Information for Ob./Gyn. Health Professionals

©Devin Starlanyl, MD 1995-1998

You have seen patients with fibromyalgia and myofascial pain syndrome, and will see more. They are both very real medical conditions, and both very different, although often confused. They may be the answer to some of your "challenging" patients.

Fibromyalgia is a systemic neuroendocrine condition with, among other things, a disrupted adrenal-hypothalamus-pituitary axis. It is nonprogressive (although it may seem so), nondegenerative, and noninflammatory. It is responsible for diffuse body-wide pain, tender points that hurt but don't refer pain, and sleep disturbances.

Chronic myofascial pain syndrome (MPS) is a musculoskeletal chronic pain syndrome. It is nonprogressive (although it may seem so), nondegenerative and noninflammatory. It is composed of many Trigger Points (TrPs), which refer pain and other symptoms in very precise, specific patterns. It seems progressive because each TrP can develop satellite and secondary TrPs, which can form secondaries and satellites of their own. With treatment of the TrPs and underlying perpetuating factors, however, these TrPs can be "reversed" and minimized or eliminated. It is not unusual, however, for pregnancy or even dysmenorrhea to activate TrPs.

When occurring together, what I call the "FMS&MPS Complex" forms. This is a condition of interconnected symptom spirals that get increasingly worse until the spiral is interrupted. For example, the pain causes muscle contraction which causes more pain which causes more contraction, etc. The patient can sometimes have muscles that are like cement, due to myofascial splinting.

Two excellent medical texts are available on MPS, "Myofascial Pain and Dysfunction: The Trigger Point Manual Vol. I and II" by Janet G. Travell M.D. and David G Simons M.D. The second volume is important to you, as it deals with lower body TrPs, but there are some TrPs at the end of the first volume that are also important. The manuals show the referred patterns, tell what causes them, and how to relieve them.

• Pregnancy: Stretches and other physical therapy to promote myofascial elasticity are important during this time, as well as extra vitamins. Benedryl is a remedy for sleep suitable in pregnancy. Unfortunately, for some of us, it causes insomnia. Many of us have the alpha-delta sleep anomaly and get little restorative sleep. Disruption of delta sleep may be tied to hormone dysregulation. Many of us also have nutritional problems, due to a malabsorption condition in the GI tract.
  
  
• Myofascial Overgrowth: People with FMS&MPS Complex have a tendency to form cysts, fibroids, heavy scarring and adhesions. Even our cuticles and pierced earring holes overgrow. This is something to keep in mind when surgery is contemplated. Some surgeons do Trigger Point injections during surgery in the area around the surgical site.
  
  
• Hysterectomies: Many FMS&MPS Complex patients have had hysterectomies to relieve pain. Often just the uterus is removed, but in many cases the ovaries are taken out later to relieve hormonal swings and ovarian pain which refers to the groin and legs.
  
  
• Hysterectomies: Many FMS&MPS Complex patients have had hysterectomies to relieve pain. Often just the uterus is removed, but in many cases the ovaries are taken out later to relieve hormonal swings and ovarian pain which refers to the groin and legs.
  
  
• Menstrual Problems: FMS is a pain amplification syndrome. Some of our touch receptors have changed to pain receptors. Your patient really hurts. During menses, it is not unusual for the patient to be able to feel what area of the uterus is sloughing off. It is like being skinned alive on the inside, every month. Menstrual problems such as severe cramping, delayed periods, irregular periods, long periods with a great deal of bleeding, membranous flow, late periods, missed periods and passing blood clots are common in FMS&MPS Complex. Part of these problems can be caused by coccygeus, ilocostalis, rectus abdominis, pyramidalis, and other pelvic and low back TrPs. There is also a high TrP in the adductor magnus which refers a diffuse pain/soreness throughout the pelvic area, and can mimic PID. There are also the thick secretions to be dealt with, and a lot of hormone problems (neurotransmitters again). Even some multifidi refer pain to the abdominal area.
  
  Since 50% of the children of people with FMS&MPS Complex also develop the condition (there is an inherited tendency towards FMS), female children of parents with FMS&MPS Complex should be monitored carefully during their first menses. If severe dysmenorrhea occurs, the patient should be checked out for signs of FMS&MPS Complex.
  
  I have found that if patients use tennis-ball acupressure (it hurts, but it is flushing out the TrPs), there will be less constriction in the abdominal area, and less bloating. It is especially important to work the line where the leg joins the trunk. They can do this by lying on the floor and placing the tennis ball between them and the floor. If the area is extremely sore, the TrP is there. There can be nerve entrapment by TrPs as well, leading to neuropraxia. If there is nerve involvement, ice will often help ease the pain. If the pain is muscular alone, the patient will find heat more comforting.
  
  
• Vaginal Discharge: Vaginal discharge, sometimes with itch, is common. So is mittelschmerz. This pain, as in menstrual pain, often triggers the adductor longus and iliopsoas TrPs. These TrPs can respond to galvanic muscle stim, sine-wave ultrasound with electrostim, spray and stretch, and craniosacral release.
  
  
• Yeast Problems: Frequent yeast infections, an itch on the roof of the mouth after eating tangy cheese, and bloating after drinking beer can be some signs that your patient has a yeast problem. Many people with FMS&MPS Complex have reactive hypoglycemia. The "Zone" diet for this works well. I also find that allergy shots for molds are very helpful.
  
  
• Hyper-sensitivity: Hyper-sensitive nipples and/or breast pain is commonly due to pectoralis TrPs. Many of us have latent pectorals and sternalis points. "Doorway stretches" help these points.
  
  
• Medication Reactions: Many FMS&MPS Complex patient have unusual reactions to medications due to altered metabolism. Sometimes just a small portion of a normal medication dose will have very strong effects. Other times we can take whopping doses of a medication and feel no effects at all.
  
  
• Thick Secretions: A lot of us have thick secretions. Guaifenesin ends this problem, and the way it thins secretions may be part of why it is so effective in "reversing" the effects of FMS. I've heard that it has been used to help promote conception.
  
  
• Pendulous Abdomen: Active TrPs in the abdominal muscles, especially in the rectus abdominus, may cause a lax, pendulous abdomen with gas. Your patient can't pull in their gut because the TrPs inhibit contraction. A fat pad forms over the abdomen. That fat pad is hard to get rid of, due to the TrPs. The first thing to do is to find and eliminate the back muscle TrPs that refer pain to the abdomen. These can cause burning, fullness, bloating, and swelling. Only then can you hope to eliminate the belly TrPs.
  
  
• Pain with Intercourse: this is often due vaginal TrPs and pelvic floor TrPs. For aching discomfort and cramps during coitus, check abdominal and low back TrPs. For sharp pain, check piriformis TrP with pudendal nerve entrapment. Vulvar vestibulitis, vulvodynia, hyperesthesia, and general pelvic muscle aches are also common. Progesterone will affect the levels of serotonin, and serotonin levels may vary from day to day as the amount of delta sleep varies. Expect mood swings and difficulties with neurotransmitter fluctuation, and hormonal irregularities. Piriformis TrP nerve entrapment can also be the cause of sharp pain during pelvic exams. Other area TrPs can cause pain and muscle spasms during vaginal and rectal exams.

Fibromyalgia Support - Ottawa West
S.C. Alder
Mar/99