ENDOMETRIOSIS & CHRONIC PELVIC PAIN

ENDOMETRIOSIS

& CHRONIC PELVIC PAIN

KEY TAKEAWAYS

Endometriosis is a condition of abnormal uterine lining growth that has systemic impacts upon the pelvic region, causing pain and dysfunction of the urogenital system. It effects 1 in 10 women.
Women who experience symptoms of endometriosis commonly go for an extended period if time without proper diagnosis, leading to feelings of mistrust and disappointment in the medical community.
Depression, anxiety, and feelings of isolation are strongly associated with the experience of living with this condition.
The pain can be severely debilitating and may have a significant impact on a woman’s ability to engage in day-to-day activities, can negatively influence relationships, and greatly decrease her quality of life (QOL).
The OT can benefit the client through the adaptation of daily routines, promotion of a healthy lifestyle, manual therapy, and facilitated engagement in meaningful activities to regain occupational balance and improved perceptions of QOL.
Women experiencing symptoms of chronic pelvic pain or have a known diagnosis of endometriosis should collaborate with their healthcare provider and discuss intervention options for referral to a skilled therapist able to deliver client-centered care from a biopsychosocial landscape.

Photo citation: Endometriosis Foundation of America (2019)

BACKGROUND AND PREVALENCE

Endometriosis is a condition that is defined by the abnormal growth of the endometrium (uterine lining) outside of the uterine cavity, creating adhesions to the surrounding reproductive and pelvic anatomy (ACOG, 2019). This atypical growth of cells and creation of scar tissue can lead to a significant complaint of chronic pain in the pelvic region, inhibiting tolerable participation in sexual activity, restricting the proper retention or elimination of urine or stool, and for many may result in decreased reproductive fertility. Pain can be especially escalated during the time of a woman’s menstruation, with increased heavy bleeding beyond the average woman’s experience.

What is ENDOMETRIOSIS?

Zero to Finals

The American College of Obstetricians and Gynecologists (ACOG; 2019) reports that endometriosis occurs in approximately 1 in 10 women of reproductive age, and is most commonly diagnosed in women in their 30s and 40s. Proper diagnosis of the condition remains one of the greatest barriers for effective intervention within this population (Agarwal et al., 2019), and may be the cause for the lack of women being diagnosed in their earlier reproductive years. The most accurate method for achieving a definitive diagnosis of the condition is via laparoscopic surgery, whereby the surgeon inserts a small scope into the pelvic cavity and visually identifies the presence of endometrial adhesions (ACOG, 2019; Argawal et al., 2019).

Agarwal and colleagues (2019) attest that endometriosis remains undiagnosed in a significant portion of affected women, which results in the continuation of progressive symptoms, which negatively impact wellbeing and quality of life. Receiving an adequate diagnosis of the underlying condition is oft the first step required for women to begin receiving services to take control of this condition’s multiple and varied symptoms of presentation (Agarwal et al. 2019). Currently, there exists a gap in the timeliness of diagnosis that may span 4 to 11 years for some women before they are able to take actionable measures against living with this debilitating condition (Agarwal et al., 2019). These researchers further estimate that 6 of 10 endometriosis cases are undiagnosed – amounting to more than 6 million American women (Agarwal et al., 2019).

PSYCHOSOCIAL AND SOCIOCULTURAL IMPACT

“As a condition that is often misdiagnosed, mismanaged, trivialized, or ignored, endometriosis entails a great personal cost to patients and their partners, and a significant financial cost to society...”

(Aerts et al., 2018, p. 2).

Despite the fact that endometriosis is identified in 10% of the female population within the United States, a collection of data suggests that women (and their partners) are grossly disappointed with the quality of care that they are able to receive in response to their complaints of pain and dysfunction (Chauvet et al., 2018; Culley et al., 2017; Hämmerli et al., 2018; Roomaney & Kagee, 2018).

