Women everywhere, especially those with chronic pain, owe Laurie Edwards, a big “You Go Girl!” 

Ms. Edwards is the author of the recent New York Times article The Gender Gap in Pain that exposes an apparently ubiquitous bias in healthcare; that symptoms experienced by women, especially pain symptoms, are mainly due to psychological and emotional causes.  Ms. Edwards, an accomplished author and writing teacher at Northeastern University, is no stranger to pain herself.  She suffers from a rare genetic lung disease for which she endured years of medical pooh-poohing before receiving proper diagnosis and treatment.   In her article for the Times, she candidly discusses the evidence for this pervasive attitude, bringing into the limelight a phenomenon that has been plaguing medicine since before the days of St. Teresa of Avila, a saint and mystic who suffered debilitating pain due to chronic illness.  

Last year Dr. Carolyn Bernstein and I co-edited a textbook published by Springer, Pain in Women: A Clinical Guide with the goal of educating medical professionals about the diagnosis and treatment of pain disorders that exclusively or primarily affect women, such as pelvic pain, vulvodynia, and fibromyalgia.   By dealing scientifically with the underlying biological basis of these conditions, the textbook dispels lingering myths that they are primarily psychological in origin.  Due to its technical nature, Pain in Women will never make the New York Times Bestseller list, but its significance and necessity to the medical community is driven home by Ms. Edwards’ article, which will fortunately reach a wider audience.

My textbook is introduced with a story from my medical school days, one that played a strong role in shaping who I later became as a physician.  The story involves a patient, who came into the Emergency Department (ED) during one of my first clinical rotations complaining of severe, recurrent abdominal pain.  She had been in the ED three times in the last two months with similar complaints, each time having been sent home with some medicine and advice to follow up with her primary care physician.  Her husband, a truck driver, was on the road frequently and she was home alone when the pain started.  This time, she was finally admitted for a diagnostic work-up.  When the resident in charge of my medical team evaluated her with me in tow, she was writhing on the gurney with tears in her eyes, her agony palpable before even touching her belly.   After a cursory examination, my resident took me aside and explained how she was a classic example of the “hysterical female patient”. In his estimation, she was clearly “drug-seeking”, “attention-seeking”, or both, probably due to her husband’s prolonged work-related absences.  The next day, a large cancerous mass was found in the proximal portion of her colon, a location frequently missed in those days by the then commonly performed screening sigmoidoscopy, that only partially imaged the colon, as opposed to a full colonoscopy, the screening test of choice today.

This experience sensitized me throughout the remainder of my medical school and residency training, raising my awareness of how men and women experience and express pain differently, how these symptoms are then interpreted by medical professionals, and how these interpretations may be translated into differing diagnostic testing, recommendations, and treatments.  I wondered at the glaringly obvious biological differences between men and women, and how, despite these, clinical variation between the sexes was hastily attributed to psychological factors.   In studying pediatrics, we learned that “children are not little adults”.  Instead, they require a unique diagnostic and management approach taking into account their developmental stage and how they differ physiologically. Yet, all around me, women were being treated as men, except with different sex organs, their medical “differentness” being either ignored or shunned.  The idea of Women’s Health, now a popular catchphrase in medicine, was an unfamiliar concept at that time.

In 2001, the Institute of Medicine (IOM) issued a report entitled “Exploring the Biological Contributions to Human Health: Does Sex Matter?” that identified the study of sex-based differences in human health conditions as a key area for future research.  These were remarkable recommendations given that prior to 1993 (not so long ago in the history of medicine), the FDA excluded women from Phase I and Phase II clinical trials to avoid potential risks to childbearing potential.  Following this report, in 2007 the International Association for the Study of Pain (IASP) declared the Global Year Against Pain in Women.  The IASP’s consensus report urged pain researchers to study sex-related differences in pain in a controlled and concise fashion to help translate their findings more readily into a clinical setting.

Research in this area has burgeoned over the last decade.  The fact that biologically driven differences in pain exist between the sexes is now accepted by the majority of Pain Medicine specialists.  However, translating this basic science research into clinically useful information takes time.  In addition, attitudes prove more challenging to alter than knowledge.  Unfortunately, many pain conditions that primarily affect women remain poorly understood, and in medicine when a condition or symptom falls into this category, the psyche becomes an easy scapegoat.  We need, not only more research to uncover the mechanisms involved in pain conditions affecting women, but also reform in medical education.  Our future doctors need to learn about pain mechanisms and sex-based differences in pain early on in their medical training when their minds are most open to influence.  For this to happen, more of us need to speak up and speak out, as medical professionals, patients, and the public.  We can’t be afraid to discuss and explore these unpopular and controversial topics. 

