Pelvic Floor Mythbusters: Endometriosis Edition

Fiona McMahon PT, DPT and Amy Stein PT, DPT

Featuring excerpts from Beating Endo by  Iris Kerin Orbuch, MD and Amy Stein D.P.T.

Welcome back to our Pelvic Floor Mythbusters series! We have explored the effects of prolonged sitting and pee holding and now it’s time to move on to endometriosis. With endo, there are so many different myths, concepts, and sorta truths, that we figured we would address them lightning round style so we can cover as much ground as possible.

Endometriosis (endo) comes with a lot of misconceptions and because of this, the time from symptom onset to official diagnosis and treatment is long. The diagnosis of endo can often take in excess of a full decade to get, which delays further intervention and prolongs suffering. It’s a huge deal and is the reason why Dr. Amy Stein, PT, DPT and Dr. Iris Orbuch, MD. set to the task of writing a book where they bust endo myths right, left, and sideways. Beating Endo goes into much more detail than we do here. If you wish to purchase it, you may here

So without further adieu, here is a list of myths and truths taken from Beating Endo:Beating Endo Cover!

 

Common Endo Myths

The abdominal and pelvic floor muscles are rarely affected by endometriosis.

False: Constipation, frequent urination or retention, Pain with vaginal penetration from endometriosis causes tightening of the abdominal and pelvic floor muscles; So too does assuming the fetal position which is our go to pose when we are in pain. Both contribute to tight abdominal and pelvic floor muscles which causes pain.

The pelvic floor and abdominal muscles do not cause bladder, bowel, sexual dysfunction or abdominal-pelvic pain in patients with endometriosis.

False: Tight pelvic floor muscles caused by years of straining or reflexive tightening due to pain, often cause a severe amount of pain which results in further tightening and shortening of the pelvic floor muscles. Good news is that pelvic floor physical therapy benefits most people who have been experiencing abdomino-pelvic or sexual pain and/or are straining due to ongoing bladder and bowel symptoms.

Hysterectomy is a cure for endometriosis.

False: Hysterectomy is neither a treatment nor a cure. By definition endometriosis consists of cells similar to those in the lining of the uterus but found outside the uterus. Only surgical ‘excision’ removes endometriosis cells.

Medical menopause is a cure for endometriosis.

False: Explanation: Just because your medicines give you hot flashes doesn’t mean your endometriosis is going away. The best treatment approach is to meet with an Endo specialist to discuss options, and in most cases PT management. As well surgical excision has much better results than ablation of Endometriosis.

There is no correlation between quantity of endometriosis and severity of disease.

Truth: Even if you have a minimal amount of endometriosis, you can be in debilitating pain with lots of symptoms and in most cases dietary changes, physical therapy and mindfulness practices can help manage a lot of your symptoms.

Teenagers are too young to have endometriosis.

False: Teenagers can have endometriosis and their endometriosis can cause debilitating symptoms.

Pregnancy is a cure for endometriosis.

False: Just plain no. Pregnancy does not cure endometriosis.

Ablation surgery is the same as excision surgery.

False: Not even close. Excision surgery is the proper treatment for endometriosis. Ablation surgery, burns the surface of the endometriosis lesion but leaves the bulk of endometrial implants behind.

Surprising Endo Facts:

Fact: Physical therapy (pelvic PT) can help many suffering from the many pains and symptoms of Endo, including back, abdominal and pelvic pain, bladder, bowel and sexual function.

Fact: The majority of patients with Endometriosis require pelvic floor physical therapy. Pelvic floor PT can be instrumental in the healing process and can help abdominal-pelvic pain, bladder and bowel urgency, frequency, retention, incomplete emptying, and any sexual pain related to the musculoskeletal system.

Truth: Painful bowel movements, constipation, diarrhea and bloating are symptoms of endometriosis as well as symptoms of pelvic floor dysfunction .

Truth: Painful sex is a symptom of endometriosis as well as a symptom of pelvic floor dysfunction.

Truth: 40 to 50% of women with unexplained infertility is caused by Endometriosis.

