#408 ‒ 第89期问答：甲状腺健康：解读症状、诊断与治疗功能障碍，以及应对灰色地带

嘿，大家好。

Hey, everyone.

欢迎收听《The Drive》播客的问答节目预告。

Welcome to a sneak peek ask me anything or AMA episode of the drive podcast.

我是主持人阿提亚。

I'm your host, Attia.

在这期短节目的最后，我会告诉大家如何完整收听问答节目，以及我们为会员准备的其他福利。

At the end of this short episode, I'll explain how you can access the AMA episodes in full along with a ton of other membership benefits we've created.

或者你现在就可以访问 peterattiamd.com/subscribe 了解更多。

Or you can learn more now by going to peterattiamd.com forward slash subscribe.

话不多说，下面就是今天问答节目的预告。

So without further delay, here's today's sneak peek of the Ask Me Anything episode.

欢迎收听第89期问答节目。

Welcome to Ask Me Anything, AMA Episode 89.

今天的问答节目，我们聊聊甲状腺的管理。甲状腺是一个特别复杂的激素系统，如果要说的话，它比其他激素系统的管理更微妙，甚至在某些方面更有争议。

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.

在这一集里，我们讨论了甲状腺的基本生物学，以及它如何受到大脑，特别是垂体和下丘脑的调控。

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.

然后我们谈到甲状腺活动在局部组织中是如何被调节的，也就是它被使用的地方。

And then we talk about how thyroid activity is regulated locally at the tissues where it's used.

我们讨论了为什么甲状腺功能减退很常见，但仅凭症状却容易被误诊。

Talk about why hypothyroidism is common but easily misdiagnosed by symptoms alone.

我们谈到甲状腺功能减退既可能被漏诊，也可能被过度诊断，以及为什么一些接受标准甲状腺激素替代治疗的患者仍然感觉不舒服。

Talk about how hypothyroid is both underdiagnosed and overdiagnosed, and why some patients on standard thyroid hormone replacement still don't feel well.

我们讨论了联合治疗的适当使用，也就是T3和T4，而不是仅仅使用标准的T4治疗。

We talk about the appropriate use of combination therapy, so that's T3 and T4, as opposed to just the standard treatments of T4.

我们谈到了那些理论上支持甲状腺的补充剂。

We talk about the theoretical thyroid supporting supplements.

在那些纷繁复杂的信息中，有没有什么真正有用的信号呢？

Is there any signal in all the noise of that stuff?

最后，我们以我们在临床中的框架作为总结，我想可以这么说。

And then we close with, I guess, what we would consider our framework in the clinic.

那么，到底谁需要做检查，合理的化验单应该是什么样的，以及如果患者的化验结果正常，但仍然感觉不舒服，你可能怀疑他实际上甲状腺激素缺乏，这种情况该怎么考虑。

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 hormones.

所以，如果你是订阅者，想观看这期播客的完整视频，可以在节目笔记页面上找到。

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.

如果你不是订阅者，可以在我们的YouTube页面上观看这个视频的预告片段。

And if you're not a subscriber, you can watch a sneak peek of this video on our YouTube page.

那么，话不多说，希望你喜欢第89期AMA。

So without further delay, I hope you enjoy AMA number 89.

Peter，欢迎来到另一期AMA。

Peter, welcome to another AMA.

你最近怎么样？

How are doing?

非常好。

Very good.

谢谢。

Thanks.

好的，今天我们来聊聊甲状腺。

Well, today we're going to talk about the thyroid.

这个话题大家好像经常听到，但其实真正了解的人不多。

So this is something that it seems like people hear about all the time, but really don't understand well.

所以我觉得在深入之前，先解释一下为什么这个话题这么复杂，可能对大家会更有帮助。

And so think I what might be helpful for people before we get into it is maybe just explaining why this is such a complex, complicated topic.

我不太……

I don't...

我是说，我觉得可以从好几个角度来看这个问题。

I mean, I think there's probably several ways to think about that.

