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9 Articles in Volume 17, Issue #3
Anxiety and Pain
Central Pain in Rheumatoid Arthritis
Imagine Dragons’ Dan Reynolds Educates People About Ankylosing Spondylitis
Letters to the Editor: Ehlers-Danlos Syndrome, Arachnoiditis
Managing Cancer-Related Pain: A Look at Alternative Approaches
Pain Management in the Elderly: Focus on Safe Prescribing
Painful Genetic Diseases
Responding to Women's Pain Early and Effectively
The 5 Most Misunderstood Terms in Pain Medicine

Responding to Women's Pain Early and Effectively

Ask the Expert April 2017

Question: Why do women’s pain complaints receive less attention than do men­’s—even for the same symptoms—and what might pain practitioners do to adjust their initial assessment to more effectively manage women’s pain, early and effectively?

Pain is a subjective and individualized perception, which can be interpreted and experienced uniquely in different people. However, sex variables encompass biological and physiological factors that affect pain perception and efficacy of treatment in women. These include sex hormones, genetic and molecular factors, cognitive processing, and neuroactivation after painful stimuli. Gender, which is a social construct, contributes to biopsychosocial differences through various mechanisms such as cultural and social role expectations and supports, coping mechanisms, and internal stressors.

Clinicians should use a gender lens when addressing complaints of pain by women

Studies have found that gender differences exist in expression of pain, especially in those younger than 40 years old.1 A woman’s perception of pain may be influenced to a greater extent by overlapping psychological influences as compared to men.2 This is not meant to imply that the woman’s pain is not organic, but rather that psychological and social stressors may influence its severity and presentation. Both sex and gender variables contribute to the complex picture of differences in pain perception, presentation, assessment/diagnosis, and treatment of women in relation to men.

Consideration is warranted regarding the initial clinical assessment of pain estimates as suboptimal and incongruent with patients’ perceptions of pain symptoms, leading to undertreatment.3-6

Initial Presentation: Impact of Communication and Implicit Bias

When soliciting a description of pain from a female patient, listen to and heed her account. There is sufficient evidence that women use both external (situational) and internal (somatic) cues in evaluating pain, whereas men predominantly utilize internal cues.3 As a result, clinicians may find that women—more often than men—will place health symptoms in the context of their lives. Instead of telling the clinician directly about the sharp pain in her lower back that gets worse when she bends over, a woman might begin with sharing a story about helping her daughter move out of her home due to a divorce.

It is important that the clinician listens to a woman without interruption before beginning to elicit the specifics of the patient’s pain. This can ensure that responses not only incorporate the physiological pain but address the social issues and stressors that likely are contributing to a more severe pain perception.

Equally important is having an awareness that gender-implicit bias can impact clinical pain assessment as well as the patient interaction. Studies have revealed evidence that an inherent bias exists when it comes to medical consulting styles in terms of gender, for both the provider and the patient.4-6 Physicians’ judgment is affected by their own and the patient’s gender.4 For example, female physicians have been found to prescribe higher doses of opioid pain medication to women with back pain than they do for men, while male physicians are more likely to prescribe activity restrictions for women with back pain.5 Female physicians pay more attention to female patients’ histories and patient cues, especially those pertinent to potential diagnoses. On the other hand, primary care physicians have been found to perceive more attractive female patients as being in less distress and having less pain as compared to women viewed as unattractive who present with similar medical histories.6

Pain Assessment: Ensuring That Pain Scales are Validated in Both Sexes

Pain assessment is more straightforward when the pain is acute and symptomatic, such as pain resulting from medical disease, surgical procedure, or traumatic episode. The clinician will want to concentrate on pinpointing the location, temporal pattern, and whether/how strongly the pain is felt at rest or is associated with certain movements (dynamic). Existing instruments for measuring pain include the commonly used visual analog scale (VAS) and numeric rating scale (NRS), both of which work best to assess current pain level at the worst, least, or average intensity.7,8 These 2 scales have a greater sensitivity than the 4-point verbal categorical rating scale. The VAS and NRS can also be utilized for pain felt recently, as in the past day or week, but will not be as accurate for chronic or persistent pain, as memory/recall becomes the limiting factor.9

Recall bias exists between women and men with respect to previous pain; women tend to recall past pain more specifically, and with greater pain intensity, than men.10 This difference enhances the need for the clinician to take the time to accurately determine a patient’s baseline pain level in order to better interpret pain-scale results later on. It is important to ensure that assessment scales have been validated in both sexes rather than assume they have been endorsed for women as well as men. The VAS has been shown to be an accurate determinant of pain in both sexes, regardless of the cause of painful symptoms.

