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Defining Nonplus
Conditions:
Different Symptoms, One Cause.
Much is known about the individual nonplus conditions. However, an
understanding of how these different conditions are related is not widely
grasped. There are four traits, which show why these ten conditions should
be grouped together and why it likely that they have the same underlying
cause.
Many of the nonplus conditions can cause a variety of
symptoms and others cause only one symptom. People who are unlucky enough
to have several nonplus conditions can wind up with dozens of different
symptoms. When a person learns that many of their different health
complaints are caused by one underlying problem it is usually accompanied by
a feeling of relief.
The four traits common to all of these conditions are:
1.
Shared symptoms and overlapping of conditions.
2. Method
of diagnosis.
3.
Treatment difficulty.
4. Guaifenesin as an effective treatment.
1. Shared symptoms
Of the nonplus conditions, three can be considered
core: Chronic Fatigue, Fibromyalgia and Irritable Bowel. This is because
they are the most common and may occur alone. The remaining nonplus
conditions can be considered satellite conditions. This is because they are
not as likely to occur alone but commonly attend one or all three of the
core nonplus conditions. If you have one or more of the core conditions then
you are likely to also have one or more of the satellite nonplus conditions.
Many books, websites and research that discuss the nonplus conditions
mention that they frequently occur together and some suggest a common
underlying mechanism is responsible for them.(1,2,3,4)
The symptoms within these conditions frequently overlap
as well. For example difficulty sleeping, muscle aches and problems with
memory and thinking are frequent in both chronic fatigue and fibromyalgia.
2. Similar method of diagnosis
Diagnosing nearly all of the nonplus conditions is
difficult for two reasons. First, many symptoms that are common in the
nonplus conditions are also present in several and possibly dozens of other
disorders. For example back pain and fatigue have many possible causes.
Second, no x-ray or laboratory test can detect the existence of the nonplus
conditions. The diagnosis for all nonplus conditions are based upon the
symptoms being experienced as well as the lack of positive medical tests
which rule out other disorders that could be responsible for the same
symptoms. This ruling out process may take many years. It is not uncommon
for a person to see dozens of doctors over a period of 4 or 5 or even 10
years before a nonplus condition is accurately diagnosed.
Some of the nonplus conditions are not difficult to
diagnose due to a symptom that is particularly unique. For example, restless
leg syndrome is easily diagnosed due to an uncontrollable urge to move the
legs.
One of the nonplus conditions, Ehlers-Danlos Syndrome
does have a known cause in a small percent of all cases. Ten percent of
Ehlers-Danlos Syndrome cases are due to a genetic defect.(5) I do not
recommend guaifenesin in cases where there is an identifiable cause.
Some people may claim that the tilt table test is a way
to positively identify neurally mediated hypotension. This is true in a
sense, but the test merely confirms the symptoms already described by the
patient. It does nothing to shed light on what is causing this symptom. The
diagnosis is still based upon the symptoms experienced by the patient. The
primary benefit of this test is that it objectively confirms the reality of
the patient’s subjective complaint. It is unfortunate that other symptoms
like fatigue, pain and digestive distress cannot be objectively confirmed by
physicians. If this were possible then sufferers of these conditions would
in some cases be treated with greater consideration..
The American College of Rheumatology has established
criteria for fibromyalgia that includes both a history of chronic widespread
pain in all four quadrants of the body and the presence of 9 of 18 “tender
points” on physical examination. It is not generally known that, “These
criteria were never intended to be strictly applied to individual patients
as diagnostic criteria, and it is widely acknowledged that many persons who
have the clinical diagnosis of fibromyalgia do not fulfill this definition.”
(6) When physicians do strictly apply these criteria the result is a
significant number of false negatives. This means some patients who actually
have fibromyalgia will show up negative based on these criteria and thus,
inaccurately be told that they do not have fibromyalgia.
An alternative to the 18 tender points is a procedure called mapping.
