Women in PainNon-Pharmaceutical Approaches to Healing & Thriving

Aviva Romm, MD

Janna

� Janna is a 38-year old mother of two grade-school aged children.

� She lives in a suburban neighborhood in the Midwest.

� She’s married to a successful lawyer.

� She is a top regional real estate agent. Or was.

� Chronic, regular, debilitating pain over 10 years has recently caused her to cut back to very part-time.

� She’s tired, irritable with her family, frustrated with her body.

� It took her 8 years to get a diagnosis of endometriosis, which she has a severe case of.

� Even after several surgeries for the pain, she’s not had relief, so she is taking a varying daily cocktail of NSAIDs and opioids.

Ouch! Many Words for Pain

PainAllodyniaAnalgesiaAnesthesiaDolorosaCausalgiaDysesthesiaHyperalgesia

HyperesthesiaHyperpathiaHypoalgesiaHypoesthesiaNeuralgiaNeuritisNeuropathic PainNeuropathy

Nociceptive PainNociplastic PainNoxious StimulusParesthesiaSensitizationCentral SensitizationPeripheral Sensitization

The Key Causes of Pain

Pain can be related to at least five things.

� Physical problems caused by injury, illness or surgery (disease pain)

� Tense muscles (which may be the body’s reaction to protect injured joints)

� Psychological stress such as fear, anger and frustration

� Depression or other negative emotions/feelings

� Fatigue caused by the disease or by inactivity

“It All Just Hurts” -

The Pain Cycle

Disease

Muscle tension

Stress

Fear/Anger

Frustration

Fatigue

Depression

Women in Pain: Wide Disparities Between Men and Women

Women are at greater risk for several chronic painful disorders, including temporomandibular disorders, fibromyalgia, migraine headache, interstitial cystitis, joint pain, irritable bowel syndrome, complex regional pain syndrome, and trigeminal neuralgia

Painful menses or dysmenorrhea affects up to 90% of women. Numerous women experience vulvodynia, 1 in 10 has endometriosis, and….

One review of findings from more than 60 studies concluded that the prevalence of headaches and migraines is higher for women than men. In the NIH American Migraine Study II, which included more than 29,000 adults, it was estimated that the one-year prevalence of migraine in the U.S. is 18% in women and 7% in men. Women experience more symptoms, greater severity, and longer duration than men.

The NIH reports that there is approximately a 3-to-1 female-to-male ratio in the diagnosis of irritable bowel syndrome in the United States.

Women are up to four times more likely to have chronic fatigue, over three times more likely to be diagnosed with autoimmune disorders, and twice as likely to have rheumatoid arthritis. Post-cesarean p

Women Feel Pain More

• Of note, women have more reasons for pain, and studies show women feel pain more intensely.

o In one study that spanned 17 countries on six continents with more than 85,000 participants, results showed that the occurrence of chronic pain is higher among females than males.

oExperimental data indicate that both a different modulation of the endogenous opioid system and sex hormones are factors influencing pain sensitivity in males and females.

oCyclic hormonal fluctuations have been associated with increased sensitivity to pain

• 1 in 4 U.S. women have experienced intimate partner violence, physical violence or rape compared to one in seven men. Data suggest that this can contribute to pain conditions.

• Women are significantly more likely to experience sleep problems, as well as physical symptoms as a result

The Gender Pain Gap: Women Missed & Dismissed

� Wide disparities in treatment of pain in women compared with men.

� Women are more vulnerable than men to unwarranted psychogenic attributions by health care providers for pain.

� Women in pain are much more likely than men to receive prescriptions for sedatives, rather than pain medication, for their ailments

� Women are half as likely as men to receive pain killers after surgery because doctors often do not take their complaints seriously

� Women and men present the same severity of abdominal pain, men wait an average of 49 minutes before being treated, while the average wait for women is 65 minutes

� Women are consistently prescribed less pain-relieving medication, even when controls for weight are applied.

� A 2000 study published in The New England Journal of Medicine found that women are seven times more likely than men to be misdiagnosed and discharged in the middle of having a heart attack.

Rooted in Sexist, Misogynistic Stereotypes

� Women seen as: ‘dramatic,’ ‘whining,’ ‘nagging,’ ‘complaining,’ ‘overly sensitive,’ ’anxious,’ ‘hypochondriacal,’ ’irrational’ and the classic, ‘hysterical.’

