Fibromyalgia syndrome (FS) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, multiple tender points and poor sleep. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders and hips. People with FS may also experience morning stiffness, fatigue, increased headaches or facial pain, irritable bowel syndrome, depression, anxiety and cognitive symptoms (troubles with concentration, short-term memory and handling multiple tasks). Other symptoms include irritable bowel syndrome (IBS), irritable bladder, headache, depression and anxiety.

Diagnosis of FS has been controversial because there are no specific laboratory tests to identify the disorder. Until the 1990s (and even during much of that decade), many health care professionals thought FS was largely psychosomatic (in a patient’s mind), in part because the disease is often associated with depression. In recent years, however, health care professionals have come to understand that psychological factors contribute to an increased risk for disability, and may actually stimulate the central nervous system mechanisms that may lead to fibromyalgia. More important, people with fibromyalgia have been found to have different pain perception thresholds than healthy people or patients with depression only. It has also been found to be different from chronic fatigue, whose victims do not have abnormal pain perception.

According to the American College of Rheumatology (ACR), FS affects three million to six million Americans and is the second most common rheumatic ailment after osteoarthritis. As many as 80 percent of individuals diagnosed with FS are women. The syndrome primarily occurs in women of childbearing age, but children, the elderly, and men also can be affected. FS can be disabling: A survey of fibromyalgia patients found that 15 percent to 25 percent considered themselves disabled and 26 percent were receiving at least one form of disability payment.

Fibromyalgia is an abnormal processing of sensory information in which non-painful stimuli are perceived as painful, and the pain of painful stimuli is increased. The severity of fibromyalgia symptoms varies from person to person. For some women, pain or other symptoms can be so intense that they interfere with daily activities. For others, symptoms may cause discomfort, but are not incapacitating.

Light, unrefreshing sleep is one of the hallmarks of FS. Women with FS often have restless sleep, and may suffer restless-legs syndrome during the day. The problem isn’t with quantity — a woman with fibromyalgia may get eight to 10 hours of sleep but not enough of a form of deep sleep called delta sleep the name stems from the brain wave pattern produced in an electroencephalogram). Lack of deep sleep makes people with or without FS feel achy, tired and less able to concentrate. Sleep problems could thus be not only a symptom of FS, but also an underlying cause of many of the symptoms.

In addition to sleep problems, researchers have found many other links between various health problems and FS:

* FS may arise following an injury or trauma. For instance, a percentage of whiplash victims develop FS. Similarly, in an injury such as carpal tunnel syndrome, which may result in a chronic persistent regional pain, the pain may spread to adjacent areas in the upper extremities and neck, becoming a widespread pain. Sometimes the widespread pain may go on to become fibromyalgia, possibly because chronic, persistent pain can result in a widening of the pain-receptor field within the central nervous system.

* An infectious agent may trigger FS in susceptible people. Lyme disease is under study as one such trigger — one study found 10 percent to 25 percent of patients with Lyme disease develop fibromyalgia. Another study found a link between small-intestinal bacterial overgrowth and fibromyalgia, with about 78 percent of patients with fibromyalgia and intestinal symptoms having such an infection. Patients whose infection was completely eradicated with antibiotics experienced an improvement in FS symptoms.

* FS is also associated with autoimmune disorders such as systemic lupus erythematosus and rheumatoid arthritis. People with these disorders are at higher risk of developing FS, however the reverse is not true. Women with fibromyalgia who develop Raynaud’s phenomenon, characterized by extreme sensitivity to cold in the extremities, may be misdiagnosed as having lupus or scleroderma.

* Recent studies show that some women with fibromyalgia may have abnormally low levels of growth hormone. People whose bodies make inadequate amounts of growth hormone experience many of the same symptoms as people with fibromyalgia. These low levels of growth hormone may be related to disturbed sleep or circadian rhythms.

