Women are about twice as likely as men to live with chronic pain conditions like IBS, endometriosis, migraines and fibromyalgia. On October 1, the journal Science dedicated a special issue to women's health, including a review on why women experience pain differently, and in this episode I'm breaking it down for you.

We chat about how estrogen and your gut bacteria team up to turn up gut pain, the immune cells in women that make their own painkiller, why pain can take longer to resolve in women, and what the research says about migraines, fibromyalgia and knee arthritis. I'm also giving you an honest look at what's proven in people versus what's still mostly mouse research, plus three things you can actually do with this information.

The science of pain: https://wellness-big-sis-the-pod.captivate.fm/episode/copy-of-pod-83-pain/

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Women are about twice as likely as men to live with chronic pain conditions.

Things like IBS, endometriosis migraines, and fibromyalgia

And for a long time, and even still, a lot of us are told it's all in our heads

However, this month in October, one of the most respected scientific journals

published a review of the actual biology behind the gap

And of course, it involves things like our hormones,

especially estrogen, gut bacteria

And a tiny squad of little immune cells that make their own

painkiller Let's get into it.

Welcome back to Wellness Big Sis: The Pod.

I'm your host, Dr.

Kelsey Vick, a board-certified orthopedic doctor of physical therapy

and a women's health physical therapist

And today is gonna be a science episode, but the fun kind

I read the new review from the Science Women's Health issue

And I'm walking you through some of the reasons women might experience

more chronic pain than men

As a woman's health PT, there are a lot of different overlapping pain patterns

that can present in the pelvic region

IBS, interstitial cystitis, or bladder pain

and endometriosis all tend to travel together

About half of women with bladder pain syndrome or IC and roughly 30% of

women with IBS also have endometriosis

And that pattern can show up in other parts of our bodies as well

In women with IBS, gut pain thresholds change throughout the menstrual cycle

While in healthy women, they stay fairly steady

In one study, women who are on the pill who have more steady hormone levels,

Their gut pain thresholds looked similar to men's

Now, a lot of this newer women's health research has to be

done in animal studies first.

So part of today I'll discuss human studies, part of today I'll

have some mice studies sprinkled in, but just know this is on the

forefront of women's health research.

So as much as we can say, "Oh, it's a mice study, we shouldn't pay

any attention to it," no, that's exactly the reason we should be.

There's a reason they're doing these studies in mice to eventually

be done in humans as well.

So in mice, the nerves that since the colon

run at a higher baseline in females

It's like our volume for those nerves is already at a seven out of 10

So the signal is louder even before anything goes wrong

In mice, estrogen

makes certain gut lining cells more responsive to compounds

your gut bacteria produce when they ferment carbohydrates

Those cells then nudge serotonin cells

which can then ping the pain nerves

That chain might be one of the reasons

A low FODMAP approach often helps IBS.

Fewer fermentable carbs

means less of that signal

Your microbiome is in the hormone business too

Gut bacteria can help convert some of our hormones into active estrogen

And mice without gut bacteria

lost some of the cycle-related swings and gut sensitivity Testosterone seems

to do the opposite and calm things down

lower free testosterone is linked with worse IBS symptoms

When trials actually split results by sex

Some IBS drugs worked differently in men compared to women

And different mental health therapy techniques like cognitive behavioral

therapy worked better in conjunction with the usual standard approach

for IBS in women more so than men

So this is a lot of science to really try and understand and prove the connection

between our hormones, our gut, and different symptoms that we have related

to IBS and our gut health So all of these studies look at various components and

neutralize various other components to see what are some of the root causes driving

the effect of our hormone levels on certain pain patterns that we might have

So if you experience any sort of IBS related symptoms, try and track

your eating habits, your menstrual cycle, different pain patterns

that you might experience in your gut, your bladder, your bowels

And keep an ongoing log to see if there might be a relationship between where

you are in your menstrual cycle and the different pain patterns you might have

And if you have IBS or any sort of gut health issue, this is something

to seek professional expertise for and not just take what I'm telling

you from the research at face value.

Any sort of dietary changes or restrictions or following sort of a

more prescribed diet like the FODMAP diet needs counsel with someone

who actually understands the deeper science and chemistry behind it.

But it might be something to look into if you do experience some of those symptoms.

With something like endometriosis

Different hormone-based treatments

And menopause actually tend to help quiet some of the symptoms Which fits

that hormone story where more level hormones help with pain patterns

If surgery helped but then the pain came back

Increased sensitivity in those nerves or different overlapping pain patterns

might be a part of the bigger picture

In my clinical world, that's where pelvic floor PT becomes part of that puzzle

The other thing this review found was that your immune system plays favorites

For decades, most pain research used male animal models

and assumed the results applied to everyone

In 2015, researchers showed

That in male mice, nerve pain runs primarily

through immune cells in the spinal cord called microglia

While female mice rely on a different set

our T cells

Same injury, different cast of players showing up to fight back

and attack with our immune response

They've also found when it comes to our immune system and painkillers, natural

painkillers within our bodies, that female mice have sort of these built-in

bodyguards, these regulatory T cells

in the membranes surrounding the spinal cord

And guess what?