Many women that are living with endometriosis express feelings of shame, inadequacy, low self-esteem, and body image concerns (Aerts et al., 2018). In a systematic review and meta-analysis of 24 studies (99,614 women) Gambadauro, Carli, and Hadlaczky (2018) found that women with endometriosis have significantly higher depressive symptoms than women without, with complex and chronic pain found to be the major determinant to these depressive symptoms. Geukens and colleagues (2018) similarly found that women with endometriosis have a worse health-related quality of life (HRQOL) and a higher incidence of depressive and anxiety symptoms.

In a specific inquiry into the HRQOL of women with endometriosis, Chauvet and colleagues (2018) outline how non-clinical symptoms of depression, emotional distress, lacking in energy, feelings of isolation, hopelessness, and worthlessness have the potential for negative impact upon physical, mental, and social wellbeing, grossly deteriorating HRQOL. Reiterated in the themes of this study are the frequent references to the way in which individuals feel unsupported by the medical community, leading Chauvet and colleagues (2018) to advocate for healthcare professionals to take greater consideration of how perceptions of quality of life are influenced by the range of symptoms and sequelae experienced in such individuals.

While the condition of endometriosis is one that occurs in the reproductive anatomy of the woman, that does not isolate the psychological impact of the diagnosis to the woman alone. Numerous studies have explored the effect that a woman’s experience of this diagnosis has upon relationships, explicitly concerning the impact upon marriage or intimate partnership resulting from avoidance or fearfulness of painful sexual activity (Hämmerli et al., 2018). Culley and colleagues (2017) sought to explore the impact of endometriosis on the male partner specifically, as very few preexisting studies have attempted to do. The researchers articulate that endometriosis has a significant and negative impact on male counterparts across several life domains, including sex and intimacy, planning for and having children, working life, and household income (Culley et al., 2017). Overall, four primary emotions were expressed within their data, helplessness, worry, frustration, and anger (Culley et al., 2017).

This qualitative research captures the voice of male partners and extends the existing knowledge of how diminished HRQOL is realized beyond the female experiencing the condition (Culley et al., 2017). Culley and colleagues (2017) specifically recommend that healthcare practitioners assume a more “couple-centered, biopsychosocial approach toward the treatment of endometriosis, inclusive of partners and relationship issues” (p. 1667). This research is not the only sample of available literature that expressively identifies the need for a more inclusive model of care. Following their conclusions about the impact of complex pelvic pain on psychological determinants of wellbeing, Gambadauro, Carli, and Hadlaczky (2018) recommend that clinicians who are assisting women with their range of symptomology need to be more aware of how the physical and psychoemotional variables are intricately connected in order to provide better patient-centered management, referencing the value of a multidisciplinary approach as outlined in the authoritative guidelines.

Roomaney and Kagee (2018) concur with cited conclusions that interdisciplinary care consisting of medical/surgical intervention, pain therapy, and psychological therapy be made available to the patient. While Aerts and colleagues (2018) elaborate upon the crucial need to include within the multidisciplinary team gynecologists, sexologists, psychotherapists, and physiotherapists, further referencing the importance of the couple-centered, biopsychosocial approach, individualized to the client’s needs.

The many names, faces, and lived experiences of endometriosis...

Endometriosis Foundation of America (2019)

