Episode 126: Perimenopause or Thyroid Problems? How to Tell the Difference (And Why It Might Be Both)
Are your symptoms perimenopause or thyroid problems?
How to tell whether symptoms are hormonal or thyroid-related? If you’re in your 40s and suddenly dealing with fatigue, brain fog, weight gain, poor sleep, low mood, or feeling unlike yourself, but your blood tests keep coming back “normal,” this episode of The Goode Health Podcast will help you understand what may actually be happening beneath the surface. Nicole Goode explores one of the most common and misunderstood health issues women face in midlife: the overlap between perimenopause and thyroid dysfunction.
In this episode, Nicole breaks down why perimenopause symptoms and hypothyroidism symptoms can look almost identical, how fluctuating hormones can directly affect thyroid function, and why so many women are told their symptoms are “just stress” or “just age.” You’ll learn the key differences between thyroid problems and perimenopause, the symptoms that may point more strongly toward one or the other, and why it’s often not a case of one versus the other, but both happening together.
Nicole also explains what a full thyroid panel should include, why TSH alone may not tell the whole story, and how thyroid antibodies, estrogen fluctuations, progesterone decline, and cortisol all interact inside the body.
This episode answers questions like:
“Perimenopause vs hypothyroidism symptoms”
“Can perimenopause affect thyroid function?”
“Why women in their 40s experience brain fog”
“TSH normal but still symptomatic”
“Hormonal changes during perimenopause”
“Signs your thyroid may be slowing down”
“How hormones and thyroid function affect each other”
Whether you’ve been struggling with unexplained exhaustion, perimenopause weight gain, hormone imbalance, Hashimoto’s symptoms, or ongoing brain fog despite normal labs, this episode will help you better understand your symptoms, recognize important patterns, and advocate for more complete testing and support.
DISCLAIMER: The content in this podcast and related website is not intended to be a substitute for medical advice. It is not intended to be used to diagnose or treat, instead it is designed to help educate and inspire. Always seek the advice of a professional medical practitioner or qualified health practitioner. Never ignore or disregard advice given to you based on information in this podcast or related website and do not delay in seeking medical advice.
Timestamps:
[01:45] - Why Perimenopause and Hypothyroidism Get Confused
Learn why thyroid dysfunction and perimenopause symptoms overlap so heavily, and why so many women struggle to get clear answers.
[03:20] - What Perimenopause Does to Your Hormones and Thyroid Function
Nicole explains fluctuating estrogen, declining progesterone, hormone chaos, and why symptoms can feel unpredictable from month to month. Discover the hidden connection between estrogen, progesterone, cortisol, thyroid hormones, and Hashimoto’s symptoms in women over 40.
[08:10]- How to Tell Whether Symptoms Are Hormonal or Thyroid-Related
The specific signs that may point more toward perimenopause vs hypothyroidism, including cycle changes, hot flushes, feeling cold, constipation, and more.
[09:40]- What Testing to Ask For + Symptoms to Track
Learn which thyroid tests to request, why symptom tracking matters, and how to identify patterns doctors may otherwise miss. You’ll learn practical steps to help you approach appointments differently, ask better questions, and look at the whole-body picture.
“Perimenopause is not always a gentle decline in hormones the way many women have been led to believe. For many women, it feels more like unpredictability. One week you feel okay, the next week you feel anxious, exhausted, emotional, foggy, or completely disconnected from your body. And when those hormonal fluctuations start interacting with underlying thyroid dysfunction, it can create symptoms that feel impossible to explain unless someone is finally looking at the whole picture together.”
Essential learnings from this episode…
Perimenopause and thyroid dysfunction share many of the same symptoms. Fatigue, brain fog, weight gain, low mood, sleep issues, and hair changes can happen with both hypothyroidism and perimenopause, which is why so many women struggle to get clear answers.
“Normal” thyroid labs do not always mean optimal thyroid health. TSH alone may not reveal the full picture. Free T3, Free T4, thyroid antibodies, and symptom patterns can provide important insight into underlying thyroid dysfunction or Hashimoto’s disease.
Hormones and thyroid function are deeply connected. Fluctuating estrogen, declining progesterone, and elevated cortisol can all directly impact thyroid hormone availability, making perimenopause symptoms and thyroid symptoms worse together.