Estrogen and progesterone help them grow.

So our hormones directly feed into these T cells around our spinal cord

The growing of these immune cells

Help our bodies release a natural opioid, a natural painkiller called Enkephalin

So we sort of have this in-house pharmacy run by our own hormones

However, they've also found that pain resolves more slowly in women

Female mice had fewer of the anti-inflammatory cells that

help with an immune attack

But giving them testosterone helped to speed up that recovery

They've done a study between men and women after car accidents and

Men reported less pain several weeks later, and that also corresponded

With more of those immune cells and more interleukin 10

which is a part of that anti-inflammatory signal

A simplified way of viewing pain in this scenario can be

like turning pain on and off

And the research suggests that women's bodies might differ on both

We have different immune cells maybe driving that on switch

And we might have a slower off switch after inflammation

And that majorly matters for drugs surrounding pain management.

The female pathways differ from the men's.

So if we are prescribing medication based on male pathways, it might

not necessarily attack the female pathways in the way that we want

So if you have an injury or pain pattern and it seems to be taking a little bit

longer than your boyfriend or your brother or your husband or your guy best friend

It's not you being dramatic

Tell your clinician or whoever you're working with

And stick with your rehab plan instead of bailing early or comparing yourself

against other people and the way that their bodies are handling pain

And when you're offered a pain medication, it's fair to look into whether or not

that was studied in women or just men.

Since there's evidence coming out, early evidence coming out that our pathways

for how we're affected by different pain medication might be different

This next one hits a little closer to home, and I have to thank one of my best

friends who is a PA in the neuro field.

So she works with everything from headaches and migraines to things like

stroke and traumatic brain injury.

And I was complaining to her the other day or talking to her about

this 24-hour headache that I often got on the left side of my eye.

And it's very, very minor, but it's there, and it definitely affects my ability to

be as productive throughout the day or do what I need to do throughout the day.

And I was telling her sleep doesn't necessarily help.

Sometimes exercise helps.

There's certain things that might help, but it's not 100% consistent all the time.

But it is brought on by a lack of sleep.

So there was a trigger.

It lasted 24 hours, and she goes, "Kelsey, that's a migraine."

And I'm so glad I brought it up to her because I was not even

thinking that it was a migraine.

I wasn't even asking necessarily for her clinical expertise.

It was more of just like friend to friend.

But I am so grateful that she actually had that expertise and sort of cleared the

air on what a migraine was and felt like for me, since I'm newer to getting them.

But

There is a difference in how women sense pain in our head, our body, our joints.

So that includes migraines as well

Migraine affects younger women two to three times more often than men.

It often starts at puberty, which mine was way past puberty, but

still it often starts at puberty and peaks just before or during periods

And they tend to ease in that second or third trimester of pregnancy

when hormones might run a little higher and a little steadier

I learned there's a key migraine molecule called CGRP, and the

CGRP-blocking antibodies on the market work especially well in women.

In mice, putting CGRP on the brain's lining made females

sensitive and barely affected males.

The hormone prolactin seems to amplify this in females

So I know when talking to my friend, she was saying There's usually a pattern

with menstrual cycle and migraines, and I definitely notice it, but I

do think it's multifactorial for me where my trigger is a lack of sleep.

There are certain times on my cycle where I get poor quality of sleep.

So is it the phase that I'm in in my cycle?

Is it just that that phase creates a greater trigger

for me and for my migraine?

It's all overlapping.

So hopefully that provides a little bit of an example, too, where when we say things

like, "If your endometriosis doesn't get better after surgery, there might be other

pain patterns overlapping," this is how I apply that scenario to my own migraines.

Where is it the menstrual cycle?

Is it my hormones?

Is it the trigger of sleep, or is it all of them combined where it's a sort of

domino effect because certain times of my cycle I have worse sleep, and lack

of sleep is a trigger for my migraines?

When it comes to fibromyalgia, so moving from the head, migraines,

to more of the body and this systemic pain called fibromyalgia

In a genetic study of more than two point five million people, including

over fifty thousand with fibromyalgia

They found that the genetic risk for fibromyalgia overlaps with things like IBS

and can point towards nerves in our gut as being one of

the contributing factors to it

Interestingly, this was not linked to male or female

Or to classic autoimmune diseases.

So fibromyalgia, we call it a dump diagnosis because it's usually once

everything else has been tested, and there are certain things that

might come back and might indicate fibromyalgia as the dump diagnosis.

