July 21st, 2022
RELIEF News
By Alice Gregorie
What Do These Medical Procedures Have in Common?
(examination of the colon), (examination of the bladder), (examination of the esophagus), (examination of the stomach), and (promotes bladder drainage).
Are these procedures invasive and potentially painful? Correct. Are pain relief and/or anesthetics offered as the standard of care? Yes.
Now, what do the following medical procedures have in common?
(examination of the uterus), (internal imaging), (internal imaging through the vagina), (examination of the cervix), (smear test), , and (or IUD 鈥� for contraception).
Are these procedures invasive and potentially painful? Correct. Are these performed on women? Correct. Are pain relief and/or anesthetics recommended by the National Health Service (in the UK) as the standard of care? No.
Discrimination based on gender in pain, from its management to basic science research, is not a new revelation. In a laboratory setting, both the cells and experimental animals used in research are overwhelmingly male. Many of the reasons given for this phenomenon are practical 鈥� most male animals are not needed for breeding and instead are given to researchers, making female animals more expensive. However, when female cells and animals have been used in research, it has been clearly established that there are in gene expression, protein markers, metabolites, immune responses, and the transmission of pain signals.
Despite clear evidence for sex-based differences in pain, there remain people within the scientific community who still that these differences in preclinical research should not be considered 鈥� that research using both sexes would even . It appears that the convention of discounting female physiology runs deep.
Shockingly, the mandatory inclusion of females in clinical trials in the . This is a relic from the 1960s , where the lack of safety testing in females, particularly in pregnant women, led to the development of fetal abnormalities following the prescription of thalidomide for nausea during pregnancy. The in 1977 that any 鈥減remenopausal female capable of becoming pregnant鈥� be excluded from Phase 1 and Phase 2 clinical trials.
Researchers may claim that women are harder to recruit to clinical trials, making up only , yet Until this is remedied, differences in presenting symptoms in women, and fundamental factors such as drug metabolism, will continue to result in medical inequality. As an example, the recommended dose of zolpidem (an insomnia medication) was based upon male data and subsequently found to be twice the dose females should receive due to
In the context of pain, it was found that upon presenting themselves with acute abdominal pain at an emergency department (and less likely to receive opioids should they be given pain relief) than men self-reporting the same pain at the same emergency department. Women reporting pain are generally taken less seriously than men, are , and before receiving treatment. There鈥檚 been shown to be a (especially in the context of chronic pain), where women are more likely to be diagnosed with psychiatric disorders and prescribed antidepressants, and many women . These issues are highlighted by endometriosis 鈥� an incredibly painful disorder where uterine lining tissue grows outside of the uterus 鈥� which has an , despite 58% of sufferers visiting their general practitioner more than 10 times.
Change on the Horizon?
With a 鈥済lass-half-full鈥� attitude, things have been changing, and for the better. In 2016, the National Institutes of Health (in the US) implemented a policy that requires all grant applications with only a few exclusions being permitted (the cost of animals no longer being an accepted reason to omit females). Since then, sex being considered as a biological variable within studies has become more commonplace, and there is hope that this will help to address the enormous overrepresentation of males within preclinical research (although that the policy still has far to go to address all imbalances). Policies that have been introduced to include gender and sex-related issues in medical teaching have been found to be , with the expectation that there will be medical professionals with a more gender-informed medical knowledge and practice.
What facilitates real change is conversation 鈥� the need to start a dialogue among the public, pain patients, and policy makers. Recently, a campaign in the UK for effective pain relief as a standard of care during IUD insertions and removals gained significant publicity. Previously, the NHS in the UK advised women to take over-the-counter pain relief medications, such as ibuprofen or paracetamol, before any IUD appointment, yet 43% of women surveyed rated their pain as a 7 out of 10 or higher, with some reporting the procedure to be worse than childbirth.
The campaign began after with IUD insertion following an , who called for pain relief to be offered during IUD-related procedures. This prompted many women to share their own stories of intense pain related to the IUD procedure. Campaigner calling for a review of the current guidelines which gained over 30,000 signatures. The result? The Faculty of Sexual and Reproductive Healthcare (FSRH) published advising that, 鈥淗ealthcare professionals should create a reassuring, supportive environment, offer appropriate analgesia … and referral to another provider if they cannot offer this….鈥�
Open conversations can lead to real, beneficial changes for women. More conversations like this need to happen, from the discussion of medical care and the attitude of healthcare professionals to the standard practices of preclinical research. After all, what is the point of researching and developing new pain-relieving compounds if they only work in 50% of the population, and if both sexes don鈥檛 have equal access to their use?
Alice Gregorie is a third-year PhD student at the University of Leeds, UK. Her project currently focuses on pain-based neuronal communication within the peripheral nervous system.