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By Ginevra Liptan, MD *Links may generate a commission for this site

Fibromyalgia pain stems from inflamed and stuck fascia, the connective tissue that runs like a three-dimensional web throughout the body. It surrounds and supports every cell, nerve, organ, muscle, and bone in your body. When it is restricted, it dehydrates and becomes like glue. It not only loses its mobility, but it can also exert force on underlying structures — up to 2,000 lbs. per square inch! This tension creates pain, reduces range of motion and can cause bizarre, seemingly unrelated symptoms when fascia entraps nerves.

Additionally, fascia is tightly integrated into the autonomic nervous system. It is particularly effective at contracting throughout the entire body when the nervous system is in fight-or-flight mode, all in the interest of keeping us safe. But in a condition such as fibromyalgia, the chronic activation of the fight-or-flight mode leaves the fascia in a constricted, tense state, which leads to pain and dysfunction.

Manual therapies that gently unstick these tight areas of fascia, such as the John F. Barnes Myofascial Release Approach (MFR) can be hugely helpful in reducing fibromyalgia pain. In fact it is MFR that gave me enough improvement in pain that I could get back to medical school after developing fibromyalgia. MFR involves applying gentle, sustained pressure into these connective tissue restrictions to eliminate pain and restore motion. By going slowly and waiting for the body’s natural rhythm, the fascia responds by elongating, rehydrating, and reorganizing. 

 But you don’t have to take my word for it! In two European studies, after 20 sessions of MFR fibromyalgia subjects reported significant pain reduction. What was really great about these studies is that they showed long-lasting pain relief, with subjects reporting reduced levels of pain one month and six months after their last session. I also led a pilot study at Oregon Health and Science University that compared six sessions of myofascial release to standard massage for fibromyalgia, and the MFR group had greater pain reduction.

 MFR is a hands-on treatment performed on the skin with no oils or creams. The gentle tension between the therapist’s hands and the patient’s skin is what allows access to the fascia in a way that the gliding effect of traditional massage cannot achieve. By following the unique lines of tension in each patient’s body, the MFR therapist can reach deeply into the tissues and uncover significant restrictions.

MFR is also something that you can learn to do at home on yourself. In fact, a 2017 study found that program of self-myofascial release reduced fibromyalgia pain and fatigue, and improved quality of life. Even doing 5 minutes a day of MFR can make a huge difference. To learn how to do this I highly recommend this self-treatment video series.

Compared to other forms of bodywork, myofascial release is very gentle and slow. Generally speaking, traditional massage and physical therapy techniques can hurt people with chronic pain because often the therapists are trying to force through fascial restrictions, and the patient’s body reflexively tenses and causes a flare. MFR never forces, but rather gently waits for the body to release restrictions on its own schedule. This eliminates most of the pain from traditional bodywork.

However, each person’s fascial restrictions are different, and addressing some very old or “stuck” restrictions can generate a temporary painful "healing crisis” that ultimately has the end result of lower pain and improved tissue health. You can find a qualified therapist at mfrtherapists.com. 

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD *Links may generate a commission for this site

Someday CBD (cannabidiol) may be given as first aid for stroke and brain injuries to lessen the brain damage caused by lack of blood flow. In fact, there is increasing evidence for CBD’s protective effects on brain and nerve cells exposed to damage from many different types of injuries due to inflammation, lack of oxygen, or toxins. 

But until recently we didn’t understand exactly how CBD acted to protect neurons. A recent Chinese study discovered that the CBD’s neuroprotection is due to its effects on mitochondria, the furnaces that produce energy in our cells. And this means CBD might be able to help mitochondrial function in other conditions like fibromyalgia, too.

This study reproduced a stroke-like injury in mouse neurons by first depriving them of oxygen and glucose (what happens when the brain is not getting enough blood flow during a stroke), and then added back glucose and oxygen (simulating reperfusion when blood flow returns to brain). Both parts of this process are damaging to brain cells, initially due to absence of oxygen and nutrients, and then by a massive release of inflammation and toxic chemicals when blood flow returns.

Click image to enlarge

This type of damage is called an ischemia/reperfusion injury and results in significant cell injury and cell death. However, when these researchers added CBD to neurons it dramatically reduced how many neurons were damaged or destroyed, as you can see in the figure at right from the study. “The administration of CBD during reperfusion markedly attenuated the morphological damage and the cells maintained a normal appearance.”

