Women Receiving Worse Treatment for Back and Neck Pain, UK Study Finds

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Every year, millions of women walk into their doctor’s office with chronic back or neck pain — pain that is real, measurable, and often debilitating — and walk out with a diagnosis that does not fully account for their biology, a treatment plan designed for a different body, and in many cases, a quiet suggestion that what they are experiencing is not as serious as it feels.

A major new study published in Physical Therapy Reviews has confirmed what many of these women have long suspected: the medical system is not treating their pain as well as it treats men’s pain, and the reason is not individual physician negligence or unconscious bias alone. The reason is structural. Clinical guidelines — the formal evidence-based documents that physicians follow when diagnosing and treating musculoskeletal conditions — are riddled with what researchers call male-default bias, systematically ignoring the biological realities of female bodies and delivering care that is, by measurable standards, inferior.

For the 1.2 billion women worldwide living with chronic pain, this study is not just a confirmation of their experience. It is a call for urgent, systematic reform.

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1. What the Study Found — And Why It Matters

Researchers at University College London, led by Dr. Sarah Khalid, conducted a comprehensive audit of 47 major clinical guidelines for musculoskeletal disorders — the category of conditions that includes chronic back pain and neck pain, the two most prevalent causes of disability worldwide. The guidelines reviewed included those issued by the National Institute for Health and Care Excellence, the Royal College of Physicians, the Chartered Society of Physiotherapy, and equivalent international bodies.

The findings were, in Dr. Khalid’s own words, brutal. The guidelines that physicians consult when deciding how to diagnose and treat their patients were found to largely ignore fundamental biological differences between male and female bodies. Hormonal cycles, pregnancy, postpartum recovery, menopause, bone structure, ligament laxity, pelvic anatomy — the full range of biological factors that distinguish female experience of musculoskeletal conditions from male experience — were addressed inadequately or not at all in the vast majority of the guidelines examined.

Hormonal cycles, which alter pain thresholds and joint laxity by measurable amounts across the monthly cycle, were mentioned in only 8 percent of the guidelines reviewed. Pregnancy and postpartum considerations — relevant to 85 percent of women at some point in their lives — appeared in just 12 percent. Menopause, which accelerates bone density loss and muscle mass decline and dramatically changes the musculoskeletal landscape for women in their forties and fifties, was addressed in only 4 percent of guidelines. Pelvic tilt and Q-angle differences — anatomical realities that place women’s lumbar spines under 15 degrees more stress than men’s — appeared in 2 percent. The impact of estrogen-driven ligament laxity, which changes monthly and has direct implications for spine stability, was mentioned in zero percent of the guidelines reviewed.

Dr. Khalid’s summary of these findings was direct: medicine has been built on male data, and women receive male-pattern protocols as a result. No wonder treatments fail them.

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2. The Biology Being Ignored: Why Women’s Pain Is Different

To understand why these guideline gaps cause real harm, it is necessary to understand the specific biological differences that make female musculoskeletal conditions genuinely distinct from male ones — not as a matter of degree, but of kind.

The most pervasive factor is hormonal. Estrogen, the primary female sex hormone, has direct effects on the musculoskeletal system that cycle with the menstrual month. At certain points in the cycle, estrogen loosens collagen throughout the body — a mechanism that evolved to facilitate childbirth but that also reduces the stability of spinal ligaments, increases joint laxity, and alters the mechanical loading on discs and vertebrae. Pain thresholds vary by as much as 30 percent across the menstrual cycle as a result of hormonal fluctuations. A woman presenting with back pain on day 14 of her cycle is experiencing that pain through a different biological filter than the same woman presenting on day 28 — a difference that has treatment implications but that clinical guidelines almost universally ignore.

Pregnancy amplifies these effects dramatically. The shift in spinal curvature caused by a growing uterus, combined with the pelvic instability produced by relaxin hormone and the additional disc pressure from increased body weight, creates a musculoskeletal environment entirely unlike anything described in guidelines designed around male anatomy. Eighty-five percent of pregnant women experience significant back pain. The vast majority of them receive advice calibrated to a body that does not have a uterus.

Menopause introduces a different but equally significant set of changes. Bone density drops by 1 to 2 percent per year in the years immediately following menopause — a rate of loss that has direct implications for disc health, vertebral integrity, and the risk of stress fractures that can present as chronic back pain. Muscle mass declines simultaneously, reducing the core support that protects the spine from mechanical loading. A 55-year-old woman presenting with back pain is navigating a skeletal and muscular environment that has changed fundamentally from what it was a decade earlier, in ways that require different diagnostic thinking and different treatment protocols. Guidelines that do not account for menopause are failing this patient population by design.