LEARN MORE ABOUT THE ROLE OF OCCUPATIONAL THERAPY IN ADDRESSING ENDOMETRIOSIS AND CHRONIC PELVIC PAIN

OT'S ROLE IN THE INTERDISCIPLINARY TEAM

ENDOMETRIOSIS' IMPACT ON OCCUPATION

OT FOR ADDRESSING CHRONIC PAIN & DEPRESSION

APPLYING AN INDIVIDUALIZED OT INTERVENTION STRATEGY

OT IN THE PROMOTION OF HEALTH AND WELLNESS

Endo OT ROLE

THE OT'S ROLE WITHIN THE INTERDISCIPLINARY TEAM

While the diagnosis of endometriosis is correlated to a biological response occurring within the physical body, the implications of the physical condition and the symptoms of associated chronic pain have a broad range of psychosocial impacts to overall wellbeing and quality of life (QOL). Much of the research calls for an individualized client-centered (extending to a couple-centered) biopsychosocial approach to intervention, emphasizing the importance of the multidisciplinary team (Aerts et al., 2018; Chauvet et al., 2018; Culley et al., 2017; Gambadauro, Carli, & Hadlaczky, 2018; Geukens et al., 2018; Roomaney & Kagee, 2018). As holistic professionals with a unique educational foundation in anatomy, biomechanics, psychological implications, neurology, and sociology, the occupational therapist has a specialized ability to integrate perceptions of the individual’s experience, determine client-centered needs, and advocate for optimal patient outcomes across a range of intervention strategies.

Pizzi and Richards (2017) have called for a paradigm shift, advocating for the profession of occupational therapy to be primarily concerned with achieving improved QOL as the apex measure of successful outcomes. Measurements of QOL and wellbeing are listed as specific outcome measures within the OTPF (AOTA, 2014), making them significant components for consideration in the OT’s plan of care. As perceptions of wellbeing and QOL are intrinsically driven and inherently person-specific, emphasizing these outcome measures increases the practitioner’s focus and sensitivity toward a client-centered approach to care. Striving to improve QOL through the engagement in meaningful and necessary activities represented throughout the occupational profile compliments the higher objective of the healthcare model’s goals in addressing endometriosis and chronic pelvic pain from a holistic perspective.

In the utilization of a biopsychosocial model of care, the OT practitioner can address multiple facets of the client’s needs as they correlate to the Occupational Therapy Practice Framework (OTPF) and promote improved QOL and wellbeing for the individual. Gentry, Snyder, Barstow, and Hamson-Utley’s (2018) Adapted Biopsychosocial Model specific to the profession of occupational therapy is an ideal model for the occupational therapist to consider in addressing the multifaceted components of this diagnosis.

ENDOMETRIOSIS’ POTENTIAL IMPACT ON OCCUPATION

While pain and infertility are two of the primary concerns expressed by women living with endometriosis, the literature clearly articulates that these individuals also experience adverse effects across the occupational profile. Consequences of daily routine and meaningful activity are observed particularly within intimate relationships, limitations in participation in daily activities, reduced social participation, loss of workplace productivity and associated income, all contributing to an overall diminished quality of life and further increased incidence of depression (Agarwal et al., 2019; Chauvet et al., 2018; Roomaney & Kagee, 2018).

It is feasible to presume that the performance or participation in the outlined occupational tasks will grossly be impacted by individual client factors relative to values, beliefs, and spirituality; body functions (e.g., specific mental functions, global mental functions, sensory functions, neuromusculoskeletal and movement-related functions, muscle functions, movement functions); and body structures (e.g., structures or the nervous system, structures related to digestive, metabolic, and endocrine systems, structures related to the genitourinary and reproductive systems, structures related to movement, skin-related structures). The impact will likely be further influenced by specific performance skills relative to motor skills and process skills or performance patterns (habits, routines, rituals, and roles) specific to the person and group or population. Overall relevance to occupations should be taken into consideration with respect to contexts (cultural, personal, temporal, virtual) and environments (physical and social). Thus, each client will have a unique manifestation of symptom presentation influencing occupational performance and therefore affecting the overall wellbeing and QOL as it is relative to their specific occupational needs.

The following table (Table 1) describes the ways in which endometriosis and chronic pelvic pain can have the potential for broad impact upon an individual’s occupational profile. The information in Table 1 representing Category and Description of occupation is directly quoted from the Occupational Therapy Practice Framework: Domain and Process [3rd edition] (AOTA, 2014, p. S19-S21), the table is further adapted to include diagnosis-specific interpretation of relevance.

