The Cost of the Current Paradigm

• Epidemiology: prevalence in reproductive-age women, prevalence in chronic pelvic pain and infertility populations, economic and quality-of-life burden.
• Diagnostic delay: 7 to 10 years average, where the years go (normalized dysmenorrhea, serial negative imaging, IBS and psych mislabels, dismissed pain), and what primary care can do to shorten them.
• Adolescent presentations: early dysmenorrhea normalized as "bad periods," school absence as a screening flag, NSAID-refractory dysmenorrhea as a referral trigger.
• Limitations of the gynecology-only, hormones-and-surgery-only model; why suppression is not resolution; why pain frequently survives anatomically successful surgery.

Endometriosis as a Multisystem Condition

• Chronic inflammatory condition: the peritoneal inflammatory milieu, prostaglandins, cytokines, oxidative stress.
• Immune dysregulation disorder: impaired lesion clearance, macrophage polarization, NK cell dysfunction, autoantibody findings, epidemiologic overlap with autoimmune disease.
• Connective tissue involvement and the overlap cluster: hypermobility spectrum disorders and hEDS, MCAS, POTS, and why these patients concentrate in endometriosis populations.
• Chronic overlapping pain conditions as a shared-mechanism family: migraine, fibromyalgia, bladder pain syndrome, TMJ, chronic fatigue.
• What the reframe changes clinically: treatment targets beyond estrogen, the case for parallel rather than sequential intervention.

Orientation to the Course Method

• The multisystem workup as a repeatable sequence: map the differential, take the discriminating history, examine, test with intent, treat in layers, refer with precision.
• How the FiGs lens will be applied selectively across the course.

Built on FIGO-IPPS categories. For each: distinguishing features, the discriminating question or exam finding, and the trap. Delivered with the downloadable reference table.

Reproductive

• Endometriosis: cyclic evolving to continuous, deep dyspareunia, dyschezia, infertility association. Positioned as the upstream driver behind many entries elsewhere on this list.
• Adenomyosis: heavy bleeding plus diffuse cramping pain, bulky tender uterus, the imaging-diagnosable one.
• Fibroids: bulk symptoms vs pain, degeneration as the acute presentation.
• Ovarian masses and cysts: the functional cyst trap, when a cyst explains pain and when it's a bystander.

Urinary

• Bladder pain syndrome/interstitial cystitis: pain with filling relieved by voiding, urinary frequency without infection.
• Bladder endometriosis: cyclic urinary symptoms, cyclic hematuria as the clue.
• The trap: recurrent "UTIs" with negative cultures.

Gastrointestinal

• IBS: Rome criteria, and the IBS-that-tracks-with-menses pattern that should trigger the endo question.
• IBD: alarm features, when to scope.
• Bowel endometriosis: dyschezia, cyclic hematochezia, pain with defecation during menses.
• Food intolerances and their overlap with mast cell activity.
• Chronic appendicitis: the RLQ never-miss.

Musculoskeletal

• Myofascial pain and trigger points: reproducible on palpation, non-cyclic.
• Pelvic floor dysfunction: hypertonicity as both consequence and generator of pain.
• SI joint dysfunction: positional pattern, provocation testing.
• Hypermobility disorders: Beighton screening, why joint laxity and pelvic pain travel together.

Vulvovaginal

• Vulvodynia, vestibulodynia, vaginismus: entry pain vs deep pain sorting. Cross-reference to FiGs: Sexual Health for full diagnosis and treatment; this course teaches the recognition and sorting only.

Vascular

• Pelvic venous disease: standing-worse, supine-better, postcoital ache, multiparity association.
• Nutcracker and May-Thurner syndromes, AVM: when anatomy compresses veins, and which imaging finds it.

Nociplastic/Sensory

• Hyperalgesia, allodynia, hypersensitivity as exam findings, not personality traits.
• Sleep disturbance as amplifier and target.
• MCAS: flushing, urticaria, food and med reactions, the multisystem reactivity pattern. Recognition here; workup and treatment depth in FiGs: MCAS.

Chronic Overlapping Pain Conditions

• Migraine, fibromyalgia, chronic fatigue, chronic low back pain: what co-occurrence tells you about central mechanism and prognosis.

