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From: B. Harris)
Subject: Re: Reaction to Benedryl
Date: 21 Sep 1998 20:00:05 GMT

In <> alvena ferreira <>

>Daniel Ganek wrote:
>> They only treat half the population that way - females.
>> Both my wife and I have experienced this - Early in our marriage
>> we would both used the same physicians. They would listen
>> to me and carefully consider everything I said.  They ignored
>> what she said. She had two potentially life threaten situations
>> ignored. She now only uses female physican - BUT EVEN SOME
>> OF THEM MANIFEST THE SAME SYNDROME! Is it genetic or med school? :-)
>'s discrimination against women, and it's still alive and
>Alvena Ferreira

   Men are less apt to go the doctor or the emergency room and complain
of a specific symptom.  This is probably not good for men, but it's
true.  This simple fact, however, mens that men, when they do present,
get more attention paid to them.  You may call this descrimination if
you like, but it's perfectly logical.  See "induction."  If doctors
worked up each and every complaint of each and every patient with no
delay, then two things would happen:

1) The system would go broke, because there isn't enough money in any
country to do this, and

2) A great deal of harm would be done by exposing patients to
unnecessary tests, all of which carry danger either from the tests
themselves, or their false positive return.

   Of course, the above considerations do not hold in the case of
individual patients who are well known, and physicians soon come to
know their own patients regarding the question of who's stoic and who's
anxious.  Some men are far more anxious than some women, of course.
But in the absense of this kind of personal knowlege, and when treating
strangers, physicans must at first go by the best criteria they can,
and that is (as explained) that men's complaints receive more attention
because they are more rare.

                                        Steve Harris, M.D.

From: B. Harris)
Subject: Men, Women, and Pain (was: Reaction to Benedryl)
Date: 22 Sep 1998 07:55:58 GMT

In <> Carey Gregory <>

>Steven B. Harris wrote:
>> But in the absense of this kind of personal knowlege, and when treating
>> strangers, physicans must at first go by the best criteria they can,
>> and that is (as explained) that men's complaints receive more attention
>> because they are more rare.
>Unveiling my crystal ball, I predict significant disagreement on this
>point. I predict it will be labeled rationalization, and I can't say I'm
>going to disagree with that assessment. While what you say may be true
>statistically (though you've offered no evidence), I find the explanation
>very, very thin. In fact, I just plain don't buy it. Nice try though.


Well, what would convince you?  I can post abstracts all night
and if you don't want to believe it, you won't.  And if you
haven't noticed the difference in men and women when reporting
medical symptoms, you haven't been paying attention <g>.

This whole thing reminds of the arguments you get into when you
say anything about groups these days.  If anything you say is
perceived as derogatory, somebody's going to argue on facts when
otherwise they would not have.  If you say: "Chemistry's a branch
of physics," chemists will nod.  If you say: "Chemistry's MERELY
a branch of physics," now you have an argument.  If you say that
men report less pain, and that's why they drop dead of heart
attacks more often before making to the ER, you get nods.  If you
say that women are more likely to report non-serious pain, and
that's why ERs pay more attention to men, now suddenly you get
people questioning your very assumptions.  Hmmm.

In pain research, however, the fact of significant gender
differences in perceived pain from a given stimulus is not even
debated any more.  The incredible thing is that nobody thinks
this should or does make any difference in medical practice.

Yes, well, women take a lot more analgesics than men, and women
say that most medical problems hurt more than men do.  But we
doctors haven't noticed.  And if we have, we shouldn't have.

Pain 1996 May;65:123-167
Gender variations in clinical pain experience.

