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October 26, 2015/Ob/Gyn & Women’s Health

Women and Pain: What New Research Reveals

Exploring gender differences in common pain conditions

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By Richard W. Rosenquist, MD, Beth Minzter, MD, Jill Mushkat Conomy, PhD

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For the past two decades, research on gender and pain has been a topic of significant scientific and clinical interest. Recent research has expanded into how the overall pain experience for women differs from that of men. As described here, we start with the knowledge that many conditions and pain syndromes are more likely to occur in women, including headache, irritable bowel syndrome (IBS), chronic regional pain syndrome (CRPS), trigeminal neuralgia, fibromyalgia, multiple sclerosis and osteoarthritis.

Historically, medical research has been conducted predominantly with male participants. Some posit that the closer look at gender and pain began in 1997 when the National Institutes of Health (NIH) issued a request for applications titled “Sex and Gender-Related Differences in Pain and Analgesic Responses.” This request generated great interest from the scientific community and sparked numerous research programs.

Why gender matters

The implications of gender differences are important for patient care. Multiple factors play a role in how an individual experiences pain, including genetics, social status, exercise and information processing in the brain. Hormonal variation, puberty, reproductive status and menstrual cycle also affect pain thresh- old and perception. Let’s take a closer look at four common pain conditions and the experience women have with them.

  1. Musculoskeletal pain

The NIH cites many studies that have looked into the prevalence of musculoskeletal pain in men and women. In one study that spanned 17 countries on six continents with more than 85,000 participants, it was shown that the prevalence
of chronic pain is higher among females than males. Other studies from Europe and Australia also indicated that chronic musculoskeletal pain is more common in females than males. Under review were several specific types of musculoskeletal pain, including back pain, whole body pain, fibromyalgia and osteoarthritis. As women age, they experience more compression fractures, vertebral changes such as kyphosis and scoliosis, loss of bone mass and osteoarthritis than do men. Any one of these conditions puts them at a higher risk of breaking a bone during a fall, which can add to their pain.

  1. Abdominal pain

According to a number of epidemiological studies recently reported on by the NIH, there is a higher prevalence of abdominal pain in women. In fact, several country-based studies of abdominal pain generally support increased prevalence among females. More specifically, the NIH reports that there is approximately a 3-to-1 female-to-male ratio in the diagnosis of IBS in the United States. This chronic syndrome is characterized by recurring symptoms of abdominal pain and problems with bowel habits.

  1. Headache

Headache is one of the most common pain conditions. After reviewing more than 60 studies, the NIH concluded that the prevalence of headaches and migraines is higher for women than men. In the NIH American Migraine Study II, which included more than 29,000 adults, it was estimated that the one-year prevalence of migraine in the U.S. is 18 percent in women and 7 percent in men.

According to the Women’s Health Office of the U.S. Department of Health and Human Services, migraines are most common in women between the ages of 20 and 45, and women more than men report more painful and longer-lasting headaches with more associated symptoms, including nausea and vomiting.

  1. Pelvic pain

For women suffering from chronic pelvic pain, absent a physical injury, childbirth or identifiable procedural cause, there is significant potential for a history of intimate partner violence. According to the Centers for Disease Control and Prevention (CDC), three in 10 U.S. women have experienced intimate partner violence, physical violence or rape versus one in 10 men. Data suggest that this can contribute to pain conditions.

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“There are different considerations when treating a 27-year-old man for pelvic pain versus treating a 27-year-old woman with pelvic pain,” says Richard W. Rosenquist, MD, Chairman of Cleveland Clinic’s Department of Pain Management. “It is crucial to listen to the responses to questions to determine the underlying cause so you can pursue the right treatment plan. We must take into account that abuse can sometimes be a factor in pain onset and longevity.”

Another women’s issue: pregnancy pain and opioids

Pain during pregnancy is another area of concern for female patients. Pregnancy pain can be caused by multiple factors, including:

  • Weight gain
  • Ligamentous relaxation due to hormones
  • Change in posture
  • Pelvic floor dysfunction

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According to the CDC, nearly one-third of women of reproductive age had an opioid prescription filled each year between 2008 and 2012. The NIH reports, “Regular exposure to such substances during pregnancy has maternal and fetal implications.” They go on to say that managing narcotic dependence should be based on the individual patient and “may include discontinuation of narcotics with careful observation, limitation of prescription dispensing, or substitution therapy with methadone or buprenorphine.”

“We have seen that some patients taking opioids on a chronic basis may feel worse overall because of the side effects, which can include constipation, sedation and depression,” says Beth Minzter, MD, a staff physician in Cleveland Clinic’s Department of Pain Management. “Some patients even experience worsened pain when treated with chronic opioids, an effect known as opioid-induced hyperalgesia. This alone may be a strong argument for avoiding regular prescription use of opioids for the majority of patients, including parturients.”

Research reveals new ways to help women

Looking at the research on these subsets of patients is instructive to our practice. We must take into account these data and look to further research to find new and better ways to approach pain treatment for female patients.

Another issue noted in current research is the possibility of gender bias in the delivery of pain treatment. According to the NIH, there is concern that women are at greater risk for undertreatment of pain, although the use of prescription and nonprescription analgesics is higher among women than men.

Pain psychologists can uncover contributing factors

For some patients, an appointment with a pain psychologist is critical in evaluating underlying causes and developing a successful treatment plan for chronic pain conditions. Specialists may refer patients for a psychological evaluation and treatment if they are concerned about issues contributing to a patient’s pain.

Cleveland Clinic pain psychologist Jill Mushkat Conomy, PhD, points out the following, specific to women and pain: “For women, issues of family stress, weight gain and sexuality can be front and center when it comes to the onset of pain. When meeting with patients, I share a long list of biological, psychological and social issues to consider to get the conversation started.”

Issues include everything from experiencing physical trauma to having feelings of depression. Once the areas of concern are pinpointed, Dr. Mushkat Conomy often uses cognitive behavioral therapy (CBT) to help patients rethink their pain and find different ways to manage and live with it.

Dr. Rosenquist can be reached at rosenqr@ccf.org or 216.445.8388; Dr. Minzter can be reached at minzteb@ccf.org or 216.444.9756; and Dr. Mushkat Conomy can be reached at jmushkat@ccf.org or 440.312.7246.

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