What is the pelvic pentad in endometriosis?

The pelvic pentad describes the frequent co-occurrence of five conditions: endometriosis, hypermobility, mast cell activation syndrome, pelvic floor dysfunction, and vestibulodynia. Recognizing this cluster is clinically important because treating any one condition in isolation often leaves the others unaddressed, and patients continue to experience symptoms even after targeted treatment.

Why do endometriosis symptoms continue after excision surgery?

Persistent symptoms after excision surgery can occur because fibrotic endometriosis — scar tissue formed by the disease — does not always show up on biopsy and may be missed during the procedure. Mast cells in endometriosis tissue also contribute to fibrosis and nerve proliferation, which can sustain pain even after visible lesions are removed. Post-surgical symptoms are real and should not be dismissed as psychological.

What is the difference between an excision surgeon and a true endometriosis specialist?

Not all surgeons who perform excision have the advanced training needed to identify and remove all forms of endometriosis, including fibrotic disease. A true endometriosis specialist has training specifically focused on the full complexity of the condition — including deep infiltrating endo and disease that does not follow standard presentation patterns. Seeking a highly specialized surgeon rather than simply one who offers excision can significantly affect outcomes.

Can endometriosis be diagnosed without surgery?

Yes. Updated guidelines now allow clinicians to begin treating endometriosis based on symptoms without requiring surgical confirmation first. This is a meaningful shift for patients who have historically waited years for a laparoscopy before any treatment was offered. However, these guidelines have limitations and are not yet uniformly adopted across providers.

How does pelvic floor physical therapy treat endometriosis?

Pelvic floor PT for endometriosis requires a whole-body approach because endometriosis is a systemic inflammatory condition, not just a pelvic one. A pelvic floor physical therapist with endometriosis training addresses pelvic floor dysfunction, connective tissue changes, hypermobility, pain with sex, and the compensatory movement patterns that develop in response to chronic pain — not just the pelvis in isolation.

What role do mast cells play in endometriosis?

Mast cells are immune cells that contribute to inflammation, fibrosis, and nerve proliferation in endometriosis tissue. Their activity helps explain why some patients continue to experience pain and sensitivity even after surgical treatment — the mast cell-driven changes to tissue and nerve endings persist beyond the removal of visible lesions.

Why Your Endometriosis Symptoms Didn't Go Away After Surgery | Jandra Mueller

May 8

Written By Sameena Rahman, MD, FACOG, IF, MSCP

Endometriosis is often talked about as a pelvic disease, but it's actually a systemic inflammatory condition that affects the entire body. In this episode, I sit down with Dr.Jandra Mueller, a pelvic floor physical therapist in San Diego and the incoming educational chair for the International Society for the Study of Women's Sexual Health. Jandra specializes in treating patients with endometriosis and went through the diagnostic odyssey herself. Even with access to specialists, it took years to figure out what was wrong. We discuss why the new guidelines for diagnosing endometriosis are a step forward but still fall short. We talk about the pelvic pentad the connection between endometriosis, hypermobility, mast cell activation syndrome, pelvic floor dysfunction, and vestibulodynia. And we get into why fibrotic endometriosis is often overlooked during surgery and what that means for patients who continue to have symptoms after excision. If you still have pain after surgery, this episode explains why your symptoms are real and what to do next.

What You'll Learn:

How pelvic floor physical therapy became a specialty and why it's still not taught in PT school.

Jandra's personal journey with endometriosis and why it took years to get diagnosed, even with access to specialists.
Why the new guidelines allow doctors to start treatment based on symptoms without requiring surgery first.
The difference between a surgeon who does excision and a true endometriosis specialist.
Why continuing symptoms after surgery don't mean the pain is in your head.
How mast cells contribute to fibrosis and nerve proliferation in endometriosis.
Why treating endometriosis with pelvic floor PT requires a whole body approach.

Every episode of Gyno Girl Presents is a conversation I wish more women could have with their doctors — without the 10-minute clock running. Subscribe wherever you listen, and if this episode helped you, share it with a woman who needs to hear it.

EndometriosisPelvic Floor TherapyWomen's HealthPelvic PainMedical GaslightingPelvic PentadMast Cell Activation SyndromeHypermobilityVestibulodyniaEndometriosis DiagnosisChronic Pelvic PainWomen's Sexual Health

Sameena Rahman, MD, FACOG, IF, MSCP

Dr. Sameena Rahman is a board-certified OB/GYN and founder of The GSM Collective in Chicago. She specializes in sexual medicine, menopause care, and complex gynecology, offering personalized, concierge-level care through an integrative lens.

Why Your Endometriosis Symptoms Didn't Go Away After Surgery | Jandra Mueller

The Practice

Insights

Connect

Why Your Endometriosis Symptoms Didn't Go Away After Surgery | Jandra Mueller

Teaching Anatomical Language, AI, Private Equity, and Why Three OB-GYNs Stopped Delivering Babies

Perimenopause, Medical Gaslighting, and Why Gen X Won't Just Disappear | Beth Crosby (Garbage Mom)

The Practice

Insights

Connect