Menstrual cycle influences on pain and emotion in women with fibromyalgia

Journal of Psychosomatic Res

Menstrual cycle influences on pain and emotion

in women with fibromyalgia

Carmen Alonso*, Barbara L. Loevinger, Daniel Muller, Christopher L. Coe

Department of Psychology, University of Wisconsin, 1202 West Johnson Street, Madison, WI 53706-1696, United States

Received 30 September 2003; accepted 12 May 2004

Abstract

Objective: This study examined the influence of the menstrual

cycle on pain and emotion in women with fibromyalgia (FM) as

compared with womenwith rheumatoid arthritis (RA) and to healthy

controls. Methods: One hundred and twenty-five premenopausal

women (21-45 years old) participated in this study (57 with FM,

20 with RA, and 48 controls). Pain and emotion assessments were

conducted during the follicular and the luteal phases of the men-

strual cycle. Results: Women with FM experienced more pain,

0022-3999/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2004.05.003

* Corresponding author. Tel.: +1 608 262 5346; fax: +1 608 262 4029.

E-mail address: [email protected] (C. Alonso).

menstrual symptoms, and negative affect than did women with RA

and the controls. All women reported less positive affect during

the luteal phase, although this pattern was more pronounced in

women with FM and RA than in controls. Conclusion: Although

FM pain did not vary across the menstrual cycle, these results

point to the importance of considering the lower level and cyclical

nature of positive affect when studying women with chronic pain.

D 2004 Elsevier Inc. All rights reserved.

Keywords: Emotion; Fibromyalgia; Menstrual cycle; Pain; Rheumatoid arthritis

Introduction

The significance of the menstrual cycle in women’s

physical and psychological well-being remains controver-

sial. With regard to pain and discomfort, it is typically

assumed that pain sensitivity varies across the menstrual

cycle and is higher in the luteal phase. This assumption has

been verified in studies that found a lower pain threshold in

response to experimentally induced pain, such as ischemic

pain or cold pressor tasks, during the luteal phase [1,2].

However, Tedford et al. [3] obtained results in the opposite

direction, with reduced pain sensitivity during the luteal

phase. Hapidou and Rollman [4] further challenged the

notion of greater pain sensitivity during the luteal phase

when they found that pain sensitivity, identified by tender

point palpation, was greater in the follicular phase in

normally cycling women. In addition, Johns and Littlejohn

[5] reported that pain sensitivity, measured using a

dolorimeter at 18 tender and 4 control points, did not

correlate with the menstrual phase.

The relationship between the menstrual cycle and pain

sensitivity is of particular relevance to women who

experience chronic pain, such as in the case of fibromyalgia

(FM). FM is a pain disorder of unknown etiology found in

an estimated 3–6 million Americans, including children and

the elderly [6]. As many as 90% of the patients are women

[7]. The FM diagnosis requires (1) widespread pain

affecting the musculoskeletal system and (2) tenderness in

at least 11 of 18 defined points [8–10]. In clinical settings,

the manifestation of pain and tenderness is often combined

with other characteristic symptoms, including nonrestorative

sleep, fatigue, stiffness, headache, irritable bowl syndrome,

and mood disorders [9]. Women with FM are thought to

experience more FM pain during the luteal phase, and

perimenstrually, as compared with healthy control women

[7,11]. More generally, a premenstrual worsening of FM

symptoms has also been reported in the literature [12].

However, Macfarlane et al. [13] conducted a large epide-

miological study involving 1178 women, of which 11.2%,

or 132 women, experienced widespread pain, and concluded

that hormonal factors were not associated with pain

symptoms. This lack of consensus led us to reevaluate the

influence of the menstrual cycle and to consider whether the

women’s presentation and emotional state might influence

the effect of the menstrual cycle on pain sensitivity.

earch 57 (2004) 451–458

Table 1

Sociodemographic profile for the three groups of participants

Sociodemographic profile HC RA FM

Age

C. Alonso et al. / Journal of Psychosomatic Research 57 (2004) 451–458452

Menstrual influences have also been extensively inves-

tigated with regard to emotion. Increased negative affect and

decreased levels of self-reported well-being have been

documented during the luteal phase (e.g., Ref. [14]).

