimulating hormone (FSH), which rises as ovarian function declines. Estrogen and progesterone levels fluctuate during perimenopause but gradually decline over time. However, because hormone levels can vary significantly from day to day, a single blood test is not particularly helpful in providing a definitive diagnosis.

Hashimoto’s thyroiditis is an autoimmune disorder in which the immune system attacks the thyroid gland, leading to inflammation, gradual thyroid hormone decline, and, eventually, an underactive thyroid. It is the most common cause of hypothyroidism worldwide and disproportionately affects women.

Epidemiology, prevalence, and risk factors

There are many risk factors for Hashimoto’s thyroiditis. Understanding these factors can help identify those at higher risk and potentially lead to earlier diagnosis and management of the condition.

Link to hypothyroidism: Hashimoto’s thyroiditis is the most common cause of hypothyroidism in the United States after age 6 years.

Iodine intake: While iodine is essential for thyroid function, excessive iodine intake can trigger Hashimoto’s in susceptible individuals. Balanced iodine consumption is crucial for maintaining thyroid health. In areas with adequate iodine intake, Hashimoto’s thyroiditis remains the most common cause of spontaneous hypothyroidism.

Prevalence: Hashimoto’s disease affects about 5 in 100 Americans, approximately 5% of the U.S. population.

Gender: Women are significantly more likely to develop Hashimoto’s thyroiditis, with studies showing they are 4 to 10 times more likely to develop Hashimoto’s disease than men.

Age: While Hashimoto’s can occur at any age, it is most commonly diagnosed between the ages of 30 and 50. However, the prevalence of hypothyroidism and thyroid disease in general increases with age.

Hormonal status: Pregnancy can trigger thyroid problems in some women, with up to 20% of those experiencing thyroid issues during the first year after childbirth later developing Hashimoto’s. The prevalence of hypothyroidism is also significantly higher in women during late perimenopause and postmenopause compared to premenopause.

Autoimmune disease history: If you have an autoimmune condition, you’re at a higher risk of developing Hashimoto’s. This includes diseases such as rheumatoid arthritis, lupus, type 1 diabetes, celiac disease, and pernicious anemia. The presence of one autoimmune disease often increases your likelihood of developing others.

Family history: There is a genetic component to Hashimoto’s disease. Studies have shown that first-degree relatives of persons with Hashimoto’s thyroiditis have a nine-fold greater risk of developing the disease.  And your chance of developing Hashimoto’s disease increases if other family members have the disease. You are also more likely to develop Hashimoto’s disease if you or your family members have other autoimmune disorders, including celiac disease, lupus, rheumatoid arthritis, Sjögren’s syndrome, and type 1 diabetes.

Genetic predisposition: Several genes have been associated with an increased risk of Hashimoto’s. These include genes related to immune response and thyroid function, such as HLA complex genes, CTLA-4, PTPN22, CD14, CD40, and IL2R3.

Radiation exposure: Increased cases of thyroid disease, including Hashimoto’s, have been reported in people exposed to high levels of radiation, such as from atomic bombs, nuclear accidents, or certain medical treatments.

Infections: Certain bacterial infections, such as Helicobacter pylori and bacterial overgrowth in the small intestines and gut, have been linked to an increased risk of Hashimoto’s.

Nutrient deficiencies: Low levels of certain nutrients, particularly Vitamin D, selenium, and zinc, have been associated with an increased risk of Hashimoto’s.

Stress: Chronic stress is known to affect the immune system and could potentially trigger or worsen autoimmune responses, including Hashimoto’s.

Global trends in Hashimoto’s disease

In the United States, the prevalence of Hashimoto’s has been steadily rising over the last few decades, possibly due to environmental factors, diet changes, and increased awareness and testing.

In iodine-sufficient countries, Hashimoto’s is the leading cause of hypothyroidism, whereas in iodine-deficient regions, iodine deficiency remains the primary cause.

Autoimmune thyroid diseases, including Hashimoto’s, affect about 12 to 15% of the global population.

Common symptoms of Hashimoto’s

Unlike perimenopause, Hashimoto’s symptoms typically don’t fluctuate on a cyclical basis. Instead, they tend to worsen over time as thyroid function declines.

Extreme fatigue: Many people with Hashimoto’s experience deep, unrelenting exhaustion, even after sleeping for eight or more hours. Some have difficulty waking up in the morning and feel sluggish throughout the day. Midday and afternoon crashes are common, often leading to a need for naps or caffeine.

