Endometriosis was recently in the news again. Awareness is finally reaching the stages where the condition is commonly discussed and people are actually asking themselves if this can be their cause of their pain. It has taken a long while, moving from a condition most medical professionals were barely aware off to something that is in our everyday language. As a Women’s Health Physiotherapist, this is something we have worked long to help achieve. A friend was part of this campaign (where I borrowed the image from) a few years back which got me involved as well. It was particularly interesting as more and more patients were starting to come in asking for help with endometriosis.
Endometriosis is a condition where the endometrium, the tissue that lines the uterus, is found outside the pelvic cavity. Typically, it is found on the ovaries, uterus, bowel sidewalls as well as the pelvic lining. It has even been found on the diaphragm, the lungs and in the space between the uterus and bowels. This tissue then causes inflammation and/or pain. The tissue can also behave like the lining of the womb, i.e. bleeding on and off, often with no direct pattern but sometimes on a monthly basis. This bleeding often represents as acute pain (I had a patient that regularly passed out due to her endometriosis pain!) but also with general discomfort among other symptoms. Endometriosis is diagnosed in four grades, from one to four, but that is determined by the extent and depth of the endometrium tissue, not the actual symptoms. You can be grade four without symptoms or a lower grade with more severe symptoms.
It is expected that around 170 or more million women suffer from the disease, many asymptomatic until the condition may have progressed to the stages where it becomes noticeable. However many patients will have had the pain from early teens, often making activities of daily life problematic. Further, endometriosis is often linked to fertility problems and it is estimated that one in ten women in reproductive age can be suffering. Some studies suggest half of all unexplained infertility can be linked to the condition.
Now, in many places endometriosis is still under-treated or simply not given enough consideration as a possible diagnosis, but as discussed above, we are moving in the right direction. It is true that it is a problematic diagnosis as it is difficulty to confirm without surgical intervention but the issue is also complicated by the many co-founding factors. In my experience, many patients report pain first; this is then firstly considered period related or perhaps related to another issue. Similarly, secondly, many reports pain on penetration such as when using tampons or during intercourse or during urination, on bowel movements or when ovulating. Again, these can all be attributed to many other causes which leads to long investigations where endometriosis were previously often only considered as a last resort. In addition, up until the last couple of years, many women were fobbed off by medical professionals once no immediate diagnosis could be made. Many patients were told it was ‘temporary’, ‘just bad periods’, ‘in your head’ among other comments. Most Women’s Health Physiotherapists have heard stories like this.
To summarise and make it easy to my readers, here is a list of common symptoms:
- Painful periods as well as similar pains outside the period itself. Pain often decapacitating – many can’t even move. Pain is often sharp and described as ‘raw’ or ‘shredding’.
- Irregular periods, or randomly prolonged periods. While this can be linked to other things, endometriosis often replicates this symptom.
- Pain on penetration. Mainly during sex, but many women report problems with tampons as well. Pain often so bad that many patients report stop having sex at all as it isn’t even possible.
- Pain on urination or bowel movements. Can come and go depending on time of month and level of inflammation/bleeding. Some patients report constipation, bloating and other bowel symptoms.
- Problems to conceive (once other fertility problems have been ruled out).
- Specific or unspecific pelvic pain. Spasms in the pelvic region, including the pelvic floor are also common.
This latter point leads me back to why I’m writing this. Endometriosis is definitely in the scope of practice of physiotherapists, but not many are aware. However, I don’t want to give false hope: the end-stage treatment for endometriosis remains removal of the tissue, a complicated surgery that often has to be repeated. But, this is for the more serious cases where everything else failed. Before then, much can be done. Management of the condition is a task for a number of health professionals working in concert with each other – GP, gynaecologist, physiotherapists, and pain specialist among others.
As everyone knows, when you are in pain you tense yourself. With long-term pain such as endometriosis we often find that people keep muscles tight for so long that they never relax. As many sufferers spend a lot of time curled up, connective tissues in the pelvic area, abdomen, hips and back often becomes very, very tight. This in turn often makes the pain worse in the long run as the body is unable to tense and relax in response to the pain as well as tight pelvis, hips and back often being linked to other pains, increasing the feeling of discomfort and helplessness.
This is where physiotherapists can help – both with managing and preventing this part of the condition but also with the pain management side as well as with the activities of daily living. If you have pain on penetration, a Women’s Health Physiotherapist might be able to help; same if you have pelvic pain or associated hip or back pain. In fact, any musculoskeletal problem your physiotherapist can probably help you with. This general focus on your pelvis may also help with the build of scar tissue internally, helping to keep the tissue supple and less likely to cause additional pain.
So how do we help? Besides general advise and education on the condition (which can be sorely lacking if you are unlucky with your immediate health professionals – remember endometriosis is quite unknown):
- Teach different types of abdominal and internal massage – manual therapy and myofascial massage can help with the scar tissue and muscle issues. This can be particularly helpful after surgery.
- Address any pelvic floor dysfunction caused by the endometriosis
- Address issues related to bowel movements
- Help with stress and urge incontinence
- Address posture and other musculoskeletal issue that either contribute or is caused by the endometriosis.
- Lifestyle advise and general exercises that have been found to be helpful
It is however very individual and it comes down to what your symptoms are and how they are affecting you. But, after three months of treatment, most patients will have had some improvement in regards to both pain and ongoing daily activities.
Hope this makes sense – always open for suggestions and more good sources!