• In the ER, women wait longer than men before receiving analgesic pain medication for acute abdominal pain and are less likely to receive opiates for equivalent levels of pain [5].
• Women report higher postoperative pain scores than men but often receive less pain medication [6].
• Support for chronic pain is often limited. For example, in Ontario, the median wait to get into one of the few available pain clinics is 6 months and can be as long as 4-5 years [7].
• Women experience longer delays in diagnosis for chronic pain conditions [8].
• Women are given fewer opioids after cardiac surgery, despite comparable levels of pain [9].
• Women suffering from acute pain are given sedatives rather than pain management more often than men, are referred for imaging less frequently, and are prescribed lower doses of opioids and analgesics [1, 10].
• In a study of men and women over the age of 65 with complex cardiovascular-metabolic multimorbidities, women were more likely to be prescribed potentially inappropriate medications such as antidepressants and sedatives and were less likely to be prescribed pain drugs [11].
• Many surgical procedures, such as cervical and endometrial biopsies and IUD insertions, are performed on women without adequate information on the level of pain involved, or the offer of anesthetics. In fact, the issue of IUD insertion pain and lack of informed consent became such a hot topic on TikTok in 2023-2024 that it prompted a critical analysis of the tone and messaging in a peer-reviewed publication [12]. The combination of social media pressure and a key obstetrics and gynecology journal taking notice was likely instrumental in the CDC updating standard of care guidelines in 2024 to recommend the use of  local anesthetics for IUD placement.

In the face of chronic pain, the situation is particularly onerous when a woman’s only definitive symptom is pain and diagnosis is uncertain. In these cases, women often get labeled as malingering, drug-seeking or in need of psychiatric treatment rather than pain management [4].

Unfortunately, women are disproportionately affected by pain from fibromyalgia, arthritis, IBS, and neuropathologies [3,13,14,15], and of course face pain that men never can experience from endometriosis, interstitial cystitis, vulvodynia, ovarian cysts, and rare and potentially life-threatening conditions like ovarian torsion and ectopic pregnancy.

The face of pain can be deceptive. Women with chronic conditions like endometriosis and fibromyalgia have mastered the ability to appear composed while enduring pain levels that would bring others to their knees [16]. Just watch the videos of men vs women wearing “period cramp simulators”– while these demonstrations may be humorous to some, our extraordinary resilience, born out of necessity, becomes a double-edged sword in medical settings. Women’s ability to function through devastating pain (out of necessity) paradoxically undermines their credibility. Medical professionals see a patient who can walk and talk, while beneath the surface, the woman is in agony.

Pain scales are based on 0 being “no pain” and 10 being “the worst imaginable pain”. When a level “10” for a woman on the pain scale is experiencing a forceps delivery without anesthetic, debilitating back pain would come in at level “8”, yet a man would likely rate the same back pain as “unimaginable” (aka 10+). She’s actually feeling MORE subjective pain, but relative to other experiences like endometriosis, she will underrate it. This cruel paradox perpetuates a cycle where women’s experience and remarkable adaptation to chronic pain are used as evidence against them, casting doubt on their suffering rather than highlighting its severity. There is a terrible irony in the fact that women have lower pain thresholds and report pain more frequently than men [14], but are better able to hide it. When a woman tells a doctor the pain is unbearable, it isn’t a plea for attention – it’s a desperate signal that something is profoundly wrong.

Sadly, pain treatment is yet another area where decades of preclinical research conducted primarily on male animals has profoundly impaired the development of more effective pain management for women. Recent work analyzing mechanistic studies of both acute and chronic pain and analgesic treatment on animals of both sexes has found that in 72% of cases, treatments only worked on males [2]. Recent research in humans supports this. Using an elegant study design to investigate how internal pain-control mechanisms are engaged in men and women, researchers found that men leverage the body’s internal opioid system for pain relief, but women do not [17]. This may explain why women have reported higher post-operative pain scores despite receiving the same level of opioid treatment as men [18]. Women also report more side-effects form opioid medications, likely due to sex differences in liver enzyme expression that impact metabolism [19].

Pain is complex, spanning an entire multifaceted field of study from physiology to cognition. Factors that intersect with sex, such as age, hormonal status, duration and type of pain, mental health, duration of treatment and personal control over dosage can all impact treatment efficacy. For example, when women can self-administer morphine for pain control they tend to use less than men [20], highlighting how a sense of self-efficacy can alter our perception of pain. These findings underscore the urgent need for more inclusive research practices and a deeper understanding of how the full spectrum of sex differences and environment interact to influence pain perception and treatment outcomes. They also emphasize the importance of patient-centered approaches that actively involve patients in treatment decisions: when we feel empowered, we are better able to cope with pain.

For many women, challenges in obtaining effective pain treatment are compounded by intersecting forms of discrimination in healthcare, where women (and particularly those from marginalized groups) are disproportionately dismissed or misdiagnosed. In our next article, we will explore how intersectionality impacts treatment in healthcare systems and examine the phenomenon of medical gaslighting, a troubling practice that leaves many women questioning their symptoms, their reality, and their worth.

References

 [1] P. I. J. Musey et al., “Gender differences in acute and chronic pain in the emergency department: results  of the 2014 Academic Emergency Medicine consensus conference pain section.,” Acad. Emerg. Med.  Off. J. Soc. Acad.  Emerg. Med., vol. 21, no. 12, pp. 1421–1430, Dec. 2014, doi: 10.1111/acem.12529.