A Qualitative Study on the Practice of Yoga for Women with Pain-Associated Endometriosis

Abstract

Objectives:

To understand the meaning women with pain-associated endometriosis attribute to yoga practice regarding their physical and emotional state at the beginning of the practice; pain management by integrating body and mind; secondary benefits of the practice of yoga, such as self-knowledge, self-care, and autonomy; and the role of the yoga group as psychosocial support.

Design:

Qualitative study conducted simultaneously with a randomized clinical trial.

Setting:

Public university hospital in southeastern Brazil between August 2013 and December 2014.

Participants:

Fifteen women with pain-associated endometriosis who practiced yoga for 8 weeks.

Intervention:

After completing the twice-a-week program, all women participated in a single, semi-structured interview. Interviews were recorded and transcribed verbatim, and thematic analyses were performed.

Outcome measures:

The main themes of analysis were women's expectations regarding the practice of yoga, physical and emotional state of women at the beginning of yoga practice, control and pain management through the integration of body and mind, secondary benefits, acquisition of self-knowledge and autonomy, and the role of yoga group as psychosocial support.

Results:

All participants reported that yoga was beneficial to control pelvic pain. They related that they were aware of the integration of body and psyche during yoga practice and that this helped in the management of pain. Women said they had identified a relationship between pain management and breathing techniques (pranayama) learned in yoga and that breathing increased their ability to be introspective, which relieved pain. The participants have developed greater self-knowledge, autonomy, and self-care and have reduced the use of pain and psychiatric medications. They created ties among themselves, suggesting that the yoga group allowed psychosocial support.

Conclusions:

Bodily and psychosocial mechanisms to control pain were identified in women with endometriosis. To reach such control, it is crucial that mind and body integrative techniques are learned.

Introduction

Endometriosis is a chronic disease characterized by the development and growth of endometrial glands and stroma outside the uterine cavity, which leads to inflammatory lesions that often cause pelvic pain and dysmenorrhea.^1,2 In 95% of cases of deep endometriosis, patients report dyspareunia, infertility, and acyclic dyschezia and dysuria.^{3

–12}

Although many treatments are available (medications and surgery) for pain-associated endometriosis in most cases, they bring only partial relief, and recurrence is common.^3

–7 The high rates of severe pain-associated endometriosis⁸ are linked to mechanical factors and to an interaction between local inflammation, the immune system, and the presence of nerve fibers. One study suggested⁹ an association between peripheral nerves, the peritoneum, and the central nervous system (CNS). Persistent pain stimuli emitted by the endometriosis injury are transmitted from the peripheral nerve fibers to the CNS. Because they are persistent, they increase the excitability of the CNS, causing its exaggerated and independent response from peripheral fibers stimuli; therefore, the pain persists even after removal of the lesion.

A systematic review on the social and psychological effects of endometriosis showed that constant pain is a destructive and central feature of women's lives. Between 16% and 61% of the participants experienced difficulties with mobility, self-care, and home activities. They had poor health, sleep disorders, and a lack of energy when compared with women in the general population. Between 19% and 48% of these women decreased their social activities because of pain or fear of its increased intensity when away from home. They described fatigue and the need to access the toilet more frequently as causing depression, melancholy, anger, lack of confidence, and less inclination to socialize.⁶

Because of the inefficiency of conventional treatments and common recurrence of symptoms, the use of complementary and alternative medicine (CAM) has been widespread, although the results of such treatment have not yet been fully evaluated or understood.^13
–15 A study correlating CAM with pain-associated endometriosis suggested a benefit from relaxation techniques for stress control because stress disrupts hormone balance, weakens the immune system, and decreases the ability to cope with pain.¹⁶ It is well known that bodily practices benefit the immune system, control stress and pain, and improve mental health.^11,17
–19

Yoga, classified as a mind–body practice by the World Health Organization,²⁰ covers myriad contemplative techniques that strengthen the muscles and relieve stress, helping to integrate the body and mind.²¹ Studies conducted in different parts of the world have suggested that yoga practice alleviates symptoms of such diseases as asthma and high blood pressure.^22
–24 However, research on the meanings and bodily experiences of yoga practice in the treatment of endometriosis is still scarce. This study sought to understand the meanings that women with pain-associated endometriosis attribute to an 8-week yoga program regarding their bodily experiences with the practice and their perceived potential benefits.

