509: Endometriosis-related pain: characteristics and sensory and cognitive-emotional interactions

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary visceral / pelvic pain, Assessment and Measurement of Pain/Nociception, Physiotherapy, Pain in Special Populations

Background and Aims: Endometriosis affects about 10% of women of reproductive age and is commonly associated with chronic pelvic pain. Beyond its nociceptive origin, increasing evidence suggests the involvement of nociplastic mechanisms, such as central sensitization (CS) and widespread pain. Considering that cognitive-emotional factors may also influence pain perception and contribute to CS, a multidimensional understanding of pain characteristics can impact how these women are assessed and treated. Therefore, this study aimed to characterize pain and cognitive-emotional factors, and to investigate predictors of pain intensity and CS, as well as the association between CS and pain distribution in women with endometriosis.

Methods: This cross-sectional e-survey study followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and included women with endometriosis who reported chronic pelvic pain. This study was conducted in Brazil, at Federal University of Sergipe, from August 2024 to September 2025. The following instruments were administered via an electronic form: 11-Point Numeric Pain Scale (pelvic pain intensity), Body Diagram (pain distribution), Central Sensitivity Inventory (CS), Pain Catastrophizing Scale (catastrophizing), Chronic Pain Self-Efficacy Scale (self-efficacy) and Depression, Anxiety and Stress Scale-21 (psycho-emotional symptoms). Descriptive, correlation and regression analysis were conducted.

Results: One hundred and one women were included (29.9±6.8 years old) and reported severe dysmenorrhea (rest: 8.2±1.9; movement: 8.6±1.7), pelvic pain (8.4±1.6), and CS levels (CS; 59.5±15.4). Pain was mostly reported in pelvis, lumbar, head, thighs, and abdomen. Higher CS increased the likelihood of non-menstrual pain in lower back (OR=1.06; p<0.05) and abdomen (OR=1.05; p<0.05). Cognitive-emotional aspects predicted pain intensity and CS. Catastrophizing was the strongest predictor of pain at rest (β=0.32; p<0.05), while psycho-emotional symptoms (β=0.43; p<0.05) and self-efficacy (β=-0.34; p<0.05) were the strongest predictors of CS.

Conclusions: Women with endometriosis-related pain presented high pain intensity, widespread pain distribution, and elevated CS levels. CS was associated with greater likelihood of pain in additional body regions, suggesting its role in pain generalization. Cognitive-emotional factors were significant predictors of both pain intensity and CS, highlighting their important role in pain modulation. These findings reinforce the interaction between sensory and cognitive-emotional dimensions within a biopsychosocial framework. Therefore, a comprehensive assessment considering these factors may improve clinical decision-making and guide more effective, individualized, and mechanism-based interventions for women with endometriosis-related pain.

