The Conversation About Fragility That Nobody Wants to Have (And Why Your Thyroid Might Be Part of It)

Written by: Meredith Paci | Functional Health Coach 

If you've been following along, you probably already know where my head has been.

When I flew to be with my father earlier this year, after the traffic light, after the diagnosis, after all of it, one of the many things that hit me hard was not just the cognitive decline. It was how fragile he looked. Physically. Structurally. Through a child's eyes I remember him as solid and sturdy. I want to be clear, he was not an "athlete" in any regard. He was more of a work-in-the-yard and constantly-tinkering kind of guy. That said, he was sturdy, or at least visually looked it. As an educated and lived adult, I now know looks are deceiving, to which age holds no secrets. It arguably reveals what was always building underneath...every deficit, every gap, every thing that went unaddressed. Age exposes fragility. The last several times I saw him, he looked like a good wind could take him out. Undermuscled. Incredibly unsteady. Breakable.

And I keep coming back to that word. Fragile.

We used it in the context of his brain. Vascular dementia building silently for years, decades probably, while everyone around him called it "part of aging… nothing to do." But his body was telling the same story his brain was. Quietly deteriorating. Unaddressed. Unexamined. Just... assumed to be fine because I mean "he functioned okay"…

That said, the only conversations that were ever had with him about his bone health were what this replacement surgery or that replacement surgery could be done, what fusion was possible. Yet physical activity beyond "oh you get around Mr. T" was never touched on. Full blood work… never ever done. He had a TSH run at some point. It was mildly elevated. Yet a full thyroid panel was never run. Not once. Nobody looked deeper and no further conversations were had.

Here is what I want to talk about today: bone health and thyroid health. Specifically, bone mineral density. And specifically, why conversations are not happening early enough, thoroughly enough, or honestly enough, and why your thyroid health is part of it whether anyone has told you that or not.

I wrote about bone health two years ago. Sarah and I even podcasted on it. My writing was thorough, it was educational, and if I'm being honest, it read like a textbook that was trying really hard to be approachable. I've evolved since then. Not just in how I write but in how I think about this topic.

For those who do not know, I struggled with ovarian torsions for almost 10 years, to which after too many surgeries I was induced into premature surgical menopause in my 30s. That is a known, significant risk factor for accelerated bone loss, and I recognized it as such because I had the education to. Not because anyone sat me down and said "hey, we need to be watching this closely now." Actually, no one told me anything. I was fortunate to, after a long and frantic hunt, find a provider who was as thorough as I am, and because of that, I've had bone mineral density scans almost yearly since my surgery. Most women in my position do not get that. Most women in my position are not even told to ask.

A year ago, we saw a noteworthy decline.

This year, we saw a remarkable and noteworthy improvement!

I am not going to sit here and tell you it was one thing. It was not one thing. It was the compounding of many things done consistently and intentionally over time: strength training, nutrition, hormonal support, micronutrient status, and yes, thyroid health, which is something I stay on top of and am supported exogenously because I need to be. I cannot isolate one variable and hand it to you as the answer. That would be dishonest. But I can tell you this: every single one of those variables is part of a picture that most women and men are never even shown.

And that is what makes me angry. Not at providers. At the system and society that waits.

Let me give you some numbers that I need you to carry with you.

Approximately one in three women over the age of 50 will experience an osteoporotic fracture in her lifetime. One in five men over 50 will face the same. Hip fractures specifically carry a one-year mortality rate of roughly 22% in women 65 and older, and men fare even worse — studies consistently show higher post-fracture mortality in men than in women. Let me say that differently: nearly one in four women over 65 who fracture a hip will not survive the following year. In women aged 60 to 69, a hip fracture increases mortality risk more than fivefold compared to the general population.

This is not a soft statistic. This is not something that only matters when you are elderly. This is the end result of decades of silent, unaddressed, unmonitored bone loss that nobody talked about until the fracture happened.

And by then, we are not having a conversation about prevention. We are having a conversation about survival.

So let me ask you what I ask every single client at some point or another who joins my roster or I consult with, and what I am now loudly and unapologetically advocating to every person I work with:

Have you had a bone mineral density test?

Have you had full blood work recently that includes a FULL thyroid and reproductive hormone panel?

Not "are you old enough for one." Not "has your doctor recommended one." Have you had one. Because the guidelines say postmenopausal women and men over 65. The guidelines say women 50 to 64 with risk factors. The guidelines do not say women in their 30s and 40s who are losing estrogen, who went through premature menopause, who had years of amenorrhea, who are on medications that affect bone, who have thyroid dysfunction that has never been fully evaluated.

The guidelines are a floor. They are not a ceiling. And they are certainly not the full conversation.

