#408 ‒ AMA #89: Thyroid health: interpreting symptoms, diagnosing and treating dysfunction, and navigating the gray zone

Peter Attia (0:10)

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Welcome to Ask Me Anything AMA episode 89 In today's AMA, we look at managing the thyroid, an unusually complex hormonal system that is, I guess, if anything, more nuanced and in some ways controversial than the management of other hormone systems. In this episode, we discuss the basic biology of the thyroid gland and how it's regulated by the brain and specifically the pituitary gland and hypothalamus. And then we talk about how thyroid activity is regulated locally at the tissues where it's used. Talk about why hypothyroidism is common but easily misdiagnosed by symptoms alone. Talk about how hypothyroid is both underdiagnosed and overdiagnosed and why some patients on standard thyroid hormone replacements still don't feel well. We talk about the appropriate use of combination therapy, so that's T3 and T4, as opposed to just the standard treatments of T4.

We talk about the theoretical thyroid supporting supplements. Is there any signal in all the noise of that stuff? And then we close with, I guess, what we would consider our framework in the clinic. So who actually needs testing, what a reasonable lab panel might look like, and then how to think about a patient whose labs are normal, but who still doesn't feel right and whom you might suspect is actually deficient in their thyroid hormone. So if you're a subscriber and want to watch the full video of this podcast, you can find it on the show notes page. And if you're not a subscriber, you can watch a sneak peek of this video on our YouTube page. So without further delay, I hope you enjoy AMA number 89

SPEAKER_2 (2:18)

Peter, welcome to another AMA. How are you doing?

Peter Attia (2:21)

Very good, thanks.

SPEAKER_2 (2:22)

Well, today we're gonna talk about the thyroid. So this is something that it seems like people hear about all the time, but really don't understand well. And so I think what might be helpful for people before we get into it is maybe just explaining why this is such a complex, complicated topic.

Peter Attia (2:39)

Yeah, I think there's probably several ways to think about that. But certainly one reason is that the regulation of thyroid hormones is quite complicated. And that's true for several reasons, but I'll state one at the outset, which is it's a hormone system for which the Goldilocks principle applies, right? Too much is a problem and too little is a problem. Now conversely, if you think about testosterone, male androgens, that's not the case, right? There's really no naturally occurring scenario where you have too much of it. And by the way, even when people are having testosterone replaced, if you give them too much, they generally just feel better.

So it's actually a more asymmetric problem. But the thyroid is particularly nuanced, and there's a feedback system in the brain that works a lot like other hormones we know about, including testosterone. But again, a second thing that then makes this really complicated is that you have an inactive hormone that is the thing that's actually getting secreted by the thyroid gland, that gets converted to an active hormone locally.

And by the way, there are different ways that it gets converted. So there are different enzymes that converted. And so I think that's that we're obviously, we're going to talk about all of these things. I guess the other thing I would say is how you interpret the lab test is a little bit problematic. Again, when you are looking at something like estrogen, progesterone or testosterone, provided you're using the right assay, like an LCMS test, you can very accurately measure those hormones. As we'll discuss in the thyroid, that's not always the case. I would say another thing that makes this complicated is the importance of how symptoms fit into the diagnosis. Now again, that should be part and parcel with every endocrine diagnosis. It's just that the symptoms of low estrogen and progesterone and testosterone are much more apparent and have fewer overlaps with other potential diagnoses than we see with thyroid. So I think when you take all of these things together, managing the thyroid hormone is sort of a ripe environment for ideologic battles and pseudoscience and sort of a little bit of chicanery when it comes to sometimes practitioners doing more harm than good when they're trying to treat patients.