{"paper_id":"53a77ff9-c82a-4141-aa38-92864138ee5e","body_text":"Journal of Obstetrics and Gynaecology\nISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: www.tandfonline.com/journals/ijog20\nIs it time to agree upon a standardised approach\nto the assessment of contributing factors and\nimpacts of adolescent pelvic pain?\nDehlia Moussaoui, Olivia G. Farrell & Sonia R. Grover\nTo cite this article: Dehlia Moussaoui, Olivia G. Farrell & Sonia R. Grover (2024) Is it time to\nagree upon a standardised approach to the assessment of contributing factors and impacts\nof adolescent pelvic pain?, Journal of Obstetrics and Gynaecology, 44:1, 2359126, DOI:\n10.1080/01443615.2024.2359126\nTo link to this article:  https://doi.org/10.1080/01443615.2024.2359126\n© 2024 The Author(s). Published by Informa\nUK Limited, trading as Taylor & Francis\nGroup\nView supplementary material \nPublished online: 30 May 2024.\nSubmit your article to this journal \nArticle views: 2774\nView related articles \nView Crossmark data\nFull Terms & Conditions of access and use can be found at\nhttps://www.tandfonline.com/action/journalInformation?journalCode=ijog20\n\nJournal of obstetrics and GynaecoloGy\n2024, Vol. 44, no . 1, 2359126\nIs it time to agree upon a standardised approach to the assessment of \ncontributing factors and impacts of adolescent pelvic pain?\nDehlia Moussaoui a*+, Olivia G. Farrell b* and Sonia R. Grover a,b,c\nadepartment of Paediatric and a dolescent Gynaecology, r oyal children’s Hospital, Parkville, a ustralia; bdepartment of Paediatrics, t he university \nof Melbourne, Parkville, a ustralia; cMurdoch children’s r esearch i nstitute, Parkville, a ustralia\nABSTRACT\nBackground:  A biopsychosocial approach to the understanding of pelvic pain is increasingly \nacknowledged. However, there is a lack of standardised instruments – or their use – to assess risk factors \nand their impact on pelvic pain in both clinical and research settings. This review aims to identify \nvalidated tools used to assess known contributory factors to pelvic pain, as well as the validated tools \nto measure the impact of pelvic pain in adolescents and young adults, in order to provide a framework \nfor future standardised, adolescent specific assessment and outcome tools.\nMethods: Literature searches were performed in MEDLINE, PsycInfo and PubMed. Search terms included \npelvic pain, dysmenorrhoea, endometriosis, adolescent, pain measurement, quality of life, sleep, mental \nhealth, coping strategies and traumatic experience.\nResults: We found validated instruments to assess adverse childhood experiences and coping strategies, \nboth known contributing factors to pelvic pain. The impact of pain was measured through validated \ntools for health-related quality of life, mental health and sleep.\nConclusions: Pelvic pain evaluation in adolescents should include a multi-factorial assessment of \ncontributing factors, such as childhood adversity and coping strategies, and impacts of pelvic pain on \nquality of life, mental health and sleep, using validated instruments in this age group. Future research \nshould focus on the development of consensus amongst researchers as well as input from young women \nto establish a standardised international approach to clinical trials involving the investigation and \nreporting of pelvic pain in adolescents. This would facilitate comparison between studies and contribute \nto improved quality of care delivered to patients.\nPLAIN LANGUAGE SUMMARY\nPelvic pain is pain located in the lower abdomen, and includes period pain, which is the most common \ngynaecologic condition in adolescents and young adults. An approach that includes biological, \npsychological and social factors is important to understand and manage pelvic pain. Nonetheless, these \nfactors are often poorly assessed in the clinic and research setting. We performed a literature review to \nidentify tools that measure risk factors for pelvic pain, and those that evaluate the impact of pelvic pain. \nWe found instruments that measure exposure to childhood trauma and coping strategies, which are risk \nfactors for developing pelvic pain. We found tools to assess quality of life, mental health and sleep as \nan impact of pelvic pain. A standardised approach to pelvic pain, including instruments to measure risk \nfactors and impact of pelvic pain, would facilitate comparison between studies and improve quality of \ncare for patients.