Materials and Method

This qualitative study was conducted simultaneously with a randomized clinical trial that evaluated pain, menstrual flow, and quality of life in women with pain-associated endometriosis who accepted to participated in a yoga program. Data were collected in a university hospital in the southeast region of Brazil between August 2013 and December 2014. The local ethical committee approved the study protocol, and all participants gave written informed consent.

Study sample

Forty women participated in the randomized clinical trial (28 were randomly assigned to the yoga group and 12 to the nonintervention group). Through the use of purposeful sampling,^22,23 15 women from the yoga group who had completed the 8-week program were invited to participate in the qualitative study. The inclusion criteria were as follows: age 18 years or older, laparoscopic diagnosis of endometriosis, pelvic pain, and availability to attend yoga practice twice a week for 8 weeks. The first author (a physical therapist and yoga instructor) led the yoga practice, which consisted of interactions among the participants (30 minutes); relaxation exercises in half lotus pose doing diaphragmatic breathing associated with the movement of the arms (5 minutes) and rotation of the neck (5 minutes); asanas (hatha yoga postures) with 5–10 respiratory movements (60 minutes); psychophysical relaxation (10 minutes), including meditation, breathing, and chanting mantras; and 10 minutes of discussion and comments.

Data collection

Semi-structured individual interviews were conducted by the first author (A.V.G.), at the end of the 8-week yoga program. The interview guide was developed specifically for this study and included items related to endometriosis symptoms and yoga practice in this context. The number of interviews was defined according to the information saturation criteria via consensus among the researchers.^22,23 All of the interviews were digitally recorded, lasted 35–110 minutes, and were transcribed verbatim. To ensure accuracy, researchers listened to each transcript twice.

Data analysis

Data were analyzed for thematic content^25,26 by one investigator (A.V.G.) and cross-checked by another (M.Y.M.). Each transcript was read and re-read, and notes of the patterns and meanings of the data were taken. Initial codes were elaborated for groups of data, and meaningful data extracts were highlighted. After all the data were coded and the excerpts identified, categories were organized according to the similarities and the differences. In discussion among researchers, themes for analysis were defined, discussed, named, checked with the data obtained during interviews, and redefined when appropriate. Thus, recurring ideas, patterns of behavior, and individual and different experiences were grouped. The main themes that emerged were as follows: women's life history, reproductive history, sexuality, endometriosis symptoms, and questions about yoga practice. The themes were organized into the following categories: women's expectations in relation to the practice of yoga, the women's physical and emotional state at the beginning of the practice, control and management of pain through the integration of the body and mind, secondary benefits, the acquisition of self-knowledge and autonomy. Discussions with researchers who had experience in qualitative analysis and CAM were conducted for external validation. The interviews were coded, and their paraphrased content was summarized and reduced according to Framework Analysis Method on NVivo software, version 10.1 (2015).

Results

The participants were age 24–49 years, more than half were married, and more than half had completed high school or higher education. More than half were working during the study. They reported that endometriosis had been diagnosed 1–26 years previously. All had undergone at least one laparoscopy and half of them had undergone a laparotomy. More than half of the women were taking some type of hormone medication. Two were using a gonadotropin-releasing hormone and were in amenorrhea. Nine women were nulliparous (Table 1).

Table 1.

