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Such a painful and isolating illness that affects the everyday life of those who suffer it, this is what endometriosis is.

Endometriosis is a serious illness that affects more than 200 million women, trans men, and non-binary individuals, and 1 out of 10 women, trans men and non-binary individuals in the US alone. In spite of these alarming facts, very few of us have actually heard of the term Endometriosis.  It is a condition that is often misdiagnosed, mistreated and as a result, a large number of women continue to live with unresolved pain that remains completely undiagnosed.

Endometriosis affects women in their reproductive years. It is a condition very commonly diagnosed between 25-35 years of age. However, it is important to remember that endometriosis can start affecting a woman’s body soon after the onset of menarche.

What exactly is endometriosis? Well, from a scientific standpoint, endometriosis is: ” a disease of menstruation. It occurs when tissue similar to the lining of the uterus, or endometrium, migrates outside of the womb, where the tissue should not be”, this tissue is sensitive to the hormonal changes of the body, and the result of it is inflammation, in the area where the tissue is now living.

Endometriosis can be found in several different places, most commonly it’s found around the reproductive organs, such as the uterus, fallopian tubes, ovaries, uterosacral ligaments, or the peritoneum. It can also be found in any of the spaces between the bladder, uterus, vagina, and rectum. Less commonly so, it can also involve the bowel, intestine, appendix, or the rectum.

So, this illness, is it curable? Current evidence supports surgical resection as the GOLD standard of treatment. Medical management is known to control the progression or suppress the progression temporarily with only limited success. Early diagnosis is critical for early damage control.

Common symptoms associated with endometriosis are

  • Unbearable abdominal cramps associated with menstruation.
  • Heavy periods that prolong for several days
  • Heavy menstrual flow
  • Bowel and urinary disorders
  • Nausea and/or vomiting
  • Pain during and after sexual activities
  • Infertility
  • Chronic fatigue
Endometriosis and Pelvic Physical Therapy

How will Pelvic Floor Pelvic Physical Therapy help with Endometriosis?

Pelvic floor dysfunction (PFD) is a common condition in women with endometriosis. Chronic inflammation of the endometrial tissue can cause severe pelvic and abdominal pain. Very often,  muscles that form the pelvic floor have tightened in response to chronic pelvic pain. 

Even after the original source of pelvic pain has been resolved, PFD persists as an acquired or secondary source of pelvic pain. Pelvic floor muscles are unable to relax or stretch secondary to associated scarring.  In severe cases, the patient suffers from pelvic floor spasms, which can be excruciating and make intercourse impossible. 

Other common symptoms are pain and/or difficulty emptying the bladder or bowel and painful intercourse. Pelvic floor dysfunction can affect all the organs in the pelvis, including the urinary, genital, and bowel systems, and can have further-reaching effects on the body (coordination, alignment, breathing, and mobility). 

Endometriosis can often affect abdominal organs causing scarring and decreased abdominal organ mobility. The result could be abdominal pain and often serious secondary complications like intestinal obstruction.

So, let us try and understand how pelvic floor physical therapy can help with managing symptoms associated with endometriosis. Chronic pelvic pain can affect body posture, muscle tone, and alignment. Muscles may become shorter, tighter and misaligned due to the perpetual responses of the body to pelvic pain. 

The role of the pelvic floor physical therapist is, therefore, to train the patient to relax her body and restore balance and alignment. While the pain emanates from the pelvis, the effects of chronic pain are far-reaching due to the role of the pelvic floor in core activities such as movement and coordination. Effective physiotherapy may need to involve muscle groups throughout the body.

Endometriosis and Pelvic Physical Therapy

Biomechanical and musculoskeletal assessment- a thorough PT exam for Endometriosis

Biomechanical and musculoskeletal assessment is critical to get to the root cause of painful symptoms. In the clinic, we pay careful attention to how the patient moves and walks, her posture and breathing, where her core areas of pain are, and takes note of the overall condition of her muscles (strength, coordination, alignment).

