{"paper_id":"ffe51925-9f04-4669-b8df-fefedf4edc8c","body_text":"GENERAL GYNECOLOGY: REVIEW\nReproductive Sciences (2024) 31:3257–3274\nhttps://doi.org/10.1007/s43032-024-01660-2\ndiagnostic difficulties and variations in prevalence across \ndifferent populations may disturb the correct result of the \nfrequency of this disease [5].\nSymptoms of endometriosis vary widely. Some women \nmay remain asymptomatic for years, while others may \nexperience painful menstruation, intermenstrual bleeding, \ninfertility, urinary issues, painful intercourse, painful bowel \nmovements, diarrhoea, or non-menstrual abdominal pain \n[2, 6, 7]. Nevertheless, the predominant symptom is pain, \nwhich can be nociceptive, inflammatory or neuropathic [8]. \nChronic pain can lead to central sensitization, which makes \npain management difficult, which is noticeable in the popu-\nlation of women with endometriosis [9].\nThe pain associated with endometriosis involves a com -\nplex interplay between peripheral nerve conduction, the \nperitoneum, and the central nervous system. Increased pres-\nence of small unmyelinated nerve fibers and neurotrophic \nfactors near endometriotic lesions suggests their role in \npain development. Furthermore, ongoing inflammatory \nIntroduction\nEndometriosis is a gynecological condition characterized \nby the presence of estrogen-sensitive tissue resembling the \nendometrium found outside the uterus [ 1]. Endometrial \nglands are typically observed in the pelvic region, includ -\ning the ovaries, ligaments, peritoneum, intestines, bladder, \nlymph nodes, and even the lungs, diaphragm, or pericardium \n[2, 3]. It is estimated that approximately 15% of women of \nreproductive age experience endometriosis [ 4]. However, \n \r Agnieszka Mazur-Bialy\nagnieszka.mazur@uj.edu.pl\n1 Department of Biomechanics and Kinesiology, Faculty of \nHealth Science, Jagiellonian University Medical College, \nSkawińska 8, Krakow 31-066, Poland\n2 Student Scientific Group, Faculty of Health Science, \nJagiellonian University Medical College, Krakow, Poland\nAbstract\nEndometriosis is one of the gynecological diseases where women suffer from pain, quality of life decreased. The aim of \nthis review was to describe the most common non-medical methods used in the treatment of symptoms associated with \nendometriosis and to determine their effectiveness. The review was performed in PubMed, Embase and Web of Science \ndatabases. Randomized controlled trials, case studies, observational studies, retrospective studies, prospective studies, \npilot studies, trails, publications in English or Polish were searched based on the Participant-Intervention-Comparator-\nOutcomes-Study design (PICOS) format. The criteria used to select studies were: women with endometriosis, no cancer, \nincluded any physiotherapeutic or non-medical intervention. 3706 articles were found, however only 26 met the inclusion \ncriteria and were included in the review. Quality of the studies was assessed by Risk of Bias 2 tool and ROBINS-1 tool. \nThe most holistic approach used in the treatment of symptoms of endometriosis include physical therapy, manual therapy, \nelectrophysical agents acupuncture, diet and psychological interventions. Most research has focused on relieving pain \nand increasing quality of life. Non-medical methods showed reduction of symptoms of endometriosis. Physical activity, \nmanual therapy, electrophysical agents, acupuncture, diet and cognitive behavioral therapy showed no negative side effects \nand reduced pain, what improved the quality of life and reduced the perceived stress.\nKeywords Endometriosis · Physiotherapy · Physical activity · Manual therapy · Quality of life · Pain\nReceived: 13 January 2024 / Accepted: 16 July 2024 / Published online: 23 July 2024\n© The Author(s) 2024\nHolistic Approaches in Endometriosis - as an Effective Method of \nSupporting Traditional Treatment: A Systematic Search and Narrative \nReview\nAgnieszka Mazur-Bialy1  · Sabina Tim1  · Anna Pępek2 · Kamila Skotniczna2 · Gabriela Naprawa2\n1 3\n\nReproductive Sciences (2024) 31:3257–3274\nprocesses cause the release of pro-inflammatory molecules \nby sensory fibers, which also contributes to increased pain \nperception. Nerve fiber sensitization due to the pro-inflam -\nmatory environment increases pain sensitivity. An impaired \nimmune response to endometrial cells and tissues in patients \nwith endometriosis may contribute to the growth and attach-\nment of endometrial cells, which further worsens pain [ 8, \n10, 11].\nAside from diminishing quality of life, pain contributes \nto myofascial changes, leading to improper body posture, \nweakened trunk muscle function, altered spine curvature, \nand decreased lung function [12, 13]. Patients with endome-\ntriosis exhibit thinner abdominal wall muscles, decreased \nlumbopelvic stability and less resistance in trunk flexor and \nextensor muscles [ 14]. Incorrect body posture affects the \npelvic floor as well, manifesting as pelvic floor hyperactiv-\nity among women with endometriosis, resulting in sexual \ndysfunction and other pelvic floor dysfunctions like urinary \nincontinence or constipation [15].\nThe primary objective of non-medical methods in man -\naging endometriosis is pain relief and pelvic floor function \nimprovement [ 16], along with post-surgical support [ 17]. \nThis techniques aim to relax muscles, reduce inflammation, \nand disrupt the pain cycle, ultimately enhancing quality of \nlife [18]. The aim of this review was to describe the most \ncommon physiotherapeutic and non-medical methods used \nin the treatment of symptoms associated with endometriosis \nand to determine their effectiveness.\nMaterials and Methods\nThe study protocol was prepared following the guidelines \nof the Preferred Reporting Items for Systematic Review \nand Meta-Analysis (PRISMA) [ 19]. The research protocol \nhas been approved by PROSPERO no. CRD42023389400 \n“Physiotherapy in endometriosis - as an effective method \nof supporting traditional treatment: a systematic review.“ \nInclusion criteria were formulated based on the Participant-\nIntervention-Comparator-Outcomes-Study design (PICOS) \nformat.\nParticipants: women with endometriosis, no cancer.\nIntervention: any physiotherapeutic or non-medical \nintervention (exercise, manual therapy, physical therapy, \ndiet, psychologic intervention).\nComparasion: no intervention, placebo.\nOutcomes: therapy effectiveness assessment, quality of \nlife, pain, pelvic floor, sex life, muscle function.\nStudy design: studies in Polish and English, no time limit, \npilot study, randomized control trial, prospective study, ret-\nrospective study, observational study.\nThe search process involved four researchers indepen -\ndently scouring databases including Medline-Pub Med, \nEmbase, and Web of Science. The following phrase was \nused to search for articles: endometriosis and (physiotherapy \nor rehabilitation or electrotherapy or electrophysical agents \nor exercise or yoga or visceral therapy or acupuncture or \nmanual therapy or physical therapy or massage or trigger \npoints or breathing or biopsychosocial or mindfulness or \nrelaxation or complementary therapy or holistic approach).