Yet gender roles play into a willingness to report pain, in that women may view pain expression as more acceptable than do men.10 When asked by a female examiner, men tend to report greater tolerance of pain. However, when women are examined by a male examiner, they tend to report lower thresholds of pain.11 Additionally, it is imperative to recognize the effects of gonadal hormones on pain and pain perception. For example, women who are on hormone replacement therapy are at increased risk for both temporomandibular disease and back pain; evidence suggests that pain thresholds differ throughout the menstrual cycle.12

Back to Basics…Questions to Ask With an Ear to Her Responses

Where is the pain?

  • Generalized or specific
  • Deep or superficial
  • Single or multiple site(s)

What is the frequency/duration of the pain?

  • Activity-related
  • Positional
  • Day, night, or all the time
  • Consistently (daily), sporadically, or other

What are reported symptoms?

  • Physiological/psychological (eg, PTSD)
  • Visceral
  • Neuropathic/neurogenic
  • Musculoskeletal/myofascial
  • Acute, subacute, or chronic, or, acute and chronic

Why might be behind the pain’s onset?

  • Family history
  • Trauma (physical, emotional, combined)
  • Single episode, repeated or degenerative
  • Surgery
  • Phantom limb
  • Oncology-related

Treatment: Selection and Efficacy

Researchers have demonstrated that types of treatments offered, and in some cases, their efficacy can differ between female and male patients.13,14 Adult women tend to be more sensitive to opioids and less responsive to nonsteroidal anti-inflammatory drugs, such as aspirin, due to decreased absorption.13,14  Clinical data suggest a better analgesic response to mixed-action opioids among females than m-opioid analgesia.15 This is important in the context of acute pain treatment since, if poorly managed, this pain could progress to a chronic pain state, which most likely would be more difficult to manage. Women are more likely to have comorbidities influencing their responsiveness to pain management, such as depression with somatic symptoms (though somatic depression may be underdiagnosed in men) and autoimmune diseases.16,17

Cognitive factors and coping strategies also commonly contribute to the effectiveness of pain treatments. Women, more so than men, catastrophize pain (eg, a negative cognitive–affective response to anticipated or actual pain).18 Clinicians’ active listening is the most effective strategy to fully probe a female patient’s pain experience and catastrophizing while aiding in the reappraisal of the pain and ensuring optimal physician-to-patient communication.

Consider Full Array of Treatments  

For every patient, consider his or her past experiences and treatment trials, as well as successes and failures in all approaches, tried to date. Explore modalities, medications/injections, alternative therapies, and home remedies in an effort to offer the quickest and best pain relief options that fit the patient’s needs and preferences. When appropriate, for example, consider referring the patient for hypnosis (even as a placebo) and medical nutrition therapy.

A Step-Wise Approach to Treating Women With a Sex & Gender Lens

Given that pain is multidimensional, it is imperative that the clinical assessment and treatment of pain symptoms be informed by both biologic differences and consideration of gender influences, including male/female social roles, in the emotional appraisal of pain.

Approaching pain with a sex and gender lens will ensure that the clinician is approaching each patient—throughout the identification, evaluation, diagnosis, and treatment phases—with personalized, patient-centric care. When presented with the complaint of pain from a female patient, remember that sex and gender matter. This will maximize the potential for a successful patient outcome.

In summary, pain practitioners should always evaluate through a sex and gender lens when faced with female patients who present with complaints of pain requiring medical management.

Last updated on: May 10, 2017
Continue Reading:
Letters to the Editor: Ehlers-Danlos Syndrome, Arachnoiditis

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