Pelvic Physical Therapy can help you normalize the pelvic dysfunction so that it can hopefully reduce the overall pain the patient is experiencing. Along with pelvic pain, there may also be other associated symptoms. such as:

  • Pain in the back, hips, and sacroiliac joint
  • Trouble emptying the bladder fully
  • Urinary frequency, burning or pain
  • Constipation or diarrhea
  • Painful bowel movements and fecal incontinence
  • Painful sex
  • Not being able to get a proper gynecological exam with the speculum
  • Pain with wearing tampons 

A pelvic floor physical therapist is able to address not only the pelvic floor dysfunction but also treat the patient’s body as a whole addressing the associated functional impairments and symptoms.

Relaxation skills

Another very important part of pelvic floor recovery is learning techniques to relax the pelvic floor.  Manual techniques are directed at loosening and relaxing muscles and relieving abdominal and pelvic pain. The patient is then directed in self-massage and relaxation exercises, which she can continue at home.

Physical examination- orthopedic/ movement evaluation

Next, the therapist performs a thorough physical exam to test overall body flexibility and mobility, paying particular attention to the hips and possible joint malformations, the sites of abdominal scars and the motility of the internal pelvic organs. The physical exam comprises both an external and an internal exam. 

During the internal exam, the different layers of the pelvic floor are assessed to check muscle spasm, tone and mobility, tissue rigidity and pain trigger points. While some patients may feel uncomfortable, internal work is essential in order to access the core muscles and tissues involved by PFD.

Retraining of muscles to help Endometriosis

Pelvic muscles that have been identified as tense and in spasm are then “down trained” by teaching the patient the difference between tensing and relaxing these muscles. This can be achieved with the help of biofeedback sensors placed on the muscles so that the patient can see her pelvic muscle activity fluctuate on the biofeedback monitor.

Home exercises

To improve flexibility and stretch tightened muscles, the patient will be instructed in stretching exercises, focused on opening the hips. The patient may also be instructed in vaginal dilation exercises to be performed digitally or with a home-dilation kit to further mobilize tissue within the pelvis. Further exercises will focus on core strength, and trunk and spine flexibility. 

Once pain and mobility improve, the patient will be retrained in basic movements such as walking and standing without tensing the pelvic floor and to improve pelvic-girdle coordination. The patient will be instructed in gentle exercises to restore coordination and mobility, such as basic yoga and Pilates, gradually building up over the course of 6 to 12 weeks.

Endometriosis and Pelvic Physical Therapy

Resolving painful Sexual intercourse

Sexual intercourse should never be painful. Because of the chronic inflammatory process, patients suffering from endometriosis  often complain of painful intercourse, 

Painful sex can occur secondary to scarred or shortened muscles because of the inflammatory process. Very often abdominal myofascial trigger points can contribute to pelvic pain. These trigger points can occur in the abdominal cavity pelvic floor, hip, back muscles, and abdomen. 

Endometriosis creates inflammation, scar tissue, and adhesions in the affected areas, and as a response, the body encourages the formation of myofascial trigger points. These trigger points can cause spasm of the pelvic floor muscles.  The resulting connective tissue dysfunctions can cause referred pain patterns, meaning muscle dysfunction in the pelvic floor muscles may result in pain that can be felt all the way down your leg or anywhere else in your body.

Endometriosis and Pelvic Physical Therapy

Help with the inflammation & bloating

Bloating and pain in the abdominal cavity is very commonly associated with endometriosis. Very commonly this condition is known as endo belly. Pelvic floor PT and visceral manual therapy can help resolve or at the least alleviate the abdominal and visceral symptoms associated with endometriosis. The reasons for Endo Belly can be varied. I have listed a few below.

  • It can be attributed to the inflammatory peritoneal insults of endometriosis. 
  • It can be caused by having tightness in the pelvic floor.
  • Years of disease in the peritoneum and organs can cause the fascia and brain to sense pain and position the organs differently

There are many solutions to it, however, here are the most common:

  • Relax the protective response.
  • Work the lymphatic system and venous return to encourage the inflammation to be absorbed.
  • Visceral manipulation therapy.

Pelvic PT can immensely help with functional recovery with endometriosis.

Endometriosis symptoms severely affect the quality of life, causing difficulties in daily life, modifying well-being and relationships.

Endometriosis can affect you irrespective of race, ethnicity, socioeconomic background, current status, or financial situation, it can and does affect everyone who suffers it equally.

Endometriosis and Pelvic Physical Therapy

If you are suffering from this disease or someone you know is, know that there are ways to manage it, things you can do to have a healthy and happy life, it’s just about getting started.