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Foreningen Bækkensmerter.dk har set mønstre, der gentager sig, når det drejer sig om øgede bækkensmerter i sammenhæng med ændringer i kroppens hormonniveau. Igennem kvindens liv sker der forandringer i den hormonelle cyklus, foruden ændringer i forholdet mellem østrogen og progesteron. Det påvirker blandt andet bindevæv, muskelvæv og ledbånd (ligamenter, sener). Erfaringsmæssigt har foreningen oplevet, at mange kvinder, der lider af bækkenrelaterede smerter, får øgede smerter og gener i forbindelse med menstruation, graviditet, ægløsning, perimenopause og selve menopausen. I mange tilfælde er det den berømte ”dråbe, der får bægeret til at flyde over”, når hormonbalancen ændres.
Af Jane Vilhelmsen og Lene Pilegaard
Hormontilstande, der kan påvirke bækkenet
Menstruation
Under menstruationscyklus er der forskellige niveauer af hormoner, der kan medføre øgede smerter i forbindelse med bækkenrelaterede problemer.
De øgede smerter kan skyldes den øgede produktion af progesteron, der dannes i det gule legeme i ægget i æggestokkene. Derudover dannes der øget relaxin i æggestokkene på ægløsnings-tidspunktet. Den øgede produktion af disse hormoner medfører løsere muskelvæv, brusk og ledbånd. Det løsere væv kan medføre øgede bækkensmerter, hvis bækkenet i forvejen er dysfunktionelt, hvor muskler og ligamenter er overbelastede på grund af fejlstillinger i bækken-/hofteregion. Det løsere væv vil bevirke, at der bliver mindre stabilitet i lænde- og bækkenområdet, og det kan medføre øgede smerter fra muskler, der bliver overbelastet.
De kvindelige kønshormoner, østrogen og progesteron, styrer menstruationscyklus. Som det ses på illustrationen, stiger niveauet af østrogen i starten af cyklus, som starter på 1. menstruationsdag. Det er det hormon, der får livmoderslimhinden til at vokse. Efter ægløsning stiger niveauet af progesteron, der sørger for, at livmoderen er klar til at tage imod et befrugtet æg. Når ægget ikke er befrugtet, falder progesteronniveauet, og det får slimhinden til at stoppe med at vokse, og derefter afstødes slimhinden som menstruation.
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Livmoderen er et organ, der er omgivet af en stor muskel, som kan påvirkes af hormoner. Den hæfter på bækkenringen med ledbånd.
Organer og muskler er omgivet af bindevæv. Bindevævet er et stort organ fyldt med nervesensorer, der kan sende signaler til hjernen. Organer har ingen nervesensorer.
Graviditet
Under graviditeten øges produktionen af det blødgørende hormon relaxin. Dette medfører den normale blødgøring af led og ledbånd i kroppen, som er nødvendigt, for at bækkenet kan udvide sig i forbindelse med, at fosteret vokser, og for at bækkenet kan udvide sig under fødsel. Denne ”bækkenløsning” er en naturlig tilstand for alle under graviditeten, men for nogle udvikler det sig til en smertefuld ”bækkenløsning”.
- Hormonet relaxin dannes under graviditeten både i moderkagen og i æggestokkene.
- Hormonet relaxin dannes i æggestokkene hos alle kvinder – også når man ikke er gravid. Relaxin indgår i menstruationscyklus, og produktionen stiger ved ægløsningstidspunkt hen imod menstruation, hvorefter det falder igen.
- Ved graviditet dannes hormonet også i moderkagen, hvorved mængden af relaxin øges.
- Produktionen af relaxin er højest i 1. trimester, og gennem hele graviditeten er niveauet højt.
Under graviditeten stiger produktionen af progesteron også, da ægget nu er befrugtet og har sat sig fast i livmoderen. Efter 12. uge er det næsten udelukkende moderkagen, der producerer progesteron, og da progesteron ligesom relaxin er et blødgørende hormon, kan dette medføre smerter fra overbelastede muskler og led og særligt, hvis bækkenet i forvejen er ustabilt.
Under graviditeten kan den stigende vægt fra livmoderen samt påvirkningen af de blødgørende hormoner relaxin og progesteron medføre øget pres på bækkenets led og væv, da ledbånd og brusk bliver løsere. Hvis der tidligere har været problemer med ryggen og bækkenet, ulykker, piskesmæld, fald eller dårlig holdning, eller hvis man er hypermobil, kan det føre til, at bækkenets led lettere forskydes (eventuelt fejlstilles). Dette kan medføre smerter fra irriterede led, ledbånd og overbelastede muskler. Denne smertefulde tilstand bliver ofte diagnosticeret som bækkenløsning.
