by Kristina Fiore, Staff Writer, MedPage Today
May 15, 2014

LAS VEGAS — Obese patients who continue to have “thyroid symptoms” even when their levels are normalized may have a hypothalamic dysfunction, researchers reported here.

In a single-center study of 50 patients referred for evaluation of thyroid symptoms, 68% had at least four symptoms that were characteristic of hypothalamic obesity disorder, Saad Sakkal, MD, and colleagues reported during a late-breaking poster session at the American Association of Clinical Endocrinologists meeting here.

Those include fatigue, temperature dysregulation, weight change, changes in sleeping patterns, pain, and mood disorders, the researchers said.

Sakkal explained that every endocrinologist sees patients who have been referred for “thyroid symptoms” with normal or low thyroid-stimulating hormone (TSH) levels.

But some overweight patients continue to have these thyroid symptoms even when they’ve had sufficient hormone replacement.

“Patients who insist they have thyroid disease causing their weight problems are frequent,” the researchers said. “Some try thyroid medications, yet they feel worse and don’t lose weight. These patients would only benefit from therapy for their hypothalamic dysfunction.”

Sakkal and colleagues hypothesized that their symptoms may relate to hypothalamic dysfunction instead.

There are no studies, however, that document the prevalence of hypothalamic obesity disorder among patients referred for thyroid disease.

So Sakkal and colleagues assessed 50 patients who had been referred for the evaluation of thyroid symptoms. They diagnosed hypothalamic dysfunction as “likely” if symptoms from three different systems were present, and as “definite” if from four or more.

The majority of cases were women (76%) with an age range of 18 to 68. Most also had normal thyroid levels (72%).

The most common hypothalamic symptoms were:

• Fatigue (76%)
• Temperature dysregulation (68%)
• Weight change (88%)
• Changes in sleep (70%)
• Pain (72%)
• Mood disorders (80%)
• Libido issues (38%)
• Sympathetic or parasympathetic complaints (64%)

The researchers noted that an important physical finding is the presence of trigger points tenderness, which occurred in 68% of this population.

Overall, more than two-thirds of these patients (68%) were determined to have definite hypothalamic dysfunction, and 22% had likely hypothalamic dysfunction, the researchers reported.

Some clinicians diagnose these patients with malingering, borderline personality disorder, adrenal depletion, or uncharacterized disorders “when hypothalamic dysfunction would explain most,” they wrote.

They concluded that hypothalamic obesity disorder is an easy diagnosis to make on clinical grounds and is the most common disease in patients who have normal thyroid tests but still report thyroid symptoms.

“Treating the thyroid in these patients often fails,” they wrote. “They need specific therapy for hypothalamic dysfunction based on stress/reward/behavioral therapy, and dual pharmacologic therapy for the dual hypothalamic nuclei pathways affecting satiety/hunger and weight/metabolism.”

In a second poster, Sakkal and colleagues described an algorithm to treat hypothalamic obesity disorder.

They evaluated 108 patients, and for those with the diagnosis, the algorithm involved a prescription for daily exercise, a Mediterranean diet, and treatment for anxiety, depression, or obsessive-compulsive disorder (OCD) with medications.

Drug treatment involved fluoxetine/spironolactone followed by topiramate/phentermine — and then buspirone for anxiety, trazodone for sleep problems or fibromyalgia, fluoxetine or bupropion for OCD, testosterone in hypogonadism, and bromocriptine for those with hyperprolactinemia.

They found that over 12 weeks, the mean weight loss for patients diagnosed with the condition was 13 pounds.

“Since the majority of clinical obesity is hypothalamic in nature, many other symptoms need to be addressed as well to treat the etiology as well as the weight problem itself,” they wrote.

“Treatment for anxiety, depression, compulsive behavior, sleep disorders, and fibromyalgia — all of which often cause the behavioral pattern leading to obesity — by weight-neutral medications is intuitive, but rarely reported.”

They called for large scale efficacy studies of various therapies in order to inform future practice guidelines.