Characteristics of the Women in the Yoga Group

Participants	Age (yr)	Time since diagnosis of endometriosis	Medicine intake	Marital status	Duration of education (yr)	Type of work	Parity
1	35	8 yr	None	Married	8	Housewife	Nulliparous
2	38	17 yr	Hormonal	Married	8	Public worker	2 children
3	38	7 mo	Hormonal	Single	>9	Biologist	Nulliparous
4	39	5 yr	None	Married	>9	Pharmaceutical	Nulliparous
5	24	2 yr	Hormonal	Single	8	Babysitter	Nulliparous
6	40	26 yr	Hormonal	Married	8	Unemployed	3 Children
7	25	1 yr	Hormonal	Single	>9	Lawyer	Nulliparous
8	34	9 yr	Hormonal	Married	8	Housewife	1 child
9	43	16 yr	Hormonal	Married	8	Housewife	1 child
10	37	2 yr	Hormonal	Married	8	Machine operator	1 child
11	30	1 yr and 3 mo	Hormonal	Married	>9	Elementary school teacher	1 child
12	49	3 mo	Antidepressive	Single	>9	Biologist (with health) license	Nulliparous
13	37	7 yr	Hormonal	Married	8	Hairdresser	Nulliparous
14	43	7 yr	Hormonal	Single	>9	Lawyer	Nulliparous
15	40	4 yr	Hormonal	Single	8	Housewife	Nulliparous

Women's expectations regarding the practice of yoga

Most of the participants reported that when beginning the yoga group activities, they were not sure about their ability to perform them because they had never practiced yoga. Some said they thought that yoga was just sitting and meditating or chanting mantras, while others wondered whether they had enough concentration or self-awareness to practice yoga.

“Look, I've never practiced before … I didn't know how. Yoga? I thought it was just going to Ahummmm! [laughs].” (Participant No. 8)

Some women reported having heard about the benefits of yoga, but they were not aware that it could be beneficial for pain-associated endometriosis. One of them said that she had tried to practice yoga on her own because she knew about the benefits of this practice and thought it could help her.

“I was very happy when I learned yoga could help relieve this pain, because it's something that I've been following via television, via internet, but I've never been able to practice alone. I thought I had to have someone to practice with me. I searched in my neighborhood but could not find anything.” (Participant No. 11)

Only one woman reported disappointment when invited to participate. It was her first consultation at the clinic, and she had high expectations of receiving surgery or medication.

“I thought: ‘I'm going to go to a super doctor who will solve all my problems…. Then … I don't believe it! I'm at UNICAMP to do yoga!?!?’ [laughter].” (Participant No. 4)

Physical and emotional state at the beginning of the yoga practice

At the beginning of the yoga practice, most of the women reported pain, tension, anxiety, fatigue, breathing difficulties, and trouble sleeping and concentrating, and one mentioned having lower-limb edema. Emotionally, they were frustrated with the lack of results from their medical treatment.

“When I did the surgery … and then felt all that pain again … it was very frustrating. It felt as if I was swimming hard in the ocean just to end up dying at the beach.” (Participant No. 2)

Some women mentioned severe premenstrual syndrome and that they were not using medication because they wanted to get pregnant. Some of them reported avoiding sexual intercourse because of the pain.

“I feel very guilty … It hurts and it's stressful for me … sex is not a nice thing for me … The pain I feel afterwards … huh….” (Participant No. 9)

Pain management through the integration of body and mind

All of the participants found that yoga was beneficial in controlling their pelvic pain. Some said they were aware of the integration of their bodies and minds during the practice and that this helped with pain management. They also described being at peace, relaxed, and calmer and feeling less pressure and a greater disposition to solve everyday life problems.

“I think it helped as well … some poses made the body relax. Sometimes I was in such a pain, too tense, too. I would do some exercises and it seemed like the tension was gone, the body relaxed … I think that's it: when we are less tense, calmer inside I think that automatically the pain gets more … quieter too. I think we can say that yoga calms the soul and the body, right?” (Participant No. 7)

Some women said they had identified a relationship between pain management and the breathing techniques (pranayama) they learned; further, they reported that the breathing increased their ability for introspection, which relieved their pain.

