Endometriosis-Related Pelvic Pain: How Physical Therapy Can Help

Endometriosis is a chronic condition that often brings with it substantial and sometimes debilitating pelvic pain. Many people with endometriosis experience painful sex, bladder and bowel discomfort, or lower back/hip pain, which can interfere with daily life, relationships, and overall well-being. While medical or surgical management of endometrial lesions is central, it often isn’t enough to fully resolve the pain and dysfunction. Physical therapy has emerged as a powerful complementary treatment—especially specialized pelvic floor therapy for endometriosis care—to help reduce pain, improve function, and restore comfort. At Femina Physical Therapy, our team is trained in endometriosis physical therapy and pelvic pain physical therapy for pelvic floor dysfunction, offering individualized, evidence-based treatments to address both the symptoms and underlying contributors. This page will explain what endometriosis is, its types, how it causes pain, what symptoms to watch for, and how physical therapy (endo-related) can support healing and improve quality of life.

What is Endometriosis?

Endometriosis is a condition where tissue similar to the uterine lining (endometrium) grows outside the uterus, often on the ovaries, fallopian tubes, peritoneal surfaces, or other pelvic organs. These ectopic implants respond to cyclical hormonal changes—growth, breakdown, and bleeding—but since they are outside the uterus, the bleeding has no exit. This process causes inflammation, scar tissue (adhesions), pain, and mobility issues. Repeated inflammation and surgeries can tether or restrict organs such as the bladder, bowel, uterus, ovaries, and fascia, leading to pelvic floor dysfunction, muscular guarding, and neuropathic or sensitized pain. Endometriosis varies in severity, from superficial disease to deep infiltrating endometriosis (DIE), where lesions extend more than 5 mm under the peritoneal surface. The extent and location of lesions can influence symptoms, but even mild disease can cause significant pain when secondary factors like muscle dysfunction, nerve involvement, myofascial restrictions, or psychological components are present. In addition, central and peripheral sensitization often amplify pain signals, meaning discomfort may persist even after surgical lesion removal. Physical therapy for endo-related pain treatment addresses these multiple layers, targeting muscular tension, scar tissue, and nerve hypersensitivity.

Types of Endometriosis

Understanding the different types of endometriosis can help in tailoring a treatment plan, including pelvic floor therapy, endometriosis, and endo-physical therapy strategies:

  1. Superficial Peritoneal Endometriosis—This is the most common type. Lesions are on the surface of pelvic organs or the peritoneum. While not deeply invasive, these lesions can still cause inflammation, pain, and some adhesions.
  2. Endometriomas (Ovarian Cysts)—These are cysts formed when endometrial tissue grows in or on the ovaries. They can cause discomfort, pull on surrounding structures, contribute to pain with movement, and sometimes compromise ovarian function.
  3. Deep Infiltrating Endometriosis (DIE)—This is a more severe form of endometriosis, where lesions invade deeply into tissue (more than 5 mm beyond the peritoneum). These often affect ligaments (e.g., uterosacral), the posterior vaginal fornix, the rectovaginal septum, the bowel, and the bladder. DIE is strongly associated with more severe pain, dyspareunia (painful intercourse), deep pelvic pain, and painful urination or defecation. 
  4. Extra-Pelvic Endometriosis—Rare, but possible when endometrial tissue implants in places outside typical pelvic organs (e.g. diaphragm, surgical scars). These can cause pain beyond the pelvis or complicate mobility and posture.
  5. Adhesive/Scar Endometriosis—Repeated surgeries (diagnostic laparoscopy, excisions, hysterectomies) or natural healing from lesion sites can lead to scar tissue and adhesions. Adhesions tether organs and connective tissue, limiting mobility, causing distortion, pulling, and amplifying pain.

The type (or combination of types) influences how painful, how widespread, and how complex symptoms are, and thus guides how we design endometriosis pain treatment.

Endometriosis causes pain through multiple mechanisms—some direct, some indirect. The causes often overlap and amplify each other in a cycle of pain, tension, and dysfunction.