Mapping, a term used by Dr. St. Amand, acknowledges the historical and
modern findings that fibromyalgia is often associated with a bumpy feeling
under the skin that is often tender as well.(7) It was William Balfour of
Edinburgh who in 1816 first mentioned the occurrence of “indurated nodules”
associated with “rheumatism”.(8) It is now recognized by most doctors using
guaifenesin that these lumps and bumps occur not only with fibromyalgia but
are believed to be present in all of the nonplus conditions. Mapping is the
process of running fingers down the muscles of the body and charting where
the lumps and bumps are located. The bumps can feel like small pebbles or
larger hardened areas and swellings. The bumps may be easily felt and are
often sensitive, but can require an experienced doctor or therapist to be
found. It should be noted that the number and size of these swellings does
not seem to be directly related to the severity of the symptoms one
experiences.
These lumps and bumps do not include lymph nodes,
lipomas, cellulite or tight muscles. Mapping should not be used as a sole
means of diagnosis for any of the nonplus conditions.
3. Treatments have limited benefit
Many of the symptoms resulting from nonplus conditions
are not unusual. Fatigue, headaches, muscle aches and pains are almost
universal and there are many helpful treatments available depending upon the
source of the problem. Exercise, relaxation, soft tissue therapy,
adjustments and medications can control or eliminate these symptoms for most
people. However, when these symptoms and others are due to chronic fatigue,
fibromyalgia etc., not only is there no detectable reason for the pain,
common treatments provide little if any long-term relief and the overall
progression of various aches, pains, fatigue and digestive upset continues.
Even if one symptom is alleviated due to a specific treatment or disappears
for no reason at all, the other symptoms remain and new symptoms may arrive
at any time.
4. Guaifenesin eliminates the symptoms associated with these
conditions
When guaifenesin is used with specific therapeutic
steps, the symptoms of these conditions gradually decrease over time and are
often eliminated completely. This is a gradual process and while most people
will experience significant improvement within several weeks to several
months, complete recovery will take many years in most cases. Although no
treatment or therapy is 100% effective in all cases, it has been my
experience that guaifenesin helps the vast majority of people who use it
properly. It is safe, inexpensive and in most instances can gradually
eliminate all of the symptoms resulting from the nonplus conditions.
Unfortunately, most doctors who try guaifenesin on
their patients simply prescribe 2400mgs of guaifenesin daily-the amount
commonly used for expectorant purposes-and know nothing about the required
therapeutic steps of proper dosing, salicylate avoidance and carbohydrate
sensitivity. Symptom remission under these circumstances is highly
unlikely.
One underlying cause.
These four traits that the nonplus conditions share
indicate that they arise from one underlying cause.
- D. Veale, G. Kavanagh, J. F. Fielding, O.
Fitzgerald,
‘Primary fibromyalgia and the
irritable bowel syndrome: different expressions of a common pathogenetic
process.’, British Journal of Rheumatology, 1991,
Jun;30(3):220-2.
- Caralyn Davis-Arthritis Foundation, 2004, ‘What’s
In A Name: Fibro vs. CFS’.
http://www.arthritis.org/resources/news/news_fibro_cfs.asp Accessed
2004 Sept. 29.
-
Darlene A. Clarke-Ehlers-Danlos
National Foundation, (n.d.), ‘Learning
To Manage Fibromyalgia Syndrome’.
http://www.ednf.org/fibro.html
Accessed 2004 Sept. 17.
- Daniel Clauw, ‘Fibromyalgia’, Kelley’s Textbook
of Rheumatology, ed. Ruddy, Harris, Sledge, (Philadelphia: W.B.
Saunders, 2001), 418, 422-24.
- Ehlers-Danlos Support Group, 2004 Aug. 2,
‘Diagnosing Ehlers-Danlos Syndrome’.
http://www.ehlers-danlos.org/Info%20Sheets/diagnosing.htm
Accessed 2004 Sept. 11.
- Daniel Clauw, ‘Fibromyalgia’, Kelley’s Textbook
of Rheumatology, ed. Ruddy, Harris, Sledge, (Philadelphia: W.B.
