Endometriosis is a condition that affects women and girls. It occurs when tissue similar to the lining of the uterus ends up in other areas of the body. These areas include the ovaries, bladder, bowel and digestive tract.
Authors
Peter Stubbs
Senior Lecturer in Physiotherapy, University of Technology Sydney
Caroline Wanderley Souto Ferreira
Visiting Professor of Physiotherapy, University of Technology Sydney
Endometriosis will affect nearly one million Australian women and girls in their lifetime. Many high-profile Australians are affected by endometriosis including Bindi Irwin, Sophie Monk and former Yellow Wiggle, Emma Watkins.
Symptoms of endometriosis include intense pelvic, abdominal or low back pain (that is often worse during menstruation), bladder and bowel problems, pain during sex and infertility.
But women and girls wait an average of seven years to receive a diagnosis. Many are living with the burden of endometriosis and not receiving treatments that could improve their quality of life. This includes physiotherapy.
How is endometriosis treated?
No treatments cure endometriosis. Symptoms can be reduced by taking medications such as non-steriodal anti-inflammatories (ibuprofen, aspirin or naproxen) and hormonal medicines.
Surgery is sometimes used to diagnose endometriosis, remove endometrial lesions, reduce pain and improve fertility. But these lesions can grow back.
Whether they take medication or have surgery, many women and girls continue to experience pain and other symptoms.
Pelvic health physiotherapy is often recommended as a non-drug management technique to manage endometriosis pain, in consultation with a gynaecologist or general practitioner.
The goal of physiotherapy treatment depends on the symptoms but is usually to reduce and manage pain, improve ability to do activities, and ultimately improve quality of life.
What could you expect from your first appointment?
Physiotherapy management can differ based on the severity and location of symptoms. Prior to physical tests and treatments, your physiotherapist will comprehensively explain what is going to happen and seek your permission.
They will ask questions to better understand your case and specific needs. These will include your age, weight, height as well as the presence, location and intensity of symptoms.
You will also be asked about the history of your period pain, your first period, the length of your menstrual cycle, urinary and bowel symptoms, sexual function and details of any previous treatments and tests.
They may also assess your posture and movement to see how your muscles have changed because of the related symptoms.
They will press on your lower back and pelvic muscles to spot painful areas (trigger points) and muscle tightness.
If you consent to a vaginal examination, the physiotherapist will use one to two gloved fingers to assess the area inside and around your vagina. They will also test your ability to coordinate, contract and relax your pelvic muscles.
What type of treatments could you receive?
Depending on your symptoms, your physiotherapist may use the following treatments:
General education
Your physiotherapist will give your details about the disease, pelvic floor anatomy, the types of treatment and how these can improve pain and other symptoms. They might teach you about the changes to the brain and nerves as a result of being in long-term pain.
They will provide guidance to improve your ability to perform daily activities, including getting quality sleep.
If you experience pain during sex or difficulty using tampons, they may teach you how to use vaginal dilators to improve flexibility of those muscles.
Pelvic muscle exercises
Pelvic muscles often contract too hard as a result of pain. Pelvic floor exercises will help you contract and relax muscles appropriately and provide an awareness of how hard muscles are contracting.
This can be combined with machines that monitor muscle activity or vaginal pressure to provide detailed information on how the muscles are working.
Yoga, stretching and low-impact exercises
Yoga, stretching and low impact aerobic exercise can improve fitness, flexibility, pain and blood circulation. These have general pain-relieving properties and can be a great way to contract and relax bigger muscles affected by long-term endometriosis.
These exercises can help you regain function and control with a gradual progression to perform daily activities with reduced pain.
Hydrotherapy (physiotherapy in warm water)
Performing exercises in water improves blood circulation and muscle relaxation due to the pressure and warmth of the water. Hydrotherapy allows you to perform aerobic exercise with low impact, which will reduce pain while exercising.
However, while hydrotherapy shows positive results clinically, scientific studies to show its effectiveness studies are ongoing.
Manual therapy
Women frequently have small areas of muscle that are tight and painful (trigger points) inside and outside the vagina. Pain can be temporarily reduced by pressing, massaging or putting heat on the muscles.
Physiotherapists can teach patients how to do these techniques by themselves at home.
What does the evidence say?
Overall, patients report positive experiences pelvic health physiotherapists treatments. In a study of 42 women, 80% of those who received manual therapy had "much improved pain".
In studies investigating yoga, one study showed pain was reduced in 28 patients by an average of 30 points on a 100-point pain scale. Another study showed yoga was beneficial for pain in all 15 patients.
But while some studies show this treatment is effective, a review concluded more studies were needed and the use of physiotherapy was "underestimated and underpublicised".
What else do you need to know?
If you have or suspect you have endometriosis, consult your gynaecologist or GP. They may be able to suggest a pelvic health physiotherapist to help you manage your symptoms and improve quality of life.
As endometriosis is a chronic condition you may be entitled to five subsidised or free sessions per calendar year in clinics that accept Medicare.
If you go to a private pelvic health physiotherapist, you won't need a referral from a gynaecologist or GP. Physiotherapy rebates can be available to those with private health insurance.
The Australian Physiotherapy Association has a Find a Physio section where you can search for women's and pelvic physiotherapists. Endometriosis Australia also provides assistance and advice to women with Endometriosis.
Thanks to UTS Masters students Phoebe Walker and Kasey Collins, who are researching physiotherapy treatments for endometriosis, for their contribution to this article.
Professor Caroline Wanderley Souto Ferreira is affiliated with Universidade Federal de Pernambuco (Federal University of Pernambuco)-Brazil. She is a professor of women's health physiotherapy for undergraduate and graduate students.
Peter Stubbs does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
