Fibromyalgia Update:


Subject: Bowel Dysbiosis and hypothyroid function should be ruled out in all cases of fibromyalgia.



There is a link between fibromyalgia and bowel dysbiosis. Dysbiosis is an esoteric sounding term used to describe atypical or harmful microbiological populations of bacteria or yeast living in the large intestine. There are vast populations of organisms living within the body; the common estimate is that only 10% of the cells in the body are human. The other 90% are mostly bacteria in the colon. Typically the relationship is symbiotic; neither the host nor the bacteria are harmed and both derive benefit. This relationship is not always benign. There are many species of bacteria and yeast which are not considered beneficial and which may cause the host, that's you, harm. Some are outright pathogens, causing disease; others are not so destructive but over the long term weaken the host. Current research points to various bacterial populations in the gut as being the stimulus which triggers certain auto-immune diseases.


Fibromyalgia was first described in the medical literature in 1843 as a type of rheumatism “with painful hard places.” There has been considerable debate over the years whether such a disease even existed. In the last decade rheumatologists have accepted fibromyalgia as a disease and given it an insurance number (CPT 729.1). Diagnosis has not changed much in a century and a half: there is no lab test; the physician still looks for painful hard places. Finding tenderness on palpation of at least 11 of 18 specific sites in the absence of any other disease to explain the tenderness is the current method of diagnosis.


Many ideas have been proposed to explain and treat fibromyalgia. Many have shown initial promise but proven useful in only a fraction of disease sufferers. At this point the consensus seems to be that there is rarely a single explanation. Some sort of trigger or combination of triggers precipitates the onset of symptoms. Stress, trauma, nutrient deficiencies and infections are all possible triggers. These triggers trip some general regulatory mechanism, some people propose the hypothalamus, which precipitates a global change in many different functions. It is common in fibromyalgia patients to also see changes in endocrine, sleep and immune function along with the chronic pain.


  The best treatment results have been achieved, not by focusing on a single treatment, but on combining a series of treatments if they are indicated. We have been following a protocol for several years first suggested in 2001 in the Journal of Chronic Fatigue Syndrome by Jacob Teitelbaum. Dr. Teitelbaum and his colleagues treated 72 patients with fibromyalgia syndrome, 34 with placebo treatments and 38 with active treatments. Of the actively treated patients, 16 were rated as much better with treatment, 14 as better and 2 the same and 1 worse. Having 30 of 38 patients improve with treatment is rare in the annals of fibromyalgia research.


  Teitelbaum's protocol involves testing and treating as indicated by lab tests or symptom surveys the following conditions:

  1. Nutrient deficiencies: Magnesium Iron, Vitamin B-12 especially.
  2. Endocrine deficiency: Thyroid, gonadal and adrenal insufficiency.
  3. Disordered sleep
  4. Opportunistic infections: especially bowel and intestinal.


It is this last category, opportunistic infections that I have become intrigued with.


  For years we have known that fibromyalgia was one possible symptom of Candida overgrowth in the intestines. Teitelbaum tested stool samples from all of his patients for Candida and treated those with positive findings. If the stool exam showed higher than normal fungal growth levels or the patient presented with symptoms suggesting fungal overgrowth, they were treated with Nystatin or in severe cases Itraconazole. If pathogenic bacteria or parasites were isolated from the stool sample, the patients were treated with Flagyl or other antibiotics.


  Now this is where it gets interesting. Of the 38 patients actively treated in Teitelbaum's study, 35 were put on Nystatin, 27 on Itraconazole and 14 on Flagyl or other antibiotics. It looks like almost all of the patients had fungal overgrowth, and almost half had either a parasitic or bacterial infection. Many patients had both.


  I bring this up because of a new study. In March 2004, Mark Pimentel, MD reported on his work with fibromyalgia and Irritable Bowel Syndrome (IBS). Dr. Pimentel subjected his patients to a Lactulose Breath Test (LBT) which measures abnormal bacterial growth in the intestines. He examined 42 patients with fibromyalgia and 111 with Irritable Bowel Syndrome. All of the fibromyalgia patients and 84% of the IBS patients had abnormal LBT results. Just 20% of healthy control subjects had abnormal LBT results. The severity of fibromyalgia symptoms correlated closely with the LBT results. Dr. Pimentel's next step will be to see what happens when he normalizes the LBT results in these patients. In order to do so he will no doubt prescribe, Nystatin, Itraconazole, Flagyl and other antibiotics. In other words, follow Teitelbaum's protocol.


