9. Autoimmune Diseases

Autoimmune Diseases: Overview

• What is an autoimmune disease?
• What are some of the most common examples of autoimmune diseases?
• What causes autoimmune diseases?
• How are autoimmune diseases diagnosed?
• How are autoimmune diseases treated?

What is an autoimmune disease?

The term "autoimmune disease" refers to a varied group of more than 80 serious, chronic illnesses that involve almost every human organ system. In all of these diseases, the underlying problem is similar the body's immune system becomes misdirected, attacking the very organs it was designed to protect. About 75% of autoimmune diseases occur in women, most frequently during the childbearing years. Autoimmune diseases can affect connective tissue. (This is the tissue which binds together various tissues and organs.) It can also affect the nerves, muscles, endocrine system, and gastrointestinal system.

What are some of the most common examples of autoimmune diseases?

Lupus, rheumatoid arthritis, and systemic sclerosis all affect the connective tissue. Multiple sclerosis, myasthenia gravis, and Gullian-Barre syndromes are neuromuscular diseases. On the other hand, Hashimoto's thyroiditis, Graves' disease, and insulin-dependent/juvenile diabetes (type 1) are all related to the endocrine system. Finally, inflammatory bowel disease is an autoimmune disease which attacks the gastrointestinal system.

What causes autoimmune diseases?

Unfortunately, autoimmune diseases remain among the most poorly understood of any category of illness. It is thought that hormones play a role in inducing autoimmune diseases; some cases suddenly improve during pregnancy, some flare-ups occur after delivery, while others will get worse during pregnancy, or flare up after menopause.

Autoimmune diseases seem to also have a hereditary component, but mysteriously, they can cluster in families as different illnesses. For example, a mother may have lupus erythematosus; her daughter, diabetes; her grandmother, rheumatoid arthritis. Research is shedding light on genetic, as well as hormonal and environmental risk factors that contribute to the causes of these diseases.

How are autoimmune diseases diagnosed?

The diagnosis of an autoimmune disease is based on an individual's symptoms, findings from a physical examination, and results from laboratory tests. Autoimmune diseases are difficult to diagnose, especially in the early stages of the disease. In some cases a specific diagnosis cannot be made; the patient must continue to follow up on the disease with frequent consultations with a physician. Although autoimmune diseases are chronic, the course they take is unpredictable. Patients should be monitored closely by their doctors so environmental factors or triggers can be avoided.

How are autoimmune diseases treated?

Autoimmune diseases are often chronic, requiring lifelong care and monitoring, even when the person may look or feel well. Currently, few autoimmune diseases can be cured or disappear with treatment. However, many people with these diseases live relatively normal and healthy lives when they receive the proper medical care.

Physicians often help patients manage the consequences of the disease. For example, people suffering from Type 1 diabetes will be prescribed insulin to control blood sugar levels. In some diseases such as lupus or rheumatoid arthritis, medication can occasionally slow or stop the immune system's destruction of the kidneys or joints. These medications are called immunosuppressive medications and sometimes can have serious side effects. Ultimately, medical science is striving to design therapies that prevent and cure autoimmune diseases.

Allergies

• What are allergies and who suffers from them?
• What is an allergic reaction?
• What symptoms are associated with allergies?
• Does asthma affect women differently than men?
• What are the most common allergies?
• What are hives?
• How are allergies diagnosed?
• How can allergies be treated? What are the possible side effects from treatment?
• Does breastfeeding effect a baby's allergic responses?

What are allergies and who suffers from them?

Allergies involve an immune response in the body to things such as plant pollen, other grasses and weeds, certain foods, rubber latex, insect bites, or certain drugs. Estimates suggest that allergies affect more than 50 million people in the United States. Nearly 10% of American women have pollen allergies. Allergic drug reactions, commonly caused by antibiotics such as penicillin, occur in 2%-3% of hospitalized patients. Severe allergic reaction to insect stings occurs in up to 5% of the population. Although most people have experienced a reaction to something they have eaten, only 1% of the adult population suffers from true immune reactions to food.

What is an allergic reaction?

Normally, the immune system is the body's defense against invading agents such as bacteria and viruses. In most allergic reactions, however, the immune system is responding to a false alarm. When an allergic person first comes into contact with an allergen, the immune system treats the allergen as an invader and mobilizes to attack. The immune system does this by generating large amounts of one type of antibody. When the allergen and the antibody connect, it signals the release of powerful inflammatory chemicals. These chemicals, like histamines, cytokines, and leukotrienes, act on the tissues of various parts of the body, such as the respiratory system. The result is the symptoms commonly associated with allergies.

What symptoms are associated with allergies?

Common symptoms for allergies include:

• Sneezing, often accompanied by a runny or clogged nose
• Coughing and postnasal drip
• Itching eyes, nose, and throat
• Watering eyes
• Allergic dermatitis: an itchy rash. (The most common skin condition in children ages 11- 14.)
• Allergic shiners: dark circles under the eyes caused by increased blood flow near the sinuses
• Allergic salute: persistent upward rubbing of the nose that causes a crease mark on the nose
• Conjunctivitis: an inflammation of the membrane that lines the eyelids, causing red-rimmed, swollen eyes, and crusting of the eyelids. Commonly known as pink eye.

Some people with allergies develop asthma. The symptoms of asthma include coughing, wheezing, and shortness of breath due to a narrowing of the bronchial passages (airways) in the lungs, and to excess mucus production and inflammation. Asthma can be disabling and sometimes can be fatal. If wheezing and shortness of breath accompany allergy symptoms, it is a signal that the bronchial tubes also have become involved, indicating the need for medical attention. Some people may have severe food allergies which left undiagnosed can result in illness or in rare cases, may even be fatal.

Does asthma affect women differently than men?

From the ages of 20 to 50, women outnumber men 3 to 1 in asthma-related hospital admissions. There is some evidence that asthma may be related to hormonal changes in combination with an allergic setting. The severity of asthma may change for women during pregnancy. In general, symptoms in pregnant women with asthma seem to improve in one-third of cases, stay the same in one-third, and worsen in one-third of cases.

Most women who have asthma are able to have safe and normal pregnancies as long as their asthma is effectively under control. It is extremely important for women to control their asthma while pregnant because asthma causes a decrease in the oxygen in the blood and can affect the amount of oxygen the fetus receives.

What are the most common allergies?

The most common allergies can be either food allergies or airborne allergies. Airborne allergies include reaction due to pollen, mold, dust mites, animals, and chemicals. The most common foods causing allergic reactions in adults are: shellfish (such as shrimp, crayfish, lobster, and crab); peanuts, which are one of the chief foods to cause severe anaphylactic reactions; tree nuts (such as walnuts); fish; and eggs. In children, the most common food allergies are associated with eggs, milk, and peanuts. Adults generally don't lose food allergies, but children may outgrow them.

What are hives?

Each year about 15% of all Americans experience hives on the skin or angioedema (swelling of the throat tissues) due to allergic reactions. Hives are an allergic reaction often due to food or plants. The reaction is characterized by a raised, itchy area of skin. It can be rounded or flat-topped, but it is always elevated above the surrounding skin. Treatment for hives usually involves identifying and avoiding the allergic catalyst. Anti-histamine over-the-counter medications can help temporarily relieve the itch. Hives can disappear as quickly as they appear.

How are allergies diagnosed?

Allergy symptoms often resemble a cold, however the cold seems to linger. Symptoms include a runny nose, itchy eyes, headaches, and sinus pain. Usually there is no fever. It is important to see a doctor about any respiratory symptoms that last longer than a week or two. Properly trained physicians can recognize patterns of potential allergens. Often skin tests or blood tests are used to determine specific antibody levels reacting to a certain allergen. If there are unusually high levels of an antibody known as IgE, it is a good indication of an allergic reaction.

How can allergies be treated? What are the possible side effects from treatment?

Allergies are usually treated in three possible ways. Some of these methods can be used alone or in combination.

1. Avoidance: This is most effective for food allergies. Once the allergen is identified, it can be avoided simply by removing it from the diet. Avoidance is more difficult for airborne allergens, however, which are often associated with a particular climate and environment.
2. Medications: Several oral antihistamine medications are available over-the-counter or by a doctor's prescription. A combination of antihistamines and nasal steroids can effectively treat allergic symptoms, especially in people with moderate or severe allergic symptoms. Oral and nasal decongestants reduce congestion sometimes caused by the allergic reaction. However, most medications are for short-term relief only. Nose drops and sprays should not be used for more than a few days at a time because they can lead to even more congestion and swelling of the nasal passages. If you find you "can't get through the day" without regular use of nasal spray see your doctor, and if you can, an allergy specialist. (For example, an ear, nose, and throat doctor.)
3. Immunotherapy: This is a series of allergy shots, and is the only available treatment that has a chance of reducing allergy symptoms over the long term. About 80 percent of people with hay fever will have a significant reduction in their symptoms and in their need for medication within 12 months of starting allergy shots.

