Endometriosis: Diagnosis, Emerging Research, and the Role of Physical Therapy
- Brittany Schroeder
- 2 days ago
- 11 min read
Written by: Lisa Lenhart, PT
Pelvic Floor Physical Therapist
Core Moves Pelvic Floor Physical Therapy & Pilates – Columbus, Ohio
Reviewed by: Dr. Brittany Schroeder, PT, DPT, WCS, NCPT
Owner, Core Moves Pelvic Floor Physical Therapy & Pilates
Endometriosis is a chronic gynecological condition in which tissue similar to the endometrium (the lining of the uterus) grows outside the uterus. These lesions can develop on the ovaries, fallopian tubes, pelvic peritoneum, and surrounding structures. In some cases, endometriosis can also affect organs beyond the pelvis, including the bowel or bladder.
Endometriosis affects approximately 10% of people of reproductive age worldwide, making it one of the most common gynecologic disorders.
Despite its prevalence and significant impact on quality of life, endometriosis remains underdiagnosed and frequently misunderstood, with research suggesting that diagnosis is often delayed by 4–11 years after symptom onset.
What is Endometriosis?
Endometriosis occurs when endometrial-like tissue grows outside the uterus. Unlike the uterine lining, which sheds during menstruation, this tissue can become trapped within the pelvis, leading to inflammation, scarring, and adhesions.
Endometriotic lesions are typically estrogen-dependent and associated with chronic inflammation, which contributes to many of the symptoms experienced by individuals living with the condition.
Symptoms of Endometriosis
Endometriosis symptoms can vary widely. Some individuals experience severe pain while others may have relatively mild symptoms.
Common symptoms include:
chronic pelvic pain
dysmenorrhea (painful menstrual periods)
dyspareunia (pain during intercourse)
infertility
fatigue and low energy
gastrointestinal symptoms such as bloating, constipation, or diarrhea
dysuria (painful urination)
dyschezia (painful bowel movements)
Many individuals also experience:
lower back or hip pain (it may even mimic sciatica)
pelvic pressure or heaviness
worsening pain during menstruation or ovulation
digestive symptoms that fluctuate with the menstrual cycle
Because these symptoms overlap with other pelvic conditions, many individuals go years without receiving a clear diagnosis.
Disease Severity and Staging
One important and often confusing aspect of endometriosis is that the severity of symptoms does not always correlate with the stage of disease.
Some individuals with relatively small or superficial lesions may experience severe pain, while others with extensive disease may have few or no symptoms. Pain in endometriosis is influenced not only by the amount of visible disease but also by factors such as inflammation, nerve involvement, and changes in how the nervous system processes pain.
How Endometriosis Is Staged
Endometriosis is commonly classified using the American Society for Reproductive Medicine (ASRM) staging system, which categorizes disease into four stages based on the location, depth, and extent of lesions and adhesions:
Stage I – Minimal Small superficial implants with little or no scar tissue.
Stage II – Mild More lesions that may extend slightly deeper into pelvic tissue.
Stage III – Moderate Multiple deep implants, small endometriomas (ovarian cysts), and early adhesions.
Stage IV – Severe Large endometriomas, extensive deep lesions, and dense adhesions involving pelvic organs.
Although staging can help describe the extent of disease, it does not reliably predict the level of pain a person experiences.
For example, individuals with Stage I disease may have debilitating pain, while some individuals with Stage IV disease may primarily experience fertility challenges rather than severe pain.
Endometriosis Outside the Pelvis
While endometriosis most commonly affects pelvic structures, lesions have also been identified in other parts of the body.
Rare cases of extra-pelvic endometriosis have been reported in areas such as:
the diaphragm
the lungs and thoracic cavity
the abdominal wall
surgical scars
and even the eyes or central nervous system
Thoracic endometriosis, for example, has been associated with symptoms such as cyclical chest pain, shortness of breath, or catamenial pneumothorax (lung collapse occurring around menstruation).
These rare presentations highlight how complex and systemic endometriosis can be, and why diagnosis may sometimes be delayed when symptoms occur outside the pelvis.
Conditions That May Overlap With Endometriosis
Endometriosis often occurs alongside other chronic pain and systemic conditions. Research suggests that individuals with endometriosis have higher rates of several overlapping disorders, including:
adenomyosis
interstitial cystitis / painful bladder syndrome
irritable bowel syndrome (IBS)
pelvic floor dysfunction
fibromyalgia
hypermobile Ehlers-Danlos syndrome (hEDS) or generalized joint hypermobility
Some emerging research has also explored possible links between endometriosis and autoimmune diseases such as thyroid disorders, lupus, and rheumatoid arthritis. In addition, interest is growing in the potential role of mast cell activation and immune dysregulation in the development of endometriosis-related inflammation and pain.
These connections are still being studied, but they highlight the complex and systemic nature of chronic pelvic pain conditions. Because symptoms may involve multiple body systems, treatment often benefits from a multidisciplinary approach that may include gynecology, pelvic floor physical therapy, pain management, and other specialists.
Why Endometriosis is Often Misdiagnosed
The exact cause of endometriosis is not fully understood, but several leading theories exist.