CBD protected cells from death and damage in two ways, the study found. First, CBD stimulated mitochondria to produce energy more efficiently from glucose, essentially extending the amount of time brain cells could survive during an “energy crisis.” CBD also enhanced the mitochondrial product of antioxidants, which defend against the type of damage created during a stroke. 

According to the study authors, “These data suggest that CBD is a mitochondria-targeting drug that markedly enhances mitochondrial function and bioenergetics, thus exerting potent protective effects against pathological conditions.”

In addition to the huge potential application in emergencies such as stroke, the ability of CBD to boost mitochondrial function has relevance for fibromyalgia treatment as well. Poorly functioning mitochondria due to excessive fight-or-flight nervous system signals are key contributors to the fatigue and fog in fibromyalgia. It is possible that CBD might have similar energy boosting effects for our mitochondria, resulting in long-term benefits to lessen brain fog and improve brain function. CBD needs to be studied for its effects on the fibromyalgia brain. Lady Gaga, I am looking at you for help in funding research on this!

Learn more about boosting mitochondrial function in fibromyalgia in Chapter 13 of The FibroManual, and more about CBD for fibromyalgia symptom reduction here

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD        *Links may generate a commission for this site

Partly due to lack of access to effective pain medications, many people with chronic pain and fibromyalgia turn to over-the-counter herbal treatments such as kratom. While this plant definitely has some pain-relieving potential, there are concerning safety and side effects that need to be considered. This article reviews our current scientific understanding of this intriguing plant.

Botany:
Kratom (Mitragyna speciosa)is a tree native to Thailand and swampy areas of Southeast Asia. It is in the plant family Rubiaceae, which also includes the coffee plant. 

Traditional Use:
The chopped fresh or dried leaves of the tree are chewed or made into tea by local farmers and manual laborers to combat fatigue and improve work productivity. In addition, kratom preparations have traditionally been used to treat fever and pain, and more recently to treat opioid dependence. Despite its widespread use, Thailand banned it in 1943 due to its abuse potential, as did Malaysia in 2004. 

Status in the US: 
More than two million Americans consume kratom every year, where it is sold over the counter as a supplement. This means it doesn’t have to pass through federally mandated testing or clinical trials and is not regulated for purity or potency. It has been banned in six U.S. states: Alabama, Arkansas, Indiana, Tennessee, Vermont, and Wisconsin. In 2016, the DEA initiated a formal process to make kratom a Schedule I drug, one with “no currently accepted medical use” such as heroin. However, the DEA backed off after a public outcry and regulation still remains in the hands of the FDA. 

Medicinal Actions:
·          Kratom’s effects on the body are dosage dependent. In lower doses it acts as a stimulant, resembling the effect of drugs such as cocaine or amphetamines. In larger doses it acts as a pain reliever and can have sedative effects that resemble drugs such as opiates.
·          The primary active ingredients of kratom are mitragynine and 7-hydroxymitragynine, which bind to some of the same receptors in the brain as opioids. They have analgesic effects comparable to morphine, but cause less constipation, respiratory depression, and tolerance compared to opioids such as morphine. They also have some anti-inflammatory effects. 
·          Chronic kratom users can develop a tolerance and experience symptoms of withdrawal. The symptoms of withdrawal are almost identical to opioid withdrawal (insomnia, anxiety, diarrhea, runny eyes and nose) and are treated in a similar manner. 
·          Pharmaceutical companies tried mitragynine on its own as a treatment, but it caused side effects of nausea and vomiting that halted further development efforts. In studies no compound isolated from kratom exhibits as much benefits as the whole leaves. This is the classic synergistic effect so often seen with herbal medicines. 
·          Kratom pharmacology is complex, containing at least 40 different known phytochemicals, and is thought to have actions on many other receptors in addition to the opioid receptors, including dopamine, serotonin, GABA, and norepinephrine receptors. However, scientists aren’t exactly sure how kratom exerts its stimulant effects.

Side Effects
There are reports of kratom causing elevated blood pressure, toxicity to kidneys and heart, impaired cognition, psychosis, and life-threatening liver failure. Long-term kratom use has been associated with drug dependency, development of withdrawal symptoms, and cravings. Long-term addicts can develop skin pigmentation on their cheeks, due to the capacity of mitragynine to increase the production of melanocytes-stimulating substance. 

We are also now learning that kratom has some of the same hormonal side effects as opioids. One of my male patients reported erectile dysfunction due to kratom, and a medical journal published a case of kratom causing increased prolactin and low testosterone levels.

