A few facts on pain and gender bias
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Far too often, those of us with FM are labeled as hypochondriacs:
Lets take a look at what the word really means for a second.
"Hypochondriac: A person who has hypochondriacs, a disorder characterized by a preoccupation with body functions and the interpretation of normal body sensations (such as sweating) or minor abnormalities (such as minor aches and pains) as portending problems of major medical moment. Reassurance by physicians and others only serves to increase the hypochondriac's persistent anxiety about their health. "
This is classed as a mental aberration. Someone who indulges in catastrophizing, thinking that perfectly normal events, portend some major medical problem.
Your average hypochondriac, is obsessed, constantly and forever thinking the mole they have is cancer for example, or the stress headache means they have a brain tumor, major things. Note the fact, that both of these examples are high profile, dangerous and life threatening.
Now, take a look at FM. Nothing glamorous about it, it's not directly fatal and when you talk about it to others, quite frankly it is likely to either get you a blank look, as they have never heard of it, or scoffed at, by those who think it is bogus. Does that sound like something anyone who is looking for major pity points would choose on purpose ? Can you say, NOT!
Those of us with FM know full well what is wrong with us, we also know it is not something else as most often the process of finally coming up with a diagnosis of FM, has eliminated many other medical problems. We do not want it to be something else and are very relieved to find out that it is not directly life threatening.
I, and many others believe that one of the main reasons FM is labeled as hypochondria, is the simple fact that most of its sufferers, are women. We ladies have long been labeled as hysterics, by the medical community. For everything from PMS to menopause. In fact, almost anything that is classed as a "woman's" issue, tends to get under treated and under researched and is often dismissed by the medical community.
Check any major disease study and its research data, and you will find a lack of data on women. From heart disease to cancer, two of the major killers of women in the USA, but little research is being done on women. Those who specialize in women's health, generally do so from a point of our reproductiive capacity. But we are much more than just a walking womb, thank you very much.
It was assumed, until just 20 or so years ago, that other than from a reproductive point of view, women were medically identical to men. This is not the case, our symptoms can be vastly different and the treatments that work for men, might not work well for women. Drugs are increasingly specialized and it is no longer a case, of one size fits all. There are definitive gender differences in drug therapy. Which often excludes women in the testing phase, unless the medication is related to our reproduction.
Most drug tests are done on middle aged Caucasian men and the results extrapolated to women, children, the elderly and other races. This has proved to be in error, in many cases.
Women are often excluded from testing, due to the risk of possible fetal damage, if during the course of the investigation, the woman becomes pregnant. The thalidomide tragedies, due to a medication given to women for morning sickness, that caused major birth defects, stands out, as a cause for this reluctance to use women in drug testing. However, this risk, higher though it might be, is no excuse for eliminating women from drug trials that will impact their lives and health.
For example, "For women, treatment of moderate to severe pain can be provided with fewer side effects by a neglected class of opioid drugs, according to researchers at the University of California, San Francisco." These drugs were developed, but are little used or known, as the first drug testing, was done, as is often the case, on men. They proved to be not very effective for men, so their use has not propagated. These are called kappa-opioids, and it was found, by accident, that there is a gender based difference, given how effective these pain medications are, for many women.
"Some doctors believe that we ( meaning women) are fixated on discomfort, that other people ( meaning men) just put up with"
Now, I don't know about you, but there is something radically wrong with that statement. It assumes that pain and discomfort, are normal, for either gender. This rather prevalent attitude, often leads to the under treatment of women in pain.
At the risk of sounding gender biased, it sounds a lot like some left over masculine concepts, that there is some kind of moral value to being stoic in the face of pain. To admit pain is often considered "womanish" or weak.
This may explain why the number of men diagnosed with FM, is so much smaller than women, not because they have it any less perhaps, but due to the fact they are reluctant to admit to the pain to their doctors. Or they are dismissed by their doctors when they do seek treatment, even more so than women are.
"Q. ... why women are more likely than men are to experience ( be diagnosed with ) fibromyalgia
A. The way we define and diagnose fibromyalgia is partly responsible for the fact that it appears to be very much over represented in women. The current diagnostic criteria for fibromyalgia require both chronic widespread pain for three months, and pain with palpation at 11 of 18 specified tender points. Population-based studies show that women are only 1½ times more likely than men to meet the criterion of chronic widespread pain, but are 10 times more likely than men to have 11 of 18 tender points. Therefore, including the requirement of 11 of 18 tender points in the diagnostic criteria makes fibromyalgia seem far more common in women than in men. ( See Diagnostics and FM on site link )
Also, it is important to recognize, that for any given symptom, women are more likely than men to seek health care. Research shows that many men with symptoms of fibromyalgia drink alcohol to self-medicate, or try to manage these symptoms without medical attention. It is also likely (although not firmly established ) that a man who comes in with the same symptoms as a women, would be much less likely to be diagnosed with fibromyalgia, because of the perception that this is a female disease. Therefore, fibromyalgia probably really affects about two-thirds women and one-third men, but in clinical practice, far more women are diagnosed.Russell Rothenberg M.D, Medical Advisory Committee of the National Fibromyalgia Partnership, Chairman"
The life stories on site link, of men with FM, seems to bear this out.