但其中一个原因肯定是，甲状腺激素的调节机制相当复杂。

But certainly one reason is that the regulation of thyroid hormones is quite complicated.

这有好几个原因，但我想先提一个，那就是这个激素系统遵循“金发姑娘原则”。

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.

太多是问题，太少也是问题。

Too much is a problem, and too little is a problem.

不过，如果你想想睾酮，也就是男性的雄激素，情况就不是这样了。

Now, if you think about testosterone, male androgens, that's not the case.

实际上，在自然情况下，你不太可能睾酮过多。

There's really no naturally occurring scenario where you have too much of it.

顺便说一句，即使是在做睾酮替代治疗的时候，如果给多了，通常人们只会感觉更好。

By the way, even when people are having testosterone replaced, if you give them too much, they generally just feel better.

所以，这不是……

So, it's not...

这其实是一个更不对称的问题。

It's actually a more asymmetric problem.

但甲状腺特别微妙，而且大脑里有一个反馈系统，它的运作方式和我们知道的其他激素（包括睾酮）很像。

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.

但还有一点让这个问题变得非常复杂，那就是甲状腺分泌出来的其实是一种无活性的激素。

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.

这种激素会在局部转化成有活性的形式。

That gets converted to an active hormone locally.

顺便说一下，它转化的方式有好几种。

And by the way, there are different ways that it gets converted.

所以有不同的酶参与转化，而且这……

So there are different enzymes that convert it and it's...

我觉得这……

I think that's...

显然，我们接下来会讨论所有这些内容。

Obviously, we're going to talk about all of these things.

我想说的另一点是，解读化验结果其实有点麻烦。

I guess the other thing I would say is how you interpret the lab test is a little bit problematic.

再说，当你检测像雌激素、孕激素或睾酮这类激素时，只要用对方法，比如LCMS检测，就能非常准确地测出这些激素的水平。

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.

但就像我们聊甲状腺时会提到的，情况并不总是这样。

As we'll discuss in the thyroid, that's not always the case.

我觉得另一个让事情变复杂的是，症状在诊断中占多大分量。

I would say another thing that makes this complicated is the importance of how symptoms fit into the diagnosis.

再说一次，这应该是所有内分泌诊断中必不可少的一部分。

Now again, that should be part and parcel with every endocrine diagnosis.

只是低雌激素、低孕酮和低睾酮的症状更明显，而且与其他潜在诊断的重叠比甲状腺要少得多。

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 than we see with thyroid.

所以我觉得把这些因素综合起来看，管理甲状腺激素很容易引发意识形态之争、伪科学，甚至有些医生在治疗病人时反而造成更多伤害，这有点像是耍花招。

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.

既然如此，最好的起点似乎是先向大家解释什么是甲状腺，它到底有什么作用。

Given that, it seems like the best place to probably start is just explain to people what is the thyroid and what does it actually do.

它是一个小腺体，有两个叶，位于喉咙两侧，实际上就坐在你的喉结上。

So it's a small gland with two lobes on either side of your throat, really sitting on top of your voice box.

它从喉结下方开始，然后向两侧延伸，再向下绕到另一侧。

Just below the Adam's apple is really where it starts and then it rises to the side and then goes down the other side.

它产生一种激素，但主要产生的是T4，之所以叫T4，是因为它上面有四个碘原子。

So it makes a hormone, but primarily the one that it makes is called T4 and it's called T4 because it has four iodine on it.

这种激素的后续作用是调节身体几乎每个细胞的新陈代谢率。

The downstream of that effect is that the, this hormone regulates the metabolic rate of basically every cell in the body.

你可以把甲状腺想象成身体代谢放大器的音量旋钮。

So you can think of the thyroid gland as the gain knob on your body's metabolic amplifier.

它其实不是决定你的细胞做什么，而是决定它们做得多起劲。

So it's not really deciding what your cells do so much as how loudly they do it.

