Endometriosis as a Feminist Issue

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Fiona McMahon PT, DPT

March is endometriosis awareness month. March is also women’s history month. It seemed like the perfect time to discuss how poor detection and treatment of the disease affects the welfare, social, economic health, physical health,  and quality of life of women. Endometriosis is a feminist issue.

Here, at this blog, we have extensively discussed treatment and various options for endometriosis. Although there are many treatments available for managing endometriosis, the time it often takes to get a proper diagnosis and referral to competent clinicians is often so long, that the disease may progress to a point where pain is a lot harder to treat and fertility is impacted. Endometriosis is a gynecological disorder, that according to the Women’sHealth.gov currently affects more than 11% of women in the United States.

Older material, in fact, posts on this page used to define endometriosis as a condition in which endometrium (the lining of your uterus) grows outside the uterus. Now, in most of the recent literature referring to the tissue growing outside the uterus, call it endometrium like, because the tissue bears some resemblance to endometrium but isn’t quite the same. Endometriosis can show up clinically in a whole host of ways. It is estimated that up to 59% never have symptoms and may only discover that they have endometriosis, if they have abdominal surgery and legions are spotted. Infertility may also be the only symptom. For those who do have pain symptoms, it can be really bad and debilitating. If you have heard of endometriosis before, you are probably aware that it can make periods intolerable, but that’s not the whole story. Endo, as it is called for short, can cause pain that extends well beyond menstruation, it can cause issues with constipation, low back pain, urination, bowel movements, and fertility. Pain with endo can be severe. It can keep you from work, and school, or even land you in the hospital. The time a woman spends trying to get a diagnosis for the pain caused by endometriosis can take up to 11 years according to the American College of Gynecology fact sheet cited below.

What Causes Endo?

As you may have gleaned from the intro to this story endo is poorly understood and frequently misdiagnosed. Up until recently, we weren’t even entirely sure what the deposits left by endometriosis were. The research community is divided on what causes endo and have offered many different theories to its origin, but the specific cause of endo is unknown.

We do know endometriosis is an estrogen dependent disease, which is why it affects mainly women. One common theory of how endometriosis is caused is the theory of retrograde menstruation. This theory posits that endometriosis is caused by shed endometrium that escapes the uterus and deposits itself in the abdomen. This theory is supported by animal studies that have produced endometriosis like legions when endometrial tissue was deposited in the abdominal cavity. The theory fails to explain cases in which endometriosis deposits are found far away from the uterus in tissues like the lung. It also fails to explain the rare cases of men who develop endometriosis with estrogen therapies. In many circles, this theory is falling out of favor and is completely disregarded by others. Another similar theory is the lymphatic vascular theory. This theory hypothesizes that endometrium travels to outside spots via the lymphatic system. Again, this theory doesn’t explain the rare cases of male endo nor does it explain that the tissue found in these outside sites. It also fails to explain that the tissue found outside the uterus is “endometrium like” and is different than normal endometrium within the uterus.

The theory of coelomic metaplasia is based on the fact the both endometrium and peritoneal tissue comes from the same embryonic ancestor, coelemic epithelium. The theory posits that certain immunologic or hormonal factors may transform this tissue into the implants we see in cases of endometriosis. The third theory is the embryonic rest theory. It purposes that endometriosis caused by stem cells derived from the embryonic müllerian system become transformed in endo deposits. This theory is supported by the rare cases of men with endo, as they, as embryos, have the same embryonic müllerian system, before it regresses as the male embryo develops.

What’s kind of crazy is the level of pain a women experiences is not directly related to the amount or size of the endo deposits she has. One theory of why a women with very little endo found surgically can have a lot of pain, is the concept of centralization, where the brain becomes more likely to perceive stimuli as painful. Read more about this process in our blogs  Navigating Life with Chronic Pain 1, and Navigating Life with Chronic Pain 2 here.