\nTitles and abstracts were initially screened for relevance, \nwith subsequent inclusion of studies addressing endome -\ntriosis symptoms such as pain, quality of life, physical func-\ntion, and infertility. Exclusion criteria comprised studies not \npublished in English or Polish, those describing surgical \nprocedures or animal models, and those involving pediat -\nric or male populations, or primarily mathematical analy -\nses. Discrepancies in study selection were resolved through \nconsensus.\nAfter initial screening, full-text versions of selected \narticles were obtained and scrutinized for study type, par -\nticipant demographics, intervention details, outcome assess-\nment methods, questionnaires utilized, and main findings, \nensuring alignment with inclusion criteria.\nRisk of bias assessment was conducted independently by \ntwo researchers using the Risk of Bias 2 tool [ 20] for ran -\ndomized studies and ROBINS-I [ 21] for non-randomized \ntrials, evaluating various domains such as randomization \nprocess, handling of missing data, intervention adherence, \noutcome measurement, and reporting integrity to determine \noverall study risk levels.\nResults\nCharacteristics of the Studies\nBased on the phrases presented, a total of 3706 works were \nfound. After removing duplicates, 2839 works remained. \nAfter analyzing the titles and abstracts, 2770 works were \nrejected. There were 69 works left to be fully read. 26 works \nmet the final inclusion criteria. A detailed analysis of the \nindividual stages of the review is presented in the PRISMA \ndiagram (Fig. 1).\nThe studies included into the analysis assess pain (19 \nstudies), quality of life (17 studies), mental health (9 stud -\nies), stress (6 studies), dyspareunia (7 studies) among \nwomen with endometriosis. The physiotherapeutic inter -\nventions that have been described are: physical activity, \nmanual therapy, acupuncture, and physical therapy. The \ncharacteristics of the studies included in the review are pre-\nsented in Table 1.\n1 3\n3258\n\nReproductive Sciences (2024) 31:3257–3274\nRisk of Bias of fifteen studies were assessed using RoB \n2 tool. Eight studies were assessed as low risk of bias, \nthen seven studies were assessed by moderate risk of bias. \nEleven studies were assessed using ROBINS-I tool. Four \nstudies have low risk of bias, seven studies have moderate \nrisk of bias. See Fig. 2; Table 2.\nPhysical Activity in the Treatment of Endometrial \nSymptoms\nAccording to Piggin [48], ‘physical activity involves people \nmoving, acting and performing within culturally specific \nspaces and contexts, and influenced by a unique array of \ninterests, emotions, ideas, instructions and relationships.’ \nResearch on physical activity (PA) among women with \nendometriosis focuses on alleviating the side effects of \ndrugs and reducing pain while improving quality of life. \nPA utilized in treating endometriosis symptoms includes \nbreathing exercises, yoga, Pilates, muscle relaxation, and \naerobic activities.\nArmour et al. [25] estimated that exercises, yoga, Pilates, \nstretching, and breathing were among the self-management \nstrategies adopted by women with endometriosis. However, \nwomen rated these interventions as less effective in reduc -\ning pain compared to cannabis, heat, diet, or acupressure. \nNonetheless, physical interventions reduced pain on aver -\nage from 4.5 to 4.9 points on a 0–10 scale (0 being inef -\nfective; 10 being extremely effective). Conversely, after \nengaging in physical activity, women reported increased \npelvic pain (especially cramp pain) and fatigue, particularly \nafter Pilates practice [25].\nFig. 1 PRISMA diagram\n \n1 3\n3259\n\nReproductive Sciences (2024) 31:3257–3274\nTable 1 Characteristics of the included studies divided into areas under observation and treatment of patients with endometriosis\nAuthor, year Areas under observation Therapy\nPain QoL Mental Health Stress Dyspareunia PA MT EPA AP SE Diet CBT\nGoncalves, 2016 [22] + + +\nGoncalves, 2016 [23] + + + +\nPetrelluzzi, 2012 [24] + + + + +\nArmour, 2019 [25] + + + + +\nBergstrom, 2005 [26] + +\nMerlot, 2022 [27] + +\nZhao, 2011 [28] + + + +\nDarai, 2014 [29] + + +\ndel Forno, 2020 [30] + + + +\nWurn, 2011 [31] + + +\nBi, 2018 [32] + + + +\nHawkins, 2003 [33] + + +\nMira, 2020 [34] + + + +\nThabet, 2018 [35] + + +\nRubi Klein, 2010 [36] + +\nMuñoz-Gómez, 2023 [37] + + + + +\nde Sousa, 2016 [38] + + + +\nSillem, 2016 [39] + +\nTian, 2022 [40] + + +\ndel Forno, 2024 [41] + + +\nNodler, 2020 [42] + + + +\nCirillo, 2023 [43] + + + +\nvan Haaps, 2023 [44] + + + +\nDonatti, 2024 [45] + + +\nWu, 2022 [46] + + + +\nKold, 2012 [47] + + +\nQoL– quality of life; PA– physical activity; MT– manual therapy; EPA– electrophysical agents; AP- acupuncture; SE– alleviating the side effects of medications; CBT– Cognitive-Behavioural \nTherapy\n1 3\n3260\n\nReproductive Sciences (2024) 31:3257–3274\nincreased self-confidence [ 23]. Ten sessions combining \nbreathing exercises, individualized stretching and strength -\nening exercises, massage, transcutaneous electrical nerve \nstimulation, and psychological intervention reduced sali -\nvary cortisol levels, thereby decreasing perceived stress lev-\nels and enhancing quality of life [24].\nMany women use pharmacotherapy to alleviate pain, \nwhich may have side effects. PA may play a role in miti -\ngating these effects. Three 30-minute brisk walking ses -\nsions and two 1-hour aerobic training sessions per week \nOne of the mind-practice activities is yoga, which inte -\ngrates meditation, physical exercises, and breathing tech -\nniques. Two-hour yoga sessions twice a week in women \nwith endometriosis reduced pain and improved quality of \nlife; however, yoga did not affect or decrease menstrual \nblood flow [ 22]. It was emphasized that yoga techniques, \nparticularly breathing exercises, were beneficial in cop -\ning with pain, leading to reduced reliance on painkillers. \nYoga also fostered self-control, self-awareness, autonomy, \nimproved sleep, better management of panic attacks, and \nFig. 2 Risk of bias of randomized \nclinical trials assessed in RoB-2 \ntool\n \n1 3\n3261\n\nReproductive Sciences (2024) 31:3257–3274\nand adhesions, thereby enhancing mobility and reducing \npain, improving quality of life, dyspareunia, and dysmen -\norrhea, as confirmed by Wurn et al. [ 31]. Their intensive \ntherapy sessions, initially lasting 2 h per week for 5 months \nand progressing to sessions lasting up to 4 h per day for \n5 days, resulted in improvements in menstrual cycle, dys -\nmenorrhea, and dyspareunia [ 31]. Manual therapy can be \nsupported by 3D/4D transperineal ultrasound to precisely \nidentify areas of increased tension and abnormal muscle \nfunction [30]. Del Forno et al. [ 30] performed five 30-min-\nutes session of Thiele massage, supported by 3D/4D trans -\nperineal ultrasound, involving stretching and acupressure of \nthe pelvic floor muscles to restore normal tone and induce \nrelaxation. This therapy led to improvements in the Leva -\ntor Hiatus Area and reductions in both deep and superficial \ndyspareunia [30]. Additionally, improvements in superficial \ndyspareunia, chronic pelvic pain, and pelvic floor muscle \nrelaxation were observed after Thiele massage, although del \nForno et al. [41] did not confirmed effects on urinary, bowel \nand sexual function [41]. Another type of manual therapy is \nOsteopathic Manipulative Therapy (OMT). Darai et al. [29] \nshowed that approximately 1-hour OMT of the mobilisation \nof uterus, colon, the peritoneum and around the vertebrae L1 \nand L2 improved physical and mental quality of life women \nwith endometriosis [ 29]. As well as osteopathic mobilisa -\ntion of sacroiliac joints, diaphragm, abdominal organ, tem -\nporomandibular joints and cervical spine mobilisation and \nPFM manual relaxation improved symptoms in women with \nlong histories of endometriosis [39].