Table 1. (link to PDF)

Endo impact on occupation

CHRONIC PAIN AND DEPRESSION

Despite there being little to no representation in the current body of occupational therapy literature speaking directly to the role of the occupational therapist in the intervention of clients diagnosed with endometriosis or chronic pelvic pain, there is a noteworthy repository of evidence supporting the role of the occupational therapy in relation to chronic pain and depression – two of the primary correlations for those living with endometriosis.

Endo Chronic Pain and Depression

OT's ROLE IN ADDRESSING CHRONIC PAIN:

Robinson, Kennedy, and Harmon (2011) articulate that “the consequences of chronic pain for occupational or activity performance are vast” (p. 106), listing areas of impact to independence, work performance, family and social role fulfillment, community participation, physical activity, leisure, sexual relationships, roles, and self-care performance due to the presence of chronic pain. In a systematic review of the current evidence available for the purposeful and occupational-based interventions in the treatment of chronic musculoskeletal pain (general), the researchers found that the review of literature articulates that programs requiring a specified amount of time for completion by subjects, in combination with consistent and frequent meetings providing a component of education pertaining to pain self-management, completed with a specified healthcare professional yield better patient outcomes for those with chronic musculoskeletal pain (Haskins, Maatz, & Zimmerman, 2015).

OTs working in multidisciplinary teams addressing chronic pain have been able to elicit successful return to work goals in addressing facets of care such as graded activity, pacing, energy conservation strategies, environmental modifications and ergonomics related to activities at home as well as at work (Hesselstrand, Samuelsson, & Liedberg, 2015). Robinson, Kennedy, and Harmon (2011) comprised a more comprehensive list of what the literature review suggests the full range of potential for occupational therapy interventions can be in addressing chronic pain, many of which can be directly applied to the more specific condition of chronic pelvic pain:

pacing
activities of daily living (ADLs)
goal setting
grading activity
ergonomics
energy conservation
fatigue management
exercise
self-management of flare-ups
distraction
vocational rehabilitation
equipment provision
body mechanics and postural education
bio-feedback
passive joint mobilization
heat modalities
electrical stimulation
splints
soft-tissue management
sleep hygiene
assertiveness training
stress management
creative modalities
therapeutic recreation
managing sexuality
facilitation of a peer-support network
alternative or complementary therapies
relaxation
psychologically based management strategies, including cognitive–behavioral therapy (CBT), behavioral approaches, psychotherapeutic approaches, and ego- strengthening psychotherapeutic approaches

OT’s ROLE IN ADDRESSING DEPRESSION:

The AOTA published the Occupational Therapy Practice Guidelines for Adults with Serious Mental Illness (2012) to establish an evidence-based perspective for delivery of the occupational therapy process when working with such a client population. Concepts of the established guidelines are derived directly from the OTPF before its most recent review in 2014. While this guideline specifically addresses diagnoses of mental illness deemed serious (e.g., schizophrenia/schizoaffective disorder, bipolar disorder, and major depression), recommendations for best practice intervention is translatable to the consideration of individuals with depressive disorders on the continuum of severity. While depression is a commonly associated diagnosis or condition in the population of women diagnosed with endometriosis or chronic pelvic pain, it may not always be distinctly labeled as major depression. For occupational therapists that have been working primarily in a biomedical setting, use of such a guideline can an extremely helpful resource when incorporating necessary tools for an integrated model of care.

The guideline outlines five primary intervention approaches (Table 2) that are best suited to the occupational therapist working with a depressed patient. The intervention approach should be selected based on the targeted goals created in collaboration with the client so that it is best suited to achieve the desired outcomes identified (AOTA, 2012).

Table 2.

Approach:

Prevent: An intervention approach designed to prevent performance problems by supporting body structures and functions, performance skills environment, and habits and routines.

Restore/Remediate: An intervention approach designed to change client variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired.

Modify: Compensate/Adapt. Designed to find ways to revise the task, method, or environment to support performance. An intervention approach that changes the demands and the contexts in which activities are performed to support safe, independent performance of valued activities within the constraints of motor, cognitive, or perceptual limitations.

