Before you can understand the rationale of exercise for the pain of endometriosis, it is important to understand what makes endometriosis painful, your pelvis and your pelvic muscles, and the two-way interaction between your endometriosis and the muscles you contract unconsciously with pain. This is a 3-part series:
Part 1: The relationship between endometriosis and your pelvic floor (pelvic floor muscles)
Why do endometriosis (“endo”) patients have pain?
Endometriosis causes pain. It does this in two ways:
- Its growth and invasion into normal tissue causes inflammation from a localized immune response which is painful in itself, and the local inflammation it causes evokes a more global immune response for further inflammation, often involving the entire abdomen.
- The organ (bladder, rectum, colon, ovary, etc.) it invades suffers dysfunction when the inflammatory response and global immune response causes tissues to stick together and remain stuck (scarred), even after the endometriosis has been removed.
Why do organs stick together with endometriosis?
The body, as a survival tactic, tends to wall off problem areas. This is why infections in your skin, for example, become abscesses: the abscess is not the infection, but your body’s walling off the infection from the rest of your body. Ideally, such a collection of germ-fighting white blood cells (pus) will erode the abscess wall, rupture, and externalize the infection, resolving it.
In endo, the same things happen, but there’s a catch. The problem areas of walled-off inflammatory areas do not expel the problem areas to the outside of the body. When an area becomes inflamed, other organs move toward the problem site to stick to it and cover it, away from the rest of the pelvis or abdomen. These are called “adhesions” because of the adhesive nature of this process.
If the organs are intact, why do adhesions cause dysfunction in them?
- Bowel—colon and rectum. The bowel has nerve endings which cause pain only one way—distension. This is why babies get colic pain with their intestines being so small. This pain response is a warning signal that something inside of the bowel is going wrong—usually obstruction from contents getting hung up in transit from the stomach to the rectum. Constipation and the pain that comes with it is one such warning signal. Also, infections can cause the bowel motion (peristalsis) to slow down, causing obstruction as things pile up and—then—distention and—then—pain. When endometriosis causes bowel to stick together, there is no longer an unrestricted path of movement of contents; twists and turns cause hang-ups that cause distension when the smoothness of the transit is impaired.
- Bladder. An inflammatory process in the bladder wall or via other things sticking to it (adhesions) will naturally be irritated with the normal goings-on of the bladder (filling/distending and emptying/snapping back to its original tone).
- Ovaries, uterus, fallopian tubes. These organs have their own unique functions involving releasing an egg for fertilization, moving it down the tube, or implanting a fertilized egg for pregnancy. The inflammation from the immunological effects of endo can mess with the biochemistry of this exquisite process, causing infertility; and the kinking of the tubes from other things “adhesing” to them can cause mechanical blockage even to the point of a tubal pregnancy if a fertilized egg gets stuck in your tube.
What else happens besides the obvious pain endo is famous for?
There is a dirty trick that the female body falls victim to, and that is pelvic floor pain. The pelvic floor gets a lot of press when it is too relaxed. This is the notorious “pelvic floor relaxation” which causes the issues of urinary stress incontinence, fecal incontinence, vaginal tissue prolapse, etc. What does NOT get a lot of press or notoriety is the opposite problem, called “Non-relaxing Pelvic Floor Dysfunction.” Translated, we’re talking about muscle spasm in the pelvic floor muscles.
What is the pelvic floor?
Most people think of the pelvic floor as the ring of fused bones that surrounds your pelvis. But this is incorrect. Those bones and the bony support they provide is only one part of it. What those bony parts do is anchor attachments for ligaments and muscles, which are important in everything from moving your hips and legs to holding in urine and feces (sphincter reinforcement). The muscles that are the under the lining of your inner vagina not only take part in those functions, but also play a part in sexual sensation for both men and women. However, they also are the problem when there is muscle spasm in the pelvic floor causing pain, which is why a woman suffering from muscle spasm—the non-relaxing pelvic floor dysfunction—has pain with intercourse. The mechanical actions against these spastic muscles make them hurt even more.