There is also a gender difference, when it comes to pain medications. Double blind studies show, that men tend to do better with non narcotic pain relievers, than do women, who state that the NSAIDS do little to ease their pain and request narcotics. This causes many male doctors to assume that the women are just drug seeking and further, female doctors will often over medicate their male patients. They do so under the assumption that the men are under reporting their pain. Hardly fair to either gender, we don't get strong enough meds, and the poor guys get too much. :(
There is a literal cellular difference in the brain and the nervous system, female to male and how it handles not only pain, but pain medications. "... morphine, the primary analgesic prescribed for the alleviation of chronic pain, works quite differently within the brain and spinal cord of males and females. This finding helps explain why women typically require twice the dosage of morphine as men, to achieve the same degree of pain relief." Anne Murphy, PhD, of Georgia State University.
Pain is not perceived in the same area of the brain, male to female. Research has found that men and women use different parts of their brain to respond to pain. Scan results showed that in women, the limbic system is more stimulated ... the more emotional center of the brain. Men, by contrast, respond to pain with the cognitive or analytical part of their brain."
This difference can also been seen as internal Vs external, women self check internal functions much more often than men, whereas men tend to seek an external target, as the cause of their pain. Pain, is a response to a threat, an internal one of possible damage being done, but none the less, it is a threat and we tend to react with many of the same responses as we do to external threats.
"There is much speculation as to why there is a brain difference, the assumption being that a cultural effect, IE that, women's response to a threat, is an emotional one, that being the safety of their children, either current or future ones, whereas males tend to respond to a threat by either running from it, or attacking the source of the threat, in a fight or flight response. These early, primitive, social differences, according to some, have become a biological, hardwired, imperative in the brains of modern day mankind."
These so called gender roles, have become pretty much moot in the current day. Well, ok it's not all the way there yet, but we are getting there. :) But the evidence is clear, for whatever reason, there is a major difference between men and women, in what part of the brain is the most stimulated during pain, and the over all reaction to pain.
recent studies have shown,
there is a major difference in brain scans in persons with FM over all,
of both genders, as compared to controls, that prove once and for all,
the pain is very much, real. Richard
E. Harris, PhD, and Daniel J. Clauw, MD
Pain is a signal from the brain that "something is wrong" it is the bodies way of saying, "hey, pay attention" something is not right here. It is NOT normal to hurt, period ! A well functioning body, is not in pain.
Further, FM is a pain amplification problem due primarily to major changes in the bodies neurochemistry. This means, what is ouch, to someone with normal chemistry, can be painful in the extreme to someone with FM. This is due, mainly to the higher amounts of substance P, in the body. We also have a heightened sensitivity to pain, that is called allodynia, where even normal activities that are considered non-painful, can cause pain. This effect is seen in many diseases and issues, such as: Migraine, Shingles, amputees and so forth.
More than one FMer, thinks their clothes are out to attack them, as it quite literally hurts to wear them. ( I wear caftans all the time at home, for this reason. Unless I have to go out, you will not see me in "street" clothes, because after a very short period of time, they hurt)
Wrinkles in the bed can be a nightmare, it's like we are the proverbial, princess and the pea here and don't even talk to us about the torture device called an underwire bra. If braless wasn't already a going thing, we would have started the Fad ! Thank all the Gods for sport bras.
Most pain is a signal, it's a life saver in many ways. We have to bless our ability to feel pain, or we would never know we have done ourselves an injury.
Chronic pain however, makes this blessing, a curse, as the body is rather limited, it knows, there is a problem, tell the mind ... but what if the pain is nearly perpetual ? Well, the pain system, keeps right on telling us "hey, there is a problem here" to which anyone with chronic pain wants to say to the body, with a very large megaphone " I heard you already, SHUT UP ! " But the body is deaf as a post to such pleas and keeps right on hammering away with pain signals.
What is pain?
To explain that, let me dip into a bit of medical geek talk for a moment.
