Does Gender Play a Role with Pain?

June 1, 2015

Any mother will tell you that if men went through the pain of childbirth, the human race would be extinct today. But do men and women really handle pain differently? Salonpas sat down with Dr. John Stavrakos, a physical medicine and rehab physician (physiatrist) on the medical staff at Texas Health Arlington Memorial Hospital for his educated, front-line perspective on the differences and similarities on how men and women feel pain: sitting with plant in background

Do you believe that men and women tolerate physical pain differently? 

Yes and no. The problem any researcher dealing with the study of pain has is that pain is a subjective factor. We can’t look at pain under a microscope, and we haven’t invented a device that can give us a 1-100 scale of pain intensity. My suspicion is that it’s not so much the pain itself as the perception of pain that’s the issue.

Most studies in the medical literature seem to conclude that men do tend to handle pain better overall, and there may be biological and evolutionary factors there – i.e., an argument can be made that the male physiology may be more resistant to physical pain; physiologically, men usually have thicker, denser bones, bigger muscles and more body mass – all plusses when it comes to absorbing injury. From an evolutionary standpoint, men were, with rare exception, the hunters in the hunter-gatherer societies we all descended from, and were typically subjected to more constant and severe forms of physical punishment (e.g. hiking up and down mountains all day and carrying the carcass of a wild boar you’d been tracking since daybreak 10 miles on your back to the campfire is harder on the body than, say, tending to the settlement and gathering herbs and digging up roots to eat. Neither is by any means easy, but the former is clearly more mechanically stressful).

Along the lines of physiology, however, there may be gender differences that might cause a perception bias: we know that women tend to have more interneuron connections between the language centers of their brain and the areas that control emotion than men do; in the case of physical pain ( = bad emotion), it stands to reason that women would be more likely to talk more about it then a male counterpart, and this might be perceived as having a poorer pain tolerance (the opposite of the ‘strong, silent type’ we think of). This may not be the case in a particular instance, but simply how a woman may be more likely to cope with the issue.

Is there a hormonal role in the way men and women tolerate pain?

There certainly seems to be. The University of Michigan has done some groundbreaking work on this subject, and found that higher estrogen levels in women are associated with higher levels of endorphins (the body’s natural pain killers), and the reverse is true when estrogen levels are lower. One common argument for advocates of women having higher pain tolerance than men, for example, is childbirth, and that men subjected to chemicals that supposedly mimicked the pain of labor all but passed out from the experience. The reality is that, while there is no doubt that childbirth is commonly very painful and takes a great deal of mental fortitude to get through, a woman’s body prepares her for this not-so-pleasant experience in advance by ramping up her natural painkillers, loosening ligaments and the like. Without hormonal changes modifying pain in this manner, the human race would likely have gone extinct long ago!

In men, low testosterone is associated with greater pain perception, particularly joint pain, and this has been seen in animal studies as well. At The Endocrine Society’s 95th Annual Meeting in San Francisco in 2013, a study was presented on this subject that showed one of the side effects of long terms use of narcotic medications is suppression of the body’s production of testosterone, and replacement therapy of this hormone decreased pain perception. As testosterone is also associated with greater muscle mass and is much higher in men than in women, it offers one plausible explanation regarding gender differences in pain tolerance.

What is the role of nociceptors and pain perception?

Nociceptors are, by definition, pain receptors. Your body has different types of them, which have slightly different functions. What is interesting is that there seem to be some genetic variability in the number and types of pain receptors among humans (redheads, for example, are a fascinating study because the MC1R gene that causes the red hair mutation in 80% of ‘gingers’ has been linked to both lower and higher thresholds of pain, depending on the type of pain stimulus, although studies are still ongoing).

The other issue is that nociceptor up-or-down regulation may be able to change in a person’s lifetime; people who suffer from chronic pain, especially those on high doses of narcotic medication for long periods of time, and/or who have suffered physical or psychological abuse, can experience a physiological change in their bodies that increases their sensitivity to pain due to changes in nociceptor. In other words, that lady with PTSD diagnosed with fibromyalgia ten years ago who’s been on Oxycontin for her low back pain and hurts from a simple finger jab into her upper back isn’t just hurting because “it’s mostly in her head,” her body may quite literally feel pain where you and I just feel pressure.

Do any non-biological factors influence how much pain men and women feel?  What are they?

