Most Common Thyroid Disease: Especially For Women With Fibromyalgia

A majority of my fibro and CFS patient's complain of low thyroid symptoms. They relate that they, and sometimes even their doctors, suspected a thyroid problem only to have their blood work come back "normal". Most physician's won't recommend thyroid replacement therapy if the blood tests come back "normal". Most don't know or choose not to accept the well-documented studies that show a low body temperature is indicative of low thyroid function and perhaps true hypothyroidism. 

And most doctors don’t realize that blood tests for low or hypothyroidism is notoriously inaccurate.

Do you have a number of these symptoms, associated with hypothyroidism- fatigue, headaches, dry skin, swelling, weight gain, cold hands and feet, poor memory, brain fog, hair loss, hoarseness, nervousness, low sex drive, brittle nails, constipation, poor immune function, chronic sinus infections, high cholesterol, high or low blood pressure, anxiety, depression, joint and or muscle pain, and burning or tingling sensations in the hands or feet? Reads like the symptoms of fibromyalgia and or CFS doesn’t it?

Ok, how many symptoms did you have? Several I imagine. So if you have most of the symptoms associated with hypothyroidism, why doesn’t your blood test show that you in fact do have hypothyroidism? Good question.

One major reason is that most doctors don’t do the complete tests to uncover hypothyroidism, especially when it comes to those with fibromyalgia and or CFS.

You may have a common autoimmune disease known as Hashimoto’s thyroiditis. It may be the most common thyroid disease, especially with women with fibromyalgia.

What is Hashimoto’s Thyroiditis - Hashimoto’s Thyroiditis is an autoimmune thyroid disease where the immune system immune system aggressively attacks your thyroid gland-attempting to destroy your gland as if it’s some dangerous enemy. It can cause nodules or lumps in the thyroid. However most of the time there is no physical change in the appearance of your thyroid.

It typically starts out silently, slowly, but soon enough inflammation, low thyroid function and gradual destruction of your thyroid gland begins-symptoms like fatigue, weight gain, or other symptoms associated with low thyroid function, become common. Unfortunately typical blood tests (TSH, T4 blood levels) won’t uncover this disease! Symptoms from thyroiditis can go on for years and years. Doctors may continue to suspect from all your symptoms you have hypothyroidism but since your blood work always comes back “normal,” you must just be depressed or lazy or….here take an antidepressant.

Year after year your doctor treats the symptoms of the uncovered Hashimoto’s disease with drug after drug-antidepressants for your depression, cholesterol medicine, high blood pressure medicine, stimulant drugs for your fatigue…it goes on and on. Why not treat the CAUSE of this symptoms-the Hashimoto’s?

What are the symptoms of Hashimoto’s thyroiditis? Again for most, the symptoms are silent–at least in the early stages. But eventually, you start to notice the same symptoms of hypothyroid, including poor stamina, easy fatigue, feeling cold, gaining weight, dry hair and skin, constipation, etc.

There are special blood tests to uncover Hashimoto’s thyroiditis, which I routinely perform on ALL my patients-why would you want to miss such a valuable piece of information? If your fortunate enough to get a doctor who isn’t blindly following the herd, and does actually have some “smarts” and runs special thyroid tests to uncover Hashimoto’s, they’ll typically take a wait and see approach to a positive test.

This ridiculous! “Miss Jones you have the beginnings of Hashimoto’s thyroiditis but since we can’t treat it affectively with prescription drugs, or at least not until your thyroid has been destroyed from the Hashimoto’s disease.”

“Doctor, how will you know when my thyroid has been destroyed.”

“Your thyroid stimulating hormone (TSH) level will finally be elevated and we will then be able to prescribe a synthetic thyroid hormone like Synthroid or Levothyroxine, which you’ll need to stay on for the rest of your life.

Allowing the attack to continue on your thyroid until your TSH is elevated is crazy-not only last for years, but cause all sorts of problems along the way of its destruction, including years and years of poor health. Instead, why not just stop the attack and all the consequences?

Why because traditional medicine doesn’t have a drug to stop the attack. Fortunately there natural over the counter remedies and protocols that will in fact stop the destruction and correct the altered thyroid function.

Listen if you have symptoms similar to the ones discussed above do yourself a favor find a doctor who’ll do more than order the typical run of the mill tests. You know what I’m talking about, the same tests your doctors runs every year and then reports your labs look great it is just your fibromyalgia that is the problem.