Saunders, 2001), 417.
- Paul St. Amand, What Your Doctor May Not Tell
You About Fibromyalgia, (New York: Warner Books, 1999)
- W. S. C. Copeman, Textbook Of The Rheumatic
Diseases, (Edinburgh: E. & S. Livingstone LTD., 1964), 3.
Nonplus Conditions
Below is a description of each nonplus condition in
alphabetical order. This is not a detailed description of every single
aspect of these conditions, but merely a brief overview of generally
accepted facts regarding these conditions.
I have seen every one of these conditions resolve with
the use of guaifenesin. This does not mean that in every single instance guaifenesin will be beneficial, few treatments are 100% effective. It is
entirely possible that some of these conditions have more than one cause and
not all of these causes will respond to guaifenesin.
There are several additional conditions that may be
eventually added to this list. These conditions include Primary Raynaud’s,
most of the pelvic pain syndromes and periodic limb movement disorder. I do
not have enough experience treating patients with these conditions to
include them at this time.
Chronic Fatigue Syndrome (CFS) and Chronic
Fatigue Immune Dysfunction Syndrome (CFIDS)
Chronic Fatigue and Chronic Fatigue Immune
Dysfunction Syndrome are complex chronic illnesses that negatively affect a
person’s energy, the ability to think clearly, mood, sleep and multiple body
systems. Some people with chronic fatigue also experience frequent cold and
flu type symptoms possibly due to some type of immune dysfunction, hence the
two names.
Although its name trivializes the illness as
seeming to be little more than tiredness, chronic fatigue with or without
immune dysfunction syndrome bring with them one or more of the following
symptoms, often with a wide range in frequency and severity. Fatigue
especially following physical activity or exercise, impairment of
thought, speech, reasoning and comprehension sometimes known as fog,
difficulties with eyes such as burning, blurring and sensitivity to light,
depression, irritability, dizziness and balance problems, sensitivity to
heat, cold or sound, irregular heart beat, pressure in the chest, throat and
jaw, unexplained fevers, low grade fever or low body temperature, sleep
difficulties, tender or swollen lymph nodes, chest pains, sore throat,
constant throat clearing, tingling and or burning sensations on the skin,
rashes/itching and extreme sensitivity to touch. The majority of people with
CFS and CFIDS concurrently experience one or more of the nonplus conditions
such as fibromyalgia irritable bowel, neurally mediated hypotension and
multiple chemical sensitivities. (1)
Diagnosis of chronic fatigue can be a
time-consuming and difficult process, which is generally arrived at by
excluding other illnesses with similar symptoms and comparing a patient's
symptoms with the symptoms commonly attributed to chronic fatigue.
Complicating the diagnostic process, people with CFS and CFIDS have symptoms
that vary considerably from person to person and frequently fluctuate in
severity. Symptoms may come and go for no reason while others may remain
constant. Most symptoms cannot be seen making it difficult for others to
understand or believe the vast array of debilitating symptoms.(2) The cause
or causes have not yet been identified and no specific diagnostic tests are
available that can clearly identify the disorder.(3) Because of the lack of
positive tests and the fact that a person with chronic fatigue often looks
fine, they may be accused of needing attention, being depressed or
malingering. Sufferers are often acutely aware that their symptoms “do not
make sense” and may eventually believe they are just stressed, depressed or
different. For unknown reasons symptoms
can be increased during times of stress (emotional, physical or chemical)
and during a woman’s menstrual cycle but are just as likely to wax and wane
for no reason at all.
Likewise, symptoms of CFS and CFIDS may
initially begin after a minor illness such as a cold or flu, after a period
of high stress or for no reason at all. For unknown reasons, CFS is
diagnosed two to four times more often in women that in men. (4) Since no
cause for CFS has been identified, (infectious agents in particular have
been extensively investigated but no association has been found), treatment
programs are directed at relief of symptoms, with the goal of the patient
regaining some level of pre-existing function and well-being.(5)
There are several unrelated health conditions
that may cause similar symptoms: lupus, hypothyroidism and Lyme’s disease.