Truth: Teens with endometriosis often have acyclic pain, that is, pain at other times of the month rather than only during their period, in addition to cyclic pain.

Truth: Back pain is a symptom of endometriosis.

Truth: If your ultrasound is normal you can still have endometriosis.

Truth: roughly 10% of women have endometriosis. That’s close to 200 million women worldwide. Endometriosis is much more than just bad period pain. 1 in 4 women have pelvic floor dysfunction.

Truth: Endometriosis commonly affects the musculoskeletal system, and in many cases can be a primary contributor to one’s pain and symptoms..

March is Endometriosis Awareness Month

abstract-art-background-1020317Amy Stein BCB-PMD, IF (Pronouns: She, Her, Hers)

Fiona McMahon PT, DPT (Pronouns: She, Her, Hers)

 

We’ve written a lot of blogs over endometriosis (endo) over the years. It is a common diagnosis at Beyond Basics Physical Therapy, and frankly, out in the world. The current estimate is 1 in 10 people with female anatomy have endometriosis, and the average time for a proper diagnosis is 11 years. This number may be subject to change as currently laparoscopic surgery is the gold standard for diagnosis. We write extensively about what endometriosis is, and how it is thought to develop in this blog, But the cliff notes version is that endometriosis is the deposition of endometrial-like cells outside of the uterus. There actually was some degree of controversy about what the deposits actually are. It was originally thought that the deposits were endometrium (the lining of the uterus), but now the endo community is moving away from that thought. The deposits can cause a whole host of symptoms, or none at all. Symptoms severity is not related to the number/amount of endometrial deposits someone has.  We still don’t know why some people with large amounts of endometrial implants and or adhesions can experience little to no symptoms, while others who have a relatively small amount of endometrial deposits may experience debilitating pain.

For most people who know anything about endometriosis, they know it is associated with painful periods. Although this is true, if we look at painful periods, we may be missing a lot of other endometriosis-related symptoms.  Endo can affect the urinary system, resulting in urinary pain, hesitancy, frequency, urgency, and incomplete emptying. It can cause painful defecation and constipation, and it can affect your sex life causing pain with penetration and or orgasm. Endo can present itself in so many diverse ways and two people with endo may present completely differently.

For individuals with symptoms from endo, there is a lot that can be done to help minimize pain. But the same approach is not always effective for everyone. It is really important to look at your own goals when deciding on what to focus on so you can express them to your care team.

There is no magic pill or treatment that works on every endo patient. Oral medicines, surgery, physical therapy, nutrition, and lifestyle changes can all help with symptoms of endo. Often times treating endo requires some combination of all of these things and the frustrating part is what may have worked for someone else may not necessarily work for you. We will take a little look, (by no means exhaustive) at each one of these interventions with the intention of piquing your interest and hopefully facilitating a discussion about these options with your healthcare provider.

Endometriosis is thought to be an estrogen-driven condition. Some people with endo may find relief from medications that affect hormone levels. Oral contraceptive pills (OCPs)  are an example of medication used to affect hormone levels. There are other options beyond OCPs that work to alter hormone levels. For some people with endo, this approach can be helpful for symptom management, although hormone altering medication won’t cure endo.  You do have to consider the side effects of all the medication options however because some of the side effects can be worse than the medication’s positive effects.

Excision surgery is both treatment and the gold standard for diagnosis and treatment of endometriosis. Surgery works by cutting out the endometrial deposits. Performing biopsies on these deposits allows the practitioner to know if the deposit is Endo.  Ablation surgery has been shown to only clear part of the endometrial implants and is not nearly as comprehensive as excision surgery. As a result, repeat surgery is commonly required with ablation, and in many cases, multiple repeat surgeries.

So we’ve just explained to you that endo is an estrogen-dependent condition that causes deposits in the abdominal cavity. Logically it makes sense that getting rid of these deposits via surgery or slowing their growth with medication could help treat endo and the pain associated with it. But what does physical therapy have to do with the treatment of endometriosis? The answers range from simple to complex, with the complex delving into some pretty heady neuroscience. Why don’t we start with the simple first, and get more complex as we go.  