\nPhysiotherapists frequently employ manual therapy to \naddress pain, with osteopathic techniques becoming increas-\ningly popular. Properly selected techniques have the poten-\ntial to alleviate pain, enhance functioning, and improve \nquality of life. The characteristics of studies outlining the \neffectiveness of manual therapy in treating endometriosis \nare detailed in Table 4.\nreduce bone density loss among women with endometriosis \nundergoing pharmacological treatment with gonadotropin-\nreleasing hormone [ 26]. Pharmacological treatment can be \ncomplemented by progressive muscle relaxation to reduce \npain and the side effects of hormone treatment. After 12 \nweeks, attending group classes twice a week with Jacob -\nson’s relaxation concept and home practice significantly \nimproved overall quality of life [28].\nPA is often chosen as a self-management strategy for \naddressing endometriosis symptoms. It enhances quality of \nlife, reduces pain, and mitigates the effects of pharmacologi-\ncal treatment. The characteristics of studies elucidating the \neffectiveness of physical activity in treating endometriosis \nsymptoms are presented in Table 3.\nManual Therapy in the Treatment of Endometrial \nSymptoms\nManual therapy, a treatment method employed by physical \ntherapists, involves a hands-on approach. It encompasses \ntechniques such as joint and soft tissue mobilization, stretch-\ning, and acupressure, which have the potential to alleviate \npain [49].\nMuñoz-Gómez et al. [ 37] performed comprehensive \ntechniques, including spinal and sacroiliac manipulation, \nmobilization of the abdominal and broad ligaments, and pel-\nvic diaphragm release. Their manual therapy intervention \nresulted in a 30.76% reduction in pain after six weeks and \nled to improvements in control, powerlessness, and emo -\ntional well-being among women with endometriosis [ 37]. \nMany women with endometriosis have increased pelvic \nfloor muscle tone [ 30] and adhesions [ 31]. Some manual \ntechniques can reduce tissue thickening and adhesion, lead-\ning to improved mobility in the area, as well as reducing \npain, improving quality of life, dyspareunia and dysmen -\norrchea, as confirmed by Wurn et al. [ 31]. Certain manual \ntechniques have been shown to decrease tissue thickening \nTable 2 ROBINS analysis of included studies of physiotherapy techniques used in reduce symptoms of endometriosis\nAuthor, year Bias due to \nconfunding\nBias in selection of \nparticipants into the \nstudy\nBias due to \nMissing data\nBias in measure-\nment of outcomes\nBias in selection \nof the reporter \nresult\nOverall\nPetrelluzzi, 2012 [24] Low Low Low Low Low Low\nArmour, 2019 [25] Moderate Moderate Low Low Low Moderate\nDarai, 2014 [29] Moderate Moderate Low Low Low Moderate\nDel Forno, 2020 [30] Moderate Moderate Low Moderate Moderate Moderate\nWurn, 2011 [31] Low Low Low Low Low Low\nBi, 2018 [32] Low Low Low Low Low Low\nHawkins, 2003 [33] Moderate Moderate Moderate Low Low Moderate\nSillem, 2016 [39] Moderate Moderate Moderate Moderate Moderate Moderate\nCirillo, 2023 [43] Low Low Low Low Low Low\nvan Haaps, 2023 [44] Moderate Low Low Low Low Moderate\nKold, 2012 [47] Moderate Low Low Low Low Moderate\n1 3\n3262\n\nReproductive Sciences (2024) 31:3257–3274\nTable 3 Characteristics of studies on the effectiveness of the use of physical activity in the treatment of endometrial symptoms\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nGoncalves \net al.\n2016 Brazil \n[22]\nAssessment of the effects of yoga \non quality of life, the severity \nof chronic pelvic pain and the \nmenstrual cycle.\nn = 40 women\nYoga group: n = 28\nMean age: 34.5 ± 7.4\nNon-yoga group: n = 12\nMean age: 35.75 ± 4.7\nYoga group:\n2-h yoga session twice a week for 8 weeks\nNon-yoga group:\nno intervention\nAssessment:\nV AS, EHP-30\nReduction of chronic \npelvic pain (p = 0.0046) and \nimprovement in QoL after \nyoga practice.\nGoncalves \net al.\n2016, Brazil \n[23]\nAssessment of the mental and \nemotional attitude to yoga, pain \nmanagement after the interven-\ntion, and peripheral benefits.\nn = 15 women aged 24–49 \nyears\nInterview after completing yoga sessions, questions about expectations regarding \nthe practice of yoga, pain management, physical and emotional stage, benefits of \nyoga.\nWomen have reported ben-\nefits of yoga in pain control \nthrough breathing control, \nincreased self-awareness, \nautonomy, self-care, and \nreduced use of painkillers.\nPetrelluzzi \net a. 2012, \nBrazil [24]\nAssessment of the influence of \nthe mind-body relation on the \nperceived by women levels of \nstress, pain, HRQL and activity of \nthe hypothalamic-pituitary-adre-\nnal axis in women with endome-\ntriosis and chronic pelvic pain.\nn = 30, completed n = 26\nmean age = 32.2 ± 1.3\n10 sessions of physical therapy, breathing therapy, stretching, TENS, and psycho-\nlogical intervention, one session per week for 10 weeks.\nAssessment:\nPSQ, SF-36, V AS, salivary cortisol levels\nPhysical and psychologi-\ncal therapies were effecting \nin reducing pain, stress \n(p < 0.05) and normalized \ncortisol levels (p < 0.05).\nArmour et \nal. 2019, \nAustralia \n[25]\nAssessment of self-management \ncoping with pain in endometriosis \nand their effectiveness.\nn = 484 women with \nendometriosis\nmean age = 31 ± 7.4\nOnline survey, questions about self-management strategies with endometriosis. Self-care and lifestyle \nchoices were commonly used \nby women with endometrio-\nsis. Cannabis was the most \neffective in pain reduction.\nBergstrom \net al.\n2005,\nSweden \n[26]\nAssessment of the effect of \nexercise on bone mineral density \nin hormone-treated women with \nendometriosis.\nn = 19 women\nExercise group:\nn = 8\nMean \nage = 27.04 ± 4.39years\nControl group:\nn = 11\nMean age = 31.27 ± 5.04 \nyears\nExercise group:\n30-min fast walks and two 1-h aerobic training per weeks for 12 months\nControl group:\nNo change in lifestyle\nAssessment:\nbone mineral density\nLess decrease in bone \ndensity in the exercise group \n(0.6%) compared to control \ngroup (3.6%) (p = 0.029).\nZhao et al.\n2012,\nChina [28]\nAssessment of the impact of \nPRM training on depression \nand quality of life in patients \nwith endometriosis treated with \nhormones.\nn = 100 women\nProgressive muscle relax-\nation (PMR) group:\nn = 50, completed n = 42\nControl group:\nn = 50, completed n = 45\nPMR group:\nTwenty-four 40-min group PMR practice sessions over 12 weeks, twice per week\nand one dose of depot leuprolide\nControl group:\none dose of depot leuprolide\nAssessment:\nSTAI, HADS-D,\nSF-36\nImproving the results of \nanxiety, depression and \noverall quality of life in the \nPMR group\n(p < 0.05).