School of Occupational Therapy; Dalhousie University; Halifax;
Nova Scotia; Canada; ANNRVH
This review is a critical summary of research examining gender
variations in clinical pain experience
Gender comparative pain research was identified through Medline
and Psychlit searches and references obtained from bibliographies
of pertinent papers and books. Review of this research demonstra-
tes that women are more likely than men to experience a variety
of recurrent pains. In addition; many women have moderate or
severe pains from menstruation, pregnancy and childbirth. In most
studies women report more severe levels of pain, more frequent
pain and pain of longer duration than do men. Women may be at
greater risk for pain-related disability than men but women also
respond more aggressively to pain through health related activit-
ies. Women may be more vulnerable than men to unwarranted
psychogenic attributions by health care providers for pain.
Underlying biological mechanisms of pain and the contribution of
psychological and social factors as they contribute to the
meaning of pain for women and men warrant greater attention in
pain research.

Comment:  Political correctness naturally mandates that such a
study as above should find both that women report more pain,
therefore are "more vulnerable than men to unwarrented
psychogenic attributions for pain."  How about that men are more
vulnerable to severe medical consequences from not reporting
pain?  Why not worry about that just as much?  Most studies do
find that doctors tend to treat pain per se on the basis of
complaint, with no particularly strong evidence for gender bias
(this is as it should be-- pain is pain, and perception is
reality with pain; patients who report more pain, should
generally get more analgesic).  The problem comes in relating
pain to other medical problems.

Ann Emerg Med 1995 Oct;26(4):414-421
Gender-associated differences in emergency department pain

Raftery KA, Smith;Coggins R, Chen AH

Stanford University;Kaiser Permanente Emergency Medicine Reside-
ncy Program; Department of Surgery; California; USA;

STUDY OBJECTIVE; To determine whether patient or provider gender
is associated with the number, type, and strength of medications
received by emergency department patients with headache, neck
pain, or back pain. DESIGN: Prospective cohort study; SETTING:
Stanford University Hospital ED PARTICIPANTS: Patients 18 years
and older who arrived at the ED with a chief complaint of
headache, neck pain, or back pain between February 1 1993 and
September 30, 1993. Provider participants included medical
students, interns, residents, nurse practitioners, and attending
physicians. RESULTS: ED administration of analgesic versus no
analgesic, strength of analgesic administered, and administration
of multiple medications. The study group consisted of 190
patients: 110 of them female. The patients were evaluated by 84
providers, 60 of them male. According to the providers
surveyed, female patients described more pain than did male
patients;P < .01; and were perceived by providers to experience
more pain P < .03; Female patients received more medications P <
01; and were less likely to receive no medication P <.01; Female
patients also received more potent analgesics (P < .03). Linear
and logistic regression analysis showed that patient perception
of pain was the strongest predictor of the number and strength of
medications given; patient gender was not a predictor.
CONCLUSION: Female patients with headache, neck pain, or back
pain describe more pain and are perceived by providers to have
more pain than male patients in the ED. Female patients also
receive more medications and stronger analgesics. In this study,
severity of patient pain rather than gender stereotyping appeared
to correlate most with pain management practices.

Pain 1998 May;76(1-2):223-229
Gender differences in pain perception and patterns of cerebral
activation during noxious heat stimulation in humans.

Paulson PE, Minoshima S, Morrow TJ, Casey KL

Neurology Research Laboratories, University of Michigan, VA
Medical Center, Ann Arbor 48105, USA.

The purpose of the present study was to determine whether gender
differences exist in the forebrain cerebral activation patterns
of the brain during pain perception. Accordingly, positron
emission tomography (PET) with intravenous injection of H2(15)O
was used to detect increases in regional cerebral blood
flow (rCBF) in normal right-handed male and female subjects as
they discriminated differences in the intensity of innocuous and
noxious heat stimuli applied to the left forearm. Each subject
was instructed in magnitude estimation based on a scale for which
0 indicated 'no heat sensation'; 7, 'just barely painful' and 10,
'just barely tolerable'. Thermal stimuli were 40 degrees C or 50
degrees C heat, applied with a thermode as repetitive 5-s
contacts to the volar forearm. Both male and female subjects
rated the 40 degrees C stimuli as warm but not painful and the 50
degrees C stimuli as painful but females rated the 50 degrees C
stimuli as significantly more intense than did the males (P=0.-
0052). Both genders showed a bilateral activation of premotor
cortex in addition to the activation of a number of contralateral
structures, including the posterior insula, anterior cingulate
cortex and the cerebellar vermis, during heat pain. However,
females had significantly greater activation of the contralateral
prefrontal cortex when compared to the males by direct image
subtraction. Volume of interest comparison (t-statistic) also
suggested greater activation of the contralateral insula and
thalamus in the females (P < 0.05). These pain-related
differences in brain activation may be attributed to gender,
perceived pain intensity, or to both factors.

