FIBROMYALGIA FROM THE GENDER PERSPECTIVE: TRIGGERING, CLINICAL PRESENTATION AND COPING

Costa, Larissa Pereira; Ferreira, Márcia de Assunção

doi:10.1590/1980-265X-TCE-2022-0299en

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Brasil

Texto & Contexto - Enfermagem

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Sumário

Literature review • Texto contexto - enferm. 32 • 2023 • https://doi.org/10.1590/1980-265X-TCE-2022-0299en copy

FIBROMYALGIA FROM THE GENDER PERSPECTIVE: TRIGGERING, CLINICAL PRESENTATION AND COPING

LA FIBROMIALGIA DESDE LA PERSPECTIVA DE GÉNERO: DESENCADENAMIENTO, PRESENTACIÓN CLÍNICA Y AFRONTAMIENTO

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to identify the gender-based differences regarding triggering, clinical presentation and coping of fibromyalgia.

Method:

an integrative literature review of the narrative type and conducted in five stages, about how research studies discuss the gender-based differences regarding fibromyalgia. It was carried out in November 2022 with the fibromyalgia/fibromialgia and gender/gênero descriptors in the LILACS, MEDLINE, BDENF and IBECS databases via BVS and PubMed. The studies included were those published in the last 10 years, available in full and of free access, in English, Portuguese and Spanish.

Results:

a total of 16 research studies conducted in United States, Spain, Mexico, Portugal, Egypt, Israel, Italy and Colombia were analyzed. No studies were found in Brazil, an only one of them includes a nurse as author. There is a prevalence of fibromyalgia in females and it is agreed that belonging to this gender can be a risk factor for the disease, due to the lower pain threshold and greater sensitivity to pressure and temperature. Men and women have different pain perceptions and experiences, which can generate underdiagnosis among the former. There are few male participants in the research studies. Only one survey addressed the transgender population.

Conclusion:

there are divergent conclusions, with controversial data and hypotheses to explain the diagnostic disparity between the genders, and the low number of diagnosed men impacts on research studies. There is a broad field to be explored in Brazil about this topic and there is an evident need for research studies with transgender people. Analyses that correlate all genders may help reorganize fibromyalgia management to promote the patients' well-being and quality of life.

