Endometriosis and Pelvic Floor Physical Therapy: A Whole-Person Approach to Pelvic Pain

Endometriosis is a chronic, estrogen-dependent inflammatory disease in which tissue similar to the lining of the uterus (the endometrium) grows outside the uterus. These growths, called lesions, are most commonly found around the pelvic organs but can also occur on the bowel, bladder, diaphragm, and other areas throughout the body.

The hallmark symptom of endometriosis is pelvic pain, often linked to the menstrual cycle because the lesions respond to hormonal fluctuations. However, endometriosis can affect far more than the reproductive system. Common symptoms include:

• Pelvic pain

• Low back, hip, and abdominal pain

• Bloating ("endo belly")

• Nausea and digestive symptoms

• Fatigue

• Heavy menstrual bleeding

• Painful urination or bowel movements

• Pain with vaginal penetration

• Infertility

  
  

Endometriosis affects approximately 1 in 10 people of reproductive age and can affect anyone with endometrial-like tissue, including transgender and gender-diverse individuals. In the United States, that represents nearly 9 million individuals—roughly the population of New Jersey.

What Causes Endometriosis?

Despite its prevalence, we still do not fully understand what causes endometriosis. Current research suggests that it involves a complex interaction between hormonal, immune, inflammatory, genetic, and nervous system factors. One leading theory is that endometrial-like tissue is allowed to implant and grow outside the uterus rather than being cleared by the body's immune system. These lesions can trigger inflammation, scarring, adhesions, and changes in the nervous system that contribute to both local and widespread pain.

Although there is currently no cure for endometriosis, treatment options continue to improve as awareness, research, and advocacy grow. Historically, many individuals waited 7 to 10 years for an accurate diagnosis. Fortunately, increased awareness and evolving diagnostic guidelines are helping people receive earlier evaluation and treatment. Excision surgery performed by a highly trained endometriosis specialist remains the gold standard surgical treatment. Depending on an individual's symptoms and goals, treatment may also include medication, nutrition and lifestyle modifications, mental health support, and pelvic floor physical therapy.

Can Physical Therapy Help Endometriosis?

Because endometriosis affects multiple body systems, treatment is most effective when it is personalized and interdisciplinary. One of the challenges of endometriosis is that symptom severity does not always correlate with the amount of disease present. Some individuals with extensive lesions experience relatively mild symptoms, while others with minimal visible disease experience significant pain and disability. This disconnect highlights the importance of treating the whole person, not just the lesions. Research demonstrates that pelvic floor physical therapy can help reduce many symptoms associated with endometriosis, including:

• Pelvic, abdominal, and low back pain

• Urinary urgency and frequency

• Painful bowel movements

• Pain with penetration and sexual activity

• Functional limitations

• Fatigue and reduced quality of life

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Endometriosis often leads to protective muscle guarding, altered breathing patterns, movement avoidance, postural adaptations, deconditioning, and nervous system sensitization. Physical therapy addresses these factors by helping the body move more efficiently and with less pain.

Treatment may include:

• Manual therapy

• Myofascial and visceral mobilization

• Neuromuscular re-education

• Therapeutic exercise

• Breathing and relaxation strategies

• Functional movement retraining

• Pain neuroscience education

Physical therapy can be beneficial both before and after excision surgery. Pre-operatively, therapy may help reduce symptoms and improve physical conditioning. Post-operatively, it can help address residual pain, mobility restrictions, scar tissue, pelvic floor dysfunction, and return to activity.

What to Expect at Hazel Physical Therapy

At Hazel Physical Therapy, we take a comprehensive and individualized approach to endometriosis care.

One patient came to Hazel Physical Therapy with chronic pelvic pain, urinary frequency, painful bowel movements, and pain with intercourse. Individually, none of these symptoms felt impossible to manage, but together they were exhausting and had gradually narrowed her daily life. During our initial conversations, endometriosis became a strong consideration based on her history of painful periods, nausea during menstruation, persistent bloating, gastrointestinal symptoms, and painful vaginal penetration that sometimes triggered an intense whole-body emotional response..

Using a trauma-informed and patient-centered approach, we collaborated closely with her mental health therapist, endometriosis specialist, and women's health dietitian.

In physical therapy, she learned to recognize and differentiate various contributors to her pain, including muscular, visceral, and nerve-related symptoms. Treatment included visceral mobilization, myofascial release, dry needling for abdominal and pelvic trigger points, and neuromuscular modulation techniques. She also learned strategies to improve movement variability and reduce tension throughout the thorax, abdominal wall, pelvic floor, hips, and spine. Through breathing strategies, down-training, movement retraining, and progressive exercise, she developed greater confidence in her body's ability to move without excessive guarding.

