Medical and self-care advice for women with

endometriosis during the COVID-19 pandemic

The COVID-19 pandemic is a source of significant worry and uncertainty for everyone. However,
we understand that if your medical care has been affected then this time may feel even more
challenging for you. We have therefore put together this information resource, to both guide
you with regards to some of the current recommendations on medical treatments and to offer
some strategies for the management of some of the associated symptoms. Please let us know
if there is anything you feel is not covered adequately and we can update the resource.

Changes to your treatment plan

Medical
We are hearing lots of stories of women being unable to obtain the drugs they were taking or
being asked to change to different drugs. This is obviously upsetting for a variety of reasons.
These are our recommendations for how hormonal treatments could be managed during the
COVID-19 pandemic, including advice from the relevant bodies as appropriate*. Please
remember that although your GP will not want to see you face to face to discuss these
treatments, most are able to offer telephone appointments and electronic prescription services.
Therefore if you have concerns we would suggest you contact them. It is also important to be
aware that prescription services are taking longer than normal and therefore you should ask
for a repeat prescription earlier than you would normally. Unplanned gaps in hormonal
treatments could lead to breakthrough bleeding and a flare in pain.
If you are currently using...
1. Combined oral contraceptive pill (COCP):
These are pills containing estrogen and progestogen (e.g. Rigevidon, Microgynon,
Femodene etc.). Normally you would need regular checks of your blood pressure and
weight before being given a repeat prescription. However, current advice is that as long
as these were OK at the last check, repeat prescriptions can be provided for the next 6-
12 months without you being seen in person.
When these pills are used to treat heavy bleeding or painful periods/endometriosis-
associated pain we find they work best if you aim to stop your periods altogether.
 Therefore, if you are currently taking them in a traditional way (e.g. 21 pills followed by
a 7 day break) you may want to switch to what is known as the “tailored regime”. To do
this, you simply run the packs one after another without a break until you get bleeding
for 2 days in a row. If this happens then don’t take the pill for 4 days and then restart,
again running the pill packets back to back. This strategy allows you to have as few
bleeds as possible per year and keeps them short when they do happen. Some women
will be lucky and be able to run the packs together continuously without getting any
bleeding, unfortunately we can’t predict who will get bleeding or how many packets can
be run together before this happens. As long as the break between pill packets is 4-7
days and doesn’t happen more than every 21 days then the pill will still work as a
contraceptive. There is no harm associated with using the pill this way and it is a
recommended way of taking the pill even if only using it for contraception.
Important: the tailored regime is only suitable for pills that are exactly the same for the
whole 21-day packet. These include most of the commonly prescribed pills (Rigevidon,
Gedarel, Loestrin, Microgynon, Cilest). If you need to check whether your brand is one of
these types there is a table here. Any pill listed as “Combined Oral Contraceptives
Monophasic 21-day preparations” is suitable.
There are also pills that come in packets of 28, however, 7 of the tablets are “dummies”
i.e. they don’t contain any hormones and are just used to remind you to take a tablet
every day. These brands are Femodene ED, Microgynon 30 ED and Zoely. You can do the
tailored regime with these if you just throw away the dummy pills, but it is probably
best to contact your GP and ask to change to one of the standard 21-day preparations.
Any pills listed as multiphasic (e.g. Logynon/Logynon ED, TriRegol, Synphase and Qlaira)
are designed to mimic the hormonal changes of the natural menstrual cycle and so the
doses of hormones in the pills varies. These pills are therefore not suitable for the
tailored regime. Again if you would rather try a regime that reduces the number of
periods you have during this time, we would suggest contacting your GP to change to a
monophasic brand.

2. Progestogen only pill (POP):

These are pills that do not contain estrogen (e.g. Cerazette, Cerelle, Norgeston,
Noriday). There are very few women who can’t take these pills, this means that they
can be given to women who can’t take the COCP because of heart disease, migraines
with aura or a history of blood clots for example. Current guidance recommends that
during the pandemic a further 12 month supply of these pills can be given without a
review.
Some women find they get irregular bleeding when using these pills and as well as
being annoying, this bleeding can flare their pain. Remember that irregular pill-taking

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 is a common cause for this, so try to take your pill at roughly the same time everyday. If
this still occurs, our recommendation is to double the dose of the pills. To do this, just
take two pills once a day rather than one. There is most experience doing this with the
pills containing desogestrel, but it is safe with any of the POPs and the dose of
progestagen is still relatively low compared to other treatments. Please discuss this with
your GP to ensure you get sufficient repeat prescriptions.
Important: remember that unlike the COCP you should not stop the POP if you get some
bleeding. Stopping and starting the POP is likely to result in irregular bleeding and it
won’t work as a contraceptive if you miss tablets.