如果信号太少，一切都会变得又冷又慢，心率会下降，体重可能会慢慢增加。

So if you have too little signal and everything is basically going to run cold and slow, your heart rate's going to drop, your weight's going to probably creep up.

你会觉得自己像在半功率运转，没精打采，诸如此类。

You feel like you're operating at half capacity, you're low in energy, etcetera.

当然，如果信号太多，而且这跟太少之间其实没有太大差距，一切都会加速。

Too much of it, of course, and again, it's not a big line between too much and too little, and everything goes up.

整个人又热又快。

Everything's hot and fast.

心率会上升。

So your heart rate goes up.

甚至可能出现意想不到的体重下降、焦虑、失眠、房颤，各种类似的问题。

You might even have unexpected weight loss, anxiety, insomnia, atrial fibrillation, all sorts of things like that.

我觉得大概有百分之五的美国成年人有临床上明显的甲状腺功能障碍。

I'd say kind of roughly like five percent of adults in The United States have some clinically meaningful thyroid dysfunction.

所以，这真的很普遍，也就是说，现在听我们节目的很多人可能就有这个问题。

So for that reason, I mean, it's wildly prevalent, and that means by definition, many people listening to us right now are experiencing that.

但就像我提到的，我觉得这是我见过的最常被误诊或处理不当的疾病之一。

But as I've kind of alluded to, I think it's one of the more commonly mismanaged conditions I see.

这也是为什么我想花很多时间讲这个。我们确实看到很多病人来我们诊所，他们的甲状腺问题被处理得不对。

I mean, that's obviously why I want to spend a lot of time on We do see a lot of patients come into our practice who are being mismanaged in this regard.

我想其他很多医生可能也遇到类似的情况。

I think by extension, many other doctors are probably seeing that too.

所以，这种处理不当，感觉大家对这个问题的看法分歧很大，对吧？

And so with that mismanagement, it's almost like there's a lot of disagreement around this, right?

这个话题不是特别清晰，生物学上也不是特别简单。

It's not a super clean topic, not a super clean biology in a way.

那你觉得为什么这个问题对医生和普通人来说都这么有争议、这么难理解呢？

And so why do you think that this can be such a contentious topic for doctors and people to understand?

我觉得是因为这个系统很复杂，这倒不是身体独有的，但再加上我们看不到它内部各个部分的运作，这就有点像完美风暴了。

I think because the system is complex, which is not unique to the body, but when you combine that with the fact that we don't have visibility into its moving parts, I think that creates a bit of a perfect storm.

就像我刚才提到的，这个腺体主要分泌一种不活跃的激素前体，叫T4，然后身体要决定有多少这种激素转化成活跃的T3，但这个决定是在各个组织局部发生的。

So as I kind of alluded to, the gland mostly secretes an inactive pro hormone, T4, and then there's a decision about how much of that hormone becomes the active hormone T3, but that decision is happening locally tissue by tissue.

而TSH，也就是促甲状腺激素，是个很好的指标，能反映腺体是否被要求更努力地工作，但它和肝脏、心脏、大脑里实际发生的情况隔了一层。

Now TSH, thyroid stimulating hormone, is a great marker of whether the gland is being told to work harder, but it's a step removed from what's actually happening inside the liver, the heart, the brain.

另外，还有一个真正的理念分歧。

Then there's also kind of a real philosophical split.

有一派医生，我觉得他们认为甲状腺功能减退被低估了，治疗也不够。

So there's a camp of physicians, I suppose, that think hypothyroidism is underdiagnosed, undertreated.

然后，你知道，这就像手里拿着锤子，看什么都是钉子那一派，对吧？

And then, you know, that's kind of the, when you're a hammer, everything is a nail camp, right?

不管病人来是什么问题，抑郁也好，肠胃问题也好，睡眠问题也好，反正都是甲状腺功能减退。

Like any problem that anybody shows up with, if you're depressed, if you're having GI issues, if you're, you know, having sleep, whatever the problem is, it's hypothyroidism.

