A long time ago I asked one of my physiotherapists, Amanda Waldock, to write a blog for me on Endometriosis. She divided it up into two parts and I promptly forgot to post Part 2 incorporating some of the treatment strategies for Endo. Tonight, when I realised the date was a significant one for us physios – World Physiotherapy Day – I wondered: “Did I have the energy to post a new blog?” I decided I would cruise through the 100 or so half-written blogs I have looking for one that was close to completion and suddenly found Amanda’s Endometriosis Treatment blog! Thank you Amanda and welcome back from maternity leave. Here is her blog.
There are so many areas that can be impacted by endometriosis, it can be confusing to know where to start. Keeping a continued, open discussion with your health practitioners, be it your GP, Gynaecologist, Pain Specialist, physiotherapist, dietician or psychologist, is a good place to start and can help you develop a management plan. A multidisciplinary approach is useful to address the relevant areas impacted by your endo.
Physiotherapy and Endometriosis
Seeing a Women’s Health or Pelvic Health physiotherapist is an important part of the Endometriosis treatment puzzle. With persistent pain, a natural response of the body and the muscles is to try and protect itself. This can lead to overactivity or hypertonicity in the muscles of the pelvic floor, abdominals, and surrounding structures such as glutes, hips, and thighs. Sometimes there are also issues with the pelvic joints and lower back. Physiotherapists can assess and treat these internal and external structures with a variety of manual therapy techniques, exercise and stretches. Surgery which can be required to diagnose and remove endometriosis tissue can also create scar tissue that can be hypersensitive and scar tissue release techniques may also be beneficial for patients.
Along with manual therapy techniques we, at Sue Croft Physiotherapist, also take a pain science approach to managing persistent pain and implement principles from Explain Pain by Lorimer Moseley and David Butler. This approach focuses on central sensitisation, or changes that happen in the central nervous system (the brain and the nerves) in response to a long history of suffering with pain.
We also look at how your endometriosis has impacted other areas of your bladder, bowel and sexual health.
Pain management strategies
Education – It is important to understand how pain is produced in the body. Research has shown that the more informed a person is about pain science, the better able they are to deal with their pain and the better many of these pain strategies work. One in four patients will get up to a 50% improvement in their pain simply by learning about pain science. (Butler and Moseley 2017)
Belly breathing- start by taking a slow breath and try to breathe into your belly. As you breathe in, your belly will rise up and as you breathe out your belly will drop down. Gradually lengthen the breath, continuing to fill up your belly and as you do so feel how the belly breath helps to relieve the tension in the pelvis. Do belly breathing 8 times a day for 1 minute as you Sit like a Man (see below).
Body scan – we have a Zen frog body scan that we teach at our clinic to help clients learn to detect and release tension throughout their body. Learning to detect and quickly release tension is a skill which with practice becomes easier and easier to do quickly throughout the day. Women often comment that they didn’t realise how much tension they carry.
Practice mindfulness – Start small. This is a skill, like the body scan, which gets easier with practice. You may find mindfulness easiest to practice thinking about parts of your body, focussing on your breath or a more abstract though such as floating on a cloud. Pick one that makes sense to you and start small. You may find an app can help. Good free apps include
- Insight timer
- Mindfulness coach
Sit like a man – one of our favourite and easy positions to allow tension out of the pelvis. Not surprisingly it is a position that many women find hard to do. We’re not used to ‘letting it all hang out’ but the truth is our muscles don’t need to be on the entire time we are upright and moving through the day. This blog called ‘Sit like a Man’ is an easy reminder.
Pelvic floor relaxation and stretches – as mentioned previously being able to release the tension in the pelvic floor helps with maintaining a healthy muscle and good blood flow throughout the pelvis, including the nervous system.
Amanda Lee who takes our online Yin Yoga class Monday nights at 7pm
Be careful about becoming hypervigilant with your thoughts – How you think and feel about your pain can influence the severity, intensity and duration of pain you experience. Reading many stories of women experiencing no relief from their horrible symptoms, or their mental health struggles with pain, or feeling you may never get better can understandably affect your mood. When stressed we produce hormones such as cortisol which can heighten our pain experience. It’s not about trying to imagine rainbows and unicorns every day.
- It’s about being careful with what you read and how much time you spend on endometriosis community pages.
- It’s about trying to reframe how you think about your health and your pain. It’s about being vigilant for those sneaky negative thoughts that can creep into your consciousness.
- It’s about taking the time to care for yourself, identify when you are feeling low and stressed and having strategies to help shift you back to a better place
What else can you do?
Firstly, it is good to work on controlling the controllables and looking at things you can start to manage in your life to help with your symptoms.
