Physiotherapy for endometriosis-associated pelvic pain: a systematic review and meta-analysis

Background Endometriosis is a chronic inflammatory gynaecological disease characterised by the ectopic growth of tissue similar to the mucous membrane of the uterus (endometrium) and affects around 10 percent of women of childbearing age worldwide [ 1 ] [ 2 ] [ 3 ]. Endometriosis is often associated with chronic abdominal pain, dysmenorrhoea, dyspareunia, infertility and a significantly reduced quality of life [ 1 ] [ 2 ] [ 3 ] [ 4 ]. Although drug treatments such as NSAIDs and analgesics are often prescribed for endometriosis-associated abdominal pain, their long-term use is often limited due to side effects and contraindications [ 1 ] [ 3 ] [ 5 ] [ 6 ] [ 7 ] [ 8 ]. Physiotherapeutic interventions could offer an alternative and act as a potential pain-reducing intervention, but their role in endometriosis has not yet been sufficiently investigated. Objective To date, there is no meta-analysis that deals exclusively with physiotherapeutic interventions for endometriosis-related abdominal pain. Therefore, the review and meta-analysis aims to evaluate the effectiveness of different physiotherapy techniques in relieving abdominal pain in women with endometriosis. Methods The review was written according to the PRISMA 2020 guidelines, it was methodologically based on the Cochrane Handbook and it was registered in PROSPERO. The literature search was conducted in PubMed, Embase and the Cochrane Library up to November 2023 without restrictions regarding language or publication date. The search terms in the search strategy included “endometriosis” in combination with terms such as physiotherapy, exercise therapy, rehabilitation, movement, electrotherapy, TENS, electrostimulation, laser therapy, manual therapy, manipulation, massage, ultrasound therapy, trigger point therapy, hydrotherapy and balneotherapy. Studies were included when they examined women with diagnosed endometriosis and endometriosis-related abdominal pain who were treated with physiotherapy. The pain intensity had to have been recorded both before and after the intervention using a 0–10-point scale (e. g. VAS or NRS) or an equivalent validated pain scale. Studies were excluded if they did not investigate physiotherapy or unconventional interventions such as yoga, Pilates or acupuncture, included populations without endometriosis-related abdominal pain, were animal or in vitro studies, did not record pain as an outcome or used non-comparable pain scales. The interventions were categorised into 3 groups: Physiotherapeutic modalities: Electrotherapy procedures (TENS, NMES, transcranial direct current stimulation, laser therapy), exercise therapy: structured or supervised exercise programmes and manual therapy: manual techniques such as Thiele massage or soft tissue and joint techniques. The bias potential was assessed independently by 2 reviewers using the Cochrane RoB 2 tool and the ROBINS-I tool. The evidence was assessed using the GRADE approach. The statistical analysis was carried out in R. The random-effects model was selected for the meta-analysis. The mean differences with 95 % confidence intervals were calculated on the basis of the change in values between the control and intervention groups. If these were not specified, they were derived from the data before and after treatment. Heterogeneity was assessed using the Cochranʼs Q test and the I² statistic. Results Of 9828 researched studies, 8 (7 randomised controlled trials and 1 retrospective study) with a total of 433 participants met the inclusion criteria. Seven studies were included in the meta-analysis. Overall, physiotherapy interventions significantly reduced pelvic pain compared to control interventions, with an average reduction of around 2 points on a pain scale of 0–10 (MD -1.97; 95 % CI -2.99−-0.95). Among the 3 intervention categories, physical measures, including TENS, transcranial electrotherapy and laser therapy, showed the greatest effect (pain intensity MD -2.03; 95 % CI -3.9−-0.14). Laser therapy led to a marked reduction in pain (MD -3.25; 95 % CI -4.96−-1.53). The side effects reported were minimal and only occurred in conjunction with electrotherapy. Manual therapy (e. g. soft tissue and joint techniques, Thiele massage) led to clinically significant but statistically insignificant effects (pain intensity MD -2.09; 95 % CI -15.84−11.67). Exercise therapy also reduced pain, albeit to a lesser extent (pain intensity MD -1.13; 95 % CI -3.94−1.68), although only limited data were available. Measures categorised as local application were more effective than measures categorised as general application (pain intensity MD -2.26; 95 % CI -3.28−-1.24). The overall risk of bias was moderate, and the quality of evidence was rated as low according to GRADE. Conclusion This systematic review and meta-analysis provides the first evidence that physiotherapy techniques are effective in relieving pelvic pain in women with endometriosis, particularly when the interventions are applied locally. Despite methodological limitations, the results speak in favour of considering physiotherapy as a valuable component of pain treatment for patients with endometriosis. Implementation of the results in clinical practice should take into account the low level of evidence. Publication History Article published online: 29 May 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany