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Treating Hypothalamic Pituitary Dysfunction (HPD): By William Wilson, M.D.
Tuesday, June 01, 2004 8:30 am Email this article
In his interview, William Wilson, M.D., discussed a condition he has named Hypothalamic Pituitary Dysfunction, or HPD for short. In this article he provides an outline for diagnosis, treatment and examples of patients he has treated.
- Improve or eliminate HPD symptoms.
- Normalize CNS neurotransmitter levels.
- Improve metabolic (Syndrome X) parameters (Body composition, glucose intolerance, lipids, blood pressure).
HPD: The Unifying Theory
- If, we consider diseases of HPD to have the same cause, then the same general treatment can be used for all the diseases.
- When confronting one HPD syndrome, look for:
- Other HPD symptoms
- Depleted neurotransmitters
- Metabolic changes
- Make the diagnosis of HPD!
- Fibromyalgia: Patients with this condition have excessive body fat.
- Type II diabetes: Most patients with this condition have carbohydrate cravings and mood swings.
- Anorexia: Patients with this condition have excessive body fat.
Patient #1: 52-year-old Female
- Severe anorexia and bulimia as teenager.
- Middle age: hyperlipidemia, mild hypertension, fibromyalgia, chronic back pain
- 6/2/99: BMI = 19.5 Percent body fat: 30.1
- 11/18/03: BMI = 20.2 Percent body fat: 24.3
- Treatment: Four pillars—healthy eating, Wellbutrin XL, fixed dose supplement (not always compliant), exercise.
- Results: Improved symptoms and health but sometimes relies too much on medications, not enough on supplements.
Her neurotransmitter levels were as follows:
- Epinephrine: Optimal range: 8-12; Baseline: 6.1; Retest: 9.9
- Norepinephrine: Optimal range: 30-55; Baseline: 57.1; Retest: 77.4
- Dopamine: Optimal range: 125-175; Baseline: 131.2; Retest: 156.9
- Serotonin: Optimal range: 175-225; Baseline: 133.7; Retest: 139.6
- GABA: Optimal range: 2-4; Baseline: NA; Retest: 6.9
Patient #2: 31-year-old Female
- 01/12/04: Irritable Bowel Syndrome (IBS), Attention Deficit Hyperactive Disorder (ADHD), depression, obesity.
- 01/26/04: BMI = 25.9; Percent body fat:34.2
- 4/20/04: BMI = 25.1; Percent body fat: 34.3
- Treatment: Dietary changes, Adderall XR, Celexa, fixed dose supplement recommended but not taken due to the cost.
- Results: Improved symptoms, but recent plateau with break through symptoms.
- Solution: Patient agrees to take supplements.
Her neurotransmitter levels were as follows:
- Epinephrine: Optimal range: 8-12; Baseline: 9.6
- Norepinephrine: Optimal range: 30-55; Baseline: 49.4
- Dopamine: Optimal range: 125-175; Baseline: 201.8
- Serotonin: Optimal range: 175-225; Baseline: 94.4
- GABA: Optimal range: 2-4; Baseline: 6.2
Patient #3: 20-year-old Female
- 04/29/99: Acute anorexia, obsessive-compulsive disorder, hypothyroidism.
- 04/29/99: BMI = 20.8; Percent body fat: 28.6
- 09/15/00: BMI = 20.8; Percent body fat: 23.5
- 08/11/01: BMI = 21.8; Percent body fat: 26.3
- Treatment: Dietary changes, Phentermine, Luvox, fixed dose supplement (poor compliance), exercise.
- Result: Gradual destabilization over time.
- Solution: Aggressive use of fixed dose supplements.
Her neurotransmitter levels were as follows:
- Epinephrine: Optimal range: 8-12; Baseline: 0.9
- Norepinephrine: Optimal range: 30-55; Baseline: 19.1
- Dopamine: Optimal range: 125-175; Baseline: 107.9
- Serotonin: Optimal range: 175-225; Baseline: 89.1
- GABA: Optimal range: 2-4; Baseline: 3.7
Four Pillars of Effective Treatment for HPD
- Dietary changes
- Targeted medications
- Precursor supplements
- Eliminate or dramatically reduce High-glycemic-index carbohydrates.