\nHADS-D– Hospital Anxiety and Depression Scale; PRM–Progressive Muscle Relaxation; STAI– State-Trait Anxiety Inventory; VAS - Visual Analogue Scale; EHP- Endometriosis Health \nProfile; PSQ- Perceived Stress Questionnaire; SF-36- 36-Item Short-Form Health Survey; QoL– Quality of Life; TENS - transcutaneous electrical nerve stimulation\n1 3\n3263\n\nReproductive Sciences (2024) 31:3257–3274\nAcupuncture in the Treatment of Endometrial \nSymptoms\nAcupuncture is a controversial therapy. Traditional Chinese \ntherapy appeals to non-anatomical structures such as merid-\nians. The analgesic effect of acupuncture may be due to the \nstimulation of the nerves in the epidermis which, by send -\ning impulses through the spinal cord to the brain, stimulate \nopioid secretion and decreased pain levels [38].\nRubi-Klein et al. [ 36] conducted 10 therapeutic acu -\npuncture sessions, with one group receiving authentic \ntreatment and the other receiving a placebo. Following a \ncrossover between the groups, better outcomes were noted \nin the authentic acupuncture group. Women reported sig -\nnificantly lower pain sensations post-therapy, accompa -\nnied by increased quality of life, compared to the placebo \ngroup [ 36]. De Sousa et al. [ 38] reached similar conclu -\nsions. They divided women with endometriosis into two \ngroups, one group receiving acupuncture at appropriate \nsites and the other group receiving a placebo. After five ses-\nsions, marked improvements in pain and quality of life were \nobserved in the authentic acupuncture group compared to \nthe placebo group. These results persisted until the second \nmonth post-therapy [38]. Acupuncture also turned out to be \nmore effective in treating menstruation pain in women with \nendometriosis, compared to women who used pain killers to \nreduce pain. Acupuncture was applied to specific points on \neach day of menstruation for 3 cycles. The effect lasted until \nthe second cycle after the end of treatment [40].\nDespite many controversies around acupuncture, stud -\nies have demonstrated its efficacy in pain relief. However, \naccording to the European Society of Human Reproduc -\ntion and Embryology, no definitive recommendation can be \nmade regarding its use in women with endometriosis [ 50]. \nThe characteristics of studies describing the effectiveness of \nacupuncture in the treatment of endometriosis are presented \nin Table 6.\nDiet and Cognitive Behavioral Therapy in the \nTreatment of Endometrial Symptoms\nEndometriosis as a proinflammatory condition may be man-\naged by diet. Some nutrients may decrease inflammatory \nfactors, which can reduce pain [42]. Cirillo et al. [43] found a \nstrong link between pain relief in endometriosis patients and \nMediterranean dietary patterns. A individual Mediterranean \ndiet shows promise for treating endometriosis-related symp-\ntoms and could be an effective long-term strategy for man -\naging chronic pain alongside other nonmedical treatments \n[43]. Nodel et al. [42] confirmed that vitamin D supplemen-\ntation in adolescents with surgically confirmed endome -\ntriosis significantly improved pelvic pain and catastrophic \nElectrophysical Agents in the Treatment of \nEndometrial Symptoms\nElectrophysical agents (EPA) contain the areas of physio -\ntherapy that uses physical factors like cold, heat, electrical \nstimulation in the treatment process. Electrotherapy has \nbeen employed for managing endometriosis pain, utiliz -\ning techniques such as electrical neuromuscular stimula -\ntion (NMES) [ 32], and transcutaneous electrical nerve \nstimulation (TENS) [34]. Women who received NMES for \n30 min, 3 times a week for 10 weeks showed decreased of \npain endometriosis symptom severity and better results in \nSF-36 (36-26-item short-form Health Survey) compared to \nthose who did not receive therapy. It is worth emphasizing \nthat NMES was the only form of therapy in this group and \nhas independently demonstrated effectiveness [ 32]. EPA \ncan also be used as a complement to other therapy. Mira \net al. [34] investigated the effects of TENS as an adjunct to \nhormone therapy for controlling pelvic pain in deep endo -\nmetriosis. Women who self-administered TENS at home \ntwice daily for 20 min over 8 weeks in the parasacral region \nexperienced significant reductions in chronic pelvic pain \nand deep dyspareunia, along with notable improvements \nin quality of life, compared to those solely receiving hor -\nmonal treatment [ 34]. Thabet et al. [ 35] evaluated the use \nof Pulsed High-Intensity Laser Therapy (HILT) in addition \nto hormonal treatment, confirming significant reductions in \npain and enhanced quality of life compared to placebo [35].\nFurthermore, better treatment outcomes were observed \nusing virtual reality (VR) compared to a standard tablet. \nMerlot et al. [ 27] conducted a study where women man -\naging endometriosis pain were treated with a specialized \napplication incorporating auditory and visual sensations. \nDivided into two groups—one using regular tablets and the \nother utilizing a VR device—the women in the VR group \nreported significantly lower pain levels post-treatment com-\npared to the control group [ 27]. Pain reduction was also \nnoted following thermal biofeedback therapy incorporating \nrelaxation techniques and breathing exercises. Additionally, \nwomen acquired pain management skills through this ther -\napy, although caution is warranted in interpreting the results \ndue to the small sample size of the study (n = 5) [33].\nElectrophysical agents in studies presents effectiveness \nalone and combined with other treatment in improve quality \nof life and pain. The characteristics of studies describing the \neffectiveness of electrophysical agents in the treatment of \nendometriosis are presented in Table 5.\n1 3\n3264\n\nReproductive Sciences (2024) 31:3257–3274\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nDarai et \nal.\n2015,\nFrance \n[29]\nTo assess the OMT on qol of \npatients with deep infiltrating \nendometriosis.\nn = 20 women (15 \ncompleted)\nMedian age = 30.4\nOMT including mobilization of the uterus, peritoneal mobility, the colon, and L1 \nand L2 for median time 60 min (range 45–73 min).\nAssessment:\nSF-36\nSignificant improvement among 80% \nof women who completed the study on \nPCS (p = 0.03) and MCS (p = 0.0009).\nDel Forno \net al.\n2020, \nItaly [30]\nTo assess the PFM physiother-\napy, including Thiele massage \nand using 3-D/4-D transperineal \nultrasound as biofeedback in \nwomen with deep infiltrating \nendometriosis and dyspareunia.\nn = 10 women\nMean \nage = 33.4 ± 9.2\nPFM physiotherapy: information about PFM, Thiele massage, PFM exercises via \n3-D/4-D ultrasound.\n5 individual session of 30 min at 1,3,5,8,11 week\nAssessment:\nGynecological examination, ultrasound examinations\nPFM physiotherapy improves superfi-\ncial (p = 0.0027) and deep (p = 0.0395) \ndyspareunia. Ultrasound was a valid \nvisual feedback technique during PFM \ntherapy.\nWurn et \nal.\n2011,\nUSA [31]\nTo assess the efficacy of manual \ntherapy in\ndyspareunia and dysmenorrhea \nassociated with endometriosis.\nRetrospective \nanalysis:\nn = 14\nMean age = 33.8\nProspective analy-\nsis: n = 18 mean \nage = 37.4\nSite-specific manual therapy for 2 h/week for 5 months, then 4 h/day for 5 days.