Persistent pelvic pain is a leading health concern for women, girls and other people with a uterus. 

There are a variety of causes but endometriosis is considered to be the predominant condition. 

Others include the related condition adenomyosis, vulvodynia, dyspareunia, irritable bowel syndrome and bladder pain syndrome (see breakout). 

While these conditions primarily affect women and girls, men can also experience complex pelvic pain. 

‘Pelvic pain can affect women right across the life span, from young girls presenting with problem periods to persistent pelvic pain at any age,’ says clinician researcher Elise Fraser MACP, APA Titled Women’s, Men’s and Pelvic Health Physiotherapist, who leads the Master of Physiotherapy (Pelvic Health) program at the University of Melbourne. 

Persistent pelvic pain is thought to affect as many as one in four women and it is currently estimated that 14 per cent of girls and women in Australia will be affected by endometriosis by the age of 49 (AIHW 2025). 

This places a significant burden on Australia’s healthcare system; in 2022–23 it cost $293 million and resulted in more than 44,000 hospitalisations. 

A key barrier to diagnosing persistent pelvic pain is identifying the many contributing factors. 

The pelvis holds several organ systems—the bladder, the bowels and the reproductive organs, including the uterus, ovaries and vagina (in women)—in very close proximity to the nervous system and the pelvic musculoskeletal system. 

Not only can it be difficult to identify where the pain is coming from, but cross-talk between nerves can sensitise other organs in the region. 

‘Because of the shared neural pathways, irritation or inflammation in one of those organs can then affect the others. 

‘That’s why someone with endometriosis might have all of these other problems as well, like bladder problems or bowel problems, even if they don’t have visible endometriosis lesions nearby,’ says Dr Jane Chalmers APAM, a pain science researcher and physiotherapist at the University of South Australia. 

Adding to the complexity is the time it takes to be diagnosed with endometriosis and other contributing conditions. 

Diagnosis of endometriosis typically takes six to eight years and relies on specialised pelvic ultrasound or MRI as a first-line option rather than surgery and biopsy to identify endometrial lesions (AIHW 2025), although as awareness and knowledge of the condition increase— both generally and among medical professionals— women are being diagnosed faster and younger. 

The role of physiotherapy 

Dr Jane Chalmers is a pain science researcher and physiotherapist at the University of South Australia.

While at first glance it may not seem that physiotherapists have a big part to play in treating pelvic pain and endometriosis, given the reliance on pharmacological and surgical management, the profession’s growing role in pain management and pelvic health makes it a player in the space. 

‘We can’t treat the disease itself—that happens through surgery and hormonal suppression—but we treat the consequences of people being in pain for a long period of time,’ explains Dr Angela James FACP, a Specialist Women’s, Men’s and Pelvic Health Physiotherapist (as awarded by the Australian College of Physiotherapists in 2022) and chair of the APA Women’s, Men’s and Pelvic Health national group. 

‘Largely that’s about addressing the consequences of a tight and tender pelvic floor, including bladder symptoms, sexual dysfunction and bowel symptoms.’ 

Pelvic health physiotherapists are specifically trained to assess the pelvic floor, says Elise. 

‘We look for increased tone and tenderness in the muscles and at the skill of pelvic floor contraction and relaxation. 

‘We can also do special tests to detect pain types such as allodynia or potential neuropathic considerations like pudendal nerve symptoms. 

‘It’s just like any physical assessment—it’s a part of the puzzle that helps us see whether the muscles of the system are sensitised and identify a treatment target.’ 

The big difference, though, is that the physical assessment takes place in a very intimate part of the body. 

Pelvic health physiotherapists receive additional training in working with patients who might have experienced trauma, which can affect both their pain and the way it is treated and managed. 

‘Our job is not to treat the trauma. 

‘Our job is to work with the patient, to recognise a trauma response and to wrap support around them and be part of a team of the right professionals that can help them,’ Elise says. 

An important aspect of treating patients with persistent pelvic pain or endometriosis is to use a whole-person approach to care. 

‘We bring an approach to the treatment that is person-centred, biopsychosocial, trauma-informed, multidisciplinary and collaborative,’ says Professor Helena Frawley FACP, a Specialist Women’s, Men’s and Pelvic Health Physiotherapist (as awarded by the Australian College of Physiotherapists in 2011) and a lecturer and women’s and pelvic health physiotherapy researcher at the University of Melbourne. 

‘Anything that’s very specific to the pelvis should be addressed by a pelvic health physiotherapist but to a certain extent, pain management can be provided by any physiotherapist who has experience and expertise in management of persistent pain. 

‘You could also provide more specific advice on general exercise, sleep, relaxation, nutrition, dealing with distress and anxiety, behaviour change techniques, lifestyle modification and selfmanagement.’ 

Specialised training 

Elise Fraser says physiotherapists need to be trained to do pelvic health assessments.

Pelvic health physiotherapy is typically not taught to students in the entry-level courses at more than an introductory level. 

The physiological knowledge and hands-on skills needed are advanced and can only be learned after registration through specific professional or post-graduation courses. 