Safety issues
Although kratom has less respiratory suppression effects compared to opioids such as morphine, it still can be a deadly substance when mixed with other compounds. There are case reports of overdose deaths due to mixtures of kratom with over-the-counter cold medications, sleep medications, or benzodiazepines (such as Valium). At present, kratom constituents are not detected by conventional drug screening tests, making it hard for health care providers to screen for abuse.

The other major safety issue is that kratom is sold only on the unregulated supplement market, meaning it can be adulterated with other medications. In Sweden, kratom laced with the active ingredient of tramadol was associated with several overdose deaths. Unregulated supplements can also be contaminated with bacteria or toxins, as occurred in a multistate Salmonella outbreak that prompted the Centers for Disease Control and Prevention to issue a warning about kratom to consumers. 

A recent scientific article on kratom recommended “testing and labeling requirements should be implemented to inform consumers of alkaloid contents and to protect consumers from adulterated products.” 

Conclusion
Everyone in chronic pain would agree that we absolutely need more treatment options, not less. In particular, we must find safer treatments that give the benefits of opioids with fewer side effects and less addiction risk. To me, kratom has some exciting therapeutic potential on that front, but is not ready yet for medicinal use due to some unanswered questions about safety and lack of reliable access to high quality, standardized products. 

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief

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By Ginevra Liptan, MD        *Links may generate a commission for this site 

Since the launch of Frida Botanicals CBD products, I have received a lot of great questions about CBD. I answered some of them in this blog post, and answer more below.

Should I smoke or vape CBD, use a CBD oil under my tongue, or take a CBD capsule? 
When comparing these three methods of taking CBD, you want to look at safety, absorption, speed of onset, and duration of effect. 

First let’s look at absorption rates, which means how much will actually get into your bloodstream and be able to exert medicinal effects. Here are the estimated absorption rates for CBD based on a recent review article:
·      Inhalation (smoking or vaping): 31%
·      Sublingual (oil held under the tongue): 22-25%
·      Ingestion (swallowing capsules or liquid): 13-19% 

Another way to look at this how many milligrams will actually get into your bloodstream from a given dose of CBD in each of these routes. For a 30mg dose this translates to:
·      Inhalation: 9.3 mg
·      Sublingual: 7 mg
·      Ingestion: 4.8 mg

Pros and Cons to each method:
While inhalation has the highest absorption rate, it is not ideal for medical usage, as smoking anything can irritate and inflame lung tissue. This is the fastest way to get CBD into your system, usually within minutes, but also has shortest duration of effect.

Ingestion has the lowest absorption rates because the liver filters out most of the CBD on its way from the GI tract to the bloodstream. This is also the slowest method, taking around three hours to reach maximal effect, but gives the most prolonged effect.

The sublingual route bypasses the liver, as CBD is absorbed directly into the blood vessels under the tongue. This route also offers fast entry into your system, and the longer you can hold the CBD oil under your tongue, the more gets into your bloodstream that way. After holding under the tongue, the rest of the CBD oil is swallowed and further absorption via the GI tract occurs. 

So sublingual use gives the best of both worlds: rapid-onset and a prolonged duration. This combined short-acting and long-acting effect explains why sublingual use can be so helpful for improving sleep issues as it can address problems both falling asleep and staying asleep. 

Sublingual CBD is safer than smoking or vaping, and more cost-effective than capsules due to the higher absorption rates. However, for some the taste or texture of CBD oil in their mouth is not palatable, and there are rare reports of stomach upset with CBD oil. In that case I think CBD capsules are a good option, and I like PlusCBD oil gel caps. 

Should I take CBD on an empty stomach or with food?
It can be taken either way, but if you want to maximize absorption, or if you have a sensitive stomach, it is best to take CBD with meals or within an hour of eating. A few human studies have found increased absorption from the GI tract when it is taken with food, especially fatty foods. And in rats given CBD orally, when combined with lipids it increased systemic availability by almost threefold!

Does CBD cause QTc prolongation?
Some medications can lengthen the amount of time it takes the heart to recharge between beats, also called QTc prolongation. However, CBD does not cause QTc prolongation. This study looked at a THC/CBD combination medication found it had no effect on any cardiac parameter including heart rate, atrioventricular conduction, or cardiac depolarization. However, THC on its own (not given with CBD) is known to increase heart rate so should be avoided if you have abnormal heart rhythms like atrial fibrillation. 