Mental Health/Neurologic

• Central sensitization (mechanism owned by Module 3), depression, anxiety, PTSD.
• Comorbidity without causality: how to hold both truths without dismissing either.

Other

• Adhesions: post-surgical and post-infectious, the evidence problem with attributing pain to them.
• Hernias: inguinal, femoral, obturator; the standing exam.

The Never-Miss List

• Ovarian torsion, malignancy, ectopic pregnancy in the acute-on-chronic presentation, chronic appendicitis, catamenial pneumothorax as the extrapelvic endometriosis flag.

Pelvic Pain History

• Key discriminators: cyclic vs non-cyclic, pain with ovulation, bowel symptoms with menses, dyspareunia sorted superficial vs deep, infertility history, progression pattern over years.
• The systems review that earns its keep: autoimmune and allergy history, acne, migraines, PMDD, urticaria and flushing, joint hypermobility, orthostatic symptoms, sleep quality.
• Menstrual history done properly: age at menarche, cycle length and flow, NSAID responsiveness, school and work absence.
• Trigger event timeline: menarche, infections, surgeries, trauma, antibiotic courses, hormonal contraception starts and stops, with life stress overlay. Timeline mapping as the FM signature method, with worksheet.
• Environmental exposure screening: endocrine disruptors, occupational exposures, plastics and personal care products. Loop closes in Module 5.
• Trauma screening done safely; what to do with a disclosure.
• Tools: ESAT, pelvic pain screener, the intake template.

Physical Examination

• The trauma-informed exam: consent at each step, patient control, stopping rules (cross-reference to FiGs: Sexual Health for full technique).
• Standing exam: hernias, varicosities.
• Abdominal wall assessment and Carnett's sign: distinguishing wall from visceral pain, the most underused two minutes in pelvic pain.
• External inspection and Q-tip vestibule screen when entry pain is reported.
• Single-digit pelvic exam before any speculum: pelvic floor tone, tenderness, trigger points, levator assessment.
• Uterosacral tenderness and nodularity, fixed retroverted uterus, adnexal findings, cervical motion tenderness.
• Beighton score when the history suggests hypermobility.
• What a normal exam does and does not tell you; documenting findings that support clinical diagnosis.

Central Sensitization Primer

• Nociplastic pain as the third mechanistic category; amplification pathways, descending inhibition failure, chronic pain rewiring.
• Recognizing the sensitized patient: allodynia, spreading pain, disproportionate findings, multi-site pain history.
• Why sensitization changes treatment sequencing. Mechanism owned here; treatment owned by Module 7.

Laboratory Workup, With Interpretation Logic

• Core panel and what each answers in a pelvic pain patient: CBC (anemia from heavy bleeding, infection screen), CMP, iron and ferritin (the fatigue driver hiding in plain sight), vitamin D, B12 and folate, hs-CRP and sed rate (the inflammation baseline and its limits), fasting insulin and HOMA-IR (metabolic-inflammatory context), full thyroid panel.
• Presentation-driven additions: day 21 progesterone and the question it actually answers, AM cortisol, total and free testosterone with SHBG, celiac screen when GI-predominant, urinalysis and culture logic.
• Gut testing: when it adds decision-changing information and when it adds cost.
• What not to order; avoiding the thousand-dollar shotgun panel; CA-125 counseling (why it misleads in this population).

Imaging

• What imaging can do: expert transvaginal ultrasound and MRI for deep infiltrating disease, endometriomas, adenomyosis findings; sliding sign; the value of an endometriosis-protocol study and how to request one.
• When does a finding indicate a driver of pain
• What it cannot do: exclude superficial peritoneal disease. A negative ultrasound never rules out endometriosis. Teach it as a rule.
• Modality selection by suspected driver: venous studies for vascular pattern, MRI for DIE mapping and surgical planning, when imaging changes management and when it delays it.