While a range of professional development courses exist to introduce interested physiotherapists to pelvic health, only two are offered at master’s level in Australia, one at the University of Melbourne and one at Curtin University in Western Australia. 

‘Unlike some other areas of physiotherapy, this is one that does require post-graduation training,’ says Helena. 

Angela agrees. 

‘Pelvic health needs that extra training because it is so complex. 

‘It takes more expertise to be able to manage these conditions competently, safely and in a trauma-informed way,’ she says. 

Despite this, it is rapidly becoming one of the more popular areas of interest in physiotherapy—the Women’s, Men’s and Pelvic Health national group is the third largest in the APA, after the Musculoskeletal and Sports and Exercise groups. 

The evidence base 

The role of physiotherapy in treatment and management of persistent pelvic pain and endometriosis is also increasingly supported by research. 

In a huge boost for the field, the Australian Living Evidence Guideline: Endometriosis, published earlier this year by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG 2025), included physiotherapy for the first time as a conservative strategy for treatment and management of people with endometriosis and adenomyosis. 

An update to the original guideline published in 2021, the 2025 guideline incorporates new research and has a broader scope. 

It was developed with input from multidisciplinary experts including gynaecologists, primary care providers, physiotherapists, pain specialists and people with lived experience. 

A comprehensive review of the evidence for the role of physiotherapy in treating persistent pelvic pain has also recently been published by a group of researchers including Helena (Starzec-Proserpio 2025). 

It shows that multimodal physiotherapy is effective in women with chronic pelvic pain. 

‘It was the first comprehensive systematic review on that question and we found quite emphatically that yes, it is effective, with a strong certainty of evidence. 

‘That’s the first time we’ve had a rigorous evaluation of the research to show the level of evidence and how confident we are in the findings,’ says Helena. 

Professor Helena Frawley has recently published two comprehensive systematic reviews on endometriosis and persistent pelvic pain research.

Helena says that while this paper specifically excluded endometriosis from the analysis, a second paper will be published later this year analysing the role of physiotherapy in treating endometriosis. 

She plans to discuss the results of the two papers in a session at the upcoming APASC25 conference. 

‘We will be able to draw them together and do a compare and contrast—is the evidence for physiotherapy different or does it actually make no difference what you call the condition? 

‘Because we now think that what we are treating with endometriosis is pain. 

‘We are not treating the disease; we are treating the patient’s pain—the symptoms and dysfunction and impact of that pain,’ Helena says. 

Her collaborator Elise says that the explosion in research and funding for persistent pelvic pain and endometriosis in recent years has led to a huge increase in studies, adding to the evidence base. 

‘We first ran our search for endometriosis papers in 2023 and we only found 13 randomised controlled trials. 

‘When we ran our search again for this 2025 paper, it had doubled to 26 papers,’ Elise says. 

Helena’s team has more research in the pipeline, with papers soon to be published looking at the best way to teach pelvic floor contraction and relaxation in women with endometriosis-associated pelvic pain and another study on the effectiveness of multidisciplinary care for persistent pelvic pain. 

Over in Adelaide, Jane is focusing on improving the delivery of pelvic pain education to women and other people with uteruses and on how it might differ from delivering pain education on less complex conditions. 

‘Pelvic pain is tricky because it’s an umbrella term and no two people with pelvic pain will ever present in the same way. 

‘While that’s true for other pain conditions, there are lots of things about pelvic pain that we want to unpack,’ Jane says. 

She notes that unlike many other conditions, it’s rare for a patient to present with a single type of pelvic pain or a single diagnosis. 

‘We see people who present with endometriosis and painful bladder syndrome or painful sex or irritable bowel syndrome or any and all of the above. 

‘It can be quite a bit more complex than other musculoskeletal pain presentations.’ 

It’s also important to consider other factors—for example, what the patient perceives as normal menstrual period pain versus what is abnormal. 

‘Often the first sign that someone has pelvic pain is in the teen years, with painful periods. 

‘I think that’s a turning point for these women to either get on the road to recovery or get set on a path that’s not helpful for recovery. 

‘It can depend on lots of factors—what they consider normal and abnormal, what they’re told by the people around them—mums and friends are great but they can also be quite a hindrance as well,’ Jane says. 

She is working towards a feasibility study looking at whether pelvic pain education can help women who are about to have a laparoscopy for suspected endometriosis. 

‘If we can help them to understand what endometriosis is and a bit more about pain from a science perspective, will that help their post-surgical outcomes?’ 

Looking at the broader picture, Jane believes physiotherapists can play a pivotal role in treating and managing persistent pelvic pain and endometriosis. 

‘Physios are well equipped to undertake a thorough subjective and objective assessment. Our bread and butter is understanding some of those physical contributions,’ she says. 

‘In some people, pelvic pain is associated with increased tone and poor relaxation of the pelvic floor muscles. Identifying the role of pelvic floor and other muscular contributors is really important.’ 

Jane says the fact that physiotherapists take a biopsychosocial and holistic approach to persistent pelvic pain is also critical. 

‘We play a huge role in validating people’s experiences, listening to women’s stories and providing them with education and strategies to address some of those contributing factors. 