The real problem is you’ve got a doctor or doctors who are content to do the same tests, ask the same questions, and prescribe the same recommendations, and you get worse every year. WHAT YOU NEED is a detective, a health professional who based on his or her experience knows that the only way to reverse a complicated illness like fibromyalgia is to order the uncommon tests (no one with fibromyalgia is common), ask the questions not asked, and pursue every health clue until you are know the TRUE cause of the symptoms-then start treating the CAUSE not the symptoms.

If you suspect you have Hashimoto’s thyroiditis or a low thyroid function and can’t get your doctor to help you then please consider taking the time to find a doctor who will listen to you and order the right tests.

I’ve been fortunate enough to have uncovered hundreds of missed Hashimoto’s thyroiditis cases and have helped spare these patients of years of misery. There are ways to correct Hashimoto’s thyroiditis short of letting your thyroid burn out and health become shattered.

I’ve helped thousands reverse their fibromyalgia and get their life back. Are you next?

Phone and in clinic new patient consults available 205-879-2383

Danger-These Drugs Are A Disaster For Your Health

Benzodiazepines

These medications are usually used as sleep and anti-anxiety medication, they include Xanax (alprazolam), Klonopin (clonazepam), Ativan (lorazepam), Restoril (temazepam), BuSpar (buspirone hydrochloride), Tranxene (clorazepate dipotassium), Serax (oxazepam),
Librium (chlordiazepoxide), Tegretol (carbamazepine), Valium (diazepam), Trileptal (oxcarbazepine), Seroquel (quetiapine), Risperdal (risperidone), and Symbyax (olanzapine and fluoxetine HCl).

Benzodiazepines are addictive, and patients build up a tolerance so that the drugs eventually lose effectiveness as a sleep aid. Addiction may occur in as little as two weeks.

The big problem with these medications, though, are the side effects, many of which mirror the symptoms of fibromyalgia and CFS. And they don’t promote deep, restorative sleep, so they are definitely not worth the risk.

Benzodiazepines depress the central nervous system and act on the neurotransmitter GABA (gamma-amino butyric acid). GABA acts as a calming chemical as it transmits messages from one cell to another. So directly or indirectly, these drugs influence almost every brain function and most other bodily systems, including those of the nervous, neuromuscular, endocrine, and gastrointestinal systems. It’s no wonder their side effects are so severe.

Benzodiazepines should be weaned off, starting as soon as possible. Be sure to work with a medical doctor as you wean off, and take it slow to avoid terrible withdrawal symptoms.

Potential side effects of benzodiazepines: Poor sleep; seizures; mania; depression and suicidal thoughts; tinnitus (ringing in the ears); transient amnesia; dizziness; agitation; disorientation; low blood pressure; nausea or vomiting; fluid retention; muscular incoordination and tremors; sexual dysfunction; prolonged drowsiness or a trance-like state; fatigue; headaches; body aches and pains; chills; runny nose; cough; congestion; difficulty breathing; feelings of discouragement, sadness, or emptiness; diarrhea; difficulty swallowing; vision and voice changes; and a host of others.

The crippling side effects and addictive nature of these drugs have been known for at least 40 years, yet doctors continue to prescribe them at an ever-increasing rate, especially for seniors. Surveys show that over 5.6 million adults over the age of 65 are now taking benzodiazepines. A mouth-dropping 50% of all women 60 and older will be prescribed a benzodiazepine drug.

And since addiction often occurs within four weeks of starting these drugs, the majority of these folks are now dependent on them.

Tolerance to the hypnotic (sleep) effects of these drugs may occur within one week. Symptoms of tolerance are identical to drug-withdrawal symptoms and may include anxiety, panic, severe insomnia, muscle pain and stiffness, depression, suicidal thoughts, rage, heart and lung problems, and agoraphobia (extreme fear of public or crowded spaces).

Tragically, only 10%–30% of people are able to successfully stop taking these drugs. The rest are addicted for life.

Please avoid these drugs if possible. Seek out alternatives, preferably over the counter natural amino acid therapy (5HTP, SAMe, L-Theanine, etc.) when facing anxiety disorder. For sleep related issues try over the counter 5HTP and or melatonin. You can read more about mood and sleep disorders at www.treatingandbeating.com

Traditional Medicine Offers Little for Fibromyalgia

With so many different symptoms, it’s no surprise that fibromyalgia and CFS patients are typically taking 6–12 different prescription drugs. Lyrica, Elavil, Klonopin, Paxil, Effexor, Xanax, Trazadone, Neurontin, Zanaflex, Ambien, Lunesta, Cymbalta,  and Provigil have all been heralded as “the drug” for fibromyalgia. 