Symptom patterns can help identify what’s driving your symptoms. Perimenopause symptoms often feel erratic and cycle-related, while hypothyroidism symptoms tend to feel more constant, progressive, and persistent over time.
Tracking symptoms can help you advocate for better care. Keeping a simple symptom log alongside your menstrual cycle can reveal important patterns and help you communicate more clearly with healthcare providers.
Feeling exhausted, foggy, or unlike yourself in your 40s is not “just aging.” Many women are told their symptoms are caused by stress or midlife alone, but underlying hormone imbalance, thyroid dysfunction, or Hashimoto’s may be contributing factors worth investigating further.
EPISODE 126
Important links & mentions from this episode
The Optimal You 7 Day Reset (£7.99)
Episode 118: Blood Tests Are “Normal” But You Feel Awful: 5 Markers Your Doctor May Miss
Episode 120: Insulin Resistance: The Hidden Cause of Fatigue, Brain Fog & Weight Gain
Episode 121: Insulin Resistance: Why Your Autoimmune & Thyroid Symptoms Aren’t Improving
Goode Health Clinic Functional Medicine Packages
Take the FREE MitoImmune Health Assessment
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(0:00 - 0:07)
Let me describe someone to you and tell me if she sounds familiar. She's in her mid-forties. She's good at what she does.
(0:08 - 0:26)
She's the one other people lean on, and over the last year or two, something has shifted. She's tired in a way that sleep just doesn't quite touch. Her brain feels that little bit slower.
Words go missing. Focus is harder to hold on to. The weight is creeping up, even though nothing about how she eats has really changed.
(0:26 - 0:46)
Her sleep is broken. Her mood is flatter than it used to be. So she does the sensible thing.
She goes to the doctor. She has her bloods done, and she's told that everything is normal. Maybe she's told that it's just her age, or that it's just stress, and she leaves with no answers and a quiet worry that this is just how it's going to be now.
(0:46 - 1:01)
If any part of that landed for you, this episode is for you. I'm Nicole Goode, and this is the Goode Health Podcast. And today we're untangling one of the most common and most misunderstood situations that I see in clinic, the overlap between thyroid dysfunction and perimenopause.
(1:01 - 1:12)
Because here's the thing that nobody explains properly. These two things share almost every symptom. They tend to arrive in the same decade of life, and they don't just look alike on the surface.
(1:12 - 1:34)
They actually influence each other underneath. So when a woman gets sent firmly down one path, it's your hormones, or it's your thyroid, she very often is only being shown half of the picture. By the end of this episode, you'll understand why the confusion exists, what's actually happening in your body, and most importantly, how to start telling what's really driving your symptoms.
(1:34 - 1:47)
Because sometimes it's one, sometimes it's the other, but very often it's both. Let's start this episode with why is this so confusing? Because it's not your imagination, and it's not failure on your doctor's part. It's structural.
(1:47 - 2:02)
Think about the symptoms of an underactive thyroid. Fatigue, weight gain, brain fog, low mood, poor sleep, hair thinning, feeling cold, dry skin. Now think about the symptoms of perimenopause.
(2:02 - 2:18)
Fatigue, weight changes, brain fog, low mood, poor sleep, hair changes, sleep disruption. You can already hear the problem. If you wrote both of those lists up on a whiteboard side by side, you would genuinely struggle to draw a clean line between them.
(2:19 - 2:47)
And then on top of that, they peak at the same time of life. Perimenopause usually begins somewhere in your 40s, though for some women it can start in the late 30s. And thyroid conditions, particularly Hashimoto's, which is the autoimmune form of low thyroid function, and thyroid conditions, particularly Hashimoto's, which is the autoimmune form of low thyroid, those are far, far more common in women, and they very often surface or get noticeably worse in that same window.
(2:47 - 2:57)
So just sit with that for a second. You've got two conditions, they have nearly the same symptoms, and they arrive at roughly the same time. And then there's the final piece.
(2:58 - 3:14)
In conventional care, these two things are handled by different people in different appointments. Your thyroid is one conversation and your hormones are another conversation. And nobody is necessarily standing back and looking at the whole woman, asking how all of this fits together.