Create/Promote: An intervention approach designed to encourages a healthy and satisfying lifestyle that includes adherence to a medication routine, appropriate diet, appropriate levels of physical activity, and satisfying levels of engagement in social relationships and activities by providing enriched contextual and activity experiences that enhance performance for all persons in the natural contexts.

Maintain: An approach designed to provide the supports that will preserve performance capabilities clients have regained so that they can continue to meet their occupational needs.

Intervention Focus:

Performance skills
Performance patterns
Context
Activity demands

Performance skills
Performance patterns
Occupation

Occupation
Context
Activity Demands

Performance patterns
Context
Activity demands

Performance skills
Performance patterns
Occupation
Context
Activity demands

(AOTA, 2012)

APPLYING A BIOPSYCHOSOCIAL MODEL

As the occupational therapist has a unique educational background in facilitating both physical modalities of intervention as well as psychosocial aspects of intervention, they are uniquely situated to deliver patient-centered care from a biopsychosocial model. The Adapted Biopsychosocial Model allows the therapist to consider the diverse factors of biological, psychological, and sociological influences when creating an intervention plan (Gentry, Snyder, Barstow, & Hamson-Utley, 2018). Each of these dimensions of care have been shown to have a direct impact on the intermediate and final rehabilitation outcomes (Gentry, Snyder, Barstow, & Hamson-Utley, 2018). Gentry and colleagues’ (2018) constructed the Adapted Biopsychosocial Model for use in the OT practice to addresses the needs of client across the continuum of care, incorporating seven key elements:

Characteristics of the condition (previously termed injury characteristics)
Sociodemographic variables that impact
Biological variables
Psychological variables, and
Social-contextual variables (which reciprocally interact with each other), to impact
Intermediate, and
Rehabilitative outcomes

These elements are represented in the following chart (Figure 1), adapted from Gentry et al.’s (2018) application of the Biopsychosocial Model in application to the occupational therapy practice.

Figure 1. (click for enhanced PDF viewing ability)

idividualized intervention

The following presentations depict Case Vignette 1 - Jennifer, which provides a client-specific scenario utilized to provide context to the completion of the biopsychosocial chart as outlined above (Figure 1), which is completed in the second presentation on Applying the Adapted Biopsychosocial Model for occupational therapy.

Case Vignette 1 - Jennifer

Applying the Adapted Biopsychosocial Model

CONSIDERING OTHER MODELS IN ACTION

The Adapted Biopsychosocial Model as created for OT is only one example of an applicable model of care to address the client presenting with endometriosis and chronic pelvic pain. As this model represents a bridge between the top-down and bottom-up approach, which is largely controversial in the current transition of the occupational therapy paradigm, it was selected to illustrate the interconnectedness of the various components as outlined within the model's flowchart. Many occupationally focused models of care can be applied to the intervention process and may serve to be beneficial when considered in parallel to the existing representation of the Adapted Biopsychosocial Model’s application.

Regardless of the model of intervention that is selected by the evaluating therapist to initiate the assessment and intervention process, the most crucial element of the therapist's decision making should be focused upon occupation. In this, that the means by which intervention is delivered is focused upon occupation as an actionable task of daily doing, and that it is meaningful and purposeful to the lived experience and need for desired outcomes within the individual.

Other options for appropriate models of occupation that can be utilized in the creation of individualized clinical care plans include (Turpin & Iwama, 2011):

Occupational Performance Model (AUSTRALIA) (OPMA)
Occupational Adaptation (OA)
Person—Environment—Occupation—Performance (PEOP) Model
Person—Environment—Occupation (PEO) Model of Occupational Performance
Ecology of Human Performance
Canadian Model of Occupational Performance and Engagement (CMOP-E) as a component of the larger text entitled Enabling Occupation II (EO-II)
Model of Human Occupation (MOHO)
Kawa Model

* The included PDF offers an expanded articulation of the use of each model

OCCUPATIONAL THERAPY IN THE PROMOTION OF HEALTH AND WELLNESS

While much of the focus of the occupational therapy profession remains aimed at the assessment and intervention of the individual, a growing trend exists in the practice of occupational therapy toward community-based and population-based interventions of care (Scaffa, Reitz, & Pizzi, 2010). Much of the traditional individual-level OT intervention may include for health promotion activities, but there exists a significant possibility for the profession to broaden the scope of impact by directly influencing public health needs via the family, community, and societal levels (Scaffa, Reitz, & Pizzi, 2010).