These and other possible conditions should be ruled out or if present
treated.
A study conducted by researchers at DePaul
University showed that CFS is many times more common than previously
believed and occurs across all ethnic groups and income levels.(6) Research
published in 2001 indicates that CFS is more common among identical twins
(who share the same genes) than fraternal twins (who share only some genes).
Inheritance, then, may play a role in many cases.(7)
Home
Ehlers-Danlos
Syndrome (EDS)
EDS results from a defect in
connective tissue, the tissue which provides support and connects parts of
the body together. Tendons and ligaments are two types of connective tissue
that are commonly affected by EDS. This condition may cause fragile or
stretchy rubber band like skin, skin that bruises or scars easily, slow
wound healing, mitral valve prolapse, hiatial hernea, pain with intercourse,
harmless bumps under the skin, loose unstable joints prone to pain or are
excessively limber, subluxation or dislocation and some types of EDS can
affect organs as well.(8) The root of the problem is faulty collagen, a
protein that acts as a glue in the body adding strength and elasticity to
connective tissue although the reason why this occurs is known in only a
small percent of cases that are due to genetic defect.
Six major types exist based upon their
symptoms and signs with each type specifically passed on in a family. A
major problem is that a person can look well, so is not taken seriously when
complaining of joint pain. Ninety percent of all cases are Types I, II, and
III in which no biochemical abnormalities are found. In these cases the
diagnosis must be made on the basis of symptoms and family history. Fibromyalgia and chronic fatigue are common in people who have these types.
The remaining ten percent, EDS types IV, VI and VII, have specific
biochemical markers which can show up in laboratory tests.(9) It is unlikely
that types IV, VI and VII will respond to guaifenesin.
Treatment is based on managing the symptoms
being experienced by the individual. Surgery is sometimes needed to repair
joints. Joint stability may be improved by carefully strengthening
muscles.(10)
Home
The word literally means pain in the muscles and fibers. But,
fibromyalgia is a condition that commonly includes many more characteristic
symptoms than just muscle, joint and body pain. Despite the condition’s
frequency, physicians often miss the diagnosis due to the fact that there
are so many different causes for most of the symptoms associated with
fibromyalgia. Another confusing aspect is that the symptoms may begin
following a physically traumatic event such as an accident, surgery or
illness, leading the doctor to believe that all the symptoms are directly
related to one of these events. It is now believed that these events are
merely triggers. The most common symptoms are muscle/joint/bone pain and
stiffness all over or in specific locations. A general feeling of intense
muscle tightness (even if the muscles are not actually tight to the
examining doctor) and an unusual sensitivity to pressure or touch on the
body in one or many places. Other common symptoms include: headaches,
sensitivity to sound, light or odors, sleeping difficulties or unrestful
sleep, intermittent blurred vision, itching and or skin rashes, fatigue, jaw
joint pain, dizziness and balance problems, depression, anxiety, digestive
complaints, pelvic pain, restless legs, painful or frequent urination and
memory/concentration problems.(11)
Additional symptoms that can involve almost
any organ system in the body are also often present and in some people may
be more primary than the previously listed symptoms. All symptoms may vary
greatly in intensity and duration and frequently mimic other diseases and
conditions. In some cases a primary symptom may leave for no apparent
reason, become intermittent or never return. In these cases the symptom that
has left is likely to be replaced by another symptom of similar intensity.
Symptoms can be “set off” by an increase of physical activity, emotional
stress, or a woman’s menstrual cycle.
Fibromyalgia is much more common in women,
approximately 80%, and tends to run in families. There are no diagnostic lab
or x-ray abnormalities associated with fibromyalgia. Diagnosis of
fibromyalgia can be difficult as there are currently no diagnostic tests for
fibromyalgia. The symptoms ascribed to fibromyalgia cannot be due to any
other medical condition and conventional treatments and drugs provide only
temporary relief. It usually takes many years for someone with fibromyalgia
to be correctly diagnosed while doctors perform tests in an attempt to
determine what is wrong. Diagnosis is based upon symptoms and the presence
of tender points.(12)
Because of substantial symptom overlap,
many people consider chronic fatigue and fibromyalgia to be essentially the
same condition. Fibromyalgia is also closely associated with other
conditions such as irritable bowel syndrome and lesser-known conditions such
as neurally mediated hypotension, Raynaud’s disease and interstitial
cystitis.