Women are also 20 percent more likely than men to develop central sensitisation — the neurological process by which the pain system becomes amplified beyond what the underlying tissue damage would normally produce. This means that women with equivalent structural findings on imaging may experience significantly more pain than male patients, and that treatment approaches focused purely on structural correction may be insufficient without addressing the sensitisation component. Guidelines that treat pain scores as interchangeable between sexes are systematically undertreating female patients with central sensitisation.

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3. The Statistics That Define a Two-Tier System

The research documenting unequal treatment of women’s musculoskeletal pain goes beyond guideline analysis into hard outcome data — and the picture it paints is deeply uncomfortable.

Women are 1.5 times more likely than men to develop chronic back pain before the age of 40, and experience recurrence rates 20 percent higher over the following decade. Despite comprising 62 percent of back pain consultations in the UK’s National Health Service, women receive 40 percent fewer MRI scans and 25 percent fewer specialist referrals than their male counterparts presenting with equivalent symptoms. Women wait 28 percent longer in emergency settings for pain assessment. Men are prescribed opioid medications at doses 15 percent higher than women, despite women consistently reporting higher pain scores — a disparity that reflects an assumption that female pain reports are unreliable or exaggerated rather than evidence of genuinely higher pain levels requiring equivalent pharmaceutical management.

Seventy percent of musculoskeletal clinical studies have used exclusively male subjects. Eighty-two percent of animal model research in this field has used male rodents. Female researchers lead only 22 percent of spine studies, compared to 48 percent in cardiology — a disparity that likely reflects both historical barriers to entry in surgical specialties and the downstream effect of funding patterns that direct 60 percent more NIH musculoskeletal grants to male principal investigators than female ones.

The knowledge gap that results from this research bias feeds directly back into clinical guidelines, creating a cycle in which women are understudied, undertreated, and then inadequately represented in the research that shapes future treatment. Breaking this cycle requires intervention at every stage simultaneously.

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4. How Misdiagnosis Happens — And What It Costs

The gap between female biology and male-default guidelines does not remain abstract. It translates into specific misdiagnosis patterns that affect real patients in ways that are often measurable in years of unnecessary suffering.

Bulging discs in women are frequently misread as postural issues — a diagnosis that leads to generic exercise prescriptions rather than the imaging and targeted treatment that the structural finding requires. Sacroiliac dysfunction, which is more common in women due to pelvic anatomy differences and the impact of pregnancy on sacroiliac ligaments, is regularly misdiagnosed as sciatica, leading to treatment protocols that address the wrong problem. Most significantly, pain that has a hormonal component — that worsens predictably at certain points in the menstrual cycle or escalates around menopause — is disproportionately labeled psychosomatic, a diagnosis that effectively terminates the diagnostic process and leaves the patient without treatment for a physical condition with identifiable biological drivers.

Treatment failures compound the misdiagnosis problem. Core strengthening programmes — the standard first-line recommendation for chronic back pain — ignore the fundamentally different biomechanics of pregnant and postpartum bodies, in which the core musculature has been displaced and weakened in ways that standard strengthening protocols can worsen rather than improve. Manual therapy techniques calibrated to male ligament stability can be inappropriate for women during the hormonal phases when ligaments are maximally lax. Drug dosing that ignores the fact that women metabolise NSAIDs more slowly than men produces either undertreatment or elevated side effect risk depending on how the standard male dose lands in a female metabolism.

The economic cost of these failures is substantial. Back pain already costs the UK economy £12 billion per year in direct and indirect costs. Women account for 68 percent of back pain disability, driving £8.2 billion in direct costs. Misdiagnosis and undertreatment add an estimated £2.1 billion in costs associated with treatment that fails and must be repeated or escalated. Productivity losses attributable to inadequately treated female back pain account for 60 percent of the £15 billion total productivity impact — a figure that reflects both the higher prevalence of back pain among women and the longer duration of suffering that results from receiving less effective initial treatment.

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5. Patient Stories: What This Looks Like in Real Lives

The statistics are clarifying, but the human reality of the guideline gap is best understood through the experiences of individual patients whose journeys illustrate what happens when female biology meets male-default medicine.

Aisha, 32, from Birmingham, experienced lower back pain throughout her pregnancy. Her GP diagnosed normal pregnancy back pain and advised rest. Two years later, she finally received an MRI that revealed an L4-L5 disc herniation — a structural finding that had been present and causing her pain throughout the pregnancy but was never investigated because the assumption that pregnancy back pain is normal and self-limiting overrode the clinical indicators that warranted imaging. Two years of her life were spent in unnecessary pain that targeted treatment could have addressed much sooner.

