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12 Articles in Volume 21, Issue #2
Advanced Practice Matters with Theresa & Jeremy: MAT and the DATA Waiver Debate
Analgesics of the Future: The Potential of Vocacapsaicin Injections for Knee Pain
Authorities Update Opioid and Naloxone Prescribing Policies as Overdoses Soar
Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
Case Report: How We Grew Our Pain Practice Amidst Pandemic, Opioid Crisis
Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment
Fentanyl Transdermal Patch: Variability is Key When Prescribing
Optimizing Opioid Therapy with Pharmacogenetics
Research Insights: Advances in Shoulder Arthroplasty and Revision Surgery
Research Insights: How to Address Osteoarthritis Treatment Gaps in Women
Topical Anti-Inflammatories: Analgesic Options for Arthritis Beyond NSAIDs

Research Insights: How to Address Osteoarthritis Treatment Gaps in Women

SWHR Working Group reports on the discrepancies in osteoarthritis pain in women and recommends ways to improve OA pain measurement, mapping, and treatment.

with Melissa Laitner PhD, MPH, SWHR’s Director of Public Policy and Government Affairs

Osteoarthritis affects significantly more women than men and yet, gaps in care remain across gender lines. To address these discrepancies, the Society for Women’s Health Research (SWHR) Osteoarthritis and Chronic Pain Working Group – a team of interdisciplinary researchers and clinicians –  published recommendations in late 2020 in the Journal of Women’s Health.1

Melissa Laitner PhD, MPH, SWHR’s Director of Public Policy and Government Affairs and lead author of the paper, spoke to PPM about the paper and moving osteoarthritis care forward for women.

“I think a lot of studies have been conducted with the assumption that men are biologically equivalent to women and their responses to treatment and the outcomes that those patient groups have in the studies can just be totally transposed to members of a different gender,” said Dr. Laitner. “And that’s really not the case. It’s certainly not true that men and women are distinct on every single characteristic or every factor of every disease, but there are notable differences in how men and women experience pain, experience this disease, what their goals are in treatment, and what treatments might be best suited for them. We need to do a better job considering that and thinking about it as we are treating patients and as we are conducting research.”

The Working Group highlighted gaps that go beyond gender as well, such as scientific gaps in understanding the pathogenesis of osteoarthritis. Better research on the influence of sex and gender may help the medical community improve that understanding.

For example, according to the paper: “A major gap in our understanding of OA is whether it is better conceptualized as a unitary disease versus a collection of many related diseases. The large number of risk factors for OA development and progression may suggest multiple pathways to pathology. Patients with OA exhibit heterogeneity in clinical presentation and long-term prognosis; these factors can vary based on gender and other demographic characteristics. Understanding the role of sex and gender in pathogenesis should contribute to improved understanding of OA.”

The group suggested that sex and gender may influence disease etiology, which may help researchers better understand its underlying mechanisms.1

The SWHR Working Group suggests that researchers prioritize osteoarthritis study designs that account for both sex and hormonal fluctuations. (Image: iStock)

Osteoarthritis: Role of Sex Hormones Should Be Recognized

While women are more likely to be diagnosed with OA than men and are more likely to have severe osteoarthritic symptoms, these discrepancies in prevalence do not occur until about 50 years of age, which the Working Group hypothesizes could be related to hormonal differences and changes. “There is some thought that sex hormones are a factor that might explain some of these differences, but we don’t really understand what that pathway is. We have different sex hormones, but how does that actually modulate the pain and the experience of pain for patients?” noted Dr. Laitner. 

The Working Group suggests, therefore, that researchers prioritize study designs that account for both sex and hormonal fluctuations. When preclinical studies are conducted, in addition to including female animal models, “researchers should consider approaches such as including ovariectomized female animals within basic science studies to more closely parallel the hormonal changes within older populations of women who are at high risk for developing OA.”

Healthcare Disparities for Women in Pain Must Be Addressed

The Working Group stresses the importance of acknowledging the role of gender bias within the healthcare system as a barrier to care for OA and chronic pain conditions. “We tend to underestimate women’s pain and overestimate men’s,” Dr. Laitner explained. “We have this historical understanding that women are dramatic, they’re hysterical, they’re not to be taken as seriously.”

Another reason behind existing gender discrepancies in pain, according to the Working Group, may be due to the way pain is measured. The pain management community needs measurements that better capture patient experience and function, noted Dr. Laitner. Improving data collection and measures may be helpful to providers to better monitor the pain’s effect on sleep and mood, for instance.

In this regard, the report suggests that body mapping may be useful, particularly since studies suggest that OA pain is not always limited to the site of joint damage. Placing patients into subgroups based on pain distribution may help to understand the heterogeneous nature of OA and aid in the evaluation of new therapeutics.

The intersection of race and gender must also be considered. For example, the report notes that “Black women with OA report more pain than white women and men of other racial and ethnic subgroups, and knee OA may be more common in Black individuals with possible variance based on gender.”1

Osteoarthritis Disease Management for Women

When it comes to managing osteoarthritis care, the Working Group cites duloxetine, a serotonin and norepinephrine reuptake inhibitor (SNRI), as an underused therapy in the treatment of OA. Although duloxetine has a long list of side effects, including fatigue, drowsiness, constipation, and high blood pressure, the medication has been shown to reduce chronic pain in animal models with regard to central sensitization in OA and has shown statistically significant improvements in pain, function, and quality of life.

With regard to surgery, such as arthroplasty for osteoarthritis of the knee, providers tend to recommend surgical interventions for men at a much greater frequency than women, even if reported symptoms and radiographic severity are consistent across gender and even though women show equal benefit from surgery as compared to men.

When it comes to orthopedic devices, these have, at times, been shown to be less effective in women, with women reporting greater frequency of adverse events. This may, in part, be due to a lack of consideration for female physiology in the design development, testing, and approval processes for these devices, notes the Working Group.

Looking back at the pathology of OA, the group further noted that there are currently no FDA-approved, disease-modifying drugs (ie, DMARDs) available to reverse joint damage. Understanding the pathology of this condition could help to change this and open up new treatment options in the future.

How to Give Women with Osteoarthritis the Care They Need

The way forward requires changes across osteoarthritis research, care, and education, including:

  1. Studies must be more inclusive of women and in numbers adequate to provide statistically significant outcomes analysis.
  2. The medical community’s implicit bias toward women, including women of color, must be addressed.
  3. Research should explore the effect of sex hormones on OA pathology and processes.
  4. Medical devices should be designed with sex and gender in mind.

See also, the 14 priority areas for OA research, care, and education proposed by the Working Group.

SWHR Working Group Participants included:

  • Daniel Clauw, MD, Professor of Anesthesiology, Medicine and Psychiatry, University of Michigan
  • Roger B. Fillingim, PhD, Director, University of Florida Pain Research and Intervention Center of Excellence
  • Anne-Marie Malfait, MD, PhD, Professor of Medicine, Rush University
  • Tuhina Neogi, MD, PhD, Chief of Rheumatology, Boston University School of Medicine and Boston Medical Center
  • Daniel L. Riddle, PT, PhD, Professor of Physical Therapy, Orthopaedic Surgery and Rheumatology, Virginia Commonwealth University
Last updated on: March 2, 2021
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Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
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