sexual pain

Endometriosis and Endo-Related Sexual Pain

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Endometriosis is a painful, chronic, inflammatory condition that is poorly understood but affects more than 1 in 10 women and an uncounted number of gender diverse people. Previous articles have discussed endometriosis in general and some of the specific symptoms and complications that may arise. Hallmark symptoms include painful periods, painful bowel movements, and painful sex. Fatigue is another major symptom associated with endometriosis, and one which is frequently discounted by physicians due to it being such a challenging symptom to objectively measure. Currently, the gold standard for diagnosis is diagnostic laparoscopy, and the gold standard for treatment is laparoscopic excision.

In this interview, Philippa Bridge-Cook, an international endometriosis advocate, describes how the disease of endometriosis involves tissue that is similar to the lining of the uterus, which grows outside of the uterus. Often this tissue is in the pelvic area, but can also be in other parts of the body completely unrelated to gynecologic structures. These tissue growths are inflammatory and can be hormone-responsive, meaning that often people with endometriosis experience increased pain during menstruation, which can be severe and debilitating. However, endometriosis has much wider-reaching consequences “just” period pain.

Painful bowel movements may occur due to the location of these lesions, either on or within the bowels, or surrounding structures. They may also be related to chronic inflammation in the body. Digestive difficulties may extend beyond pain and include severe bloating, gas, painful cramping, and sensations of fullness, food sensitivities, diarrhea or constipation.

Painful sex can occur and may be related to either the location of these pain-producing lesions (for example, if they are in a place that is directly affected by sexual contact, and therefore directly irritated), or it may be related to pelvic floor dysfunction that arises due to chronic pain. Pain may be experienced during arousal, sexual touch, sexual penetration, orgasm, or after sexual activity.

As a Doctor of Physical Therapy, this specific complication of endometriosis falls squarely into my wheelhouse, and I treat many patients who are suffering from pelvic floor dysfunction related to chronic pain. In this interview, Philippa and I talk about how the pelvic floor muscles (muscles in the area of the groin that control urination, defecation, and contribute to sexual function) can become tense and tender due to the stress of chronic pelvic pain. During sexual activity they may be painful to touch, painful to penetration, or painful when they contract reflexively during orgasm. I discuss physical therapy for sexual pain here (link: Physical Therapy for Female Sexual Pain).

Dr. Bridge-Cook discusses not only the generalities of endometriosis and endo-related sexual pain, but also actionable, specific strategies for charting symptoms, speaking with your physician, and pain management. She reviews different imaging techniques, surgical techniques, and incomplete/inaccurate treatments. She is a true expert in the subject, informed by her years of personal experience as well as her extensive research and advocacy work. She speaks in a way that is easy to understand and provides hope, closing by encouraging women to not give up and to seek help with physicians that are willing to take them seriously.

Endometriosis and Sexual Pain

Share Your Endometriosis Story

Endometriosis affects millions of women but goes largely undiagnosed for years and treatment options are limited. To raise awareness about endometriosis and build the knowledge base, we need your help. Share your experience and your knowledge about living with endometriosis. To learn more, click here and send us a note.

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, like it, please help support it. Contribute now.

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Thirty Years of Painful Sex Resolved With Pelvic Therapy – An Interview

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In a previous article (Sexual Pain: It wasn’t the ovarian cyst), I presented the clinical case of a woman in her 50s who had experienced painful sex for 30 years. This patient had seen scores of physicians, received multiple diagnosis, and had two surgeries to try to address her pain. Unfortunately, her pain with sex continued.

Over the years she had received diagnoses ranging from endometriosis, to fibroids, to ovarian cysts. She had surgery to remove endometriosis and later on also a hysterectomy. Her pain with sex, known as dyspareunia, continued. She experienced the pain with deep vaginal penetration, that felt like stabbing deep into the right side of her pelvis, her back, and up her right side. Eventually she was experiencing this pain throughout the day, as well as during sex. In addition she experienced digestive difficulties, with no explanation to be found. She says, “Nothing was changing, and I gave up. I pretty much gave up and said to myself ‘this is what I’m dealing with.’”