\nIntroduction\nPersistent or chronic pelvic pain is described a s cyclic or acyclic \npain below the umbilicus of more than six months duration \n(Howard 2003). In the context of menstrual pain, this can be \nfurther divided into primary or secondary dysmenorrhoea. \nPrimary dysmenorrhoea, or menstrual pain in the absence of \nidentifiable disease is reported to affect up to 93% of adoles -\ncents (De Sanctis et  al. 2015). This pain, which is associated \nwith th e physiological proc ess of endometrial shedding, is \nknown to be an inflammatory process involving prostaglandins \nand inflammatory cytokines. Higher circulating levels of prosta -\nglandins have been found in individuals with dysmenorrhoea \ncompared to those without, and these substances are thought \nto contribute to variations in menstrual symptoms and pain \npresentations (Iacovides et  al. 2015). Less commonly, menstrual \npain in adolescents is asso ciated with pelvic pathology and \n© 2024 t he a uthor(s). Published by i nforma uK limited, trading as taylor & f rancis Group\nCONTACT dehlia Moussaoui  dehlia.moussaoui@hcuge.ch   d epartment of Paediatrics, obstetrics and Gynaecology, Geneva university Hospitals, rue \nWilly-donzé 6, 1205 Geneva, s witzerland\n*t hese authors share first-authorship.\n+c urrent address: d epartment of Paediatrics, obstetrics and Gynaecology, Geneva university Hospitals, rue Willy-d onzé 6, 1205 Geneva, s witzerland\n supplemental data for this article can be accessed online at https://doi.org/10.1080/01443615.2024.2359126.\nhttps://doi.org/10.1080/01443615.2024.2359126\nt his is an o pen a ccess article distributed under the terms of the c reative c ommons a ttribution license ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, \ndistribution, and reproduction in any medium, provided the original work is properly cited. t he terms on which this article has been published allow the posting of the a ccepted \nManuscript in a repository by the author(s) or with their consent.\nARTICLE HISTORY\nReceived 7 January 2024\nAccepted 18 May 2024\nKEYWORDS\nPelvic pain; \ndysmenorrhoea; risk \nfactor; quality of life; \nmental health; adolescent\nGYNAECOLOGY\n\n2 D. MOUSSAOUI ET AL.\ncongenital anomalies of the genital tract and is referred to as \nsecondary dysmenorrhoea (Sanfilippo and Erb 2008).\nLike all pain, pelvic pain is considered a personal experi -\nence that is influenced by biological, psychological and social \nfactors (Raja et  al. 2020). Data reported on period and pelvic \npain in adolescents usually include biological factors such as \nthe age of the participants, age at menarche, menstrual cycle \ncharacteristics, body mass index and smoking status. The \nextent to which current studies explore and acknowledge the \nimpact of psycho-social factors—including adverse childhood \nexperiences—in the presentation of period and pelvic pain is \nvariable. Many of these factors are acknowledged in the set -\nting of other paediatric and adolescent pain conditions \n(Groenewald et  al. 2020). Currently however, there are no \nagreed-upon standardised measures for identifying risk fac -\ntors for the development and the persistence of pelvic pain, \nnor are there standardised core outcome measures used by \nresearchers assessing period and pelvic pain in adolescents, \nmaking it difficult to compare and contrast studies that \nendeavour to implement intervention strategies.\nInternationally it is increasingly recognised that having a \nstandardised approach is valuable in optimising research and \nhence care for people with specific diagnoses. This approach \nhas been developed in the setting of specific pain conditions \nas occurs in the Initiative on Methods, Measurement, and \nPain Assessment in Clinical Trials (IMMPACT) with the devel -\nopment of consensus reviews and recommendations for \nimproving the design, execution, and interpretation of clinical \ntrials of treatments for pain (Dworkin et  al. 2005). The Core \nOutcome Measures in Experimental Trials (COMET) Initiative \nshares a similar objective: to create a standardised set of out -\ncomes for studies (Gargon et  al. 2017). Neither of these inter -\nnational initiatives has considered a standardised approach to \nadolescent period and pelvic pain. Having a standardised \napproach to measuring predisposing factors as well as out -\ncomes for adolescents with pelvic pain would allow the opti -\nmal opportunity for comparison between investigators and \ndifferent patient cohorts, and ultimately help clinicians pro -\nvide the best care tailored to their adolescent patients. The \nfirst step to achieving this is to review the current literature \nfor evidence regarding which factors and outcome measures \nto include, prior to an international expert group developing \na consensus.