Brain fog and memory issues: People with Hashimoto’s often struggle to concentrate, focus, or process information. Many report feeling mentally slow, forgetful, or disoriented. Difficulty finding words or keeping up with conversations is also common.

Unexplained weight gain: Many people gain weight despite making no changes to their diet or exercise routine. Some experience puffiness or bloating due to water retention. Losing weight can be tricky, even with strict calorie control.

Cold intolerance: People with Hashimoto’s often feel cold all the time, even in warm environments. Some have cold hands and feet, sometimes with a blue or purple tint. Many prefer warmer rooms or extra layers of clothing, even when others feel comfortable.

Dry skin, hair thinning, and brittle nails: Hashimoto’s can cause flaky, dry skin that worsens in the winter. Many experience thinning hair, especially near the temples and crown. Brittle nails that break easily or develop ridges are also common.

Depression and anxiety: Many people with Hashimoto’s experience increased feelings of sadness, low motivation, or hopelessness. Heightened anxiety is also common, even when there is no apparent reason. Some people struggle with irritability or mood swings, which can be mistaken for perimenopause.

Menstrual changes: Many people with Hashimoto’s have heavier, longer, or more painful periods, which contrasts with perimenopause, where periods usually become lighter or irregular. Some experience shorter cycles, where periods occur every 21 to 24 days. Increased premenstrual syndrome (PMS) symptoms, such as breast tenderness and bloating, are also common.

How Hashimoto’s is diagnosed

Doctors can confirm Hashimoto’s with blood tests. These may include:

• Thyroid-stimulating hormone (TSH): This pituitary hormone is often elevated in hypothyroidism.

• Thyroid peroxidase (TPO) antibodies: The presence of these antibodies indicates an autoimmune attack on the thyroid.

• Free T3 and Free T4: Measures available levels of triiodothyronine (T3), the active thyroid hormone, and thyroxine (T4), the storage hormone. Low levels of thyroid hormones can diagnose hypothyroidism that develops as a result of Hashimoto’s.

In some cases, a thyroid ultrasound may be performed to detect inflammation, nodules, or structural changes in the thyroid gland.

Early detection of Hashimoto’s disease is crucial for preventing a range of serious complications associated with untreated hypothyroidism. Identifying the condition in its early stages allows for timely intervention and management, significantly reducing the risk of long-term health issues.

Cardiovascular complications

Untreated Hashimoto’s disease can lead to an increased risk of heart problems. Low levels of thyroid hormones can result in high cholesterol levels, particularly LDL (low-density lipoprotein) cholesterol. This elevation in cholesterol contributes to the development of atherosclerosis, a condition where fatty deposits build up in the arteries, restricting blood flow. Additionally, hypothyroidism can cause hypertension (high blood pressure) and fluid retention, potentially leading to congestive heart failure. Early detection and treatment can help maintain healthy lipid levels and reduce the risk of cardiovascular disease.

Reproductive health issues

Hashimoto’s disease can significantly impact fertility and pregnancy outcomes. Untreated hypothyroidism can cause irregular or heavy menstrual periods, making it difficult to conceive. For pregnant women with untreated Hashimoto’s, the risks are even more severe. These include an increased likelihood of miscarriage, premature birth, and various congenital disabilities such as cleft palate, autism, or intellectual disabilities. Early diagnosis and proper management of thyroid function during pregnancy are essential for the health of both the mother and the developing fetus.

Cognitive function and mental health

As Hashimoto’s disease progresses, it can affect cognitive function and mental health. Untreated hypothyroidism may lead to difficulty concentrating, memory problems, and mood changes. In older adults, there is an increased risk of cognitive decline and dementia if the condition remains undetected and untreated. In addition, depression and other mental health disorders may occur early in Hashimoto’s disease and can become more severe over time.

Myxedema: A life-threatening complication

One of the most serious potential complications of untreated Hashimoto’s disease is myxedema, a rare but life-threatening condition. Myxedema occurs when thyroid hormone levels become extremely low, leading to severe hypothyroidism. Symptoms can include unnatural sleepiness, extreme sensitivity to cold temperatures, and, in severe cases, coma. While rare, myxedema requires immediate medical intervention and can be fatal if left untreated.

