By Jandra Mueller, DPT, MS, PHRC Encinitas
March is the month where we get to talk about all things Endometriosis. Endometriosis (‘endo’) is an estrogen mediated, inflammatory disease characterized by endometrial-like tissue found outside of the uterus. Most commonly it is found in the abdominal and pelvic cavity, but can be found elsewhere in the body as well. Endo may be referred to as ‘an invisible’ disease, which is unfortunate because while we cannot see it from the outside, it can wreak havoc to someone’s life in many ways.
Endo is best characterized as painful periods (dysmenorrhea) and a leading cause of infertility. However, there are many other symptoms such as bloating, constipation, diarrhea, painful bowel movements, urinary frequency, urgency and pain, systemic inflammation, brain fog, pelvic floor dysfunction, and chronic pelvic pain. While the disease itself is not an auto-immune disease, it is associated with other auto-immune diseases.
There is no cure, the gold standard for treatment involves laparoscopic surgery with removal (excision) of the tissue with a doctor that has extra training. Unfortunately, most obgyn’s cannot thoroughly perform this surgery. First-line therapies include hormonal suppression medications such as birth control pills for symptom management only. We currently do not have a cure for endometriosis and we have minimal non-invasive diagnostic tests otherwise to help detect this disease.
That being said, in the past few years, there have been some amazing practitioners that have been working hard to improve care for those with endometriosis. Here is a review of some of the exciting updates!
Advances in Imaging
We have some exciting news from Dr. Matthew Leonardi about updates in the use of ultrasound and MRI in diagnosing endometriosis. The use of new techniques in both 3D and 4D ultrasound are showing promise in better identifying endometriosis before surgery. This helps clinicians better understand the extent and location of the disease. However, there are limitations and advanced ultrasound imaging is not widely used, nor is the standard of care yet. If you’ve ever undergone a transvaginal ultrasound, more than likely it is a basic pelvic ultrasound and findings may be missed. In advanced ultrasound imaging, the training of the tech performing the US is different and the imaging is more precise.
What does this mean?
Performing advanced ultrasound imaging is not standard of care as of yet. This means that if they don’t see endo in the ultrasound or MRI, this does not mean endo can be ruled out. However, with new research, the hope is that more clinicians will be trained and able to visualize endo before going into surgery. However, if they do see endo, that stats are in your favor that you now have a diagnosis and can plan accordingly.
Genetics and Biomarkers
This is another rapidly developing interest in endometriosis and several recent studies have identified genetic markers that are associated with an increased risk of endometriosis. They are also finding certain proteins and molecules in the blood that could be used as biomarkers to help diagnose endometriosis more accurately.
Researchers are using gene expression profiling to better understand the molecular mechanisms underlying endometriosis to better understand the development and progression of the disease. Researchers are using genetic studies to identify potential therapeutic targets for endometriosis, which is very promising since the only option we’ve had for a number of years is suppressing hormones, which only helps some with symptom management and can have unwanted side effects.
What does this mean?
Currently, the only definitive way to diagnose endometriosis is through surgery and histological confirmation of the biopsy. Surgery is invasive and requires a highly skilled surgeon knowledgeable in endometriosis. Unfortunately, the access to these doctors is not feasible for many either financially or geographically. While we need more research, this is promising for those suffering from endometriosis to better detect it using less invasive methods and potentially more effective treatment.
Endometriosis and the Microbiome
This is a relatively new area of research, but an exciting one! Many people with endometriosis suffer from GI issues such as bloating, food sensitivities, constipation, and diarrhea among others. Additionally, as we have understood more about inflammation and endometriosis, this area adds some interesting findings about the microbiome of those with endo compared to those without. Some studies have suggested that the microbiome may actually play a role in both the development and progression of endometriosis. The differences found in those with endometriosis compared to those without typically have higher amounts of pro-inflammatory bacteria and lower amounts of other bacteria that are thought to be more beneficial and protective.
Endometriosis Phenotypes
This area is of particular interest as this disease is heterogeneous – meaning that the presentation, symptoms, and lesions are varied. However, right now treatments are not specific and recommendations are the same for all. Dr. Paul Yong, a gynecologist and researcher at the University of British Columbia in Vancouver, Canada presented his research on subtyping and comparing certain types of endometriosis and other pelvic pain conditions such as neuroproliferative vestibulodynia. The work Dr. Yong and others or doing in this area give promise to better understanding this disease and the various underlying mechanisms, paving the way for more effective and targeted treatments that can improve outcomes
Endo What?
Shannon Cohn created a documentary in 2016 to spread awareness about endometriosis and help detect it when it often presents, when menstruation starts. The second film, Below the Belt, has further raised awareness both at a government level and in medical education. Below the Belt has been shown at various medical schools and universities in multiple countries, to increase knowledge and awareness of this disease to healthcare providers and the public.
In the last few years, so much more is becoming known about this disease and there is hope in the future we will have a more thorough understanding of this disease, detection methods, and more therapeutic considerations for treatment options.
Lastly, if you are a healthcare provider and want to learn more about endometriosis care and improving care for this population, Jandra Mueller, DPT, MS and Britt Gosse-Jesus, DPT, WCS are teaching a live-online course hosted through pelvic health solutions this coming April. For more information and to sign-up click here.
Blog Posts
These blog posts all have relevance for those women suffering from endo and/or if you have been on oral contraceptives or had hormonal treatment for endo related symptoms.
Endometriosis: Beyond the lesions
Thinking outside the gut: could endometriosis be the culprit behind your constipation or bloating?
Managing life on or after “the pill”
Jagged Little Pill: How Oral Contraceptives Wreak Havoc on the Female Body
Treatment solutions for endometriosis
Youtube Videos
Pelvic Pain After Endometriosis Surgery
Yoga Flow for Post Laparoscopic Surgery for Endometriosis
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.