Osteopathy in Endometriosis: An Interview with Tobias Hopfner

Dr. Nadine Rohloff: Endometriosis encompasses a wide range of symptoms. Are there specific concerns that patients frequently approach you with or that osteopathy might mainly assist with? Could you highlight the most prevalent issues you address?

Tobias Hopfner: The classic presentation is dysmenorrhea, the pain during menstruation. Additionally, depending on the location of the endometriosis, there are often intestinal and digestive issues, bladder-related discomforts, and problems during urination. Pain during intercourse is a common concern, although it sadly remains a largely unspoken topic. I often clarify that my focus is purely on structural adjustments, not sex therapy. The diaphragm is frequently impacted, leading to respiratory disturbance due to tension in the supporting structures.  This can be followed by back pain and pain radiating to the legs. In essence, I have encountered virtually all the symptoms known in endometriosis. The pivotal question is always: What is the root cause? Is it centered around localized inflammation, or could it involve adhesions that can be released?

Dr. Nadine Rohloff: Your approach likely varies based on the nature of the complaints and their underlying causes—pelvic floor tension or adhesions, for instance. Could you elaborate on that? How does the treatment work?

Tobias Hopfner: When a patient visits me, we begin with an in-depth initial conversation. It is always critical to me that my patients feel wholly heard and respected. I trust and acknowledge everything a patient shares with me without skepticism, simply listening attentively. Equally important is creating an environment where patients feel entirely at ease during our interactions. There should be no room for embarrassment or discomfort. Patients need to communicate with me openly. What suits one person might not suit another, and this is where we start. During the preliminary discussion, we addressed various aspects related to the origin of the issues. Whether the problems have persisted from the outset, evolved, or were possibly triggered by other factors. Subsequently, a standing examination is conducted, followed by one on the examination table. Finally, a manual assessment is performed, involving hands-on palpation of the pelvis and abdomen, based on the location of symptoms and their anatomical explanations. For instance, radiating pain seldom originates from the leg, usually due to nerve irritation along the path from the back to the leg. My specialization lies in vaginal treatment, known as “touché.” However, this term can be misleading. It is not about treating the vagina but using it as a practical access point to the relevant structures. Just as a gynecologist conducts vaginal palpation, I do the same – always with the patient’s consent, as it is a voluntary option. I encourage patients to bring a companion to ensure they feel comfortable and safe. This part of the treatment occurs in the final minutes. I put on gloves and apply a small amount of coconut oil to a finger. The examination is conducted very gradually and in constant communication with the patient. It should not be rushed or painful. My fundamental belief in osteopathy is that when someone seeks relief from pain, they should encounter no additional discomfort. The essence of osteopathy is engaging in a dialogue with the body’s tissues. I closely observe my patient’s reactions and expressions during the process, noting when tissues tense up. If they do, I have pushed too far and further strained the tissue. It is essential to find the boundary: How much can I do, and when does a counter-reaction arise, leading to heightened tension and stress? Consequently, communication during the treatment – especially during vaginal treatment – is paramount. If a patient reports pain or discomfort, I take it seriously and adjust accordingly. It is not uncommon for patients to say, “When you apply pressure there, it hurts. How is that possible?” If they feel it, I acknowledge its validity. I would not counter by saying, “No, it cannot be.” Another objective of my practice is to enhance self-esteem, self-confidence, and self-awareness, re-establishing a connection with one’s body. Patients should be able to say, “I feel better.” Or even: “I do not feel better.” In that case, we address it in our discussions.

Dr. Nadine Rohloff: That is a crucial point, especially for those who have undergone a lengthy journey where their experiences were not taken seriously. It becomes critical to regain trust in your feelings.

Tobias Hopfner: And also to feel comfortable sharing those experiences. It is a recurring situation where, in the third or fourth session, someone says, “I haven’t mentioned this before because nobody has ever believed me.” In response, I reassure them, “I believe you. Once you tell me, it holds weight.” Why should I doubt it? What incentive would there be to deceive me? If someone confides, “I experience pain during bowel movements,” should I respond with disbelief? It is only reasonable to acknowledge their truth.

Dr. Nadine Rohloff: What is the typical duration of the treatment plan? And regarding frequency, how often do patients return for appointments, given that multiple sessions are usually necessary?

Tobias Hopfner: Each treatment session lasts one hour, constituting a single appointment. However, the frequency of these appointments varies based on individual needs. When a patient arrives with intense pain, perhaps at level 10, and complications like bowel resection, the starting point differs from someone with suspected endometriosis experiencing pain at level 1. For instance, with a pain level 10 patient, the goal could be to alleviate it to around 5 or 7, enabling them to manage their day with occasional ibuprofen. On the other hand, the plan for the latter patient might be pain reduction to 0. That is why I refrain from setting rigid guidelines on appointment frequency since it hinges on time availability and financial considerations. Additionally, I do not dictate when treatment concludes; the patient determines that.  If a patient feels satisfied and says, “I am feeling great now, I do not need further sessions, I desire my space,” I completely respect that. I wish I received more feedback. It would help refine my approach, but patients often disappear after their sessions. It is valuable when patients communicate what worked well and what did not. This way, subsequent patients can benefit from my 25 years of experience.