� Clinical studies have found that doctors are more likely to think women’s pain is caused by emotional issues rather than physical causes, even in the presence of clinical tests which show their pain is real.

� Going from doctor-to-doctor increases a woman’s likelihood of a psychiatric diagnosis as the cause of her symptoms

� Another disturbing trend in medical research has found that the more ‘attractive’ medical staff find a patient, the less treatment they receive.

� Yet another found that more put together women are likely to be dismissed as not needing pain medication, while more ‘disheveled’ appearing woman are dismissed as ‘pain med seeking.’

� 70% of the people impacted by pain are women; 80% of pain studies are conducted on male mice or human men.

PainImpact

POOR SLEEP, FATIGUE

COPING FATIGUE, WEARINESS

REDUCED QUALITY OF LIFE, SOCIAL, RELATIONSHIPS,

STIGMA

ANXIETY, DEPRESSION

WORK (OR SCHOOL) ABSENTEEISM, MISSED

OPPORTUNITIES

MEDICATION RISKS

Women and Pain Meds

� Motrin, ibuprofen and other NSAIDS have risks; even short-term use of NSAIDs for just 5 to 14 days has been proven to cause fertility problems, gastric bleeding is increased with just 1 week of use, and heart attack is increased in women, even without prior risk

� Women are more likely to be prescribed opioids with other medications that increase the likelihood of an overdose.

� Between 1999 and 2016, overdose deaths from opioid prescriptions increased by 404% for men and 583% for women.

� Women exposed to an addictive substance develop a drug use disorder more rapidly than men.

Many Meds a Dangerous Road for Women

• A 2001 Government Accountability Office report found that eight out of the 10 prescription drugs removed from the market between 1997 and 2000 posed greater health risks for women.

� Overall, women have a 1.5 to 1.7 times higher chance of having an adverse drug reaction.

� Impact of opioids on women vs. men not elucidated, but evidence suggests women may be more sensitive to these drugs and experience more analgesia yet dose is not adjusted.

� Research suggests that women metabolize drugs differently from men and thus may require distinct doses, yet dosages are rarely broken down by sex. Failing to do so can have disastrous results.

� In 2013, the Food and Drug Administration (FDA) cut the recommended dose of Ambien and other sleep aids containing zolpidem for women by half after numerous instances of women sleepwalking, sleep-eating, and even sleep-driving—some car accidents were reported—while using the drug.

� Recent data (2019) found that women XYZ% of women using opioids for endometriosis pain are also taking benzos for endometriosis-related anxiety; yet this combination increases risk of opioid overdose 10-fold.

Of the more than 350,000 deaths that occurred since 1999 as a result of opioid overdose, an estimated 40% involved prescription opioids.

The majority of women in the case group involving opioid abuse reportedly begin with a medical prescription, used primarily to treat chronic pain or acute postsurgical pain. Endometrial surgery and cesarean section both increase a woman’s risk of being over-prescribed opioids.

Common Pain Causing Conditions

Pelvic Pain

IBS

Fibromyalgia, RA

Endometriosis

Headache, Migraine

Dysmenorrhea

Musculoskeletal Conditions

Hidden Roots of Pain

• Diet - Inflammation, Food IntolerancesInflammation,

Oxidative Stress

• Chronic Inflammation• Gut-brain-painGut Dysbiosis

• Trauma, Stress, ‘Brainflammation’, Decrease in cortisol and pain control

• Stuck In Pain, Inflammation, Pain Perception, Bi-directional

HPA Axis Hypervigilance

• Pain Perception, Inflammation, Bi-directionalPoor Sleep

• Bi-directional, also related to sleep exacerbation, cortisol, Brainflammation, and pain perception

Anxiety, Depression

• Chronic cytokine production and inflammatory injury

Hypothyroid, AI Conditions

Specific Therapies Non-Pharmaceutical Approaches to

Common Conditions

Therapeutic Strategies

Address Root Causes

Body work: Movement, PT, myofascial release, yoga,

hydrotherapy acupuncture, Arvigo, etc.

