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Global Year Against Pain in Women
www.iasp-pain.org
Introduction
IASP and its members are committed to raising global
awareness of the disparity of pain recognition, treatment
and research between men and women.
Why Real Women, Real Pain?
IASP chose this important theme because:
Many pain conditions are far more prevalent in
women than in men.
While chronic pain affects a higher proportion of
women than men worldwide, women are less likely
to receive treatment.
Research shows that women have more recurrent,
severe and long-lasting pain than men.
Women’s pain has a significant global impact, but
a lack of awareness and recognition persists.
Resources
IASP will offer a number of resources to ensure the
success of the Real Women, Real Pain campaign:
» Special November 2007 issue of PAIN, our
official journal
» Various issues of our Pain: Clinical Updates
newsletter focusing on women’s pain topics
» 18 fact sheets on female-specific pain issues –
offered in English, Russian, Arabic, Chinese,
Spanish, French, Hindi and Gujarati
» Other publications available from the IASP website
Special Issue of PAIN
View the Table of Contents or access this special edition
via ScienceDirect by visiting www.iasp-pain.org/pain.
Fact Sheets – Available on Website
» Differences in Pain Between Men and
Women
» Endometriosis and its Association with Other
Painful Conditions
» Epidemiology of Pain in Women
» Vulvodynia
» Sex Differences in Pain – Basic Science
Findings
» Irritable Bowel Syndrome (IBS)
» Sex Hormones and Pain
» Fibromyalgia Syndrome (FMS)
» Gender and the Brain in Pain
» Sex and Gender Differences in Orofacial
Pain
» Pain During Pregnancy
» Pain in Women in Human Immunodeficiency
Virus (HIV/AIDS)
» Obstetric Pain
» Pain in Women in Developing Countries
» Dysmenorrhea: Contemporary Perspectives
» Violence Against Women: Gender-based
Violence
» Chronic Pelvic Pain
» Children with Chronic Pain: Sex and Gender
Differences
»Migraine
Definitions
• Sex: biologically determined aspects of
maleness and femaleness
• Gender: modifiable, socioculturally shaped
behaviour
Pain in Women: experimental
evidence
• Experimental studies show that women
have lower pain thresholds and tolerance
to a range of pain stimuli when compared
to men.
• However, these differences are often
subtle and vary in magnitude
• Largest in pressure pain and electrical
stimuli-smallest for thermal pain
• Visceral pain- varies
Female Prevalence
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•
•
Migraine headache with aura
Chronic tension headache
Post-dural puncture headache
Cervicogenic Headache
TMD
Occipital neuralgia
Burning mouth
CTS
Fibromyalgia
Complex Regional Pain Syndrome
Oesophagitis
Twelth Rib Syndrome
Raynaud’s disease
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Post-cholecystectomy Syndrome
Gall bladder disease
Rheumatoid Arthritis
Multiple Sclerosis
Peroneal Muscular Atrophy
Piriformis syndrome
Proctalgia Fugax
Interstitial Cystitis
Irritable Bowel Syndrome
Chronic constipation
Temporal arteritis
Gout (after age 60)
Osteoarthiritis (after age 45)
Livedo reticularis (after age 40)
Male prevalence
•
•
•
•
•
•
•
•
•
•
•
Migraine without aura
Cluster headache
Post-traumatic headache
SUNCT headache
Thromboangiitis obliterans
Pancoast tumour
Brachial plexus avulsion
Abdominal migraine
Lateral femoral cutaneous
neuropathy
Post-herpetic neuralgia
Ankylosing spondylitis
•
•
•
•
Gout (before age 60)
OA (before age 45)
Coronary Artery Disease (before
age 65)
Erythromyalgia (over age 50)
Brain, gender and pain
• Brain differences between genders can
be assessed in general population
• Structural differences-size, morphology
% of grey matter, neuron density
• Functional differences
• Greater opioid receptor availability in high
oestrogen states
• Considerable variations- no conclusions
Hormonal influence
• Pain perception varies according to menstrual
cycle in women with chronic pain
• Oestogens modulate certain pains e.g. migraine,
TMD, arthritis
• Oestrogens also seem to play a role in inducing
antinociception
• Testosterone can improve angina threshold in
men
• Testosterone protects against pain in adjuvant
induced arthritis in rats
Cross-sex hormones administration
changes pain in transexual women
and men
Aloisi AM et al Pain 2007:132; S60-67
Irritable Bowel Syndrome
•
•
•
•
•
•
•
Female to male 4:1 clinic setting in west
Less pronounced in community
Asian countries-gender differences less
Gender differences occur at puberty
Older age-similar prevalence
Women more constipation > men
Women more GI, visceral and somatic
symptoms
IBS
• Higher risk for abdominal surgery
• Reduced colonic distention volumes in
dysmenorrohea
• Ovariectomy associated visceral and somatic
hypersensitivity
• Lower levels of oestradial in women with IBS
• Lower levels of testosterone in men with IBS
• Progesterone may influence visceral motility and
sensitivity
Sex differences in analgesia
Pharmacokinetics
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•
•
•
•
Drug absorption
Distribution
Protein binding
Metabolism
Excretion
Pharmacodynamics
• In females:
– Mu agonists less effective
– Kappa agonists more effective
– Ibuprofen less effective
– More side-effects from medications
Coronary Heart Disease
• Leading cause of death in men and
women
• Below 55 years: risk in men 4 x women
• Women get CHD 10 years later than men
• Mortality for men decreased > women
Gender differences in symptom
presentation with CHD
• Chest pain more likely to be
pressure,heaviness,tightness,squeezing
• Less likely to be central or left chest
• Midback pain
• Nausea/vomiting
• Palpitations
• Indigestion
• More total symptoms
Milner 1999
Myocardial infarction
• 4,497 patients
• No gender differences for frequency of
chest pain, fainting or epigastric pain
• Women more nausea, dyspnoea, less
sweating
• Gender related to time delay to hospital
Meischke 1999
MONICA study
5072 men: 1470 women
• Typical chest pain 86.3% men cf 80.8%
women
• Atypical pain common both sexes
• No pre-hospital delay up to 65 years age
• Over 65 years: longer delay for women
Isaksson et al 2008
HIV
• Women represent largest percentage of newly
infected persons
• Sub-Saharan Africa- 59% HIV+ are women
• 14 women for every 10 men
• 2.6 million adults died from AIDS in 2006
• Pain related to HIV infection,
immunosuppression, HIV therapies, unrelated to
therapy
• Active treatment and palliative care needed
Violence
• Major contributor to death, illness, pain,
suffering, social isolation, loss of
employment and restriction of freedom.