 

The deposits created in the abdominal cavity by endo can cause the tissues of the abdomen to get stuck and not slide and glide freely, we call those stuck areas, tissue restrictions or adhesions. The scars created by endo removal surgery cause adhesions. Sounds pretty bleak, but it’s not as bad as it sounds. Physical therapists have been treating scars for eons (actually since the start of the civil war, but we digress). Whether or not you have had surgery, chances are you will benefit from some myofascial release, which can help reduce endo and surgery related adhesions. Although most physical therapists know their way around scar massage, it is important to go to one who has been specially trained in pelvic floor conditions and ideally has been trained in visceral mobilization. This training will allow your PT to address adhesions of the viscera (your organs) as well as allow them to work on adhesions in the pelvic bowl by performing intravaginal and intrarectal release.

Here’s where it gets heady, bare with me. Let’s start with defining my subheading. Trigger points are taut bands of muscle that are extremely irritable. Trigger points can be described as “latent”, meaning they are painful when touched, or they may be an active myofascial trigger point, which is constantly angry and can refer pain elsewhere in the body. Trigger points in the abdominal-pelvic region can radiate to some funny places far away from where they actually are. Someone may feel the referred pain from a trigger point in their belly or back, near their bladder, or in their “ovary”, as well as other places.  Physical therapy can help relieve these trigger points by performing myofascial release as well as using techniques like biofeedback to help you learn how to relax your pelvic floor and prevent trigger points from reoccurring.

People who have been in pain for a long time may experience a phenomenon called central sensitization. What that means is the body, in an effort to protect you, starts perceiving things that wouldn’t necessarily be painful as painful. No one actively does this, and it is not in your head. It actually happens in the spinal cord and brain. This is what I mean by endo lowering pain thresholds. Physical therapy can be instrumental in improving pain thresholds through a process of desensitization.

What we just discussed are some of the most common things physical therapists address in patients with endometriosis. But let us not forget that everyone with endo experiences it differently. Pelvic floor physical therapists may address issues with urination, sex, and bowel movements directly as well as other issues like weakness, joint pain, and instability. It really is specific to the individual with endo.

Many people find relief in making adjustments to their lifestyle and diet. There have been numerous studies on the benefits of yoga on endo pain, as well as making changes in diet such as avoiding gluten, dairy, sugar, caffeine or committing to an IC and anti-inflammatory diet. In my experience, different things will work better for different people, but we have seen these changes be extremely helpful for some people. We write more about these changes in this blog.

We hope this blog was helpful to you. Having endo can really suck (we can’t think of a better word for it). If you think you may have endo, talk to a gyno who specializes in the treatment of endometriosis, because there is something you can do about your symptoms. Endo is a disease which requires much more research and awareness. Please take time this March to wear some yellow and do your part to spread endo awareness to physicians and other healthcare providers, to high schools and to your community.  

endo
This is the cover from Dr. Amy Stein and Iris Obruch’s latest book on endometriosis, available soon

 

Alimi Y, Iwanga J, Loukas M, et al. The clinical anatomy of endometriosis: A review. Cureus. 2108

 

Aredo J, Heyrana K, Karp B, et al. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med. 2017; 35(1):88-97

 

Mayo Clinic. “Endometriosis”.

. Accessed on February 19, 2019  

 

Mehedintu C, Plotogea MN, Ionescu S. Endometriosis is still a challenge. Journal of Medicine and Life. 2014. 7(3); 349-57

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)

Diet and Endometriosis

Fiona McMahon, DPT

Yellow ribbon
Yellow ribbon, Bone cancer / Osteosarcoma. Endometriosis awareness.