\nAssessment:\nFSFI, MPS\nImprovement in each area of \nFSFI (p < 0.001) and dyspareunia \n(p < 0.001).\nMuñoz-\nGómez et \nal. 2023, \nSpain \n[37]\nTo analyze the effectiveness of a \nmanual therapy\nprotocol in relation to the pelvic \npain, lumbar mobility, and clini-\ncal features related to quality of \nlife and\nthe emotional of women who \nsuffer from pelvic pain due to \nendometriosis.\nManual therapy \nGroup:\nn = 21\nmean \nage = 34.85 ± 7.23\nPlacebo Group:\nn = 2 0\nmean \nage = 37.4 ± 6.62\nManual therapy Group: 8 weeks, with one session for 30 min every 15 days, soft \ntissue and articulatory techniques included: (a) Occiput, atlas, and axis manipula-\ntion technique. (b) Thoraco-lumbar manipulation technique. (c) Global sacroiliac \nmanipulation technique. (d) Abdominal mobilization technique. (e) Broad liga-\nment mobilization technique. (f) Pelvic diaphragm release technique. (g) Sphenoid \ntechnique. (h) Fourth ventricle technique.\nPlacebo Group: The participants received light contact on the same points and for \nthe same amount of\ntime as the experimental group with no intention to treat.\nFollow up: after intervention, one-month and six-month\nAssessment:\nEHP-30, SF-36, V AS, BDI-II, STAI, PGICS\nThere was a significant pain reduction \nin the manual therapy group at each \npoint of follow-up\n(p < 0.001). There were no\nsignificant differences after the placebo \ngroup or at the follow-up (p > 0.05).\nManual therapy Group significantly \nimproved at one-month follow-up for \nthe domains: pain (p < 0.001), control \nand powerlessness (p = 0.001), emo-\ntional wellbeing (p = 0.01), and EHP-\n30 total score (p < 0.001). Placebo \ngroup did not significantly improve\nany of the EHP-30 items after the \nintervention and at the follow-up.\nTable 4 The characteristics of studies describing the effectiveness of manual therapy in the treatment of endometrial symptoms\n1 3\n3265\n\nReproductive Sciences (2024) 31:3257–3274\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nSillem et \nal. 2016, \nGermany \n[39]\nTo assess the efficacy of osteo-\npathic diagnosis\nand treatment for women with \nchronic pelvic pain and painful\npelvic floor muscle tightness not \nrelated to the menstrual cycle.\nn = 28 women\n14 women with \nendometriosis\n14 women without \nendometriosis\n1 to 24 (range 6) treatment sessions lasting 30 min:\nSacroiliac joints, diaphragm, abdominal organ, temporomandibular joints and \ncervical spine mobilisation. PFM released by movement of the abdominal organ \ncompartment in a cranial direction.\nAssessment:\nGynecological examination, ultrasound examination, questions about satisfaction\n10 of 14 women with endometriosis \nshowed improvement in pain and \npelvic floor muscle tightness after \nosteopathy sessions.\nDel \nForno et \nal. 2024, \nItaly [41]\nTo assess the effect of pelvic \nfloor physiotherapy on urinary, \nbowel, and sexual\nfunctions in women with deep \ninfiltrating endometriosis.\nn = 31\nExperimental \nGroup: n = 17\nMean \nage = 32.5 ± 7.6\nControl Group: \nn = 13\nMean \nage = 32.8 ± 6.7\nExperimental Group: Information on pelvic floor anatomy\nand function, five individual 30 min PFM physiotherapy sessions at weeks 1, 3, 5, \n8, and 11.\nControl Group: standard of care without receiving pelvic floor physiotherapy \nsessions.\nAssessment:\nultrasound examinations, BFLUTS, KESS, FSFI\nImprovement in superficial dyspa-\nreunia, chronic pelvic pain, and PFM \nrelaxation were shown in Experimental \nGroup. No statistically significance \nin urinary function, bowel and sexual \nfunction were found between groups \n(p > 0,05).\nOMT- Osteopathic manipulative therapy; qol– quality of life; PFM– pelvic floor muscles; SF-36- Short Form Health Survey; PCS- Physical Component Summary; MCS- Mental Component \nSummary; FSFI- Female Sexual Function Index; MPS- Mankoski Pain Scale; EHP-30 - Endometriosis Health Profile Questionnaire; VAS– Visual Analogue Scale; BDI-II- Beck Depression \nIndex; STAI - State Trait Anxiety Index; PGICS - Patient Global Perception of Change Scale; BFLUTS - Bristol Female Lower Urinary Tract Symptoms questionnaire; KESS - Knowles–Eccer-\nsley–Scott–Symptom questionnaire; FSFI - Female Sexual Function Index\nTable 4 (continued)\n \n1 3\n3266\n\nReproductive Sciences (2024) 31:3257–3274\nTable 5 Characteristics of studies describing the effectiveness of electrophysical agents in the treatment of endometriosis\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nMerlot et \nal., 2022, \nFrance, \nCanada \n[27]\nTo assess the effec-\ntiveness of digital \ntherapeutics on pain \nin women with \nendometriosis.\nn = 45 women\nDigital treatment Endo-\ncare Group: n = 23\nMean age = 32.2 ± 8.02\nControl Group: n = 22\nMean age = 33.2 ± 8.12\nEndocare Group: 20-minute treatment consisting of a combination of auditory and thera-\npeutic procedures integrated in a 3D virtual reality environment.\nControl Group: 20-minute treatment with the same composition as the Endocare treatment \nbut without any immersive effects of the virtual reality nor the auditory and visual stimuli.\nFollow up: at 15, 30, 45, 60, 240 min after treatment.\nAssessment:\nNRS\nThe mean reduction of\npain was greater in the Endocare \ngroup (p < 0.001) than in the \ncontrol group (p = 0.008). The \nmean maximum reduction in pain \nwas 42% (95% CI 30.82–53.18) \nfor Endocare and 22% (95% CI \n15.38–28.53) for the control group.\nBi et al.\n2018, \nChina [32]\nTo assess the effect of \nNMES for the treat-\nment of endometriosis-\nassociated pain.\nn = 154 women\nNMES Group: n = 83\nMean age = 31.6 ± 3.6,\nControl Group: n = 71\nMean age = 32.2 ± 4.1\nNMES Group:\nApplied NMES on selected acupoints with 2–100 Hz for 30 min, 3x per week for 10 \nweeks.\nControl Group:\nNo intervention.\nAssessment:\nNRS, ESSS, SF-36\nSignificant improvement on all \nscales\nNRS (p = 0.02),\nESSS (p = 0.04),\nSF-26 (p < 0.01)\nin the NMES group. after 10 \nweeks.\nHawkins, \nHart\n2003,\nUSA [33]\nTo assess the effec-\ntiveness of thermal \nbiofeedback in the \ntreatment of pain \nassociated with \nendometriosis.\nn = 10 women\n(5 completed)\nThermal biofeedback relaxation session for 15-min intervals with a 2-min break between, \ntwice weekly for 2 months + daily home relaxation practice\nAssessment:\nWHYMPI\nAfter the end of the therapy, the \nWHYMPI scores improved in 4/5 \nof the women and the quality of \nlife improved significantly\n(p < 0.05).\nMira et al.\n2020, Bra-\nzil [34]\nTo assess the effective-\nness of complementary \ntreatment\nusing self-applied \nelectrotherapy treat-\nment for pain\nfor deep infiltrative \nendometriosis.\nn = 101 women\nElectrotherapy Group: \nn = 53\nMean \nage = 35.06 ± 6.17,\nHormonal Group: n = 48\nMean age = 37.21 ± 6.51\nElectrotherapy Group: hormonal treatment + TENS applied on S3-S4, frequency: 85 Hz; \npulse duration: 75 ms; intensity\noptions: 10, 20, or 30 mA, twice a day for 20 min for 8 weeks.\nHormonal Group: Only hormonal treatment.\nAssessment:\nEHP-30, V AS, FSFI, DDS\nReduction of pain (36%), number \nof painful days (32.11%) and \nsexual function (9.16%) in the \nElectrotherapy Group, the level \nof dyspareunia and quality of life \nimproved in both groups.