OMT for Common Gynecologic Disorders
Objectives:
 Review Sympathetic and Parasympathetic innervations pertinent to the female GU system.
 Recognize and explain MFTrP (Myofascial Trigger Points) for the Pelvic Floor.
 Review and discuss common structural findings and treatment of somatic dysfunction(s) associated with Pelvic
Disorders such as:
 Premenstrual Tension Syndrome
 Endometriosis
 Dysmenorrhea
 Etc.
 Female GU Anatomy
 Sympathetic Innervation
 Visceral Organ
 Spinal Cord Level
 Kidneys
 T9-L1
 Adrenal Medulla
 T8-T10
 Upper Ureters
 T10-T11
 Lower Ureters
 T12-L1
 Bladder
 T11-L3
 Ovaries
 T9-T11
 Uterus/cervix
 T9-L2
 Erectile tissue of
clitorus
 T11-L2
 Fallopian tubes
 T10-L2
 Parasympathetic Innervation
Visceral
Organ
Nerves
Kidney/upper
ureter
CN X (vagus)
Ovaries
CN X (vagus)
Lower
ureter/bladder
S2-4 (pelvic
splanchnics)
Uterus and
genitalia
S2-4 (pelvic
splanchnics)
 Viscerosomatics
 Normal Physiology
 Ovarian Cycle
 Follicular Phase
 Maturing of the follicle via FSH stimulation
 Ovulation
 LH surge causes release of the ovum from the follicle
 Luteal Phase
 Corpus luteum produces progesterone
 Uterine Cycle
 Menstruation
 Shedding of the endometrium
 Proliferative Phase
 Estrogen stimulates proliferation of the endometrium
 Secretory Phase
 Progesterone stimulates gland development in the endometrium
 Common Gynecologic Disorders
 Dysmenorrhea
 Endometriosis
 Premenstrual Syndrome
 Pelvic floor dysfunction
 Dysmenorrhea
 Defined as painful menstruation
 Consists of recurrent, crampy lower abdominal pain that occurs just before or during menses
 Due to prostaglandin release during endometrial sloughing that causes nonrhythmic uterine contractions
 No specific physical findings related to the dysmenorrhea itself, but may find pelvic/sacral somatic dysfunctions
 Treatment includes NSAIDs, OCPs, acupuncture and OMT
 Chapman’s points along IT band, pubic bone, or sacrum, addressing sympathetics as well as
parasympathetics
 Pelvic Diaphragm to relieve edema and increase drainage
 Endometriosis
 Defined as the presence of implanted endometrial glands and/or stroma in extrauterine locations
 Often leads to pelvic pain, dysmenorrhea, dyspareunia and infertility
 Physical exam findings including tenderness and palpable nodules in posterior cul-de-sac and/or uterosacral
ligaments, tender adnexal masses and pain with uterine movement
 Confirmatory diagnosis made by direct observation of endometrial implants (surgery)
 Treatment includes pain control, hormone treatments, surgical intervention, as well as OMT
 Sacral rocking for normalizing parasympathetic tone
 Treatment of any dysfunction at T10-L2 (uterus)
 Mobility of pelvic diaphragm to relieve pelvic congestion
 Premenstrual Syndrome
 Presence of both physical and behavioral symptoms that occur repetitively with the menstrual cycle and
interfere with a woman’s daily functioning
 Physical symptoms include abdominal bloating, fatigue, headaches, and breast tenderness
 Behavioral symptoms include labile mood, irritability, difficulty concentrating and depressed mood
 Treatment is focused at specific symptoms
 Headache Tx includes NSAIDs, OCPs or OMT aimed at suboccipital and cervical regions
 Abdominal bloating Tx includes collateral ganglion release, mesenteric releases of small intestine, ascending
and descending colon and colonic milking, as well as associated thoracic and lumbar dysfunctions
 Pelvic Floor Dysfunction
 Consist of urinary or fecal incontinence, as well as pelvic organ prolapse
 Can be due to childbirth, pregnancy, nerve injury, or injury to coccygeus or levator ani muscles
 These can lead to or stem from somatic dysfunction, including TPs
 Treat with Kegel exercises, injections and OMT
