Why women feel pain differently from men
With chronic pain, equality doesn't exist between men and women.
Women have it worse: They are much more likely to experience chronic pain than men, and are much more likely to have almost every condition associated with chronic discomfort such as migraines, fibromyalgia, irritable bowel syndrome and autoimmune conditions like rheumatoid arthritis, among others. Many of these are "contested conditions" since they might not show up on a CT scan or a blood test, causing some doctors to wrongly dispute their existence.
While women have benefited more than men from the seismic increase in longevity over the past two centuries, and on average live five years longer than men, they also often live longer with disability.
In addition to being more likely to have chronic pain, most women experience significant discomfort on a monthly basis for much of their adult lives with menstruation and most feel extreme pain during childbirth.
Yet the vast majority of clinical and experimental research shows a surprising finding: females are more sensitive to pain than males. This is true when tested for in the lab. Whether pricked with a pin prick, touched with an electrical probe, exposed to a caustic chemical, or asked to hold a heat probe or dunk their hand in freezing water, the majority of studies show that females experience more pain more quickly than males.
These findings also hold true in the real world.
Females report more pain after surgery than men. An analysis of 18 studies showed that women are more likely to report experiencing painful responses from placebo pills compared to men.
Some of these differences come down to how pain is processed differently between males and females. Initial research focused on the role hormones play: Testosterone reduces sensitivity to distress, and individuals undergoing male-to-female transition who receive estrogen and testosterone blockers experience an increased frequency of migraines. More recent work, however, appears to suggest that differences in the immune system mediate differences in how noxious signals travel across the bodies of males and females.
The experience of pain and access to its relief is not just affected by biology but many other factors, as well. For centuries in western civilization, women's pain was defined by a single sentence in Genesis. When Eve succumbed to the charms of the snake and ate the forbidden fruit, God was furious. "To the woman he said, 'I will surely multiply your pain in childbearing; in pain you shall bring forth children.' " The pain that women felt, particularly that during childbirth, was therefore punishment for Eve's transgression. Some midwives who attempted to provide pain relief during labor were accused of witchcraft and burned at the stake.
The discovery of anesthesia in the 19th century, however, destigmatized pain relief, and, feminist activists advocated for a protocol developed in Germany called "twilight sleep," which involved injections of the opioid morphine and scopolamine (which induces amnesia), to help ameliorate the agony of labor. But the twilight sleep was dangerous, causing many women to become delirious, and it likely contributed to the death of one of its most vocal advocates-referred to as Mrs. Francis X. Carmody in news accounts of the day - in 1915. (The pendulum subsequently swung away from that, with more women opting for births entirely free of analgesia.)
Opioids such as oxycodone and morphine are still used frequently for patients with chronic pain, even though the cumulative evidence suggests that opioids are no better, or even worse, at alleviating chronic pain than medications such as acetaminophen or ibuprofen.
Yet multiple studies show that women are more likely to be prescribed opioids, in higher doses, and for longer periods than men. (The reason may be because chronic pain is more common among women than men and women are more likely to seek medical care for their ailments.)
This is a problem: research shows women are often given opioids while also being prescribed benzodiazepines and other medications that can increase overdose risk. These patterns have contributed to opioid overdose deaths among women doubling from 2009 to 2019. Women are also at higher risk of developing drug cravings and relapse, have greater breathing problems, and develop more severe psychiatric, medical and employment complications from opioids than men.
Scant research has been performed in understanding women's pain, and part of that is because of medical researchers' historical tendency to ignore diseases that exclusively afflict women.
In a survey of medical students and physicians, when asked to rank 38 diseases by how "prestigious" they were considered, fibromyalgia, a chronic pain condition that predominantly afflicts women, was ranked least prestigious while heart attacks, largely misperceived to predominantly afflict men, were ranked No.1.
But attitudes are changing. Emerging research is raising the possibility of therapies tailored to providing comfort to painful conditions that heavily afflict women. Migraines, for instance, are much more frequent in females. A new category of medications inhibits CGRP, a molecule associated with more pain in females than males. There is increasing hope that this category of medications might help women with a variety of painful conditions beyond migraines.
More research that uncovers why males and females hurt differently could provide insights into alleviating suffering for both sexes.
The key to managing chronic pain in women is an approach that focuses on the entire person. Pain is often one piece in a larger puzzle and a more holistic, multidisciplinary approach to pain management is necessary for both women and men.
Yet insurance companies are less likely to provide coverage for multidisciplinary pain care than opioids or invasive procedures for chronic pain, which are often no better than a placebo.
Modern medicine only affords those patients legitimacy who carry a diagnosis, which validates a person's experience. Yet the goal of medical care is not just about making diagnoses, but alleviating suffering. In addition to performing more research into diseases that cause women to suffer indefinitely, and to provide greater access to multidisciplinary pain management, clinicians should better understand the role pain plays in the stories of women.
At its core, pain is an agonizing combination of physical sensation, searing emotion and traumatic memory. Any strategy that addresses only one aspect without integrating the others will not abate the wave of chronic pain experienced by women around the world.
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Haider J. Warraich is a physician at VA Boston Healthcare System, Brigham and Women's Hospital and Harvard Medical School. He is also author of the forthcoming "The Song of Our Scars: The Untold Story of Pain."
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