而另一极端呢，有一派人说，不不不。

At the other end of the spectrum, have a camp of, you know, other folks who say, no, no, no.

这完全是被那种“人人都有甲状腺功能减退”的观点过度诊断了。

This is completely over diagnosed by this kind of everybody has hypothyroidism school of thought.

基本上，我们只会在甲状腺功能减退非常明显，以至于医学院学生上一小时内分泌课就能蒙着眼睛诊断出来的情况下才进行治疗。

And basically, we're only going to treat hypothyroidism if it is so overt that a medical school student after one hour of an endocrinology class would be able to make this diagnosis blindfolded.

你大概也能猜到，我觉得这两种观点都不对，真相可能就藏在这两者之间那个混乱的中间地带。

As you can probably imagine, I think both of these schools are incorrect, and that there's a messy middle ground where the truth probably lies.

当然，这期播客的目标就是带大家仔细了解生理机制，让你看到这两种观点各自有道理的地方，但更重要的是，看到它们可能遗漏了什么，从而希望我们能找到一个治疗患者的合适位置。

And the goal of this podcast, of course, is then to kind of walk people through the physiology carefully enough that you can see both the grains of truth on each side of those schools of thought, but perhaps more importantly, what they might be missing and therefore where we can hopefully land on a place to treat people.

说到这个，很多人第一次开始考虑甲状腺问题，通常是因为感到疲倦、体重增加，或者就是感觉“不太对劲”。

And so on that, it seems like for a lot of people, first time they start thinking about the thyroid is they're either tired, gaining weight, something just quote unquote doesn't feel right.

你会像所有人一样，去谷歌搜索，结果发现一大堆人和内容都在说，嘿，你的甲状腺有问题。

You do what anyone does, and they go to Google, they search it, and there's a ton of people, a ton of things saying, hey, there's something wrong with the thyroid.

你是甲状腺功能减退。

They're hypothyroid.

那么，从这些像这样的笼统症状中，你实际上能判断出多少呢？

And so how much can you actually tell from some of those, like, generic symptoms like that?

可惜的是，疲劳和感觉不对劲几乎不能说明是哪个器官系统或原因引起的。

Unfortunately, almost nothing about, fatigue and feeling off is specific to any one organ system or cause.

我们在正式的盲法研究中看到，仅凭症状群来诊断甲状腺功能减退，而不做任何生化检查，结果就是这样。

And we see this in formal blinded studies trying to diagnose hypothyroidism purely off of symptom clusters without any biochemistry.

他们基本上无法区分甲状腺功能减退和甲状腺功能正常，也就是说患者的甲状腺水平正常。

They essentially couldn't distinguish hypothyroid from euthyroid, meaning patients have normal levels of thyroid.

同样的症状也会出现在睡眠不足、缺铁性贫血、围绝经期和更年期相关症状中。

The same complaints show up with sleep deprivation, iron deficiency anemia, perimenopause, and menopause related symptoms.

顺便说一句，最后一个可能是我诊所里最大的干扰因素之一，尤其是因为时间上常常重叠，但这可能是以后要讨论的问题。

And the last one, by the way, may be one of the single biggest confounders in my practice, especially since the timing often overlaps, but that's maybe a later issue.

但内分泌系统内部发生了什么以及如何修复，实际上是两回事。

But what's going on inside the endocrine system and how to fix it are actually kind of different.

所以你需要多个数据来源的严谨性。

So you do need the rigor of multiple data sources.

我认为，先看化验结果而不是先看症状的方法，更有可能让你接近高概率的诊断区域。

And I think that a lab first approach rather than a symptom first approach is more likely to get you in the high zone of probability.

再说，这些症状本身就不太有特异性。

Again, based on how nonspecific these symptoms are.

所以我觉得这是个好时机，从临床角度来审视一下你的实践，对吧？

So I think it's a good place to then kind of look at it clinically in your practice, right?

那么，医生在哪些地方可能会漏掉真正的甲状腺问题呢？

So where are you seeing doctors potentially missing a real thyroid problem?

