Endometriosis And Physical Activity

What is endometriosis?

Endometriosis is a common disease affecting a woman’s reproductive organs. The female uterus is lined with tissue called the endometrium which is shed each month during a woman’s menstrual period. Endometriosis happens when endometrial cells migrate outside of the womb to other sites around the body. Usually,, this abnormal tissue takes hold in the abdominal cavity, ovaries, and fallopian tubes, however, it can even affect the lungs and other organs of endometriosis patients.¹ The tissue cannot be shed during normal menstruation and becomes trapped, causing lesions, ovarian cysts, and scarring to form. These cause inflammation and chronic pain associated with the disease. These and other physical changes can lead to problems with fertility, and around 30-40% of women with endometriosis may struggle with getting pregnant.² 

Endometriosis affects around 1 in 10 women of reproductive age and for many of these sufferers chronic pain disrupts the ability to work and socialise, severely impacting upon quality of life.³ However it is also possible to have endometriosis without any symptoms (asymptomatic endometriosis), and it has been suggested most women will experience some of the symptoms endometriosis at some point in their lifetime.⁴

Symptoms typically start around the time of first menstruation, when heavy bleeding and pelvic pain are often dismissed in young girls as ‘normal’ and/or nothing to worry about. Stigma, embarrassment, and a general lack of awareness about the disease, including among healthcare professionals, may lead to delays in medical diagnosis or treatment, and it can take endometriosis sufferers on average six and a half years to receive a medical diagnosis, according to the charity Endometriosis Australia.⁵ 

Symptoms

Chronic pain (pain lasting for three months or longer) is the most common symptom which prompts endometriosis sufferers to seek diagnosis or treatment.⁶ This pain typically occurs during menstruation (dysmenorrhea), but may persist throughout the entire menstrual cycle, and can also occur following penetrative sex. Dyspareunia - deep pelvic pain occurring during or after intimacy, occurs in around half of the women with endometriosis and is associated with significant sexual dysfunction which can affect relationships.⁷

Endometriosis symptoms can be wide-ranging and many overlap with other conditions including ovarian cysts, irritable bowel syndrome, and depression, making endometriosis difficult to diagnose. Symptoms of endometriosis can include:

• Pain in the abdomen, back, hips, and hamstrings
• Pain during sexual intercourse
• Heavy and irregular menstrual bleeding
• Bowel and bladder symptoms such as; painful bloating, constipation, frequent urination, blood in the stool or urine around the time of menstruation
• Extreme tiredness or chronic fatigue
• Musculoskeletal problems
• Anxiety and depression
• Infertility

Chronic pain that interferes with work and socialisation, fertility issues, problems with intimate relationships, and delays in  receiving diagnosis and treatment all contribute to significant psychological distress associated with endometriosis. One-third  of women with the disease are also diagnosed with a mental health condition such as depression, anxiety, or other psychiatric disorders⁸, and around half of 13,500 women interviewed by the BBC said their endometriosis had led to suicidal thoughts.⁹

If you suspect you may have endometriosis it is important that you contact your doctor for an assessment. Endometriosis is a progressive disease, meaning that if left untreated symptoms can worsen over time.

Endometriosis management

There is no known cure for endometriosis and the goal of treatment is to control chronic pain and other symptoms. Analgesic (pain relieving) and anti-inflammatory drugs are usually prescribed, sometimes in combination with hormonal treatments such as the oral contraceptive pill.¹⁰

Endometriosis is a chronic inflammatory condition and, whilst the exact cause is still unknown, hormonal imbalance is thought to play an important role in the disease. Women with endometriosis typically have high levels of oestrogen which is linked to inflammation.¹¹ Oestradiol is the primary steroid hormone responsible for the development of female sexual characteristics and is what we typically mean when referring to ‘oestrogen’. During a woman’s cycle, oestradiol causes thickening of the endometrium and maturation of follicles from which the egg is released (ovulation).¹² Oestradiol is highest during the follicular phase of a woman’s cycle - (day one of menstruation until ovulation) and peaks mid-cycle, several days before ovulation.  

Oestradiol is produced primarily by the ovaries; however, lesions of endometriosis seem to have the ability to make their own oestradiol, which is thought to drive the progression of the disease.¹³ In severe endometriosis, surgery may be necessary to remove the tissue when oestrogen-lowering medications are not effective. 

Moderate exercise can help manage endometrial pain

During the follicular phase, when oestrogen is highest, a woman will also have higher levels of antibodies in her blood. This provides a temporary increase in resistance to infection - as well as an increase in systemic inflammation.¹⁴ This inflammation is responsible for many of the symptoms of PMS that women experience before their period. Inflammation is a normal part of the body’s immune system’s defences, however chronic (prolonged) inflammation can worsen certain health conditions.