References: [1] Ali P, Younas A. Understanding and interpreting regression analysis. Evid Based Nurs 2021;24:116–118. doi:10.1136/ebnurs-2021-103425.
[2] American College of Obstetricians and Gynecologists. Practice Bulletin No. 218: Chronic Pelvic Pain. Obstet Gynecol 2020;135:e98–e109. doi:10.1097/AOG.0000000000003716.
[3] Anderson KO, Dowds BN, Pelletz RE, Thomas Edwards W, Peeters-Asdourian C. Development and initial validation of a scale to measure self-efficacy beliefs in patients with chronic pain. Pain 1995;63:77–83. doi:10.1016/0304-3959(95)00021-J.
[4] de Arruda GT, Driusso P, Rodrigues JC, de Godoy AG, Avila MA. Numerical rating scale for dysmenorrhea-related pain: a clinimetric study. Gynecological Endocrinology 2022;38:661–665. doi:10.1080/09513590.2022.2099831.
[5] As-Sanie S, Harris RE, Harte SE, Tu FF, Neshewat G, Clauw DJ. Increased Pressure Pain Sensitivity in Women With Chronic Pelvic Pain. Obstetrics & Gynecology 2013;122:1047–1055. doi:10.1097/aog.0b013e3182a7e1f5.
[6] Bajaj P, Bajaj P, Madsen H, Arendt-Nielsen L. Endometriosis is associated with central sensitization: A psychophysical controlled study. Journal of Pain 2003;4:372–380. doi:10.1016/S1526-5900(03)00720-X.
[7] Ballard KD, Seaman HE, De Vries CS, Wright JT. Can symptomatology help in the diagnosis of endometriosis? Findings from a national case-control study - Part 1. BJOG 2008;115:1382–1391. doi:10.1111/j.1471-0528.2008.01878.x.
[8] Boonstra AM, Stewart RE, Köke AJA, Oosterwijk RFA, Swaan JL, Schreurs KMG, Schiphorst Preuper HR. Cut-Off Points for Mild, Moderate, and Severe Pain on the Numeric Rating Scale for Pain in Patients with Chronic Musculoskeletal Pain: Variability and Influence of Sex and Catastrophizing. Front Psychol 2016;7:1–9. doi:10.3389/fpsyg.2016.01466.
[9] Brawn J, Morotti M, Zondervan KT, Becker CM, Vincent K. Central changes associated with chronic pelvic pain and endometriosis. Hum Reprod Update 2014;20:737–747. doi:10.1093/humupd/dmu025.
[10] Caumo W, Antunes L, Lorenzzi Elkfury J, Herbstrith E, Busanello Sipmann R, Souza A, Torres I, Souza dos Santos V, Neblett R. The Central Sensitization Inventory validated and adapted for a Brazilian population: psychometric properties and its relationship with brain-derived neurotrophic factor. J Pain Res 2017;Volume 10:2109–2122.
[11] Dahmani D, Taik FZ, Berrichi I, Fourtassi M, Abourazzak FE. Impact of central sensitization on pain, disability and psychological distress in patients with knee osteoarthritis and chronic low back pain. BMC Musculoskelet Disord 2023;24. doi:10.1186/s12891-023-07019-z.
[12] Damush TM, Kroenke K, Bair MJ, Wu J, Tu W, Krebs EE, Poleshuck E. Pain self-management training increases self-efficacy, self-management behaviours and pain and depression outcomes. European Journal of Pain (United Kingdom) 2016;20:1070–1078. doi:10.1002/ejp.830.
[13] Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004;6:1–6. doi:10.2196/JMIR.6.3.E34.
[14] Facchin F, Barbara G, Dridi D, Alberico D, Buggio L, Somigliana E, Saita E, Vercellini P. Mental health in women with endometriosis: Searching for predictors of psychological distress. Human Reproduction 2017;32:1855–1861. doi:10.1093/humrep/dex249.
[15] Ferreira KA, Teixeira MJ, Mendonza TR, Cleeland CS. Validation of brief pain inventory to Brazilian patients with pain. Supportive Care in Cancer 2011;19:505–511. doi:10.1007/s00520-010-0844-7.
[16] Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain 2011;152:2399–2404. doi:10.1016/j.pain.2011.07.005.
[17] Fullwood D, Means S, Merriwether EN, Chimenti RL, Ahluwalia S, Booker SQ. Toward understanding movement-evoked pain (MEP) and its measurement: A scoping review. Clinical Journal of Pain 2021;37:61–78. doi:10.1097/AJP.0000000000000891.
[18] Gentles A, Goodwin E, Bedaiwy Y, Marshall N, Yong PJ. Nociplastic Pain in Endometriosis: A Scoping Review. J Clin Med 2024;13:1–17. doi:10.3390/jcm13247521.
[19] Ghaferi AA, Schwartz TA, Pawlik TM. STROBE Reporting Guidelines for Observational Studies. JAMA Surg 2021;156:577–8. doi:10.1001/jamasurg.2021.0528.
[20] Green IC, Burnett T, Famuyide A. Persistent Pelvic Pain in Patients With Endometriosis. Clin Obstet Gynecol 2022;65:775–785. doi:10.1097/GRF.0000000000000712.