- Consider the serving size when it comes to glycemic load.
- Too many high glycemic carbohydrates equals failure regardless of treatment.
The Danger of High-Glycemic Index Carbohydrates
They are dangerous, not because they cause weight gain, but because they:
- Deplete neurotransmitters.
- Trigger famine protective metabolic mode.
- Result in inappropriate fat storage & other metabolic changes.
The diet should consist of:
- 40% low glycemic index carbohydrates
- 30% protein
- 30% healthy fats
The type of carbohydrate is most critical.
A patient should:
- Consume small amounts throughout day.
- Avoid skipping meals.
- Eat a good breakfast.
- Don???t count calorie, instead focus on diet composition.
Traditional dieting consists of under-eating, however, this:
- Almost always makes HPD worse.
- Causes loss of lean body mass, not fat.
- Accelerates HPD.
- Worsens famine protective metabolic mode.
Precursor Supplements: Unlocking the Mystery
The Key to treating patients with HPD is restoration of neurotransmitters to optimal or therapeutic ranges.
This is the only way to reach and maintain long term clinical stability.
The Key???s Composition
The essential components are:
- Precursor amino acids including:
- 5-HTP which is converted to serotonin.
- Glutamate which is converted to GABA.
- Tyrosine and phenylalanine which is converted to epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine.
Catecholamine (adrenaline, noradrenaline and dopamine) and serotonin systems are intimately intertwined, so both must be addressed.
Trying the Key
Phase 1: The primary focus should be on serotonin.
Phase 2: Treatment should address both the catecholamine and serotonin systems.
Turning the Key
Dopamine and serotonin are restored within months, however, it may take a year of continuous treatment to restore epinephrine and norepinephrine (adrenaline and noradrenaline).
People with HPD stages II and III may require life-long use of supplements.
Testing the Door
Symptoms are the guide to effective clinical outcomes.
The first goal of treatment is to eliminate symptoms.
The success or failure of treatment should be evaluated by its ability to eliminate symptoms.
Short-term relief can be obtained with low dose medication, however, this is not a long-term solution.
Long-term relief results when neurotransmitter levels are restored.
Long-term effective treatment cannot be obtained without amino acid supplementation.
Targeted Medications: The Primary Purpose of Medications is to:
- Manage stage II & III HPD.
- Control symptoms.
- Improve compliance.
- Buy time to change:
- Restore neurotransmitters with supplements
It is Difficult to Treat Some Patients with HPD Because:
- They find it difficult or impossible to comply with lifestyle changes.
- Their symptoms are too severe.
- Quick symptom resolution is needed.
Certain things can be done to improve compliance, including:
- Use certain psychotropic medicines aimed at depleted neurotransmitters.
- Typically SSRIs for serotonin.
- Dopamine/Norepinephrine enhancers for catecholamines.
- 80% require a combination of treatments.
Guidelines for Using Medications when Treating a Patient with HPD
Baseline testing is a must before adding medications.
- Use the lowest possible dose that:
- Doesn???t cause side-effects.
- Gives satisfactory therapeutic effect.
Masking the Problem: How Medications Mask the Condition.
Medications provide temporary symptom relief, however, the problem is that they:
- Do not restore neurotransmitter levels.
- Worsens depletion of neurotransmitters.
- Symptom relief lessens with time.
- Improper use of medications accelerates HPD.
Removing the Mask: Tapering
It is important to:
- Wait a minimum of 6 months.
- Wait until neurotransmitters are in their therapeutic range.
- Constantly monitor neurotransmitter levels.
- Consider increasing the dose if symptoms break through.
Catecholamine-enhancing medications include:
- Phentermine: 30-60 mg per day
- Adderall (a combination of dextroamphetamine and amphetamine): 10-30 mg per day
- Tenuate Dospan (diethylpropion): 75 mg per day
- Wellbutrin XR or XL (bupropion extended-release): 100-200 mg per day
85% of patients respond well to Phentermine or Adderall.