3. Depo-Provera (contraceptive injection):

This is the injection that lasts for 12 weeks. We know that this has been worrying many
women, as they have been advised to change to the progestogen only pill to avoid the
need for a face-to-face appointment. This recommendation is reasonable if the injection
is only for contraceptive purposes, however, if it is to control symptoms associated with
endometriosis this might not be the best solution. It is therefore worth discussing this
with your GP and reminding them of the reason why you use this treatment. Some GP
clinics may be offering “drive thru” services, where you could be given the injection. If
you do need to switch to a tablet treatment during the pandemic we would suggest two
alternatives:
a) Provera tablets – these need to be taken three times a day (10mg dose)
b) Desogestrel POP (e.g. cerazette) – consider starting on a double dose (150 mg,
once a day)
Provera tablets are not licensed as a contraceptive and therefore if you do need
contraception too we would suggest you use a condom or opt for the POP.
There is also a different version of the injection called Sayana Press, which is an
injection you can give yourself. This has been unavailable for a number of months but
that may be changing. Therefore, if you would be happy to give yourself an injection, it
might be worth discussing this with your GP to see if it is available locally. Current
recommendations are that up to 12 months of this preparation can be given without
needing a face-to-face review or blood pressure check.

4. Provera tablets:
If you are taking Provera tablets already, there is no reason why you cannot continue on
this treatment without a face-to-face review for the duration of the pandemic. If you are
only taking 5mg three times a day and find you are getting some irregular bleeding then
it might be worth considering increasing this to 10mg three times a day. Please discuss

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 this with your GP to ensure that you can get sufficient repeat prescriptions, as stopping
it abruptly is very likely to cause bleeding.

5. Contraceptive Implant:
There is no need to get your implant removed currently, even if it is beyond 3 years
since it was inserted. It is thought that the risks of pregnancy in the 4th year are very
low, however its effectiveness as a contraceptive although likely is not guaranteed. If
you find that you start getting breakthrough bleeding and/or flares in your pain, we
would recommend adding in the desogestrel containing POP even if the implant is not
yet out of date.

Obviously if you wish to start trying to get pregnant you will need to have the implant
removed, but please see the information in the fertility section below.

6. Progestogen-secreting coils (Mirena, Levosert, Jaydess, Kyleena):

There is no need to get your coil removed currently unless you wish to start trying to
get pregnant. If this is the case, then please see the information in the fertility section
below.
It is thought that the risks of pregnancy in the 6th year of Mirena/Levosert use are likely
to be very low. However, we do often find that bleeding and/or pain start to recur before
the end of 5 years of use. If this is the case, then we would recommend adding in the
desogestrel containing POP or Provera tablets. It is fine to use a double dose of the POP
as described above even in combination with the coil.
Important: if you are using your coil as part of your HRT in combination with a
menopause injection such as Zoladex, Prostap etc., then it can not be used beyond 5
years. This doesn’t mean that the coil needs removing, but your HRT preparation will
need to change. Please let your GP know if this is the case.
The other coils, Jaydess and Kyleena, are not often used to control symptoms, however,
if you do have one of these and are due to have it changed, current recommendations
are that you use condoms or the desogestrel containing POP as well for contraception
as there is not evidence that they will work beyond their change date. Again, there is no
need to have it removed however.

7. Menopause injections (Zoladex, Prostap):

These are the injections that make you temporarily, but reversibly, menopausal. We have
heard from a variety of sources that women are having trouble accessing these
injections or being told that they are not an essential treatment. We feel very strongly