Does breastfeeding effect a baby's allergic responses?

Exclusive breast-feeding (excluding all other foods) of infants for the first 6 to 12 months of life is often suggested to avoid milk or soy allergies from developing within that time frame. Such breast feeding often allows parents to avoid infant-feeding problems, especially if the parents are allergic (and the infant therefore is likely to be allergic). There are some children, who are so sensitive to a certain food, however, that if the food is eaten by the mother, sufficient quantities enter the breast milk to cause a food reaction in the child. Mothers must themselves sometimes avoid eating those foods. However, there is no conclusive evidence that breast-feeding prevents the development of allergies later in life.

Arthritis

• What is arthritis?
• Are there different types of arthritis?
• What causes arthritis?
• What does arthritis do to a person's joints?
• What are the symptoms of arthritis?
• How is arthritis diagnosed?
• What are the treatments for arthritis?
• What research is being done on arthritis?

What is arthritis?

We can all feel a bit stiff in the morning. From time to time, we may even feel achy or sore. But with arthritis, a person can feel stiff, achy, or sore all the time. Arthritis means "joint inflammation" and refers to a group of diseases that cause pain, swelling, stiffness, and loss of motion in the joints (places in the body where bones meet like elbows, knees, and hips). "Arthritis" is often used as a more general term to refer to the more than 100 rheumatic diseases that may affect the joints but can also cause pain, swelling, and stiffness in other supporting structures of the body such as muscles, tendons, ligaments, bones, and internal organs. Throughout this FAQ the terms "arthritis" and "rheumatic diseases" are sometimes used interchangeably.

The amount of discomfort caused by this disease varies from person to person. Some people can have pain so severe, they have to limit their daily activities. Other people have mild to moderate pain that doesn't limit them much or at all. Sometimes there are periods of time without any pain or discomfort.

Arthritis is a chronic, or life long, disease that has no cure. The good news is that many advances have been made in arthritis research. There are medicines and other treatments for the disease. Getting enough rest and exercise, controlling weight, and keeping a good diet can also help ease symptoms. Other treatments include the use of pain relief methods and assistive devices, such as splints or braces. When arthritis is severe, surgery may be needed.

Are there different types of arthritis?

There are over 100 different types of rheumatic diseases. The most common rheumatic diseases are:

• Osteoarthritis. Also called degenerative joint disease, this is the most common type of arthritis, which occurs most often in older people. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint. With osteoarthritis, the cartilage starts to wear away over time. In extreme cases, the cartilage can completely wear away, leaving nothing to protect the bones in a joint, causing bone-on-bone contact. Bones may also bulge, or stick out at the end of a joint, called a bone spur.
  Osteoarthritis causes joint pain and can limit a person's normal range of motion (the ability to freely move and bend a joint). When severe, the joint may lose all movement, causing a person to become disabled. Disability most often happens when the disease affects the spine, knees, and hips.
• Rheumatoid arthritis. This is an autoimmune disease in which the body's immune system (the body's way of fighting infection) attacks healthy joints, tissues, and organs. Occurring most often in women of childbearing age (15-44), this disease inflames the lining (or synovium) of joints. It can cause pain, stiffness, swelling, and loss of function in joints. When severe, rheumatoid arthritis can deform, or change, a joint. For example, the joints in a person's finger can become deformed, causing the finger to bend or curve.
  Rheumatoid arthritis affects mostly joints of the hands and feet and tends to be symmetrical. This means the disease affects the same joints on both sides of the body (like both hands or both feet) at the same time and with the same symptoms. No other form of arthritis is symmetrical. About two to three times as many women as men have this disease.
• Fibromyalgia. This chronic disorder causes pain throughout the tissues that support and move the bones and joints. Pain, stiffness, and localized tender points occur in the muscles and tendons, particularly those of the neck, spine, shoulders, and hips. Fatigue and sleep disturbances may also occur.
• Gout. When a person has gout, they have higher than normal levels of uric acid in the blood. The body makes uric acid from many of the foods we eat. Too much uric acid causes deposits, called uric acid crystals, to form in the fluid and lining of the joints. The result is an extremely painful attack of arthritis. The most common joint gout affects is the big toe. This disease is more common in men than in women.
• Infectious arthritis. Arthritis can be caused by an infection, either bacterial or viral, such as Lyme disease. When this disease is caused by bacteria, early treatment with antibiotics can ease symptoms and cure the disease.
• Reactive arthritis. This is arthritis that develops after a person has an infection in the urinary tract, bowel, or other organs. People who have this disease often have eye problems, skin rashes, and mouth sores.
• Psoriatic arthritis. Some people who have psoriasis, a common skin problem that causes scaling and rashes, also have arthritis. This disease often affects the joints at the ends of the fingers and can cause changes in the fingernails and toenails. Sometimes the spine can also be affected.
• Systemic lupus erythematosus. Also called lupus or SLE, this is an autoimmune disease. When a person has an autoimmune disease, the immune system attacks itself, killing healthy cells and tissue, rather than doing its job to protect the body from disease and infection. Lupus can inflame and damage a person's joints, skin, kidneys, lungs, blood vessels, heart, and brain. African American women are three times more likely to get lupus than Caucasian women. It is also more common in Hispanic, Asian, and American Indian women.
• Ankylosing spondylitis. This disease most often affects the spine, causing pain and stiffness. It can also cause arthritis in the hips, shoulders, and knees. It affects mostly men in their late teenage and early adult years.
• Juvenile rheumatoid arthritis. The most common type of arthritis in children, this disease causes pain, stiffness, swelling, and loss of function in the joints. A young person can also have rashes and fevers with this disease.
• Polymyalgia rheumatica. Because this disease involves tendons, muscles, ligaments, and tissues around the joint, symptoms often include pain, aching, and morning stiffness in the shoulders, hips, neck, and lower back. It is sometimes the first sign of giant cell arteritis, a disease of the arteries characterized by inflammation, weakness, weight loss, and fever.
• Polymyositis. Causing inflammation and weakness in the muscles, this disease can affect the whole body and cause disability.
• Psoriatic arthritis. This form of arthritis occurs in some persons with psoriasis, a scaling skin disorder, affecting the joints at the ends of the fingers and toes. It can also cause changes in the fingernails and toenails. Back pain may occur if the spine is involved.
• Bursitis. This condition involves inflammation of the bursae, small, fluid-filled sacs that help reduce friction between bones and other moving structures in the joints. The inflammation may result from arthritis in the joint or injury or infection of the bursae. Bursitis produces pain and tenderness and may limit the movement of nearby joints.
• Tendinitis. Also called tendonitis, this condition refers to inflammation of tendons (tough cords of tissue that connect muscle to bone) caused by overuse, injury, or a rheumatic condition. Tendinitis produces pain and tenderness and may restrict movement of nearby joints.

What causes arthritis?

For many types of arthritic diseases, no cause is known. Researchers are looking at possible causes for many of these diseases. With osteoarthritis, extreme stress on a joint may play a role in how this disease develops. Stress can be caused by weak cartilage (which runs in families) or from repeated injury to the joint. Biological make-up and family history may play a role in gout, rheumatoid arthritis, lupus, anklosing spondylitis, and some other arthritic diseases.

Researchers are also looking at why some people develop these diseases and others do not. Being overweight and aging appear to increase a person's chances of getting osteoarthritis. And, women are more likely than men to get lupus and rheumatoid arthritis.

What does arthritis do to a person's joints?

Osteoarthritis and rheumatoid arthritisthe two most common types of rheumatic diseases affect a person's joints, causing discomfort and pain. The range of motion in a joint can lessen, making it harder for a person to perform daily activities. Sometimes the joint can lose all function (not be able to move).

Normal Joint In a normal joint (where two bones come together), the muscle, bursa (sacs of fluid that protect moving muscles, skin and tendons) and tendons (tissue that attaches muscle to bone) support the bone and help the joint to move. The synovial membrane releases a slippery fluid into the joint space. Cartilage covers the ends of the bone to absorb shocks and to keep the bones from rubbing together when the joint moves.

Joint with Osteoarthritis With osteoarthritis, cartilage breaks down and the bones rub together. The joint then loses shape and moves. The ends of the bone become thick, forming spurs (bony growths). Bits of cartilage or bone float in the joint space.

Joint with Rheumatoid Arthritis With rheumatoid arthritis, the joint becomes inflamed and the synovial membrane becomes thicker. This causes the joint to swell, causing damage to bone and cartilage. Over time, the bone and cartilage gets destroyed. Space between the joint gets smaller, and the joint loses shape and moves.

*Source of Images: U. S. Food and Drug Administration.

What are the symptoms of arthritis?