\nThis narrative review aims to explore the validated instru -\nments required to comprehensively assess the factors contrib -\nuting to and impacts of pelvic pain in adolescents and \nyoung adults.\nMethods\nMEDLINE using the Ovid interface, PsycInfo and PubMed were \nsearched using a combination of terms including pelvic pain, \nendometriosis, pain measurement, quality of life, sleep, men -\ntal health, abuse and impact in October 2022. The search \nstrategy can be found in Supplementary Material . There was \nno systematic search of the literature. Papers reporting vali -\ndated tools to assess contributing factors to and impacts of \npelvic pain (including dysmenorrhoea) in female adolescents \nand young adults (10–25 years old) were identified. Data \nabout validated tools were extracted, however we did not \ninclude all studies reporting on these instruments, and \nfocused on the most relevant (in terms of quality, number of \nparticipants and date of publication). Demographic data of \nparticipants, pain scores and instruments used to evaluate \nrisk factors and impacts of pelvic pain were retrieved by two \nauthors (DM and OF) and reported in a self-design form for \ndata abstraction. Disagreements were resolved by a third \nauthor (SG). Studies investigating only urinary tract causes of \npelvic pain were excluded, because these are rare in female \nadolescents and young adults. Due to the study design, ethi -\ncal registration was not required.\nResults\nTable 1  summarises included studies and validated instru -\nments used to assess predisposing factors and impacts of \npelvic pain.\nContributing factors\nAdverse childhood experiences\nAdverse childhood experiences (ACEs) are defined as trau -\nmatic events occurring before the age of 18, such as experi -\nencing abuse, neglect or household dysfunction (Felitti et  al. \n1998), and have been linked to poor health outcomes, includ -\ning chronic pelvic pain (Krantz et  al. 2019, Moussaoui et  al. \n2023). A recent systematic review on ACEs and pelvic pain in \nadolescents and young adults found only one study explor -\ning this association through a validated score (Moussaoui and \nGrover 2022): You et  al. used the Early Trauma Inventory \nSelf-report (ETISR), which is a 27-item questionnaire covering \nfour domains of traumatic events (general, physical, emo -\ntional and sexual trauma) before the age of 18 (You et  al. \n2019). They showed an association between the number and \nseverity of ACEs and the risk of dysmenorrhoea (You et  al. \n2019). A 1 SD increase in ETISR score was associated with a \n39% increase in the odds of dysmenorrhoea (OR = 1.39; 95% \nCI, 1.24–1.57) (You et  al. 2019).\nBMI\nBody Mass Index (BMI) was explored as a predisposing factor \nin many cross-sectional studies and no relationship was found \nbetween menstrual pain and BMI (Gagua et  al. 2013, Slater \net al. 2015, Suvitie et al. 2016, Gallagher et al. 2018, Wong 2018).\nCoping strategies\nCoping strategies relate to how stressful and difficult life \nevents are managed by individuals. In the setting of chronic \npain conditions, maladaptive coping strategies may impact \nnegatively on pain experience and quality of life (Alok et  al. \n2014). The Coping strategies inventory (CSI) is a 40-item scale \nwith a 5-point Likert response format, assessing eight main \nstrategies to cope with stress and difficulties, including \nProblem solving, Cognitive restructuring, Social support, \nExpress emotions, Problem avoidance, Wishful thinking, Social \n\nTOOLS TO ASSESS CONTRIBUTING FACTORS AND IMPACTS OF PELVIC PAIN 3\nTable 1. c ontributing factors to and impacts of pelvic pain and their validated tools.\na ssessment c itation study design Population, with age range and/or mean age, yr\ninstruments \nused Key results\nc ontributing factors to pain\na dverse childhood \nexperiences\nyou at al. Pain Medicine \n2019 – usa\nc ross-sectional 2222 f emale students, mean age 18.8. etisr c orrelation between the number and severity of adverse \nchildhood events and the risk of dysmenorrhoea.