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that these injections should continue as they allow women to have some control over
their symptoms and to continue to work and care for their families. The drugs are only
licensed for 6 months to treat endometriosis, however, there are many women who use
them “off-license” for a number of years in combination with a low dose of Hormone
Replacement Therapy (HRT) to protect their bones and heart/blood vessels and to
reduce the associated menopausal symptoms. We suggest you contact your GP to
discuss how you are going to access your injection well in advance of the date it is due.
These are our recommendations for how this treatment might be able to be accessed
during the pandemic:
a) If you usually receive Zoladex, discuss with your GP changing this to Prostap.
Although the drug works in the same way and so should be just as effective, it is
given through a different type of needle. GPs may be able to provide this as a
“drive thru” service similar to Depo-Provera.
b) If you usually have monthly (every 28 days) injections of Zoladex or Prostap,
discuss with your GP changing to the 3-monthly preparation. You might find it
wears off a bit earlier than it is supposed to, but there is no reason why you can’t
have it a couple of weeks early if that is the case (we often give the 28 day
injection on day 25 for women who get a flare in symptoms just before the next
injection is due).
c) If you have been using one of these injections successfully with the plan to stop
it after 6 months or when you have your surgery, then we would recommend that
you continue it throughout the pandemic. Although this is not a licensed use, as
mentioned above, many women do this and it will hopefully allow your
symptoms to be controlled. If you are going to use it beyond 6 months, however,
then this does need to be in combination with some HRT to prevent irreversible
side effects – you are also likely to feel much better with a bit of estrogen on
board! This HRT should be a low-dose continuous combined preparation (i.e. it
contains a low dose of both estrogen and progestogen and the same dose is
taken every day), however, it doesn’t matter whether this is a tablet or a patch.
Some preparations that are commonly used include Kliovance, Tibolone [Livial]
and Evorel Conti. If you have a Mirena coil (that was inserted less than 5 years
ago) then you can use this as the progestogen part of the HRT and therefore only
need an estrogen. Estrogen-only preparations commonly used include Elleste
Solo (1mg), Evorel and Sandrena. Your GP will be able to discuss these options
over the phone as they are very familiar with prescribing low dose HRT to post-
menopausal women. Please note that the risks of HRT you may have heard about
in the media, apply to women of menopausal age. If you are using these drugs to
replace hormones taken away by the menopause injections but would not
otherwise be menopausal the benefits far outweigh the risks.

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 Important: if you will have been using the menopause injections for two years or
more (even with HRT) by the end of the pandemic it is important that you have
a bone scan to make sure that your bones are strong. These scans will not be
available during the pandemic however. You can maintain bone strength by
ensuring your diet contains plenty of calcium-rich foods and that you get regular
weight-bearing exercise. We know this may be difficult during times of social-
distancing/isolation but it is worth trying to do this where possible, for example
by walking, gentle running or following one of the many online exercise
programs that are freely available currently. Please listen to your body when
doing these though and stop if you find it worsens your pain.

If you are not using any hormonal treatment currently but would like to start something new,
either because you are struggling with symptoms or because your surgery has been
cancelled/postponed:
1) Progestogen only pill (POP):
The desogestrel containing POP (e.g. Cerazette, Cerelle, Feanolla) is currently
recommended for women who want to start an hormonal contraceptive during the
pandemic. This is because it is safe for the majority of women and does not require any
checks of blood pressure or weight before starting it. If you would like to start this to
control your endometriosis symptoms we would recommend starting at a double dose
(two tablets once a day) as this is more likely to control your bleeding and any associated
flares in pain.
Important: remember that you should not stop the POP if you get some bleeding, it is
designed to be taken every day. Stopping and starting the POP is likely to result in
irregular bleeding and it won’t work as a contraceptive. It can often take a number of
months for bleeding to settle down, so its worth persevering for 3 months at least.

2) Provera tablets:
If you have tried a double dose of a desogestrel POP previously and it didn’t work for
you or even a single dose gave you unacceptable side-effects (it suits most women very
well, so please don’t expect side-effects...) then our next recommendation would be
Provera tablets. These need to be taken three times a day and we would suggest starting
at a dose of 10mg, though this can be reduced to 5mg if it is working for your symptoms
but you don’t like the side effects (although again it is usually very well tolerated).
Important: Provera is not a licensed contraceptive and therefore you should use
condoms as well if contraception is required. If the tablets work for you and you need
contraception, you could consider asking your GP whether they are giving Depo-Provera

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 injections currently, however, we are aware that many are not. We usually recommend
at least a month’s trial before switching to ensure you don’t have side-effects as the
injectable form can’t be taken out after it is given.