Pathophysiology

• Origin theories and current thinking: retrograde menstruation and why it alone fails to explain the disease, coelomic metaplasia, stem cell and lymphovascular spread, the genetic and epigenetic layer.
• Lesion biology: local estrogen production and aromatase expression, progesterone resistance at the receptor level, why lesions are endocrine organs in miniature.
• The inflammatory and immune machinery: impaired clearance, macrophage behavior, cytokine environment, neuroangiogenesis and how lesions acquire their own nerve supply, peripheral pain generation.
• Lesion phenotypes: superficial peritoneal, ovarian endometrioma, deep infiltrating disease; why phenotype matters for imaging, surgery, and prognosis.
• Why stage does not predict pain, and what does.

Hormone Effects and Progesterone Resistance

• The receptor-level explanation for why suppression underperforms; implications for progestin selection and dosing.

Adenomyosis

• Distinct entity, frequent companion: junctional zone findings, presentation differences (bleeding-predominant, diffuse cramping), imaging diagnosis, treatment divergence, the hysterectomy conversation and its timing.

Diagnosis in 2026

• The clinical diagnosis movement: presumptive diagnosis on history and exam, empiric treatment without laparoscopy, current guideline support, documentation that protects the patient and the clinician.
• When tissue diagnosis still matters: diagnostic uncertainty, surgical planning, patient preference.
• Staging systems (rASRM, Enzian, EFI): what each is for, what none of them do.

Fertility

• Mechanisms of endometriosis-associated infertility: inflammatory oocyte environment, tubal factors, implantation effects.
• When to refer to REI, and why early referral beats watchful waiting after 35.
• Fertility preservation counseling; how each treatment choice interacts with fertility timelines; the endometrioma-and-ovarian-reserve problem.

Extrapelvic Endometriosis

• Thoracic endometriosis and catamenial pneumothorax, abdominal wall and scar endometriosis, brief survey for recognition.

Sequencing Philosophy

• Layered treatment: foundation first, pharmacology in parallel where pain severity demands it, nervous system work running alongside from day one. Against the everything-at-once protocol dump.

Foundation

• Mediterranean-style anti-inflammatory pattern: the evidence in endo populations, practical translation, cultural adaptability.
• Removals: excess sugar, excess alcohol; the honest conversation about both.
• Elimination diets: when, how, for how long, and how to run one without creating food fear or disordered eating patterns; reintroduction discipline.
• Sleep as an anti-inflammatory intervention: targets, hygiene, when to treat sleep as the primary problem.
• Stress physiology and the HPA layer: what stress does to pain thresholds and immune behavior; realistic interventions.
• Movement: gentle, paced, graded for the sensitized patient; why "just exercise" backfires and what to prescribe instead.

Supplements, With Evidence Tiers and Dosing

• Omega-3: dose, formulation, the dysmenorrhea data.
• NAC: the endometrioma data, dosing protocol.
• Vitamin D: repletion targets in an inflammatory condition.
• Resveratrol, vitamins C and E: what the evidence supports, what it doesn't.
• Curcumin and magnesium as reasonable additions; interactions and quality considerations.
• Which ones to cut first when patients are overwhelmed or budget-limited.

Gut Health

• The estrobolome and estrogen recirculation: beta-glucuronidase, enterohepatic cycling, the mechanism made prescriber-friendly.
• Dietary interventions for the gut layer; fiber targets; fermented foods.
• Dysbiosis, SIBO overlap with IBS-labeled patients; when gut testing adds decision-changing value.
• Cross-reference to FiGs: Gut & Metabolic Health for full workup depth.

Mast Cell Stabilization

• Mast cells in endometriotic lesions; the endo-MCAS overlap and what it means for refractory patients.
• H1/H2 blockade protocols, stabilizing supplements (quercetin, vitamin C, luteolin), trigger identification and lifestyle load reduction.
• Depth boundary: full MCAS workup and treatment lives in FiGs: MCAS; this module covers the pelvic pain application.

Environmental Load

• Closing the Module 3 loop: endocrine disruptor reduction that patients can actually execute, prioritized by exposure impact; plastics, personal care products, occupational counseling.
• Supporting detoxification physiology without detox theater.