DESCRIPTORS:
Fibromyalgia; Chronic pain; Gender; Sex; Literature review

Identification Year	Journal/ Language	Type of study	Objective	LE*
11212. Moshrif A, Shoaeir MZ, Abbas AS, Abdel-Aziz TM, Gouda W. Evaluating gender differences in egyptian fibromyalgia patients using the 1990, 2011, and 2016 ACR criteria. Open Access Rheumatol [Internet]. 2022 [cited 2022 Nov 3];14:67-74.Available from: https://doi.org/10.2147/OARRR.S358255 https://doi.org/10.2147/OARRR.S358255... 2022	Open Access Rheumatol English	Cross-sectional and prospective study	To assess gender-based differences in terms of characteristics of the symptoms, cognitive dysfunction and disease severity in Egyptian patients with FM, considering the ACR 1990, 2011, and the latest ACR 2016 diagnostic criteria.	3
21313. Iannuccelli C, Lucchino B, Gioia C, Dolcini G, Rabasco J, Venditto T, et al. Gender influence on clinical manifestations, depressive symptoms and brain-derived neurotrophic factor (BDNF) serum levels in patients affected by fibromyalgia. Clin Rheumatol [Internet]. 2022 [cited 2022 Nov 3];41(7):2171-8.Available from: https://doi.org/10.1007/s10067-022-06133-y https://doi.org/10.1007/s10067-022-06133... 2022	Clin Rheumatol English	Cross-sectional study	To assess the influence of gender on the clinical manifestations and to investigate the BDNF serum levels as a potential biomarker for fibromyalgia.	3
31414. Henao-Perez M, López-Medina DC, Arboleda A, Monsalve SB, Zea JA. Patients with Fibromyalgia, depression, and/or anxiety and sex differences. Am J Mens Health [Internet]. 2022 [cited 2022 Nov 3];16(4):15579883221110351.Available from: https://doi.org/10.1177/15579883221110351 https://doi.org/10.1177/1557988322111035... 2022	Am J Mens Health English	Cross-sectional study	To explore the association of sociodemographic and clinical factors in fibromyalgia patients with depression and/or anxiety.	3
41515. Conversano C, Ciacchini R, Orrù G, Bazzichi L, Gemignani A, Miniati M. Gender differences on psychological factors in fibromyalgia: a systematic review on the male experience. Clin Exp Rheumatol [Internet]. 2021 [cited 2022 Nov 3];39 Suppl 130(3):174-85.Available from: https://doi.org/10.55563/clinexprheumatol/73g6np https://doi.org/10.55563/clinexprheumato... 2021	Clin Rheumatol English	Systematic Review	To systematically review the available findings on men affected by fibromyalgia, to highlight their psychological and clinical characteristics, and to highlight the therapeutic options available for this population group.	1
51616. Levit D, Yaish I, Shtrozberg S, Aloush V, Greenman Y, Ablin JN. Pain and transition: evaluating fibromyalgia in transgender individuals. Clin Exp Rheumatol [Internet] 2021 [cited 2022 Nov 3];39 Suppl 130(3):27-32.Available from: https://doi.org/10.55563/clinexprheumatol/pq0qp6 https://doi.org/10.55563/clinexprheumat... 2021	Clin Rheumatol English	Cross-sectional and retrospective cohort study	To assess the prevalence of fibromyalgia among transsexual individuals.	3
61717. Meester I, Rivera-Silva GF, González-Salazar F. Immune system sex differences may bridge the gap between sex and gender in fibromyalgia. Front Neurosci [Internet]. 2020 [cited 2022 Nov 3];13:1414.Available from: https://doi.org/10.3389/fnins.2019.01414 https://doi.org/10.3389/fnins.2019.01414... 2020	Front Neurosci English	Hypothesis	To present the biological data of the autoimmune hypothesis that can explain the female prevalence of fibromyalgia, followed by how it can explain the central sensitization and sleep disturbance that characterize the syndrome.	4