Biopsychosocial, EMDR, CBT, somatic therapy, meditation

Targeted nutrients/

nutraceuticals

Botanicals

Pain-Less Mindset

Set pain scale improvement

goals

Provide coping tools

Rewrite the pain story

From Pain to Gain –

Learner or Judger

Mindset

Address Root Causes� Sleep

� Gut

� Inflammation

� HPA Axis

� Anxiety/Depression

� Trauma History

� Biopsychosocial model: resilience, coping skills, social support

Root Cause Examples: Gynecologic Pain

� Increased fruit and vegetable intake associated with decreased risk of endometriosis, and endometrial pain

� In one study of 207 women with severe endometriosis pain, 75 percent experienced significant decreases in pain after 12 months on a gluten-free diet, and another study compared 300 women who either went gluten free or took medication; at the end of the study, the group following the gluten-free diet experienced significant reductions in pelvic pain, even without having celiac disease.

� The Nurses’ Health study concluded that there is a strong association between eating trans-fats and having endometriosis, versus a lower risk of endometriosis in women who consumed fats from fish and avocados, instead. More inflammation also means more pain

� Menstrual cramps, depression with PMS, linked to inflammation.� Poor sleep and circadian rhythm disruption associated with significantly

increased dysmenorrhea, as well as pain perception and reduced coping ability.

� LPS secondary to leaky gut are now considered a possible root cause in endometriosis due to immune and inflammatory changes

� Vaginal dysbiosis may also play a role in chronic pelvic pain, due to chronic inflammation in the uterus and pelvis.

Migraines

� Migraine affects about 28 million women in the U.S.� 85% of chronic migraine sufferers are women.� Before puberty, boys are affected more than girls, but during

adolescence, the risk of migraine and its severity rises in girls.

� Roughly 1 in 4 women will experience migraine in their lives.� Three times as many women as men suffer from migraine in adulthood.� More severe and more frequent attacks often result from mid-cycle or

premenstrual fluctuations in estrogen levels.

� About half of female sufferers have more than one attack each month, and a quarter experience 4 or more severe attacks per month.

� More than 4 million people have chronic daily migraine, with at least 15 migraine days per month.

� More than 90% of sufferers are unable to work or function normally during their migraine.

MigrainePain

Natural Rx

Riboflavin

� Migraine treatment has been sparked by the potential role of mitochondrial dysfunction in migraine pathogenesis.

� A randomized, double-blind, placebo-controlled trial of 55 patients who were suffering from two to eight migraines per month found that the administration of oral vitamin B2 at a dose of 400 mg/day compared with placebo resulted in a significantly higher proportion of patients with greater than 50 % improvement in the frequency of headaches (54 versus 19 %), headache days (57 versus 15 %), and the migraine index (headache days and mean severity, 39 versus 8 %).

� The benefits only became significant after three months of therapy.

� Riboflavin is well tolerated and is considered safe and recommended for migraine in pregnancy.

� DOSE: 400 mg/day

Coenzyme Q10

� In a small, randomized controlled trial of 42 patients with migraine, CoQ10 was effective for migraine prevention; significantly more patients treated with CoQ10 (100 mg three times daily) experienced a ≥50 % reduction in attack frequency at three months than patients treated with placebo (47.6 versus 14.4 %).

� DOSE: 150 mg/day

Petasites

� The extract was previously registered as a licensed pharmaceutical medicine in Germany (Petadolex), but the registration expired and it is no longer available in Germany.

� At least two small placebo-controlled clinical trials found some efficacy for Petasites extract in migraine prevention.

� In the larger of these studies, Petasites at a dose of 150 mg daily (given in two divided doses) but not 100 mg daily was effective and well tolerated as preventive therapy for migraine.

� Butterbur contains pyrrolizidine alkaloids (PAs) that are hepatotoxic and potentially carcinogenic; they are removed from the commercially prepared Petasites root extract.

� Gastrointestinal upset, predominately burping, was the most common side effect.

� Do not use in pregnancy or lactation.

� DOSE: 75 to-100 mg BID

Melatonin

� Small, short-term randomized controlled trials evaluating melatonin for episodic migraine prevention have provided conflicting results.

� One such trial found that melatonin 2 mg (extended release) was not more effective than placebo for reducing headache frequency, while another trial reported that melatonin 3 mg (immediate release) was more effective than placebo, and equally as effective as amitriptyline, for reducing headache frequency.

� DOSE: 3 mg/day

Dysmenorrhea

� Several studies have found that supplementing magnesium can reduce menstrual cramps.

