Dr. Jacob Teitelbaum's Column
...expert advice on CFS, Fibromyalgia and other Health Topics.
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Monday, May 12th, 2008:
Q & A On CFS/FMS and Pregnancy
An interview with Jacob Teitelbaum MD
Q. Do you agree with the following advice for women with FM or CFIDS prior to conceiving (and do you give any other advice)?
• Get in the best shape possible physically
• Wait to conceive until you are not in a flare
• Reduce stress
A. In terms of exercise, it is important to realize that people should not push to the point of crashing. Instead, they should slowly increase walking as is tolerated without causing next day flares. It is a good idea for fibromyalgia patients to reduce stress in general.
Most importantly, I think that the fibromyalgia should be treated with an integrated metabolic regimen for about a year before pregnancy, so that people have largely recovered before they get pregnant. Our randomized double-blind placebo controlled study showed that treatment can be very helpful (P. < .0001 versus placebo).
Q. Would you agree that fertility problems with FM are no different than the general population?
A. Although infertility is not a significant problem, I do find it to be more frequent in fibromyalgia than in the general population. On the other hand, when the nutritional deficiencies (especially iron) and subclinical hypothyroidism are treated, the infertility problems often resolve (as is also seen in the Non- fibromyalgia general population).
Q. Do you see problems with irregular cycles, hormone imbalances, ovarian cysts, vaginosis, endometriosis, or other GYN problems in women with FM/CFIDS?
A.Yes, especially hormonal imbalances, irregular periods, and endometriosis. There is also an increased frequency of polycystic ovary syndrome associated with elevated DHEA—S and testosterone as well as glucose intolerance. This can result in infertility, which responds well to treatment. In addition, elevated prolactin is common in associated with the hypothalamic dysfunction (and rarely pituitary adenoma). This can also result in infertility, and also responds excellently to therapy.
Q. Should women stop all meds? (please list any acceptable ones to take, if known) particularly:
• NSAIDS, acetominophen
• muscle relaxants
• medications for migraines
• medications for irritable bowel
A. I leave my pregnant patients on the Energy Revitalization System (Berry or Citrus) as this was also made to be excellent support for pregnancy. They also need to be on a stabilized, mercury free fish oil (I recommend Eskimo 3 or Arctic Omega), calcium 1500 milligrams, and iron if needed (i.e. if the ferritin is less than 40). They can also stay on thyroid hormone, and if needed, Ultra low-dose Cortef—both of which supports pregnancy. If critical, they can stay on Prozac, which has not been associated with increased birth defects. Besides for these, I stop almost all medications and herbals. I would note that in general, acetaminophen (Tylenol) is a poor choice for fibromyalgia patients as it depletes glutathione—a critical antioxidant that is likely already deficient in CFS/fibromyalgia.
PREGNANCY & DELIVERY:
Q. Do you agree with the following concerning treatment of FM flares (pain, fatigue, stiffness) while pregnant (and do you give any other advice)?
• massage therapy
A. Pregnant women need to be careful to avoid hot tubs and hot baths (and likely hot packs in the area of the fetus) as the increased body temperature is associated with an increased risk of birth defects. Taking calcium and magnesium at night can help sleep. In addition, a taking 5-HTP 200-300 mg/night can help both sleep and pain, although it takes six weeks to work. As long as the PT is done gently it can be helpful, as can stretching and massage therapy. Most importantly, by giving appropriate treatment before pregnancy, flares can usually be avoided during pregnancy.
Q. What can a woman do if she experiences a flare of: depression, migraine or irritable bowel while pregnant?
A. Migraine attacks can often be knocked out by giving magnesium 2 g IV over a ten minute period. In addition, avoiding chocolate and sugar, which are common triggers for migraines, is helpful. Taking magnesium orally (and this is already present in the vitamin powder) decreases migraine attacks as well. Taking the fish oil and the nutrients in the vitamin powder and B-complex (plus 5-HTP) decreases the tendency to depression considerably. Our study and clinical experience show that most people will find that their irritable bowel syndrome resolves when the underlying opportunistic bowel infections have been treated (e.g. Clostridium, SIBO, fungal infections, and parasites). These do however need to be treated before the patient becomes pregnant. If the patient is constipated, taking magnesium is very helpful. Adjusting the thyroid dose for those who are hypothyroid is also critical, and constipation can be a marker for this. The iron and calcium dose can be adjusted to help with diarrhea.
Q. Anecdotaly, women with FM report improvement of symptoms with pregnancy. The few studies and surveys generally report the opposite. What is your experience? Are there particular trimesters when an improvement or exacerbation is likely to occur? What would be the reason for improvement (immune system turned off, particular hormones, or other reason?)
A. In my experience with treating thousands of patients, once the patient has gotten past the morning sickness, they usually feel much better during pregnancy. Morning sickness can often be avoided by taking adequate vitamin C (500 milligrams a day) and vitamin B6 (100-200 milligrams a day). The improvement that occurs during pregnancy can occur for many reasons (increased CRH, blood volume, estradiol levels which improve immune function, relaxin levels, etc.). Overall, people do great during pregnancy (if given proper nutritional and thyroid hormone support) but may crash after. Even the crash after pregnancy can often be avoided with proper therapy.
Q. Are there any particular complications of pregnancy or delivery related to FM or CFIDS (ectopic pregnancies, miscarriages, symphysis pubis disruption, breech presentation, for example)? Do women with FM lack muscle strength or tone for pushing? Do you advocate warm water birthing to ease the muscle pain of FM?
A. As long as the woman is on adequate magnesium to decrease to risk of eclampsia, they tend to do just fine with their delivery. Warm water birthing would be reasonable for anybody.
Q. Does an epidural help to conserve energy during birth and speed recovery afterwards?
A. I think that an epidural is quite reasonable, but leave this to the preference of the mother as in any other delivery.
Q. Does FM affect length of stay in the hospital for mom or baby?
A. Not in my experience.
Q. If FM or CFIDS inheritable? Do you find many parents worried about that?
A. Although approximately half of my patients have a family member with CFS/fibromyalgia, the risk of any one individual child getting it is low because we have so many family members. This reassurance is very helpful for the parents. In addition, regardless of the popular misconception, fairly effective treatment has shown to be available for fibromyalgia—as demonstrated in a placebo-controlled study. (I would note that the journal of the American academy of pain management—one of the largest multidisciplinary societies of pain specialists in the U.S. had an editorial noting that our treatment protocol is "an excellent and highly effective part of the standard of practice for treating fibromyalgia and myofascial pain syndrome.)
Q. Should moms with FM breastfeed? Are there the same restrictions on meds? Is it too tiring to breastfeed?
A. I generally apply the same principles to breast-feeding as being pregnant. If possible, I have the Mother breast-feed for at least six months and avoid the same medications that were avoided during pregnancy. I do not think it is too tiring to breast-feed and breast-feeding also helps with weight loss—which is emotionally important to the patient as well (while also decreasing the risk of sleep apnea). It is, of course, also very healthy for the baby. It is critical however that the Mother stay on her nutritional regimen while breast-feeding.
Q. Is the severity or incidence of postpartum depression worse in moms with FM?
A. If adequate support is given with fish oils and progesterone, postpartum depression seems to be less common.
Q. Do you have any other advice for women concerning pregnancy and fibromyalgia?
A. Be sure that thyroid hormone levels are adjusted to the level that feels optimal while keeping the free T4 within the normal range. Otherwise, the information in the top 10 tips for pregnancy article apply.
Used with permission from Dr Jacob Teitelbaum's free newsletters-available at www.Vitality101.com
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