Benefits of early detection

Routine screening and early detection of Hashimoto’s disease offer numerous benefits. Regular thyroid function tests, including measurements of TSH, T4, and T3 levels, can identify abnormalities before noticeable symptoms appear. Early diagnosis allows you to get started on thyroid hormone replacement therapy, which can effectively manage symptoms and prevent the progression of the disease. Moreover, early detection is vital for high-risk groups, such as women over 35 and women with a family history of thyroid conditions.

In conclusion, early identification of Hashimoto’s disease is critical for preventing severe complications and ensuring optimal health outcomes. Regular thyroid screening, especially for those at higher risk, can lead to timely diagnosis and treatment, significantly reducing the likelihood of developing serious health issues associated with untreated hypothyroidism.

Here’s a quick symptom comparison to help identify which condition might be affecting you:

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How will your healthcare provider tell whether your symptoms are due to Hashimoto’s, perimenopause, or both?

A knowledgeable provider takes a comprehensive approach, starting with a detailed medical history and symptom evaluation, including onset, duration, and severity. They may also check for thyroid enlargement (goiter), a sign of Hashimoto’s.

For a Hashimoto’s diagnosis, your doctor will assess thyroid function through free T4, free T3, TSH, and thyroid peroxidase (TPO) antibodies. A thyroid ultrasound may also be recommended.

For perimenopause, blood tests have limited reliability due to fluctuating hormone levels. While follicle-stimulating hormone (FSH) may be tested, it varies widely. Diagnosis is primarily based on symptoms and menstrual history, though some providers assess additional hormones like luteinizing hormone (LH), estrogen, progesterone, testosterone, and DHEA.

It’s important to understand that diagnosis can be challenging due to the significant overlap in symptoms between these conditions. Your healthcare provider may need to conduct multiple tests and evaluations over time to accurately determine whether your symptoms are due to Hashimoto’s, perimenopause, or a combination of both. This thorough approach ensures you receive the most appropriate treatment and management plan for your situation.

The primary treatment for Hashimoto’s thyroiditis is thyroid hormone replacement therapy. The most commonly prescribed medication for this condition is levothyroxine, a synthetic form of the T4 hormone. In some cases, levothyroxine is combined with synthetic T3 (liothyronine) in T4-T3 combination treatment, or natural desiccated thyroid (NDT) – which combines natural forms of T4 and T3 – is prescribed. A treatment that includes T3 may be considered to optimize thyroid function and resolve symptoms.  Low-dose naltrexone (LDN) is sometimes prescribed to help calm autoimmunity and reduce thyroid antibodies.

In addition to medication, lifestyle, and dietary changes can play a supportive role in managing Hashimoto’s. Anti-inflammatory diets, such as the autoimmune protocol (AIP) diet, may help reduce thyroid antibody levels and support immune system function.

Emerging treatments for Hashimoto’s thyroiditis are also being explored. Red light therapy and infrared therapy promise to stimulate cellular repair and reduce inflammation in the thyroid gland. Additionally, mesenchymal stem cell therapy is an area of ongoing research, with potential benefits in regulating the autoimmune response associated with Hashimoto’s.

Perimenopause is managed through a combination of hormone replacement therapy (HRT), non-hormonal alternatives, lifestyle modifications, and natural treatments.

HRT remains the most effective treatment for perimenopausal symptoms, such as hot flashes, night sweats, and vaginal dryness. Estrogen therapy is available in various forms, including patches, gels, sprays, implants, and tablets. For women with a uterus, combined HRT, which includes both estrogen and progesterone, is recommended to protect against endometrial cancer. In general, bioidentical forms of HRT are considered safe for most women under 60 or within 10 years of menopause, with doctors advising the lowest effective dose for the shortest necessary duration.

For those who prefer non-hormonal alternatives, certain antidepressants can reduce the frequency and severity of hot flashes by 24% to 69% compared to placebo2. Some of the effective selective serotonin reuptake inhibitors (SSRIs) include paroxetine (Paxil), escitalopram (Lexapro), and citalopram (Celexa). Effective serotonin-norepinephrine reuptake inhibitors (SNRIs) include venlafaxine (Effexor), desvenlafaxine (Pristiq), and duloxetine (Cymbalta). A newer option, fezolinetant (Veozah), was approved by the FDA in 2023 as the first non-hormonal medication specifically designed to reduce hot flashes by regulating body temperature.