Some of these are helpful, some worthless, and some really dangerous.

Drug management alone typically fails to yield lasting relief from the most common fibromyalgia and CFS symptoms, and patients’ and doctors’ optimism over a new drug treatment eventually gives way to this sad reality. Oh well, a new drug with an even larger marketing budget is on the horizon. (Forgive my cynicism. I’ve just seen this situation so many times!)

Many of the most commonly prescribed drugs for fibromyalgia have side effects that are similar or identical to the symptoms of FMS and CFS. These similarities can cause a lot of confusion when doctors are trying to determine the effectiveness of treatment. Ambien, for instance, can cause flu-like symptoms, achy muscle pain, sore throat, and fatigue. Sounds like CFS, doesn’t it?

Tranquilizers are often prescribed for restless leg syndrome; achy, tight muscles; and sleep problems. But these drugs deplete the sleep hormone melatonin, which then leads to a disruption of a person’s circadian rhythm (sleep-wake cycle). Instead of promoting deep restorative sleep, these drugs prevent it!

It’s important to realize that your drug or drugs may be causing or contributing to some or all of your symptoms. 

I spend a great deal of time with my new patients reviewing and discussing their current drugs—how they interact with each other, and the potential side effects. I often find that by asking the right question, I can help the patient realize that her symptoms began or worsened soon after the drug treatment began.

Sometimes, though, I do find drug-induced symptoms that began months after the start of the drug treatment. Drugs deplete essential nutrients that the body needs to properly function, but it can take weeks, months, or even years for the drug to fully deplete the nutrient and for you to see the side effects surface.

Still, not everyone can be drug free, and most of my patients are on at least one prescription medication. But the least offensive drug should be used—sparingly—and only to manage symptoms unresponsive to more natural therapies.

A study conducted by the Mayo Foundation for Medical Education and Research demonstrates the need the limitations of traditional medicine alone for treating fibromyalgia.

Thirty-nine patients with FMS were interviewed about their symptoms. Twenty-nine were interviewed again 10 years later. Of these 29 (mean age 55 at second interview), all had persistence of the same FMS symptoms. 

Moderate to severe pain or stiffness was reported in 55% of patients, moderate to a great deal of sleep difficulty was noted in 48%, and moderate to extreme fatigue was noted in 59%. These symptoms showed little change from earlier surveys. 

The surprising finding was that 79% of the patients were still taking medications to control symptoms. 

We can conclude that the medications weren’t making a significant impact.

Conventional medical treatments for FMS and CFS is a controversial topic, and I certainly have no desire to offend the many brilliant medical doctors out there. 

Still, in my experience, most traditional doctors continue to rely on prescription medications to treat fibromyalgia, even though their own studies show them to be ineffective and potentially dangerous. 

They still just don’t get it. Those with fibromyalgia and CFS are sick and they want to feel well, not drugged.

Just try to find a doctor who really knows anything about these illnesses. Most don’t. It’s even harder to find one who is having any lasting success treating these illnesses. How many folks with fibromyalgia get well under the care of a traditional rheumatologist? 

I rest my case.

I speak to fibromyalgia support groups across North America, and I can tell you what the answer is: very few. The three-month wait for a new patient appointment typically ends in a two-hour interview and exam followed by a 10 minute visit to discuss test results, and then several prescription drugs and a follow-up appointment every 3–6 months.

And let’s face it, those with fibromyalgia are medical misfits, they don’t usually respond to medications like other folks. The ACR has, like many physicians, thrown up their hands and admitted they have little if anything to offer for those suffering from fibromyalgia. They focus more on helping their patients “cope.” At least they’re honest about their limitations.

Treating and Beating Fibromyalgia

Note this is an abbreviated version of my feature article that appeared in the November issue of the medical journal "Townsend Letter for Doctors and Patients."

Fibromyalgia syndrome (FMS) is an illness characterized by diffuse muscle pain, poor sleep, and unrelenting fatigue.

Individuals with fibromyalgia may also experience headaches, anxiety, depression, poor memory, numbness and tingling in the extremities, cold hands and feet, irritable bowel syndrome, lowered immune function, and chemical sensitivities. Over 10 million Americans suffer with fibromyalgia; ninety percent of them are women between 25 and 45 years old. 1

Fibromyalgia is now thought to arise from a miscommunication between the nerve impulses of the central nervous system. The neurons, which supply the brain, become more excitable, exaggerating the pain sensation. This over-amplication of pain is referred to as "central sensitization". 19

Fibromyalgia patients have a reduction in their pain threshold (allodynia), an increased response to painful stimuli (hyperalgesia) and an increase in the duration of pain after nociceptor stimulation (persistent pain).

