Endometriosis or ‘endo’ is a chronic inflammatory disorder where endometrial cells, cells that normally line the walls of the uterus, are found elsewhere in the body. It can severely impact people’s lives causing painful periods, chronic pain particularly in the back and pelvis, fatigue, pelvic floor dysfunction, infertility, and gastrointestinal issues.
Around 1.5 million or 1 in 10 women and those assigned female at birth are affected by endometriosis in the UK.
At the moment there is no known cure though treatments and lifestyle changes have proven to be helpful in managing symptoms. Exercise is one of these factors. Increasingly exercise has been used to manage a range of chronic pain conditions, this includes dysmenorrhea (painful periods) and endometriosis.
The exercises detailed in Pilates for Painful Periods can be made beneficial for people with endometriosis by easing off the abdominal engagement element.
In Pilates we encourage people to engage their transverse abdominis (TVA), a deep abdominal muscle that stabilises low back and pelvis. Without proper guidance it can be difficult to recruit TVA which could result in recruiting other muscles instead or squeezing pelvic floor. This would not be great for people with endo especially as many people with pelvic pain already gripe their pelvic floor and abdominal muscles.
If you are familiar with Pilates abdominal engagement and feel confident then go ahead, otherwise I would advise focusing on the movements and the breathing.
As a protective mechanism pain will often cause muscles to contract and resist movement. With pelvic and back pain you often spend time curled into a foetal position causing the muscles through the front to become tight.
The exercises below focus on lengthening, strengthening and mobilising. Take it slow and work with your body. Start with small movements with recovery time in between. This is kinder to your body and your brain.
Always start off slow, work with your body and how it is feeling that day, don’t push it, and if you feel pain then stop. None of these exercises should provoke pain.
Release and Breathe
A study showed that mindfulness techniques, including breathing, helped to reduce pain and anxiety I patients with endometriosis.
Release
01) Find a comfortable laying position on your back, place a towel or cushion under the neck to ensure it is supported and in a comfortable position. Place a rolled up towel under the knees if the hips are tight and place the arms by your side or on your stomach. Relax your shoulders and neck
02) Release your tummy, relax any hold on it you have and allow it to expand. Often times we suck in or flex our stomachs to give the stomach a smooth, flat appearance. You may not be aware of doing it at all. For the diaphragm to work effectively it needs space to expand into and tightening the stomach can prevent that
a) Relax into the ground, trust it to take your weight as you allow your body to become heavier and looser. Start with the jaw, then work your way down to the neck, shoulders, ribs, arms, hips, fingers, legs, ankles, and then toes. Allow and trust the ground to support you
03) Release the ribcage, this is for a similar reason to releasing the tummy – the diaphragm and lungs need space to expand
The diaphragm and the pelvic floor work together to facilitate – as the diaphragm drops when you inhale, the pelvic floor also drops, when you exhale the diaphragm returns to its start position as the pelvic floor lifts up. Without the space to expand all that pressure is forced down on the pelvic floor which can lead to lots of pelvic floor issues
a) Place your closed fingers on the sides of your ribs. As you breathe in, send the air to the outside of the ribs under your fingers. Soften the ribs and allow them to expand, gently filling the hands and separating the fingers
b) Exhale, return to centre. On each inhale imagine the ribs becoming softer and more malleable, able to move as you breathe in. The cue I use – and that everyone laughs about in class – is imagine your ribs are noodles or pasta in a pot and every time you breathe in a little bit more boiling water is added to the pot until your ribs are all wibbly wobbly and soft
Breathe
01) Stay in your comfortable position. This is combining the release work with the breath. Try to keep the idea of releasing the belly, releasing the ribs as the breathing becomes more deliberate
02) Breath in slowly through your nose sending the air down into the belly, allow the ribcage and belly to expand. This should be comfortable and not forced. Relax the tummy and the ribs, just let them move freely
03) Breathe out slowly through the mouth and just let everything relax. If the belly domed, let it return to neutral, if the ribs expanded, let them come back to centre
04) Try to keep the chest relaxed, a very common breathing pattern is chest breathing where the neck and shoulder muscles lift the ribs to force air in and out of the lungs rather than the diaphragm moving.