In implementing population health strategies with the goal of reducing the incidence of any condition, Scaffa, Reitz and Pizzi (2010) articulate that this is to be achieved through the combination of two primary strategies: early detection and prevention. Additional strategies to impact population health include health services, health promotion, and health protection. The combination of these critical strategies represents the most comprehensive approach to effectively achieving community and population health outcomes. Table 3 elaborates on the definitions of these key terms.

KEY TERMS:

Prevention:

Actions and interventions designed to identify risks, and reduce susceptibility or exposure to health threats prior to disease onset (primary prevention), detect and treat disease in early stages to prevent progress or recurrence (secondary prevention), and alleviate the effects of disease and injury (tertiary prevention).

Health Services:

Interventions typically provided by health-care medical professionals after symptoms are present or diagnosis is evident.

Health Promotion:

Interventions directed at lifestyle and involve any planned combination of educational, political, regulatory, environmental, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities.

Health Protection:

Any planned intervention or services designed to provide individuals and communities with resistance to health threats, often by modifying policy or the environment to decrease potentially harmful interactions.

(Scaffa, Reitz, & Pizzi, 2010, p. 211)

Table 3.

endo promotion of health and wellness

Applying these strategies to positively impact the public health concern of endometriosis and chronic pelvic pain requires the creation of effective community health promotion programs which integrate interventions that span educational, social, and environmental domains (Scaffa, Reitz, & Pizzi, 2010). Scaffa and colleagues (2010) articulate that effective use of occupational therapy models directed at community health outcomes requires careful consideration of intrinsic (person-specific) and extrinsic (environmental specific) factors that impact perceptions of wellbeing and quality of life. The authors reference Baum, Bass-Haugen, and Chrostiansen’s (2005) use of the term situational analysis which is defined as “a process that involves the collection of information and the analysis of factors intrinsic and extrinsic to the individual, the organization or the population to determine the occupational performance issues that will impact the ability to reach client-centered goals” (p. 372; as quoted by Scaffa, Reitz, & Pizzi, 2010, p. 216).

Table 4 represents the authors’ recommended components of a situational analysis for the purpose of designing community-health interventions, and how those apply to the goal of impacting the lived experiences and quality of life outcomes of those with endometriosis and chronic pelvic pain (Baum et al., 2005; as quoted by Scaffa, Reitz, & Pizzi, 2010, p. 216).

Table 4.

Situational Analysis Component and the Application to

Endometriosis and Chronic Pelvic Pain:

A general description of the population, including health behaviors, disease, injury, and disability incidence and prevalence statistics.

Impacts women of reproductive age, most commonly diagnosed in 30s and 40s
Prevalent in 1:10 women nationally, how does this compare to community prevalence?
Research indicates a strong correlation with diagnoses of depression, anxiety, and poor HRQOL
Impaired health behaviors include isolation, catastrophizing, and resentment toward the medical community

An environmental scan to identify environmental enablers and barriers.

What percentage of the female population of reproductive age has access to healthcare coverage? How is it being utilized?

Are clinics or specialists in the intervention of endometriosis present within the community?
What is the correlated rate of referral for mental health services by providers treating endometriosis or chronic pelvic pain?
Are there pain clinics within the community, and what is their interventions strategy towards endometriosis and chronic pelvic pain?
Are there any pelvic health rehabilitation therapists practicing within the community?

Interviews with stakeholders to ascertain community goals related to health and occupation.

