Endometriosis is often called an invisible illness — and due to its symptoms and situations when pain is experienced, much of the suffering happens in private. What is endometriosis? It is a disease in which tissue that is similar to the lining of the uterus grows outside it, including surfaces in the abdominal cavity, ovaries, bladder, rectum and abdominal/pelvic walls.
Women going through this aren’t alone: The World Health Organization shares that at least 190 million women and girls of reproductive age worldwide are affected. This includes those who live with symptoms, but do not identify as female, and some may suffer beyond menopause. Here in Singapore, 10% of women are affected by endometriosis according to SingHealth, but it is a global issue that an endometriosis diagnosis can take years as symptoms can be confused with conditions such as irritable bowel syndrome or pelvic inflammatory disease.
Nobody should have to live with pain – and endometriosis impacts so many aspects of women’s lives, from issues around fertility, to intimacy, fatigue and anxiety in correlation to chronic pain — which the medical community now talks about as persistent pain as there is a way forward. There is support available, and room to change and move away from suffering. By arming yourself with greater awareness of endometriosis symptoms and treatment options available to you, it is possible to live with less pain, enjoy a healthy sex life and support your fertility – there are many endometriosis and pregnancy success stories.
At Embrace Physiotherapy we advocate a holistic approach to women’s health — it must be stressed upon, first and foremost, that physio does not cure endometriosis, but rather, helps manage the symptoms of endo. There is currently no known cure, or prevention. Early diagnosis and management are the key.
What life with endo feels like
What are the first signs of endometriosis? It affects women in varying degrees of severity, and one woman’s experience will be unique to another’s. Women who come to Embrace Physiotherapy who live with endo, or want to manage endometriosis and pregnancy, describe feelings of exhaustion, a sensation of heaviness in the pelvic area, pain during sex, and particularly painful periods. A certain amount of discomfort with periods may be normal; pain that stops you from living everyday life is not. There are endometriosis symptoms that are hallmarks of the condition, which may include:
- Painful periods (dysmenorrhea)
- Pain during or after sex (dyspareunia)
- Pain during or after bowel movements (dyschezia)
- Pain when you urinate (dysuria)
- Pain in the, lower back or legs
- Having trouble holding on when you have a full bladder or having to urinate frequently
- Persistent pelvic pain
- Heavy bleeding or irregular bleeding
- Difficulties with fertility
- Nausea and/or vomiting
Unfortunately, in many cultures it’s still taboo for adolescent girls and women to talk about their menstrual cycle, and there is a perception that periods are painful and this should just be accepted — so symptoms can be dismissed by families and even medical professionals. What’s important is that you receive compassionate support, that your symptoms are taken seriously, and then managed.
Surprising endometriosis symptoms
You may be aware of the top signs that you have endometriosis, but there are lesser known symptoms that can lead to a misdiagnosis, or the root cause of endometriosis may be missed entirely.
- Bowel issues — which include bloating, constipation and diarrhea, which is why endometriosis is often misdiagnosed as Irritable Bowel Syndrome. If you’re experiencing nausea and vomiting during your period, this could be a sign of endometriosis stuck to the bowel and stomach.
- Shoulder pain that isn’t responding to physiotherapy, osteopathy or chiropractic care, which could be endometriosis affecting the diaphragm.
- Acid reflux – you may be managing this with antacids, but the underlying cause could be endometriosis on the bowel.
- No pain. You may have lived with endometriosis for some time and be at an advanced stage with the growth of ovarian cysts, but only receive a diagnosis if you’re having trouble conceiving.
Endometriosis diagnosis and treatment
Now all these symptoms could mean a million and one things, so how can you know for sure? A clinical assessment and ultrasound or MRI may be involved, but the gold standard for diagnosis is laparoscopic surgery and biopsy.
Endometriosis treatment options include surgical removal of endometriosis lesions and scar tissue (excision), hormone management to lower estrogen or increase progesterone (often through the contraceptive pill) and anti-inflammatory and anti-neuropathic pain medications are prescribed.
Understanding the pain you’re feeling
When you are in pain it’s common for your muscles to tighten in response. If you’ve been suffering from pain for months — or even years — it becomes your body’s norm and you don’t even realise you are holding your muscles in a tight position. The pelvic floor then loses its ability to contract and relax properly — this is known as an increased tone pelvic floor, and sometimes called an overactive pelvic floor. It can lead to discomfort while the bladder fills, doing a poo, pain in the pelvis, and sex can be painful as a result.
Women with endometriosis are also more likely to have bladder pain syndrome (also known as interstitial cystitis) and experience pain that can start in one organ and spread through the pelvis.
Endometriosis inflammation, scar tissue and adhesion formation between organs can also lead to the surrounding structures having reduced mobility. This consequently reduces blood circulation in the tissue and organs, tight muscles and trigger points — ultimately resulting in pain and movement dysfunction.
When we are in pain our bodies move into a ‘fight-or-flight’ state, and sometimes we grip our abdominal or pelvic floor muscles to protect ourselves. This can, in turn, irritate and tighten already angry and inflamed areas impacted by endo. This is usually an unremitting cycle that impacts quality of life and emotional and psychological well being.
