The male-versus-female pain experience stems from some unknown mix of biology and differing sex roles (men are supposed to be stoic; women are freer to report weaknesses). Sex hormones in particular may play a part in pain severity, although researchers aren’t exactly sure how the relationship works. “It is clear that estrogen influences some clinical pain conditions,” says a recent review article in Clinical Orthopaedics and Related Research. For instance, migraines tend to become more frequent in women when their estrogen levels dip around their periods but less frequent when this female hormone hits high levels during pregnancy. Postpartum, when estrogen declines rapidly, the occurrence of migraine headaches increases.
“Menopausal fluctuations in estrogen are believed to affect pain levels as well,” explains Tarvez Tucker, MD, director of the headache and pain clinic at the University of Kentucky Medical Center in Lexington. Estrogen appears to play a protective role. “A drop in estrogen can make women more vulnerable to pain syndromes,” Tucker adds.
While no one is sure why there’s a sex-hormone connection, research suggests that one of the body’s networks of internal painkillers (called the endogenous opioid system) responds more strongly when estrogen levels are higher in women. And some subtypes of opioid painkillers work better in women, while others are more effective in men.
Another sex difference may play an important role in how doctors treat women. “Women tend to report their pain experience with more emotion,” says Linda S. Fidell, PhD, a professor emeritus of psychology at California State University, Northridge, who studies the effects of sex-role stereotypes on American physicians. That’s because male and female brains process pain differently. Functional MRI scans, which measure changes in blood flow in response to neural activity in the brain, show that women experience pain more in the limbic area of the brain, a center of emotions, while in male brains, pain lights up the frontal cortex, where intellectual processing takes place. As a result, women’s response to pain tends to be more dramatic and raw, and men’s response is more tempered and intellectual, says Tucker.
Why this matters: “The expression of emotion can lead a doctor to discount a woman’s pain experience,” Fidell says. It becomes easy for a physician to label a woman as hysterical. Partly for that reason, the medical establishment may continue to perpetuate the myth that women make up pain where it doesn’t exist and that their pain is in their heads, says Fishman.
The Problem of Ambiguity
Pain is invisible, and people with similar physical signs of damage in, for instance, osteoarthritic knees can have wildly different levels of discomfort, ranging from nonexistent to debilitating. But health care providers “tend to focus on conditions and diseases in which there is an objective test that can show that something is wrong,” says Sean Mackey, MD, PhD, chief of the division of pain management at Stanford University School of Medicine. In other words, many doctors are simply less practiced at dealing with the subjective experience of pain.
Without an objective test for pain, physicians must formulate treatment plans on the basis of their patients’ reports and descriptions. This situation does not serve women well if their doctors believe, consciously or subconsciously, that women exaggerate their discomfort. Here’s one example of how this bias might interfere with adequate treatment, based on a 2008 study in the Canadian Medical Association Journal. Researchers tasked a two-person team, one male and one female, with consulting 71 physicians and presenting nearly identical cases of moderate osteoarthritis of the knee. The two team members suffered from the condition, and both had been deemed candidates for a knee-replacement operation by physicians.