� DOSE: 600 mg/day starting about 5 days before period onset, and continuing throughout the month at about 300 mg/day.

� Ginger is widely respected for its anti-inflammatory and pain-relieving effects, with several studies showing impressive results for menstrual cramps and pain. Probably the most reliable and easiest way to take it is powdered in capsules.

� The effective dose is 500 mg three times/day, though up to 3,000 mg/day is considered safe, so you can take 1000 mg 3 times/day or 500 mg 6x/day. It can also help with nausea, vomiting, bloating, and headaches that sometimes come along with crampy painful periods.

Cinnamon

� Cinnamon has been found to be similarly effective for reducing pain, menstrual bleeding, nausea, and vomiting with primary dysmenorrhea.

� The dose in the most impressive study was 420 mg of cinnamon bark in capsules with 2 capsules taken three times/day for the first 3 days of the period.

� Both cinnamon and ginger have also been found to lessen heavy menstrual bleeding. I haven’t used cinnamon much in my practice because the data is newer and I’ve been very impressed with the ginger.

� A 2012 clinical trial found that when a high dose of vitamin D (300,000 IU) was given to women aged 18-40 with vitamin D levels below 45 ng/mL for at least 4 consecutive months, after just two months or two menstrual periods their pain scores decreased by 41% – while there were no improvements in a placebo group.

� Yet other studies have found that 100 mg of thiamine (Vitamin B1), taken daily, can significantly improve even severe menstrual pain.

Vitamins D and B1

Fenugreek

� A recent study found fenugreek seed to benefit symptoms of dysmenorrhea.

� The participants included 101 women of similar age, who received either 900 mg of ground fenugreek seed in capsules 3 times daily or placebo control for the first 3 days of menses for two consecutive cycles.

� Both placebo and fenugreek treatment groups exhibited lower pain levels compared to baseline after two months, but the decrease observed with fenugreek was far more statistically significant.

Endometriosis(and Chronic Pelvic Pain)

� Endometriosis is a chronic gynecologic disorder that affects approximately 10% of women of reproductive age.

� Endometriosis is associated with pain and substantial indirect costs (e.g., lost work time and productivity).

� Up to 87% of women with chronic pelvic pain, defined as pain that persists for more than 6 months, have endometriosis.

� Over the past 20 years, chronic pain has increasingly been treated with opioid therapy. Also, concomitant benzo use increases overdose risk dramatically.

� 7 out of 10 endometriosis patients experience unresolved pain despite medical management

� Endometriosis patients commonly undergo surgical procedures for diagnostic and therapeutic purposes, opioids are also commonly used for postoperative pain management.

:The percentage of women with endometriosis reporting various symptoms is:

� Painful periods (79%)

� Pelvic pain (69%)

� Pain with sex (45%)

� Bowel upset (e.g., constipation, diarrhea) (36%)

� Bowel pain (29%)

� Infertility (26%)

� Ovarian endometrial mass/tumor (20%)

� Pain with urination (10%)

� Other urinary problems (6%)

To Treat Endometriosis and Relieve Pain

Relieve inflammation and Oxidative DamageRelieve

Balance HormonesBalance

Reduce Environmental Triggers (ewg.org)Reduce

Heal Gut Dysbiosis and Leaky Gut (4R Program)Heal

Release Adhesion (Arvigo Massage)Release

Endometriosis Pain Natural Rx - Pycnogenol

� Pycnogenol is a French maritime pine bark extract that has been used as a natural remedy to treat endometriosis.

� In a study published in the Journal of Reproductive Medicine, 58 women with endometriosis were followed at four, 12, 24 and 48 weeks after starting treatment to check for endometriosis symptoms.

� Thirty-two patients in the pycnogenol treatment group took 60 milligrams orally per day for 48 weeks. The 26 other patients were treated in the standard way, using gonadotropin-releasing hormone agonist.

� Treatment with pycnogenol slowly but steadily reduced endometriosis symptoms and lesions.

� Women taking 30 mg twice daily for 48 weeks showed a 33% reduction in pain, including severe pain. While the pain reduction wasn’t as strong as hormonal treatment, it persisted without relapse, unlike the medication group. Further, 5 women in the pycnogenol group became pregnant.

