As we start this fibromyalgia casestudy, please do not throw away the medicines prescribed by your GP or consultant if they are working for you. As you hopefully improve you can discuss tapering and eventually discontinuing the medicines in cooperation with your prescribing doctor
Fibromyalgia Casestudy: A typical enough case history
The Patient and her symptoms
A 45-year-old female who has fibromyalgia with a history of hypothyroidism, is on Eltroxin, has low baseline energy which dips even more accompanied by sugar cravings for a week before her period. Energy is very poor during the period itself, and she is also experiencing very heavy menstrual bleeding which has been investigated and uterine fibroids. Energy recovers to its normal poor baseline on about the sixth-day of her cycle but the fibromyalgia goes on for all of the month but is definitely worse in the week preceding her menstrual period. This lady also suffers from vaginal dryness, cognitive issues (aka ‘brain fog’) , abdominal bloating, constipation and vaginal candidiasis/thrush. Libido has been low for some time and she finds her mood is very low during winter –she has a problem from when the clocks go back at the end of October until the beginning of April.
The patient consultation process in fibromyalgia
A detailed patient history is the first priority.
During the first patient visit it should become obvious what the most important diagnostic leads to follow up on are.
Appropriate laboratory testing is then organised to either rule in or rule out the various diagnostic possibilities.
How to ‘think’ about fibromyalgia using a functional medical model
This lady is a typical enough example. Having assessed the medical history I then will decide how to investigate
Part of the thinking process in the first visit would include:
Checking oestrogen progesterone FSH and LH hormone levels during the menstrual period ( usually during days 2 to 5 )and also checking the oestrogen and progesterone later in the cycle probably around days 18 to 21. I will also look at, as well as general bloods, DHEA level, testosterone and free testosterone.
Standard laboratory tests for magnesium are meaningless because the majority of magnesium is within cells (intracellular) so measuring magnesium within the serum or plasma is a waste of time. Thankfully the patient’s symptoms of low magnesium are usually very obvious which is a great help diagnostically.
I also would be very concerned as to whether or not this lady has enough stomach acid and digestive enzymes to absorb minerals like magnesium and zinc and to maintain a normal microbiome /gut bacterial balance.
I will look at free thyroid hormone 3 (tri-iodo-thyronine) and three as well as free thyroid hormone 4(free thyroxine).
It would be important to consider whether or not to investigate urinary mycotoxins i.e. get the urine tested for toxins made by fungi which may be an indication that there is an overgrowth of fungi.
If there are urinary mycotoxins present then, at some stage, but probably further down the road, it may be important to consider whether mercury leeching from dental amalgam is playing a negative role.
It may also be important to consider testing for a methylation abnormality or elevated free copper. There usually will be useful pointers in the medical history
Then let’s imagine that cortisol levels are very high showing a high level of stress on the adrenal glands.
In the real world it is not always possible nor is it cost-effective to investigate everything at once. One tries to pick out the action areas which will likely make the biggest contribution to the patient’s health.
The priorities in treatment
The second patient visit is devoted to three things: Review of initial symptoms and medical history to make sure nothing was missed at the first visit. By this stage all the results of laboratory investigations will be available and these need to be integrated with the clinical findings from history and examination. This process then leads to the organisation of an initial treatment plan:
So let us suppose that is now the second consultation and we have our blood results and other tests back which will help us in decision-making.
In my opinion it is still worthwhile to test basics like vitamin B12 level all over again because, sometimes, an individual has a long-term illness. Although the basic investigations are often done in the beginning , say, perhaps five years on from the initial diagnosis, basic lab tests like B12 level may have been forgotten about and B12 may have, unbeknownst to all, slipped down to a low level
From history it sounds like this lady’s oestrogen levels have dropped but we also know she is having heavy periods (she probably is having anovulatory cycles and not producing adequate amount of progesterone) so giving her more oestrogen without balancing it with progesterone would be incorrect. Thus she probably needs both oestrogen and progesterone supplementation – progesterone, by itself, would render our patient more tired, fuzzy-headed and more constipated and also likely make period heavier
Let’s suppose that on the thyroid testing we find that free T4 levels are up near the top of the range but that free T3 levels are at the low end of the range and the patient also feels quite cold a lot of the time with a slow pulse. Then I may suggest either strategies to improve conversion of T4 to T3 (T3 is biochemically significantly more potent than T4) or else we may try adding in a little bit of T3 supplementation.
Also important to remember that the half-life of T3 is much shorter than that of T4 so T3 – if it is being supplemented – will need to be dosed twice daily usually.
Let’s suppose that bicarbonate testing is suggestive of low stomach acid. So this will then need to be supplemented. Probably digestive enzymes will also need supplementation.
Magnesium and or zinc supplementation may be indicated from the medical history.
Because of the vaginal thrush we are suspicious that this lady has a reservoir of fungal overgrowth in her bowel. Hopefully supplementing with stomach acid and digestive enzymes and a probiotic will improve this without needing to use antifungal antibiotics. Hopefully also getting the fungus under control will reduce the level of inflammation in the body. Although official medicine states that fibromyalgia is not an inflammatory disease I consider it to be an inflammatory/autoimmune disorder.
If we have found an elevated free copper then this will also need to be treated.
We will hope that having supplemented stomach acid, provided good quality digestive enzymes and probiotics gastrointestinal function, will hopefully improve with the constipation going away and the gastrointestinal contribution to the ongoing inflammation which is at the root of the fibromyalgia, will also improve.
If this lady has been demonstrated to have a probable methylation abnormality then improving methylation chemistry will hopefully help with the sugar cravings and also improve or resolve the seasonal affective disorder component.
Some of the brain fog and the physical pain is possibly due to low oestrogen levels so hopefully the oestrogen supplementation will help resolve the tiredness before and during the period and also help significantly with the sore limbs.
Between all the above steps one would hope that this patient would have a significant improvement when reassessed in six weeks. Then, depending on response, the treatment would need modification.
The third patient visit takes place 6 to 8 weeks after the second patient visit and this visit focuses on : how well is the initial treatment plan working for the patient. If, as we hope, the treatment is working well, then we will need to judge what aspects of the treatment need to be improved. If the treatment is not making a difference, then what has been missed diagnostically?
At that six week stage the treatment will need to be adjusted and fine tuned .
If, after six weeks stage there is no significant improvement then all of the treatment would need to be seriously reviewed because, within a six weeks window, one would expect that any effective treatment given to a patient with fibromyalgia would have begun to bear some fruit – even if the response has not been dramatic there ought at least to have been some shift in how the patient is feeling e.g. even if the pain was still bad the patient might say “I’m sleeping better” or “I have more energy “ or their digestion or fatigue before their period has improved even though their baseline fatigue may remain the same. It’s then a matter of managing all the detail as one proceeds.