Similarly, women with FM have been shown to experience

more psychological distress and less positive affect than do

healthy controls during the luteal phase [7,11,15].

Although both pain and affect have been related to the

menstrual cycle, the specific relationship between those two

factors remains unclear. For instance, Herrera et al. [16]

found that among forty 19- to 24-year-old women, depres-

sive subjects reported more pain across the menstrual cycle

than the nondepressive subjects did. On the other hand,

Laessle et al. [17] found that although somatic complaints,

such as abdominal pain and breast tenderness, were

significantly related to the phases of the menstrual cycle in

30 healthy young women, the cycle-related hormone

fluctuations could not be directly linked to marked changes

in affect. Therefore, it seemed critical to combine a study of

objective pain measures, including tender point and dolo-

rimetry assessments, with an evaluation of positive and

negative affect. In addition to examining the influence that

the menstrual cycle has on pain and emotion in women with

FM, we compared their responses to women with another

chronic pain condition, rheumatoid arthritis (RA). RA has a

more established etiology as an autoimmune disorder and is

not as likely as FM to be associated with depression and

other types of psychological disturbance [18,19]. The

primary hypotheses of the study were that (1) women with

FM would experience increased pain sensitivity and a

worsening of symptoms during the luteal phase, and (2)

FM women would manifest more negative and less positive

affect than will the women with RA and the healthy controls,

especially during the luteal phase of the menstrual cycle.
Mean 33 35 36
S.D. 7.6 6.5 7.4

Education (highest level completed) (%)

High school 4 10 12

College level 58 65 58

Graduate level 38 25 30

Employment status (%)

Employed 92 75 80

Not employed 8 25 20

Income (%)

bUS$0 – 29,999 42 30 38

US$30,000 – 69,999 35 45 46

NUS$70,000 23 25 16

Partner status (%)

Married, living w/partner 54 60 58

Single, divorced, widowed 46 40 42

Children (%)

0 54 60 53

1 13 10 16

N1 33 30 31

HC= healthy controls, RA= rheumatoid arthritis, FM= fibromyalgia.

Method

Participants

A total of 132 premenopausal women (21– 45 years of

age, 92% Caucasian), with regular menstrual cycles,

participated in this study: 64 with FM, 20 with RA, and

48 healthy controls. Potential participants were recruited

from local rheumatology and pain clinics and from

advertisements in a local newspaper and in a local women’s

magazine. To be eligible for the study, FM patients had to

have been diagnosed by a rheumatologist or primary care

physician and had to meet the American College of

Rheumatology (ACR) 1990 diagnostic criteria for FM

[20]. Seven participants who stated that they had an FM

diagnosis but did not meet the 11 positive tender points

criterion were omitted from the analyses. The RA patients

also had been diagnosed by a rheumatologist and were

screened for rheumatoid factor and antinuclear antibody.

Healthy control participants were excluded if they reported

any chronic physical illness. Participants were excluded

from the study if they had been diagnosed with both

conditions, FM and RA, if they had been taking cortisone

during the previous 3 months, and if they were taking any

narcotic medication. In addition, any other physical illness

that could cause pain, such as systemic lupus, diabetes,

polycystic ovarian syndrome, or thyroid disease, was

considered as an exclusion criterion. The three groups of

participants were not significantly different regarding age,

education level, employment status, income, partner status,

or number of children (see Table 1).

Procedure

Potential participants were screened via phone interview

and were invited to come for a first consent meeting if they

met the study criteria. During the first meeting, written

consent was obtained, as approved by the Institutional

Review Board, and menstrual cycle symptoms were

assessed. After the initial meeting, pain and psychosocial

evaluations were conducted on two occasions: during the

follicular and the luteal phases of the menstrual cycle. The

date of the luteal visit was scheduled during the week prior

to next menses and the date of the follicular visit during the

week after menstruation. The order of the two visits was

counterbalanced across participants. When women came for

each evaluation, they provided weekly logs of their

C. Alonso et al. / Journal of Psychosomatic Research 57 (2004) 451–458 453

menstrual status and pain symptoms for the week prior to

the appointment date. In addition, on the date of their

appointment, a pain assessment was conducted (tender point

and dolorimeter assessments and self-reported pain levels).

