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period like cramps, can it be this cystocele? period like cramps, can it be this cystocele?

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Unread 05-09-2003, 03:35 PM
period like cramps, can it be this cystocele?


I too have those horrible leg aches....So bad that I can barely walk, and can never get comfortable standing or in bed. I always blamed it on the Fibro...But now I'm wondering if it is more related to Restless Leg Syndrome (RLS) that I've recently been diagnosed with. Or could it have something to do with the nerve damage I wonder.

I hope and pray you are able to get into your GP's tonight. Please post and let us know....

((((((Sheri)))))) I've never heard of PPOD...but when I started looking at your link too many things applied to me. Geesh. Do you have this? It does sound like a hard dx to make. Thanks for always posting so much great information and for always being there. I've missed you my friend. I haven't been posting as much these past few weeks, but I do come by usually once a day, and read/lurk. I appreciate all of the info you give us soooo much
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Unread 05-09-2003, 03:39 PM
period like cramps, can it be this cystocele?

Hey Jude, I'm going to give it my best shot tonight but if it's another 2 and a half hour wait I'm going to wait until the week after next when I'm on holidays and have all the time in the world.....I'm crampy as heck today and my legs are just starting up so tonight's going to be a doozy!!

I've still got to read all that PPOD stuff but I"m stinkin' busy here at work so i'll have to look at it over the weekend!

thanks for being there girls....what would I do without you all?? "s!!!
Unread 05-09-2003, 04:07 PM
period like cramps, can it be this cystocele?

((((Gidge)))) Please excuse my horrendous But have you ever seen a Rheumatologist??? I can't remember. As ((Sheri)) pointed out, you have been on this road (with those other precious sisters) for so very long. I know we've talked about you seeing a Rhuemy, but I can't remember....

I hope and pray you don't have to wait very long to see your GP tonight my dear.... Can you post from home tonight to let us know?
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Unread 05-09-2003, 04:16 PM
period like cramps, can it be this cystocele?

Hey Jude, no I have never been sent to a rheumy, my GP has done bloodwork at least 3 times to test me for Lupus and RA because both run in the family but has never suggested seeing an Rheumy, I know he said if the bloodwork showed something conclusive that would be the next step so I guess cause it didn't he just dropped it? Also , the joint pain seems to come and go I"ll have to start tracking it but there are definitely periods of time when it's really bad and then it backs off??

I will try to post tonight if I get in at the doc's it will depend on what time it is and how awful I"m feeling.....if you don't hear from me I didn't get in and I will chat with y'all on Monday......I will suggest the Rheumy tonight along with all the other stuff!!!

Unread 05-09-2003, 04:48 PM
period like cramps, can it be this cystocele?

Hello again

I think pushing to see a Rheumy is a good idea. Those are the kind of docs that dx FMS/ perhaps it is time for you to see that type of dr my dear. And if RA does run in your family (as it does mine) combined with your symptoms, I truly think you need to see a Rheumy. Okay? I'll get off my soapbox - for now

Good Luck Hun...I hope you get some relief over the weekend too...S
Unread 05-09-2003, 04:53 PM
period like cramps, can it be this cystocele?

thanks Jude, I'm going to ask for a referral....hopefully he's in an agreeable's so awful I don't even know where to start with him with all my symptoms......I can almost see his eyes glazing over now!!!

hope you have a good weekend too!!!'s!!
Unread 05-09-2003, 10:22 PM
period like cramps, can it be this cystocele?

((((Gidge))))), (((((Sheri))))), (((((Jude))))) So sorry you're still on this road, dealing with much of the same things you were dealing with 3 years ago

Gidge: I just wanted to mention that your joint pains sound a lot like mine. Like yours, mine are mostly in my ankles and wrists, sometimes in my knees, elbows, fingers and hands. I also tend to have tons of "stiff neck" episodes... that sound a lot like the pains you have in your neck.

Like you, my pains, except for the neck pains, are always on both sides at the same time. And, usually, in both ankles and both wrists at the same time.

I have been sent to a Rheumy, last December, despite the fact that all the test ran by my GP didn't show anything. Unfortunately, the day I saw the Rheumy was the first day since July that I had absolutely NO PAIN!!! So it was hard for him to get a handle on what was going on. Furthermore, I've since learned that that particular doctor I was sent to is being referred patients because he's got lots of vacancy, but he's also far from good

I hope you do get answers very soon, (((Gidge))). Hopefully your GP will refer you to a Rheumy so some of these issues can be addressed with a specialist.

Lots of s going your way.
Unread 05-10-2003, 06:49 AM
period like cramps, can it be this cystocele?

(((Gidge))), I'm hoping you got in to see your doc last night! I said that I was unsure if my DX was 100% on target, but after re-reading the info (((Sheri))) posted, it sounds 200% on target!

(((Dany))) -- I get the stiff neck thing too. I have 2 bad discs at C5/C6 and C6/C7 so am pretty sure of the problem there. Have you had MRIs of your spine?

I hope all of you ladies have an extraordinary weekend!
Unread 05-11-2003, 09:59 AM
More FMS/

Chronic Fatigue Syndrome Guidelines:
The Canadian ME/CFS guidelines in this journal are aimed at assist-ing
healthcare professionals including medical general practitioners,
specialist physicians, physiotherapists, occupational therapists, psy-chologists
and social workers who deal with patients with abnormal fa-tigue
states. This set of guidelines is now the third to be published, with
the British and Australian guidelines preceding them. These clin-ical
guidelines should not be confused with the research guidelines for
The method of development of the Canadian guidelines differs from
both the British and Australian guidelines principally in the manner of
selecting the committee that developed them and also in the level of
evidence accepted as indicating whether research findings were consid-ered
relevant. The British and Australian guidelines were developed by
selected committee (the Australian committee also included a consumer
representative) from within the country to develop their guidelines.
Australian guidelines committee called for submissions from interested
Journal of Chronic Fatigue Syndrome, Vol. 11(1) 2003
Although it is unlikely that a single disease model will account for
every case of ME/CFS, there are common clusters of symptoms that al-lows
a clinical diagnosis.
Clinical Working Case Definition of ME/CFS:

A patient with ME/CFS will meet the criteria for fatigue, post-exertional
malaise and/or fatigue, sleep dysfunction, and pain; have two or more
neurological/cognitive manifestations and one or more symptoms
from two of the categories of autonomic, neuroendocrine and immune
manifestations; and adhere to item:
  • 1. Fatigue: The patient must have a significant degree of new onset,
    unexplained, persistent, or recurrent physical and mental fatigue
    that substantially reduces activity level.
    2. Post-Exertional Malaise and/or Fatigue: There is an inappropriate
    loss of physical and mental stamina, rapid muscular and cognitive
    fatigability, post exertional malaise and/or fatigue and/or pain and
    a tendency for other associated symptoms within the patient's clus-ter
    of symptoms to worsen. There is a pathologically slow recovery
    period–usually 24 hours or longer.
    3. Sleep Dysfunction:* There is unrefreshed sleep or sleep quantity or
    rhythm disturbances such as reversed or chaotic diurnal sleep rhythms.
    4. Pain:* There is a significant degree of myalgia. Pain can be experi-enced
    in the muscles and/or joints, and is often widespread and mi-gratory
    in nature. Often there are significant headaches of new
    type, pattern or severity.
    5. Neurological/Cognitive Manifestations: Two or more of the fol-lowing
    difficulties should be present: confusion, impairment of
    concentration and short-term memory consolidation, disorienta-tion,
    difficulty with information processing, categorizing and word
    retrieval, and perceptual and sensory disturbances–e.g., spatial in-stability
    and disorientation and inability to focus vision. Ataxia,
    muscle weakness and fasciculations are common. There may be
    overload 1 phenomena: cognitive, sensory–e.g., photophobia and
    hypersensitivity to noise–and/or emotional overload, which may
    lead to “crash”2 periods and/or anxiety.
    6. At Least One Symptom from Two of the Following Categories:

