Purpose <p>To compare changes in pain-related symptoms, bowel and bladder function, rectal bleeding, quality of life, and treatment satisfaction in women with rectovaginal endometriosis treated either surgically or with hormonal treatment alone in a tertiary referral centre.</p> Methods <p>This retrospective cohort study included women with rectovaginal endometriosis treated at a tertiary endometriosis centre with either surgical excision or hormonal treatment alone after informed consent. Standardised questionnaires assessed pain, functional symptoms, quality of life, and treatment satisfaction. Symptom changes were categorised as improvement, stability, or worsening. Between-group comparisons were performed using Mann–Whitney U tests and Pearson’s chi-square tests, with effect sizes reported (r or Cramér’s V). The analysis was exploratory.</p> Results <p>A total of 210 women were included (surgical <i>n</i> = 164; hormonal <i>n</i> = 46). Baseline pain intensity did not differ significantly between groups, although bowel dysfunction and rectal bleeding were more prevalent in the surgical cohort. Following treatment, approximately 80% of women in both groups reported improvement in pelvic pain and dysmenorrhoea. Improvements in dyspareunia, dyschezia, and functional outcomes were observed in substantial proportions. Between-group comparisons revealed no statistically significant differences in change categories across pain, functional symptoms, quality of life, or treatment satisfaction (all <i>p</i> ≥ 0.08), with consistently small effect sizes.</p> Conclusion <p>Both surgical and hormonal treatment were associated with substantial improvements in patient-reported outcomes in women with rectovaginal endometriosis. Direct comparison revealed no significant differences in outcome trajectories, supporting an individualised treatment approach.</p>