Thyroid Strong

6 Things that Can Make Hashimoto’s Fatigue Worse

by | Dec 21, 2022 | Symptoms

Hashimoto’s fatigue is real. I remember spending most of my days and evenings napping on the couch. For years, the exhaustion robbed me of my most precious time with my kids and kept me from being the best chiropractor I could be. The good news is that you can get your energy –and yourself– back once you address all the underlying factors that contribute to the fatigue of Hashimoto’s. 

Of course, the first step is to get your thyroid hormones optimized. If that means getting on thyroid hormone medications under your doctor’s recommendations, you should do so. However, I know that many women with Hashimoto’s still feel exhausted even though their TSH is in the normal range. Hypothyroidism can cause other issues that can keep you tired or make the fatigue worse. In this article, I’m going to share with you the 6 things that can make your Hashimoto’s fatigue worse.

Fatigue Factor #1 Nutrient Deficiencies

Low thyroid hormones can contribute to low stomach acid, low digestive enzyme production, and poor nutrient absorption [1]. Many women with Hashimoto’s also have an inflamed gut lining. Because your gut lining is responsible for nutrient absorption, the gut lining inflammation reduces nutrient absorption. Therefore, nutrient deficiencies are very common among women with Hashimoto’s. 

You can have enough thyroid hormones, but if you are deficient in vitamins and minerals, your body will struggle to produce energy and red blood cells. Also, low thyroid hormones means poorer circulation and often anemia, so your body struggles to deliver enough oxygen to your brain and body. This will leave you feeling fatigued and unable to exercise adequately. You may also experience muscle pain and cramps. 

Other nutrient deficiencies can worsen the autoimmunity and inflammation, which can also make you tired. The following are the most common nutrient deficiencies among women with Hashimoto’s that can make your fatigue worse.


Iron’s most important job in your body is to help build heme inside your red blood cells. Heme is what carries oxygen inside the red blood cells so it can be delivered everywhere in your body. Low iron levels can cause anemia, so your body can’t deliver oxygen to all the tissues.

Some of the primary symptoms of iron deficiency are [2]: 

With similar symptoms as Hashimoto’s, iron deficiency could actually make you think it’s your thyroid when it’s another problem. The inflammation from Hashimoto’s can also further lower your iron absorption [3].

Iron deficiency can also reduce thyroid hormone production and activation (from inactive T4 to active T3) [4]. 

So, it’s important to check for anemia and low iron with your doctor. Tests include:

  • A panel called complete blood count along with hemoglobin
  • Ferritin. While ferritin is a good test for iron stores, it can be higher than your actual iron levels if you have inflammation [5]. So, your doctor will take into account your symptoms and other labs to diagnose iron deficiency.
  • Serum iron levels
  • Total iron binding capacity
  • Transferrin saturation

Many women struggle to absorb their iron so you want to improve your stomach acid levels with betaine HCl and eat red meat. You want your ferritin (iron storage) levels to be at least 50 mcg/L. Click here to read our iron deficiency article.

Vitamin B12

You need B12 to make red blood cells and energy. Although it works through a different mechanism from iron, the end result can be the same: B12 deficiency anemia with similar symptoms as iron deficiency anemia. The chance of nervous system problems is also high.

Common causes of B12 deficiency include low stomach acid and another autoimmune condition that impairs your ability to absorb B12. It’s a common comorbidity with Hashimoto’s [6]. To read more about this, read my pernicious anemia article.


Sub-optimal magnesium levels are common due to the standard American diet and magnesium deficient topsoil on our farms. Magnesium is one of the most important minerals in the human body. Deficiency in magnesium leads to a laundry list of symptoms, including poor sleep and daytime fatigue. 

Magnesium also directly impacts thyroid hormone function. You need it to convert the inactive thyroid hormone, T4, into the active thyroid hormone, T3. Low magnesium levels are associated with positive thyroid antibodies and hypothyroidism [7]. Magnesium is also necessary at multiple steps for your cells to make energy [8]. Lastly, magnesium deficiency can contribute to depressed mood, muscle cramps, and restless legs. 