    a. Autonomic Manifestations: orthostatic intolerance–neurally me-diated
    hypotenstion (NMH), postural orthostatic tachycardia
    syndrome (POTS), delayed postural hypotension; light-headed-ness;
    extreme pallor; nausea and irritable bowel syndrome; uri-nary
    frequency and bladder dysfunction; palpitations with or
    without cardiac arrhythmias; exertional dyspnea.
    b. Neuroendocrine Manifestations: loss of thermostatic stability–
    subnormal body temperature and marked diurnal fluctuation,
    sweating episodes, recurrent feelings of feverishness and cold
    extremities; intolerance of extremes of heat and cold; marked
    weight change–anorexia or abnormal appetite; loss of adaptabil-ity
    and worsening of symptoms with stress.
    c. Immune Manifestations: tender lymph nodes, recurrent sore
    throat, recurrent flu-like symptoms, general malaise, new sensi-tivities
    to food, medications and/or chemicals.

    7. The illness persists for at least six months. It usually has a distinct
    onset,** although it may be gradual. Preliminary diagnosis may be
    possible earlier. Three months is appropriate for children.
    To be included, the symptoms must have begun or have been signifi-cantly
    altered after the onset of this illness. It is unlikely that a patient
    will suffer from all symptoms in criteria 5 and 6. The disturbances tend
    to form symptom clusters that may fluctuate and change over time.
    Children often have numerous prominent symptoms but their order of
    severity tends to vary from day to day. *There is a small number of pa-tients
    who have no pain or sleep dysfunction, but no other diagnosis fits
    except ME/CFS. A diagnosis of ME/CFS can be entertained when this
    group has an infectious illness type onset. **Some patients have been
    unhealthy for other reasons prior to the onset of ME/CFS and lack de-tectable
    triggers at onset and/or have more gradual or insidious onset.
    Exclusions: Exclude active disease processes that explain most of the
    major symptoms of fatigue, sleep disturbance, pain, and cognitive
    dysfunction. It is essential to exclude certain diseases, which would be
    tragic to miss: Addison’s disease, Cushing’s Syndrome, hypothyroid-ism,
    hyperthyroidism, iron deficiency, other treatable forms of ane-mia,
    iron overload syndrome, diabetes mellitus, and cancer. It is also
    essential to exclude treatable sleep disorders such as upper airway re-sistance
    syndrome and obstructive or central sleep apnea; rheuma-tological
    disorders such as rheumatoid arthritis, lupus, polymyositis
    and polymyalgia rheumatica; immune disorders such as AIDS; neuro-logical
    disorders such as multiple sclerosis (MS), Parkinsonism,
    myasthenia gravis and B12 deficiency; infectious diseases such as tu-berculosis,
    chronic hepatitis, Lyme disease, etc.; primary psychiatric
    disorders and substance abuse. Exclusion of other diagnoses, which
    cannot be reasonably excluded by the patient’s history and physical
    examination, is achieved by laboratory testing and imaging. If a
    potentially confounding medical condition is under control, then the
    diagnosis of ME/CFS can be entertained if patients meet the criteria
    Co-Morbid Entities: Fibromyalgia Syndrome (FMS), Myofascial Pain
    Syndrome (MPS), Temporomandibular Joint Syndrome (TMJ), Irrita-ble
    Bowel Syndrome (IBS), Interstitial Cystitis, Irritable Bladder
    Syndrome, Raynaud’s Phenomenon, Prolapsed Mitral Valve, Depres-sion,
    Migraine, Allergies, Multiple Chemical Sensitivities (MCS),
    Hashimoto’s thyroiditis, Sicca Syndrome, etc. Such co-morbid enti-ties
    may occur in the setting of ME/CFS. Others such as IBS may pre-cede
    the development of ME/CFS by many years, but then become
    associated with it. The same holds true for migraines and depression.
    Their association is thus looser than between the symptoms within the
    syndrome. ME/CFS and FMS often closely connect and should be
    considered to be “overlap syndromes.”
    Idiopathic Chronic Fatigue: If the patient has unexplained prolonged
    fatigue (6 months or more) but has insufficient symptoms to meet the
    criteria for ME/CFS, it should be classified as idiopathic chronic fa-tigue.

General Considerations in Applying the Clinical Case Definition
to the Individual Patient:

1. Assess Patient’s Total Illness: The diagnosis of ME/CFS is not ar-rived
at by simply fitting a patient to a template but rather by observ-ing
and obtaining a complete description of their symptoms and
interactions, as well as the total illness burden of the patient.
2. Variability and Coherence of Symptoms: Patients are expected to ex-hibit
symptoms from within the symptom group as indicated, how-ever
a given patient will suffer from a cluster of symptoms often
unique to him/her. The widely distributed symptoms are connected
as a coherent entity through the temporal and causal relationships re-vealed
in the history. If this coherence of symptoms is absent, the di-agnosis
is in doubt.
3. Severity of Symptoms: A symptom has significant severity if it sub-stantially
impacts (approximately a 50% reduction) on the patient’s
life experience and activities. In assessing severity and impact, com-pare
the patient’s activity level to their premorbid activity level. Es-tablishing
the severity score of symptoms is important in the diagnostic
procedure (46,45), and should be repeated periodically. A chart for
severity of symptoms and symptom hierarchy can be found in Ap-pendix
3. While this numerical scale has been developed as a tool to
assist the clinician and position the patient within the overall spec-trum
of ME/CFS severity, the severity and impact of symptoms
should be confirmed by direct clinical dialogue between physician
and patient over time.
4. Symptom Severity Hierarchy: Periodic ranking of symptom severity
should be part of the ongoing evaluation of the clinical course. (Ap-pendix
3) This hierarchy of symptom severity will vary from patient
to patient and for an individual patient over time. Thus, although fa-tigue
and post-exertional malaise are universal symptoms of ME/CFS,
they may not be the most severe symptoms in the individual case,
where headaches, neurocognitive difficulties, pain and sleep distur-bances
can dominate, at least temporarily. Establishing symptom se-verity
and hierarchy helps orient the treatment program.
5. Separate Secondary Symptoms and Aggravators: It is important to
try to separate the primary features of the syndrome from those that
are secondary to having a poorly understood chronic illness in our
society such as secondary stress, anxiety and depression and inactiv-ity.
It is also important to consider symptom interaction and dynam-ics,
and distinguish the effects of aggravators and triggers.
Discussion of Major Features of ME/CFS
The fatigue of ME/CFS comes in many ‘flavours’ (47). Patients learn
to recognize the difference between ‘normal’ and ‘ME/CFS’ fatigue by
its qualitative flavour, its temporal characteristics and its correlation
with other events and activities. The patient must have a marked degree
of unexplained, persistent or recurrent fatigue. The fatigue should be
severe enough to substantially reduce the patient’s activity level, usu-ally
by approximately 50%. When considering the severity of the fa-tigue,
it is important to compare the patient’s activity level to their
premorbid activity level. For example, a former world class athlete