The mentality of her doctors was, in her words, ‘suck it up, buttercup’. She describes how relationships can start to drift apart when sexual pain is a chronic problem. So, she decided that she would just have to live with it, and lied to her husband about the frequency and intensity of her sexual pain. Eventually, after so many years and so many doctors, she lost hope. Fortunately, though, she never gave up.

With luck and through an indirect path, she was introduced to pelvic floor physical therapy and finally, after a series of treatments, found relief. She explains,

I gave up. I thought I had tried, and I had googled, and I had looked, and all the doctors… And I want to put the onus on other women, the female physicians that I saw! No one talked about physical therapy ever, ever.

In the previous article, I discuss the clinical side of her case. In this interview, she tells about the personal side, her many years of pain, doctors, and finally how it felt to find relief. She gave permission for these articles and interviews because she wants other women to know that it is possible to find relief, even if it’s been many years of pain. She doesn’t want other women to give up hope. She stated it best, saying

Put yourself first, make sure that you’re listening to your body, doing what’s good for your body, making sure that you’re going to the doctor, getting checked out, not taking no for an answer, or not taking that first answer. Look at how many doctors I saw… 8? 10? Who knows how many different OB GYNs or just GYNs that I saw? And none of them gave me that answer that potentially could have avoided surgery. But the goal is to listen to your body and make sure to find the answers. And know that it’s okay to question a physician. It’s okay to question, right? As long as there’s respect there, the physician should be open to you asking questions.

Painful Sex Resolved With Pelvic Therapy

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, and like it, please help support it. Contribute now.

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Why Does It Hurt When I Have Sex?  An Overview of Possibilities

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The Mayo Clinic terms pain associated with sexual stimulation or vaginal contact as “sexual pain disorder,” and categorizes this as a type of female sexual dysfunction.  More commonly we speak of “dyspareunia” to refer to pain with sex. It can present in a number of different ways; it may be internal or external, it may or may not prevent orgasm, and it may even occur after sexual activity.

Unfortunately, pain with sexual activity is rarely discussed or considered seriously.  I’ve sat face to face with health care professionals who tell me that the primary cause of pain is that the women’s partner is too large for her.  Sexual dysfunction in women is typically treated as either an inevitable “female problem” or an emotional disorder requiring antidepressants or anti-anxiety medications.

Pain is not uncommon, and it is treatable. Consider how many people suffer low back pain, headaches, or stomachaches.  Imagine how much effort goes into diagnosing and treating these issues. Why then would we not be just as open about discussing and treating female sexual pain?  Given the complexity of the anatomy, which I outline below, and the intersections of hormones, pregnancy and childbirth, postural habits, and the possibility of infection and trauma, it should be no surprise that many women experience pain or other dysfunction.

In my experience as a physical therapist, I find that while some women seek treatment, most either presume it is normal or don’t realize that there are treatment options. I can’t tell you how many times a woman will report “no” to sexual pain on my intake forms, then later during the evaluation report with surprise “I have had that pain my whole life, I thought it was normal!”

I will say now what I always tell these women: with the possible exception of disruption of a hymen or a significant size difference between partners, discomfort during sexual stimulation is never considered normal. And even in these situations pain is not inevitable, and should never be allowed to continue as this can result in further trauma and future discomfort.

First, an overview of the anatomy.  The external female genital area is composed of muscles known as the pelvic floor, as well as extensive nerves, glands, and other soft tissue.  The muscles work to support of organs against gravity, for control of urination and bowel movements, and for sexual function. In the pelvic floor, there are three separate openings:  the urethra, the vagina, and the anus.  The clitoris, which is composed of highly sensitive erectile tissue, functions solely for sexual stimulation.  It is covered by a “hood” of soft tissue externally, but also extends internally.  The entirety of the labia, external clitoris, and vaginal opening are known as the vulva. Internally, the vagina extends to the uterus.

Female anatomy
Painting by: Meryl Ranzer

Clearly, this is a complex area, with many functions, and it makes sense that there might be many possible locations and causes for discomfort.  Pain may be experienced with initial penetration or superficial stimulation, with deep penetration, with orgasm, or after orgasm.  I will briefly overview some of the possible causes of each.  In a subsequent article, I will address strategies for dealing with some of these causes, from the perspective of a physical therapist specializing in women’s health and pelvic rehabilitation.

A thorough examination by a gynecologist is always the first step in assessing pelvic pain, as not all causes of pain can be treated with physical therapy.