One, all, some, or none of these theories could explain how endo is formed and maintained. The truth is we don’t fully understand the pathogenesis of this disease, yet. We need to know the cause. If we know the cause we may be better able to design treatments to ease the pain of endo and optimize the fertility of its suffers. Knowing the cause of endo will at least, aid in diagnosing the disease earlier or possibly curing or preventing it all together, which brings us to our next section.

 

Why does it take so long to get an endo diagnosis?!

Here’s the deal. The gold standard for endometriosis diagnosis is laparoscopic exploratory surgery with pathological biopsy confirming a lesion. Before laparoscopic surgery was a mainstay of medical practice, it was often believed that endometriosis was a disease that did not affect adolescent girls, as it was only seen in laparotomy, a more invasive technique reserved for more severe symptoms and conditions. When laproscopy became widely available in the 1980’s the diagnosis of endometriosis grew rapidly in all women and especially adolescent girls.

There are other tools available to detect endo but they are not definitive like surgery and may miss cases. Even laparoscopic surgery can miss endo especially in adolescents, because the endo deposits may be better disguised because of its color, usually clear or red in younger girls. Endo is also not suspected often until after the start of a girl’s first menses, new recommendations suggest that abdominal and pelvic pain complaints in girls be investigated for endo at the start of breast bud development (Brosens) as endo was found in between 50- 62% of adolescent girls undergoing laparoscopy for chronic pelvic pain ( Agarwal and Chaichian).

Doctor’s need better, less invasive tools to detect endo and get women out of pain. Although laparoscopic surgery is considered non invasive, the recovery from it can be difficult, dissuading patient and physician alike from using it as a diagnostic procedure. There is emerging science working on less invasive ways to screen or even detect for endo. More research dollars should be spent to develop early diagnosis and treatment in order to save women the years, lost work and education secondary to pain, and infertility from prolonged endometriosis.

Conversely, women without true endo are undergoing surgery needlessly, sometimes sustain hysterectomies to “cure” endo that is in fact not even there (also hysterectomy does not cure endo, Endo by its definition is a disease that occurs outside of the uterus). 25% of 4000 women studied who underwent hysterectomy for suspected endometriosis pain, were found to not actually have endo, which is outrageous on so many levels. 1. Hysterectomies do not cure endo. 2. Infecting infertility and the risks of major surgery on a woman who does not need it, regardless of whether she has endo or not, is awful. 3. Those 25% of women who had their hysterectomy likely have more pain and were not given a proper diagnoses so they can pursue the proper intervention for their pain.

Why is Endo Such a Big Deal as Feminist Issue?

Endo is a disease the effects women and only in very rare cases, men. If you get 10 of your gal pals in a room, statistically 1 of them will have the condition. Before I start in with this next argument, I want to make clear, that a diagnosis of endo does not necessarily impair one’s success later on in life; however, it can make achieving life’s milestones a lot more challenging.

Girls with painful endo symptoms miss more school a month than girls without endo (Brosens), setting them up for a harder battle to succeed academically and potentially limiting college options. In the workforce, they may continue to miss more days limiting their chances for raises and advancement. These missed opportunities have the ability to compound and further place women with endo at an economic disadvantage.

As women, it is sometimes harder to have our pain taken seriously. In a shattering article in the Atlantic, Joe Fassler, describes the ordeal his wife had to go through to have her potentially life threatening ovarian torsion taken seriously. He recounts how many times his wife was told to buck up, while she was actually in the process of losing her ovary. He also sites the disturbing statistic that women wait approximately 25% longer than men in the ER for pain relief. There is evidence to support that if you are a woman of color, you are even less likely to be given an analgesic at all when you go to the ER for pain. The fact our pain, as women, is taken less seriously means that in order to get a timely diagnosis women may have to scream louder and longer just to be heard.

The longer women wait for diagnosis, the more likely the pain is likely to enter a centralized state in which stimuli that were previously not painful are perceived as pain. Centralized pain is a lot harder to treat and will take longer to resolve than non centralized pain, possibly leading to more time out of the workforce, and requiring more money spent on treatments. Women with endo must be taken seriously. Our financial independence and personal lives require it.

What Can I Do If I am In Pain?

