Fibromyalgia---(once called "Fibrositis") was first described in 1843 as a type of rheumatism "with painful hard places." Afflicted patients were often labeled neurotic because of their many, unexplained symptoms. There are no diagnostic tests for fibromyalgia. The disease was renamed recently. Multiple research publications and descriptive efforts have been devoted to improve definition. Interested physicians must link patient complaints and physical findings for diagnosis and exclude mimicking diseases. 

Today, fibromyalgia is accepted as a distinct illness. Patients present with fatigue, insomnia, non-restorative sleep and generalized pain. Common symptoms include: irritability, nervousness, depression, impaired memory and concentration; headaches, dizziness, blurring of vision, eye irritation; sensations of heat, flushing or actual sweating; unexplained anxieties; sugar craving; nasal congestion, post-nasal drip; abnormal tastes, either foul or metallic; transient ringing or other sounds; numbness and tingling anywhere, but usually of the hands and feet; gas, bloating, constipation, often alternating with diarrhea ("irritable bowel syndrome" or "spastic colon"); burning on urination, pungent urine and frequent bladder infections, mainly in women; sometimes, vaginal irritation, discharge, pain especially with intercourse and increased menstrual cramping. Restless legs and cramps are frequent as are brittle nails, itching with or without various rashes. Symptoms are cyclic, initially followed by normal times but progressively worse, finally constant. 

The most prevalent areas of pain are: shoulder muscles or tendons, neck, between shoulder blades, lower back often with sciatica. The knees, inner and outer elbow regions, wrists, hips and chest are equally frequent sources of discomfort. However, other sites are so often involved, pain should be expected from any skeletal muscle, tendon, ligament or fascia. Morning, flu-like, generalized stiffness is common. Previously injured or operative sites are often affected. Though accidents and stress aggravate the condition, they do not cause it. We often observe joint involvement though current wisdom denies any such component. I believe fibromyalgia is the early phase of a complex disease leading to osteoarthritis. Damage to cartilage and arthritic spurs do not appear overnight. Years of pain and often, joint swelling occur before discernible X-ray changes. 

A familial, inherited pattern is obvious. A meticulous history reveals that the disease often begins at an earlier age than first suspected. Childhood cycles certainly exist and are manifested by headaches, "growing pains" and often, many of the above symptoms. Our youngest patients with fibromyalgia were four years old; one complained of significant pain by age two. 

Many fibromyalgics suffer primarily fatigue, emotional and cognitive defects and complain less of pain and other symptoms. This presentation is often labeled "chronic fatigue syndrome" and has been attributed to the Ebstein-Barr or other viruses. It is progressively recognized as merely a facet of the same disease with symptoms predominantly at one end of a spectrum. To us, "systemic candidiasis" and "myofascial pain syndrome" are merely synonyms for fibromyalgia. 

Over thirty-six years ago, a patient taking gout medication could easily strip tartar off his teeth with his fingernail. Dental calculus is a calcium phosphate deposit in the form we recognize as "apatite." It seemed probable a serum derived abnormality existed in saliva that allowed such deposition. Though well dispersed and remaining in solution, total body calcium and phosphate could attain excessive, critical levels. Cellular accumulation would interfere with energy formation and cause malfunction of susceptible systems. This would explain not only tenderness, tissue swelling and spasm we palpated but also the generalized complaints. I began using "gout drugs" for patients with the above symptoms and findings. I stress, uric acid and gout have no relationship to fibromyalgia. To be effective, a medication must act on nearly the same area of the kidney that malfunctions in most cases of gout. Allopurinol does not affect renal excretion and is useless for fibromyalgia. I feel an inherited defect permits some type of excessive, kidney retention that leads to an abnormality in the metabolism of phosphate and calcium. 

We now rarely use the two gout medications, probenecid (Benemid^TM) and sulfinpyrazone (Anturane^TM) for fibromyalgia. Another medication, guaifenesin, has proven more effective. It is normally prescribed to loosen mucus (mucolytic effect) in patients with chronic sinusitis, bronchitis and various lung diseases. Unlike the previous drugs, it only weakly increases excretion of uric acid and would be useless for gout. Guaifenesin is extremely effective and it has no listed side-effects though we have heard of nausea, heartburn, itching or rash in rare instances. We usually begin with one half tablet (300 mg.) twice a day for two weeks, an adequate dosage for twenty percent of individuals. If needed, we increase to 600 mg. (full tablet) twice daily according to changes we and patients note. For about 70 percent, one of these two dosages suffices. Obviously, 30 percent will need larger amounts. Adjustment is made as indicated by our subsequent mapping.

Some observations led us to suspect the primary defect lies in phosphate not calcium metabolism. Calcium tablets taken with meals allowed lower dosages of medication. Calcium and magnesium bind phosphates from food, increase fecal excretion and thereby lessen absorption. Some patients have fingernail changes that suggest an abnormal calcium phosphate deposition at the root. Similar to concentric tree rings, they grow and eventually break or peel at the tip. Primarily phosphate, some calcium and oxalate, increased in the urine as we initiated treatment in the few patients we tested. Our hypothesis is that an inherited, abnormal renal retention of phosphate and secondarily, calcium, leads to an intracellular excess of both. Cells and their power stations, the mitochondria, malfunction and produce inadequate ATP, the currency of energy. An energy deprivation syndrome develops and affects susceptible, widespread, bodily functions. We realize this is simplistic and the chemistry would be far more involved. 