Just 20 minutes of moderate exercise such as brisk walking has been shown to reduce systemic (whole-body) inflammation¹⁵ and has a beneficial effect on other diseases involving inflammatory processes such as type-2 diabetes, heart disease, and colon and breast cancers. One important protein with anti-inflammatory benefits is sex-hormone-binding globulin (SHBG). Produced by the liver, uterus, breasts, and ovaries, SHBG regulates the balance of steroid(-sex) hormones in the body by binding to oestradiol and testosterone (male sex hormone).¹⁶ Results analysed from 40 clinical trials have shown that exercise increases SHBG and reduces oestradiol in women.¹⁷ Intensity is an important consideration when exercising with endometriosis. However, acute (high-intensity) aerobic and resistance training appears to increase oestradiol.¹⁸ So, it may be best to avoid high-intensity activities such as interval and sprint training, HIIT, and heavy resistance training around your mid-cycle when oestradiol is already high.

Other factors associated with systemic inflammation (and low levels of SHBG) are being overweight and having high insulin levels. Exercise can help to achieve and maintain a healthy weight and improve insulin sensitivity, which may in turn improve endometriosis symptoms. Though there is inconclusive evidence from clinical trials that exercise relieves chronic pain associated with endometriosis, many women report that regular, moderate-intensity physical activity helps them to manage their symptoms.¹⁹ 

Recommended activities

Endometriosis can be a painful and distressing disease to live with. Many sufferers however miss out on the stress and pain-relieving benefits of regular physical activity because they simply do not feel well enough to exercise. Exercise reduces the stress hormone cortisol (which in turn helps lower oestrogen!) and releases endorphins which boost mood and act as natural pain-killers.²⁰ The key is to engage in activities which are relaxing and enjoyable, be that going on walks, swimming or dancing to favourite music; and to try to incorporate some gentle exercise on most days of the week. High-impact activities such as running, aerobics, and burpees can aggravate symptoms, however many people with endometriosis are still able to exercise at high intensities by choosing lower-impact workouts, such as indoor biking.²¹

Stretching

Endometriosis scarring and postural changes due to chronic pain can lead to problems involving the hips, back, hamstrings, and abdominal and pelvic floor muscles.  Physical activity which engages these muscles can be beneficial and physical therapy techniques which aim to stretch and strengthen these areas have been shown to reduce pain and improve quality of life in endometriosis sufferers.²² Yoga has been found to be a helpful form of exercise - in a small randomised trial, women with endometriosis who completed 2 x 90 min yoga sessions per week for 2 months all reported reductions in daily pain compared to a control group who did not participate in yoga.²³ Some recommended yoga poses can be found here, at the Endometriosis Foundation of America website.²⁴ Besides stretching and strengthening, the practice of yoga includes an awareness of the mind-muscle connection, breathing (‘pranayama’) and relaxation techniques, which can be useful tools for helping to manage chronic pain.

Exercise and pelvic floor disorders

It is normal for muscles all around the body to become tense in response to pain. Chronic endometriosis pain can lead to tightness in the pelvic floor muscles, and a condition called pelvic floor dysfunction, (or ‘PFD’). The pelvic floor muscles form a ‘hammock’ which supports the pelvic organs and growing a baby during pregnancy; they help with breathing, bladder and bowel control, the passing of urine and faeces, and normal sexual function. When these muscles become either weakened or too tight and overactive, PFD can result. Symptoms of PFD overlap with many of the symptoms of endometriosis. These include:

• Painful, slow urination
• Constipation, incomplete or painful bowel movements
• Lower back pain
• Muscle spasms in the pelvis area
• Pain in the rectum or genitals
• Painful sexual intercourse

If you suspect you may have PFD you should consult your doctor who will usually diagnose the condition through a physical exam and thorough assessment of your symptoms. To treat PFD you should see a physical therapist specialising in pelvic floor disorders or an accredited exercise physiologist, who will be able to design an appropriate program of pelvic rehabilitation exercises.

If your pelvic floor muscles are overly tight, abdominal crunches, situps and ‘kegel’ exercises’ (squeezing or ‘lifting’ of  the pelvic floor muscles) are best avoided as they will cause the muscles to shorten and contract even further which could lead to painful muscle spasms.²⁵ Instead, holding the ‘plank’, which strengthens the muscles in a lengthened position, is ideal. A progressive muscle relaxation technique such as yoga Nidra or the Jacobson Method²⁶ can also be very beneficial to teach pelvic relaxation.

Summary

Endometriosis is a too often debilitating disease which may sometimes require surgical treatment or even a hysterectomy and which can lead to problems with fertility. Despite the seriousness of the condition, endometriosis remains poorly researched and its causes are not very well understood.²⁷ 

Stress reduction and natural pain management are keys to improving emotional well-being  and quality of life with endometriosis, and exercise is one tool which can help. Regular physical activity reduces inflammation and is associated with a reduced risk of developing endometriosis. There have been few randomised-controlled clinical trials which have investigated the effects of regular exercise on endometriosis pain specifically, however available research points to improved mental well-being and quality of life in women who engage in regular, moderate-intensity  physical activity and include stretching and relaxation techniques.