Omega-3 fats

The omega-3 fatty acids from fish or algae oil, including EPA and DHA, regulate total body levels of inflammation. Since inflammation is at the core of Hashimoto’s, balancing it can have profound effects. While you can get the omega-3, alpha-linolenic acid (ALA), from plants, your body poorly converts it to EPA and DHA. For this reason, fish oil or algae sources are ideal. 

Vitamin D

Vitamin D deficiency is very common with Hashimoto’s. This vitamin modulates the immune system and also helps balance inflammation and your mood. Ensuring adequate vitamin D levels may slow Hashimoto’s progression and overall help with energy [9]. 

Lab normal vitamin D levels may range from 20 – 100 ng/mL (50 – 250 mmol/L) [10]. However, the optimal levels that correspond to the lowest all-cause mortality are 30 – 40 ng/mL (75 – 100 nmol/L) [11]. Inflammation can make it much harder to increase blood vitamin D levels [12], so you want to test and adjust your supplemental dosage every few months until you’re well within optimal ranges. Then, test seasonally. Also, cofactors like vitamin K and magnesium work closely with vitamin D and help it function well in your body.

Fatigue Factor #2 Suboptimal Sleep

Sleep can be a real struggle with Hashimoto’s but its importance can’t be overstated. Sleep balances your immune system and helps maintain a healthy metabolism. It impacts these so profoundly that chronic sleep disturbance actually increases your risk of autoimmune disease [13]. Clearly, already having one is only made worse by poor sleep.

Diet, exercise, and sleep hygiene are 3 lifestyle factors you can use to improve your sleep quality. I’ve written everything you need to know about the what, why, and how of getting better sleep with Hashimoto’s here.

Fatigue Factor #3 Too Much of the Wrong Kind of Exercise

The right kind of exercise should improve your fatigue. However, a common mistake women with Hashimoto’s make is to engage in exercise programs designed for healthy people without an autoimmune condition. If you engage in long cardio, intense Crossfit, or even do 1-hour sessions with a trainer, chances are it will send you to the couch for hours or days. 

Where you need to focus is on getting results by building muscle tissue within the volume and intensity that your body can handle. This is why I created Thyroid Strong to help you build muscles with functional exercises, in 20 – 30 minutes, and with enough rest time in between sets so you don’t exceed your exercise tolerance capacity. As a result, you’ll leave your workout energized rather than drained.

Building muscles will improve your inflammation levels and thyroid hormone conversion from inactive T4 to active T3. In the long term, this will also boost your energy levels [14–16]. If you’re on thyroid medication, your body will better utilize the medication. Muscles also help with overall Hashimoto’s symptoms and well-being. This is why I emphasize strength training and muscle building as a key pillar to managing and putting Hashimoto’s into remission.

Fatigue Factor #4 Thyroid Hormones Remain Unoptimized

Conventional medicine will use thyroid-stimulating hormone (TSH) to assess when your thyroid hormone dose is correct. This is a helpful start but does not take into consideration individual differences in thyroid function and T3 conversion (the active form). Also, while most labs still use the TSH cutoff between 4 – 5.5 uIU/mL, studies are showing that patients have better outcomes when the TSH is under 2.5 IU/L [17]. 

When it comes to your thyroid hormone levels, you want to shoot for optimal, not normal, especially if you’re still feeling awful after thyroid hormone replacement.

When TSH is at 2.5 IU/L or higher, many women still feel fatigued and have cold extremities and other hypothyroid symptoms. You’re better off getting your TSH lower and at least periodically having a full thyroid panel, including antibodies. Work with a functional medicine doctor so they can help you keep track of your inflammation, antibody levels, thyroid hormone levels, and thyroid hormone conversion.