Home
IBS is a common “functional” disorder of the intestines. Functional means
that the bowel does not work the way that it should, but that no other
problem, chemical, bacterial or structural can be found. There are no signs
of disease or infection when the bowel is examined. Symptoms vary and are
often intermittent and include: cramping,
pain, gassiness, bloating, and changes in bowel habits. Some people with IBS
have constipation, others have diarrhea and some people experience both
intermittently. Another symptom is abdominal cramps with an urge to move the
bowels but without being able to do so. For most people, IBS is a
chronic condition, although there will likely be times when signs and
symptoms are worse and times when they improve or even disappear
completely.(13)
Through the years, IBS has
been called by many names--colitis, mucous colitis, spastic colon, spastic
bowel, and functional bowel disease. Most of these terms are inaccurate.
Colitis, for instance, means inflammation of the large intestine (colon).
IBS, however, does not cause inflammation and should not be confused with
another disorder, ulcerative colitis.
The cause of IBS is not known, and no
particular test can determine the presence of irritable bowel. Diagnosis of
irritable bowel depends largely upon symptoms and the lack of other
conditions that can cause similar symptoms. Treatment is limited to
alleviating symptoms. It is known that emotional stress does not cause a
person to develop irritable bowel, but if you already have IBS, stress can
trigger symptoms. IBS causes a great deal of discomfort and distress, but it
is not believed to cause permanent harm to the intestines and does not lead
to intestinal bleeding of the bowel or to a more serious disease such as
cancer. Researchers have found that the colon of a person with IBS begins to
spasm after only mild stimulation making the colon more sensitive than
normal.(14)
One in five Americans has IBS, making it one of the most common disorders
diagnosed by doctors. It occurs more often in women than in men, and it
usually begins around age 20.
Patients with IBS have a high frequency of non-gastrointestinal symptoms,
including muscle and joint symptoms, headache, genitourinary symptoms such
as urinary frequency and urgency, pain during sexual intercourse and
sleep-related disturbances.(15)
Home
IC, one of the chronic pelvic pain disorders, causes discomfort or pain
in the bladder and surrounding pelvic region. Additional symptoms include a
feeling of pressure, tenderness, an urgent need to urinate (urgency), a
frequent need to urinate (frequency), or a combination of these symptoms.
Pain resulting from sex is common. These symptoms can change from time to
time in an individual and may even disappear for weeks or years before
returning.(16)
Some websites state that IC is a chronic inflammation of the bladder
wall, while others do not emphasize this. Interstitial cystitis is not the
same as common cystitis, which is also known as a UTI or urinary tract
infection. Urinary tract infections are caused by bacteria and in most cases
responds to antibiotics. Interstitial cystitis is not believed to be caused
by bacteria and does not respond to antibiotic therapy.(17)
As little as 20 years ago few doctors knew what interstitial cystitis was
and it was considered to be a rare disease found only in postmenopausal
women. Now it is known to affect any age and sex although 90% are women. A
1997 study found that over 700,000. people are affected in the United
States.(18) This is 50% more than previously thought.
Because the symptoms of IC are similar to other disorders of the bladder
and pelvis and because there is no definitive test that can identify IC,
other conditions must be ruled out before a diagnosis if IC is given. It is
unknown what the cause of IC is and current treatments are aimed at
relieving symptoms.(19)
“Once a patient has a diagnosis of interstitial cystitis, they are often
frustrated by the lack of knowledge about IC in the medical community.