How exactly does CBD affect mood?
CBD has been shown to lessen anxiety in humans, and it does so through actions on a variety of brain receptors but primarily those for serotonin. One exciting study shows CBD has a rapid-onset antidepressant effect on the brain by promoting changes in synaptic plasticity and release of growth factors such as BDNF (brain-derived neurotrophic factor). This study was on mice, but CBD is thought to have similar effects on the human brain which may contribute to its mood-boosting effects, along with actions at the serotonin receptors.

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD        *Links may generate a commission for this site

In the first two parts of this series, we discussed the different ways that fibromyalgia can affect libido and how to improve it. Another huge factor affecting sexual enjoyment in fibromyalgia is pain—both widespread pain and painful intercourse can wipe out any enjoyment of sex. To lessen overall fibromyalgia pain, the focus is on reducing inflammation, lessening pain triggers, along with specific pain-reducing treatments. You can learn more about my approach to reducing fibromyalgia pain in The FibroManual.

In this post I want to talk specifically about how to lessen pain experienced during sex. In fibromyalgia it can hurt to have pressure on the hips or weight on the body, and creativity may be required to find the most comfortable position. Taking a short-acting opiate pain medication just before sex can be helpful to reduce overall pain, but many of my patients find this can make achieving orgasms more difficult or less satisfying. Opiates use the same receptors in the brain as do the endorphins released during orgasm, so can blunt the orgasm experience. 

However, cannabis (marijuana) derived treatments do not have these issues, and in fact are more often associated with increased sexual enjoyment. If using cannabis systemically is not an option for you, consider applying a topical cannabis (THC plus CBD) or a CBD-only balm to painful areas around hips and low back 30–60 minutes prior to sexual activity.

But what if the actual act of intercourse is physically painful? Pelvic soft-tissue pain with intercourse is really common in fibromyalgia. Sometimes this pain is due to muscle tension from excessive fight-or-flight nerve signals, so doing activities to activate a relaxation response like taking a hot bath, gentle stretching, deep breathing, or meditation can allow for softer muscles and less pain. Other times pelvic soft-tissue pain is due to myofascial restrictions and trigger points in the pelvic floor muscles, which frequently occur in fibromyalgia. Severe fascial adhesions and restrictions are often seen in women that have had multiple abdominal or pelvic surgeries or suffer from endometriosis.

In fibromyalgia a combination of muscle tension and myofascial restrictions both contribute to pain with intercourse. Targeted manual therapy such as myofascial release is the best way to gently break up those adhesions. In my personal experience, the John Barnes Myofascial Release Approach is the specific form of manual therapy that is most effective at reducing both overall fibromyalgia pain and painful intercourse. 

Manual therapy for painful intercourse or pelvic pain often does involve internal vaginal and/or rectal work, so it is really important to find a therapist you trust. Sometimes intense emotions around past sexual traumas can come up during treatment as well. Releasing these stuck emotions is an important part of the healing process, and is yet another reason why feeling comfortable with your manual therapist is so key. To find a local provider in your area, visit www.mfrtherapists.com.

Several studies support the effectiveness of manual therapy directed at the pelvic fascia to reduce pain with intercourse:
·        One study reported this technique both reduced painful intercourse and increased orgasms: “Several of our patients volunteered the fact that they were having ‘the best sex, the best orgasms ever.’” (I will say this article was much more interesting than the usual dry scientific articles that I read!)
·        In a small study on manual physical therapy for pelvic floor dysfunction, 9 of 16 patients were able to return to pain-free intercourse after treatment with a combination of myofascial release, joint mobilization, muscle energy techniques, stretching, and neuromuscular reeducation.
·        57% of those getting targeted myofascial release reported improvement in chronic pelvic pain compared to only 21% who received standard massage.

In addition to myofascial release therapy, one other important way to lessen painful intercourse is to ensure there is adequate vaginal moisture, which may mean using a sexual lubricant. There are CBD and cannabis infused lubricants that a few of my patients report lessened pain and increased pleasure with intercourse. For post-menopausal women, estrogen applied topically or vaginally can help to restore natural lubrication. 

Since orgasms generate a huge release of natural pain-relieving endorphins and oxytocin, they can be a valuable contribution to our pain-management tool box in fibromyalgia. And orgasms help us remember that our body is not only a source of pain, but also a source of pleasure.

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD * Links may generate a commission for this site

In part one of this series on sex and fibromyalgia, we dove into investigating and treating low libido. Now let’s discuss oxytocin, a brain chemical that modulates bonding and social behaviors. It is sometimes referred to as the “love hormone” because levels of oxytocin increase during hugging and orgasm. Some researchers have proposed a correlation between the concentration of oxytocin and the intensity of orgasm.

