Gender Differences in Pain

Question 1

Sentinel Questions

Answer 1

Referencing Pain:

• Location
• Onset / Duration
• Quality
• Timing
• Severity
• Radiation
• Functional Status
• Associated Symptoms
• Modifying Factors
• Previous Episode / Injury

Question 2

Nociception

Answer 2

The neural processing (physiology) of noxious stimuli that results in the perception of pain.

Question 3

Nociceptive

Answer 3

• Peripheral nerve receptor (Nociceptors or pain receptors)
• Stimulated by specific types of activity (mechanical, chemical, thermal changes above set points)
• Produce afferent activity from actual tissue damage or potentially tissue-damaging stimuli
• Receptors then send info into to spinal cord and from there to the brain and might result in pain sensation
• Examples:
  
  • Motorcycle falls on her leg and results in a second-degree burn (thermal)
  • Handled a chili pepper and stuck finger into eye (chemical)
  • Closed hand in car door (mechanical)
  • Diffuse abdominal pain (visceral pain)
  • Fracture of toe (deep somatic pain)
    
    • Meaning stimulation of pain receptors by ligaments, bones, blood vessels, fascia, muscles)

Question 4

The Clinical “Wish” of Pain

Answer 4

• Logical that the amount of tissue damage should be a barometer of the amount of pain a patient perceives
• Perception is a sensory and emotional experience
• Problems in pain treatment result when doctors think that they know best on amount of medication for pain control
• Accurately using appropriate medications for optimal goal of pain relief is important

Question 5

Women and Pain

Answer 5

Women have more pain that is:

• Recurrent
• Severe
• Anatomically Affected
• Diffuse and longer lasting
• Under-diagnosed and under-treated
• More side effects and debility
• Insufficient research and effective targeted treatment
• Lack of access and coverage

Question 6

Having multiple pain conditions is…

Answer 6

• Associated with higher levels of disability and psychological distress than having a single pain condition
• A risk factor for onset of new pain conditions

Question 7

Women vs Men

Answer 7

• Pain threshold
  
  • Higher in men
• Tolerance
  
  • Higher in men
• Adaptation
  
  • May be higher in women
• Evidence for sex differences in pain is wide ranging
  
  • Includes basic science, epidemiology and clinical research

Question 8

Female Pain Perception

Factors

Answer 8

• Hormones
  
  • Changes in sex hormones have been found to moderate pain (eg, menstrual cycle, pregnancy)
• Lifespan
  
  • Sex differences in pain can vary across the lifespan
  • Many of the observed gender differences in pain prevalence appear to reduce beyond the reproductive years
• Culture
  
  • Sex differences in pain can vary across different cultures as well

Question 9

Top Pain Areas for Women

Answer 9

• Musculoskeletal
• Autoimmune
• Neurologic
• Vascular
• Gastrointestinal
• Genitourinary
• Gyn Only Conditions

Question 10

Musculoskeletal Pain

&

Sex Differences

Answer 10

• More Common in Women
  
  • TMJ disorder
  • Occipital neuralgia
  • Carpal tunnel syndrome
  • Fibromyalgia (7x)
  • Slipping rib / 12^th rib syndrome
  • Piriformis syndrome
  • Rheumatoid Arthritis
• More Common in Men
  
  • Ankylosing Spondylitis
  • Reactive Arthritis (formerly Reiter’s Syndrome)
  • Hemophilic Arthropathy

Question 11

Neurologic Sex Differences and Pain

Answer 11

• More Common in Women:
  
  • Headaches – Migraine with aura; Chronic tension; Post-dural puncture; Cervicogenic
  • Ticdouloureux
  • Multiple Sclerosis
  • Interstitial cystitis
• More Common in Men:
  
  • Headaches: Migraine without aura; Cluster; Post-traumatic
  • Pancoast tumor
  • Lateral femoral cutaneous neuropathy

Question 12

No Sex Prevalence

Answer 12

• Acute tension headache
• Cluster tic syndrome
• Secondary trigeminal neuralgia
• Painful ophthalmoplegia
• Maxillary sinusitis
• Burns

Question 13

Gyn Pain Conditions

Answer 13

• Dysmenorrhea
  
  • Extremely common, affecting 40- 90% of women
  • Excruciating in about 15%
  • Prevalence & severity of primary are highest in late adolescence and the young adult years
• Low Back Pain with Pregnancy
  
  • 45% lower back/pelvic girdle during pregnancy
  • 25% of all women have pain of sufficient severity to require medical attention
• Postpartum
  
  • 25% experience lower back/pelvic girdle pain
  • About 5% of all women experiencing severe pain
• Labor Pain
  
  • Over 95% of labors
• Vulvodynia
  
  • Chronic pain in the vulvar area in the absence of known infectious, dermatological, metabolic, autoimmune or neoplastic causes
  • In one community study, vulvar pain in over 18% of women
  • 12% reporting knifelike pain or pain on contact
  • Over 6% reporting persistent itching or burning sensations
• Chronic (Non-menstrual) Pelvic Pain caused by:
  
  • Gynecological conditions (eg, endometriosis, infection
  • Nongynecological conditions (including irritable bowel syndrome or bladder-related pain)
  • All cause prevalence 15% among reproductive age women
  • 30-50% women with pelvic pain have urinary frequency
  • IBS commonly coexists with pelvic pain

Question 14

Sex Hormones and Pain

Answer 14

Pain, and in particular chronic pain, shows important sex differences:

• Several reasons for higher reactivity of females vs males to a similar painful stimulation
  
  • Genes, hormonal, and cultural influences
  • Pain perception varies according to the menstrual cycle phases in women with chronic pain
• For example, temporomandibular pain is highest in the premenstrual period and during menses
• Androgens and estrogens are vital for the proper development and maintenance of the male and female reproductive systems
• Also play an important physiological role in the activity and wellbeing of males and females
• Androgens are able to affect nociception and pain
• Inverse relationship was found between plasma testosterone and work-related neck and shoulder disorders in female workers
• Low dose transdermal testosterone therapy was found to improve angina threshold in men with chronic stable angina
• Testosterone, administered to both male and female rats, change formalin induced responses and analgesia

Question 15

Unrecognized Factors with Pain

Answer 15

History of sexual abuse (disclosed or not)

Incidence of unattended depression

Question 16

Sex Differences in Pain Treatment

Answer 16

• Sex differences in analgesia exist
• Differences include
• Side effects associated with drugs, including analgesics
• Non-pharmacological chronic pain treatments

Question 17

Pain and Analgesia Gender Difference

Causes

Answer 17

• Biological mechanisms include:
  
  • Sex hormones
  • Genetics
  • Anatomical differences
  • Cardiovascular / Respiratory
  • BP inversely related to Pain Sensitivity
  • Some of these biological factors (ie Gonadal hormones) become less apparent in the postmenopausal years
• Psychosocial influences include:
  
  • Emotion (eg Anxiety, depression)
  • Coping strategies
  • Gender roles
  • Health behaviors
  • Use of health care services

Question 18

Genes/Proteins

Involved

Answer 18

• Estrogen Receptor
• Mu/ Kappa/Delta Opioid (MOR, KOR, DOR) Receptors
• GABA A Receptors
• N-methyl D aspartate (NMDA) Receptor
• Melanocortin 1 Receptor (MC1R)
• Orphanin FQ/Nociceptin (OFQ/N) Receptor
• Protein Kinase A/C
• G-protein coupled Inwardly Rectifying Potassium Channel (GIRK2)
• Acid Sensing Ion Channel (ASIC)
• Alpha2 Adrenergic Receptor