By Dr. Mathew Leonardi, Medical Director; Jill Mueller, Pelvic Health Physiotherapist; Dr. Laura Katz, Health, Rehabilitation and Clinical Psychologist; and Emily Arthur, Registered Dietitian
Endometriosis is a complex, systemic inflammatory condition that affects an estimated 1 in 10 individuals of reproductive age globally. Characterized by tissue similar to the uterine lining growing outside of the uterus and into other areas of the body, it manifests through a spectrum of symptoms including debilitating pelvic pain, painful periods, pain with sex, pain with bowel movements, chronic fatigue, and infertility.
For decades, the conventional clinical approach has relied primarily on a framework of medicine and surgery, and while these interventions remain vital pillars of management, they frequently fall short of truly addressing the comprehensive, systemic, and day-to-day realities of living with the disease. True endometriosis care requires embracing an interdisciplinary care team approach that acknowledges the critical overlap between physiological, lifestyle, and psychological systems.
The Limitations of Medicine Alone
Medical treatments for endometriosis often seek to reduce symptoms and remove active disease. Medications, such as combined oral contraceptives, progestins, and GnRH agonists or antagonists, are designed to down-regulate ovarian function in order to deprive lesions of the hormones that drive their growth and offer some pain reduction. While these can be effective for some people, others may struggle with side effects and find them a poor fit for their goals such as planning a pregnancy.
Surgery, particularly advanced laparoscopic excision, is widely considered the gold standard for removing visible lesions and restoring pelvic anatomy. However, the underlying immune and inflammatory concerns are not well-addressed by these procedures and central sensitization, a state where the central nervous system becomes hyper-reactive and amplifies pain signals, can contribute to chronic pelvic pain even after surgical healing is done. And this highlights the limitations and the underlying truth of only focusing on medical management of endometriosis: suppressing or removing the disease is not equal to whole-body healing or addressing pain. But this also creates an incredible opportunity for a new approach, looking beyond the pelvis alone and supporting overall health.
The Neurobiology of Central Sensitization
Living with a chronic, unpredictable pain condition places an immense, unyielding burden on the autonomic nervous system. Prolonged physical pain acts as a chronic stressor, triggering the continuous release of cortisol and adrenaline from the adrenal glands. This sustained sympathetic activation (“fight or flight” mode) directly heightens pain perception, exacerbates systemic inflammation, and compromises immune regulation. Over time, chronic pain alters the structure and function of the central nervous system. In a process akin to turning up the volume dial on an amplifier, the brain and spinal cord become highly sensitized to sensory input.
Psychological therapeutic approaches, such as Cognitive Behavioral Therapy (CBT), are not used to imply that the pain is psychological; rather, they serve as powerful neurological tools to help patients reframe the cognitive appraisal of pain, develop adaptive coping strategies, and reduce the catastrophic anxiety that naturally accompanies flare-ups, ultimately dampening the neurological amplification of pain, and rewiring the neurobiology of the system.
Somatic and Stress-Reduction from the Top Down
Living with endometriosis means living with a body that often feels unpredictable. Pain can arrive without warning, symptoms can fluctuate, and years of navigating medical uncertainty can leave people constantly monitoring, anticipating, and protecting themselves from the next flare, along with perceived medical trauma. From a health psychology perspective, this matters—not because stress causes endometriosis, but because the brain and nervous system play an important role in how we perceive, process, and respond to pain. When pain persists over time, the nervous system can become increasingly protective and reactive, with the brain paying closer attention to signals from the body and becoming more responsive to sensory input. This process, known as pain system hypersensitivity or central sensitization, can amplify pain and contribute to a cycle in which pain increases vigilance, vigilance increases threat perception, and the experience of pain becomes even more overwhelming.
This is where working from the top down becomes an important part of endometriosis care. One of the most valuable things a health psychologist can offer is a framework for understanding what is happening in the body. Pain neuroscience education can help people understand why pain may persist even when surgery or imaging does not fully explain its intensity—without suggesting that the pain is psychological or “all in your head.” Pain is a complex experience influenced by the brain, nervous system, immune system, tissues, thoughts, emotions, past experiences and traumas, and environment. Understanding this can help people move away from fearing every sensation and toward having more tools and choices for responding to their symptoms.
Somatic and nervous-system regulation strategies can also help the body move out of a constant state of protection. Practices such as diaphragmatic breathing, grounding, mindful awareness, and other body-based approaches can help people recognize physiological activation and develop skills to respond differently to it. Psychological therapies can help individuals understand pain-related thoughts, reduce fear and catastrophizing, develop more flexible coping strategies, and reconnect with the activities and values that matter to them—even when symptoms are present. This isn’t about thinking pain away or pushing through symptoms. It is about expanding the toolkit available to someone so that endometriosis doesn’t have to dictate every decision, increasing cognitive flexibility and helping them understand that their emotions are often important environmental cues.
Ultimately, top-down care is about moving from “How do I stop my body from doing this?” to “What can I do when my body does this?” The goal isn’t to eliminate every symptom or create a perfectly regulated nervous system. It is to help people gain insight, feel less afraid of their bodies, more equipped to respond to symptoms flexibly, and more able to participate in the lives they want to live. Top-down approaches don’t replace medical treatment for endometriosis—they complement it by addressing the nervous system, brain, behaviours, emotions, and lived experience that are also part of the pain experience.
