Women and Pain, Why it Hurts and What You Can Do

Review - page 1 2 3

Excerpt
The following is an excerpt from the book Women and Pain: Why It Hurts and What You Can Do
by Mark Young, M.D., F.A.C.P., with Karen Baar, M.P.H.
Published by Hyperion; December 2002; $24.95US/$34.95CAN; 0-7868-6794-9
Copyright © 2001 Mark Young, M.D., F.A.C.P.

INTRODUCTION
Tell Me Where It Hurts

Do you suffer from constant, agonizing pain? Have you been to doctor after doctor, only to receive nothing that helps or be told "it's all in your head," "it's stress," or "you're just getting old"? If so, you're not alone.

Women have said it -- and men have denied it -- for years. Now we know that it's true: Women feel more pain, seek help more aggressively, and make more active attempts to cope with pain than men.

Unfortunately, we also know that too frequently women aren't taken seriously. Although we think of medicine as a professional discipline, rooted in science and free of bias, this isn't always the case. Frankly, our health care system often disregards women in pain. At best, it's ignorance of gender differences. But some physicians stereotype women as complainers who are less self-controlled and more likely to overreport symptoms than men. They dismiss female patients with antidepressants, antianxiety drugs, and platitudes. This adds insult to injury. When you're in pain, it's the last thing you need.

Given how much we know about pain, it's scandalous that women suffer needlessly. As a physiatrist, a physician board certified in physical medicine and rehabilitation, I specialize in treating disabling painful conditions with gentle, simple conservative modalities. Using my skills in acupuncture and complementary medicine, I have helped thousands of people find relief from pain. My background as a member of the teaching faculty of Johns Hopkins University has instilled in me a strong commitment to patient education and empowerment. Since my specialty places so much emphasis on properly balancing the emotional and physical needs of patients, often people with painful chronic disabilities, I am keenly aware of the frustration, anger, and depression that many women patients face when they are in pain and don't know where to turn for help.

Irene's Story

Irene is a sixty-four-year-old woman who works as a stadium vendor, selling pretzels at the local ballpark. She spends most of her workday on her feet.

She came in to see me complaining of a dull ache in her right heel, along with pain, swelling, and decreased movement in her knee. She'd had discomfort for a while, but the pain was becoming considerably more disabling. Although she had developed a mild limp, that wasn't the worst of it: "Doc, at the end of the day, my foot feels like it's about to fall off and my knee hurts like the dickens."

Irene was feeling desperate. She had been to a couple of other doctors and had gotten little relief. But something else was also eating away at her: "They keep telling me that it's just because I'm getting old, and they say I have to quit my job. But I love my work; it's so much fun to be out there, especially when the Orioles win! Besides, I need the money," she confided.

When I examined Irene, I discovered that she had a large heel spur and an osteoarthritic knee. I knew right away that we could come up with a plan that would relieve her pain and let her keep working.

Irene usually wore the same shoes day in and day out, a pair of worn-out espadrilles she picked up at Payless. I told her she needed to invest in comfortable, cushioned sneakers to wear at work. I also recommended that she buy a viscoelastic horseshoe-shaped heel cushion (which allows the spur to "float" without direct contact) and to think about getting fitted for custom-made orthotics. It was essential that she provide some padding for that heel. Also, what goes on in your foot affects the rest of your leg, so good footwear would also have a positive impact on her arthritic knee.

In addition, I suggested that she soak her feet in an herbal bath after work each day. She laughed when I suggested that her husband learn the arts of foot massage and acupressure, but she took the handouts and put them in her purse.

For her knee, I suggested glucosamine and chondroitin supplements, two nutritional remedies that effectively relieve osteoarthritis. I also showed her how to do quadriceps strengthening exercises to bolster the stability of her knee joint, and urged her to add some light aerobic exercise to her daily routine.

I ran into Irene the next time I went to a game. She was in the next section of the stadium, but when she spotted me, she flashed a big smile and gave me a thumbs-up. After the game, she caught up with me. "The pain is so much better, Doc, and my limp is gone." Then, she winked and said: "And those foot massages are great!"

Gender Matters

Happily, times are changing. Gender has become a "hot button" issue on the national research agenda, so important that a conference on gender and pain was held at the National Institutes of Health (NIH) in 1998. Eye-opening biomedical research presented there concluded that:

• Women experience more pain than men.
• Women discuss pain more than men.
• Women cope better with pain than men.
• Society's attitudes toward men and women in pain may influence physicians' treatment.
• The open expression of pain sometimes helps people obtain better pain control, but being seen as "too emotional" may work against a woman and lead to inadequate care.
• Pain treatment that works for one sex may not work as well, or at all, for the other.

