Exploring the Role of Pelvic Floor Physical Therapy in  Managing Endometriosis

Symptoms of Endometriosis

A hallmark sign of endometriosis is debilitating period pain that often progresses to pain in between periods and does not respond to typical over-the-counter medications, like Ibuprofen. However, symptoms can vary greatly and extend beyond just painful periods.

The location of endometriosis lesions significantly influences the type of symptoms experienced by individuals. Common sites include the ovaries, fallopian tubes, rectouterine pouch, rectovaginal septum, uterosacral ligaments, bladder,  intestines, bowel, rectum, and appendix. For instance, pain during bowel movements may stem from endometrial tissue located on the uterosacral ligament or rectum. Lesions on the bladder can cause bladder pain, often mistaken for urinary tract infections. Additionally, endometrial tissue pressing on nerves can lead to back pain and radiating pain down the legs.

Endometriosis can also affect reproductive organs such as the ovaries, fallopian tubes, and the uterus, potentially impacting reproductive function. Many individuals with endometriosis also report abdominal and pelvic pain associated with gastrointestinal disorders, bloating, and pelvic floor dysfunction. Pain during penetration is another common complaint among those with endometriosis which can impact one’s ability to tolerate gynecological exams, use tampons, and to engage in penetrative sex comfortably. The disease also impacts pain processing pathways, leading to pain sensitization and persistent discomfort.

Individuals with endometriosis often experience other pain conditions, known as chronic overlapping pain conditions. Historically, these conditions were treated in isolation. However, recent research has prompted specialists to address these conditions concurrently, while exploring how they interact with one another. Some  common conditions that may occur alongside endometriosis include:

• Interstitial cystitis
• Chronic fatigue syndrome
• Chronic low back pain
• Temporomandibular disorder
• Irritable bowel syndrome
• Chronic migraine
• Vulvodynia

With a personalized approach to treatment, individuals with endometriosis can find relief and regain control over their health.

Diagnosing Endometriosis

On average, it can take a jaw-dropping 10 years for someone to receive a diagnosis of endometriosis. The current gold standard for diagnosing endometriosis is laparoscopic surgery, during which tissue samples can be directly visualized and biopsied. This needs to be performed by an endometriosis specialist as often lesions can be hard to identify and missed by an untrained eye. Endometriosis lesions can also sometimes be observed on Ultrasound (US) and Magnetic Resonance Imaging (MRI),  depending on their location and characteristics, and the radiologist interpreting the images. However, finding a skilled radiologist familiar with the nuances of the presentation of endometriosis can be challenging. While non-invasive diagnostic tools show potential, they have not yet matched the accuracy of laparoscopy, which remains the gold standard. This is partly due to significant variability in the training of radiologists reading images of those with endometriosis. The good news is that there continue to be ongoing efforts to make these non-invasive diagnostic tools a reliable alternative to laparoscopic surgery.

Most people only see an endometriosis specialist when referred, which is why it’s crucial for healthcare providers to be on alert for it and know who to refer to when appropriate. We need to be especially vigilant for individuals who experience chronic pelvic pain, infertility, and menstrual irregularities. Early and accurate diagnosis can significantly improve treatment outcomes and enhance the quality of life for those affected by this chronic condition.

Treatment of Endometriosis

Managing endometriosis requires a comprehensive approach that may include pain management strategies, exercise, dietary modifications, hormonal therapies,  surgery to remove endometrial growths and lifestyle modifications. Seeking support from healthcare providers who specialize in endometriosis can help individuals navigate the complexities of this chronic condition and improve their quality of life. In this article,  we will focus on how Pelvic Floor Physical Therapy can serve as a treatment option for the management of endometriosis.

What is Pelvic Floor Physical Therapy?

Pelvic floor physical therapy is a specialized subset of physical therapy focused on treating musculoskeletal dysfunctions of the pelvic floor. The pelvic floor is a group of muscles and connective tissue that span the area underneath the pelvis between the pubic bone and tailbone. The pelvic floor muscles have five important jobs: supporting the organs, maintaining healthy bladder and bowel function, supporting sexual function,  promoting blood flow, and providing stability to the core and spine.

While pelvic floor physical therapists specialize in treating the pelvic floor, their assessments extend beyond this area. Many individuals with endometriosis also experience musculoskeletal issues such as restricted hip mobility, poor coordination,  neural tension, and weakness, which can contribute to pelvic floor dysfunction,  exacerbate symptoms, and impact overall function. For this reason, pelvic floor physical therapists are trained to evaluate the entire body, from head to toe.

Pelvic floor physical therapy is suitable for individuals looking to manage their current symptoms, prepare for endometriosis excision surgery, or undergo rehabilitation post-surgery to enhance outcomes.

What is Pelvic Floor Physical Therapy?

Pelvic floor physical therapy is a specialized subset of physical therapy focused on treating musculoskeletal dysfunctions of the pelvic floor. The pelvic floor is a group of muscles and connective tissue that span the area underneath the pelvis between the pubic bone and tailbone. The pelvic floor muscles have five important jobs: supporting the organs, maintaining healthy bladder and bowel function, supporting sexual function,  promoting blood flow, and providing stability to the core and spine.