FM symptoms and negative and positive affect were also

assessed on those two occasions. Participants received a

total of US$200 for their time and participation at the end of

the study.

Measures

Tender points

All participants were assessed by palpation of the 18

tender points specified by the ACR in 1990 (see Fig. 1).

Manual palpation was achieved by applying the right

thumb on each tender point with a pressure of approx-

imately 1 kg/s. Participants indicated when they first felt

pain (as opposed to pressure), and tender point data are

reported as the sum of positive tender points.

Dolorimeter

Dolorimetry evaluation was conducted with a pressure

algometer. The algometer had a 1-cm-diameter rubber head,

which was applied to 8 of the 18 ACR tender points and to 3

control points (right and left thigh and forehead; Fig. 1).

Pressure on each point was increased at a rate of

approximately 1 kg/s, and participants indicated when they

first felt pain (as opposed to pressure). The reported

dolorimetry score is considered a measure of pain threshold

Tender Points (18)

Control Points (3)

Dolorimetry Points (8)

Fig. 1. Location of tender points, dolorimetry, and control pressure points

(modified from Freundlich and Leventhal [34]).

and reflects the mean of the eight sites examined. The mean

of the three control points was also recorded and used for

the analyses. The minimum score was 0 and was recorded

for those women for whom the contact of the algometer with

any of their eight tender or three control points was already

painful (without any pressure). In contrast, if no pain was

reported, the threshold maximum of 4 kg was recorded.

Self-reported pain

A visual analog scale (VAS) was used to assess

subjective perception of pain based on a 10-cm line (0 no

pain, 10 pain as bad as it could be).

Pain diaries

A pain diary was created using a modified version of the

McGill Pain Questionnaire [21]. The short-form McGill

Pain Questionnaire includes 15 descriptors of pain (11

sensory; 4 affective), which are rated on an intensity scale

(0 = none, 1=mild, 2 =moderate, 3 = severe), and VAS (0 =

no pain, 10 =pain as bad as it could be). Participants filled

out the daily questionnaire for 7 days prior to the hospital

visit during both the follicular and luteal phases.

Mood and anxiety symptoms

The Mood and Anxiety Symptom Questionnaire-Short

Form (MASQ; Ref. [22]) is a 62-item questionnaire that

includes four scales, two of which assess general distress

factors associated with anxiety and depression. The Anxious

Arousal scale includes symptoms theorized to be specific to

anxiety (such as somatic tension and hyperarousal), and the

Anhedonic Depression scale was devised to be specific to

depression (low positive affect, anhedonia).

Positive and negative affect

The Positive and Negative Affect Schedule (PANAS;

Ref. [23]) is a 20-item questionnaire that includes two 10-

item mood scales assessing Positive Affect (enthusiastic,

active, alert) and Negative Affect (upset, guilty, afraid).

FM symptoms

The Fibromyalgia Impact Questionnaire (FIQ; Ref. [24])

is a 10-item questionnaire that measures physical function-

ing, work status, depression, anxiety, sleep, pain, stiffness,

fatigue, and well-being. Using the listed items, we created

five subscales, including days felt good (well-being), days

missed work (work status), physical functioning, FM

symptom score (sleep, pain, stiffness, fatigue), and negative

emotion (depression, anxiety).

Menstrual cycle symptoms

The Menstrual Cycle Questionnaire (MCQ; Ref. [25])

is a 30-item standardized instrument including 23 ques-

tions about symptoms experienced during a typical

menstrual cycle and questions regarding typical cycle

and period length. Answers are rated on an intensity scale

of 0 (does not apply to me) to 6 (extremely or intense).

