Why do women make up 70% of chronic pain sufferers? The answer involves more than just biology. Dr. Megan and Holly examine how hormones, pain thresholds, and social conditioning create vastly different pain experiences for men and women.

You'll discover:

1. Why pain thresholds change dramatically at puberty and menopause
2. How testosterone acts as a buffer and estrogen fluctuations trigger pain
3. Insights about that viral study where men couldn't last through simulated labor pain
4. Why menstrual pain is chronically underreported (and how that leads to worse outcomes)
5. How memory and pain are linked through estrogen receptors in the brain
6. What happens to transgender individuals' pain perception during hormone therapy

Holly and Dr. Megan also tackle the social costs of pain - from women hesitating to report debilitating cramps to men feeling pressured to "gut it out" - and why finding a practitioner who asks about your full pain experience matters.

The good news? Pain is malleable, and there are evidence-based approaches that can help.

Links to interesting things from this episode:

1. Dr. Jen Gunter, website

I can't name anything specific about it, but I think it might jog something in your memory that you've probably seen as a pain scientist.

The study that put men under the conditions to experience birth pains, labor pains, and I heard or, you know, sort of read the headline that these guys lasted like six seconds. I mean, they didn't even stay on as long as it as like a bull riding. Like, they didn't even cover the bull. They didn't make it to eight seconds.

They just got bucked off the table.

I'm sorry to laugh, but it's, you know, considering what women go through with childbirth, it's just kind of hilarious that, you know, six seconds they were like, yeah, you know, they just had to come right off. So do you think that's because that's a kind of pain that they're not used to experiencing?

Whereas if it were, you know, the calf muscle or a shoulder or something, is. Is that because it's like, whoa, this part of my body is not experienced with this.

Welcome to Unpacking Pain, a podcast dedicated to understanding the complexities of chronic pain, what causes it, how it affects our lives, and what we can do about it.

Join doctor of physical therapy and pain science researcher, Dr. Megan Steele, and me, Holly Osborne, a chronic pain sufferer, as together we explore the biological science, psychological and social aspects of chronic pain and create community and understanding in the process.

Nice to see you, Holly.

You too, Dr. Megan.

Excited for today's topic?

Yeah, me too. In fact, you might be able to help settle some debates we're having around the household.

So last time we got together, we were talking about social media construct and how it's such a big part of how people experience and talk about their pain. And a big piece of that that we've been looking forward to unpacking here is around gender, which is largely a social construct.

So kind of makes sense for us to talk about it in here.

And the debate that's been raging around our house is my husband and I will come home from, like, the same workout, and let's say we both got, you know, the same hamstring problem, and we are experiencing the pain very differently.

And it's not just that my pain is higher or lower, but the way the pain impacts us and the way we talk about or don't talk about the pain is very different. And I've.

I've talked to lots of other couples where, you know, there's a male and female in the couplehood, and they are talking about how pain feels very different for the one will complain and one just refuses to talk about it.

So I want to hand it over.

To you to help us understand, first of all, are biological men and biological women, except experiencing pain differently to begin with?

Yes. Short answer. Yes.

And I think it is important for us to give the caveat here, the disclaimer, that when we say men and women or male and female, in this podcast today, we're going to be talking about people who are born as a biological man or a biological woman, because the biology of their hormones and their pain perception is that and, and follows that pattern. We will talk a little bit about gender and you know, as you mentioned, it is a social construct and that also plays into things here.

So typically in Western society, men are taught that they are meant to be tough and strong and not have a large exposure expressive experience around pain, because that then maybe somehow diminishes their level of manhood or toughness and things like that. So conditionally, socially, most men in Western society have been conditioned to have a more stoic response around pain, and that's not always true.

Like we talked about last time in the social component of pain talk, that there are some cultures that tend to be more expressive with pain versus others.

And so if you're a man from an expressive culture and you're married to a woman from a non expressive culture, you may have, you may see the man in that relationship be the person who's more expressive about their pain experience.

So is that from childhood? Even if you grew up in a family, let's say that was, was a little bit more forgiving of or, you know, more nurturing around pain?

Could that social sort of expectation just come from school, from a teacher, from a coach?

Pain is, number one, an individual experience. So we're all experiencing it very differently from each other, and that's normal. And typically we learn about pain.