I am not suggesting everyone sprint to get a DEXA tomorrow. What I am suggesting is that after a thorough look at your health history, your hormonal status, your lifestyle, your risk factors, the recommendation for a BMD test might come a lot sooner than you've been told. And I am fine being the annoying person who brings this up before you wanted to think about it. I would rather be annoying now than heartbroken for you later.

Now, here is where I want to take this somewhere that most bone health conversations never go.

Your thyroid.

When most people hear "thyroid problem" they think weight gain. Fatigue. Maybe hair loss. The cultural narrative around thyroid dysfunction has been almost entirely co-opted by the weight loss conversation. "My metabolism is slow" becomes "maybe it's your thyroid" and the entire clinical picture gets reduced to a scale and a single TSH value.

But here is what is actually happening in your bones when your thyroid is not functioning properly…

Every cell in your body has thyroid hormone receptors. Your bones are not an exception. Thyroid hormones directly regulate bone remodeling, the constant cycle of old bone being broken down by osteoclasts and new bone being built by osteoblasts. In a healthy system, this cycle is balanced. Breakdown and buildup happen in proportion.

When thyroid hormone is in excess, whether from overt hyperthyroidism, subclinical hyperthyroidism, or even over-replacement with thyroid medication, that cycle speeds up. Bone resorption accelerates faster than bone formation can keep up. The result is a net loss of bone with every remodeling cycle. Research consistently shows that hyperthyroid states, even subclinical ones where TSH is suppressed but free hormones look normal, are associated with decreased bone mineral density and increased fracture risk, particularly in postmenopausal women.

And here is something that should stop you in your tracks if you care about this topic at all: a study examining euthyroid postmenopausal women, meaning women whose TSH looked completely normal, found that the presence of TPO antibodies alone, a marker of autoimmune thyroid disease, was independently associated with decreased bone mineral density at both the spine and hip and an increased risk of future fracture. The TSH was normal. The bone loss was not.

Let me say that again for the people in the back: you can have a normal TSH and still be at elevated fracture risk because of autoimmune thyroid activity that nobody tested for.

This is why a single TSH is not enough. This is why Sarah and I look at the full panel: TSH, Free T4, Free T3, Reverse T3, TPO antibodies, thyroglobulin antibodies. Because the thyroid is not just a weight loss conversation. It is a bone health conversation. It is a cardiovascular conversation. It is a brain health conversation. And if nobody is looking at the full picture, nobody is actually assessing your risk.

I think about my father. Elevated TSH. No full panel. Frail in a way that was visible for years. His bones were not examined. His thyroid was not examined. His cardiovascular risk was not discussed beyond a medication that would potentially help…

And I think about myself. Surgical menopause in my early 40s. Recognized risk. Proactive testing. Declining density. And then, through consistent, intentional, multi-variable work, a reversal that my provider called "remarkable" and "I never get to see this!"

The difference between those two stories is not genetics. If it were genetics, then I'd be a joint replacement, a spinal fusion, and a heart attack at this point. The difference is information and action. It is access to a conversation that one of us had (and welcomed) and the other one avoided and arguably never got.

That is what I want for you. Not a guarantee. I will never promise you that. But the conversation. The one that covers the full picture. The one that does not wait until fragility is the presenting complaint.

And while I am riding my honesty Fire Horse, there is one more thing before I close this out.

Nobody wants to think about this or any of the things we talk about. It is a fact, I know that. Bone density is not exciting. It is not the content that gets shared a thousand times on Instagram or TikTok unless it is some action shot of someone actively breaking their bone while performing some profound stunt. It is not the thing you bring up over coffee with your friends ....unless you are us, or maybe one of our clients or mentees, ha ha. And I get it. I really do. You do not feel your bones weakening. You cannot see it in the mirror. There is no symptom that screams at you to pay attention until there is a fracture, and by then the conversation has changed entirely.

But I have watched what fragility looks like when it arrives. And it will arrive.

So yes. I am going to keep being the person who brings this up. I am going to keep advocating that every person I work with assess their BMD. I am going to keep pushing for full thyroid panels, not just a TSH, because the data supports it and because I have seen what happens when nobody asks the next question.

You do not have to be ready for this conversation. But I hope you will let yourself have it anyway.

If something in this landed for you, if you are realizing that there are questions about your own health that have not been asked yet, that is what Sarah and I built Fortify for. The full picture. Not the surface-level version. Not the "your labs are normal, you're fine" version. The picture that says "here is where you are, now lets show you all the tools at your disposal now and lets maximize them! Then, allow us to open up more doors if you so choose. " 

Sarah and I are hosting a free live training on April 29th at 6 PM EST : Beyond TSH: The Thyroid Conversation Most Appointments Never Get To (And the Questions Nobody Is Answering). Everything I touched on here about thyroid and bone health is just a piece of what we are covering. If you want the full conversation, this is it.

Sign up HERE 

And, IF you'd like to chat 1:1 reach out HERE... We are here when you are ready!