Can Physical Rehab Reduce Endo and Adeno Pain?

When your pelvis hurts, “exercise” can sound insulting

If you live with endometriosis or adenomyosis, you’ve probably been told (directly or indirectly) that your pain is “just cramps,” or that you should “move more.” Meanwhile, you may be dealing with debilitating period pain, pain with sex, bowel/bladder pain, fatigue, and the kind of constant pelvic tension that makes sitting, walking, or working feel impossible.

Here’s the validating part: a growing body of evidence suggests physical rehabilitation—things like pelvic floor physiotherapy, targeted exercise programs, and certain clinic-based modalities—can meaningfully improve pain and quality of life for many people. This isn’t about pushing through pain or doing random workouts. It’s about using the body-focused tools that can calm an overprotective, painful pelvic system and improve function alongside medical care.

A 2025 systematic review and meta-analysis pulled together controlled trials of rehabilitation for endometriosis and adenomyosis symptoms and found overall improvements—especially in pain and quality of life—with benefits described as particularly promising for endometriosis. (More on what that means for adenomyosis in a bit.)

What “physical rehabilitation” means for endo/adeno (in real life)

In this research, physical rehabilitation isn’t one single program. It’s a category that included three broad approaches:

Therapeutic exercise programs. These are typically structured plans (not “just go to the gym”) that can include strength, mobility, gentle aerobic work, posture/hip stability, breathing, and graded activity that respects flare patterns.

Manual therapy-based approaches. This includes pelvic floor physiotherapy (PFP) and other hands-on care (one example mentioned was Swedish massage). Pelvic floor PT may involve external and/or internal assessment and treatment, education, down-training for overactive pelvic floor muscles, gentle mobility, and strategies to reduce pain with penetration or pelvic exams.

Electrophysical agents. These are clinic-delivered modalities (the review groups them together as “electrophysical agents”) which are drug-free and include modalities like TENS (nerve stimulation), ultrasound, heat/cold packs, laser and red light therapy, and interferential current (IFC). The important takeaway isn’t the device name—it’s that some studies used non-drug physical modalities aimed at reducing pain and improving function.

What matters for you: you don’t have to pick “rehab” instead of hormones/surgery. For many people, rehab is a layer of treatment—especially when pain has started to affect pelvic floor muscles, movement patterns, sex, sleep, mood, and daily function.

What you can realistically expect it to help most

Across the controlled trials included in the review, the most consistent improvements after rehabilitation were in:

• • Pain
  • Quality of life
  • Mental health measures (in some studies)

When the data could be pooled across studies, the meta-analyses favored rehabilitation for pain (11 studies) and quality of life (5 studies). The paper excerpt provided doesn’t include the exact size of benefit (how many points pain dropped, for example), so it’s not responsible to promise “your pain will drop by X.” But the direction is consistent: many patients improve.

A practical way to use this: if your biggest goals are “less pain” and “a more livable day-to-day life,” rehab is one of the non-surgical options with controlled-trial evidence behind it.

What about sex pain, pelvic tightness, and “my whole core feels broken”?

Some trials also looked beyond pain scales and quality-of-life questionnaires, including:

• • Lumbopelvic impairments (think: hip/back/pelvic mobility and stability issues that make movement painful or restricted)
  • Sexual function
  • Bone mineral density (important if you’ve used medications that affect estrogen or if activity has been limited)

This matters because endometriosis and adenomyosis pain often doesn’t stay neatly in the uterus/lesions. Over time, your body can develop protective muscle guarding, altered movement, and fear of triggering flares—none of which are “in your head,” and all of which can be legitimate targets for skilled rehabilitation.

Endometriosis vs adenomyosis: set expectations honestly

The review authors describe the benefits as particularly promising for endometriosis. That does not mean rehab can’t help adenomyosis. It means the evidence base may be stronger or more plentiful for endometriosis, and adenomyosis-specific conclusions may be less certain.

If you are suspected to have adenomyosis based on symptoms and imaging, your best move is to bring this up explicitly and ask for a plan that targets your symptom pattern: heavy bleeding and cramping, deep pelvic aching, pain with sex, bladder/bowel symptoms, pelvic floor spasm, back/hip pain, fatigue, and any activity limitations.

Who tends to be a good candidate for rehab?

You may be especially likely to benefit if any of these sound like you: pain with sex or penetration, pelvic exams are intolerable, you feel pelvic tightness/“clenching,” pain spreads into hips/back, sitting is difficult, flares happen with activity, or you’re avoiding movement because it triggers symptoms.

Rehab can also be useful if you’re:

• • on hormonal treatment but still symptomatic,
  • trying to avoid escalating medication side effects,
  • preparing for surgery (prehab) or recovering after surgery (at Lotus we use this routinely)
  • dealing with persistent pain even after excision/hysterectomy (which can happen).

How long before you know if it’s working?

Because the review included different types of rehab with different schedules, there isn’t one universal timeline. A practical, patient-centered approach is to agree on a time-limited trial with your provider (often several sessions over weeks) and track a few concrete outcomes: pain severity, flare frequency, ability to sit/walk/work, bowel/bladder comfort, and sexual pain.

If nothing is improving—or if therapy repeatedly triggers significant flares without adjustment—that’s not a sign you “failed rehab.” It’s a sign the plan needs to change (different therapist, different approach, different pacing) or that another layer of treatment is needed.

Practical takeaways: how to talk to your doctor or physiotherapist

Use this as your script—because walking in with clear questions can save months.

• • “I want to add physical rehabilitation to my endometriosis/adenomyosis treatment plan. Do you have referrals to pelvic floor physiotherapists who routinely treat pelvic pain?”
  • “Given my symptoms (pain with sex / bowel pain / bladder pain / hip-back pain / pelvic tightness), which approach fits best: pelvic floor PT, an exercise-based program, or both?”
  • “How will we measure progress? Can we set goals like fewer flares, improved ability to sit/walk, and changes in pain with penetration?”
  • “What should I do if sessions trigger a flare—what’s the plan for pacing and symptom-guided progression?”
  • “If it looks like I have adenomyosis, what’s your experience using rehab specifically for adeno-related symptoms, and how will we coordinate it with my bleeding/pain management?”

Red flags and “don’t-let-anyone-gaslight-you” signs

Rehab should not be a situation where you’re repeatedly pushed through severe pain. Be cautious if you’re told you must endure high pain to “release” something, or if internal work is done without informed consent, clear explanation, and ongoing permission.

Seek urgent medical care for severe symptoms that could indicate something else (for example: sudden severe abdominal pain, fainting, heavy bleeding you can’t control, fever, or signs of infection). Rehab is supportive care—it doesn’t replace medical evaluation when something feels dangerous.

Reality check: what we still don’t know

This is promising, but it’s not a magic fix. The review included a mix of randomized and controlled non-randomized studies because high-quality RCTs are still limited in this area. Different rehab modalities were grouped under the same umbrella, and they may not work equally well for every symptom profile.

Most importantly: this excerpt doesn’t provide the actual effect sizes, so we can’t translate it into “expected pain reduction” for an individual person. Your outcome will depend on factors like disease burden, bleeding control, pelvic floor tone, nervous system sensitization, prior surgeries, coexisting conditions (IBS, bladder pain syndrome, hypermobility, migraines), and the skill of the provider.

Still, if you’ve felt stuck—especially if medication alone hasn’t given you your life back—adding a rehab layer is a reasonable, evidence-supported next step to discuss.