‘It’s not in your head’: Why pain may linger longer in women – even when scans are normal

Women are more likely to experience chronic pain, from migraines and fibromyalgia to endometriosis and painful periods. It isn’t simply about pain threshold. Experts explain why women may be more vulnerable and how persistent pain can be managed.

Studies show that women are more likely than men to experience chronic pain. (Photo: iStock/AsiaVision)

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After covering health stories for more than a decade, many involving women’s health, I’ve noticed a recurring pattern: Women living in significant pain can become very good at enduring it.

One 18-year-old I interviewed had chronic headaches so severe she spent most of her childhood and teenage years “ at home, in pain”. Others have expressed the relief of finally being believed, becoming emotional as they recount their experiences.

A 29-year-old became tearful as she recounted how a doctor finally took her complaints about intense period cramps seriously enough to investigate. It was severe endometriosis, which had invaded her fallopian tube, colon and rectum.

These stories made me wonder how much pain they were expected to put up with, and why persistent pain seemed more common in women.

WHAT NEW RESEARCH SAYS

Research has long suggested that women are more likely to develop certain chronic pain conditions, but the reasons are complex .

A global study published in October in Nature Medicine found that women were more likely than men to report pain across all 11 body sites studied; researchers analysed data from more than six million across 118 countries.

A study published in February this year in Science Immunology suggested that biological differences may explain why pain can take longer to resolve in women. It found that pain resolved more slowly in female mice than in male mice, and identified differences in immune cells involved in switching pain off.

In males, these cells are more active due to higher levels of sex hormones such as testosterone, while females experienced longer-lasting pain because their monocytes – a type of white blood cell in the immune system – were less active.

The researchers also found evidence of a similar pattern in human patients recovering from traumatic injuries.

“The difference in pain between men and women has a biological basis,” lead researcher Dr Geoffroy Laumet from Michigan State University said in a statement. “It’s not in your head, and you’re not soft. It’s in your immune system.”

Endometriosis and dysmenorrhoea (painful menstrual cramps) are among the conditions seen in women that can cause persistent pain. (Photo: iStock/AndreyPopov)

“We see this in Singapore as well,” said Dr Singaraselvan Nagarajan, senior consultant and head of Department of Women’s Anaesthesia at KK Women’s and Children’s Hospital (KKH).

He pointed to a local study that found chronic pain in 10.9 per cent of women, compared with 7.6 per cent of men. Among Singaporeans aged 60 and above, women were 1.8 times more likely than men to report pain.

But Dr Singaraselvan cautioned against attributing this simply to women having a lower pain tolerance.

“Pain is a much more complex biological experience,” he said. “There are differences in hormones, immune and neural pathways, as well as psychological and social factors, that can influence how pain is experienced and how it persists.”

Pain is a “fight or flight response”, said pain specialist and anaesthesiologist Dr Diana Chan, medical director of Advanced Pain Specialists.

When there is acute, intense pain, pain signals are transmitted from the area experiencing pain to the brain, which then analyses the character and site of pain, said Dr Chan.

“The pain signals act as warning signals to help the body move away from the source of the pain or help the brain interpret that something is wrong with the body,” she explained.

Pain warns the body to move away from the source of pain or helps the brain interpret that something is wrong with the body. (Photo: iStock/Silver Place)

The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

The definition has been expanded to include pain as a personal experience that is influenced to varying degrees by biological, psychological and social factors, said Dr Tay Yoong Chuan, visiting consultant and director of KKH Women’s Pain Centre.

Dr Tay is also a senior consultant at the department of pain medicine at Singapore General Hospital.

In other words, pain is more than a signal from an injured body part. Two people with a similar injury may experience it differently.

For example, a bone fracture sends intense pain signals to the brain, prompting the body to avoid moving the injured area. But sometimes, these warning signals can continue long after the bone has healed.

“When pain lasts beyond the period of tissue healing – around three months – and affects daily activities, mood or quality of life, it becomes chronic and may be a malfunction of the pain response system rather than it being protective,” said Dr Chan.

Pain that lasts more than three months and affects quality of life may be a malfunction of the body’s pain response. (Photo: iStock/Sopaphan Romphongoen)

KKH Women’s Pain Centre manages around 100 new and follow-up consultations per year for pain-related conditions, said Dr Tay.

Patients may experience chronic back and limb pain, abdominal pain and headaches, as well as pain following trauma.