Oxytocin is being explored as a treatment for low libido and sexual dysfunction. In addition to sexual benefits, studies have shown it may benefit depression, anxiety, autism, obsessive compulsive disorder (OCD), and leaky gut

There is even some evidence that oxytocin reduces pain by binding to opioid and cannabinoid receptors in the brain and stimulating the brain to release endorphins, and has been suggested as a treatment for chronic pain. 

One study found that blood levels of oxytocin were no different in fibromyalgia subjects compared to health controls. However in that same study they found lower amounts of oxytocin for those who reported higher fibromyalgia pain levels. 

Daily oxytocin nasal spray (80 IU once a day) did not reduce fibromyalgia pain in one small study, but was found be safe and well tolerated. Typically, when being used for pain management, you would use it three to four times daily, so that might explain the lack of benefit.

More Studies on Oxytocin for Pain
·      Oxytocin placed in the spinal fluid resulted in dose-dependent reduction of pain in a placebo-controlled evaluation of men and women with acute or chronic low back pain
·      Intranasal oxytocin reduced headache frequency and pain severity in a sample of individuals with chronic migraine 
·      Oxytocin nasal spray increased pain thresholds in healthy adults for a noxious cold-water stimulus when compared to placebo

As a brain chemical, oxytocin is associated with empathy, trust, sexual activity, and relationship building. In 2012, researchers reported that people in the first stages of romantic attachment had higher levels of oxytocin, compared with non-attached single people. Those couples with higher oxytocin levels at the first assessment were more likely to still be together six months later.

Another study analyzed the acute effects of intranasally administered oxytocin on sexual drive, arousal, orgasm, and partner interactions. They found it increased the intensity of orgasm and contentment after sexual intercourse. These effects were more pronounced in men, but female participants also had some benefit and reported feeling more relaxed and able to share sexual desires and connect with their partners. And a case report described a male who had significant, broad-spectrum improvements in sexual function during a course of intranasal oxytocin treatment for social anxiety.

However, a longer-term study of the effects on oxytocin or placebo self-administered by women within 50 minutes before sexual intercourse found that both groups reported about equal improvement in sexual function and desire. Since the placebo receivers also reported significant benefit, the researchers theorized that perhaps the real benefit came from the increased focus on sex and increased communication with sexual partners required by participation in the study. 

Several of my patients who tried it for libido report that oxytocin makes them “more in the mood for sex.” Just like any treatment, it does not work for everyone, but nobody had any side effects. A few patients who tried taking oxytocin regularly 3–4 times a day did report some pain and anxiety improvement. 

Oxytocin can be given intranasally or sublingually, but not orally as it is rapidly destroyed by enzymes in the GI tract. It is usually given as a sublingual immediate release tablet or more commonly as a nasal spray. Oxytocin requires a prescription and it has to be obtained from a compounding pharmacy. For libido, a typical dosage is 24IU intranasal spray 30 minutes before desired sexual activity. Some providers are trying a new approach of topical oxytocin cream for vaginal lubrication for post-menopausal dryness and low libido. 

Coming up in part three of this series, we will cover strategies to make intercourse less painful.

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctorand The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD

Lack of desire for sex is a really common issue with fibromyalgia. Although it can be an awkward topic, lack of sexual intimacy can be a huge strain on relationships and quality of life, so it is important to find the specific causes and address them head on. 

The top three fibro sex blockers are:
·      Fatigue
·      Pain with intercourse 
·      Low libido or sexual desire

Generalized fatigue from any cause, including fibromyalgia, will wipe out interest in sex. Because when you are exhausted and foggy and climb into bed, activity of any type, even pleasurable, is not going to win out over sleep. It is just not. 

To lessen fatigue we have to first focus on that other important bedroom activity: sleep. Improving sleep quality is the foundational treatment to lessen fatigue in fibromyalgia (learn how to do this in The FibroManual). Less fatigue means more energy for sexual activity. But there are two other major factors that can limit sexual desire and enjoyment in fibromyalgia—painful intercourse and low libido—that need to be found and treated to get back sexual inspiration. 