So pain is also a learned response. And we tend to learn about it most from our primary caregivers.

We can learn about it from other adults in our life as we're growing up, but we're most influenced by our primary caregivers, which is true for a lot of other things too, right?

And so when we see our primary caregivers being either very expressive or very stoic about pain, or you've probably seen children on a playground that fall and then they look back to mom or dad to see, you know, how should I be responding to this? So we learn based on how they respond to their own pain, but we also learn based on how they respond to our pain.

And so all of those components play a role in how we experience and express pain in our day to day lives.

Okay, so guys are for the most part conditioned really from, you know, society, at least western society is like you kind of said, you know, get, get back up there tough guy, you know, shake it off, walk it off. And I mean that's, that's kind of the expectation in sports and I think, you know, to certainly for, for female sports as well.

But I think it's really, you know, like you're almost, it's a badge of honor as a male if you've been injured and you've kind of worked through it.

Right.

Like that's the smart, tough kind of thing to do. And I've got guy friends and my husband says I'm just going to gut it out. Which sounds deeply unhealthy.

Agreed. Yeah, rub some dirt in it, walk it off.

Yeah, you hear these things all the time from certain males and then, you know, there are females that are participating in very high level sports these days and you hear sometimes similar things from them.

And it's really interesting when we think about them and when they've studied people in pain, they tend to study people who have a maladaptive experience experience or who have a great deal of pain or have a higher level of sensitivity to pain. But the other end of that coin, athletes are also very interesting to study because they have what we call conditioned pain modulation.

So they've experienced enough pain that they have a different type of a relationship with pain. So oftentimes they don't have, have a lot of fear around pain, which is good and bad.

So a lot of times they'll say, you know, this is just par for the course. This is something I've experienced many times before and you know, it's not a big deal. I'm not going to sound the alarm about it.

And for some athletes or former athletes, they let things go too long because of that, because they have a relationship with pain.

Particularly I, this is just anecdotally in my experience, dancers have a very almost positive connection with pain where they're like, yeah, this means you're doing it right or something.

And I'm hardcore and I don't give up.

And I, yeah, it's hard to get them not to have a pain and feel okay with it. It's hard to get them to kind of reel things in a little bit.

And do you find in your physical therapy practice that men and women, again, biological men and biological, when they come in Born biologically. Do they come in and sort of talk to you about their pain differently? Like, let's say you're doing a new patient assessment.

Do you find that there's a big difference in just how to get your male patients to really come out with it and really talk about your. Do they tend to kind of minimize or what's your experience. Experience with that in your practice?

Yeah, again, it really depends on the individual, but by and large, I see primarily female patients in my practice because I am a chronic pain specialist. And the numbers in terms of prevalence, women suffer from chronic pain at 70% of the time. So 70% of the chronic pain population is made up of female.

And we don't know exactly why, but we know that hormones likely play a role. And so we think that for a couple reasons. One is men and women or boys and girls have similar pain thresholds. Meaning I'm going to push on you.

Typically, you do it with pressure. You can do it with temperature and chemicals and other things.

But.

But typically they'll do a pain threshold test with a certain amount of pressure and they'll measure the amount of pressure that they are pushing on you, and they'll say, let me know when you start to experience this as painful. And that measures your pain threshold. And boys and girls up until the age of puberty tend to have very equivalent pain thresholds.

Then women's pain threshold goes lower throughout most of their menstrual cycle.

There is a little bit of time after ovulation, around ovulation, where women tend to have a little bit of a higher pain threshold or at least equivalent to men. Excuse me. Okay. And then the other time is after menopause.

So once someone is fully in menopause, their pain threshold goes back to being equivalent with men again. Okay.

So I got that. To look forward to at least one benefit of aging. All right. Okay. So appreciating that, it is really down to the individual, but the numbers don't lie.

And the 70% number is pretty staggering. You said there's no kind of clear answer, but hormones play a big role. I think that's super interesting to know. But what about for men with.

They've got hormones too, right? I mean, I know that sounds so silly of me to say they, you know. So what about testosterone?

Is that also since we have so little of it as biological women, do men get a boost from that?

Yes. And so men have hormones, too, believe it or not. Yeah.