Although the first IC case may have been recognized as early as the mid
1800's, it wasn't until 1987 that the US National Institutes of Health
convened the first meeting to discuss IC. As such, patients face the unique
challenge of becoming educators and advocates for the IC community as they
spread the word that IC is, indeed, a disease that is worth care and
treatment.”(20)
IC is associated with other pelvic pain syndromes such as vulvar pain
syndrome, as well as fibromyalgia and irritable bowel syndrome and chemical
sensitivities.(21)
Home
MCS remains a medical
mystery and the medical community remains divided over whether it really
exists. The Centers for Disease Control, for example, does not recognize MCS
as a clinical diagnosis. This may be because symptoms and chemical exposures
are often unique and are widely varied between individuals.(22)
Problems most commonly arise
as a result of smelling perfume, paint, and dyes in clothing or because of
using common personal care products. Exposure typically causes one or more
of the following: immediate headache, burning sensation on the skin or face,
nausea, heart palpitations, itching, feeling feverish, muscle weakness,
mental confusion, asthma or a sick feeling and can
last for minutes to days. Levels of exposure that are generally well
tolerated by most people trigger the symptoms or signs. It occurs more
commonly in women than men. In addition, 40% of people with chronic fatigue
and 16% of people with fibromyalgia have MCS.(23)
The diagnosis is suspected
on the basis of history and physical examination, and the condition may be
confirmed by removing the offending agents and re-challenging patients under
properly controlled conditions. Treatment consists of avoiding offending
substances.
The National Academy of Sciences estimates that 15
percent of Americans are unusually sensitive to common chemicals. Chemical
sensitivity is recognized as a disability under the Americans with
Disabilities Act. Multiple chemical sensitivity and Gulf War Syndrome have
many similarities and are possibly the same condition. However, I have no
experience with Gulf War Syndrome, so I am unable to predict if guaifenesin
would be helpful in these cases.
Home
The symptoms of NMH include feeling lightheaded or uncomfortable with an
increase in pulse rate when sitting or standing for a prolonged time. Sometimes fainting occurs. NMH is most likely to occur in susceptible people
in the following settings: after periods of quiet up right posture, after
being in a warm environment, immediately after exercise, after emotionally
stressful events and after eating. Symptoms may disappear for no reason only
to return, unexplainably, days months or years later.
The dizziness that occurs when rising up from
a lying or stooped position is commonly called “postural hypotension”
and is not related to Neurally Mediated Hypotension.
NMH may be associated with decreased blood
volume. Increasing fluid and salt intake often helps to reduce symptoms but
is not a consistently helpful treatment. There has been information in the
media that salt is unhealthful. This is not true for everyone. A strong
association exists between NMH, chronic fatigue and fibromyalgia.(24,25)
Home
Restless Leg Syndrome
(RLS)
Restless leg syndrome was described as early as the 16th century but was not
studied until the 1940s. People with RLS complain of an irresistible urge to
move their legs. This most frequently occurs during periods of inactivity
and may become more severe in the evening and at night. A person with RLS
will experience pain, a vague uncomfortable feeling or a creepy crawly
feeling that is only relieved by moving the legs. Some people explain that
they move constantly in an attempt to get comfortable. The symptoms of RLS
may also be present all day long, making it difficult for an individual to
sit motionless. Late evening symptoms can lead to sleep onset insomnia,
which tends to compound the effects of RLS.
One study found RLS to be most
prevalent in middle-aged females and its incidence increases with age. RLS
tends to run in families. Though RLS is diagnosed most often in people in
their middle years, many individuals with RLS can trace similar symptoms
back to childhood. These symptoms may have been called growing pains.
With its classic symptoms, RLS is
diagnosed by reviewing your medical history. No laboratory test exists that
can confirm your diagnosis of RLS. After ruling out other medical conditions
as the cause of your symptoms, your healthcare provider can make the
diagnosis of RLS. Restless leg syndrome is estimated to affect up
to15% of the population. There is no cure for this condition and treatments
are aimed at relieving or decreasing symptoms.(26)
Home
Vulvodynia also known as vulvar pain are
associated with a variety of symptoms of the external female genitalia and
often occur along with fibromyalgia, chronic fatigue and irritable bowel. Problems can include sensitivity of the skin, general discomfort, itching
and dryness, parchedness, tiny cuts in the skin that are extremely painful, swelling and drawing sensations all over the vulvar skin, or only certain parts of it as well as in the rectal skin.