Retrograde menstruation
Menstrual blood flows backward through the fallopian tubes into the pelvic cavity, allowing endometrial-like cells to implant outside the uterus. Retrograde menstruation alone does not fully explain all cases of endometriosis, so additional theories involving immune dysfunction, stem cells, genetics, and metaplasia are also being studied.
Coelomic metaplasia
Certain peritoneal cells may transform into endometrial-like tissue.
Immune dysfunction and stem cell theories
Abnormal immune responses may allow ectopic endometrial-like tissue to survive and grow.
Endometriotic lesions can lead to inflammation, fibrosis, and adhesions, contributing to chronic pelvic pain and fertility challenges.
Diagnosis of Endometriosis
Diagnosing endometriosis can be challenging because symptoms often overlap with other pelvic conditions and imaging techniques may not detect smaller lesions.
Clinical Assessment
Evaluation typically begins with a detailed health history and physical examination.
Symptoms that may raise suspicion include:
severe menstrual pain
heavy menstrual bleeding or clotting
chronic pelvic pain
pain with intercourse
infertility
bowel or bladder symptoms that worsen during menstruation
cyclical musculoskeletal pain
Recent clinical guidelines increasingly support symptom-based diagnosis combined with imaging, allowing treatment to begin even before surgical confirmation in some cases.
Imaging Techniques
Transvaginal Ultrasound
Transvaginal ultrasound is usually the first-line imaging tool when endometriosis is suspected.
Advanced ultrasound techniques may detect:
ovarian endometriomas
deep infiltrating endometriosis
pelvic adhesions
Magnetic Resonance Imaging (MRI)
MRI provides more detailed visualization of pelvic structures and is particularly useful for identifying:
deep infiltrating endometriosis
bowel or bladder involvement
rectovaginal lesions
MRI is often used for surgical planning and evaluation of complex cases.
Laparoscopy (Historically the Gold Standard)
Laparoscopic surgery has historically been considered the gold standard for diagnosing endometriosis.
During laparoscopy:
surgeons can directly visualize lesions
tissue samples may be collected for histologic confirmation
Because surgery is invasive and costly, there is growing interest in non-invasive diagnostic tools and earlier symptom-based treatment strategies.
Medical Management of Endometriosis
Medical treatment for endometriosis typically focuses on three goals:
reducing hormonal stimulation of endometriotic tissue
reducing inflammation and pain
addressing changes in pain processing that can occur with chronic pelvic pain
Treatment is individualized based on symptoms, fertility goals, and response to prior therapies.
Hormonal Therapies
GnRH Antagonists
Hormonal treatments are commonly used because endometriotic lesions are generally estrogen responsive.
Examples include oral GnRH antagonists such as:
Orilissa
Myfembree
Yselty (approved in some regions)
These medications reduce gonadotropin signaling and lower estradiol levels, which can decrease stimulation of endometriotic tissue and reduce pain.
Unlike older GnRH agonists such as Lupron Depot, oral GnRH antagonists suppress hormones more rapidly and without the initial hormone “flare.”
Because these medications lower estrogen levels, treatment is often time-limited or combined with add-back hormone therapy to reduce side effects such as bone density loss and menopausal symptoms.
Combined Hormonal Contraceptives
Combined hormonal contraceptives, such as birth control pills, patches, or vaginal rings, are also commonly used to help suppress ovulation, reduce menstrual bleeding, and improve endometriosis-related pain. For some individuals, they are used continuously to reduce the frequency of painful periods.
Progestin Therapies
Progestin-based treatments are commonly used as first-line medical management for endometriosis because they help counteract estrogen’s stimulatory effect on endometriotic tissue.
Examples include:
oral progestins such as norethindrone acetate
injectable progestins such as Depo‑Provera
the levonorgestrel-releasing intrauterine device Mirena
The levonorgestrel IUD works primarily by releasing progestin locally within the uterus, which can suppress endometrial growth, reduce menstrual bleeding, and decrease pelvic pain for some individuals with endometriosis.
Several studies suggest that progestin IUDs may help reduce dysmenorrhea and pelvic pain and are sometimes used after endometriosis surgery to reduce recurrence of symptoms.
Because the hormone is delivered locally, systemic side effects may be lower than with some oral therapies, though individual responses vary.
Pain Management
Anti-Inflammatory Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for symptom relief, particularly for dysmenorrhea.
For example, Celebrex, a selective COX-2 inhibitor, may be prescribed to reduce inflammatory pain.
However, NSAIDs are considered symptom management rather than disease-modifying treatment.
Neuropathic Pain Modulators
In some cases, chronic pelvic pain involves central sensitization, where the nervous system becomes more sensitive to pain signals.
Medications that affect pain processing may sometimes be used, such as the SNRI Cymbalta.
These medications do not treat endometriosis lesions directly but may help reduce pain amplification in the nervous system for some individuals with chronic pelvic pain.
Surgical Treatment of Endometriosis: Excision vs. Ablation
Surgery may be recommended for some individuals with endometriosis, particularly when symptoms are severe, when lesions involve organs such as the bowel or bladder, or when fertility is affected.