Collaborate with…

Obstetrics and Gynecological clinics

Urogynecological clinics
Urological clinics
Proctological clinics
Psychological/Psychiatric clinics
Community hospitals
Pain clinics

… to determine service goals and gaps in provisions of care that elicit positive impact to client populations served.

Measures of health status and intrinsic factors to determine the constraints and capabilities for occupational performance.

Quantitative data extraction to determine frequency and severity of correlated diagnoses such as stress, depression, and anxiety through screening tools within the community (e.g., Generalized Anxiety Disorder 7-Item Scale, Severity Measure for Depression—Adult [adapted from the Patient Health Questionnaire–9 (PHQ-9)], and Perceived Stress Scale [PSS])
Use of survey to generate qualitative data inventory to determine perceptions of occupational impact upon the population of women living with endometriosis or chronic pelvic pain within the community

Measures of occupational participation and community engagement.

How are existing programs within the community being accessed and utilized?
What methods of advertising reach the greatest number of potential women in need (e.g., social media platforms, web-based advertising, doctor office pamphlets, direct inquiry to healthcare professionals)?
Collect quantitative/qualitative data regarding perceived needs and interests for occupational resources/outlets or programs that may be implemented.

(adapted from Scaffa, Reitz, & Pizzi, 2010, p. 216)

The desired outcomes of occupational therapy intervention at the community level are congruent with the objectives for outcomes at the individualized level of care. As outlined within the OTPF, the primary objectives of occupational intervention are to achieve health and wellness; prevention of injury, disease, and disability; occupational performance; role competence; adaptation; client satisfaction; and quality of life (AOTA, 2014; Scaffa, Reitz, & Pizzi, 2010). To achieve these outcomes, intervention may potentially include one or more of the following approaches: create, promote, prevent, educate, consult, compensate, adapt, modify, maintain, remediate, restore, and establish (Scaffa, Reitz, & Pizzi, 2010).

CONCLUSION

Endometriosis is a condition that deeply impacts the lived experience of a woman who is enduring it. While the current medical model has made strides to improve the methods for identification and intervention of the condition, many women are left unsatisfied and frustrated by their experiences of care. As a healthcare community, there is much left to be desired in the provision of quality intervention from a client-centered perspective addressing the range of symptoms, experiences, and sequelae associated with this condition.

The role of the occupational therapist (OT) in addressing the needs of this population is not directly linked to the intervention of the biological process of uterine growth, but rather in the lived experience of the woman through analysis and intervention directed at her day-to-day function. Through the adaptation of necessary occupations, the introduction of new coping skills and compensatory strategies, and facilitation of meaningful, purposeful tasks, the OT has a valuable role to play in improving the wellbeing and quality of life of the female living in chronic pain. As the diagnosis of endometriosis is directly linked to an increased incidence of depression and anxiety, the OT has unique skills in approaching the patient’s needs from a biopsychosocial landscape. Thus, making the OT an integral part of facilitating interventions at the individual and community level of influence.

ADDITIONAL RESOURCES

PROFESSIONAL ORGANIZATIONS:

American Chronic Pain Association

Endometriosis Association

Endometriosis Foundation of America

International Pelvic Pain Society

International Society for the Study of Women's Sexual Health

RECOMMENDED BOOK LIST:

Sex Without Pain: A Self-Treatment Guide to the Sex Life You Deserve - Heather Jeffcoat, DPT (2014)
Heal Pelvic Pain - Amy Stein, MPT (2008)
Ending Female Pain, A Woman's Manual, Expanded 2nd Edition: The Ultimate Self-Help Guide for Women Suffering From Chronic Pelvic and Sexual Pain - Isa Herrera, MSPT (2009)
The V Book: A Doctor's Guide to Complete Vulvovaginal Health - Elizabeth G. Stewart, M.D. & Paula Spencer (2002)
A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes - David Wise, Ph.D. & Rodney & Rodney Anderson, M.D. (2010)

