Chronic pelvic pain has been described as a silent epidemic. It has been estimated to affect up to 1 in 5 women, however many of us have never heard of it. Chronic pelvic pain can affect women of all ages and many suffer in silence for many years. Due to the variety and extent of symptoms experienced, causes of chronic pelvic pain are notorious for taking a long time to diagnose.
What causes chronic pelvic pain?
Endometriosis is observed in 71 to 87 percent of women with chronic pelvic pain (Ozawa et al., 2006); however, pelvic pain is also commonly associated with other conditions, including interstitial cystitis, irritable bowel syndrome and adhesions.
What is Endometriosis?
Endometriosis occurs when tissue that normally lines the inside of your uterus — the endometrium — grows outside of your uterus. This can lead to the development of painful scarring and adhesions deep within the pelvis. Endometriosis is a highly individualised disease which means each woman is affected to a different degree and may present with differing symptoms.
Symptoms may include severe pain in the pelvic and abdominal regions associated with periods, ovulation or sex, heavy periods and painful bladder or bowel motions. The common factor in most endometriosis presentations is PAIN - which in turn can be associated with a range of more generalised symptoms such as excessive tiredness and mood changes.
The exact cause of endometriosis remains unclear, however, it is likely that there is no single cause and that genetic, biological and environmental factors may all contribute.
Endometriosis and ‘Chronic pelvic pain’
Endometriosis is commonly treated via laparoscopic surgery, where endometrial tissue found outside the uterus is removed via small holes in the abdomen. This can be a highly effective method of management for some women, however others are disheartened or frustrated to find that they experience a lack of improvement or short term reduction in their pain before the problem returns. Many women also find surgical excision becomes less effective the more times they receive the treatment.
Often, the amount of endometriosis found on a laparoscopy doesn’t always fit with the amount of pain a women describes. Some women have a small amount of endometriosis and a lot of pain, whereas others have a lot of endometriosis and very little pain. So even when there is little or no ‘endometriosis’ present on laparoscopy, why do some women still have pain?
Endometriosis, when left untreated or when recurrent over long time periods, can lead to the brain and associated nerve pathways becoming highly sensitised to the presence of pain which leads to the brain and nervous system developing protective responses.
In simple terms, in order to try to ‘protect’ the body from future pain or insult, the brain ramps up its pain-detection radar which means it may start to perceive movements or activities which would not usually cause discomfort as threatening and therefore trigger a pain response.
Physical protective responses may also develop and a common example of this is muscle spasm within the pelvic floor and abdominal muscles which can lead to further pain.
Persistent pain is commonly associated with increases in anxiety, stress and an overwhelming feeling of loss of control. In a vicious cycle, these factors contribute to the increased perception of pain and can further promote muscle tightness.
So, in some cases, even though the initial ‘threat’ is removed, the body doesn’t necessarily turn off these defensive mechanisms and the pain remains.
How can Physiotherapy help?
Physios are well versed in dealing with musculoskeletal pain and in educating patients about the mechanisms that contribute to both acute and chronic pain.
Often, solely providing information and an explanation of how chronic pain develops can help to reduce ‘fear’ and restore some sense of control for pain sufferers, which in turn helps to lower pain perception.
Pelvic floor physios are also skilled in utilising manual therapies to address the compensatory strategies that may have developed in response to pain. Soft and deep tissue massage therapy can help to relieve pelvic, abdominal and back pain arising from inflamed, tight and spasming muscles and can also assist with releasing scar tissue. Reeducation of Pelvic Floor Muscle activity can help to relax tight pelvic floor muscles (see our blog on Overactive Pelvic Floor Muscles.) and is often a very important part of the treatment.
It is within our specific expertise to guide our patients to return to normal daily activities as well as general exercise that may have been reduced or prevented as a side-effect of persistent pain. It is important to re-introduce activity in a controlled way in order to avoid triggering the brain’s ‘threat detection’ system. There is also strong evidence to support the role of general physical activity in pain management.
This blog is intended to give an overview of a Pelvic Floor Physiotherapists role in managing chronic pelvic pain associated with endometriosis. There are further medical and surgical interventions (not covered here) which all have a role in the management of endometriosis and you can read more about these at Jean Hailes: https://jeanhailes.org.au/health-a-z/endometriosis.
We hope that in future we hear less “why didn’t I realise you existed” comments and are able to extend the knowledge of physiotherapy in this space to help more women manage what can become a debilitating, isolating and unbearable condition.
If you suffer from endometriosis, or have a friend or loved on who does, reach out and ask us more about how we can help (or encourage them to do the same), it could be life changing.
Special acknowledgement to Melissa French, pelvic floor physiotherapist, for her expert contribution to this post. Melissa consults at MPPP on Wednesdays.