The Connective IssueThe Fascia Institute & Treatment Center Journal
A weekly report from the long course of fascia medicine — where pain, patience, and the right diagnosis are decided.
Most women wait years to be believed. Then the surgery is over, and it still hurts.
Endometriosis is real. It is common. And it is often not the only thing causing your pain. Sometimes it is not the cause at all.
Women who come to us tend to tell the same story. Years of pain. A long wait before anyone took it seriously. Then a name: endometriosis. Often surgery, too. And then the pain came back. Or it never really left. Nobody knew what to try next.
This week I want to pull apart two questions. Doctors mix them up constantly.
Do you have endometriosis?
That is a question about disease. Your history, an exam, imaging, and sometimes surgery can answer it.
What tissue is causing the pain you feel today?
That is a different question. Having endometriosis does not answer it.
Both can be true at once. You can have real endometriosis, proven by biopsy. And most of today's pain can still be coming from your belly wall, your pelvic floor muscles, or your low back. The research behind that is stronger than it might sound.
One more thing before we start. We are building something new: a hotel room, set up for the people who fly in to see us. More on that below.
Inside This Issue
- Endometriosis, hypermobility, and the pain that is not your uterusThe Long Run
- The two-minute test you can do at homeSplit Times
- You no longer need surgery to be diagnosedMile Markers
- When the operation is over and it still hurtsThe Wall
- Hypermobility, mast cells, POTS: what we will and will not claimPace Group
- The FIT Recovery RoomCourse Support
- CoreSalt™ — the long-effort problemAid Station
- What makes us send you somewhere elseCourse Marshals
On your marks.
Endometriosis, hypermobility, and the pain that is not coming from your uterus
If we can press on one spot and bring your pain back, and a numbing shot changes it, that pain is coming from your belly wall.
Endometriosis is when tissue like the lining of your uterus grows outside the uterus. It feeds on estrogen. It causes inflammation. Most experts now call it a whole-body disease, not a local pelvic problem.
It is also a scarring disease. A review of 142 studies found that scarring is not a side effect of endometriosis. It is central to it. Cells change into a type that lays down collagen and pulls tissue tight. The pelvis ends up stiff and tethered.
That is a connective tissue problem. It is one reason endometriosis and fascia pain are so easy to mix up. Scar tissue in the pelvis does not care where the gynecology label ends and the muscle label begins.
Stage tells you how hard the surgery is, not how much it hurts
This is one of the better-established findings in the field, and one that does not get passed on often enough.
In 1,054 women having their first surgery, the link between stage and symptoms was weak. A recent review of many studies found that how much pain you are in is not tied to stage. There is one exception worth knowing: long-lasting pelvic pain does turn up more often in advanced disease. In one study of 52 women, pain scores were the same whether or not endometriosis was found. What did track with pain was the number of immune cells in the pelvic fluid.
Brain scans say the same thing from another angle. Women who had endometriosis and pain showed changes in several brain areas. Women who had endometriosis and no pain showed none of those changes in that study. The brain followed the pain, not the disease.
This cuts in both directions
We are not saying the disease is small. The opposite. If stage does not predict pain, then “your endometriosis was mild” is not a reason to doubt what you feel. And “your endometriosis was severe” does not prove the growths are what hurt today. Both mistakes send women down the wrong path.
The full article runs to 75 references. It covers what the disease is, how diagnosis changed, the hypermobility link, the copycats, and where each of our treatments stops being supported by evidence.
Two minutes, no equipment, and it changes the question
Your organs are not tender when someone presses on your belly wall. Muscle and fascia are.
So if pressing on one exact spot brings your pain back, the pain is coming from the wall. There is a trick that makes this clearer. It is called Carnett's sign. Doctors described it a hundred years ago, and it is still underused.
- Lie on your back with your knees bent. Relax your stomach.
- Press one finger into the spot that hurts. Note how bad it is.
