Physiotherapy and endometriosis

1 in 10 women of reproductive age in the UK suffer from endometriosis, that’s 176 million worldwide. Endometriosis is characterised by pain — period pain, abdominal & pelvic pain, pain with urination and with bowel movements, and pain with sex. Hands on therapy such as women’s health physical therapy or pelvic physiotherapy can go a long way in helping endometriosis sufferers manage their pain
When women suffer from endometriosis, they often spend a lot of time curled up in bed during their period, and often outside of period time too. All of those cramps, spasms, inflammation and pain make the tissues in the abdominal, pelvic and back area really tight. There is also a build up of scar tissue from the endometriosis or from the surgeries to remove endometriosis. This tightness in the muscles and connective tissue (fascia) in the area can then cause further pain. The pain cycle begins, going round and round in a vicious circle of increasing pain, tightness and inflammation. Manual therapy and myofascial massage in the pelvic and abdominal area help release scar tissue, adhesions, spasms, fascial and muscle tightness, and to restore the correct alignment of the bones, soft tissues and the pelvic and abdominal organs. Sometimes the pelvic bones and joints are not in a neutral or appropriate alignment and this can further affect the muscles and fascia in the lower back, pelvic and hip regions. This can usually happen after surgery as often the endometriosis or scar tissue can be more one-sided within the pelvic organs. When surgery is performed to remove this, one side of the pelvic tissues can scar and tighten up more and pull the joints out of alignment. Myofascial massage, muscle energy techniques and exercise help restore the pelvis, hip and spine joints back to a good neutral alignment. Often women with endometriosis have been told they have sacro-iliac joint dysfunctions in the pelvic joints, so an integrative approach of external and internal physiotherapy techniques is important for optimal results. Endometriosis severely impacts the pelvic floor, and more often than not, women who suffer from endometriosis also suffer from a hypertonic, overactive or tight pelvic floor. If the pelvic floor muscles and fascia are tight, then they are often also very painful, leading to pain with sex. Overactive pelvic floor muscles can also make period pain worse because when the uterus contracts to expel blood, the pelvic floor muscle and fascia system will be contracting too (it’s like trying to walk with a sprained ankle). This is why a lot of women with period pain also experience vaginal pain during their periods. Women with endometriosis often has tightness or trigger points in her pelvic floor muscles, so a lot of the treatment would have involve internal vaginal muscle releases. Internally and externally treatments ( the outer muscles of the hip, buttocks, spine and abdomen), decrease pelvic and sexual pain, improve bladder and bowel control, regular bowel emptying, better digestion, and best of all, less period pain. After physiotherapy periods can become shorter, more regular, with less spotting before and after periods. Part of the reason for this is because the uterus is now aligned ‘neutrally’ from all the muscle and fascial release work around it, rather than tipping forwards or sideways. If the uterus isn’t positioned ‘neutral’ or well within the pelvis, blood can stay back in the curves rather than flowing straight down and stay there until the next period, when it comes out as dark spotting. Diaphragmatic exercices:

Deep breathing helps to allow for the ribs to expand, easing tension in the back, right up to the neck, and down into the pelvis. Often women with pain will take shallow breaths into their upper chest so their diaphragm doesn’t really get a stretch. The diaphragmatic breath calms the nervous system, which leads to less pain. You can do deep, wide breathing anywhere, but You can use yoga strap or
band around lower ribcage, to get that feedback of my breath into the band. Take 5–10 deep wide breaths every hour.

Pelvic floor droops Very often women with endometriosis and pelvic pain actually have a tight and tense pelvic floor, so useful might be reverse kegels or pelvic floor relaxation exercises. We want to lengthen and relax the pelvic floor, especially with women who have pain with sex. Do 5–10 breaths combined with pelvic floor drops every hour.

Hip and buttock stretch This is a really great simple hip opening stretch that also allows your buttocks and deep hip rotators to stretch. Simply lay back on your mat or on your bed with your knees bent, then take one ankle onto the
opposite knee and use your hand to gently press away at the knee. Because a lot of women with endometriosis and pelvic pain often curl up in pain, we really want to open the hips, but in a gentle way. Hold this stretch for 60 seconds or as long as your feel comfortable and repeat daily.

Groin stretch This is another effective hip opening stretch that also lengthens the pelvic floor and allows the tailbone to soften away from the hips. You can do this laying back on your mat or in bed. Slowly bring both knees up towards your chest, and then when you are comfortable, slowly take the knees apart towards your shoulders. You can rest here for 60 seconds, and focus on your deep breathing and pelvic floor drops.

Hip flexors stretch This yoga variation of the hip flexor stretch give a lot of lengthening of the muscles and connective tissue along the front of the body. The front of the hips, the pelvis, the belly and the chest all get a deep stretch. Start in kneeling on your knees on a mat (you can have a towel or blanket under your knee), then take a step forwards with one foot. Rest here for a moment before starting to bring bot arms up towards the ceiling. Rest here again and start to lunge forwards and lift your belly to the ceiling. Take a slow deep breath as you move from each position, but only go to a place where you are comfortable. Hold this stretch for 60 seconds as your breathe deeply and feel your pelvic floor melting down.

Shell stretch Finish off with a shell stretch by sitting back on your heels and curling forwards bringing your forehead to the mat. Reach your arms forward on the mat. If you feel comfortable, you can even take your knees out into a child pose stretch. This is a really great restorative pose that allows you to expand into your diaphragm more as your breathe in, and also lengthens the pelvic floor. Spend some time here whilst you breathe and visualize your pelvic floor muscles softening down, as your chest and breastbone also melt to the mat.

Author: Physiotherapist- Iwona Gibała



1.Rogers PA, D’Hooghe TM, Fazleabas A, et al. Priorities for endometriosis research: recommendations from an international consensus workshop. Reprod Sci 2009;16(4):335-46.
2.Ginekologia w praktyce klinicznej ,Nieplodnosc’ Emre Seli, Aydin Arici 3.University College London Hospitals. General information about Endometriosis. Accessed February 2014.