3) Menopause injections:
If you are really struggling with symptoms, it might be worth discussing with your GP
whether you could start on a menopause injection such as Prostap. Although these drugs
are only licensed for 6 months to treat endometriosis, there are many women who use
them “off-license” for a number of years in combination with a low dose of Hormone
Replacement Therapy (HRT) to protect their bones and heart/blood vessels and to
reduce the associated menopausal symptoms. They can be very effective at controlling
symptoms and may also allow you to see how much of your pain is driven by factors
other than endometriosis/adenomyosis/your hormones (see below). If you are going to
start this treatment we would suggest having three months of treatment without HRT
and then adding HRT in, in our experience this achieves better pain relief than starting
them at the same time.
It is worth noting that the way the drug works means that you will often get a flare in
your symptoms (both pain and bleeding) in the first couple of weeks of treatment,
however beyond that you are likely to notice menopausal side effects (hot flushes, mood
changes and sometimes joint pain) but your pain should begin to decrease and your
bleeding stop. If after 3 months there has been no improvement to your pain, we would
suggest stopping the treatment, however, if it has been effective then we recommend
starting some HRT to remove/reduce the side effects and protect your bones, blood
vessels and heart. This HRT should be a low-dose continuous combined preparation (i.e.
it contains a low dose of both estrogen and progestogen and the same dose is taken
every day), however, it doesn’t matter whether this is a tablet or a patch. Some
preparations that are commonly used include Kliovance, Tibolone [Livial] and Evorel
Conti. If you have a Mirena coil (that was inserted less than 5 years ago) then you can
use this as the progestogen part of the HRT and therefore only need an estrogen.
Estrogen-only preparations commonly used include Elleste Solo (1mg), Evorel and
Sandrena. Your GP will be able to discuss these options over the phone as they are very
familiar with prescribing low dose HRT to post-menopausal women. Please note that
the risks of HRT you may have heard about in the media, apply to women of menopausal
age. If you are using these drugs to replace hormones taken away by the menopause
injections but would not otherwise be menopausal the benefits far outweigh the risks.
Important: Menopause injections are not contraceptive. Although it is unlikely that you
would conceive on them, we have seen this occur, and the effect of these injections on
a developing baby are not known. Therefore you should use condoms if you require
contraception and are using this treatment.

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Surgical
We can only imagine how disappointing it must be to have had your surgery postponed due to
the pandemic, especially if you had been waiting a long time for it. Whilst there is nothing we
can do to alter that situation, we would like to offer you some reassurances and suggest
alternative strategies to get you through the coming weeks to months as best as possible:
• There is no evidence that endometriosis is a progressive disease. Therefore not
operating on less surgically complex stage I (mild) disease does not mean that by the
time you do get your surgery you will have, for example, more complex stage III (severe)
disease.
• Current recommendations are that endometriosis can be managed with either medical
treatment (with hormones) or surgical treatment as a first line. There is no good
evidence that one is better than the other. Therefore if this was to be your first operation
and you have not tried hormonal treatments before, we would strongly suggest that you
read the section above on medical treatment and then discuss with your GP about
starting one of the treatments that are currently available. Even if you have tried
hormones before it would still be worth reading this information, as there may be
different options to consider or different ways of taking a treatment that may work
better for you.
• Some clinicians believe that retrograde menstruation (bleeding from the womb into
your pelvis through your fallopian tubes at the same time as your period) may continue
to gradually increase the amount of endometriosis present and therefore recommend
therapies that stop your periods in combination with surgery. Even if this is not the case,
the experience of painful periods is unpleasant and may exacerbate other pains.
Therefore, unless you have a reason why you don’t want to take hormones, we would
recommend considering a hormonal treatment that stops your periods whilst waiting
for repeat surgery. Possible options available to start despite the current situation are
suggested in the section above on medical treatments.
• Surgery for endometriosis often does not remove all the pain. There are a number of
explanations for this observation, but one possible reason is that there are other factors
that contribute to the pain too. In our experience factors that contribute to chronic
pelvic pain in women without endometriosis, commonly also occur in women with
endometriosis too. We describe some of these factors in the section below on
endometriosis-associated pain, along with some strategies you can put in place yourself
to start to help with these. Whilst they may not take away the pain altogether, they may
help clarify how much of your pain is driven by endometriosis and mean that when you
do finally get your surgery it has the best chance of being effective.
• If surgery is being done to improve fertility or before fertility treatments, there is some
evidence that this is best done immediately before trying to conceive/IVF treatment.
Therefore, given the current recommendations on planning for pregnancy during this

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 pandemic (see below), it would probably have been advisable to delay surgery until this
is over anyway.
After the acute period of the pandemic is over the NHS will start to reschedule surgery and
routine appointments. This will be on the same basis as it was done before the pandemic, with
treatments and appointments likely to be arranged in the order they would have been
previously scheduled.