Melatonin

� One study demonstrated that 10 mg of melatonin per day significantly reduces chronic pelvic pain due to endometriosis, pelvic pain during menses and during sex, pain during urination and associated with bowel movements, to the tune of an overall 80% reduction in the need for pain medication in women taking it.

� At this dose, melatonin supports the body’s natural detoxification processes. In animal studies, melatonin led to regression and shrinkage of endometriosis tissue.

� I recommend starting at 1-3 mg/day, and build up, and preferably take it in the evening, as it can make you feel tired. It is the natural substance that increases at night in our brains to tell us to get some sleep!

NAC

� NAC is a powerful antioxidant with some impressive data behind it specifically for endometriosis.

� In a 2013 study of 92 women in Italy, 47 took NAC and 42 took a placebo.

� Of those who took 600 mg of NAC three times a day, three consecutive days each week for three months, 24 patients cancelled their scheduled laparoscopy due to a decrease or disappearance of endometriosis, improved pain reduction or because they had gotten pregnant.

� Fourteen of the women in the NAC group had decreased ovarian cysts, while 8 had a complete disappearance; 21 had pain reduction and 1 became pregnant.

� In the other group, only 1 patient cancelled surgery. A total of 8 women got pregnant in the NAC group, while 6 did in the placebo-only group.

Musculoskeletal

Ginger � Clinical research shows that taking ginger extracts can modestly improve pain in

some patients with osteoarthritis. May be comparable to ibuprofen in a dose of 500 mg twice daily

� Some evidence that ginger might be helpful for decreasing joint pain in patients with RA

o Dose: Up to 2 g ginger powder daily

Turmeric/Curcumin: � NIH: positive studies for UC, Crohn’s, OA, RA

� Antioxidant (downreg of COX2, LOX, NFkB, TNF)

� Analgesia, anti-inflammatory effects.

� Dose: 1200-2400 mg/d curcumin for IBD

o 20 mg black pepper/1 kg curcumin -> approx. 2000% absorption increase

Boswellia

� From osteoarthritis to inflammatory bowel disease, this herb’s ability to reduce inflammation and pain is an important addition to supplements.

� Dose: 350 mg/day three times/day.

� Devil’s Claw: 2 high quality trials found strong evidence that daily doses standardized to 50 mg or 100 mg harpagoside were better than placebo for short-term improvements in pain & rescue medication. RCT: chronic LBP, superior to placebo and better than NSAIDs.

oDose: Products providing 50-100 mg harpagoside daily

� Sam-E: specifically beneficial for osteoarthritis knee pain, the dose is 200-400 mg three times daily.

� Capsaicin from hot peppers, and essential oils of wintergreen, peppermint, and lavender – all used topically – alleviate the discomforts of painful joints and headaches. They usually need to be applied at least 3 times/day to the affected area to be maximally effective

What aboutCannabis or CBD?

� Cannabis has been used as a medicinal herb for thousands of years. As late as the early 20th century it was still included as a medication from many common symptoms in the United States Pharmacopoeia, including for ‘nervous’ conditions, as a general analgesic, and specifically for menstrual and other gynecologic pain.

� Then in the 1930s, it was vilified, and the federal government made it a Schedule 1 drug.

� The need for safer treatments for sleep, pain, and anxiety, has led to a resurgence in use of this plant, as well as research, and with it, changing laws.

� As of this writing, 30 states allow for legal medical use, and many states now also allow legal recreational use.

� Cannabidiol, or CBD, is one of the main cannabinoids, a group of active compounds, in the cannabis plant. Because it isn’t psychoactive, you don’t get high from using CBD

� Possible areas of benefit include sleep, anxiety, spastic pain, including musculoskeletal and dysmenorrhea pain.

� Preliminary research suggests benefit for women with endometrial pain.

� Use as: oTincture (hemp, cannabis), CBD oil orally

� Safety:oCannabis: Overall high level of safety but can cause anxiety, paranoid

response, possible psychiatric concerns in at risk populationsoCDB: generally safe but a has been associated with liver damage in

mice at high doses, as well as some possible herb—drug interactions.

� Product safety remains a wild card. Avoid vaping and edibles; try to find 3rd

party reviewed products; avoid products with ‘big claims’

� CBD Dose: 25 mg 1-2 times daily.

� Cannabis dose: variable, unestablished

Thank you!

To learn more: avivaromm.com/wimi

(References on next slides.)

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