- Now tighten your stomach muscles, like you are starting a sit-up. Keep pressing the same spot.
- Ask yourself one question. Did the tenderness get worse? Staying just as strong counts too. What argues against the wall is the pain clearly easing.
Tightening pulls your organs away from your finger. If the pain gets worse anyway, or does not let up, the problem is in the wall and not behind it.
What the research says
- In 120 emergency room patients with sudden belly pain, 24 were tender on the wall. Only one of those 24 turned out to have a problem inside the abdomen. That was an emergency population rather than a years-of-pelvic-pain one, so it points a direction rather than giving you your own odds.
- In a blinded trial, 48 patients got a shot in a tender spot in the belly wall. Half got numbing medicine, half got salt water. Success: 13 of 24 with the medicine, 4 of 24 with salt water. That difference held up statistically.
And the honest limits. One good shot is a clue, not proof — the salt water still worked 17% of the time. Numbing medicine spreads, so a shot aimed at the wall can numb nearby things too, which is a good reason to use ultrasound rather than guess. A shot alone rarely cures it: in 186 patients with lasting belly wall pain after surgery, shots alone worked long-term in about 13%. The shot is mostly a test. And a positive test can also come from a lump — a tumor or a hidden hernia is tender too. The test says the problem is in the wall. It does not say what the problem is.
And one limit that matters for our hypermobile readers. A 2026 randomized trial of 135 people found numbing medicine works less reliably in people with Ehlers-Danlos syndrome — adequate numbness in about 60% at fifteen minutes, against 84% in the comparison group. That is a real difference, not a failure. If you are hypermobile and a block does not seem to do much, tell us. It does not automatically mean we aimed at the wrong tissue.
You do not need surgery to be diagnosed. And a clean scan does not mean you are fine.
For years the rule was that only surgery could prove endometriosis. That rule is gone. All three major guideline groups now agree.
| Guideline | What it says now |
|---|---|
| ESHRE · 2022 | Surgery is no longer the gold standard. You can start with imaging and treatment, or start with surgery. Neither path has proven better. |
| NICE · updated Nov 2024 | Every woman with suspected endometriosis should be offered an internal ultrasound, ordered by her regular doctor. And plainly: do not rule it out just because the exam and the scan look normal. |
| ACOG · 2026 | Their first full guideline on diagnosis. Symptoms and exam are enough to start medicine. Ultrasound comes first for imaging. MRI is for planning surgery on deep disease. |
This is real progress. It will not fix the wait on its own, though — most of the delay happens long before anyone considers surgery, in the years of being told the pain is normal. And for teenagers the picture is different: guidance there still leans toward surgery when hormones and anti-inflammatories have not worked.
But a normal scan does not mean you are fine
This part often gets left out. Ultrasound and MRI are good at finding cysts on the ovaries and large, deep growths. They are bad at finding the flat, shallow kind on the surface of the pelvic lining. That shallow kind is the most common kind.
The Cochrane review looked closely. Ultrasound found ovarian cysts about 93% of the time and deep disease about 79% of the time. But no scan of any type has ever been shown to find shallow surface disease reliably. The best recent result, from an expert center, caught only about half of shallow cases — which means a normal scan misses roughly half the women who have it.
A positive scan tells you a lot. A negative scan tells you very little.
“Your ultrasound was clean” is not a reason to stop looking. It is also not proof that the pain must be endometriosis nobody can see. It is a reason for someone to examine you properly.
And there is still no blood test
Cochrane reviewed 141 studies covering more than 15,000 women. None of the tests worked well enough. CA-125, the one doctors order most, caught only about 40% of cases. ACOG's 2026 guideline says not to use blood, urine, or tissue markers to diagnose endometriosis.
Saliva tests are getting attention, and a large French study reported high accuracy. But there is no FDA approval, and the test cannot tell you where the disease is or how bad it is. We watch this closely. We do not treat it as an answer yet.
The operation is over. So why does it still hurt?