Fertility treatment or plans to start trying for a pregnancy

We know that many women have had their fertility treatment delayed and this is another source
of considerable distress and anxiety. As with surgery, there is nothing that can be done to
change that, however, it is worth bearing in mind current guidance about COVID-19 and
pregnancy and think about how this time could be used to maintain or optimise your health
for fertility treatment/a pregnancy in the future. Alternatively you may have been planning to
stop your hormonal treatments around this time to start trying to conceive naturally, and are
now unsure whether that should still be your plan.
The current advice is that now may not be the best time to stop contraception to plan a
pregnancy. This is because:
1) We have limited information about the risks of COVID-19 on pregnant women and their
unborn babies.
2) Clinical care during pregnancy and labour involves contact between healthcare
professionals and women and therefore increases the risk of COVID-19 transmission.
3) Medical resources are likely to be very overstretched in the coming weeks/months and
therefore if complications relating to pregnancy occur (including miscarriage and
ectopic pregnancy) it may be harder to access the care you need. Again, any such care
would increase the risk of COVID-19.
4) If you need your coil or implant removed before starting to try to get pregnant, it is
unlikely that GPs or family planning/sexual health clinics will be able to provide this
service during the pandemic.
It is recommended that both you and your partner use this time to optimise your health:
• Aim to stop/don’t start smoking, lose weight if you need to, moderate/reduce your
alcohol intake. We acknowledge that all of these are likely to be much harder to do than
they would normally be. However, it is important that at the end of this pandemic you
don’t realise that you are no longer suitable for fertility treatment (e.g. because you are
overweight or a smoker) or reduce your chances of pregnancy occurring because of
these factors.
• Make sure any other chronic medical problems continue to be well-managed including
diabetes, asthma, high blood pressure. This is important both because some medical

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 conditions increase the risk associated with COVID-19 and because of their impact on a
future pregnancy.
• Continue to take/or start taking folic acid. The current advice is to take folic acid
supplements for 3 months before pregnancy if possible. There is no harm in taking folic
acid supplements for many months and therefore it is far better to continue with these
than stop them and not have restarted in time.

Clearly if you do fall pregnant during this pandemic, everyone will do their best to offer you
the care that you need. However, it would probably be sensible to let your GP know earlier than
you might do normally.

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Endometriosis-associated pain
Endometriosis-associated pain is complicated! As you may be aware, there is no relationship
between the amount or location of disease and the amount or type of pain experienced. This
is also true in other chronic pain conditions such as lower back pain. We know that a variety of
different factors can contribute to the experience of pain. Some of the factors known to have
a role in chronic pelvic pain are shown in the diagram below. Whilst endometriosis is clearly
important, the presence of one or more of the other factors may explain why treatment just
targeting the endometriosis (e.g. hormones or surgery) isn’t always successful at removing all
the pain.

In addition to changes to your clinical care, it is likely that the COVID-19 pandemic is impacting
on many of these other factors, potentially leading to a worsening of your pain currently. We
would like to offer you some suggestions as to how you might be able to address these factors
during this time. You might be surprised how much help some of these suggestions can be and
may even decide that some of them are strategies you wish to continue with even when all of
this is over and you can have the treatments previously planned. It is worth remembering that
in lots of other conditions associated with chronic pain, a team approach is usually standard

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care including physiotherapy and psychology, however, in endometriosis we tend to focus only
on targeting the disease and only bring in these other options after many years of repeated or
unsuccessful treatments.

The nervous system

The nerves in the spinal cord, the brainstem and the brain itself become more sensitive to
painful stimuli over time which is known as central sensitisation. Painful periods over many
years may contribute to ‘central sensitisation’. Things that used to only be mildly painful can
become very painful. Even non-painful experiences, like clothing or a duvet resting on the skin,
can become painful or the nervous system may just generate a painful signal without a trigger
at all. People can be more sensitive to a variety of experiences including bright lights and loud
noises. You can think of this as like turning up the volume of the pain sensing system. This type
of pain is difficult to treat: it doesn’t respond to painkillers traditionally prescribed for
endometriosis-associated pain and needs to be approached differently.
If none of the other strategies described here are helping, or your pain feels very like nerve-
related pain (burning, tingling, electric-shock like), then it might be worth discussing with your
GP whether a trial of a drug targeting nerve pain (known as neuropathic pain) might be a good
idea. These drugs are not licensed for endometriosis-associated pain and have never been
tested for this reason, however, they are licensed for neuropathic pain and are used in a variety
of other chronic pain conditions including fibromyalgia, so your GP will be familiar with them.
Possible drugs to consider are:
• Gabapentin
• Pregabalin
• Duloxetine
• Amitriptyline
Your GP will be able to discuss the risks and benefits of these and advise you which would suit
you best.

Bladder – Bowel – Womb communication

Bladder and bowel symptoms are common in women with endometriosis even if they do not
have disease on their bladder/bowel. The same nerves supply the womb, bowel, bladder and
the top of the vagina and discomfort in one organ may result in discomfort in other areas over
time (known as ‘crosstalk’). We also know that bladder and bowel symptoms can be dependent
on diet and that bowel symptoms particularly are worsened during times of stress or anxiety.

