Endometriosis is a disease that is characterized by the presence of uterine lining tissue anywhere outside of the uterine cavity. It’s a chronic disease and it affects 1 out of 10 women during the reproductive age. With every menstrual cycle, this tissue proliferates creating lesions that may cause pelvic pain and infertility. Laparoscopy with biopsy has been the gold standard for diagnosing the disease, although more recently vaginal ultrasound and even presumptive diagnosis based on symptoms are employed.
Management of endometriosis in adolescent women requires special consideration. Approximately 80% of adolescents with chronic pelvic pain that does not improve with conventional pain medication have endometriosis. Research on surgical treatment in this population is insufficient, though there are a few studies that show that laparoscopic excision can significantly reduce pain, and rate of recurrence.
Adolescent women with pain are commonly prescribed hormonal contraceptives even if the cause is unknown. This is preferred to recommending laparoscopy which would be a more invasive option. However, this empirical form of treatment is controversial because it doesn’t reduce the course of the disease and it may delay its diagnosis, which would result in adolescents carrying the condition into adulthood. One study found that two-thirds of women diagnosed with endometriosis as adults presented with symptoms in the adolescent period.
The delay in diagnosis in the adolescent population is due to several reasons. Most females will be seen by several physicians before receiving a diagnosis, taking an average time of 7 years. The presence of other comorbid conditions such as polycystic ovary syndrome or chronic pelvic pain may further complicate the diagnosis. Finally, pain in adolescents is both cyclic and non-cyclic and the lesions are atypical in appearance, differently from those in adult women, and may be missed.
The delay in the diagnosis may have important consequences. Intermittent or ongoing pain may result in pain sensitization and result in pain chronification. The risk of developing comorbidities or more severe ones may increase, such as fibroids, ovarian cysts, interstitial cystitis, irritable bowel disease,or pelvic inflammatory disease Finally decisions regarding fertility may be impacted. For instance, a woman who doesn’t know that her fertility may be affected might not choose to freeze her eggs.
Although there is to date no research specifically focusing on adolescents regarding mechanisms of pain it is likely that pain secondary to endometriosis behaves similarly to chronic pain, about which there is extensive research. Endometriosis lesions are a significant source of pain, however, it is complex and can’t be explained solely on the basis of pain resulting from them. Currently, theories based on rodent studies suggest a model in which cross-talk of pain signals via the nerves that carry pain sensation from pelvic organs and lesion tissue into the spinal column would result in central sensitization. In addition, a comprehensive understanding of pain must also include other aspects that are known to contribute to the pain experience, such as the psychological impact, environmental influences, and social variables.
Based on this understanding of chronic pelvic pain secondary to endometriosis, treatment plans need to consider the whole pain experience and require a collaborative effort amongst the different professionals involved in the care of the patient: gynecologists, psychotherapists, Pain Management MDs, and physical therapists. The role of pelvic physical therapy is to address the fascial, muscular and pelvic floor dysfunction aspects associated with the disease. The musculature of the pelvic floor will likely present with elevated tone causing dyspareunia(painful intercourse) and affect bladder and bowel mechanics. Scar tissue and adhesions from surgeries may also be a source of pain and limitation in mobility.
Pelvic physical therapy includes various manual techniques aimed at improving soft tissue mobility. This includes myofascial techniques, trigger point release, visceral mobilization, active release techniques, and muscle energy. Strengthening of the pelvic floor muscles is critical to support the bladder, bowel, and uterus. There is a critical relationship between the abdominal muscles, respiratory diaphragm, and pelvic floor muscles that need s to be assessed. (PIX Canister) Breathing techniques to release tension in the pelvic floor muscles include the hypopressive method and yoga. We also utilize Indiba when indicated, which aids in the healing of the tissues. We are the only providers in NYC of Indiba radiofrequency which is a key technology used to improve the effectiveness of pelvic physical therapy in the management of pelvic pain. To find more about Indiba see *here* (link to our website).
At Sutton Place Physical and Aquatic Therapy, we have experience treating females with endometriosis since adolescence. Some have received surgery and others have not. We have learned from our patients what has worked and has not worked for them. We have heard stories of patients that had several surgeries yet their lesions were not completely removed and their pain persisted. On the other hand, we have also heard stories from patients who were treated by a highly skilled surgeon and had a dramatic improvement in their symptoms. For all of them, pelvic physical therapy has been crucial in giving them tools to decrease their pain and has allowed them to get their lives back.
If you or someone you know is experiencing pain from Endometriosis, call us today to schedule a free 10-minute phone consultation with a Pelvic Health Physical Therapist to learn more about our services.