Conclusions
CFS in women is associated with self-reported menstrual abnormalities, endometriosis, pelvic pain unrelated to menstruation, early age at hysterectomy/surgical menopause, and other gynecologic conditions and surgical operations. It should be emphasized, however, that our findings do not demonstrate causality. These findings could be used for further hypothesis generation for future studies. Nevertheless, the significantly higher prevalence of various gynecologic conditions in women with CFS warrants clinicians' attention on tailoring these women's medical care. Gynecologists need to be aware that women who have had early hysterectomy and/or other gynecologic conditions discussed here may be at risk for CFS. Therefore, gynecologists need to assess these women periodically for symptoms suggestive of CFS (such as persisting/ relapsing problems with memory and concentration, sleep problems, muscle and joint pain without swelling or redness, persistent or relapsing fatigue that reduces previous levels of functioning, headaches of new onset or severity, postexertional malaise [ie, worsening of symptoms after mental or physical exertion], and other symptoms; for a detailed list of symptoms and differential diagnosis, see Fukuda et al ). When CFS is suspected, supportive care and appropriate clinical referrals are needed. Similarly, physicians seeing women with CFS need to carefully evaluate their gynecologic history for risk factors associated with CFS and work with gynecologists for further management of identified gynecologic problems. The exact reasons for the reported associations cannot be determined from this study; future studies need to examine whether any of the associations reported here may be pathophysiologically related to the onset or perpetuation of CFS in some women. Further work may be warranted to determine whether aberrations in endogenous sex hormones contribute to the pathogenesis and/or perpetuation of CFS in a subset of women with this illness.