Treating Low Libido in Fibromyalgia
·      Activate the relaxation response 
·      Limit medications suppressing arousal
·      Look for and treat adrenal burnout and low testosterone levels
·      Treatments to boost libido like oxytocin

In fibromyalgia our nervous system is constantly in fight-or-flight or “danger” mode, and this really drains any sexual desire. There has to be a certain amount of relaxation of the nervous system in order to allow arousal feelings to arise. This means we have to specifically activate our body’s relaxation response to convince the brain to let down its guard and move into sexual desire and arousal. Deep breathing, gentle stretching, yoga, laughter, meditation, and taking a bath are all ways we can move the nervous system to relaxation mode. 

Foreplay can also serve as a relaxation trigger. Ask your partner to touch you in gentle ways that feel good or comforting. Many of my patients find that it takes more foreplay before their bodies start to respond sexually. This can require a lot of good communication and patience between sexual partners. 

Medications that calm the brain such as sedatives and anti-anxiety medications can in low doses help to reduce the fight-or-flight response and lighten the brain’s arousal blockade. However, these medications can make someone so sleepy or groggy that they are not interested in sex anymore, so it’s a delicate balance! CBD can be useful here as a non-sedating option. I had one patient who felt CBD really improved her desire for and enjoyment of sex.  

Some types of medications commonly used to treat fibromyalgia can block sex drive. In particular, antidepressant medications that raise serotonin levels in the brain can both lower sex drive and make it more difficult to orgasm. In that case, health care providers often will try changing to a different antidepressant or prescribe a second antidepressant that works on different pathways to counter sexual side effects. For example, the addition of the antidepressant bupropion (Wellbutrin) or the anti-anxiety medication buspirone (Buspar) may ease sexual side effects caused by antidepressants.

Another option is the addition a medication to improve blood flow to the genitals such as sildenafil (Viagra) or tadalafil (Cialis). Although these medications are primarily used to treat erectile dysfunction in men, initial research suggests sildenafil may also improve sexual problems caused by antidepressants in some women. 

Hormones and Low Libido

Adrenal burnout, also called adrenal fatigue, is common in fibromyalgia and is a major libido stealer for both men and women. Our adrenal glands become overworked by the constant demands of the fight-or-flight nervous system and start to make less cortisol and testosterone. In addition to fatigue, the symptoms of adrenal burnout include anxiety, low blood pressure, nausea, and low libido

For any patient dealing with low libido along with other signs of adrenal burnout, it is important to test for adrenal burnout with salivary cortisol and DHEA levels. Often testing will reveal low levelsof DHEA, a building-block hormone the adrenals use to make sex hormones. Sometimes just adding a DHEA supplement is all it takes to get libido levels back up, and other times we may need more thorough adrenal support efforts. Learn more about treating adrenal burnout here and in The FibroManual

Some medications have the side effect of suppressing testosterone levels, which can really interfere with sex drive. Long-term use of opiate-based pain medicines can reduce testosterone levels, and has been coined as opiate-induced androgen deficiency(OPIAD). 

I always check testosterone levels for my male patients on long-term opiates that experiencing sexual dysfunction, and treat with testosterone gels or patches if appropriate.

With women, the issue of testing for and treating low testosterone is trickier. Females do produce testosterone, although at much lower levels than seen in males. And testosterone has some effect on female sex drive, but it is not the whole story, as there are complex interactions between testosterone and estrogen and progesterone. A few studies suggest that low-dose testosterone supplementation improves the sexual function of women that are post-menopausal, but these were associated with some side effects such as increased hair growth and acne. Currently, no testosterone product is FDA-approved for use in treating female sexual dysfunction. Due to side effects, I have found it is a better approach with most women with low testosterone to address the issue indirectly by addressing adrenal burnout and supplementing with DHEA.

In part two of this post, we will discuss boosting libido with oxytocin. Part three will cover strategies to make intercourse less painful. Stay tuned!

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD

Yoga can be “medicine” for fibromyalgia, with several studies showing benefit for pain and fatigue, but like any medicine it has to be the right type and right dosage. Yoga comes in many different styles, from very gentle and meditative to aggressively athletic.

In this article I review the science—and my personal and clinical experience—to help you choose the right form of yoga to ease fibromyalgia pain. (Spoiler alert: It is not the athletic strength-building form!)

One of the biggest underlying contributors to fibromyalgia symptoms are tight and painful fascia and muscles stemming from a continually activated fight-or-flight response. In yoga, physical postures (“asanas”) are generally practiced in tandem with breathing techniques (“pranayama”) and meditation. The combination of gentle stretching and deep breathing lower the volume of the fight-or-flight response and ease tension in the muscles and surrounding fascia.