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The current situation is therefore likely to be impacting on bowel and bladder symptoms in at
least two ways and therefore potentially increasing the amount of pain from your pelvis. Things
you could think about to improve this include:

• Taking care of your diet. The current restrictions on access to shopping and limited
availability of supermarket home deliveries means many people’s diets may have
changed considerably. A lack of fresh fruit and vegetables or a focus on dried/tinned
beans and pulses may well have altered your bowel function causing either diarrhoea
or constipation. It might be worth exploring whether there are local farms or shops who
are delivering some of your more familiar foods to help with this.
• Avoiding too much comfort food/alcohol. Being stuck inside and a bit anxious/unsettled
often means we resort to comfort foods like chocolate and cake or feel the temptation
to have a bit more alcohol in the evenings than we would otherwise. These foods can
again impact on bowel function and women with sensitive bladders for whatever reason
will often describe their pain being worsened by alcohol.
• Staying well hydrated. Not drinking enough fluid as you are out of your routine or don’t
feel so thirsty because of a change in your activity levels can lead to constipation and
to more concentrated urine which can irritate your bowels and bladder respectively.
• Trying to reduce stress and anxiety. Whilst we understand how difficult this is currently,
it is likely to have benefit for your bowel function particularly as well as your pain in
general. We offer some suggestions for how to go about this in the section on
“Emotional well-being and managing stress” below.

The musculoskeletal system

Muscles, joints and other tissues can very commonly be involved in chronic endometriosis-
associated pain. We often see these become dysfunctional and then begin to create problems
of their own. Some examples of this are:
• The pelvic floor muscles become tense and painful which can cause pain during
intercourse and/or bladder and bowel issues.
• The back joints can become stiff which can cause pain when sitting or standing.
• The pelvic joints can become irritated causing pain on walking and rolling.
We envisage that lots of people will have increasing levels of musculoskeletal pain as activity
levels fall during the pandemic. This is likely to have a significant impact on your general levels
of pain if you already experience pelvic pain. Things you could consider to reduce this impact
are:
1) Making sure you get outside for some daily exercise as long as you stick within current
Government recommendations for social distancing/isolation. If long walks flare your
pain, then this can just be a slow, gentle walk or bike ride. However, the benefits of
being outside for your mental health as well as your physical health are huge.
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 2) Making time within your day to do some gentle “pelvis friendly” exercises at home. You may
already have a routine that was given to you by a physiotherapist or personal trainer, in
which case please continue with this. Otherwise we have put together a set of exercises
that may be helpful to you and are available here.
3) Keeping an eye on your diet and your weight. Constipation is likely to worsen any pain
from your pelvic floor, whilst carrying excess weight puts a strain on muscles, which if
they are already weak can cause or exacerbate pain.

Emotional well-being and managing stress

Living with chronic pain is incredibly difficult. It is likely to have a big impact on how you think,
feel and what you feel/are able to do. The experience of constant/repeated episodes of pain is
stressful and can make it difficult to relax. The current situation is likely to have made the
situation worse; therefore, here are some suggestions for how you can look after your own
emotional well-being during this time. As mentioned, you may find that some of them are so
helpful that you choose to continue them in the future too.

The importance of taking care of ourselves

It is especially important to consider how we can best take care of ourselves during this
unsettling and stressful time. You might be experiencing additional challenges for a number
of reasons, including: worries about accessing medical treatment, addition stress and disturbed
sleep which may exacerbate pain or reduce confidence to cope, and loss of routine and reduced
opportunities for socialising or physical activity, or other things which helped you to cope.

Understandable increased sense of threat

The coronavirus may well contribute to an increased sense of threat. However, for women who
have been living with endometriosis, this sense of threat may already be ‘online’ more of the
time as it can also be triggered by health concerns, pain, unpredictability and medical
treatments. Some common experiences that come along with the sense of threat include:
Thoughts: I can’t cope, there is nothing I can do, things are out of control,
what if….
Body: heart racing, palpitations, muscle tension, stomach ache, tearful, poor
concentration, pain.
Emotions: Stressed, worried, irritable, numb, disconnected, sad, angry,
frustrated, self-criticism.

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 Behaviour: Push self, withdraw, skip meals/comfort eat, snap at others, stay up
late, difficulty relaxing.

*** IT IS COMPLETELY UNDERSTANDABLE AND NORMAL TO FEEL LIKE THIS AT THIS TIME ***

Humans have three basic emotional regulation systems: threat, drive and soothing systems. All
serve very useful functions, but we need balance. The threat system may be especially online
at the moment. To maintain balance, enable us to rest and for our well-being we need to bring
the ‘soothing system’ online. Some tips strategies for this are described in the next section.

Tips and strategies for taking care of ourselves

• Establish a routine: Build in a range of activities into your life so that your time does not
feel entirely taken over by worries about your health and the current situation. Of
course, these concerns will be there but see if you can ‘grow’ around the challenges you
are facing.

