#373 – Thyroid function and hypothyroidism: why current diagnosis and treatment fall short for many, and how new approaches are transforming care | Antonio Bianco, M.D., Ph.D.

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter's Weekly Newsletter Antonio Bianco is a world-renowned physician-scientist and expert in thyroid physiology and metabolism. In this episode, Antonio explores the complex biology of thyroid hormone production, conversion, and regulation—highlighting how deiodinase enzymes modulate hormone activity at the tissue level and why that matters for interpreting lab results. He discusses the shortcomings of relying solely on TSH as a marker of thyroid function, the ongoing debate around combination therapy with T3 and T4 versus standard T4 treatment, and how genetics, tissue sensitivity, and individual variability influence thyroid hormone metabolism. The conversation also examines how hypothyroidism affects energy, mood, cognition, and longevity; why some patients remain symptomatic despite "normal" labs; and how future research could reshape treatment paradigms. We discuss: How the thyroid produces, stores, and activates hormones like T4 and T3 to finely regulate thyroid activity [2:45]; How fasting alters thyroid hormones to conserve energy [12:45]; Action of the deiodinases: how D1, D2, and D3 enzymes control the activation and inactivation of thyroid hormones [19:15]; The normal function of thyroid hormone and the roles of the hypothalamus, pituitary gland, and deiodinases in maintaining hormonal balance [23:30]; Why understanding thyroid physiology is essential for proper diagnosis and treatment of hypothyroidism [33:45]; Testing for thyroid hormones: understanding free vs. total levels, the limitations of current T3 assays, best practices, and more [36:00]; Genetic and sex-based variability in thyroid hormone regulation and their limited clinical significance [43:45]; Hyperthyroidism: causes, symptoms, diagnosis, and treatment options [46:00]; Hypothyroidism: diagnosis and autoimmune causes of hypothyroidism [56:30]; More on hypothyroidism: diagnostic bio