Fatigue Factor #5 The Wrong Diet

Inflammation, oxidative stress, blood sugar fluctuations, and nutrient deficiencies can make Hashimoto’s fatigue worse. So, eating right is a key factor to help you improve your Hashimoto’s fatigue by helping you:

  • Modulate inflammation
  • Reduce oxidative stress
  • Eliminate food sensitivities/immune triggers
  • Balance your blood sugar
  • Provide your body with all the vitamins and minerals it needs to efficiently produce energy. 

I usually recommend people follow some form of the autoimmune protocol diet (AIP). This covers all of the aspects mentioned above with a food-first approach to healing and can have a profound impact on Hashimoto’s symptoms.

Fatigue Factor #6 Unhealthy Mitochondria

Your mitochondria are the energy-producing stations present in nearly every cell in your body. Thyroid hormones work by stimulating the mitochondria [18]. When your mitochondria are unhealthy, you can feel exhausted despite having all the thyroid hormones you need.  

Aside from eating, sleeping, and exercising properly, consider the following to support your mitochondria health:

  • Removing hormone disruptors from your home care, body care, cosmetics, and food. Hormone disruptors tend to also be mitochondrial disruptors [19]. Look up your products on the SkinDeep Database by the Environmental Working Group to see if they contain hormone disruptors.
  • Red light or low-level laser therapy can help jumpstart mitochondria function. 
  • Mitochondrial support supplements, such as CoQ10 and Acetyl-L-Carnitine

Supplements for Hashimoto’s Fatigue

There is no one-size fits all for supplements that work best for Hashimoto’s fatigue. I’m a big fan of addressing the root cause rather than using supplements to get by. That said, if you’ve identified with the causes above or tested and found nutrient deficiencies, the following supplements may help:

  • For low iron, try NFH Heme Iron SAP. It’s the only heme iron supplement on the market. Heme iron comes from an animal source but is easily absorbed even in people with suboptimal stomach acid.
  • For low B12, check out this article on pernicious anemia.
  • For low magnesium, try BiOptimizers Magnesium Breakthrough for the most bioavailable one with 7 forms of magnesium. Use code THYROIDSTRONG at checkout.
  • For Omega-3, try HiPo Avail.
  • For mitochondrial function, try Mitochondrial NRG

To see my Thyroid Strong Fatigue supplement protocol and get our exclusive discount, make your FullScript account or login here.


The take home is, you can get your energized self back despite Hashimoto’s, but it takes dedication and diligence far beyond simply taking thyroid hormone replacement. I spent years figuring this out while I was beyond exhausted. This is why I created the Thyroid Strong program to give you the playbook.

Hundreds of women just like you have joined Thyroid Strong and together, have gotten stronger, more energized, lost weight, and put their Hashimoto’s into remission.

Affiliate disclaimer: This article contains affiliate links, which means that I may receive a small percentage of your purchase. The price will either remain the same or at a discount to you if I can negotiate for the Thyroid Strong community discount. Thank you so much for your support.


Article References

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2 DeLoughery, T. G. (2017) Iron Deficiency Anemia. Med. Clin. North Am. 101, 319–332.

3 Wiciński, M., Liczner, G., Cadelski, K., Kołnierzak, T., Nowaczewska, M. and Malinowski, B. (2020) Anemia of Chronic Diseases: Wider Diagnostics-Better Treatment? Nutrients 12.

4 Eftekhari, M. H., Keshavarz, S. A., Jalali, M., Elguero, E., Eshraghian, M. R. and Simondon, K. B. (2006) The relationship between iron status and thyroid hormone concentration in iron-deficient adolescent Iranian girls. Asia Pac. J. Clin. Nutr. 15, 50–55.

5 Dignass, A., Farrag, K. and Stein, J. (2018) Limitations of Serum Ferritin in Diagnosing Iron Deficiency in Inflammatory Conditions. Int. J. Chron. Obstruct. Pulmon. Dis. 2018, 9394060.

6 Osborne, D. and Sobczyńska-Malefora, A. (2015) Autoimmune mechanisms in pernicious anaemia & thyroid disease. Autoimmun. Rev. 14, 763–768.