What, they. Even if they, like, pretend they're not hormones?

Yes, exactly. Well, what they don't have. Are these large fluctuations multiple times throughout each month.

And so men have estrogen, men have testosterone, women have testosterone. We've sort of genderized estrogen and testosterone a lot in our society.

But men and women have both of those things, just in different quantities and in different fluctuations. So certainly men have more testosterone, and they tend to have more steady levels of testosterone.

And that 10 tends to be a buffer to things like pain, and that contributes to their higher pain threshold.

Okay, so they. They can tolerate it a little bit. They have a higher tolerance. Right. And. And can they go longer with it, too? I mean, is. Is that part of the.

The endurance around pain? Is that not just like the. The depth of the pain, but also then how long it sticks around?

Sure. So I think what you're talking about is the tolerance and pain threshold. So those are two different things.

And so pain threshold means when do you start to experience this as painful? And pain tolerance is, okay, I'm going to continue to push until you say, I cannot tolerate anymore.

So, for example, if I push down and I'm pushing down with 40 newtons of force, and you say, ouch, then I say, tell me when I have to stop, and you get to 80 newtons of force before you say, uncle. There. There was a time when the research was showing that women had a higher pain tolerance, whereas men had a higher pain threshold.

But now what we're seeing is more research is coming out. It does seem like men do have a higher pain tolerance and pain threshold.

Okay, so we know hormones are playing a big role, but can I ask you, Dr. Megan, what have we learned or found for transgender individuals? When someone has transitioned from male to female or female to male, do we see that their biological. What they.

The.

The biological sex of which they were born continues to determine how they experience pain? Or now that they're experiencing hormone treatment, does it all change?

So this research is pretty early in its. In. It's not in its infancy, but maybe in early adolescence. And so they have not been looking into this for.

For decades and decades, like other things.

But what they're finding with at least rats, because oftentimes they'll do research on mice and then rats and then, you know, hire primates and things like that.

But what they're seeing is that when transgender men are given testosterone, their pain threshold improves, so it increases much to similar to biological men, but it's not true in all situations.

So when they go for things like cervical cancer screening, they have increased pain levels, and that may be due to A triggering of a gender dysphoria because of their anatomy, that their anatomy that they were born with. And so here again we're seeing the complexity of pain. It's not the same for every individual and it's not the same in every situation.

And hormones cannot be just universally applied and thought, oh well, this is just going to be kind of the catch all or the fix all or the change all of anything.

Right? It's not like a light switch where you're either one or the other.

It's going to become a confluence of factors and become, okay, you know what, that actually, you know, I don't want to vilify all the stuff flying around on Instagram.

Some of it maybe is valuable, but this is, it just goes to remind us that what people are saying they can't live without what people are touting as the magic bullet, it is. You've really got to figure out what's right for you individually and not feel like you're falling behind because you're not doing this protocol.

It's, you know, I, every day I'm on there and it's like, whoa, I screwed up another thing. I'm obviously, I'm not getting any creatine.

Or you're not eating colostrum, or you're not eating, you know, twice your body weight and protein every day or fiber.

Or like snake semen. I'm not like rubbing snake ejaculate all.

Over my, you know, that's, that's coming. Wait for it.

It'll be the most expensive ounce on the market. But yeah.

So I think, and that must really enter your consciousness a lot as a practitioner, because not only as a pain scientist, but also as a hands on physical therapist. You see every day the fact that things can't be put in simple boxes.

They cannot. They cannot.

And I just had somebody this morning send me their screenshot from ChatGPT that said they needed an MRI and they wanted to know, do you, do I need an mri? And it's, you know, it's, first it was Google, then it was WebMD, now it's ChatGPT. There's always going to be misinformation out there.

And you know, practitioners are licensed for a reason. We go through decades of education for a reason. We have board exams, we have licensing boards, we're accountable for misinformation.

You know, all of that actually matters. And unfortunately, sometimes you don't know until you know. And practicing medicine, practicing physical therapy, these are individual sports.

And what works for your neighbor, husband, brother, cousins, uncle, sister, nephew is not always going to work for you.

I think that is such a healthy reminder because it's easy to get caught up in almost a self incriminating blame game when your pain is extended and you feel like you need to clean it up. You got to get it, you got to get this wrapped up, you got to put this behind you.