Some pain conditions are more commonly seen in women, said Dr Chan. They include fibromyalgia , migraines and tension headaches, irritable bowel syndrome , rheumatoid arthritis, osteoarthritis and female-specific conditions like endometriosis and painful periods.

One of the most frustrating experiences for people living in pain is being told that nothing is wrong, particularly when abnormalities do not show up on scans.

Dr Singaraselvan said: “The first and most important thing is to believe the patient when she tells you she is in pain. We should never dismiss pain simply because a scan is normal.”

While scans can show changes in the body’s structure, they do not measure the patient’s pain experience, he explained.

The first and most important thing is to believe the patient when she tells you she is in pain. We should never dismiss pain simply because a scan is normal.

Research by Dr Singaraselvan and colleagues at KKH’s Women’s Anaesthesia involving women undergoing Caesarean delivery, hysterectomy (womb removal surgery) and breast cancer surgery has found that persistent pain is influenced not only by the original tissue injury.

Other factors, including pre-existing pain, stress, anxiety, pain catastrophising (dwelling on pain and fearing the worst) and individual differences in pain processing, also play a role, he said.

“It is not simply a question of whether someone has a ‘low pain threshold’ or is unable to tolerate pain. The pain is real. The nervous system itself is part of the biology of pain,” said Dr Singaraselvan.

For someone who has been living in pain, being believed can be an important step towards effective pain management.

“I always acknowledge their pain is real so that they feel validated, and explain how pain works in the body,” said Dr Chan. “I also let them know that sometimes a cause may not be found but we need to deal with their pain from a multi-prong approach – not just biologically, but also psychologically and socially.”

HOW MUCH PAIN IS “NORMAL”?

Dr Chan emphasised that there is usually no universally “acceptable” amount of pain.

Scans can show changes within the body’s structure, but they do not measure a person’s pain experience. (Photo: iStock/whyframestudio)

Pain is often measured using a numerical rating scale from zero to 10, with zero being no pain and 10 being the worst pain ever.

“Pain is a subjective experience. A person’s pain score of three may be another person’s pain score of eight,” Dr Chan said.

Doctors may also use a comprehensive history with physical examination and investigations, where necessary, to diagnose the possible source of the pain.

Dr Chan advised seeking medical attention when pain continues for more than three months, has an intensity of more than five, or has no obvious cause.

The same applies when pain is accompanied by red flags such as unexplained weight loss, difficulty passing urine or stools, numbness or swelling, fever, night sweats, progressive weakness or a significant change in everyday functioning.

WHAT PAIN TREATMENT MAY INVOLVE

A holistic, multidisciplinary approach is often used to manage pain. It may involve medical specialists, physiotherapists, occupational therapists and psychologists, among others. (Photo: iStock/goc)

Dr Chan said pain treatment requires a concise and holistic pain management plan involving not just medications and interventions, but also lifestyle changes. Treatment may take weeks to months or even years, she added.

Treatment may take a multidisciplinary approach involving pain or other medical specialists, physiotherapists, occupational therapists, psychologists and acupuncturists, said Dr Tay.

“Management of chronic pain may not obliterate pain,” he said.

Pain may persist even after the initial cause has been treated or may occur alongside other chronic pain conditions. However, a personalised, comprehensive approach would often reduce pain and improve function, Dr Tay added.

To women who feel that their pain has been dismissed, Dr Chan’s advice is to persist and continue to express concerns. Finding the right pain specialist and keeping a pain diary (to track pain levels, symptoms and triggers) can help them communicate more clearly with their doctors.

CNA Women is a section on CNA Lifestyle that seeks to inform, empower and inspire the modern woman. If you have women-related news, issues and ideas to share with us, email CNAWomen [at] mediacorp.com.sg .

