How to Train If You Have Endometriosis

By Heba Shaheed

Endometriosis affects one in 10 women worldwide with the main sign being period pain. Thriving with endometriosis can be challenging, and many women with endo may find it difficult to train and exercise in the way they love, if at all. Yet, women with endometriosis can live a healthy, productive life, and can achieve their fitness goals.

Although endometriosis is commonly characterized by pain, which can sometimes be aggravated by certain activities, it is really important for overall health and well-being that women continue to be physically active. After all, movement is medicine.

What is Endometriosis?

Endometriosis occurs when cells that are similar to the cells that make up the uterine lining exist in other places, such as on the ovaries, fallopian tubes, bowels and even the lungs [1]. During a period, these cells behave in the same way as the uterine lining. However, as there’s nowhere for them to leave the body, this results in inflammation, scarring, adhesions, pain and infertility.

Symptoms of Endometriosis

Women with endometriosis can have a varied assortment of symptoms, including [2]:

  • Period pain
  • Heavy, prolonged and irregular periods, including spotting between periods
  • Pelvic pain
  • Painful sex (during and after)
  • Painful urination during periods
  • Pain with bowel movements
  • Abdominal pain
  • Bloating (“endo belly”)
  • Food intolerances e.g. dairy, wheat, soy and sugars
  • Constipation
  • Diarrhea
  • Infertility

Endometriosis and Pelvic Floor Dysfunction

Many women with endometriosis will develop hypertonic pelvic floor muscles. Due to pain, holding patterns, inflammation and adhesions, the pelvic floor muscles may become tight and unable to relax.

The pelvic floor muscles need to be released and retrained to relax, so it is ideal for women with endometriosis to see a pelvic health physical therapist. The physical therapist can also address other contributors to pain such as tight abdominal tissue, sensitized nerves and weak muscles.

If you have endometriosis, it is important to identify if you have a hypertonic pelvic floor. This will affect the way you exercise and the types of exercise you need to do.

Endometriosis and Exercise Considerations

Women with endometriosis can become generally weakened from the cycle of inflammation, stress and pain. Strength training becomes especially important in order to build strength through all the muscles groups, especially the weakened muscles.

In most women, pelvic floor engagement is recommended during the exhale breath. However in women with hypertonic pelvic floor muscles, cueing for pelvic floor engagement can cause more pain and discomfort. Therefore, in these circumstances, pelvic floor relaxation is encouraged.

Instead of doing “kegels” or pelvic floor lifts, women with hypertonic pelvic floor muscles need to do “reverse kegels” or pelvic floor drops. Visualize the way a pebble drops into a pond, and the ripples the pebble makes outwards; now feel this in your pelvic floor.

It is also important for women who have endometriosis to stretch the muscles around their hips, pelvis, back and abdomen. Incorporating yoga into your exercise habits, or having a diligent stretch routine during your warmup and cool-down that flows through these muscles on the days when you’re strength training, are both useful ways of addressing this.

Keep in mind that the connective tissue in the pelvic floor and in the abdomen can become tight due to scarring and adhesions. Therefore, exercises that shorten these muscle groups such as crunches and sit-ups may not be ideal. Exercises that strengthen the muscles in these areas in an elongated position would be more justified.

Endometriosis and Nutrition Considerations

Women with endometriosis will typically have some gut dysbiosis — an imbalance of the microbiota — due to the ongoing inflammatory and immune responses, as well as persistent pain and stress. Many women with endometriosis may have received a previous or concurrent diagnosis of irritable bowel syndrome, and may have food sensitivities.

Research shows that women with endometriosis are likely to benefit from a gluten-free diet [3]. Eliminating other food sensitivities, such as sugars, dairy or soy, can also be beneficial [4]. Taking supplements and eating foods that are high in omega-3 fatty acids, B-vitamins, antioxidants, and zinc have all been shown to reduce the inflammatory and immune responses in women with endometriosis [5][6][7][8].

Having lived with endometriosis myself, with a delayed diagnosis of 11 years resulting in persistent pelvic pain and gut issues, I know it’s possible to exercise and live pain-free, because I’ve been there myself and am now on the other side. I’ve also personally helped hundreds of women with endometriosis to overcome their pain and return to the exercise that they love.

If you are a woman with endometriosis or suspect you may have endometriosis, it is important to seek professional help from your gynecologist. I also recommend searching for a physical therapist and a functional nutrition practitioner who works with endometriosis and pelvic pain.

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About the author:  Heba Shaheed

Heba Shaheed is an Australian physiotherapist and nutritionist with over seven years of experience in pelvic health physiotherapy, women's health nutrition, pain neuroscience, clinical pilates, and yoga therapy. Heba is the Co-Founder of The Pelvic Expert, where she provides online programs combining women's health physiotherapy, integrative nutrition, and functional exercise for women with chronic pelvic pain, pregnant women, and mothers. She is also the host of the Pregnancy and Motherhood Summit. Deeply passionate about recovery after birth trauma and living well with chronic conditions such as endometriosis due in part to her own personal experiences, Heba is also a new mum to a cute little daughter.


  1. Vercillini P, Vigano P, Somigliana E, Fedele L. Endometriosis: pathogenesis and treatment. Nature Reviews Endocrinology. May 2014; 10(5): 261-75.
  2. Bloski T, Pierson R. Endometriosis and chronic pelvic pain. Nursing Women’s Health. October 2008; 12(5): 382-95.
  3. Marziali M, Venza M, Lazzaro S, et al. Gluten-free diet: a new strategy for management of painful endometriosis related symptoms?. Minerva Chirurgica. December 2012; 67 (6): 499-504.
  4. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. Journal of Gastroenterology and Hepatology. February 2010; 25(2): 252-8.
  5. Mismmer SA, Cramer DW. The epidemiology of endometriosis. Obstetrics and Gynecology Clinics of North America. March 2003; 30(1): 1-19.
  6. Darling AM, Chavarro JE, Malspeis S, et al. A prospective cohort study of Vitamins B, C, E, and multivitamin intake and endometriosis. Journal of Endometriosis. January 2013; 5(1): 17-26.
  7. Santanam N, Kavtaradze N, Murphy A, et al. Antioxidant supplementation reduces endometriosis-related pelvic pain in humans. Translational Research. March 2013; 161(3): 189-95.
  8. Messalli EM, Schettino MT, Mainini G, et al. The possible role of zinc in the etiopathogenesis of endometriosis. Clinical and Experimental Obstetrics and Gynecology. 2014; 41(5): 541-6.

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