Widespread Pain Hypersensitivity and Lumbopelvic Impairments in Women Diagnosed with Endometriosis

Bringing Endometriosis to the Road of Contemporary Pain Science

BACKGROUND

Endometriosis pain is mainly understood based on peripheral lesion characteristics and an outdated perspective equating nociception with pain. This limited view may divert understanding of interventions beyond peripheral logic, leading clinicians to see approaches targeting other processes as supplementary, limiting the effective addressing of treatment failure. Integrating critical advancements in pain and endometriosis can promote more comprehensive knowledge.

OBJECTIVES

This article provides a conceptual framework focusing on overlooked or less clearly linked areas concerning the interplay between nociception and factors influencing endometriosis pain. It explores the complexity of nociceptive processing, the association between neuromerically connected structures, and the role of the brain in pain perception. Further, it emphasizes adopting mechanism-based understanding of pain that integrates neurobiological aspects of the nociceptive apparatus and related systems, shaped by psychosocial factors contributing to a possible negative spiral in those living with endometriosis.

CONCLUSION

Aware of such a broader perspective can incentivize a balanced effort to inquire into peripheral lesion-related mechanisms and other domains potentially impacting endometriosis pain.

Prevalence of Temporomandibular Disorders in Adult Women with Endometriosis

Background/Objectives: The prevalence of endometriosis varies between 10% and 18%, while temporomandibular disorders (TMDs) concern between 29 and 34% of the general population. Both conditions share similar etiological factors and symptoms such as widespread, chronic pain. Therefore, both are qualified as Chronic Overlapping Pain Conditions. Even though TMDs and endometriosis appear to be comorbidities, up until now, no research has examined how the incidence rates compare between them. Thus, this study aimed to analyze the prevalence of TMD symptoms in women with endometriosis in the Polish population. Methods: 163 adult women with endometriosis, aged 32.41 ± 6.76 years, completed an anonymous online survey regarding their medical history and TMD symptoms. The participants were screened for TMD symptoms using two questionnaires-3Q/TMD and TMD Pain Screener (part of the DC/TMD protocol). The history mainly consisted of a chronology of symptoms' appearance, medical consultations, and final confirmation of the diagnosis, to establish delay time. Results: The analysis revealed that 77.3% of women with endometriosis showed TMD symptoms, and 49.08% of the whole studied population showed important pain levels. Then, the sample was divided into two groups according to the 3Q/TMD questionnaire-a TMD and an nTMD group. The results showed significantly higher pain levels in the TMD group (r = 0.721) compared to non-symptomatic subjects. The mean patients' delay time (T1) was 2.81 ± 4.40 years, and the mean doctors' delay (T2) was 5.32 ± 5.65 years. Conclusions: The results provide a new insight into the relationship between endometriosis and TMD. The prevalence of the latter condition was found to be high, creating a strong recommendation for the use of TMD screening tools in this particular population.

Holistic Approaches in Endometriosis - as an Effective Method of Supporting Traditional Treatment: A Systematic Search and Narrative Review

Endometriosis is one of the gynecological diseases where women suffer from pain, quality of life decreased. The aim of this review was to describe the most common non-medical methods used in the treatment of symptoms associated with endometriosis and to determine their effectiveness. The review was performed in PubMed, Embase and Web of Science databases. Randomized controlled trials, case studies, observational studies, retrospective studies, prospective studies, pilot studies, trails, publications in English or Polish were searched based on the Participant-Intervention-Comparator-Outcomes-Study design (PICOS) format. The criteria used to select studies were: women with endometriosis, no cancer, included any physiotherapeutic or non-medical intervention. 3706 articles were found, however only 26 met the inclusion criteria and were included in the review. Quality of the studies was assessed by Risk of Bias 2 tool and ROBINS-1 tool. The most holistic approach used in the treatment of symptoms of endometriosis include physical therapy, manual therapy, electrophysical agents acupuncture, diet and psychological interventions. Most research has focused on relieving pain and increasing quality of life. Non-medical methods showed reduction of symptoms of endometriosis. Physical activity, manual therapy, electrophysical agents, acupuncture, diet and cognitive behavioral therapy showed no negative side effects and reduced pain, what improved the quality of life and reduced the perceived stress.