Superficial Sexual Pain

Sexual pain may be experienced with initial (shallow) penetration or with light touch to the vulva, perineum, or anus.  It may feel like burning, stretching, or sharp stabbing discomfort.  It may increase or dissipate if sexual activity continues.  It may even be intense enough to prohibit all touch.

Decreased lubrication, related to hormone changes or lack of physiologic arousal, may cause pain with initial penetration (arousal includes increased blood flow to the genital area as well as increased lubrication). Thinning of vaginal tissues, known as atrophy, often occurs with hormone shifts associated with menopause, and may result in discomfort and light bleeding with penetration if adequate lubrication is not present.

Active infections can cause sensitivity and irritation of the vulva and vagina. These infections may be acute, or low-level and chronic. Even after infection has resolved, residual irritation or fascial restrictions within the tissues can cause pain.

Sensitivity to perfumes and dyes, such as in laundry detergent, pads, or tampons, can cause irritation and sensitivity.  There are also skin conditions that may cause unusually fragile skin and pain to touch. Swelling of glands at the opening of the vagina may also occur and is frequently found in women with vulvar vestibulitis (pain and irritation at the opening of the vagina).

An intact hymen may be the cause of pain with initial penetration. However, given the variety of shape and thickness of the hymen, and the many activities that can change it over the course of a woman’s life from childhood to adulthood, pain with penetration during a woman’s first sexual encounter should not be presumed to be inevitable.

There may be atypical anatomy, such as thickened hymenal remnants or fascial bands that restrict the vaginal opening. There may also be scar tissue that is restricting the vaginal opening, due to trauma, tearing during childbirth or episiotomy.

Tightness of the muscles of the pelvic floor can cause pain with initial penetration. This pain may be right at the opening of the vagina or referred to other areas.  In severe cases, this is known as vaginismus, which is an involuntary spasming of the muscles that prevent penetration. It can be associated with hypersensitivity of the skin and muscles so that even light touch in the genital area causes pain. Vulvodynia refers to chronic pain of the vulvar area without a known cause. It is often accompanied by tight pelvic floor muscles.

Deep Pain with Sex

Pain is often reported with deep penetration, and may be described as a deep ache, cramping, or as if a woman’s partner is “hitting something” in her pelvis.

The sensation of something being bumped or hit with penetration is often related to uterine positioning. The uterus may be tilted (which in some women is their normal anatomy, or in other women may be related to tight ligaments, scar tissue, or fascial structures). The uterus may also not be mobile enough to shift comfortably during sex.  There may be scar tissue deep in the vagina that restricts vaginal or uterine mobility. Fibroids at the uterus may make it larger, asymmetrical, or less mobile and more prone to discomfort. Finally, the cervix may be sensitive due to fascial restrictions, surgical interventions such as colposcopy for abnormal cells, or irritation from IUD placement. In these cases changing sexual position or angle of penetration sometimes improves the discomfort, although in severe cases there may be no position of comfort.

Due to the proximity of the bowels to the vaginal canal, constipation or bowel irritation may result in pain with deep penetration. A sensitive or infected bladder may also be irritated for the same reason. Bowel pain may feel like cramping or a deep ache. Bladder pain may feel like a deep ache above the pubic bone, burning, or a painful bladder pressure.

Finally, active infections in the abdomen and pelvis may also cause pain with deep penetration. Acutely, infections and accompanying irritation can cause direct sensitivity and pain.  In addition, chronic processes can cause pain due to adhesions that are formed with chronic inflammation. Endometriosis is an example of this.  Adhesions restrict the movement of tissues and can put pressure on pain-sensitive structures.  Unfortunately, adhesions are challenging to see on imaging, but they are palpable to trained therapists and physicians and are often visible when investigated surgically.

Pain with Orgasm

This type of pain is less common, but from my experience, it may indicate decreased mobility of pelvic structures, spasm or trigger points in pelvic floor muscles, or inflammation and irritation of pelvic structures.

Pain after Sexual Activity

Pain after sexual activity is often a response to irritation and trauma caused by the activity itself.  In these cases, patients may experience pain or discomfort during activity and have it continue or worsen afterward.