March is Endometriosis Awareness Month. Endometriosis is a condition that is near and dear to our hearts at Beyond Basics Physical therapy. Endometriosis is a gynecological disease that occurs when a tissue similar to the lining of the uterus implants itself outside of the uterus in the abdominal and pelvic cavity. It is an inflammatory condition, whose symptoms can vary from mild to severe. Most commonly endo is seen as causing painful periods, but it can also cause bowel and bladder symptoms, issues with fertility, pain with sexual activities and general pain. For the past two years we have done a post about endometriosis during endometriosis awareness month on how musculoskeletal pain can be a contributor or the primary cause of abdomino-pelvic pain condition. To learn more about how the disease affects the body and its symptoms as well as how we treat the condition at BBPT click here:

For this year’s Endometriosis Awareness Day I decided to review an article on how diet may or may not affect endometriosis. The full version is here for free:

http://www.rbmojournal.com/article/S1472-6483(13)00007-2/abstract

About this Article

The article by Fabio Parazzini and his colleagues is a literature review. The point of a literature review is to aggregate many studies on one topic and determine a general trend in the data in one place. A literature review is not as powerful as its cousin a meta-analysis, in which more powerful statistical tools can be applied to interpret the data. Nonetheless, literature reviews can provide us with a general sense of what is going on in a certain field of research.

First things first, let’s talk about the limitations of this review. Designing a single study on endo and diet can be rather difficult. First of all, not all endo is the same. Women with endo can experience vastly different symptoms that don’t always correspond to the amount of endometrial deposits seen on laparoscopy. It can be really difficult for researchers to ensure they have a homogeneous (or similar) study population. Secondly, studying something like diet it usually correlational and not causal. Diet can reflect a lot of other components besides the nutrients going into one’s body. Diet may reflect factors such as culture, wealth, education, geographic region, which all may play independent roles in the diagnosis and progression of endo. Most of the studies examined were based on self-report, which also may not be entirely accurate.

Now that we have the caveats out in the open, let’s talk about why a study like this is useful. Like I said before, this article is an aggregation of multiple other publications. When we see similar results produced by different authors in different groups of people, it lends a little more weight to the individual study’s findings. Most importantly Parazzini is also careful to include information on why a particular food group may be more beneficial or even harmful in the progression of endometriosis.

What the Article Found

Green Vegetables and Fruit

The authors found two studies that show that a higher intake of green fruits and vegetables reduce the risk of endometriosis. They found that the higher the intake of green fruits, specifically (think okra, etc) caused the decreased risk of endometriosis and did not find the same relationship with green vegetables (think kale, spinach, and lettuce). Parazzini notes that green vegetables and particularly fruit are high in a compound called organochlorine, which has been shown in other studies to reduce the risk of endometriosis. Organochlorines are a particularly broad class of molecules and can be found in healthy things but also make up compounds used in industrial purposes. This study is referring to those occurring naturally in vegetables and fruits.

Vitamin A

Vitamin A is found in animal products like fatty fish, dairy, and animal kidneys and livers. Its building blocks are found in green and orange vegetables and fruits and can be manufactured into vitamin A in the body. Parazzini and colleagues found mixed results some with no benefit for development of endo and some that did show benefit. No studies showed harm.

Vitamin C and E

These vitamins were not consistently found to be helpful in reducing endometriosis risk. Some studies reported that increased amounts of vitamin C and E intake reduced risk of endometriosis, while other studies failed to yield significant findings. Parazzinni did provide evidence from other studies which demonstrates the antioxidant properties of vitamins C and E. Parazinni purposes that because there may be a link between oxidative stress and disease, vitamin C and E may be helpful in reducing the inflammation associated with endometriosis.

Red Meat and Saturated Fat

Again, results were mixed. Saturated fat mainly occurs in animal products. Some studies found a correlation between red meat and endo risk, but no association with butter. In other the results were flipped.

Other items investigated

  • Soy
  • Olive Oil
  • Fish and Omega 3
  • Minimal to no evidence supporting associations between endo and dietary intake for any of these products were found.

 

What’s it All Mean?

One of my patients once told me she was instructed to finish every study, with the phrase, “more research is needed.” This is certainly the case in the field of endometriosis treatment. There’s a lot about endometriosis that we don’t understand We need well constructed studies that will allow researchers to do more powerful meta-analysis to help guide our treatment. This review was only able to include 11 studies for review out of the 256 initially found.