(3:14 - 3:30)
So the confusion isn't some great mystery, it's almost designed into how we treat people. Now to tell these two things apart, you have to actually understand each one properly. And I think perimenopause in particular is widely misunderstood, even by women who are living through it.
(3:30 - 3:39)
Most women assume that perimenopause means low oestrogen. It doesn't, or at least not necessarily at first. Perimenopause is not a steady, graceful decline.
(3:40 - 3:51)
Perimenopause is hormonal chaos. Your oestrogen doesn't necessarily gently glide downwards. It can swing, it can actually spike higher than it did in your 30s, and then it can crash, sometimes within the same month.
(3:51 - 4:09)
And at the same time, your progesterone, which is your calming and steadying and settling hormone, that's in a more reliable decline, because you're ovulating less consistently than you used to. So the lived experience of perimenopause is really the experience of unpredictability. One month feels fine, the next month can feel like chaos.
(4:09 - 4:18)
You feel like you can't get a fixed read on your own body. And this can go on for anywhere from four to 10 years. So here's the practical point that I want to take from this.
(4:19 - 4:45)
If your symptoms are feeling erratic, if they feel like they come and they go, if they kind of loosely track with your cycle, but there's just no consistency to them, that erratic quality in itself is a clue. That unpredictability is the fingerprint of fluctuating hormones. Okay, so what about the thyroid? Your thyroid is a small gland at the base of your neck, and its job is to set the metabolic pace for essentially every cell in your body.
(4:46 - 4:59)
Your energy, your temperature, your weight, your mood, your digestion, your brain. So when your thyroid slows down, everything slows down with it. And that's why the symptoms are so wide ranging, because the thyroid touches everything.
(4:59 - 5:07)
Now here's where so many women get stuck. When most people get their thyroid checked, they get that one number back. They get the TSH.
(5:07 - 5:15)
And the TSH is a useful number. I'm not dismissing it, but it's one number. And technically it's a signal from your pituitary gland.
(5:15 - 5:36)
It's the message that is being sent to the thyroid. It's not a direct measure of how much active thyroid hormone is actually reaching your cells and doing the work. So you can be told that your thyroid is normal on the strength of that single marker, or maybe on the strength of TSH and T4 having been tested, but the fuller picture would tell a much more nuanced story.
(5:37 - 5:47)
So what is the fuller picture? And I want you to know that these exist. There's free T4 and free T3. These are the actual thyroid hormones, including T3, which is the active one.
(5:47 - 6:04)
This is the important one. And then there are the thyroid antibodies, TPO antibodies, and thyroglobulin antibodies. And those antibodies matter enormously because they can be raised, meaning that your immune system is already engaging with your thyroid years before your TSH will ever drift out of range.
(6:04 - 6:15)
So please hear this really clearly. Normal TSH and healthy thyroid are not the same thing. And in range is not the same as optimal.
(6:15 - 6:29)
Those are different things. And the difference is often where a woman's missing year of answers is hiding. Now here's the part I really want you to take away from this episode, because this is the bit that almost never gets explained, not in the appointment and not online.
(6:29 - 6:40)
Thyroid and perimenopause are not two separate problems that just happen to be sitting next to each other. They are wired together and they talk to each other. So let me give you the cleanest example of that.
(6:40 - 6:52)
When oestrogen rises, and remember in perimenopause, it doesn't just fall. Sometimes we see surges. Rising oestrogen increases a protein in your blood called thyroid-binding globulin.
(6:52 - 7:03)
Now the easiest way to picture that protein is as a taxi service for your thyroid hormones. When there's more of that protein around, more of your thyroid hormone is sitting in the taxi. It's bound up, it's in transit.
(7:03 - 7:34)
So less of it will be free and available and actually getting out at the destination to do the work inside your cells. So an oestrogen surge can effectively reduce the amount of usable thyroid hormone that you have, even if your thyroid itself is producing exactly the same amount as it always has done, which means perimenopause can unmask a thyroid problem that was quietly compensating in the background for years, or it can take an existing thyroid issue and make it suddenly feel much, much worse. And it doesn't stop there.
(7:35 - 7:51)
Progesterone, the hormone that is steadily declining in perimenopause, progesterone actually supports thyroid function. So you're losing a support at the very same time. And then sitting on top of it all is stress, cortisol, which interferes with your thyroid and your sex hormones both at once.
