Endometriosis

--What is Endometriosis?

Endometriosis is a common yet under-diagnosed chronic condition, which is distinguished by the presence of endometrial-like tissue outside the uterine cavity, often found in the pelvis, and less commonly in tissues and organs outside of the pelvic cavity. There are a few theories of how this occurs, one being ‘retrograde menstruation’, whereby endometrial cells escape from the uterus via menstrual blood flowing in the wrong direction. It is understood that during menstruation, these escaped cells then cause a general inflammatory response within the peritoneal cavity. This may lead to significant pelvic pain during menstruation, bladder and bowel irritability, sexual pain/dysfunction or compromised fertility. If left untreated, endometriosis can cause debilitating persistent pelvic pain, whereby many experience pain on all or most days, not only during a menstrual bleed.

Although, symptoms do vary greatly, with studies revealing no association between the extent of endometriosis discovered during a laparoscopic surgery and the severity of symptoms experienced. Some women have very little or no pain/associated symptoms, and others can have recurring symptoms that impact them on a daily basis. Endometriosis can affect all women, girls, transgender, non-binary, and gender diverse people biologically assigned female at birth, regardless of age, background or lifestyle, from pre-pubescence to beyond menopause. It is diagnosed via surgical laparoscopy although there is current research looking into diagnosis via imaging/ultrasound.

--What are the causes?

The causes of endometriosis are not yet completely understood nor defined. Suspected risk factors for endometriosis include family history, early age of menarche (first period) and short menstrual cycle length. There has also been recent evidence to suggest that a history of trauma, especially childhood and/or sexual trauma can increase the likelihood of being diagnosed with endometriosis.

During a typical menstrual bleed, a normal inflammatory process takes place, with an increase in prostaglandin release. This response can be amplified in those with endometriosis, leading to pain, nausea, lower abdominal pain, bloating, cramping, back pain, numbness or pain down the legs, and sometimes issues with bladder voiding or urgency, or rectal pain and constipation/IBS-like symptoms. What we now know is that a persistent input of pain over time can lead to an increase in resting tone or tension of the pelvic floor muscles, as they are in chronic protection of the area. This leads to further pain and potential problems e.g. with toileting and/or intercourse. Furthermore, chronic pain can also cause sensitisation of pain receptors which can lead to central sensitisation, whereby nerves are constantly on high alert and begin to inappropriately fire off pain signals.

--How can physiotherapy help?

Pelvic floor physiotherapy plays an important role in the assessment and management of symptoms related to endometriosis. Often it is found that an increase in pelvic floor muscle tension is contributing to pain, spasms and associated symptoms related to endometriosis. A trained pelvic floor physiotherapist may be able to reproduce pain experienced e.g. during menstruation or intercourse, which is helpful in guiding a treatment plan aiming to decrease the resting and reactive tone of the pelvic floor muscles. This may include strategies to relax pelvic floor muscles such as biofeedback (to assist in connection to the pelvic floor), breathing techniques, contract-relax exercises, pelvic stretches and gentle movements. It may also be helpful for self-internal release of muscles e.g. with the use of a wand.

Your pelvic floor physiotherapist can help you to identify individualised management options for other symptoms including pain with endo flares, intercourse and bladder/bowel concerns. It may be appropriate for your pelvic floor physiotherapist to perform an internal vaginal exam in order to assess your pelvic floor muscles, however if you do not feel comfortable with this, there are other ways to assess your pelvic floor, including transabdominal real-time ultrasound. It is important to view this condition holistically and address not only the physical implications of endometriosis, but the psychological and emotional impacts that it can have on not only the person experiencing it, but loved ones who support them.

--What can I do at home?

Here are some simple low-risk exercises and strategies that you can do on your own to help symptoms associated with endometriosis. A trained pelvic floor physiotherapist will also be able to offer you individualised advice based on each of these areas:

• Exercise has been associated with decreasing the inflammatory effects related to endometriosis – start with low impact physical activity that you enjoy e.g. walking or swimming
• Diaphragmatic breathing (relaxed belly breathing) is commonly used to connect to and relax your pelvic floor muscles, which may be contributing to pelvic pain and other symptoms. It also helps to relax your sympathetic nervous system, which is often inappropriately ramped up when you are experiencing pain
• Stretches to relax the pelvic floor
• Gentle yoga is great for stretching, breathing and mindfulness
• Healthy bladder habits – drinking plenty of water and avoiding bladder irritants, addressing symptoms of frequency and urgency with bladder retraining strategies if necessary
• Healthy bowel habits – aiming for regular and easy to pass bowel motions with a healthy diet, including fibre and optimising your defecation dynamics (positioning and pelvic floor muscle control) so as to avoid straining
• Healthy anti-inflammatory/Mediterranean diet – consider a review with a dietitian trained in this area if you are unsure about optimising your diet
• Address anxiety related to symptoms, such as simple daily self-care activities. This may include meditation/mindfulness, time out, journaling, things that bring you joy.
• Consider input from a psychologist if you suspect trauma may be impacting on your condition
• Compose a symptom action plan – you may find it helpful to list things that work when you are having a flare (e.g. pain flare) so that you know what works, which you can build upon as you trial different strategies. This may include things like using a heat pack, doing gentle stretches/pelvic movements, TENS machine or having a warm relaxing bath with salts that help to relax your abdominal and pelvic muscles.

--Where can I get further information?

The best opportunity to receive individualised advice, education and a management plan is to find a trained pelvic floor physiotherapist who can perform a compressive assessment and provide you with a treatment plan. Find a physio at: choose.physio/find-a-physio or www.pelvicpain.org.au. The Pelvic Pain Foundation of Australia also has some excellent articles and resources on endometriosis.