Responding to Women's Pain Early and Effectively
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.
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?