71818. Jiang L, D'Souza RS, Oh T, Vincent A, Mohabbat AB, Ashmore Z, et al. Sex-related differences in symptoms and psychosocial outcomes in patients with fibromyalgia: a prospective questionnaire study. Mayo Clin Proc Innov Qual Outcomes [Internet]. 2020 [cited 2022 Nov 3];4(6):767-74.Available from: https://doi.org/10.1016/j.mayocpiqo.2020.06.009 https://doi.org/10.1016/j.mayocpiqo.2020... 2020	Mayo Clin Proc Innov Qual Outcomes English	Prospective study	To investigate gender-related differences in patients with fibromyalgia in terms of demographic and clinical characteristics, including number of pain points, mood disorders, sleep problems, severity of the FM symptoms, fatigue, cognitive dysfunction and quality of life.	3
81919. Wolfe F, Walitt B, Perrot S, Rasker JJ, Häuser W. Fibromyalgia diagnosis and biased assessment: sex, prevalence and bias. PLoS One [Internet]. 2018 [cited 2022 Nov 3];(9):e0203755.Available from: https://doi.org/10.1371/journal.pone.0203755 https://doi.org/10.1371/journal.pone.020... 2018	PLOS One English	Analysis of databases from longitudinal research studies	To define the role of environment, severity, prevalence of symptoms and gender in the diagnosis of fibromyalgia and, when possible, to measure the extent and mechanisms of biased diagnostic.	3
92020. Arout CA, Sofuoglu M, Bastian LA, Rosenheck RA. Gender differences in the prevalence of fibromyalgia and in concomitant medical and psychiatric disorders: a national veterans health administration study. J Womens Health (Larchmt) [Internet]. 2018 [cited 2022 Nov 3];27(8):1035-44.Available from: https://doi.org/10.1089/jwh.2017.6622 https://doi.org/10.1089/jwh.2017.6622... 2018	J Womens Health (Larchmt) English	Quantitative research study	To compare sociodemographic characteristics, medical and psychiatric comorbidities, and use of services among veterans diagnosed with fibromyalgia when compared to veterans with other pain diagnoses; to examine differences between men and women diagnosed with fibromyalgia in sociodemographic characteristics, concurrent diagnoses and use of services, including psychotropic and opiate prescription fillings; to replicate previous findings on gender-based differences in prevalence and to extend them with an examination of gender-based differences in multimorbidity and use of services.	3
102121. Muraleetharan D, Fadich A, Stephenson C, Garney W. Understanding the impact of fibromyalgia on men: findings from a Nationwide Survey. Am J Mens Health [Internet]. 2018 [cited 2022 Nov 3];12(4):952-60.Available from: https://doi.org/10.1177/1557988317753242 https://doi.org/10.1177/1557988317753242... 2018	Am J Mens Health English	Qualitative research study with interviews and thematic analysis	To understand the phenomenon of fibromyalgia, examining its multiple impacts on men in terms of the interactions in society and the USA health system.	4
112222. Danet A, Prieto-Rodriguez MA, Valcárcel-Cabrera MC, March-Cerdà JC. Evaluación de uma estrategia formativa entre iguales em fibromialgia. Un análisis de género. Aquichan [Internet]. 2016 [cited 2022 Nov 3];16(3):296-312.Available from: https://doi.org/10.5294/aqui.2016.16.3.3 https://doi.org/10.5294/aqui.2016.16.3.3... 2016	Aquichan Spanish	Quantitative and quasi-experimental study with pre- and post-test	To assess, from a gender perspective, the training strategy for fibromyalgia patients of the Patients' School, based on training “among peers”.	3