could have a substantially reduced activity level and still exceed the
norms for sedentary persons. Some patients may be able to do some
work, but in order to do that they have had to eliminate or severely re-duce
other aspects of their life activities. Such interactive effects should
be considered in the assessment of whether activity reduction is sub-stantial.
Evidence of cognitive fatiguing should be sought in the history and
may be evident during the clinical interview. Over the duration of the
interview the patient’s responses may become slower and less coherent.
The patient may begin to have difficulty with choosing the correct
words, recalling information, or become confused. Occasionally asking
more than one question at a time may make the fatiguing more evident.
However these changes may be quite subtle, as patients have often
learned to compensate for cognitive fatigue with hyper-concentration,
and have often developed strategies for taking cognitive micro-rests
such as changing the subject, taking postural breaks, reducing sensory
stimulation, etc. They may be quite unaware of these strategies.
Post-Exertional Malaise and/or Fatigue
The malaise that follows exertion is difficult to describe but is often
reported to be similar to the generalized pain, discomfort and fatigue as-sociated
with the acute phase of influenza. Delayed malaise and fatigue
may be associated with signs of immune activation: sore throat, lymph
glandular tenderness and/or swelling, general malaise, increased pain or
cognitive fog. Fatigue immediately following activity may also be asso-ciated
with these signs of immune activation. Patients who develop
ME/CFS often lose the natural antidepressant effect of exercise, feeling
worse after exercise rather than better. Patients may have a drop in body
temperature with exercise. Thus fatigue is correlated with other symp-toms,
often in a sequence that is unique to each patient. After relatively
normal physical or intellectual exertion, a patient may take an inordi-nate
amount of time to regain her/his pre-exertion level of function and
competence. For example, a patient who has bought a few groceries
may be too exhausted to unpack them until the next day. The reactive
fatigue of post-exertional malaise or lack of endurance usually lasts 24
hours or more and is often associated with impairment of cognitive
functions. There is often delayed reactivity following exertion, with the
onset the next day, or even later. However, duration of symptoms also
varies with the context. For example, patients who have already modi-fied
their activities to better coincide with the activity level they can

handle without becoming overly fatigued will be expected to have a
shorter recovery period than those who do not pace themselves ade-quately.
Sleep Dysfunction
Sleep and other diurnal rhythm disturbances may include early, mid-dle
or late insomnia, with reversed or irregularly irregular insomnia,
hypersomnia, abnormal diurnal variation of energy levels, including re-versed
or chaotic diurnal rest and sleep rhythms. This results in lack of
tolerance for shift work/activity or time zone shifts when travelling.
Loss of the deeper phases of sleep is especially characteristic, with
frequent awakenings, and loss of restorative feelings in the morning.
Restless leg syndrome and periodic limb movement disorder often ac-company
sleep disturbance. A very small percentage of ME/CFS pa-tients
do not have sleep dysfunction, but do not fit any other disease
Sleep Study: It is important to rule out treatable sleep disorders such
as upper airway resistance syndrome, obstructive and central sleep
apnea and restless leg syndrome. Indications: the patient wakes up out
of breath, or there is great disturbance of the bed clothes, or a sleep part-ner
indicates that the patient snores and/or appears to stop breathing at
times and/or has significant movement of her/his legs while sleeping. If
poor sleep is a troublesome symptom, which does not improve with
medication and sleep hygiene, it may be appropriate to have the patient
assessed at a sleep clinic.
Pain is often generalized and ‘nonanatomical,’ i.e., not confined to
any expected structural or nerve root distribution. The pain occurs in
unexpected places at unexpected times. There are pains of many quali-ties:
sharp, shooting, burning and aching. Many patients have signifi-cant
new onset headaches of many types, including tension and pressure
headaches and migraines. There is often generalized myalgia and ex-cessive
widespread tenderness or pain that is usually perceived to origi-nate
in the muscles but is not limited to the classical FMS tender points.
Patients have a lowered pain threshold or “chronic, widespread allodynia”
with approximately 75% of ME/CFS patients exhibiting positive
FMS tender points. Pain may also spread from pressure on myo-fascial
trigger points (MTP). Arthralgia without joint swelling may be experienced but is not discriminatory for ME/CFS (45,47). A very
small percentage of ME/CFS patients do not have appreciable pain, but
do not fit any other disease criteria. ME/CFS should only be entertained
as a diagnosis for this group when otherwise classical features follow an
infectious illness, and where other diseases have been adequately ruled

Neurological/Cognitive Dysfunctions:<-sound all to familiar

The neurological/cognitive symptoms are more characteristically
variable than constant and often have a distinct fatiguing component to
them. Especially common are cognitive ‘fog’ or confusion, slowed in-formation
processing speed, trouble with word retrieval and speaking or
intermittent dyslexia, trouble with writing, reading, and mathematics,
and short-term memory consolidation. There may be ease of interfer-ence
from concomitant cognitive and physical activities, and sensory
stimulation. It is easy to lose track of things and/or many things are for-gotten:
names, numbers, sentences, conversations, appointments, ones’
own intentions and plans, where things are in the house, where one has
left the car, whether one has brought the car, where one is and where one
is going. The memory dysfunction tends to primarily affect short-term
memory. There are selective deficits in memory processing arising
against a background of relatively normal cognitive functioning in
ME/CFS patients. They experience more difficulty in recalling infor-mation
under conditions of greater semantic structure and contextual
cues, the opposite of what is found in controls and patients with other
sorts of CNS impairments. They also experience difficulty maintaining
attention in situations that cause them to divide their efforts, e.g., be-tween
auditory and visual channels.
Perceptual Disturbances: Less ability to make figure/ground distinc-tions,
loss of depth perception or inability to focus vision and attention.
One may lose portions of the visual field or one can only make sense of
a small portion of it at a time. There are dimensional disturbances in
timing which affect the ability to sequence actions and perceptions, and
cope with complex and fast paced changes such as shift work and jet
lag. Spatial instability and disorientation come in many varieties, with
gait tracking problems, loss of cognitive map and inaccurate body
boundaries–e.g., one bumps into the side of the doorway on trying to
go through it and/or walks off the sidewalk, where the ground feels un-stable.