Individuals with fibromyalgia syndrome have low levels of serotonin, a 4-fold increase in nerve growth factor, and elevated levels of substance P.20 Nerve growth factor (NGF) is a member of a family of peptides known as the neurotrophins. The exposure of nociceptive sensory neurons to NGF leads to up-regulation of substance P in sensory neurons. 21

Substance P, the neuropeptide in spinal fluid, is a neurotransmitter that is released when axons are stimulated. Increased levels of substance P increase the sensitivity of nerves to pain or heighten awareness of pain. Although it’s not fully understood, fibromyalgia patients have an imbalance of the hypothalamus-pituitary-adrenal  (HPA) axis. This imbalance creates hormonal inconsistencies, which disrupt the body’s ability to maintain homeostasis.

Many of the most common fibromyalgia symptoms including widespread muscle pain, fatigue, poor sleep, gastrointestinal problems, and depression regularly occur in people with various neuroendocrine disorders, including those manifested by HPA dysfunction. 22

Researchers believe suppression of the HPA (quite likely from chronic stress), which results in lowering human growth hormone (HGH), dehydroepiandrosterone (DHEA), cortisol, and other hormones, is aggravated by the chronic pain and poor sleep associated with fibromyalgia. 23, 24

Hypothalamus-Pituitary-Adrenal Axis (HPA) Dysfunction 

The main function of the hypothalamus is homeostasis, or maintaining the body's status quo.

The hypothalamus receives and transmits messages from the nervous system and hormonally through the circulatory system. Because of its broad sphere of influence, the hypothalamus could be considered the body’s master computer. The hypothalamus receives continuous input about the state of the body, and must be able to initiate compensatory changes if anything drifts out of line.

The Hypothalamus regulates such bodily functions as:

1. Blood pressure- is often low in those with fibromyalgia.

2. Digestion- bloating, gas, indigestion, and reflux are common in FMS patients.

4. Circadian rhythms (sleep/wake cycle)- which is consistently disrupted in FMS.

6. Sex drive- loss of libido is a common complaint for FMS patients.

7. Body temperature-   is often low in FMS patients.

8. Balance and coordination- FMS patients have balance and coordination problems.

9. Heart rate- mitral valve prolapse (MVP) and heart arrhythmias are a common finding in FMS patients.

10. Sweating- it’s not unusual for FMS patients to experience excessive sweating.

11. Adrenal hormones- are consistently low in FMS patients.

12. Thyroid hormones and metabolism-hypothyroid is a common finding in FMS patients.

Recent studies show that over 43% of FMS patients have low thyroid function. It's estimated that those with FMS are 10 to 250,000 times more likely to suffer from thyroid dysfunction.25

Stress and Fibromyalgia

A survey by The Fibromyalgia Network reports that 62% of their respondents list physical or emotional stress as the initiating factor in their acquiring fibromyalgia. 32

I believe chronic stress is the underlying catalyst for the onset of HPA dysfunction and fibromyalgia. Several studies have demonstrated how chronic stress undermines the normal hypothalamic-pituitary-adrenal axis (HPA) function.33

When explaining the role of stress in fibromyalgia, I find the following analogy helps put stress and fibromyalgia into perspective.

“We are all born with a stress coping savings account. This account is filled with numerous chemicals we use to help us deal with daily stress-serotonin, norepinephrine, cortisol, magnesium, and other important hormones and nutrients. The more stress we encounter, the more stress coping chemicals we use. We replenish our stress coping savings account with adequate rest. Consistent deep restorative sleep ensures we are making more deposits than withdrawals from our stress coping account.

Since fibromyalgia patients struggle with getting a consistent good nights sleep they eventually bankrupt their stress coping account.

The Importance of a Good Night’s Sleep

Studies have shown that individuals who were prevented from going into deep sleep for a period of a week develop the same symptoms associated with FMS and CFS; diffuse pain, fatigue, depression, anxiety, irritability, stomach disturbances, and headaches. 34,35.

