Dr Wendy Holden

In my clinic, a familiar story repeats itself. A woman in her thirties or forties describes years of pain that started quietly and grew steadily worse. She has been told it is stress, or her hormones, or something she needs to learn to manage better. By the time she reaches me at Curaleaf Clinic, she is often close to despair. This is not a handful of unfortunate cases. It is a pattern that runs through several of the conditions I see most often in rheumatology chronic pain clinics. It has consequences that go well beyond a difficult consultation. Women with chronic pain tend to wait longer for a diagnosis, are more likely to have their symptoms attributed to psychological causes, and are significantly underrepresented in the research that shapes how we treat them. Put simply, we have built a system that is slower to recognise pain in women, and slower still to treat it properly once it is recognised. A pattern across conditions Fibromyalgia is diagnosed far more often in women than in men. Women make up the large majority of the patients I see with it, and even population studies using stricter modern criteria put the ratio at somewhere around two to one. It can also be slow to diagnose. A survey of fibromyalgia patients across eight countries found it took, on average, more than two years, and consultations with around four different doctors, before a diagnosis was reached. That delay is not surprising given how the condition presents. Widespread pain with no clear marker on a scan or blood test is easily mistaken for stress, fatigue, or simply something to live with. With each clinician who cannot find a physical cause, a patient often faces another round of tests, another referral, and more waiting. Endometriosis tells a related but distinct story. It affects around one in ten women of reproductive age worldwide, and roughly 1.5 million people in the UK, and is one of the most common causes of chronic pelvic pain we see. Yet the average time from first symptoms to diagnosis in the UK has risen, not fallen – from eight years in 2020 to nine years and four months in the most recent figures from Endometriosis UK. Nearly half of those eventually diagnosed had seen their GP ten or more times beforehand. Periods severe enough to stop someone working or studying are still, too often, treated as something to endure rather than investigate. Then there is chronic widespread pain more broadly, which cuts across rheumatology, gynaecology and pain medicine, and which disproportionately affects women at every stage of the journey, from how their pain is described in a consultation to how quickly they are referred on for specialist review. Why women's pain is so readily dismissed None of this happens because clinicians set out to dismiss their patients. It happens because of assumptions that are old, largely unconscious, and remarkably persistent. The idea that women exaggerate pain, or that their pain has an emotional rather than a physical cause, has a long history in medicine, stretching back to the language of 'hysteria' and the belief that women's bodies were inherently less reliable narrators of their own symptoms. The word hysteria of course, originating from the Greek word for uterus, hystera. The evidence that this bias still operates today is substantial. Researchers studying how people judge others' pain have repeatedly found that when a man and a woman report identical pain, observers, including trained healthcare staff, tend to rate the woman's pain as less severe. This has been described as a 'gender pain gap', and it does not stop at perception. Women whose pain is judged less severe are also more likely to be steered towards psychological support, and less likely to be offered the same pain relief, or the same further investigation, that a man reporting the same symptoms would receive. This matters because a great deal of pain, particularly the kind associated with fibromyalgia, endometriosis and chronic widespread pain, does not show up clearly on a scan or in a blood test. When there is no objective marker to point to, clinical judgement fills the gap, and that judgement is not immune to bias. A patient whose pain is 'unexplained' is at the mercy of how seriously her account is taken, and the evidence suggests that, for women, it is taken less seriously. What the funding gap has cost Underneath the clinical bias sits a research bias that has been building for decades. Women have historically been underrepresented in clinical trials, including trials of pain medicine, which means much of what we think we know about how pain responds to treatment was established in male-dominated samples and simply assumed to apply equally to women. Globally, only around 5% of health research and development funding is directed towards women's health, and roughly four-fifths of even that small share goes to women's cancers – leaving conditions such as fibromyalgia, endometriosis and chronic widespread pain desperately short of the investment their prevalence would justify. In the UK, only around 2% of medical research funding is spent on pregnancy, childbirth and reproductive health, despite reproductive and gynaecological problems affecting a large proportion of women at some point in their lives. The result is a research base that cannot properly answer the questions patients are asking. We do not have anywhere near enough good-quality trial evidence on how chronic pelvic pain should be managed once first-line hormonal and surgical options have been exhausted. We do not have a strong understanding of why fibromyalgia clusters so heavily, though not exclusively, in women, or why some patients respond well to treatment and others do not. Every year this gap persists is a year in which patients are offered less, simply because we have not done the work to know what more might look like. Where medical cannabis fits in This is the backdrop against which I look at the emerging evidence for medical cannabis in these conditions. It is not, and should not be presented as, a solution to a problem this deep-rooted. But it is one of the areas where the evidence base for these specific conditions is beginning to build, and for a small number of carefully selected patients who have exhausted conventional options. After a full specialist assessment, it may be one further avenue worth exploring. Data from the UK Medical Cannabis Registry, drawn from real-world prescribing rather than a trial setting, gives us the clearest picture so far. In a case series of 497 patients treated for fibromyalgia, more than two-thirds of them women, treatment with medical cannabis was associated with improvements across every patient-reported outcome the researchers tracked. This included both fibromyalgia symptom severity and widespread pain, as well as sleep, anxiety and quality of life up to eighteen months. A separate, smaller case series of 63 patients with endometriosis-associated pelvic pain reported similar improvements in pain-specific measures over the same period. These findings have to be read with the same caution I would apply to any observational data. There was no control group and some patients were lost to follow-up. The authors of both studies, including myself, were explicit that this is not yet strong enough evidence to change standard practice. What it does justify is properly designed randomised trials, the kind of investment that has for so long been denied to conditions that predominantly affect women. What this means in practice If you live with fibromyalgia, endometriosis or chronic widespread pain, and feel you have been talked out of your own symptoms more than once, that instinct deserves to be trusted rather than second-guessed. The single most useful thing a patient can do is keep asking, and keep a record of what is happening, so that a pattern of pain becomes harder to explain away as an isolated or subjective complaint. For clinicians, the task is to recognise that an absence of visible pathology is not evidence of an absence of pain, and that a woman describing severe symptoms deserves the same clinical curiosity a man would receive presenting with the same complaint. For the system as a whole, the task is bigger still: funding research into these conditions at a level that reflects how many people they affect, not how quietly those people have historically been expected to cope. Medical cannabis may end up playing a small part in closing that gap for some patients. Closing it properly will take a great deal more than any single treatment can offer. Find out more about how medical cannabis can support womens health here. This is a paid-for article published in conjunction with the brand as part of an advertising campaign. Paid-for content helps support our mission of delivering quality journalism.