When using Addreral, extended-release Adderall XR is preferred.
Abuse potential of Phentermine and Adderall
Phentermine is rarely abused.
Adderall has minimal abuse potential. Abuse of this drug usually occurs in teenagers.
The following serotonin-enhancing medications and dosage ranges are useful in some patients with HPD:
- Celexa (citalopram hydrobromide): 5-20 mg per day
- Lexapro (escitalopram oxalate): 5-10 mg per day
- Effexor (venlafaxine): 37.5-75 mg per day
- Prozac (fluoxetine): 10-20 mg per day
- Zoloft (sertraline hydrochloride): 25-50 mg per day
Avoid These Drugs
The following drugs should be avoided in patients with HPD:
- High-dose SSRIs.
- Paxil (paroxetine)
- Remeron (mirtazapine)
- Neurontin (gabapentin)
- Other mood stabilizers
- Atypical anti-psychotics including:
- Zyprexa (olanzapine)
- Risperdal (risperidone)
- Seroquel (quetiapine)
- Geodon (ziprasidone)
Watch Out For:
- Patients on psychotropic drugs for the wrong reasons.
- HPD triggered by high dose SSRIs used to treat depression.
The Benefits of Exercise Include:
- Improved glucose intolerance.
- Improved blood lipids (decrease in total cholesterol, increase in HDL cholesterol, and decrease in triglyceride levels).
- Decrease in blood pressure.
- Maintains healthy body composition.
- Maintains healthy levels of neurotransmitters.
The Problem with Diet and Exercise Alone
Eating “right” and exercise alone may result in weight loss, but the problem for patients with HPD is that:
- Body fat does not decrease proportionally.
- HPD symptoms worsen without restoring neurotransmitters.
When is Exercise Effective?
Exercise is effective when neurotransmitters are balanced. When they are balanced, exercise can:
- Increase resting metabolic rate.
- Fatigue is no longer an issue.
- Lowers morbidity and mortality.
- Improves metabolic parameters such as body compositions, glucose intolerance, lipids, blood pressure.
Making Therapeutic Decisions
Use the presence or absence of HPD symptoms; they precede metabolic changes.
Measure neurotransmitter levels.
Do not be influenced by BMI, size, or weight, look at body composition instead.
Initial treatment is trial and error; watch symptoms to determine effectiveness of the treatment.
It is necessary that treatment, including the use of medications, be individualized for each patient.
Medical Evaluation for HPD: The First Appointment Should Include:
- General medical history.
- Detailed history of HPD symptoms.
- Complete physical exam including body composition.
- Appropriate labs and x-rays including:
- Possibly adrenal
Key Parameters to Look For Include:
- HPD symptoms, especially carbohydrate craving.
- Inappropriate fat storage and other metabolic parameters.
- Neurotransmitter depletion.
When Diagnosis Is Confirmed, Initiate the 4 Pillars
First Follow-up Visit Should Include:
- Dietary history of high glycemic index carbohydrates.
- Changes in HPD symptoms.
- Re-evaluate body composition, look for body shrinkage.
- Adjust medications and supplements.
Follow-up visits should be scheduled monthly.
Retest neurotransmitters every 4-6 weeks until therapeutic levels have been achieved or if there is a change in clinical presentation.
Maintenance Begins When The Following Have Been Achieved:
- Symptoms are fully suppressed.
- Percent body fat is acceptable.
- Neurotransmitter levels are in therapeutic range.
Then you can:
- Taper off the medicines.
- Test neurotransmitter levels every 6-12 months.
Keys to Maintenance Include:
- Maintain a low-glycemic index diet with calories equal to daily metabolic needs.
- Maintenance supplements.
- Regular exercise which includes 50% aerobic exercise and 50% strength training.
Key to Long-Term Management Include:
- Focus on HPD as disease requiring life long treatment.
- Relapse is certain if treatment is stopped.
- Return of HPD symptoms indicates progression of the illness.
How Can Patients Prevent HPD?
- Avoid high glycemic carbohydrates!
- Avoid other triggers.
- Regular exercise.
- Low dose supplements to help avoid depletion.
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