A Holistic approach to managing persistent period and pelvic pain by Dr Peta Wright

A Holistic approach to managing persistent period and pelvic pain.

Disclaimer* Gendered language 

Disclaimer* this is not a sponsored blog

I am a gynaecologist working at Vera Women’s Wellness – a women’s health practice just outside Brisbane.  I see women day after day with period pain,  chronic or persistent pelvic pain with and without endometriosis.  Through my work I know that many women feel lost and unsupported on their pelvic pain journey – particularly those who have either had multiple surgeries to remove endometriosis, and those who have had a laparoscopy but found not to have endometriosis and still have pain. 

There is also often a feeling of helplessness for women who are suffering with pain and are on a waiting list for surgery feeling that there is nothing they can do to improve their pain prior to surgery. 

I can really empathise with you if you are in one of these positions and feel powerless and hopeless.  Unfortunately, these are very common scenarios I see facing women with pelvic pain every day. 

I want to tell you that although, through lack of support, access to treatment and services and lack of knowledge about all the causes and treatment for pelvic pain – it is understandable to FEEL powerless, you are not. 

When you understand more about your amazing body, all the possible causes that trigger and perpetuate pain, you can begin to take empowering action that will lead you down the path to healing.    While access to support and treatment is sometimes outside of our control – access to knowledge that can change the way you view your body and your pain, is available and knowledge is power.  We know through pain science that simply educating someone about how chronic pain works we can begin to reduce fear, pain and suffering – so let’s start there.  

Knowledge:

Because endometriosis is felt to be such a big part of the pain puzzle and yet treatments that purely tackle endometriosis lesions like surgery or hormonal drugs are far from completely effective, I believe that an accurate understanding of the role endometriosis may play in pain is important.  Currently almost all the focus when it comes to pelvic pain is on endometriosis, and while this is long overdue, it can also lead to increasing fear (which increases pain), potentially unnecessary surgeries, other factors in the development of pain being left out of the conversation and women who have pain but no endometriosis in the dark about support and treatment options.

What are the facts about endometriosis and it’s contribution to pelvic pain?

-        Endometriosis is a condition where cells like those that line the inside of the uterus and shed with each period grow inside the pelvis – sometimes on the pelvic side walls, the ovaries, the bladder, the bowel, and the area beneath the uterus. 

-        While there are multiple theories as to the origins of these cells – most people agree that most of the time lesions are caused by blood going back through the fallopian tubes and cells implanting in the pelvis.  Therefore, women with heavier or more frequent periods are more likely to have endometriosis.   

-        It is thought that when endometriosis is more severe it is due to a dysfunctional immune system – that instead of cleaning up the endometriosis cells – it overreacts and creates more inflammation and sometimes scar tissue. 

-         Endometriosis isn’t a single entity; 

-        80% of women with endometriosis have mild superficial lesions – which may be representive of the normal process of menstruation rather than a true disease state.

-        15% of women with endometriosis have ovarian cysts containing endometriosis – endometriomas

-        5% of women with endometriosis have  more severe deep infiltrating lesions – the kind the most likely to respond well to surgery.

-        Many women will have evidence of endometriosis at surgery with no pain (up to 44% in one study).

-        Many women will have pelvic pain and no endometriosis found at surgery (between 30-50% of women who have a diagnostic laparoscopy for pelvic pain have no endometriosis).

-        Surgery has been shown to improve pain in around 70% of women with endometriosis however the true effect considering a placebo effect of 30% is around 40% improvement.   

-        30 – 50% of women who improve with surgery  have recurrence of pain after 5 years.

-        If women have pain all the time (not just with periods) surgery is less effective with higher recurrence rates

-        Endometriosis is mostly NOT progressive; Studies have shown that 70% of endometriosis lesions either stay stable or improve with no treatment with only 30% of lesions getting worse.

-        While endometriosis can be a cause of infertility – most women with known endometriosis (around 70%) have no issues falling pregnant. 

Considering these facts you can see that while endometriosis can be associated with pelvic pain, it is not the whole story.

What are the other factors that drive pelvic pain?

If you have pain or have had multiple surgeries and still experience pain, its important to look at other major drivers of pelvic pain which include:

·         Trauma and a dysregulated nervous system which effects pain, inflammation, the immune system, the gut, the way we breathe and the way we hold our bodies.

·        Gut microbiome disturbance/intestinal hyperpermeability, Immune dysfunction and increased inflammation

·        Pelvic floor muscle tension or overactivity

·        Upregulation of pain pathways and the nervous system – Pain system hypersensitivity.

None of these things are improved by surgery.  Which is the  reason surgery and hormonal drugs can be ineffective by themselves for so many women.

