26 May, 2014

The April 16 issue of JAMA included a kind of a review on fibromyalgia, which was actually based on a conference that took place at the Medicine Grand Rounds at Beth Israel Deaconess Medical Center, Boston, Massachusetts, on October 2012 [1]. The article starts with a case history of a 64-year-old woman with ongoing, long-term, diffuse muscle pain and fatigue. Interestingly enough, the patient's testimony on how she sees her health condition was given as well. Her wish was to find a treatment regimen that would allow her to be more functional while avoiding adverse effects. The rest of the manuscript addresses the topics of diagnosis, epidemiology, pathophysiology and therapeutic options (both pharmacological and non-pharmacological). Treatment advices were: all patients should have a good therapeutic trial of a low-dose tricyclic compound; patients with co-morbid depression or fatigue should next try a serotonin norepinephrine reuptake inhibitor; non-steroidal anti-inflammatory drugs and acetaminophen can be used to treat co-morbid 'peripheral pain generators'. Complementary and alternative therapies have been less well studied but show promise. The authors also stressed the need for patient's education on the disease and counseling on the role of exercise and cognitive behavioral techniques.

Comment

You are probably asking yourselves what is the relevance of fibromyalgia to menopause. While reading the current JAMApaper, I remembered an intriguing publication a year and a half ago in Maturitas, entitled: 'Is fibromyalgia part of the climacteric syndrome?' [2]. The claim was very straightforward and pointed at the features of fibromyalgia. According to a survey in Germany in 3996 fibromyalgia patients, they were typically 40–50-year-old women complaining of generalized body pain and the most frequent symptoms associated with it were fatigue, morning stiffness, non-restorative sleep, concentration problems, lack of energy, low productivity and forgetfulness [3]. These symptoms certainly ring a bell in the minds of menopause specialists, since women often complain of similar problems during the menopause transition and beyond. Muscle and joint pain are very common among perimenopausal women, together with sleep problems, mood changes, fatigue and cognitive decline. At this point, one should wonder whether the etiology of fibromyalgia has anything to do with serum estrogen levels or with the typical abrupt changes in estrogen levels during the perimenopausal period. The consequences of becoming menopausal in regard to the perception of chronic pain at various sites were evaluated in 109 women [4]. They suffered from headache, or osteoarticular pain or back pain. It was found that, while in many women headache eased or disappeared after entering menopause, there were women who reported no change in pain or even worsening of pain, and others who experienced the emergence of new pain after menopause. As for joint pain, there are good-quality data that demonstrate a positive effect of estrogen. One good example is the WHI trial which recorded a modest but sustained reduction in the frequency of joint pain in the estrogen-alone users [5]. It is also well supported that as much as half of the women with breast cancer who receive aromatase inhibitors may experience new-onset of pain as a result of estrogen deprivation [6]. Thus, it seems that estrogen has a role in the pathophysiology of pain at certain organs. Muscle and joint pain is the hallmark of fibromyalgia, a common disease which appears mostly in midlife women. Clinical features and treatment options for fibromyalgia resemble those for menopausal symptoms. Yet, in the meantime, there is no direct, proven link between the two.

Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

References

1. Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311:1547-55.
http://www.ncbi.nlm.nih.gov/pubmed/24737367

2. Blümel JE, Palacios S, Legorreta D, Vallejo MS, Sarra S. Is fibromyalgia part of the climacteric syndrome? Maturitas 2012;73:87-93.
http://www.ncbi.nlm.nih.gov/pubmed/22771264

3. Häuser W, Zimmer C, Felde E, Köllner V. What are the key symptoms of fibromyalgia? Results of a survey of the German Fibromyalgia Association. Schmerz 2008;22:176–83 [article in German]
http://www.ncbi.nlm.nih.gov/pubmed/18210165

4. Meriggiola MC, Nanni M, Bachiocco V, Vodo S, Aloisi AM. Menopause affects pain depending on pain type and characteristics. Menopause 2012;19:517-23.
http://www.ncbi.nlm.nih.gov/pubmed/22334057

5. Chlebowski RT, Cirillo DJ, Eaton CB, et al. Estrogen alone and joint symptoms in the Women's Health Initiative randomized trial. Menopause 2013;20:600-8
http://www.ncbi.nlm.nih.gov/pubmed/23511705

6. Laroche F, Coste J, Medkour T, et al. Classification of and risk factors for estrogen deprivation pain syndromes related to aromatase inhibitor treatments in women with breast cancer: a prospective multicenter cohort study. J Pain 2014;15:293-303.
http://www.ncbi.nlm.nih.gov/pubmed/24365325