Table 3

Means (M) and standard deviations (S.D.) of pain scores for the three

groups of participants

Pain measures

HC RA FM

M S.D. M S.D. M S.D.

Tender point number

(18 points)

1.9 2.7 4.8 4.7 14.6a 2.5

Dolorimetry

(Kg., 8 points)

3.7 0.5 3.2 0.8 2.0a 0.5

Dolorimetry

(Kg., 3 points)

3.9 0.2 3.6 0.5 2.8b 0.7

Visual analog scale

(0-10)

0.4 0.6 2.3 1.9 4.8a 2.3

Pain diary 0.7 0.8 2.5 1.8 4.8a 1.8

a FM significantly different from both RA and HC.b FM significantly different from HC.


We used a global scale and also, based on the results of a

factor analysis, created four subscales (premenstrual pain,

perimenstrual negative affect, premenstrual water reten-

tion, and menstrual pain) to measure specific menstrual

cycle symptoms.

Data analysis

To analyze the effect of menstrual phase on pain and

affect, a series of repeated measures analyses of variance

(MANOVAs) were conducted. For all the analyses, men-

strual phase (follicular, luteal) was considered as a within-

subject variable and group (healthy controls, RA, FM) as a

between-subjects variable. Post hoc analyses were based on

the Tukey HSD test. Associations between pain and

psychological variables were evaluated with Pearson’s r

statistics, and Bonferroni corrections were applied for

Table 2

Means (M) and standard deviations (S.D.) of menstrual scores for the three

groups of participants in relation to use of oral contraceptives (OC)

Menstrual cycle

characteristics

HC RA FM

M S.D. M S.D. M S.D.

Typical cycle length

All 29.2 3.3 28.0 2.1 28.3 3.1

OC users 28.4 1.3 28.0 0.0 27.4 1.9

Non-OC users 29.4 3.7 28.0 2.6 28.6 3.3

Typical menses length

All 5.0 1.4 4.5 1.5 5.1 1.1

OC users 4.8 0.9 3.9 1.8 4.9 1.0

Non-OC users 5.0 1.5 4.9 1.3 5.1 1.2

Total menstrual symptoms

All 33.4 19.6 43.1 28.4 58.3a 24.8

OC users 30.9 20.3 35.6 23.1 65.2 17.3

Non-OC users 34.1 19.6 47.4 31.2 55.5 26.2

Premenstrual pain

All 1.4 1.2 1.6 1.6 2.7a 1.6

OC users 1.4 1.2 1.0 1.0 2.9 1.4

Non-OC users 1.4 1.3 1.9 1.8 2.6 1.6

Perimenstrual negative affect

All 2.0 1.4 2.4 1.4 3.2b 1.6

OC users 2.0 1.6 2.1 1.2 3.3 1.6

Non-OC users 2.0 1.4 2.6 1.5 3.2 1.6

Premenstrual water retention

All 2.8 1.6 3.2 1.6 3.7b 1.4

OC users 2.4 1.7 2.9 1.8 3.9 1.3

Non-OC users 2.9 1.6 3.4 1.5 3.6 1.5

Menstrual pain

All 1.1 0.9 1.7 1.5 2.1b 1.2

OC users 0.9 0.8 1.3 1.2 2.4 1.0

Non-OC users 1.1 0.9 2.0 1.6 1.9 1.2

HC = healthy controls, RA= rheumatoid arthritis, FM= fibromyalgia,

OC= oral contraceptives.a FM significantly different from both RA and HC.b FM significantly different from HC.

multiple correlations. The SPSS 10.0 software package

was employed for all the analyses.

Results

Menstrual cycle characteristics

Women in the three groups did not differ in typical cycle

length or mean duration of menses. However, women with

FM endorsed significantly more menstrual symptoms, in

general, on the MCQ than did either women with RA and

controls [F(2,122) = 14.3, P b.001; Table 2]. In addition,

women with FM also reported higher levels of premenstrual

pain, negative affect, water retention, and menstrual pain on

each of the four MCQ subscales (all Psb .02). It is important

to note that for the three groups, the use of oral contra-

ceptives did not have a significant effect on typical cycle

length, mean duration of menses, total menstrual symptoms,

or on any of the four MCQ subscales (see Table 2).