Central sensitization has been proposed as the unifying concept for FS and related conditions such as chronic fatigue syndrome, irritable bowel syndrome, Gulf War syndrome, and temporomandibular pain and dysfunction syndrome. There are especially strong links between irritable bowel syndrome and fibromyalgia and between chronic fatigue syndrome and fibromyalgia. More than half of women with IBS or CFS also have fibromyalgia symptoms.

In central sensitization disorders, the nervous system develops heightened sensitivity in response to trauma, stress or overstimulation. This sensitivity can make ordinarily nonpainful stimuli — such as mild pressure on the skin or muscle exertion — painful. Abnormal levels of biochemicals such as hormones and neurotransmitters (chemicals that relay pain signals and other sensations) appear to be the direct physical agents.

A neurotransmitter is a chemical substance released by nerve cell endings to transmit impulses across the space between nerve cells, tissues or organs. In the brain, these chemicals — such as serotonin, dopamine and norepinephrine — affect mood as well as other emotional and physical functions.

The sensation of pain and quality of sleep may be modified by levels of neurotransmitters. Low levels of norepinephrine and serotonin have been implicated in fibromyalgia, and drugs such as Elavil — which boosts the levels of serotonin — may help relieve pain and improve sleep in some women with fibromyalgia.

Fibromyalgia is difficult to diagnose because many of the symptoms mimic those of other diseases. A health care professional reviews a patient's medical history and makes a diagnosis of fibromyalgia based on a history of chronic widespread pain that persists for more than three months. The American College of Rheumatology (ACR) has developed criteria for diagnosing fibromyalgia. According to ACR criteria, a person is considered to have fibromyalgia if he or she has widespread pain in combination with tenderness in at least 11 of 18 specific tender point sites.

Irritable bowel syndrome (IBS) is a common disorder of the intestines that leads to abdominal discomfort or pain, bloating and changes in bowel habits. The abdominal pain or cramping can be a dull ache over one area of the colon, or several areas and, for some women, it can be intolerable and without relief. It can also lead to a tired feeling and even low-grade depression. Some people with IBS suffer from constipation, others from diarrhea and some people experience bouts of both. If you have IBS, you may feel the urge (perhaps accompanied by cramps) to move your bowels but have to strain to do so. Sometimes, individuals with IBS pass mucus with their bowel movements.

According to the International Foundation for Functional Gastrointestinal Disorders (IFFGD), a nonprofit education and research organization founded in 1991, approximately 15 to 20 percent of all U.S. adults are affected by IBS, which involves an abnormality of the muscular action that passes food along the colon, as well as an increased sensitivity of the nerves in the colon. The syndrome can affect men and women of all ages, but it most often strikes the young and female. IBS generally first appears in people in their 20s to 40s, and women are roughly three times more likely than men to suffer from it. Women with IBS seem to have more symptoms during their periods, suggesting that reproductive hormones may play a role in this disorder.

IBS is a major women's health issue. Data reveals an increased risk of unnecessary surgery for extra-abdominal and abdominal surgery in IBS patients, according to the IFFGD. For example, hysterectomy or ovarian surgery has been reported in as many as 47 to 55 percent of female patients with IBS.

"Syndrome" refers to a collection of symptoms, not just one or two. In fact, IBS isn’t a disease; it is considered a "functional disorder" because there is no sign of disease. It can strike otherwise healthy people. The causes are multiple: biologic, psychologic and social factors can all contribute to symptoms.

A small percentage (about 10 percent) of IBS patients report that their symptoms appear to have originated shortly after a bacterial infection, such as severe gastroenteritis. Clinicians have recognized this “post-infective IBS” for many years and there is increasing evidence that, in at least a subset of patients, infection and inflammation may play key roles.

