The place of manual therapy in patients with endometriosis: A review of the literature - Introduction

According to the French National Authority for Health: "The definition of endometriosis is histological. It is defined by the presence of glands or endometrial stroma outside the uterus". (1). It is classified into several stages, according to the American Society for Reproductive Medicine grading system (2):

• the minimal and mild stages represent implantation of endometrial cells in the peritoneum (the membrane lining the abdominal cavity), and the lesions are small: less than 3 centimetres.

• the moderate stage corresponds to an endometrioma larger than 3 centimetres. An endometrioma is a benign tumor composed of epithelial and connective tissue elements identical to those of the endometrium, growing outside the uterus.

• the severe stage represents bilateral endometriomas and/or complete effacement of the cul de sac of Douglas.

Worldwide, endometriosis affects around 10% of women of childbearing age and 30-50% of infertile women. Women suffering from chronic pelvic pain and dysmenorrhea have a 30-80% risk of developing endometriosis, and two-thirds of teenage girls have the same symptoms (3)(4)(5).

Although endometriosis is an increasingly well-known pathology, there is still a great deal of under-diagnosis. There is a delay of 6 to 7 years between the appearance of the first symptoms and definitive diagnosis (6). It is a highly disabling condition for patients, who suffer from a variety of symptoms: dysmenorrhoea, dyspareunia, chronic or cyclical pelvic pain, digestive pain, urological pain, asthenia, infertility, etc., often resulting in a reduced quality of life. These symptoms have no correlation with the stage of the endometriosis: a patient can endure very severe symptoms with a minimal stage of endometriosis (7)(8).

Patients suffering from endometriosis can receive treatments designed to improve their daily lives. At present, medical treatments are available to relieve patients' pain, with 2 objectives: to stop ovulation by abolishing menstruation, and to obtain a stable steroid hormone environment. A wide range of medical treatments are available (3), including non-steroidal anti-inflammatory drugs (NSAIDs), estrogen-progestin contraception, anti-gonotropic progestins, the Levonogestrel intrauterine device (IUD), Danazol (synthetic androgens) and gonadotropin-releasing hormone (GnRH) analogues. Medical treatments often have an effect on the symptoms of endometriosis in the short term, while they are being taken, but can become deleterious in the long term, as they are heavy treatments with numerous side effects such as weight gain, hypertrichosis, depression, osteoporosis, etc. Depending on the stage of the endometriosis and the patient's symptoms, surgical treatment is sometimes recommended. Although the effect of surgery on pain is usually temporarily satisfactory, many patients experience a recurrence of pain, and one in five requires a second operation (2). Surgery therefore does not appear to be the most recommended treatment, as it is highly invasive for the patient, and there is no guarantee that other lesions will not subsequently appear. Some studies have also shown that post-surgery, patients often have impaired vision of their own body (9). All these treatments are suppressive, as no etiology of the disease is yet known. To date, there is no curative treatment (4). Ultimately, care systems recommend that patients receive multidisciplinary treatment, including access to manual therapies (10).

Finally, it is a very costly pathology for both the patient and the healthcare system, as it is a chronic disease that takes a long time to diagnose and requires numerous, often very expensive, tests (11)(12).

The French Health Authority (Haute Autorité de Santé) contrasts so-called conventional medicine, which encompasses the medical field, with complementary medicines, which are referred to as non-conventional medicines. For example, physiotherapy is classified as conventional medicine, while osteopathy and chiropractic are classified as non-conventional medicine. According to the French National Academy of Medicine, the latter are defined as : "practices that may be used in addition to conventional care, to contribute to the well-being of patients" (13)(14).

Among these complementary medicines are manual medicines, which are practices using only the hands, including osteopathy (13). The WHO defines osteopathy as "based on the use of manual contact for diagnosis and treatment, taking into account the relationships between body, mind, spirit, health and disease" (15). It is a therapy that respects the relationship between body, mind and spirit in patients' health and illness. Osteopathy emphasizes the integrity of structure, function and the body's intrinsic capacity for self-healing.

At present, research into manual therapies and endometriosis is limited. Some studies demonstrate the efficacy of certain manual treatments, but call for a larger sample size and a more rigorous therapeutic protocol, to ensure a more appropriate transmission of knowledge (12).

Endometriosis is a hot topic right now, affecting more and more women from adolescence onwards. Patients are advised to be treated using a multidisciplinary approach, but are still too rarely referred to manual therapists (16). This study will enable us to synthesize all the data already available on manual therapy, in order to provide healthcare professionals and patients suffering from endometriosis with the best possible information on the pathology and complementary treatments.

What role do manual therapies play in the evolution of chronic or cyclical pelvic pain in patients with endometriosis and in their quality of life thanks to manual therapy?