Endometriosis is a life-long condition which means that tissue similar to the lining of the womb can grow in other places. This tissue bleeds monthly and most experience a cyclical pain with monthly 'flare-ups'. Adenomyosis grows into the muscle of the uterus, whereas Endometriosis grows on the outside and anywhere else. Due to the variability of symptoms and difficulty in diagnosis, it can take roughly 7-8 years to be diagnosed in the UK.
In this article, we will run through how physiotherapy can help Endometriosis, Adenomyosis and Chronic pain conditions, and what to expect during a session with a pelvic physiotherapist. This is to allow you to make your own decisions, and if you think physiotherapy might be helpful for your condition.
What is physiotherapy?
Physiotherapy allows restoration of function and movement in the body via gentle exercises, postural training or stretches. It goes without saying, that if the body is experiencing cycles of pain, that there are periods of time where it is very difficult to move your body as usual. Physiotherapy helps to remind the body on how to move as easily as possible, to minimise pain.
Why might physiotherapy be needed?
The amount of time it usually takes someone to get diagnosed with Endometriosis or Adenomyosis, means that the body can start to compensate around the pain, and move with altered movement patterns. These new movement patterns aren't always helpful and can increase overall pain levels.
Those times where you might have been hunched over, or perhaps at awkward angles with a hot water bottle, may have added to aches and pains in your body. Painful sex and a hypertonic pelvic floor is also common, as the body is responding and protecting from pain in the pelvic region.
Which pain is which?
Our brains also get very clever at ignoring or down-playing pain signals, which means it's sometimes hard to tune in to some aches and pains which actually aren't directly linked to your Endometriosis conditions.
One of the very tricky elements of Endometriosis and Adenomyosis, is that everyone is slightly different, just like a fingerprint, and there is no 'one size fits all' approach.
This means some detective-work is required to gather the information on what symptoms are linked to your endo, and which could be general inflammation or muscle-tension-related aches and pains. The latter can gererally be eased with massage and physiotherapy, but requires 'tuning in' and reconnecting to your body, too.
Why does muscle tension occur?
Muscle tension could be caused by muscle weakness, or where that particular muscle gets consistently over-used as you move. A paper from the Journal of Pain in 2018, suggested that women around the age of 46 and with endometriosis reported a higher likelihood of having musculo-skeletal pain. If we are in pain often around the pelvic region, it is common to 'grip' the pelvic floor through the day, which can add further to the pain.
Why do we feel pain?
Our brains and limbs are connected via our nervous sytem to communicate danger via pain. For example, a hand to a hot pan will cause a reflex to move the hand away from the burning heat. Sometimes, the nervous system and pain loop gets overstimulated, and amplifies the pain to a constant 'red alert' status. This 'red alert' status can be amplified by anxiety, stress and our previous experience of pain.
How can we reduce pain?
'Interupting' those pain signals is how TENS (transcutaneous electrical stimulation) works, to prevent the pain response. Products like Myoovi have tapped into this pain science and use TENS to block pain signals the the brain.
Studies have also shown that regular exercise and yoga can improve pain tolerance. With endometriosis, it is really difficult to follow a strict schedule, so allowing your body to move on the week(s) you feel able is enough. If you're in a lot of pain, using your breath and very gentle stretches may help.
How physiotherapy can help?
A specialist pelvic and sports physiotherapist can analyse your posture and movement, to let you know areas of tension you could focus on releasing with stretches or massage. They may advise some gentle strength work, depending on your pain levels month to month.
They can teach you how to release your pelvic floor and settle your nervous system via yoga-style poses and a pelvic floor internal examination can be helpful for some. An internal examination is always optional, but can sometimes be helpful to understand if you have extra tension in your pelvic floor which can cause back, hip and pelvic pain.
A pelvic physiotherapist may use hands-on techniques to release tension in the pelvic floor, just like any other muscle group of the body.
What to expect in a session?
