Endometriosis is a multifactorial condition characterised by the presence of endometrial-like tissue outside the uterus, leading to chronic pelvic pain, fertility issues, and severe psychosocial burdens. Traditionally conceptualised through a biomedical model, recent research underscores the importance of social and psychological factors such as stress, trauma, and adverse experiences in the pathogenesis and symptomatology of endometriosis. Integrating psychological interventions early into treatment regimens can enhance patient outcomes, improve quality of life, and address the underlying biopsychosocial contributors to the disease.^1,2

Comorbidities and Psychological Impact

Patients with endometriosis frequently experience multiple comorbidities, both immune-mediated and autoimmune, including rheumatoid arthritis, systemic lupus erythematosus, and Crohn’s disease. These comorbid conditions often share a stress-related pathogenesis and symptomatology. Mood disorders are present in approximately 30–50% of people with endometriosis, and PTSD or CPTSD reported in around 20–25%.^3,4

Endometriosis imposes a significant strain on individuals seeking treatment, affecting physical, emotional, and social well-being. The complexity of endometriosis, coupled with frequent delays in diagnosis and treatment, exacerbates these issues. Many patients report experiences of medical trauma, such as feeling dismissed or misunderstood by healthcare providers, which further undermines their mental health. Managing a chronic condition like endometriosis also takes a financial and emotional toll on those affected.⁵

It is increasingly evident that therapeutic interventions should focus on addressing the underlying stress contributing to the cluster of symptoms associated with endometriosis, rather than solely alleviating the distress caused by the disease. Targeting overall life stress can potentially disrupt the cycle of symptom exacerbation. A growing body of evidence supports the efficacy of various therapies aimed at reducing stress in the management of endometriosis.⁶

Evolving Psychological Treatments

The landscape of psychological treatments for endometriosis has evolved significantly over the past decade. Cognitive Behavioral Therapy (CBT) remains a cornerstone of psychological intervention, with robust evidence supporting its efficacy in helping patients identify and modify maladaptive thoughts and behaviors related to pain and stress. CBT is effective in reducing pain catastrophising, improving coping skills, and fostering adaptive stress responses. Tailored CBT programs have demonstrated success in decreasing pain severity and enhancing quality of life for women with endometriosis.^7,8

Beyond CBT, Mindfulness-Based Stress Reduction (MBSR) has gained traction as an effective intervention. MBSR promotes present-moment awareness and acceptance, helping to reduce emotional reactivity to pain and stress. Studies indicate that MBSR can significantly decrease pain intensity, anxiety, and depression, facilitating a more balanced emotional response to chronic illness.^9,10 In addition, therapies such as relaxation, grounding techniques, and meditation are all effective in reducing stress.

Addressing Trauma and Emotional Processing

Avoidance is a common coping mechanism among individuals with chronic pain and can hinder the processing of emotions and trauma. Emotional Processing Therapy (EPT) is a recent addition to the therapeutic toolkit for endometriosis. It is designed to help patients process intense emotions in a safe and supportive environment. EPT focuses on confronting traumatic memories, improving emotional regulation, and reducing symptoms such as hyperarousal and avoidance.

Addressing unresolved trauma through therapies like EPT, Eye Movement Desensitisation and Reprocessing (EMDR), somatic therapies, and CPT can decrease symptom severity and improve emotional regulation, thereby mitigating the impact of trauma-related dysregulation on pain perception.¹¹

Promoting Lifestyle Changes

Psychological interventions also play a crucial role in promoting lifestyle changes that are essential for managing endometriosis. Techniques such as motivational interviewing and health coaching empower patients to adopt healthier lifestyle practices, including regular physical activity, balanced nutrition, and effective stress management. These interventions support patients in setting achievable goals, enhancing motivation, and sustaining long-term behavioural changes, ultimately improving overall well-being and disease management.¹²

Sexual Health and Relationship Therapy

Sexual dysfunction is a common challenge for individuals with endometriosis, often arising from pain, hormonal fluctuations, and psychosocial factors. The World Health Organisation defines sexual health as a state of physical, emotional, mental, and social well-being in relation to sexuality. For many with endometriosis, sex therapy is helpful to achieve this state of well-being. Therapy addresses issues such as dyspareunia, loss of libido, body image concerns, and relationship stress. By fostering open communication and exploring flexible sexual norms, sex therapy can significantly enhance sexual health and relationship satisfaction.¹³

Relationships can promote emotional regulation and stress reduction when functioning well. They are a primary regulation method for humans, starting in utero and continuing outside the womb. Positive, supportive relationships can reduce stress, enhance emotional wellbeing and even modulate the experience of pain. This is particularly relevant in cases of dyspareunia (pain during intercourse), where the quality of intimate relationships can significantly affect pain intensity. Conversely, poor relationship quality, characterised by conflict or lack of support, can increase stress and emotional distress, potentially exacerbating pain. Emotional intimacy and effective communication are key factors in managing chronic pelvic pain and improving overall quality of life.¹⁴

Support Groups and Peer Support

Support groups provide a vital — yet often underused — platform for individuals with endometriosis to share experiences, reduce feelings of isolation, and learn coping strategies from peers. Peer support complements individual therapy and fosters resilience, enabling patients to navigate the challenges of living with a chronic condition more effectively.¹⁴

Domestic Violence Assessment, Treatment, and Safety Planning

People with endometriosis report a higher incidence of domestic violence, making it crucial to provide a safe space for disclosure. Domestic violence is a major ongoing global issue and has wide-ranging impacts, including the exacerbation of pain perception. Providing resources, safety planning, and trauma-informed care is essential for these individuals.^15,16

Conclusion

As clinicians, we have long been aware that multidisciplinary care is an important part of endometriosis management. The challenge has always been to facilitate strong multidisciplinary teams and normalise psychology (and physiotherapy) as essential first-line components of treatment. An integrative approach to endometriosis management that incorporates psychological and allied health interventions early in treatment improves patient outcomes.