So we talked about the larger systemic issues affecting women with endometriosis. But what are some realistic steps you can employ to help with your pain?

  • Get moving! A review by Bonocher and colleagues, found exercise may help women who are already suffering from endometriosis related pain. The pain caused by endometriosis is thought to occur because of inflammation caused by endometriosis implants outside of the uterus. Exercise has been shown in repeated studies to increase anti-inflammatory chemicals in the blood and therefore reduce pain caused by inflammatory processes.
  • Stretch it out. Zahra Rakhshaee, published a 2011 article that found yoga could ease painful periods and may be helpful in managing the symptoms of endometriosis. In this study, a yoga routine consisting of daily 20 minute sessions had a significant effect in reducing pain in the study participants.
  • Put a pin in it, or you! Acupuncture is an ancient Chinese healing practice and can be used to treat many conditions. In a review by Leong in 2014, acupuncture reduced painful periods in 92% of study participants. The review also cited an article in which 73% of participants reported an improvement in their symptoms versus 42% receiving a placebo (fake) treatment
  • Physical therapy treatment can be helpful in treating many of the issues associated with endometriosis. In a study by Wurn in 2011 , physical therapy was shown to have a significant effect on reducing pain and improving sexual function in women who have endometriosis. Physical therapists are trained healthcare practitioners who can guide you in strengthening and stretching programs to help ease your pain, apply hands-on techniques to restore mobility lost due to endometriosis and other conditions, as well as guide you through lifestyle modifications you can make to ease your pain symptoms.

If one or all of these methods of pain management strategies sounds like they will work for you, Beyond Basics Physical Therapy, as well as other specialized clinics can help guide you. We at Beyond Basics, have an excellent team of physical therapy practitioners who are experts in the field of pelvic health, who do one on one, hands on work, who can develop an appropriate exercise plan tailored to your needs, and can guide you through other lifestyle modifications to help reduce your pain. We also partner with acupuncture and yoga professionals who offer services on site at our Midtown clinic. We hope to see you soon as you begin your journey of healing.

For more on PT and how it can help endo pain, check out Amy’s Video

What do we do for everyone affected by endometriosis or pelvic pain?

Seems pretty bleak, doesn’t it? It’s not. Collectively women and endo specialists are working to advance the awareness, diagnosis, and multidisciplinary approach to treating endo. It is an exciting time with new discoveries being presented in the literature, and more women and doctors becoming outspoken about this condition. But we have a heck of a long way to go to help out our sisters with endo.

The first thing you can do is speak up. If you feel you have not been diagnosed correctly, seek a second opinion. Also feel free to share the articles below with your doctors in order to broaden their exposure to endometriosis, I particularly like Brosen’s article. Share this blog and others on endo so more women and practitioners know about it. For those of you with the resources to do so, consider donating to an organization like the Endometriosis Association or the International Pelvic Pain Society (IPPS). Both are organizations that study and advocate for effective diagnosis and treatment for people with pelvic pain, including those with endo, as well as advocate for a multidisciplinary approach to healing. Together, we can improve society’s awareness of this disease and reduce the challenges that endo has on women.

 

ACOG. Endometriosis Fact Sheet. https://www.acog.org/about_acog/news_room/~/media/newsroom/millionwomanmarchendometriosisfactsheet.pdf. Accessed March 12, 2018

Agarwal N, Subramanian A. Endometriosis- morphology, clinical presentations and molecular pathology. J Lab Physicians. 2010; 2(1)-19

Bonocher C, Montenegrow M, Rosa e Silva, et al. Endometriosis and physical exercises: a systematic review. Reproductive Biology and Endocrinology. 2014, 12:(4)

Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Human Reproduction. 2013; 28(8) 2-26-31

Dickasen M, Chauhan V, Mor A, et al. Racial Differences in opiate administration for pain relief at an academic emergency department. Western Journal off Emergency Medicine. 2015; 16(3) 372-80

Chaichian S, Kabir A, Mehdizadehkashi A, et al. Comparing the efficacy of surgery and medical therapy for pain management in endometriosis: A systematic review. Pain Physician. 2017; 20 185-95

Fassler, Joe. How Doctor’s Take Women’s Pain Less Seriously. The Atlantic. October 15 2015

Leong F. Complementary and alternative medications for chronic pelvic pain. Obstetrics and Gynecology Clinics of North America. 2014, 41:(3): 503-10

Mowers EL, Lim CS, Skinner B, et al. Prevalence of endometriosis during abdominal or laparoscopic hysterectomy for chronic pelvic pain. Obstet Gynecol. 2016 Jun;127:1045–1053.