 Myofascial release, counterstrain, reciprocal inhibition
 Treatment of Gyn Disorders
 Osteopathic Manipulation
 Lymphatic drainage
 Tx of thoracic/lumbars
 Tx of innominates
 Tx of pubic bone
 Tx of sacrum
 Chapman’s Points
 Smooth, firm palpable nodules located in the deep fascia
 Rotary stimulation for 20-60 seconds
 Travell’s Myofascial Trigger Points
 Lymphatics
 Helps improve vascular congestion
 Enhances lymphatic drainage
 Start with thoracic inlet release, then move to the thoracoabdominal diaphragm release, then to pelvic
diaphragm
 Pelvic innominates
 Can have anterior or posterior innominates due to hamstrings or quadriceps muscles, as well as other pelvic
somatic dysfunction
 Helpful for patients who have pelvic pain
 Can treat these with muscle energy
 Pubic Bone Dysfunction
 Can be due to extreme innominate rotation
 Can also be due to trauma, such as childbirth, or pelvic floor muscle tightness
 Can treat with muscle energy
 Sacral dysfunction
 Dysfunction can lead to altered parasympathetic tone
 Caused from other somatic dysfunctions, trauma, childbirth or pelvic floor muscle dysfunction
 Can treat with articulatory or muscle energy
 Anterior Chapman’s Pointsovaries, urethra, uterus
 Posterior Chapman’s Pointsuterus, vagina, prostate, broad ligament, fallopian tubes, seminal vesicle
 Travell’s Myofascial Trigger Points
 Trigger point (TP): hypersensitive focus within taut band of muscle, may or may not follow an injury
 Direct stimuli initiates trigger points by causing abnormal, continuous input from the muscle spindle, leading to
reflex tension in the associated muscle
 Somatic dysfunction and TPs are closely related and potentiate each other
 Ex. Emotional stress may be associated with clenching of the teeth and may produce TPs in the masseter
and pterygoid muscles
 Embryology of Myotomal Pain
 Mesoderm forms somites, which divide into:
 Dermomyotome
 Dermatome - the lateral wall of each somite in a vertebrate embryo, giving rise to the connective tissue of
the skin, an area of the skin supplied by nerves from a single spinal root
 Myotome – the dorsal part of each somite in a vertebrate embryo, giving rise to the skeletal musculature
 Sclerotome – part of the somite in a vertebrate embryo, giving rise to bone or other skeletal tissue (referral
pattern follows a ligament, bone or joint that shares innervation from the same nerve root) – deep, achy,
toothache quality (ex. Iliolumbar ligament)
 Myotomal distribution pattern of trigger points myotomal referral patterns are associated with cramps,
weakness, and myofascial trigger points related to muscles that are innervated from the same nerve root
 Sequence of development in pictures:
 Pelvic Floor Muscle Trigger Points




TPs in lower abdomen may cause urinary frequency, urgency, sphincter spasm, or bladder discomfort
Dysfunction of muscles of the pelvic floor can cause innominate rotations, pubic shears
Can also cause somatic dysfunction leading to pelvic pain, dysmenorrhea or urinary problems
Treatment
 Muscle Energy
 Myofascial release
 Reciprocal inhibition
 Injection with local anesthetics
 Spraying with vapocoolant spray
 Trigger Point vs. Tender Point
 Trigger points mapped all over body in the belly of muscles
 Exam reveals taut band within the muscle with local tenderness, as well as tenderness radiating to an area of the
body specific for that muscle
 Referred pain is reproducible
 Trigger Points
 Tender Points
 Characteristic pain pattern
 No typical pain pattern
 Located in muscle tissue
 Located in muscle, tendons and ligaments
 Radiating pain pattern
 No radiating pain pattern
 Locally tender
 Locally tender
 Taut band of tissue
 Taut band not present