Thyroid Health in Perimenopause & Menopause: Why ‘Normal’ Isn’t Always Optimal
- klosik
- Sep 4
- 10 min read
Updated: Sep 12
Written By Brandi Mulryan, MSN, APRN, WHNP-BC
Women’s Health Nurse Practitioner, Horizon MedSpa and Wellness
Perimenopause and menopause are often transitional stages in a woman’s life that can certainly lead to profound hormonal shifts but even more importantly, a barrage of new or worsening symptoms. Fatigue, weight gain, brain fog, mood swings, skin and hair changes, temperature instability, and slower bowel function are frequently attributed to “just getting older” or “normal menopause.”
However, for many women, these symptoms are not simply a result of declining testosterone, estrogen, and progesterone—they may be signs of sub-optimal thyroid function.
As a Women’s Health Nurse Practitioner specializing in hormone optimization, I see countless women who have been told their hormone and thyroid labs are “normal,” yet they continue to struggle with these symptoms that can impede on their quality of life.
This blog post will explore the critical role of the thyroid during perimenopause and menopause, why standard lab ranges may not be enough, and how a comprehensive, individualized approach to thyroid optimization can help you feel your best.
How The Thyroid Works in Midlife
The thyroid is a small butterfly shaped gland that sits at the front base of your neck. Men and women both possess this gland, however the incidence of thyroid dysfunction is markedly increased in women.
Don’t let this gland’s small size fool you. This little gland has a massive impact on nearly every single body system.
The thyroid gland makes two main hormones: T4 (thyroxine) and T3 (triiodothyronine). These hormones are like the “gas pedals” for your body’s metabolism and energy production.
T4: The Storage Hormone
T4 is the main hormone your thyroid produces. Think of T4 as a storage form—it travels through your bloodstream and gets converted into T3 when your body needs it. On its own, T4 doesn’t do much, but it’s important because it’s the source for making T3.
T3: The Active Hormone
T3 is the “active” thyroid hormone. It’s made from T4, mostly outside the thyroid gland, in places like your liver and other tissues. T3 is the hormone that actually gets into your cells and tells them to speed up or slow down.
Much like a car’s engine is responsible for driving the car; the thyroid can be likened to our metabolism’s engine which drives and regulates our metabolic system, body temperature, energy production, digestion, heart rate, and even our mood. When the thyroid is malfunctioning, or wearing out, every cell in the body will then subsequently slow down or inadequately function.
This can manifest itself as a wide array of symptoms, many of which overlap with those of perimenopause and menopause.
Perimenopause, Menopause, and Thyroid Health
Hormonal Shifts and Thyroid Function
During perimenopause (the years to decade leading up to menopause) and menopause (only able to be diagnosed retrospectively, after going 12 consecutive months without a natural menstrual period), the levels of estrogen and progesterone fluctuate very erratically and then eventually come to a screeching halt.
Estrogen, progesterone, and thyroid-binding globulin
These often abrupt hormonal swings and ultimate hormonal crashes can both directly and indirectly affect how the thyroid functions:
Estrogen and Thyroid Binding
Estrogen helps by increasing the production of a protein called thyroid-binding globulin (TBG). TBG is a protein that picks up binds) and carries these thyroid hormones in your blood, helping to store and deliver them where needed. It helps keep your thyroid hormone levels balanced and available for your body to use. As estrogen levels drop (as seen in Menopause), our TBG also decreases, potentially altering the amount of free (active) thyroid hormone available to the tissues to use.
Progesterone and Thyroid Sensitivity:
Progesterone acts directly on thyroid cells to boost the machinery needed to produce more thyroid hormone and may also help the body to use the thyroid hormones more effectively, thus “sensitizing” cells to thyroid hormone action. Declining progesterone can make tissues less responsive to thyroid hormones, even if blood levels are “normal.”