And, and so in an effort to accelerate that process, we start looking elsewhere. You know, what's she doing, what's he doing? What are they quote unquote, they doing out there?

And while there's a lot of merit and there's a lot of help out there, I think we have to just be really take it a pace at a time.

Talk to your practitioner, talk to your version of Dr. Megan or find a practitioner and bring like that chat GPT screenshot, you know, to them just like your MRI requester did. But I think it's just a good reminder you're not falling behind, you're not failing to take all the right supplements.

You know that you have to work, walk this journey a step at a time, do some experimentation and be willing to do that along the way. It requires patience, which I know is.

Hard, but it's, it can be. Yeah, absolutely. You know, it's.

I can't help but think to this study that I can't name anything specific about it, but I think it might jog something in your memory that you've probably seen as a pain scientist. The study that put men under the conditions to experience birth pains, labor pains.

And I heard or, you know, sort of read the headline that these guys lasted like six seconds. I mean, they didn't even stay on as long as it as like a bull riding. Like they didn't even cover the ball. They didn't make it to eight seconds.

They just got buffed off the table.

And I'm sorry to laugh, but it's, you know, considering what women go through with childbirth, it's just kind of hilarious that, you know, six seconds they were like, yeah, you know, they just had to come right off. So do you think that's because that's a kind of pain that they're not used to experiencing?

Whereas if it were, you know, the calf muscle or a shoulder or something, is, is that because it's like, whoa, this part of my body is not experienced with this?

It may be. And part of the problem with simulating menstrual pain or birth pain is that men don't have a uterus with which we can stimulate painfully.

And so this is Actually, an area of research that I am currently involved in where we're giving a pain stimulus to a visceral organ and we're looking at behavioral responses. I'm only looking at it in women. And so I'm comparing groups between women who have pain during menstruation and those that don't.

So part of the problem when we, when we ask a man to experience a quote unquote labor pain or a menstrual pain is we don't have a uterus with which to stimulate. Right. And. And so they tend to use electrical stimulation, which is on the surface of the skin, which is the closest we can get.

It's kind of a proxy for that. And yes, they do not tend to last very long.

There are also hilarious videos where, where they're doing it with men and they're having them do like daily tasks and sort of like washing the dishes and then they get a pain and the, you know, the soapy water goes flying and everybody's screaming. But yeah, so, so part of the, part of it is that pain is a learned response. Right. So I learn about pain from previous experiences.

And if I'm a dancer who's normalized pain in my body or, or I'm a woman who experiences menstrual pain every month, I've sort of normalized that as well. That may allow me to tolerate more of it before I say, okay, I need help here. I need uncle. I'm going to call uncle.

I'm going to reach for the aspirin or the Advil or whatever it is. And part of that too goes back to that kind of social conditioning piece. And menstrual pain is a really big. It's a mind bleep. Yeah.

And because there are, there's like the bookends of it where it's sort of like it's dismissed as like, everyone has that, don't talk, don't talk about it. Why are you even bringing that up? We're all in pain once a month and excruciating. And why are you even bringing it up?

And then there are people on the other side that say, oh, that's so taboo. How dare you? And we don't talk about that. And you know, so as a result, the numbers, the prevalence of menstrual pain is 40 to 90%.

I cannot think of anything else in research that has that broad of a prevalence which tells you, like, we don't really know how many people are suffering with this. Like, there's a 50%, like, error rate in the prevalence here, that's a problem that tells you that we don't know.

And part of that has to do with the fact that it's really underreported. Yeah, I.

You're hitting on something that fascinates me, really. I mean, there's. There are so many layers to that because there's the sort of social stigma around it. I mean, certainly not.

Not traditionally women with each other, but if you were in a situation where you had debilitating menstrual cramps as a female, you might think twice before mentioning to your boss that you're in too much pain to work today, whereas you had twisted your ankle that morning coming down your stairs, or you are experiencing an acute migraine. You know, for the most part, people wouldn't hesitate. They'd say, hey, boss, you know, man or woman, this is what's happening.

But I found even when I've had debilitating menstrual cramps and was reporting to a female manager, I still didn't mention it because of the other part of what you said where there's just expected. It's like, hey, this is your lot in life. Suck it up. Yeah.

