Rethinking Endometriosis: A Multidisciplinary Approach

by Dr. Erin Kinneen, PT, MS, DMT, CLT, OCS, CDNS, DPT, Clinic Director

Endometriosis is a complex, chronic, estrogen-dependent disease that involves the growth of endometrial-like tissue outside the uterus¹. This misplaced tissue, unlike the uterine lining, has no way to exit the body during menstruation, leading to inflammation, adhesions, and chronic pelvic pain². The condition can significantly impact an individual's physical, mental, social, and financial health. It affects approximately 6-10% of reproductive-aged women worldwide, totaling millions of individuals¹.

What is Endometriosis?

The disease is characterized by ectopic tissues which are often found in the pelvic cavity, on the ovaries, fallopian tubes, and surrounding organs. While the exact cause of this misplaced endometrial-like tissue is unknown, it is believed that genetics, environmental factors, and hormonal factors contribute to a retrograde menstruation, or when menstrual blood flows backward through the fallopian tubes into the pelvic cavity. Many women experience retrograde menstruation but only some develop endometriosis, which points to a complex interplay between the immune system, hormones, and genetic susceptibility².

Common Symptoms and Diagnosis Challenges

The symptoms of endometriosis vary greatly among individuals, contributing to diagnostic difficulty. Common symptoms include:

• Painful periods (Dysmenorrhea)
• Nonmenstrual pelvic pain
• Pain during intercourse (Dyspareunia)
• Bowel and urinary issues, such as constipation
• Fatigue
• Infertility
• Chronic nerve pain (Nociplastic pain)

Due to the variable presentation, the need for tissue biopsy, and the requirement for skilled practitioners proficient at identifying the tissue in lesions, diagnosis is often significantly delayed. Many individuals do not have confirmation of the condition for 7-9 years³.

Beyond Physical Pain: The Emotional Toll

The chronic pain, infertility, and delayed treatment associated with endometriosis can deeply affect an individual's mental health. Many patients also experience anxiety, depression, and a diminished quality of life. Addressing these psychological aspects is considered essential for holistic care.

A Multidisciplinary Approach to Comprehensive Care

Given the debilitating physical and emotional toll, experts strongly advocate for a multidisciplinary chronic care model (CCM) for endometriosis management. This collaborative approach focuses on providing long-term care and improving quality of life, addressing not only the physical symptoms but also the emotional and social challenges of chronic illness¹.

A comprehensive care team may include:

• Gynecologists
• Surgeons
• Pelvic floor physical therapists
• Pain specialists
• Mental health professionals
• Nutritionists
• Integrative providers, such as acupuncturists and yoga therapists

Key Treatment Strategies

Treatment for endometriosis typically involves a combination of strategies, tailored to the individual's needs. Hormonal therapies are often a cornerstone of medical management. Their goal is to suppress ovarian function and reduce symptoms by preventing the growth of endometrial-like tissue. Common examples include progestins, GnRH agonists, and aromatase inhibitors⁵.

Surgical interventions aim to excise or ablate endometriotic lesions. While surgery can significantly improve symptoms and support fertility, studies indicate high recurrence or re-operation rates for pain, with some showing up to 50% of patients requiring another procedure within 5 years^3,5. Finding a surgeon with success in removal of endometriosis lesions can improve recurrence rates¹.

The Crucial Role of Physical Therapy (Pelvic Floor PT)

Pelvic floor physical therapy is a specialized and often overlooked, yet powerful, component of comprehensive endometriosis care. It focuses on the muscles, connective tissues, and nerves of the pelvic region, which frequently become tense, painful, or dysfunctional in individuals with chronic pelvic pain². Pelvic floor PT is non-invasive, empowering, and effective, utilizing techniques such as:

• Manual therapy to release soft tissue restrictions, mobilize painful adhesions, and improve pelvic congestion.
• Biofeedback and relaxation techniques to "down-train" overactive pelvic floor muscles.
• Neuromuscular re-education to improve coordination.
• Pain neuroscience education and exercise instruction, including guided heart rate training to address central sensitization and chronic pain pathways.
• Postural and movement training to reduce tension⁴.

Pelvic Floor Physical Therapy can improve pain management by relaxing overactive pelvic floor muscles that exacerbate pain, reducing adhesions and improving mobility, and addressing the body’s pain response to the present tissue changes. This latter aspect of pelvic health care is an area of recent progress in research. While physical therapy cannot reverse infertility directly, it can support reproductive health by improving pelvic alignment, mobility, and reducing stress. It also empowers patients with tools to better understand and manage their condition, reducing fear and improving control over symptoms².

Other Supportive Therapies:

• Pain Management: Beyond targeted interventions, general analgesics like NSAIDs are used, but long-term opioid use carries risks like dependency.
• Dietary Adjustments: An anti-inflammatory diet may provide supportive benefits. Evidence also suggests reducing red meat consumption and moderating alcohol intake.
• Mind-Body and Psychological Support: Addressing the emotional burden is crucial. Psychotherapy, meditation, acupuncture, and yoga may be integrated to support mental well-being and provide holistic care.

Endometriosis is far more than just "painful periods." It's a complex, chronic condition requiring a comprehensive and individualized approach to care. By integrating medical and surgical treatments with crucial support from pelvic floor physical therapy, mental health professionals, and other complementary therapies, individuals can achieve better outcomes and significantly improved quality of life¹. If you are living with endometriosis, discussing a multidisciplinary care plan that includes pelvic floor physical therapy with your healthcare provider can be the first step toward effective management and relief.

For more information about pelvic floor physical therapy or to find a clinic near you, click here.

References

1. Agarwal SK, Foster WG, Groessl EJ. Rethinking endometriosis care: applying the chronic care model via a multidisciplinary program for the care of women with endometriosis. Int J Women's Health. 2019;11:405-410.
2. Mechsner S. Endometriosis, an ongoing pain—Step-by-step Treatment. J Clin Med. 2022;11:467.
3. Vercellini P, Viganò P, Somigliana E, et al. Endometriosis: pathogenesis and treatment. Nat Rev Endocrinol. 2014;10(5):261-275.
4. Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Research. 2020;9(F1000 Faculty Rev):83.
5. Falcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557-571. doi:10.1097/AOG.0000000000002469.