Autoimmunity and Hashimoto’s risk in midlife women
The risk of autoimmune thyroid disease (such as Hashimoto’s thyroiditis) is more common in women, especially during times of hormonal transitions, as well as a higher incidence with increasing age. Autoimmunity, or our body’s “self-attack” causes the immune system to attack and damage the thyroid gland, leading to a gradual decline in thyroid hormone production. This process is a leading cause of hypothyroidism in women, especially during midlife hormonal changes.
Overlapping menopause and hypothyroid symptoms
Many classic symptoms of perimenopause and menopause can also be potential signs of reduced thyroid function:
Symptoms of Perimenopause, Menopause, and Reduced Thyroid Function
Reduced Energy
Fatigue
Weight gain or difficulty losing weight
Brain fog, forgetfulness, and lack of focus
Hair loss or thinning
Dry and brittle nails
Drier Skin
Sensitivity to cold
Constipation
Mood swings
Anxiety and/or Depression
Muscle and joint aches and pains
New onset heavier or irregular periods (in perimenopause)
This overlap in symptoms between peri/menopause and thyroid dysfunction can certainly lead to an oversight leading to misattributing these complaints solely to the menopausal transition.
What Is Sub-Optimal (Subclinical) Hypothyroidism
Sub-optimal, or subclinical, hypothyroidism is a state where thyroid hormone levels are within the conventional “normal-ish” lab reference range, but are not truly optimal for your body—especially in the context of your symptoms and life stage. ‘Subclinical Hypothyroidism’ is defined by a mildly elevated TSH with normal free T4, but many women experience symptoms even with a “normal” TSH.
Normal TSH with low Free T3 or elevated Reverse T3
You may have a TSH (thyroid-stimulating hormone) that is “normal,” but your free T3 (the active thyroid hormone) is low, or your reverse T3 is elevated, blocking the effects of thyroid hormones at the cellular level.
The unfortunate problem that exists in today’s medical world, that patients are not made aware of, is that a “normal” TSH does not mean normal thyroid function, and the lab assessment or checking of the Free T3 (available and active hormone), is not standard medical practice.
Why symptoms matter more than population reference ranges
Relying only on TSH to assess thyroid function without measuring the free T3 is like checking the thermostat setting in your house but never looking at the actual room temperature. The thermostat (TSH) tells the heating system (thyroid gland) when to turn on or off, but it doesn’t always reflect whether the room (your body’s cells) is actually warm enough (has enough active thyroid hormone, Free T3).
This isn’t the only flaw in the typical thyroid and hormonal assessment lab work-up. The other being that in general, lab reference ranges are based on population averages, not on what is optimal for each individual, especially women in midlife.
Symptoms matter. We treat patients, not labs. If you feel unwell, it’s important to look beyond the numbers.
Why Are Women in Perimenopause and Menopause at Higher Risk?
There are a few main reasons why women in perimenopause and menopause are at higher risk of hypothyroidism:
Hormonal transitions can unmask or worsen underlying thyroid dysfunction.
Aging increases the risk of both overt and subclinical hypothyroidism.
Autoimmune thyroid disease is more common in women, particularly during times of hormonal change.
Comprehensive Thyroid Testing for Women
TSH, Free T4, Free T3, Reverse T3, TPO antibodies
Most routine thyroid screenings only check TSH. While TSH is a useful marker, it does not provide a complete picture of thyroid health. Many women with “normal” TSH still have significant symptoms because:
Free T3 and Free T4 (the active thyroid hormones) may be low or suboptimal.
Reverse T3 may be elevated, blocking the action of T3 at the cellular level.
Thyroid antibodies (TPO and TG antibodies) may be present, indicating autoimmune thyroid disease even before TSH is abnormal.
Comprehensive Thyroid Panel Should Include at Least:
TSH (Thyroid Stimulating Hormone)
Free T4 (Thyroxine)
Free T3 (Triiodothyronine)
Thyroid Peroxidase Antibodies (TPOAb)
The Impact of Sub-Optimal Thyroid Function on Quality of Life Energy and Metabolism
Thyroid hormones are the body’s metabolic regulators. Even a slight deficiency can lead to persistent fatigue, sluggishness, and difficulty maintaining a healthy weight. Many women notice that despite eating well and exercising, weight loss becomes nearly impossible until thyroid function is optimized.