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女性更容易患上慢性疼痛，从偏头痛、纤维肌痛到子宫内膜异位症和痛经，不一而足。这不仅仅是疼痛阈值的问题。专家解释了为什么女性更容易受到慢性疼痛的困扰，以及如何应对持续性疼痛。

研究表明，女性比男性更容易患慢性疼痛。（图片：iStock/AsiaVision）

这段音频由人工智能工具生成。

在报道健康新闻十多年后，其中很多都涉及女性健康，我注意到一个反复出现的模式：长期遭受巨大痛苦的女性可以变得非常擅长忍受痛苦。

我采访的一位18岁女孩患有严重的慢性头痛，她的童年和青少年时期大部分时间都“待在家里，忍受着疼痛”。其他一些人则表示，终于有人相信她们，她们如释重负，在讲述自己的经历时甚至激动得热泪盈眶。

一位29岁的女子在讲述医生如何终于重视她严重的痛经症状并进行检查时，不禁潸然泪下。结果发现她患有严重的子宫内膜异位症，癌细胞已经侵入她的输卵管、结肠和直肠。

这些故事让我不禁思考，她们究竟要忍受多少痛苦，以及为什么持续性疼痛在女性中似乎更为常见。

最新研究表明

长期以来的研究表明，女性更容易患上某些慢性疼痛疾病，但其原因很复杂。

10 月份发表在《自然医学》杂志上的一项全球研究发现，在所有 11 个研究的身体部位中，女性比男性更容易报告疼痛；研究人员分析了来自 118 个国家/地区超过 600 万人的数据。

今年2月发表在《科学免疫学》杂志上的一项研究表明，生物学差异或许可以解释为什么女性的疼痛消退时间更长。该研究发现，雌性小鼠的疼痛消退速度比雄性小鼠慢，并确定了参与疼痛抑制的免疫细胞存在差异。

男性体内的这些细胞由于睾酮等性激素水平较高而更加活跃，而女性则经历更长时间的疼痛，因为她们的单核细胞（免疫系统中的一种白细胞）活性较低。

研究人员还在从创伤中恢复的人类患者身上发现了类似的模式。

“男性和女性对疼痛的感知差异是有生物学基础的，”密歇根州立大学首席研究员杰弗里·劳梅特博士在一份声明中说。“这不是心理作用，也不是因为你娇气。而是你的免疫系统出了问题。”

子宫内膜异位症和痛经（月经痉挛）是女性常见的可引起持续性疼痛的疾病。（图片：iStock/AndreyPopov）

“我们在新加坡也看到了这种情况，”KK妇女儿童医院（KKH）高级顾问兼妇女麻醉科主任辛加拉塞尔万·纳加拉詹医生说。

他指出一项本地研究发现，10.9%的女性患有慢性疼痛，而男性这一比例为7.6%。在新加坡60岁及以上的人群中，女性报告疼痛的可能性是男性的1.8倍。

但辛加拉塞尔万博士告诫说，不要简单地将此归因于女性的疼痛耐受力较低。

“疼痛是一种更为复杂的生物学体验，”他说。“激素、免疫和神经通路方面的差异，以及心理和社会因素，都会影响人们对疼痛的体验和持续时间。”

疼痛专家兼麻醉师、高级疼痛专科诊所医疗主任戴安娜·陈医生表示，疼痛是一种“战斗或逃跑反应”。

陈医生说，当出现急性、剧烈的疼痛时，疼痛信号会从疼痛部位传递到大脑，然后大脑会分析疼痛的性质和部位。

她解释说：“疼痛信号起到警告信号的作用，帮助身体远离疼痛源，或者帮助大脑判断身体出了问题。”

疼痛会警告身体远离疼痛源，或者帮助大脑解读身体出现了问题。（图片：iStock/Silver Place）

国际疼痛研究协会将疼痛定义为与实际或潜在的组织损伤相关的或类似于与组织损伤相关的令人不快的感觉和情绪体验。

KKH妇女疼痛中心访问顾问兼主任郑永泉医生表示，疼痛的定义已经扩大，将其视为一种个人体验，这种体验在不同程度上受到生物、心理和社会因素的影响。

Tay医生同时也是新加坡中央医院疼痛医学科的高级顾问。

换句话说，疼痛不仅仅是身体受伤部位发出的信号。即使伤情相似，两个人的疼痛感受也可能不同。

例如，骨折会向大脑发出强烈的疼痛信号，促使身体避免移动受伤部位。但有时，即使骨头已经愈合，这些警告信号仍会持续很长时间。

陈医生说：“当疼痛持续超过组织愈合期（大约三个月）并影响日常生活、情绪或生活质量时，它就变成了慢性疼痛，这可能是疼痛反应系统的功能障碍，而不是保护作用。”