\nThabet et \nal.,\n2018, \nEgypt, \nSaudi Ara-\nbia [35]\nTo assess the effective-\nness of pulsed high-\nintensity laser therapy\nin women with \nendometriosis.\nn = 40 women\n(24–32 years old)\nHILT Group: n = 2 0\nSham Group: n = 2 0\nHILT Group: HILT, 120–150 ls pulse duration, duty cycle\nof 0.1%, frequency of 10–40 Hz for 20 min, 3 times per week for 8 weeks.\nSham Group: sham laser treatment\nAssessment:\nPPi, PR, laparoscopy, EHP-5\nSignificant reduction in pain \n(+ 77.27%) and better quality of \nlife (+ 73%), (p < 0.0001) in HILT \nGroup.\nNMES– neuromuscular electrical stimulation; NRS– Numerical Rating Scale; ESSS– Endometriosis Symptom Severity Score; SF-36–36-Item Short Form Health Survey; VAS– Visual \nAnalogue Scale; TENS - transcutaneous electrical nerve stimulation; DDS– Deep Dyspareunia Scale; EHP-30– Endometriosis Health Profile; FSFI– Female Sexual Function Index; EHP-5– \nEndometriosis Health Profile, PPi– Present Pain Intensity; PR– Pain Relief scale; WHYMPI– West Haven-Yale Multidimensional Pain Inventory\n1 3\n3267\n\nReproductive Sciences (2024) 31:3257–3274\nmuscle ischemia, worse trophic, stimulating pain receptors \n[55], which in turn leads to pelvic floor dysfunction [ 15]. \nNevertheless, theories regarding trigger points are contro -\nversial [56]. Studies showed, that many women resign from \nphysical activity due to pain [ 57]. Pain induces reduced \nactivity, which precipitates trophic alterations in soft tis -\nsues, compromising their function, thereby weakening \nmotor control in the lumbopelvic region, amplifying pain, \nand curtailing activity and social engagement [ 51]. The \nphenomenon of central sensitization is also often observed \nin women with endometriosis, which may be related to a \nlower response to treatment [ 58]. Nociceptive neurons in \nthe dorsal horn of the spinal cord increase their excitabil -\nity by repeated exposure to noxious stimuli, such as dam -\nage. Long-term irritation of nociceptive neurons causes a \nreduced pain threshold and an increased response to pain. \nLong-term pain also causes changes in the activity and \nstructure of the brain, leading to changes in the processing \nof pain and sensory impulses. In addition, changes are also \nobserved in the hypothalamic-pituitary-adrenal axis, which \nis also responsible for pain modulation [59].\nEndometriosis exerts a profound impact on women’s \nlives, manifesting in reduced quality of life. Endometriosis-\nassociated conditions, including sleep disturbances, fatigue, \ndepression, anxiety, infertility, diminished productivity, and \nsexual dysfunction, impinge upon various aspects of life. \nLiterature review and multivariate analysis of the impact \nof endometriosis on life performed by Missmer et al. [ 60] \nshowed that endometriosis affects educational achieve -\nments, social, family and emotional life, and mental health \n[60]. To reduce the negative impact of the disease on the \nquality of life, it’s crucial to detect endometriosis early and \ninitiate treatment promptly. Pharmacological therapies are \ncommonly used for endometriosis symptoms, however may \nbe associated with sleep disturbances, hot flashes, vaginitis, \nheadaches, nausea and decreased bone density [ 61]. Phar-\nmacotherapy typically results in a reduction of pelvic pain \nby approximately 2 points on a 10-cm visual analogue scale \nafter 3 months [62]. However, despite the many side effects \nassociated with pharmacological treatment, physiotherapy \nappears to offer an equally effective alternative for allevi -\nating symptoms linked with endometriosis. Physiothera -\npeutic interventions employed in managing endometriosis \nsymptoms encompass physical therapy, comprising exer -\ncises [25], aerobic training [ 26], yoga [ 22] and relaxation \ntechniques, such as stretching, breathing [ 24] and progres -\nsive muscle relaxation [ 28]. Physical activity seems to be \nan effective, non-invasive method of alleviating the side \neffects of medications, delaying the decline in bone density, \nincreasing the quality of life, and reducing pain. Physical \ntherapy proves efficacious in reducing stress, anxiety, and \nnormalizing cortisol levels [ 24]. Pain, dysmenorrhea and \nthinking, but these improvements were similar to those seen \nin the placebo group. Fish oil showed some improvement in \nV AS pain, but it was not statistically significant and was less \neffective than the other treatments. The study highlighted \na strong placebo effect, indicating that participation in the \nstudy itself, rather than the supplements [ 42]. Van Haaps et \nal. [44] found that LOWFOOD diet or Endometriosis diet \nlead to reduced pain and improved quality of life for women \nwith endometriosis after six months. Notably, those follow-\ning the diet experienced less bloating and better quality of \nlife in medical treatment and social support area [44].\nThe other treatment Cognitive Behavioral Therapy (CBT) \nmay be beneficial for women with endometriosis due to the \ncomplex interplay between physical symptoms and mental \nhealth challenges associated with endometriosis. Donatti et \nal. [45] presented that CBT decreased depression from 64 \nto 12% in women, as well as stress prevalence decreased \nfrom 72 to 24%, and quality of live improved ( p > 0.001) \n[45]. Wu et al. [ 46] assessed the impact of CBT and Tai \nChi training on the quality of life of women who under -\nwent surgery for endometriosis. Tai Chi training has shown \neffectiveness in reducing anxiety and stress, while the inclu-\nsion of CBT increased the positive effect on the quality of \nlife and reduced depression [ 46]. In turn, Kold et al. [ 47] \nconfirmed the effectiveness of mindfulness techniques, indi-\nvidual and group therapy. Women participating in the study \nsignificantly increased their quality of life and reduced pain \nassociated with endometriosis.\nSymptoms associated with endometriosis can also be \neffectively managed through psychological interventions \nand diet. A detailed description of the research can be found \nin Table 7.\nDiscussion\nThe aim of this review was to outline the most prevalent \nphysiotherapeutic and non-medical approaches utilized \nin addressing symptoms linked with endometriosis and to \nassess their efficacy.\nEndometriosis is often associated with chronic pelvic \npain [ 51], frequently intensifies during menstruation [ 12]. \nPain prompts individuals to adopt antalgic postures, and \npoor body posture, in turn, fosters myofascial disorders, \nsuch as muscle shortening, heightened tension, and conse -\nquently, weakness [12, 52]. Women may present Myofascial \nTrigger Points in the pelvic floor muscles as well as devious \nlocations, complicating their identification. Trigger Points \nare a hypersensitive spot in the taut band and stimulation of \nthis point cause referred pain [53]. These Points can disrupt \nboth motor and autonomic function, disrupting the function \nof visceral organs [ 54]. Prolonged muscle tension causes \n1 3\n3268\n\nReproductive Sciences (2024) 31:3257–3274\nTable 6 Characteristics of studies describing the effectiveness of acupuncture in the treatment of endometriosis\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nRubi-Klein \net al., 2010, \nAustria \n[36]\nTo assess the effective-\nness of acupuncture as an \nadditional pain treatment \nfor endometriosis.