The Benefits of an Integral HAMMAM Experience Combining Hydrotherapy and Swedish Massage on Pain, Subjective Well-Being and Quality of Life in Women with Endometriosis-Related Chronic Pelvic Pain: A Randomized Controlled Trial

Background and Objectives: To evaluate the effectiveness of an integral HAMMAM experience, a 4-week therapeutic program that combined hydrotherapy and Swedish massage, applied in a multisensorial immersive environment, on pain, well-being and quality of life (QoL) in women with endometriosis-related chronic pelvic pain that is unresponsive to conventional treatment. Materials and Methods: This randomized controlled trial included 44 women with endometriosis. They were randomly allocated to either the 'HAMMAM' group (n = 21) or to a control group (n = 23). The primary outcome, pain intensity, was evaluated using numeric rating scales (NRSs). The secondary outcomes were pain interference, pain-related catastrophic thoughts, pressure pain thresholds (PPTs), subjective well-being, functional capacity and QoL, which were evaluated using the brief pain inventory (BPI), the pain catastrophizing scale (PCS), algometry, the subjective well-being scale-20 (EBS-20), the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) and the Endometriosis Health Profile-30 Questionnaire (EHP-30), respectively. The primary and secondary outcomes were measured at the baseline and after the intervention. The statistical (between-group analyses of covariance) and clinical effects were analyzed by the intention to treat. Results: The adherence rate was 100.0% and the mean (± standard deviation) satisfaction was 9.71 ± 0.46 out of 10. No remarkable health problems were reported during the trial. The 'HAMMAM' intervention improved dysmenorrhea and dyspareunia after the intervention with large and moderate effect sizes, respectively. Improvements in pain interference during sleep and PPTs in the pelvic region were also observed in women allocated to the 'HAMMAM' group. No effects were observed in catastrophizing thoughts, well-being nor QoL, except for the sleep subscale. Conclusions: A 4-week program of an integral 'HAMMAM' experience combining hydrotherapy and massage in a multisensorial immersive environment is a feasible and effective intervention to alleviate pain during menstruation and sexual intercourse as well as pain interference with sleep in women with endometriosis.

Effect of a Multimodal Supervised Therapeutic Exercise Program on Quality of Life, Pain, and Lumbopelvic Impairments in Women With Endometriosis Unresponsive to Conventional Therapy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of "Physio-EndEA", a multimodal nine-week supervised exercise intervention, on quality of life, pain, and lumbopelvic impairments in women with endometriosis unresponsive to conventional therapy.

DESIGN

Parallel-group randomized controlled trial. Outcomes were measured at baseline, post-intervention, and at 1 year.

SETTING

Two Public University Hospitals.

PARTICIPANTS

This trial included 31 women with endometriosis (N=31) randomly allocated to "Physio-EndEA" group (n=16) or control group (n=15). Four participants dropped out of the study for causes unrelated to the intervention.

INTERVENTIONS

The "Physio-EndEA" program consisted of a 1-week lumbopelvic stabilization learning phase followed by an 8-week phase of stretching, aerobic, and resistance exercises focused on the lumbopelvic area. It was sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. Control group received the usual treatment stipulated by their gynecologist.

MAIN OUTCOME MEASURES

The primary outcome was quality of life. Secondary outcomes were pain intensity, pressure pain thresholds, pain-related catastrophic thoughts, abdominal and back strength, lumbopelvic stability, and muscle architecture.

RESULTS

Adherence rate was 90.6% and mean (±standard deviation) satisfaction was 9.44±0.73 out of 10. No remarkable health problems were reported during the trial. In comparison with controls, the quality of life was improved post-intervention and at 1 year in the Physio-EndEA group with large effect sizes (d>0.80). This group also evidenced: a reduced intensity of dyspareunia, catastrophic thoughts; an increase in pelvic, lumbar, and distal pressure pain thresholds; increases in abdominal and back strength and lumbopelvic stability; and increased thickness of transversus abdominis (right side) and width of lumbar multifidus (left side).

CONCLUSION

A 9-week program of multimodal supervised therapeutic exercise is a feasible and effective intervention to improve QoL in women with endometriosis. This program also offers benefits in terms of pain/sensitization and lumbopelvic impairments.

Effectiveness of a Manual Therapy Protocol in Women with Pelvic Pain Due to Endometriosis: A Randomized Clinical Trial

A randomized controlled trial was carried out to assess the effectiveness of a manual therapy protocol in terms of the clinical characteristics, quality of life, and emotional condition of the women with endometriosis-related pelvic pain. Forty-one women (mean age of 36.10 (6.97) years) with pelvic pain due to endometriosis were randomly divided into (i) a manual therapy group (MTG) (n = 21) and (ii) a placebo group (PG) (n = 20). Both groups received an 8-week intervention. Pain, lumbar mobility, endometriosis health profile, quality of life, depression and anxiety levels, and the patient's perception of change were assessed before (T0) and after (T1) the intervention, as well as at a one-month follow-up (T2) and a six-month follow-up (T3). The MTG significantly improved pain intensity, powerlessness, lumbar mobility, and physical quality of life at T1 (p < 0.05). The results were maintained for pain intensity at T2 and T3. In addition, both the MTG and PG improved emotional wellbeing at T1 (p < 0.05). Neither group improved in terms of social support, self-image, and depression and anxiety levels after the intervention (p > 0.05). In conclusion, manual therapy may be an excellent complement to the gynecological treatment of endometriosis-related pelvic pain by alleviating pain and improving women's endometriosis health profile and physical quality of life.