Pain in the belly wall, the pelvic floor, and the low back gets blamed on endometriosis all the time. Much of the time it is coming from muscle and fascia instead.
Two words first. Fascia is the connective tissue that wraps and links your muscles and organs. Myofascial pain means pain coming from muscle and fascia.
The cleanest study in the field
Researchers examined three groups. Eighteen women with biopsy-proven endometriosis and pain. Eleven women with pelvic pain whose surgery found no endometriosis. And twenty women with no pain.
Skin that hurt to light touch: 83%, 82%, and 15%. Tender muscle knots: 94% and 91% in the two pain groups. The muscle findings followed the pain, not the disease.
And after surgery
- In one small blinded trial — 39 women, real surgery or a look-only fake, and nobody knew which — 80% improved after the real operation and 32% improved after the fake one. Surgery clearly beat the sham. But one in five got nothing from the real operation, and one in three got better from an operation in which nothing was removed. Both halves of that matter.
- In 176 women followed 2 to 5 years after expert surgery, 36% needed another operation. When surgeons went back in, they found endometriosis in only 68% of them. About a third of repeat surgeries for returning pain found no endometriosis at all.
- Most studies on recurrence do not separate pain coming back from growths coming back. That is exactly the difference that matters here.
Where the copycats live
The C-section scar is the one missed most often. Researchers followed 866 women who had one. About two years later, 32% still had pain at the scar, moderate or severe in 7%. Of the women who were examined, more than half had a trapped nerve.
Small nerves run from your back around to the front of your belly, and they can get pinched on the way. The giveaway is one fingertip-sized spot that is extremely tender, hurts more when you tighten your stomach, and calms down with a well-placed shot. That is a pinched nerve rather than a muscle knot, and it needs a different treatment.
Two more places. The pelvic floor muscles, where tenderness lines up with trouble emptying your bladder and pain when you go — symptoms that sound like organ disease but are not. And the spot where your ribs end and your low back begins, where irritated nerves can send pain into your lower belly and groin. Researchers call that “pseudovisceral” — it feels like an organ problem but is not one.
A gap in the evidence. We went looking for a study that says what percent of women with lasting pain after endometriosis surgery have belly wall or pelvic floor muscle pain. That study does not exist. The pieces above support the idea strongly. The single headline number is not out there. If you see one quoted, it did not come from a study.
And treating the muscle side works
A trial across 11 centers in North America studied 81 women with bladder pain and tender pelvic floor muscles. Half got targeted hands-on muscle therapy. Half got general massage — a real comparison, not a waiting list. 59% of the targeted group improved, versus 26%. That is a condition treated as an organ problem, improved by treating muscle. Worth knowing: it enrolled women whose symptoms were under three years old, and measured at three months.
One more finding, and it changes the order of operations. In 239 women scored before endometriosis surgery, a higher pain-sensitivity score beforehand meant worse pain afterward. That is a questionnaire, not a lab test, and it does not match laboratory measures well. But it is why we check it before anyone operates instead of after.
Hypermobility, mast cells, POTS — and what we will not claim
This is an area where confident claims run far ahead of the evidence. We have tried to be careful here, including about our own.
What is solid
Hypermobile women have a lot of pelvic and period trouble. This part of the research is strong and deserves more attention than it gets.
At a French expert center, 386 women with hEDS were examined in person by a senior gynecologist. Heavy bleeding, 76%. Painful periods, 72%. Painful sex, 43%. About a third said their hEDS symptoms got worse around their periods.
So if you are hypermobile and your periods are brutal, sex hurts, and your pelvic floor does not work right, that is a known pattern. It is not in your head. And you do not need an endometriosis diagnosis to make it real.
