A middle-aged woman experiences a slow or fast onset of some combination of the following: loss of energy, poor sleep, weight gain, depressive symptoms, dry skin, brittle hair, and brain fog. Digestion is sluggish, constipation is constant, she feels cold all the time, and menstrual periods are heavy. No matter what she does, she can’t lose weight, feel energetic, or get warm. Her symptoms wreck her quality of life, but her medical providers say nothing is clinically wrong. Do you know anyone like this?
This is a description of subclinical hypothyroidism: The thyroid is not functioning well, but hormone secretions show “normal” levels in blood tests.
I recently corresponded with a person in the massage therapy community who generously gave me permission to share their experience with hypothyroidism:
“About 10 years ago, my energy level crashed, and I started putting on weight. I could barely function. My naturopath ordered labs, and comparing my numbers to the research, it showed my thyroid numbers were pretty low.
“I sought out a doctor. I showed her the test results, and she said they were fine. I very politely suggested the research said otherwise. She got furious that I disagreed; she said no endocrinologist would treat me, walked out of the exam room, and never came back.
“I finally found an endocrinologist who looked at my test results and agreed they were way off. I started thyroid supplementation. It took about a year to get it right. I got my energy back and started feeling better—but I have to be tested every six months and I can never miss my daily pills. I still fight the weight and have never felt like myself again, but without the drugs I wouldn’t be able to get out of bed.”
Hypothyroidism isn’t rare. Estimates suggest that up to 11 percent of the US adult population has been diagnosed and about 85 percent of those patients are women. This estimate is low because the diagnostic criteria for primary hypothyroidism are based on measurements of specific hormones in the bloodstream, and those numbers are assumed to have the same “normal” range for every person.
Consequently, many people have all the symptoms, but they are neither diagnosed nor labeled with “subclinical hypothyroidism” and have difficulty getting appropriate treatment.
To discuss this situation in a bit more detail, we need to do a quick review of what we mean by metabolism, and then we’ll look briefly at the structure and function of the thyroid gland.
A simple way to think about metabolism is that it determines how we use incoming nutrition. When we consume fuel in the form of food and drink, we have essentially three options for how that nourishment is used: (1) we can turn it into new growth; (2) we can turn it into work and energy; (3) we can put it into storage in our fat cells. New growth is determined by many complicated systems that are not our topic here. But the conversion of fuel into energy or storage is largely related to the secretion (or lack thereof) of specific hormones.
The thyroid gland is located at the lower part of the anterior neck. It has two lobes and a connecting isthmus, and it wraps around the trachea. As an endocrine gland, it secretes a variety of hormones under the direction of the hypothalamus and pituitary glands. The hormones that matter for this discussion include thyroid-stimulating hormone (TSH), which comes from the pituitary at the direction of the hypothalamus, and triiodothyronine (T3) and thyroxine (T4), both of which come from the thyroid itself.
One of the most important benefits massage therapy can offer for clients with hypothyroidism is a chance to rediscover one’s body in a positive way.
When the hypothalamus/pituitary unit senses that the body needs the thyroid to be active, it sends a message saying, “Hey thyroid, get active,” in the form of TSH. The thyroid complies and secretes a whack of T3 and T4 into the bloodstream—but it’s mostly T4, by a ratio of 20 to 1. Here’s where things get tricky: T3 is more metabolically available to the target cells than T4. So all the T4 must be converted into T3 before the body can use it. The liver does most of this work, but other tissues, especially muscle cells, are also involved.
When the thyroid underperforms, a blood test typically shows very high TSH, suggesting that the hypothalamus/pituitary unit is shouting at the thyroid. But T4 levels are low because it’s being converted into T3 and is used up faster than it can be produced.
The most widely recognized cause for hypothyroidism is an autoimmune condition called Hashimoto’s thyroiditis. In this condition, T-cells and autoantibodies attack the follicular cells of the thyroid (where T3 and T4 come from).
The gland becomes fibrotic and enlarged—this is called a goiter. In the absence of adequate thyroid hormones, the body’s working cells produce less adenosine triphosphate (ATP), and consequently they have less fuel for doing work. The entire system becomes sluggish. Incoming nutrition is routed toward fat cells instead of being used for the creation of energy. This can also lead to high cholesterol, high blood pressure, and the risk of atherosclerosis and heart attack.
Several other situations can cause an underactive thyroid gland. This can be a complication of pregnancy, the result of thyroid nodules that interfere with function, or a birth defect where a person is born with a partially missing or inactive thyroid gland. Viral infections can disrupt thyroid function. Some medications, especially anything with lithium, can damage this gland. Iodine deficiency used to be a major cause of hypothyroidism, until we began iodizing table salt. Finally, treatment for hyperthyroidism often leads to inadequate thyroid function, which is considered easier to manage.
The good news is that treatment for hypothyroidism is available and effective for the majority of patients. The standard treatment is to supplement T4. Common name brands include Synthroid, Levoxyl, and Unithroid. This is sufficient for most patients, but about 10 percent of patients find that symptoms persist even with supplemented T4.
