By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles

Did you know that severe menstrual pain is not normal?

 If you experience severe pain during your period it is possible you are suffering from a very underdiagnosed disease called Endometriosis.

 

Endometrial tissue lines the uterus. In response to hormonal influences, the endometrium of a healthy uterus thickens and then sheds through the cervix, into the vagnina and out of your body. This is your normal period and it should not hurt.

 

When endometrial tissue implants outside of the uterus, it also thickens and needs to shed, but there is no outlet. These implants can adhere to other organs such as the bowel and bladder; they can cause cyclical urinary and bowel dysfunction, severe pain, pain with intercourse, bloating, and nausea.  One in ten women have endometriosis; it is the leading cause of pain in women, and it is responsible for more than half of all female infertility.

 

What makes matters worse is that it takes women an average of 11.4 years in the United States to get diagnosed. This is not acceptable. March is Endometriosis Awareness Month and we here at PHRC want to help raise awareness about this disease and the role physical and occupational therapy can play in treatment.  Many people do not realize that pelvic floor dysfunction is common in women with endometriosis and can be causing some of their symptoms. Pelvic floor physical and occupational therapy can help!

 

While diagnosing and treating endometriosis has been a challenge, the treatment landscape is improving for women. In this post we will examine some of the current management controversies and discuss the range of available treatment options. .

 

PROBLEM: Endometriosis is hard to diagnose.

 

1. Endometriosis cannot be detected through diagnostic tests such as ultrasound, MRIs, blood work, or physical examination.
2. The symptoms of endometriosis mimic other syndromes and women with endometriosis often also have comorbid conditions, such as Irritable Bowel Syndrome, Interstitial Cystitis, Vulvodynia, and pelvic floor disorders, leading to further diagnostic confusion.
3. The diagnosis is only truly confirmed from surgical extraction and (+) histological findings.
4. Not enough physicians are adequately trained to surgically diagnosis and treat endometriosis.

 

Generally speaking, people prefer conservative therapies over surgical options. People rarely rush to the operating room to get relief from back pain, knee issues, etc., and they do not want to rush to the operating room for endometriosis treatment either. As a result, women are often treated with medications empirically without diagnostic confirmation. These treatments can be effective for some people but they can also have significant physiological consequences.

 

THE PROBLEMS: Oral Contraceptive Pills and Progesterone Treatments

 

1. These medications do not cure the disease; they work by suppressing menstruation and therefore also the painful endometrial implants.
2. This may act as a temporary ‘band-aid’ in some cases but can also be less effective in others based on the severity of the disease.
3. The majority of women have their symptoms return when they stop taking the medication.
4. Oral contraceptives may lead to the development of vulvar pain in certain women, adding a second pain condition into the picture.
5. Oral contraceptives have a negative effect on libido and can be associated with mood disorders, both of which have a significant impact on a woman’s quality of life.

 

THE PROBLEMS: Intrauterine Devices (IUDs)

 

1. The insertion of a small device into the uterus can also help the symptoms by suppressing menstruation. However, the insertion process and adjustment to the IUD is more painful in women who have not yet had children.
2. Certain women experience significant ongoing side effects such as headaches and nausea from the hormones.
3. Possibly uncomfortable for several months as the body gets use to it.

 

THE PROBLEMS: Gonadotropin-Releasing Analogs Treatments

 

1. These medications stop the production of estrogen which in turn ‘starves’ the endometrial implants.
2. This also ‘starves’ other tissues of the estrogen they need, such as the vulva and peri-urethral tissues, which can lead to vulvar pain and urinary urgency and frequency.
3. Estrogen is necessary for health bone density and these medications therefore have side effects of bone density loss.
4. Endometriosis symptoms can begin when a woman first gets her period. The average age of menarche in the United States is 13. These medications create ‘chemical menopause’ in the bodies of teenagers and the end result can be teenage women with osteoporosis.
5. The symptoms return when the medication is stopped in most woman and may not be completely controlled while on this medication.

 

THE PROBLEM: Hysterectomy or Prengnancy

 

1. The glaring problem with the hysterectomy suggestion is many of the women who need help are in their childbearing years and have not yet had children.
2. Due to a lack of comprehensive interdisciplinary care, young women are often told a having a baby may be their solution if they do not want a hysterectomy. This information is understandably shocking to teenage women with endometriosis and their families.