[21] Jackson T, Wang Y, Wang Y, Fan H. Self-efficacy and chronic pain outcomes: A meta-analytic review. Journal of Pain 2014;15:800–814. doi:10.1016/j.jpain.2014.05.002.
[22] Jensen MP, Turner JA, Romano JM, Fisher LD. Comparative reliability and validity of chronic pain intensity measures. Pain 1999;83:157–162. doi:10.1016/s0304-3959(99)00101-3.
[23] Kardash L, Wall CL, Flack M, Searle A. The role of pain self-efficacy and pain catastrophising in the relationship between chronic pain and depression: A moderated mediation model. PLoS One 2024;19. doi:10.1371/JOURNAL.PONE.0303775.
[24] Karlı N, Baykan B, Ertaş M, Zarifoğlu M, Siva A, Saip S, Özkaya G. Impact of sex hormonal changes on tension-type headache and migraine: a cross-sectional population-based survey in 2,600 women. J Headache Pain 2012;13:557–565. doi:10.1007/S10194-012-0475-0.
[25] Kho KA, Shields JK. Diagnosis and Management of Primary Dysmenorrhea. JAMA - Journal of the American Medical Association 2020;323:268–269. doi:10.1001/jama.2019.16921.
[26] Leuenberger J, Kohl Schwartz AS, Geraedts K, Haeberlin F, Eberhard M, von Orellie S, Imesch P, Leeners B. Living with endometriosis: Comorbid pain disorders, characteristics of pain and relevance for daily life. European Journal of Pain (United Kingdom) 2022;26:1021–1038. doi:10.1002/ejp.1926.
[27] Liew BXW, Valera-Calero JA, Varol U, Nijs J, Arendt-Nielsen L, Plaza-Manzano G, Fernández-De-las-peñas C. Distress and Sensitization as Main Mediators of Severity in Women with Fibromyalgia: A Structural Equation Model. Biomedicines 2022;10:1–11. doi:10.3390/BIOMEDICINES10051188.
[28] Liu Y, Noga H, Allaire C, Bedaiwy M, Lee C, Williams C, Booth A, Galea L, Kaida A, Ogilvie G, Brotto L, Paul Y, Mann GK, Koenig N, Hartse SH, Mazzia C, Kosa SD, Harris A, Berndl A. Central sensitization and mental health outcomes of endometriosis patients during the COVID-19 pandemic. Journal of Obstetrics and Gynaecology Canada 2023;45:361. doi:10.1016/J.JOGC.2023.03.065.
[29] Lovibond SH, Lovibond PF. Manual for the Depression Anxiety & Stress Scale. 2nd ed. Sydney: Psychology Foundation of Australia, 1995.
[30] Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Williams MJ, Perez Y, Gatchel RJ. The Development and Psychometric Validation of the Central Sensitization Inventory. Pain Practice 2012;12:276–285. doi:10.1111/j.1533-2500.2011.00493.x.
[31] McPeak AE, Allaire C, Williams C, Albert A, Lisonkova S, Yong PJ. Pain Catastrophizing and Pain Health-Related Quality-of-Life in Endometriosis. Clinical Journal of Pain 2018;34:349–356. doi:10.1097/AJP.0000000000000539.
[32] Melzack R, Casey K. Sensory, motivational, and central control determinants of pain. In: Kenshalo DR, editor. The skin senses: Proceedings of the first International Symposium on the Skin Senses. Springfield: Charles C Thomas, 1968. pp. 432–439.
[33] Moradi Y, Shams-Beyranvand M, Khateri S, Gharahjeh S, Tehrani S, Varse F, Tiyuri A, Najmi Z. A systematic review on the prevalence of endometriosis in women. Indian J Med Res 2021;154:446–454. doi:10.4103/ijmr.IJMR_817_18.
[34] Moreira MF, Oliveira MAP. Exploring the interplay between catastrophizing and endometriosis pain through 2-wave and intensive longitudinal data. Pain Medicine (United States) 2025;26:207–215. doi:10.1093/PM/PNAE132.
[35] Morotti M, Vincent K, Becker CM. Mechanisms of pain in endometriosis. European Journal of Obstetrics and Gynecology and Reproductive Biology 2017;209:8–13. doi:10.1016/j.ejogrb.2016.07.497.
[36] Neblett R, Hartzell MM, Mayer TG, Cohen H, Gatchel RJ. Establishing Clinically Relevant Severity Levels for the Central Sensitization Inventory. Pain Practice 2017;17:166–175. doi:10.1111/papr.12440.
[37] O’Hara R, Rowe H, Fisher J. Self-management factors associated with quality of life among women with endometriosis: A cross-sectional Australian survey. Human Reproduction 2021;36:647–655. doi:10.1093/humrep/deaa330.
[38] Orr NL, Huang AJ, Liu YD, Noga H, Bedaiwy MA, Williams C, Allaire C, Yong PJ. Association of Central Sensitization Inventory Scores With Pain Outcomes After Endometriosis Surgery. JAMA Netw Open 2023;6:1–12. doi:10.1001/jamanetworkopen.2023.0780.