Hypersensitivity along the edge of the small labia, which makes it difficult
to walk, is common as is pain or discomfort on touching or pulling pubic
hair. Some women cannot even wear underwear for these reasons. In some
instances pain is primarily evoked by insertion of a tampon or by sexual
intercourse. The symptoms of interstitial cystitis may also be present as
well as burning pain at the level of the pubic bone, pain in the buttocks,
thighs and pain or numbness in other areas of the body.(27)
The origin of vulvodynia is not known. Medical examinations and diagnostic
workups remain unrevealing and no specific cause of the pain can be
identified.
Treatment is limited to symptom relief.. Preliminary findings from a
Harvard Medical School study reveal that vulvodynia may affect millions of
women.(28) Vulvodynia and interstitial cystitis are the most widely known
conditions in a group of health problems known as chronic pelvic pain. The
pelvic pain syndromes share many characteristics, but with the pain centered
in different locations. These conditions include orchialgia (pain in the
testicles), urethral syndrome (aching and cramping in the area above the
pubic bone, may occur with frequent or painful urination, and low back
pain), penile pain, prostatodynia (pain in the prostate), coccygodynia (pain
at the tip of the tailbone) and perineal pain (pain in the pelvic floor,
between the thighs).(29)
According to Johns Hopkins School of Medicine,
hyperesthesia of the vulva was apparently a well-described entity in
American and European gynecological textbooks in the last century. However,
despite these early reports the medical literature did not mention vulvar
pain again until the early 1980's, when a new interest in this chronic pain
syndrome developed. It is not clear, why the chronic vulvar pain syndromes
disappeared from the medical literature for almost 100 years. It is possible
that the medical community denied and neglected these pain syndromes, or
that chronic vulvar pain syndromes indeed were quite rare for a period of
time. Further epidemiological studies are necessary to clarify these
issues.(30)
- Chronic Fatigue and Immune Dysfunction Syndrome
Association of America, 2004, ‘Symptoms’,
http://www.cfids.org/about-cfids/symptoms.asp Accessed 2004 Sept.
17.
- Ibid.
- National Center For Infectious Diseases, Center
For Disease Control, 2003 Sept. 18, ‘CFS Information’
- National Institutes of Health, 2004 May, ‘Chronic
Fatigue Syndrome’,
http://www.niaid.nih.gov/factsheets/cfs.htm Accessed 2004 Sept. 24.
- National Center For Infectious Diseases, Center
For Disease Control, 2003 Sept. 18, ‘Chronic Fatigue
Syndrome-Treatment’,
http://www.cdc.gov/ncidod/diseases/cfs/treat.htm Accessed 2004
Oct. 4.
- L. A. Jason, J. A. Richman, et.al., ‘Politics,
Science, and the Emergence of a New Disease’, American Psychologist, 1997, Vol. 52, pp. 973-983.
- University of
Maryland Medicine, 2001, ‘What Causes Chronic Fatigue Syndrome?’,
http://www.umm.edu/patiented/articles/what_
causes_chronic_fatigue_syndrome_000007_3.htm
Accessed 2004 Oct. 3.
- Ehlers Danlos
National Foundation, (n.d.), ‘What is Ehlers-Danlos Syndrome?’,
http://www.ednf.org/whatiseds.html
- Ehlers-Danlos Support
Group, 2004 Aug. 2, ‘Diagnosing Ehlers-Danlos Syndrome’
http://www.ehlers-danlos.org/Info%20Sheets/diagnosing.htm Accessed
2004 Sept. 28.
- University of
Washington Orthopedics and Sports Medicine, 2004 Nov. 18, ‘Ehlers-Danlos
Syndrome’,
http://www.orthop.washington.edu/arthritis/types/ehlersdanlos/04
Accessed 2004 Nov. 24.