Pain

Consistent with their diagnosis and reports of increased

pain, a series of analyses of variance (ANOVAs) indicated

that women with FM had more positive tender points and

were less able to tolerate the dolorimetry pressure than did

women with RA and the healthy control women (all

Psb .001; Table 3). Women with FM had a mean of 14.6

positive tender points, whereas the RA and healthy control

women had 4.8 and 1.9, respectively. RA and healthy

control women tolerated significantly more dolorimetry

pressure both at the eight tender point locations, as well as at

the three control points. The latter difference indicates that

women with FM are also more sensitive to pain in areas

other than the 18 utilized in the standard diagnostic test.

When analyzing all pain measures for the entire sample

of women, tender points, dolorimeter scores, self-reported

pain, and the pain diary scores were significantly correlated.

However, when considering the FM women separately, only

10

20

30

40

50

60

70

80

GDA GDD AA AD

MASQ Subscales

MA

SQ S

core

HC

RA

FM

Fig. 2. Means (mS.E.) of depression and anxiety scores for the three

groups of participants. HC= healthy controls, RA=Rheumatoid Arthritis,

FM= fibromyalgia, MASQ=Mood and Anxiety Symptom Questionnaire,

GDA= general distress anxious symptoms, GDD= general distress depres-

sive symptoms, AA= anxious arousal, AD= anhedonic depression.

0

2

4

6

8

10

12

14

16

18

Follicular Luteal

Menstrual Phase

Tot

al N

umbe

r of

Ten

der

Poi

nts

HCRAFM

Fig. 3. Mean (mS.E.) number of tender points for the three groups of

participants during the follicular and luteal phases. HC= healthy controls,

RA= rheumatoid arthritis, FM= fibromyalgia.


the correlations between tender points and dolorimeter

scores and between the VAS and pain diary scores remained

significant at the P b.001 level (tender points and eight

dolorimetry locations: r =� .53; tender points and three

dolorimetry control locations: r =� .49; VAS and pain diary

scores: r = .78).

Positive and negative affect

Women with FM reported higher levels of both general

and specific symptoms of anxiety and depression, as

measured by the MASQ (Fig. 2), and more negative and

Table 4

Correlations among affect, pain, and menstrual symptoms for the three

groups of participants

Pain and menstrual

symptoms

PANAS MASQ

NA PA GDA GDD AA AD

Tender point number

(18 points)

.47 �.36 .59 .44 .62 .47

Dolorimetry

(Kg., 8 points)

�.40 .34 �.51 �.38 �.54 �.43

Dolorimetry (Kg., 3

control points)

�.23 .22 �.38 �.25 �.46 �.29

Visual analog scale

(0 – 10)

.50 �.45 .60 .48 .54 .52

Pain diary .47 �.51 .60 .49 .59 .56

Total menstrual

symptoms

.40 �.28 .49 .32 .52 .34

Correlations greater than .30 are statistically significant at P b .001 with the

Bonferroni adjusted probability for multiple comparisons. PANAS = Positive

and Negative Affect Schedule, MASQ =Mood and Anxiety Symptom

Questionnaire, NA= negative affect, PA= positive affect, GDA= general

distress anxious symptoms, GDD = general distress depressive symptoms,

AA= anxious arousal, AD = anhedonic depression.

less positive affect on the PANAS than did RA and healthy

control women (all Psb .001). Across all participants,

negative affect scores from the PANAS were significantly

correlated with the total number of tender points (r = .46,

P b.001) as well as with overall menstrual pain (r = .40,

P b.001). Similarly, positive affect was inversely correlated

with total number of tender points (r =� .36, P b.001) and

with overall menstrual pain (r =� .28, P b.003). In addition,

depression and anxiety scores from the MASQ were also

significantly correlated with menstrual pain and tenderness

(Table 4).