In the case of a deep, heavy aching discomfort after sexual activity, pain may be related to venous congestion in the pelvis. During activity, blood flow into the pelvis increases, but for these women, the blood flow out cannot keep up just like swelling or varicosities commonly found in the legs. This may be directly related to inefficiencies of the veins themselves, but in many cases is related to scar tissue and fascial restrictions that restrict blood flow.

Clearly, there are many causes of discomfort with sexual activity, but for each cause, there are treatment strategies!  There is no reason to accept discomfort as normal or inevitable. The first step in addressing pain is to visit a gynecologist well versed in sexual pain to rule out infection, fibroids, cysts, hormonal shifts, or other issues and to discuss treatment strategies. One strategy may be physical therapy, as specialized women’s health PT has excellent results in treating pelvic and sexual pain. In my next article, I will discuss which types of sexual pain can be treated with physical therapy, and what treatment may entail.

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, and like it, please help support it. Contribute now.

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This post was published originally on Hormones Matter on September 21, 2015.  

Sexual Pain: It Wasn’t the Ovarian Cyst

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In previous articles, I have discussed female sexual pain, some common diagnoses, and options for treatment via physical therapy. In this article, I’d like to describe a less common source of sexual pain that I encountered in a patient, and how we successfully treated it. I am describing her case with her permission, and we both hope that it is useful to other women who may be experiencing something similar.

Although it was assumed that her pain with sex was coming from an ovarian cyst, the source of her pain was actually elsewhere, and she is now essentially pain-free. When this woman arrived for treatment, she described a 30-year history of pain with vaginal penetration during sex (pain with penetration during sex is called “dyspareunia”). This pain was on the right side, deep and stabbing, and pierced from her front to her back and all the way up her abdomen. It occurred all the time, but she didn’t let it prevent her from having sex. In fact, she often didn’t tell her husband about the pain, because she knew that it was unavoidable and still wanted to have an intimate physical connection with him. Although some positions were better than others, the pain was always there.

She had made several attempts to evaluate and address the pain. In 1991 she was diagnosed with endometriosis and was told that the only cure would be to have children and then have a hysterectomy. Surgery for endometriosis didn’t improve her dyspareunia. When her doctor found a fibroid on the right side of her uterus, she had a partial hysterectomy (removing the uterus but leaving the cervix and ovaries). Unfortunately, the pain continued. From then on her and her doctors assumed the dyspareunia was related to chronic ovarian cysts. She came in for physical therapy treatment because she knew she had scar tissue from the endometriosis and surgeries. She believed that addressing this scar tissue could benefit her, and would hopefully improve her symptoms.

Pelvic Therapy For Dyspareunia

To understand what we were evaluating and treating, it is helpful to have some background information on what “pelvic health” physical therapy is and what treatment of the “pelvic floor” involves.

The pelvic floor is a group of muscles that are located in the area of the genitalia in both men and women. It functions to support the organs, to coordinate with the other “core” muscles for postural stability, to control urination and defecation, and to contribute to sexual function. Treatment of these muscles and pelvic structures can be done externally, vaginally, or rectally, and should only be done by a practitioner specifically trained in this area, such as a pelvic health physical therapist.

When she arrived for Pelvic Health physical therapy evaluation, this patient did have an ovarian cyst that was being actively monitored by her physician. The lateral location of her sexual pain, how it was triggered by deep penetration during sex, and the diagnosis of ovarian cysts, seemed consistent. I evaluated her with the initial presumption that her diagnosis was correct, and that her painful sex was indeed coming from the ovarian cyst.

However, during my evaluation, I found that I could reproduce her pain by palpating some of her deep pelvic floor muscles. I could also reproduce the pain by palpating around (but not on) the ovary externally. I found connective tissue restrictions in the area of her ovary, small intestines, and colon. Curious and encouraged, we started treating these areas, albeit very cautiously since she did have an active ovarian cyst that was being monitored. We didn’t want to risk irritating or even rupturing it.

By the end of her series of sessions (12 sessions spread out over 5 months), which were focused on treating the pelvic floor muscles, connective tissue restrictions, and visceral mobility, she had almost no pain with sex. Her ovarian cyst was still there, but she could have sex in almost any position without pain. This was an excellent outcome.

