www.drlowe.com--Swelling--Fibromyalgia, Hypothyroidism, Thyroid Hormone Resistance

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The Metabolic Treatment
of Fibromyalgia
by Dr. John C. Lowe
Readers' Comments

Swelling
[Q&As are placed in reverse chronological order. In other words,
the latest Q&As come first. Earlier ones are further down the page.]

Latest Updates to drlowe.com

November 12, 2002

Question: I attended your seminar in the Seattle-area a couple of months ago. At the seminar, you mentioned a word doctors once used to describe puffiness in hypothyroid patients. You said that in the past, doctors used the puffiness to diagnose hypothyroidism and that many fibromyalgia patients also have the puffiness.

Will you let me know how to spell the word so that I can find information on it? I’m interested because of something that’s happened to me since I started using thyroid hormone after your seminar. Before I started thyroid hormone, I had puffy, swollen places below my knees. These have now disappeared—which is just wonderful! Any help you can give me will be very much appreciated.

Dr. Lowe: In the early part of the 20^th century, doctors believed that all hypothyroid patients had the tissue puffiness, and they used the puffiness as a diagnostic sign of hypothyroidism. The term doctors used back then is the same one we now today: "myxedema."

In the 1930s, researchers showed that only a small percentage of hypothyroid patients have the puffiness. Similarly, only a small percentage of fibromyalgia have myxedema. Some of the fibromyalgia patients are hypothyroid, and others are partially resistant to thyroid hormone. In either case, when the patients reach effective doses of thyroid hormone, the swelling disappears, usually with a week or two.

The puffiness is caused by too little thyroid hormone suppression of connective tissue cells called "fibroblasts." When thyroid hormone fails to suppress the cells normally, they release too many water-binding molecules into the ground substance of the skin and other connective tissues. These water-binding molecules are a complex of protein and sugar. Researchers used to call them "mucopolysaccharides," but most of us now call them "glycosaminoglycans." The excess number of the molecules holds too much water in the connective tissues. The excess water expands the tissues, causing them to feel and appear puffy. This is the basis of carpal tunnel syndrome in hypothyroidism; the ligament that surrounds the wrist swells and compresses the median nerve. Compression of the nerve induces the carpal tunnel symptoms. Subtle myedematous swelling most likely accounts for the "subjective" swelling that many fibromyaglia researchers report that patients complain of.

That the puffiness beneath your knees (a common site for the swelling) has disappeared is indeed a positive sign. This makes it likely that too little regulation by thyroid hormone is the cause of your other "fibromyalgia" symptoms and signs. With the disappearance of the swelling, it’s now reasonable for you to expect other positive changes to soon occur from your use of thyroid hormone.

May 22, 2001

Question: For many years now my hands, face, feet, and I think maybe overall body (because of the way I feel) swell. My hands swell so badly that the knuckles are white, and wearing a wedding ring is impossible because of the serious indentation left when I swell. It comes and goes throughout the day, but in the morning when I awake, I’m miserable. My face becomes 'bloated' sometimes, and under my eyes are deep, dark circles, as if I were sleep deprived. My physician tested my thyroid but said the results were normal. I read your statement that someone may have a thyroid problem even though her thyroid tests are normal. What do you think is my problem?

Dr. Lowe: In the early part of the 20th century, tissue swelling (called "myxedema") was the main sign doctors used to decide that a patient was hypothyroid. Of course, too little thyroid hormone regulation isn't the only cause tissue swelling. It is important to learn the underlying cause of the swelling and to treat it properly.

Unfortunately, I don't have enough information on you to give an opinion about the cause of your swelling. However, many people who have normal thyroid test results also have too little thyroid hormone regulation of cells in their connective tissues called "fibroblasts." A result of the inadequate regulation of these cells is the perception of tissue swelling or actual swelling. In some people, connective tissue swelling leads to regional problems. For example, the tendons and ligaments in the wrist may swell, compress the median nerve, and cause the symptoms known as "carpal tunnel syndrome."

With actual swelling, the patient’s skin usually looks puffy. But the swelling is "non-pitting." This means that pushing a finger into the swollen skin and quickly removing it doesn't leave a pit (indentation) in the skin. You wrote that your wedding ring leaves an indentation around your finger. This may mean that your swelling involves fluid retention unrelated to thyroid hormone regulation of your fibroblasts.

That your thyroid test results are "normal," however, does not mean that you have adequate thyroid hormone regulation of your tissues. Many people who have so-called "normal" blood levels of TSH and thyroid hormone nonetheless have less-than-normal tissue responses to thyroid hormone. The result is that the people have symptoms and signs similar to those of the hypothyroid patient. Tissue swelling can be one of the sign.

Your best bet is to find an alternative doctor who uses patients' symptoms and signs in his assessment of whether they have enough thyroid hormone regulation of their tissues. If you have other symptoms and signs that suggest inadequate thyroid hormone regulation, the doctor may give you a trial of thyroid hormone therapy to see if this reduces or relieves your swelling—even though the results of your thyroid hormone tests are "normal."

February 15, 1988

Question: Four years ago I was diagnosed with fibromyalgia. This may seem petty but the most irritating problem associated with this disease is the tremendous swelling that I incur daily. For me, the swelling seems to worsen as the day goes on. Pants I put on in the morning do not fit me by the end of my work day. My legs and feet seem to be the most affected. I have gained weight, which I cannot lose. I exercise daily and have faithfully for 10 years. I am truly at my wits end. Can you offer any suggestions?

Dr. Lowe: Your complaints are not petty to me. If your swelling is a product of too little thyroid hormone regulation, it may only be the most obvious abnormality. Despite your normal thyroid test results (see part 2 below), your weight gain may be an effect of inadequate thyroid hormone regulation. And your swelling may be due to one of two other effects of the inadequacy.

One is what used to be termed "myxedema." This is swelling caused by an increase in water-binding molecules in the connective tissues. It results from inadequate thyroid hormone inhibition of the cells that produce the molecules. This occurs in some patients with hypothyroidism and others with thyroid hormone resistance. Awad in 1973, and Yaron and coworkers in 1997, provided research data that suggest some fibromyalgia patients have the connective tissue abnormality (increased hyaluronic acid) underlying myxedema. I have found myxedema in some fibromyalgia patients before treatment, and I've seen it disappear during their treatment with thyroid hormone. Skin and underlying tissues that are myxedematous do not "pit" when pressed into with a finger. If the tissue "pits," the swelling is more likely caused by fluid retention from another source. (Swelling of the wrist ligaments in hypothyroid patients can cause carpal tunnel syndrome.)

The other possible cause of swelling is an increase in the amount of fluid outside cells. This happens in the bodies of some patients who have deficient thyroid hormone regulation, and occurs because the blood vessels in the kidneys constrict in response to low blood pressure. The constriction of the vessels is water conserving. It reduces the amount of water lost to the urine and reabsorbs it into the circulation. The increased water in the blood helps prevent the blood pressure from further decreasing. Some of the fluid, however, is lost to the tissue spaces. This can result in swelling that may be distinguished by "pitting" when pressed into with a finger.

If either or both of these effects account for your swelling, they should disappear and cease occurring when you take a high enough dosage of the proper form of thyroid hormone.