[39] Orr NL, Wahl KJ, Lisonek M, Joannou A, Noga H, Albert A, Bedaiwy MA, Williams C, Allaire C, Yong PJ. Central sensitization inventory in endometriosis. Pain 2022;163:e234–e245. doi:10.1097/j.pain.0000000000002351.
[40] Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A Simulation Study of the Number of Events per Variable in Logistic Regression Analysis. J Clin Epidemiol 1996;49:1373–1379. doi:10.1016/S0895-4356(96)00236-3.
[41] Phan VT, Stratton P, Tandon HK, Sinaii N, Aredo J V., Karp BI, Merideth MA, Shah JP. Widespread myofascial dysfunction and sensitisation in women with endometriosis-associated chronic pelvic pain: A cross-sectional study. European Journal of Pain (United Kingdom) 2021;25:831–840. doi:10.1002/ejp.1713.
[42] Rees M, Kiemle G, Slade P. Psychological variables and quality of life in women with endometriosis. Journal of Psychosomatic Obstetrics and Gynecology 2022;43:58–65. doi:10.1080/0167482X.2020.1784874.
[43] Salvetti M, Pimenta C. Validação da Chronic Pain Self-Efficacy Scale para a Língua Portuguesa. Rev Psiq Clín 2005;32:202–210. doi:10.1590/S0101-60832005000400002.
[44] Saunders PTK, Horne AW. Endometriosis: Etiology, pathobiology, and therapeutic prospects. Cell 2021;184:2807–2824. doi:10.1016/j.cell.2021.04.041.
[45] Schober P, Boer C, Schwarte LA. Correlation Coefficients: Appropriate Use and Interpretation. Anesth Analg 2018;126:1763–1768. doi:10.1213/ANE.0000000000002864.
[46] Sehn F, Chachamovich E, Vidor LP, Dall-Agnol L, de Souza ICC, Torres ILS, Fregni F, Caumo W. Cross-Cultural Adaptation and Validation of the Brazilian Portuguese Version of the Pain Catastrophizing Scale. Pain Medicine 2012;13:1425–1435. doi:10.1111/j.1526-4637.2012.01492.x.
[47] Shapiro SS, Wilk MB. An analysis of variance test for normality (complete samples). Biometrika 1965;52:591–611. doi:10.1093/biomet/52.3-4.591.
[48] Simoens S, Dunselman G, Dirksen C, Hummelshoj L, Bokor A, Brandes I, Brodszky V, Canis M, Colombo GL, Deleire T, Falcone T, Graham B, Halis G, Horne A, Kanj O, Kjer JJ, Kristensen J, Lebovic D, Mueller M, Vigano P, Wullschleger M, Dhooghe T. The burden of endometriosis: Costs and quality of life of women with endometriosis and treated in referral centres. Hum Reprod 2012;27:1292–1299. doi:10.1093/humrep/des073.
[49] Skegro B, Bjedov S, Mikus M, Mustac F, Lesin J, Matijevic V, Coric M, Gasparovic VE, Medic F, Karadjole VS. Endometriosis, pain and mental health. Psychiatr Danub 2021;33:632–636. doi:10.1055/s-0039-1693057.
[50] Stratton P, Khachikyan I, Sinaii N, Ortiz R, Shah J. Association of chronic pelvic pain and endometriosis with signs of sensitization and myofascial pain. Obstetrics and Gynecology 2015;125:719–728. doi:10.1097/AOG.0000000000000663.
[51] Sullivan M, Bishop S, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychol Assess 1995;7:524–532. doi:10.1037/1040-3590.7.4.524.
[52] Szypłowska M, Tarkowski R, Kułak K. The impact of endometriosis on depressive and anxiety symptoms and quality of life: a systematic review. Front Public Health 2023;11:1–10. doi:10.3389/fpubh.2023.1230303.
[53] Tomassetti C, Johnson NP, Petrozza J, Abrao MS, Einarsson JI, Horne AW, Lee TTM, Missmer S, Vermeulen N, Zondervan KT, Grimbizis G, De Wilde RL. An international terminology for endometriosis, 2021. Hum Reprod Open 2021;2021:1–10. doi:10.1093/hropen/hoab029.
[54] Vannuccini S, Lazzeri L, Orlandini C, Morgante G, Bifulco G, Fagiolini A, Petraglia F. Mental health, pain symptoms and systemic comorbidities in women with endometriosis: a cross-sectional study. Journal of Psychosomatic Obstetrics & Gynecology 2018;39:315–320. doi:10.1080/0167482X.2017.1386171.
[55] Vignola RCB, Tucci AM. Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. J Affect Disord 2014;155:104–109.

Presenting Author: Camilla Feitosa Mendes, PT, MSc
Submitting Author: Camilla Mendes

Senior Author: Josimari Melo DeSantana, PT, PhD

IASP 2026 Global Year theme of Neuropathic Pain: No

• Alice da Silva Almeida: PT, MSc - Federal University of Sergipe
• Letícia Ádrien Santos de Oliveira: PT - Federal University of Sergipe
• Letícia Menezes Lima: PT - Federal University of Sergipe
• Thaysa Passos Nery Chagas: PE, PhD - Federal University of Sergipe
• Patrícia Driusso: PT, PhD - Federal University of São Carlos
• Josimari Melo DeSantana: PT, PhD - Federal University of Sergipe