IBS is indeed irritable, often causing a great deal of discomfort and distress. But the good news is that the syndrome does not cause permanent harm to the intestines, it doesn’t lead to intestinal bleeding and it doesn’t cause cancer or inflammatory bowel diseases (such as Crohn's disease or ulcerative colitis). Moreover, if you have IBS, you may not suffer all the time: some people can go for weeks or months with no symptoms. Others may experience symptoms daily. Also, it is possible — by paying attention to the triggers of your symptoms — that you can modify your diet, make lifestyle changes to reduce stress and use medication to reduce these symptoms.

Depression and anxiety disorders can aggravate IBS, and some research indicates that the syndrome may be more common among people who were abused as children. But psychological factors notwithstanding, the symptoms are real and have a physiological basis. While stress may aggravate IBS symptoms, other factors — particularly colon motility and sensitivity of the nerves in the colon — play an important role. (Colon motility — the contraction of intestinal muscles and movement of its contents — is controlled by nerves and hormones.)

While there is no cure, you often can control symptoms through diet, stress management and prescription drugs. IBS is rarely debilitating, but in some cases, it restricts the ability to attend school or social functions, go to work or even travel short distances.

IBS has been called by many names, including colitis, mucous colitis, spastic colon, spastic bowel and functional bowel disease. Some of these terms are inaccurate. Colitis, for instance, means inflammation of the large intestine. IBS, however, does not cause inflammation and should not be confused with another disorder, ulcerative colitis. There is no evidence that IBS leads to more serious medical problems such as colitis or cancer or that it affects life span in any way. However, left untreated, the symptoms will often persist, leading to pain and discomfort.

The colon, or large intestine, is about six feet long. Its primary function is to absorb water and salts from digestive products that enter from the small intestine. About two quarts of liquid matter enter the colon from the small intestine each day; it can remain there for days until most of the fluid and salts are absorbed. The leftover matter — the stool — then passes through the colon by a pattern of movements to the left side of the colon, where it is stored until a bowel movement occurs.

Movements of the colon propel the contents slowly back and forth but mainly toward the rectum. A few times each day strong muscle contractions move down the colon pushing fecal material; some of these contractions result in a bowel movement.

Adequate restful sleep, like diet and exercise, is critical to good health. Sleep allows your body to rest and restore energy, while at the same time carry out important physiological and psychological functions that affect your physical and mental well-being.

Healthy sleep is defined as whatever amount and quality of sleep is needed to maintain optimal alertness while awake. Most adults need about eight hours of sleep each night, although ideal sleep requirements are highly individualized. Children and adolescents need much more than eight hours, but after age four, require little to no daytime sleep. Many people don’t get the ideal amount of sleep they need and become chronically sleep deprived. For others who suffer from sleep disorders, such as narcolepsy and other illnesses, sleep is not refreshing.

Research has shown that sleep loss accumulates over time, causing a sleep debt. Insufficient restful sleep can result in mental and physical health problems, low energy , memory lapses, and difficulty maintaining equilibrium.

Typical sleep patterns can be disrupted by many factors:
* stress
* family demands or an overly busy schedule
* hormonal influences and changes in core body temperature (e.g., during ovulation or menstruation, hot flashes and night sweats characteristic of menopause)
* dieting, which can lower a woman’s body temperature
* symptoms of pregnancy, such as body aches, nausea, leg cramps, fetal
movements and heartburn
* depression, anxiety and worry

Sleepiness and Fatigue
In 1998, the National Sleep Foundation (NSF) conducted a national poll of 1,012 women between the ages of 30 and 60 to better understand the impact of sleepiness and fatigue. Thirty-one percent of the women polled reported some daytime sleepiness and 25 percent reported significant daytime sleepiness. As a result of disturbed sleep, 27 percent reported impaired job performance; 24 percent reported impaired ability to care for the family; and 14 percent said that they fell asleep while driving.

For many women, feeling tired is simply the result of hectic and demanding lifestyles that make it difficult to get a full night’s sleep. However, this tiredness can be a sign of an underlying medical condition. What’s more, sleepiness and fatigue are two distinct problems that signal different kinds of medical conditions.

