How movement supports endometriosis management
A client walks in right before class, tells you about their day and how stressful life is as they put on their grip socks. Then right before you lie them on the Cadillac they also mention, ‘oh and by the way I’ve just found out I have endometriosis’. What do you do? How do you support them best?
Senior Polestar Educator / Physiotherapist Jen Guest explains how the best thing for women with Endometriosis is just simply movement.
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So what is Endometriosis?
Endometriosis is a chronic, non-cancerous, idiopathic condition where endometrial tissue grows outside of the uterus. The exact cause is unclear, but it is influenced by the hormone oestrogen. It is a familial condition, rather than genetic, and is unable to be cured. Our role is to help our client to manage the presenting symptoms of endometriosis and maintain mobility and function.
The endometrium is the inner lining of the uterine wall. The endometrial cells, in the case of Endometriosis, present and multiply outside of the uterine wall creating thickened masses of cells, or Endometrial Implants. These cellular deposits may occur throughout the pelvic cavity; around the fallopian tubes, the bowel, the bladder, the ovaries and the general tissue of the pelvis. With the hormonal flux of the menstrual cycle, these scar tissues grow, thicken and then slough away, each month, as would normally happen inside the uterine wall. However, the bloodied material sloughing away is contained within the pelvic cavity, causing an ongoing cycle of inflammation and pain. This inflammation perpetuates the problem from month to month increasing the scarred tissue over time and binding down the organs within the pelvic cavity. Although we don't yet understand the exact cause for this obscure endometrial cell growth, we do understand that it is affected by the cyclical increase and decrease of Oestrogen with the female's menstrual cycle. Endometriosis presents during the menstrual phase of a female's lifespan, beginning in puberty and increasing over time. The effects subside post menopause. It is understood that pregnancy and to a lesser degree, breastfeeding, can reduce the inflammatory process temporarily.
The common symptoms noted with someone presenting with Endometriosis do vary between individuals, but we see pelvic pain, excessive menstrual cramping, bloatedness, constipation, pain on penetration and lower back pain. In the more severe cases, we can see associated depression and infertility.
There are several theories as to why Endometriosis occurs, though none have been indefinitely proven. Theory One is Retrograde Menstruation, where the menstrual blood leaks back through the uterine wall into the pelvic cavity. Theory Two is that Oestrogen may transform the outer uterine wall cells into endometrial cells. Theory Three considers the embryological phase, where abdominal cells are converted to endometrial cells. These cells attach to the bladder, the ovaries and the rectum and grow/thicken/ bleed with the menstrual cycle. Theory Four looks at potential menstrual bleeding back into the pelvic cavity post Caesarian Section. Theory Five states that endometrial cells are transported outside of the uterus via the Lymphatic System and Theory Six (Mullerian Theory) states that endometrial cells are mistakenly laid outside the uterine walls in the embryological stage.
As noted above, Endometriosis presents post puberty and worsens over the menstrual cycle of a female. It is mostly diagnosed through the 30s and 40s and then subsides post menopause. Since endometriosis is driven by Oestrogen presence, the symptoms will be reduced during pregnancy and breast feeding and furthermore post menopause, due to the reduction in Oestrogen. Note that the degree of symptoms does not necessarily indicate the amount of scarring present.
Since Endometriosis is an inflammatory pathology, we understand that inflammatory foods may increase the problem. Inflammatory foods include alcohol, caffeine, gluten, red meat and fatty essential fats. Rather, we should encourage our clients to consume fibrous foods, iron rich foods and good fatty acids and antioxidants in the form of brightly coloured fruit and vegetables.
The symptoms of endometriosis may present the same as those of Pelvic Inflammatory Disorder or irritable bowel syndrome. The condition can be confirmed by a Pelvic Ultrasound to determine scar levels, a Transvaginal or an Abdominal Ultrasound Scan. More severe presentations may be investigated via laparoscope (camera into the pelvic cavity) Once diagnosed, we can consider appropriate treatment options, remembering that it cannot be cured, but simply managed with confidence and good health team support.
Pharmalogical Intervention is the prescription of non-steroidal anti-inflammatory or pain killers simply for symptom relief.
Hormonal Therapy options include Medroxprogesterone (Depo Provera) injections which holt menstruation, therefore stopping the growth of the endometrial implants. The side effect of this is weight gain and reduced bone density, with accompanying depression. Gonadotropin- releasing hormone (GnRH)agonists and antagonists (Lupran Depot injectable or Elagolix orally) work together to reduce the stimulation of the ovaries and to block Oestrogen production. Blocking Oestrogen prevents menstruation but does put the client into menopause, with side effects such as vaginal dryness, hot flushes and weight gain. These could be offset by taking a low dose of Progesterone at the same time. Donazel is another oral medication to stop menstruation with the side effects of acne and hirsutism (Facial and body hair)
Conservative surgical treatment option is a Laparoscopy to remove excessive endometrial implants from the pelvic cavity. This is the cleanup procedure, if you like, and is often performed so that the female has a 3-month opportunity of falling pregnant either naturally or a more effective embryo implantation procedure.
A more radical surgical treatment is a Hysterectomy to remove the reproduction organs and therefore the production of Oestrogen. A Subtotal Hysterectomy removes the upper uterus but leaves the cervix. The Radical or Total Hysterectomy removes the entire uterus, cervix and top of the vagina. Both leave the mumma infertile and force her into menopause, no matter what age. This is a big step.
The key presentation we will see in our assessment of an endometriotic client, is the pain excitation muscle guarding around the pelvis. There may well show hypertonicity in the pelvic floor muscle group, transverse abdominus, internal obliques, gluteus medius and minimus and piriformis. More globally, guarding will be present in the rectus abdominus, diaphragm, adductor groups and psoas. The client may present in a hip flexed and adducted position with poor basal breath expansion, lack of spinal extension, tension in the cervical musculature and pectorals. Due to years of discomfort, general fitness has been lost and activation of the core has been limited by pain. Ongoing inflammation around the pelvic girdle causes the layers of the myofascia to become sticky and adhere. This means that the Tranversus Abdominus can adhere to the internal obliques above or even the psoas below. This effects the interglide between the planes of muscle and the ability to activate the TvA in isolation. We also need to remember that our client will move through waves of increased pain during the month, so sessions may need to be varied according to the time of the inflammatory cycle. Depending on the type of treatment the client is receiving, they may also be entering early menopause and have osteoporosis. The client may also be working through IVF so be in a prenatal state.
When working with our endometriotic client, we want to look at gentle dissociation of the pelvis to hips and pelvis to lumbar spine, spinal mobility and articulation in all directions, work on breath, basal expansion, relaxation techniques through movement and postural realignment out of a guarded flexed and adducted posture. These women have been in chronic pain for a long time. In the early days, their pain may not have been recognised nor understood. For some, there is a realisation they cannot have children and associated depression. These are a very special group of women who just need to be understood and managed in a safe and caring movement environment that nurtures and protects them.
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Jennifer Guest is a Senior Educator Polestar Pilates Australasia and Senior Physiotherapist at Smart Health, South Australia.