Sophia Orlando

Public Health Honors Ad Hoc Project

Design Plan

Understanding Women’s Pain: A Continuing Medical Education Curriculum

I. Rationale
Women’s pain is often improperly treated, disregarded and ignored. Understanding
Women’s Pain seeks to address this issue as a targeted intervention for general medical
professionals. The curriculum is designed to educate general practitioners (GPs) about pain
treatment disparities, sex-based differences in pain and gender-specific pain conditions that
may present in their patients. As a certified continuing medical education (CME) course, the
curriculum is designed for practicing physicians who may be required to complete annual CME
credits as required by the state or hospital in which they practice. The course is implemented
online in five modules along with a brief introduction and conclusion, with each module
followed by a quiz to self-evaluate learning and accompanied by a list of further learning
resources. Following completion of all modules, participants will apply their learning through
patient case scenarios. The total course can be completed in less than 2 hours, including the
time to complete learning exercises.
The first module provides an overview of the gender disparity in pain treatment that
exists in medicine. Along with the second module, which outlines sex-based differences in the
experience of pain, this first section of the course provides a foundation for deeper exploration
of pain conditions that uniquely impact women and that are insufficiently covered in GP
training. The third, fourth and fifth modules focus on endometriosis, dysmenorrhea and
vulvodynia respectively.
The topics discussed in this course draw upon the experiences of real women. One of
the goals of this course is to address the paternalistic and often misogynistic relationship
between physicians and their female patients that allows for dismissal of their pain and
prolonged time until diagnosis. In order to begin to change perspectives of physicians, this
course will include qualitative data and the experiences of real women who have been
impacted. The following rationale provides a brief justification for the course.

Treatment disparity

Research repeatedly shows that doctors do not view women’s pain as seriously or with
the same urgency as pain experience by men. Gender disparities in treatment have implications
for the quality of care women receive as well as how quickly care is delivered. Women wait an
average of 65 minutes before being treated for abdominal pain while men presenting with the Commented [SMO1]: Intent versus reality; doctors
intentions might be good (they might get defensive)
same symptoms wait an average of 49 minutes.1 Additionally, women are less likely to receive
diagnostic procedures or interventions for chest pain. 2 Some studies have also shown that
women are more likely to be prescribed sedatives whereas men are more likely to be
prescribed analgesics in response to pain. While not unanimous, current findings suggest that
gender bias may be involved in pain treatment and influenced by clinical presentations of the
Commented [SMO2]: Psychological impacts
patient or the sex of the provider.
Commonality is pain, difficulty in diagnosing (how do
physicians respond to pain, is there something they can do to
make the patient feel listened to)
Gender-based differences in pain

Disparities in treatment of pain conditions exist despite the fact that women report
more acute and chronic pain than men.3 Women are also more sensitive to experimentally
induced pain, which suggests that women have lower pain thresholds.2 This may help explain
the observed higher rates of treatment-seeking behaviors for pain conditions among women.1
Epidemiological studies have found higher use of pain medication as well as alternative forms
of pain management among women, even when controlling for pain severity and frequency
across gender.4
The factors that underlie these differences are complex and range across biological,
cultural, social and psychological origins. The multifactorial nature of this phenomenon makes
research regarding gender-based pain differences exceedingly difficult. While there is no
consensus in regards to the cause of these differences, current research findings point to a
need for clinical approaches to women’s pain that better reflect variations between sexes.