- National Institute of
Arthritis and Musculoskeletal and Skin Diseases, 2004 June, ‘What Is
Fibromyalgia?’,
http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm#fib_a
Accessed 2004 Oct. 3.
- Ibid.
- Mayo Clinic.com, 2003
Nov. 6, ‘Irritable bowel syndrome’,
http://www.mayoclinic.com/invoke.cfm?objectid=F32C84B7-11F3-4E9
D-80A5AD5354F27F4E&dsection=2
Accessed 2004 Oct. 3.
- National Digestive
Diseases Information Clearing House, 2003 April, ‘Irritable Bowel
Syndrome’
http://digestive.niddk.nih.gov/ddiseases/pubs/ibs/ Accessed 2004
Sept. 29.
- P. J. Whorwell,
et.al., ‘Non-colonic features of irritable bowel syndrome.’, Gut.
1986; 27:37-4.
- National Institute of
Diabetes and Digestive and Kidney Diseases, (n.d.), ‘Interstitial
Cystitis’,
http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/index.htm
Accessed 2004 Oct. 3.
- Interstitial Cystitis
Association, 2003 July, ‘Interstitial Cystitis’,
http://www.ichelp.org/WhatIsIC/TheMostFAQ.html Accessed 2004 Oct. 4.
- G. C. Curhan, et al.,
‘Interstitial Cystitis: An Update of Current Information’, (Urology
Supplement 5A, May 1997), 1999, The Journal of Urology 161:549-552,
1999.
- National Institute of
Diabetes and Digestive and Kidney Diseases, (n.d.), ‘Interstitial
Cystitis’,
http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/index.htm
Accessed 2004 Oct. 3.
- Interstitial Cystitis
Network, 2003 May, ‘Interstitial Cystitis’,
http://www.ic-
network.com/handbook/basics.html Accessed 2004 Oct. 3.
- M. Alagiri, S.
Chottiner, V. Ratner, et al., ‘Interstitial Cystitis: unexplained
associations with other chronic disease and pain syndromes.’, Urology,
1997; 49(suppl 5A): 52-57.
- National Institute of
Environmental Health Sciences, 2004 Jan., ‘Allergies: Multiple Chemical
Sensitivities’,
http://www.niehs.nih.gov/external/faq/allergy.htm Accessed 2004 Oct.
4.
- The Merck Manual, (n.d.),
‘Multiple Chemical Sensitivity Syndrome’,
http://www.merck.com/mmhe/sec25/ch306/ch306d.html Accessed 2004 Oct.
4.
- National Fibromyalgia
Research Association, 1997 Sept. 15, ‘Neurally Mediated Hypotension in
Fibromyalgia Patients’,
http://www.nfra.net/NewRowe1.htm Accessed 2004 Oct. 5.
- Chronic Fatigue and
Immune Dysfunction Syndrome, 2004, ‘Neurally Mediated Hypotension and
Orthostatic Hypotension in Children and Adolescents’,
http://www.cfids.org/youth/articles/medical/nmh.asp Accessed 2004
Oct. 5.
- University of
Pittsburgh Medical Center, 2004, ‘Restless Leg Syndrome’,http://restlesslegsyndrome.upmc.com/Treatment.htm
Accessed 2004 Sept. 29.
- The Vulvar Pain
Foundation, 2003 Spring, ‘A Word About Vulvar Pain’
http://www.vulvarpainfoundation.org/vpfabout.htm Accessed 2004 Oct.
4.
- Harvard Medical
School, 2003 April, ‘Chronic Vulvar Pain May Be a Highly Prevalent
Disorder’,
http://www.hms.harvard.edu/news/pressreleases/bwh/0403c
hronic_vulvar_pain.html
Accessed 2004 Oct 5.
- Johns Hopkins
Medicine, (n.d.) ‘Chronic Pain Syndromes in Women’http://www.neuro.jhmi.edu/PelvicPain/home.html
Accessed 2004 Oct. 4.
- Ibid.
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