Rakhshaee Z. Effect of three yoga poses (cobra, cat and fish) in women with primary dysmenorrhea: A randomized clinical trial. Journal of Pediatric Adolescent Gynecology. 2011;24(4):192-6

Sasson I, Taylor H. Stem cells and the pathogenesis of endometriosis. Ann N Y Acad Sci. 2008; 1127: 106-15

Stratton P, Khachikyan I, Sinaii N, et al. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obset Gynecol. 2015; 125(3) 719-28

Womenshealth.gov. https://www.womenshealth.gov/a-z-topics/endometriosis . Page last updated: March 05, 2018. Accessed March 12 2018

Sources:

Wurn B, Wurn L, Patterson K. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual therapy: results from two independent studies. 2011;3(4)

Ph101 Why is Pooping so Difficult?

 

toilet

Fiona McMahon, PT, DPT

The number of Americans who deal with constipation issues is massive (4 million)! It seems like every time I mention that I’m a pelvic floor physical therapist, another friend of a friend pulls me aside with bowel movement concerns. Why is it that so many people have issues? And more importantly – what can we do about it? This is the topic of our next Pelvic Health 101 seminar  on March 14th at 7pm.

Not only will constipation be discussed but other bowel conditions, such as irritable bowel syndrome, fecal incontinence, bloating, and hemorrhoids will be addressed. The lecture will also go in depth on the role of fiber, water intake, toilet posture and pelvic floor muscles in having a successful bowel movement. You will even go home with easy techniques that you can implement immediately to help you get that smooth move! Don’t miss out on this FREE event – it’s a MUST for anyone who struggles on the porcelain throne. Seats are going fast!  Light snacks and refreshments will be served.

Check out Stephanie’s video on what next Wednesday has in store!

 

Register at pelvichealth101.eventbrite.com today.

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Check out or upcoming courses!

Pelvic Health 101 Spring 2018 (2)

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On September 20th, 2017 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes:

Pelvic Health 101 Fall 2017

Irritable Bowel Syndrome and Physical Therapy

IBSFiona McMahon, DPT

Hello everyone! April was Irritable Bowel Syndrome(IBS) Awareness Month. Although, we are a bit late, we wanted to take some time to talk about IBS and what can be done to help with its symptoms. IBS can present in different ways. People with IBS may experience diarrhea or constipation, or both. At Beyond Basics, we work with issues associated with IBS, from ensuring that your digestive organs move well in order to function properly, to toilet posture, to training the pelvic floor to have the coordination to help you toilet comfortably.

Tips for living with irritable bowel and other digestive symptoms

Posture

Over the years we have used our blog to discuss many different tips, tricks, and techniques you can use at home to make the process of having a bowel movement just a bit easier. The first thing you can do is super simple: sit on the toilet with good posture. There are heaps of ways to sit on the toilet and believe it or not, there is an optimal way to sit and poop. The reason why the way we sit is so important is the anal rectal angle. The anal rectal angle refers to the angle of your rectum. When we stand and sit our angle is more bent or acute, which makes it harder for poop to drop out of out of our rectums (yay!), which increases our chances of continence. But when we are trying to poop, we want our anal rectal angle to straighten out so it is easier to poop and we don’t have to strain. The position that best allows us to do that is squatting, the way one would over an eastern style toilet. Most of us have western style commodes that don’t allow for a nice anal rectal angle opening squat. So we have to get creative. By placing a stool or the now ubiquitous squatty potty under your feet you can simulate a squat and allow for easier passage of stool. For more on posture, check out Sara Paplanus’s blog on posture and bowel movements.