\nn = 101 women (83 \ncompleted)\nExp.Gr: n = 47\n(42 completed)\nMean age = 34.8\nCon.Gr: n = 54\n(41 completed)\nMean age = 32.5\nCon. Gr: non-specific acupuncture\nExp.Gr: verum-acupuncture\nTwo units for 10 treatments sessions, twice a week, observation for at least two men-\nstrual cycles, then cross-over.\nAssessment:\nSF-26, V AS, PDI\nVerum acupuncture is effec-\ntive in the treatment of pain \n(p < 0.0001) and increases the \nquality of life of patients.\nde Sousa et \nal., 2016, \nBrazil [38]\nTo assess the effectiveness \nof an acupuncture protocol \non chronic pelvic pain, \ndyspareunia, and qual-\nity of life in women with \nendometriosis.\nn = 42 women\nExp.Gr: n = 20 women\nMean age = 30.45 ± 5.89\nCon.Gr: n = 22 women\nMean age = 31.14 ± 6.92\nCon.Gr: Five session of acupuncture, needles inserted 3 cm apart from original points\nExp.Gr: Five session of acupuncture, needles inserted in specific places\nAssessment:\nV AS, EHP-30\nAcupuncture reduced pain \nin both groups (p = 0.004). \nHowever, 2 months after the \ntherapy, the results were main-\ntained only in the Exp.Gr.\nTian et \nal., 2021, \nChina [40]\nTo assess therapeutic effect \non dysmenorrhea in the \npatients with adenomyosis \nbetween acupuncture and \nibuprofen sustained release \ncapsules.\nAcupuncture group: \nn = 2 0\nIbuprofen Group: n = 2 0\nAcupuncture Group: Insertion of needles in specific acupoints during menstruation \n(every day of menstruation) and in non-menstrual period (twice a week) for 3 menstrual \ncycles.\nIbuprofen Group: Oral Ibuprofen capsules, starting from 1st day of menstruation, 1 \ncapsule twice a day for 5 days, for 3 menstrual cycles.\nAssessment:\nV AS, EHP-5, CMSS\nTwo menstrual cycles after \ntreatment V AS score at the most \npainful time during menstrua-\ntion was lower in Acupuncture \nGroup (2.175 ± 1.507) than Ibu-\nprofen Group (6.075 ± 0.748). \nCMSS and EHP-5 scores was \nlower in Acupuncture Group \n(p < 0.005).\nSF-36–36-Item Short Form Health Survey; VAS– Visual Analogue Scale; PDI– Pain Disability Index; EHP-30– Endometriosis Health Profile; HRQOL - Health-Related Quality of Life; EHP-\n5– Endometriosis Health Profile-5; CMSS - COX menstrual symptom scale\n1 3\n3269\n\nReproductive Sciences (2024) 31:3257–3274\nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nNodler et \nal., 2020, \nUSA \n[42]\nTo assess whether supplementa-\ntion with\nvitamin D or ω-3 fatty acids reme-\ndiates pain, changes frequency of\npain medication usage, or affects \nquality of life in young women \nwith\nendometriosis.\nVitamin D: n = 27\n(23 completed)\nMean \nage = 20.0 ± 2.7\nFish oil: n = 2 0\n(17 completed)\nMean \nage = 18.9 ± 3.1\nPlacebo: n = 22\n(19 completed)\nMean \nage = 20.1 ± 3.5\nVitamin D: 2000 IU vitamin D3 (cholecalciferol) daily\nFish oil: 1000 mg fish oil [720 mg ω-3 fatty acids, includ-\ning 488 mg EPA (20:5n–3) and 178 mg DHA (22:6n–3)] \ndaily\nPlacebo: taking white gelatin capsules with inert lactose \npowder.\nAssessment:\nbaseline, 3 and 6 month after enrolment\n128-item FFQ, SF-12, V AS, serum samples\nV AS pain scores improved from baseline to\n6 months in the placebo (5.5 to 4.6, p = 0.32), vitamin D (6.3 \nto 5.3, p = 0.15), and fish oil (5.6 to 5.1, p = 0.67). Participants \nin all 3 study arms demonstrated improvement in catastrophic \nthinking score, with a statistically significant mean score \nimprovement from baseline to 6 months only in the vitamin D \n(25.3 to 20.8, p = 0.04).\nCirillo et \nal., 2023, \nItaly \n[43]\nTo assess\nthe role of dietary changes accord-\ning to the Mediterranean Diet \npattern on pain\nperception in women with endome-\ntriosis and their relationship with \noxidative stress.\nn = 35 \nwomen with \nendometriosis\n(26 completed)\nEach woman received an individually selected Mediterra-\nnean diet for 6 months.\nAssessment:\nblood sample, V AS, dyspareunia\nPatients experienced reduced pain in dyspareunia (p = 0.04), \nnon-menstrual pelvic pain (p = 0.06). Additionally, there was a \nsignificant positive correlation between lipid peroxidation and \nV AS non-menstrual pelvic pain.\nVan \nHaaps et \nal., 2023, \nthe Neth-\nerlands \n[44]\nTo assess the impact of the Low \nFODMAP diet and the endometrio-\nsis diet on endometriosis-related \nsymptoms and quality of life.\nLow FOODMAP \ndiet: n = 22\nMean \nage = 36.9 ± 5.9\nEndometriosis \ndiet: n = 21\nMean \nage = 39.1 ± 15.8\nControl: n = 19\nMean \nage = 37.6 ± 8.5\nThe Low FODMAP diet involves three phases: elimination \nof high-FODMAP foods for 6–10 weeks to reduce IBS \nsymptoms, reintroduction of high-FODMAP foods one at \na time to identify triggers, and personalization based on \nindividual tolerance.\nIn the endometriosis diet women avoid nutrients they\nnoticed provoked or aggravated their endometriosis-related \nsymptoms (e.g. red meat, gluten, cow milk, sugars).\nControl group did not received any diet.\nAssessment:\nV AS, EHP-30; GIQLI\nAll participants adhering to a diet reported significantly less \ndeep dyspareunia and tiredness after adhering to the diet \nfor 6 months compared to their baseline scores (p < 0.001). \nParticipants adhering to the Low FODMAP diet reported \nsignificantly less dysuria (p = 0.015) and bloating (p < 0.001), \nwhereas participants adhering to the endometriosis diet \nreported significant less bloating (p < 0.001) and tiredness \n(p = 0.002) after 6 months compared to their baseline scores. \nParticipants in the control group reported no significantly \ndifferent pain scores in endometriosis-related symptoms at 6 \nmonths follow-up.\nDonatti, \n2024, \nBrazil \n[45]\nTo assess the efficacy of CBT in \nenhancing coping strategies, allevi-\nating depression,\nstress, reducing pain perception, \nand improving\nthe quality of life for women suf-\nfering from\nendometriosis and chronic pelvic \npain.\nExperimental \ngroup: n = 25\nControl group: \nn = 27\nExperimental Group: 16 CBT session, 1session/week\nControl Group: no intervention\nAssessment:\nSF-36, Brief Cope, Beck Depression Scale, Lipp’s Adult \nStress Symptoms Inventory, V AS\nAfter 4 months, control group depression decreased to \n55.56%, while the experimental group dropped to 12% post-\nCBT. For dysmenorrhea and chronic pelvic pain, post-inter-\nvention, likelihood of pain-free status was 14 times higher \n(p < 0.01). In quality of life, experimental group showed \nsignificant improvements in SF-36 scores, including physical \nfunctioning, role limitations, pain, general health, vitality, \nsocial functioning, emotional role limitations, and mental \nhealth.