持续超过三个月并影响生活质量的疼痛可能是身体疼痛反应功能紊乱的表现。（图片：iStock/Sopaphan Romphongoen）

Tay医生表示，KKH女性疼痛中心每年处理约100例与疼痛相关的疾病的新发和复诊咨询。

患者可能会出现慢性背部和四肢疼痛、腹痛和头痛，以及外伤后的疼痛。

陈医生表示，有些疼痛疾病在女性中更为常见，包括纤维肌痛、偏头痛和紧张性头痛、肠易激综合征、类风湿性关节炎、骨关节炎以及一些女性特有的疾病，例如子宫内膜异位症和痛经。

对于饱受疼痛折磨的人来说，最令人沮丧的经历之一就是被告知一切正常，尤其是在扫描结果显示没有异常的情况下。

辛加拉塞尔万医生说：“首先也是最重要的是，当病人告诉你她感到疼痛时，一定要相信她。我们绝不能仅仅因为扫描结果正常就忽视疼痛。”

他解释说，虽然扫描可以显示身体结构的变化，但并不能测量患者的疼痛体验。

首先也是最重要的是，当患者告诉你她感到疼痛时，一定要相信她。我们绝不能仅仅因为检查结果正常就忽视患者的疼痛。

辛加拉塞尔万博士及其同事在KKH妇女麻醉科对接受剖腹产、子宫切除术（子宫切除手术）和乳腺癌手术的妇女进行的研究发现，持续性疼痛不仅受原始组织损伤的影响。

他还表示，其他因素，包括既有的疼痛、压力、焦虑、疼痛灾难化（过度关注疼痛并担心最坏的情况）以及个体在疼痛处理方面的差异，也发挥着作用。

“这不仅仅是某人是否‘痛阈低’或无法忍受疼痛的问题。疼痛是真实存在的。神经系统本身就是疼痛生物学的一部分，”辛加拉塞尔万博士说。

对于长期饱受疼痛折磨的人来说，被人相信是有效控制疼痛的重要一步。

陈医生说：“我总是承认他们的痛苦是真实的，这样他们就会感到被理解和重视，并解释疼痛在身体中的运作机制。我还会让他们知道，有时可能找不到病因，但我们需要从多方面入手来应对他们的疼痛——不仅要从生物学的角度，还要从心理和社会角度。”

怎样的疼痛才算“正常”？

陈医生强调，通常没有普遍“可接受”的疼痛程度。

扫描可以显示身体结构的变化，但无法测量人的疼痛体验。（图片：iStock/whyframestudio）

疼痛通常使用 0 到 10 的数字评分量表来衡量，0 表示无痛，10 表示最剧烈的疼痛。

“疼痛是一种主观体验。一个人感觉疼痛程度为3分，而另一个人感觉疼痛程度可能为8分，”陈医生说。

医生还可以通过全面的病史询问、体格检查和必要的检查，来诊断疼痛的可能来源。

陈医生建议，如果疼痛持续超过三个月，强度超过五级，或者没有明显原因，就应该就医。

同样的情况也适用于伴有不明原因的体重减轻、排尿或排便困难、麻木或肿胀、发烧、盗汗、进行性虚弱或日常功能发生重大变化等危险信号的情况。

疼痛治疗可能包括哪些内容

疼痛管理通常采用整体性、多学科综合方法。这种方法可能涉及医学专家、理疗师、职业治疗师和心理学家等。（图片：iStock/goc）

陈医生表示，疼痛治疗需要一个全面而具体的疼痛管理方案，不仅包括药物和干预措施，还包括生活方式的改变。她补充说，治疗可能需要数周、数月甚至数年。

Tay 医生表示，治疗可能需要采取多学科方法，包括疼痛或其他医学专家、理疗师、职业治疗师、心理学家和针灸师。

他说：“慢性疼痛的治疗可能无法消除疼痛。”

即使最初的病因得到治疗，疼痛也可能持续存在，或者与其他慢性疼痛同时出现。然而，Tay医生补充说，个性化的综合治疗方案通常可以减轻疼痛并改善功能。

对于那些感觉疼痛被忽视的女性，陈医生建议她们坚持不懈，继续表达自己的担忧。找到合适的疼痛专科医生，并坚持记录疼痛日记（追踪疼痛程度、症状和诱因），可以帮助她们与医生更清晰地沟通。

CNA Women是CNA Lifestyle旗下的一个版块，旨在为现代女性提供信息、赋能和灵感。如果您有与女性相关的新闻、议题或想法想要与我们分享，请发送电子邮件至CNAWomen[at]mediacorp.com.sg。

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