PMID: 9696477, UI: 98359666

Anesth Analg 1998 Jun;86(6):1257-1262
Experimental pain in healthy human subjects: gender differences
in nociception and in response to ibuprofen.

Walker JS, Carmody JJ

School of Physiology and Pharmacology, University of New South
Wales, Sydney, Australia.

We used electrically induced pain in healthy young subjects to
study gender differences in nociception and the analgesic
efficacy of ibuprofen. Cutaneous stimulation of the earlobe
allowed measurement of pain detection thresholds and
maximal pain tolerance. Drug and placebo were each administered
twice using a double-blind, randomized, multiple cross-over
design. Male subjects had greater stimulus thresholds (lower
nociception) compared with female subjects (18 +/- 0.3 vs 15 +/-
0.3 volts, mean +/- SEM; n = 10 in each group) and a greater pain
tolerance (24 +/- 0.4 vs 21 +/- 0.4 volts). Response variability
was also greater in the male subjects, yet only the men exhibited
a statistically significant analgesic response to ibuprofen
(deltavolts; ibuprofen versus placebo: 2.80 +/- 0.33 vs -0.18 +/-
0.34; P < 0.05, n = 10). None of these results could be attri-
buted to pharmacokinetic differences. The finding that ibuprofen
was less effective in women than in men has potential clinical
significance, especially as a factor in the response variability
to nonsteroidal antiinflammatory drugs. Implications: In this
study, we examined ibuprofen, a widely used nonsteroidal anti-
inflammatory drug, for its ability to reduce experimental pain.
We found that it had such properties in healthy young male
subjects but not in young female subjects. This is a paradox
because many of the painful conditions for which nonsteroidal
antiinflammatory drugs are used (e.g., rheumatoid arthritis)
occur more often in women.

Publication Types:
  Clinical trial
  Randomized controlled trial

PMID: 9620515, UI: 98281825


Pain 1998 Apr;75(2-3):177-185
Prediction and assessment of the severity of post-operative pain
and of satisfaction with management.

Thomas T, Robinson C, Champion D, McKell M, Pell M

St Vincent's Private Hospital, Darlinghurst, NSW, Australia.

A prospective observational study of cohorts of patients
undergoing hip replacement (30), knee replacement (31), and
spinal nerve root decompressive surgery (30) were interviewed
pre-operatively to identify factors which might correlate with
and potentially predict severe post-operative pain and
dissatisfaction with analgesic management. The hip patients
comprised 33% females and averaged 64 years, while the knee
patients were 45% female and older (mean 71 years) and the spinal
patients were 43% female and averaged 50 years. The three groups
were similar with respect to all other pre-operative
variables. Pain intensity was assessed mainly by self-report
using the Present Pain Intensity (PPI) and Visual Analogue Scales
(VAS) of the McGill Pain Questionnaire. The PPI was preferred by
patients and nurses and, as there were no analytical advantages
for the VAS, the PPI data are presented. The average post-operat-
ive pain during routine management mainly with patient controlled
intravenous opiate, was mild to moderate and declined over days
1-5, declined further at discharge but rose slightly 1 month
after discharge. The hip replacement patients experienced
significantly (P < 0.01) less pain overall than the patients in
the other two groups. Nurses' assessments of pain severity
from observed behaviour were low and agreed poorly with the
patients' self reports. Assessed on Likert Scales (0-6), the
patients generally indicated good or excellent pain control,
better than expected pain experience, and high levels of satis-
faction with analgesic management. Significant (P < or = 0.01)
multivariate correlates of severe post-operative pain assessed by
logistic regression analysis of 11 variables were female gender,
high pre-operative pain severity, and younger age. Significant (P
< or = 0.01) multivariate correlates of both worse than expected
pain experience and low satisfaction were female gender, high
pre-operative pain severity, high anxiety about risks and
problems, low expected pain severity, age (younger) and high
willingness to report pain. These variables may reasonably be
tested in further studies as potential predictors of adverse
post-operative pain experience.