Den stigende produktion af de blødgørende hormoner relaxin og progesteron har indflydelse på hele kroppen, og hvis der i forvejen er ubalancer, fejlstillinger og/eller hypermobilitet, kan dette sammen med den generelle vægtøgning, den ændrede kropsholdning på grund af den øgede vægt fra livmoderen medføre smerter i muskler og led i hele kroppen på grund af overbelastning af disse.
Der er en overvægt af progesteron i forhold til østrogen under graviditeten, da progesteron også produceres i moderkagen.
Under graviditeten falder to af de tre forskellige østrogener, og det er primært østradiol, der er aktivt. Det er det mindst aktive østrogen, der blandt andet er med til at holde på fedtvæv og derved beskytte moderkagen.
Ryg- og bækkensmerter behøver ikke altid stamme fra ryg- og bækken-leddene. Der er mange strukturer i bækkenet, som kan give smerter under en graviditet – som fx livmoderen. Det meste af livmoderen ligger frit i bughulen og holdes fast af ledbånd, der er hæftet på bækkenringen. Livmoderen understøttes desuden af bækkenbundsmuskulaturen.
Hvad er bækkenløsning?
Ordet bækkenløsning hentyder til den blødgøring, der sker af muskelvæv, brusk og ledbånd for alle gravide. Det er ikke en direkte diagnose, hvor der kan måles, hvad der er galt, men mere en betegnelse på et smertesyndrom, der bruges til gravide, der har mange smerter fra bækkenet under graviditeten. Selve diagnosen siger ikke noget om, hvorfor der er smerter, og smerterne kan have mange forskellige årsager.
- Bækkenløsning er en naturlig tilstand, der forårsages på grund af den øgede produktion af de blødgørende hormoner relaxin og progesteron i graviditeten.
- Disse hormoner er med til at blødgøre ledbåndene (ligamenterne), brusk og bindevæv, hvorved leddene løsnes til større bevægelighed, så bækkenet forberedes på at kunne udvide sig under graviditet og fødsel.
- Principielt kan man sige, at alle gravide har bækkenløsning, og at det er en naturlig tilstand, for at fødsel kan finde sted.
- Mere end 80 pct. af alle gravide oplever bækkensmerter i en eller anden grad i løbet af en graviditet, og i langt de fleste tilfælde går smerterne i sig selv igen, så snart fødslen er overstået.
- For fem til syv pct. af denne gruppe udvikler tilstanden sig imidlertid meget smertefuldt og kan vare ved længe, efter at de hormonelle forhold er normaliseret. For nogle kan tilstanden være meget invaliderende og særdeles smertefuld.
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Symptomer, der kan opstå i kvindens frugtbarhedscyklus.
Peri- og menopause
I perimenopausen dannes der mindre af det blødgørende hormon progesteron, da ægløsning gradvist ophører. Progesteron dannes og øges primært i det gule legeme i ægget ved ægløsning, men også i den modne follikel. Da ægløsning langsomt stopper, dannes der væsentligt mindre eller ingen progesteron i peri- og menopause, og forholdsmæssigt vil der nu være mere østrogen i forhold til progesteron i en periode. Dette medfører, at led og muskelvæv kan blive mere ufleksibelt og kan føre til bækkenproblemer, særligt hvis bækkenet i forvejen er i ubalance.
Ved perimenopause og menopause spiller forholdet mellem østrogen og progesteron ind, og der kan være påvirkning af muskel- og bindevæv, alt efter hvordan forholdet mellem de to hormoners niveauer er. Progesteronniveauet falder meget over tid, og det kan også påvirke livmoderen, og det kan medføre refererede smerter til bækkenets øvrige muskulatur via den viscero-somatiske refleks.
Refererede smerter/viscerale smerter
- Refererede smerter (den visecero-somatiske refleks) betyder forskudt smerte og er en smerte, som føles et andet sted, end hvor den egentlige årsag er.
- Viscerale smerter er smerter, der vedrører organer – fx er livmoderen et organ.
- Somatisk betyder det, som tilhører kroppen.
Den viscerosomatiske refleks:
Da organer ikke har nervesensorer, kan der ikke føles smerte direkte i organerne. Men organer refererer smerten til de muskler og led, der har samme nerveudspring som organet, da muskler, sener og væv i høj grad har nervesensorer.