05) Stay here and breathe for several minutes
Stretch & Mobilise
Small Pelvic Tilt
01) Lay on your back, knees bent and feet on the floor about hip distance apart. Hands can be by your sides or resting on your stomach. Make sure your head and neck are comfortably supported
02) Inhale, soften the ribcage and on the exhale you’re going to tuck the tailbone, letting the spine rest on the mat and bringing the pubic bone higher than the hip bones. On the exhale relax
03) Inhale, then on the next exhale press the back of the pelvis into the ground, rocking the pelvis forward so the hip bones are higher than the pubic bone. Go slowly and gently. If you have any low back issues then maybe skip this part
04) Work with the breath and rock the pelvis backwards and forwards. Eventually start to make the movements smaller and smaller and rock into a neutral position where the hipbones and pubic bone are at the same level
Glute Bridge
01) This is adding on to the pelvic tilts if you want to. Lay on your back, knees bent and feet on the floor about hip distance apart. Hands can be by your sides or resting on your stomach. If you have anything underneath the neck, remove it to avoid placing the neck in a compromising position
02) Inhale to prepare, on the exhale tuck the tail bone under into your small pelvic tilt then press the hips up using the glutes and hamstrings. You are aiming for a straight line from shoulder to knee, or just left the hips as high as is comfortable without rolling onto the neck
03) Inhale at the top, use the glutes and hamstrings to keep the pelvis steady. Imagine lengthening through the tops of the thighs by sending the knees away – yes, this sounds really dumb. You aren’t moving your legs, you are thinking of lengthening through the thighs to activate and lengthen the muscles
04) Exhale to release the hips slowly down and relax the pelvis
Hug a Tree
01) Lay on your back, upper body relaxed. You can have your knees bent, legs long, legs in butterfly, whatever is comfortable
02) Float the arms straight up, palms facing. Keep the shoulders and chest relaxed. From here bend the elbows and bring the fingertips to touch. Imagine you have a beach ball balancing on your front and you’re holding it there with your arms or you’re giving a tree a hug hence the name
03) On the exhale take the arms out and lower them to the ground, keeping the bend in the elbows. Lengthening through the chest and getting the shoulder blades moving
04) Inhale to return the arms over the chest, fingertips touching and elbows bent, hugging that beach ball or tree
Single Leg Stretch
01) Lay on your back with your knees bent and feet on the floor. Draw one knee into the chest holding it with hands on the shin or back of the thigh, avoid pressing it down into the abdomen. Then you’re going to lengthen the other leg
02) Inhale to swap the legs then exhale as you lengthen the leg away
03) On that exhale gently draw the bent knee closer to the chest if comfortable
04) Add in single arm floats to gain more of a stretch along the thigh and hip flexor – as you extend the leg, take the same arm (right leg, right arm) overhead keeping the ribcage soft and not allowing it to pop up
Groin Stretch
01) Lay on your back with your knees bent and feet on the floor. This is an hip opening exercise that will lengthen through pelvic floor, it can be quite awkward at first so take it at your own pace
02) Inhale to ground the pelvis, then exhale one leg up towards the chest and then bring the second one to join it, keep the knees bent. It doesn’t matter where the legs come to just avoid pressing down on the abdominal area
03) Breathe into the stretch and then, when you are ready, on the next exhale take the knees apart aiming for them to be in line with your shoulders (don’t worry if they are nowhere close). You want your knees and feet to be in line, you are taking the entire leg out not just dipped the knee
04) Take several breaths here then bring the knees back together and take one foot down to the mat, then the other and reset yourself into that neutral position
Leg Lift
01) Start in for point kneeling, you want your wrists under your shoulders, knees under hips, and spine in a comfortable position. Try to keep the shoulders broad – don’t sink down into the shoulder blades and keep the neck lengthened by looking at a point on the floor in front of your fingertips.
