Are Men (With FM) Different From Women?
By Muhammad B. Yunus, MD

“I’m a man…able to do anything. The head of my family, the warrior, the hunter, the king of the hill,” one man begins. Then his anger comes alive. “People used to respect me, and now how can anyone respect what I’ve become? Weak, frail, in pain night and day, tired all the time, and not enough energy to do anything.”

It is clear that men with fibromyalgia suffer as much as women. Like women, men with FM also have generally severe pain and severe functional difficulties. Other symptoms, such as sleep difficulties, are also similar to those in women. Fatigue in most men is very bothersome. Additionally, psychological factors such as anxiety, stress, and depression are just as distressing in men as in women. 

And yet, fibromyalgia is not often diagnosed in men since it is viewed as a “woman’s disease.” Thus men’s misery goes largely unnoticed and untreated. Part of the problem is cultural in the sense that many men are reluctant to seek help and instead suffer in silence. They do not want to be seen as weak.

Studying Men with FM
Studies involving clinic patients, including many of our own, show that only five to seven percent of FM patients are men. However, population studies show the prevalence of this disease among men to be greater—12 -14 percent (1, 2). This would imply that many men with fibromyalgia do not seek healthcare.

Only a limited number of studies have directly addressed the issue of fibromyalgia among men (3-5). Two from the United States, one based on clinic patients (3) and the other on the general population (4), have shown similar results: fatigue, morning fatigue, sleep difficulties, irritable bowel syndrome, and hurting all over were significantly less common among men than women. Moreover, the total number of tender points was fewer among men. Similar to our study (3), a population study from Canada demonstrated fewer symptoms among men (2). However, no differences were found between men and women in age, education, severity of pain, duration of stiffness, tension-type headaches, overall (global) severity, and general health status (3, 4).

The report from Israel (5), however, showed different results from those in the U.S. (3, 4). in several areas. In general, FM was worse among men. Men had significantly more severe symptoms, including pain, fatigue, morning stiffness and irritable bowel syndrome. Similarly, quality of life was poorer among men (5). It is unknown if generally worse symptoms among men in this population were due to cultural or other factors. There was no significant difference in the years of education between men and women in this study.

Three U.S. studies showed that men and women with fibromyalgia have similar poor physical functioning (3, 4, 6). However, another investigation from the Mayo Clinic in Rochester, Minn., found men with fibromyalgia to have more physical limitations than women (7). This is similar to the Israeli report (5). From these studies one may conclude that men with fibromyalgia have a degree of physical functioning as poor as, if not worse than, women. 

It seems that disability in men seen in a pain clinic (including patients with FM and myofascial pain syndrome) is more directly related to pain rather than depression, whereas disability among female patients is more likely mediated via negative mood rather than pain (8).

Our study showed no differences between men and women with fibromyalgia in levels of anxiety, stress, and depression as measured by validated instruments (9). Statistically speaking, in fact, the results were strikingly non-significant. As we had discussed (9), no significant differences were found in the psychological status between men and women in other conditions similar to fibromyalgia, e.g. IBS and tension-type headaches.

Similar to our study, Wolfe and his colleagues also failed to find significant differences in anxiety and depression between men and women with FM (4). Interestingly, Buskila and his associates from Israel did not find gender differences in anxiety and depression among their male fibromyalgia patients as compared with women despite generally more severe disease among men in this population (5). Thus, contrary to some studies in the general population, men with fibromyalgia are just as likely to have emotional distress as women.

Why the Gender Differences in Fibromyalgia?
Unfortunately, the answer is disappointing and unsatisfactory. Similar to studies of fibromyalgia patients in the clinic (3) or the general population (4), studies of the general population (10) or a small number of healthy individuals (11) showed fewer tender points or a higher pain threshold among men than women. Studies in rats have also shown a higher pain threshold among the males (12). Thus, it is unlikely that the greater sensitivity of women (with or without fibromyalgia) to painful stimuli is solely determined by cultural bias. Biologic factors clearly play an important role.

Studies of sex hormones in asymptomatic women with low pain threshold, or in those with fibromyalgia and other central sensitivity syndromes (13) such as IBS or headaches, have not shown a consistent abnormality. Hormonal fluctuations during different menstrual phases make such studies challenging.