Each day try to tick off a few from this list:

• Being active/exercise
• Contact with others
(friends/family)
• Pleasurable activity
• Time to relax
• Do something fun
• Give yourself a challenge (e.g.
puzzle)

• Limit exposure to ‘threat’ information: The empty shelves, news, social media, school and
shop closures all keep this threat at the fore of our attention. Thoughts and worries
about managing endometriosis at this time may add to this and will inevitably affect
how we are thinking and feeling. Limit the amount of time you listen to the news, look
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 on social media or spend looking up health information. Try to have some conversations
or some allocated time which is ‘threat’ free.
• Taking in the good: Negative events are like Velcro, positives are like Teflon: we notice
and remember negative information more easily (e.g. we notice/remember what went
wrong in our day, not what went well). In the current circumstances we may need to
take some steps to balance our inbuilt negative attention bias by focusing on some of
the good in our lives. For example,
o At the end of the day, see if you can think of 10 things you appreciate (e.g. the
smile from a stranger, the smell of your coffee)
o Make time for pleasurable experiences and give them your full attention. You
can do this for brief experiences (e.g. the feel of the sun on your skin) as well as
longer ones (e.g. watch your favourite film)
o Do something kind – call a friend, make a cup of tea for someone, smile at
someone
• Look after your body: Try to eat healthily and regularly; if your appetite is low eat little
and often, choose things you find easy to eat. Take a bath or long shower. Try to keep
active.
• Our thoughts: We may find ourselves overwhelmed with negative thoughts; how we
think about a situation will affect how we feel. Remember, thoughts are not facts, and
it might be helpful to keep other perspectives in mind, such as….
o I am limited in what I can do, but I will do what I can
o I can’t control many things, but I can look after myself
o This will end, we will get through this
o I’m not alone/others are facing challenges too
This isn’t about positive thinking. It’s about holding a balanced perspective in mind.
• Living with uncertainty: It is common to find uncertainty difficult to live with, but
sometimes our need for certainty can end up adding to our problems. For example, we
might find ourselves going over and over things in our mind, feeling more stressed or
frustrated, but the situation stays the same. Sometimes, no matter how hard we try to
solve a problem, there is nothing we can do to change the situation or resolve the issue.
Learning to accept situations we can’t change may sometimes be the most helpful thing
to do. A helpful question to ask yourself is: Is this a worry I can do something about? If
the answer is ‘no’, try the steps for accepting uncertainty (below).
Steps for accepting uncertainty:
o Be aware – What do you notice yourself thinking and feeling when the need for
certainty comes up?

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 o Don’t respond – What can you tell yourself to help you not respond? (e.g. These
feelings will pass)
o Let go – What can you do to help you let go of the need for certainty? (e.g. I
can’t fix/change this)
o Focus on the present – See the grounding techniques below.
o Deal with a wandering mind – Notice when your mind wanders, perhaps
automatically getting caught up in worry again and again. Each time gently bring
your attention back to the present moment.
• Acknowledging and naming emotions: Acknowledging and naming the emotion, either to
ourselves or talking with someone else, can be helpful. Research shows this can help to
give perspective and to calm emotions. For example, you could say to yourself “I notice I
am feeling overwhelmed; I can see that I am feeling irritable”. Keeping a diary might be
helpful.
• Grounding techniques: When overwhelmed with emotion we can feel lost and
disconnected from the present moment: our ability to think clearly and rationally may
go ‘off-line’. Grounding techniques are a way of helping us to feel a little steadier and
manage strong emotions, helping us connect with the present moment – the here and
now. They can be quick strategies (like taking five mindful breaths) or longer, more
formal exercises (like mindfulness meditation or yoga). Different strategies work for
different people, and there is no “wrong” way to ground yourself. The main aim is to
keep your mind and body connected and working together. Some ideas include:
o Come into your senses – stop, notice 5 things you can see, close your eyes and
notice 5 things you can hear, and then notice 5 points of contact between your
body and something else. Breathe. Then open your eyes.
o Take 5 breaths, paying full attention to the sensations of the breath.
o Focus on sensations in your feet as you walk from one place to another.
o Get outside – notice nature around you if you can access this. Feel the air on
your skin.

