Sex and Gender in Relation to a Chronic Pain Disorder

“We now know that women’s pain is treated less aggressively and less promptly in the ED.”

By Barret J. Zimmerman, MD and Alyson J. McGregor, MD, MA, on behalf of the SAEM Sex and Gender in Emergency Medicine Interest Group

Pain is one of the most common inflammatory markers are significantly We now know that women’s pain presenting complaints to the emergency increased in both the acute and chronic is treated less aggressively and less department (ED), and in light of the opioid phases of the disorder; therefore, it promptly in the ED. The authors suspect epidemic, increased attention is being has even been suggested that early that this phenomenon is exaggerated paid to individualized pain treatments identification and treatment with anti- in those patients who are returning for based on the underlying causes of inflammatories may be able to prevent the same symptoms regularly, as would pain. One of the most fundamental this disorder. Although diagnosing be the case in a patient with CRPS. individualizing factors easily garnered CRPS is purely clinical, and some tests This is despite higher rates of chronic about a patient is their biological sex and correlate, it should be noted that even pain conditions and more sensitivity to current gender identity. Men and women in a patient with normal inflammatory acute pain among women. CRPS is one have different physiology, psychology, and markers, a diagnosis of CRPS must still of many chronic pain disorders which socialization affecting the manifestation be considered. can be differentiated from one another of pain. One important sex difference involves the role of sex hormones in modulating pain, specifically the protective effect of estrogen on pain, which occurs through upregulating opioid receptors and the release of endogenous opioids. This could help explain why many conditions manifesting predominantly as chronic pain become more prevalent after menopause, less prevalent with pregnancy, and why differences in pain sensitivity between genders become As mentioned, the diagnosis of CRPS is clinical, and the Budapest diagnostic criteria is often used in order to make the diagnosis. This disease of disproportionate pain in an extremity must also be accompanied by a certain number of other signs and symptoms, which may include swelling, changes in nails, skin, hair, or temperature, changes in motor function, and allodynia. It usually occurs in the arms, classically is more distal than proximal, typically occurs after trauma (most often fracture), does not largely by a careful history and physical examination. Every effort should be made to explore possible diagnoses and explanations of any patient’s pain, bearing in mind the sexually dimorphic physiology of pain and the changes in chronic pain conditions that correlate with fluctuating hormone levels. Clinicians should be familiar with the diagnostic criteria for CRPS, aware of the physiology and epidemiology of this and other similar chronic pain disorders, and be on the lookout for this uncommon disorder. more pronounced after age 12. follow an anatomical distribution from One such condition, complex regional pain syndrome (CRPS) is at least three times as common in women, predominantly post-menopausal women. Researchers believe the reason females experience higher levels of chronic pain disorders and greater pain sensitivity in general is rooted in the a single nerve or spinal segment, and can spread over time. It can be acute or chronic and can persist for years. In addition to an increased likelihood of initially developing CRPS, females are more likely to have symptoms persist beyond one year from the inciting incident. ABOUT THE AUTHORS Dr. Zimmerman is a PGY-1 in the Brown Emergency Medicine Residency Program interplay between the immune system Treatment for CRPS involves patient and certain sex hormones, including education, physical therapy, occupational Dr. McGregor is an associate androgens and estrogen. (Ann Ist Super therapy, psychosocial assessment, and professor of emergency Sanità, J Neurosci Res) Immune system pain management with low-risk agents. medicine in The Warren Alpert activation appears to have a central role Treatment failure and expanded options Medical School of Brown in the pathophysiology of CRPS as well; include various other modalities, including University CRPS is believed to occur because of interventional approaches. In cases of an inflammatory response after physical delayed diagnosis, treatment is less trauma which leads to a cascade of effective. nervous system changes. Certain