Both genetic and non-genetic factors (such as hormones) are likely to govern greater pain sensitivity among females. Sex steroids have been shown to modulate functions of neurotransmitters in the brain which synthesize such hormones (14). Estrogen increases the excitatory function of the nervous system and also affects the levels of other neurotransmitters, such as serotonin.

Estrogen seems to play a role in pain modulation in women with chronic pain, but the nature of these changes is not consistent among studies, and they vary in different chronic pain conditions (14). One study in fibromyalgia found no differences in estrogen, progesterone, and other sex hormones during the follicular phase of menstruation between patients and controls (15).

FM’s Other Impacts
 “Heartbreak is a symptom of fibromyalgia as far as I’m concerned,” said one man in an online FM forum.

Often the cause of such heartbreak is family, friends, and co-workers. If few understand the pain of fibromyalgia among women, such apathy is worse for men.

Men are not particularly empathetic toward other men’s suffering, particularly when there are no apparent physical signs and when doctors continue to declare that all tests are normal. In fact, studies have shown that men are less empathetic than women (16). Friends soon begin to stop calling and cease to miss a patient’s participation in favorite activities.

Young children do not understand why Dad stopped playing with them or taking them places as he used to. Frictions in marriage or relationships are not uncommon. Sexual dysfunction, including a lack of sexual desire, occurs in men as much as in women. Pain, fatigue, depression, poor sleep, loss of self-esteem, and side effects of many antidepressant drugs contribute to such dysfunction.

Loss of a job, particularly in those with physical labor, can be devastating to self-esteem, causing depression, guilt, and more suffering. Once out of work, procuring disability benefits is a nightmare. Financial hardship and monetary ruin ensue in some cases, only aggravating the torment.

Fibromyalgia in war veterans poses another special challenge. Severe physical and emotional stress are important contributory factors in bringing about the neurochemeical abnormalities of this disease, resulting in distressing symptoms and disability. Recognition and acceptance of fibromyalgia by the military is of vital importance so that adequate treatment and medical support can be provided as soon as possible. 

There Is Help
The first person to help a patient should be himself. Accepting that symptoms are real (based on objective abnormal neurochemistry) and seeking medical help are the first step. The role of an understanding and supportive physician cannot be overemphasized.

I ask a patient to have his spouse or significant other accompany him during a physician visit. Family’s understanding of the disease and its genuine nature provides the basis for an empathetic support system at home. The patient should be assured by a physician that, while the symptoms are real and based on demonstrable neurochemical imbalance, fibromyalgia does not cause tissue damage.

 A compassionate physician should help a patient undertake self-care and self-responsibility that include a positive attitude, physical exercise, appropriate sleep hygiene, avoiding stress, and employing relaxation techniques that can be practiced at home. Despite much pain and fatigue, every fibromyalgia patient can exercise. The key is to “start low, go slow.” Patients may begin with as little as five minutes of exercise and increase by only two minutes every week (as tolerated).

The form of exercise should be chosen by the patient so that he does not find it boring. This may include walking, swimming, or dancing movements with music. I ask a patient to keep a diary or chart of such activities that records time spent in the exercise and the pace of such exercise, both of which should be gradually increased as tolerated. The ultimate goal of these exercises is to achieve cardiac fitness that is measured by an increased pulse rate. It may take some time to achieve this goal, but a patient should continue his exercise on a regular basis. Pulse rate should also be recorded in the chart. Research on health-related behavior has shown that such record-keeping is effective in establishing a habit of regular exercise and in losing weight. The chart should be presented to the physician during each visit.
Sleep may be disturbed in fibromyalgia by muscle and joint pain, heartburn, noise, caffeine intake within four hours of bedtime, emotional stress and worries, restless legs syndrome, and waking up to pass urine. These issues should be addressed and treated.

A patient should always be encouraged to maintain employment, even if it is part-time. Employment keeps one’s mind occupied so that less time is focused on pain. It also provides wages and helps maintain self-esteem. Disability benefits should be the last option. A physician should communicate with an employer regarding adjustment of physical work (such as restriction of heavy lifting) and providing opportunity to stand and walk and stretch every hour or so in a sedentary job. The important issue of both physical and mental stress at work should also be addressed.

