Gender disparities exist in many diseases, from certain types of cancer and heart disease to mental health and autoimmune disorders. One area of medicine where the gender balance of patients is particularly skewed is rheumatology.
Rheumatology encompasses a wide variety of diseases and conditions that affect the joints and soft tissues, the most common of which is osteoarthritis, and many of them are more common among women than men. The Centers for Disease Control and Prevention reports that “women are more likely to develop OA than men, especially after age 50.” The same is true for rheumatoid arthritis, an inflammatory form of arthritis that’s caused by the immune system mistakenly attacking the body’s own tissues. The CDC reports “new cases of RA are typically two-to-three times higher in women than men.”
An even greater disparity is seen in fibromyalgia, a disorder the Mayo Clinic reports is “characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.” The National Fibromyalgia Association reports that between 75 and 90 percent of fibromyalgia cases occur in women. But that means some 10 to 25 percent of people with fibromyalgia are men, and the syndrome might sometimes be overlooked in that population.
What Is Fibromyalgia?
Fibromyalgia is a chronic condition that causes widespread pain. To diagnose it, the patient must experience pain on both sides of the body above and below the waist for more than three months. Other symptoms commonly include:
— Pain and stiffness all over the body.
— Waking up tired or feeling unrefreshed after sleep.
— Cognitive and memory issues or brain fog.
— Headaches or migraines.
— Tingling in hands and feet.
— Digestive problems, including bloating, constipation and irritable bowel syndrome.
— The absence of another condition that could be causing these symptoms.
The CDC reports that “fibromyalgia affects about 4 million U.S. adults, about 2 percent of the adult population.” Other organizations place that estimate higher. The American College of Rheumatology estimates it may affect up to 4 percent of people.
Although some doctors still claim that fibromyalgia is not a “real” disorder or that it’s a catch-all term for when another diagnosis can’t be made, science is beginning to unravel the mystery of this common pain disorder, and while its origins may be in the brain, the pain isn’t just in a patient’s head.
Dr. David Trock, a rheumatologist at Danbury Hospital in Connecticut, says the brains of people with fibromyalgia process pain differently from those of people who don’t have the disorder. “You can think about fibromyalgia as a brain injury or a defect in the way you process sensory information. This is why when you touch someone with fibromyalgia, it hurts them. There’s a pathology there in the brain that is misinterpreting normal touch as pain.”
Why Is Fibromyalgia More Common in Women?
Some of why fibromyalgia is more commonly seen in women is genetic, Trock says. “For example, if you have a mother or a sister with fibromyalgia, your risk of getting it is eight times increased.”
Dr. Kevin Hackshaw, a rheumatologist at The Ohio State University’s Wexner Medical Center, says that genetics doesn’t account for all of the disparity in diagnosis, but it’s unclear why women seem to develop it more often. Some of that goes back to the fact that we don’t yet know everything about fibromyalgia and the people it impacts. “The male population hasn’t been studied nearly as extensively as the female population with fibromyalgia,” Hackshaw says.
While there is a difference between the diagnosis rates and incidence rates, and it’s believed that some men with fibromyalgia aren’t receiving the diagnosis when maybe they should, it does appear that the condition occurs more frequently in women.
[Read: Pain You Shouldn’t Ignore.]
Why Is Fibromyalgia Sometimes Overlooked in Men?
One reason why fibromyalgia is less commonly diagnosed in men relates to how the disorder was previously diagnosed, Trock says. Prior to 2010, “the criteria that we used to use to make a diagnosis of fibromyalgia had some gender bias associated with it.” That criteria required that patients present with pain in “11 out of 18 symmetric tender points above and below the waist. And when those criteria were used, the ratio of female to male was close to 9:1.”
Newer criteria put forth in 2010 reduced the number of symmetric tender points and reduced their importance so that other symptoms could also be considered. These guidelines introduced “something called the symptom severity score, which means that beyond the usual aches and pains, other factors were considered such as nonrestorative sleep, fatigue, irritable bowel, migraine headaches and other associated phenomena that were seen,” Trock says. “When those criteria were applied, the ratio went from 9:1 down to 3:1” for the number of women versus men who were being diagnosed, he says.
Hackshaw agrees that changing the diagnostic criteria has helped some men get the appropriate diagnosis. “Men tended to have fewer tender points. They might have all the cognitive dysfunction,” and other symptoms of fibromyalgia, but without that key component, the diagnosis couldn’t be made. “The idea was if we do away with the tender points, we might be able to identify more men with fibromyalgia,” Hackshaw says.
But changing the criteria can only identify the men who seek help for the disorder. Some men are reluctant to visit the doctor, particularly if it’s for aches and pains that they may not realize are potentially connected to a larger problem. “Men can be a little bit more stubborn or afraid of the doctor or just try to plow through it for whatever reason,” Trock says. “There are so many factors that play into that,” with societal expectations and pressures figuring in prominently.