Why do the muscles of the pelvic floor have spasm? What exactly causes non-relaxing pelvic floor dysfunction?
Mammals—all mammals, including human beings—reflexly and defensively tense their muscles when challenged. It’s part of the “fight or flight” response to threats. We brace ourselves for impact. It is interesting that a knock-out in a boxing match comes most often after a punch the boxer never saw coming; that is, he couldn’t brace for the impact, and the impact landed without resistance. Similarly, we all brace our muscles for impact as a reflex.
Looking at the pelvis, especially in women, it is essentially the center of gravity, and these muscles take part in bracing (called “splinting” of muscles)—usually as an involuntary reflex. This would explain why women who were sexually abused as girls have twice to three times the frequency of chronic pelvic pain than those who had not: their habit of defensively splinting those pelvic muscles began early in their lives until the usual tone of those muscles is locked in spasm. Any muscle, when it is called upon to outperform what it was designed to do, will use up all of its oxygen and convert to other means for energy, which builds up lactic acid. Add lactic acid to muscles and they will spasm, which is why out-of-shape runners often have to stop because of cramping. Staying in shape tones muscles and makes them capable of doing more; out-of-shape muscles fatigue more quickly and cramp. A woman who tenses up her pelvic floor muscles unconsciously hundreds of times a day will outpace their capability.
What does spasm (cramping) of the pelvic floor muscles feel like?
It is different from how cramping in muscles like your calves will feel. Even though the bunching up of muscle fibers still happens (what are called trigger points), the natural inclination to “rub” them out is not feasible in the pelvic muscles. Therefore, these spasms go unattended, which then cause constriction to the blood supply from the muscles pushing on the blood vessels. This decreases the oxygen supply even more, setting up a vicious cycle.
It gets worse!
The blood supply to the nerves that run through the muscles is also compromised, and the areas that are supplied by those nerves start feeling unusual. Think about when your arm “falls asleep” at night because of the way you’re lying. However, even in your sleep you will change position unconsciously, relieving the pressure on the blood vessels and/or nerves, and soon all is well. But with pelvic floor muscle blood supply affecting nerves, you cannot merely change position. The compromise to the blood supply continues. The areas supplied by those nerves have variations to their sensations, a process similar to the “pins and needles” you feel when a limb “falls asleep.” These are called “paresthesias,” and paresthesias can range from the aforementioned pins and needles, to itching, to burning, to exquisite over-sensitivity:
- Vulvodynia: the skin outside the vagina (the vulva) becomes overly sensitive to touch.
- Abdominal pain: nerves misbehaving in the pelvis send referred pain to the abdominal wall, much like heart attack pain may make the left arm hurt.
- Rectal pain: a double impact of pain, as nerve entrapment can also alter sphincter function in addition to the pain.
- Pain with urination: painful bladder contractions are responsible for the mysterious “painful bladder syndrome,” which involves inflammatory substances within the very wall of the bladder.
- Tailbone pain: “coccydynia,” from inflammation of the ligaments of the tailbone (coccyx), which—although a fused bone of vertebral segments—is still mobile, and when inflamed can hurt even when just sitting.
- Pain with intercourse: called “dyspareunia,” the mechanical actions of intercourse impact overly sensitive muscles
The confusing cross-section of pelvic pain
You can only imagine the confusion! Certain problems are common in women with pelvic pain. It is very telling that women suffering from different problems tend to have similar pelvic pain presentations. Why is this? As stated above, endometriosis is a main culprit to cause it. But is also commonly associated with the following:
- TMJ (temporomandibular joint) problems
- Irritable Bowel Syndrome/Inflammatory Bowel Disease
- Painful bladder syndrome
- Sexual abuse, especially as young girls.