Motor Disturbances:
Ataxia, muscle weakness and fasciculations,
loss of balance and clumsiness commonly occur. There may be an in-ability
to automatically ‘attune’ to the environment, as in accommodat-ing
footfall to irregular ground while walking and temporary loss of
basic habituated motor programs such as walking, brushing one’s teeth,
making the bed and/or dialing a telephone.
Overload phenomena affect sensory modalities where the patient
may be hypersensitive to light, sound, vibration, speed, odors, and/or
mixed sensory modalities. Patients may be unable to block out back-ground
noise sufficiently to focus on conversation. There is also cogni-tive/
informational overload–inability to multi-task, and trouble making
decisions. There is emotional overload from extraneous emotional
fields that unduly disturb the patient. There is motor overload–patients
may become clumsy as they fatigue, and stagger and stumble as they try
to walk, are not able to keep a straight line, as well as showing general-ized
and local weakness, and need to slow down their movements. All
of these overload disturbances may form symptom clusters characteris-tic
of the individual patient such as dizziness, numbness, tinnitus, nau-sea,
or shooting pain. These overload phenomena may precipitate a
‘crash’ where the patient experiences a temporary period of immobiliz-ing
physical and/or mental fatigue.
Autonomic Manifestations
Orthostatic intolerance is commonly seen in ME/CFS patients and
€ Neurally mediated hypotension (NMH): Involves disturbances in
the autonomic regulation of blood pressure and pulse. There is a
precipitous drop that would be greater than 20-25 mm of mercury
of systolic blood pressure upon standing, or standing motionless,
with significant accompanying symptoms including lightheaded-ness,
dizziness, visual changes, sometimes syncope, and a slow re-sponse
to verbal stimuli. The patient is weak and feels an urgency
to lie down.
€ Postural orthostatic tachycardia syndrome (POTS): Excessive ra-pidity
in the action of the heart (either an increase of over 30 beats
per minute or greater than 120 beats per minute during 10 minutes
of standing); and a fall in blood pressure, occurring upon standing.
Symptoms include lightheadedness, dizziness, nausea, fatigue,
tremor, irregular breathing, headaches, visual changes and sweat-ing.
Syncope can but usually does not occur.
€ Delayed postural hypotension: The drop in blood pressure occurs
many minutes (usually ten or more) after the patient stands rather
than upon standing.
Tilt Test: Further investigation by tilt test is indicated if there is a fall
in blood pressure and/or excessive rapidity of heart beat upon standing,
which improves when sitting or lying down. Patients often report that
they experience dizziness, feeling light-headed or ‘woozy’ upon stand-ing,
or feeling faint when they stand up or are standing motionless such
as in a store checkout line. Patients may exhibit pallor and mottling of
the extremities. These historical symptoms and signs are sufficient for
the initial diagnosis. As ME/CFS patients often have a delayed form of
orthostatic intolerance, taking the blood pressure after standing may not
be effective in diagnosis. Rather than having the patient stand for a pe-riod
of time where there is a risk of him/her falling, we recommend us-ing
the tilt test where the patient is strapped down. The tilt test involves
the patient lying horizontally on a table and then tilting the table upright
to a 60°-70° angle for approximately 45 minutes during which time
blood pressure and heart rate are monitored. It is recommended that
orthostatic intolerance be confirmed by tilt testing prior to prescribing
medication for it.
Palpitations with or without cardiac arrhythmias may be present.
Further investigation by 24-Hour Holter Monitor may be indicated if a
significant arrhythmia is suspected. Repetitively oscillating T-wave in-versions
and/or flat T-wave may be found. (Request to be informed of
this pattern as it may not be reported or subsumed under non-specific
T-wave changes by the interpreter.)
Other common symptoms related to ANS disturbances include breath-ing
dysregulation–holding the breath inappropriately, irregular breath-ing,
exertional dyspnea; intestinal irregularities and hypersensitivity to
pain–irritable bowel syndrome, diarrhea, constipation, alternating diar-rhea
and constipation, abdominal cramps; bloating, nausea and an-orexia.
Bladder dysfunction and pain sensitivity can manifest as urinary
frequency, dysuria, nocturia, and pain over the bladder region.
Neuroendocrine Manifestations
Loss of thermostatic stability may be experienced as altered body
temperature–usually subnormal and/or marked diurnal fluctuation. Having patients take their temperature a number of times a day for a few
days can confirm temperature fluctuation. It may be helpful to have pa-tients
note their asctivity prior to taking their temperature. Patients may
have alternating feelings of hot or cold, sometimes in unusual distribu-tion,
e.g., feet are often cold, fingers may be hot, or the right side may
feel hot while the left feels cold, or there may be localized feelings of
heat and flushing. Many patients are intolerant of extremes in weather
and experience worsening of symptoms. There are recurrent feeling of
feverishness and sweating episodes. There is often a marked weight
change–a reduction in some patients with loss of appetite or anorexia
and a weight gain in others and an appetite that is inappropriate to their
activity level.
Dysfunction of the autonomic system and hypothalamic/pituitary/
adrenal axis: bodymind ‘crashing’ may lead to a general loss of adapta-tion
to situations of overload. Excessive speed in the overloading situa-tion
or attempted response will aggravate these ‘crashes.’ Anxiety
states and panic attacks may also be part of the syndrome and coherent
with the other symptoms. They may not be tied to environmental events
that trigger them, or they may be secondary to the symptoms. When
‘crashing,’ the patient becomes destabilized and disoriented, and thus is
naturally frightened. Anxiety and panic may also appear without any
external trigger. Patients with ME/CFS have worsening of their symp-toms
under increased stress, and with excess physical and mental activ-ity.
They also show slow recovery.
Immune Dysfunctions
Some but not all patients exhibit symptoms coming from immune
system activation, which may or may not be in response to an appropri-ate
stimulus. For many patients this type of symptom is prominent at the
acute onset stage and then diminishes or becomes recurrent as the ill-ness
becomes chronic. There is often general malaise–flu like feelings
of being ‘ill’ and feeling feverish. Tender lymphadenopathy in the cer-vical,
axillary inguinal or other regions may be present. The patient may
have a recurrent sore throat with or without faucial injection. Such clini-cal
evidence of immune system activation may occur in the absence of
demonstrable viral exposure and/or be associated with inappropriate
events such as physical exercise and stress. New sensitivities to food,
medications and/or various chemicals are common. Patients with an
acute viral onset tend to show more immune dysfunction compared to
those whose onset is gradual.-Faucial injection and crimson crescents may be seen in the tonsillar
fossae of many patients but are not diagnostically specific. These red
crescents are demarcated along the margins of both anterior pharyngeal
pillars. They will assume a posterior position in the oropharynx in pa-tients
without tonsils. Oscillating or diminished pupillary accommoda-tion
responses with retention of reaction to light is also common.
Cervical and axillary lymph adenopathy, often tender, may be felt. Posi-tive
fibromyalgia tender points and myofascial trigger points are com-mon.
Neurological dysfunction is often seen, including hypersensitivity
to vibration sense, positive Romberg test and abnormal tandem gait.
Simple mental status measures are often normal, but abnormal fatiguing
on serial seven subtraction testing is common. Mutual aggravation
when tandem gait and serial sevens are done simultaneously, may be
evident when the baseline serial sevens test and tandem gait are both
normal. As more of these signs are elicited in the same patient, the diag-nosis
of ME/CFS is increasingly confirmed.
There are selective deficits in memory processing arising against a
background of relatively normal cognitive functioning in ME/CFS pa-tients.
The results of neurocognitive testing will depend on the focus of
the test as well as many variables including the test, the milieu, sched-ule,
pacing and duration of the test. A well controlled study (50) showed
patients significantly overestimated their memory (meta memory), their
performance on recall tests significantly worsened as the context in-creased
(e.g., recognition), they made more errors when rehearsal was
prevented, and had delayed mental scanning as memory load increased.
Neuropsychological testing is expensive and the cost is rarely covered
by provincial health plans.
Features of ME/CFS in Children
Children can be diagnosed with ME/CFS if symptoms last more than
three months. They tend to have numerous symptoms of similar overall
severity but their hierarchy of symptom severity may vary from day to
day. Severe, generalized pain is a common feature. Children may
become dyslexic, tearful, physically weak, and exhibit exhaustion or
profound mood changes. Previously active children may shun physical
activity and academic standings deteriorate. They tend to do worse in
mathematics and analytical subjects such as science. They are often
classified as having school phobia.
  • € Musculoskeletal System: myalgia, muscle weakness, arthralgia
    € CNS: cognitive fatigue, fatigue and post exertional exacerba-tion,
    neurocognitive complaints, headaches, and sleep distur-bances
    € ANS & Cardiorespiratory System: symptoms suggestive of
    orthostatic intolerance, neurally mediated hypotension, postural
    orthostatic tachycardia syndrome, delayed postural hypotension,
    palpitations, respiratory disturbances, vertigo, light-headedness,
    extreme pallor
    € ANS & GI & GU System: intestinal or bladder disturbances
    with or without irritable bowel syndrome or bladder dysfunc-tion
    € Neuroendocrine System: loss of thermostatic stability, heat/
    cold intolerance, abnormal appetite, marked weight change,
    loss of sleep rhythm, loss of adaptability and tolerance for
    stress and slow recovery, emotional lability
    € Immune System: tender lymph nodes, sore throat, recurrent
    flu-like symptoms, general malaise
"The VALUE national hysterectomy study: description of the patients and their surgery"
M.J.A. Maresh