你又看到哪些人走得太远，往另一个方向过度了呢？

And where do you see people on the other end going too far in that other direction?

你看，我觉得很多医疗护理在孤立地看待化验值而忽视患者整体情况时，会漏掉真正的疾病。

Well, look, I think a lot of medical care misses real disease when it treats a lab value in isolation from the patient.

比如，有人甲状腺有结节、抗体阳性、还有家族史，但因为TSH正常在4.2就被忽视了。

So dismissing somebody with a patchy gland, positive antibodies, and a family history because their TSH is, you know, normal at 4.2.

这确实是个失误。

So that's a legit failure.

但同样常见的是，我看到另一个方向的过度治疗。

But just as often, I'm seeing the overreach in the other direction.

这最明显地体现在所谓的功能性医学这一流派中，他们把亚临床甲状腺功能减退症几乎当作普遍存在的现象来对待。

This is most visibly in this strand of what people call functional medicine that treats subclinical hypothyroidism as close to basically ubiquitous finding.

所以如果你去找，会发现有些从业者坚持认为标准的TSH范围过于宽松，并把边缘性的游离T3或升高的反向T3当作组织水平甲状腺功能减退的铁证，不管TSH或游离T4如何，有时甚至不管症状如何。

So if you go looking, you'll find practitioners who insist that the standard TSH ranges are too permissive and treat a borderline free T3 or elevated reverse T3 as irrefutable proof of tissue level hypothyroidism, regardless of TSH or regardless of free T4, and sometimes regardless of symptoms.

一旦认定病人有甲状腺问题，他们就会围绕一个在大多数情况下其实属于正常变异或会自行恢复正常的化验结果，构建一个复杂的根本原因叙事，比如肠道健康、肾上腺疲劳、毒素负担等等。

Having decided that a patient has a thyroid problem, they will build an elaborate root cause narrative, gut health, adrenal fatigue, toxic burden, etcetera, around kind of a lab picture that in a large share of cases is actually within a normal variation or will normalize on its own.

所以，与其接受当血液检查按常规标准正常时病人没有甲状腺功能减退，他们可能会利用这种功能性医学框架，基本上假设在组织中T4向T3的转化层面存在问题。

So rather than just kind of accepting that a person doesn't have hypothyroidism when their blood work comes back normal by conventional standards, they will maybe use this kind of functional medicine framework to basically assume that there's a problem at the level of the conversion of T4 to T3 in the tissue.

然后问，是什么导致了转化障碍？

Ask the question, what's driving the conversion impairment?

我认为实际上，大多数TSH轻度升高的患者在重复检测时会自行恢复正常。

I think in reality, a large share of patients with mildly elevated TSH will normalize spontaneously on repeat testing.

而且我认为过度使用标准甲状腺激素治疗并非无害。

And I think over treatment with standard thyroid hormone is not benign.

它实际上可能导致认知症状、心房颤动（我们见过无数次）、骨质流失等等。

It can actually cause cognitive symptoms, atrial fibrillation, which we've seen countless times, bone loss, and more.

所以，我觉得这两种极端情况都是真实存在的，有些病人从家庭医生那里出来，被一边的问题困扰，然后又走进一个庸医的诊所，被另一边的问题困扰。

So, I think both failure modes are real and some patients go from their family doctor and get hit at one end of it and then are driven into the clinic of a quack who hits them with the other end.

再说一遍，我想强调，这两种极端做法很可能都是弊大于利。

And again, just to reiterate, I think both extremes are likely doing more harm than good.

感谢您收听今天的《The Drive》AMA抢先预览集。

Thank you for listening to today's sneak peek AMA episode of The Drive.

如果您想收听这期AMA的完整版，可以成为我们的高级会员。

If you're interested in hearing the complete version of this AMA, you'll want to become a premium member.

对我来说，提供所有这些内容而不依赖付费广告非常重要。

It's extremely important to me to provide all of this content without relying on paid ads.