“…when I started to feel the pain … I'm going to do the breathing that ‘A’ taught me. So I sat down and started practicing … I tried to calm down, to stay very quiet and keep going and I … The pain I used to have I do not have it anymore … Wow! I realize a lot of things about myself … I feel like … I don't know [how to describe it] … as if someone is holding me on the lap … and I remember my mother. So, it is something that touches you….” (Participant No. 10)

Some of the women reported that they had reduced their drug dosages and increased the time between intake by exploring other strategies, such as massage and drinking tea—in other words, not depending exclusively on medication to control their pain. They felt they had learned to anticipate intense pain and get it under control by using breathing and relaxation techniques. They also said that when combined with these strategies, pain medication was more effective.

“After yoga, I learned to control myself better, to be aware of when my pain starts to get worse and to know what to do for it. Before [yoga], I did not know….” (Participant No. 6)

Some of the women reported feeling muscle pain after the first few sessions of yoga. One participant said that the pain-associated endometriosis worsened after yoga; however, she did not quit the study. Nevertheless, even with an initial increase in pain, none of the women withdrew from participating in the yoga group because they learned through the practice to cope with all kinds of pain: muscle- or endometriosis-related as well as either physical or psychological pain.

“I felt a lot of pain after the classes, but the impression I had is that … my heart was in peace, that's what I felt! That is why sometimes I would come even when in pain.” (Participant No. 2)

Secondary benefits of yoga practice: autonomy, self-knowledge, and self-care

All of the participants reported that through yoga, they developed self-control and self-awareness, improving their self-care and granting them greater autonomy. They said that yoga helped because they learned to be more aware of their bodies and their breathing.

“I know now that depending on the posture or the breathing I practice, I can improve it. I may not improve 100%, but it provides relief and I know what I am doing.” (Participant No. 6)

Some of the women noticed improvement in their sleeping patterns and said they had developed a new lifestyle. Furthermore, a few reported increased self-esteem after losing weight and mentioned dealing better with panic attacks.

“Yoga sparked things in me that I already knew. [I have a] food problem … [but] the [greatest] benefit that yoga brought me was related to anxiety: it [helped me] to control my panic attacks … because now I'm in control of my life.” (Participant No. 12)

Role of the yoga group in psychosocial support

Most of the participants referred to the benefits of the bonds with the other women in the yoga group. They said that by sharing their stories and life experiences, they were able to reinterpret the myths and beliefs related to pain-associated endometriosis. They said they realized their pain was real and not just in their imagination and that they had learned how to deal with it. Also, some realized that their pain was not as severe as the pain of other women. One woman, who was trying to have a second child, realized that she was luckier than those who could never have children.

“For me [the group] made a big difference, because we can chat … Each one of us spoke of our life, as it is, so we identified a lot with each other…. Many of the things I was ashamed of, which I thought I was the only one they also went through it. So, we can exchange a lot of experiences.” (Participant No. 13)

Discussion

In this study, the women with pain-associated endometriosis who practiced yoga were very similar to those described in the literature. They began the study with several of the symptoms found in over 60% of endometriosis cases.^{1,6,8,13,27

–31} The literature describes frequent and severe pelvic pain, with psychological and physical consequences, such as depression, anxiety, isolation, loss of working days, and difficulty adhering to treatments and the many years of treatment, which did not relieve symptoms, confirming the difficulty of treating endometriosis.^{3

–8,32
–34}

In Brazil, not many physicians recommend CAM, such as yoga, to manage pain-associated endometriosis.³⁴ Furthermore, recent publications on CAM and endometriosis mainly focus on Traditional Chinese Medicine and herbal remedies.^14,15 In the current study, the women were unaware of the possibility that yoga could relieve pain associated with endometriosis.

A recent United Kingdom–based study described the following reasons why patients seek CAM: dissatisfaction with allopathic medicine and with their doctor–patient relationship; preference for alternative therapies with individualized attention, longer time with the practitioner, and more information during consultations; and identification with this emergent holistic philosophy of treatment.^35,36

To the best of the authors' knowledge, this study is the first to explore the role of yoga in the control of pain associated with endometriosis. However, this study had some limitations. There was no long-term follow-up after the yoga program ended to determine whether the acquired benefits were maintained. Another limitation could be that the meanings the women attributed to yoga reflect a “courtesy bias” to please the yoga instructor, who also conducted the interviews.