Diagnostic bias is also thought to be at work in why some men aren’t diagnosed with fibromyalgia when maybe they should be. “When doctors see patients with aches and pains, they may not be thinking about fibromyalgia as readily if there’s a male patient sitting on the table in front of them,” simply because it’s long been thought of as a “woman’s problem” rather than as a syndrome that can affect both sexes. “Some of it is a generational thing, and it’s changing,” Trock says.
Combating diagnostic bias can be as simple as asking your doctor. “For men, sometimes they have to put it on the table,” Trock says. If you think perhaps you might be dealing with fibromyalgia, he recommends speaking up and suggesting it. That way, “the doctor might be alerted to that possibility and start thinking in those terms. You can be your own best advocate,” whether you’re male or female.
Is Fibromyalgia Treated Differently in Men Versus Women?
Trock says his treatment approach “would not be too different” in men versus women. But the first order of business is to make sure that the diagnosis is correct. “You want to make sure you haven’t overlooked things that could mimic fibromyalgia, like Lyme disease or polymyalgia rheumatica,” a condition that causes muscle pain and stiffness in the shoulders and hips, “or other common forms of aches and pains like chronic back pain.”
He says it’s also important to determine whether other conditions could be contributing symptoms. “It’s not unusual for patients with fibromyalgia to also have issues regarding post-traumatic stress disorder, migraine headaches and irritable bowel syndrome. You want to make sure you don’t just zero in on one symptom complex and ignore all the things that are bothering the person,” Trock says.
In addition, trying to pinpoint a triggering factor or episode can be helpful. “Whether it’s in a man or a woman, the first thing I try to do after clarifying the diagnosis is to find out why it happened and when it happened. So often there’s a triggering phenomenon,” such as the onset of PTSD, a concussion or a head injury. “What these things have in common is they interrupt not only your routine but also restorative sleep,” which can lead to symptoms of fibromyalgia. “A good night’s sleep is crucial to protecting yourself against fibromyalgia,” he says, because it’s during the delta sleep phase just before you drop off into the REM sleep phase (when dreaming occurs) when your body gets to work tidying up. During delta sleep, your body is “making growth hormone and insulin-like growth factors, repairing the damage of the day and getting your memories organized and intact so you’re ready for the new day.”
He explains that “if you take a bunch of healthy, normal people and deprive them of sleep night after night, it’s very common for them to develop these predictable symmetric tender points above and below the waist” that are similar to those exhibited in fibromyalgia. Therefore, it’s important to consider what factors could be disrupting sleep — injuries, a new baby, abuse, excessive stress, etc.; the list of potential culprits is lengthy.
These sorts of triggering factors can occur in both sexes, and if fibromyalgia is detected in a man, “it should be treated similarly to fibromyalgia in women,” Hackshaw says. “The medications that are beneficial in women should be also considered in men as well.” But that doesn’t always happen. “Many men who are treated seem to be treated for more of a comorbid (co-occurring) condition rather than receiving treatment that is targeted to classic fibromyalgia,” he says. “Often men with fibromyalgia may be treated for generalized osteoarthritis. Alternatively, women are more likely to be treated with psychotropic medications — things like duloxetine or milnacipran. If there is an underlying depression in men, that might not be addressed as frequently as it should be.”
Even with the revised diagnostic criteria that is now identifying more men with fibromyalgia, “when we look at how men are being treated relative to how women are being treated, when they both have the same diagnosis, you might see the men leave the clinic setting with just anti-inflammatories, whereas the women might leave the clinic setting with SNRIs.” Serotonin–norepinephrine reuptake inhibitors are antidepressant medications used to treat mental health and chronic pain conditions. Desvenlafaxine (Pristiq, Khedezla), duloxetine (Cymbalta), levomilnacipran (Fetzima) and venlafaxine (Effexor XR) are examples of SNRIs.
That difference in approach “might be more a problem related to the practitioner,” Hackshaw says. “Whoever is seeing that individual — it’s still an issue with them not recognizing the neuropathic nature of fibromyalgia and even the prevalence of fibromyalgia.” For men with fibromyalgia who don’t receive the right treatment, “in general they will just continue to have a decreased quality of life,” Hackshaw says.
No matter your sex or gender, if you’re experiencing chronic pain or other symptoms that could be connected with fibromyalgia, you should talk with your doctor. There are treatments available and you may be able to achieve a much higher quality of life with some concerted effort. Plus, it’s smart to find out what’s going on, rather than just trying to “man up” and get on with it. “We should try to not stigmatize people with fibromyalgia just because you can’t measure what they’re complaining of,” Trock says. Even though blood work and X-rays may not show anything abnormal, people with fibromyalgia are “not malingering or complaining. They’re really suffering and they need some attention.”
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