Mark Allen Young, M.D., F.A.C.P., is a board-certified specialist in Physical Medicine and Rehabilitation and a licensed acupuncturist. His subspecialty interest is in pain management. He graduated from the Finch University Chicago Medical School, completed his residency at the Albert Einstein Montefiore Medical Center, and was recruited to the faculty of the Johns Hopkins University School of Medicine in 1991. He also serves as Chairman of the Department of Physical Medicine and Rehabilitation at the Maryland Rehabilitation Center at the Maryland State Department of Education. He is the author of the book Women and Pain: Why It Hurts and What You Can Do.

Women and Pain: 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. Some physicians also stereotype women as complainers who are less self-controlled and more likely to over-report symptoms. 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.

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 pre-surgery 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.

Created: 3/18/2002  -  Mark Allen Young, M.D., F.A.C.P.