The treatment of fibromyalgia in men is no different than in women, and the response rate is generally similar. Besides the non-pharmacological approach (which may include biofeedback, cognitive behavioral therapy for coping strategies, and other measures), a variety of medications have been found to be efficacious in fibromyalgia. These include drugs that boost serotonin and norepinephrine—the neurotransmitters that normally inhibit pain and have been found to be decreased in fibromyalgia. Though some of these drugs are anti-depressants, not all of them are—providing an aspect of evidence that depression and fibromyalgia are not the same disease.

Depression does not cause fibromyalgia, but contributes to worsening of symptoms. Thus, depression should be treated adequately. Freedom from depression motivates a patient to do exercise and engage in other healthy behaviors and attitudes. Medications to aid sleep should be prescribed as necessary. Dopamine is another neurotransmitter that is involved in the inhibitory pathway of pain. Drugs that increase dopamine availability (such as pramipexole) have been found to be efficacious in fibromyalgia. Several such drugs are currently undergoing clinical trials.

In conclusion, fibromyalgia in men causes as much pain, disability, and suffering as it does in women—and it is equally treatable in men and women.

References
1. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995;38:19-28.
2. White KP, Speechley M, Harth M, et al. The London fibromyalgia epidemiology study: comparing demographic and clinical characteristics in 100 random community cases of fibromyalgia versus controls. J Rheumatol 1999;26:1577-85.
3. Yunus MB, Inanici F, Aldag JC, et al. Fibromyalgia in men: comparison of clinical features with women. J Rheumatol 2000;27:485-90.
4. Wolfe F, Ross K, Anderson J, et al. Aspects of fibromyalgia in the general population: sex, pain threshold, and fibromyalgia symptoms. J Rheumatol 1995;22:151-6.
5. Buskila D, Neumann L, Alhoashle A, Abu-Shakra M. Fibromyalgia in men. Semin Arthritis Rheum 2000;30:47-51.
6. Goldenberg D, Mossey CJ, Schmid CH. A model to assess severity and impact of fibromyalgia. J Rheumatol 1995;22:2313-8.
7. Hooten WM, Townsend CO, Decker PA. Gender differences among patients with fibromyalgia undergoing multidisciplinary pain rehabilitation. Pain Med 2007;8:624-32.
8. Hirsh AT, Waxenberg LB, Atchison JW, et al. Evidence for sex difference in the relationship of pain, mood and disability. J Pain 2006;7:592-601.
9. Yunus MB, Celiker R, Aldag JC. Fibromyalgia in men: comparison of psychological features with women. J Rheumatol 2004;31:2464-7.
10. Croft P, Schollum J, Silman A. Population study of tender point counts and pain as evidence of fibromyalgia. BMJ 1994;309:696-9.
11. Garcia E, Godoy-Izquierdo D, Godoy JF, et al. Gender differences in pressure pain in a repeated measures assessment. Psychol Health Med 2007;12:567-79.
12. Aloisi AM, Albonetti ME, Carli C. Sex differences in the behavioral response to persistent pain in rats. Neurosci Lett 1994;179:79-82.
13. Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum 2007;36:339-56.
14. Aloisi AM, Bonifazi M. Sex hormones, central nervous system and pain. Hormones and Behavior 2006;50:1-7.
15. Korszun EA, Young NC, Engleberg L, et al. Follicular phase hypothalamic-pituitary-gonadal axis function in women with fibromyalgia and chronic fatigue syndrome. J Rheumatol 2000;27:1526-30.
16. Toussaint L, Webb JR. Gender differences in the relationship between empathy and forgiveness. J Soc Psychol 2005;145:673-85.

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View other articles in vol. 10, no. 5 of FMOnline:
 
In the Spotlight
The Significance of Gender
 Are Men (With FM) Different From Women?

Men with FM
 
In the News
Gender and Drug Abuse
Menstrual Cycle Impacts FM Pain

Feeling Misunderstood?
Weighing in on Exercise

NFA News
A Look Back at Awareness Day

Make Fibromyalgia Visible

Artículos en Español
Hombres con FM