\nbMi suvitie et  al. JPaG 2016 \n– f inland\nc ross-sectional 1103 s tudents, including 354 without menstrual pain, 101 with mild \npain, 279 with moderate pain and 355 with severe pain, aged \n15–19 years (mean 16.8).\nbMi no relationship between bMi and menstrual pain severity.\nWong et  al. r eproductive \nHealth 2018 – Hong \nKong\nc ross-sectional 653 s econdary school students, including 428 with dysmenorrhoea and \n225 without, aged 13–19 (mean 15.7).\nno difference in bMi between participants with and \nwithout dysmenorrhoea.\nGallagher et  al. JaH 2018 \n– usa\nc ross-sectional 567 Participants in the ‘Women’s health study: from adolescence to \nadulthood’ , including 360 cases (surgically confirmed endometriosis) and \n207 controls, aged 10–24 years.\nno difference in bMi between participants with surgically \nconfirmed endometriosis and controls.\nGagua et  al. JPaG 2013 \n– Georgia\nc ross-sectional 424 s tudents, including 276 with dysmenorrhoea and 148 without, aged \n14–20.\nno difference in bMi between participants with and \nwithout dysmenorrhoea.\nslater et  al. Pain 2015 \n– a ustralia\nc ross-sectional 432 Participants in the ‘Western a ustralian Pregnancy c ohort s tudy’ , who \ncompleted the question of period pain at 20 and 22 year old.\nno relationship between bMi and menstrual pain severity.\nc oping strategies Gonzalez-echevarria et  al. J \nPsychosom obstet \nGynaecol 2019 – usa\nc ross-sectional 24 Participants from the ‘endo teens initiative’ with surgically confirmed \nendometriosis, aged 13–25.\ncsi Positive correlation between HrQol scores and autocriticism \nin young people with endometriosis. negative correlation \nbetween HrQol and emotion expression, social support, \ncognitive restructuring and social withdrawal.\nKato et  al. Pain Practice \n2017 – Japan\nc ross-sectional 186 c ollege students with menstrual pain, aged 18–23 years (mean 18.9). csQ-r c orrelation between menstrual pain coping flexibility and \nreduced depressive symptoms during menstruation.\nimpact of pain\nHealth-related \nquality of life\nWong et  al. r eproductive \nHealth 2018 – Hong \nKong\nc ross-sectional 653 s econdary school students, including 428 with dysmenorrhoea and \n225 without, aged 13–19 (mean 15.7).\nsf36 l ower HrQol score in adolescents with dysmenorrhoea \ncompared to controls.\nGallagher et  al. JaH 2018 \n– usa\nc ross-sectional 567 Participants in the ‘Women’s health study: from adolescence to \nadulthood’ , including 360 cases (surgically confirmed endometriosis) and \n207 controls, aged 10–24 years.\nl ower HrQol scores in adolescents and young adults \nwith endometriosis compared with controls.\nVannucini et  al. r eprod s ci \n2020 – i taly\nc ross-sectional 112 a thletes, including 69 with dysmenorrhoea, mean age 19.3. sf12 no association between HrQol and dysmenorrhoea.\nsahin et  al. r eproductive \nHealth 2018 – turkey\nc ross-sectional 101 adolescents presenting to an outpatient clinic, including 60 for \ndysmenorrhoea, and 41 for another reason, aged 12-18.\nPedsQl l ower HrQol score in adolescents with dysmenorrhoea \ncompared to controls.\nnur a zurah et  al. JPaG \n2013 – a ustralia\nc ross-sectional 184 adolescents presenting to a gynaecology clinic for menstrual \ndisorders, aged 13–18 (mean 15.1).\nl ower physical and school functioning HrQol scores in \nadolescents with dysmenorrhoea compared to \nadolescents with other menstrual disorders.\niacovides et  al. a cta obstet \nGynecol s cand 2014 \n– s outh a frica\nProspective \nlongitudinal\n21 f emale (12 with severe dysmenorrhoea and 9 with no/mild/moderate \ndysmenorrhoea), mean age 21 and 22 respectively.\nQ-les -Q-sf l ower HrQol score in women with severe dysmenorrhoea in \nthe menstruation phase compared with controls and with \ntheir own pain-free follicular phase.\nHoppenbrouwers et  al. eur J \nPediatr 2016 – b elgium\nc ross-sectional 363 Girls, including 146 with dysmenorrhoea, aged 12.2–13.6 (mean \n12.8).\nMdot Painful menstruation have a negative impact on HrQol \ncompared to menstruation that are not painful.\nParker et  al. bJoG 2009 \n– a ustralia\nc ross-sectional 1051 students, including 317 with no or mild dysmenorrhoea, 505 with moderate \ndysmenorrhoea and 217 with severe dysmenorrhoea, aged 8–19 (mean 16.8).\nc orrelation between severity of dysmenorrhoea and \ninterference with life activities.