 

THE SOLUTIONS: Differential Diagnosis and Interdisciplinary Treatment Options

 

In the last decade there has been an exponential increase in the amount of evidence-based information on pelvic pain, including endometriosis. We know that endometriosis itself can be a source of pain. We also know endometriosis is associated with other treatable pelvic pain syndromes and impairments, such as Interstitial Cystitis, Vulvodynia, and Pelvic Floor Dysfunction. The key to successful treatment is to identify which impairments are causing the most bothersome symptoms and start to treat them with the appropriate therapies. This needs to be individualized per patient, each woman with endometriosis will present with different sources of pain despite having the same disease.

 

Earlier this month I was able to participate in a program called Tendo (Link:http://thepelvicexpert.leadpages.co/tendo2016/), organized by Heba Shaheed of The Pelvic Expert. Heba organized 20 experts from around the world to participate in a series of video lectures on Endometriosis management. There is no charge for this service, please sign up and join the discussion!

 

During my lecture, I discuss the following therapeutic options. We recognize that many of things may be new concepts for people, giving them the opportunity to explore conservative therapies that may dramatically improve their quality of life.

 

1. Physical and Occupational Therapy
   1. pain physiology education
   2. manual therapy
   3. case management
   4. restore function
   5. temporary lifestyle modifications
   6. Home Exercise Programs: therapeutic and general fitness
   7. dry needling

 

1. Behavior Health Strategies
   1. CBT
   2. mindfulness training
   3. sex therapy
   4. hypnosis
   5. pain psychology education

 

1. Complimentary Integrative Medicine
   1. yoga
   2. acupuncture
   3. nutrition education/diet modifications
   4. rolfing/massage/bodywork

 

1. Pharmacologic
   1. Simple analgesics
   2. Neuropathic analgesics
   3. NMDA antagonists
   4. Cannabis
   5. Antidepressants/antianxiety
   6. Benzodiazepines

 

1. Female Pelvic Pain: Hormonal
   1. topical estradiol/testosterone
   2. systemic hormonal therapy

 

1. Interventional Pain Management
   1. Trigger Point Injections
   2. Peripheral Nerve Blocks
   3. Ganglion Impar Blocks
   4. Caudal Epidural
   5. Pulsed RF/ Ablation/ Cryoablation
   6. Botulinum Toxin
   7. Neuromodulation
   8. Transcranial Magnetic Stimulation
   9. Ketamine Infusions

 

1. Surgical Intervention
   1. Skilled extraction of endometrial implants

 

1. Home program/self care

 

It is important to understand that most women with pelvic pain may not tolerate or may not respond to certain therapies or treatments and often more than once. Hopefully knowing this will make women feel less ‘broken’ as they work through the process of finding the treatment that is right for them. Women can and do get better with persistence and a solid medical team!

 

Finally, a documentary titled Endo What? will be released around the world. If you are suffering from Endometriosis or know someone who is this movie is a must-see. You can view the movie trailer here: https://www.youtube.com/watch?v=dq03TyziL58.

 

All my best,

Stephanie Prendergast, MPT

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical and occupational therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.

 

 

Some things about childbirth are easy to plan: where to deliver, at a hospital or at home; who to have by our side, an obstetrician or a midwife; what to call the new baby once he or she is born. However, there are plenty of complications that we can’t predict, such as perineal tears, pelvic organ prolapse, onset of urinary and/or fecal incontinence, delivering with forceps or vacuum assistance, and emergency c-section, to name  a few – and it’s these unpredictabilities that make us anxious.  I am often asked by patients and doulas if one birthing position is better than another to help reduce the chances of these unpleasant complications. It’s a good question!

 

Most women in the USA who give birth in hospitals do so lying on their backs, in what is called the “dorsal position.” Why is this? Are there alternative positions that could be somehow better, either for mother or child? I found a Cochrane Review, from 2012, to help us find the answer.  