Menstrual variation in pain and affect

To analyze the effect of menstrual phase on pain and

affect, a series of MANOVAs were conducted. FM partici-

pants evinced consistently higher levels of pain sensitivity or

self-reported more pain during both phases of the cycle1.

This invariant pattern of more tender points across the cycle

is illustrated in Fig. 3. Similarly, none of the other four pain

measures varied significantly across the menstrual cycle for

any of the three groups of participants. However, there was a

nonsignificant trend for greater sensitivity to dolorimetry

pressure for all participants during the luteal phase of the

menstrual cycle [F(2,122) = 3.55, P b.07], suggesting that

women, in general, were able to tolerate less pressure from

the dolorimeter at that time of the month.

While the pain indices were relatively constant across the

menstrual cycle, there was a striking shift in emotionality. A

1 Because a high percent of the healthy controls endorsed no pain on

the VAS and thus received a 0 score, the results were analyzed with both

parametric and nonparametric statistics. The Friedman nonparametric test

yielded the same outcome as the MANOVA did, indicating just an effect of

group and no differences between the two time periods.

0

10

20

30

40

Follicular Luteal

Menstrual Phase

PA

NA

S P

osit

ive

Aff

ect

Scor

e

HC

RA

FM

Fig. 4. Means (mS.E.) of positive effect scores for the three groups of

participants during the follicular and luteal phases. HC= healthy controls,

RA= rheumatoid arthritis, FM= fibromyalgia, PANAS=Positive and Neg-

ative Affect Schedule.


main effect for menstrual phase indicated that all women

reported less positive affect during the luteal phase in

comparison to the follicular phase [F(2,122) = 4.76,

P b.04]. Furthermore, post hoc tests indicated that women

with FM and with RA reported significantly less positive

affect during the luteal phase than did the controls

[F(2,122) = 3.60, P b.04; Fig. 4]. Based on the MASQ

scale, there were some similar trends suggesting that

women, in general, seemed to experience more symptoms

of anhedonic depression during the luteal phase [F(2,122) =

3.80, P = .05]. Post hoc tests indicated that this increase in

depressive symptomatology was more accentuated in

women with FM as compared with control women

(P b.001) and that women with RA also experienced

significantly more anhedonic depression than did controls

during the luteal phase of the cycle (P b.008).

Discussion

The aim of the present study was to examine the effects

of the menstrual cycle in women with FM and RA. Our

findings emphasize the importance of considering men-

strual cycle variation for understanding the relationship

between pain and emotion. Despite similarities in the

temporal aspects of the menstrual cycle, in terms of cycle

length and duration of menses, the FM participants reported

higher levels of premenstrual discomfort and dysmenor-

rhea. This is consistent with many reports suggesting that

women with FM have greater sensitivity to painful stimuli

and, perhaps, are even more likely to anticipate that

potentially painful experiences will actually be painful

[26]. Nevertheless, we did not find that the specific painful

symptoms associated with FM, in terms of the diagnostic

tender points, varied across the follicular and luteal phases.

This result concurs with those studies that also found

consistent and persistent pain across the cycle [5] but

differs from reports of hyperalgesia during the follicular [4]

or luteal [7] phase. Although it has been reported that

reproductive hormones can affect pain perception in other

pain conditions, such as myofascial pain [27], in our sample

of FM women and in a previous study involving college

students [28], we did not find an effect of oral contra-

ceptives on the menstrual pain.

More dramatic than any change in the objective measures

of pain, however, were the shifts in psychological state,

especially with regard to the decrease in positive affect

during the luteal phase. Consistent with Anderberg et al. [7],

we found that women with FM experienced less positive

affect than did the other two groups of women during the

luteal phase. This result supports previous work that has

emphasized the importance of measuring not only the

presence of negative affect, but also the absence of positive

affect in chronic pain [29] and in depressed patients [30].

Because women with FM are more likely to de depressed or

anxious, a rise in dysphoric mood, accompanied by less

positive emotion, might alter the experience and tolerance

for pain, as well as color how the individual presents to the

treating clinician.

