Mintziori G, Veneti S, Poppe K, Goulis DG, Armeni E, Erel CT et al. EMAS position statement: Thyroid disease and menopause. Maturitas, 2024. https://doi.org/10.1016/j.maturitas.2024.107991
Key takeaways
- Thyroid disorders and menopause share so many symptoms that one is frequently mistaken for the other, or missed entirely when the other is present. A blood test is the only reliable way to distinguish them.
- Women with underactive thyroid who take levothyroxine need to be aware that oral HRT can increase the body’s needs for thyroid hormone, potentially requiring a dose review. Transdermal HRT (patch or gel) does not carry the same risk.
- Having a thyroid condition does not prevent you from taking HRT. With the right formulation and appropriate monitoring, most women with thyroid disease can benefit from menopause treatment.
Introduction
Two of the most common conditions affecting women in midlife share a remarkably similar symptom profile. Thyroid disorders and menopause both cause fatigue, weight changes, mood disruption, sweating, hair loss, sleep problems, and cognitive difficulties. When they occur together, which they do more often than most women realise, the diagnostic picture becomes genuinely complicated.
The first EMAS (European Menopause and Andropause Society) position statement on thyroid disease and menopause, published in Maturitas (Mintziori et al., 2024), confirms this symptom overlap and highlights the diagnostic challenges this creates. The position statement recommends a personalised approach involving shared clinical decision-making, not a one-size-fits-all protocol.
This article sets out what the overlap looks like, who is most at risk, how to investigate it properly, and what having a thyroid condition means for your HRT options.
How common is thyroid dysfunction in women during menopause?
More common than most women, and many clinicians, realise.
A review published in Climacteric (Uygur et al., 2018) found that the incidence of thyroid disorders increases in postmenopausal and elderly women, and that diagnosis is challenging because symptoms are subtle and often attributed to menopause. A review published in Menopause Review (Gietka-Czernel, 2017) identifies that the chance of various thyroid problems including cancer is highest among postmenopausal and elderly women.
The NHS notes that thyroid disease is significantly more common in women than in men. For women in perimenopause and beyond, this combination of elevated baseline risk and overlapping symptoms creates a real diagnostic gap.
If you have been struggling with symptoms that feel like menopause but are not responding as expected to treatment, or if you have never been tested for thyroid function, this is worth raising with your clinician.
The overlapping symptoms: a side by side view
The overlapping symptoms: a side by side view
The challenge for both women and clinicians is that the symptom lists for hypothyroidism (underactive thyroid) and menopause are almost interchangeable. Hyperthyroidism (overactive thyroid) adds a further layer of confusion with its own partial overlap.
Hypothyroidism and menopause share fatigue, weight gain, brain fog, low mood, hair thinning, sleep disruption, and dry skin — which is exactly why the two get mistaken for one another. Hyperthyroidism overlaps too, but differently: sweating, palpitations, anxiety, irritability, sleep disruption, and fatigue can all point either way.
What actually helps tell them apart are the features unique to each condition. Hot flushes and night sweats point firmly to menopause. Feeling persistently cold, constipation, and a slow heart rate point toward hypothyroidism. Unintentional weight loss with palpitations and heat intolerance point toward hyperthyroidism.
But many women don't present with these clear-cut distinguishing signs, which is exactly why testing matters. Research published in the Journal of Endocrinological Investigation (Slopien et al., 2020) found that thyroid function influences menopause symptoms even in women that didn't have a formal diagnosis of a thyroid disorder — in other words, subtle thyroid changes can make menopause symptoms feel worse, even without meeting the threshold for a thyroid disorder.
Hashimoto's thyroiditis: the autoimmune link to watch for
Hashimoto's thyroiditis is an autoimmune condition (this means the immune system gradually attacks and damages the thyroid gland), reducing its ability to produce hormones. It is the most common cause of hypothyroidism in women in midlife.
A comprehensive review published in Climacteric (del Ghianda et al., 2014) explains that thyroid function and menopause influence each other in both directions and have a complex relationship. Fluctuating oestrogen affects the immune system and this may result in attack of the thyroid gland.
What matters practically is this: Hashimoto's often develops gradually and can remain subclinical (below the threshold of recognisable hypothyroidism) for years. Women in their 40s and 50s may have Hashimoto's driving a slow accumulation of symptoms without ever receiving a diagnosis, because their TSH is still technically within the normal range. An antibody test (thyroid peroxidase antibodies, or TPO antibodies) is needed to identify Hashimoto's specifically, and this is not always included in a standard thyroid screen. If you have a strong family history of autoimmune conditions or thyroid disease, this is worth discussing with your clinician.
How do you know if it is your thyroid, menopause, or both?
The short answer is: you need a blood test. Symptoms alone cannot reliably distinguish between the two conditions or confirm their coexistence.
The primary test is TSH (thyroid stimulating hormone): a blood test that measures how hard the brain is working to stimulate the thyroid. A high TSH suggests the thyroid is underperforming (hypothyroidism); a low TSH suggests it is overperforming (hyperthyroidism). Most UK GP practices include TSH as a first-line thyroid screen.