Sleep deprivation markedly increases inflammatory cytokines (pain causing chemicals)—by a whopping 40%. 36

Serotonin

Serotonin helps regulate sleep, digestion, pain, mood, and mental clarity.37

Serotonin helps:

1. Raise the pain threshold (have less pain), by blocking substance P.

2. You fall asleep and stay asleep through the night.

3. Regulate moods. “The happy hormone” reduces anxiety and reduces depression.

4. Reduce sugar cravings and over-eating.

5. Increase a person’s mental abilities.

6. Regulate normal gut motility (transportation of food-stuff) and reverse irritable bowel syndrome (IBS).

Surveys have shown that as many as 73% of FMS patients have irritable bowel syndrome.

You have more serotonin receptors in your intestinal tract than you do in your brain.

Emotionally stressful situations cause the body to release adrenaline, cortisol and insulin. These stress hormones stimulate the brain to secrete serotonin. Long term stress and poor dietary habits can deplete the body’s serotonin stores.38

Tryptophan, 5 Hydroxytryptophan  (5HTP) and Serotonin

Individuals with fibromyalgia have low levels of tryptophan38, serotonin39, and

5-HTP.40 Studies show that fibromyalgia patients have higher levels of metabolites in the kynurenine pathway, which diverts tryptophan away from serotonin production.41

Tryptophan is one of eight essential amino acids. Tryptophan is absorbed from the gut into the bloodstream and then dispersed throughout the body. Ninety percent of tryptophan is used for protein synthesis, one percent is converted to serotonin, and the balance is used to make niacin. In the formation of serotonin, tryptophan is hydroxylated to 5-hydroxy-tryptophan (5-HTP) by tryptophan hydroxylase.

5-HTP is converted to serotonin by the decarboxylase enzyme, which is vitamin B6 dependent.

Selective Serotonin Reuptake Inhibitor (SSRI) Medications

Prescription antidepressants can be helpful. However, antidepressant drugs have potential side effects including anxiety, depression, fatigue, decreased sex drive, and disruption of normal circadian rhythms.42

SSRI’s are supposed to help a patient hang onto and use their naturally occurring stores of the brain chemical serotonin. It’s like using a gasoline additive to help increase the efficiency of your cars fuel.

Most of the patients I see with fibromyalgia are running on fumes and a gasoline additive won’t help. 

Please keep in mind that several studies show that between 19-70% of those taking antidepressant medications do just as well by taking a placebo or sugar pill.43

I recommend my patients boost their serotonin levels by taking 5HTP.

5HTP and Depression

Studies (including double-blind) comparing SSRI and tricyclic antidepressants to 5HTP have consistently shown that 5HTP is as good if not better than prescription medications in treating mood disorders. Furthermore, 5HTP doesn’t have some of the more troubling side effects associated with prescription medications. 44, 45

5HTP and Sleep

5HTP has been shown to be beneficial in treating insomnia, especially in improving sleep quality by increasing REM sleep and increases the body’s production of melatonin by 200%. 46,47

5HTP and Fibromyalgia

Double-blind placebo-controlled trials have shown that patients with FMS were able to see the following benefits from taking 5HTP: 48.

• decreased pain.

• improved sleep.

• less tender points.

• less morning stiffness.

• less anxiety.

• improved moods in general, including in those with clinical depression. 49

• increased energy.

Irritable Bowel Syndrome, 5HTP and Serotonin

There are more serotonin receptors in the intestinal tract than there are in the brain. This is one reason people get butterflies in their stomach when they get nervous.50

Serotonin controls how fast or how slow food moves through the intestinal tract.51, 52

It’s common for the symptoms associated with IBS, diarrhea and constipation, to disappear within 1–2 weeks once serotonin levels are normalized with 5HTP replacement therapy.

My 5HTP and Sleep Restoration Protocol

I instruct my patients to take 50mg of 5HTP 30 minutes before bed on an empty stomach (90 minutes after or 30 minutes before eating), with 4 ounces of grape juice. I know 5HTP doesn’t have to compete with other amino acids to cross the blood brain barrier, but this routine seems to heighten the effect of 5HTP.

One of three things will happen when taking 5HTP.

1. The patient falls asleep within 30 minutes and sleeps through the night. If so, they stay on this dose until their next scheduled visit with me (typically 2 weeks).

2. Nothing happens. This is typical response to such a low dose. The patient should add an additional

50 mg. each night (up to a max of 300 mg.) until they fall asleep within 30 minutes and sleep through the night.

