The word “hysteria” is used today to describe expressions of out-of-control emotions, but it was originally coined in the fifth century BC. of Hippocrates, the Greek physician and philosopher. He believed that a woman who showed signs of extreme distress was troubled by her uterus roaming around her body—naming the condition “hysteron” after “hystera,” the Greek word for womb, according to a history of the expression.
Over the centuries, hysteria has been attributed to a variety of causes, from an inadequate sex life to demonic possession.
And although the understanding of hysteria has evolved over the millennia, it was still classified as a mental health condition by the American Psychiatric Association until 1980.
So it comes as no surprise to Jocelyn Fitzgerald, MD, a urogynecologist, pelvic reconstruction surgeon and assistant professor at the University of Pittsburgh School of Medicine, that recent research suggests that women’s health problems—and especially pain—are sometimes misunderstood and dismissed by clinicians.
e.g. one study found that young women with chest pain waited, on average, longer to be seen in the emergency room than young men reporting the same symptoms. The Centers for Disease Control and Prevention updated its guidelines in 2024 to recommend that clinicians offer their patients pain medication for the insertion of intrauterine contraceptive devices (IUDs) after women posted about their pain experiences on social media. And you understand a little fibromyalgiaa condition characterized by generalized pain, fatigue and cognitive problems that is diagnosed mostly in women.
Fitzgerald works with patients who have endometriosis. A condition in which the lining of the uterus grows outside the uterus, endometriosis can produce a number of symptoms, including pain. It is believed to affect approx 1 out of 10 women of childbearing age, but a correct diagnosis can take seven to 10 years, thus delaying treatment.
“It’s an extremely under-researched and very poorly understood disease,” says Fitzgerald. “[Historically, it was] probably most commonly described as female hysteria. [This shows] historical gaslighting and labeling of women as being crazy.”
In general, women’s health has been under-researched. In the United States, women were rarely included in clinical trials until 1993 and remain underrepresented in studies.
When it comes to pain, a symptom that has no objective measure and can be influenced by biological, psychological and sociological factors, understanding gender differences is particularly complicated.
“Women’s pain has been greatly underrecognized or dismissed as psychological in nature, leading to unequal pain treatment,” says Emily J. Bartley, PhD, an assistant professor at the University of Florida College of Dentistry who studies chronic pain. “It’s not just something that’s in someone’s head. Pain is real.”
Biological factors
The experience of pain can be different from person to person, but a research group suggest that biological gender characteristics influence the processing of pain.
For example, several studies have found that sex hormones (including testosterone and estrogen) affect pain, explains Rui Li, PhD, a pain epidemiologist and research assistant professor in the Department of Anesthesiology and Pain Medicine at the University of Washington School of Medicine and a principal investigator at the Seattle Children’s Research Institute.
In particular, some data show that testosterone reduces pain intensity, with effects seen as early as the onset of puberty, according to Li’s research. She and her team analyzed data from a large multicenter study of adolescents and found that over one year, 10- and 11-year-old boys who were pain-free at the beginning of the study and had higher levels of testosterone at the one-year follow-up appointment were less likely to report pain than boys with lower levels of testosterone.
Even in controlled laboratory environments, studies suggest that when men and women are exposed to the same trigger for painful sensations, such as cold, heat or pressure, women tend to express a higher level of pain.
Research shows that that the endogenous opioid system, which is a neurochemical network responsible for the modulation of pain and stress, functions differently in men than in women. These differences appear to make opioid medications less effective for pain relief for women. One study reported that the women in the cohort required, on average, 30% higher doses of morphine than men to achieve a similar level of reported relief.
And yet researchers have documented Although opioid use lowers testosterone levels in men, little is known about the impact of women’s long-term opioid use, including on their bone density and mental health, says Akiko Okifuji, PhD, professor of anesthesiology in the Department of Pain Medicine at the University of Utah.
Some preliminary investigation in rodents suggests that microglia, a type of immune cell that protects the brain from pathogens, participates in the regulation of pain among men but not women. Another survey reported that drugs that target microglia in women may help increase the effectiveness of opioid medications for pain relief.
Other research with rodents suggests that there are gender differences at a genetic level that may influence pain modulation to the International Association for the Study of Pain. The gender differences associated with these mechanisms are poorly understood, in part because until recentlyresearchers often excluded female rodents from laboratory studies due to hormonal fluctuations related to the menstrual cycle.
Psychosocial factors
While Bartley emphasizes that pain is not “just something that’s in someone’s head,” that doesn’t mean that psychological factors aren’t related to the subjective experience of pain.
“There are various psychological and sociological influences, and these factors can alter the experience of and response to pain,” says Bartley. “There is a lot of research looking at how psychological factors such as anxiety and depression often coexist with chronic pain and can amplify the experience.”
Okifuji studies fibromyalgia and has tried to understand the mechanisms that result in chronic pain, especially among women. The research team considered the role of sex hormones in fibromyalgia, but did not find conclusive evidence of a link.
“We now consider pain, especially chronic pain, to be a bio-psycho-social phenomenon,” she says. “Our life experience seems to play a role. It probably influences how our bodies process noxious stimulation.”
There are also proof that gender, in addition to biological sex, can also influence a person’s expression of pain. Biological sex is defined by a person’s chromosomes and sex hormones, and gender is defined as the social and cultural characteristics associated with being male or female.
Bartley says societal gender roles can affect how a person can manage their pain.
“Women tend to be more emotionally focused, seek social support and use more positive self-talk,” she says. “Men tend to use more distraction and avoidance behaviors, which can lead to more negative outcomes.”
While women report higher rates of chronic pain, men are overrepresented among “deaths of despair,” such as by suicide or drug abuse.
Social and environmental factors can also amplify the experience of pain.
Studies have reported that experiences regarding childhood adversitysuch as abuse, neglect or experiencing or witnessing other traumatic events, significant increase the risk of chronic pain later in life. Experiencing discrimination, poverty and other social hardship can increase the likelihood of also reporting chronic pain.
Because multiple factors can contribute to a person’s pain experience, Bartley says patients should have access to a multidisciplinary medical team that can approach the problem from different angles.
While exploring all medical options, clinicians can also direct their patients to resources that can increase resilience to pain, including physical therapy, psychological counseling, mindfulness exercises, yoga and social support, she says.
“As a medical profession, we must step outside the biomedical model and look at [pain] more holistic,” says Bartley.