  1. Inflammation: The growth of endometriotic tissue triggers immune responses. Local inflammation sensitizes tissues, irritates nerves, and can lead to swelling, pain, and discomfort before and during menses. ([turn0search1]turn0search4turn0search0)
  2. Adhesions & Scar Tissue: Adhesions form as part of the body’s healing processes. After lesion growth, breakdown, or surgical removal, scar tissue can develop. These adhesions can bind organs, muscles, and fascia together, reducing mobility and creating tension. The pulling and restriction from adhesions often contribute to chronic pelvic pain and may also affect bowel or bladder function. ([turn0search1]turn0search0)
  3. Myofascial Dysfunction & Pelvic Floor Hypertonicity: Many people with endometriosis also show hypertonic (overactive) pelvic floor muscles and trigger points in the pelvic floor, abdominal wall, and lower back muscles. Muscle guarding (a reflex protective tightening) may result from pain or fear of pain, and this, in turn, increases pain, reduces blood flow, and causes more dysfunction. 
  4. Nerve Sensitization (Peripheral & Central): Over time, repeated pain signals, inflammation, or injury can cause nerves to be more sensitive (lower thresholds for pain), a phenomenon known as sensitization. This may mean pain persists even after lesions are removed or treated medically. Physical therapy often includes strategies to downregulate this heightened sensitivity. ([turn0search4]turn0search1)
  5. Mechanical & Positional Factors: Lesions in certain locations (e.g., uterosacral ligaments, bladder, bowel, posterior vaginal wall) can create mechanical strain. Poor posture, lack of mobility, weak core or hip muscles, or limited movement of visceral organs may exacerbate strain. ([turn0search5]turn0search0)
  6. Hormonal & Other Systemic Influences: Cyclical hormonal fluctuations (especially estrogen), menstrual cycles, and treatments (hormonal suppression, OCPs) can influence pain severity, tissue sensitivity, and healing. Additionally, fatigue, stress, digestive or bladder comorbidities (e.g., IBS, interstitial cystitis) often compound the symptom picture. ([turn0search1]turn0search0)

Symptoms vary widely in type, timing, and severity. Some people have mild discomfort; others experience debilitating pain. Common symptoms associated with endometriosis that physical therapy may help address include:

  1. Pelvic pain, especially during menstruation (dysmenorrhea), or chronic pelvic pain outside of menses 
  2. Painful intercourse (dyspareunia), especially deep penetration pain 
  3. Pain with urination or bladder discomfort 
  4. Pain with bowel movements, constipation, or pain with defecation 
  5. Lower back, hip, or sacral pain or stiffness, particularly related to lesion location or muscular compensation 
  6. Bladder or bowel urgency/frequency, sometimes with incomplete emptying or urgency incontinence
  7. Tenderness, hypersensitivity of vulvar or pelvic tissues, and sometimes pain with tampon use and gynecological exams.
  8. Fatigue, mood or emotional strain, and sexual dysfunction beyond pain—including reduced libido and difficulty with arousal or orgasm due to pain or muscular tension or dryness ([turn0search5]turn0search0turn0search1)

Physical therapy (endo-physical therapy) does not remove endometrial lesions, but at Femina Physical Therapy, it plays a critical role in reducing pain, improving function, and helping people navigate symptoms more effectively. Pelvic floor physical therapy for endometriosis incorporates multiple modalities—often used together—with the goal of breaking the pain-tension-scar cycle, restoring mobility in pelvic tissues, reducing inflammation, and supporting overall pelvic health. 

Pelvic floor physical therapy at FeminaPT uses specialized techniques to:

  1. Pain Reduction & Scar Tissue Management – Manual therapy, myofascial release, trigger point therapy, and visceral mobilization relieve muscle tension, reduce adhesions, and ease pain from restricted tissues.
  2. Pelvic Floor Muscle Relaxation—Internal techniques, dilator therapy, and guided exercises help reduce overactivity, guarding, and discomfort in the pelvic floor.
  3. Improved Muscle Coordination—Neuromuscular re-education retrains the pelvic floor and core to work together, decreasing dysfunction and flare-ups.
  4. Nervous System Regulation – Breathing strategies, autogenic relaxation, and gentle movement calm central sensitization and reduce nerve hypersensitivity.
  5. Restored Mobility & Function—Postural training, therapeutic yoga, and movement therapy improve circulation, tissue mobility, and daily comfort.
  6. Education & Individualized Care—Patients receive self-care strategies, toileting guidance, pacing techniques, and home exercises, all tailored to their unique needs and goals.