Two primary surgical techniques are used to treat endometriotic lesions:
Excision Surgery
Excision surgery involves cutting out (removing) endometriotic lesions completely from surrounding tissue.
This approach aims to remove the full depth of the lesion, including tissue that may extend beneath the surface of the peritoneum.
Potential advantages of excision include:
removal of deeper disease
ability to send tissue for histologic confirmation of diagnosis
potentially lower rates of symptom recurrence in some studies
Because excision requires greater surgical precision and knowledge of pelvic anatomy, it is often performed by surgeons who specialize in advanced endometriosis surgery.
Ablation (Fulguration)
Ablation surgery destroys endometriotic lesions using heat, laser, or electrical energy.
Instead of removing the tissue, the surgeon burns or vaporizes the surface of the lesion.
Ablation may be effective for superficial endometriosis, but it may not fully treat lesions that extend deeper beneath the surface of the tissue.
For this reason, some patients experience persistent or recurrent symptoms after ablation.
Comparing Outcomes
Research comparing excision and ablation has shown mixed results; however, several studies suggest excision may provide improved long-term pain relief for deep infiltrating endometriosis.
However, the best surgical approach depends on many factors, including:
lesion location and depth
patient symptoms
surgical expertise
fertility goals
risk of complications
A gynecologic surgeon experienced in endometriosis management can help determine the most appropriate approach for each individual. Most endometriosis specialists consider excision surgery the most reliable technique for removing visible disease, particularly when lesions extend beneath the surface. For this reason, many surgeons who specialize in endometriosis often counsel appropriate patients toward excisional surgery rather than surface ablation.
Why Pain Can Persist After Surgery
Even when lesions are successfully removed, pain may persist due to other factors such as:
pelvic floor muscle dysfunction
myofascial pain
scar tissue or adhesions
central sensitization of the nervous system
This is one reason that multidisciplinary care, including pelvic floor physical therapy, is often recommended both before and after surgery.
Physical therapy can help address the musculoskeletal and nervous system adaptations that develop with chronic pelvic pain.
How Endometriosis Affects Muscles and Movement
Endometriosis affects more than reproductive organs. Chronic inflammation and persistent pain can lead to secondary changes in surrounding tissues and movement patterns.
These changes may include:
pelvic floor muscle tension
myofascial trigger points
fascial restrictions
altered posture and movement patterns
central sensitization (increased pain sensitivity)
Over time, persistent pain can cause protective muscle guarding in the pelvic floor, abdomen, hips, and lower back, which can further contribute to discomfort and functional limitations.
Think of pain in endometriosis as layers of an onion.
One layer may come from the disease itself—endometriotic lesions, inflammation, and adhesions.
Another layer may involve changes in how the nervous system processes pain, sometimes called central sensitization. Think of it as the nervous system turning the volume up on pain signals.
A third layer can develop from musculoskeletal adaptations, where muscles in the pelvis, abdomen, hips, and lower back become tight or overactive in response to chronic pain as a protective strategy.
Emerging Research in Endometriosis
Recent research is focused on improving early detection, precision diagnosis, and targeted treatments.
Biomarkers for Non-Invasive Diagnosis
Researchers are investigating potential biomarkers that could be detected in:
blood
urine
menstrual fluid
endometrial tissue
Candidates include inflammatory cytokines, microRNAs, and immune markers.
Although promising, no single biomarker has yet proven reliable enough for routine clinical use.
Artificial Intelligence and Imaging
Artificial intelligence (AI) is increasingly being studied as a tool to improve diagnostic accuracy.
AI-assisted analysis of MRI or ultrasound images may help detect patterns associated with endometriosis that can be difficult for clinicians to identify, particularly in subtle or complex cases.
Early studies suggest AI may improve detection of deep infiltrating disease, though these tools remain under development.
Targeted drug therapies
Researchers are exploring new ways to treat endometriosis in the future. Areas of investigation include targeted drug therapies, including repurposing some chemotherapy drugs for use in endometriosis.
Some early research is also investigating cellular pathways such as ferroptosis, a form of iron-dependent cell death that may play a role in endometriosis biology.
These approaches remain experimental and are not currently part of standard clinical treatment but may influence future therapies.
Pelvic Floor Physical Therapy for Endometriosis in Columbus, Ohio
If you are living with endometriosis and pelvic pain, specialized care can make a meaningful difference.
At Core Moves Physical Therapy & Pilates in Columbus, our pelvic floor physical therapists specialize in treating complex pelvic pain conditions including endometriosis, painful intercourse, and chronic pelvic pain.
Our team of pelvic pain specialists integrates:
pelvic floor physical therapy
soft tissue release
nervous system regulation
Pilates-based rehabilitation
whole-body movement retraining
This comprehensive approach helps patients reduce pain, restore movement, and return to the activities they love.
Ready to Start Peeling Back the Layers of Chronic Pelvic Pain?
If you are experiencing pelvic pain, painful periods, or symptoms related to endometriosis, you are not alone—and effective treatment options are available.
At Core Moves Physical Therapy & Pilates, we specialize in helping individuals with pelvic pain regain comfort, confidence, and function.
📍 Located in Victorian Village in Columbus, Ohio
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