"37,298 cases were reported which is estimated to reflect about 45% of hysterectomies performed during the period studied. The median age was 45 years, and the most common indication for surgery was dysfunctional uterine bleeding (46%). Most hysterectomies were carried out by consultants (55%). The proportions of women having abdominal, vaginal or laparoscopically-assisted hysterectomy were 67%, 30% and 3%, respectively. Forty-three percent of women had no ovaries conserved after surgery. The median length of stay was five days. The overall operative complication rate was 3.5%, and highest for the laparoscopic techniques. The overall post-operative complication rate was 9%. One percent of these was regarded as severe, with the highest rate for severe in the laparoscopic group (2%). There
were no operative deaths; 14 deaths were reported within the six-week post-operative period: a crude mortality rate soon after surgery of 0.38 per thousand (95%)."
"Hysterectomy Rates in the United States: 1990-1997." February 2002. Obstetrics and Gynecology 99:229-234.
Cynthia M. Farquhar and Claudia A. Steiner
"Each year, 600,000 women in the United States have hysterectomies.
  • By the age of 60, nearly 1 in every 3 women will have had a hysterectomy in the United States.

    The rates of hysterectomy (how many hysterectomies per 100,000 women) are 3 to 4 times larger in the United States than in Australia, New Zealand, and most of Europe.

    The lowest rates are in Norway and Sweden.

    Each year, 40,000 women (6.6%) will find that hysterectomy failed to achieve the desired results.

    A small but significant percentage will have new problems.

    The average number of days spent in the hospital dropped by almost half from 1990 to 1997.

    The average age of the women for all kinds hovered in the early 40's.
Of the 598,929 hysterectomies performed in 1997
63% were abdominal
23% were vaginal
2% were subtotal
10% were LAVH (laparoscopically assisted vaginal hysterectomies)
2% were radical

Vaginal hysterectomies take less than an hour, hospital stays are about 2 days, there are fewer complications (compared to abdominal), it is cheaper, there are fewer infections, and there is a faster recovery time. Some conditions are better treated with LAVH or abdominal surgery. The rates of vaginal hysterectomy are lower in the U.S. than elsewhere. LAVH is relatively new and designed to shift some abdominal surgeries to the advantages of vaginal. Its use increased from 1990 to 1997 to 10% and abdominal hysterectomies dropped by 10%. The entirely laparoscopic surgery was not available in the period of this study. LAVH involves a shorter hospital stay, speedier postoperative recovery, and less use of pain killers--but there is a higher risk of bladder injury and the surgery itself lasts longer.

For fibroids, the method most used is abdominal -- 76%
For endometriosis, the method is abdominal--67% with LAVH at 17%
For menstrual disorders, the method is more evenly divided--55% abdominal, 29% vaginal, 14% LAVH
For prolapse, the method most used is vaginal--76%
For cancer, the surgeries were mostly abdominal--73%--but almost all radical hysterectomies are for cancer.
For pelvic inflammatory disease, the method most used is abdominal--77%
"Commonly, a lot of blood is lost during the operation, and many women require transfusion, especially if they were anaemic before surgery. There is a small risk of damage to other pelvic organs like the ureters, bladder and bowel during surgery. Immediately after the operation, most women will experience a lot of pain. In the postoperative period, wound infections, lung infections, and thromboembolism (blood clots to the lungs) are possible. While individuals vary, most women require weeks or months of rest and limited activities. About 20% of women report weight gain after a hysterectomy, which appears related to the reduction in activity in the recuperation period.
In the longer term, many women find they experience new symptoms, such as urinary problems, pelvic pain and menopausal symptoms. Vaginal prolapse, in which the top of the vagina sags down, is another possible long term complication.
Despite all of the above, many women are satisfied with their hysterectomies, and would go through it all again if they had to. Women who have a hysterectomy have often endured more severe and incapacitating symptoms than women who obtain relief through non-surgical means, and they have often waited years before deciding upon hysterectomy. However in other women, surgery does not solve their problems. It can be said that the outcomes of hysterectomy are mixed, as Table 2 shows:

Table 2:[list]
Possible complication:
Rates of complication:

Best Result
Rates of complication:

*Worst Result:*
Urinary problems
Decreased sexual function
Persistent pelvic pain

Figures from Dennerstein, Wood & Westmore (1995: 86-7)
Perhaps one of the hardest things to quantify is the extent to which women are affected psychologically and sexually by hysterectomy. Many women are distressed prior to the operation, and one study found that the rate of psychological problems reduced from 55% before to 32% after the operation. These authors concluded that they found no evidence that the operation led to psychological consequences. Ryan (1997) reports that the levels of psychological disorder before and after hysterectomy are higher than would be expected in a normal population in the samples this author studied. It has been suggested that psychological distress that is attributed to the operation may reflect psychological states that developed during the period of stress or ill health leading up to the surgery. In short, it’s impossible to generalise and say that hysterectomy either causes or relieves psychological distress. However, if you have gynaecological problems and you are contemplating or have had a hysterectomy, the sensible thing to do is address any concomitant psychological problems in an appropriate way, in addition to obtaining proper medical treatment. It’s well known that gynaecological problems and psychological distress are often interlinked, but not in any simple way. For example, while heavy or irregular periods are distressing, significant stress in a woman’s life can lead to disturbances in her menstrual cycle.
Additionally, any major surgery is a stressful life event, and its impact upon a person’s wellbeing should not be underestimated.

As mentioned above, it is now recommended that the ovaries of pre-menopausal women having a hysterectomy are preserved. However, even when a woman’s ovaries are left intact, up to a third of pre-menopausal women who have a hysterectomy will experience ovarian failure as a direct consequence of the surgery. In other words, their ovaries will stop producing the hormones oestrogen and progesterone, and the woman will experience symptoms of an early menopause. These may include hot flushes, vaginal dryness, bladder irritability, tiredness and lack of energy. Women who have an early menopause are at a higher risk of osteoporosis and heart disease as they age. Studies show that women aged between 45 and 55 years who have had a hysterectomy are more likely to be on hormone therapy, as Table 3 shows:

Table 3
  • Hysterectomy - ovaries removed
    50% on hormone therapy
    Hysterectomy - ovaries spared
    30% on hormone therapy
    No hysterectomy

Figures from Dennerstein, Wood & Westmore (1995: 92)

A common fear is that hysterectomy will impact upon a women’s ability to enjoy sex. Once again, studies of these consequences report mixed results. While between 7 and 20% of women report that hysterectomy had an adverse effect on their sexual function and enjoyment, equal numbers report a positive effect, and about 50% of women report no significant change. On the positive side, women after hysterectomy needn’t worry about pregnancy or contraception, and hopefully will have been relieved of the distressing symptoms that may well interfere with sexual enjoyment.
On the negative side, it appears the uterus is important to some women’s sexual pleasure while scar tissue in the vagina or deep in the pelvis may result in pain during sex. Removal of the ovaries, even in post-menopausal women, may result in lowered testosterone levels and subsequent reduction in a woman’s libido (sexual drive), and hysterectomy may result in an early menopause, even when the ovaries are left intact. Menopausal symptoms such a vaginal dryness can reduce women’s pleasure in sex, but this can be remedied with oestrogen vaginal creams, or hormone therapy.
Thanks to Trish for the Surgical statistics

How is fibromyalgia diagnosed?