PMID: 9583753, UI: 98243111


Ann Pharmacother 1998 Apr;32(4):485-494
Prescription and nonprescription analgesic use in Sweden.

Antonov KI, Isacson DG

Department of Pharmacy, Pharmaceutical Services Research,
University of Uppsala, Sweden.

OBJECTIVE: To analyze patterns of prescription and nonprescript-
ion analgesic use in the general Swedish population, in associa-
tion with predisposing factors, enabling factors, need, and
health behavior. DESIGN: Cross-sectional interview survey.
SETTING: The Swedish Surveys of Living Conditions for the
2-year period 1988-1989. PARTICIPANTS: A probability sample of
all inhabitants of Sweden aged 18-84 years (n = 11996). MAIN
OUTCOME MEASURES: Prescription and nonprescription analgesic use
during a 2-week period. RESULTS: Women reported
use of analgesics both with and without prescriptions to a
greater extent than did men. Among women, 12.2% reported pre-
scription analgesic use and 30.4% reported nonprescription
analgesic use. The corresponding proportions among men
were 7.2% and 20.0%, respectively. In the descriptive analyses,
prescription analgesic use was most common among persons aged 45
years and older, while use of nonprescription analgesics was most
common in people aged 18-44 years. The polychotomous logistic
regression analyses showed that headache and musculoskeletal pain
were strongly associated with prescription analgesic use
to a similar extent among men and women. Headache was associated
with nonprescription analgesic use among men and women, but a
gender difference was found in the association between musculo-
skeletal pain and nonprescription analgesic use. Women with
musculoskeletal pain used nonprescription analgesics to a greater
extent than did men with musculoskeletal pain. Poor health--me-
asured as self-perceived health status and physical
function--and high use of health care were related only to
prescription analgesic use. Smoking and being overweight were
associated with prescription analgesic use among men and with
nonprescription analgesic use among women; alcohol
consumption was associated with both types of analgesic use only
among women. CONCLUSIONS: This study shows that men and women
differ in their choice between prescription and nonprescription
analgesics and that the choice between prescription and nonpre-
scription analgesics is influenced by an individual's
pain, self-perceived health, and lifestyle.

PMID: 9562147, UI: 98220616


Pain 1998 Mar;75(1):121-127
Sex differences in temporal summation but not sensory-discrimina-
tive processing of thermal pain.

Fillingim RB, Maixner W, Kincaid S, Silva S

Department of Psychology, University of Alabama at Birmingham,
35294-1170, USA.

Gender differences in experimental pain sensitivity have been
widely investigated, and the results generally indicate that
females exhibit greater sensitivity to noxious stimuli than
males. However, results using thermal pain procedures have been
inconsistent, with some studies reporting greater
responses among females and other studies reporting no gender
differences. The present study investigated gender differences in
thermal pain perception using several different psychophysical
procedures. Twenty-seven females and 22 males underwent thermal
testing, including: determination of thermal pain threshold
and tolerance, a thermal discrimination procedure, real-time
magnitude estimates of heat pulses, and temporal summation of
thermal pain. The results indicated lower thermal pain threshold
and tolerance and greater temporal summation of thermal pain
among females, but no gender differences in thermal discrimina-
tion or real-time magnitude estimates of discrete heat pulses.
These findings suggest that gender differences in thermal pain
perception may be more robust for sustained, temporally dynamic
thermal stimuli with a strong C-fiber component.

PMID: 9539681, UI: 98199089


Headache 1998 Jan;38(1):31-34
Gender, primary headache, and psychological distress.

Gilbar O, Bazak Y, Harel Y

School of Social Work, University of Haifa, Israel.