Diet

veggies

Diet is a very important thing to consider when trying to optimize your bowel movements. The first thing we usually consider is fiber. There are two types of fiber. Soluable and insoluable. Soluble dissolve in water and allows the stool to absorb water and adds mass and heft ( in a good way) to your feces. Insoluble fiber does not dissolve in water and can help push the poo out. The fact is we need to balance both types and most of us aren’t getting enough. In addition, some people need more of one type and some need more of the other or else you can end up with increased gas and bloating. Read how you can increase your fiber intake here. If you are having difficulty balancing the two or are not sure which to add, it is best to seek advice from an expert nutritionist in abdomino-pelvic pain and IBS.

Water Intake

The colon, the last stop for poop before it enters your rectum is the place where water is absorbed from the stool. In cases where you are too dehydrated, your body will recycle water anywhere it can, including your stool. If too much water is taken from your stool, it can be dry and hard to push out. We suggest drinking about one half your body weight in ounces of water daily and even slightly more if you are constipated, sweat a lot or suffer from IBS. For example, if you weigh 200 lbs, drink 100 ounces of water to make sure to ease your bowel movements.water-life-crop

Physical Therapy

Pelvic floor physical therapy can help a lot with issues with IBS. In last year’s IBS awareness blog, we discussed the benefits of pelvic floor PT

“Dysfunction in organs can also cause dysfunction in the skeletal muscles that are close by. This is called the visceral-somatic reflex. One of the most common examples is when someone feels left arm pain when they are having a heart attack. The dysfunction in the heart causes pain and spasm in nearby muscles. The same thing can happen when the gut is irritated in conditions like IBS. Typically, people with IBS will feel pain and spasm in the muscles of their abdomen and pelvic floor as a result of repeated irritation in their gut. To add insult to injury, spasm in the pelvic floor, (specifically the levator ani and sphincter muscles) can adversely affect the passage of stool out of the body and make symptoms even worse.

Pelvic floor physical therapy can help symptoms caused by the visceral somatic reflex greatly. At Beyond Basics we have an excellent crew of pelvic floor physical therapists with expertise in visceral mobilization and pelvic floor dysfunction. Our physical therapists can work to eliminate painful spasms, mobilize restrictions, retrain the muscles and teach self-management techniques to keep symptoms at bay, or to eliminate some of the symptoms in the future.”

 

IBS is an important condition that affects many different people. Although there currently is no cure for IBS, there is a lot you can do to make living with this condition more manageable. If part, or all, of the symptoms are from musculoskeletal dysfunctions of the pelvic floor and abdomen, than there IS a cure and we are here to help! If you are suffering, please make an appointment with us today.

Sources

R Saeed. Impact of Ethnic habits on defecographic measurements. Arch Iranian Med 2002; 5(2) 115-16

Ph101 Why is pooping so difficult?

toiletFiona McMahon, DPT

The number of Americans who deal with constipation issues is massive (4 million!)! It seems like every time I mention that I’m a pelvic floor physical therapist, another friend of a friend pulls me aside with bowel movement concerns. Why is it that so many people have issues? And more importantly – what can we do about it? This is the topic of our next Pelvic Health 101 seminar  on  March 30th at 7pm. 

Not only will constipation be discussed but other bowel conditions, such as irritable bowel syndrome, fecal incontinence, bloating and hemorrhoids will be addressed. The lecture will also go in depth on the role of fiber, water intake, toilet posture and pelvic floor muscles in having a successful bowel movement. You will even go home with easy techniques that you can implement immediately to help you get that smooth move! Don’t miss out on this FREE event – it’s a MUST for anyone who struggles on the porcelain throne. Seats are going fast!  Light snacks and refreshments will be served.

Register at pelvichealth-101.eventbrite.com  today.