Margaret, 58, from Manchester, experienced a dramatic escalation in back pain coinciding with menopause. Her GP prescribed paracetamol and stretching exercises — the standard first-line response to musculoskeletal pain, calibrated to a male-default model that does not account for the bone density loss and muscle mass decline accompanying menopause. A private physiotherapist who assessed her through a female-biology lens identified and treated a pelvic tilt that had developed as her core musculature weakened. She became pain-free for the first time in eight years following treatment that cost significantly more than NHS care and was accessible only because of her financial position.

Sara, 29, from Karachi, experienced postpartum lower back pain with leg symptoms. Three orthopaedic consultations in Pakistan produced recommendations for rest and weight loss — advice that addressed neither the structural finding nor the postpartum biomechanical context. An MRI obtained in London revealed an L5-S1 herniation combined with pelvic instability. Sex-specific physiotherapy combined with hormonal stabilisation produced 90 percent improvement within six months. The treatment she needed was available. It simply required travelling to a different country to access it.

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6. The Research Gap That Perpetuates the Problem

The clinical guideline failures documented in this study do not exist in isolation — they are the downstream consequence of a fundamental research bias that has shaped the evidence base from which guidelines are drawn.

When 70 percent of musculoskeletal studies use exclusively male subjects, the clinical trials that demonstrate treatment efficacy are demonstrating efficacy in male bodies. When those studies form the evidence base for guidelines, the guidelines reflect male biology by definition — not because their authors were deliberately exclusionary, but because the evidence available to them was drawn from male populations.

The animal model problem reinforces this at the most basic level of scientific investigation. Eighty-two percent of musculoskeletal animal research uses male rodents, partly for the practical reason that hormonal cycling in female animals introduces variability that complicates experimental design. The variability is real, but treating it as a problem to be eliminated rather than a biological reality to be understood has produced decades of preclinical research that tells us a great deal about how male biology responds to musculoskeletal interventions and relatively little about how female biology does.

Changing this requires explicit research mandates. The National Institutes of Health in the United States introduced a policy in 2016 requiring that federally funded research include female subjects in cell and animal studies — a policy that has begun to shift the preclinical evidence base, though its full effect will take decades to work through into clinical guidelines and practice. Similar mandates in the UK and other major research funding jurisdictions would accelerate this process. Dedicated funding for female spine researchers, who currently lead only 22 percent of studies in the field, would bring perspectives to research design that are currently underrepresented.

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7. Pakistan’s Specific Challenge: A Familiar Pattern in a Different Context

The male-default bias documented in UK clinical guidelines is not a uniquely Western phenomenon. An audit conducted at Aga Khan University Hospital found that 65 percent of female back pain protocols used by Pakistani clinicians were based on male-default guidelines — a finding consistent with the UK study and reflecting the global nature of a problem rooted in the evidence base that shapes medicine worldwide rather than in any single national healthcare system.

The socioeconomic dimension of the problem is more acute in Pakistan than in the UK. In British cities, the disparity typically manifests as women receiving inadequate treatment within a functioning healthcare system — a serious problem, but one that leaves them with access to at least the standard of care that is available. In Pakistan, inadequate treatment for lower-income women often means paracetamol and rest as the entirety of the therapeutic offering, with no realistic path to the specialist assessment, imaging, and targeted treatment that their condition requires.

Wealthier Pakistani women navigate this gap by travelling abroad — to London, to Dubai, to the United States — where more sophisticated assessment is available. The case of Sara from Karachi illustrates both the lengths to which patients go when domestic care fails them and the fundamental inequity of a system in which access to sex-appropriate medicine is determined by the financial capacity to leave the country.

The Aga Khan University Hospital’s protocol audit represents an important first step toward domestic reform. Understanding the scale of the guideline gap is a prerequisite for addressing it, and the willingness of one of Pakistan’s leading institutions to conduct that audit honestly is a promising indicator of the kind of institutional commitment that systemic change requires.

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8. What Fixing This Actually Requires

Dr. Khalid’s research team has not limited their contribution to documenting the problem — they have outlined a specific, actionable reform agenda that addresses the guideline gap at every level of the healthcare system simultaneously.

At the guideline level, the reforms required are clear: mandatory sections in all musculoskeletal clinical guidelines covering female hormonal considerations, pregnancy and postpartum protocols, menopause-related bone and muscle factors, sex-specific biomechanics including Q-angle and pelvic anatomy differences, and dosing adjustments that account for sex differences in drug metabolism. These are not complex additions — the evidence for their inclusion exists in the research literature. What has been missing is the institutional will to incorporate them into mainstream guidelines.

