Jean Cummings, a 38-year-old urban policy analyst from Cambridge, lives in almost constant pain.
Diagnosed with rheumatoid arthritis 10 years ago, she’s had two hip replacements and will have both knees replaced in June, right after her wedding.
She’s tried every medication in the book — and some in the pipeline. “There’s almost nothing left for me to take,” she says. She can barely stand or walk without crutches. There are times her body hurts so much she can’t roll over in bed.
Yet she copes, “with humor, mostly,” and sheer grit. “There’s a temptation to stop everything and stay in bed. But that doesn’t work for me. It makes the pain more apparent and makes you stiffer. And it’s so boring.”
Both her problems with pain and her fortitude in dealing with it are impressive. And both may be enhanced, a growing body of research suggests, by one basic fact: Cummings is female.
Not only are there some painful afflictions — migraines, arthritis, lupus, problems with jaw joints — that are more common in females, there may be gender differences in the perception of and response to other types of pain as well.
Furthermore, many differences show up not just in human beings — who are clearly subject to cultural teachings about how men and women should deal with pain — but in lab animals, too.
Not long ago, the question of gender differences in pain might have been hooted off the research agenda. But tomorrow, researchers from around the country will gather at the National Institutes of Health in Bethesda, Md., for a first-of-its-kind conference to discuss just that.
“Women do report more pain. . .and that’s likely related to varied mechanisms, physiological and cultural,” says M.A. Ruda, a neuroscientist at the National Institute of Dental Research and the conference organizer.
There will, of course, be a few skeptics, among them psychologist Dennis Turk from the University of Washington. He studied about 400 men and women at a pain clinic and found few differences, except the women were more depressed.
But since other data show women in general are more depressed than men, this doesn’t prove much, he says. And when he studied cancer patients, men and women had equally severe pain and were equally depressed, probably because a life-threatening illness is upsetting for anyone, male or female.
But other researchers have uncovered provocative evidence that there are gender-specific responses to pain. For instance:
– Men get more upset about pain, at least when it lingers. In a study of 48 men and women having surgery for dental implants, McGill University dentist Jocelyne S. Feine found that in the 10 days afterwards, they rated pain equally. But as pain ebbed, men got more impatient.
– Some medications work differently in men and women. Christine A. Miaskowski, a nurse and physiologist at the University of California in San Francisco, has studied people having wisdom teeth extracted. Morphine, a painkiller that works through one type of receptor (called mu) in the brain and spinal cord, works equally well in men and women. But other morphine-like drugs that work through a different receptor (called kappa) work better in women, suggesting the biology of pain control is gender-specific.
– In mice, too, pain control differs by gender, at least for stress-induced analgesia — the phenomenon that occurs when overwhelming stress, like childbirth or running from a predator, temporarily blocks awareness of pain. In mice, says neuroscientist Jeffrey S. Mogil of the University of Illinois/Urbana-Champaign, a drug called MK-801 reverses stress-induced analgesia, but only in males. He believes females have a separate system for some types of pain control, and he’s found a region on chromosome 8 that may carry the gene for it.
– Though studies are somewhat mixed, women seem to be more sensitive to experimentally-induced pain than men, and some research suggests female sensitivity to pain may fluctuate with the menstrual cycle, indicating hormones may play a role.
In fact, researchers recently identified receptors for the hormone estrogen “in the portion of the spinal cord through which pain signals pass,” says Dr. Daniel Carr, medical director of pain management at New England Medical Center.
Another clue that hormones may affect pain sensitivity is that pregnant women who have surgery need less anesthesia than nonpregnant women, probably because progesterone, secreted during pregnancy, blocks some pain.
The data on gender differences have important implications for treatment, especially the growing evidence that doctors tend to ignore or undertreat pain in women.
In a study of 550 AIDS patients, for instance, Dr. William Breitbart, chief of psychiatry at Memorial Sloan-Kettering Cancer Center in New York, found women’s pain was twice as likely to be undertreated.
It’s not that women are more reluctant to tell doctors about pain, he says. It’s how doctors respond. “I didn’t want to believe it, but it all boils down to the stereotypes about women being hypochondriacal. . .exaggerating symptoms.”
But ignoring any patient’s report of pain can be costly, because it can be the first signal of serious disease.
Several studies, for instance, show that doctors take chest pain more seriously in men, says Dr. C. Noel Bairey Merz, director of the prevention and rehabilitation medicine center at Cedars-Sinai Medical Center in Los Angeles.
One shows doctors are less likely to refer for further evaluation patients who talk about chest pain in “histrionic” terms, versus those who are “more businesslike.” Another shows doctors are simply less likely to refer women with chest pains.
And two studies presented last week at a meeting of the American College of Cardiology showed that women are 13 percent more likely than men to die of their heart attacks. One reason is that women take longer to get to the hospital because instead of the crushing chest pain that men often have, women often have more ambiguous symptoms such as shortness of breath, an ache in the neck or jaw or something that feels like gas pains.
Merz and others are now studying whether chest pain in women correlates to estrogen levels, on the hunch that higher estrogen levels — as in younger women — lead to more awareness of pain.
Even among children, pain can manifest itself differently in boys and girls. At Children’s Hospital, Drs. Charles Berde and Christine Greco are studying a disorder called reflex sympathetic dystrophy, in which one arm or leg becomes painful and gets cold, turns blue, or becomes sweaty while the other doesn’t, suggesting a neurological abnormality.
For mysterious reasons, the condition is six times more common in girls than in boys, says Berde.
Despite inequities in the incidence of pain, research suggests that women and men believe that women cope better, perhaps because nature has somehow endowed them to withstand the pain of childbirth.
Part of women’s skill is an ability to control their emotions during intense pain, says Francis Keefe, an Ohio University psychologist. Even though arthritis caused more intense pain in women than in men in his study, women were better able to maintain a positive mood.
Cummings can buy that, especially when guys approaching 40 complain to her about minor injuries cramping their athletic style. “It’s stunning to me,” she says. Stacked against the pain she copes with every day, “there is no comparison.”