Endometriosis is a common contributing factor to pelvic pain. Just to give you an idea of its prevalence: in laparoscopic procedures done to uncover possible causes of pelvic pain, endometriosis was found 80% of the time. The good news is that endo-related pelvic pain can be successfully treated with the proper pelvic floor PT!
But, I’m getting ahead of myself. First, in this blog post, I’m going to tackle how endo can either cause or impact pelvic pain, then I’ll explain how pelvic floor PT can successfully manage endo pain.
What is Endometriosis?
Endometriosis is a condition where tissue like that which lines the inside of the uterus (known as endometrial tissue) grows outside of the uterus, most commonly in the abdominal cavity. This tissue can implant on any surface within the abdominal cavity including the ovaries, bladder, rectum, and along the abdominal/pelvic wall.
Commonly reported symptoms of endometriosis are painful cramping one to two weeks prior to menstruation, pain during menstruation, pain with sexual intercourse, pain in the location of the bladder, painful bowel movements and infertility.
Now, just how endo causes pain is the topic of much research, but here is a rundown of one theory:
Normally, when a woman is not pregnant, her endometrial tissue builds up inside her uterus, breaks down into blood and tissue, and is then shed during her period. Endometrial tissue growing outside the uterus goes through a similar cycle; it grows, breaks down into blood and tissue, and is shed once a month. Researchers believe that one reason for the pain that endo produces is that the endometrial tissue produces chemicals that may irritate the nearby tissue, as well as some other chemicals that are known to cause pain. In addition, because this tissue isn’t inside the uterus, it can’t leave the body the way a woman’s period normally does, so it can build up and wreak havoc.
The most common way that physicians diagnose endometriosis is using a laparoscopic procedure where a camera is inserted through a small incision in the abdomen. In addition, transrectal or transvaginal ultrasound, CT scans, and contrast MRIs can be used. In more advanced stages of the disease, endometriosis can be detected with a pelvic exam.
A few lines of treatment currently exist for endometriosis, including medication, hormone therapy and surgery. (See the list below for a more detailed look at these different treatment options.)
A spectrum of pain levels exist among women with the condition ranging from completely asymptomatic to relatively minor to severely debilitating symptoms. Interestingly, there has been no correlation made between the severity of the endometriosis disease process and the degree of pain a person experiences.
Endometriosis and the Pelvic Floor
Endometriosis can impact the pelvic floor musculature in a variety of ways.
For one thing, as I mentioned above, endometriosis tends to bleed with menstruation, often leading to inflammation, scar tissue and adhesion formation inside the abdominal and pelvic cavity. (Adhesions are fibrous bands of scar tissue that can attach to organs, muscles, and fascia.)
This can set up an unhealthy environment within the pelvic floor because the decrease in pelvic and abdominal organ/muscle/fascia mobility can lead to decreased circulation, tight muscles, myofascial trigger points , connective tissue dysfunction and pain.
In addition, people that have undergone laparoscopies for diagnoses and/or removal of affected tissue have now undergone additional trauma to the abdomen, which in turn can lead to increased pain in that area. For instance, the abdominal muscles have a very close relationship with the pelvic floor muscles and when there is trauma or irritation as a result of surgery, trigger points can form.
Subsequently, these abdominal trigger points can cause pain in the abdomen and can also refer pain to areas in the pelvis that can cause increased tension of the pelvic floor muscles. The result oftentimes is the creation of a vicious pain cycle where muscle tension creates pain, which creates more muscle tension (plus trigger points plus connective tissue dysfunction)–all of which creates…you guessed it, even more pain.
So on top of dealing with all of the symptoms that already come with endometriosis, a patient can develop a host of secondary pelvic floor dysfunction. Indeed, for some patients, the majority of their pain is actually due to the secondary pelvic floor symptoms themselves.
The good news is that pelvic floor PT can successfully treat symptoms associated with endometriosis, both the primary symptoms and the secondary pelvic floor symptoms.
PTs can help to manage the symptoms of endometriosis such as painful menstrual cramping, abdominal discomfort, pelvic floor pain, and painful intercourse by:
Here’s is an example of how I’ve put these strategies into action as a pelvic floor PT: I treated a patient who had been dealing with an endo diagnosis for five years, let’s call her Annie. After undergoing several laparoscopic procedures for endometriosis removal, Annie continued to suffer with abdominal, vaginal ,and lower back pain. Her surgeon ruled out endometriosis as the primary cause of these symptoms and suggested a trial of six to eight weeks of pelvic floor PT to see if it could help relieve her pain.
While treating Annie, I uncovered myofascial trigger points and connective tissue dysfunction in her abdomen, hip, low back and adductors, not to mention significant hypertonus and trigger points in her internal pelvic floor musculature.
By treating these objective findings, after 12 weeks Annie began working part time. Prior to seeking PT, she had been on disability for one and a half years. After about six months of treatment, although she still had occasional flare ups of her symptoms, Annie’s daily pain subsided. Ultimately, she was able to manage her occasional flare ups on her own. As a result, she regained her quality of life, and began to exercise and socialize again.
While PT does significantly help patients diagnosed with endo, I want to stress that it will not be able to get rid of the endometrial deposits or change the disease process. So it’s important that women who have or think they have endometriosis be followed by a physician. A multidisciplinary team of health care providers is absolutely the best approach for management of endometriosis because there are so many different ways that it can affect a woman’s life.
*Source: Dr. Matthew Siedhoff with the division of advanced laparoscopy and pelvic pain at the University of North Carolina at Chapel Hill’s IPPS presented a lecture titled: Diagnosis and treatment of gynecologic causes of chronic pelvic pain.
The first line of treatment for endometriosis tends to be with medication. Non-steroidal anti-inflammatories are often prescribed to alleviate the pain. Oral contraceptives can also be prescribed to be taken either cyclically (you will have a period) or continuously (no period) to stabilize or virtually eliminate the growth of the endometrium and subsequent menstruation. Progestin, such as Depo-Provera, is a synthetic progestogen that can be used as another line of defense against endometrium hyperplasia. An intrauterine device (IUD) is also an option to decrease uterine lining proliferation.
The second line of treatment typically consists of prescribing gonadotropin-releasing hormone . GnRH agonists lead to suppression of the secretion of estrogen from the ovaries. This causes a reversible change in the reproductive system where menstrual periods are stopped and it has also been found to stop the growth of and shrink active endometriosis sites. Although relief of symptoms does not constitute a diagnosis of endometriosis, many symptomatic women report decreased or complete resolution of pain with this treatment. Use of GnRH agonists can lead to premature bone loss and osteopenia or osteoporosis, so it is suggested that women receiving this treatment get a regular dual-energy x-ray absorptiometry (DEXA) scan to evaluate bone mineral density. Danazol is a modified testosterone which leads to a stop in ovulation and a state of pseudomenopause. The use of danazol has been largely replaced by GnRH agonists due to some of the undesired side effects such as weight gain, excessive hairiness (hirsutism), acne, and a deepening of the voice.
Although surgery is typically the third line of treatment in patients with endometriosis it can be very effective in removing endometrium deposits outside of the uterus. There is some debate over the technique used. Some surgeons tend to favor excision (cutting out) of the lesion while others prefer ablation (burning) of unwanted deposits. At this point, there is no evidence to suggest that one technique is better than the other and physician preference is the deciding factor.
If you have any further questions about endometriosis and pelvic floor PT, please leave them in the comment box below. Also, please share your experiences with endometriosis and PT in the comment section! We look forward to hearing from you!
Allison Palandrani, DPT, is a PHRC physical therapist who works in our San Francisco location. To learn more about Allison, click here .