Different types of arthritis have different symptoms. In general, people who have arthritis feel pain and stiffness in the joints. Some other common symptoms of arthritis are:

• Swelling in one or more joints
• Stiffness around the joints that lasts for at least one hour in the early morning
• Joint pain or tenderness that is constant or comes and goes
• Feeling like it's hard to use or move a joint
• Warmth or redness in a joint

Sometimes a person can lose weight, feel weak, and have fevers or joint pain for no reason. See a health care provider if you have any one of these symptoms for longer than two weeks.

How is arthritis diagnosed?

Diagnosing rheumatic diseases can be difficult because some symptoms are common to many different diseases. Your health care provider will first do a complete physical exam, looking for any swelling, redness, warmth, deformity, ease of movement, and tenderness in your joints. Your heart, lungs, eyes, ears, throat and other parts of your body may be examined as well. This is because some types of arthritis can affect your organs. Lab tests may also be ordered and samples of blood, urine, or synovial fluid may be taken. Your doctor may have you also see a rheumatologist, a doctor who specializes in arthritis.

What are the treatments for arthritis?

Treatments for arthritis help to reduce pain and swelling in the joints, keep the joints moving, and keep the disease from getting worse. When you have arthritis, it is important to develop a good relationship with your health care provider. Together, you can develop a treatment plan that will work best for you.

Treatments include:

• Over-the-counter medicines like analgesics (aspirin), other nonsteroidal anti-inflammatory drugs, or NSAIDS (Advil, Motrin, Nuprin), and acetaminophen(Tylenol).
• Prescription drugs to relieve pain, such as celecoxib (Celebrex) and refeoxib (Vioxx).
• Over-the-counter creams and sprays for pain relief.
• Corticosteroids (prednisone, cortisone, solumedrol, hydrocortisone) to decrease inflammation and suppress the immune system (used for rheumatoid arthritis) taken by mouth, injection, or applied as creams to the skin.
• Applying heat or ice to reduce pain and inflammation.
• Daily exercise (without overdoing it) to keep the joints moving and strengthen the muscles around the joints. Rest is also needed for joints affected by arthritis. You will need to find the right type of exercise and the right amount of rest. Your doctor can send you to a physical ther apist to help you with an exercise and rest program. Walking and swimming in a heated pool can help arthritis. Stretching and gentle yoga can also help maintain flexibility.
• Controlling or losing weight to reduce stress on joints.
• Hydrotherapy, or exercising (swimming, water aerobics) or relaxing in warm water (baths, hot tubs) to help relax tense muscles and relieve pain.
• Mobilization therapy, including traction (gentle, steady pulling), massage, and manipulation (using the hands to restore normal movement to stiff joints) to help control pain and increase joint motion and flexibility.
• Relaxation therapy, or learning ways to release muscle tension by yourself, such as progressive relaxation where you tighten muscle groups one by one, relaxing tension throughout your body.
• Assistive devices for treating arthritis pain include splints and braces, which are used to support weakened joints or allow them to rest. Some of these devices prevent the joint from moving; others allow some movement.
• Surgery to repair or replace damaged joints. Knees and hips, for example, can be replaced. A new, artificial knee or hip is put in your body to take the place of the damaged joint (in severe cases).
• Nutritional supplements are often reported as helpful in treating rheumatic diseases. These include products such as S-adenosylmethionine (SAM-e) for osteoarthritis and fibromyalgia, dehydroepiandrosterone (DHEA) for lupus, and glucosamine and chondroitin sulfate for osteoarthritis. Reports on the safety and effectiveness of these products should be viewed with caution since very few claims have been carefully evaluated.

Note: Be aware that there are many products you can buy that make lots of promises to cure arthritis, but don't. Some of these products, such as snake venom, are even harmful. While not harmful, other products like copper bracelets don't cure the disease or ease symptoms.

What research is being done on arthritis?

Scientists are looking at new ways to treat rheumatoid arthritis. They are experimenting with new drugs and "biologic agents" that selectively block certain immune system activities associated with inflammation. Newly developed drugs include etanercept (Enbrel) and infliximab (Remicade).

Some genetic and behavioral studies are focusing on factors that may lead to osteoarthritis. Researchers recently found that daughters of women who have knee osteoarthritis have a significant increase in cartilage breakdown, making them more susceptible to disease. This finding has important implications for identifying people who are susceptible to osteoarthritis. Other studies of risk factors for osteoarthritis have identified excessive weight and lack of exercise as contributing factors to knee and hip disability.

Chronic Fatigue Syndrome

• What is Chronic Fatigue Syndrome (CFS)?
• What causes CFS?
• What are the signs of CFS?
• How common is CFS? Who gets it?
• How would my health care provider know if I have CFS?
• How is CFS treated?
• What can a person do to cope with CFS?
• What is the latest research on CFS?

What is Chronic Fatigue Syndrome (CFS)?

Having chronic fatigue syndrome, or CFS, means more than just getting tired. With the busy lives American women lead, we all get tired from time to time. But, the fatigue with CFS is extreme and overwhelming, and doesn't get better with bed rest. And, it is often made worse with physical or mental activity.

This illness seems to happen all of a sudden one day you may notice that you are very tired and can't manage your normal activities. Your energy level is lower and you often get tired for no reason. You may also feel weak and have muscle pain, difficulty focusing, or insomnia (not being able to sleep). After you engage in physical activity or exert yourself, you may feel tired for more than 24 hours. The extreme fatigue may then come and go, giving you times when your energy level is normal. Sometimes, though, the extreme tiredness never stops, leaving you feeling exhausted and depleted all the time. You notice that you can't get done in a day what you normally would have been able to, before having this condition. CFS is diagnosed only when other possible causes of the fatigue are ruled out, and the fatigue has lasted for at least 6 months. There are treatments to help a person cope with CFS, some of which include medication. Sometimes CFS goes away on its own or a person can have long periods of time, even years, without symptoms.

What causes CFS?

No one knows for sure what causes CFS. For more than 100 years, doctors have reported seeing illnesses like CFS. Some causes of CFS offered over the years by health experts include anemia (low iron in the blood); hypoglycemia (low blood sugar); environmental allergies; and candidiasis (yeast infection) in the entire body.

Sometimes CFS develops on its own, for no reason. But, most persons with CFS say that it started after having a cold, bronchitis, hepatitis, or an intestinal virus. It can also follow a bout of infectious mononucleosis (mono), the "kissing disease" that drains the energy of many teenagers and young adults.

Some persons with CFS say their illness began after a time of extreme stress, such as the loss of a loved one or undergoing major surgery.

It can be hard to figure out if a person has CFS. This is because many illnesses have extreme fatigue as a symptom and many treatments, such as chemotherapy, can cause extreme fatigue.

What are the signs of CFS?

CFS symptoms either stay with a person or come and go for more than 6 months. Initial symptoms can feel like you have the flu. Besides extreme fatigue and weakness, CFS symptoms include:

• Headaches of a new type, pattern, or intensity
• Tender lymph nodes
• Sore throat
• Muscle pain or aches
• Pain or aches in several joints without swelling or redness
• Not being able to concentrate, focus, or remember
• Feeling tired even if sleeping
• Feeling discomfort or "out-of-sorts" after physical exertion

How common is CFS? Who gets it?

The Centers for Disease Control and Prevention estimates as many as half a million Americans have a CFS-like condition. In the early 1980s it was first called the "yuppie flu" because mostly well-educated women with high incomes in their 30s and 40s sought help for CFS-like symptoms. It is now known that this illness affects people of all ages, racial/ethnic backgrounds, and economic situations. And, it isn't just an American illness people all over the world are affected by CFS.

More women than men are diagnosed with CFS. But, it isn't known for sure that this illness affects women more than men. Women may be more likely than men to talk to their doctors about symptoms like exhaustion and pain.

How would my health care provider know if I have CFS?

There has been much debate among CFS experts about a standard way to define CFS. This is because the cause for CFS is not known and there is no one standard symptom. Your health care provider will first do a physical exam and order any needed tests. She or he will rule out the presence of any other diseases or problems that may have CFS-like symptoms, such as multiple sclerosis and systemic lupus erythematosus (autoimmune diseases). To be diagnosed with CFS, you must have severe chronic fatigue for 6 months or longer, with other medical conditions ruled out by a provider, and 4 or more of the symptoms bulleted out in the question "What are the signs of CFS" in this FAQ.

How is CFS treated?

Right now, there is no treatment that works to cure CFS. The good news is there are things you can do to feel better, increase the level at which you can function, and improve your quality of life.

Talking with your health care provider about treatments for your symptoms, along with ways to manage your fatigue, is a good place to start. And, building a good relationship with your provider is key to managing your illness over time. This will help you to talk more freely with your provider about your symptoms, which can improve the treatment of your illness. Keep in mind your provider may need to learn more about CFS to better help you. If you feel your provider doesn't know a lot about CFS or has doubts about whether it is a "real" illness, see another provider for a second opinion. Try a local university medical school or research center for help with finding providers with expertise in CFS.