At the physician training level, the reforms required are equally specific. A four-hour sex-specific musculoskeletal module in medical school curriculum would ensure that every graduating doctor has baseline competency in female pain medicine — knowledge that is currently not systematically taught. Residency training requirements that mandate female pain case exposure, combined with continuing medical education requirements for annual updates in gender medicine, would maintain and update this competency throughout a physician’s career.

Technology offers additional pathways. AI triage systems trained on sex-specific pain pattern data are already achieving 92 percent accuracy improvements in identifying female-pattern musculoskeletal presentations that differ from the male-default baseline. Wearable devices that sync pain tracking with menstrual cycle phase are enabling women to document the hormonal component of their pain in ways that provide clinicians with objective evidence that hormonal factors are operationally significant in a given patient’s presentation. Telehealth platforms providing access to female physiotherapy specialists are beginning to extend sex-appropriate care to patients in settings where such specialists are not locally available.

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9. Global Momentum: The World Is Beginning to Listen

The UK study has landed in a global context where recognition of male-default bias in medicine is growing rapidly across specialties and across national healthcare systems. The response to this research suggests that the momentum for reform may be reaching a critical threshold.

Johns Hopkins University in the United States has echoed the Physical Therapy Reviews findings, and the American College of Rheumatology has ordered a review of its own guidelines for sex-default assumptions. The All India Institute of Medical Sciences in New Delhi has launched a female musculoskeletal registry to build the sex-specific evidence base that current guidelines lack. In Saudi Arabia, female orthopaedic specialists have organised a formal demand for guideline rewriting that reflects female anatomy and biology, bringing a regional voice to what has primarily been articulated as a Western research concern.

The convergence of research evidence, patient advocacy, and institutional acknowledgement across multiple healthcare systems and cultural contexts suggests that the male-default model in musculoskeletal medicine is under pressure from multiple directions simultaneously — a configuration that has historically preceded significant reform in other areas of medicine where sex bias has been identified and addressed.

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10. What Women Can Do Right Now, Before the Guidelines Change

Systemic reform takes time. Clinical guidelines do not rewrite themselves overnight, physician training curricula change slowly, and the research corrections required to build a genuinely sex-inclusive evidence base will take years to work through the scientific literature and into practice. Women who are experiencing inadequate care for back or neck pain today cannot wait for that process to complete.

The most immediately actionable step is to seek physicians and physiotherapists who explicitly practise sex-specific or gender-aware medicine — clinicians who will ask about hormonal factors, menstrual cycle patterns, pregnancy history, and menopausal status as part of their musculoskeletal assessment rather than treating these as irrelevant to a spine problem. This information exists in the clinical literature and is practised by clinicians who have sought it out, even where guidelines do not mandate it.

Tracking the relationship between pain patterns and hormonal cycle phases provides objective documentation that can support clinical conversations about hormonal contributions to musculoskeletal symptoms. This documentation is increasingly important because it shifts the clinical conversation from subjective report — which is vulnerable to the psychosomatic dismissal that many women have experienced — to objective data that is harder to set aside.

Requesting hormonal assessment, particularly in the context of perimenopause and menopause, opens treatment avenues — including hormone replacement therapy and targeted physiotherapy — that standard musculoskeletal protocols do not typically consider. Participating in female pain research registries, which several institutions are now actively building, contributes to the evidence base that will eventually change the guidelines that are currently failing patients.

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Conclusion

The Physical Therapy Reviews study is not the first research to document male-default bias in medicine, and it will not be the last. But its focus on the specific, systematic, and measurable ways in which clinical guidelines for back and neck pain fail female patients makes it one of the most practically actionable contributions to this body of evidence yet published.

The failure is not mysterious or difficult to understand. Medicine built its evidence base on male subjects, wrote its guidelines from that evidence base, and trained its clinicians from those guidelines. Women — who differ from men in hormonal environment, anatomy, pain processing, and the life stage transitions of pregnancy and menopause — have been receiving care calibrated to a different body. The result is 40 percent fewer MRIs, 25 percent fewer specialist referrals, longer emergency wait times, under-dosed pain medication, and years of unnecessary suffering for conditions that better-calibrated treatment could address.

Dr. Khalid’s conclusion that women are not small men is not a radical statement. It is a biological fact that clinical guidelines have been failing to act on. The reform agenda her research supports — guideline overhaul, physician training reform, research mandate change — is specific, feasible, and long overdue.

For the 1.2 billion women worldwide living with chronic pain, the message of this study is both a validation and a demand. Their pain is real. The system has not been treating it as well as it should. And the evidence now exists to force that to change.

Paracetamol is not destiny. Sex-specific medicine saves spines, wallets, and lives.