122323. Segura-Jiménez V, Estévez-López F, Soriano-Maldonado A, Álvarez-Gallardo IC, Delgado-Fernández M, Ruiz JR, et al. Gender differences in symptoms, health-related quality of life, sleep quality, mental health, cognitive performance, pain-cognition, and positive health in spanish fibromyalgia individuals: the Al-Ándalus Project. Pain Res Manag [Internet]. 2016 [cited 2022 Nov 3];2016:5135176.Available from: https://doi.org/10.1155/2016/5135176 https://doi.org/10.1155/2016/5135176... 2016	Pain Res Manag English	Cross-sectional study	To test gender-based differences in sensitivity, impact of fibromyalgia, health-related quality of life, fatigue, sleep quality, mental health, cognitive performance, pain-cognition and positive health in Spanish patients with fibromyalgia and in age-matched individuals without fibromyalgia from the same region; to test the optimal cutoff score of the different “tender points” for women and men.	3
132424. Lourenço S, Costa L, Rodrigues AM, Carnide F, Lucas R. Gender and psychosocial context as determinants of fibromyalgia symptoms (fibromyalgia research criteria) in young adults from the general population. Rheumatology (Oxford) [Internet]. 2015 [cited 2022 Nov 3];54(10):1806-15.Available from: https://doi.org/10.1093/rheumatology/kev110 https://doi.org/10.1093/rheumatology/kev... 2015	Rheumatology English	Cohort study	To quantify the prevalence of fibromyalgia to describe its components - symptom severity score (SSS) and Widespread Pain Index (WPI) - and to identify biopsychosocial predictors of SSS severity as well as WPI using a population-based sample comprised by young adults.	3
142525. Pujal i Llombart M, Mora E. Dolor, trabajo y su diagnóstico psicosocial de género. Un ejemplo. Univ Psychol [Internet]. 2013 [cited 2022 Nov 3];12(4):1181-93.Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=4972787 https://dialnet.unirioja.es/servlet/arti... 2013	Univ Psychol Spanish	Qualitative research study	To describe and understand the phenomena of chronic pain without any organic cause (fibromyalgia) from a feminist and critical perspective through a tool to diagnose this pain with biopsychosocial dimensions: the psychosocial diagnosis of gender.	4
152626. Aparicio VA, Ortega FB, Carbonell-Baeza A, Femia P, Tercedor P, Ruiz JR, et al. Are there gender differences in quality of life and symptomatology between fibromyalgia patients? Am J Mens Health [Internet]. 2012 [cited 2022 Nov 3];6(4):314-9.Available from: https://doi.org/10.1177/1557988312436872 https://doi.org/10.1177/1557988312436872... 2012	Am J Mens Health English	Quantitative research study with application of a questionnaire	To examine the gender-based differences in terms of quality of life and symptoms among patients with fibromyalgia.	3
162727. Castro-Sánchez AM, Matarán-Peñarrocha GA, López-Rodríguez MM, Lara-Palomo IC, Arendt-Nielsen L, Fernández-de-las-Peñas C. Gender differences in pain severity, disability, depression, and widespread pressure pain sensitivity in patients with fibromyalgia syndrome without comorbid conditions. Pain Med [Internet]. 2012 [cited 2022 Nov 3];13(12):1639-47.Available from: https://doi.org/10.1111/j.1526-4637.2012.01523.x https://doi.org/10.1111/j.1526-4637.2012... 2012	Pain Med English	Cross-sectional study	To determine differences in pain, disability, depression and pressure sensitivity between men and women with fibromyalgia syndrome (FMS) and to analyze the relation between pain and pressure sensitivity in FMS.	3

