Endometriosis: Understanding the Condition, Diagnosis, and How Pelvic Health Therapy Can Help
If you have been told that your period pain is “normal,” that painful sex is something you simply have to live with, or that your pelvic pain is all in your head, you are not alone.
Endometriosis is a chronic inflammatory condition that can cause significant pelvic pain, bowel and bladder symptoms, painful intercourse, fatigue, and fertility challenges. It can affect nearly every aspect of daily life—and yet many people spend years searching for answers.
The good news is that our understanding of endometriosis continues to evolve. In 2026, the American College of Obstetricians and Gynecologists (ACOG) released new clinical guidance specifically addressing the diagnosis of endometriosis, with an emphasis on recognizing symptoms earlier and using clinical findings and imaging to support diagnosis and treatment.
Understanding what endometriosis is, how it is diagnosed, and what specialized care can look like can help you become a more informed participant in your healthcare.
What Is Endometriosis?
Endometriosis is a chronic inflammatory condition in which tissue resembling the lining of the uterus develops outside of the uterus.
These lesions can occur in the pelvis and may involve structures such as the ovaries, fallopian tubes, pelvic peritoneum, bowel, bladder, and other surrounding tissues. In some cases, endometriosis can also occur outside of the pelvis.
Endometriosis is more than “bad period cramps.”
The condition can contribute to:
Severe menstrual pain
Pelvic or abdominal pain outside of your period
Pain with sex, particularly deep penetration
Pain with bowel movements
Pain with urination
Bloating and gastrointestinal symptoms
Fatigue
Low back or hip pain
Pain that radiates into the legs or surrounding areas
Heavy or irregular menstrual bleeding
Fertility challenges
Pelvic floor dysfunction
Sexual dysfunction
Difficulty exercising or participating in activities you enjoy
Not everyone with endometriosis experiences the same symptoms. Some people have extensive disease with relatively few symptoms, while others experience severe pain despite having a smaller amount of visible disease.
This is one reason endometriosis can be so difficult to identify and treat.
Why Does Endometriosis Cause So Much Pain?
Endometriosis pain is not necessarily coming from the lesions alone.
When pain persists for months or years, the body can develop additional protective responses. The pelvic floor muscles may become tense or overactive. The nervous system can become more sensitive to signals from the pelvis. Muscles throughout the abdomen, hips, back, and pelvis may begin compensating for pain.
This can create a cycle:
Pain → muscle guarding → increased sensitivity → movement changes → more pain
This does not mean that the pain is “just muscular” or “all in your nervous system.”
It means that multiple systems can contribute to the pain experience—and all of those systems may need to be addressed.
This is one reason endometriosis care often benefits from a multidisciplinary approach.
How Is Endometriosis Diagnosed?
Historically, many people were told that the only way to definitively diagnose endometriosis was through laparoscopic surgery.
The diagnostic process is evolving.
Current guidelines recognize that a diagnosis can be approached through a combination of:
Your symptoms and medical history
Menstrual and pain patterns
Physical examination
Pelvic ultrasound
MRI when appropriate
Other diagnostic testing when clinically indicated
Laparoscopic evaluation in appropriate situations
Importantly, a normal ultrasound or MRI does not necessarily mean you do not have endometriosis.
Imaging can be extremely useful, particularly for identifying ovarian endometriomas and some forms of deep endometriosis, but not every lesion will be visible on imaging.
The 2022 European Society of Human Reproduction and Embryology (ESHRE) guideline specifically notes that a negative imaging result does not rule out endometriosis. ACOG's 2026 diagnostic guideline similarly incorporates clinical evaluation and imaging into the diagnostic process.
What about laparoscopy?
Laparoscopy is a minimally invasive surgical procedure that allows a surgeon to directly visualize the pelvis. It may be used when the diagnosis remains uncertain, when symptoms persist despite treatment, or when surgical treatment is appropriate.
If endometriosis is identified during surgery, treatment may be performed during the same procedure depending on the circumstances and surgical approach.
Importantly, you should not feel that you have to “prove” your pain through surgery before your symptoms deserve treatment.
Your symptoms are real and deserve appropriate evaluation and management even while the diagnostic process is ongoing.
