What is Endometriosis?
Endometriosis is a complex, estrogen-dependent gynecological disorder in which endometrial tissue (the tissue that lines the uterus) is identified outside of uterine cavity, most commonly in the abdominal and pelvic cavities (1-4). Endometriosis is estimated to affect approximately 10% of women worldwide (1-4), however, the actual prevalence is unknown due to the need of surgery for a definitive diagnosis (1,2). Endometriosis primarily occurs in reproductive-aged women between the ages of 25 and 45 years, however, cases of endometriosis have been identified in post-menopausal or premenarcheal females (1-3).
Unfortunately, pain, particularly pelvic pain is a common symptom experienced by patients with endometriosis (1-4). Women suffering with endometriosis may experience constant or cyclic pelvic and/or abdominal pain, low back pain, worsening pre-menstrual pain, painful and/or irregular menstruation (dysmenorrhea), periovulatory pain, painful intercourse (dyspareunia), pain with bowel movements (dyschezia), and painful urination (dysuria). Additionally, women with endometriosis may encounter difficulty achieving pregnancy. The disease can manifest significant consequences on mental health, sexual health, social well-being and educational and professional life (1, 3).
It is important to recognize that women can have endometriosis and be asymptomatic, and that the severity of the disease does not parallel the severity of symptoms, which adds to the complexity of understanding this disorder (1-3).
What causes endometriosis?
The underlying cause of endometriosis is unknown. Theories attempting to explain how and why it may occur include retrograde menstruation, transformation of peritoneal cells into endometrial tissue, embryotic cells in ectopic locations activated by estrogens at puberty and lymphatic or vascular cell transport of endometrial cells (1,2). Retrograde menstruation, where menstrual blood containing endometrial cells flows back through the fallopian tubes and into the pelvic cavity where they can grow and proliferate, was the front runner to explain endometriosis for decades (1-3). Interestingly, nearly all women experience retrograde menstruation but only a relatively small percentage of women develop endometrial lesions (1). In addition, this theory does not explain the occurrence of endometrial tissue outside of the pelvic cavity. Endometriosis likely results from multiple overlapping factors including endocrine (sex-steroid pathways), genetic, biochemical, inflammatory, environmental and immunological events (1-4).
How is endometriosis diagnosed?
Endometriosis is typically diagnosed with surgery, ideally laparoscopy in conjunction with histopathology of the tissue (1-3). Unfortunately for most women, a diagnosis comes after multiple years of suffering. Nnoaham et al. documented an average diagnostic delay of 6.7 years among patients with endometriosis mainly due to delays in referral from primary care to a specialist (5).
How do you treat endometriosis?
Treatment for endometriosis should be unique to each patient and their specific symptom presentation and usually involves a multidisciplinary team. This may include reducing pain, preventing exacerbations or reoccurrence of the disease, improving quality of life, and preserving fertility.
Medical management commonly begins with surgical removal of endometrial lesions and the use of hormone treatments, both of which carry risk, side effects and questionable efficacy (1-3). According to Chantalat et al., surgery commonly provides only temporary relief, and symptoms reoccur in up to 75% of women within two years (1). Surgery may be a necessary consideration for patients with infertility secondary to endometriosis. Hormonal treatments for symptomatic endometriosis focus on suppressing estrogen, inhibiting endometrial tissue proliferation and controlling inflammation (1-3). The effectiveness of hormone therapy can vary from patient to patient and must be closely monitored secondary to potential side-effects (1-3).
Conservative treatment including physical therapy should focus on identifying neuromusculoskeletal and connective tissue changes associated with the disease specific to the patient and facilitating restoration of function. This may include the use of soft-tissue mobilization and myofascial release techniques, dry needling/neuromodulation, joint mobilization/manipulation, exercise prescription, breathing mechanics, meditation or other complimentary therapies. Patient education on the disorder and pain physiology are also important components of recovery!
If you have questions regarding physical therapy and innovative dry needling treatment interventions for symptoms of endometriosis, do not hesitate to reach out!
Tina Anderson, PT, MS
References:
1. Chantalat E, Valera MC, Vaysse C, et al. Estrogen Receptors and Endometriosis. Int J Mol Sci. 2020;21(8):2815. Published 2020 Apr 17. doi:10.3390/ijms21082815
2. Zondervan K, Phil D, Becker C, Missmer S. Endometriosis. N Engl J Med 2020;382:1244-56. Doi: 10.1056/NEjMra1810764.
3. Smolarz B, Szyllo K, Romanowicz H. Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature). INTERNATIONAL JOURNAL OF MOLECULAR SCIENCES. 2021;22(19):10554.
4. Gibson D, Collins F, De Leo B, et al. Pelvic pain correlates with peritoneal macrophage abundance not endometriosis. Reproduction and Fertility 2021;2:47-57.
5. Nnoaham KE, Hummelshoj L, Webster P, et al. Impact of endometriosis on quality of life and work productivity: a multicenter study across ten countries. Fertil Steril. 2011;96(366–73):e8