Sleep
Sleep is incredibly important. We know that poor quality or insufficient sleep makes it difficult
to cope with things that you would normally manage fine. There is also increasing evidence
that sleep deprivation can amplify pain, such that sensations that were previously only mildly
painful become more severe. Even if your sleep is not disrupted by pain it can be difficult to
get off to or to stay asleep during these unsettled times. Here are some top tips for getting
your sleep back on track during this time:

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 • Routine: Establish a relaxing bedtime routine and give yourself longer to wind down at
bed time (up to 90 minutes can be helpful)
• Keep bed for sleep (if you can): If you spend time in bed for reading, watching TV or
resting, your body/mind may not associated bed with sleep. It’s important to create a
strong link between bed and sleep by avoiding using bed for other activities.
• Rise time: If you haven’t slept well it can be tempting to have a lie in to catch up.
Unfortunately, this is likely to decrease the likelihood of a good night sleep the
following night, because you won’t have been awake long enough to build up ‘sleep
pressure’ across the day. Set a regular rise time and see if you can stick to it. It might be
hard work in the short term but will improve your chances of falling asleep each night.
To help with getting out of bed at your rise time, plan some things to help get you going;
perhaps a lively piece of music, a nice breakfast or a shower.
• Napping: If you can, it is best to avoid napping as it can lead to a disrupted sleep at
night. The longer we are awake, the greater the ‘sleep pressure’ will be at night. If you
do need to nap, try to keep it short (20 minutes) and earlier in the day to allow sleep
pressure to build up again.
• Avoid stimulants before bed (caffeine, alcohol, nicotine)
• Natural light: Natural light suppresses the production of melatonin (a hormone
associated with sleep). Try to avoid bright light before bedtime to promote melatonin
production. It is also helpful to expose yourself to lots of natural daylight when it’s time
to be awake (particularly early morning). This will help you to feel awake, alert and ready
for the day.
• Screens/blue light: Avoid screens for an hour (or more) before bed as the blue light can
supress melatonin production.
• Relaxation/mindfulness: Do a relaxation or mindfulness exercise (e.g. look on the internet
for progressive muscle relaxation or a body scan) to help your mind and body wind down
and ready for sleep.
If you can’t sleep, try not to worry about your sleep and see it as a time for rest – the more you
worry, the less you will sleep! Try a relaxation exercise or mundane mental activity (e.g.
counting down from 100 in 7’s; remember the details of a walk you know well).

Activities and relationships

We know that some activities can improve pain whilst others worsen it and this is likely to be
different for different women. Similarly some relationships are helpful whilst others can make
us feel worse. How we structure our day and interact with other people is likely to have
changed significantly since the COVID-19 pandemic and particularly since the stricter

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government recommendations have come into force. If you have noticed a marked change in
your pain (for better or worse...), it might be worth spending some time reflecting on what has
changed and how this might be having an impact. If you think these changes have worsened
your pain, then you may need to alter the way you structure your day, either to avoid doing
things that make the pain worse; give yourself more/longer rest periods; increase or alter your
social interactions. On the other hand, you may notice benefit, in which case it would be worth
remembering these things for the future to see if positive changes could be incorporated into
your life going forwards.
Things to consider include:
• Are you doing more activities like housework?
If you are normally used to a desk job but are spending your time hoovering or moving
furniture around to keep yourself busy, this may have put more of a strain on your
muscles or alternatively may have improved the back pain you normally get from sitting
all day.
• Are you spending lots of time sitting on the sofa watching TV or listening to music?
If you normally keep active, this might be worsening your pain and your mood. On the
other hand, making some time for relaxation is really important and therefore this bit
of “me-time” may actually be making you feel better.
• Are you interacting less with your extended family/friends/work colleagues?
This may be making you feel isolated and lonely and thus worsening the situation. In
which case why not look into novel ways of linking up. Many people are using
technology to have virtual coffee mornings, dinner parties or an evening drink.
Alternatively, if that technology isn’t available a simple phone call may be enough to
help you stay in touch. Or have you noticed that you feel much better not interacting
with a certain person? In which case this may be something to think about for the future.
• Is spending 24/7 with your close family stressful or enjoyable?
Many people are enjoying the opportunity to play games or watch films with their family
that they wouldn’t normally. Maybe this is something you can continue to plan in the
future? However, it is challenging to spend all our time at home and this may be even
more difficult if you are trying to both homeschool and work from home, or if one of
your family is particularly stressed or anxious about the current situation. If you don’t
feel safe at home then you should seek some advice, this resource may be helpful. If
you are in immediate danger, call 999 and ask for the police - the police will continue
to respond to emergency calls. If you are in danger and unable to talk on the phone, call
999 and then press 55. This will transfer your call to the relevant police force who will
assist you without you having to speak.

* Faculty of Sexual and Reproductive Health (FSRH), Royal College of Obstetricians and Gynaecologists
(RCOG), British Menopause Society (BMS), Royal College of General Practitioners (RCGP)

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