Absolutely – and they are way too many to list! Many factors go into pain perception, and things like an individual’s personality, their background/upbringing, activities, understanding of the causes of their pain, etc., all play enormous roles in the perception of pain that both women and men feel. There are professional athletes and everyday working people who suffer pain from the moment they wake until they fall asleep who don’t breathe a word of it to anyone.

Conversely, there are people who come to the doctor’s office asking for Vicodin or a pain killing shot because of low back pain described as “10 out of 10” while sitting comfortably in a chair. For a frame of reference: 10/10 pain is what you’d experience if you were being burned alive, while someone was peeling your charred skin off with a pair of pliers. Even after this analogy is explained to some patients, they will persist at quantifying their pain at this level with normal X-rays and MRI’s and average physical exam findings. Pain has not changed as a biological constant among human beings over the ages, but perception of pain may have.

Some people are better equipped to handle pain than others, and I strongly suspect that it’s a combination of physiological and mental/psychological factors, with the nod going towards the latter as to which is more important in most cases.

Reported incidence of low back pain in industrialized nations, for example, has a pretty strong association with unhappiness at the work place, poor work relations and lack of social support. Conversely, spine surgeons often get patients who have physically demanding jobs who want an operation so that they can get their pain under control and get back to work as soon as possible; not so they can claim disability or force their bosses’ hands to give them an easier job.

Are there research studies you recommend that measure male vs. female pain perception?

Yes. The work of psychologist Roger Fillingim from the University of Florida is a great resource, as he has put a lot of study into the subject. Dr. Jon-Kar Zubieta, M.D., Ph.D. and colleagues at the University of Michigan’s Mental Health Research Institute have been ‘mapping’ centers of the brain associated with pain perception and doing comparison studies in men and women, as well as studies on women in relation to their menstrual cycle.

Is the ability to overcome adverse circumstances (i.e., resiliency), whether you are male or female, help determine the high or low acceptance of pain?

As a rule of thumb, resilient ‘mentally tough’ individuals tend to have a higher pain tolerance; they usually see pain as simply one more thing they have to deal with, improve upon, or simply accept on a given day, like having to take out the trash, clean the garage or do your taxes. It goes back to perception of pain, which is just as, if not more, important than the actual pain itself.

My family, for example, comes from a small village in the mountains of southern Greece. I know of men and women there in their 70’s and 80’s who have been doing hard physical work since the age of seven who get up at dawn and put in a full day’s work, only getting a partial break on Sunday (when you’re supposed to go to church and refrain from hard labor). One gentleman was hunting up in the mountains at the age of 90 and climbing olive trees to prune them at age 94.

In Victoria, Australia, a media campaign was launched in September, 1997 to provide people with straightforward advice on back pain based on evidence-based medicine. The television commercial ads encouraged people to stay active, exercise and stay at work, i.e. don’t take your back pain ‘lying down,’ so to speak. Afterwards, there were significant improvements in both the community and physicians’ beliefs about how to deal with back pain, and the number of workers’ compensation claims went down. What changed? Not the viewers’ backs or the physiological elements causing their pain – their perceptions changed. In essence, they were told (with a positive spin) to be mentally tough, it’s OK to have back pain, not OK to let it take over your life.

Are there natural supplements you recommend for the treatment of low to moderate physical pain? 

Certainly; there are some that have shown promise that are also readily available:

SAMe (S-Adenosyl L-Methionine) is an amino acid that has been used for treatment of diseases such as osteoarthritis, bursitis, tendonitis, low back pain and chronic fatigue syndrome; as a rule it tends to be well tolerated with few side effects (check out WebMD.com for a good recap on this supplement).

Many people with aches and pains are Vitamin D deficient, or have sub-optimal Vitamin D levels, so in those cases I recommend getting Vitamin D3 (not D2) which can be found at any pharmacy or grocery store chain nowadays, and recommending a dose based on the deficiency level.

Conenzyme Q10 also has a variety of potential uses, but recently has shown some promise in treatment of fibromyalgia symptoms. This should not be taken without physician guidance, however, as some side effects (e.g. lowering of blood pressure – usually a good thing, but if a patient is already on anti-hypertensives the blood pressure drop can be dangerous).

Omega 3 fatty acids and cod liver oil (yes, I know it sounds gross) have been used for some time for relief of joint pain, as have glucosamine/chondroitin sulfate. These are also typically very well tolerated (some of these come in large, hard to swallow ‘horse pill’ sizes, and cod liver oil can be taken as a liquid. Despite coming in different added flavors, it still tastes like, well, cod liver oil). My usual advice is to take them consistently for three months and see if there is any appreciable difference in pain and function.

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