Hormone Modulation

• Progestins vs progesterone: pharmacologic difference, receptor behavior, when each is the right tool.
• The progestin menu: norethindrone acetate, dienogest, levonorgestrel IUD, DMPA; selection by symptom pattern, side effect profile, and fertility timeline.
• Combined hormonal contraception: continuous dosing logic, who it helps, who it fails.
• The GnRH agonist/antagonist discussion, evidence-forward: where elagolix and relugolix combination products have trial data, bone density loss and add-back complexity, cost and access, hypoestrogenic side effect burden, and the case for placing them late in the algorithm rather than early. Position stated with the counterargument included; patient selection criteria for when they are the right call.
• Aromatase inhibitors in refractory disease: niche use, co-suppression requirements.
• Endometriosis in peri/menopause: does it end, recurrence on HRT, HRT formulation decisions with an endo history. Cross-reference to the Peri/Menopause course.

Non-Hormonal Pharmacology

• NSAIDs done properly: timing ahead of menses, adequate dosing, GI protection.
• Low dose naltrexone: proposed mechanism, titration protocol, expectations timeline, side effect counseling.
• GLP-1/GIP agonists: the inflammatory and metabolic rationale, current evidence honestly graded as early. Cross-reference to FiGs: GLP-1s.
• Vaginal and rectal suppositories, compounded options (diazepam, baclofen, ketamine combinations): what's in them, what the evidence supports, sourcing and cost.
• Cannabinoids/CBD: formulations, dosing reality, drug interactions, legal counseling by state.
• Duloxetine and centrally-acting agents: patient selection for the sensitized phenotype, SNRI vs gabapentinoid logic.
• Why opioids have no role in chronic pelvic pain: the evidence, opioid-induced hyperalgesia, and the exit conversation for inherited patients on chronic opioids.

Choosing and Combining

• Matching pharmacology to phenotype: cyclic-predominant vs continuous, bleeding-heavy vs pain-heavy, fertility-now vs fertility-later vs fertility-never.
• Defining treatment failure and trial duration before switching.

• Pain neuroscience education as a first-line intervention: what to say, the patient explainer, why understanding pain changes pain.
• Reframing catastrophizing: a treatable amplification pattern, not a character flaw; screening and response.
• Pelvic floor PT: referral criteria, what a session involves, internal vs external work, setting expectations, writing a referral that gets the right treatment.
• Down-regulation practices: vagus nerve stimulation practices, breathwork, mind-body therapies with evidence (CBT for chronic pain, ACT, mindfulness-based interventions).
• Somatic therapy and trauma-processing modalities: when trauma history is active in the pain presentation.
• Acupuncture: evidence tier, what to tell patients.
• Neuromodulation: TENS, percutaneous tibial, sacral; who benefits.
• Red light therapy: evidence tier stated plainly.
• Pelvic floor injections (trigger point, botulinum toxin): when, who performs them, what they buy you and for how long.
• Abdominal wall injections
• Sleep circling back as pain modulation.
• Sequencing: why nervous system work runs parallel to, not after, tissue-directed treatment; the mistake of saving it for last.

Surgery

• Excision vs ablation: why the distinction matters, outcome and recurrence data, why "I had a laparoscopy and they burned some spots" is not definitive treatment.
• Finding the right surgeon: volume and specialization, questions patients should ask, red flags in a surgical consult.
• Reading an operative report: what was found, what was done, what was left, and what that means for ongoing symptoms.
• Realistic outcome counseling: what surgery fixes, what it doesn't, recurrence timelines.
• Surgical referral criteria and the do-not-delay presentations: endometrioma characteristics, DIE with organ involvement, ureteral or bowel compromise.

The Rest of the Team

• REI referral criteria and timing; coordinating medical treatment with fertility plans.
• Finding and vetting a pelvic floor therapist; internal-work training as the screening question.
• Mental health referrals framed without "it's in your head": pain psychology, trauma therapy, couples support when dyspareunia has reshaped a relationship (cross-reference to FiGs: Sexual Health).
• GI, urology, vascular referrals: when the differential demands them.

Running the Long Game

• The primary clinician as coordinator of a chronic multisystem condition: follow-up cadence, flare planning, re-evaluation triggers, documentation that supports disability and accommodation requests when needed.
• Patient self-advocacy tools and community resources; steering patients away from predatory wellness offerings.