3. Instead of making the patient sleepy, the first dose makes them more alert. This occurs more often in CFS and chemical sensitivity patients who have a sluggish liver. If this happens, they’re to discontinue taking 5HTP at bedtime and instead take 50 mg. with food for 1–2 days. Taking 5HTP with food seems to help slow down it’s absorption, allowing the liver to process it more effectively. Taking 5HTP with food will not (usually) make a person sleepy. After 1-2 days on 5HTP with no further problems, they should increase to 100 mg. of 5HTP with each meal (300mg a day).

Can patients take 5HTP along with antidepressant medications?

Yes, patients can take 5HTP with antidepressant medications. I’ve treated thousands of patients with amino acid replacement therapy, 95% of which were already taking antidepressants when they come to see me. I’ve never had a patient report a problem with combing 5HTP with prescription drugs. It can happen, but I believe it to be rare.

Can patients take 5HTP with sleep medications?

Yes. I don’t recommend patients discontinue taking their sleep medications. Instead I suggest they start using 5HTP and increase the bedtime dose until they sleep through the night. At some point they should be able to work with their doctor and slowly wean off the prescription sleep medication. Remember all prescription sleep medications have side effects. No one has an Ambien deficiency, however, fibromyalgia patients certainly have 5HTP and serotonin deficiencies, which need to be corrected.

What if my patient is taking a prescription sleep medication and sleeping through the night?

Prescription drugs that promote deep restorative sleep include Ambien, Elavil, Trazadone, Flexeril, and Lunesta. These medications can be helpful. However, these medications have potential side effects that may cause the very symptoms associated with fibromyalgia. Ambien may cause short-term memory loss, fatigue, depression, and flu-like aches and pains.

Other common sleep inducing drugs, including benzodiazepines (Klonopin, Ativan, etc.), muscle relaxants (Zanaflex), Neurontin, and Lyrica don't promote deep delta wave sleep and therefore are not recommended. Remember the reason they’re taking these prescription drugs is because they have a serotonin (and perhaps a melatonin) deficiency, not a drug deficiency. You want them to build up their serotonin levels so that eventually they may not need prescription sleep medications. You should have them add 5HTP (50 mg.) three times daily with food. If no problems arise after 2–3 days, they should then increase to 100 mg. with each meal.

What if someone has a serotonin syndrome reaction?

A serotonin syndrome may occur if a person gets too much serotonin. This can cause rapid heartbeat, increased pulse rate, elevated blood pressure, agitation, and in its worst-case scenario, life threatening irregular heartbeats (arrhythmia).

I’ve recommended 5HTP to thousands of individuals over the last 7 years, rarely have I encountered a problem. I always start with a low dose (50 mg.) and warn the patient to stop taking it at bedtime if she has a funny reaction.

What are some of the other potential side effects of 5HTP?

Other than some patients becoming more alert when taking 5HTP at bedtime, I have had very few complaints from patients. The literature reports that individuals may have transient headaches and nausea from taking 5HTP. I have had less than half a dozen patients have one of these side effects. The headaches and any nausea usually go away after a couple of days.

What do you do when your patient still can’t fall asleep and sleep through the night even when taking 300mg of 5HTP?

If after two weeks, someone is not falling asleep and staying asleep through the night, I add melatonin. First, I make sure she is taking 5HTP as she should be and at the maximum dose of 300mg.

1. Nutrition reviews  52(7)p249 1994.

2. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: Arthritis Rheum 1990;33:160-72

3. Goldenberg D 1989 Fibromyalgia and its Relationship to CFS, Viral Illness and Immune Abnormalities. Journ of Rheum 16 (S19): 92)

4. Moldofsky H 1993 Fibromyalgia, sleep disorder and chronic fatigue syndrome. In: Bock G Whelan J (eds) CIBA Foundation Symposium 173. Wiley, Chichester, pp 262-279.

5. Russell IJ. Neurohormonal aspects of fibromyalgia syndrome. Rhum Dis Clin North Amer 1989;15:149-168.

6. Buskila D, Neumann L et al 1997 Increased rates of fibromyalgia following cervical spine injury. Arthritis and Rheumatism 40(3):446-452.

7. Moldofsky H 1993 Fibromyalgia, sleep disorder and chronic fatigue syndrome. CIBA Symposium 173, 1993, pp 262-279.

8. Anne Marit Mengshoel, Center for Rheumatic Diseases, The National Hospital, Akersbakken 27, N-0172 Oslo, Norway.

9. Fibromyalgia Network Newsletter October 1999p1-3.

10. Lowe J C, Garrison R L, Reichman A J, Yellin J, Thompson M, Kaufman D 1997a Effectiveness and Safety of T3 (triiothyroxine) therapy for euthyroid Fibromyalgia: a double-blind placebo-controlled response-driven crossover study. Clinical Bulletin of Myofascial Therapy 2(2/3):31-58.

