I used to be left with agonising joint ache as a result of medical doctors assume solely MEN get gout. Now they’re warning others about frequent misdiagnoses and learn how to defend your well being

Crawling into bed to rest her painful left toe, Mel Gardener winced as she covered herself with a cotton sheet. Even the touch of this light fabric was excruciating.

‘I’d never experienced anything like this before – a searing, burning, throbbing pain – and couldn’t believe that even a sheet on my foot could hurt so much,’ she recalls. ‘I hadn’t injured my foot. Yet the pain was so awful, particularly at night. The only way I could sleep was with my foot hanging out of the bed.’

Given her trim figure, active lifestyle and healthy, alcohol-free diet, the diagnosis came out of the blue. She had gout.

This is a form of arthritis perhaps usually associated with the cartoonish image of a portly man nursing an oversized toe. Yet it’s anything but funny.

‘Gout is exquisitely painful,’ says Dr Kelsey Jordan, a consultant rheumatologist at University Hospitals Sussex NHS Trust, and a trustee and director of UK Gout Society. ‘In my view, it is one of the top three most painful things a person can suffer with.’

The condition is caused when needle-like urate (or uric acid) crystals are deposited in the joints, and sometimes the soft tissues and tendons, causing inflammation and intense pain.

Gout affects one in 40 Britons – ten times as many of them men than women. But women do suffer from it and their numbers are rising.

‘There’s potential for gender blindness because patients and clinicians don’t think of it as an illness that affects women,’ says Dr Stephanie Barrett, a consultant rheumatologist at The London Clinic. ‘As a result, women can suffer for far longer than is necessary.’

If their symptoms are not being dismissed, they’re being misdiagnosed as having cellulitis (a bacterial infection of the tissues below the skin) or rheumatoid arthritis (a joint issue linked to the immune system) – for which the treatments are different.

Women’s choice of footwear is also blamed. ‘Often gout comes on in the bunion joint that connects the big toe to the foot, so in women it might be dismissed as being the result of poorly fitting footwear or the wrong shoes,’ adds Dr Jordan.

‘In fact, gout is more common in those with existing joint problems such as a bunion or osteoarthritis, a condition more common in women after the menopause.

‘You could also have gout in one joint or area and osteoarthritis in another, as these are separate conditions with different causes, but they can coexist. However, gout often occurs in damaged joints so it can happen in an area where there is also osteoarthritis.’

Another issue causing delayed diagnosis is the fact gout can present differently in women, explains Professor Rod Hughes, a consultant rheumatologist at Ashford and St Peter’s Hospitals NHS Trust.

‘About 50 per cent of men get gout in their big toes – but women are more likely to get gout in their upper limbs, knees or ankles. We don’t know why.’

The uric acid which builds to cause gout is produced when the body breaks down compounds called purines, found in foods and drinks including liver, lentils, shellfish and red wine.

Purines can occur naturally, as a result of cell damage. Most of it should pass through the kidneys and out in urine. But this sometimes doesn’t happen because of a malfunction in the kidneys.

‘If the uric acid isn’t removed it can form crystals that gather around the joint and get studded into the soft tissues,’ explains Dr Barrett. ‘Sometimes these crystals, known as “gout tophi” can appear as hard, creamy bumps under the skin.

‘The body regards these crystals as foreign bodies and this causes a cascade of inflammation resulting in hot, swollen joints,’ adds Professor Hughes. ‘The body works hard to defend itself against this inflammation, but its capacity to do this is at its lowest at night – which is why gout sufferers often feel the pain is at its worst when they go to bed.’

When Mel, who works in catering, developed the painful swelling under her big toe two years ago, the only cause she could think of was that she’d accidentally knocked the joint when rushing around.

‘At first the pain was manageable but within a few days it intensified – especially at night,’ says Mel, 57, who lives in Surrey with her husband Mark, 63, and their two children. ‘I couldn’t exercise and I’d struggle to put certain shoes on.’ After a few weeks Mel saw a nurse at her GP practice.

Assuming it was an infection, she prescribed antibiotics. Yet the condition worsened. ‘It was so hard trying to get through the day with this awful pain,’ she says. ‘I’d be limping, but even when I sat down it was there.’

After two weeks Mel went back to the surgery where she saw a female GP who identified it as a classic case of gout. ‘I was mortified,’ says Mel. ‘I thought gout was something that affected old men who were fat, ate rich foods and drank too much.

‘I exercised five times a week – including swimming and tap dancing. But I was also relieved that I had a diagnosis. Not every woman is as lucky.’

It’s not clear what causes the kidney malfunction, though having a family history of gout can raise your risk.

So, too, can having certain conditions. For instance, a 2023 analysis of more than 100,000 adults hospitalised with gout, published in the journal RMD Open, found women with gout were significantly more likely to also have heart failure, diabetes, obesity and frequent urinary tract infections – probably because these conditions put pressure on the kidneys.

‘The fact that these conditions are on the rise is likely to explain why gout is also increasing in women,’ says Dr Edward Sames, a consultant rheumatologist at Nuffield Woking Hospital.

Similarly, lifestyle factors such as obesity and drinking too much increase the risk, as do certain medications. Aspirin and diuretics, for instance, can raise levels of uric acid. The main reason fewer women develop gout than men is because, until the menopause, they are protected by the hormone oestrogen which lowers levels of uric acid.

But ‘artificial’ oestrogen may raise the risk. A 2021 study of a million postmenopausal women found HRT and birth control hormones increased gout risk.

Treatment for gout is the same for men and women and is important as, without it, urate crystals form hard deposits that can erode the bone and deform the joint. ‘The first approach is to treat the inflammation with non-steroidal anti-inflammatories, steroids or a medication called colchicine,’ says Dr Sames.

Depending on the frequency or severity of attacks, long-term medication such as allopurinol and febuxostat can be given to lower uric acid in the blood.

After being given colchicine, Mel found that in a fortnight her foot had healed. ‘I was overwhelmed with relief,’ she recalls.

The experts Good Health spoke to agree more needs to be done to encourage clinicians to consider gout when they see female patients with swollen joints.

‘Where women are concerned, it may not be the first thing doctors think of because it is more rare,’ says Dr Barrett.

‘It can look like cellulitis, for instance, causing the foot or elbow to be hot and swollen. What makes it stand out is that gout generally is incredibly painful.’

The longer gout goes undiagnosed, not only will it prolong suffering but there is a greater chance of it causing mobility issues. ‘That’s why women who suspect they have gout or feel they’ve been dismissed must ask for their uric acid to be assessed,’ says Dr Jordan, who was involved in developing the NICE guidelines for gout management. This is typically done via a blood test. Normal levels should be less than 360 micromol/L. ‘You should be measured again two to three weeks after a flare-up to see if treatment is working,’ adds Dr Jordan.

Dr Barrett points out that uric acid levels are at their lowest during a painful attack. This may be because an increase of uric acid triggers more excretion via urine due to the body’s inflammatory response to the gout attack. So it is best to wait until the pain has settled before being tested.

Last November, Mel experienced another flare-up in her foot which was again treated with the anti-inflammatory drug.

Rather than going on to other medication to lower her uric acid levels, she has decided to take a holistic approach: drinking cherry juice (some studies suggest it can reduce gout inflammation) and having acupuncture (limited evidence suggests it eases the pain).

‘I haven’t forgotten how agonising gout can be and I want other women to know they don’t need to suffer,’ she says.