Treatment with guaifenesin requires more than a prescription. A detailed history is necessary to ascertain the duration of the illness and permit prognostication regarding speed of reversal. Simple palpation should find most of the lesions. They should be recorded on body maps for location, hardness, shape, and size of swellings (see illustration). Patients are asked to keep at least a mental note of their symptoms with attention to pain and emotional swings. Mappings are repeated as treatment progresses and are used to monitor affected regions for change and ultimate disappearance. Our mutual input readily identifies the dosage and discerns improvement. 
 

Guaifenesin lacks significant side effects. It can be taken at any age and has been in use for many years for its previous indications. Treatment reverses fibromyalgia in less time than it took to develop. This accelerated process reproduces previous pain and emotional symptoms, sometimes intensely. Some time after proper, individual dosage has been attained "good days" appear and eventually cluster. Similar to a bouncing ball, symptoms gradually lessen, lesions soften, break-up and clear. Two months of adequate treatment reverses at least one year of accumulated disease. Thus, the longer the duration of illness, the longer to total clearing. Damage from scarring and X-ray abnormalities are permanent and will not reverse. However, pain even in the same location, may not be due to such changes. 
 

It is important that no aspirin be used since it completely blocks the benefit of all medications we have used, including guaifenesin. The greatest source of patient error comes from taking aspirin-related agents, salicylate or salicylic acid, which interfere with guaifenesin at the kidney level. Skin readily absorbs these compounds. All plants manufacture salicylates and many do so in large quantities. The parts concentrated to make herbal drugs, result in a sharp rise in salicylate content. Patients can neither take these nor use any skin creams which contain herbs, including aloe products. All ingredients applied to the skin must be properly identified. Our warnings do not apply to foods, cooking herbs and spices though they do harbor salicylates. The content is insufficient to block desired effects if extraneous sources are not added. 
 

This is deliberately repetitious because it is important. We cannot determine how easily or completely the genetic make-up allows blocking. Assume all patients are very sensitive. Be meticulous in conducting the following search. 
 

Many pain medications contain aspirin or have "salicylate" or "salicylic acid" as part of their contents. You cannot use these. Tylenol, Advil, Darvocet-N and anti-inflammatory drugs are acceptable. 
 

Heed the warning: all plants make salicylates. "Natural" refers to something made in nature. Poison ivy, oleander and hemlock are natural yet not safe. Caution patients to avoid products with that word including such things as aloe, ginseng, almond oil etc. in creams, lotions and herbal medications. 
 

All cosmetics with such contents including some long-acting lipsticks, lip balms and eyeliners will block. If not listed on the container, the original wrapper or box should be checked. 

All creams and lotions for muscle and rheumatic pains such as Ben Gay that contain the above. 
 

All sunscreens or sunless tanning products with the same chemicals, including oxylsalicylate. 
 

Cleansing lotions, astringents, exfoliants, lotions for oily skin and acne compounds, such as Stridex, often contain salicylates. 
 

It is best to avoid herbal shampoos and hair conditioners though they are not on the scalp long. Hair sprays with herbs will land on the skin and deliver salicylates for absorption. Avoid mens' shaving creams with menthol or aloe. 
 

Wart and callus removal products almost all contain salicylates. Read these labels carefully. 
 

Peptobismol is bismuth subsalicylate. 
 

Mouthwashes such as Listerine, contain salicylate as toothpastes with gum care ingredients often do. 

These offending substances will be absorbed and partially or totally block the effect of guaifenesin. No adverse reaction ensues but no benefit is attained . Be aware, a few pharmacies have made serious errors. Patients should obtain plain "guaifenesin," not a tablet containing decongestants or anti-cough preparations. 
 

Our therapeutic approach is not for the weak of courage. As I warned above, reversal of the disease often produces many symptoms causing some patients to doubt their progress during the initial two to four months. It takes confidence and strength to get through this early phase. Cyclic appearance of good days and improvement on mapping provides the needed encouragement to go on. 
 

R. Paul St. Amand, M.D. 

Assistant Clinical Professor Medicine 

Endocrinology--UCLA 

August 1996. 
 
 
 
 
 
 
 
 
 

Recommended reading:
 

1. The American Journal of Medicine: Proceedings of a Symposium: The Fibromyalgia/Fibrositis Syndrome September 29, 1986. 
 

2. The Journal of Rheumatology: Fibromyalgia Syndrome, November 1989. 
 

3. Starlanyl, Devin M.D. and Copeland, Mary Ellen: Fibromyalgia and Chronic Myofascial Pain Syndrome. A Survival Manual. Oakland, Ca: New Harbinger Publications Inc, 1996. 
 

4. Williamson, Miryam Ehrlich: Fibromyalgia: A Comprehensive Approach. New York, Walker and Co. 1996.