\na l Jefout et  al. JPaG 2015 \n– Jordan\nc ross-sectional 272 Medical students, including 152 with moderate or severe \ndysmenorrhoea, aged 19–25 (mean 22).\nc orrelation between severity of dysmenorrhoea and \ninterference with life activities.\nGonzalez-echevarria et  al. J \nPsychosom obstet \nGynaecol 2019 – usa\nc ross-sectional 24 Participants from the ‘endo teens initiative’ with surgically confirmed \nendometriosis, aged 13–25.\neHP-5 no correlation between HrQol and pain levels among \nyoung women with endometriosis.\n(Continued)\n\n4 D. MOUSSAOUI ET AL.a ssessment c itation study design Population, with age range and/or mean age, yr\ninstruments \nused Key results\nMental health balik et  al. JPaG 2014 \n– t urkey\nc ross-sectional 159 Participants presenting to a gynaecology clinic, including 51 with \ndysmenorrhoea and 108 without, aged 13–18 (mean 17.7).\nbdi, bai Higher scores of depression and anxiety in adolescents \nwith dysmenorrhoea compared with those without \ndysmenorrhoea.\nGagua et  al. JPaG 2013 \n– Georgia\nc ross-sectional 424 s tudents, including 276 with dysmenorrhoea and 148 without, aged \n14–20.\nbdi, stai and \nt Mas\nHigher proportion of depression and anxiety among \nindividuals with dysmenorrhoea compared to those \nwithout dysmenorrhoea.\nGonzalez-echevarria et  al. J \nPsychosom obstet \nGynaecol 2019 – usa\nc ross-sectional 24 Participants from the ‘endo teens initiative’ with surgically confirmed \nendometriosis, aged 13–25.\nbdi-ii, bai Moderate-severe levels of depression in 33.4% of \nparticipants. Moderate-severe levels of anxiety in \n45.8% of participants.\nslater et  al. Pain 2015 \n– a ustralia\nc ross-sectional 432 Women from the ‘Western a ustralian Pregnancy c ohort s tudy’ , who \ncompleted the question of period pain at 20 and 22 year old.\ndass -21 severe dysmenorrhoea associated with higher scores of \ndepression, anxiety and stress.\na mbresin et  al. JPaG 2012 \n– s witzerland\nc ross-sectional 3340 a dolescents, including 414 with severe dysmenorrhoea and 2926 \nwith no, mild or moderate dysmenorrhoea, aged 16–20.\ndepressive \ntendencies \nscale\na djusted odds ratio of depressive symptoms of 1.83 \n(95%ci 1.49–2.25) in adolescents with severe \ndysmenorrhoea compared to those with no, mild or \nmoderate dysmenorrhoea.\nPost traumatic \nstress disorder\ntakeda et  al. JPaG 2013 \n– Japan\nc ross-sectional 1180 s tudents, including 167 with no dysmenorrhoea, 396 with mild \ndysmenorrhoea, 471 with moderate dysmenorrhoea and 146 with severe \ndysmenorrhoea, aged 15–18 (mean 16.7).\nies-r significant association between the severity of \ndysmenorrhoea and Ptsd symptoms.\nsleep liu et  al. sleep 2017 \n– china\nc ross-sectional 5800 a dolescents from the ‘shandong a dolescent b ehaviour and Health \nc ohort’ , aged 12–18 (mean 15).\nPsQi increased risk of insomnia symptoms in adolescents with \nsevere dysmenorrhoea compared to those with no or \nmoderate pain.\nWang et  al. sleep J 2019 \n– china\nc ross-sectional 5813 a dolescents from the ‘shandong a dolescent b ehaviour and Health \nc ohort’ , aged 12–18 (mean 15).\ncadss a ssociation between daytime sleepiness and level of \ndysmenorrhoea.\nslater et  al. Pain 2015 \n– a ustralia\nc ross-sectional 432 Women from the ‘Western a ustralian Pregnancy c ohort s tudy’ , who \ncompleted the question of period pain at 20 and 22 year old.\nPsQi no relationship between sleep quality and menstrual pain \nseverity.\nAbbreviations:\nbai: b eck a nxiety i nventory;\nbdi: b eck d epression i nventory;\nbdi-ii: b eck d epression i nventory – ii;\nbMi: body mass index;\ncadss: chinese a dolescent daytime sleepiness s core;\ncsQ-r: c oping s trategies Questionnaire – r evised;\ncsi: c oping s trategies i nventory;\ndass -21: d epression a nxiety s tress s cale-21;\neHP-5: endometriosis Health Profile-5;\netisr: early t rauma i nventory s elf r eport;\nHrQol: health related quality of life;\nies-r: i mpact of e vent s cale – r evised;\nMdot : menstrual disorder of teenagers;\nPedsQl: Paediatric Quality of life i nventory;\nPPiQ: Pelvic Pain i mpact Questionnaire;\nPsQi: Pittsburg sleep Quality i ndex;\nPtsd: post-traumatic stress disorder;\nQ-les -Qsf : Quality of life enjoyment and s atisfaction Questionnaire short f orm;\nsf12: short f orm 12;\nsf36: short f orm 36;\nstai: spielberger s tate-t rait a nxiety i nventory Questionnaire;\nt Mas: taylor Manifest a nxiety s cale.\nTable 1. c ontinued.