(7:51 - 8:12)
So this is one interconnected system. And when you treat it as two separate silos, thyroid over here and hormones over there, you completely miss the way that they are pulling on each other. So the practical question, the one you actually came here for, how do you start to tell what's driving your symptoms? You start with the symptoms that actually discriminate because most of them don't.
(8:13 - 8:25)
The big shared symptoms, the fatigue, the fog, the weight, the mood, the sleep, those genuinely can't tell you very much on their own. They point in both directions at once. But some symptoms lean.
(8:26 - 8:35)
Let me give you the ones that do lean. Hot flushes and night sweats. That pattern of sudden surging heat that leans strongly towards perimenopause.
(8:36 - 8:48)
Changes in your actual cycle. So the length changing, the flow changing, skipping periods, that's perimenopause. On the thyroid side, feeling cold all the time when everyone around you is quite comfortable.
(8:49 - 9:03)
Constipation, skin that's becoming dry, hair that's thinning or changing texture, a slower heart rate, a kind of puffiness. Those lean towards thyroid. And the single clearest thyroid-specific signal is raised antibodies on a blood test.
(9:03 - 9:16)
There's no ambiguity with that. Now, some of these symptoms can cross over, but if you're seeing a pattern of one type of symptoms, it can help you to assess which side it might be that's affecting you. And remember, it could be both.
(9:17 - 9:25)
And then the other big clue, maybe the most useful one, is a pattern over time. Perimenopause symptoms tend to be erratic. Good weeks, bad weeks.
(9:25 - 9:33)
Good months, bad months. Often loosely linked with where you are in your cycle. Thyroid symptoms tend to be more constant and more progressive.
(9:34 - 9:43)
So it's a steady downhill rather than a roller coaster. Here's what I'd actually have you do. For the next six to eight weeks, I want you to keep a simple log, nothing elaborate.
(9:43 - 10:02)
Just your main symptoms rated, even just out of 10, alongside where you are in your cycle. And you're watching for the shape of it. Is it erratic? Is it cycle-linked? Or is it constant and slowly creeping? Is it consistently getting worse? Or is it that roller coaster picture? And then get proper testing.
(10:02 - 10:13)
For the thyroid, that means asking for a full panel. TSH, free T4, free T3, both antibodies, TPO and TG. Not just TSH on its own.
(10:13 - 10:25)
If you can get it, reverse T3 as well. For perimenopause, I want you to know there isn't one clean definitive blood test. FSH often gets measured, but in perimenopause, it fluctuates so wildly that a single result can genuinely mislead you.
(10:25 - 10:37)
So perimenopause is largely a clinical picture. Your age, your cycle changes, your symptom pattern, all of that taken together with some hormone testing. And then that way you go in with the pattern, not just the complaint.
(10:38 - 10:49)
Because I'm tired is very easy to wave away. But here is eight weeks of data showing my symptoms are constant and progressive or fluctuating around my cycle. Here's my raised antibodies.
(10:50 - 11:00)
That's a completely different conversation. Now I want to be honest with you about something because I've just handed you all of that advice. Keep your log, get the full panel, bring the pattern.
(11:00 - 11:09)
And I don't want to hand it over and pretend it always works smoothly the first time you try. Because for a lot of women, it doesn't. And I think you deserve to understand why.
(11:09 - 11:17)
So let's talk about why this overlap gets missed so often. And I want to be really clear right from the start. This is usually not about a bad doctor.
(11:17 - 11:29)
Most doctors are working inside a system that simply isn't built for this kind of problem. Think about what you're actually walking in with. Your symptoms are vague, that fatigue, fog, low mood.
(11:30 - 11:37)
They're multi-system. They cross your thyroid, your hormones, your brain, your gut all at once. They fluctuate.
(11:37 - 11:52)
So they're genuinely different on the day that you're describing them than they were last week. And you're trying to explain all of that inside what is probably a 10-minute appointment that is really designed for one clear single complaint. That's how our system was built.
(11:52 - 12:04)
A 10-minute GP appointment for one single complaint. But that's impossible when we come to these sorts of problems. A fluctuating whole body picture does not fit into that box.