02) Inhale, stabilise through pelvis and shoulders, then exhale and lengthen one leg behind you keeping the toe on the ground. The pelvis stays square, imagine that your hipbones are headlights and they are both pointing towards the ground.
03) On the next exhale lift the leg, and then inhale it down. You aren’t taking the leg super high, just enough to activate through the back of the thigh and bum without having to dip through the spin
04) Do equal number on each leg. This is going to lengthen through the front of the thighs and get the hamstrings and glute muscles working as you lift
Donkey Kicks
01) Start in for point kneeling, you want your wrists under your shoulders, knees under hips, and spine in a comfortable position. Try to keep the shoulders broad – don’t sink down into the shoulder blades and keep the neck lengthened by looking at a point on the floor in front of your fingertips
02) Inhale, stabilise through pelvis and shoulders, then exhale and take one leg behind you keeping the knee bent. You are aiming to have the thigh parallel to the ground with the foot facing the ceiling
03) On the next exhale aim the foot towards the ceiling as if you were going to kick it. You will feel this along the front of the thigh and glutes. Keep the back still as you do several little kicks upwards
04) Repeat on both sides
Adductor Stretch
01) Start in for point kneeling, you want your wrists under your shoulders, knees under hips, and spine in a comfortable position. Try to keep the shoulders broad – don’t sink down into the shoulder blades and keep the neck lengthened by looking at a point on the floor in front of your fingertips
02) Inhale, take one leg out to the side, aiming to keep it in line with the hips. Pelvis should stay square, hipbones facing down, and try not to sink into the shoulders or move through the back
If you find yourself doing that, don’t take the leg out so far
03) Taker a few breaths here, you should feel a stretch along the inner thigh. Inhale to return to four point kneeling then exhale and take the other leg out
Side Stretch
01) From your four point kneeling position you are going to aim the bum towards the heels, keeping the palms on the mat. It doesn’t matter where your hips are in relation to your heels; find the position that is comfortable and not taxing on the body
Avoid placing pressure on the abdomen; take the knees apart if that is a more comfortable position. You can also place a cushion under the bum
02) Inhale, reach the fingertips forward as you draw the shoulders away from the ears aiming for a stretch along the back
03) On the exhale, walk the fingertips over in one direction, taking the body with it. This is going to be a side stretch so you’ll feel a stretch along the outside line of the body. Take a breath here then walk the fingertips back to centre and on the next exhale take them to the other side
04) Do this several times to each side, or just chill out in child’s pose (bum on heels)
References
Armour, M., Sinclair, J., Chalmers, K.J. et al. Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC Complement Altern Med 19, 17 (2019)
Awad, Eman et al. “Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design.” Journal of physical therapy science vol. 29,12 (2017): 2112-2115
Ball E, Khan KS. Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Res. 2020;9:F1000 Faculty Rev-83. Published 2020 Feb 4
Mathew Leonardi, Andrew W Horne, Katy Vincent, Justin Sinclair, Kerry A Sherman, Donna Ciccia, George Condous, Neil P Johnson, Mike Armour, Self-management strategies to consider to combat endometriosis symptoms during the COVID-19 pandemic, Human Reproduction Open, Volume 2020, Issue 2
Mette Kold, Tia Hansen, Hanne Vedsted-Hansen & Axel Forman (2012) Mindfulness-based psychological intervention for coping with pain in endometriosis, Nordic Psychology, 64:1, 2-16
Mira, T.A., Buen, M.M., Borges, M.G., Yela, D.A. and Benetti-Pinto, C.L. (2018), Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int J Gynecol Obstet, 143: 2-9
Nezhat, Camran MD; Vang, Nataliya MD; Tanaka, Pedro P. MD, PhD; Nezhat, Ceana MD Optimal Management of Endometriosis and Pain, Obstetrics & Gynecology: October 2019 – Volume 134 – Issue 4 – p 834-839
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