11. Russell I, Vipraio G, Lopez Y et al 1993 Serum seorotonin in FMS and rheumatoid arthritis and healthy normal controls. Arthritis and Rheumatism 36(9):S2231

12. Jeffries W McK The present status of ACTH, cortisone, and related steroids in clinical medicine N Engl J Med 253:441-446;1955.

13.Selye H The general adaptation syndrome and diseases of adaptation J Clin Endocrinol Metab 6:117-230;1946.

14.Jeffries W McK. Safe Uses of Cortisone Charles C Thomas Publisher;1981.

15. Gerhard K. Endresen, Mycoplasma blood infection in chronic fatigue and fibromyalgia syndromes  2003. Rheumatology International 23(5):211-215.

16. Gail K. Adler, Neuroendocrine Abnormalities in†Fibromyalgia [abstract]Current Pain and Headache Reports 2002, 6:289-298

17. P.Koch-Sheras and A. Lemley, The Dream Sourcebook. Los Angeles: Loweel House.

18. Harding S. MD Sleep in Fibromyalgia Patients: Subjective and Objective Findings.

American Journal of the Medical Sciences. Fibromyalgia. 315(6):367-376, June 1998.

19. Staud R, Smitherman . 2002 Aug;6 Peripheral and central sensitization in fibromyalgia: pathogenetic role. Curr Pain Headache Rep. (4):259-66.

20. Russell IJ. Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum.1994 Nov;37(11):1593-601

21. Woolf CJ. Nerve growth factor contributes to the generation of inflammatory sensory hypersensitivity. Neuroscience 1994; 62:327–331.

22. Gail K. Adler, Neuroendocrine Abnormalities in Fibromyalgia. Current Pain and Headache Reports 2002, 6:289-298

23. Calis M, Gokce C, et al. Investigation of the hypothalamo-pituitary-adrenal axis (HPA) by 1 microg ACTH test and metyrapone test in patients with primary fibromyalgia syndrome. J Endocrinol Invest. 2004 Jan;27(1)42-6.

24. Okifuji A, Turk DC. Stress and psychophysiological dysregulation in patients with fibromyalgia syndrome. Appl Psychophysiol Biofeedback. 2002 Jun;27(2):129-41.

25. Lowe J C, Garrison R L, Reichman A J, Yellin J, Thompson M, Kaufman D 1997a Effectiveness and Safety of T3 (triiothyroxine) therapy for euthyroid Fibromyalgia: a double-blind placebo-controlled response-driven crossover study. Clinical Bulletin of Myofascial Therapy 2(2/3):31-58.

26. Rudman, D. Growth hormone, body composition, and aging, Journal of the American Geriatrics Society. 1985;33:800-7.

27. Lopez, J. F., et al. Serotonin 1a receptor mRNA regulation in the hippocampus after acute stress. Biological Psychiatry 45: 943-947.

28. Chalmers, D. T. et al. Molecular Aspects of the Stress Axis and Serotonergic Function in Depression. Clinical Neuroscience 1: 122-128. 1993.

29. M. Biondi, A. Picardi . Psychological Stress and Neuroendocrine Function in Humans: The Last Two Decades of Research. Psychotherapy and Psychosomatics 1999;68:114-150.

30. Wisniewski TL, Hilton CW, Morse EV, et al. The relationship of serum DHEA-S and cortisol levels to measures of immune function in human immunodeficiency virus-related illness. Am J Med Sci. 1993 Feb; 305(2):79-83.

31. Altamus M, Dale JK, Michelson D, Demetrick MA, Gold PW, Straus SE Abnormalities in response to vasopressin infusion in chronic fatigue syndrome. Psychoneuroendocrinology.2001 Feb; 26(2):175-88

32. Fibromyalgia Network Newsletter October 1999p1-3.

33. Mengshoel, A. Center for Rheumatic Diseases, The National Hospital, Akersbakken 27, N-0172 Oslo, Norway.

34. P.Koch-Sheras and A. Lemley, The Dream Sourcebook. Los Angeles: Loweel  House.

35. Harding, S. Sleep in Fibromyalgia Patients: Subjective and Objective Findings.

American Journal of the Medical Sciences. Fibromyalgia. 315(6):367-376, June 1998.