Lack of knowledge in health care professionals of gender specific pain

There are some pain-inducing conditions that uniquely affect women. Conditions such
as endometriosis, vulvodynia and dysmenorrhea only impact those with female genitalia. These
conditions may present with very general symptoms that lead women to consult primary care
physicians before being referred to gynecological specialists. However, general practitioner
knowledge of these conditions is often lacking and contributes to significant delays in
treatment. The delays due to lack of knowledge are on top of those that may result from
physician dismissal or disbelief of women’s experiences. This CME seeks to increase knowledge
of the endometriosis, vulvodynia and dysmenorrhea as well begin a conversation about the
gender bias present in medical treatment.
Endometriosis causes chronic pelvic pain due to growth of endometrial tissue outside of
the uterus. The prevalence of endometriosis in the United States is approximately 1 in 10
women. Despite the significant impact, studies suggest that women experiencing endometriosis
are misdiagnosed or dismissed and as a result typically visit multiple providers before receiving
an accurate diagnosis. Half of women with endometriosis see at least five health care
professionals before diagnosis or referral.5,6 A 2017 study estimated that there is a 2.4-year
delay from onset of symptoms to first physician consultation and an additional 2.0-year delay
from consultation to diagnosis.7 Endometriosis can present in many ways and its symptoms
overlap with conditions including irritable bowel syndrome and pelvic inflammatory disease.
This overlap creates difficulties in differentiating between conditions, especially for general
practitioners whose knowledge and training in this area is extremely limited. Patients who seek
care from a primary care physician experience a 30% longer delay in diagnosis than those who
seek care from an OB/GYN.7 Additionally, time from first consultation to diagnosis was almost
two times shorter among those diagnosed by an OB/GYN. 7 This points to the importance of
increasing general practitioner knowledge surrounding endometriosis in order to limit the time
women spend unaware of their diagnosis.
Dysmenorrhea, also referred to as menstrual pain, is one of the most common causes of
pelvic pain.8 Estimates of the prevalence of dysmenorrhea vary widely as the condition goes
widely underreported and lacks clear diagnostic criteria. Some estimates put the prevalence
between 45% and 95% of menstruating women globally.9 Dysmenorrhea is also the leading
cause of school absences and lost work hours for women.9 Despite its impact on the quality of
life for women, dysmenorrhea is often poorly treated or dismissed by medical practitioners or
dismissed by women themselves. In the United States, up to 86% of women with dysmenorrhea
do not seek care from health clinicians. 9 Menstrual pain may be seen as a natural part of the
menstrual cycle rather than as a part of a disorder that has medical treatment. Women also
avoid seeking treatment because they believe health professionals will dismiss their symptoms
as inconsequential.9 The gap between the number of women who have dysmenorrhea and
those that seek treatment can be ameliorated by increased training of physicians to avoid
trivializing symptoms.
Vulvodynia refers to chronic pain or discomfort in the vulva. This is an especially difficult
condition to diagnose because it is often identified only through excluding all other potential
causes.10 Studies have estimated the prevalence somewhere between 4% and 16% of the
female population in the U.S.10 A study investigating the knowledge of junior gynecologists
regarding vulvodynia found a lack of any basic form of training surrounding the condition.11 This
finding is consistent with the level of difficulty involved in obtaining a diagnosis for vulvodynia.
A tiny fraction of women that seek help for their symptoms even receive a diagnosis (around
2%).10 Of these women, approximately 35% attend more than 15 appointments and wait more
than 36 months before receiving a diagnosis of vulvodynia. 10 Qualitative studies suggest that
the limited knowledge of general practitioners was the first barrier women faced in receiving a
diagnosis.10 Lack of expertise in this area may lead to inappropriate referrals, misdiagnosis or
prescription of medications that exacerbate symptoms.10

II. Target Population

The population for this course is primary care physicians or other general practitioners.
Physicians practicing in specialties that may receive referrals due to symptoms related to
endometriosis, dysmenorrhea or vulvodynia may also wish to participate. This course is not
intended to provide in-depth knowledge surrounding these conditions and thus is not
appropriate for gynecologists, obstetricians or other physicians that are more familiar with
women’s health.
The course intends to provide physicians with a strong foundation for recognizing
complex pain conditions they may observe in their female patients and making accurate
referrals in response. The goals of this course may have significant impact on the lives of the
patients these physicians serve. Therefore, it is very important that evaluation of mastery in this
population is rigorous and participants demonstrate clear increases in knowledge.
The course will be designed to take into account the schedules and competing
responsibilities of the target population. GPs have limited time to complete CME courses and
may have limited mental capacity to devote to the curriculum. Material will be presented at the
appropriate level for the education level of the target population, but the relevant research will
be summarized and presented in a manner that does not require extra effort on the part of the
participant. The course can also be completed remotely and does not require completion in one
session. Participants can thus complete the course according to their own schedule.
 III. Description

The table below summarizes the approximate timing of each session, which adds to a
total of 100 minutes to complete the course. The entire course will be administered online so
that participants can proceed through each module at their own pace and from a convenient
location. The course employs the case scenario activity to evaluate learning in addition to
formal testing through quizzes administered at the end of each module. The only necessary
materials are a device capable of accessing the internet and access to Wi-Fi. The course will also
provide a set of readings for further learning and to accompany material presented in the
modules.