The more you understand what is happening in your body and your management options, the more in control you may feel.
Endometriosis and Pelvic Pain is a comprehensive resource book written by Dr Susan Evans, the chair of Pelvic Pain Foundation Australia. This book is also available in the clinic, call Sue Croft Physiotherapist today to get yourself a copy.
Websites with good quality information include
Maintain good bladder and bowel habits
- Sit with the correct posture on the toilet
- Keep a healthy diet and ensure good water intake
- Use products such as stool softeners or fibre to ensure a soft, easy to pass stool, if needed
- Maintain good function of pelvic floor muscles (as described below)
Maintain good pelvic floor function
This is not about doing lots of pelvic floor exercises. Often the pelvic floor muscles are overactive and tight in response to the pelvic pain.
- Learn how to relax these muscles and do this throughout your day. This may be incorporated with more whole-body relaxation or stretches.
- Performing pelvic floor stretches regularly.
- “Sit like a man”: give your muscles permission to switch off through the day when they’re not needed. (Yes slouching is allowed for short periods through the day!)
Exercise causes an increase in the body’s level of progesterone which may result in reduced prostaglandin levels. Remember these prostaglandins contribute to period pain, so less of them is better.
- Pick an exercise you enjoy so you can sustain it
- Don’t try to do too much too soon
- On days when you aren’t feeling great do a bit less but still do something
- Moderate to high intensity exercise performed 3 times per week has shown improved outcomes
- Try to keep regular hours of going to bed and getting up
- Avoid screen time immediately before bed
- Avoid eating or exercising in the late evening
Looking after yourself is not just about the managing the physical symptoms you experience. It is important to look after your general well being and mental health. This can include:
- Taking time out through the day to do some belly breaths, switch off, have a cup of something you enjoy, rest.
- Be careful of what and how much you read on social media and the internet. It is great to have support and understanding from those who have experiences similar to yours, but it can be overwhelming and too much to take in. One person’s experience is just that.
- Speak to your health professional about your concerns. There are a number of great health professionals working in the area of pelvic pain that can help.
Walking surrounded by nature is very refreshing for an upregulated nervous system.
Managing dyspareunia (painful sex)
- Positional advice
- Work on good arousal
- Using a suitable lubricant
- Accepting that at different times non-penetrative intimacy is better
Olive and Bee Ohnut
- Herbal medications
- Heat (in the form of a heat pack or warm shower etc)
- TENS: a battery-operated machine that produces a tingling sensation on the skin which helps to relieve pain. It is easy to use and can be left on while you go about your daily activity.
Your medical team may look at prescribing medications to help with the management of your symptoms. All medication should be taken only as prescribed
Medications prescribed to reduce the symptoms caused by periods may be:
- Oral Contraceptive Pill
- Progesterone tablet
- Mirena or other intra-uterine device
- Progesterone implant or injection
- Gonadatropin releasing hormone analogs
Medications to reduce levels of pain may include:
- Anti-inflammatory medications
- Amitriptyline and nortriptyline
- Other pain medications
- Local application through compounded creams with medications within them
Please contact the practice on 0407659357 to book an appointment with one of our Physiotherapists who can help you on your journey with Endometriosis or to get a copy of the book Endometriosis and Pelvic Pain by Dr Susan Evans. (available online)
Such a comprehensive blog Amanda – thank you so much for all your efforts.
To all my wonderful physiotherapists, I wish you a Happy World Physiotherapy Day. To all my wonderful secretaries who patiently and respectfully assist patients to make their appointments and help them feel comfortable about coming to see us – you deserve a Happy World Physiotherapy Day – because without you we would have no patients to treat. And to all the devoted, caring, compassionate pelvic health physiotherapists around the world – well done for taking the time to care for patients who suffer with persistent pain. You are doing amazing things.
Sue and Bob Megan Sam Molly Haleh
Amanda W Amanda L Josephine Roxanne Fara
Evans. S and Bush. D (2016). Endometriosis and pelvic pain. Adelaide, South Australia. Dr Susan F Evans
Hallam, T (2020). WHTA – Advanced Pelvic Floor. Pelvic Pain Genitourinary and Anorectal Pain disorders.
Parasar, P., Ozcan, P., & Terry, K. L. (2017). Endometriosis: Epidemiology, Diagnosis and Clinical Management. Current Obstetrics and Gynecology reports, 6(1), 34–41. https://doi.org/10.1007/s13669-017-0187-1
Pelvic Pain Foundation of Australia. 2019. Available at: www.pelvicpain.org.au
Women’s Health Queensland Wide Inc. Endometriosis Fact Sheet. Available at: https://womhealth.org.au/conditions-and-treatments/endometriosis-fact-sheet