Et eksempel er, når der opstår en blodprop i hjertet, som er et organ, kan hjernen ikke opfatte signaler/smerter fra selve hjertet, men fra de muskler, der også forsynes via nerver fra og til hjertet. Typiske symptomer på blodprop i hjertet kan fx være ondt i brystregionen, nakke, hals og underkæbe og venstre arm.
Østrogendominans i starten af peri- og menopause
I starten af menopause opstår der en ubalance, der skyldes et højere niveau af østrogen i forhold til et lavere niveau af progesteron, hvorved der bliver østrogen-dominans. Bækkenets væv og muskulatur kan blive ufleksibelt og stramt som følge af mangel på det blødgørende hormon progesteron.
Når forholdet mellem østrogen og progesteron er i balance, er der ingen problemer – problemet opstår, når der er ubalance i forholdet mellem de to hormoner. Perimenopause og menopause giver typisk østrogendominans og symptomer derefter – især indtil østrogenproduktionen falder helt.
Når kvinden kommer længere hen i menopausen, vil forholdet mellem østrogen og progesteron udjævnes, og derved bliver symptomer på østrogendominansen mindre.
Østrogendominans kan give øgede bækkensmerter, hvis bækkenet i forvejen er ustabilt og måske dysfunktionelt
Progesteron afslapper bækkenmuskulaturen og ledbånd, mens østrogen strammer op og gør det mere stift og ufleksibelt. Når vævet er ufleksibelt og stift på grund af østrogendominans, kan det påvirke venerne, der er de blodårer, som pumper det iltfattige blod tilbage til hjertet og derfra videre til lungerne, hvor det iltes. Venerne og blodcirkulation kan risikere at fungere dårligere, når vævet påvirkes af østrogendominans, og dette kan medføre, at der dannes øget væske i bækkenområdet.
Symptomerne kan være træthedsfølelse og tyngdefornemmelse i bækkenbunden og ned i benene. Hvis der i forvejen er problemer med et dysfunktionelt eller ustabilt bækken, kan denne øgede stivhed og ufleksibilitet og eventuelt øget væskedannelse være den sidste dråbe, der får bægeret til at flyde over, og smerter kan forøges.
Mangel på progesteron påvirker livmoderen
Da progesteronniveauet falder drastisk i peri- og menopause, kan der være østrogendominans i en periode. Livmoderen, som er et muskuløst hult organ (livmodervæggen er stærk muskulatur), påvirkes. Livmoderen bliver mindre, og muskelvævet, der omkranser denne, kan påvirkes af mangel på det blødgørende hormon progesteron, og vævet bliver dermed mere stift og ufleksibelt. Dette kan medføre gener og smerter i bækkenlænde-området, da livmoderen ligger midt i bækkenet mellem blæren og endetarmen og hæfter med ledbånd på bækkenringen. Selve livmoderen har ikke nervesensorer, men kun livmodervæggens muskulatur og bindevævet omkring denne har nervesensorer. Selve organet livmoderen kan ikke sende signaler til hjernen om, at her gør det ondt, og i stedet opfatter hjernen det som smerte fra de områder, der har samme nerveforsyning som livmoderen (refererede smerter). Det kan fx være lænde- og bækkensmerter.
Stress påvirker også hormonbalancen
At være i en stresstilstand spiller også en meget væsentlig rolle, da stress kan påvirke hormonbalancen negativt. Stresstilstanden medfører øget produktion af kortisol, der dannes ud fra hormonet pregnenolon.
Pregnenolon er “moderhormonet” til både kortisol og østrogen/progesteron, og når kroppen danner mere kortisol end normalt, bliver der ikke nok pregnenolon til dannelse af østrogen og progesteron.
Ved perimenopause/menopause, hvor progesteronniveauet i forvejen falder voldsomt, og der kan opstå østrogendominans, kan stress derfor have en relativt stor indflydelse på hormonbalancen. Der kan derved opstå forskellige symptomer såsom stivhed i led og muskler, psykisk ubalance, hævede ben m.m. Hvis bækkenet i forvejen er ustabilt og dysfunktionelt, kan en stresstilstand forværre smerter og gener i bækken- og lændeområdet.
Foreningen Bækkensmerter.dk er en nonprofit patientforening, der har 35 års erfaring. Foreningen driver en rådgivningslinje for medlemmer og tilbyder individuel rådgivning. www.baekkensmerter.dk
Du kan også læse mere i artiklen på sund-forskning hjemmeside: https://sund-forskning.dk/artikler/baekkenlosning-det-meste-af-graviditeten/
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