Introduction: 5 minutes
Module 1- Treatment Disparities in Women’s Pain: 10 minutes
Quiz 1: 5 minutes
Module 2- Sex-Based Differences in Pain: 10 minutes
Quiz 2: 5 minutes
Module 3- Endometriosis: 10 minutes
Quiz 3: 5 minutes
Module 4- Dysmenorrhea: 10 minutes
Quiz 4: 5 minutes
Module 5- Vulvodynia: 10 minutes
Quiz 5: 5 minutes
Patient Case Scenarios: 15 minutes
Conclusion: 5 minutes

IV. Objectives

Terminal Objective
Given five online modules and five opportunities to self-evaluate learning through
online quizzes, each Understanding Women’s Pain participant should be able to diagnose and
refer each patient case scenario without error.

Enabling Objectives
Given five online modules and five opportunities to self-evaluate learning through
online quizzes, each Understanding Women’s Pain participant should be able to:
 Identify at least two consequences of pain treatment disparities for women
 Describe at least three symptoms of endometriosis
 Describe at least three symptoms of dysmenorrhea
 Describe at least three symptoms of vulvodynia
 Diagnose and refer each patient case scenario without error

V. Evaluation Strategy
 This course will use evaluation at the learning level throughout the modules and
following training. The quizzes that follow each module serve to evaluate learning objectives
and ensure that participants are retaining information. Following training, the patient case
scenarios evaluate the ability for participants to apply their learning as a measure of how they
will do in real-life patient encounters.
Participants will also take a survey following training to evaluate the course itself
including the quality of materials and research presented. Their responses will be used to
improve the modules for further participants.
Participant Prerequisites: Participants must have a medical license in order to register
for the course. The course is not limited to general practitioners, but it is geared towards their
level of expertise.
 References

1. Chen et al. Gender Disparity in Analgesic Treatment of Emergency Department Patients

with Acute Abdominal Pain. Academic Emergency Medicine. 2008;15(5): 414-418. doi:
10.1111/j.1553-2712.2008.00100.
2. Fillingim et al. Sex, Gender, and Pain: A Review of Recent Clinical and Experimental
Findings. Journal of Pain. 2009;10(5): pp.447–485. doi:10.1016/j.jpain.2008.12.001.
3. Unruh, A.M. Gender variations in clinical pain experience. Pain, 1996;65(2): pp.123–167.
doi: 10.1016/0304-3959(95)00214-6
4. Paller, C., Campbell, C., Edwards, R., & Dobs, A. Sex‐Based Differences in Pain Perception
and Treatment. Pain Medicine. 2009;10(2): pp.289–299. doi:10.1111/j.1526-
4637.2008.00558.x.
5. Ballweg, M., Cowley, T., Drury, C., McCleary, K., Veasley, C. Chronic Pain in Women:
Neglect, Dismissal and Discrimination. http://www.painmed.org/files/cecpw-policy-
recommendations.pdf. Published May, 2010. Accessed [November 24, 2018].
6. Shah, D., Moravek, M., Vahratian, A., Dalton, V., & Lebovic, D. Public perceptions of
endometriosis: Perspectives from both genders. Acta Obstetricia Et Gynecologica
Scandinavica. 2010;89(5): 646-650. Doi: 10.3109/00016341003657900
7. Soliman, A., Fuldeore, M., & Snabes, M. Factors Associated with Time to Endometriosis
Diagnosis in the United States. Journal Of Women’s Health. 2017;26(7): 788-797. Doi:
10.1089/jwh.2016.6003
8. Lacovides, S., Avidon, I., & Baker, F. What we know about primary dysmenorrhea today:
A critical review. Human Reproduction Update. 2015;21(6): 762-778.
9. Chen, C., Shieh, C., Draucker, C., & Carpenter, J. Reasons women do not seek health care
for dysmenorrhea. Journal of Clinical Nursing. 2018;27(1-2): E301-E308. Doi:
10.1111/jocn.13946
10. Shallcross, R., Dickson, J., Nunns, D., Taylor, K., & Kiemle, G. Women's Experiences of
Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward
Diagnosis. Archives of Sexual Behavior. 2018:e 1-14.
11. Toeima, E., & Nieto, J. Junior doctors’ understanding of vulval pain/Vulvodynia: A
qualitative survey. Archives of Gynecology and Obstetrics. 2011;283(Supplement 1):
101-104.