What is truly unsettled
Whether endometriosis itself is more common in hypermobile women. The two best studies are usually described as pointing in opposite directions, so we will give you both.
| The case for a link | The case against |
|---|---|
| A US medical records network with about 50,000 patients per group found endometriosis in 6.3% of women with EDS and 0.9% of controls — seven times more. The problem: 0.9% is roughly a tenth of the rate we know is out there, so the comparison group was badly under-diagnosed. Women with EDS also see more doctors and get more scans, so more of their endometriosis gets found. The real gap is almost certainly much smaller. | In the best hands-on study — those 386 hEDS women examined by a gynecologist — endometriosis was not more common than usual. The authors' conclusion matters: knowing what hEDS pelvic pain looks like helps doctors tell it apart from endometriosis, and helps avoid surgery that will not help. |
It is worth noticing what they agree on: the two studies landed on nearly the same number. About 6% in the French cohort, 6.3% in the US records. They only look like they disagree because one had a comparison group and that group was badly under-counted. Neither figure is above the rate in women generally.
Two claims we traced and will not repeat. One says 60% of women with stage IV endometriosis are hypermobile. That comes from a single paper in a journal outside this field, with no control group. The other says 6 to 23% of people with EDS have endometriosis. There is no original source for it at all. We also will not tell you a shared collagen defect explains both conditions. hEDS has no single causative gene, and the first genetic signals found in it point at nerve and immune signaling rather than collagen. The large genetic studies of endometriosis point at pain genes. Nobody has run the study that would test the two against each other. It is a reasonable idea people are working on. It is not a finding.
Mast cells: separate the tissue from the label
Inside endometriosis growths, mast cells are well documented. There are more of them, they are more active, and they sit right next to nerve fibers. The highest counts are in deep growths, which are the most painful kind. That part is solid.
Saying that a whole-body condition called MCAS links endometriosis and hypermobility is a different claim. That claim is being challenged hard right now. Several papers from allergy specialists in 2025 and 2026 found no evidence that MCAS is more common in hEDS or POTS. One review found that not a single study had properly diagnosed MCAS using set criteria alongside POTS or EDS.
We treat mast cell symptoms when we see them. We will not build a diagnosis on a triad the research does not currently support.
POTS
Among 1,322 women seen at a specialty center for POTS, 17.3% had endometriosis. That was higher than the general population, and higher than the 10.2% in their own comparison group who tested negative for POTS. In about two-thirds of the women with both, endometriosis came first.
A separate survey of people whose POTS started in childhood found endometriosis in 8.9%, which is not above average. But 72% said their POTS got worse around their periods.
The same caution applies here as to the records study above. A specialty POTS center is exactly where heavily investigated women end up, so both numbers are inflated. The honest version is a modest gap — about seven percentage points — inside one clinic's own chart review. Having a tilt-test-negative comparison group is a real strength. It is still not a population.
The FIT Recovery Room
A hotel room built for the people who fly in to see us
A large share of our patients travel for care. They land, get treated, and then go back to an ordinary hotel room that was designed for a business traveler with a working body.
So we are building one that is not. The FIT Recovery Room is a hotel room set up for our patients to recover in while they are in town for treatment.
We will share the details — where it is, what is in it, what it costs, and exactly what our own stake in it is — as soon as they are settled. We would rather tell you that up front than at launch.
If you have traveled here for care, tell us what would actually have helped that week. Getting in and out without stairs. Temperature you control. A bed you can get out of after an injection. How far it is from the clinic.
Nobody finishes a long effort on water alone
Built because my patients kept quitting their electrolytes— not because the science was wrong, because the powder was undrinkable
Pelvic pain wears people down over years, not hours. And a lot of the women reading this are also carrying POTS, heavy periods, or a job that keeps them upright in Louisiana heat. For orthostatic intolerance, sodium loading is standard first-line advice. The advice was never the problem. The problem was that patients would try a flavored powder for two weeks and stop, because of the taste, the sweeteners, or a stomach that already does not cooperate.