With all that said, I do think there are some key takeaways from this study. There was a general trend in healthier foods and more promising results. Parazinni was also diligent to include mechanisms by which these healthy foods could be helpful. Secondly, there was no harm found by eating what is considered a healthy diet, (high in greens and vitamins). These findings, although small, in combination with the general benefits of a healthy diet, should encourage patients with endo to explore in more depth how eating certain foods affects their symptoms.

At Beyond Basics we take pride in treating our patients from a holistic perspective and we appreciate that we can collaborate with other healthcare providers in our community, including expert nutritionists, naturopaths, functional medicine doctors and mental health therapists. We find that the combination of diet, specific physical therapy techniques, mental health and self-care, can significantly reduce pain and other symptoms and improve function in many patients. Our clinicians specifically are experts in manual therapy techniques such as visceral and connective tissue mobilization techniques, myofascial release and other soft tissue mobilization techniques discussed in the previously mentioned endometriosis blogs. If you are suffering from endometriosis, come visit us today.

Learn more about what we do at BBPT with our upcoming PH101 classes, which are free to the public. Here are some you may find interesting:

April 6th: Does my diet really matter?

April 13th: Pain & Sexuality: Is it all in my head? No, it is not!

April 20th: Ladies Only Session

April 27th: Optimize reproductive health

May 4th: Improve your birthing experience.

All events are at 7pm with light snacks.

Register at: pelvichealth-101.eventbrite.com because space is limited!!

See full list of classes below

pelvic-health-101-spring-2017

How can I manage my endometriosis-related pain?

Whether you are newly diagnosed or have been living with endometriosis for many years, you may find yourself asking, “Is there anything else I can do to help with the pain?” While there are many medical and surgical options available, a lot of women are not fully satisfied with their pain reduction. In honor of Endometriosis Awareness Month, and every month, we’re here to help.

Image courtesy ResolveNewEngland.org.

Endometriosis is the name given to a condition in which endometrial tissue (the lining of your uterus) grows in places outside of the uterus. The growth of endometrial tissue outside of the uterus can cause areas of restricted or “stuck” tissue called adhesions. Adhesions and scar tissue from surgeries to treat endometriosis, as well as endometrial implants themselves, can cause constipation, painful sex, and severe pain, which worsens during your period. Pain or irritation from endometrial implants on a pelvic organ may refer or appear in muscles that are innervated by the same spinal level as the irritated organ. This is known as the viscerosomatic reflex and can result in muscle spasms and trigger points, which may seem completely unrelated to endometriosis. Scientists still do not agree on a definitive cause of endometriosis; however, scientists have recently published many studies about steps individuals can take to help with their endometrial pain.

Getting in daily exercise has been shown to be helpful in alleviating and preventing many health conditions. The benefits of exercise on endometriosis-related pain have been reviewed in an article by Bonocher(2) and colleagues. The authors of this review found that exercise may indeed have a preventative effect on the development of endometriosis in women who exercised between two and four hours a week.

The same article also suggests 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 endometrial implants outside of the uterus. Exercise had been shown in repeated studies to increase anti-inflammatory chemicals in the blood and therefore reduce pain caused by inflammatory processes.

In a study by Zahra Rakhshaee(4), published in 2011, yoga was found to 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.

Acupuncture is an ancient Chinese healing practice and can be used to treat many conditions. In a review by Leong in 2014 (3), 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 (5), 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 and other pelvic floor symptoms.

Physical therapy can also be helpful to mobilize and “free up” tissues that have become stuck as a result of adhesions caused by endometriosis. A physical therapist can use his or her hands to loosen adhesions to allow the organs of your abdominal cavity to move more freely, and thus reduce pain, improve issues with constipation and even make sexual intercourse more comfortable. (Arung, 2011)

If one or all of these methods of pain management strategies sounds like they will work for you, Beyond Basics Physical Therapy can help guide you. We have an excellent team of physical therapy practitioners who are experts in the field of pelvic health, who do 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.

Sources:
1.) Arung W, Meurisse M, Detry O. Pathology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011: 17(41) 4545-53

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

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

4.) 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

5.) 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)