Women’s Pain: Taking a Closer Look at the Disparity

Women are at a greater risk than men of developing a chronic pain condition. These stats provide insights as to why.

It’s clear that women have a very specific, and often tumultuous, relationship with chronic pain when compared to their male counterparts. A recent Harvard Health blog post on women’s experience and treatment of pain1 outlines some of the frustrations that women deal with when it comes to properly diagnosing their chronic pain. Women’s pain is often labeled as psychological rather than physical, and is not taken with the same seriousness and severity that men often receive.

Not only that, but history has shown the women have been underrepresented in clinical trials about pain, despite regulatory calls for change in this matter. Practical Pain Management had the unique opportunity to engage leading experts from the American College of Gynecology (ACOG), the Society for Women’s Health Research (SWHR), and Johns Hopkins Medicine about this very issue. “Sex and gender bias has its roots in the way medical research was conducted for centuries — by simply assuming women’s biology was the same as men’s and excluding women from research. As recently as 25 years ago, women of reproductive age were actively excluded from most clinical trials,” said Amy Miller, PhD, president and CEO of SWHR.

Added Tina Doshi, MD, assistant professor of pain medicine at Johns Hopkins University School of Medicine in Baltimore, MD, “Although the National Institutes of Health (NIH) Policy on the Inclusion of Women in Clinical Research has ensured that women now account for roughly half of all participants in NIH-supported clinical research, only recently has the NIH adopted the consideration of sex as a biological variable in preclinical biomedical research.”

The need to recognize these disparities and implement new techniques and mindsets to better care for female patients is further reinforced by the statistics below.

Women and Chronic Pain

  • Women report more intense pain than men in virtually every disease category,2 including endometriosis, which affects 1 in 10 (10%) women worldwide, and vulvodynia, which affects as many as 16% of women in the US at some point in their lives.3,4
  • The literature reveals that men and women differ in their responses to pain and in responses to pain interventions, with increased sensitivity and risk for clinical pain commonly observed among women.5
  • A high proportion of reproductive-age women may be experiencing pelvic pain that goes untreated. Roughly one-third of women reported that they have experienced chronic pelvic pain that has gone untreated for six months or longer.6
  • It has been acknowledged in recent decades that clinical trials have not always adequately enrolled women or analyzed sex-specific differences in the data.7
  • The gender of both the patient and the healthcare provider may influence pain care, with one study showing that female practitioners are more likely to recommend psychosocial treatments for female than for male pain patients.8
  • Expression of pain is generally more socially acceptable among women, an effect potentially leading to biased pain reporting. In studies, both sexes believed that a man was less willing to report pain, for example, than a woman.5

“The contrast in pain treatment between women and men has not gone unnoticed. In a recent survey of more than 2,400 women with chronic pain, 84% reported feeling that they were treated differently by doctors because of their sex, and 90% felt that the healthcare system discriminates against female patients,” said Dr. Doshi.

“With society often dismissing women’s pain and a relatively brief record of research inclusive of women, it is unsurprising that many of the chronic pain conditions for which we do not have direct treatments are more common in or exclusively affect women,” said Dr. Miller.

For example, chronic pelvic pain is prevalent among women and still largely under-studied. Explains Katherine McHugh, MD, executive board member of ACOG, “Some of the most common and yet, least understood, etiologies of chronic pelvic pain in women are endometriosis, dyspareunia, and localized provoked vulvodynia.”

When it comes to prescribing for pain among women, including the use of opioids, the statistics also diverge between the sexes.9

Women and Opioid Use

  • Women are more likely to be prescribed opioids for pain for longer periods and in higher doses than men.10 Between 1999 and 2010, overdose deaths from prescription pain medications increased more than 400% among women, compared to an increase of 265% among men. Although nonmedical use of prescription opioids among women has generally decreased since then, heroin use among women has increased and at a faster rate than among men.10,11
  • Reproductive age women who receive Medicaid may be more likely to be prescribed opioids. Among women aged 15 to 44, one-quarter of privately insured women and one-third of female Medicaid beneficiaries were prescribed opioids between 2008 and 2012.12 However, researchers have suggested that women use fewer opioids than men after surgery, and women in general show better pain relief in response to mu-opioid analgesics, particularly morphine.13
  • Among female veterans, they have a 79% increased risk of a new depression episode after more than 90 days of opioid use when compared to male veterans (25%).14 In fact, psychological and emotional distress are known risk factors for hazardous prescription opioid use among women, but not among men.15-17
  • Men are nearly three times more likely than women to receive naloxone as part of emergency overdose resuscitation efforts.18
  • Women are more likely to have co-occurring mental health and substance use disorders than men.15 Substance use interventions and services have been historically developed and tailored to the concerns of men, leading women to experience a greater stigma when identified with a substance use disorder. Thus, women are less likely than men to enter traditional substance use treatment programs.19,20
  • Women tend to become dependent on prescription pain relievers more quickly than men and may experience more cravings than men;9 despite this, co-prescribing opioids with other medications that increase overdose risk, such as benzodiazepines, is more common in women.21
  • Women receiving medication-assisted treatment, or MAT, have greater functional impairments, leading to problems with maintaining employment, housing, relationships, and personal care, for example, than men.22 They are more likely to seek and stay in MAT if they are able to maintain their caregiving role.23
  • Among those in need of MAT, men are much more likely to obtain treatment than women.9 According to a 2014 survey of MAT programs in the US, 44% provided special programs or groups for adult women and only 20% offered programs or groups for pregnant or postpartum women.24

Women and Addiction Treatment

The Substance Abuse and Mental Health Services Administration (SAMHSA) has since issued guidance23 on the types of services that should be included in comprehensive MAT programs for women, including:
  • special groups to address challenges faced by opioid-addicted pregnant women, education and discussion groups on parenting and childcare;
  • available treatments for women addicted to opioids, including pharmacotherapies;
  • education and discussion groups on parenting and childcare;
  • special groups and services for children and other family members;
  • couples counseling;
  • assistance in locating safe, affordable housing.

Dr. McHugh also recommends specific treatment plans designed for women—not just MAT but overall pain care. In treating chronic pelvic pain, or CPP, for instance, she suggests that female patients have multidisciplinary teams, which may include primary care, gynecology, gastroenterology, urology, as well as physical therapy, mental health counseling, sex therapy, osteopathic manipulation therapy, and nutrition counseling. “These collaborative teams are useful for the holistic care of women suffering from CPP,” she said, adding that, “In the current environment of an opioid epidemic and ongoing legislative reactions, it is also important to emphasize that opioids are not an appropriate first-line treatment for CPP.”

So, where do women with chronic pain conditions go from here? While further—and fairer—research is needed to diagnose and effectively treat women living with painful diseases, women as patients can work to make sure their doctors acknowledge their reported pain, learn more about their specific condition in order to advocate for its treatment, and support more female practitioners, who may better understand their pain. To help in these efforts, consider reading the full commentaries by Drs. McHugh, Doshi, and Miller in Practical Pain Management. While these articles were written for physicians, their messages ring true for patients as well.

Updated on: 08/14/18
Continue Reading:
Pain in Women: Hysteria or Misjudgment?