\nTable 7 Characteristics of studies describing the effectiveness of diet and cognitive-behavioural therapy in the treatment of endometriosis\n1 3\n3270\n\nReproductive Sciences (2024) 31:3257–3274\ndyspareunia may be also treated by manual therapy [29–31, \n37, 39]. Through myofascial connections, tensions can be \ntransferred to other areas of the body, while inflammation \nand an increased number of inflammatory mediators in the \npelvic organ area can contribute to myofascial disorders, \nintra-organ movement and vascular drainage [ 63]. Visceral \ntherapy improved physical and mental function among \n80% of women with endometriosis [ 29]. Transvaginal \nmanual therapy relaxes muscles and restores normal pelvic \ntone, consequently reducing dyspareunia [ 30]. Adhesions \ncommonly occurre with endometriosis and can be identi -\nfied by physiotherapists; specialized techniques enable the \ndetachment of adhesive crosslinks and alleviate pain dur -\ning menstruation and intercourse [31]. Specialists may also \nuse transperineal ultrasound to evaluate pelvic floor muscle \nfunctioning and localize muscles dysfunction [ 30]. Other \ncomplementary treatment for symptoms associated with \nendometriosis may be electrotherapy, exactly transcutane -\nous electrical nerve stimulation (TENS), which reduce pain. \nStudies suggest that TENS reduced chronic pelvic pain in \nV AS scale for approximately 2.55 points, whereas hor -\nmonal treatment alone reduced pain for approximately 0.27 \npoints in V AS scale [34]. Positive outcomes have also been \nobserved in studies on electrical neuromuscular stimulation \n(NMES); after 5 weeks of NMES treatment, pain decreased \nby approximately 1.4 points on a scale ranging from 0 to 10 \n[32]. Besides electrotherapy, epth are important [35]. Virtual \nreality may also prove to be a helpful technique in modern \nphysiotherapy treatment aimed at better pain modulation \n[30]. Acupuncture is more and more often used as a therapy \nfor gynecological disorders, despite the controversies. It \ndemonstrates positive effects in women with endometriosis, \nreducing chronic pelvic pain by 66% and dyspareunia by \n65%, with the effects persisting for at least 2 months post-\nacupuncture therapy [38]. Acupuncture exhibited a superior \nanalgesic effect compared to Ibuprofen during menstruation \nin women with endometriosis [ 40]. Endometriosis, a pro -\ninflammatory condition, may be managed through dietary \ninterventions, such as the Mediterranean diet, which has \nbeen linked to pain relief in patients [ 42]. Vitamin D sup -\nplementation and fish oil showed some benefits, though a \nstrong placebo effect was noted [42]. The LOWFOOD diet \nalso reduced pain and improved quality of life, particularly \nin reducing bloating and enhancing social support [ 44]. \nCognitive Behavioral Therapy (CBT) has proven effective \nin reducing depression, stress, and improving the quality of \nlife for women with endometriosis [ 45]. Additionally, Tai \nChi and mindfulness techniques, both individual and group \ntherapy, have shown significant benefits in managing anxi -\nety, stress, and pain associated with endometriosis [46, 47].\nOur review has its limitations. Firstly, many of the studies \nincluded had small sample sizes, and participant selection \nAuthor, \nyear, \ncountry\nPurpose Participants Intervention Results\nWu, \n2022, \nChina \n[46]\nTo assess whether usual care \ncombined with CBT improves \ndepression, anxiety,\nand stress in patients after surgery \nfor endometriosis as compared to \nusual care alone.\nIntervention \ngroup: n = 48\nControl group: \nn = 48\nIntervention group: 1 pre-surgery and\n6 post-surgery CBT sessions in addition to their routine \nusual care.\nControl group: usual care - Tai Chi, 30 min/per day, 5 days \na week\nAssessment: DASS-21\nDepression, anxiety, and stress of the case group and the con-\ntrol group were decreased as compared to baseline (p < 0.001).\nUsual care plus CBT significantly increased the number of \nfemales with no symptoms of depression (p = 0.0356). Usual \ncare plus CBT significantly decreased the number of females \nwith symptoms of extremely severe anxiety (p = 0.035).\nKold, \n2012, \nDenmark \n[47]\nTo assess the feasibility of \nmindfulness approach in patients \nwith chronic pain secondary to \nendometriosis.\nn = 1 0\nMedian age = 23\n5 individual and 5 group session of mindfulness, visualiza-\ntion, psycho-education and group support methods.\nAssessment:\nSF-36, EHP-30\nBodily pain significantly and consistently improved from \npre- to post-intervention and follow-up measures (p < 0.05). \nThe work life scale showed significant improvement on all \nmeasurement points. Pain decreased from 52.53 to 28.18 \n(p < 0.001).\nSH-12– Short form 12; FFQ - Food Frequency Questionnaire; VAS– visual analogue scale; EHP-30 - Endometriosis Health Profile; GIQLI– Gastro-intestinal health; CBT– Cognitive behav -\nioural therapy; SF-36 - The Short Form Health Survey; DASS-21 - Depression anxiety and stress scale\nTable 7 (continued)\n \n1 3\n3271\n\nReproductive Sciences (2024) 31:3257–3274\nReferences\n1. Parazzini F, Esposito G, Tozzi L, Noli S, Bianchi S. Epidemiol -\nogy of endometriosis and its comorbidities. Eur J Obstet Gynecol. \n2017;209:3–7. https://doi.org/10.1016/j.ejogrb.2016.04.021.\n2. Zondervan KT, Becker CM, Koga K, Missmer SA, Taylor RN, \nViganò P, Endometriosis. Nat Rev Dis Primers. 2018;4(1):9. \nhttps://doi.org/10.1038/s41572-018-0008-5.\n3. Alimi Y , Iwanaga J, Loukas M, Tubbs RS. The clinical anatomy \nof endometriosis: a review. Cureus. 2018;10(9):e3361. https://\ndoi.org/10.7759/cureus.3361.\n4. 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Int J Mol Sci. 2021;22(19). https://doi.\norg/10.3390/ijms221910554.\nwas not always heterogeneous, thus caution should be exer-\ncised in interpreting the results. Often, the research included \nwomen with severe endometriosis, which may not neces -\nsarily reflect outcomes in women with milder symptoms. \nAnother constraint is the lack of validation of questionnaires \nfor specific populations. Additionally, a considerable num -\nber of participants were lost during the study and follow-up. \nNot all studies were randomized, and some lacked proper \ncontrols. Short follow-up periods hindered the determina -\ntion of long-term therapy effects. Furthermore, publications \nwere restricted to those available in Polish and English. It’s \nimportant to note that specific criteria regarding the dura -\ntion and type of research were not uniformly applied, which \ncould influence the findings. Nonetheless, this allowed us to \nidentify common non-medical methods for treating endo -\nmetriosis and pinpoint areas requiring further investigation.\nIn conclusions, it is worth add physiotherapy methods in \nthe reduce of symptoms of endometriosis. Physical activity, \nmanual therapy, electrophysical agents, acupuncture, diet \nand cognitive behavioral therapy showed no negative side \neffects and reduced pain, what improved the quality of life \nand reduced the perceived stress.\nSupplementary Information  The online version contains \nsupplementary material available at https://doi.org/10.1007/s43032-\n024-01660-2.\nAcknowledgements None\nData availability not applicable.\nCode availability not applicable.\nDeclarations\nCompeting interests None.\nEthics Approval not applicable.\nConsent to Participate not applicable.\nConsent for Publication not applicable.\nOpen Access   This article is licensed under a Creative Commons \nAttribution 4.0 International License, which permits use, sharing, \nadaptation, distribution and reproduction in any medium or format, \nas long as you give appropriate credit to the original author(s) and the \nsource, provide a link to the Creative Commons licence, and indicate \nif changes were made. 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