ENDOMETRIOSIS

Definition

Endometriosis is when tissue similar to the uterine lining - the endometrium - grows outside the uterus. Globally, this disease affects 1 in 10 women and those assigned female at birth, though the data suggests that numbers are even higher than this. Patients may develop endometriosis before reproductive age, though the onset of menstruation certainly accentuates the presence of the disease as main symptoms include heavy bleeding, irregular cycles, painful menstruation (dysmenorrhea), cramping, painful sex. Endometriosis can grow on any organ in the body, typically in the lower abdomen but can spread as far as the lungs and diaphragm. Though there are 4 stages of endometriosis, the severity and location of endometriosis is not correlated with the degree of pain a patient will experience. The majority of patients will experience cyclic pain accompanying their periods, however, if the disease is on an organ and affects its functionality, cyclic pain may become chronic pain.

LITERATURE - DIAGNOSIS AND TREATMENT of endometriosis

It has been increasingly difficult to find a theory that fits the origin of this disease as many once believed the backflow of menstrual blood through the tubes and into the extra-pelvic area would fully explain the displacement of these cells. However, pathophysiological assessment of this tissue reiterates that this tissue is similar to, but significantly different than, the endometrium. Moreover, this tissue is able to produce its own estrogen, thus allowing the endometriotic tissue to perpetuate even in the absence of systemic estrogen (through hormone therapy, hysterectomy or menopause).

Patients with endometriosis might find some reprieve using non-specific anti-inflammatory drugs such as ibuprofen, but likely with secondary dysmenorrhea, pain will persist. Ultimately these patients need to be referred to an endometriosis specialist and/or a fertility specialist - not a gynecologist - for medical management of this disease. A patient dealing with debilitating symptoms should be offered proper excision of endometriosis by way of an endometriosis specialist. Since wait times for surgery can often be long that patient can be offered medical management. What this means short term may be variations of hormone therapy to regulate the cycle and minimize bleeding, fertility assistance, and pain medications.

To help put the patient on the right path a number of diagnostics can be helpful to determine the severity of endometriosis. Imaging such as MRI and ultrasound are a helpful initial diagnostic to determine the presence of endometriomas (blood filled sacs) and other masses, constricting of any organs, and any emergency outcome that could be addressed immediately.

A normal pelvic ultrasonography or physical examination does not eliminate the possibility of endometriosis. - ACOG

In addition to the 4 stages of endometriosis there are currently three categories of the disease.

Category I: Peritoneal (or superficial) endometriosis - The most common form of endometriosis in which disease grows on the outside of the organs and peritoneum without any infiltration.

Category II: Ovarian Endometriomas (Chocolate Cysts)

Category III: Deep Infiltrating Endometriosis I (DIE I) - The less common but certainly more risky form of endometriosis where the lesions have penetrates (deep infiltrating) into the organs causing organ malfunction.

Reiterating that while categories II and III are more likely to appear on imaging it is crucial that imaging is not used as a means of ruling out endometriosis given that the vast majority of patients experience superficial endometriosis which typically does not appear on imaging.

Currently there is no proper way to diagnose endometriosis without pathology through excision. For this reason and many others it is crucial that patients are given the opportunity to have an excision by someone who can explore the pelvic and extra pelvic areas, and reliably test for pathology.

Prior to surgery the mechanisms of pain have shown to reduce through the use of pelvic floor physiotherapy, acupuncture and diet management. One study showed that the use of myofascial release in conjunction with breathing exercises provided patients a useful coping mechanism during flares. Likewise the interventions of massage and pelvic floor physiotherapy were helpful in reversing ‘central sensitization’. In one study, patients found acupuncture / moxa / acu + moxa to be more effective than pain medications. Given that there is an inflammatory component to the disease patients often identify food triggers that exacerbate the swelling - known as endo belly - and can help to remove those from their diet.

Survey Results

It is clear that patients with pelvic pain, endometriosis and adenomyosis are well aware of the aiding properties of pelvic floor physiotherapy, and acupuncture. On average it takes an endometriosis patient ten years and seven doctors to receive a proper diagnosis. During this dreadfully long wait time patients often experience muscle pain as a response to constantly holding their bodies in a protective mode. It is not surprising that so many of these patients are seeking massage therapy to reduce the muscle tonicity, and to help them relax both mentally and physically.

Femade approach to treating endometriosis

Since the etiology of pelvic pain is not always understood at the onset of meeting a patient, it is critical that practitioners determine whether the origins and pathways of pain are considered more systemic (ie the organs themselves, the orientation of the pelvis, the surrounding hypertensive muscles), related to menstruation (i.e. primary or secondary dysmenorrhea), neuronal (ie the innervating nerves themselves) vs nociplastic (residual ‘central sensitization’ or heightened pain signals lasting after the stimulus as been removed).

If the patient is coming in for pain associated with endometriosis, we always introduce pelvic floor physiotherapy and acupuncture to the patient. The pelvic floor physiotherapy gives us a better understanding of where the pain is located, trigger points, and other surrounding organs such as the bladder and colon that may be impacted. We then try to layer the utility of the acupuncturist who - using a combination of intake methods - can help the body channel more resources to the affected area. Frankly, the needles can be placed in a variety of combinations to achieve results. Thirdly, if the patient is amenable we do like to add in massage therapy as pelvic pain - either cyclic or chronic - can take a toll on the muscles throughout the body. This not only impacts the soreness of the muscles but can affect sleep and mood.

If a patient has undergone surgery and is experiencing ongoing pain, it is worth exploring the nociplastic mechanism of pain which entails the body reacting to the pain stimulus long after it has been removed. Again, due to the long wait times for diagnosis and treatment the nervous system has altered itself to manage heightened pain and will take time and practice to lower the pain reaction. Here we would recommend a combination of both massage therapy (psychological pain) and pelvic floor physiotherapy (pelvic pain and muscle tone).

If the patient is subsequently trying to conceive - naturally or through IVF - prior to excision, we would certainly utilize acupuncture first and foremost to achieve fertility outcomes and then can address more of endometriosis management post birth / post surgery.

With patients who suspect they have or are diagnosed with endometriosis it has been helpful to have them catalogue some of the triggers that cause endo belly or any other debilitating symptom including pain and diarrhea. If the patient is open to lifestyle change - before surgery and/or after - it is helpful to try naturopathic medicine. In this approach we are not only looking at diet and nutrition but also better understanding hormone levels, triggers, comorbidities, etc.

Lastly, we understand that endometriosis is grossly misunderstood. We offer psychotherapy to address some of the root causes of stress, and stress management. We also offer peer support for a more casual mental health support outlet as well as virtual group support sessions to help build a community.

Resources

ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent https://pubmed.ncbi.nlm.nih.gov/30461694/

Primary dysmenorrhea https://pubmed.ncbi.nlm.nih.gov/10465224/

Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents https://pubmed.ncbi.nlm.nih.gov/32041388/

Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction https://pubmed.ncbi.nlm.nih.gov/28049214/

The complementary and alternative medicine for endometriosis: a review of utilization and mechanism https://pubmed.ncbi.nlm.nih.gov/24701237/