Pain Thresholds, Gender and More Ranting

A couple of weeks ago, in response to my rant about the medical literature talking about the alleged hyperalgesia (i.e., lower pain thresholds) in people living with RA, Carrie (sorry - forgot the link) asked a very good question. Namely whether it wasn’t a good thing to identify that RA appeared to lower your pain thresholds, because it would have implications for treatment to better deal with that pain. Good point. Except my concern is - and this would seem to be somewhat substantiated by literature reviewed by RA Warrior that got me ranting in the first place - that the impact on treatment is not towards treating this increased pain, but rather to dismiss it. As RA Warrior says, "[i]t is believed that they [people living with RA] perceive pain to be worse than 'actual pain'".

There's a multi-page rant just begging for attention in the assumption that you can measure somebody's “actual pain,” but I'm not going there today (and aren't you grateful for that?). Suffice it to say that pain specialists, who it could be argued know more about pain than perhaps your random researcher or GP does, reject the idea of pain existing in a vacuum, separate and physical only. We recently published a post from a pain specialist on MyRACentral and he states "pain can be thought of as a complex experience that encompasses sensation, emotion and cognition". It's why pain is better treated with pharmaceuticals plus other therapies like biofeedback, meditation, etc., rather than just painkillers alone.

Earlier this week, I read another post on our Chronic Pain site, written by Dr. Christine Lasich, also a pain specialist, specifically about women and pain. And I learned something very interesting. Namely that until the 1980s, "the FDA prohibited the participation of women in clinical drug trials". Shall we all take a brief pause to boggle at that?

And since I read that, the implications of this past ban on studying half of the population has zinged around in my mind. We know many women died – and still die - of misdiagnosed heart attacks because as far as medicine was concerned, the knowledge about the symptoms of heart attacks was based exclusively on the way they present in men. And then they discovered that the symptoms of a heart attack are different in women. So what happens to an area of knowledge - in this case how drugs work – that is tested only on men? Even if gender bias in such studies was eliminated 30 years ago (and alas, it wasn't), knowledge is built on previous knowledge, which is built on knowledge gained before that and if the previous knowledge did not include half of the population, how do we know how accurate our present knowledge about how drugs work is?

And here's another thing. Dr. Lasich talks about the "epidemic affecting primarily women, an epidemic of chronic, painful conditions with names like fibromyalgia and thoracic outlet syndrome" and although I hadn't heard of the latter, of the people living with fibromyalgia, 9 out of 10 are women. Ninety percent! And RA affects women twice as often as men. Another interesting fact I learned in that article is that "women respond to pain differently than men".

And this brings me back to the question regarding the validity of the studies that hold forth about hyperalgesia. Given that there is a lack of research specific to women in pain, given that women respond differently to pain than men do and given that many of the chronic illnesses that cause pain affect women more than men, is it possible that there is a gender difference within the studies that simply hasn't been measured and accounted for? That perhaps the "perceived pain" may not differ from "actual pain"? I mean, other than the fact that RA Warrior mentions other studies that didn't find a lower pain threshold in people living with RA and then there is the conclusions from pain specialists that perception of pain is what matters, not someone’s idea of “actual pain,” should we take another moment to boggle at the shortsightedness and tunnel vision of the research upon which such conclusions and thereby treatment are based?

Or lack of treatment, I should say. Because women still tend to be patted on the head and sent away when reporting pain. Or told it’s all in their head, because they’re “too sensitive or emotional” (Lasich). Compared to whom? Men? If there are gender differences within the population of people living with chronic pain and women react differently to medications due "to having different metabolisms, hormonal interactions and clearance rates," (Lasich) what implications does that have for treatment? How many women out there aren't being treated appropriately because their doctor approaches their medical care from a base of knowledge that's riddled with a built-in gender bias?