Endometriosis Treatment Is About More Than Surgery
There is no single treatment that works for everyone with endometriosis.
Depending on your symptoms, disease characteristics, reproductive goals, and medical history, treatment may involve:
Hormonal medication
Pain management
Surgery
Pelvic health therapy
Exercise and movement
Nutrition support
Fertility care
Psychological support
Sleep and stress management
Other multidisciplinary approaches
The goal should not simply be to identify a lesion.
The goal is to help you function and live your life with less pain and fewer limitations.
Where Does Pelvic Health Therapy Fit In?
Pelvic health therapy does not remove endometriosis lesions.
It also does not replace medical or surgical treatment.
Instead, pelvic health therapy addresses the musculoskeletal and functional consequences of endometriosis and chronic pelvic pain.
This can be incredibly important.
The pelvic floor and endometriosis
The pelvic floor is a group of muscles that supports the pelvic organs and contributes to bladder, bowel, sexual, and reproductive function.
When you experience pelvic pain, these muscles may respond by becoming chronically tense or protective.
Over time, you may develop:
Pelvic floor overactivity
Difficulty relaxing the pelvic floor
Pain with penetration
Pain during pelvic examinations
Pain with bowel movements
Urinary symptoms
Hip or low back pain
Difficulty sitting for long periods
Pain with exercise
Difficulty coordinating breathing and pelvic floor movement
And sometimes, the pelvic floor itself becomes a significant contributor to your pain—even though endometriosis was the original trigger.
What Can Pelvic Health Therapy Actually Do?
A pelvic health therapist can perform a comprehensive evaluation of your movement, breathing, abdominal wall, hips, spine, pelvic floor, and functional activities.
Treatment may include:
Pelvic floor down-training
If your pelvic floor is chronically tense, doing more Kegels is not necessarily the answer.
Your therapist may teach you how to recognize tension and practice pelvic floor relaxation, coordination, and lengthening.
Manual therapy
When appropriate and with your consent, treatment may address muscles and connective tissues around the pelvis, abdomen, hips, and low back.
Internal pelvic floor treatment is not required for pelvic health therapy to be effective, and it should never be performed without informed consent.
Breathing and nervous system regulation
Breathing mechanics can influence abdominal pressure, pelvic floor activity, and overall muscle tension.
Learning how to reduce unnecessary guarding can be an important part of treatment for someone living with chronic pelvic pain.
Movement and exercise
Endometriosis should not automatically mean that you need to stop exercising.
Instead, you may need to modify how, when, and how much you exercise.
A pelvic health therapist can help you gradually return to activities such as:
Strength training
Running
Yoga
Pilates
Walking
Hiking
Recreational sports
The goal is to help you build confidence in your body rather than becoming afraid of movement.
Bowel and bladder support
Endometriosis can be associated with bowel and bladder symptoms, particularly when disease or pain affects these systems.
Pelvic health therapy may help address muscle coordination, toileting mechanics, bladder habits, bowel function, and other contributing factors.
Sexual health
Pain with sex is common in people with pelvic pain and endometriosis.
Pelvic health therapy can address pelvic floor muscle tension, movement patterns, fear and guarding around penetration, and gradual return to comfortable sexual activity.
Your sexual health matters.
You deserve care that recognizes that intimacy is part of quality of life—not an optional extra.
Post-surgical rehabilitation
If you undergo endometriosis surgery, pelvic health therapy may also be part of your recovery.
Your therapist can help address mobility, scar sensitivity, abdominal and pelvic muscle function, movement, strength, and return to normal activities.
What Pelvic Health Therapy Cannot Do
This distinction is important.
Pelvic health therapy cannot:
Remove endometriosis lesions
Cure endometriosis
Replace appropriate medical management
Replace a gynecologic evaluation
Guarantee that your pain will disappear
But it can address the movement, muscle, bowel, bladder, sexual, and functional components of your symptoms.
For many people, that is an important piece of the larger treatment picture.
How Do I Know If My Provider Is Actually an Endometriosis Specialist?
This is one of the most important questions you can ask.