• Can be accepted as normal
• Within family, community, stated custody
and armed conflict.
• Physical and sexual assault
Female Sexual abuse
Associated with:
• Increased pain complaints
• Health Care utilisation
• Poorer perceived health
• Greater psychological disturbance
• Specific pain complaints amongst
females
Fillingim 1999
Frequencies of abuse in males
and female students (%)
Child PA
Child SA
Adult PA
Adult SA
Total
Females (275) Males (151)
4.7
3.3
21.3
12.7
6.2
0.7
31.3
14.1
43.3
23.8
Fillingim 1999
Incidence of sexual trauma
Pelvic Pain Patients
N
%
Harrop Griffiths 1988
As child any
severe
As adult
Reiter 1990
As adult and child
Walker 1992
As child Any
severe
Controls
N
%
16/25
4/25
12/25
64.0
16.0
48.0
7/30
0
4/30
23.3
0
13.3
51/106
48.0
6/92
7.0
18/22
12/22
82.0
55.0
9/21
1/21
43.0
5.0
Comparison of sexual abuse
histories for the 3 groups
Chronic
pelvic pain
n = 30
Number of
women abused
Age at
which
abuse
occurred
Forced
Intercourse
Chronic non
pelvic pain
n = 30
No pain
n = 30
12 (40)
5 (17)
5 (17)
<16
6 (20)
2 (7)
4 (13)
16 +
6 (20)
3 (10)
1 (1)
8 (27)
2 (7)
4 (13)
Collett et al 1996
NSEs and Pelvic Pain
 An association between NSEs and pelvic
pain does not imply causality.
 Sexual abuse may be a correlate rather
than a causal variable and may be related to
many lifestyle risk factors (Fry 1993)
 A history of abuse may be associated with a
poorer ability to cope with the pain (Linton
1996)
 Retrospective self-report of childhood
victimisation associated with unexplained
pain (Raphael 2001)
Do CPP patients with reported history
of NSE differ from CPP patients
without such a history?
• More psychologically distressed (Toomey et al
1995)
• Higher levels of somatisation and dissociation
(Badura et al 1997)
• No difference on pain dimensions (Toomey et
al 1995)
Disclosure
Gastrointestinal disorders
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•
•
•
•
206 patients
44% sexually or physically abused
33% never disclosed to anyone
17% had informed their doctors
Abused patients had more functional
disorders, pelvic pain and life-time
surgeries.
Drossman 1990
Assessment
• Doctors are often very reluctant to ask about
NSEs. In one study only 18% of women were
asked (Robohm & Buttenheim 1996)
There are a number of possible reasons for
this
–
–
–
–
Time constraints
Fear of offending their patients
Feeling ill equipped to respond
Feeling uncomfortable asking the questions
Assessment
• When women referred to a gynaecologist
were asked whether they thought they
should be asked about any negative sexual
encounters >90% answered in the
affirmative
65% of survivors gave an unqualified ‘yes’
(Robohm & Buttenheim 1996)
• In another study 85% of primary care
patients favoured routine sexual abuse
enquiry (Friedman et al 1992)
Assessment
• Such questions may elicit a strong emotional
response from the patient e.g. distress, shame.
• Some women may find their experience too
distressing to talk about in any detail or choose not
to talk about it at all.
• Ascertain whether they have spoken about their
experience to anyone and if not whether they would
like to – need to know about local referral services
• In the majority of women there is no direct
association between a NSE and the onset of their
pelvic pain
Management
• There is very little in the literature on intervention with women
with pelvic pain who have a history of NSEs
• Many abuse survivors do not want to work on remembering,
solving or changing their perceptions of the abuse (Drews &
Bradley 1989)
• They may discount any association with their pain on present
functioning.
• Linton et al (1996) found >85% of women in his sample of
patients with chronic musculoskeletal pain did not believe their
history of sexual abuse affected their pain or sex lives.
Socio-cultural
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Poverty
Ignorance
Poor healthcare systems
Low priority for patient, family and healthcare
worker
• Government priorities
• More likely to work in informal sector
• 75% of worlds 876 million illiterates are women
Female coping strategies
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Active CBT coping
Seeking social support
Emotional focused support
Avoidance
Distraction
Catastrophising
Relaxation
Male coping strategies
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Direct action
Problem focused coping
Talking problems down
Denial
Looking on bright side
Smoking
Alcohol
Drugs