REFERENCES

Aerts, L., Grangier, L., Streuli, I., Dällenbach, P., Marci, R., Wenger, J.-M., & Pluchino, N. (2018). 1: Psychosocial impact of endometriosis: From co-morbidity to intervention. Best Practice & Research Clinical Obstetrics & Gynaecology, 50, 2–10. https://doi-org.prx-usa.lirn.net/10.1016/j.bpobgyn.2018.01.008

Agarwal, S. K., Chapron, C., Giudice, L. C., Laufer, M. R., Leyland, N., Missmer, S. A., … Taylor, H. S. (2019). Call to Action: Clinical diagnosis of endometriosis: a call to action. American Journal of Obstetrics and Gynecology. https://doi-org.prx-usa.lirn.net/10.1016/j.ajog.2018.12.039

American College of Obstetricians and Gynecologists. (2019). Endometriosis. Retrieved from https://www.acog.org/Patients/FAQs/Endometriosis?IsMobileSet=false

American Occupational Therapy Association. (2012). Occupational therapy practice guidelines for adults with serious mental illness. Bethesda, MD: The American Occupational Therapy Association, Inc.

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1-S48.

Chauvet, P., Guiguet-Auclair, C., Comptour, A., Denouël, A., Gerbaud, L., Canis, M., & Bourdel, N. (2018). Original Article: Feelings and expectations in endometriosis: Analysis of open comments from a cohort of endometriosis patients. Journal of Gynecology Obstetrics and Human Reproduction, 47, 281–287. https://doi-org.prx-usa.lirn.net/10.1016/j.jogoh.2018.05.010

Culley, L., Law, C., Hudson, N., Mitchell, H., Denny, E., & Raine-Fenning, N. (2017). A qualitative study of the impact of endometriosis on male partners. Human Reproduction,32(8), 1667–1673. https://doi-org.prx-usa.lirn.net/10.1093/humrep/dex221

Gambadauro, P., Carli, V., & Hadlaczky, G. (2018). Systematic Review: Depressive symptoms among women with endometriosis: a systematic review and meta-analysis. American Journal of Obstetrics and Gynecology. https://doi-org.prx-usa.lirn.net/10.1016/j.ajog.2018.11.123

Gentry, K., Snyder, K., Barstow, B., & Hamson-Utley, J. (2018). The biopsychosocial model: Application to occupational therapy practice. The Open Journal of Occupational Therapy: Vol. 6: Iss. 4, Article 12. Available at: hDps://doi.org/10.15453/2168-6408.1412

Geukens, E. I., Apers, S., Meuleman, C., D’Hooghe, T. M., & Dancet, E. A. F. (2018). 2: Patient-centeredness and endometriosis: Definition, measurement, and current status. Best Practice & Research Clinical Obstetrics & Gynecology, 50, 11–17. https://doi-org.prx-usa.lirn.net/10.1016/j.bpobgyn.2018.01.009

Hämmerli, S., Kohl Schwartz, A. S., Geraedts, K., Imesch, P., Rauchfuss, M., Wölfler, M. M., … Leeners, B. (2018). Original research: Does endometriosis affect sexual activity and satisfaction of the man partner? A comparison of partners from women diagnosed with endometriosis and controls. The Journal of Sexual Medicine, 15, 853–865. https://doi-org.prx-usa.lirn.net/10.1016/j.jsxm.2018.03.087

Haskins, A. M., Maatz, K. L., & Zimmerman, J. Q. (2015). Purposeful and Occupation-Based Interventions for Chronic Musculoskeletal Pain: A Systematic Review...AOTA/NBCOT National Student Conclave, Dearborn, Michigan, November 18-19, 2016. American Journal of Occupational Therapy, 69, 1059–1062. https://doi-org.prx-usa.lirn.net/10.5014/ajot.2015.69S1-RP202A

Hesselstrand, M., Samuelsson, K., & Liedberg, G. (2015). Occupational therapy interventions in chronic pain - A Systematic Review. Occupational Therapy International, (4), 183. https://doi.org/10.1002/oti.1396

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