Why this frequently found list of comorbidities exists isn’t exactly known, but it probably has something to do with the excessive splinting of the pelvic musculature (defensively) when challenged with a threat, actual pain (or the fear of pain), or even when reminded of a painful memory (abuse).
What comes first, the pelvic pain or the problem causing pelvic pain?
Things like endometriosis, bowel disease, adhesional pain, a broken tailbone, and a painful bladder will cause the pelvic muscle splinting-to-cramping-to-pain, certainly. But the pelvic pain itself can cause problems such as vulvodynia and painful intercourse due to the nerve involvement within the spasming pelvic muscles. For example, painful intercourse can be so debilitating that it contributes (along with the possible endo that caused the pelvic muscle pain) to infertility. The dominos, indeed, fall.
Whether the pelvic pain is a cause—or a result—if it is just a dysfunction of muscle, can’t exercise be used to address it?
After all, that’s how a long-distance runner prevents cramping—by toning and improving the function of the muscles involved. Could this be used to advantage with the pelvic pain often seen with endometriosis.
Yes and no. No: first of all, without removal, endometriosis continues and, with it, your muscle splinting. Secondly, there are many muscles in the pelvis, so which one should be addressed? Is it even possible to address one muscle or one side of the pelvic musculature? Yes: knowing which muscle to address requires a detailed evaluation of the pelvic floor, done best by a pelvic floor physical therapist. [SEE PART 2, next: How to diagnose and begin treatment for pelvic floor pain]
What about Kegel exercises?
These are not only useless for non-relaxing pelvic floor dysfunction, but may actually be harmful. Kegel exercises are used for relaxation dysfunction, to tone muscles that are not supporting the sphincter. Piling such contractions on top of muscles that are spasming only compounds the pelvic pain.
Now, the importance of the correct diagnosis becomes evident. There are various pelvic floor problems, and strategies for one type can worsen other types if there is no diagnosis or if the diagnosis is wrong.
In the next part of this 3-part series, I will discuss how the correct diagnosis is achieved, which—sadly—is rare. This is why the patient with pelvic pain who comes to me has been to an average of 8 other doctors before me, with incorrect diagnoses ranging from “fibromyalgia” to “previous birth trauma” to (cruelly) “it’s all in your head.” When a woman goes through a series of doctors who cannot diagnose the cause of her pelvic pain correctly, she is often referred to a pain management doctor, and this specialist is notorious for knowing very little gynecology, causing her to be sent back to yet another gynecologist who doesn’t understand the philosophy of chronic pain. Back and forth she goes, with more doctor visits resulting in no help whatsoever.
How does endometriosis and exercise fit into all of this?
Endometriosis can hurt directly (inflammation); it can hurt indirectly (adhesions and organ dysfunction). It will cause pelvic floor pain from spasm, which can then progress on to become its own disease, which correct exercises can help or incorrect exercises can worsen. And this pain can even continue when the endometriosis has been removed surgically. If the endo is gone, you may be tempted to ask, then why does it still hurt? While some surgeons give up at this point and proceed to hysterectomy, a trip to a pelvic floor physical therapist may make that drastic step unnecessary. This is especially poignant, since endo sufferers often have endo-related infertility, and removing the uterus (womb) is a final burning of the bridges.
This is a tragedy which happens all too often!
Endometriosis involving your pelvis and abdominal cavity brings innocent bystanders into the commotion of pain and inflammation—your bladder, your ovaries, tubes, and uterus, and your intestinal and urological system. Your response to pain involves clenching your pelvic muscles defensively, which leads to relentless cramping, which then can impact tissues supplied by nerves that are entrapped. If you already have spasm from other influences (e.g., bowel disease or prior sexual abuse), it has a head start long before endo rears its ugly head. Thus, chronic pelvic pain is a vicious cycle which can remain even when your endometriosis has been completely eradicated.
The world of pelvic floor pain is fraught with danger and traps when the mysterious two-way connection between endo and pain is not clearly understood. At NYCEndometriosis, we “get it.”