Allen Young, M.D., F.A.C.P.,
is a board-certified specialist in Physical Medicine and Rehabilitation
and a licensed acupuncturist. His subspecialty interest is in pain management.
He graduated from the Finch University Chicago Medical School, completed
his residency at the Albert Einstein Montefiore Medical Center, and was
recruited to the faculty of the Johns Hopkins University School of Medicine
in 1991. He also serves as Chairman of the Department of Physical Medicine
and Rehabilitation at the Maryland Rehabilitation Center at the Maryland
State Department of Education.
He is the author of the book Women
and Pain: Why It Hurts and What You Can Do.
Women and Pain: Tell Me Where It Hurts
Do you suffer from constant, agonizing pain? Have you been to doctor after
doctor, only to receive nothing that helps or be told "it's all in your
head," "it's stress," or "you're just getting old"?
If so, you're not alone.
Women have said it -- and men have denied it -- for years. Now we know that
it's true: Women feel more pain, seek help more aggressively, and make more
active attempts to cope with pain than men.
Unfortunately, we also know that too frequently women aren't taken seriously.
Although we think of medicine as a professional discipline, rooted in science
and free of bias, this isn't always the case. Frankly, our health care system
often disregards women in pain. At best, it's ignorance of gender differences.
Some physicians also stereotype women as complainers who are less self-controlled
and more likely to over-report symptoms. They dismiss female patients with antidepressants,
antianxiety drugs, and platitudes. This adds insult to injury. When you're in
pain, it's the last thing you need.
Given how much we know about pain, it's scandalous that women suffer needlessly.
As a physiatrist, a physician board certified in physical medicine and rehabilitation,
I specialize in treating disabling painful conditions with gentle, simple conservative
modalities. Using my skills in acupuncture and complementary medicine, I have
helped thousands of people find relief from pain. My background as a member
of the teaching faculty of Johns Hopkins University has instilled in me a strong
commitment to patient education and empowerment. Since my specialty places so
much emphasis on properly balancing the emotional and physical needs of patients,
often people with painful chronic disabilities, I am keenly aware of the frustration,
anger, and depression that many women patients face when they are in pain and
don't know where to turn for help.
Happily, times are changing. Gender has become a "hot button" issue
on the national research agenda, so important that a conference on gender and
pain was held at the National Institutes of Health (NIH) in 1998. Eye-opening
biomedical research presented there concluded that:
- Women experience more pain than men.
- Women discuss pain more than men.
- Women cope better with pain than men.
- Society's attitudes toward men and women in pain may influence physicians'
- The open expression of pain sometimes helps people obtain better pain control,
but being seen as "too emotional" may work against a woman and lead
to inadequate care.
- Pain treatment that works for one sex may not work as well, or at all, for
Some of the most galvanizing research concerns the medications we use to treat
pain. This work calls into question the age-old pain management practice of
"one size (or one drug) fits all." For example, a series of landmark
studies has shown that morphine-like drugs, called kappa-opioids, produce significantly
greater pain relief in women than in men. (These drugs work through receptors
in the central nervous system. There are multiple types of opioid receptors
-- kappa, mu, delta, and sigma. The mu and kappa categories are the two major
classes thought to be responsible for analgesia.) Kappa-opioids are not as commonly
used as other narcotic pain medications. Drugs that work on the mu-receptors
are the standard of care and are much more frequently prescribed. Yet they cause
more nausea, itching, cardiac effects, constipation, and depression of the respiratory
system. Treating women with kappa-opioids, then, may provide better pain relief
with fewer side effects.
Other studies show that common pain relievers do less for women than for men.
For example, in a recent study of experimentally induced pain, ibuprofen --
the key ingredient in Advil, Motrin, and other over-the-counter analgesics known
as NSAIDS (for nonsteroidal anti-inflammatory drugs) -- was less effective at
providing pain relief for women than men. Perhaps dosages for NSAIDS need to
take gender into account.
In addition, many painful diseases and injuries disproportionately affect women.
Even when men and women suffer from the same illness, the symptoms may be different:
- Osteoarthritis (OA), or degenerative joint disease, is far more common
among women over the age of fifty-five, and women may suffer from a more severe
form of this disease. In one recent study, women experienced 40 percent more
pain, as well as worse pain. In addition, women are more likely to develop
inflammatory types of OA that lead to knobby deformities of the DIP and PIP
joints (the two sets of joints below the knuckles).
- Rheumatoid arthritis (RA) occurs two and a half times more often among women,
and it may also affect them more severely. Women have reported more painful
joints, more swollen joints, and worse function. And the majority of studies
show that RA is slightly more disabling for women than it is for men.
- Migraine headaches are more severe, longer lasting, and more frequent in
women than in men. In addition, women have more nausea, vomiting, numbness,
and tingling with their headaches, while men are more likely to have a visual
- Tension headaches occur two to three times more frequently among women,
who also experience much higher levels of tenderness in all the muscles surrounding
- Women athletes experience knee injuries two to eight times more frequently
than their male counterparts. This is particularly true for tears of the anterior
cruciate ligament (ACL).
- Osteoporosis affects both sexes, but women develop it at a much younger
age and in far greater numbers because of hormonal differences.
Gender differences play out on the operating table, too. In a study recently
published in the British Medical Journal, women emerged from general
anesthesia faster than men. However, they returned to their pre-surgery health
status significantly more slowly and they experienced more postoperative complications.
Women Aren't Just Small Men
We don't know why these differences exist, but a wide range of scientific studies
shows that the sexes differ on nearly every level. From the molecular to the
psychological, from the basic genetic codes to the hormones, biology, physiology,
and the overall functioning of the immune response systems -- men and women
We aren't doing enough to understand and close this gender gap. The prestigious
Institute of Medicine (IOM) of the National Academy of Sciences recently issued
a call for biomedical researchers to "study sex differences from womb to
tomb." The IOM's report recommended that researchers take sex differences
into account in clinical trials, including studies of new drugs.
Even when women participate in clinical trials -- and more women do now than
five years ago -- there is little gender-specific information coming out of
the studies. Scientists at drug companies and research institutions have largely
ignored sex-based differences in their data analysis.
We also know precious little about how drugs behave during pregnancy or breast-feeding.
Most women who participate in research are postmenopausal. Admittedly, there
are serious ethical concerns about allowing women of childbearing age to enter
studies. But there may be other, less worthy issues at stake: Perhaps pharmaceutical
companies are worried about the marketing consequences of defining a drug as
more effective in one sex than another.
Sticking our heads in the sand is not the answer. We must develop guidelines
that allow all women to fully participate in research. Failure to do this has
serious ramifications; it could, in fact, be a matter of life and death. For
example, of the ten prescription drugs withdrawn by the FDA from the market
since 1997 because of adverse reactions, eight posed greater risks for women
than for men. (In some cases, the drugs were more widely prescribed to women;
however, even with medications prescribed equally to males and females, they
were more dangerous for women.) And when you are pregnant, physiological changes
may affect your response to a drug; you may be more vulnerable to its toxicity
or its effectiveness. When you take a drug, you need to know that it is safe
and effective for you.
Created: 3/18/2002  - Mark Allen Young, M.D., F.A.C.P.