\n\nTOOLS TO ASSESS CONTRIBUTING FACTORS AND IMPACTS OF PELVIC PAIN 5\nwithdrawal and Self-criticism (Ryan-Wenger 1990). The CSI \nwas used in a study specifically assessing HRQOL in young \npatients with endometriosis: HRQOL scores were positively \ncorrelated with autocriticism, and negatively correlated with \nemotion expression, social support, cognitive restructuring \nand social withdrawal (Gonzalez-Echevarria et  al. 2019). In the \nsame study, pain scores did not correlate with HRQOL, \nwhereas coping strategies did (Gonzalez-Echevarria et al. 2019).\nAnother assessment tool reported in the literature is the \nCoping Strategies Questionnaire-Revised (CSQ-R), which is \nspecifically designed to measure chronic pain coping strate -\ngies (Riley and Robinson 1997). It includes 27 items and 6 \nsubscales: distraction, catastrophizing, ignoring of pain, dis -\ntancing from pain, self-statements and praying (Riley and \nRobinson 1997). The Coping Flexibility Scale (CFS) is a 5-item \nscale assessing the extent of flexibility of individuals in cop -\ning with stress (Kato 2012). Using both the CSQ-R and the \nCFS, a cross-sectional study among 186 students found that \nmenstrual pain coping flexibility was significantly associated \nwith reduced depressive symptoms during menstruation \n(Kato 2017).\nImpacts of pelvic pain\nHealth related quality of life\nThe impact of dysmenorrhoea and pelvic pain on \nhealth-related quality of life (HRQOL) was measured using \nboth validated generic and condition specific instruments. \nGeneric instruments included the Short Form 36 (SF-36) \n(Gallagher et  al. 2018, Wong 2018), Short Form 12 (SF-12) \n(Vannuccini et al. 2020), the Paediatric Quality of Life Inventory \n(PedsQL) (Nur Azurah et  al. 2013, Sahin et  al. 2018) and the \nShort Form of Quality of Life Enjoyment and Satisfaction \nQuestionnaire (Q-LES-Q-SF) (Iacovides et  al.  2014). \nCondition-specific instruments included the Menstrual \nDisorder of Teenager (MDOT) (Parker et  al. 2010, Al-Jefout \net al. 2015, Hoppenbrouwers et al. 2016) and the Endometriosis \nHealth Profile-5 (EHP-5) (Gonzalez-Echevarria et  al. 2019).\nThe SF-36 consists of 36 questions measuring eight HRQOL \ndomains: physical functioning, role-physical, bodily pain, gen -\neral health, vitality, social functioning, role-emotional and \nmental health (Ware and Sherbourne 1992). A case-control \nstudy reported that participants with surgically diagnosed \nendometriosis scored lower in both physical (mean ± SD: \n43.7 ± 11.2) and mental components (43.5 ± 12.2) compared to \ncontrols with no history of endometriosis (53.9 ± 7.8, p < 0.001; \nand 46.4 ± 11.1, p = 0.01 respectively) (Gallagher et  al. 2018). \nWhile all domains were impaired, limitations due to bodily \npain were the most considerable (Gallagher et  al. 2018). Using \nthe SF-36, Wong et  al. showed that adolescents with severe \ndysmenorrhoea had lower scores in the bodily pain domain \ncompared to those with only mild or moderate dysmenor -\nrhoea (Wong 2018). The SF-12 consists of 12 questions, all \nselected from the SF-36. A cross-sectional study showed no \nassociation between SF-12 score and the presence of dys -\nmenorrhoea among a population of young athletes and con -\ntrols (Vannuccini et  al. 2020).\nThe PedsQL self-report form designed for adolescents \naged 13–18 years includes 23 items and explores psychosocial \nand physical health by assessing physical, emotional, social \nand school functioning (Sweeney et  al. 2020). Using the \nPedsQL, Sahin et  al. reported that adolescents with dysmen -\norrhoea had a significantly lower quality of life (mean ± SD: \n63.60 ± 8.98) compared to adolescents without period pain \n(79.67 ± 9.37, p = 0.000) (Sahin et  al. 2018). Another study per -\nformed among adolescents presenting with menstrual issues \nto a gynaecology clinic, showed that adolescents with dys -\nmenorrhoea scored lower in the physical and school func -\ntioning than girls with other menstrual problems (Nur Azurah \net  al. 2013).