We will never know precisely, but I believe that due to endometriosis, surgeries, and chronic ovarian cysts, she had developed connective tissue restriction that limited her tissue mobility during sex. I believe that she also developed pelvic floor muscle dysfunction related to years of irritation and tension. While I do believe that the ovarian cysts probably contributed to her sexual pain, the major driver turned out to be connective tissue restriction and muscle dysfunction.

This was a good reminder for me as a practitioner to acknowledge the known issues, but also to stay curious and investigate further. This patient had suffered for 30 years, receiving multiple surgeries and even removed an organ (her uterus) to try to resolve her pain. Through specialized physical therapy, she finally found relief and is now able to have a pain-free sex life.

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More people than ever are reading Hormones Matter, a testament to the need for independent voices in health and medicine. We are not funded and accept limited advertising. Unlike many health sites, we don’t force you to purchase a subscription. We believe health information should be open to all. If you read Hormones Matter, and like it, please help support it. Contribute now.

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Uterus Interrupted: Endometriosis is not in my Head

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It was actually in my uterus, on the cul de sac, on my right lower ligaments, on my appendix, on my bowel stretching across to the right side of my rib cage as well as in the muscle lining of my uterus (adenomyosis). No, endometriosis was most definitely not in my head as so many doctors proclaimed.

As long as I can remember I’ve been living with pain, and it all started back when I was 11 years old when I had my first menstrual cycle. I would get so sick with vomiting and cramping, and be in so much pain I wouldn’t be able to leave my bed or the washroom for the first two days of my period. I never understood why my friends wouldn’t get as sick as me. This was the first time I felt isolated. Every month I would miss at least two days of school–I’d miss out on birthdays, holidays, special occasions (I still do).

My mom used to console me and tell me that she used to have the exact same thing when she was young. When I would go to my doctor she would tell me that this is “normal, everyone woman goes through this” and “it’s nothing a little advil can’t help.”

I have endometriosis. Actually, I have endometriois and adenomyosis, chronic back and pelvic pain, vulvodynia, pelvic floor dsyfunction and I also suffer from depression and anxiety.

It wasn’t until I started becoming sexually active that I also noticed something else seemed off. Sex wasn’t fun… it sucked actually. It was painful and it felt like I was being stabbed. I would be nauseous afterwards and always have horrible back pain and cramping for days.

At this point, I was living in Vancouver. I went to a doctor out there and told him what was happening. His initial reaction was “cervical cancer” and after that was ruled out, he threw the word “endometriosis” at me. This was the first I time ever heard about “endometriosis” but I didn’t think much of it since he insisted it wasn’t a big deal and that the Mirena IUD would be my lifesaver. Well it wasn’t! Insertion was horribly painful and I cramped and bled for about two years straight. I have never felt the same since!

Finally, I was told that my body was rejecting it and had an emergency removal. I was told to just stay off of any type of birth control for a bit and see what happens, since I had been on continuous birth control from the age of 14. I was 25 at this point.

I started experiencing multiple ruptured cysts resulting in over three hospital stays in the course of four months, and I was told this time that surgery was the answer. I was trying to pursue my dreams in Vancouver, where the surgery was performed. The outcome was that he couldn’t find anything: in his words “ I had a beautiful looking uterus and everything looked fine.” I was in SEVERE pain yet there were NO answers! The pain just got worse and worse to the point where I could not work any longer. I was forced to give up my dreams and move back home to my parents’ house in Ontario and wait patiently for my turn to get into one of the best pain clinics in Toronto. Waiting patiently… my Endo-warriors know exactly how that feels.

In the meantime, my gyno referred me to a pelvic physiotherapist who I would see weekly to help with my vaginal spasms as well as internal manipulation to aid in my pelvic floor dysfunction. I was excited knowing that I would have some of the best doctors working on my case. Finally, some answers and some help! It was many months before I was admitted, where in an effort to end my pain I would try anything they suggested.

Blind nerve block injections were suggested as a treatment to numb my pelvic pain. Two to four needles were inserted into my pelvis on two different occasions. This was another let down. I now suffer from chronic pain in that area and constant hip locking as a result of these injections.

Yet another specialist suggested hormonal therapy (Visanne). The side effects from this resulted in a brief breast cancer scare (which did wonders for my anxiety). I now have permanent agonizing cysts in my breasts (fibrocystic breasts) and have an even deeper hatred for my own body.