Medications can work to relieve the symptoms of CFS. Nonsteroidal anti-inflammatory drugs, or ibuprofin (Advil, Motrin, Alleve), can help with body aches, headaches, and muscle and joint pain. Non-drowsy antihistamines can relieve allergy symptoms, such as runny nose and itchy eyes. While there is no proof these practices help, some people report symptom relief with massage, acupuncture, and chiropractic care. Physical activity and exercise can also help with symptom relief, but be sure to talk with your provider about developing an activity and exercise program that's best for you. For some people, physical activity and exercise can worsen symptoms. (See next question on "What can a person do to cope with CFS?" for more information on physical activity and exercise.)

Drugs used to treat depression, or antidepressants, are sometimes used to treat CFS. This is because studies have found that people with fibromyalgia, an illness similar to CFS, get relief from taking these drugs. Some experts believe these drugs improve the quality of sleep, helping decrease fatigue with CFS. Two types of antidepressants are most often prescribed by providers low-dose tricyclic antidepressants or the newer selective serotonin reuptake inhibitors (SSRIs).

What can a person do to cope with CFS?

When you have CFS, learning how to pace yourself and manage or avoid physical and emotional stress is important. Physical activity helps you to feel better not just physically, but emotionally as well. Regular exercise can lessen body aches, joint and muscle pain, and increase energy. But, be careful not to over do it. Too much exercise can end up causing more fatigue. As you build up strength over time, you may be able to increase the intensity of your exercise program. Physical therapists and rehabilitation medicine specialists can help you develop an exercise program and a daily activity plan that won't be too stressful or something you can't handle.

Cognitive behavioral therapy is a special treatment that can help you to change the way you think about your condition. It also helps you to develop ways to improve both your daily functioning and quality of life.

Yoga, stretching, and self-hypnosis are some alternative treatments that some people report help with CFS. Keep in mind that there are many alternative treatments, dietary supplements, and herbal remedies touted to cure illnesses like CFS, which can end up doing a person more harm than good. Remember to always keep your health care provider informed of the other health care professionals and alternative practitioners you are seeing.

Having an illness for which there is no cure can cause psychological stress and even depression for some people. It is normal to feel cranky, sad, angry, and frustrated with an illness that causes extreme fatigue and pain. Psychotherapy (sometimes called "talk therapy") can help you learn how to manage your feelings about this difficult illness. It may also be helpful to join a support group, where you can talk with other people who are going through the same thing. See the "For more information…" section at the end of this FAQ for referrals to consumer organizations that can help you to cope with CFS.

If a person becomes so disabled with CFS that they can no longer work, they can contact the Social Security Administration for help with disability benefits. There are two social security programs that have the same medical requirements for disability payments the Social Security Disability Insurance Program and the Supplemental Security Income (SSI) Program. Your prior work history will determine if you can receive Social Security disability. SSI payments are made on the basis of financial need. Contact the Social Security Administration toll-free at (800) 772-1213 or check out their web site, http://www.ssa.gov for more information.

What is the latest research on CFS?

Both the National Institutes of Health and the Centers for Disease Control and Prevention have research programs to fund CFS studies. Researchers are focusing on doing more long-term studies with people with CFS, to look at changes in CFS symptoms over short- and long-time periods. The neuroendocrine system, which is involved in how the body reacts to stress, is also being studied. The role of hormones, cytokines in particular, in the body may also provide clues about how the body responds to stress, as well as CFS. Studies are also being done to look for the presence of infectious agents in people with CFS, and how the body responds to these agents.

Researchers are looking at how disturbed sleep and pain reactions affect CFS. Some experts think that disrupted sleep may cause many of the symptoms of CFS. Others think that women may experience pain differently than men, as well as have different reactions to drugs. CFS-related depression caused by disturbed sleep is also being studied. And, research into fatigue is being done, which may help develop better approaches to dealing with fatigue.

Fibromyalgia

• What is fibromyalgia (FM)?
• What are the symptoms of fibromyalgia?
• How common is fibromyalgia? Who is mainly affected by it?
• What causes fibromyalgia?
• How is fibromyalgia diagnosed?
• How is fibromyalgia treated?
• What is the difference between fibromyalgia and chronic fatigue syndrome?
• What research is being done on fibromyalgia?

What is fibromyalgia (FM)?

Fibromyalgia (FM), is a disorder with symptoms of widespread muscle pain, fatigue (feeling tired and having low energy), and multiple tender points. "Tender points" refers to tenderness that occurs in certain areas of the body. Tender points are located in the neck, spine, shoulders, hips and knees and are painful when pressure is applied to them. People with FM often have sleep problems and may have many other symptoms. FM is not thought to be an autoimmune disease at this time, but it shares symptoms with several autoimmune illnesses.

What are the symptoms of fibromyalgia?

The main symptoms of FM include:

• Muscle pain in many areas of the body.
• Fatigue.
• "Tender points" in specific areas of the body that are painful when pressure is applied to them.

In addition to these symptoms, other common symptoms of FM include:

• Sleep problems. People with FM often have poor quality sleep that is not refreshing.
• Depression or anxiety.
• Stiffness, especially in the morning.
• Problems with thinking and concentrating.
• Headaches, jaw pain, or abdominal pain.
• Digestive problems such as bloating and trouble swallowing.
• Bladder problems such as interstitial cystitis.
• Feelings of numbness or tingling in hands, feet, or other areas.

Other conditions sometimes found in FM patients include irritable bowel syndrome (IBS), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), temporomandibular joint (TMJ) pain, and myofascial pain syndrome (MPS).

How common is fibromyalgia? Who is mainly affected by it?

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) estimates that the number of adults in the United States with FM is about 3.7 million. Other organizations estimate that the number may be as high as 8 million. It mainly occurs in women of childbearing age, but children, the elderly, and men are sometimes diagnosed with FM.

What causes fibromyalgia?

Although the cause of FM is unknown, researchers have several theories about causes or triggers of the disorder. Some scientists believe that an injury or trauma may sometimes cause the syndrome. This injury may affect the central nervous system. FM may be linked to muscle changes that cause fatigue and decreased strength. Others believe that an infection caused by a virus or other agent may trigger FM in susceptible people.

Other possible factors in FM include psychological stress, hormonal changes, or other changes in body chemicals such as serotonin and Substance P. The hormones produced by the hypothalamus-pituitary-adrenal (HPA) axis may be important in FM. Sleep problems, so common in people with FM, may be a cause as well as a symptom of FM. Increased sensitivity to and perception of pain seems to be involved.

How is fibromyalgia diagnosed?

Fibromyalgia is hard to diagnose because many of the symptoms are like those of other disorders. There is no lab test for FM. The American College of Rheumatology (ACR) has developed criteria for FM. According to ACR criteria, a person is considered to have FM if he or she has:

• widespread pain for at least 3 months, and
• tenderness in at least 11 of 18 specific tender point sites in the neck, spine, shoulders, hips, and knees.

There is some controversy about the criteria for diagnosing FM. Some experts believe that it is not necessary to have at least 11 tender points for diagnosis, or pain that affects all segments of the body at the same time.

How is fibromyalgia treated?

If you have FM, you may need to work with your doctor to find a treatment plan that helps you. FM patients may benefit from a combination of exercise, medicine, physical therapy, and relaxation. There are medicines that may help elevate mood, improve quality of sleep, reduce pain, and relax muscles.

Drug therapies used in fibromyalgia include:

• Drugs for pain. These include aspirin, ibuprofen, and other pain relievers.
• Antidepressants. These drugs can help relieve depression and may also help with sleep. Low doses of certain tricyclic antidepressants and the newer serotonin boosters (SSRIs) are often used.
• Drugs for anxiety (anxiolytics). These medicines can help with anxiety and with sleep.
• Muscle relaxants such as cyclobenzaprine.

Exercise, including low-impact aerobic exercise (such as walking and swimming) and strength training have been found to be helpful in FM patients. But it is important to pace yourself and not overdo it. Exercise may help you increase your flexibility and strength, help with pain and sleep, and make you feel better in general. Heat and massage may also give short-term relief from pain and stiffness.

Cognitive behavioral therapy (focuses on helping you develop ways to manage your illness) is another form of treatment that can be helpful. Stress reduction and a healthy lifestyle are also important.

What is the difference between fibromyalgia and chronic fatigue syndrome?

Chronic fatigue syndrome (CFS) and FM have many similarities. In fact, it is not uncommon for a person to have both conditions. Some experts believe that the two conditions are variations of the same disorder. Both CFS and FM have pain and fatigue as symptoms.

