Endometriosis: What is it and How can Physical Therapy Help?

Joanna is a 30-year-old female who has suffered with painful periods, abdominal pain, and discomfort with intercourse throughout most of her life. She was finally diagnosed with endometriosis after years of telling her healthcare providers that something was not right. Now she is being told her only option is hormonal birth control, which she doesn’t feel is fully addressing her concerns and symptoms. After plenty of self-research, Joanna finds that there are other avenues of treatment to help address her condition. 

Endometriosis is a chronic, inflammatory disease that occurs when endometrial tissue is found outside of the uterus. No specific cause of endometriosis has been found and it affects 6-10% of reproductive-aged women. This can contribute to various chronic pain symptoms, such as dysmenorrhea (painful periods), dyspareunia (painful intercourse), non-menstrual pelvic pain, uncoordinated defecation (pooping), bladder pain, abdominal pain, and back pain. Women are often left undiagnosed for long periods of time - upwards of 6-12 years. It can require a team approach that includes a gynecologist and/or primary care physician, pelvic floor physical therapy (PT), pain management, urology, gastroenterology, possibly surgeons, integrative medicine like acupuncture and nutrition, as well as mental health due to the complex nature of this condition.

Endometriosis is expensive! It has been estimated to directly cost a patient $12,118 per year in the United States and indirectly costs an additional $15,737. It is also well known that endometriosis and chronic pelvic pain have a negative effect on mental health and quality of life, as well as sexual dysfunction, usually as a result of the pain.

While there is typically a structural change associated with endometriosis (endometrial lining cells outside the uterus), it is common for a person to experience persistent pain even after the endometriosis tissue has been removed. For example, a woman can have excision surgery to remove endometrial tissue within the abdominal cavity but can continue to experience pain. This is due to a hypersensitivity created in the nervous system and can be due to increased sensitivity of the body’s pain perception in general. Interestingly, women with endometriosis and chronic pelvic pain have changes in the brain that are not found in women with endometriosis who are asymptomatic. This means that simply having surgery will not always cure pain. In fact, 20-28% of patients will not experience a reduction in pain following surgery and 40-50% will have another surgery within 5 years.

Therefore, addressing endometriosis and chronic pelvic pain with a holistic approach is important! Pelvic floor physical herapy, nutrition, sleep, psychological intervention, and alternative medicine approaches, such as acupuncture, have been shown to reduce painful side effects. Progressive muscle relaxation, which occurs with tensing of a certain muscle group followed by relaxation, has been found to improve anxiety, depression, and mindfulness (a state of being present). These improvements have been found to improve quality of life and are beneficial for chronic pain. Additionally, although further research is needed to determine specific type and intensity, exercise has been found to have a protective effect against inflammation and inhibit, or reduce, estrogen. Both inflammation and estrogen have been found to contribute to endometriosis symptoms. For example, Hatha yoga twice a week for 8 weeks was found to significantly reduce daily pain as compared to those that did not practice yoga.

A study conducted on 20 women with mild to moderate endometriosis age 26-32 years old found that 8 weeks of exercise resulted in decreased pain and improved posture, such as a reduction of thoracic kyphosis (increased curvature in the mid-back).

It has been suggested that 85% women with chronic pelvic pain (CPP) have musculoskeletal dysfunction and postural changes, including spasms of the pelvic floor muscles. A large review that looked at non-surgical interventions for the management of chronic pelvic pain, including those with pain caused by endometriosis, found that skilled pelvic floor PT to address painful pelvic structures was found to be significantly better than counselling in reduction of self-reported pain scores and pain with intercourse.

Pelvic floor PTs can also utilize myofascial release techniques for chronic pelvic pain, which includes deep pressure massage, stretching, and joint mobilization or movement, in conjunction with tools to manage pain like breathing and relaxation exercises. Small studies have found that pelvic floor PT benefits up to 63% of patients who participate.

In fact, two studies conducted found that manual pelvic floor PT improved sexual function, including improvements with regards to pain with intercourse, arousal, lubrication, as well as reduced pain during menstruation (dysmenorrhea).

Long story short, reach out to your local pelvic floor PT if you suspect that you have endometriosis and the symptoms discussed above! They will perform a thorough evaluation to determine your individual areas in need of improvement and will use appropriate tools to address these areas, such as manual therapy (stretching, massage, etc), pain neuroscience education to calm the nervous system down, and exercise. A PT will also ensure that you have appropriate tools to address and manage your pain when flares occur, especially around your cycle. The only thing you have to lose is your pain!

Written by Jordan Schmidt, PT, DPT

Edited by Molly Hart, PT, DPT

References:

• Agarwal, S. K., Foster, W. G., & Groessl, E. J. (2019). Rethinking endometriosis care: applying the chronic care model via a multidisciplinary program for the care of women with endometriosis. International journal of women's health, 11, 405–410. https://doi.org/10.2147/IJWH.S207373
• Ball, E., & Khan, K. S. (2020). Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Research, 9, F1000 Faculty Rev-83. https://doi.org/10.12688/f1000research.20750.1
• Ball, E., & Khan, K. S. (2020). Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Research, 9, F1000 Faculty Rev-83. https://doi.org/10.12688/f1000research.20750.1
• Awad, E., Ahmed, H., Yousef, A., & Abbas, R. (2017). Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design. Journal of Physical Therapy Science, 29(12), 2112-2115.
• Cheong, Y. C., Smotra, G., & Williams, A. C. (2014). Non-surgical interventions for the management of chronic pelvic pain. The Cochrane database of systematic reviews, (3), CD008797. https://doi.org/10.1002/14651858.CD008797.pub2
• Aredo, J. V., Heyrana, K. J., Karp, B. I., Shah, J. P., & Stratton, P. (2017). Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction. Seminars in reproductive medicine, 35(1), 88–97. https://doi.org/10.1055/s-0036-1597123
• Wurn, B., Wurn, L., Patterson, K., King, C., & Scharf, E. (2012). Decreasing Dyspareunia and Dysmenorrhea in Women with Endometriosis via a Manual Physical Therapy*: Results from Two Independent Studies. Journal of Endometriosis, 3(4), 188-196.