The Power of Nourishing, from the Inside Out
Endometriosis lesions can produce a variety of pro-inflammatory compounds (such as cytokines, prostaglandins, and chemokines), often contributing to pain and digestive symptoms. Nutrition has to be more than just identifying and removing triggers to discomfort, and this is where a Registered Dietitian comes in. The body and the mind benefit when food choices address inflammation healing and tissue integrity, and promote a healthy relationship with food.
While it’s commonly suggested as the primary goal in nutrition for endometriosis, restriction and food removal is counterintuitive. As restriction of food groups grows and grows, an increased risk of inadequate energy availability for body function and malnutrition compromise the integrity of the digestive system and the brain. An under-fueled brain leads to increased anxiety around food choices, and poor food intake alters gut motility negatively. Prioritizing adequate and regular eating patterns is an essential first step to nourishing the gut with endometriosis, and acts as a foundation for repairing the relationship the gut has to the nervous system and the pain response.
Antioxidant density of foods selected is the best support for inflammation management, including increasing omega-3 fatty acids, vitamins A, C, and E, and minerals including zinc and selenium. There are no “right” or “wrong” foods in this domain – the more variety, the better! And as the gut bacteria interact with more diversity of fibres, the estrobolome (a subset of gut bacteria DNA responsible for estrogen circulation and metabolism) can more effectively function to process hormone breakdown and improve digestive structures. Food intake doesn’t have to be restrictive to provide benefits!
And building a healthy relationship with food cannot be forgotten in the process. Willpower and discipline are not ingredients in a well-balanced endometriosis nutrition plan – they are stressors that make it hard to focus on what actually matters in nutrition: enjoyment, balance, and variety! Learning to recognize and attend to your own body cues, to create enjoyable eating experiences that are truly safe and comfortable, and to notice trends in the action of the nervous system alongside the digestive system creates strong interoceptive awareness and coping skills to stay well-nourished and in the driver’s seat when it comes to pain reduction.
Pelvic Floor Physical Therapy: Working from the Bottom Up
Pelvic Floor Physical Therapy/Physiotherapy (PFPT) is now being recommended in treatment guidelines for Endometriosis (SOGC, ESHRE), recognizing the importance of involving a team of different therapies in patient care.
Chronic pelvic pain, and bladder, bowel and sexual function are common findings in someone with Endometriosis. In response to years of visceral pain from endometriosis lesions, years of meandering a medical system not well educated in this disease, and years of trying to function at work or school every month, the muscles of the pelvic floor frequently contract defensively – entering a state of chronic tension, or high-tone pelvic floor dysfunction. Muscles are like soldiers (including the pelvic floor), just doing what they are told…sometimes this is to help protect and guard.
Pelvic Floor Physical Therapy is a specialized discipline focused on helping to retrain these muscular imbalances. Therapy in this case, is much more than focusing on strengthening exercises like Kegels. A qualified pelvic physical therapist will include looking at the whole you, including assessing sleep, eating, sexual and movement routines; stress levels, bowel and bladder habits; and utilize manual therapy techniques to retrain the pelvic floor muscles, improve tissue mobility, and desensitize the pelvic nerves.
Treatment will extend to include modifying these habits and routines to optimize your health, and may integrate diaphragmatic breathing and somatic (body) exercises, designed to improve function and sensation.
Pelvic floor physio extends beyond the pelvis, and becomes a great teammate to add to your Endometriosis care team. It can help you better understand what’s happening in your body, and provide strategies so you can feel more equipped to respond when symptoms show up.
So you can start spending less time organizing your life around endometriosis and more time working toward the life you want to live.
Building a Comprehensive, Patient-Centered Team
This is why we created Endometriosis360 – no single specialist possesses all the tools required to manage the complex and multifaceted landscape of endometriosis. But an innovative and interdisciplinary team rooted in one integrated message across pelvic health, nutrition and mind-body pain science is the roadmap forward.
Endometriosis360 is Canada’s first online, interdisciplinary consultation and group program for people with endometriosis, focusing on the often-missed opportunities to change the experience of pain, nervous system sensitization, gut and pelvic floor symptoms, and the emotional burden of living with a chronic condition.
Guided by Dr. Mathew Leonardi, Medical Director and co-founded by Jill Mueller, Pelvic Health Physiotherapist, Dr. Laura Katz, Health Psychologist and Emily Arthur, Registered Dietitian, Endometriosis360 offers a novel opportunity to meet with an experienced interdisciplinary team and learn more about the groundbreaking Endometriosis360 Group Program.
For Ontario residents, an Interdisciplinary Consultation provides a simultaneous meeting with a physiotherapist, dietitian and psychologist, who are leaders in the pelvic health and endometriosis field. This comprehensive assessment allows the team to learn about you and your goals in a holistic framework, and offers a number of recommendations in your care plan, including possible referral to the Endometriosis360 Group Program. This virtual group brings together perspectives from pelvic health, nutrition, psychology and endometriosis-focused medical research and teaching to provide high-quality and evidence-informed skills so you can make sense of common challenges associated with endometriosis, and learn practical strategies for daily living. For those outside of Ontario, a consultation is not required and Group Program registration is offered on a regular basis to support individuals “beyond borders”.
Empowering the Path Forward
Endometriosis is an intricate, multi-layered journey that demands far more than a singular clinical intervention. True progress begins when we recognize that managing endometriosis requires looking at the whole person instead of only trying to treat with medicine and surgery, and equipping them with a diverse and powerful toolkit to reclaim control over their body, their health, and their life.
We’re ready to help you build your life again.