It was right around this time that I hit an all time low. I was completely discouraged and hesitant to try any other kind of hormonal treatment that was being offered to me for fear of the side effects to my body. I was tired of being a guinea pig, and I felt very alone. I was so tired of hearing that it was “all in my head” and that maybe “I just needed to take some anti-depressants.”

It was right around this time last year that I reached out and found this amazing support group! And after having met other people who had such similar stories to mine, I started to see things in a different light. Maybe I wasn’t crazy? It was so comforting to know that I was not alone in my pain. I started hearing from more and more people who said it was very common to have a number of surgeries before endometriosis was found, and that sometimes the surgeons aren’t necessarily trained to spot endo in all of its forms. I went to the Endometriosis Symposium last year hosted by The Endometriosis Network Canada and educated myself even more. I left feeling empowered. There WAS something I could do…

With the encouragement and financial support of my parents, as well as some generous donations from friends through an online campaign, I finally sent all my health records to a world-renowned endometriosis specialist in Atlanta, Georgia. For two years I had been bouncing back and forth from doctor to doctor who all kept referring to that original surgery, saying that it obviously could not be endometriosis because none had been found. Well, a week after sending my records in, this endometriosis specialist called and after reviewing my past surgery report from Vancouver he confirmed that I most likely had endometriosis and that it was possible that he could improve my quality of life by 85%.

So, I took the trip out to Atlanta. During the surgery he found endometriosis in my cul de sac, on my right lower ligaments, on my appendix, on my bowel stretching across to the right side of my rib cage as well as in the muscle lining of my uterus (adenomyosis). He removed all the lesions as well as my appendix and he performed a presacral neurectomy, which involves snipping the main nerve to your uterus/bladder/bowel area. This is said to work for 75% of patients who no longer feel pain in that area. I, unfortunately, was not one of the lucky 75% of patients this works for. I was told to give my recovery at least six months. I was devastated when there was barely any improvement. Since the PSN didn’t work for me because of my adenomyosis, I will most likely need a hysterectomy in order to get the pain relief I was hoping for, which I am not ready for at the age of only 28.  How bittersweet…I finally had an ANSWER, but still NO pain relief!

After constantly getting knocked down by this disease, I am standing up yet again. I am still in pain… I still fight to get through the days, today included. I want my voice to be heard. I am NOT crazy. The symptoms are NOT all in my HEAD. They are actually in my UTERUS!

In the spirit of The Endometriosis Network Canada’s #awishnoted campaign I’d like to share my three wishes.

I wish for more pain free days that I can spend laughing and making memories with my loving boyfriend, and with my incredibly supportive family that I am blessed to have (that includes my endo family too) and with my friends who thanks to this disease I don’t get to see as often anymore.

My second wish is for more funding for endometriosis research right here in Canada.

And last but definitely not least, I wish for the next generation to be educated about endometriosis in health classes at school. Knowledge is power, and together our voices will be heard!

To read more about my journey with endometriosis and adenomyosis, follow my blog at http://uterusinterrupted.blogspot.ca/.

Pelvic Therapy for Endometriosis, Adhesions and Sexual Pain

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While doctors disagree on the exact cause of endometriosis, theories include heredity, environmental problems, or retrograde flow of endometrial tissue from the uterus, out the fallopian tubes, and into the body. Whatever the cause, most doctors agree that endometrial implants and adhesions (internal scars) are frequently found together. Adhesions are tiny but powerful structures that act like straight jackets wherever they form, causing pain or infertility – or both; because adhesions do not appear on any diagnostic test (x-ray, MRI, CT scan), they can elude even the most savvy physician. Thus, our patients often tell us “my doctor says he can’t find anything” or even “he says it’s all in my head.” The truth is, the pain is exactly where you are feeling it.

Endometriosis adhesions
Endometriosis (left) and adhesions (right) can cause pain and infertility.

Endometriosis Pain

While there is no consensus as to the cause of endometrial pain, increasing evidence from the studies published from our clinic and elsewhere indicates that the pain is caused, or significantly increased by adhesions – internal scars that form where endometrial tissues attach to underlying structures. In the past, the only method to treat endometrial adhesions was surgery. However, physicians and their patients are stymied by the fact that, no matter how skilled the surgeon, surgery to decrease endometriosis or adhesions tends to cause more adhesions to form as the body heals from surgery. A large retrospective study of post-surgical outcomes [Digestive Surgery, 2001] reported that between 50% and 100% of all pelvic anAdhesion Formation after Surgeryd abdominal surgeries created additional adhesions.

