Chronic Fatigue and Fibromyalgia Syndromes and Hysterectomies

Frederick R. Jelovsek MD

" A lot of the members of [hysterectomy support groups] are complaining about joint pain, and FMS, either before and/or after their hysterectomy. I also noted when I was on an endo support group that there was a lot of fibromyalgia and CFS amongst the members. Is there a connection? ". Valerie

Fibromyalgia syndrome (FMS) and chronic fatigue syndrome (CFS) are both considered rheumatological diseases whose causes are not known. They can be similar in their presenting symptoms of muscle aches, pains and fatigue which are present in both syndromes. The conditions are overlapping and many women with one of the conditions also meet the diagnostic conditions of the other (1). Criteria have been developed for the diagnosis of fibromyalgia and although the criteria are mainly based on specific muscle or tendon points of pain, the syndrome also includes "aching all over, poor sleep, stiffness on waking, and being tired all day, headaches, memory and concentration problems, dizziness, numbness and tingling, itching, fluid retention, crampy abdominal or pelvic pain and diarrhea." With fibromyalgia, the fatigue and tiredness factor is based primarily on sleep deprivation.

Chronic fatigue syndrome may include muscle and joint pain, but it is characterized by overwhelming fatigue that is not related to exertion. Exertional physical activity can make it worse but the fatigue is present constantly. Diagnosis of chronic fatigue syndrome also includes symptoms of "substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headach

es of a new type, pattern, or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. "

Relationship Between Chronic Fatigue And Fibro

Is there a relationship of symptoms in chronic fatigue syndrome (CFS) and fibromyalgia syndrome (FMS) to the menstrual cycle?

With FMS, symptoms tend to get worse premenstrually (2). Oral contraceptives do not make symptoms worse but during the third trimester of pregnancy and the first 6 months of postpartum period, women with FMS will report worsening of pain symptoms. The condition itself, however, does not adversely affect pregnancy outcome.

Chronic fatigue syndrome has not been noted to fluctuate with the menstrual cycle phases except that PMS type of symptoms tend to be somewhat less (3).

Do women with chronic fatigue syndrome (CFS) and fibromyalgia syndrome (FMS) have more menstrual bleeding irregularities?

Women with chronic fatigue syndrome do have more menstrual cycle irregularity than do women without CFS (3). They report more irregular cycles, periods of no menses, and sporadic intermenstrual bleeding.

Fibromyalgia does not seem to produce bleeding or menstrual abnormalities.

Is there a relationship with these conditions and other hormones?

A common working hypothesis about the etiology of chronic fatigue syndrome is that it represents a depletion of or a low basic level of some of the hormones of the adrenal gland such as cortisol and dehydroepiandrosterone (DHEA). Blood hormone level measurements have not always been consistent but it appears there may be a lowering of cortisol and DHEA (4, 5, 6). Also it has been shown that the adrenal glands are physically smaller, perhaps by 50% in women with chronic fatigue syndrome (7). Treatment with low dose cortisol supplements have been shown to reduce some of the fatigue in the short run (8).

Just as with CFS, fibromyalgia has also been studied and thought to represent lowered secretion of adrenal hormones, especially DHEA (9). The problem with all of these studies of CFS and FMS is that the control groups used were not women with a chronic stress of some sort other than their health condition. The findings of lowered adrenal hormones in women with CFS and FMS are consistent with anyone who has a chronically stressful condition. Some investigators have noted that these findings may be more stress related than disease related (10). If this is true, then any menstrual abnormalities and lowered pain thresholds associated with stress are likely to be present in women with CFS and FMS.

How then is hysterectomy likely to be related to chronic fatigue and fibromyalgia syndrome?

We have made a case above for the concept that women with CFS or FMS have increased pelvic pain and menstrual bleeding abnormalities. They may well have a lowered pain threshold and coping skills with abnormal bleeding. It is certainly conceivable that women having these conditions are more likely to:

• seek medical care and see physicians
• receive medical diagnoses and treatments for them
• fail to respond to those treatments because the associated CFS or FMS is not cured or in remission
• seek hysterectomy as a treatment for pelvic pain or abnormal menstrual bleeding

What about after hysterectomy? Is a woman more likely to develop these conditions after she has had surgery? I could not find any evidence that hysterectomy alone caused such symptoms. We have to remember, however, that many woman undergoing hysterectomy are also undergoing menopause because their ovaries are being removed at the time of the hysterectomy.

While most women undergoing removal of the ovaries before natural menopause receive estrogen replacement, not all of them do. Additional women may be on estrogen replacement but not receiving a high enough dose or may not be absorbing the full dose they are receiving. Therefore, they may have some estrogen deficiency symptoms. While we think of menopause as mostly hot flashes, menopause causes other symptoms that can be mistaken for CFS or FMS. Fatigue, insomnia, bone and joint pains, paresthesias (areas of tingling or numbness), headaches and dizziness are also symptoms described by many menopausal women (11 , 12). You can see how some of these are the same and might result in an incorrect diagnosis of CFS or FMS when in fact, the main problem is estrogen deficiency.

When you were on the endometriosis board, pelvic pain is certainly a symptom of both fibromyalgia syndrome and endometriosis that you would have heard about. Women who had Lupron® treatment of endometriosis would also have had estrogen deficiency symptoms which have similarities to both CFS and FMS which may be why you made the association. I'm not aware of any other cause and effect relationship between endometriosis and these rheumatological conditions.

For more information on fibromyalgia symptoms and treatments, please visit http://www.fibromyalgia-symptoms.org.

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