A review of clinical data referenced in the EMAS position statement (Mintziori et al., 2024) highlights that diagnosis is challenging because symptoms can mimic many things and blood tests are less reliable in menopause. TSH alone does not always give the full picture; free T4 (the active form of thyroid hormone) adds important context, particularly when symptoms persist despite a normal TSH.
One practical note worth knowing: if you take biotin supplements for hair or nail health, let your clinician know before a thyroid blood test. Biotin can interfere with some thyroid function assays and produce misleading results.
Voy's Women's Midlife MOT Blood Test includes both Free Thyroxine (Free T4) and TSH alongside a panel of 16 biomarkers relevant to women aged 40 and over. This provides a broader hormonal picture than a TSH screen alone, though interpretation should always involve a clinician who can consider your full symptom history.
Why undiagnosed thyroid dysfunction matters
The Gietka-Czernel (2017) review is explicit: if thyroid disorders remain undiagnosed in women after menopause, they have increased cardiovascular risk, bone fractures, cognitive impairment, depression, and mortality. The Uygur et al. (2018) review supports this, noting that untreated dysfunction carries significant risks across multiple health domains.
“This is not a reason to catastrophise. Most thyroid dysfunction responds well to treatment once identified, and the risks described are associated with conditions that go unrecognised and unmanaged for extended periods.”
The practical message is a straightforward one: if your symptoms are not responding as expected to menopause treatment, or if you have never had a thyroid screen, getting tested is a protective step with minimal downside.
Can you take HRT if you have a thyroid condition?
Yes, in most cases. A thyroid condition is not a contraindication to HRT.
The EMAS position statement (Mintziori et al., 2024) recommends a personalised approach: most women with treated thyroid disease can take HRT, but the formulation and the monitoring plan both matter. For women with hyperthyroidism (overactive thyroid), the heart-related effects of both conditions (particularly palpitations and elevated heart rate) warrant specialist input before starting HRT. For women with hypothyroidism using levothyroxine, the key consideration is the route of HRT administration, which is covered in the next section.
Having both a thyroid condition and menopause symptoms is precisely the kind of clinical complexity that benefits from a specialist consultation rather than a standard GP appointment. The decisions involved, including HRT formulation, levothyroxine dose review, and monitoring schedule, require someone with the time and knowledge to hold both conditions in view at once.
How oral HRT affects thyroid hormone levels, and what to do about it
Oral HRT (oestrogen taken by mouth as a tablet) is processed through the liver before entering the bloodstream. As a result, the oestrogen stimulates the liver to produce more of a protein that binds thyroid hormone in the bloodstream. Once thyroid hormone is bound up, it can’t be active in the body.
For women whose thyroid can produce more hormone in response, this compensates automatically. But for women already taking levothyroxine for hypothyroidism, whose thyroid cannot produce additional hormone, this creates a genuine problem: the fixed dose of levothyroxine may become insufficient and hypothyroid symptoms can return or worsen.
A landmark study published in the New England Journal of Medicine (Arafah, 2001)studied women with hypothyroidism who took HRT and directly proved this effect.
The practical implication: if you take levothyroxine and are starting oral HRT, your specialist should plan to check your TSH approximately 6 to 8 weeks after you start, and a dose adjustment may be needed. The EMAS position statement (Mintziori et al., 2024) recommends this monitoring approach.
Transdermal HRT (oestrogen delivered via patch, gel, or spray) does not pass through the liver in the same way. It therefore does not cause binding up of thyroid hormone.. For women on levothyroxine, transdermal HRT is generally the preferred route because it avoids this interaction entirely. A review published in Climacteric (del Ghianda et al., 2014) supports this distinction.
This does not mean oral HRT is off limits for women with hypothyroidism. It means the interaction is understood, manageable, and requires a monitoring plan.
Monitoring: what to check and when
If you have thyroid disease and are starting or changing HRT, a monitoring schedule is not optional. It is how potential interactions are caught before they become a problem.
The key recommendation from the EMAS position statement (Mintziori et al., 2024) is to check TSH approximately 6 to 8 weeks after initiating or changing HRT in women with existing thyroid disease, particularly those taking levothyroxine. If a dose adjustment to levothyroxine is made, the same 6 to 8 week review cycle applies.
For women without diagnosed thyroid disease who start HRT and find that their symptoms persist or change unexpectedly, a thyroid blood test is a reasonable next step and worth raising with your specialist.
Getting the right support
The combination of thyroid disease and menopause is one of the most genuinely complex clinical pictures a woman in midlife can navigate. The symptoms overlap. The treatments interact. The monitoring requires coordination. This is exactly the scenario that benefits from specialist care rather than fragmented GP management.
A 45 minute consultation with a BMS trained menopause specialist provides the time to review both conditions together, discuss the most appropriate HRT formulation given your thyroid history, and build a monitoring plan that covers both. That is a fundamentally different conversation from a brief standard appointment where one condition or the other is likely to be addressed while the other waits.
Voy's outcome data, presented at The Menopause Society 2025 (forthcoming in Climacteric), found that 88% of members felt more hormonally balanced at three months, compared to 62% of women receiving standard care. In the same dataset, 93% reported an improvement in quality of life. These figures reflect what happens when menopause care is specialist led, properly monitored, and built around the individual, including women whose clinical picture is not straightforward.