Consistent with the FM diagnosis, these women reported

higher levels of pain, had more positive tender points, and

were less able to tolerate the pressure from the dolorimeter

than were women with RA and healthy control women. It is

also important to highlight that women with RA were

intermediate in these pain evaluations and that our sample of

mild RA averaged only 4.8 tender points, significantly

below the cutoff of 11 used as diagnostic criterion for FM.

These RA participants also reported less premenstrual and

menstrual discomfort than did the FM participants. While

our exclusion criteria for RA, which included the use of

steroidal medications, prevented us from recruiting women

with more severe disease, this finding of a difference in pain

sensitivity and tolerance when compared with FM concurs

with other papers (e.g., Ref. [18]). Moreover, our psycho-

logical evaluations of women with these two conditions

yielded similar differences, with a greater likelihood of

depressive and anxious symptoms in FM.

However, it should be reiterated that some shift in

general mood across the cycle was evident in many women

from the three groups, including the healthy controls. Our

analyses from the PANAS and MASQ instruments indicated

that there was a significant tendency for more negative and

less positive affect during the luteal as compared with the

follicular phase. Because women with FM already show a

bias for dysphoric mood, when compared with RA and

healthy women, this type of monthly variation would tend to

make a shift in emotional state of greater clinical signifi-

cance. From a statistical point of view, the change in


psychological well-being from the follicular to the luteal

phase was not greater in women with FM, but the lability in

mood could be pronounced in certain patients. Indeed, if

one considers that the pain associated with menstruation

would be summative with the generic body pain and

tenderness in FM, then these women may have an added

pain burden to tolerate.

Nevertheless, with regard to our initial and specific

hypothesis, we did not replicate the conclusion that FM pain

is greater during the luteal phase [7,12]. Thus, our study

supports the conclusions of Johns and Littlejohn [5] and

Macfarlane et al. [13]. Several factors may have influenced

our findings, including the specific way of defining the

cycle phases. We focused on the early follicular phase and

may have missed some remission in symptoms closer to

ovulation. Similarly, our scheduling during the luteal phase

did not restrict visits to the days immediately before menses.

Thus, we may have missed an accentuation of FM

symptoms in conjunction with dysmenorrhea during the

perimenstrual days. Because our study was designed to

investigate the dual influence of emotional state and

menstrual phase primarily, we also did not consider some

other important factors known to affect the experience and

tolerance for pain. For example, exercise can affect both

premenstrual symptoms and dysmenorrhea, and, because of

their pain, individuals with FM and RAwould be less likely

to exercise or would do so in a modified way [31-33]. We

and others have also reported that social relationships and,

in particular, disruptions of social support can influence the

subjective experience and tolerance for dysmenorrhea, even

in healthy young women [28]. This may reflect a direct

effect of psychological state on hormone and pain-related

physiology or, perhaps, the ways in which mood and

outlook can sensitize or minimize the attention given to

symptoms. Finally, because our sample was composed of

women who responded to an announcement of our study,

there is a potential for selection bias as compared with a

clinic population.

In sum, the critical finding of this study was that FM

pain was relatively constant across the cycle, but that our

participants were more likely to report the occurrence of

additional premenstrual pain and dysmenorrhea. With re-

spect to temporal variation, a cyclical shift in mood was

perhaps the more important domain to vary, and it was

most manifest by a decrease in positive affect. The re-

sulting dysphoria might undermine an individual’s ability

to tolerate painful symptoms and could color presentation

to a clinician. Indeed, one could imagine that the diagno-

stician might be biased to perceive a worsening of disease,

unless they used objective and quantifiable measures of

pain, such as dolorimetry. Finally, our results point to the

importance of considering specific interventions designed

to increase positive affect not only in general, but espe-

cially during the luteal phase, when designing interven-

tions to improve the psychological well-being of women

with FM.

Acknowledgments

Special acknowledgments are due to Holly Schleicher and

Julie Surbaugh for the invaluable assistance with participant

recruitment, evaluations, and data analyses.

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Menstrual cycle influences on pain and emotion in women with fibromyalgia

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