"Pain is the result of nociception; activity in the nervous system that results from the stimulation of nociceptors. This activity is carried to the brain, usually via the spinal cord, and conveys information, without conscious awareness, about damage or near-damage in body tissues"
"A nociceptor is a sensory receptor that sends signals that cause the perception of pain in response to potentially damaging stimulus. Nociceptors are the nerve endings responsible for nociception, one of the two types of persistent pain (the other, neuropathic pain, occurs when nerves in the central or peripheral nervous system are not functioning properly). Nociceptors are silent receptors and do not sense normal stimuli. Only when activated by a threatening response, do they invoke a reaction."
"All nociceptors are free nerve endings that have their cell bodies outside the spinal column, in the dorsal root ganglia and are so named, based upon their appearance at their sensory ends. Nociceptors can detect mechanical, thermal, and chemical stimuli, and are found in the skin and on internal surfaces such as the periosteum or joint surfaces. Deep internal surfaces are only weakly supplied with pain receptors..."
Ok, now, what does all that mean, in English ? Pain is, in short, a sense. We feel pain and the reason we can feel it is because of the pain receptors we have built into the body. Pain is a survival mechanism, we hurt in order to tell us that we are doing or nearly doing, damage to the body and to stop doing whatever is creating the response. Pain makes us do things that will end the pain response. Pain also teaches, in that we tend not to do whatever it was, that caused the pain again.
This is how it works in acute pain, put your hand near a fire and your body goes, "hey ... you are gonna get burned, stop that" and almost without thought, yank, back comes the hand, away from the fire. We don't even have to think about it, we just do it ! Moreover, you learn one hopes, not to stick your hand in the fire. :)
This is a problem with chronic pain however, as the body treats it the same as it does acute pain. Signals are sent to the brain of, something is wrong. However, unlike our hand in the fire example, the cause of the pain is not so obvious, to where avoidance of what is causing the pain, is not always possible. Pain threshold VS Pain tolerance on site link.
Does Pain Wear Out Your Brain?
"If you sit in your driveway and rev up your car a lot, you put a lot of wear and tear on certain parts of your car. Those parts are apt to wear out long before other parts, right? It's pretty simple logic.
Now apply that logic to your brain. When you have fibromyalgia (FM), chronic fatigue syndrome (CFS or ME/CFS) or other types of chronic pain, all those pain signals keep certain parts of your brain revved up, all the time. So, does that mean we're wearing out our brains?
It appears so, according to research published in the Feb. 6 issue of The Journal of Neuroscience. And they say, that could be why we have to deal with things like short-term memory problems, decision making, irritability, mood swings, depression, etc.
Researchers used functional MRI to compare the brains of pain-free people (lucky souls!) with chronic-pain patients, as they watched a moving bar on a computer screen. The scans showed that in healthy people, brain activity is balanced. Essentially, when you use one area, the other areas kind of take a back seat. But in people with chronic pain, one area - which is mostly associated with emotion - just never quiets down. That, researchers say, wears out your neurons and alters the way they communicate with each other - or it could even kill the neurons.
This is the first time we've seen a difference in brain activity between those in chronic pain and those that are not, that wasn't directly related to how we feel pain. The researchers say this shows that it's essential to study new approaches to pain treatment, that not only control pain, but also prevent pain's effects on your brain." ( written and contributed by, Piney on site link )
Pain and gender differences, the research on nocicpetion response:
Most of the research into gender differences in nocicpetion response to date, has been done on rodents. There is increasing evidence, that nocicpetion response is radically different from female to male and further, that females with lower estrogen levels, experience higher pain levels.
Which could very well explain why FM tends to rear its ugly head at or near menopause, in women. However, it is not estrogen itself that is said to be the problem, it is the variability of those levels. Which, during the peri menopausal stages, varies widely and unpredictably from day to day.
It is of importance to note, that the introduction of synthetics or hormones from other species, had little, to no effect in pain response, whereas, injections of live estrogen, say from healthy female rats into estrogen deprived rats, invoked a positive response. Which means, the typical hormone replacement therapy, based as it is on synthetics or compounds from other species, is of little value for pain relief in FM.
Sorry ladies, so don't rush out and get yourself on the currently available hormone replacements. As according to all the research, it won't help." A recent study suggests that the current day hormone replacement therapy may actually aggravate pain, even in healthy menopausal women, with the women on HRT reporting more pain–sensitivity than those who were not." In fact, ditching your HRT pills, might even help, something to consider.
And before you sell the idea of rodent based research short, realize, the rats have absolutely no reason or means to fake reactions, it is literally impossible to assume that female rats are more emotional for example, or that there is some social advantage to exhibiting more pain. I don't think the other rats would care. :)
Yet, in test after test, these results are repeatable, by myriad's of researchers. This is one reason biologically identical rats and mice have such value in research, it is possible to breed identical clones of each other, so all factors are identical, save for the tests. Therefore, gender bias, unless it's on the part of the researcher reporting their results, is not possible.