Dr. Nadine Rohloff: I believe that the craving for feedback is universal. At the same time, it is understandable that when you finally feel better, you might want to shift your focus to other aspects of life. Here is a little shout-out: Whether you are content or have concerns, feel free to reach out with your thoughts, even if it is after months. You mentioned that osteopathy can be a potential option for addressing a wide range of endometriosis symptoms. Are there instances or stages during treatment when you might advise against osteopathy? Or is it more about adjusting the intensity of the approach?

Tobias Hopfner: That is a matter of intensity and working respectfully with the body’s tissue. I always compare it quite provocatively, as every individual with endometriosis experiences bowel movements, for instance. The pressure I apply during treatments is a fraction of what the abdomen undergoes during such processes. Adhesions are the core challenge in endometriosis and can occur across various areas. After surgeries, these adhesions frequently develop. Thus, gentle osteopathic interventions post-surgery make sense as preventive and supportive measures. Depending on the surgery, efforts can be made to maintain organ mobility unless any organs have been removed. We might even aim to reestablish connections between organs if there are internal scars. In cases where an organ has been removed, it is crucial to consider the appropriate measures carefully, as we’re dealing with altered dynamics.

Dr. Nadine Rohloff: Do you provide patients with any recommendations or exercises they can do at home? And for our listeners today, is there anything you would suggest?

Tobias Hopfner: I advise you to always do what feels right. There is often a fear of causing harm or breaking something, but rest assured that if something were amiss, your body would promptly signal with intense pain, prompting you to stop. Mimicking the abdominal mobilization I perform is beneficial. Gently pushing the abdomen back and forth, tilting the pelvis, creating figure-eight movements –  any form of mobilization is helpful. Equally important is abdominal breathing: a deep breath into the lower abdomen, activating abdominal drainage through the diaphragm. Now, let us tackle a complex topic for me as a man, which sometimes invites the label of mansplaining. I want to discuss vaginal self-touching.  If you recognize that internal structures are impacted, why not explore self-palpation vaginally and apply gentle pressure? Here, we enter a sociopolitical domain, addressing perceptions of femininity. As a father of two daughters, we strive to approach things differently. It saddens me how we discuss and perceive our bodies. Women often refer to their intimate area as “down there”. Men, on the other hand, do not utilize such euphemisms. If a woman’s self-reference involves “down there,” this might hinder comfort with self-exploration and vaginal awareness. My encouragement is to normalize this experience. Explore and acknowledge what you feel. In treatment, a notable moment arises during the first session when I ask patients, “Can you feel when I press here?” Many admit, somewhat shyly, that they do not feel anything at all. But remember, the sensation is cultivated and learned. A patient might eventually say, “I am starting to sense my uterus.” For many women, the uterus is initially associated with discomfort and monthly pain. Thus, forming a connection with it is often challenging. Only when the desire for a child arises does a new relationship with the uterus form. This realization might be the turning point, where the uterus evolves from a source of pain to an organ with purpose.

Dr. Nadine Rohloff: Absolutely. I think that is a big issue. As you mentioned, if an organ consistently brings discomfort, it naturally forms a negative perception. This perception tends to solidify over time. Thank you very much for sharing your insights. And when is the official opening of your new practice?

Tobias Hopfner: The new practice will open its doors on August 1.

Dr. Nadine Rohloff: That is essential information. We will include it on the website notes so interested individuals can access it. Now, for those who might not be located near Munich or are seeking osteopathic care elsewhere, is there a dedicated platform or website where they can find qualified osteopaths with expertise in endometriosis or pelvic floor issues?

Tobias Hopfner: Unfortunately, finding specialized osteopaths for these conditions can be challenging. I am constantly researching this matter, and an interesting trend has emerged. Through my Instagram and YouTube videos, I often receive inquiries from people near places like Cologne or Flensburg, wondering if there are specialized osteopaths nearby. Unfortunately, there is a notable scarcity in this area. I find this concerning, particularly given that gynecology is a fundamental component of osteopathy. Our training extensively covers it, emphasizing the importance of conducting comprehensive gynecological assessments and discussing menstrual patterns. Yet, I encounter scenarios where patients approach me with recurring headaches correlated with their menstrual cycles. My simple question, “Do they coincide with your period?” often leads to revelations. Surprisingly, some patients have already sought help from multiple osteopaths with no substantial progress. The pattern highlights an issue—effective osteopathy should address root causes. To illustrate, if a woman experiences headaches during her period, the solution might not be directly treating the head. Instead, exploring gynecological aspects could hold the key. Regrettably, few have genuinely delved into gynecology within the osteopathic field, and even fewer are skilled in treatments like Touché. Now, here is where it gets tricky. I frequently recommend checking out the websites of reputable osteopathic associations, like the VOD, which ensure a certain level of training. However, relying solely on this can be misleading. The field has seen a surge in popularity, leading many to jump on the bandwagon without the necessary expertise. So, here is a pragmatic tip for patients, even though it might seem a bit stern: give potential practitioners a call and ask a few probing questions. If their responses reveal gaps in medical understanding, it’s fair to question their competence.