What does the research on yoga and fibromyalgia show?
Several studies have reported that yoga reduces pain and fatigue, and improves function, in fibromyalgia. All of these studies looked at fairly gentle styles of yoga practice

  • One small study reported that eight weeks of Hatha yoga improved symptoms by about 30%, about the same percentage symptoms improvement seen in studies on the FDA approved medications!

  • A large study of the Hatha yoga style reported significant fibromyalgia pain reduction.

  • Women who participated in an 8-week Yoga of Awareness program—gentle poses, meditation, and breathing exercises—showed significant improvements in pain, fatigue, and mood.

What type of yoga should I choose?
When I recommend yoga to my patients, I sometimes have to do a little convincing, because patients are imagining the type of yoga that involves handstands and getting into pretzel shapes. But that is definitely not what I am recommending, and this is where choosing the right type makes all the difference. Make sure to avoid any classes that have Core, Power, Flow, or Hot in their title, as these tend to be more aggressive and intense and are an almost guaranteed flare! Instead look for classes that are gentle, slow, or restorative.

Generally, the best-tolerated forms of yoga for fibromyalgia are the gentler and slower-styles, such as Hatha, Iyengar, and Yin yoga. Hatha yoga is a gentle, basic yoga that includes stretching and breathing exercises, but no repetition of sequences of poses as seen in Flow or Vinyasa yoga. Iyengar yoga is a specialized type of Hatha yoga that is slow, methodical, and focused on correct musculoskeletal alignment in each posture, which lessens any chance of hurting yourself or generating more pain. I personally have found this precise and slow form of yoga to be a good way to build strength gently without injury or strain.

Yin yoga (also called restorative yoga) is my favorite type of yoga for fibromyalgia pain relief, since it is extremely gentle and involves primarily supported stretching poses. Yin yoga generally uses props such as pillows and bolsters to get you into a comfortable stretch where you rest for several minutes, allowing the fascia to melt and soften. In fact, Yin or Restorative yoga is essentially self-myofascial release and can be highly therapeutic for fibromyalgia.

If you have never tried yoga for fibromyalgia, I highly encourage you to try Yin yoga. There are quite a few free videos on Youtube, but if at all possible it is best to start with live classes so the instructor can help guide you on how to make adjustments for your body. With Yin yoga it is really important to get just the right support so your body is comfortable and can really melt into the pose. Once you have learned the basics from a teacher and are familiar with the feeling of fascia comfortably stretching, you will be able to get a lot more from videos. When doing any yoga class—whether in person or with a video—make sure to listen to your body and skip any postures or stretches that don’t feel right for your body.

And if you are in Portland, my absolute favorite local yoga studio for gentle classes of all types is Unfold Yoga.

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.

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By Ginevra Liptan, MD

You have probably noticed that CBD is being touted as a panacea for many illnesses, including fibromyalgia. According to a recent New York Times article about CBD, “It’s hot, everywhere and yet almost nobody understands it.”

While CBD can certainly help with some fibromyalgia symptoms, it is not a cure-all and does not work for every person. There is a big need to go beyond the hype and look at the experience of real patients, and so I gathered information from a chart review of 20 of my clinic patients that tried CBD. Here are the results from this small, informal study focusing on symptoms for which they found benefit (or not), side effects reported, and total effective dosage.

Click image to enlarge

I specifically looked at whether they reported any benefit on any of three different symptom categories: pain, sleep, or mood. In this chart, green squares represent those that reported benefit for pain, blue squares if it helped mood, and purple if for sleep improvement. I added any specific comments recorded in their chart notes about their individual experience, as these can be really informative.

These patients were using a variety of different hemp-derived CBD brands, mostly sublingual oils. Some tried topical CBD products as well. They were all female with an average age of 52.

Major findings:

Click image to enlarge

  • Average daily CBD dosage was 43 mg per day

  • No one reported any major side effects (a few reported some mild sleepiness or grogginess from CBD)

  • 17 of the 20 patients (or 85%) reported some benefit from CBD for either mood, pain, or sleep

  • 60% found benefit specifically for pain

  • 50% reported CBD helped mood, especially anxiety reduction

  • About 1/3 reported sleep improvement

Of course, we need larger, more formal, and standardized studies on CBD for fibromyalgia, but this report is at least a good start! Learn more about my doctor-formulated CBD products by clicking here.

20 of My Patients' Experiences with CBD... - YouTube

Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.