Sleepiness during the day, or excessive daytime sleepiness (EDS), is defined as an inability to stay awake, especially in situations when wakefulness is important — at work, while caring for children and behind the wheel of a car. Fatigue, on the other hand, is a state of overwhelming sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. In general, EDS can be a symptom of a sleep disorder or insufficient sleep, while fatigue can occur even after a full night’s sleep and is associated more with neurological conditions such as multiple sclerosis or Parkinson’s disease, and psychiatric conditions such as depression.

While the medical community distinguishes between sleepiness and fatigue, both conditions negatively affect quality of life, performance, safety and productivity.

Sleep Disorders
There are nearly 70 different sleep disorders. Four of the most common disorders are described below.

* Insomnia, the most common sleep disorder, is defined as difficulty falling and staying asleep every night or most nights despite an adequate opportunity to sleep. Other symptoms of insomnia include waking up too early in the morning and being unable to fall back to sleep, and experiencing an unrefreshing night’s sleep. As a result of a poor night’s sleep, one usually feels tired and irritable the next day and has trouble concentrating on everyday tasks. Insomnia also can be a symptom of other physical and mental conditions, such as depression.

Insomnia can last one night or up to several weeks. Transient insomnia lasts for short periods of time and is described as “intermittent” when it occasionally re-occurs. Chronic insomnia is when episodes occur on most nights and last one month or more. According to the National Sleep Foundation’s 2002 Sleep in America poll, 58 percent of adults surveyed reported experiencing one or more symptoms of insomnia at least a few nights a week in the past year; of that number, 63 percent are women and 54 percent are men. More than three in ten (35 percent) say they have experienced insomnia every night or almost every night.

* Narcolepsy is a condition characterized by sudden sleep attacks during the day. Individuals with narcolepsy may fall asleep at inappropriate times and without warning and repeatedly in a single day. Although it is estimated that narcolepsy afflicts as many as 200,000 people in the United States, fewer than 50,000 are diagnosed. Often mistaken for depression, epilepsy or the side effects of medications, narcolepsy can occur in men or women at any age, although its symptoms usually are first noticed in adolescence and young adulthood. There is strong evidence that narcolepsy may run in families; eight to 12 percent of people with narcolepsy have a close relative with the disease.

Other symptoms that may appear alone or in combination, months or years after onset of daytime sleep attacks, but not necessarily in everyone with narcolepsy are:

* Cataplexy. These sudden episodes of loss of muscle function can range from slight weakness, such as limpness at the neck or knees, sagging facial muscles, or inability to speak clearly, to complete body collapse. Attacks may be triggered by sudden emotional reactions such as laughter, anger or fear and may last from a few seconds to several minutes.

* Sleep paralysis. These episodes, which may last for a few seconds to a few minutes, are characterized by a temporary inability to talk or move when falling asleep or waking up.

* Hypnagogic hallucinations. These vivid, often frightening, dream-like experiences occur while dozing or falling asleep.

Daytime sleepiness, sleep paralysis and hypnagogic hallucinations also can occur in people who do not have narcolepsy. The development, severity and order of appearance of symptoms vary from person to person. Only about 20 to 25 percent of people with narcolepsy experience all four symptoms. Excessive daytime sleepiness generally persists throughout life, but sleep paralysis and hypnagogic hallucinations may not. The symptoms of narcolepsy, especially the excessive daytime sleepiness and cataplexy, can become severe enough to cause serious disruptions to personal and professional life and severely limit activities.

* Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. It is characterized by brief interruptions of airflow during sleep.

Obstructive sleep apnea, the most common form of apnea, occurs when airflow is blocked, often due to the narrowing of the airway by excess tissue, enlarged tonsils or a large uvula (the small fleshy pendulum of tissue that hangs from back portion of the soft pallet on the roof of the mouth).