\nThe MDOT is a questionnaire exploring characteristics of \nmenstruation, period pain and interference of periods with \nquality of life (Parker et  al. 2010). Impact on different life \nactivities is investigated, such as school or work, social activ -\nities, sport, relationships with family, friends and partner, and \nsexual activity. The MDOT study performed among more than \n1000 adolescents showed a significant association between \nseverity of pain and interference with life activities (Parker \net  al.  2010). Similar results were found in another \ncross-sectional study among medical students (Al-Jefout et  al. \n2015). Also using the MDOT, another study found that a \nhigher proportion of 13-year old girls indicated that menstru -\nation negatively impacted their quality of life if their periods \nwere painful than if they were not (41.3 vs 14.2%, RR = 2.9, \nIC 2–4.4, p < 0.001) (Hoppenbrouwers et  al. 2016).\nThe EHP-5 is an instrument measuring different domains \nof HRQOL relating to endometriosis, such as illness, indepen -\ndent living, physical ability, psychological state and social \ninteractions, and is validated for use in individuals 17 years or \nolder. Gonzalez-Echevarria et  al. found no correlation between \nEHP-5 score and pain levels in 24 young women with endo -\nmetriosis (Gonzalez-Echevarria et  al. 2019).\nThe Q-LES-Q-SF is a short form derived from a 93-item \nquestionnaire and evaluates overall enjoyment and satisfac -\ntion regarding physical health, mood, work, household and \nleisure activities, family and social relationships, ability to func -\ntion in daily life, sexual drive, economic status, living/housing \nsituation, ability to get around physically, ability to do work \nand hobbies and sense of being (Endicott et  al. 1993). Using \nthe Q-LES-Q-SF, Iacovides et  al. showed that young women \nwith dysmenorrhoea reported poorer HRQOL in the menstru -\nation phase (mean ± SD: 54 ± 18%) compared with controls \n(81 ± 10%; p < 0.0001) and compared with their own pain-free \nfollicular phase (80 ± 14%; p < 0.0001) (Iacovides et  al. 2014).\nMental health\nThe findings in relation to mental health were largely consis -\ntent, with more anxiety and depressive symptoms in adoles -\ncents with severe pelvic pain compared to those without \npelvic pain (Ambresin et  al. 2012, Gagua et  al. 2013, Balık \net  al. 2014, Slater et  al. 2015). Standardised tools used to \nassess depressive symptoms included the Beck Depression \nInventory (BDI) and BDI-II (revised version of the BDI), which \nare 21-item self-report questionnaires (Beck et  al. 1997), and \n\n6 D. MOUSSAOUI ET AL.\nthe Depressive Tendencies Scale, which includes 8 items \n(Holsen et  al. 2000).\nAnxiety was assessed using the Beck Anxiety Inventory \n(BAI), which is a 21-item self-report scale (Beck et  al. 1988), \nthe Spielberger State-Trait Anxiety Inventory questionnaire \n(STAI) (Spielberger et  al. 1983; Manual for the State-Trait \nAnxiety Inventory. Consulting Psychologists Press, Palo Alto), \nand the Taylor Manifest Anxiety Scale (TMAS) (Taylor 1953).\nThe Depression, Anxiety and Stress Scale (DASS-21) (Slater \net  al. 2015) was used in one study, and includes 21 items \nassessing degrees of depression, anxiety and stress over the \nlast week (Page et  al. 2007).\nOne cross-sectional study identified that adolescents with \npost-traumatic stress disorder (PTSD) were more likely to have \nsevere pelvic pain (Takeda et  al. 2013). PTSD symptoms were \nassessed using the Impact of Event Scale-Revised (IES-R), \nwhich includes 22 items on experiencing symptoms of intru -\nsion, avoidance, and hyperarousal over the last 7 days (Weiss \nand Marmar 1997; The Impact of Event Scale—Revised. In J. \nP . Wilson & T. M. Keane (Eds.), Assessing psychological trauma \nand PTSD (pp. 399–411). The Guilford Press).\nSleep\nTwo studies on the same cohort of adolescents identified a \nrelationship between dysmenorrhoea and sleep disturbance, \nusing the Pittsburg Sleep Quality Index (PSQI) (Liu, Chen, \net  al. 2017) and the Chinese Adolescent Daytime Sleepiness \nScale (CADSS) (Wang et  al. 2019). The PSQI includes 19 \nself-reported items related to sleep quality (Buysse et  al. \n1989). Using the PSQI, Liu et  al. found an increased risk of \ninsomnia symptoms in adolescents with severe dysmenor -\nrhoea compared to those with no or moderate pain in a \ncross-sectional study (Liu, Chen, et  al. 2017). The CADSS is a \n7-item questionnaire measuring daytime sleepiness (Liu, Yang, \net  al. 2017). Wang et  al. identified in their bootstrapping anal -\nysis that it was not just menstrual pain severity that was \nassociated with increased daytime sleepiness, but also mental \nhealth symptoms (Wang et  al. 2019).