Let's get aware- Endometriosis

By Liam Neyland
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As march is Endometriosis awareness month, we at HMC Osteopath’s thought it would be a great time to share some helpful information about this condition.

What is Endometriosis?
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A fair few of you may be wondering what exactly is Endometriosis? Despite the condition affecting approximately 1 in 9 women before they hit their 40’s in Australia, it is a relatively unknown condition within the public. Simply put endometriosis is when cells (endometrium) that usually line the cavity of the uterus, better known as the womb, grow in other parts of the body. These cells can occur at almost any site within the pelvis, but is most commonly found to be sitting on the peritoneum of the pelvis, behind the vagina and uterus, underneath the ovaries and sometimes on the ovaries themselves. In it’s more severe forms this condition can even grow inside the Fallopian tubes or even within the ovary itself. However, there have been cases where these cells have been found outside the pelvis like for example the lungs (thankfully these cases are extremely rare). Despite the fact these cells are not present in the uterus they still respond to hormonal messages from the ovaries. This is especially true during the menstruation period of a women’s cycle, as these cells will bleed every month resulting in inflammation, scarring and in some cases organs to stick together. It is for this reason why women suffering from endometriosis can have such debilitating pain. Along with debilitating pain the disease can affect fertility.

How does Endometriosis affect Fertility?

The link between fertility and endometriosis is unfortunately unclear, however the stage of the condition and location do play a major role on possible fertility issues. Examples of this are if extensive scarring within the pelvis could result in pain during intercourse, lowering a women’s enjoyment and or dreading the act of intercourse as a whole. Another example would be the Fallopian tubes could become tangled in the scar tissue limiting it’s ability to safely transfer the egg from the ovary to the womb. These are two of many possible outcomes that endometriosis can effect a women’s fertility. Thankfully, many women with this condition can still become pregnant as an estimated 70% of women with mild to moderate endometriosis get pregnant without the use of external treatment.

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What are the Symptoms of Endometriosis?
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The symptoms that women experience while suffering from endometriosis will be different by a case to case matter. As the severity of the condition does not necessarily coincide with the symptoms felt but instead where the lesions are located. 

Common Symptoms include:

•  Abdominal (tummy) or pelvic pain: either before or during a period, during or after sex, when going to the toilet. 
• Bloating or the sensation of bloating with or without pain
• Increased fatigue
• Infertility 
• Heavy or irregular periods 
• Changes to bowel habits: needing to urinate more frequently or blood being present during urination

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What causes Endometriosis? 

Currently there is no known cause of endometriosis, however factors that increase the likelihood of the condition are as follows.
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• Retrograde menstruation: When menstrual blood flows backwards into the Fallopian tubes and pelvis.
• Family History
• Frequent or short periods
• Long and heavy periods
• Starting your period before the age of 11

 How is it Diagnosed?

Unfortunately due to difficult it is to identify many women go undiagnosed for many years with the average being around 7.  Currently the only way to confirm a diagnosis of endometriosis is to have a laparoscopy, which is a particular surgery where doctors are able to look for endometriosis tissue within the abdomen and take a sample to examine in a laboratory. During the surgery the grading of endometriosis would be determined as well.

Grade 1 (mild): small patches scattered around the pelvis

Grade 2/3 (moderate): disease is more widespread and can be found on ovaries and other parts of the pelvis.

Grade 4 (severe): Has spread to most of the pelvic organs.

If you suspect that yourself or someone else may have endometriosis, please talk to your doctor about any and all symptoms you may be experiencing. A helpful tool has been designed to help health professionals and yourself in identifying and assessing endometriosis symptoms, which may also reach a faster diagnosis. It is called the Raising Awareness Tool for Endometriosis (RATE), which can be accessed through the provided link. RANZCOG - RATE

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What are your treatment options?

Conventional treatment of endometriosis is wide ranging as not all therapies may be effective or the possible side effects could have an overall net negative for a person’s health. It is important to discuss with your doctor about any and all side effects with any treatment options. As stated in the previous blog, currently there is no cure for endometriosis, so in that regard all treatments are aimed at pain management or general management of the condition. 

Non-manual therapy treatment option
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• Use of pain relief medications, such as non- steroidal anti-inflammatory drugs (NSAIDS) such as Nurofen (Ibuprofen).

Hormone Therapies, are used to help suppress the growth of the endometrial cells and stop or limit bleeding, including during the menstrual cycle. Examples include:
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• ​​Combined oral contraceptive pill (COCP), where the contraceptive pill is taken continuously without the sugar (hormone free pills).
• Progestogens (both natural and synthetic): It is not known how Progestogens provide pain relief but it is believed they suppress the growth of endometrial tissue in some way. It has been found that up to 80% of women experience pain relief from this treatment.
• ​GnRH (Gonadotrophin- releasing hormone) agonists and antagonists: Is used to suppressing ovulation and in turn the production of oestrogen and progesterone by the ovaries. This low level of oestrogen in the body creates a ‘temporary chemical menopause’ where endometrial cells are no longer stimulated and gradually shrink. 

