Effectiveness of Supervised Exercise and Pelvic Floor Muscle Training in Alleviating Pelvic/Genital Pain in Women with Endometriosis

To investigate whether exercise training, including pelvic floor muscle training (PFMT) combined with pain education, can better reduce pelvic/genital pain than pain education alone in women with endometriosis. 

An assessor-blinded, two-armed, parallel-group randomized controlled trial (RCT) conducted between 2022-2024. Eighty-one women aged 18-45 years, with laparoscopic-confirmed endometriosis and pelvic/genital pain were included. All the participants attended an interdisciplinary pain education course. After randomization, a women's health physiotherapist led the exercise group (n=41) with weekly 60-minute group sessions for four months. The program included endurance, strength, PFMT, flexibility, relaxation, and a home training program. The control group (n=40) received no further follow-up. The primary outcome was change in pelvic/genital pain_worst and pelvic/genital pain_best measured on a numeric rating scale (NRS) 0-10 throughout four weeks and conditional pain (pain_conditional) measured on NRS 0-10. Secondary outcomes were patient-reported experience measures to assess the master of the condition; change in dyspareunia; worries related to intercourse, dysuria, dyschezia; vaginal resting pressure (VRP); maximal voluntary pelvic floor muscle (PFM) contraction (MVC); PFM endurance; vaginal resting activity (VRA). Analysis was based on intention to treat (ITT) and per-protocol: attending >50% of the group training/home training program, >2 PFMT per/week and >2 exercises per/week on average. 

The ITT analysis revealed no statistically significant difference between groups in pain_worst or pain_best, but a significantly larger reduction of pelvic/genital pain_conditional in the exercise group compared to the control group [mean difference: 1.2 (95%CI 0.1–2.2)]. Eighty-three (n=30) from the exercise group reported significantly greater improvement in disease mastery (RR=1.613, 95% CI: 1.059–2.456) compared to the control group. There was no significant change in the other outcome variables. The per-protocol analysis revealed a significant reduction in pelvic/genital pain_worst [mean difference: 1.6, (95%CI 0.2–3)] and pain_conditional [mean difference: 1.7, (95%CI 0.4– 2.9)] favoring the exercise group. No adverse effects were reported.

We found that pain education and exercise training, including PFMT, may improve conditional pelvic/genital pain among women with endometriosis. The participants in the exercise group were significantly more likely to report better disease management. The prescribed exercises may not have directly affected PFM function; further research should explore whether more intensive and frequent PFMT enhances PFM function and more pain relief.

This RCT provides a much-needed study of non-pharmacological treatment of women with endometriosis and pelvic/genital pain. The study indicates that exercise training, including PFM training, can benefit women with endometriosis. Thus, clinicians should carefully empower their patients with knowledge and skills in implementing exercise training and PFMT as part of their treatment. The study underscores the need for multidisciplinary management, including physiotherapists and gynaecologists.