The main symptom of CFS is extreme fatigue. CFS seems to often begin following an episode of flu-like symptoms. People with CFS only do not have the tender points that people with FM have. The criteria for diagnosing CFS are chronic fatigue for at least 6 months plus 4 or more other typical CFS symptoms such as muscle pain, headaches, sore throat, tender lymph nodes, problems with thinking, and sleep problems.

What research is being done on fibromyalgia?

Researchers are studying the ways that the nervous system, the endocrine (hormonal) system, and the adrenal glands interact in FM patients. Studies have shown that abnormally low levels of the hormone cortisol (made by the adrenal glands) may be associated with FM. People whose bodies make too little cortisol have many of the same symptoms as people with FM.

Other researchers are looking at how specific brain structures are involved in the painful symptoms of FM. Scientists are studying the causes of a post-Lyme disease syndrome as a model for FM. Some patients develop a FM-like condition following Lyme disease, an infectious disorder associated with arthritis and other symptoms.

Another area of research is related to behavioral factors in FM. It is hoped that these studies will increase understanding about FM and may suggest new ways to treat the disorder.

Graves' Disease

• What is Graves' disease?
• What is an autoimmune disease?
• What are the symptoms of Graves' Disease?
• How do I know if I have this disease?
• What is the treatment for this disease?
• What could happen if this disease is left untreated?

What is Graves' disease?

Graves' Disease is a type of autoimmune disease in which the immune system over stimulates the thyroid gland, causing hyperthyroidism. Over-activity of the thyroid gland is also sometimes called "diffuse toxic goiter." The thyroid gland helps set the rate of metabolism (the rate at which the body uses energy), and when it is over-stimulated, it produces more thyroid hormones than the body needs. High levels of thyroid hormones can cause difficult side effects. This is an extremely rare disease that tends to affect women over the age of 20. The incidence is about 5 in 10,000 people.

What is an autoimmune disease?

An autoimmune disease occurs when the body's immune system becomes misdirected and attacks the very organs, cells, or tissues that it was designed to protect. About 75% of autoimmune diseases occur in women, most frequently during their childbearing years.

What are the symptoms of Graves' Disease?

The most common symptoms of Grave's Disease, or thyroid over-stimulation include insomnia, irritability, weight loss without dieting, heat sensitivity, increased perspiration, fine or brittle hair, muscular weakness, eye changes, lighter menstrual flow, rapid heart beat, and hand tremors. Grave's Disease is the only kind of hyperthyroidism that is associated with inflammation of the eyes, swelling of the tissue around the eyes, and protrusion, or bulging, of the eyes. Some patients will develop lumpy reddish thickening of the skin in front of the shins called pretibial myxedema. This skin condition is usually painless. The symptoms of this disease can occur gradually or very suddenly and are sometimes confused with other medical problems. Women can have Grave's Disease and have no obvious symptoms at all.

How do I know if I have this disease?

The only way to positively know if you have Graves' Disease is to visit your doctor. Your doctor will perform a simple blood test that will be able to tell if your body has the correct amount of thyroid hormones.

What is the treatment for this disease?

There are many treatments for Graves' Disease.

• Medications: There are some prescription medications that can lower the amount of thyroid hormones produced by the body, regulating them to normal levels.
• Surgery: Part or all of the thyroid gland will be removed. In most cases, people who have surgery for Graves' Disease will develop an under-active thyroid (hypothyroidism), and will have to take thyroid replacement hormones for the rest of their lives.
• Radioactive iodine: The iodine damages thyroid cells to shrink the thyroid gland, to reduce hormone levels. Like surgery, this condition usually leads to hypothyroidism, requiring medication for the rest of the patient's life.

After a diagnosis is made and a treatment is selected, you should return to your health care provider annually to make sure that your thyroid levels are normal and do not need to be adjusted.

What could happen if this disease is left untreated?

If left untreated, Grave's Disease can lead to more serious complications, including birth defects in pregnancy, increased risk of a miscarriage, and in extreme cases, death. Graves' Disease is often accompanied by an increase in heart rate, which may lead to further heart complications.

Hashimoto's Thyroiditis

• What is Hashimoto's Thyroiditis?
• What is an autoimmune disease?
• What are the symptoms of Hashimoto's Thyroiditis?
• Is this disease hereditary?
• How can I know for sure if I have this disease?
• What is the treatment for this disease?
• What would happen without medication to regulate my thyroid function?

What is Hashimoto's Thyroiditis?

Hashimoto's Thyroiditis is a type of autoimmune thyroid disease in which the immune system attacks and destroys the thyroid gland. The thyroid helps set the rate of metabolism the rate at which the body uses energy. Hashimoto's prevents the gland from producing enough thyroid hormones for the body to work correctly. It is the most common form of hypothyroidism (underactive thyroid).

What is an autoimmune disease?

An autoimmune disease occurs when the body's immune system becomes misdirected and attacks the organs, cells or tissues that it was designed to protect. About 75% of autoimmune diseases occur in women, most frequently during their childbearing years.

What are the symptoms of Hashimoto's Thyroiditis?

Some patients with Hashimoto's Thyroiditis may have no symptoms. However, the common symptoms are fatigue, depression, and sensitivity to cold, weight gain, muscle weakness, coarsening of the skin, dry or brittle hair, constipation, muscle cramps, increased menstrual flow, and goiter (enlargement of the thyroid gland).

Is this disease hereditary?

There is some evidence that Hashimoto's Thyroiditis can have a hereditary link. If autoimmune diseases run in your family, you are at a higher risk of developing one yourself.

How can I know for sure if I have this disease?

Your doctor will perform a simple blood test that will be able to tell if your body has the correct amount of thyroid hormones. This test measures the blood TSH (Thyroid Stimulating Hormone) to

determine if the thyroid hormone levels are in the normal range. The range is set by your doctor and should be discussed with you. Work with your doctor to find what level is right for you.

What is the treatment for this disease?

Hashimoto's Thyroiditis can usually be treated with thyroid hormone replacement. A small pill taken once a day should be able to regulate the thyroid hormone in the body to normal levels. This medication will, in most cases, need to be taken for the rest of the patient's life. When trying to determine the correct hormone dosage, you may have to return to your doctor several times for adjustments in medication. A yearly visit to your health care provider will help keep your levels normal and help maintain normal health. Be aware of the symptoms. If you note any changes or the return of symptoms, return to your doctor to see if you need to have your medication changed.

What would happen without medication to regulate my thyroid function?

If left untreated, Hashimoto's Thyroiditis can cause further complications, including changes in menstrual cycles, prevention of ovulation, and an increased risk of miscarriage. It is also important to know that too much thyroid replacement hormone can mimic the symptoms of hyperthyroidism. This is a condition that occurs from overproduction of thyroid hormones. These symptoms include insomnia, irritability, weight loss without dieting, heat sensitivity, increased perspiration, thinning of your skin, fine or brittle hair, muscular weakness, eye changes, lighter menstrual flow, rapid heart beat and hand tremors.

Lupus

• What is lupus?
• Who has lupus?
• What are the different types of lupus?
• What causes lupus?
• How is SLE diagnosed?
• What are flares?
• How is lupus treated?
• Is it safe for me to become pregnant?
• How can I cope with the stress of having lupus?
• How can I tell the difference between symptoms of lupus and symptoms of pregnancy?
• What research is being done on lupus?

What is lupus?

Lupus, also called systemic lupus erythematosus (sis-teh-mik lew-pus er-eh-thee-muh-toh-sis) or SLE, is a disease that affects your immune system. Normally, your immune system fights infections caused by germs. Instead of protecting your body, your immune system makes the mistake of attacking your body's healthy cells. Lupus can affect almost any part of your body, including your joints, skin, kidneys, heart, lungs, blood vessels, and brain. There is no way to know what part of your body will be affected. For most people though, lupus is a mild disease affecting only a few parts of your body, and some patients don't get inner organ problems (like in the heart and lungs), but do have skin and joint problems. Normally, lupus develops slowly, with symptoms that come and go. For some, it can cause serious and even life-threatening problems. Even for patients with diseases that hurt their organs, with good care and management and a strong partnership between a patient and her health care provider, the prognosis is good.

Who has lupus?

Lupus affects up to 1.4 million people in the United States. About 9 out of 10 people who have lupus are women. Lupus is 3 times more common in black women than in white women. It is also more common in women of Hispanic/Latina, Asian, and American Indian descent. Black and Hispanic/Latina women tend to develop symptoms at an earlier age than other women. African Americans have more severe organ problems, especially with their kidneys.

What are the different types of lupus?

