Endometriosis: More Than Period Pain
Understanding Endometriosis: More Than Painful Periods
Written by Dr. Fiona Callender, ND and Pelvic Therapist
Endometriosis is a complex, often misunderstood gynecological condition that affects an estimated 1 in 10 women and people assigned female at birth worldwide. It is defined by the presence of endometrial-like tissue (similar to the lining of the uterus) growing outside the uterus.
These lesions are most commonly found on the ovaries, fallopian tubes, the outer surface of the uterus, and other organs within the pelvis. In some cases, they can also appear outside the pelvic cavity.
While many people associate endometriosis with “bad periods,” the reality is far more nuanced.
Common Symptoms
Symptoms vary widely from person to person. Some individuals are severely impacted, while others may have few or no symptoms at all.
Common symptoms include:
Chronic pelvic pain (which may or may not follow the menstrual cycle)
Painful periods that interfere with daily functioning
Pain with intercourse
Pain with bowel movements
Fertility challenges
Fatigue and other more full body symptoms
Importantly, the severity of pain does not reliably correlate with the severity of disease. Someone with minimal visible lesions may experience debilitating pain, while another with extensive disease may have little to no discomfort. In fact, up to 25% of individuals with endometriosis are asymptomatic.
This disconnect can be confusing. I find that validating this reality is an important part of care.
Diagnosis: Why It Can Take So Long
Symptoms are often what guides us toward further investigation.
Period pain that limits work, school, or daily life
Pain with bowel movements or intercourse
Ongoing pelvic pain outside of menstruation
Difficulty conceiving
The “gold standard” for diagnosis is laparoscopic surgery, which allows direct visualization (and often removal) of lesions. However, imaging techniques and our ability to interpret them - including ultrasound and MRI - have significantly improved and can now detect certain types of lesions more reliably.
One important finding is an endometrioma - a cyst on the ovary filled with endometrial tissue. The presence of an endometrioma strongly suggests endometriosis elsewhere in the pelvis. Only about 15% of people with an endometrioma do not have additional endometriosis lesions.
Even so, many individuals wait years for diagnosis. During that time, pain can become more complex and more deeply embedded in the nervous system.
Why Pain and “Severity” Don’t Always Match
The most widely used staging system is the revised American Society for Reproductive Medicine (rASRM) classification from the American Society for Reproductive Medicine. This system categorizes endometriosis into four stages (minimal to severe) based on the number, size, depth, and location of lesions and adhesions.
While helpful for surgical documentation and communication, this staging system does not reliably predict:
Pain intensity
Fertility outcomes
Quality of life
This is why someone can be told they have “mild” endometriosis while still living with severe pain.
It also helps explain why surgery or hormonal suppression does not always eliminate symptoms. Pain in endometriosis is multifactorial.
Understanding the Different Types of Pain
Pain in endometriosis is rarely just one thing. Often, multiple pain mechanisms overlap.
1. Nociceptive Pain
This type of pain results from tissue injury or inflammation. In endometriosis, inflammatory processes surrounding lesions trigger pain signals. This is the pain most directly tied to visible disease.
2. Neuropathic Pain
Neuropathic pain develops when nerves become sensitized or when lesions invade or irritate nerve fibers. This is more common in deeply infiltrating endometriosis. In these cases, lesion depth may correlate more strongly with pain intensity.
3. Nociplastic Pain (Central Sensitization)
This type of pain reflects changes within the central nervous system. Over time, repeated pain signals can amplify how the brain processes discomfort.
Central sensitization may present as:
Widespread body pain
Fatigue
Sleep disturbances
Heightened pain sensitivity
This mechanism explains how someone with minimal lesions can experience severe, persistent pain.
Most individuals with long-standing endometriosis have some combination of these pain types.
What This Means for Treatment
Understanding pain mechanisms helps explain why removing visible lesions doesn’t always eliminate pain and why hormonal therapies that shrink lesions may not fully resolve symptoms. A comprehensive approach is often necessary,
My approach involves helping you advocate for treatments and referrals within the medical system as treatment may involve a combination of the following:
Medical management (hormonal or non-hormonal options)
Anti-inflammatory strategies
Nervous system regulation
Pelvic floor physical therapy
Pain education and psychology
Lifestyle and supportive therapies
Pain is complex, so our treatment is often a combination of supports that approach your concerns as fully as we can. There are a number of supports that I am able to offer, pelvic floor therapy being a big one:
Why Pelvic Floor Therapy Matters
Chronic pelvic pain often leads to protective muscle tension in the pelvic floor. Think of it as the body “guarding” against anticipated pain. Over time, this guarding can lead to:
Muscle spasms
Myofascial restriction
Increased pressure and sensitivity
Pain with intercourse or bowel movements
This muscular tension can perpetuate pain, creating a feedback loop:
Pain → muscle guarding → more pain → nervous system sensitization → amplified pain.
Pelvic floor therapy works to gently interrupt this cycle by addressing muscular and myofascial dysfunction or tension, nervous system regulation, breathing and movement patterns, and aspects of central sensitization.
For many individuals, this becomes an important part of a comprehensive pain plan.
A Whole-Person Approach
In my office, conversations often include:
Reviewing medications your physician has offered
Advocating for options aligned with your goals
Addressing inflammation and nervous system health
Supporting with lifestyle and nutrition
Exploring pelvic floor therapy
Pain that has been building for years - especially while waiting for answers - does not resolve overnight. Rewiring a sensitized nervous system takes time, patience, and support.
Endometriosis is more than painful periods. It is a complex condition that deserves nuanced care, validation, and an individualized treatment plan.
You deserve to be heard and supported at every stage of that journey.
If you would like to know more about how I can support you, you can book a complimentary meet and greet in my schedule by clicking the link below.