What motivated you to test supervised exercise and pelvic floor muscle training as part of pain management for people with endometriosis? 

At Akershus University Hospital, women with pelvic and genital pain—including women with endometriosis—already take part in group training sessions led by women’s health physiotherapists. 

These sessions have been well received, but there are currently no established treatment guidelines that recommend exercise specifically for women with endometriosis. 

The National Institute for Health and Care Excellence guidelines emphasise the need for further research in physical activity and pain management. 

There is a lack of good conservative treatment options for women with endometriosis, which further motivated us to explore the potential benefits of exercise and pelvic floor muscle training alongside pain management strategies. 

Many people with endometriosis report muscle pain, particularly in the pelvic floor muscles. 

After years of living with pain, some also become hesitant about using their body, worrying that activity might make their symptoms worse. 

Supervised training provided us with the opportunity to adjust intensity levels, offer reassurance and create a safe environment for exploring movement. 

Physical activity is generally recognised for its positive health effects and it may be particularly beneficial in the context of long-term pain. 

Your trial found that exercise reduced women’s current pelvic and genital pain but not their worst pain. How should clinicians and patients interpret this difference? 

Endometriosis is a complex condition and multiple factors often influence the most severe pain. 

When pain is at its worst, clinicians should discuss different pain management strategies with their patients. 

Strategies may include applying heat (such as from a warm bottle), transcutaneous electrical nerve stimulation or breathing exercises. 

Our study suggests that supervised exercise and pelvic floor muscle training can reduce women’s current, day-to-day pain. Even small amounts of tailored exercise may make a difference. 

No adverse effects were reported from the program. Is this enough to establish the safety of exercise and pelvic floor muscle training for women with endometriosis? 

The absence of reported adverse effects is an encouraging finding. 

One likely reason is that the sessions were supervised, allowing instructors to monitor participants closely and suggest alternatives when needed. 

Exercise should be adapted not only to each participant’s pain level but also to daily variations in energy, sleep and pain. 

Some women achieved better results by reducing intensity, while others benefited from encouragement to get started. 

Striking the right balance between activity and rest appears to be a key factor for this group. 

Adherence to home training and pelvic floor muscle exercises was relatively low. What strategies might help women sustain these routines in real life? 

In our trial, the physiotherapist leading the group encouraged participants to complete their home-based training. 

Adherence might be further enhanced through follow-up appointments and the integration of supportive tools, such as exercise applications or daily reminders. 

A potential explanation for low adherence with home-based exercises is the symptom burden commonly experienced by this population, including significant pain, poor sleep and fatigue. 

Endometriosis-related pain is complex, involving both physical and psychological factors. How do you see exercise fitting into a multidisciplinary approach to care? 

Effective teamwork is crucial; women should first be evaluated and monitored by a gynaecologist to ensure suitable medical treatment, including hormonal therapy when needed. Psychologists and psychiatrists also play a vital role in supporting patients through pain management approaches. 

Conservative interventions such as physical activity offer patients an active, self-directed approach that can be tailored in terms of type and intensity according to individual needs, fostering a greater sense of agency and control over their condition.

Looking ahead, what further research is most needed to strengthen the evidence for exercise as a treatment option for endometriosis pain? 

It would be valuable to conduct a study focusing exclusively on pelvic floor muscle training. 

If this had been the sole focus, participants might have found it easier to perform the exercises more consistently. 

Further research is needed to explore the differences in exercise modalities and intensity levels in order to better understand their relative effectiveness for women with endometriosis. 

>>Rakel Gabrielsen is a PhD student at the Department of Obstetrics and Gynaecology in Akershus University Hospital. Her research focuses on exercise and pain management. She has worked as a women’s health physiotherapist since 2015, specialising in pelvic floor dysfunction and endometriosis.

Email inmotion@australian.physio for references.