The Role of Pelvic Health Physiotherapy in Endometriosis
Endometriosis affects approximately 1 in 10 women of reproductive age, yet it takes an average of 7 to 11 years to receive a diagnosis. It is a chronic condition in which tissue similar to the uterine lining grows outside the uterus, causing inflammation, scarring, and pain that can affect every aspect of daily life. While surgery and hormonal therapy remain the primary medical treatments, there is a growing and compelling body of evidence for the role of pelvic health physiotherapy as an essential part of the care team.
Why Pelvic Pain Is About More Than the Lesions
One of the most important things to understand about endometriosis is that pain is not solely caused by the endometrial lesions themselves. Over time, chronic pain drives a process called central sensitisation, where the nervous system becomes hypersensitive, amplifying pain signals even after the original tissue damage has resolved or been treated surgically.
This is why many people continue to experience significant pain after surgery. The nervous system has, in effect, learned pain, and this needs to be actively addressed in treatment.
Additionally, living with persistent pelvic pain causes the muscles of the pelvic floor, hips, and lower back to contract as a protective response. The result is pelvic floor hypertonicity, where the muscles are chronically overactive and shortened rather than weak. This muscle guarding becomes a significant pain driver in its own right.
What Does Pelvic Health Physiotherapy Actually Do?
Pelvic health physiotherapy for endometriosis is not simply about pelvic floor strengthening. In fact, for many people with endometriosis, strengthening exercises are counterproductive. The focus instead is on relaxation, lengthening, coordination, and nervous system regulation.
Evidence-based physiotherapy approaches include:
Manual Therapy
Hands-on techniques targeting myofascial restrictions, trigger points, and adhesions in the pelvic floor, abdomen, and surrounding tissues. A 2023 clinical trial published in the Journal of Clinical Medicine found that an 8-week manual therapy programme significantly improved pain intensity, mobility, and quality of life in women with endometriosis-related pelvic pain, with benefits lasting up to six months.
Pelvic Floor Muscle Retraining
Assessment and treatment of pelvic floor muscle dysfunction, including hypertonic (overactive) patterns. A randomised controlled trial published in Medicina (2023) found that women with deep infiltrating endometriosis reported improvements in dyspareunia and greater pelvic floor relaxation following physiotherapy.
Pain Neuroscience Education
Understanding pain changes pain. Physiotherapists trained in pain neuroscience education help patients understand the mechanisms driving their symptoms, which has been shown to reduce nervous system sensitivity and improve function in people with chronic pain conditions.
Bowel and Bladder Rehabilitation
Bowel and bladder symptoms are extremely common in endometriosis, including pain with defecation, urgency, and painful urination. Pelvic health physiotherapy directly addresses the muscle impairments driving these symptoms, improving quality of life and daily function.
Exercise Therapy and Lifestyle
Supervised exercise, including general movement and mobility work, has been shown to ease current pain levels and reduce symptom burden. Physiotherapists can guide patients in finding exercise approaches that are tolerable and beneficial even during flare-ups.
The Case for Multidisciplinary Care
The evidence increasingly supports a multidisciplinary model for endometriosis management. A systematic review found that multidisciplinary care may lead to lower pain intensity scores and greater sexual function compared to single-discipline treatment. Physiotherapy as part of an interdisciplinary team, alongside gynaecology, pain medicine, psychology, and nutrition, offers patients far better outcomes than any one intervention alone.
Adolescents are not excluded from this benefit. A 2022 study showed that young people with biopsy-confirmed endometriosis had clinically meaningful improvements in function and pain after pelvic floor therapy as part of multidisciplinary care.
What Physiotherapy Cannot Do
It is important to be clear: physiotherapy does not remove endometrial lesions. It does not replace surgery or hormonal therapy for those who need it. What it does is treat the consequences of living in pain for a prolonged period — the muscle guarding, the nervous system sensitisation, the movement avoidance, the bowel and bladder dysfunction, and the impact on sexual function and quality of life.
A non-pharmacological systematic review published in the American Journal of Obstetrics and Gynecology identified physiotherapy as among the most effective conservative interventions for chronic pelvic pain in women.
What to Expect From a Pelvic Health Physiotherapy Assessment
A thorough assessment will explore:
The nature, location, and pattern of pain
Bladder and bowel function
Sexual function, including pain with intercourse
Posture, movement, and musculoskeletal factors
Breathing patterns and nervous system regulation
The impact on daily activities, work, and wellbeing
Treatment is always tailored to the individual and progressed gradually. Some people also benefit from techniques such as dry needling to address trigger points, visceral mobilisation, and breathing retraining.
Getting Referred
If you are living with endometriosis and experiencing pelvic pain, dyspareunia, bowel or bladder symptoms, or pain limiting your daily activities, a referral to a pelvic health physiotherapist is appropriate and evidence-supported at any stage of your journey, whether you are awaiting diagnosis, post-surgery, or managing long-term.
Pelvic health physiotherapy is not a last resort. It is a core component of modern endometriosis care.
This blog post is for educational purposes. If you have concerns about your symptoms, please speak with your GP or gynaecologist.
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