And haven't you learned to deal with this yet?

Exactly, yes. You've had, you know, X number of years to get this under control. Why isn't it under control?

The other side of that can be very problematic because you're twice as likely to experience chronic pelvic pain if you are someone who has painful menstrual cycles.

And so there's the other aspect of learning that your nervous system experiences when you've had pain, where it takes less and less stimulus each time that you have a pain in order to send the signal or sound the alarm. I like to say, for. We're thinking about our pain as a kind of an alarm system.

And so over time, it takes less and less stimulus for your body to have that same alarm response. And now your body's responding to very minor changes in pressure or tension or even anticipatory pain.

There's a thought that your hormone levels can be an interoceptive trigger, that your body says, okay, we're doing that dip in hormones right before the menstrual cycle. I know what that means. And so then your body sounds the alarm. This is just a theory. This hasn't been proven yet.

This is part of what I would like to look into in my research. Because we know that pain can occur. We can experience the sensation of pain in anticipation of pain.

We don't even have to have an actual tissue damage.

We don't actually have to have the contraction of the uterus and the increased prostaglandins, which are thought to contribute to people who have increased pain. Yeah, that's that.

I was actually thinking about that in the dentist chair yesterday, and I was channeling you and trying to talk my brain out of anticipating pain. Because there's always one spot.

We, most of us have at least one spot, one tooth, one section of gum that's a little bit more nervy, maybe a little bit more sensitive. And read when the dentist or the hygienist is going to go over that one piece, that one part. And I could feel it coming.

You know, she had her scraper two teeth over. She wasn't in the bad spot yet, but I was already tensing up. I was already dreading it and ready to kind of yelp.

And sure enough, when she hit that, it was almost, you know, like starting a song. Like, you can't stop the music. Like, it is now going. And it is reverberating through my brain.

How come it doesn't work the opposite with our menstrual periods as women when this is happening every month? How come we're just not getting used to it? It's like instead we're sort of like we're ready for it. Right. Like you said, the brain, the interoception.

Am I saying that right?

Yeah, our interoceptive nervous system, which is the nervous system that kind of like scans and monitors your internal environment and gives you information about that. Yeah, I think. I don't know that we have a hundred percent answer on that yet, but we have a negativity bias.

We all are biased towards negativity and especially in terms of pain, because it's part of our survival mechanism.

Okay, Yes, I remember that now. You taught us that in the first episode, actually. Yeah.

It goes back to the purpose of pain. And oftentimes people think like, can't you just burn it out and. Or cut it off and.

But we know from things like phantom limb pain that even if you do cut it off, you may not be pain free afterwards.

So part of our survival depends on our ability to sense and relay signals from our nervous system to our brain that tell us, hey, I need a little attention here. Part of the hard part in our Western society is that most often we associate pain with damage. And that's really true in an acute pain situation.

Like you mentioned, the ankle sprain, you're going to have swelling, you're going to have Bruising, you're probably, probably going to have a little bit of micro trauma on the ligaments, maybe even the muscles in the area, and that's going to send a pain signal. And that's normal. It's normal for about six to eight weeks. And that's how long tissue healing takes.

And if it goes on longer than that, then you say maybe there's something else going on.

And would you say that at that point, at that six to eight week. Mark. Week, Mark, more women, based on what we're seeing in the studies, more women are likely to continue on that pain journey.

Right.

Versus men, who are more than likely either going to not experience it or at least just not report that their pain has continued beyond that six to eight week mark, Is that right?

Right. I mean, certainly if we, if they're not reporting, they're not presenting to healthcare, we can't measure them, but yeah.

So about 30% of people do not recover. They continue to have pain. And so Those are the 30% with an acute injury that will continue to have pain. And of those 30%, 70% are women.

It's really interesting to me how men are almost expected to, you know, to kind of push past something that's totally physiological. But then again, to be fair, so are women all the time.

I mean, just back to having debilitating menstrual cramps, and you're still still supposed to present, you know, to the board, or you're still supposed to discipline an employee, or you're still supposed to treat your patients or paint that day or whatever it is that that is your occupation? Right. Do you.

Yeah.

Like, do, do women. Is it that we're not also giving ourselves as much permission, I think, in those moments to, you know, to express what's happening hormonally.