There are several forms of lupus:

• Systemic lupus erythematosus (SLE). SLE is the most common type of lupus. SLE can affect many parts of the body including joints, skin, kidneys, lungs, heart, blood vessels, nervous system, blood, and brain. Although SLE usually develops in people between the ages of 15 and 44 years, it can occur in childhood or later in life. The signs of SLE vary and there are usually periods of both illness and wellness (also called remission or having no symptoms). Some people have just a few signs of the disease while others have more. Its symptoms can include:
  • "butterfly" rash across the nose and cheeks
  • skin rashes on parts of the body exposed to the sun
  • sores in the mouth or nose
  • painful or swollen joints
  • fever
  • weight loss
  • hair loss
  • fatigue
  • chest pain when taking deep breaths
  • purple or pale fingers or toes from cold or stress
  • abdominal pain
  • kidney inflammation
  • headaches
  • paranoia
  • schizophrenia
  • hallucinations
  • depression
  • trouble thinking
  • memory problems
  • seizures
  • strokes
  • blood clots
• Discoid (diss-koid) lupus erythematosus (DLE). DLE just affects the skin. It does not affect other organs, like SLE. Its symptoms can include:
  • a red, raised rash on the face, scalp, or other parts of the body. The rash may become thick and scaly and may last for days or years.
  • sores in the mouth or nose (sometimes)
  A small group of people with DLE later develop SLE. There is no way to know if someone with DLE will get SLE. A skin biopsy (removing a piece of skin to look at under a microscope) of the rash is taken to diagnose this type of lupus.
• Drug-induced lupus. This type of lupus is a reaction to some prescription medicines. The symptoms of this type of lupus are similar to SLE, except you don't have problems with your kidneys or central nervous system. It can take months to years of taking the medicine before symptoms appear. After you stop taking the drug, it could take days, weeks, or months for symptoms to go away.
• Neonatal lupus. While rare, some newborn babies of women with SLE or other immune system disorders get lupus. Babies with neonatal lupus may have a serious heart defect. About one-half of babies with neonatal lupus are born with a heart condition. This condition is permanent, but it can be treated with a pacemaker (a device that helps the heart set a rhythm). Other affected babies may have a skin rash or liver problems. Some babies have both heart and skin problems.

What causes lupus?

The cause of lupus is not known. It is likely that there is no single cause but a combination of genetic, environmental, and possibly hormonal factors that work together to cause the disease. Lupus is not contagious-you can't catch it from someone. No specific "lupus gene" has been found, but it does run in families.

How is SLE diagnosed?

SLE may be hard to diagnose and is often mistaken for other diseases. For this reason, lupus has often been called the "great imitator." No single test can tell if a person has lupus. There are many ways to diagnose SLE:

1. Medical history. Give your health care provider (HCP) a complete, accurate medical history. This information, along with a physical exam and special tests, helps your HCP rule out other diseases that can be confused with lupus.
2. Symptoms. Having 4 (or more) of the 11 symptoms of lupus, as defined by the American College of Rheumatology. For a list of these symptoms, go to www.rheumatology.org/research/classification/sle.html
3. Lab tests. The Antinuclear antibody (ANA) test is a commonly used test. An antibody is a chemical the body makes to fight off infections. The test looks for the strength of your antibodies. Most people with lupus test positive for ANA. However, other health problems, like malaria (a disease from a mosquito bite), can also give you a positive test. That's why other tests may be needed.

What are flares?

When symptoms appear, it's called a "flare." These signs may come and go. You may have swelling and rashes one week and no symptoms at all the next. You may find that your symptoms flare after you've been out in the sun or after a hard day at work. Even if you take medicine for lupus, you may find that there are times when the symptoms become worse. Learning to recognize that a flare is coming can help you take steps to cope with it. Many people feel very tired or have pain, a rash, a fever, stomach discomfort, headache, or dizziness just before a flare.

Take steps to prevent flares:

• Learn to recognize that a flare is coming.
• Try to set realistic goals and priorities.
• Limit the time you spend in the sun.
• Maintain a healthy diet.
• Develop coping skills to help limit stress.
• Get enough rest and quiet.
• Exercise moderately when possible.
• Develop a support system by surrounding yourself with people you trust and feel comfortable with like family and friends.

How is lupus treated?

There is no known cure for lupus, but there are effective treatments. Most of the symptoms of lupus are from inflammation (swelling), so treatment focuses on reducing the swelling.

Treatment may include taking these medicines:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are often used to reduce joint and muscle pain and inflammation in people who have mild SLE (pain isn't bad or organs aren't affected). There are many different types of NSAIDs, both prescription drugs and over-the-counter drugs. They include aspirin, ibuprofen, naproxen, and other medicines. Common side effects of NSAIDs can include stomach upset, heartburn, drowsiness, headache, and fluid retention. If you have any side effects, talk to your HCP. NSAIDs can also cause problems in your blood, liver, and kidneys. Stay in touch with your HCP to ensure these problems aren't happening to you.
• Antimalarial drugs. Medicines used to prevent or treat malaria are used to treat joint pain, skin rashes, and ulcers. Two common antimalarials are hydroxychloroquine (Plaquenil) and chloroquine (Aralen). Side effects of antimalarials can include stomach upset, nausea, vomiting, diarrhea, headache, dizziness, blurred vision, trouble sleeping, and itching.
• Corticosteroid hormones. These are powerful drugs that reduce inflammation in various tissues of the body. They can be taken by mouth, in creams applied to the skin, or by injection. Prednisone is a corticosteroid that is often used to treat lupus. Corticosteriods can have various side effects, so HCPs try to use the lowest dose possible. Short-term side effects include swelling, increased appetite, weight gain, and emotional ups and downs. These side effects generally stop when the drug is stopped. Long-term side effects of corticosteroids can include stretch marks on the skin, excessive hair growth, weakened or damaged bones, high blood pressure, damage to the arteries, high blood sugar, infections, and cataracts. People with lupus who are using corticosteroids should talk to their HCPs about taking calcium supplements, vitamin D, or other drugs to reduce the risk of osteoporosis (weakened, fragile bones).
• Immunosuppressive agents/chemotherapy. These agents are used in serious cases of lupus, when major organs are losing their ability to function. These drugs suppress the immune system to limit the damage to the organ. Examples are azathioprine (Imuran) and cyclophosphamide (Cytoxan). These drugs can cause serious side effects including nausea, vomiting, hair loss, bladder problems, decreased fertility, and increased risk of cancer and infection.

Work closely with your HCP to ensure that your treatment plan is as successful as possible. Because some treatments may cause harmful side effects, promptly report any new symptoms to your HCP. It is also important not to stop or change treatments without talking to your HCP first.

Is it safe for me to become pregnant?

Today, most women with lupus can safely become pregnant. With proper medical care, you can lower the risks of pregnancy and deliver a normal, healthy baby. However, you must carefully plan your pregnancy. Your disease should be under control or in remission for 12 months before you get pregnant. Find an obstetrician (OB) who is experienced in managing high-risk pregnancies and who can work closely with your primary HCP. Plan your delivery at a hospital that can manage high-risk patients and provide the specialized care you and your baby may need. Talk to your doctor about which medicines are safe to take while pregnant.

Women with lupus may face certain problems during the pregnancy. While flares are not caused by pregnancy, flares that do develop often occur during the first or second trimester or during the first few months following delivery. Most flares are mild and easily treated with small doses of corticosteroids. Another complication is pre-eclampsia. If you develop this serious condition, you will have a sudden increase in blood pressure, protein in the urine, or both. This is a serious condition that requires immediate treatment, and you might have to deliver your infant early.

Babies born to women with lupus have no greater chance of birth defects or mental retardation than do babies born to women without lupus. As your pregnancy progresses, your OB will regularly check the baby's heartbeat and growth with sonograms (an machine that creates pictures of your baby's organs). Although giving birth to your baby early (prematurely) presents a danger to the baby, most problems can be successfully treated in a hospital that specializes in caring for premature newborns. About 3% of babies born to mothers with lupus will have neonatal lupus.

Breastfeeding your baby is safe for mothers with lupus. If you are on medications and breastfeeding, talk with your provider about how the medicine might affect your baby.

How can I tell the difference between symptoms of lupus and symptoms of pregnancy?

It may be hard to tell the difference. You may have symptoms from being pregnant that you mistake for lupus symptoms. Here are just some problems that may cause confusion:

• Skin. While pregnant, you may have red palms and a rash. Lupus can also cause a rash.
• Joints. Lupus can cause arthritis, and pregnancy can cause aching in your joints.
• Lungs. It may be hard for you to breathe if you have lupus. Pregnancy can also cause a shortnessof breath and hyperventilation.

Talk to your health care provider about how to tell the difference between the physical changes you will have during your pregnancy and symptoms of lupus.

How can I cope with the stress of having lupus?

Staying healthy takes extra effort and care for women with lupus. Sometimes, women with lupus may feel tired, and you may need extra rest because of your treatments. If you feel tired, make a point to allow yourself extra time in your schedule for rest.