Here are several treatment options and strategies offered at Femina PT for endometriosis pain treatment and pelvic dysfunction therapy in endometriosis:

Treatment Options at Femina PT

Below are at least 6-9 of the main modalities we use, with a brief description of each:

  1. Manual Therapy & Myofascial Trigger Point Release—Therapists work on soft tissue, muscles, connective tissue, and fascial restrictions in the pelvic floor, abdomen, lower back, and hips to release hypertonicity and trigger points. This helps reduce pain, especially for painful intercourse, dyspareunia, or pain during defecation. ([turn0search1]turn0search0)
  2. Visceral Mobilization—Gentle mobilization of internal organs (uterus, bladder, bowel, ovaries) to improve mobility, reduce adhesions, and restore tissue sliding. This can help relieve pain associated with tethering or internal scarring from endometriosis. ([turn0search1]turn0search0)
  3. Dilator Therapy/Relaxation Techniques—For pain with penetration (dyspareunia), physical therapy may include the use of vaginal dilators or tools and guided relaxation of pelvic floor muscles to decrease guarding and discomfort.
  4. Postural & Movement Training—Strengthening and coordinating supporting muscles (core, hips, back), improving posture and movement patterns. This helps reduce mechanical strain on the pelvis, supports better alignment, and reduces secondary pain.
  5. Neuromuscular Re-education & Relaxation / Autonomic Nervous System Down-Training—Techniques to help reduce overactivity of pelvic floor muscles, improve coordination of contraction/relaxation, and teach breathing and relaxation to mitigate central sensitization. ([turn0search0]turn0search1turn0search4)
  6. Therapeutic Exercise & Stretching/Movement—Exercise programs that include stretching of tight muscles (hips, low back, abdomen), gentle strengthening, yoga, or movement patterns to maintain tissue mobility, improve circulation, and reduce stiffness. ([turn0search1]turn0search2)
  7. Scar Mobilization & Post-Surgical Rehabilitation—After endometriosis surgery (e.g., excisions, hysterectomies), therapy to mobilize scar tissue, support abdominal wall and pelvic floor health, restore flexibility, and reduce pain from adhesions or surgical damage. ([turn0search8]turn0search1)
  8. Self-Treatment & Home Practice (including Self-Massage/Myofascial Release, Relaxation Strategies)—Education on techniques people can perform at home to manage flare-ups, release tension, regulate breathing, manage visceral discomfort, etc. ([turn0search1]turn0search9)
  9. Complementary & Multidisciplinary Approaches—Working alongside medical (gynecologist, surgeon), hormonal therapy, pain specialists, nutritional interventions, and emotional or psychological support. This ensures a holistic plan for endometriosis pain treatment. ([turn0search0]turn0search1)

Each of these is personalized: your therapy plan might combine several of them depending on lesion location, pain severity, previous surgeries, and personal goals.

Frequently Asked Questions

Here are some commonly asked questions about endometriosis-related pelvic pain and how physical therapy can help:

1. Can pelvic floor physical therapy for endometriosis reduce pain even if I’ve already had surgery?
 Yes. Many people continue to experience pain after surgery due to scar tissue, adhesions, muscular guarding, or nerve sensitization. The physical therapy modalities above (manual therapy, visceral mobilization, and neuromuscular re-education) are often very helpful to address those secondary pain generators. ([turn0search1]turn0search0)

2. How long will it take to see improvement with endometriosis physical therapy?
– It depends on multiple factors—severity of disease, presence of adhesions or previous surgeries, how long pain has been present, consistency with home exercises and self-care, and whether multiple modalities are being used. Some patients notice decreased pain with intercourse or better pelvic comfort within a few sessions; more substantial improvements (in flexibility, reduction of adhesion discomfort, etc.) often take several weeks to months.

3. Is endometriosis therapy painful?
 -Therapy can sometimes feel uncomfortable, especially when working with tight muscles, trigger points, or scar tissue, but it should not be overly painful. Skilled physical therapists adjust pressure, pace, and techniques to your tolerance. The goal is to reduce pain and restore comfort over time.

4. Will therapy also help sexual functioning (painful intercourse, arousal, orgasm)?
– Yes. Many people with endometriosis and dyspareunia report improvements in pain during intercourse, better lubrication, greater comfort with penetration, and improved sexual satisfaction when physical therapy (endo-related) is included in the treatment plan. Dilator work, relaxation of the pelvic floor, postural changes, and attention to vaginal tissue health all support this. ([turn0search0]turn0search1)

5. What if I have bladder or bowel symptoms along with endometriosis?
– That is common. Endometriosis often affects adjacent organs and structures (bowel, bladder), and therapy can include interventions for urinary urgency/frequency, painful urination, pain with defecation, constipation, or discomfort associated with visceral adhesions. Visceral mobilization, manual therapy, and pelvic floor training help.

6. Can physical therapy prevent endometriosis from getting worse?
– Physical therapy doesn’t stop endometrial growth, but it can reduce the impact, slow down the worsening of symptoms, improve tissue mobility, reduce the formation or discomfort of adhesions, reduce muscular compensation, and protect against secondary damage. So in that sense, yes, it can help in maintaining or improving the quality of life over time.