 In my practice approximately 90% of  the women I care for with persistent pelvic pain, – regardless of whether they had been diagnosed with endometriosis have a history of significant developmental trauma or ongoing stress.  There is now over 30 years of research that chronicles the effects of trauma on both the brain and the physical body.  Not only does exposure to trauma dial up the sympathetic nervous system, affect the gut, impair the immune system, and increase inflammation it has been shown through studies such as the ACE (Adverse childhood events) study, to  increase the chance of chronic disease including pain and even endometriosis, in later life.

Once the sympathetic nervous system is dialled up to be on high alert to keep you safe – other parts of the nervous system such as our pain pathways can be dialled up too.  So that pain signals in the body are amplified.  The brain can then become used to receiving these continuous pain signals and become ‘sensitised’ which means that the pain messages received in the brain become further amplified and pain and discomfort to any stimulus in the body (even something that most people wouldn’t feel or may just feel as a sensation) become severely painful.  It is important to understand that women do have more inframammary events taking place in their bodies.  Both ovulation and periods are a time where the body makes inflammatory chemicals to allow these natural processes to occur.  Most women report some discomfort or mild pain during these times in their cycles, but if you have any of the drivers of pelvic pain – especially pain system hypersensitivity because your nervous system is in a stressed-out state – pain gets turned up to 10/10 because your body and brain are perceiving danger everywhere it looks – even in normal bodily sensations. 

This is often part of why women who started off with just pain around the time of their periods start to have pain every day or after the endometriosis lesions are removed.

The other huge factor in pelvic pain is pelvic floor muscle tension.  This is when the muscles that line the pelvis become tight and prone to spasm.  This often results in sharp stabbing pains.   It can start as a protective mechanism – when your pelvis hurts you unconsciously tense the pelvic floor – which then contributes to ongoing pain.  It can also be part of a trauma response and for many women the pelvis is where we hold trauma, stress and tension in our bodies particularly for all too many women who have experienced sexual trauma.

A practical path to healing:

-        Seek help early – debilitating pain is never normal and you deserve validation, time to get to the root of all of the factors in your pain story and good education about the menstrual cycle, the nervous system and chronic pain.  Early help – does not necessarily mean an early laparoscopy.

-         Before you have surgery, ensure you have had a good quality ultrasound which can diagnose >90% of deep endometriosis, that you see a practitioner who address the whole person, especially your nervous system, diet and pelvic floor muscles.  There are so many other effective treatments including pelvic floor physiotherapy, an anti-inflammatory diet, medications and supplements to reduce inflammation, and hormones to reduce or supress periods.  If  you do choose to have surgery know the facts about the likelihood of success when it comes to pain and remember to tackle all the other factors involved in your pain story.  Also know that surgery is an option, it is not necessary for most women and there are alternative effective treatments if surgery is not for you.

-        Learn about your nervous system and how to feel safe in your body.  Things like, deep breathing, exercise, being in nature, journaling, yoga, dance, laughing, doing what makes your soul sing – all bring you back into your rest and digest state where pain and inflammation is less likely.  These might sound like optional extras in a treatment plan, but they are crucial.  A recent study on endometriosis in rats even showed that both endometriosis lesions and pain behaviours increased when rats exposed to dangerous environments or their Vagus nerve (rest and digest nerve) where removed.  Unsurprisingly both pain behaviours and the size of endometriosis lesions decreased when rats were exposed to an enriched, low stress environment.

The sooner we begin to take the link between our environment, the way our nervous system responds to it and the state of our physical health – including pain, seriously, the sooner we can get to the root of the pain problem. 

This way of looking at pain also looks at the environment of the woman, the things she is exposed to and the trauma she may have experienced.  It means examining the culture and the soup she swims in.  Perhaps this is why it rarely happens – its’ much easier for the woman to continue to be the broken one rather than acknowledge a broken culture in the way we view women’s bodies. 

Only when your pain is addressed from this holistic perspective can you be empowered with the tools to move beyond it.  If we are focused only on surgery and suppression of women’s cycles, we are missing so much in the drivers of pelvic pain and disempowering women to think that the only solution lies in invasive procedures  or drugs to switch off hormones. 

While these things can be part of the treatment – alone – they are often not enough.  Building the right team of people to support you but not fix you (you don’t need fixing – you are whole and amazing as you are) is crucial.  I know from experience that healing from pelvic pain is possible. I see it every day when women are empowered and given back the tools to help bring them into safety in their bodies.   

You can read more about the pathway to healing pelvic pain in Dr Peta’s new book – Healing Pelvic Pain.