Some approaches that may help you to cope with lupus include:

• exercising
• relaxing using techniques like meditation
• setting priorities for spending time and energy
• educating yourself about the disease
• having a good support system

A support system may include family, friends, HCPs, community organizations, and organized support groups. Participating in a support group can provide emotional help, boost self-esteem and morale, and help develop or improve coping skills. Also, talk to your family about how they can support your efforts to take care of yourself.

What research is being done on lupus?

There are many promising areas of research on lupus. Studies are looking at the safety of estrogen use (HT and birth control pills) by women with lupus; causes or risk factors for lupus (including behavior, genetics, environment, and culture); and lupus in minority women.

Myasthenia Gravis

• What is myasthenia gravis (MG)?
• What causes MG?
• Who gets myasthenia gravis?
• What is the role of the thymus gland in MG?
• What are the signs and symptoms of MG?
• How is MG diagnosed?
• What is the treatment for MG?
• What is a myasthenic crisis?
• How can I help take care of myself if I have MG?
• Is MG associated with other conditions?

What is myasthenia gravis (MG)?

Myasthenia gravis is an autoimmune disease that affects the transmission of signals from nerves to muscles. The name myasthenia gravis comes from Greek and Latin words meaning "grave muscle weakness." Today, however, most cases of MG are not as "grave" as the name implies. In fact, most people with MG can expect to live normal or nearly normal lives.

The hallmark of MG is muscle weakness that increases during activity and improves after rest. MG often involves muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing. The muscles that control breathing and neck and limb movements may also be affected.

The thymus gland, part of the immune system, is abnormal in most MG cases. Some people with MG have benign (noncancerous) tumors of the thymus gland called thymomas. Some drugs can trigger or worsen MG symptoms.

What causes MG?

MG is caused by a defect in the transmission of nerve signals to muscles. Normally, nerve endings release a substance called acetylcholine that binds or attaches to receptors on the muscle. This leads to muscle contractions. In MG, the body's own immune system produces antibodies that block this transmission.

Who gets myasthenia gravis?

Estimates of the number of people affected by MG vary, ranging from five to 14 people per 100,000.

MG occurs in all ethnic groups and both genders. It most commonly affects young adult women (under 40) and older men (over 60), but it can occur at any age. Children sometimes develop MG.

MG is not directly inherited nor is it contagious. Sometimes the disease may occur in more than one member of the same family. If a woman with MG becomes pregnant, sometimes the baby acquires antibodies from the mother and has MG symptoms for a few weeks or months after birth. This is called neonatal myasthenia, and the symptoms can be treated.

In rare cases, myasthenia is caused by a defective gene and appears in infants born to non-myasthenic mothers. This type is called congenital myasthenia.

What is the role of the thymus gland in MG?

The thymus gland, found in the upper chest area beneath the breastbone, is a part of the body's normal immune system. In most adults with MG, the thymus gland is abnormal. Some people with MG develop thymomas or tumors on the thymus gland. Generally thymomas are benign, but they can become malignant (cancerous). The relationship between the thymus gland and MG is not yet fully understood.

What are the signs and symptoms of MG?

The muscles that control eye and eyelid movement, facial expression, and swallowing are most often affected. The onset of the disorder may be sudden. Symptoms often are not immediately recognized as MG.

In most cases, the first noticeable symptom is weakness of the eye muscles. In others, difficulty in swallowing and slurred speech may be the first signs. While rare, first signs of MG can also include difficulty with breathing. The degree of muscle weakness involved in MG varies greatly among persons with this disease. Symptoms, which vary in type and severity, may include:

• Drooping of one or both eyelids(ptosis)
• Blurred or double vision (diplopia) due to weakness of the muscles that control eye movements
• Unstable or waddling gait
• Weakness in arms, hands, fingers, legs, and neck
• Change in facial expression
• Difficulty in swallowing and shortness of breath
• Impaired speech (dysarthria)
• Shortness of breath

How is MG diagnosed?

Unfortunately, a delay in diagnosis of one or two years is not unusual in cases of MG. Weakness is a common symptom of many other disorders. The diagnosis is often missed in people who have mild weakness or in those whose weakness is restricted to only a few muscles.

The first steps of diagnosing MG include a review of the person's medical history and physical and neurological exams. If the doctor suspects MG, several tests are available to confirm the diagnosis.

• Antibody blood test. A special blood test can detect the antibodies that prevent nerves from signaling to muscles. While most people with MG have abnormally high levels of these antibodies, some individuals (about 10 percent) can actually test negative for antibodies. And, antibodies may not be detected if only eye muscles are affected.
• Edrophonium test. When this drug is injected, the weak eye muscles of people with MG will briefly get stronger.
• Nerve conduction test/repetitive stimulation. This is a test of specific muscle fatigue by repetitive nerve stimulation.
• Single fiber electromyography (EMG). In this test, pairs of single muscle fibers are stimulated by electrical impulses. It can detect impaired nerve-to-muscle transmission.
• Computed tomography (CT) or magnetic resonance imaging (MRI). These tests cn help identify an abnormal thymus gland or a thymus gland tumor.

What is the treatment for MG?

Today, MG can be controlled. There are several therapies available to help reduce muscle weakness. Most persons with MG have good results from treatment. In some people MG, like many other autoimmune diseases, may go into remission (a period of time without symptoms) and muscle weakness may disappear completely.

Remission or improvement can occur without treatment in some cases. According to the Muscular Dystrophy Association, up to 20 percent of person with MG may have complete remission of symptoms without any treatment, and another 20 percent may improve without treatment. These spontaneous improvements are more likely to occur during early stages of MG.

Treatment of MG may include:

• Medications. Drugs used include cholinesterase inhibitors such as neostigmine and pyridostigmine. These drugs help improve nerve signals to muscles and increase muscle strength. Immunosuppressive drugs such as prednisone, cyclosporine, and azathioprine may also be used to suppress the production of abnormal antibodies. They must be used with careful medical follow-up because they can be associated with major side effects.
• Thymectomy, the surgical removal of the thymus gland (which is abnormal in most persons with MG). This surgery is done for persons with MG who have tumors, as well as for individuals without tumors. It improves symptoms in more than half of individuals without tumors. It may cure some people with MG, possibly by re-balancing the immune system.

Other therapies sometimes used to treat MG during especially difficult periods of weakness include:

• Plasmapheresis or plasma exchange. This is a procedure that removes abnormal antibodies from the blood.
• High-dose intravenous immune globulin. This treatment temporarily interferes with the ability of the immune system to damage the nerve muscle junction. Treatment options for a person with MG depend on the severity of the weakness, which muscles are affected, and the person's age and other medical problems.

In a few cases, MG may cause severe weakness resulting in acute respiratory failure. But most people can expect to lead normal or nearly normal lives.

What is a myasthenic crisis?

A myasthenic crisis occurs when weakness affects the muscles that control breathing. This can create a medical emergency requiring a respirator to help the person breathe or measures to prevent a person from taking in, or aspirating, too much air into their lungs. In individuals whose respiratory muscles are weak, infection, fever, a reaction to medication, or emotional stress can trigger a crisis.

How can I help take care of myself if I have MG?

You can follow a few simple steps to help cope with the condition in your daily life. Plenty of rest and a well balanced, potassium-rich diet can help ease fatigue. Good sources of potassium include oranges, orange juice, and bananas. It is important to avoid overexertion, and if necessary, to rest the eyes or to lie down briefly a few times a day.

Is MG associated with other conditions?

Since it is an autoimmune disease, it may occur in combination with other autoimmune conditions such as rheumatoid arthritis, Sjorgrens syndrome, lupus, pernicious anemia, or autoimmune thyroiditis.

Thyroid Disorders

• What is the thyroid and why should I worry about it?
• What are the different types of thyroid disorders?
• What are the signs of a thyroid disorder?
• How are thyroid disorders treated?

What is the thyroid and why should I worry about it?

The thyroid is a small gland in the neck, just under the Adam's apple. Shaped like a butterfly, the thyroid plays an important role in a person's health and affects every organ, tissue, and cell in the body. It makes hormones that help to regulate the body's metabolism (how the body uses and stores energy from foods eaten) and organ functions. When the thyroid is not working properly (called thyroid disorder), it can affect your body weight, energy level, muscle strength, skin health, menstrual cycle (periods), memory, heart rate, and cholesterol level. Thyroid disorders happen: when the thyroid gland is not as active as it should be (called underactive thyroid); when the thyroid is more active than it should be (called overactive thyroid); or when the thyroid is enlarged (called goiter or nodule). People with thyroid enlargement can have underactive, overactive or normal thyroid function. Thyroid disorders are much more common in women than in men. About 1 out of every 8 American women will develop a thyroid disorder. Underactive or overactive thyroid can be found with a simple blood test (called a thyroid stimulating hormone or TSH test), and is most often treated with medication and sometimes surgery or radioactive iodine.

