Pelvic pain is a common symptom of endometriosis, a condition that can be complex to understand and manage due to the involvement of multiple body systems. However, pelvic pain is not exclusive to endometriosis, it's estimated to affect around 25% of women overall. Among those experiencing pelvic pain, a significant proportion (approximately 35-50%) are diagnosed with endometriosis.

Pelvic pain isn't just painful but can also severely impact on the quality of life of those living with it. It can impact intimacy and sex, toileting, use of period products like tampons or period cups. It can make exercise feel out of reach and impact mental health.

Even in 2026, there are ongoing issues with delayed diagnosis of the underlying causes of pelvic pain in women. This matters as a delayed diagnosis can worsen pain outcomes overall, lead to higher health care use and impact negatively on a woman's quality of life.

Although pelvic pain is a common symptom of Endometriosis, we know that there is no correlation between grade or severity of endometriosis disease diagnosed and pain as a symptom. Many women feel confused when they are diagnosed with grade one endometriosis after laparoscopic surgery but have debilitating pain. They may also be the women who have had normal scans, on-going pain after surgery and fluctuating symptoms. On the contrary women may have more "silent" symptoms of Endometriosis such as subfertility but experience minimal pain with periods or pelvic pain.

Surgery for investigation of Endometriosis is still deemed as the most reliable way to diagnose Endometriosis. But when women still present with pain after surgery what other options should they be given to help them to understand their pain and manage this often-debilitating symptom?

Women with Endometriosis living in Australia and New Zealand may have seen the recent documentary exposing the over use of surgery in women with pelvic pain. This article aims to explore some of the other elements of pelvic pain which deserve attention when working with your specialist and hopefully empowers you to explore your own symptoms and zoom out on your journey with pelvic pain.

Nervous system and pelvic pain:

Our nervous system plays an obvious part in our experience of pain. At the local tissue level, or peripheral sensation, women might experience bowel, bladder and nerve pain. This is where the pain may often start and examples could be endometriosis lesions or bladder and bowel inflammation. Nerves in the pelvis then become more sensitive, imagine someone has dialled up a volume dial communication sensation to your brain. This hypersensitivity in essence mean your threshold becomes lower, causing increased sensation of pain. Sometimes with pelvic pain some of the organs in your pelvis can become over responsive also, meaning that normal stretching of your uterus, bowel or bladder can become more painful. Your brain and spinal cord, or central nervous system, also have a large role to play in this pain story. The dial being "turned up" can cause pain processing pathways to become overactive and the brain learns pain. Imagine the strength in communication between your foot and your brain if you walked around with a stone in your shoe all day, your body would be sending signals to your brain more readily.

Inflammation and pelvic pain:

Endometriosis is known to be an inflammatory disease and we understand that this inflammation can contribute to pelvic pain in several ways. Chronic inflammation can, as explained earlier, make the nerves within the pelvic space and organs more reactive and hypersensitive over time. Inflammation can also cause the release of inflammatory substances in the body such as cytokines and even Prostaglandins which can stimulate pain receptors and increase pain. Prostaglandins are produced naturally around the time of our period and are involved in uterine contraction and period cramps but it is thought that women with Endometriosis produce more Prostaglandins than women without Endometriosis.

Inflammation can also cause an increase in communication between other organs and systems in the pelvic floor. This can influence the digestive system, bladder and even the pelvic floor muscles which can become activated, hypersensitive and contribute to pelvic pain.

This is why management often goes beyond just treating lesions, and may include strategies to reduce inflammation, support the nervous system, and address contributing factors like gut health and pelvic floor dysfunction.

Physiotherapy support for pelvic pain:

Pelvic floor function and muscle tension are elements of pelvic pain management that pelvic floor physiotherapists are able to diagnose and treat for their clients. Pelvic floor muscles can become overactive, tight, weak, or poorly coordinated, all of which can contribute to pain. This is why physio targets muscle tone, coordination, and relaxation, not just strength.

In women with endometriosis, adding pelvic floor training and exercise improved current pelvic pain, with benefits lasting up to 12 months.

Psychology and pelvic pain:

Research shows a strong two-way relationship between chronic pelvic pain (CPP) and psychological distress, with high rates of anxiety, depression, and trauma commonly reported in affected individuals. The brain and pelvic floor muscles are closely linked, and psychological factors such as stress and catastrophic thinking can amplify pain by increasing muscle tension and nervous system sensitivity, creating a self-reinforcing cycle of pain and stress.

There are many psychological impacts of pelvic pain. More than 50% of women with chronic pelvic pain report moderate-to-severe anxiety, and over 25% have moderate-to-severe depression, often worsening quality of life. Living with pain not only changes how women think but can also reduce participation in aspects of life due to fear of pain. Pain is exacerbated by "catastrophizing" (expecting the worst) and "fear-avoidance" (avoiding activities or sexual intercourse due to fear of pain).

Research currently suggests that a multidisciplinary approach including mental health professionals is considered most effective for managing chronic pelvic pain.

Psychological interventions, including Cognitive Behavioural Therapy (CBT) and mindfulness-based strategies, can be helpful in disrupting the cycle of anxiety, pain, and muscle tension. These approaches also support reduced catastrophic thinking (expecting the worst) and improved stress regulation.