There is no blood or x-ray test to help the doctor determine whether someone has fibromyalgia. Therefore, the diagnosis of fibromyalgia is made purely on clinical grounds based on the doctor's history and physical examination. In patients with widespread body pain, the diagnosis of fibromyalgia can be made by identifying point tenderness areas (typically, patients will have at least 11 of the 18 classic tender points), by finding no accompanying tissue swelling or inflammation, and by excluding other medical conditions that can mimic fibromyalgia. Many medical conditions can cause pain in different areas of the body, mimicking fibromyalgia. These conditions include:
  • low thyroid hormone level (hypothyroidism)
    parathyroid disease (causing elevated blood calcium level)
    muscle diseases causing muscle pain (such as polymyositis)
    bone diseases causing bone pain (such as Paget's disease)
    elevated blood calcium (hypercalcemia)
    infectious diseases (such as hepatitis, Epstein Barr virus, AIDS)
    cancer Even though there is no blood test for fibromyalgia, blood tests are important to exclude other medical conditions. Therefore, thyroid hormone and calcium blood levels are obtained to exclude hypercalcemia, hyperparathyroidism and hypothyroidism. The blood alkaline phosphatase (a bone enzyme) level is often raised in patients with Paget's disease of the bone. The CPK (a muscle enzyme) level is often elevated in patients with polymyositis, a disease with diffuse muscle inflammation. Therefore, obtaining alkaline phosphatase and CPK blood levels can help the doctor decide whether Paget's disease and polymyositis are the causes of bone and muscle pains. A complete blood count (CBC), and liver tests help in the diagnosis of hepatitis and other infections.

Fibromyalgia can occur alone, or in association with other systemic rheumatic conditions. Systemic rheumatic conditions refer to diseases that can cause inflammation and damage to numerous different tissues and organs in the body. Systemic rheumatic conditions associated with fibromyalgia include systemic lupus, rheumatoid arthritis, polymyositis, and polymyalgia rheumatica. Blood tests which are helpful in evaluating these diseases include erythrocyte sedimentation rate (ESR), serum protein electrophoresis (SPEP), antinuclear antibody (ANA), and rheumatoid factor (RF). In patients with fibromyalgia without associated systemic illnesses, the ESR, SPEP, ANA, and RF blood tests are usually normal.

Questions for your Dr concerning this DX:

1. What is my diagnosis and how can I learn more about it?_

2. Does my type of arthritis condition only affect the joints or are there other areas of my body that can be involved? Can my eyes, heart, lungs, brain, or kidneys be affected? How?_

3. What is the likely course of this form of arthritis? What is the long-term outlook?_

4. What are my treatment options? What are the risks of not treating at all?_

5. If my symptoms worsen, what should I do on my own? When should I contact you?_

6. How and when should I exercise?_

7. What are the local support groups or foundations that are available to me? (note: Arthritis Foundation, [email protected]

8. I have certain special concerns (for example; offspring, alternative medicines, surgery, special diets, relatives with tragic outcomes with similar diseases or medications, etc.). How do these particular issues relate to my situation and how do you feel about them?_

9. Are my children likely to be affected by this illness? If so, how can I best help them?_

10. While I take the medications that you currently recommend, how should we monitor for possible side effects (for example; examination, blood pressure check, lab testing)?

MedicineNet Reminder: Establishing an accurate diagnosis is kkey to proper treatments. You are the most important person in this process by accurately describing to your doctor the character, location, duration, and time of onset of your symptoms. You should also inform your doctor about vitamins, herbs, and medications you are taking. For example, long-term use of certain vitamins and non-prescription medications may be the cause of your abnormal liver tests; magnesium-containing antacids and supplements may be causing your diarrhea; certain blood pressure pills can be the reason for your constipation.

Abdominal or Pelvic Pain Occurring Monthly:

Diagnosis of chronic fatigue syndrome(CFS):

**Relationship of Hysterectomy to Chronic Fatigue and Fibromyalgia Syndromes:

Adhesion causes:

Chronic Pain Info & Organizations:

Medical history and physical exam for systemic lupus erythematosus (SLE):

Fatigue Takes a Special Toll on Women:

Self-Discovery Through Journaling:

*Daniel J. Clauw, M.D. - Effective Treatment of Fibromyalgia:

The Role of Vitamin A Deficiency in Autoimmune Diseases:

Pelvic and Abdominal Pain and Endometriosis:

Hysterectomy and Surgery:

Does Endometriosis Always Cause Pain?

Muscle Pain Presenting as Pelvic Pain:

Chronic Fatigue Syndrome (CFS) :
Summary of the underlying philosophy for revising the case definition:
The 1988 chronic fatigue syndrome working case definition (Holmes, et al) did not effectively distinguish CFS from other types of unexplained fatigue. For this reason, it was decided during a 1993 meeting of CFS investigators to develop a logical revision of that definition. The core of the revised CFS case definition is a set of uniformly applicable guidelines for the clinical and research evaluation of CFS and the other forms of fatigue. In the revised definition, a consensus viewpoint from many of the leading CFS researchers and clinicians (including input from patient group representatives), chronic fatigue syndrome is treated as a subset of chronic fatigue, a broader category defined as unexplained fatigue of greater than or equal to six month's duration. Chronic fatigue in turn, is treated as a subset of prolonged fatigue, which is defined as fatigue lasting one or more months. The expectation is that scientists will devise epidemiologic studies of populations with prolonged fatigue and chronic fatigue, and search within those populations for illness patterns consistent with CFS.