This past weekend I was invited to teach second year medical students at the University of New England (UNE) in Maine. The experience inspired me for many reasons. One was that Friday was a gorgeous, nearly 60-degree day and UNE is located near Goose Rocks Beach in Kennebunkport, Maine. The photo is where I stopped for lunch before my talk.

The other, more important, reason was that because of my colleague, Dr. Frank Willard, medical students at UNE are learning about pain and how to manage it early on in their training. I was thrilled to have had the opportunity to lecture on the topic of Pelvic Pain during their Reproductive Unit! 

The students were attentive and eager to learn about unique methods of pelvic pain treatment, such as physical therapy and acupuncture. Having the opportunity to influence developing doctors at a time when their minds are most open is hopeful. By encouraging interest in pelvic health starting early in medical training and across specialties, I believe the treatment of these issues will no longer be left entirely in the gynecologist’s realm.

There is evidence that interest in pelvic disorders is growing in my own specialty, Physical Medicine and Rehabilitation. This month my specialty’s academic journal, PM&R, published a study looking at female athletes and pelvic floor muscle strength (1).  The authors examined 40 women aged 18-30 years of age. 30 of them were athletic (10 handball players, 10 volleyball players and 10 basketball players) and 10 were classified as nonathletic, since they didn't participate in regular exercise. The pressure generated during a maximum contraction of the pelvic floor muscles (the muscles surrounding the vagina and urethra) was measured with a device called a perineometer. This is basically a pressure gauge (see photo) that was placed in the vagina and the women were then asked to squeeze as hard as they could. 

One might guess that the athletic women were better able to generate a pelvic floor muscle contraction due to being fitter and generally stronger. But this study found just the opposite. Athletes, especially those playing volleyball and basketball, involving a lot of jumping, generated lower perineal pressures on pelvic floor testing than nonathletic women.  Also, lower pelvic floor pressures correlated with symptoms of urinary incontinence during sport.  The activities that appeared to put them particularly at risk included the number of games played per year, strength training, and on court workouts, as opposed to abdominal exercises which were not correlated with low pelvic floor muscle pressures.

There has been some interest in this topic from a research perspective with evidence that female athletes may suffer high rates of pelvic floor muscle dysfunction. The risk appears mainly related to the degree of stress put on the pelvic floor muscle during their particular sport.  For example, Bo et al found that 26.3% of female fitness instructors reported urinary incontinence (2), while Eliasson et al found that 80% of elite female trampolinists reported urinary leaking during activity (3). Another survey by Nygaard et al found that 7-38% of women who exercised regularly had problems with leaking (4).

Despite these high rates of urinary symptoms reported on anonymous surveys, female athletes (and women in general) tend to under report incontinence presumably due to shame and embarrassment.  Maybe they talk to their girlfriends, mothers and sisters about this, but apparently not to their doctors. OK, so maybe this has to do with being embarrassed, but there are a lot of embarrassing things patients tell their doctors every day without hesitation. So, why so hush-hush when it comes to urinary incontinence?

Acceptance may be a big part of it. Could it be that women are indoctrinated at young ages to accept urinary incontinence as just another female annoyance?  Certainly, this seems to hold true for older women or those who have born children.  The “what do you expect, you’ve had x-number of children attitude”. Does this start so young that even female athletes accept urine leakage as a “normal” part of athletic participation? If so, that’s too bad. Excellent, non-surgical treatments for urinary incontinence do exist.  In another study, strengthening of the pelvic floor muscles was shown to be effective in reducing symptoms of urinary incontinence (5).  

Although pelvic floor physical therapy remains a less popular career choice for physical therapists, The American Physical Therapy Association (APTA) is working to change those statistics. Increasing effort is being dedicated toward recruitment of physical therapists into the field of pelvic health. Hopefully, we will see a rise in readily available treatments for urinary incontinence with awareness starting even at young ages in female athletes and non-athletes alike.  After all, why accept symptoms as “normal”, when good treatments exist? The talk with a clinician may be well worth the initial embarrassment!

1. da Silva Borin LCM, Nunes FR, de Oliveira Guirro EC. Assessment of Pelvic Floor Muscle Pressure in Female Athletes. PM&R 2013; 5:189-193.