Nutrition and pelvic pain:

The two main goals of nutrition for management of pelvic pain are to:

• Support digestion and minimise symptoms of gut issues including irritable bowel syndrome which is common (up to 80%) in women with Endometriosis and pelvic pain

• Include anti-inflammatory foods, nutrients and in some cases supplementation which can improve symptoms associated with inflammation and pelvic pain

While we are currently lacking a large diet focused randomised controlled trial (RCT) for Endometriosis and diet, the highest quality research model in gathering of scientific evidence, last year a large observational study of diet habits and pelvic pain in women with Endometriosis was published. This study found that 45% of those who stopped eating gluten and 45% of those who cut out dairy reported experiencing an improvement in their pain.

When women cut down on coffee or other caffeine in their diet, 43% said their pain was reduced, while 53% of women who cut back on alcohol reported the same.

The exact mechanism of how these eliminations of gluten, dairy, caffeine and alcohol reduce pain is not clear but there are various theories.

Many women with Endometriosis are thought to have a non-coeliac gluten intolerance which can cause symptoms such as bloating, constipation or abdominal pain which can worsen pelvic pain. Gluten is also found in wheat foods and wheat is a FODMAP or a type of fermentable carbohydrate that is more likely to cause fermentation and bloating in women with Endometriosis and irritable bowel syndrome. Many dairy foods also contain lactose such as milk, ice cream and yoghurt and lactose too is a FODMAP containing food. Caffeine intake can impact the nervous system which has a key role in pelvic pain and can also impact mood, sleep and the gut which are all important elements of anti-inflammatory treatment for women with Endometriosis. Alcohol intake can impact on the gut microbiome which again have a role in digestion, inflammation and hormone clearance from the body. While we can't yet make the universal statement that women with Endometriosis should reduce or avoid these foods there is evidence that for those with on-going pelvic pain symptoms it would be worth at least trialling a reduction in gluten, dairy, caffeine and alcohol to see if it can impact on their symptom of pain.

The low FODMAP diet, developed initially by Monash University in Australia also can be recommended for those with irritable bowel syndrome and Endometriosis. While not a direct treatment for pelvic pain, the low FODMAP diet and reintroduction protocol can help women identify foods which increase their bowel symptoms that might in turn contribute to pelvic pain.

Anti-inflammatory nutrition principles may also help reduce pelvic pain in women with Endometriosis. The Mediterranean diet continues to be the lead dietary pattern recommended for many conditions associated with inflammation, including Endometriosis. The Mediterranean diet focuses on inclusion of:

• Omega-3 fatty acids: salmon, mackerel, sardines, flaxseeds, chia seeds, and walnuts, avocados and olive oils

• Plant based antioxidant rich foods: colourful vegetables (leafy greens, cruciferous veg) and fruits especially berries

• Increase fibre intake from higher fibre foods such as wholegrains, beans, legumes, seeds. These foods play a role in microbiome health which aid in the breakdown of Oestrogen which can help improve symptoms

• Swap to healthy fats in cooking such as olive oil and avocado oil

There is also some evidence that specific nutrients may play a role in reducing inflammation. These include Magnesium, found in dark chocolate, seeds and dark green vegetables, and Zinc, found in wholegrains and seafoods. Supplementation with Vitamin E, Vitamin D, Curcumin (derived from Turmeric) and N-acetyl-cysteine (NAC) may also reduce inflammation and pelvic pain.

Pelvic pain is common and often complex, and it can affect many areas of a woman's life. This includes quality of life, mood, and the ability to enjoy things like intimacy and exercise or sport. Because of this, managing pelvic pain usually requires more than just medical care, and is best supported through a team approach that may involve nutrition, physiotherapy, and psychological support.

References:

https://nzendo.org.nz/endo-news/major-endometriosis-study-reveals-impact-of-gluten-coffee-dairy-and-alcohol/

Gabrielsen R, Tellum T, Bø K, Engh ME, Frawley H, Nedregård Tveito S, Tennfjord MK. Supervised exercise and pelvic floor muscle training eases current pelvic and genital pain but not worst pelvic and genital pain in women with endometriosis: a randomised trial. J Physiother. 2025 Oct;71(4):246-253. doi: 10.1016/j.jphys.2025.09.012. Epub 2025 Sep 25. PMID: 41006088.

Till, S. R., As-Sanie, S., & Schrepf, A. (2019). Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment. Clinical obstetrics and gynecology, 62(1), 22–36. https://doi.org/10.1097/GRF.0000000000000412

Abulughod, N., Valakas, S., & El-Assaad, F. (2024). Dietary and Nutritional Interventions for the Management of Endometriosis. Nutrients, 16(23), 3988. https://doi.org/10.3390/nu16233988

Rakel, D. (2007). The anti-inflammatory diet: How the “Western” diet promotes inflammation. Accessed October 27, 2012 at http://www.fammed.wisc.edu/integrative/modules

Rakel, D., & Rindfleisch, A. (2005). Inflammation: Nutritional, botanical, and mind-body influences. Southern Medical Journal, 98(3), 302-310. Mills, D. S., & Vernon, M. (2002). Endometriosis: A key to healing and fertility through nutrition.

Thorsons. University of Wisconsin School of Medicine and Public Health (2007). The anti-inflammatory diet. Accessed October 27, 2012 at http://www.fammed.wisc.edu/integrative/modules