Do you think it's because it's, it's hormonal that the issue?

Or do you think overall that, you know, we find that reporting pain over and over, over time, just starts to feel like a general weakness in society, which would be more applicable to men than women.

That's interesting. It, it may be that, you know, it's harder for women to continue to report, depending on their support system or lack thereof.

But there are true changes in our hormones throughout the month that contribute to pain. And, and estrogen is kind of the most widely studied.

And so what we find with estrogen is it's not the state of estrogen, it's not the level of estrogen, it's the swings. So it's the fact that it goes up and comes back down. That's where people tend to report pain is during those transition periods.

And so that's oftentimes why the majority of women who are diagnosed with chronic pain come in diagnosed around perimenopause, around that midlife stage, because hormones are doing their kind of typical thing throughout our reproductive years. And then perimenopause happens and that just becomes a crazy scene.

And, you know, it's sort of like if you're looking at an EKG and the heartbeats go and just boop, boop, boop, you know, very metronome down the line there. And then you get like a big heart attack.

And it's like that's kind of what hormones, at least estrogen especially, is doing around the midlife change of perimenopause. And then after menopause, you see a very significant drop in menopause and it stays low.

And that's oftentimes when women say, oh my gosh, I feel so much better. Especially women who have had terrible menstrual pain throughout their lives, they get to menopause and they're like, this is great.

Again, looking forward to the horizon. Yes, there's going to be a silver lining out there. Yes.

The problem there is that perimenopause can last 10 years. Right.

And, and sorry, but the part of the problem with that is that, you know, this has been ignored for so many years and women in perimenopause were told like, you know, aren't you fine? Really? Is this a big deal? And, you know, now it's kind of gone the other way where they're sort of medicalizing it and they're, they're wanting to.

A lot of people are capitalizing on it, you know, from a supplement standpoint or a treatment plan standpoint and things like that. I really like Dr. Jen Gunder, who gives a really kind of no nonsense approach to it where she says, you know, we don't medicate puberty. Right.

We haven't medicalized puberty yet. You know, people haven't found a way to monetize that yet, I guess. And this is a normal human life change that 50% of the population will go through.

And yes, if we can give women more comfort and less pain, absolutely, they should have that. But we don't have to treat it like a disease. That is like a problem to be solved.

A girlfriend and I were talking about the other day that we almost just won't even say the P word perimenopause to a male counterpart Whether that's a boyfriend or a brother. I mean, my brother and I are very close. I wouldn't hesitate to tell him that I'd had cluster migraines last month or that my.

My hip was still really bothering me. But I would probably not mention the aches and pains that come with perimenopause. And I think depending on. To.

You know, I don't mean to go off on a little tangent here, but it does feel as though society has a sort of label that they're ready to put on that perimenopausal or menopausal woman of like, okay, it's time for you to sit down. It's time for you to go into the back. Yeah, honey, sure. Time to shine is over. Which is far from. Yes, but. Okay. So another question for you, Dr. Megan.

If we were to take out the kind of pain that comes from the reproductive system, either, you know, kind of menstrual pain or cervical pain, you know, birth pains, if we take that out for a minute and we just are thinking about the kind of pain that both men and women could experience. So a torn acl, you know, fibromyalgia, you know, nerve pain, any of those kinds of things, is. Is it still would be equal between men and women?

Or do you think also part of what's bumping up that number of chronic pain reporters being women is also due to the fact that we've got this additional, you know, issue to reckon with, you know, when it comes to the fluctuation of our hormones.

Yeah, I don't think you can take the hormones out of the gender picture because we're so influenced by our hormones on a daily basis as women that you really can't separate these two things. It's kind of like separating race and socioeconomic status. They're so dependent on each other.

You really can't have one without the other in the United States. I'll say. I'll say that.

Yeah, absolutely.

And even things like progesterone, you know, we. Much of the focus has been on estrogen in hormones and pain in. In women. But there have been also studies on progesterone.

And what they find is that higher levels of progesterone, particularly after ovulation, have been shown to reduce the unpleasantness of pain. So it doesn't affect the intensity of pain, but it reduces the unpleasantness of pain.

Which, again, just kind of goes to show us the complexity of pain. It's not just about. It's never just about the physical experience.