Identification/Year	Synthesis of the main results in relation to the gender of the people with fibromyalgia
11212. Moshrif A, Shoaeir MZ, Abbas AS, Abdel-Aziz TM, Gouda W. Evaluating gender differences in egyptian fibromyalgia patients using the 1990, 2011, and 2016 ACR criteria. Open Access Rheumatol [Internet]. 2022 [cited 2022 Nov 3];14:67-74.Available from: https://doi.org/10.2147/OARRR.S358255 https://doi.org/10.2147/OARRR.S358255... 2022	Higher proportion of women with fibromyalgia. Women present more symptoms, more pain points and greater severity of the disease. The disparities in prevalence are closely related to how the diagnosis is made. Applying diagnostic criteria enables a higher proportion of men diagnosed with fibromyalgia.
21313. Iannuccelli C, Lucchino B, Gioia C, Dolcini G, Rabasco J, Venditto T, et al. Gender influence on clinical manifestations, depressive symptoms and brain-derived neurotrophic factor (BDNF) serum levels in patients affected by fibromyalgia. Clin Rheumatol [Internet]. 2022 [cited 2022 Nov 3];41(7):2171-8.Available from: https://doi.org/10.1007/s10067-022-06133-y https://doi.org/10.1007/s10067-022-06133... 2022	The Brain-Derived Neurotrophic Factor levels are lower in people with fibromyalgia, which can be a possible biomarker for the relation between fibromyalgia and psychopathologies. Gender exerts an influence on the disease, as women present more varied symptomatology and men have more depressive symptoms.
31414. Henao-Perez M, López-Medina DC, Arboleda A, Monsalve SB, Zea JA. Patients with Fibromyalgia, depression, and/or anxiety and sex differences. Am J Mens Health [Internet]. 2022 [cited 2022 Nov 3];16(4):15579883221110351.Available from: https://doi.org/10.1177/15579883221110351 https://doi.org/10.1177/1557988322111035... 2022	Of all 1,106 patients diagnosed with fibromyalgia, 1,052 were women 54 were men. 318 were diagnosed with depression and/or anxiety and 42.6% of them were male, indicating an important relationship between fibromyalgia, depression and/or anxiety and gender.
41515. Conversano C, Ciacchini R, Orrù G, Bazzichi L, Gemignani A, Miniati M. Gender differences on psychological factors in fibromyalgia: a systematic review on the male experience. Clin Exp Rheumatol [Internet]. 2021 [cited 2022 Nov 3];39 Suppl 130(3):174-85.Available from: https://doi.org/10.55563/clinexprheumatol/73g6np https://doi.org/10.55563/clinexprheumato... 2021	Men with fibromyalgia may present fewer pain points when compared to women. There may be certain variation in the symptoms and a catastrophic perception of the future, impacting on the male identity and social role. These affects and attitudes lead to silence, culminating in underdiagnosis, non-treatment and reduction in men's self-esteem. Therefore, they present worse coping with the disease, and are generally anxious and depressive when compared to women.
5¹⁶ 2021	Stress and trauma are important triggers for the onset of fibromyalgia and, due to psychological overload and gender dysphoria, fibromyalgia is highly prevalent among Israeli transgenders.
61717. Meester I, Rivera-Silva GF, González-Salazar F. Immune system sex differences may bridge the gap between sex and gender in fibromyalgia. Front Neurosci [Internet]. 2020 [cited 2022 Nov 3];13:1414.Available from: https://doi.org/10.3389/fnins.2019.01414 https://doi.org/10.3389/fnins.2019.01414... 2020	Autoimmunity is a hypothesis for the high prevalence of fibromyalgia among women, as it is influenced by gender. Emotional and stressful factors are understood as triggers for onset of the disease, although not as causes. Confirmation of his hypothesis can generate advances in the diagnostic tests for fibromyalgia.
71818. Jiang L, D'Souza RS, Oh T, Vincent A, Mohabbat AB, Ashmore Z, et al. Sex-related differences in symptoms and psychosocial outcomes in patients with fibromyalgia: a prospective questionnaire study. Mayo Clin Proc Innov Qual Outcomes [Internet]. 2020 [cited 2022 Nov 3];4(6):767-74.Available from: https://doi.org/10.1016/j.mayocpiqo.2020.06.009 https://doi.org/10.1016/j.mayocpiqo.2020... 2020	Belonging to the female gender can be a risk factor for more pain points, lower pain threshold and greater sensitivity to pressure and temperature.
81919. Wolfe F, Walitt B, Perrot S, Rasker JJ, Häuser W. Fibromyalgia diagnosis and biased assessment: sex, prevalence and bias. PLoS One [Internet]. 2018 [cited 2022 Nov 3];(9):e0203755.Available from: https://doi.org/10.1371/journal.pone.0203755 https://doi.org/10.1371/journal.pone.020... 2018	There are many biases in the relation between fibromyalgia and gender, as many do not meet the American College of Rheumatology diagnostic criteria, generating biased evaluations about prevalence of the disease between the genders. The results indicate that, in the general population or in an unbiased sample of people with fibromyalgia, a mean of 60% will belong to the female gender.