It’s important to know that pain is generated by the brain: pain is a protector, but hurt does not equal harm. Pain is also not a reliable indicator of tissue damage, as pain from endo can come from inflammation, adhesions, other organs or hypersensitivity to pain — and we can change this.
Can physiotherapy help with endometriosis?
Physiotherapy works to improve pain symptoms, functionality and quality of life as a result. While there are more important studies emerging on the impact of endometriosis on women’s lives, there still isn’t a great amount of research into therapeutic options for endometriosis. At Embrace Physiotherapy, we draw on studies into pain management, persistent pelvic pain, overactive pelvic floors and use our clinical judgment alongside empirical evidence to treat patients with endometriosis.
However, one recent study published in Ultrasound in Obstetrics and Gynecology journal found that women suffering from deep infiltrating endometriosis and associated pain during sex, benefited from pelvic floor physiotherapy and displayed significant improvement in pelvic floor relaxation and also chronic pelvic pain.
The researcher behind the study, Dr Simona Del Forno of St. Orsola University Hospital in Bologna, told Contemporary OB/GYN: “I believe that in women with endometriosis suffering from chronic pelvic pain, the use of multiple therapeutic strategies, including pelvic floor physiotherapy, may be the key to success.”
What physiotherapists do to treat endometriosis
As women’s health physiotherapists we can use manual therapy to help with trigger points, prescribe stretching and release exercises, use hands-on-techniques to help ensure your organs can move naturally as they should, give advice on gentle movements to help release and relax angry muscles. We can also help you identify hypersensitivity to pain. Together, we can work on your goals and a management plan for when flare-ups occur. This could involve:
- Giving you a better understanding of your anatomy
- Education on your body’s natural pain response, to help you calm your thoughts and re-frame your pain and suffering
- Provide advice on calming your nervous system, including breathing, mindfulness and body scanning techniques
- Advice on exercise and movement strategies, including yoga for managing endometriosis-related pain
- Educate and guide you on good bladder and bowel habits
- Advice on techniques, positions and exercises to help sex become less painful and more pleasurable
- Strategies to optimise pelvic floor function and the use of machines or manual techniques as treatment options
- Sleep hygiene, as quality of sleep has been shown to have an impact on women living with endometriosis
- Pre and post surgery- help you prepare for surgery and recover
There is no single best treatment and we can refer you to psychologists, nutritionists or pain specialists for support. We don’t just recommend a multidisciplinary approach: between your GP, gynecologist or urogynecologist, we all need to talk.
Our goal is to help you feel like you are in control of your body, with a whole body approach. There is no one size fits all.
As with most conditions, finding relief takes time and dedication to your programme. Remember that there can be good and bad days and knowing how to manage during these times will go a long way in improving your health and well being.
If you’d like advice on how physiotherapy can help you manage life with endometriosis, we’re here. Please call us or WhatsApp 9780 7274, or get in touch with us at email@example.com to make an appointment.
Arion A, Orr N, Allaire C et al. ‘A quantitative analysis of sleep quality in women with endometriosis’. Journal of Women’s Health, 2020, https://doi.org/10.1089/jwh.2019.8008.
Del Forno S, Arena A, Pellizzone V, et al. ‘Assessment of pelvic floor muscles with 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: a randomized controlled trial’, Ultrasound in Obstetrics and Gynecology, 2021, DOI: https://doi.org/10.1002/uog.23590
Dos Bispo AP, Ploger C, Loureiro AF, et al. ‘Assessment of pelvic floor muscles in women with deep endometriosis’, Archives of Gynecology and Obstetrics, 2016; DOI: 10.1007/s00404-016-4025-x
G. Lorimer Moseley and David S. Butler, Explain pain supercharged: the clinician’s manual, Noigroup Publications, 2017.
Goncalves, A., Barron, N., & Bahamondes, L. (2017). ‘The practice of hatha yoga for the treatment of pain associated with endometriosis’, Journal of alternate and complementary medicine, 2017, DOI: 10.1089/acm.2015.0343
Mira TA, Giraldo PC, Yela DA, Benetti-Pinto CL,’ Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial’, European Journal of Obstetrics, Gynecology and Reproductive Biology, 2015, DOI: 10.1016/j.ejogrb.2015.07.009
National Institute for Health and Care Excellence (NICE), Endometriosis: Guidelines and Management’, 2017
Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Australian clinical practice guideline for the diagnosis and management of endometriosis, 2021
Wu CC, Chung SD, Lin HC, ‘Endometriosis increased the risk of bladder pain syndrome/interstitial cystitis: A population-based study’ Neurourol Urodyn, 2018, DOI: 10.1002/nau.23462
Yoke-Fai Fong, Soon-Kit Hon, Li-Lian Low, et al. ‘The clinical profile of young and adolescent women with laparoscopically diagnosed endometriosis in a Singapore tertiary hospital’, Taiwanese Journal of Obstetrics and Gynecology, 2017, DOI: https://doi.org/10.1016/j.tjog.2016.07.013