Guidelines for the evaluation and study of CFS:
A thorough medical history, physical examination, mental status examination, and laboratory tests (diagram) must be conducted to identify underlying or contributing conditions that require treatment. Diagnosis or classification cannot be made without such an evaluation. Clinically evaluated, unexplained chronic fatigue cases can be classified as chronic fatigue syndrome if the patient meets both the following criteria: 1. Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. 2. The concurrent occurrence of four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. These symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue. Conditions that exclude a diagnosis of CFS 1. Any active medical condition that may explain the presence of chronic fatigue, such as untreated hypothyroidism, sleep apnea and narcolepsy, and iatrogenic conditions such as side effects of medication. 2. Some diagnosable illnesses may relapse or may not have completely resolved during treatment. If the persistence of such a condition could explain the presence of chronic fatigue, and if it cannot be clearly established that the original condition has completely resolved with treatment, then such patients should not be classified as having CFS. Examples of illnesses that can present such a picture include some types of malignancies and chronic cases of hepatitis B or C virus infection. 3. Any past or current diagnosis of a major depressive disorder with psychotic or melancholic features; bipolar affective disorders; schizophrenia of any subtype; delusional disorders of any subtype; dementias of any subtype; anorexia nervosa; or bulemia nervosa. 4. Alcohol or other substance abuse, occurring within 2 years of the onset of chronic fatigue and any time afterwards. 5. Severe obesity as defined by a body mass index [body mass index = weight in kilograms ÷ (height in meters)2] equal to or greater than 45. [Note: body mass index values vary considerably among different age groups and populations. No "normal" or "average" range of values can be suggested in a fashion that is meaningful. The range of 45 or greater was selected because it clearly falls within the range of severe obesity.] Any unexplained abnormality detected on examination or other testing that strongly suggests an exclusionary condition must be resolved before attempting further classification. Conditions that do not exclude a diagnosis of chronic fatigue syndrome: 1. Any condition defined primarily by symptoms that cannot be confirmed by diagnostic laboratory tests, including fibromyalgia, anxiety disorders, somatoform disorders, nonpsychotic or melancholic depression, neurasthenia, and multiple chemical sensitivity disorder. 2. Any condition under specific treatment sufficient to alleviate all symptoms related to that condition and for which the adequacy of treatment has been documented. Such conditions include hypothyroidism for which the adequacy of replacement hormone has been verified by normal thyroid-stimulating hormone levels, or asthma in which the adequacy of treatment has been determined by pulmonary function and other testing. 3. Any condition, such as Lyme disease or syphillis, that was treated with definitive therapy before development of chronic symptoms. 4. Any isolated and unexplained physical examination finding, or laboratory or imaging test abnormality that is insufficient to strongly suggest the existence of an exclusionary condition. Such conditions include an elevated antinuclear antibody titer that is inadequate, without additional laboratory or clinical evidence, to strongly support a diagnosis of a discrete connective tissue disorder. A note on the use of laboratory tests in the diagnosis of CFS:A minimum battery of laboratory screening tests should be performed. Routinely performing other screening tests for all patients has no known value. However, further tests may be indicated on an individual basis to confirm or exclude another diagnosis, such as multiple sclerosis. In these cases, additional tests should be done according to accepted clinical standards. The use of tests to diagnose CFS (as opposed to excluding other diagnostic possibilities) should be done only in the setting of protocol-based research. The fact that such tests are investigational and do not aid in diagnosis or management should be explained to the patient. In clinical practice, no tests can be recommended for the specific purpose of diagnosing chronic fatigue syndrome. Tests should be directed toward confirming or excluding other possible clinical conditions. Examples of specific tests that do not confirm or exclude the diagnosis of chronic fatigue syndrome include serologic tests for Epstein-Barr virus, enteroviruses, retroviruses, human herpesvirus 6, and Candida albicans; tests of immunologic function, including cell population and function studies; and imaging studies, including magnetic resonance imaging scans and radionuclide scans (such as single-photon emission computed tomography and positron emission tomography).
Pain and pain relief in FM patients followed for three years:

Pain and pain relief in fibromyalgia patients followed
for three years.
Arthritis Rheum 2001 Aug;45(4):355-61
Poyhia R, Da Costa D, Fitzcharles MA.
McGill-MGH Pain Centre, McGill University, Montreal,
Quebec, Canada.
PMID: 11501723

OBJECTIVE: To examine the natural clinical course of
pain in fibromyalgia (FM) and patients' reports of the
use of interventions for pain relief.

METHODS: This prospective 3-year study examined pain,
and the treatment thereof, in a cohort of 82 women
with FM, of whom 59 (72%) were reassessed on 3
subsequent occasions. Pain was measured by the
following parameters: visual analog scale (VASpain),
tender point count (TP), and the occurrence of
widespread pain (WP). Function was assessed by the
Health Assessment Questionnaire and the Fibromyalgia
Impact Questionnaire, and depression and anxiety by
the Arthritis Impact Measurement Scales. All
treatments for FM were recorded, and patients
identified the treatment that they believed had helped
their symptoms of FM.

RESULTS: Pain reporting as measured by all parameters
decreased significantly for the whole group over the
duration of the study. The mean VASpain decreased from
66 to 55, the mean TP count decreased from 13.5 to
10.5, and the number of patients with WP decreased
from 100% to 63%. VASpain correlated positively with
TP and WP. One third of patients experienced a
reduction in pain by at least 30% from baseline as
well as a better outcome in overall status of FM.
There was a decline in the use of prescribed
medications, whereas the use of alternative products
increased. Physical treatment modalities were more
often perceived to be of benefit than prescribed

CONCLUSION: We have observed a spontaneous improvement
in pain reporting and less medication use in FM
patients, suggesting that the course of this condition
may be more favorable than has previously been
Traumatic Events, Health Outcomes, and Health Care Use in Patients with Fibromyalgia:

Journal: J of Musculoskeletal Pain, Vol. 9(2) 2001, pp. 19-38
Objectives: Fibromyalgia syndrome [FMS] is a chronic condition that is
resistant to treatment and has no known cause. However, researchers have
hypothesized a number of possible antecedents, including traumatic
events. The present study examined the relationship between the
occurrence and perceived severity of different traumatic events, health
outcomes, and health care use in patients with FMS.

Methods: Participants were 600 members [95% females, 85% Caucasian, mean
age =54] of a health maintenance organization who met the American
College of Rheumatology criteria for FMS. A self-administered
questionnaire was used to assess a patient's trauma history. The
dependent variables included health status, sleep, pain, depression, and
health care utilization.

Results: Ninety-one percent of the participants reported experiencing at
least one traumatic event prior to the onset of FMS symptoms. The average
number of events experienced was 3.6 [SD = 2.3] and, using a 10-point
scale, the average severity rating was 7.5 [SD = 2.4]. Analyses
demonstrated modest support for a relationship between the recall of past
traumatic events, their perceived severity, and several outcomes.

Conclusions: While the effect sizes of the relationships between trauma
and outcomes were small, results suggest that prospective studies
including an examination of the occurrence and perceived severity of
traumatic events may provide useful information about the etiology of

Fibromyalgia syndrome [FMS] is a chronic condition that is resistant to
treatment and has no known cause. While the most prominent feature of FMS
is widespread muscular pain, other symptoms include fatigue, sleep
disturbances, morning stiffness, headaches, depression, and irritable
bowel syndrome. Because there are no agreed-upon biological markers
for FMS, a diagnosis relies on a patient's report of widespread chronic
pain, a tender point examination, and ruling out diseases with similar

While studies of FMS and its correlates have increased recently, there is
continuing uncertainty about the causes and consequences of FMS.
Researchers have hypothesized sleep deficits, neurotransmitter
imbalances, muscle fiber irregularities, and psychological problems as
plausible causal mechanisms. It has also been suggested that trauma
may precede the onset of symptoms.

"Stress" and "trauma" are sometimes used interchangeably [or together as
in stressful trauma or traumatic stress]. Considerable research on stress
includes life events that are positive [such as marriage or the start of
a new job], but in this paper we restrict our examination to events that
are perceived as extremely negative [e.g., physical injury, sexual abuse]
and significant.

The association between traumatic events and poor health outcomes, such
as chronic pain, is consistent with the theoretical framework suggesting
that exposure to stress precedes adverse health outcomes. Catastrophic
stress, such as that associated with post traumatic stress disorder
[PTSD], is related to poor subjective health status, increased health
care utilization, morbidity, and mortality. Early work investigating
the stress-illness relationship had a biochemical focus, emphasizing
adrenomedullary and adrenocortical responses to stress. This
research laid the groundwork that has implicated prolonged and repeated
secretion of catecholamines and corticoids in the development of
illnesses like cardiovascular disease, hypertension, and various other
immune-related deficiencies.

Later work involved the psychological, or cognitive, component of the
stress response. This work recognized the critical role of the
person's cognitive appraisal of an event in determining its effects. The
acknowledgment that people respond differently to similar stressors gave
birth to a literature investigating coping mechanisms. Personality
variables, like optimism, negativity, hardiness, and efficacy have all
been implicated in the management of stressful events. Such coping
strategies affect the social and behavioral aspects of disease [i.e.,
social support, pain behaviors, etc.], as well as the consequent
physiological response to stress.
An example of the relationship between traumatic events and health is
found in the abuse literature. Sexual and physical abuse have been linked
to poor physical and psychological outcomes. A history of sexual and/or
physical abuse is pervasive among women suffering from chronic pain;
women with a past history of sexual abuse report more sleep disorders and
chronic pain with no identifiable cause, greater use of medical
services, and poorer perceptions of their health, than nonabused controls.
While the prevalence of abuse varies widely among studies, the
rates reported with chronic pain patients are higher than those typically
reported among healthy controls.