As her symptoms became more manageable, she also began returning to activities that brought her joy. While she still experiences some discomfort during her menstrual cycle, she achieved her physical therapy goals and regained a greater sense of control over her body and her life. Every person with endometriosis has a unique experience. At Hazel Physical Therapy, our goal is not simply to reduce pain but to help people better understand their bodies, expand their movement options, and return to the activities and relationships that matter most.

Looking for Endometriosis Physical Therapy?

Hazel Physical Therapy provides highly skilled and trauma-informed pelvic floor physical therapy for people living with endometriosis, chronic pelvic pain, painful intercourse, urinary and bowel symptoms, abdominal pain, and related musculoskeletal conditions. We believe that endometriosis care works best when it is collaborative, evidence-informed, and tailored to the individual.

Our approach integrates hands-on treatment, movement retraining, pain neuroscience education, exercise, and coordination with gynecologists, endometriosis specialists, mental health professionals, and dietitians when appropriate. Whether you are preparing for excision surgery, recovering afterward, or looking for conservative treatment options, physical therapy can be an important part of your care team.

Hazel Physical Therapy is a specialty pelvic floor and orthopedic physical therapy practice serving the Philadelphia region. We provide evidence-based, inclusive care for people experiencing endometriosis, chronic pelvic pain, pelvic floor dysfunction, pregnancy and postpartum concerns, and complex orthopedic conditions, helping them move with greater confidence and less pain.

Patient Resources

• Endo What?: A film to provide an accurate base of knowledge about endometriosis straight from the experts.

• Endometriosis Summit: an annual conference to train physicians and educate patients, offers up-to-date content on the website

• Endo Warriors: face to face and online support organization

• Tight Lipped: a grassroots movement by and for people with chronic vulvovaginal and pelvic pain

• EndoThrive: an online program for people with suspected or diagnosed endometriosis

• The Endometriosis Journey: A Comprehensive Resource from Diagnosis to Treatment: a resource from the NYC pelvic specialists at Beyond Basics Physical Therapy

References

• Abril-Coello R, Correyero-León M, Ceballos-Laita L, Jiménez-Barrio S. Benefits of physical therapy in improving quality of life and pain associated with endometriosis: A systematic review and meta-analysis. International Journal of Gynecology & Obstetrics. 2023;162:233-243.

• American College of Obstetricians and Gynecologists. Diagnosis of Endometriosis: ACOG Clinical Practice Guideline No. 11. Obstetrics & Gynecology. 2026;147(3):432-448.

• As-Sanie S, Mackenzie SC, Morrison L, Schrepf A, Zondervan KT, Horne AW, Missmer SA. Endometriosis: A Review. JAMA. 2025;334(1):64-78.

• Friggi Sebe Petrelluzzi K, Garcia MC, Petta CA, Ribeiro DA, de Oliveira Monteiro NR, Céspedes IC, Spadari RC. Physical therapy and psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. Journal of Psychosomatic Obstetrics & Gynecology. 2012 Dec 1;33(4):191-8.

• Hartmann TE, Baker KA, Girard D. Is exercise duration more important than intensity in endometriosis?. BMC Women's Health. 2025 Dec;25(1):625.

• Saunders PT, Horne AW. Endometriosis: new insights and opportunities for relief of symptoms. Biology of Reproduction. 2025 Nov;113(5):1029-43.

• Shrikhande A, Patil S, Subhan M, Moody E, Natarajan J, Tailor Y, Mamsaang M, James N, Leishear K, Vyas R, Sandhu S. A comprehensive treatment protocol for endometriosis patients decreases pain and improves function. International Journal of Women's Health. 2023 Dec 31:91-101.

• Tennfjord MK, Gabrielsen R, Tellum T. Effect of physical activity and exercise on endometriosis-associated symptoms: a systematic review. BMC women's health. 2021 Oct 9;21(1):355.

  Tennfjord MK, Gabrielsen R, Bø K, Engh ME, Molin M. Can general exercise training and pelvic floor muscle training be used as an empowering tool among women with endometriosis? Experiences among women with endometriosis participating in the intervention group of a randomized controlled trial. BMC women's health. 2024 Sep 12;24(1):505.

• Wurn BF, Wurn LJ, Patterson K, King CR, Scharf ES. Decreasing dyspareunia and dysmenorrhea in women with endometriosis via a manual physical therapy: results from two independent studies. Journal of Endometriosis. 2011;3(4):188-96.