Endometriosis Explained

What is endometriosis?

Endometriosis is a condition in which endometrial-like tissue grows outside of the uterus (at extrauterine sites). These extra-uterine sites may include the ovaries, bladder, bowel and recto-vaginal septum. This tissue can form adhesions between internal organs and the abdominal wall. It is an estrogen-driven and inflammatory condition.

Symptoms may include pelvic/low back pain (cyclical or non-cyclical), dysmenorrhea (painful periods), dyspareunia (painful intercourse), bowel/bladder dysfunction and infertility.

This condition is found in 10-15% of women worldwide.

Types/Stages of Endometriosis

There are 3 main types of endometriosis: superficial endometriosis, ovarian endometrioma and deep endometriosis. In addition, endometriosis can be classified into 4 stages. However, the stage of disease has not been found correlate with severity of symptoms.

Diagnosis

The diagnosis on endometriosis is based on a combination of methods:

  • Subjective history
  • Physical exam
  • Position/size/mobility of uterus
  • Recto-vaginal exam
  • Imaging (transvaginal/abdominal ultrasound, MRI)
  • Laparoscopy


The gold standard to diagnose endometriosis consists of laparoscopy and hystology. In other words, a surgery in which a camera can visualize in the pelvis so suspected tissues are removed and tested to confirm the presence of endometriosis. However, there are studies indicating that transvaginal ultrasound and MRI may be helpful in cases of deep endometriosis.

Treatment

  • Lifestyle modifications (diet, exercise, sleep, mental health)
  • Complimentary therapies (pelvic floor physiotherapy, massage therapy, naturopathy, osteopathy, chiropractic)
  • Medications
    • Pain control (eg. NSAIDs)
    • Pain neuromodulators (eg. pregabalin, gabapentin)
    • Hormonal treatment (eg. Oral contraceptives)
  • Interventions
    • Surgery
      • Laparoscopy
        • Tissues may either be removed via excision (cut-out) or ablation (laser)
        • The recommended method is excision as it is more effective at removing the abnormal tissues
        • The goal so surgery are to remove abnormal tissue, cut through adhesions, reduce symptoms, restore organs to normal physiological functioning reducing the risk of re-operation
      • Hysterectomy/oophorectomy
    • Nerve block


Pelvic Floor Physiotherapy

When treating a patient with endometriosis, the pelvic floor is only part of the action plan. Lifestyle/behaviour modifications are the first thing that are often discussed with patients. This includes diet modifications, exercise habits, sleep hygiene and mental health. Your therapist may then assess your abdomen by looking at muscle overactivity, connective tissue restriction and visceral mobility. Lastly, the pelvic floor is assessed for hypertonicity, connective tissue restrictions, strength and coordination.

Based on your assessment, your physiotherapist will give you a series of exercises and strategies for pain management. They may also suggest a referral to another healthcare practitioner depending on your assessment.

References:

  • International Pelvic Pain Society Conference 2019 – Endometriosis and Adenomyosis; Dr. Sukhbir S. Singh MD, FRCSC, FACOG; Associate Profressor, Department Ob/Gyn; The Ottate Hospital & University of Ottawa
  • https://www.yourperiod.ca/endometriosis/
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