2. Bo K, Bratland-Sanda S, Sundgot-Borgen J. Urinary incontinence among group fitness instructors including yoga and Pilates teachers. Neurourol Urodyn 2011; 30: 370-373

3. Eliasson K, Larsson T, Mattsson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports 2002; 12: 106-110

4. Nygaard IE, Delancey JOL, Arnsdorf L. Exercise and incontinence. Obstet Gynecol 1990; 75: 848-851

5. Bo K, Hagen B, Kvarstein B, Larsen S. Female stress urinary incontinence and participation in different sport and social activities. Scand J Sports Sci 1989; 11: 117-121

An article on last week’s cover of the New England Journal of Medicine caught my eye. I have to admit that the topics covered here sometimes make me yawn, for example Four-Year Efficacy of RTS,S/AS01E and its interaction with Malaria Exposure (ok, I’m really glad there are smart doctors out there who know what this means, but its just not for me).  This one, however, was worth the read. The study was performed to address the question of the usefulness of MRI in helping to figure out why some patients treated for sciatica (pain radiating down the back of the leg) improved after treatment and some didn’t. 

The researchers (NEJM 2013;38:999-1007) report on a study of 283 patients from the Netherlands who had suffered with 6 to 12 weeks of sciatica and had a confirmed disc herniation on MRI. Patients either received early disc surgery or “prolonged conservative care” (such as medications and physical therapy). After one year, all participants underwent a follow up MRI and were questioned about their recovery.  84% of study participants reported a favorable outcome (hey, that’s pretty good). But, interestingly, their MRIs looked terrible. In fact, 85% of this group (this is the group with favorable outcome) had evidence of ongoing disc herniation and nerve root compression on their MRI, regardless of which treatment they received, surgery or conservative care.

Even more stunning were the participants with favorable outcomes whose MRIs showed evidence of scar tissue wrapped around the nerve where the surgery was performed. Of the 170 patients who underwent surgery, 88% had visible scar tissue on MRI and of these, 96% had scar tissue surrounding the nerve root, and yet 86% reported favorable outcomes. This compares to only 75% reporting favorable outcomes in the surgical group without evidence of scar tissue formation.  Huh?

Of course, this is far from the first study to show the lack of correlation of MRI findings with patients’ symptoms.  A seminal study by Jensen in 1994 showed that if you evaluate 100 individuals who have no pain or other symptoms with an MRI of their lower back, only 36% of those had normal MRIs.  The rest (the other 63% of those with no pain) had disc bulges and protrusions (Jensen, NEJM 1994;331:69-73).

When physicians evaluate patients who have had poor outcomes after disc surgery or who have back pain and sciatica to begin with, they often look to the MRI for an explanation of symptoms or for lack of improvement.  After surgery, scar tissue around a nerve root, in particular, is often used to explain ongoing pain.   This study strongly suggests that this finding could be completely unrelated to the pain.  Of course, then the question is; how do we discover the cause? I believe the answer lies in the physical examination, a nearly lost art in medicine these days.

As healthcare professionals, we have become overly reliant on technology, in general, losing touch with the finely honed physical exam skills that our predecessors relied on exclusively. Many patients with back pain and sciatica get treatment recommendations for conservative care, injections or surgery based completely on their MRI findings. So-called “abnormal” findings on MRI are thought to validate their pain.  Meanwhile patients with relatively normal MRIs, are often told that there is “nothing wrong”, the suggestion being that their pain is wholly psychological. Patients lose in both scenarios. What is really needed is a careful musculoskeletal and neurological examination to uncover the root source of pain.  I believe the answer is often there, if we are only willing to look.  

What a way to start a blog! Full of inspiration and motivation, after spending three days at the Harvard Writers Course, surrounded by other healthcare professionals with book ideas they want to publish. My life is changed – already – because of it.  Yes, I got to pitch my book idea (more on that later) to an incredibly talented and supportive group of writers, literary agents, and editors.  I am incredibly appreciative of the constructive criticism I received and all that I learned about the nitty-gritty of the publishing industry. With Dr. Julie Silver (www.juliesilvermd.com) as the course director, I expected nothing less. But, I never imagined the personal fulfillment I would get from my contact with the course participants. Of all the benefits of this course, I value this experience most highly. During the oral book pitches and in the small group sessions, I heard stories of courage, survival, innovation, wisdom, and hope. In this time of managed care and increasing focus on productivity in the medical workplace, it can be easy to feel alone in my desire to simply help and to heal. This weekend I was not alone, but surrounded by hundreds of others who want to change the world, one sentence at a time.