Surgery: aim is to remove as much visible endometriosis as possible and to repair any damage found.

• ​Laparoscopy: Keyhole surgery, where a thin telescope with a light is inserted into the abdominal cavity. If endometrial tissue is found it is removed by vaporising (destroying cells with electrical energy) or by cutting the tissue, the method depends on location and severity. 
• Laparotomy: A similar surgery to a Laparoscopy but instead of key hole the surgery is an open operation requiring a larger cut into the lower belly. Is only used for severe/extensive or if Laparoscopy isn’t an option.
• Hysterectomy: Only considered an option if the patient does not plan on having kids, when quality of life is severely impaired or all other treatments have failed. This surgery is the removal of the uterus and both ovaries along with the Fallopian tubes, resulting in a surgical menopause. This treatment usually is in combination with Menopausal hormone therapy to help offset the symptoms or effects of the early menopause. 

Self care treatment 

It is important to remember that the pain and or discomfort a women may experience from Endometriosis is unique to them and will vary from person to person. With that in mind here are some examples of at home treatments you can use to help with managing your pain.
 
Exercise

• ​Is a natural pain relief as when the body exercises feel good hormones are released that naturally dull the pain experienced. A study found that women with endometriosis experienced a reduced level of daily pain and improved quality of life when completing 2x 90 min sessions of yoga per week over a 2 month period, when compared to women who did not participate.
• Exercise has been found to improve fatigue and ‘brain fog’ that is commonly experienced with endometriosis 
• ​Exercise has also been found in many studies to help improve mood and manage symptoms of anxiety or depression: Women with endometriosis or other chronic pain issues are more likely to experience anxiety or depression. Evidence suggests that people suffering from anxiety or depression experience a negative feedback loop with pain levels where more pain equals more anxiety and more anxiety increases perceived pain.  

Other supportive self care treatments are:

• Heat: heat packs or hot water bottles are helpful in managing pain levels that do not involve pharmaceutical intervention. Just be cautious as to avoid overuse as skin burns can occur with too much use. 
• Mindfulness and Meditation: Evidence suggests that the use of psychological and healthy mind body practices show positive outcome on pain levels, depression, anxiety, fatigue and stress in women with endometriosis. 
• Sleep: Most chronic pain sufferers struggle getting the recommended hours of sleep, studies have shown that poor quality of sleep is associated with a poorer quality of life and depressive symptoms in women with endometriosis.

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What can my Osteopath do?

When treating endometriosis, it is best that a multi-disciplinary approach is used. Where a range of health professionals including your GP work together to provide the best possible care for you. Osteopathy would provide a range of hands on, non-invasive treatment methods to best optimise the body’s natural function. Examples of possible treatments that an Osteopath could provide you are as follows.

• Nervous system desensitisation: With long lasting pain the nervous system becomes more sensitive and easily triggered. Osteopaths would provide treatments or advice that can reduce this sensitivity of the nervous system either through movement, manual therapy and or education.
• Stretching/flexibility exercises: Osteopath’s can provide a wide variety of stretch’s and exercises to improve mobility in the hips, abdominal’s and spine which can be useful in reducing pain and relaxing the pelvic floor.
• Whole Body treatment: Chronic pain sufferer's rarely ever have only one thing causing or contributing to their pain. Osteopaths may use a wide variety of techniques such as soft tissue, joint articulation, muscle energy techniques or manipulation depending on if other issues are found. 
• General Advice: currently there are a wide variety of at home treatment tools that you may implement. These tools range from TENS (Transcutaneous electrical stimulation) machines which uses a low level electrical stimulation for pain relief, all the way to devices that can play a role in limiting pain during intercourse. An Osteopath can help give advice or even suggest the use of these equipment’s for at home treatment.
• Goal Setting and patient education: An Osteopath wants to make you better and make you the best possible version of yourself. By educating patients and creating realistic and obtainable goals, patient and practitioner can work together to achieve these goals. As an added bonus by setting goals and becoming more knowledgeable about your condition, studies suggest you can experience a lower pain intensity then those who do not.

What can my friends and family do to help?
The best thing that friends or family can do to help is be a reliable source of support. Many people suffering from endometriosis feel alone in their struggles. Something as simple as bringing your loved one a heat pack when you notice them struggling or allowing them to sleep in a little longer can go a long way in helping someone suffering to feel more validated. Always remember that just because you cannot see the illness does not mean that it does not exist. It is important to remember that symptoms for endometriosis are varied and unique to the individual and that the condition does not have a set rhyme or rhythm. So please be understanding that someone with this condition cannot control or predict when a ‘flare’ will occur.

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References
How does endometriosis affect fertility? | Tommy's (tommys.org) 
Where Does Endometriosis Occur | Gynaecology Molloy 
Endometriosis | healthdirect 
Endometriosis (who.int)
Exploring effect of pain education on chronic pain patients’ expectation of recovery and pain intensity (degruyter.com) 
Management & treatment of endometriosis | Jean Hailes 
Treating endometriosis | The Royal Women's Hospital (thewomens.org.au) 
Endometriosis Australia | Home