A quick aside: a Cochrane Review is the highest standard in evidence-based research within the medical community.1 It is a systematic review on the primary research given for a specific topic. A team of authors comes together to answer a specific question: in our case, what is the best position to give birth in? The authors comb through published journal articles, including international ones, excluding any articles that are biased, and come up with a conclusion. This conclusion helps practitioners provide consistent treatment. Cochrane Reviews are even regularly updated in order to maintain this standard.

 

So, what does the Cochrane Review have to say about birthing positions? In Position in the second stage of labour for women without epidural anaesthesia (Review), authors Gupta, Hofmeyr, and Shehmar assessed 22 studies involving a total of 7,280 women.2  They initially compared any upright position (squatting, kneeling, sitting, using a birthing stool or a chair) to  “dorsal” position: lying on your back (“supine”), being in a semi-reclined position, or in “lithotomy” position (which means lying on your back, your legs up and open, and your feet in stirrups, like in the movies). They also compared specific upright positions (birthing or squatting stool, birth cushion, and birthing chair) to supine position.

 

The authors looked at how the position used during birth affected the chances of various complications. When comparing any upright position to supine position, the authors found that, women giving birth in an upright position had about a 20% lower chance of needing an assisted delivery, a 20% lower risk of episiotomy, and about 50% lower probability of their fetus having an abnormal heart rate.

 

They also found that while some studies seemed to show that giving birth in an upright position could lead to higher risk of blood loss and 2nd degree perineal tearing, they did not find these studies convincing.

 

The chances of needing a C-section was about the same between the two positions. They also found there was no significant reduction in the duration of the second stage of labor when the upright position was used. Being upright doesn’t necessarily mean you’ll deliver quickly!

 

At least, not very quickly: many of the studies’ conclusions are in terms of the differences between positions being “not significant,” which means that the data they had wasn’t good enough to detect small effects. If the birthing position was going to make a big difference in the chances of a complication, perhaps they would have seen it. Weighing all of this up, the review’s authors concluded that upright positioning seems to lead to no harmful effects to either the mother or the baby.

 

So, why is a dorsal position so often recommended? The Cochrane Reviewers put it this way: “It is claimed that the dorsal position enables the midwife/obstetrician to monitor the fetus better and thus to ensure a safe birth, but it may be more convenient and give better control for the caregiver.” Lying on your back makes it easier for the medical staff to make sure everything is alright with your baby.

 

The research  featured in this review came from a study where the mother had not had an epidural painkiller. I’m not sure what impact this will have on the pros and cons of upright positioning, but there’s a 2013 follow-up Cochrane Review on this very topic. I’ll make that the subject of a future post!

 

Please feel free to share your comments or questions in the reply box below. Also, please feel free to check out our prior blogs on Labor and Delivery, Coached vs. Maternal Pushing, and Understanding Breech Babies.

 

1. The Cochrane Collaboration. Cochrane Community (beta). http://community.cochrane.org/cochrane-reviews 2015.
2. Gupta, J.K., et al. Position in the second stage of labour for women without epidural anaesthesia (Review). The Cochrane Library 2012; Issue 5.

By Stephanie Prendergast

 

Last fall, I began seeing the logo you see above, appear in my Twitter feed and on Facebook. As a physical and occupational therapists, I was happy to see an organization committing to improving awareness about our field. It’s safe to say that most of the world has no idea what a pelvic floor physical and occupational therapists is or what we do. This includes the suffering people who need us the most AND their physicians. This is very important because most people go to a physical and occupational therapists because their doctors tell them to. If their physician doesn’t know about pelvic floor dysfunction the patient who needs it doesn’t get sent to physical and occupational therapy. This is a HUGE problem and one of the many reasons we at PHRC support the GetPT1st Movement.

 

GetPT1st is a non-profit educational organization whose mission is to increase awareness in the general public, as well as in the medical community, about the benefits of Physical and Occupational Therapy. Here is what the founders have to say:

 

“GetPT1st is a website just for YOU, the healthcare consumer. We promise to bring the best information possible to help you, whatever your journey. And don’t worry, you won’t have to have a medical dictionary handy or know all the latest research to follow along. This is 100% for you.