92020. Arout CA, Sofuoglu M, Bastian LA, Rosenheck RA. Gender differences in the prevalence of fibromyalgia and in concomitant medical and psychiatric disorders: a national veterans health administration study. J Womens Health (Larchmt) [Internet]. 2018 [cited 2022 Nov 3];27(8):1035-44.Available from: https://doi.org/10.1089/jwh.2017.6622 https://doi.org/10.1089/jwh.2017.6622... 2018	High prevalence of fibromyalgia was identified in young women when comparing American veterans who received this diagnosis to those who received other pain diagnoses. These women were younger than the men and more susceptible to associated psychopathologies and headache, whereas the men were more likely to present alcohol dependence, cardiovascular diagnoses, dementia, diabetes and paraplegia.
102121. Muraleetharan D, Fadich A, Stephenson C, Garney W. Understanding the impact of fibromyalgia on men: findings from a Nationwide Survey. Am J Mens Health [Internet]. 2018 [cited 2022 Nov 3];12(4):952-60.Available from: https://doi.org/10.1177/1557988317753242 https://doi.org/10.1177/1557988317753242... 2018	High discrepancy between the prevalence and diagnosis of fibromyalgia in men. The main hypothesis is the influence of social stigma. For men, the impacts on affective and work relations are more significant than for women due to social demands, worsening the harms to men's mental health.
112222. Danet A, Prieto-Rodriguez MA, Valcárcel-Cabrera MC, March-Cerdà JC. Evaluación de uma estrategia formativa entre iguales em fibromialgia. Un análisis de género. Aquichan [Internet]. 2016 [cited 2022 Nov 3];16(3):296-312.Available from: https://doi.org/10.5294/aqui.2016.16.3.3 https://doi.org/10.5294/aqui.2016.16.3.3... 2016	Both men and women mention a negative perception about their health status and of the everyday limitations, although with differences in the experience between the genders. Men have a worse perception of their health, limitations and stress levels, in addition to greater difficulty managing and controlling the physical and emotional symptoms.
122323. Segura-Jiménez V, Estévez-López F, Soriano-Maldonado A, Álvarez-Gallardo IC, Delgado-Fernández M, Ruiz JR, et al. Gender differences in symptoms, health-related quality of life, sleep quality, mental health, cognitive performance, pain-cognition, and positive health in spanish fibromyalgia individuals: the Al-Ándalus Project. Pain Res Manag [Internet]. 2016 [cited 2022 Nov 3];2016:5135176.Available from: https://doi.org/10.1155/2016/5135176 https://doi.org/10.1155/2016/5135176... 2016	There were no gender-based differences in relation to the fibromyalgia symptoms; however, it was identified that men are more affected than women in terms of sensitivity, sleep latency and mental health.
132424. Lourenço S, Costa L, Rodrigues AM, Carnide F, Lucas R. Gender and psychosocial context as determinants of fibromyalgia symptoms (fibromyalgia research criteria) in young adults from the general population. Rheumatology (Oxford) [Internet]. 2015 [cited 2022 Nov 3];54(10):1806-15.Available from: https://doi.org/10.1093/rheumatology/kev110 https://doi.org/10.1093/rheumatology/kev... 2015	It was identified that women are more susceptible to generalized pain. Considering severity of the symptoms, it is related to socioeconomic factors in men, such as schooling level, work situation and income. In turn, the psychological factors are more involved in deterioration among women. There are important gender-based differences in terms of fibromyalgia somatization.
142525. Pujal i Llombart M, Mora E. Dolor, trabajo y su diagnóstico psicosocial de género. Un ejemplo. Univ Psychol [Internet]. 2013 [cited 2022 Nov 3];12(4):1181-93.Available from: https://dialnet.unirioja.es/servlet/articulo?codigo=4972787 https://dialnet.unirioja.es/servlet/arti... 2013	Men with fibromyalgia do not identify with the masculinity model proposed by the hegemonic ideas, thus generating negative behaviors and reduction in quality of life. Women with fibromyalgia also have a feeling of failure given when faced with their socially-imposed role, thus triggering physical and personal crises.
152626. Aparicio VA, Ortega FB, Carbonell-Baeza A, Femia P, Tercedor P, Ruiz JR, et al. Are there gender differences in quality of life and symptomatology between fibromyalgia patients? Am J Mens Health [Internet]. 2012 [cited 2022 Nov 3];6(4):314-9.Available from: https://doi.org/10.1177/1557988312436872 https://doi.org/10.1177/1557988312436872... 2012	Women with fibromyalgia present less vitality in the quality of life assessment than men. Physical impairment is more intense for men with fibromyalgia. Fatigue and tiredness in the morning are more intense for women. However, the female gender seems to employ better strategies to cope with the disease.
162727. Castro-Sánchez AM, Matarán-Peñarrocha GA, López-Rodríguez MM, Lara-Palomo IC, Arendt-Nielsen L, Fernández-de-las-Peñas C. Gender differences in pain severity, disability, depression, and widespread pressure pain sensitivity in patients with fibromyalgia syndrome without comorbid conditions. Pain Med [Internet]. 2012 [cited 2022 Nov 3];13(12):1639-47.Available from: https://doi.org/10.1111/j.1526-4637.2012.01523.x https://doi.org/10.1111/j.1526-4637.2012... 2012	When compared to women, men with fibromyalgia present greater reductions in their physical functions, inabilities and longer pain history. On the other hand, women present higher depression levels, pain intensity, number of pain points and hyperalgesia under pressure.

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