In these cases, they might be prescribed a synthetic form of T3 (such as Cytomel), or they might be recommended to use desiccated porcine thyroid extract (such as Armour Thyroid) instead of or in addition to T4.
Prescriptions of T3 have less reliable potency and uptake in individuals, so many doctors are reluctant to recommend them. The FDA is also in the process of phasing out desiccated extracts. But thyroid supplements remain the best choice for many patients.
The process of preparing this column and other recent projects centered on thyroid disorders has prompted me to consider several frustrating issues.
First, tinkering with hormones is a tricky business, and as a medical culture, we’re still not good at it. When we tug on one string (like T4), we can’t always predict the other ways that tension might reverberate through the body. Of all the endocrine disorders, hypothyroidism might be the easiest to treat—but that doesn’t make it easy to live with.
Second, I confess that I get frustrated when doctors (whom I inherently respect and support) focus on treating the numbers rather than the person. The impression this creates is that if we can just get your TSH and T4 levels right, you’ll be fine. But we have seen that this isn’t the case. And further, if someone’s TSH and T4 levels are within what is considered a “normal” range, that doesn’t mean the person is symptom-free. We see that a lot in the context of subclinical hypothyroidism. On the other side of this struggle is the fact that dosing excess T3 or T4 when the thyroid is actually healthy can be dangerous. General practitioners and endocrinologists are understandably unwilling to take this risk, which may leave a patient vulnerable to atrial fibrillation, osteoporosis, and other serious problems.
And finally, hypothyroidism is a condition that is seen almost exclusively in middle-aged women. This is not a population group that receives a lot of attention in research and innovation in medical care. Because hypothyroidism’s symptoms can be shared with other conditions common with women (e.g., perimenopause, depression), it is often not taken with the seriousness it deserves.
People with insufficiently treated hypothyroidism live with constant fatigue, brain fog, weight gain, sluggish digestion, and other signs and symptoms that are chronically uncomfortable or even painful. Massage therapy will not change the speed or efficiency with which the thyroid secretes thyroid hormones. However, if hypothyroidism is determined to be the cause of a person’s symptoms, we can address our work to many of these challenges.
Because hypothyroidism, perimenopause, fibromyalgia, and several other under-addressed issues often affect the same population, which is to say middle-aged women, it is not surprising that many people who fit this profile become frustrated with the medical community—especially if a useful diagnosis eludes them or if treatment is not sufficient. Not surprisingly, they may also become frustrated with their bodies.
The strategies that used to work to recover energy, lose weight, or clear away mental fogginess don’t work anymore. Furthermore, many of these changes can accrue slowly over years. They are easy to miss or to dismiss as simply a part of aging. The result is a large part of the population feels their body is not their friend. They are unhappy with themselves, their bodies and brains, and their place in society. A massage sounds pretty good, then, doesn’t it?
Two main risks are present for people with hypothyroidism who want to receive massage therapy. One is that this condition can cause abnormally dry skin, which is not particularly dangerous but can be uncomfortable.
The other, which is more serious, is that the hormonal changes seen with hypothyroidism raise the risk for high cholesterol, high blood pressure, atherosclerosis, and heart attack. It’s relevant for a massage therapist to ask about history or risk of heart disease, but more than half of all adults aged 45–60 in the US are at risk for heart disease, so this is a caution we must acknowledge with many clients.
In my opinion, one of the most important benefits massage therapy can offer is a chance to rediscover one’s body in a positive way. Our work can remind our client that their body is a beloved gift full of potential, strength, and life force, even if it feels the opposite.
Massage therapy will not change circulating levels of TSH, T3, or T4. But it can help people remember the simple joy of feeling good—even if it’s just for an hour at
a time.
Having clients answer the following questions can help practitioners craft a safe, effective, enjoyable session well-tailored to a client who may not feel positive about their body.
The standard intake questions that massage therapists probably use with most clients certainly apply to those who have the symptoms of hypothyroidism. These include the basics:
What would you like to accomplish with your massage today?
What’s bothering you the most right now in terms of your body?
In addition, it might be helpful to add these:
What do you do to treat your hypothyroidism?
Do you feel like your treatment is successful, and does it create any side effects for you?
Do you have any other conditions associated with hypothyroidism?
Has your health-care team discussed your cardiovascular health with you? Are you doing anything to manage high blood pressure or cholesterol?
How is the temperature in the room? Is it warm enough for you?
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Cleveland Clinic. “Thyroid Nodules.” Last modified June 21, 2022.
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Feldt-Rasmussen, U. et al. “Risks of Suboptimal and Excessive Thyroid Hormone Replacement Across Ages.” Journal of Endocrinological Investigation 47, no. 5 (2024): 1083–90.
Lu, M. et al. “Therapeutic Benefits of Acupoint Massage at Yuji (LU10) and Zhaohai (KI6) for Postoperative Hoarseness in Thyroid Surgery Patients.” BMC Surgery 25 (2025): 148.
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