 

Physical therapy is so much more than the pictures you see in a Google search! We take care of every step of the lifespan, from pediatrics to geriatrics, from babies with torticollis to 90 year-olds with balance problems. We work with clients from the ICU, to the pool, to the sports field, to your very own home. Physical therapists truly are movement specialists, but that’s not all. For many people, their first thought may be sports and orthopedics, but we also play a huge part in men’s and women’s health, chronic pain, progressive disorders like Parkinson’s and Alzheimer’s Disease, stroke and cardiac rehab, and hospice care.”

 

On March 1, 2016, GetPt1st is organizing a social media event as part of their physical and occupational therapy awareness campaign. PHRC wants to contribute by talking about the role physical and occupational therapy plays in pelvic floor disorders and informing people that they can GetPT1st. Many people are unaware they can go to a pelvic floor physical and occupational therapists without a physician referral. We created this blog to help people identify the signs and symptoms of pelvic floor disorders. If you answer yes to any of the questions below you will benefit from a physical and occupational therapy evaluation.

 

So, what do you need to know about pelvic pt?

 

Here are the basics:

 

Your pelvic floor muscles are responsible for urinary, bowel, and sexual functioning:

• they keep you from leaking urine
• they are responsible for orgasm
• they allow you to pee and poop
• they help women deliver babies
• they keep your organs in your pelvis

When they are not functioning properly:

• you leak urine or feces
• you have trouble or cannot orgasm
• you may have to urinate more often than you want to or have trouble starting your stream
• you have trouble or can’t poop
• your organs descend into your pelvis
• sex hurts, sitting hurts, exercise can cause genital pain, clothing may be uncomfortable, normal day to day things are just not possible or painful

Pelvic floor disorders are prevalent and the range of symptoms can range from bothersome to disabling. (For more information on the stats, read our December GetPT1st Blog: https://pelvicpainrehab.com/female-pelvic-pain/3448/get-pt-1st-facts/).

 

Do these symptoms sound familiar to you? If you answer yes to any of the following questions you will benefit from an evaluation with a pelvic floor physical and occupational therapists.

 

Men:

Urinary function:

 

• Do you void more than 6-8 times in a 24-hour period or wake more than one time per night to void?
• Do you have trouble starting your stream and is it interrupted?
• Do you leak urine when you cough, sneeze, or laugh?
• Have you had more than 3 urinary tract infections in the last year?

• Do you feel like you have an infection and your cultures are negative?

Bowel function:

•    Do you experience constipation?
•    Do you have difficulty with bowel movements, or pain during a bowel movement?

Male Pain/Sexual function:

 

• Do you have trouble achieving or maintaining an erection?
• Do you experience penile, scrotal, perineal, or anal pain with sitting, after exercise, or after ejaculating?

 

Women:

Bowel function:

•    Do you experience constipation?
•    Do you have difficulty with bowel movements, or pain during a bowel movement?

Female Pain/Sexual function:

•  Do you experience pain with intercourse?
•  Has your quality or ability to orgasm changed?
• Do you ever experience pain/itching/burning in the clitoris, labia, vulva, vagina, perineum, or rectum?
• Have you had more than 3 yeast infections in the last year?

Prepartum/postpartum women:

•    Do you have low back, hip or pelvic pain?
•    Do you have pain radiating down one or both of your legs?
•    Do you leak urine?
•       Do you have vaginal, anal, or perineal pain?
•    Do you experience pain with intercourse?
•    Has your bladder function changed since pregnancy/delivery?
•    Do you have a hard time controlling gas?
•    Do you leak urine when your cough or sneeze?

 

These symptoms commonly drive people to a urologist, gynecologist, or colorectal physician. These physicians can help rule out infections, disease, and other pathology. If the tests return negative the pelvic floor muscles may be involved and physical and occupational therapy can help!

 

How to find a pelvic floor physical and occupational therapists near you:

 

Resources are available through the American Physical and Occupational Therapy Association’s section on Women’s Health (http://www.womenshealthapta.org/pt-locator/) and the International Pelvic Pain Society (http://pelvicpain.org/patients/find-a-medical-provider.aspx).

 

 

 

Best,

Stephanie Prendergast, MPT

 

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical and occupational therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.