7 Wang, K., Wei, H., Zhang, W., Li, Z., Ding, L., Yu, T., Tan, L., Liu, Y., Liu, T., Wang, H., et al. (2018) Severely low serum magnesium is associated with increased risks of positive anti-thyroglobulin antibody and hypothyroidism: A cross-sectional study. Sci. Rep. 8, 9904.

8 Garfinkel, L. and Garfinkel, D. (1985) Magnesium regulation of the glycolytic pathway and the enzymes involved. Magnesium 4, 60–72.

9 Ucan, B., Sahin, M., Sayki Arslan, M., Colak Bozkurt, N., Kizilgul, M., Güngünes, A., Cakal, E. and Ozbek, M. (2016) Vitamin D Treatment in Patients with Hashimoto’s Thyroiditis may Decrease the Development of Hypothyroidism. Int. J. Vitam. Nutr. Res. 86, 9–17.

10 Ross, A. C. (2011) The 2011 report on dietary reference intakes for calcium and vitamin D. Public Health Nutr. 14, 938–939.

11 Sempos, C. T., Durazo-Arvizu, R. A., Dawson-Hughes, B., Yetley, E. A., Looker, A. C., Schleicher, R. L., Cao, G., Burt, V., Kramer, H., Bailey, R. L., et al. (2013) Is there a reverse J-shaped association between 25-hydroxyvitamin D and all-cause mortality? Results from the U.S. nationally representative NHANES. J. Clin. Endocrinol. Metab. 98, 3001–3009.

12 Mangin, M., Sinha, R. and Fincher, K. (2014) Inflammation and vitamin D: the infection connection. Inflamm. Res. 63, 803–819.

13 Kok, V. C., Horng, J.-T., Hung, G.-D., Xu, J.-L., Hung, T.-W., Chen, Y.-C. and Chen, C.-L. (2016) Risk of Autoimmune Disease in Adults with Chronic Insomnia Requiring Sleep-Inducing Pills: A Population-Based Longitudinal Study. J. Gen. Intern. Med. 31, 1019–1026.

14 Tuttle, C. S. L., Thang, L. A. N. and Maier, A. B. (2020) Markers of inflammation and their association with muscle strength and mass: A systematic review and meta-analysis. Ageing Res. Rev. 64, 101185.

15 Westbury, L. D., Fuggle, N. R., Syddall, H. E., Duggal, N. A., Shaw, S. C., Maslin, K., Dennison, E. M., Lord, J. M. and Cooper, C. (2018) Relationships Between Markers of Inflammation and Muscle Mass, Strength and Function: Findings from the Hertfordshire Cohort Study. Calcif. Tissue Int. 102, 287–295.

16 Zupo, R., Castellana, F., Sardone, R., Lampignano, L., Paradiso, S., Giagulli, V. A., Triggiani, V., Di Lorenzo, L., Giannelli, G. and De Pergola, G. (2020) Higher Muscle Mass Implies Increased Free-Thyroxine to Free-Triiodothyronine Ratio in Subjects With Overweight and Obesity. Front. Endocrinol. 11, 565065.

17 Chakera, A. J., Pearce, S. H. S. and Vaidya, B. (2012) Treatment for primary hypothyroidism: current approaches and future possibilities. Drug Des. Devel. Ther. 6, 1–11.

18 Sinha, R. A., Singh, B. K., Zhou, J., Wu, Y., Farah, B. L., Ohba, K., Lesmana, R., Gooding, J., Bay, B.-H. and Yen, P. M. (2015) Thyroid hormone induction of mitochondrial activity is coupled to mitophagy via ROS-AMPK-ULK1 signaling. Autophagy 11, 1341–1357.

19 Marroqui, L., Tudurí, E., Alonso-Magdalena, P., Quesada, I., Nadal, Á. and Dos Santos, R. S. (2018) Mitochondria as target of endocrine-disrupting chemicals: implications for type 2 diabetes. J. Endocrinol. 239, R27–R45.

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