What are the different types of thyroid disorders?

Thyroid disorders include:

• Hypothyroidism (underactive thyroid). This is the most common type of thyroid disorder, where the thyroid makes too little of the thyroid hormone that your body needs to function properly. It is most often caused by Hashimoto's disease. With this disease, the body's immune system (which normally protects you from disease) thinks the thyroid is a foreign invader and tries to destroy the thyroid. When damage is done to the thyroid, it can become larger (called goiter). Not getting enough iodine in a person's diet can also cause hypothyroidism, but this is more common outside of the United States (in the U.S., many products such as salt and bread are supplemented with iodine, making iodine deficiency rare).
  Being female, over 40 years of age, having a close family member with thyroid disease, and recently having had a baby are things that can increase the chance of getting hypothyroidism.
• Hyperthyroidism (overactive thyroid). When the thyroid gland is overactive, it makes too much of the thyroid hormone that your body needs to be healthy. This condition affects women more than men. In young women, hyperthyroidism is most often caused by Graves' disease. With this disease, the body's immune system tricks the thyroid into making too much thyroid hormone. The entire thyroid becomes enlarged and overactive. Older women may get another form of hyperthyroidism (toxic nodular goiter), where overactive thyroid cells group together and form a lump in the neck (called a thyroid nodule) that makes more of the thyroid hormone than the body needs. Some thyroid disorders initially cause overactive thyroid, but at a later point in time cause underactive thyroid, due to damage done to the thyroid gland.
• Postpartum thyroiditis. After giving birth, a woman's thyroid can swell and become larger or inflamed. This can cause changing levels of thyroid hormone in the body. Sometimes high levels can be followed by low levels of thyroid hormone. After 6 months or less, this condition usually goes away with no permanent damage to the thyroid. While common, thyroid disorders after pregnancy are often hard to detect since some of the symptoms, such as having trouble sleeping, fatigue, depression, or weight change are viewed as normal when a woman has a new baby. The symptoms can also be mild. Usually only short-term treatment is required until the thyroid recovers normal function. Sometimes after pregnancy, a woman can get hypothyroidism (underactive thyroid), which persists and needs long-term treatment with medication.
• Thyroid cancer. This type of cancer is most often found as a lump (or nodule) in the thyroid gland. It is not a common type of cancer and most thyroid nodules are benign (not cancer). Other signs of thyroid cancer include swelling in the lymph nodes of the neck and trouble swallowing or breathing. Although anyone can get thyroid cancer, people who as children had head or neck x-ray treatments for tonsillitis or other conditions (from about the 1920s to the 1960s) are more likely to get this cancer. It is treated with surgery, which removes the cancer, sometimes followed by radioactive iodine therapy, which kills the cancer.

What are the signs of a thyroid disorder?

It can be hard to tell if you have a thyroid disorder because these disorders can have signs that are common and often confused with other conditions. If you think you have a thyroid disorder, talk with your health care provider and ask if a blood test for a thyroid disorder is indicated. A simple blood test measures thyroid stimulating hormone, or TSH, to find overactive and underactive thyroid disorders.

Signs of hypothyroidism, or underactive thyroid, include:

• Fatigue
• Weight gain
• Mood swings
• Forgetfulness
• Hoarse voice
• Dry, coarse skin and hair
• Trouble swallowing
• Not being able to stand the cold
• Increased cholesterol
• Heavy or irregular periods or trouble getting pregnant
• An enlarged thyroid (goiter)

Signs of hyperthyroidism, or overactive thyroid, include:

• Weight loss
• Feeling irritable and nervous
• Weakness in muscles and tremors
• Having menstrual periods that are not regular
• Troubled, or disturbed sleep
• Problems seeing or eye irritations
• Having an enlarged thyroid (goiter)
• Not being able to stand the heat
• Palpitations or rapid heart beats
• Frequent bowel movements

How are thyroid disorders treated?

Thyroid disease can be treated with medication alone or with surgery, radioactive iodine or a combination of these treatments. Hypothyroidism (underactive thyroid) is treated with thyroid replacement therapy. A synthetic hormone is taken daily to increase the amount of thyroid hormone in a person's body. The drug most health care providers prescribe is levothyroxine sodium. This is the same hormone the thyroid normally makes. Treatment for hyperthyroidism (overactive thyroid) aims to decrease the amount of thyroid hormone in a person's body. This is done through medications that block the formation and release of thyroid hormone into the body or with radioactive iodine treatment, which destroys the overactive thyroid tissue. Surgery can also be done to remove part or all of the thyroid gland, but this is usually done to remove a nodule rather than to treat overactive thyroid. If you have ever had a thyroid disorder, it is important to check your thyroid levels with your health care provider on a regular basis.

For more information

Alliance for Lupus Research
Phone Number(s): 212-218-2840
Internet Address: www.lupusresearch.org/

American Academy of Dermatology
Phone Number(s): (888) 462-3376, (847) 330-0230
Internet Address: http://www.aad.org

American Association for Chronic Fatigue Syndrome
Phone Number(s): (206) 781-3544
Internet Address: http://www.aacfs.org

American Autoimmune Related Diseases Association, Inc.
Phone Number(s): (810) 776-3900 or
(800) 598-4668 Literature Requests
Internet Address: www.aarda.org

American College of Rheumatology
Phone Number(s): (404) 633-3777
Internet Address: www.rheumatology.org

Arthritis Foundation
Phone Number(s): (800) 283-7800
Internet Address: http://www.arthritis.org

Arthritis National Research Foundation
Phone Number(s): (800) 558-2873
Internet Address: http://www.curearthritis.org

Center for Disease Control 24-Hour Chronic Fatigue Syndrome Voice Information System
Phone Number(s): (888) 232-3228
Internet Address: http://www.cdc.gov/ncidod/diseases/cfs

Chronic Fatigue and Immune Dysfunction Syndrome Association of America
Phone Number(s): (800) 442-3437
Internet Address: http://www.cfids.org

Fibromyalgia Network
Phone Number(s): (800) 853-2929 or (520) 290-5508
Internet Address: http://www.fmnetnews.com

Lupus Foundation of America
Phone Number(s): (800) 558-0121
Internet Address: www.lupus.org

Myasthenia Gravis Foundation
Phone Number(s): (800) 541-5454
Internet Address: http://www.myasthenia.org

National CFIDS Foundation
Phone Number(s): (781) 449-3535
Internet Address: http://www.ncf-net.org

National Chronic Fatigue Syndrome and Fibromyalgia Association
Phone Number(s): (206) 313-2000
Internet Address: http://www.ncfsfa.org

National Fibromyalgia Research Association
Phone Number(s): (503) 588-1411
Internet Address: http://www.nfra.net

National Heart, Lung, and Blood Institute (NHLBI)
Phone Number(s): 301-592-8573
Internet: www.nhlbi.nih.gov

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Phone Number(s): (301) 496-4484
Internet Address: www.niams.nih.gov

National Institute of Diabetes & Digestive Diseases and Kidney Diseases
Phone: (301) 496-3583
Internet Address: http://www.niddk.nih.gov/

National Institute of Environmental Health Sciences (NIEHS)
Phone Number(s): 301-496-3511
Internet: www.niehs.nih.gov

National Institute of Neurological Disorders and Stroke
Phone Number(s): (800) 352-9424
Internet Address: http://www.ninds.nih.gov

National Institute of Neurological Disorders and Stroke (NINDS)
Phone Number(s): 800-352-9424
Internet: www.ninds.nih.gov

National Institute on Aging
Phone Number(s): (800) 222-2225
Internet Address: http://www.nih.gov/nia

National Library of Medicine's MEDLINEplus
Phone Number(s): (888) 346-3656
Internet Address: www.nlm.nih.gov/medlineplus/lupus.html

National Organization for Rare Diseases
Phone Number(s): (800) 999-6673 or 999-NORD
Internet Address: http://www.rarediseases.org/

National Psoriasis Foundation
Phone Number(s): (800) 723-9166
Internet Address: http://www.psoriasis.org

Office of Minority Health, Office of the Secretary
Phone Number(s): (800) 444-6472
Internet Address: www.omhrc.gov

SLE Foundation
Phone Number(s): 212-685-4118
Internet Address: www.lupusny.org

The Thyroid Society, Inc.
Phone: (800) 849-7643
Internet Address: http://www.the-thyroid-society.org/

Thyroid Center
Phone: (800) 227-CPMC
Internet address: http://cpmcnet.columbia.edu/dept/thyroid/

Thyroid Foundation of America
Phone: (800) 832-8321
Email: info@tsh.org
Internet Address: http://www.tsh.org/

National Heart, Lung, and Blood Institute (NHLBI)
Phone Number(s): 301-592-8573
Internet: www.nhlbi.nih.gov