The study compared the psychological symptoms of 26 young men and
65 young women referred to a neurology clinic in northern Israel
by their family physicians for medical advice regarding headache.
The main findings indicated that the women had more severe
psychological symptoms than the men in six subscales, although
only in somatization, depression, and additional items did
the differences reach statistical significance. The authors
recommend, in addition to medical intervention, special
psychological intervention for women, which would offer
counseling in developing coping skills.

PMID: 9505000, UI: 98165898

From: B. Harris)
Subject: Re: Men, Women, and Pain (was: Reaction to Benedryl)
Date: 22 Sep 1998 16:54:14 GMT

In <> Daniel Ganek <>

>I brought the subject up because I believed there was a bias on the part
>of physicians. Steve, I won't argue the point about men and women feeling
>pain differently. The point was was trying to make and that you seem to
>have verified is the physicians make gross generalizations. I.e. "some
>women are hypochondriacs therefore, we'll treat them all that way."

   Medicine is generalities.  Some people with acute MIs have
dysrrhythmias.  Therefore I'll treat them all as though they were ALL
going to have one.  Some people with fever and shock have a bacterial
infection.  Therefore I'm going to treat this guy who I've never seen
with empiric antibiotics until I find out more.  And so on.  There
aren't any patient names in a textbook of medicine--  just
generalities.  I'm sorry your doctor didn't know your wife better. If
you were dead certain she was mortally ill, that means it was a lack of
personal knowledge problem.  On the other hand, doctors cannot be
expected to know patients as well as their families do.  Which is one
reason a good doctor cribs by listening to family members.  If your
doctor didn't, I'm sorry.  He should have.

                                        Steve Harris, M.D.

From: B. Harris)
Subject: Re: Men, Women, and Pain (was: Reaction to Benedryl)
Date: 23 Sep 1998 07:36:33 GMT

In <> Carey Gregory <>
>Steven B. Harris wrote:
>> Well, what would convince you?  I can post abstracts all night
>> and if you don't want to believe it, you won't.  And if you
>> haven't noticed the difference in men and women when reporting
>> medical symptoms, you haven't been paying attention <g>.
>I'm not arguing there aren't differences. Not at all. I'm merely
>suggesting that a physician must take those differences into account and
>deal with the patient at hand. When they're used as the sole basis to
>rule something out or ignore a symptom, bad medicine is happening.

    Absolutely not.  You ignore symptoms every day and so do I.  The
doctor who didn't would be in severe trouble.  If not with the patient
being seen (and even that patient is likely not being served well),
then with the ten patients who haven't, while a 3 hour H&P is being
performed on the first.  The tough part of medicine is knowing (or
guessing correctly) what to ignore.  One does not generally ignore
chief complaints, but even this generality has limits.

>Of course it should be taken into account, but you seemed to be using
>gender differences to rationalize another doctor's poor handling of a

    Not at all.  I came into this conversation just as somebody was
suggesting that all we doctors learn this pigeonholing stuff in medical
school, even the female MDs.  Geeze there must be some really bigotted
classes out there that everybody takes, right?

   Wrong.  Look at the average medical student and you'll see somebody
who believes everything anyone says, takes all complaints equally
seriously in all situations, and who really does (yes, just as I once
did) take 3-hours to do a history and physical exam.  Which amounts to
6 or 8 closely spaced typewritten pages.  After a time in the school of
hard knocks, however (that which doesn't come in a classroom) all that
eventually changes.  That is why this "problem" is so universal among
physicans.  It's what the job itself teaches you, if you pay attention.
If the patient knew what part of what he was telling you was important,
and stuck to just that, he probably could treat himself.  You and I
could take up veternary practice.

>Differences in pain perception are just one little factor in the
>diagnostic process. They should be considered, but they should almost
>never account for a significant difference in approach, diagnosis, tests,
>Carey Gregory

    Almost never?  "What, never?"  "Well, hardly ever!" sings the
chorus.  I really can't pass up this opportunity to have you explain

                                  Gilbert Sullivan, M.D.

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