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By Ginevra Liptan, MD
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Adrenal burnout is common in fibromyalgia and can really worsen fatigue and fog. Adrenal burnout (also referred to as adrenal fatigue) stems from overworked adrenal glands. The hyperactive stress response in fibromyalgia causes the adrenal glands to work hard—all the time. The continual bombardment of stress response on the adrenals in fibromyalgia forces them to try to pump out cortisol at a high rate continuously. This results in overworked adrenal glands that never get a “rest” period until they “burn out” and start secreting cortisol in abnormal patterns.

There are two ways to diagnose adrenal burnout. One is to look at symptoms. If you have many of the symptoms listed above, especially the highlighted ones, this is a strong indication that adrenal burnout may be an issue for you.

Symptoms of Adrenal Burnout
Fatigue
Brain Fog
Low blood pressure/dizziness
Feeling faint when standing up quickly
Nausea
Severe anxiety
Feeling shaky/irritable when you are hungry
Frequent thirst
Salt cravings
Low libido
Dark circles under eye
Multiple food or environmental sensitivities

Click image to enlarge.

The more scientific way to assess the function of the adrenal glands is to look at the pattern of cortisol secretion by measuring saliva levels four times in a day, at around 7am, 11am, 5pm, 10pm.  Any deviation from the normal cycle indicates strain on the adrenals.

Most fibromyalgia patients show mild adrenal burnout with a flattening of the usual curve of hormonal release throughout the day. Several studies have shown this “blunting” of the normal pattern of cortisol secretion in fibromyalgia patients (studies here, here, and here).

My treatment approach to adrenal burnout
I treat adrenal burnout with a combination of supplements for at least three months. Several vitamins and minerals are used heavily by the adrenal glands and may need to be supplemented for adrenal support. These include vitamins C, B5 and B6, and folic acid. Folic acid can be hard for some people to utilize, so I recommend an activated form of folic acid called L-5MTHF. Magnesium is the most important mineral for adrenal function, along with zinc and copper. There are also several important herbs that have balancing effects on the adrenals, including panax ginseng, rhodiola, ashwaganda.  CBD or cannabidiol is also very supportive for the adrenals, and can be useful to add in to any adrenal support protocol, especially if symptoms of anxiety are a big issue for you, with dosing of CBD tincture of 5-20mg up to four times daily.

Don't expect instant results—it usually takes at least a month before your fatigue will lessen. I tell my patients to think of their adrenals as a bowl that they are trying to fill with sand- but they can only put in a pinch of sand at a time, so the supportive nutrients must be given to your adrenals multiple times a day in small amounts. Cases of severe adrenal dysfunction may require six months to a year of this extra support.

In addition to supplements there are other important actions to take for adrenal burnout:

  • Nutritionally, we can support adrenal glands by eating well and emphasizing protein with every meal, and by limiting stimulants like caffeine, sugar, and alcohol.

  • Drinking plenty of water, and increase salt, especially sea salt. I like to add ¼ teaspoon sea salt to 16 oz. of water twice daily (it should be dilute enough that it doesn’t taste salty). This sea-salt water help increase blood pressure by keeping more fluid in your bloodstream and supplies needed minerals to the adrenal glands. Drinking it is useful to stop the “peeing all the time and still feeling thirsty” feeling that is so common in fibromyalgia. If you don’t want to drink dilute sea-salt water, you can also liberally add sea salt to your food along with increasing water consumption. Don’t add sea salt if you have high blood pressure, however.

  • Reducing stress by activating your own relaxation response with deep breathing, gentle stretching and doing things that give you joy.

  • Get as much high quality sleep as you can.

Here is the approach I use at The Frida Center for Fibromyalgia. Keep in mind a few things with this. This is just a general guide and must be adapted to your own personal health situation. It is always best to consult with a health care provider before starting any new treatments. (Click on supplement names for my recommended product.)


Supplement Breakfast Lunch Dinner Bedtime

SR-Adrenal 2 capsules 2 capsules —- —-

L-5MTHF —- —- 1 capsule —-
(Folate 1000mcg)

Magnesium Glycinate 1 capsule 1 capsule 2 capsules 3–4 caps
(120mg capsule)

Ascorbic Acid 1 capsule 1 capsule 1 capsule —-
(1000mg capsule)

Sea-salt Water ¼ tsp sea salt in 16 oz. water, twice daily

Optional: If ascorbic acid bothers your stomach, use less acidic form in Ester-C instead. If magnesium gives you loose stools, take as much as you can tolerate orally and then apply magnesium cream topically.


Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.


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