The word “specialist” can be used loosely in healthcare. Someone may have an interest in endometriosis without having advanced training or substantial clinical experience caring for complex cases.
Instead of focusing only on a title, ask questions.
If you are looking for a medical provider, consider asking:
“How much of your practice involves endometriosis?”
A provider who routinely treats endometriosis should be comfortable discussing the condition in detail.
“How do you approach diagnosis when imaging is normal?”
A normal scan should not automatically end the conversation if your symptoms remain highly suggestive of endometriosis.
“How do you approach endometriosis-related pain?”
Look for an approach that recognizes that pain can involve multiple systems—not simply the presence or absence of visible lesions.
“Do you work with a multidisciplinary team?”
Endometriosis care may involve gynecology, surgery, pelvic health therapy, fertility specialists, pain management, nutrition professionals, and mental health professionals depending on the individual.
“If surgery is recommended, what surgical approach do you use?”
If you're considering surgery, it is reasonable to ask about the surgeon's experience with endometriosis specifically, the types of disease they routinely treat, and whether they collaborate with other specialists when disease involves structures such as the bowel or bladder.
How Do I Know If My Pelvic Health Therapist Understands Endometriosis?
Not every pelvic health therapist specializes in endometriosis.
A therapist can be excellent at treating pelvic floor dysfunction and still have limited experience with complex endometriosis.
Ask questions such as:
“How often do you work with patients who have endometriosis?”
“What additional training have you completed in endometriosis or chronic pelvic pain?”
“How do you approach pelvic floor tension?”
“Do you work with patients before and after endometriosis surgery?”
“How do you modify exercise for someone with endometriosis?”
“How do you coordinate care with gynecologists or other providers?”
“Do you understand the difference between pelvic floor weakness and pelvic floor overactivity?”
You should also pay attention to how the therapist talks about your pain.
A knowledgeable provider should understand that:
Your pain is real.
Pain does not always correlate with the amount of visible disease.
A tight pelvic floor does not mean endometriosis isn't contributing to your symptoms.
You do not need to “push through” severe pain to get stronger.
And pelvic health therapy should be collaborative, consent-based, and individualized.
You Don't Have to Choose Between Medical Care and Pelvic Health Therapy
Endometriosis care does not have to be an either/or situation.
You can work with your gynecologist or endometriosis specialist while also working with a pelvic health therapist.
You can pursue fertility care while addressing pelvic pain.
You can have surgery and still benefit from rehabilitation.
You can use medication while also working on movement, pelvic floor function, bowel or bladder symptoms, and pain management.
The best care often involves looking at the whole person rather than one body part.
When Should You Consider Seeking Evaluation?
Consider talking with a healthcare provider if you experience:
Period pain that significantly interferes with your life
Pain that causes you to miss work, school, or activities
Pain with sex
Pain with bowel movements, particularly around your period
Pain with urination, particularly around your period
Chronic pelvic or abdominal pain
Unexplained infertility or difficulty becoming pregnant
Significant bloating or gastrointestinal symptoms that cycle with your period
Persistent pelvic pain despite treatment
Pelvic pain after endometriosis surgery
Pain that has repeatedly been dismissed as “normal”
You do not have to wait until your symptoms become unbearable to seek care.
Your Pain Deserves to Be Taken Seriously
Endometriosis can be complicated.
Diagnosis can take time. Treatment can require multiple approaches. Symptoms can change throughout your life.
But living with endometriosis does not mean you have to accept severe pain, painful sex, bowel dysfunction, bladder symptoms, or limitations in your daily life as something you simply have to tolerate.
If you suspect endometriosis, start by finding a provider who will listen carefully, take your symptoms seriously, and help you build an appropriate care team.
And if you already have an endometriosis diagnosis, remember that your treatment does not have to stop with medication or surgery.
Your muscles, movement, nervous system, bowel and bladder function, sexual health, exercise capacity, and quality of life matter too.
Pelvic health therapy can be one piece of a comprehensive endometriosis care plan—and the right therapist can help you better understand your body, reduce contributing factors to pain, and return to the activities and life that matter to you.
Curious if Pelvic Health Therapy can support your endometriosis journey? Book a free discovery call today!
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