Why Endometriosis Is Not Always the Cause of Pelvic Pain:A Neuropelveological Perspective

For decades, endometriosis was a largely misunderstood condition. Thirty years ago, it was often dismissed as nothing more than “painful periods,” and countless women were told their suffering was normal or psychological. Thankfully, the last 20 years have transformed this landscape. Increased awareness, driven by the internet, patient advocacy groups, and committed medical professionals worldwide, has turned endometriosis into a widely recognized and legitimate disease that finally receives the attention it deserves.

This progress has been life-changing for many women. Awareness has empowered patients, encouraged earlier consultations, and built momentum for improving diagnosis and treatment. But with this progress comes a paradox:Endometriosis is now, in many parts of the world, both over-diagnosed in some contexts and still diagnosed too late in others.

Two Realities That Could Not Be More Different

On one hand, endometriosis has become a “universal explanation” for almost any pelvic pain. Many women presenting with genito-anal pain, bladder dysfunction, bowel symptoms, sciatic pain, or diffuse pelvic discomfort are rapidly labeled with endometriosis, even when imaging or surgery shows minimal or no lesions. This tendency creates a diagnostic shortcut that is understandable but potentially misleading.

On the other hand, despite enormous awareness efforts, deep infiltrating endometriosis - the form that can seriously affect health by involving the bowel, ureters, bladder, or pelvic nerves - is still diagnosed far too late. This type of endometriosis is a medical indication for surgery because of the risk of permanent organ damage. Yet many women wait years before receiving a proper diagnosis, and these delays often lead to more extensive surgeries, including bowel resections or ureteric reconstruction, which might have been avoidable with earlier intervention.

A deeply infiltrating endometriotic lesion that eventually invades the rectum typically requires 8 to 10 years to reach the point where bowel resection becomes necessary. This means that if the disease were identified and treated earlier, the overwhelming majority of these aggressive surgical procedures could be avoided.And yet, on the international stage, bowel resection for endometriosis remains a recurring topic at almost every major congress - a sign that diagnosis still comes too late far too often.

When Endometriosis Is Treated, but Pain Persists

Another challenge emerges when patients continue to experience severe pain despite surgical excision of endometriosis, hormonal therapy, or both combined.

At this point, two problematic paths often unfold:

1. the patient is redirected toward a psychosomatic interpretation of her symptoms, or

2. she is placed on long-term hormonal suppression without further investigation.

Yet this situation should immediately prompt a different and far more important question:

What if the patient’s pain is not (or no longer) caused by endometriosis?What if something else has been missed?

This is where Neuropelveology becomes essential.

A New Perspective: Beyond Endometriosis Alone

Neuropelveology views endometriosis not as “the universal cause of pelvic pain,” but as one possible cause - sometimes an important one, sometimes only a contributing factor, and sometimes not the cause at all.

Endometriosis can irritate, inflame, compress, or even destroy pelvic nerves. This is well known and frequently observed. But it is only one of several mechanisms through which pelvic nerve disorders arise. Many women with severe endometriosis experience remarkably little pain, while others with only minimal lesions suffer profoundly. Conversely, during laparoscopy, some women show almost no visible endometriosis yet present with disabling pain. These discrepancies are not inconsistencies - they are signs that not all pelvic pain originates from endometriosis itself.

The role of Neuropelveology is precisely to answer the question:Are the symptoms truly coming from endometriosis, or is another pelvic pain generator responsible - such as nerve irritation, nerve entrapment, vascular compression, or sacral radiculopathy?

Before proposing further surgery or prolonged hormonal therapy, this distinction is crucial.

Why This Matters for Millions of Women

Understanding whether pain is caused by endometriosis, by nerve pathology, or by both, changes everything:

• It prevents unnecessary or repeated surgeries.

• It avoids long-term hormonal suppression when it is not indicated.

• It protects fertility when possible.

• It directs the patient toward targeted treatment for the true underlying cause.

• It shortens the journey to relief — sometimes after years of misdiagnosis.

Understanding whether pain is caused by endometriosis, by nerve pathology, or by both, changes everything. It prevents unnecessary or repeated surgeries, avoids long-term hormonal suppression when it is not indicated, protects fertility, directs the patient toward targeted treatment for the true underlying cause, and shortens the journey to relief, sometimes after years of misdiagnosis.But beyond all of this, a neuropelveological perspective can be genuinely life-saving. Vascular entrapment of pelvic nerves - compression or irritation of a nerve by an atypical pelvic vein - can produce almost exactly the same symptoms as endometriosis: chronic pelvic pain, radiation to the legs or perineum, worsening of symptoms during menstruation, and even symptom improvement under birth-control pills due to reduced pelvic blood flow.

This overlap is extremely dangerous when not recognized. In most women with chronic pelvic pain, hormonal therapy is prescribed early, often a combined estrogen–progestin formulation. Yet in the presence of abnormal pelvic veins and vascular malformations - which already carry an intrinsic risk -adding combined hormonal contraception can significantly increase the probability of thrombosis or pulmonary embolism, potentially escalating to a life-threatening situation. For this reason, no woman with chronic pelvic pain should receive hormonal therapy for a presumed diagnosis of endometriosis without first excluding vascular nerve entrapment. This is essential patient safety. Unfortunately, most gynecologists are not trained to identify this pathology and, in many cases, are not even aware that vascular entrapment of pelvic nerves exists. As a result, the condition remains widely underdiagnosed, while its clinical consequences can be profound.

A neuropelveological evaluation fills this critical diagnostic gap. It ensures that treatment for presumed endometriosis does not inadvertently put a patient at risk, and that the true cause of her pain is identified before therapy begins. Most importantly, it acknowledges that persistent pain after “successful” endometriosis treatment is not psychological and not the patient’s fault. It is often a sign that something else has not yet been correctly identified.

Conclusion: Endometriosis Matters — but Diagnosis Must Be Complete

Endometriosis is a real, impactful, and often debilitating condition. Thanks to incredible awareness efforts, it is finally recognized as such. But recognition must not lead to oversimplification.

Not all pelvic pain is caused by endometriosis.Not all persistent symptoms are due to “residual disease.”And not every woman with chronic pelvic pain should undergo repeated surgeries without exploring alternative causes.

A neuropelveological approach brings clarity to this complexity. It ensures that women are not only treated for the disease they may have, but also fully evaluated for the causes they may actually be suffering from.

This is a modern, patient-centred, and scientifically grounded perspective — one that can spare millions of women unnecessary suffering and guide them toward the right diagnosis at the right time.