The findings corroborate studies in the literature showing that through greater integration of body and mind, women can reduce pain-associated endometriosis. Many studies have shown the relationship of practicing yoga to the reduction of pain and stress as well as to improved body awareness and empowerment.^37

–40 The practice of yoga involves breathing stabilization, which allows for greater regulation of mental and emotional states, leading to greater insight, better perception of the body, and expanded strategies to deal with pain.^39,41
–43

Recent research reports^44,45 that practicing asanas and relaxation promotes relief from muscle tension and stimulates blood circulation in the muscles and viscera. Yoga can reduce autonomic nervous system activity through such parameters as oxygen intake (i.e., increased respiratory volume), which eases muscle tension and pain. The practice of yoga also helps to regulate the psycho–neuro–endocrine structures by balancing the hypothalamic–pituitary–adrenal systems, reorganizing the autonomic nervous system.^43,46,47 Some studies suggested that pain-associated endometriosis can be related to cellular oxidative stress and low cortisol levels, which can increase inflammatory responses.^1,26 Women with endometriosis have a high perception of stress, low quality of life, and low levels of cortisol (taken from saliva samples).¹ This may be related to an imbalance of the hypothalamic–pituitary–adrenal glands, which yoga practice can correct, as some studies suggest.^{40

–49}

Through the postures, breathing, relaxation, and meditation, women created new internal strategies to cope with pain, connecting more intensively with their own bodies, noticing pain in advance, and using the resources they learned in yoga to control their symptoms. Similar findings were also found in studies relating yoga practice with other conditions, such as asthma, rheumatoid arthritis, neck pain, depression, and treatment of cancer.^{22
–24,41,48

–52} By learning how to manage breathing, postures, and asanas, women can develop self-care and implement new ways of dealing with the physical and emotional stress associated with pain-associated endometriosis.

By achieving greater self-knowledge and body awareness, the women in our study also experienced secondary benefits. They favored self-care and expanded autonomy, causing a reduction in anti-inflammatory, psychiatric, and pain medication intake. They incorporated new strategies for dealing with symptoms, in ways similar to those in participants in a Denmark-based qualitative study, which described it as “derivative benefits,” suggesting the transferability of this concept internationally.³⁵ Just like the women in the yoga group in the current study, those investigators found that patients using CAM noticed positive benefits even when their main symptoms were not totally resolved. They considered continuing their treatment because of their newly acquired sense of body responsibility. Supporters of CAM, including yoga, argue that the holistic orientation it provides puts the responsibility of health and disease in the hands of the individual—one of the main features of autonomy.

Studies on the benefits of yoga groups suggested that a safe environment provides implicit understanding and mutual respect for limitations.⁴⁸ Group members identified with each other by sharing the same symptoms, the similar therapeutic circuit in search of diagnosis and treatment, and common complications of a disease; thus, the members can find support in the group. Interaction between participants allows for feelings and experiences to be shared, bringing new meaning to their own lives. A welcoming instructor is a determining factor in social support.⁴⁰ As an interactive technique, yoga replaced other social activities, removing the women from isolation and depression.^48,49 The current study is in agreement with these results, suggesting that joining a yoga group with other participants who have endometriosis helped women experience psychosocial support.

Conclusion

Yoga practice techniques that integrate mind and body have the potential to control pain associated with endometriosis. The women developed greater self-knowledge, autonomy, and self-care, causing them to reduce their use of medication while participating in the study. The yoga group created links between the women, fulfilling an important role of psychosocial support.

Footnotes

Acknowledgments

The authors thank the CAISM physiotherapy group for providing a room for the yoga sessions. Financial support came from the Ministry of Education, Brazil, CAPES CNPq grant #2008-573747/3.

Author Disclosure Statement

No competing financial interests exist.

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