Thus, while the surgery may help some women, the relief may be temporary; recurring, and sometimes greater pain can appear as the body forms internal scars to heal from the surgery. Some evidence indicates that endometrial implants tend to recur with greater frequency at the surgical site.

 

Endometriosis and Pelvic Pain

In our own published studies, we have come to understand that the pelvic, abdominal, hip or back pain often associated with endometriosis comes from the pull of tiny but powerful cross-links, the building blocks of adhesions. Where endometrial implants appear, adhesions tend to bind the foreign tissue to the underlying structure. As the tissues swell with each menstrual cycle, the adhesions pull on the delicate underlying structures, causing pain. Our manual physical therapy appears to detach the adhesive bonds so endometrial tissues can expand and contract naturally, without pain from the adhesive bonds.

Post therapy release of endometriosis adhesionsHormone medications such as birth control pills can stop the menstrual cycle totally. Since the endometrial tissue does not swell, it does not pull on the adhesions and pain is relieved. However, if the woman wants to have a child, she has to stop the birth control pills and the pain returns. Thus, the medications address the symptoms, but not the cause of the pain.

 

 

Pain with Sexual Intercourse: Definitions and Therapies

Our patients tend to report three different types of intercourse pain:

  1. Pain with initial penetration
  2. Vaginal pain during intercourse
  3. Pain with deep penetration

The body creates adhesions (tiny internal scars) wherever we heal – whether due to an infection (e.g., bladder, bacterial, yeast, STD), a trauma (abuse, fall onto the tailbone or perineum), or a surgery (abortion, C-section, laparoscopy) – or due to inflammation from the endometriosis itself. These adhesions can be small enough that they form between muscle cells, causing pain when your partner pushes on them.

Vaginal pain and adhesionsBecause of its unique position in the body, a woman’s vagina is subject to numerous traumas in life. Falls onto your bottom cause adhesions to form. Once your body heals, the adhesions remain there for life, causing tiny but powerful straight-jackets that can cause pain when pressure is exerted on them – such as during intercourse.

With the warm, moist environment, the vagina tends to be a perfect place for bacterial infections. Again, adhesions form as the first step in the healing process – to help contain the infected area so your body can heal more easily. Once you have taken antibiotics or are otherwise healed, the adhesions that formed remain in the body for life – unless removed by a skilled physical therapist who specializes in work in this delicate area.vaginal pain and adhesions 2

Women who have pain with deep penetration say “it feels like my partner is hitting something,” – and he is! The usual cause for this deep pain is either a stenosed (adhered) cervix caused by adhesions following a healing event (shown in the drawing below), or a forward tailbone – caused by a fall, trauma, abuse or surgical scars.

Physicians are generally stymied to cure intercourse pain. Their prescriptions generally consist of any of a combination of therapies that address the symptoms, but not the cause. Physicians may suggest:

  1. Abstinence
  2. Pain relievers
  3. De-sensitizing drugs

These approaches do not help a woman get the pleasure or function (desire, lubrication, orgasm, pain relief) that should be hers. Many of our patients feel their lives deeply impacted; some are concerned that the pain will impact or even end their relationship with their partners.Sexual penetration pain adhesions

Fortunately, there is now a non-surgical, drug-free treatment for endometriosis pain. The Clear Passage Approach® has been examined for treating pelvic, menstrual and intercourse pain associated with endometriosis for decades. In a recent study update in the Journal of Endometriosis, this therapy was found as effective as surgery – even a year after therapy.

Besides studies in that journal, studies on this work are published in WebMD’s Medscape General Medicine, and housed in the U.S. National Library of Medicine (see study results below). In all of our studies, the treatment is a manual physical therapy that can feel like a deep massage. A brief look at the results are provided below. Learn more about treatment for endometriosis pain.

 

Improved sexual function after manual therapy for adhesions

Pain Decrease and Function Improvements from a study on the Clear Passage Approach, Published in WebMD’s Medscape General Medicine, 2011.

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