Several other medications have shown promise in managing hot flashes. Gabapentin (Neurontin) appears to be effective for reducing hot flashes, although potentially not as effective as estrogen therapy. Another study found that pregabalin (Lyrica) was more effective than placebo in reducing both the frequency and severity of hot flashes.

Lifestyle modifications can also play a crucial role in managing perimenopausal symptoms. Temperature control strategies – such as keeping the bedroom cool, using layered bedding, and carrying a portable fan – can provide relief during hot flashes. Dietary adjustments, including reducing caffeine, alcohol, and spicy foods, may help lessen symptom severity, while a nutrient-rich diet supports overall well-being. Stress management techniques, such as yoga, meditation, and cognitive behavioral therapy, can further alleviate symptoms, especially those related to anxiety and mood fluctuations. Improving sleep hygiene by maintaining a cool and quiet bedroom environment, using moisture-wicking fabrics, and engaging in regular exercise can also contribute to better rest and overall symptom management. Choosing breathable, lightweight clothing can help provide comfort during sudden temperature changes.

Natural treatments, including herbal supplements like maca, black cohosh, and dong quai, have been used to support hormonal balance, though scientific evidence on their effectiveness remains mixed. Dietary changes may provide additional benefits, particularly incorporating phytoestrogen-rich foods like flaxseeds and soy. Mind-body practices, such as mindfulness, yoga, and deep breathing exercises, can help regulate stress levels and promote hormonal balance. For those experiencing vaginal dryness, over-the-counter lubricants and moisturizers offer an effective, non-hormonal solution.

By combining medical treatments with lifestyle adjustments and natural remedies, many women can successfully manage perimenopausal symptoms and maintain a high quality of life during this transition.

Hashimoto’s thyroiditis and perimenopause are both conditions that can significantly impact your health, and their treatment approaches can overlap. Here’s how each condition is treated and how they can be managed simultaneously:

When treating perimenopause and Hashimoto’s thyroiditis concurrently, a comprehensive and personalized approach is crucial:

• Integrated care: An integrative approach – like Paloma Health’s focus on comprehensive care -- considers both conditions, providing tailored treatment options to address symptoms and support hormonal balance.
• Personalized treatment plans: Healthcare providers should develop individualized plans that address both thyroid function and perimenopausal symptoms.
• Regular monitoring: Periodic testing and follow-ups are essential to manage the interplay between these conditions.
• Holistic approach: Combining conventional medical treatments with complementary therapies, nutritional guidance, and lifestyle modifications can effectively manage both conditions.
• Consideration of symptom overlap: Many symptoms of perimenopause and Hashimoto’s overlap, making it crucial to distinguish between them for proper treatment.

By working with healthcare providers like Paloma, experienced in both thyroid health and hormonal transitions, women can receive comprehensive care that addresses the complexities of managing perimenopause and Hashimoto’s thyroiditis, including both conditions simultaneously. This integrated approach ensures that treatment plans are tailored to individual needs, optimizing hormonal balance and overall well-being.

Perimenopause and Hashimoto’s share many symptoms, but proper testing can help pinpoint the cause. If you suspect Hashimoto’s, getting a full thyroid panel is essential. Paloma’s convenient home thyroid test kit is a good starting point.

Paloma Health specializes in thyroid testing and treatment for women struggling with fatigue, brain fog, weight gain, and other symptoms. If you’re unsure whether it’s perimenopause, Hashimoto’s, or both, book an online consultation today to get the answers you need.

• Both perimenopause and Hashimoto’s thyroiditis have overlapping symptoms like fatigue, brain fog, weight gain, and mood swings, often leading to misdiagnosis.

• This perimenopausal transition before menopause is marked by fluctuating hormone levels, irregular periods, hot flashes, mood changes, and metabolic changes.

• Hashimoto’s is an autoimmune thyroid condition that leads to hypothyroidism, causing persistent fatigue, cold intolerance, depression, and unexplained weight gain.

• Perimenopause is diagnosed based on symptoms and menstrual patterns, while Hashimoto’s requires thyroid function tests and antibody screenings.

• Perimenopause can be managed with hormone replacement therapy and lifestyle changes, whereas Hashimoto’s requires thyroid hormone therapy and nutritional lifestyle modifications.

• Women experiencing both conditions benefit from a personalized, comprehensive approach that considers both thyroid function and hormonal balance.