It's sort of what we categorize people as, give them a diagnosis

when nothing else checks out.

So fibromyalgia and pain in general is still poorly understood, but I think

tackling it from a lot of different angles, looking at the male-female

connections, looking at different hormones and things that might affect different

areas of our bodies and where they create pain is one of the ways to look at it

We've also done an entire episode on pain.

Pain is something I educate patients on a lot, and pain is very misunderstood.

It's hard to understand because

It's hard to research, and as we've discussed today, there's so many

overlapping reasons for someone to have pain in certain areas

But we've done an entire episode on pain from more of a physical

therapy standpoint and how I educate patients on pain, how the structure

of your body doesn't necessarily correspond to pain that you might have.

That's a big one for people.

People always say, "My back looks like this on X-rays or on imagings or on

MRI, and therefore I have this pain.

I have pain because my disc or my nerve or my skeletal structure or my scoliosis."

And they're proving with different research studies that isn't what we should

be relying on for deciding whether or not someone has pain, because someone with

the same exact imaging could have no pain.

So we can't necessarily equate pain to structure.

We've done a whole entire episode on that.

I'll leave that link below.

This is sort of getting into the newer women's health research surrounding

pain, which I think is cool, but from a more standardized approach, there's

a great educator out of Australia, Lorimer Moseley, who talks a lot about

pain, and he has a great TED Talk.

I've linked it all in the pain video that I'll link below this

video too if you guys are interested

And then lastly, knee osteoarthritis.

So as estrogen drops with age, women's risk climbs, and knee osteoarthritis

rates can be double that of men's.

And they've also found that certain inflammatory signals

tracked with blood testing

and knee fluid

were found in women with knee pain, but not with men

So across head, shoulders, knees, and toes

The common thread is that hormone shifts or affecting your hormones in

certain ways change how inflammation and the nerves talk together

The specifics might differ by condition

And for migraine specifically,

The review notes

Some of the female bias might not even come from some of

those reproductive hormones

So same as before, if you're experiencing pain patterns, start to

relate it back to your menstrual cycle.

Start to track your menstrual cycle in relation to your pain patterns, in

relation to how you're feeling with some of the gut symptoms, what you're

craving, your blood sugar levels.

Things like that might give a better picture as to where to

attack the pain problem from

And of course, from a PT lens

Strength training and exercise are often a first-line approach

for any sort of pain pattern.

The more we feed into pain, the more it runs down those same highways in

our brains and sort of solidifies them, the more they're driven down.

I think about it as like dirt gravel roads or hiking through a forest.

The more you travel down it, the more clearer that path gets

and the easier it is to take.

So if we can add in movement and healthy movement in a certain way, no matter

the pain that you're experiencing, the more we're able to sort of help

rewire the brain and come at it from a physical behavioral standpoint,

not just a medication standpoint.

So this is a recap over that review, but I thought it was so

interesting to start to look at pain from a women's health perspective

Some of it's humans, some of it's mice

But it's all helping to form a better picture of pain for us as women

And we've done quite a few menstrual cycle episodes and how our bodies in that luteal

phase starts to go into protective mode from an inflammation standpoint, from a

white blood cell count standpoint, where some of our body's built-in protective

mechanisms might be there for evolutionary reasons - to protect a potential

fertilization and pregnancy in that phase.

So they're saying the same thing might be the case for pain, where pain is a

communication signal for our bodies, and if we're able to have more pain

in a certain phase of our cycle, it might actually be a protective thing

So when we say it's not all in your head, it doesn't necessarily

mean the brain is not involved.

Usually the brain is very involved because it registers what is pain and what is not.

I think one of the most interesting studies done is

on neck pain in, I believe it was rally car drivers versus neck

pain in the general population.

And similar experiences in a car crash, but because the rally drivers picture

it in a different way as part of their jobs, their neck pain heals a lot quicker.

So pain is more than just the physical.

Pain is how our brain perceives it, how our hormones affect how our

brain perceives it, how our hormones affect the signals that get sent

from different areas in our bodies.

It's a very fascinating field of research, and I'm so excited that the women's health

perspective is now getting added to that.

So a few actionable steps, just track your symptoms, especially

against your menstrual cycle.

I feel like that's one of my huge passions in life is like convincing women

to actually track and understand their menstrual cycle and all that comes with

it because there's so many things that once we establish that foundation, once we

understand what's happening throughout our cycle, whether it's normal or whether it's

abnormal, we can start to overlay certain other conditions or experiences that

we might be having to see what might be causing this from a hormonal standpoint.

And the more we understand what our bodies are going through day to day

throughout those 28 days or, you know, plus or minus a few, the better we're

able to problem solve what's happening in our own bodies throughout life.

So I hope you guys enjoyed this episode, and I'll see you guys again on the

next episode of Wellness Fixes the Pod.