'Physio-EndEA' Study: A Randomized, Parallel-Group Controlled Trial to Evaluate the Effect of a Supervised and Adapted Therapeutic Exercise Program to Improve Quality of Life in Symptomatic Women Diagnosed with Endometriosis

Aim: The ‘Physio-EndEA’ study aims to explore the potential benefits of a therapeutic exercise program (focused on lumbopelvic stabilization and tolerance to exertion) on the health-related quality of life (HRQoL) of symptomatic endometriosis women. Design: The present study will use a parallel-group randomized controlled trial design. Methods: A total of 22 symptomatic endometriosis women will be randomized 1:1 to the Physio-EndEA or usual care groups. The ‘Physio-EndEA’ program will consist of a one-week lumbopelvic stabilization learning phase followed by an eight-week phase of stretching, aerobic and resistance exercises focused on the lumbopelvic area that will be sequentially instructed and supervised by a trained physiotherapist (with volume and intensity progression) and adapted daily to the potential of each participant. The primary outcome measure is HRQoL. The secondary outcome measures included clinician-reported outcomes (pressure pain thresholds, muscle thickness and strength, flexibility, body balance and cardiorespiratory fitness) and patient-reported outcomes (pain intensity, physical fitness, chronic fatigue, sexual function, gastrointestinal function and sleep quality). Discussion: Findings of this study will help to identify cost-effective non-pharmacological options (such as this exercise-based intervention) that may contribute to the improvement of HRQoL in symptomatic endometriosis women.

Pelvic floor, abdominal and uterine tenderness in relation to pressure pain sensitivity among women with endometriosis and chronic pelvic pain

OBJECTIVE

Pelvic floor pain, abdominal wall pain, and central nervous system pain amplification can be contributing factors in chronic pelvic pain (CPP), however; limited research has investigated the association of pelvic floor, abdominal, and uterine tenderness with central nervous system pain amplification. We assessed whether pressure pain thresholds on the non-dominant thumbnail, a marker of central nervous system pain amplification, were associated with pelvic floor, abdominal, and uterine tenderness among women with endometriosis or CPP.

STUDY DESIGN

We conducted a cross-sectional study among 88 females with endometriosis and/or CPP. Abdominal (6 locations), pelvic floor (6 locations) and uterine (1 location) tenderness were assessed via a standardized physical exam. Participants reported their pain levels (0-10 scale) with application of 2 kg of pressure at each area, with a pain rating of ≥4 on the 0-10 scale considered moderate to severe pain. Pain sensitivity was measured on the non-dominant thumbnail by applying discrete pressure stimuli using a previously validated protocol.

RESULTS

Overall, 50% (44/88), 42% (37/88), and 58% (51/88) of participants reported high pelvic floor, abdominal, and uterine tenderness, respectively. Pressure intensities needed to elicit 'faint' and 'mild' pain were lower for participants with high vs. low pelvic floor tenderness (median intensity for 'faint' pain = 0.50 kgf/cm²(min-max:0.25-3.25) vs. 1.06(0.25-3.00), p-value = 0.006; median intensity for 'mild' pain = 2.00(0.63-4.88) vs. 2.63(0.75-6.00), p-value = 0.03). No association was observed between pressure pain sensitivity and abdominal or uterine tenderness (p > 0.11). Participants with endometriosis without pain were less likely to have high pelvic floor (22.2%), abdominal (11.1%), and uterine (25.9%) tenderness compared to participants with endometriosis with pain (63.0%, 50%, 65.2%, respectively) and participants with chronic pelvic pain (60%, 73.3%, 93.3%, respectively).

CONCLUSIONS

These results suggest that high pelvic floor tenderness among women with endometriosis/CPP may be a marker of heightened pain sensitivity suggestive of central nervous system pain amplification and may impact treatment response. Future research should examine whether this clinical phenotype predicts response to medical and behavioral treatments (e.g, anti-convulsants, behavioral therapy, Physical Therapy).