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March is Endometriosis Awareness Month, so we thought it would be appropriate to dive into some of the specifics about the diagnosis and its relevance to pelvic floor physical therapy. In this blog, we will cover the basics of the anatomy and physiology related to endometriosis, prevalence, symptoms, common treatment options, and how PT can help mitigate these symptoms and optimize function, bladder, bowel and sexual health.
First off, what is endometriosis? It is helpful to look at the anatomy to picture this condition. A woman’s uterus is made up of perimetrium, myometrium, and endometrium. The perimetrium is the outer layer of the uterine wall, the myo (muscle) metrium is the thick muscle of the uterus, and the endometrium is the inner lining which builds up and sheds cyclically. Endometriosis is the condition in which the lining of the uterus grows outside of the uterus. These endometrial implants can adhere to surrounding organs, the peritoneum (the abdominal lining) and, in severe cases, can work its way up towards the thoracic cavity. This endometrial tissue responds similarly to the way it should inside the uterus, so it can shed and spread with each cycle. For this reason, endometriosis tends to get worse with time.
Symptoms associated with endometriosis can include painful periods, painful intercourse, abdominal pain, ovarian pain, fatigue, painful urination or bowel movements around your cycle, and infertility. Endometriomas or “chocolate cysts” can form in and around the ovaries which can burst and be painful as well. While these cysts can be seen on ultrasound, they can often be confused with another structure called the corpus luteum which forms during the luteal phase of your cycle. Because of this and the fact that not all women with endometriosis develop these cysts, reaching diagnosis can be difficult. Surgery is currently the gold standard for diagnosis and treatment, which doctors are hesitant to do for obvious reasons. Here are some statistics to be aware of: 1 in 10 women will be diagnosed with endometriosis. In women with a first degree family history, painful cycles and/or infertility, that statistic can go up to as high as 5 in 10 women.
Endometriosis is graded by stages. Stage 1 is minimal, Stage 2 is mild, Stage 3 is moderate, and Stage 4 is severe. It is important to note that staging is related to the amount of spread, organs involved and blockage of fallopian tubes but it is NOT related to pain severity. It could be possible to have stage 4 endometriosis with minimal or no pain. Oftentimes women aren’t aware of their diagnosis until they have difficulty getting pregnant.
While the cause is still undefined, there are many theories regarding what contributes to the development of endometriosis. Some theories suggest a genetic component, as we know women are more likely to have endometriosis if a mother or sister also has it. It is believed that there is also an autoimmune component. It has been proposed that many women have retrograde cycles, meaning the flow of endometrial shedding comes out of the fallopian tubes as well as out of the vagina during the menstrual cycle. Some women will experience an inflammatory autoimmune reaction, which may be contributory to endometriosis, while others are not affected by the surrounding blood.
Now, let's talk about treatment options and the role of your pelvic floor physical therapist. Like we mentioned above, excision (surgery) is the current gold standard for removing the endometrial adhesions. There are several medications physicians will use, including high-progestin birth control, to reduce the estrogen and growth of the tissue. Lifestyle changes also have great impact, as we know managing inflammation in general can help reduce overall pain and symptoms associated with endometriosis. These changes can include eliminating hormone disruptors from your environment which can be found in plastics, skincare products and cleaning supplies. Switching to a metal water bottle and a cleaner makeup or shampoo line can make a big difference over the course of weeks and months as the chemical exposure starts to decrease in the body. Diet is another variable that is huge in managing inflammation. Many sources recommend an elimination diet to start to get an idea of what types of foods are triggering for you. The typical culprits involved with increasing inflammation are gluten, dairy, caffeine and alcohol. It is also recommended to avoid citrus and potassium. If at all possible, it is also a great idea to choose organic fruits and vegetables to decrease the pesticide exposure. Budget can make this tricky, so if that is an issue, definitely check out the Dirty Dozen and Clean 15 List of fruits and vegetables to know which ones are most important to buy organic or avoid entirely.
How does pelvic floor PT play into the treatment of women with endometriosis? While pelvic floor PT cannot cure endometriosis, there is a lot we can do in terms of symptom and lifestyle management. Pelvic PT’s can help with internal and external tissue mobilization to make sure the fascia and organs are free from restrictions. With chronic pain or cramping that often accompanies endometriosis, many patients develop increased tone and trigger points within the pelvic floor over time. Pelvic floor PTs are adept at assessing tone, motor control and providing tools and exercises to down regulate these muscles and the Central Nervous System. We educate patients on how to perform their own abdominal and pelvic floor massage as necessary to optimize mobility. We serve as educators regarding modalities for pain, exercises for mobility and breath work. In addition, pelvic floor PT can help a woman recover from the laparoscopic procedures to address scar tissue restrictions. Most importantly, pelvic floor PT’s spend, on average, about an hour with their patients each visit. This time can allow a patient to feel heard, supported and advocated for in a process which can be painful and intimidating.
If you are a woman struggling with endometriosis or know someone who is, we hope you glean some hopeful takeaways from this blog.
Endometriosis is very common. You are not alone.
This is not your fault, but there are some empowering and natural ways to manage your symptoms in addition to the medical support you are receiving from your provider.
Pelvic PT can help mobilize tissue and organs that may be causing pain when restricted.
We hope this blog was informative, and would love for you to reach out with any questions! Happy March, Happy Endometriosis Awareness Month!
Health & Happiness,
Dr. Carly and Dr. Katie