Cognitive Function
Brain fog, forgetfulness, and difficulty concentrating are common complaints in perimenopause and menopause. Sub-optimal thyroid function can exacerbate these symptoms, impacting work performance, relationships, and self-confidence.
Mood and Emotional Health
Thyroid hormones influence neurotransmitters like serotonin and dopamine, which regulate mood. Low thyroid function is associated with increased risk of depression, anxiety, and mood swings—symptoms that are already more common during midlife hormonal transitions.
Skin, Hair, and Nails
Dry, thinning hair; brittle nails; and dry, flaky skin are classic signs of both menopause and hypothyroidism. Optimizing thyroid function can improve the health and appearance of skin and hair.
Cardiovascular Health
Untreated hypothyroidism, even in its subclinical form, is associated with increased cholesterol, higher risk of heart disease, and blood pressure changes. This is particularly important for women in midlife, as cardiovascular risk increases after menopause.
Our Approach to Thyroid Optimization at Horizon MedSpa and Wellness
Comprehensive Assessment
We begin with a detailed health history, symptom review, and a comprehensive thyroid panel (TSH, Free T4, Free T3, TPO antibodies). We also assess other hormones (estrogen, follicle stimulating hormone, DHEA, sex-hormone binding globulin, total and free testosterone, a complete blood count, a comprehensive metabolic panel, CRP (inflammation marker), vitamin B and vitamin D levels) to understand the full picture.
Individualized Treatment Plans
No two women are alike. Our aim is always to tailor your individualized treatment uniquely to your specific combination of needs, symptoms, medical history, and lab results.
Treatment Options may include:
- Bioidentical thyroid hormone replacement: This may involve NDT (non-dessicated thyroid) which by the way well pre-dates traditional pharmaceutical Synthroid (levothyroxine); or depending on the scenario the right option may be T4 (levothyroxine) +/- T3 (liothyronine), all depending on your specific needs.
Learn More About Hormone Replacement Therapy >
- Nutritional support: Key nutrients for thyroid health include selenium, zinc, iodine, iron, and vitamin D. We assess for deficiencies and recommend targeted supplementation.
- Lifestyle modifications: Stress management, sleep optimization, regular exercise, and a balanced diet all support thyroid function.
- Addressing coexisting hormonal imbalances: Optimizing estrogen, progesterone, and testosterone can improve thyroid sensitivity and overall well-being.
Ongoing Monitoring and Support
Thyroid optimization is not a “set it and forget it” process. We monitor your symptoms and labs regularly, adjusting your treatment plan as needed to ensure you continue to feel your best.
Frequently Asked Questions About Perimenopause, Menopause, and Thyroid Health
My doctor says my thyroid labs are normal, but I still feel terrible. What should I do?
Standard lab ranges are based on population averages and may not reflect what is optimal for you, especially during perimenopause and menopause. If you have persistent symptoms, a comprehensive thyroid evaluation and individualized approach can help identify and address sub-optimal thyroid function.
What is the difference between T4 and T3?
T4 (thyroxine) is the main hormone produced by the thyroid gland. It is converted in the body to T3 (triiodothyronine), the active form that exerts effects at the cellular level. Some women have difficulty converting T4 to T3, leading to symptoms despite “normal” TSH or even T4 levels.
Can optimizing my thyroid help with weight loss?
Yes, optimizing thyroid function can improve metabolism and energy, making it easier to lose weight and maintain a healthy body composition. However, thyroid optimization should be part of a comprehensive approach that includes nutrition, exercise, and other hormone balance. Our indication for recommending thyroid optimization is more holistic and not used as a first line option for weight loss, when symptoms and labs don’t reflect a thyroid deficiency.
Is thyroid medication safe?
