Shoulder Pain

Shoulder pain isn’t usually the first symptom people associate with pelvic conditions, but in some patients it can be linked to endometriosis outside the pelvis, particularly on the diaphragm. This is often described as pain in the right shoulder (though it can be left-sided or both), and it may occur with chest discomfort, pain with deep breathing, or symptoms that follow a cyclical pattern. If you’re living with suspected or confirmed endometriosis, shoulder pain can be an important clue that disease may involve the upper abdomen.

In endometriosis, endometrial-like tissue can implant on or near the diaphragm. During the menstrual cycle, these implants may swell, bleed, and trigger inflammation—irritating the diaphragm and nearby nerves. The diaphragm shares nerve pathways with the shoulder (particularly via the phrenic nerve), so the brain can “interpret” diaphragmatic irritation as shoulder pain. This is called referred pain, and it can feel surprisingly intense even when the shoulder joint itself is normal.

Adenomyosis (tissue growing into the uterine muscle) doesn’t typically cause shoulder pain directly. However, adenomyosis often co-occurs with endometriosis, and people with adenomyosis may experience higher overall inflammatory burden, heavier bleeding, and more frequent pain flares. In real life, that overlap can make it hard to separate what’s driving symptoms without a specialized evaluation.

Because shoulder pain is common in the general population, it’s easy for cyclical, endometriosis-related shoulder pain to be mistaken for a rotator cuff injury, pinched nerve, gallbladder issues, reflux, anxiety, or even “sleeping wrong.” The key differentiator many patients notice is timing (worse before/during periods or ovulation), recurrence, and association with other symptoms like pelvic pain, bloating, fatigue, or chest pain. If you suspect diaphragmatic involvement, exploring resources in our Diaphragmatic Endometriosis category can help you recognize patterns and prepare for next steps.

People often describe endometriosis-related shoulder pain as a deep ache, pressure, or stabbing sensation near the top of the shoulder, under the collarbone, or along the shoulder blade. Some feel it as a sharp pain when taking a deep breath, stretching tall, coughing, or laughing. Others notice a constant soreness that doesn’t behave like a typical muscle strain and doesn’t improve much with massage or rest.

A common theme is cyclicity: it may start a day or two before bleeding, peak during the first days of the period, and then ease—only to return the next cycle. Some patients also experience shoulder pain around ovulation, especially if they have broader inflammatory flares. If disease involves the diaphragm or nearby lining tissue, the pain can be paired with Chest Pain or even Shortness of Breath, which can be frightening.

Experiences vary widely. Some people have occasional mild twinges; others have disabling pain that interrupts sleep, work, exercise, or driving. Over time, symptoms can become more frequent or less clearly cyclical—especially when inflammation and nerves become sensitized—so keeping a symptom diary can be helpful when you go in for evaluation.

Shoulder pain is not among the most common endometriosis symptoms overall, but it is a recognized hallmark symptom when endometriosis affects the diaphragm or upper abdomen. Diaphragmatic endometriosis is considered less common than pelvic disease, and it’s also underdiagnosed because symptoms can mimic orthopedic or gastrointestinal issues and imaging may miss superficial lesions.

Research estimates vary widely depending on the population studied and how thoroughly the diaphragm is evaluated during surgery. Importantly, symptom presence doesn’t always match what’s seen on imaging—and the absence of findings on scans does not reliably rule it out. When shoulder pain is cyclical and paired with pelvic symptoms, the likelihood of endometriosis involvement increases, even if overall “stage” of endometriosis is not severe.

Adenomyosis alone isn’t strongly associated with shoulder pain, but because adenomyosis frequently coexists with endometriosis, patients diagnosed with adenomyosis who also have cyclical shoulder/chest pain may warrant assessment for extra-pelvic endometriosis as well.

In endometriosis, the most endometriosis-specific cause of shoulder pain is diaphragmatic irritation with referred pain. Endometrial-like implants can trigger local inflammation and scarring on the diaphragm. The diaphragm is innervated by the phrenic nerve (C3–C5), and irritation there can be felt as pain in the shoulder—often on the right side.