Other forms of pain:
Pain comes from other sources, besides direct nocicpetion. The other forms are called, Neuropathic pain on site link, and Visceral pain. With neuropathic pain, the nerve fibers themselves may be damaged, injured or dysfunctional. They then send incorrect signals to other pain centers though a process called, demyelination.
Demyelination, is a degenerative process, that erodes away the myelin sheath that normally protects nerve fibers. Mylein is like a thin plastic wrap, that normally covers the cells, except for the very tiny tips at the ends, which permit the cells to chemically "talk" to each other.
What happens when you get demyelination ? It's rather like putting a red shirt, in a load of white laundry. The red bleeds over into the whites and you wind up with pink underwear. Or another analogy, a hose, that instead of all the water coming out one end, someone poked holes all over the end with an ice pick and now you have a sprinkler, that is spreading water all over the place, instead of being directed to only one place.
The nerve fibers "leak" information at the axons, which is basically the end of the nerve cell, this causes neural impulses to spread to other nearby demyelinated fibers, "bleeding" over onto other cells. If the adjacent fibers belong to the same sensory pathway, these misdirected neural impulses, give rise to pain. This is so, even if the newly affected neurons, now dyed metaphorically pink, are not damaged.
Neuropathic pain is often described as shooting, stabbing, burning, or searing, it is commonly seen in conditions like, back, leg, and hip problems (sciatica), Cancer chemotherapy, Diabetes, Facial nerve problems (trigeminal neuralgia), HIV infection or AIDS, Multiple sclerosis, FM, CMP, and many many others. "The most dramatic example of neuropathic pain is called "phantom limb syndrome." This occurs when an arm or a leg has been removed, because of illness or injury, but the brain still gets pain messages from the nerves that originally carried impulses from the missing limb."
The difficulty in treating neuropathic pain is that is does not respond as well, to typical pain killers, the ones that blunt pain sensations in the brain. "Neuropathic Pain does not respond well, to conventional pain killers, because the drugs follow the wrong neural pathways to achieve this function successfully."
The ANS is the main regulatory system of the body in charge of maintaining essential involuntary functions. ANS means, your autonomic nervous system. This system works, 365 days a year, every moment of our lives, from before our birth, to the moment we die. It is automatic, and by and large, not under our voluntary control. This is what makes your heart beat, your lungs breathe, your eyes blink, etc., a 1001 things to maintain the body, that are not under our direct control.
Now, FM and CMP are central nervous system disorders. "ANS dysfunction may explain the diverse clinical manifestations of FM. It has been suggested that, due to a ceiling effect, the hyperactive sympathetic nervous system of such patients becomes unable to further respond to different stressors, thus explaining the constant fatigue and morning stiffness these patients suffer. Relentless sympathetic hyperactivity may explain sleep disorders, anxiety, Raynaud's phenomenon, sicca (Sjogrens syndrome), and intestinal irritability."
So, the very thing that is responsible for so many different essential functions, is in a dysfunctional state, effecting the entire body.
Women, are 3 times more likely than men to suffer from conditions that cause neuropathic pain, including Migraine headaches, osteoarthritis, fibromyalgia, diabetes and rheumatoid arthritis. Pain threshold VS Pain tolerance on site link.
Visceral pain originates from body's viscera, or organs. Visceral nociceptors are located within body organs and internal cavities. There is a scarcity of nociceptors in these areas, compared to the muscles, joints and skin. However, the pain from them, can be agonizing.
Injury and inflammation can be particularly problematic, as organs become highly sensitive to any kind of stimulation, as in IBS and other disorders. The most well known of the Visceral pains, is the pain of Labor in child birth.
"Labor is associated with two different kinds of pain. The first arises from the uterine muscle when it begins to contract at the onset of labor. Because the uterus is an internal organ, the pain associated with contractions is called visceral pain. Like all sources of visceral pain (e.g.intestinal colic, gallstones, appendicitis), pain arising from the uterus, cannot be accurately pin-pointed.
Visceral pain is also often felt in a different part of the body than from where it originated. This is called "referred pain." In the case of the uterus, contraction pain is commonly referred to the lower back and sacrum; indeed, some women find that their labor feels more 'painful in the back' than in the abdomen. In other words, uterine contractions are typically felt over a large area of the body:"
" Many forms of visceral pain are particularly prevalent in women." Further, female tolerance for Visceral pain is lower, and women require more and stronger pain medications for visceral pain, than men with identical disorders. Sex differences in morphine-induced analgesia.