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

Check out or upcoming courses!

pelvic-health-101-spring-2017

BPPT Health Tip: Best Positioning Tips for Optimal Bowel Movements

By Sarah Paplanus, DPT, PT

Are you among the 4 million Americans who suffer from constipation? Or the 1 in 5 American adults with Irritable Bowel Syndrome? Do you occasionally experience the pain and itchy feeling associated with hemorrhoids? If so, the Squatty Potty or similar stool may be the perfect addition to your bathroom! Even if you haven’t been diagnosed with any of these conditions, it is important to note that straining or holding your breath to complete a bowel movement is never normal and is usually a sign of dysfunction. Colorectal medical conditions can vary in their cause, in their presentation and in their severity, but your pelvic floor muscles will always be affected.

null( Image via: squattypotty.com )

Anatomy!

 

Your colon carries waste out of your body, and where the colon meets your rectum is called your anorectal angle. This anorectal angle is an important factor in continence.

Your pelvic floor muscles work together to support the rectum, change the anorectal angle and control opening/closing. One of your pelvic floor muscles (the puborectalis) forms a sling around your rectum and works to maintain the anorectal angle. If that muscle is tight, it can essentially “choke” your rectum and contribute to straining.

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What does squatting do?

Squatting straightens the anorectal angle and helps to relax the puborectalis muscle, which helps to facilitate emptying. It also decreases the amount of pressure in the abdomen, which has been shown to decrease the time and effort needed for defecation. This all helps to reduce excessive pressure and strain on your pelvic floor muscles. In cultures where squatting is still prevalent for defecation, such as parts of Asia and Africa, it has been found that bowel movements tend to be more complete and that there is a decreased incidence of colorectal dysfunctions such as hemorrhoids, constipation and hernias.

Why is straining bad?

A principle of elementary mechanics states that “any system exposed to excessive pressures ultimately sustains injury”.These injuries can be in the form of a hemorrhoid, a hernia, a muscle strain or a chronic pelvic floor dysfunction. Straining also increases your risk of the Valsalva maneuver, which is exhaling against a closed airway. This causes a sudden increase in intra-abdominal pressure which can cause abrupt changes in blood pressure.

Toilet Posture

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Using a squatty potty, stool, or even two yoga blocks can help you assume a “squat” position. Lean forward and rest your elbows on your knees. Take deep breathes in, using your diaphragm. Place your hands on your belly and feel your breathe fill up your abdomen. Keep your mouth open and jaw relaxed!

Other Strategies to Improve Bowel Health

  • Cardiovascular exercise
  • Proper nutrition (see our previous post on fiber!)
  • Make sure you are drinking enough water
  • Relaxation training, diaphragmatic breathing

 

What to do if you are still suffering?

If the above tips are not helping defecate regularly and comfortably, you may be suffering from pelvic floor dysfunction. Pelvic floor dysfunction can occur when the muscles of the pelvic floor become too tight, weak, or both to do their job properly. Physical Therapy can help! Visit us at Beyond Basics Physical Therapy to help better your BM’s.

The School of Pelvic Health: Why is pooping so difficult?

By Stephanie Stamas

The number of Americans who deal with constipation issues is massive (4 million!)! It seems like every time I mention that I’m a pelvic floor physical therapist another friend pulls me aside with bowel movement concerns. Why is it that so many people have issues? And more importantly – what can we do about it? This is the topic of our next Pelvic Health 101 seminar.

Not only will constipation be discussed but other bowel conditions, such as irritable bowel syndrome, fecal incontinence, bloating and hemorrhoids will be addressed. The lecture will also go in depth on the role of fiber, water intake, toilet posture and pelvic floor muscles in having a successful bowel movement. You will even go home with easy techniques that you can implement immediately to help you get that smooth move! Don’t miss out on this FREE event – it’s a MUST for anyone who struggles on the porcelain throne. Seats are selling out fast so reserve your spot here.

All seminars will be held at Beyond Basics Physical Therapy in New York City and start at 7pm. A free “Healing Pelvic and Abdominal Pain” DVD will be given to first time guests, and $20 voucher for Beyond Basics Physical Therapy products will be given to individuals attending five seminars. Space is limited, so reserve your spot today!