Some of the most galvanizing research concerns the medications we use to treat pain. This work calls into question the age-old pain management practice of "one size (or one drug) fits all." For example, a series of landmark studies has shown that morphine-like drugs, called kappa-opioids, produce significantly greater pain relief in women than in men. (These drugs work through receptors in the central nervous system. There are multiple types of opioid receptors -- kappa, mu, delta, and sigma. The mu and kappa categories are the two major classes thought to be responsible for analgesia.) Kappa-opioids are not as commonly used as other narcotic pain medications. Drugs that work on the mu-receptors are the standard of care and are much more frequently prescribed. Yet they cause more nausea, itching, cardiac effects, constipation, and depression of the respiratory system. Treating women with kappa-opioids, then, may provide better pain relief with fewer side effects.

Other studies show that common pain relievers do less for women than for men. For example, in a recent study of experimentally induced pain, ibuprofen -- the key ingredient in Advil, Motrin, and other over-the-counter analgesics known as NSAIDS (for nonsteroidal anti-inflammatory drugs) -- was less effective at providing pain relief for women than men. Perhaps dosages for NSAIDS need to take gender into account.

In addition, many painful diseases and injuries disproportionately affect women. Even when men and women suffer from the same illness, the symptoms may be different:

• Osteoarthritis (OA), or degenerative joint disease, is far more common among women over the age of fifty-five, and women may suffer from a more severe form of this disease. In one recent study, women experienced 40 percent more pain, as well as worse pain. In addition, women are more likely to develop inflammatory types of OA that lead to knobby deformities of the DIP and PIP joints (the two sets of joints below the knuckles).
• Rheumatoid arthritis (RA) occurs two and a half times more often among women, and it may also affect them more severely. Women have reported more painful joints, more swollen joints, and worse function. And the majority of studies show that RA is slightly more disabling for women than it is for men.
• Migraine headaches are more severe, longer lasting, and more frequent in women than in men. In addition, women have more nausea, vomiting, numbness, and tingling with their headaches, while men are more likely to have a visual aura.
• Tension headaches occur two to three times more frequently among women, who also experience much higher levels of tenderness in all the muscles surrounding the skull.
• Women athletes experience knee injuries two to eight times more frequently than their male counterparts. This is particularly true for tears of the anterior cruciate ligament (ACL).
• Osteoporosis affects both sexes, but women develop it at a much younger age and in far greater numbers because of hormonal differences.

Gender differences play out on the operating table, too. In a study recently published in the British Medical Journal, women emerged from general anesthesia faster than men. However, they returned to their presurgery health status significantly more slowly and they experienced more postoperative complications.

Women Aren't Just Small Men

We don't know why these differences exist, but a wide range of scientific studies shows that the sexes differ on nearly every level. From the molecular to the psychological, from the basic genetic codes to the hormones, biology, physiology, and the overall functioning of the immune response systems -- men and women are different.

We aren't doing enough to understand and close this gender gap. The prestigious Institute of Medicine (IOM) of the National Academy of Sciences recently issued a call for biomedical researchers to "study sex differences from womb to tomb." The IOM's report recommended that researchers take sex differences into account in clinical trials, including studies of new drugs.

Even when women participate in clinical trials -- and more women do now than five years ago -- there is little gender-specific information coming out of the studies. Scientists at drug companies and research institutions have largely ignored sex-based differences in their data analysis.

We also know precious little about how drugs behave during pregnancy or breast-feeding. Most women who participate in research are postmenopausal. Admittedly, there are serious ethical concerns about allowing women of childbearing age to enter studies. But there may be other, less worthy issues at stake: Perhaps pharmaceutical companies are worried about the marketing consequences of defining a drug as more effective in one sex than another.

Sticking our heads in the sand is not the answer. We must develop guidelines that allow all women to fully participate in research. Failure to do this has serious ramifications; it could, in fact, be a matter of life and death. For example, of the ten prescription drugs withdrawn by the FDA from the market since 1997 because of adverse reactions, eight posed greater risks for women than for men. (In some cases, the drugs were more widely prescribed to women; however, even with medications prescribed equally to males and females, they were more dangerous for women.) And when you are pregnant, physiological changes may affect your response to a drug; you may be more vulnerable to its toxicity or its effectiveness. When you take a drug, you need to know that it is safe and effective for you.

Copyright © 2002 Mark Young, M.D., F.A.C.P.