Research conducted specifically within the FMS population has revealed a
higher reported incidence of physical and sexual abuse among FMS
sufferers than controls. For example, one study found a higher prevalence
of lifetime sexual or physical abuse in a sample of FMS patients than in
a sample of rheumatic disease controls: 17% versus 6% and 18% versus 4%,
respectively. However, the rates for any prior abuse were much
higher: 53% for FMS versus 42% for controls. Similarly, Walker and
colleagues compared FMS patients with rheumatoid arthritis [RA] patients
and reported rates of sexual or physical assault to be 92% for the FMS
sample versus 67% for the RA sample. Taylor and colleagues report
rates of sexual abuse for FMS to be 65% compared to 52% for healthy
controls. Thus, different definitions of abuse and the way it is
assessed produce considerable variability in the estimates of rates, but
women with FMS tend to have a greater prevalence of abuse than controls.

Other less studied events have also been related to poorer physical and
psychological outcomes. For example, involvement in motor vehicle
accidents is associated with both PTSD and major depression.
Investigations of physical trauma among FMS patients have revealed that
physical injury, such as that resulting from motor vehicle accidents or
surgeries, was related to loss of employment, receiving long-term
disability, and a decrease in physical activity. Some studies
suggest that physical trauma is a precipitating event in the development
of FMS. For example, in a sample of patients who had recently experienced
a neck injury [primarily whiplash], 21.6% were later diagnosed with FMS;
none of the patients had a chronic pain syndrome prior to the trauma.
Greenfield and colleagues reported that 23% of FMS sufferers
experienced a physical trauma prior to the onset of FMS symptoms,
while Turk and colleagues found that 47% of their FMS sample reported
surgery [9.8%], illness [6.6%] or injury as a result of an accident [30%]
as precipitating events.

Not only are there higher prevalence rates of past abuse among FMS
patients, as well as an established association between physical trauma
and FMS, but also there is also evidence that the occurrence of such
events is strongly related to various outcomes for this population. For
example, a study comparing women with FMS to those with RA indicated that
total maltreatment scores and trauma severity were significantly related
to both psychiatric distress and functional impairment outcomes, but only
for the women with FMS. In another study of women with FMS,
emotional trauma was related to more physician visits, functional
disability ratings, and fatigue, while physical trauma was related to the
receipt of disability compensation. Thus, research has produced
evidence that sexual and physical abuse, as well as other physical
traumas, is associated with FMS.

Establishing relationships between trauma and outcomes is the first step
in understanding the mechanisms connecting the variables. The specific
aim of the present study was to examine the relationship between the
occurrence and severity of specific traumatic events and several health
outcomes: health status, sleep, pain, depression, and health care
utilization, among FMS patients.

Past research led us to hypothesize that the occurrence and perceived
severity of traumatic events would significantly predict health outcomes
within the FMS population. Specifically, physical traumas were
hypothesized to have consistent significant relationships with physical
and psychological health outcomes.
Pain Coping Strategies and Quality of Life in Women with FMS:
Objectives: To characterize and compare the demographics, symptom
profiles, pain coping strategies, and quality of life in three age groups
of women with fibromyalgia [FMS].

Methods: Self-report questionnaires. including the Fibromyalgia Impact
Questionnaire [FIQ], Beck Depression Inventory, Coping Strategies
Questionnaire, and Quality of Life Scale, were filled out by 343
consecutive women who were participating in FMS treatment programs.
Patients were divided into three age groups for purposes of data

The youngest age group had their symptoms for a significantly
shorter period of time than the middle age and older age groups. Tender
point pain score, the FIQ physical functioning and well-being items, and
perceived ability to decrease pain were significantly worse for the
youngest age group when compared to the other two groups. The youngest
group had significantly higher catastrophizing scores and lower quality
of life than the oldest age group. Discriminant function analysis between
the youngest and oldest groups revealed that a combination of six
variables: length of symptoms, quality of life, tender point pain score,
morning tiredness, behavioral activity strategies, and a pain
control/rational thinking factor were 84% accurate in classifying these
patients into their original groups. When length of symptoms was
excluded, the remaining five variables were 79%, accurate in classifying
the patients.


Young women with FMS perceive the severity of FMS to be
higher and respond with more distress than older women with FMS. This
finding is largely independent of symptom length.


Coping with chronic illness is a life-long task that cuts across
developmental stages. For women with fibromyalgia [FMS], these stages may
range from childhood to old age. Fibromyalgia is known to affect children
and adolescents as well as adults ; however, the average age at
onset is about 45-48 years. Thus, much of the research to date has
focused on women in midlife. Nevertheless, many women in their 20's and
30's are diagnosed with FMS at the same time that they are taking on the
roles and responsibilities of work, marriage, and parenthood.

Most younger as well as middle-aged women with FMS worry that their
symptoms will become worse as they grow older. The general belief among
many clinicians is that symptom severity is enduring and less amenable to
treatment the longer symptoms have been present. To date, this belief has
not been subjected to scientific scrutiny in FMS clinical groups.
Although symptoms tend to remain persistent for many patients with FMS, two studies have found that a majority of women with FMS rate
their symptoms as decreased in intensity from when they were first
diagnosed. Another report, which compared elderly women with FMS to
younger FMS patients, found that symptoms of anxiety as well as symptom
aggravation by weather, mental stress, and poor sleep were significantly
less common among the elderly women. Additionally, a 4.5 year
follow-up study of FMS patients given a 14 week course of treatment found
that increasing age predicted lower levels of pain and lack of energy.
Whether these findings represent changes in the symptoms
themselves, changes in coping with symptoms, adaptation to life
circumstances, or simply faulty memory is largely unknown. In any case,
one thing is clear, longitudinal studies to date have failed to confirm
any pattern of worsening with age.

The possibility exists that FMS may be at its highest intensity in the
early years after diagnosis. Getting through the period of uncertainty,
learning about the illness and its treatment, coming to terms with having
a chronic problem, and establishing new patterns of living are stressful
tasks to accomplish at any time in life. When these tasks are
coupled with the heavily task-oriented work of young adulthood, one might
expect that symptom severity and distress would be unusually high and
that satisfaction with one's quality of life might be lower. If this
is the case, more attention should be paid to developing strategies that
assist young women with FMS to better cope with symptoms and decrease
them to manageable levels so that they can concentrate more fully on the
developmental tasks of young adulthood.

Earlier we reported the use of coping strategies by a group of women who
entered and a subsample that completed an FMS treatment program. The use of positive coping strategies was found to be associated with positive
outcomes. Depression and negative beliefs, such as catastrophizing, were
significantly related to more symptoms and decreased quality of life.
In this paper we extend the work to a larger cohort of patients
from two sites. Specifically, we report the results of analyses designed
to answer the question of whether a set of demographic and role
variables, FMS symptoms, depression, perceived control, coping
strategies, and quality of life assessment could distinguish younger from
older patients with FMS.
Unread 05-11-2003, 07:59 PM
period like cramps, can it be this cystocele?

vbjacks: I've never had a MRI... but the stiff necks have been a problem right from childhood... maybe I'll mention it to my doctor when I next see here and ask for a MRI

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