36. Andrea Alberti1, et al. Plasma cytokine levels in patients with obstructive sleep apnea syndrome: a preliminary study Journal of Sleep ResearchVolume 12 Issue 4 Page 305  - December 2003.

37. Russell IJ, Vaeroy H, Javors M, Nyberg F. Cerebrospinal fluid biogenic amine metabolites in fibromyalgia/fibrositis syndrome and rheumatoid arthritis. Arthritis Rheum 1992;35:550-556.

38. Winberg S, Overli O, Lepage O. Suppression of aggression in rainbow trout (Oncorhynchus mykiss) by dietary L-tryptophan. J Exp Biol. 2001 Nov;204(Pt 22):3867-76.

39. Karl G. Henriksson, MD, PhD. Is Fibromyalgia a Central Pain State? Source: Journal: J of Musculoskeletal Pain, Vol. 10, No. 1/2,2002, pp. 45-57.

40. Yunus MB, Dailey JW, Aldag JC, et al. Plasma tryptophan and other amino acids in primary fibromyalgia: a controlled study. J Rheumatol 1992;19:90-94.

41. Hrycaj P, Stratz T, Muller W. Platelet 3H-imipramine uptake receptor density and serum serotonin levels in patients with fibromyalgia/fibrositis syndrome. J Rheumatol 1993;20:1986-1988. [letter].

42. Russell IJ, Vipraio GA, Acworth I. Abnormalities in the central nervous system metabolism of tryptophan to 3-hydroxy kynurenine in fibromyalgia syndrome. Arthritis Rheum 1993;36:S222.

43. Russell IJ. Neurohormonal abnormal laboratory findings related to pain and fatigue in fibromyalgia. J Musculoskeletal Pain 1995;3:59-65.

44.Monthly Prescribing Reference Publication Nov 2005, New York NY

45. Joan-Ramone Laporte and Albert Figueras, “Placebo Effects in Psychiatry,” Lancet 334 (1993):1206-8.

46. Byerley WF; Judd LL; Reimherr FW; Grosser BI. 5-Hydroxytryptophan: a review of its antidepressant efficacy and adverse effects.
J Clin Psychopharmacol (HUD), 1987 Jun; 7 (3): 127-37

47. Birdsall T., “5-Hydroxytryptophhan: A Clically Effective Serotonin Precursor”  Altern Med Rev 1998;3(4):271-280.

48. Puttini PS; Caruso I Primary fibromyalgia syndrome and 5-hydroxy-
L-tryptophan: a 90-day open study. Rheumatology Unit, L Sacco Hospital, Milan, Italy.
J Int Med Res 1992 Apr;20(2):182-9

49. J. Angst, B. Woggon, and J. Schoepf, “The treatment of depression with L-5-hydroxytrptophan versus Imipramine: Results of two open and one double blind study, Archiv fur Psychiatrie und Nervenkrankheiten 224 (1997): 175-86.

50. Delvaux MM. Gastroenterology Unit and Laboratory of Digestive Motility, CHU Rangueil, Toulouse, France. Stress and visceral perception. Can J Gastroenterol 1999 Mar;13 Suppl

51. Goldberg PA, Kamm MA, Setti-Carraro P, van der Sijp JR, Roth C. Modification of visceral sensitivity and pain in irritable bowel syndrome by 5-HT3 antagonism (ondansetron). Digestion 1996 Nov-Dec;57(6): 478–83A:32A–36A.

52. Johanson JF. Options for patients with irritable bowel syndrome: contrasting traditional and novel serotonergic therapies. Neurogastroenterol Motil 16(6):701-11, 2004

53. Wehr T, et al. (2001). A circadian signal of change of season in patients with seasonal affective disorder. Archives of General Psychiatry, 58(12): 1108–1114

54. Waldhauser F et al. Sleep laboratory investigations on hypnotic properties of melatonin. Psycho Pharm 1990. 100: 222–6.

55. Dollins AB, Zhadanova IV, Wurtman RJ, Lynch HJ, Deng MH. Effect of inducing nocturnal serum melatonin concentrations in daytime on sleep, mood, body temperature, and performance. Proc Natl Acad Sci USA 1994;91: 1824–28.

56. Functional Assessment Resource Manual from Great Smokies Laboratory, 1999.

57. ibid.

58. ibid.

59. Citera G, Arias MA, Maldonado-Cocco JA, Lazaro MA, Rosemffet MG, Brusco LI, Scheines EJ, Cardinalli DP. The effect of melatonin in patients with fibromyalgia: a pilot study. Clin Rheumatol 19(1):9-13, 2000.