While pelvic floor physical therapists specialize in treating the pelvic floor, their assessments extend beyond this area. Many individuals with endometriosis also experience musculoskeletal issues such as restricted hip mobility, poor coordination,  neural tension, and weakness, which can contribute to pelvic floor dysfunction,  exacerbate symptoms, and impact overall function. For this reason, pelvic floor physical therapists are trained to evaluate the entire body, from head to toe.

Pelvic floor physical therapy is suitable for individuals looking to manage their current symptoms, prepare for endometriosis excision surgery, or undergo rehabilitation post-surgery to enhance outcomes.

Pelvic Floor Physical Therapy Treatment for Endometriosis

Pelvic floor physical therapists are specifically trained to identify the signs and symptoms of endometriosis and to treat the condition from a neuromusculoskeletal perspective. Their specialized training and knowledge about endometriosis enables
them to often provide a more validating experience. This is particularly important, as many patients with endometriosis experience medical gaslighting, where their symptoms are dismissed or minimized by many healthcare professionals.

Endometriosis and pelvic floor dysfunction often go hand in hand. Typically those with endometriosis present with overactive pelvic floor muscles as a guarding response to pain. Abdominal pain, cramping, or gastrointestinal issues can lead to significant tension in the abdominal wall, which even further exacerbates pelvic floor muscle tension. This increased tension can impair muscle function, making it difficult for the pelvic floor muscles to contract, relax, and coordinate effectively, ultimately worsening symptoms.

Seeing a pelvic floor physical therapist to address pelvic floor dysfunction can therefore be greatly beneficial to help reduce pain and manage symptoms. In some cases, patients may find that they can manage their symptoms effectively through pelvic floor physical therapy alone or in conjunction with other treatments enough to delay surgery or avoid it altogether. The decision to undergo surgery varies for each individual and depends on factors such as the severity of the disease and symptoms, as well as unique considerations like age, finances, family planning, and personal preferences.  Always consult with an endometriosis excision specialist to determine the best course of action for your specific situation.

If you do decide to proceed with endometriosis excision surgery, pelvic floor physical therapy remains highly beneficial and is strongly recommended. By reducing symptom severity, pelvic floor physical therapy can improve surgical outcomes and aid in recovery. This approach, known as “prehabilitation,” helps your body move and function as efficiently as possible prior to getting operated on. Whether you’re using pelvic floor physical therapy to manage symptoms or to prepare for surgery, your physical therapist can assist with a variety of treatment methods, including carefully selected exercises, manual therapy techniques, and guidance on lifestyle and behavior modifications.

Your physical therapist can help you manage symptoms or prepare for endometriosis  excision surgery by:

• Improve joint mobility
• Improve nerve mobility
• Improve spine mobility
• Improve visceral mobility
• Improve pelvic floor function
• Regulate your nervous system to dampen pain signals
• Make modifications to your exercise routine so it doesn’t flare you
• Improve breathing mechanics
• Improve muscle strength and coordination
• Improve blood flow
• And more!

It is also important to note that surgery alone does not guarantee a resolution of endometriosis symptoms. Many patients believe that removing diseased tissue will automatically alleviate their symptoms, but various factors can contribute to ongoing discomfort. In fact, many endometriosis patients experience persistent symptoms even after having had endometriosis excision surgery. For these patients, it is important to consider the pelvic floor muscles as a potential source of symptoms as muscle spasms can contribute to continued pain. While excision surgery is a critical component of treatment, it is often not the only treatment needed.

Postoperatively, pelvic floor physical therapy can be helpful for addressing residual pelvic floor dysfunction, managing post-surgical scar tissue adhesions, and supporting long-term symptom management. Depending on your surgeon’s recommendations, you may be able to begin physical therapy as early as 1-2 weeks after surgery, once the incisions have healed.

A major component of pelvic floor physical therapy involves learning about the anatomy and function of the pelvic floor. Many individuals with endometriosis may not fully understand how their pelvic floor muscles work or how they interact with other bodily systems. Gaining insight into the anatomy and function of these muscles helps patients better understand their condition and equips them to manage symptoms more effectively in the long term.

Integrating Multidisciplinary Care

Managing endometriosis effectively often requires a multidisciplinary care team.  In addition to pelvic floor physical therapy, collaborating with specialists such as endometriosis excision experts, gynecologists, nutritionists, functional medicine doctors,  and mental health professionals can be highly beneficial. Each specialist offers unique insights and expertise that contribute to a comprehensive management strategy for the disease. For instance, a nutritionist can provide dietary guidance to help address gastrointestinal symptoms associated with common coexisting conditions like IBS and  SIBO, while a mental health professional can offer crucial support for the emotional and psychological challenges of living with a chronic condition. This integrated approach ensures that all aspects of endometriosis are addressed, promoting overall well-being and effective symptom management.