It's about our interpretation of that experience and how pleasant or unpleasant we find it.

Yes. And in fact, I.

This is where the three legged stool of chronic pain becomes so helpful to always, at least for a layman like me to keep in mind, is that if we go back to one of the other legs, which is the psychological element of things, maybe that's having an impact as well. We can't ignore that part of it. So why are we feeling it more one month versus the other?

Like, hey, my, my period was so miserable last month, but I'm doing pretty well this month. Could that be related to mood, anxiety, depression, stress, cortisol levels?

Right, so it's, it's almost like not only can we not take the hormones out of the picture, but we can't even take the sort of psychology or brain out of the picture.

Right, Absolutely.

I mean, how much you slept last night or over the last week and what did you have to eat and you know, maybe you had the extra glass of wine and so you're perceiving pain a little bit differently.

So, yeah, that's why I encourage my students when I'm teaching physical therapy students, we've really got to look at all three legs of the stool and in many cases we need to shut up and let people talk and tell us what's going on. I had somebody come in this week who is dealing with a lot of lower back pain.

And we worked on it and we had two visits together and she started to do well and she's getting ready to go on a trip. And so we said, well, why don't you try surfing between this week and next week and we'll see how you do.

And she said, great, I'm really excited, I'm so excited to be getting back to this thing that I love.

And she called me midway through the week and said, you know, I don't know if I should try surfing this weekend because I've had a big flare in my pain. I don't know what happened. I can't explain it. And I said, okay, well, let's, let's talk about this. What might have happened differently?

And I said, okay, well where were you driving? And she said, oh, I'm driving my dad to his medical appointments.

And I said, oh, that's interesting because I remember when you first came in, you were telling me that your dad had just had a very big medical event that was very scary. And it's not uncommon that those two things got linked in her nervous system.

And so the act of caring for dad, taking dad to these doctor's appointments, maybe even the sounds or smells of the doctor's office, reminded her nervous system of this original incident. And her body went into protect mode and sounded the alarm.

That does that. Along the lines of that. I think you've said this phrase to me before. What, fires together, wires together?

Yes, absolutely.

Okay. And would it be fair to say, based on what we know from the studies about tolerance and endurance, pain and threshold and all that, that.

That perhaps those correlations are happening more readily for women that may also be.

A part of it. And there are researchers looking into memory and pain and how much our memory of past experiences contributes to pain. My mentor has this kind of.

As an area of specialty in his research.

And so what he did was he took a group of people and had them recall an incident, and they split them into groups where half had had a significant lower extremity injury and the other half didn't.

And when he had the people recall the injury and then tested them for strength before and after, and pain threshold before and after their strength went down around 20% and their pain threshold went down around 20%, somewhere around maybe 17%. I can't remember exactly. But memory of pain affects us tremendously.

And there are more estrogen receptors in the hippocampus, which is in a memory center in our brain. So there may be a component of that as well.

I wonder if sometimes that. That memory triggers the pain. As a pro, is it almost trying to protect us a little bit or the. The memory is scary.

It's conjuring up whether this is conscious or subconscious. Right. We.

We.

The pain maybe flares up to kind of say, Megan, protect yourself. Holly, go get low here. Like, this is. You're entering into rocky territory. And that pain flashes almost as a.

Like a leash and a collar that it puts around you, sort of like trying to pull you back out of something. Is that. Do you think that's a good way to describe it?

Sure.

And that's a great way to describe it, because, remember, if we think about the definition of pain, it's an unpleasant sensory and emotional experience associated with or resembling that, associated with actual or potential tissue damage. And so if we sense the potential of tissue damage, our nervous system will sound the alarm and say, hey, warning, warning.

I need you to pay attention. Here. I need you to do something differently.

I think men tend to shove things down memories down a little bit, and I'm just kind of putting that out there as a general. This is certainly not true of every man. There's so many exceptions.

But by and large, most females that I talk to have a very active and vivid memory around things that were challenging or difficult. And we continue to talk about those things over time, either with a family member or with each other in an effort to support each other. Men.

I have not found that men are as likely to kind of hold on to those things and talk about them as much. And they sort of shove it down so far and so deep. It's like, what are you talking about? My childhood was fine. It's like. Like really?