为了实现这一点，我们的工作完全依靠会员的支持。

To do this, our work is made entirely possible by our members.

作为回报，我们提供仅限会员的专属内容和福利，比免费内容更丰富。

And in return, we offer exclusive member only content and benefits above and beyond what is available for free.

所以，如果您想进一步提升对这个领域的了解，我们的目标就是确保会员获得的回报远超订阅费用。

So if you wanna take your knowledge of this space to the next level, it's our goal to ensure members get back much more than the price of the subscription.

高级会员享有多种福利。

Premium membership includes several benefits.

首先，全面的播客节目笔记，详细记录每集我们讨论的每个话题、论文、人物和事物。

First, comprehensive podcast show notes that detail every topic, paper, person, and thing that we discuss in each episode.

听说我们的节目笔记无人能敌。

And the word on the street is nobody's show notes rival hours.

第二，每月的“问我任何问题”即AMA节目。

Second, monthly ask me anything or AMA episodes.

这些节目包含对订阅者问题的详细回答，通常聚焦单一主题，旨在为会员特别感兴趣的话题提供大量清晰度和细节。

These episodes are comprised of detailed responses to subscriber questions typically focused on a single topic and are designed to offer a great deal of clarity and detail on topics of special interest to our members.

当然，你也能获得这些节目的节目笔记。

You'll also get access to the show notes for these episodes, of course.

第三，我们会发送高级新闻通讯，由我们专门的研究分析团队精心制作。

Third, delivery of our premium newsletter, which is put together by our dedicated team of research analysts.

这份通讯涵盖与长寿相关的广泛话题，比我们的免费每周通讯提供更多细节。

This newsletter covers a wide range of topics related to longevity and provides much more detail than our free weekly newsletter.

第四，访问我们的私人播客订阅源，你可以通过它收听所有节目，包括AMA，而且没有你现在听到的这些开场白。

Fourth, access to our private podcast feed that provides you with access to every episode including AMA's sans the spiel you're listening to now and in your regular podcast feed.

第五，Qualys，这是我们制作的另一个会员专属播客，相当于一个精选集，收录了《The Drive》往期节目中最精彩的部分。

Fifth, the Qualys, an additional member only podcast we put together that serves as a highlight reel featuring the best excerpts from previous episodes of the drive.

这是一个很好的方式来回看往期节目，不用再回去一集一集地听。

This is a great way to catch up on previous episodes without having to go back and listen to each one of them.

最后，还有其他陆续增加的福利。

And finally, other benefits that are added along the way.

如果你想了解更多并享受这些会员专属福利，可以访问peterattiamd.com/subscribe。

If you wanna learn more and access these member only benefits, you can head over to peterattiamd.com forward slash subscribe.

你也可以在YouTube、Instagram和Twitter上找到我，账号都是Peter Attia MD。

You can also find me on YouTube, Instagram, and Twitter, all with the handle Peter Attia MD.

你也可以在Apple Podcasts或你使用的任何播客播放器上给我们留下评价。

You can also leave us a review on Apple Podcasts or whatever podcast player you use.

本播客仅供一般信息参考，不构成医疗、护理或其他专业医疗保健服务的实践，包括提供医疗建议。

This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.

这并不构成医患关系。

No doctor patient relationship is formed.

使用这些信息以及本播客中链接的材料，风险由用户自行承担。

The use of this information and the materials linked to this podcast is at the user's own risk.

本播客的内容不旨在替代专业的医疗建议、诊断或治疗。

The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

用户不应因任何医疗状况而忽视或延迟获取医疗建议，如有此类情况，应寻求医疗专业人员的帮助。

Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions.

最后，我非常重视所有利益冲突问题。

Finally, I take all conflicts of interest very seriously.

关于我所投资或提供咨询的公司的所有披露信息，请访问 peterattiamd.com/About，那里有我保持更新和活跃的完整披露清单。

For all of my disclosures in the companies I invest in or advise, please visit peterattiamd.com/ About where I keep an up to date and active list of all disclosures.