A physiotherapist will go through your full medical history, including surgeries, scans and medication. They will also want to understand what your life looks like day-to-day, so they'll ask about your work and how you manage at more painful times of the month. As noted above, an internal pelvic floor examination is always optional.
How do I know it will help?
Several studies suggest that pelvic physiotherapy can help with reduced pain during sex (dyspareunia), chronic pelvic pain and pelvic floor relaxation for those with Endometriosis.
Generally, a multifaceted, multidisciplinary strategy with different, patient-guided therapeutic options gives the best chance for success.
Physiotherapy is more helpful to some than others, and this completely depends on you personally. Your pelvic physiotherapist will give you tips and tricks to release off your usual tension, to tune into your pelvic floor and diaphragm and maybe even offer gentle strength exercises for when your flare-ups aren't unmanageable. Generally 2-3 sessions will give you a good idea on how much physiotherapy will help your body and symptoms.
Physiotherapy will not reverse any endometriosis or adenomyosis symptoms, but could help you better manage your pain. You'll also be able to reduce mechanical pain and tension and know what feels good for your body.
Please note, any pelvic physiotherapist offering internal pelvic floor examinations must be qualified accordingly. Qualified physiotherapists for this treatment can be found on the Pelvic Obstetric Gynaecological Physiotherapist (POGP) registry in the UK.
What else can I try?
Optimising your nutrition to prevent constipation is extremely useful in minimising any pelvic pain. Seek guidance from a registered dietitican or nutritionist who specialises in women's health and Endometriosis if possible.
Further information on Endometriosis support here:
Blog by Liz Brown MSc MCSP Sports & Pelvic Physiotherapist
Book online via www.almaphysiotherapy.co.uk/book-online or contact Liz's PA Sophie at pa@almaphysiotherapy.co.uk or 07942 494506, and ask for Caroline or Liz.
References:
Del Forno S, Arena A, Pellizzone V, et al. ‘Assessment of pelvic floor muscles with 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: a randomized controlled trial’, Ultrasound in Obstetrics and Gynecology, 2021, DOI: https://doi.org/10.1002/uog.23590
Dos Bispo AP, Ploger C, Loureiro AF, et al. ‘Assessment of pelvic floor muscles in women with deep endometriosis’, Archives of Gynecology and Obstetrics, 2016; DOI: 10.1007/s00404-016-4025-x
Mira TA, Giraldo PC, Yela DA, Benetti-Pinto CL,’ Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial’, European Journal of Obstetrics, Gynecology and Reproductive Biology, 2015, DOI: 10.1016/j.ejogrb.2015.07.009
National Institute for Health and Care Excellence (NICE), Endometriosis: Guidelines and Management’, 2017
Rivest-Gadbois E, Boudrias MH. What are the known effects of yoga on the brain in relation to motor performances, body awareness and pain? A narrative review. Complement Ther Med. 2019 Jun;44:129-142. doi: 10.1016/j.ctim.2019.03.021. Epub 2019 Apr 5. PMID: 31126545.
Scioli-Salter E, Forman DE, Otis JD, Tun C, Allsup K, Marx CE, Hauger RL, Shipherd JC, Higgins D, Tyzik A, Rasmusson AM. Potential neurobiological benefits of exercise in chronic pain and posttraumatic stress disorder: Pilot study. J Rehabil Res Dev. 2016;53(1):95-106. doi: 10.1682/JRRD.2014.10.0267. PMID: 27006290; PMCID: PMC7217610.
Vuontisjärvi et al (2018) The Long-Term Footprint of Endometriosis: Population-Based Cohort Analysis Reveals Increased Pain Symptoms and Decreased Pain Tolerance at Age 46, The Journal of Pain, https://doi.org/10.1016/j.jpain.2018.02.005.
Wu CC, Chung SD, Lin HC, ‘Endometriosis increased the risk of bladder pain syndrome/interstitial cystitis: A population-based study’ Neurourol Urodyn, 2018, DOI: 10.1002/nau.23462