Because I've heard different. So do you think that's part of it? Is that, you know, for the female brain, we.

We keep some of those memories, bad and good, alive a little bit more, or am I getting too far on a limb here?

No, I don't think you're getting too far out on a limb, but I don't know if that's necessarily true for everyone, like you say. And men tend to bond with each other differently. Not in ways that women do. We love. We love to talk about it more often than not.

And men bond maybe more physically or in other ways where they're not necessarily verbalizing memories and things like that. In my practice, like I say, I more often see females, and I practice a little bit differently where I talk to people about some.

Sometimes their memories and their thoughts and their feelings about their pain. And I am. I do tend to be met more often with women who are ready for that.

So they're sort of primed for that in a way, maybe because they've heard more about it on Instagram or from other friends or things like that.

But when I work with men, sometimes I have to say, okay, try some more traditional physical therapy first, because that sounds like it's where your comfort level is. And then if that doesn't work, then we'll. We'll talk about some other things.

I think sometimes women tend to be a little more proactive in seeking out care. And so maybe they've seen more providers by the time they get to me and they're ready to say, let's talk about something else.

I'm happy to think about things other than tissue damage. I'm. I'm here for it. And maybe it's just because I often then will get referred their husbands or their brothers or their uncles.

Yeah.

And so then. Then we start from a different place, potentially.

That makes a lot of sense. Even when I need to send my husband to. If I see him hobbling around, I have to describe the practitioner I want to recommend as very straightforward.

You know, even if I see the same practitioner, same chiropractor, and let's say she and I talk a little bit about stress and about emotion and about, you know, maybe depression fluctuating or what have you, I. If I told my husband that that was going to be part of the protocol, you know, he may not sign up.

I think he wants to know that it's, you know, just really straightforward, you know, kind of chiropractics, you know, and.

And so that, you know, that is very interesting and actually is a really cool segue into what we're going to be talking about in our next episode, which is all about when we start diving deeper into the mind and exploring memories, or we have difficult moments of stress and so forth.

How can we use mindfulness and visualization and other techniques that maybe, Dr. Megan, you're saying you're able to use with patients who are ready to go on that journey. When someone is saying, yeah, I've thrown everything at the wall, nothing has helped.

If we need to unpack, you know, some trauma here, I'm here for it.

If we need to unpack, you know, some beliefs that I have or a narrative or anything that's playing sort of in the mind, you know, I know that you are an advocate of that and that that has tremendous potential, and I'm really curious to explore why that is, you know, how that can come into play.

Yeah, I'm really excited to talk about that as well.

And, um, you know, up until this point, we've been talking about a lot of hard things, and it may sound like it's all doom and gloom, but the good news is there are a lot of things that we can do to change pain. There's a lot of things that you can do on your own to change your pain.

And there are a lot of ways that people can come out of this and have a complete recovery from pain, no matter how long they've been experiencing it.

And I think that's what's exciting, is that you just. You have to know that it is malleable. It is, right? It's a sort of, so to speak, plastic kind of phenomenon.

And if you're working with a practitioner, this is me as a non practitioner talking to you, you know, chronic pain sufferer to chronic pain.

Sufferer if you're not working with someone who is willing to ask you those questions or at least listen to that part of your pain experience, you've got to change the channel on that. You've got to find someone else because you know if your pain is sticking around for long enough, it's time to start unpacking.

What else is going on beside traditional tissue damage? Right?

Dr. That's a really great way to talk about it and way to think about it because as we've said many times before, if you are breathing air, you. You can change your pain.

Yes, I love that.

We love to sign off episodes like that because we want you to remember no matter how hard it gets or how how circuitous the journey can be, there is a way through. You have to continue to be willing to try new things.

Which I think is going to be very interesting in our next episode because while there are many of us out there who've dabbled in mindfulness meditation, breathing exercises, many more of us haven't. And it often can feel like woo, woo. Why do I go there? So we're going to go ahead and unpack that for you, as we like to do. And on Unpacking Pain.

Yes. And there is some science behind it, so we'll unpack the literature and see what's worth your time and what may be worth skipping.

All right, thanks everybody for joining us. We'll see you next episode of Unpacking Pain. Till then, take care of yourself.

Thank you so much for listening to this episode.

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