Endometriosis, Pelvic Pain and the Pelvic Floor: Why Treatment Is About More Than the Lesions
When we talk about endometriosis, the conversation understandably focuses on the disease itself: where the endometriosis is located, what imaging has shown, whether hormonal management may help, and whether surgery should be considered.
But after months or years of pelvic pain, something else can begin to happen.
The muscles, nervous system, bowel and bladder can start adapting to pain too.
This is why treating endometriosis isn't always just about treating the endometriosis. For some women, we also need to help the body gradually unwind the protective patterns it has developed along the way.
Your Pelvic Floor May Be Protecting You
When something hurts, our body naturally protects it.
Think about injuring your back. Without consciously deciding to do it, you may move differently, brace your abdominal muscles or hold yourself more stiffly.
The pelvic floor can do exactly the same thing.
Repeated pelvic pain, painful intercourse, bowel pain or uncomfortable medical examinations can encourage the pelvic floor muscles to remain partially contracted. Eventually, this protective response can become habitual.
We call this a high-tone or hypertonic pelvic floor.
Importantly, a high-tone pelvic floor isn't necessarily weak. In fact, during an assessment the muscles may produce a very strong contraction.
The problem can be that they don't know how to let go again.
And healthy muscles need both.
They need to contract when we need support and relax when we need movement.
Why "More Kegels" May Not Be the Answer
Imagine clenching your fist as tightly as possible.
Now keep holding it.
Eventually your hand becomes tired and uncomfortable—and when you actually need to use it, you don't have much movement left.
A pelvic floor that is constantly "switched on" can behave similarly.
For these women, simply prescribing more pelvic floor strengthening exercises may miss an important part of the problem.
Instead, physiotherapy may focus on restoring the ability to relax, lengthen and coordinate the muscles.
This is often called pelvic floor down-training.
Endometriosis and Painful Sex
This protective response becomes particularly important when we think about painful intercourse or vaginal examinations.
When the nervous system anticipates pain, the pelvic floor can contract automatically.
This isn't something a woman is choosing to do.
And simply being told to "relax" may not be enough.
Repeatedly pushing through significant pain may reinforce the body's expectation that penetration is threatening. Rehabilitation may therefore involve breathing, pelvic floor relaxation, external mobility work, pain education and carefully graded reintroduction of penetration when appropriate.
Importantly, pelvic health physiotherapy doesn't always require an internal examination. External assessment and tools such as transabdominal ultrasound can sometimes help us understand pelvic floor movement without immediately introducing vaginal examination.
And Then There Is the Bowel
One of the most interesting overlaps we see clinically is between pelvic pain and bowel dysfunction.
Women may describe:
constipation
bloating
pelvic or abdominal pressure
difficulty completely emptying
needing to change position to empty their bowel
bowel pain
symptoms that seem better when they are relaxed.
Bowel emptying isn't simply about how frequently you go to the toilet.
The bowel, abdominal muscles, pelvic floor and nervous system all have to work together.
To empty effectively, the pelvic floor and anal sphincter need to relax while the bowel and abdominal system generate appropriate pressure.
If the pelvic floor is still protecting and gripping, that coordination may become more difficult.
This is one reason pelvic health physiotherapy can be valuable alongside appropriate medical investigation of bowel symptoms.
Your Nervous System Matters Too
Persistent pain can gradually change the way the nervous system responds to sensation.
That doesn't mean the pain is imagined.
It means we need to recognise both the underlying medical condition and the way the body has adapted to living with it.
Strategies such as pain education, relaxation, diaphragmatic breathing, graded movement and pain-reprocessing approaches may therefore complement medical treatment.
I often encourage women to think less about "fighting" their pelvic floor and more about teaching their body that it is safe to move again.
So What Can Pelvic Health Physiotherapy Actually Do?
Physiotherapy doesn't remove endometriosis lesions.
That distinction is important.
Medical and sometimes surgical management belongs within an appropriately qualified multidisciplinary team.
What physiotherapy can address are some of the physical consequences that may develop around persistent pelvic pain.
Depending on the individual, management may include pelvic floor down-training, diaphragmatic breathing, hip and spinal mobility, gentle stretching, bowel-emptying strategies, pain education, manual therapy, graded return to sexual activity and external TENS for pain modulation.
Sometimes ten minutes of gentle mobility and breathing at the end of the day is a much more appropriate starting point than another strenuous exercise program.
The Goal Is to Give Your Body More Options
The healthiest pelvic floor isn't simply the strongest pelvic floor.
It's an adaptable pelvic floor.
One that can support you when you lift, run or cough.
One that can relax when you empty your bowel.
One that can lengthen during intimacy.
And one that isn't constantly preparing for the next painful experience.
For women living with endometriosis and persistent pelvic pain, treatment may therefore involve several layers.
We investigate and appropriately manage the underlying disease.
But we also look at the muscles, movement, bowel function, nervous system and the very real impact that years of pain can have on confidence and everyday life.
Because sometimes recovery isn't about teaching your body to work harder.
It's about helping it finally feel safe enough to let go.
Melinda Sandon
Principal Physiotherapist
Matremaga Physiotherapy
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