Inflammation also matters. Endometriosis is associated with inflammatory signaling molecules that can sensitize nerves and amplify pain. Over time, this may contribute to heightened pain responses (sometimes called “central sensitization”), where pain becomes easier to trigger and slower to settle.

In adenomyosis, the uterus becomes inflamed and can generate significant pelvic pain, heavy bleeding, and cramping. While adenomyosis doesn’t typically refer pain to the shoulder, living with persistent pelvic pain can increase overall muscle tension (neck/upper back guarding) and make seemingly “separate” pain problems worse. That’s why comprehensive evaluation often looks at both gynecologic causes and musculoskeletal/nerve contributors.

Other factors can influence symptoms: posture changes during pain flares, reduced diaphragmatic movement from guarding, constipation/bloating pushing upward, and stress-related muscle tightening can all magnify shoulder discomfort. This is also why a multidisciplinary plan—rather than a single treatment—often helps most.

Treatment depends on whether the shoulder pain is coming from diaphragmatic endometriosis, pelvic disease with referred/nerve pain, coexisting adenomyosis, or a non-gynecologic shoulder/chest condition. A first step is a thorough history (especially cycle timing) and targeted evaluation through a specialist experienced in complex endometriosis. Learn what that process can look like on our Evaluation & Diagnosis page.

Medical therapy may reduce cyclic flares by suppressing ovulation and menstruation. Options can include continuous combined hormonal contraceptives, progestin therapy, or other hormonal approaches discussed in our Hormonal Therapy resource. For symptom control, individualized plans from Pain Management can include anti-inflammatories, neuropathic pain medications when appropriate, and strategies to calm sensitized nerves.

When diaphragmatic endometriosis is suspected and symptoms are significant—or when quality of life is being impacted—surgical treatment may be considered. In expert hands, minimally invasive excision surgery is widely considered the gold standard approach for removing endometriosis lesions, especially deep or complex disease. Lotus Endometriosis Institute specializes in advanced, minimally invasive techniques—see Surgery & Advanced Excision and learn more about Dr. Steven Vasilev. Diaphragm disease may require careful mapping and a surgeon experienced with upper-abdominal endometriosis.

For adenomyosis-driven symptoms (heavy bleeding and uterine pain), treatments may include hormonal suppression, non-hormonal medications for bleeding/pain, and—depending on fertility goals—uterus-sparing or definitive options. You can explore the range on our adenomyosis page.

Supportive care can matter too: gentle breathing exercises, heat, pacing, and anti-inflammatory lifestyle support may reduce flare intensity. Pelvic floor physical therapy can be helpful when the nervous system is “on high alert,” and integrative approaches such as acupuncture, nutrition support, and mind-body techniques can complement medical/surgical care—see Integrative Medicine & Lifestyle Care and our Pain Relief resources. The goal isn’t to make you “cope” with severe pain—it’s to reduce suffering while treating root causes.

Seek urgent medical care right away if shoulder pain occurs with red-flag symptoms such as severe chest pressure, fainting, sudden shortness of breath, coughing blood, new one-sided weakness/numbness, fever with worsening pain, or pain after an injury. These can signal heart, lung, or vascular problems that must be ruled out promptly.

Schedule a specialist evaluation if your shoulder pain is recurrent, cyclical (worse around periods/ovulation), paired with pelvic symptoms, or not improving with standard musculoskeletal care. It can help to bring a symptom timeline: when it starts in your cycle, what makes it worse (deep breaths, lying down), and whether it comes with Chest Pain or Shortness of Breath. If you feel dismissed, it’s appropriate to advocate for yourself—upper-abdominal endometriosis is real and can be missed.

If you suspect diaphragmatic endometriosis or complex endometriosis/adenomyosis, we’re here to help you get clarity and a plan. You can schedule a consultation to discuss symptoms, diagnostic options, and whether advanced excision may be appropriate.