When prescribed and monitored appropriately, thyroid hormone replacement is very safe and effective. We use bioidentical hormones and adjust dosing based on your symptoms and labs to achieve optimal results.
How often should my thyroid be checked?
We recommend checking your thyroid panel at least annually, or more frequently if you are starting or adjusting thyroid medication, experiencing new symptoms, or going through significant hormonal changes.
The Science Behind Thyroid Optimization
Several studies support the benefits of a comprehensive, symptom-based approach to thyroid management, especially in women:
Subclinical hypothyroidism and quality of life: Research shows that women with subclinical hypothyroidism often report lower quality of life, increased fatigue, and cognitive difficulties, even when TSH is within the reference range (Razvi et al., 2018, Thyroid).
Thyroid and menopause: A 2021 review in Climacteric highlights the importance of evaluating thyroid function in women with persistent menopausal symptoms, as thyroid dysfunction is common and often underdiagnosed in this population.
T3 therapy: Some women benefit from combination T4/T3 therapy, particularly those who do not feel well on T4 alone (Hoermann et al., 2019, Frontiers in Endocrinology).
Real Stories: The Impact of Thyroid Optimization
Names and details have been changed for privacy.
Case 1: Sarah, Age 55
Sarah came to our clinic exhausted, frustrated by weight gain, and struggling with brain fog. Her TSH was 3.8 (within the “normal” range), but her free T3 was low. After starting a low dose of bioidentical T3/T4 combination therapy and addressing her vitamin D deficiency, Sarah’s energy improved, her mind felt clearer, and she lost 12 pounds over six months.
Case 2: Lisa, Age 44
Lisa was experiencing severe mood swings, fatigue, and hair loss during perimenopause. Her labs showed positive thyroid antibodies and a borderline TSH. With a combination of thyroid support, stress management, and bioidentical hormone replacement therapy, Lisa’s symptoms improved dramatically, and her hair began to regrow.
Why Choose Horizon MedSpa and Wellness: You Deserve To Feel Your Best
Perimenopause and menopause are natural transitions, but they should not mean accepting a lower quality of life. If you are struggling with persistent symptoms—fatigue, weight gain, brain fog, mood changes, or changes in skin and hair—don’t settle for “normal” when optimal is possible.
At Horizon Med Spa and Wellness, we are committed to helping women thrive through every stage of life. Our comprehensive, personalized approach to thyroid optimization can help you reclaim your energy, clarity, and vitality.
Schedule a Consultation
Ready to take control of your health and feel your best? Schedule a consultation today at Horizon Med Spa and Wellness. Together, we’ll create a plan to optimize your thyroid and support your well-being through perimenopause, menopause, and beyond.
Brandi Mulryan, MSN, APRN, WHNP-BC, is a board-certified Women’s Health Nurse Practitioner with specialties in hormone optimization, medical-assisted weight loss, and whole-body wellness. With over 20 years of nursing experience in both hospital and outpatient settings, she combines advanced clinical knowledge with a compassionate, collaborative approach to patient care. Her own journey with infertility sparked a passion for hormone therapy, fueling her dedication to helping women achieve balance, energy, and vitality. In addition to hormone optimization, Brandi has a strong interest in peptides, gut health, and nutrient replacement as part of a holistic approach to wellness. Outside of her practice, she loves traveling, attending concerts, and spending time with her two daughters, who inspire her to live fully and empower others to do the same.
References:
Razvi S, et al. Subclinical hypothyroidism and quality of life: a systematic review. Thyroid. 2018;28(6):707-721.
Davis SR, et al. Menopause and thyroid disease: a narrative review. Climacteric. 2021;24(2):123-130.
Hoermann R, et al. Combination treatment with T4 and T3: toward personalized therapy in hypothyroidism? Front Endocrinol (Lausanne). 2019;10:706.
This blog post is for educational purposes and is not a substitute for individualized medical advice. For a comprehensive evaluation and personalized care, schedule your consultation today.
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