Dr David L. J. Freed, MB, MD, MIBiol
43-year-old lady referred by her GP with a diagnosis of ’chronic sinusitis, post-viral syndrome, query fibromyalgia’. Apart from the chronic fatigue her main problems were aches and pains, sometimes severe, in the face and in muscles in various parts of the body. She was having frequent ’urinary infections’ for which she was receiving intermittent antibiotics.
Among her most painful areas were her breasts, which frequently became tense, lumpy and irritable. She had been told she had chronic mastitis and she was on the waiting list to have her mammary ducts surgically stripped (!). She had found that if she squeezed and massaged her breasts when they were feeling bad, she could express some pus from the nipples and after that the breasts would feel better for a while.
Examination of the breasts confirmed that they were firm and somewhat fibronodular, as is often the case in fibromyalgia syndrome, but not red or hot. Mastalgia with fibronodularity is a fairly common complaint in FMS, maybe one in 5 or 6 patients that I have seen. There was no fever. I asked her to squeeze out some of the ’pus’, and she did so there and then. There were no inflammatory cells to be seen under the microscope but lots of fat globules. The ’pus’ was normal human milk. She had last breast-fed a baby 17 years previously, and this problem of ’chronic mastitis’ had been persistent ever since then.
Examination of the other painful areas confirmed what by now I was expecting: numerous confluent areas of stiffened tender skin and subcutaneous fascia – the "rheumatic patches" of Fox [I]. These are detected by rolling the skin fold between thumb and fingers, fairly firmly – it usually makes the patient yelp and I am of the view that these rheumatic patches are the primary pathology in FMS, though the pain may well be amplified in the CNS [2]. They slowly respond to a stone-age diet, though it may take months or years. In all, I thought she was pretty typical of FMS, except that (a) the recurrent UTJ’s are often really caused by allergic intestitial cystitis and respond to allergy manoeuvres, but not always and (b) I had not seen this persistent galactorrhoea before.
Harrison’s Textbook of Medicine told me that the commonest cause of galactorrhoea is hyperprolactinaemia brought about by a tumour of the pituitary. Apparently no one had checked her serum prolactin so I asked the GP to organise that, and the result came back raised at 1263 mU/ L (normal range 50-500).
By now I felt pretty sure that she must have a pituitary tumour, particularly since she had listed among her minor symptoms loss of smell and restricted vision, but a scan of the sella turcica was normal. Harrison’s next suggestions were a range of drugs (which she was not taking), a variety of neoplasms and brain diseases (which she did not have), and "idiopathic&qupt;, so I felt we had drawn a blank.
Nevertheless she was still complaining bitterly of the chronic fatigue and pains, so ignoring the unsolved question of the milk secretion I instituted the treatment package that I usually use for FMS, rotating stone-age diet and comprehensive neutralisation to cover all permitted ingestants and a good range of inhalants. I expected her to lose weight, to go through a miserable withdrawal syndrome, and then get better, and to my gratification she did all of those things. To my even greater gratification, the mastalgia and the sensation of fullness in the breasts improved and she no longer felt the need to massage and squeeze her breasts. As a result, they were no longer secreting milk (though she could still express some if she tried). The sense of smell and normal vision returned, and a course of nystatin cleared away the residual brain fog. The "recurrent UTI’s", disappointingly, continued and I could not work out why, but they responded to cranberry juice acid nutrients from my local nutritionist.
Now almost two years later, she has stopped her neutralising jabs but still keeps fairly faithfully to the diet. She does cheat on wheat from time to time and that of course is probably her biggest enemy, she herself notices that when she indulges too much in wheat the fatigue, aches and pains and mastalgia return. When she is strict with the diet the mastalgia and the need to express both disappear. The prolactin is still high.
Fibromyalgia is mainly a female complaint and I have had a special interest in this condition for many years. It has considerable overlap with the other functional syndromes of migraine, lBS. chronic fatigue syndrome, and some forms of depression and my general working hypothesis is that they are all mainly forms of food/chemical intolerance as about the same proportion (around 80%) of each responds (at least somewhat) to my standard therapeutic package. The breast, as we all remember from anatomy, is a modified sweat gland. It is a skin organ. and the weight is entirely carried (apart from the elusive "ligaments of Astley Cooper") by the skin. Following Fox [1], my colleagues and I at Wrightington have located a distinctive mild inflammation in the dermis and superficial fascia in the painful areas, and this appears to be universal in FMS patients (as well as many people with lesser degrees of illness). It seems eminently likely to me that the same process that makes the skin painful will also sometimes make the breast painful. When normal lactation is just ending, as in this case, the sensation of fullness caused by the mild inflammation of FMS is likely to be conflated with that of the milk, leading the woman to express in order to gain relief I suppose that this constant manipulation of the breast has maintained an artificial state of hypcrprolactinaemia and lactation.
When working at Wrightington I am, constrained by the terms of the trial to treat FMS patients with injections only but when I see than in private practice I hit than with diet and desensitisation as well, with much more long-lasting and gratifying results.
REFERENCES
1) Fox WW. Arthritis: Is Your Suffering Really Necessary?
London, Robert Hale, 1981.
2) Freed DLJ, Chattopadhyay C, Gupta I.
Intradermal salicylate injections for fibromyalgia.
J Orthopaed Med (2001) 23:12-15.>/p>