So I built a taste-free capsule: sodium, magnesium and potassium, plus tyrosine, taurine, and ginger so it sits easy. No fillers, no artificial sweeteners or colors, made in an NSF-certified facility. Nothing to drink and nothing to taste — which is the entire point, because the version you actually keep taking is the one that works.
Plainly: CoreSalt™ is our own product, formulated by Dr. Courseault — so this is a house advertisement, not a neutral comparison. Read it that way. CoreSalt™ is a dietary supplement and is not intended to diagnose, treat, cure, or prevent any disease. Sodium loading is not appropriate for everyone — talk with your physician first, particularly if you have high blood pressure, heart failure, or kidney disease.
This article argues one direction. The opposite mistake is just as harmful.
A fascia clinic is exactly the kind of place where pain that really is disease could get treated as muscle. So here is what makes us look elsewhere, or send you elsewhere.
- Endometriosis can invade nerves itself. There is published research on it growing into nerves and looking exactly like a nerve or muscle problem. When we find that, the right answer is a surgeon, not a shot.
- New pelvic symptoms after menopause. Also bleeding after menopause, losing weight without trying, constant bloating, feeling full after a few bites, or a fixed lump. Those are ovarian cancer warning signs. Those go to your gynecologist or your primary doctor first, not to us. Use those words when you call.
- A lump in the belly wall. Endometriosis in a C-section scar, tumors, and hidden hernias all present this way.
- Two uncommon hernias: Spigelian and obturator. Often impossible to see or feel. Both can strangle. Sudden severe pain, vomiting, or a bulge that will not push back in means the emergency room, that day.
- Inflammatory back pain. A form of spinal arthritis can look just like muscle pain. Warning signs: morning stiffness over 30 minutes, pain that wakes you in the second half of the night, pain that improves with exercise rather than rest, and buttock pain that switches sides.
- Fever, unusual discharge, or a mass near an ovary. A pelvic infection is not a fascia problem.
And about our own equipment, plainly. Shockwave, TECAR, and PEMF do not treat endometriosis. A shockwave head does nothing to endometrial tissue growing in your pelvis. What they treat is the muscle and fascia part. There is no published randomized trial of any of the three in endometriosis. What exists is short-term, modest evidence in other muscle and fascia problems — a sham-controlled trial in pelvic floor pain, a few in trigger-point pain — and in one knee trial the benefit was gone by three months. That is the size of the evidence. TECAR is at our Los Angeles location, not New Orleans.
And about our own procedures. Ultrasound can show us that a layer is not gliding. No study has yet shown that a layer which does not glide is the thing causing your pain, or that freeing it predicts who gets better. We use that finding as a target, checked against your exam and against a numbing shot — not as a verdict. The order still matters more than the machine: look first, test it with a shot, then pick the tool. A treatment aimed at the wrong structure wastes your time and your money.
And plainly: some of this we will not be able to fix. Some pain comes from disease that needs a surgeon. Some comes from a nervous system that will take a long time to settle. We will tell you which of those we think is going on, and we would rather say so at the first visit than at the tenth.
Two steps, and they are the same two steps for everybody
Step one: find the real source of the pain. Not an area. Not a guess. The exact tissue. That means your history, a real hands-on exam, moving ultrasound with probe pressure, and targeted numbing shots to confirm.
Step two: find the right tool, and use the tools in the right order. Hydrofascia Release™ where the imaging and a numbing shot agree on a stuck layer. Nerve hydrodissection where they agree on a pinched nerve. Pelvic floor physical therapy for the pelvic floor. Hormone suppression, a surgeon, or both for the disease itself.
Most of the women we see have had step two tried over and over. Step one never got done. You cannot pick the right tool if nobody found the target.
Bring us the pain nobody could find.
None of the above is medical advice or a treatment plan for you. It is what a first visit looks like. What you actually need is decided after an examination, and sometimes the answer is a surgeon rather than us.
Know someone who had the surgery and still hurts? Send her this issue. That is how most of our pelvic pain patients found us.