Women and pain 2 | Endometriosis

This is the second part in a series highlighting common painful problems that I see in women (Part 1 here). Endometriosis would not usually the reason for the referral, however this problem can often be mentioned as we talk about painful problems that are seemingly unrelated. To the individual, endometriosis can significantly affect quality of life, impacting upon day to day living in many ways. There are perhaps 2 million women with the problem.

What is endometriosis? The classic viewpoint

Endometriosis is a condition when the cells of the womb lining are found outside of their normal habitat. Commonly the cells are seen in the pelvic area and abdomen (ovaries, fallopian tubes, ligaments which hold the womb in place, the area between the rectum and the womb named the Pouch of Douglas) but occasionally in other locations in the body (bowel, bladder, intestines, vagina, rectum, on operation scars, in the muscular wall of the uterus and rarely in the skin, eyes, spine, lungs and the brain).

What are the symptoms?

There are a range of symptoms and problems that vary in their severity including:

  • Painful periods
  • Persistent pain in the pelvic area (chronic pain)
  • Bowel and bladder symptoms
  • Issues conceiving
  • Fatigue
  • Depression
  • Relationships difficulties
  • Limited or avoided socialising
  • Problems at work
The symptoms can often begin in adolescence (see article here), a time of great change and challenge in any case, complicated by this painful condition.

Reconceptualising pain – beyond the tissues

Although we feel pain in our bodies, the construction of the experience occurs within the brain via a widespread network of neurons. They are not specific for pain and have a large number of different functions including memory, concentration, movement, sensation, decision-making and fear to name but a few. In brief, we experience pain as an output or as the end result of the brain scrutinising the information from the body that is compared and analysed in the light of prior experience and the knowledge base. On concluding that there is danger or a threat to the body, the brain allocates the sensation of pain to the area deemed to require attention and protection.

Pain is a motivator, a need state that requires action to be taken to promote healing and survival. Pain emerges from the self and is hugely influenced by a range of factors beyond the ‘structure’ where the unpleasant experience resides.

Undoubtedly pain is complex and modulated by many factors, in particular emotional state, attention and lifestyle – see here. It is also useful to understand the pain mechanisms that can play a role in the maintenance of symptoms, including peripheral and central sensitisation that are not in isolation of immunological and endocrine activity that can hugely influence the perception of pain. The health of the tissues depends upon normal functioning of these body systems as well as movement to nourish both locally via blood flow and the representation of the body that exists in the brain. This representation relies upon regular updates from the body via signals about movement and chemical balance.

Recent neurobiology studies have identified mechanisms that may underpin pain and the process of sensitisation in endometriosis and other chronic pain problems – click here, here & here. There are many papers that help to explain the changes in the nervous system and other systems that contribute to a persisting pain problem. Basing one’s thinking purely around a structure as a cause for on-going pain is simply not encompassing enough to tackle the issue.

Researchers last year published a paper that described an imbalance between the sympathetic nervous system and the sensory nerves (click here) in peritoneal endometriosis, suggesting that this may underpin an on-going inflammation and consequential pain. The sympathetic nervous system (SNS) is a branch of the autonomic nervous system (ANS) and is responsible for the feelings one may experience when in danger, e.g. sweaty palms, increased heart rate, a feeling of anxiousness. The SNS is a direct link between our thinking and feeling self and the physical responses and therefore the way we perceive a painful problem can influence the pain we feel via this system but also the immune system that is responsive to our thinking and stress – click here and here. There are well established links between nerve and immune functions – click here.

The meaning or salience that is given to the pain and the context of the pain are both key considerations. Of course both can and do change, therefore affecting the pain perception at any given time. The meaning one ascribes will relate to beliefs about pain and its consequences upon health and lifestyle. The greater the perceived threat, the greater the chance that the brain will protect. Pain is part of that protection alongside other adaptations such as increased muscle tension that can cause further pain and discomfort.

Neuroscience confirms what people have been saying for years, that our thinking process affects our pain. The discovery of communication between different parts of the brain has helped us to understand this and actually target this mechanism with specific strategies. Changing our thinking really does change our pain. Interestingly, it was discovered that when we catastrophise about pain (cognitive and emotional factors) it can affect the immune system’s inflammatory profile. In other words, over-worrying about the meaning of our pain can potentially make us more inflammatory–see here. It does appear that some people are not able to turn off their inflammatory responses as effectively, thereby continuing to provoke sensitisation and pain. There is a genetic basis to this over or prolonged response.

How can we tackle pain in endometriosis?

Traditionally the pain of endometriosis is managed with analgesia, hormone based medication, surgery and complimentary therapies or a combination thereof. Considering the brief overview of the pain mechanisms above, although complex do provide a range of levels at which we can intervene to change the pain experience.

The contemporary way in which pain is considered is called the biopsychosocial approach. This means that the neurobiology, psychology and social aspects of pain are addressed in an integrated manner. We have said that pain is complex and multidimensional on the basis that the areas of the brain  responsible for the pain experience have a range of additional roles. They are not specific for pain and indeed there is no pain centre. Consequently, the need is for a wider lens and this is exactly what the biopsychosocial model offers.

Reasoning that there are different mechanisms, we can design and create programmes of treatment and training for each.

For example, we know that movement and muscular activity is different when we are in pain. These altered movement patterns feed back to the brain and are a mismatch for the expected patterns thereby maintaining protective measures. There are a number of ways that we can look at how the motor system has adapted and then seek to re-train normal movement and sense of the body that is often affected. Muscles that are overactive because we lose precise control can be the cause of local sensitivity, adding to the unpleasant picture.

Re-framing one’s thinking about pain with high quality education (informational medicine) actually changes pain perception and for good reason. Biologically the areas of the brain involved in thinking communicate with other regions that are part of the network we have been talking about, therefore negative thinking and anxiety can increase vigilance to pain, attention and focus towards pain, both of which can amplify the experience. Remember that a thought and an emotion is as much brain activity as a movement and both are potent ways of further sensitisation.

At our clinics we draw all this information together, blending with the individual’s narrative and experiences to develop a personalised care package that is as much about the person as the condition suffered. Several of the ways in which we look at and tackle pain are mentioned. These sit well with a range of strategies and treatment techniques that we employ to promote wellness and living. Interestingly, there are frequently other painful conditions that co-exist with endometriosis and the science demonstrates that there are usually similar mechanisms underpinning the seemingly unrelated problems (e.g. IBS, fibromyalgia, chronic fatigue syndrome, migraine, pelvic pain, bladder dysfunction). In targeting the peripheral and central mechanisms as outlined here, we often see a change in the other symptoms as well.

For further information about our clinics and treatment please contact us here or call 07932 689081



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