When air cannot easily flow into or out of the nose or mouth, the lungs respond by pulling harder, causing suction. This can result in heavy snoring or a pause in airflow, low levels of oxygen and increased levels of carbon dioxide in the blood, which in turn alerts the brain to resume breathing, causing an arousal. With each abrupt change from deep sleep to light sleep, a signal is sent from the brain to the upper airway muscles to open the airway; breathing is resumed, often with a loud snort or gasp.

Frequent arousals, although necessary for breathing to restart, prevent restorative, deep sleep. Drinking alcohol or taking sleeping pills increases the frequency and duration of breathing pauses by sedating the brain and preventing the arousal.

Sleep apnea occurs in all age groups and both sexes but is more common in men. However, it simply may be under diagnosed in women. As many as 18 million people in the U.S. suffer from sleep apnea. Four percent of middle-aged men and two percent of middle-aged women experience sleep apnea along with excessive daytime sleepiness (EDS), and the rate of sleep apnea increases in women over age 50. Although not everyone who snores has this condition, if you snore loudly and also are overweight, have high blood pressure, or have some physical abnormality in the nose, throat or other part of the upper airway and are excessively sleepy, you may well have sleep apnea. This sleep disorder seems to run in some families, suggesting a possible genetic predisposition to the condition.

* Restless legs syndrome (RLS), also called Ekbom’s syndrome, is a sleep disorder characterized by unpleasant sensations in the legs or arms, often described as creeping, crawling, tingling, pulling or painful. These symptoms occur when lying down or sitting for prolonged periods of time, such as at a desk, riding in a car, watching a movie or trying to sleep. RLS symptoms tend to follow a set daily cycle, with the evening and night hours being more troublesome than the morning hours. The sensations usually occur in the calf area, but they can occur anywhere from the thigh to the ankle. One or both legs may be affected; for some, the sensations also are felt in the arms. RLS produces an irresistible urge to move your legs when the sensations occur, making sleep almost impossible. If you have RLS, you probably sleep best toward the end of the night or during the morning hours. Symptoms may improve, then worsen and improve again, over the years.

Many people with RLS also have a related sleep disorder called periodic limb movements in sleep (PLMS). PLMS is characterized by involuntary jerking or bending leg movements during sleep that typically occur every 10 to 60 seconds. Some people may experience hundreds of such movements per night, which can wake them, disturb their sleep and awaken bed partners.

As many as two to five percent of the population has RLS with varying degrees of intensity. The National Sleep Foundation’s 2001 Sleep in America poll showed that 14 percent of adults report symptoms of RLS a few nights a week, with 57 percent saying that it kept them from sleeping. Symptoms can begin at any time, but are usually more common and more severe among older people. Children with RLS are sometimes thought to have "growing pains" or may be labeled hyperactive because they cannot easily sit still in school.

* Circadian rhythm disorder is a disruption of the body’s natural psychological and biological rhythm. More than 100 million people have some kind of sleep disorder that affects the body’s circadian rhythms. Shift workers who work non-traditional hours — usually between 10 p.m. and 6 a.m. — are particularly vulnerable to this condition. According to the U.S. Department of Labor, 10 percent of all companies operate at night, and more than 15 million Americans (about 20 percent of the work force) work the late shift. Other people who are at risk for disrupted circadian rhythm are those who frequently travel and experience jet lag, individuals with irregular sleep patterns and people with a genetic predisposition for this problem.

* Fatigue can be a sign of an underlying neurological or psychiatric disorder. The most common neurological disorders associated with fatigue are multiple sclerosis (MS) and Parkinson’s disease (PD). Up to 87 percent of people with MS report that fatigue is a debilitating feature of the disease. Fatigue affects up to 96 percent of people with PD and can be caused by muscle stiffness and tremors symptomatic of PD, or the medication used to treat these and other symptoms of the condition.

Fatigue also is a common symptom of depression, as is a change in sleeping patterns – either sleeping too much or too little. One in five women will experience depression at some point in her lifetime. About 20 percent of people with depression experience fatigue or excessive sleepiness.