By Rachael Freeland

During a healthy menstrual cycle, hormones are released which regulate the production of endometrial tissue, the tissue that lines the uterus in preparation for a fertilised egg to be implanted. This lining is then shed in the event that no fertilised egg is implanted – otherwise known as menstruation (Martini, 1998). Endometriosis is a condition in which this endometrial tissue is found in places other than the uterus. For example, the ovaries, fallopian tubes, pelvic lining, pelvic ligaments, and in some cases (but less frequently so), the lining of the bowel or intestines. How this occurs exactly is still unclear, one hypothesis suggests that either the lymphatic or circulatory systems transport the cells to other places (www.merck.com, 2007). Despite the dysfunctional location of this tissue, it is still regulated by the reproductive hormones, and will build up and shed cyclically, just like the endometrial tissue in the uterus (www.endometriosis.org, 2007). This monthly cycle of bleeding can lead to the development of cysts, scar tissue, adhesions and areas of inflammation. Endometriosis then, is often a chronic and painful condition.

For many women, the most striking symptom may be severe abdominal pain (usually in the week leading up to menstruation); however it is not uncommon for women to experience pain in their pelvis and/or back, or in some cases during sexual intercourse, urination or with bowel movements (depending on where the tissue has spread to). In other women there may not be any obvious symptoms, but they may find it difficult to get pregnant - Endometriosis is one of the leading causes of infertility in women. Diagnosis of Endometriosis is via laparoscopy (the insertion of a fibre-optic tube into the upper abdomen) (www.endometriosis.org, 2007)).

Once a diagnosis has been made, numerous treatment options exist, however most treatments under the medical model include drugs to suppress ovarian function and endometrial tissue growth, and in moderate to severe cases surgery to remove the implants is advised. A hysterectomy is reserved for clients experiencing “intractable pelvic pain and who have completed childbearing” (www.merck.com, 2007). There are many natural therapies available that can help support women’s management and be of significant benefit to improving their quality of life, yoga being one of them, however it is important that a student presenting to yoga therapy with suspected or diagnosed endometriosis be receiving medical support also.

Yoga Therapy Program

The cyclical nature of endometriosis means the client is likely to move into and out of more acute phases of pain. Therefore the practise design needs to be flexible enough to support the person’s needs at any time.

During the more acute phases the focus would need to be on resting and nurturing – aiming to ease the pain and discomfort (annamaya kosha).
o Gentle and supported back bends (like bridge, supta baddha konasana and supta virasana) to stretch out the abdominal and lower back muscles, open the abdomen and loosen and relax the pelvic muscles.
o Perhaps even a few gentle cat curls to ease the tension, alleviate cramps and begin to move the energy
o Apanasana (preferably linked with the breath to encourage energy flow) to again relieve pressure in the abdomen and also to encourage apana vayu.
o Lying Twist

o A relaxation practise would be of huge benefit here to counter the physical and emotional stress and frustration that debilitating pain can bring. It would be important then to spend time exploring and creating a comfortable, nurturing space (whether that be through creating a “nest”, with lots of bolsters and cushions, gentle music and minimal distractions or perhaps even viparita karani might be more comfortable, or the flapping fish pose often taught during pregnancy). Whilst in this pose, the student might like to practise a gentle pranayama (whereby the exhalation is lengthened, or full yogic breathing) – which would not only help to relax the mind and body, but if used as part of a mindfulness practise, it can also provide a useful tool for noticing the sensations (including pain) and learning not to necessarily attach to them.

At other times, when the client may feel stronger the following practises may be of benefit:

o Self Awareness - A number of physicians and healers believe that Endometriosis can be a “wake up call” for women who’s “emotional needs are in direct conflict with what the world is demanding of her” (www.yogajournal.com, 2007). Likewise, focus groups with women experiencing Endometriosis have shown that this is a condition of multiple losses – relationships, career, and often a sense of self worth (Cox, Henderson, Wood and Cagliarni, 2003). Thus, for many women, yoga therapy may really need to emphasise the reconnection with self, encouraging a curiosity and exploration about identifying and honouring one’s needs, and grieving any sense of loss as they may be recognised.
o Asana – At other times, when the pain is not so acute, the client may like to practise other asanas. Included in Appendix B is a “Monthly Moon Sequence” written by Leanne Clancy, which has a few stronger poses, but all of which have the focus of stretching the abdominal and lower back muscles, and creating space and openness in the pelvis.
o Pranayama - Continuing full yogic breathing but including mula bandha after the exhalation can help encourage Samana vayu and Apana vayu to increase and help eliminate more thoroughly (www.yogaforums.com, 2007).

Other Advice:
o Warm Baths or hot water bottles/heat packs can be a wonderfully relaxing way to ease pain and cramping.
o Changes to diet can be beneficial. Some studies have shown increasing Calcium and Vitamin D can ease symptoms. Likewise following a diet rich in fibre (eases pressure on the abdomen and digestive systems), essential fatty acids (which can help to reduce certain inflammatory processes associated with endometriosis).
o Referrals to other practitioners: Herbal therapy, Pain Treatment Services, Acupuncture, Chinese medicine, Homeopathy and Counselling can all be of benefit for different people.

Contraindications:
As the focus of the yoga therapy program is on relieving tension and pain, conserving energy and vitality whilst simultaneously increasing the flow of energy through the abdomen, in particular apana vayu, it would be important the student avoided those practises that are physically demanding, that create restriction through the abdomen and pelvis, and also inversions (as we are trying to cultivate apana vayu).

Please Note: A yoga therapy practise is designed by a yoga therapist for an individual and cannot really be generalised out to others. The above is written as a general plan. So please consult with a medical practitioner and a yoga therapist if you think you have Endometriosis.

References:

Cox H, Henderson L, Wood R and Cagliarni G. Learning to take charge: women’s experiences of living with endometriosis. Complementary Therapies Nursing Midwifery. 2003 May 9(2):62-8.

Martini. Fundamentals of Anatomy and Physiology, 4th Ed.

www.endometriosis.org.au, 13/05/2007.

www.merck.com, 2007

www.yogaforums.com/forums/q-yoga-practice-yoga-therapy/75-endometriosis.html, 2007

www.yogajournal.com/health/130_6.cfm, 2007