(12:04 - 12:30)
So it gets rounded down to stress, to low mood, to this is just your age. And there's a pattern sitting on top of that one that I think every woman listening should know about. When a woman in her 40s walks in tired, flat, gaining weight, those symptoms get pattern matched very, very quickly to anxiety, to low mood, to midlife, to stress, to you're just doing too much.
(12:30 - 12:41)
And that often happens before anyone actually investigates the physiology underneath them. And that isn't malice, it's a shortcut. But the cost of that shortcut is measured in years.
(12:42 - 13:00)
Years of a woman being told that she's fine while she absolutely knows that she's not. And if that has been your experience, if you've ever walked out of an appointment feeling unseen or quietly questioning whether you're imagining the whole thing, I want you to hear this clearly. The problem is not you.
(13:00 - 13:13)
You were not failing to explain it well enough. You were describing something real into a format that wasn't built to catch it. And then there's that word itself, normal, when you're told your results are normal.
(13:13 - 13:28)
What that usually means is that your number sits somewhere inside a very wide reference range, a range that was built for the whole population. And a population includes an awful lot of people who aren't thriving either. You're not on your own in this.
(13:28 - 13:35)
So normal really just means common. It does not automatically mean optimal. And it certainly doesn't mean optimal for you.
(13:36 - 13:50)
And remember, one result on one day in a system that genuinely fluctuates week to week is a snapshot. It's not the full film. So what do you actually do with all of that? How do you make yourself heard? Let me give you four things.
(13:51 - 14:03)
First, ask for your actual numbers. So don't accept it's normal as the end of it. Ask, please can I have a copy of my results with the reference ranges? Write them down or get them to print them off for you.
(14:03 - 14:12)
Because numbers you can track over time. Normal, you can't do anything with. Second, describe your symptoms by their impact, not just their name.
(14:13 - 14:25)
So not just, I'm tired. Instead, say something like, I'm having to plan my entire week around my energy. Or I can't hold my focus through a meeting in the way that I used to be able to two years ago.
(14:25 - 14:33)
Function is much harder to wave away than a feeling is. Third, ask the linking question out loud. Say it plainly.
(14:33 - 14:44)
I'd like us to look at my thyroid and my hormones together. Because I think they might be connected. You are explicitly and gently asking someone to stop looking at one silo at a time.
(14:45 - 14:50)
And fourth, and please really hear this one. Be persistent. It's not being difficult.
(14:50 - 14:55)
Ask for a fuller panel. Ask for your numbers. Ask for a second opinion.
(14:55 - 15:04)
Or to see someone who looks at this differently. None of that makes you a nuisance. That makes you one person in that room whose only job is your whole picture.
(15:04 - 15:13)
Because that in the end is the real gap here. The system is built to look after one part of you at a time. And you are not lived in parts.
(15:14 - 15:31)
You can also take my mitoimmune health assessment, which may help guide you onto whether hormones or thyroid are a part of your picture. We'll drop the link to that in the show notes below this episode. Because the answer to is it my thyroid or is it my hormones is almost never cleanly one or the other.
(15:31 - 15:43)
And you shouldn't have to guess at it. You shouldn't have to try and stitch it together yourself across three separate appointments where nobody is looking at the whole of you. The assessment is designed to look at these systems together and give you a score for the different areas.
(15:43 - 16:00)
Your thyroid, your hormones, your adrenals to look at that cortisol picture and the immune picture to see whether any underlying immune dysfunction might be going on. The way they actually function in your body as one connected system. So if this episode has basically been describing your last two years, that's your next step.
(16:00 - 16:13)
And it's linked in the show notes below. And if you want the deep foundation underneath all of this, how your thyroid and your hormone pillars really work and how to support them, that's exactly what I walk you through properly in my book, Optimal You. Here's what I want to leave you with today.
(16:13 - 16:25)
If you're in your forties, you're exhausted and foggy and you don't feel like yourself and you've been told that everything is normal. You're not imagining this. And it's just your age is not a diagnosis.
(16:25 - 16:33)
It is very often the thyroid. It's very often perimenopause. And far more often than anyone tells you, it's both.
(16:33 - 16:41)
Two systems that are wired together quietly pulling on each other. You don't have to choose a side. You just have to look at the whole picture.
(16:41 - 16:51)
So keep your log, get the full panel and bring the pattern. Thank you for being with me here today. Look after yourself and I'll see you next week on the Goode Health Podcast.
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