‘It might be education about pain itself and the science of what pain is but also addressing fear avoidance and behaviours that are derived from a cognitive component, like being fearful of a particular activity—the one that often springs to mind in the realm of pelvic pain is sex. 

‘We help women to identify where that fear stemmed from and to implement strategies to reduce the fear and change their behaviours to get back to what they want to be doing.’ 

How can I help my patients? 

Pelvic health physiotherapist Angela James is interested in trauma-informed approaches to pelvic health physiotherapy.

With so many women experiencing persistent pelvic pain, all physiotherapists should be aware of it and have some understanding of what is and isn’t in their scope of practice, says Angela. 

While the complex nature of persistent pelvic pain and endometriosis means that patients will generally need to see a pelvic health physiotherapist for treatment and management, there are things you can do to help your patient if they bring up pelvic pain or endometriosis during their appointments, even if you end up referring them on to a pelvic health physiotherapist or back to their GP. 

Angela suggests starting with some simple screening questions about pelvic health to identify any problem that needs further investigation. 

‘That could include asking whether the patient experiences period pain that stops them participating in their sport or life. 

‘You could also say something like, “Many women with pelvic pain experience problems with bladder, bowel or sexual function. Pelvic health physiotherapists are able to help with these problems. If this is something that you would like to follow up, I can refer you to a colleague who works in this area,”’ she says. 

‘These patients are desperate for someone to know about their pain but they’re often not forthright in telling you that they can’t have sex because it’s too painful or they’re devastated by their period pain. 

‘Because of the shame, stigma and embarrassment that surround these functions, they wouldn’t necessarily think you’re the right person to say anything to and they don’t offer up the information easily. 

‘We’d love for general physios to know these problems exist and that pelvic health physios can help, so it’s great if you can have a resource that you can refer to in your area.’ 

Jane says that it is important to work out who is in your referral network so you can send patients to get the help they need. 

‘Realistically, if you’re a musculoskeletal physiotherapist, your ability to manage pelvic pain will be limited unless you’ve done additional training in the area,’ she says. 

While a pelvic health physiotherapist is essential for assessing and managing persistent pelvic pain, the referring physiotherapist can provide general information on pain management and on persistent pain and endometriosis (see resources), especially for patients who might have to wait for access to a pelvic health physiotherapist. 

‘It might be useful to teach a patient some general relaxation techniques, such as pelvic and hip stretches, and to give them encouragement to exercise at a level they feel comfortable with when they do have their period or other pelvic pain because exercise has been shown to be effective,’ says Angela. 

It’s also important to listen to your patient and validate their concerns. 

Many people with persistent pelvic pain have spent years waiting for a diagnosis or even to be told that their pain is real. 

‘Hearing the story and acknowledging the patient’s experiences is actually part of therapy. 

It helps them to make sense of their story and the contributing factors and to identify what we can work on,’ says Elise. 

‘We can explain that there are other possible contributing factors that we can work on—the muscles, the mind, bladder and bowel function, and other factors that aren’t addressed by surgery.’ 

Finally, be aware of the possibility that your patient has experienced trauma and provide trauma-informed care to all patients who present with persistent pelvic pain. 

‘You need to be sensitive to that—act in a trauma-informed way because one in three of your patients will have a history of trauma,’ says Angela, who recently co-authored an article on the topic of trauma-informed care for pelvic physiotherapy (Stirling et al 2025). 

What conditions can cause persistent pelvic pain? 

(Adapted from jeanhailes.org.au) 

Persistent pelvic pain is complex and encompasses a number of conditions. It is usually defined as pain that occurs on most days for at least six months. 

• Dysmenorrhoea, or period pain, happens when the uterus muscles tighten (contract). Pain might include cramping and heaviness in the pelvic area and pain in the lower back, stomach or legs.
• Endometriosis is a condition where cells similar to those that line the uterus are found in other parts of the body, mainly in the pelvis and reproductive organs, causing pain, scarring and inflammation.
• Adenomyosis is similar to endometriosis but the cells from the uterine lining grow inside the muscle walls of the uterus.
• Vulvodynia is a chronic pain, discomfort or burning sensation in the vulva that can last for months or years. It is triggered by touch and cannot be linked to a specific cause.
• Dyspareunia is painful vaginal sex. Potential causes include vaginal dryness and hormonal changes, overactive pelvic floor muscles or involuntary muscle spasms, vulvodynia and endometriosis.
• Irritable bowel syndrome is associated with symptoms such as pain and bloating in the belly (abdomen) and changes in bowel movements (eg, constipation and diarrhoea).
• Bladder pain syndrome (including interstitial cystitis) is a condition involving discomfort in the bladder area, which can be associated with a frequent and urgent need to urinate. Most people with this condition are women.  

Resources 

• Endometriosis Australia—general information for patients  
• Pelvic Pain Foundation of Australia—general information for patients  
• Jean Hailes for Women’s Health  
• Health Direct  
• Matilda Health—a digital health app and website developed by Australian physiotherapists to support patients with endometriosis before, during and after surgery  
• Australian Living Evidence Guideline: Endometriosis—The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Quick Links: 

• references