Women experience delays in receiving a diagnosis of thyroid disease, even though incidence is higher among women. No single factor accounts for this delay.

Gendered patterns of symptom misattribution in thyroid care often result because some of the symptoms of hypothyroidism and hyperthyroidism overlap with those of other conditions and diseases, including menopause, clinical depression, sleep apnea, and anemia.

Similar Symptoms and Gender Bias

The similar symptomatology of thyroid disease and menopause makes differential diagnosis challenging, according to the European Menopause and Andropause Society. Both conditions typically present with menstrual irregularities, mood disorders, fatigue, sleep disturbance, and diminished quality of life.

“The delay in diagnosis for women is multifactorial,” Archna Gupta, MD, a family physician and clinician scientist at St Michael’s Hospital in Toronto, told Medscape News Canada. “We know that more thyroid disorder occurs in women, but it can often present during periods of other physiological changes that can sometimes mask or confuse the underlying disorder. Changes in estrogen levels during pregnancy and menopause, for instance, can mimic thyroid disease, and so can aging,” she said.

Gender bias can result in dismissing or delaying a diagnosis, Gupta stated. “It can be either conscious or unconscious and can influence a clinician’s diagnostic pathway for women. In women who present with symptoms like fatigue or hair loss or who have multisystem complaints that can be caused by thyroid problems, these complaints are often misattributed to stress, psychological factors, or benign causes. As a result, testing may not be done in these cases.”

A population-wide study examining disease progression patterns in men and women analyzed hospital admissions from 6,909,676 patients, of whom 48.2% were women. The researchers studied major disease areas, including infectious diseases, circulatory system diseases, respiratory disease, and endocrine and metabolic disorders. In most cases, women were, on average, diagnosed at an older age than men.

Lack of knowledge and understanding and underdiagnosis of hypothyroidism have led to substantial unawareness and often late diagnosis of hypothyroidism, according to large observational studies and meta-analyses. One study reported that the prevalence of undiagnosed hypothyroidism is higher in older subjects, women, and some ethnic groups. The researchers attributed this finding in part to the fact that people with hypothyroidism typically present with nonspecific symptoms, such as feeling cold, weight gain, constipation, slowed cognition, and weakness. 

Sana Ghaznavi, MD, an academic endocrinologist at the University of Calgary, Calgary, treats patients with thyroid cancer and thyroid nodules. “Thyroid symptoms such as tiredness, gaining weight, and low mood are vague and common,” she told Medscape News Canada. “Many people with symptoms of hypothyroidism have thyroid-stimulating hormone (TSH) in the normal or slightly subnormal range. They may fall in the subclinical range where their TSH is mildly elevated. In these cases, naturally, it’ll take longer to achieve a diagnosis.

“There is a mounting body of literature that talks about gender bias creating a repeated pattern where women’s physical symptoms aren’t taken seriously and, as a result, they’re not worked up. This [phenomenon] dates back many decades when healthcare providers viewed some women as hysterical. It’s a mishmash of a lot of different things. This lack of diagnosis is due to a constellation of factors, rather than just one thing,” said Ghaznavi.

Minna Woo, MD, PhD, an endocrinologist at the Toronto General Hospital University Health Network and a clinician scientist, described the diagnosis of thyroid disease as straightforward, although the symptoms may be confusing. “The really big message I’d like to get across is that unless the physician really thinks about the problem, the diagnosis can be missed. The diagnosis and lab test are straightforward and inexpensive. So, the barrier is the physician not thinking about the issue correctly.”

Effects of Delayed Diagnosis

Woo highlighted the importance of avoiding gender-based disease assessment because of the seriousness of undiagnosed thyroid disease. “It can be life-threatening because of its impact on a person’s overall health, although most of the time it doesn’t reach that point,” she said.

“Deep disease progression can occur, and untreated thyroid disorders can have significant impact on pregnancy, for example, if it occurs during that phase,” said Ghaznavi. “It impacts patients’ quality of life, their ability to work, and their overall function. A woman may have a heavy period for no specific reason, but it could also be because of a thyroid disorder. If this was attributed to the correct cause and was properly treated, as opposed to simply giving the patient iron, the bleeding could have been prevented in the first place,” she concluded.

Gupta, Ghaznavi, and Woo reported having no relevant financial relationships. 

Evra Taylor is a widely published freelance medical writer and reporter with 20 years of experience covering a broad range of therapeutic sectors, including family health, cardiology, psychiatry, ophthalmology, and dermatology.