‘It’s not in your head’: Why pain may linger longer in women – even when scans are normal
Women are more likely to experience chronic pain, from migraines and fibromyalgia to endometriosis and painful periods. It isn’t simply about pain threshold. Experts explain why women may be more vulnerable and how persistent pain can be managed.
Studies show that women are more likely than men to experience chronic pain. (Photo: iStock/AsiaVision)
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After covering health stories for more than a decade, many involving women’s health, I’ve noticed a recurring pattern: Women living in significant pain can become very good at enduring it.
One 18-year-old I interviewed had chronic headaches so severe she spent most of her childhood and teenage years “at home, in pain”. Others have expressed the relief of finally being believed, becoming emotional as they recount their experiences.
A 29-year-old became tearful as she recounted how a doctor finally took her complaints about intense period cramps seriously enough to investigate. It was severe endometriosis, which had invaded her fallopian tube, colon and rectum.
These stories made me wonder how much pain they were expected to put up with, and why persistent pain seemed more common in women.
WHAT NEW RESEARCH SAYS
Research has long suggested that women are more likely to develop certain chronic pain conditions, but the reasons are complex.
A global study published in October in Nature Medicine found that women were more likely than men to report pain across all 11 body sites studied; researchers analysed data from more than six million across 118 countries.
A study published in February this year in Science Immunology suggested that biological differences may explain why pain can take longer to resolve in women. It found that pain resolved more slowly in female mice than in male mice, and identified differences in immune cells involved in switching pain off.
In males, these cells are more active due to higher levels of sex hormones such as testosterone, while females experienced longer-lasting pain because their monocytes – a type of white blood cell in the immune system – were less active.
The researchers also found evidence of a similar pattern in human patients recovering from traumatic injuries.
“The difference in pain between men and women has a biological basis,” lead researcher Dr Geoffroy Laumet from Michigan State University said in a statement. “It’s not in your head, and you’re not soft. It’s in your immune system.”
“We see this in Singapore as well,” said Dr Singaraselvan Nagarajan, senior consultant and head of Department of Women’s Anaesthesia at KK Women’s and Children’s Hospital (KKH).
He pointed to a local study that found chronic pain in 10.9 per cent of women, compared with 7.6 per cent of men. Among Singaporeans aged 60 and above, women were 1.8 times more likely than men to report pain.
But Dr Singaraselvan cautioned against attributing this simply to women having a lower pain tolerance.
“Pain is a much more complex biological experience,” he said. “There are differences in hormones, immune and neural pathways, as well as psychological and social factors, that can influence how pain is experienced and how it persists.”
WHAT IS PAIN?
Pain is a “fight or flight response”, said pain specialist and anaesthesiologist Dr Diana Chan, medical director of Advanced Pain Specialists.
When there is acute, intense pain, pain signals are transmitted from the area experiencing pain to the brain, which then analyses the character and site of pain, said Dr Chan.
“The pain signals act as warning signals to help the body move away from the source of the pain or help the brain interpret that something is wrong with the body,” she explained.
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.
The definition has been expanded to include pain as a personal experience that is influenced to varying degrees by biological, psychological and social factors, said Dr Tay Yoong Chuan, visiting consultant and director of KKH Women’s Pain Centre.
Dr Tay is also a senior consultant at the department of pain medicine at Singapore General Hospital.
In other words, pain is more than a signal from an injured body part. Two people with a similar injury may experience it differently.
For example, a bone fracture sends intense pain signals to the brain, prompting the body to avoid moving the injured area. But sometimes, these warning signals can continue long after the bone has healed.
“When pain lasts beyond the period of tissue healing – around three months – and affects daily activities, mood or quality of life, it becomes chronic and may be a malfunction of the pain response system rather than it being protective,” said Dr Chan.
KKH Women’s Pain Centre manages around 100 new and follow-up consultations per year for pain-related conditions, said Dr Tay.
Patients may experience chronic back and limb pain, abdominal pain and headaches, as well as pain following trauma.
Some pain conditions are more commonly seen in women, said Dr Chan. They include fibromyalgia, migraines and tension headaches, irritable bowel syndrome, rheumatoid arthritis, osteoarthritis and female-specific conditions like endometriosis and painful periods.
THE INVISIBLE PAIN
One of the most frustrating experiences for people living in pain is being told that nothing is wrong, particularly when abnormalities do not show up on scans.
Dr Singaraselvan said: “The first and most important thing is to believe the patient when she tells you she is in pain. We should never dismiss pain simply because a scan is normal.”
While scans can show changes in the body’s structure, they do not measure the patient’s pain experience, he explained.
The first and most important thing is to believe the patient when she tells you she is in pain. We should never dismiss pain simply because a scan is normal.
Research by Dr Singaraselvan and colleagues at KKH’s Women’s Anaesthesia involving women undergoing Caesarean delivery, hysterectomy (womb removal surgery) and breast cancer surgery has found that persistent pain is influenced not only by the original tissue injury.
Other factors, including pre-existing pain, stress, anxiety, pain catastrophising (dwelling on pain and fearing the worst) and individual differences in pain processing, also play a role, he said.
“It is not simply a question of whether someone has a ‘low pain threshold’ or is unable to tolerate pain. The pain is real. The nervous system itself is part of the biology of pain,” said Dr Singaraselvan.
For someone who has been living in pain, being believed can be an important step towards effective pain management.
“I always acknowledge their pain is real so that they feel validated, and explain how pain works in the body,” said Dr Chan. “I also let them know that sometimes a cause may not be found but we need to deal with their pain from a multi-prong approach – not just biologically, but also psychologically and socially.”
HOW MUCH PAIN IS “NORMAL”?
Dr Chan emphasised that there is usually no universally “acceptable” amount of pain.
Pain is often measured using a numerical rating scale from zero to 10, with zero being no pain and 10 being the worst pain ever.
“Pain is a subjective experience. A person’s pain score of three may be another person’s pain score of eight,” Dr Chan said.
Doctors may also use a comprehensive history with physical examination and investigations, where necessary, to diagnose the possible source of the pain.
Dr Chan advised seeking medical attention when pain continues for more than three months, has an intensity of more than five, or has no obvious cause.
The same applies when pain is accompanied by red flags such as unexplained weight loss, difficulty passing urine or stools, numbness or swelling, fever, night sweats, progressive weakness or a significant change in everyday functioning.
WHAT PAIN TREATMENT MAY INVOLVE
Dr Chan said pain treatment requires a concise and holistic pain management plan involving not just medications and interventions, but also lifestyle changes. Treatment may take weeks to months or even years, she added.
Treatment may take a multidisciplinary approach involving pain or other medical specialists, physiotherapists, occupational therapists, psychologists and acupuncturists, said Dr Tay.
“Management of chronic pain may not obliterate pain,” he said.
Pain may persist even after the initial cause has been treated or may occur alongside other chronic pain conditions. However, a personalised, comprehensive approach would often reduce pain and improve function, Dr Tay added.
To women who feel that their pain has been dismissed, Dr Chan’s advice is to persist and continue to express concerns. Finding the right pain specialist and keeping a pain diary (to track pain levels, symptoms and triggers) can help them communicate more clearly with their doctors.
CNA Women is a section on CNA Lifestyle that seeks to inform, empower and inspire the modern woman. If you have women-related news, issues and ideas to share with us, email CNAWomen [at] mediacorp.com.sg.
Source: CNA/pc
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