Both these studies suggest that abnormal bowel flora is ubiquitous in fibromyalgia but they do not tell us if it is a cause of the disease or just another symptom. Remember that both low endocrine function and poor immune function are common with fibromyalgia. Bowel infections may simply be the result of a compromised immune system. Nevertheless treating bowel infections and especially yeast and even more so Candida infections have certainly been therapeutic in many individuals.


Readers of William Crook's books, especially the Yeast Connection will recognize that fatigue, sleep disturbances, depression and other symptoms of fibromyalgia are all associated with Candida.


On the other hand readers of Broda Barnes's book, Hypothyroidism: the unsuspected illness will recognize this same set of symptoms as common for individuals with low thyroid function. Teitelbaum used tight diagnostic criteria: anyone with a TSH over 2.5 was treated for hypothyroidism. Of the 38 patients treated in his study, 33 were prescribed thyroid hormone supplements.


  John Lowe in his text, The Metabolic Treatment of Fibromyalgia , argues that the primary treatment of fibromyalgia should be thyroid hormone replacement, often at doses well above physiologic norms. Our experience is that people do respond to his treatment.


  There are many considerations in treating people with fibromyalgia but ruling out and treating bowel dysbiosis and low thyroid function should be part of any work up. Our preferred method is to rule out dysbiosis using a stool sample submitted to either Great Smokies Diagnostic Lab or Doctor's Data. Both labs run a microbiology study on stool samples and determine if abnormal levels of fungus or bacteria are present. Both will run drug sensitivity tests for any pathogens which they find. This may allow the use of natural products rather than antibiotics or prescription antifungals to treat the infections.

  To rule out low thyroid function we start by measuring Thyroid Stimulating Hormone (TSH) levels. Although some say that this test will not catch all cases of hypothyroidism, it is a good place to start: easy to obtain, inexpensive and accepted.


  There are so many other considerations regarding the treatment of fibromyalgia that I have not touched on in this article that this is clearly only Part 1. No discussion of fibromyalgia is complete without also discussing magnesium, malic acid, Vitamin B-12, adrenal function, disordered sleep and the particular personality types prone to suffer from this disease.


Text of Jacob Teitelbaum's Study which appeared in the Journal of Chronic Fatigue:  The most important part is in the appendix and lists his treatment protocols:[click here]


The Reuter's Article that inspired this letter:

Breath Test Links Muscle And Bowel Conditions
Reuters Health

Monday, March 29, 2004
NEW YORK (Reuters Health) - A test for microbes in the intestine, known
as the lactulose breath test (LBT), may provide a link between
fibromyalgia and irritable bowel syndrome (IBS), new research suggests.
Fibromyalgia is a painful muscle condition and IBS is an intestinal
disorder associated with pain, bloating, and diarrhea. Dr. Mark Pimentel
from Cedars-Sinai Medical Center , Los Angeles , California and colleagues
note that nearly a third of fibromyalgia patients in some studies are
also diagnosed with IBS, suggesting a link between the two disorders.

The researchers tested their hypothesis that the LBT would be abnormal
in both IBS and fibromyalgia by performing the test in 42 fibromyalgia
patients, 111 IBS patients, and 15 healthy subjects. The findings are
reported in the Annals of the Rheumatic Diseases.

All 42 patients with fibromyalgia had an abnormal LBT result, as did 93
(84 percent) of IBS patients but only three (20 percent) of the
controls. Moreover, the amount of hydrogen gas produced during the LBT
seemed to correlate with the degree of pain in fibromyalgia patients.
"The additional finding in our study that the degree of pain in
fibromyalgia seems to correlate with the degree of hydrogen suggests a
possible link between the LBT findings and" increased pain, the
investigators write. "This study suggests that an abnormal LBT may be a
common link between subjects with fibromyalgia and IBS," the authors
conclude. "Further study is needed to determine if treatment and
normalization of the breath test with antibiotic treatment can produce
an improvement in fibromyalgia in addition
to bowel complaints." SOURCE: Annals of the Rheumatic Diseases, April



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