\nConversely, Slater et  al. found no association between \nsleep quality and menstrual pain, but it should be noted that \nthey used only one of the 19 items of the PSQI to assess \nsleep quality (Slater et  al. 2015).\nDiscussion\nPelvic pain is multifaceted, with physiological, psychological \nand social factors all contributing to pain experience (Edwards \net  al. 2016). As such, the experience of adolescents is unique \nand warrants its own standardised assessment approach. \nDespite this, a consensus guideline on the assessment of ado -\nlescent pelvic pain has yet to be achieved, in both clinical \nand research settings.\nThis review enabled us to identify several relevant and val -\nidated tools to assess contributing factors and impacts of pel -\nvic pain in adolescents and young adults.\nConsistent with the PedIMMPACT consensus for trials \ninvestigating paediatric chronic and recurrent pain (McGrath \net  al. 2008), we found that ACEs, HRQOL and sleep should be \nincluded in the assessment of adolescent pelvic pain. However, \nour review found that exposure to ACEs was studied through \na validated instrument in only one study. Impact of pelvic \npain on HRQOL and sleep was explored through various \nassessment tools, making comparisons between studies com -\nplicated. Moreover, some of these tools were not designed or \nvalidated in adolescents and young adults, making their inter -\npretation difficult. Instruments validated for adolescents and \nyoung adults should be used where such instruments exist. \nWhile the PedIMMPACT guidelines also recommend that over -\nall satisfaction with treatment should be included when \nassessing chronic and recurrent pain in adolescents, no stud -\nies included in this review explored treatment satisfaction. In \nsome cases, this is explained by the study design, where par -\nticipants may have been yet to seek treatment. Future studies \nmight consider adding this outcome.\nIn addition to the factors already mentioned, this review \nfound that coping strategies and mental health should also \nbe explored when assessing pelvic pain in adolescents and \nyoung adults. The relationship between pelvic pain and men -\ntal health is bidirectional, since pelvic pain may lead to poorer \nmental health, and conversely poorer mental health may \nincrease vulnerability to pelvic pain (Gagnon et  al. 2022). This \nwas highlighted in a study of greater than 500,000 people \nfrom Sweden, where participants were twice as likely to \ndevelop mental illness after experiencing significant pain—\nincluding pelvic pain—and similarly were 1.9 times as likely \nto develop significant pain after a mental illness diagnosis \n(Bondesson et  al. 2018). Among the studies included in this \nreview, there was no evidence of a temporal or causal rela -\ntionship between pelvic pain and mental health symptoms, \nowing to the cross-sectional design of the studies. A clear \ndocumentation of mental health when assessing pain may \nbetter inform the treatment of pelvic pain in adolescents.\nIn addition, this review found an interplay between pelvic \npain, mental health symptoms and sleep quality, highlighting \nthe need for a multidisciplinary approach to management \nincorporating all factors.\nStudies exploring coping strategies and pelvic pain sug -\ngest that adolescents’ approach to managing pain, more than \nthe severity of pain, may impact their pain experience, includ -\ning associated mental health, and provide important informa -\ntion when assessing pelvic pain as well as further avenues for \nintervention.\nThe PedIMMPACT consensus suggests that economic fac -\ntors should be considered in the assessment of adolescent \nchronic pain. Socio-economic status may have an impact on \npelvic pain, though inconsistent results have been found in \nthe literature (Armour et  al. 2020, Sachedina et  al. 2021). \nHowever, this factor was not explored in this review, owing to \na lack of standardised measurement tools available to com -\npare across studies and study populations.\nSimilarly, impact of pelvic pain on school participation was \nnot included in this review because of the lack of validated \ninstruments to measure this outcome. Many studies have \nhighlighted the negative impact of pelvic pain on school par -\nticipation, with various and non-standardised outcomes such \nas missed days at school (Suvitie et  al. 2016, Wong 2018, \nArmour et  al. 2020, Munro et  al. 2023), poor concentration in \n\nTOOLS TO ASSESS CONTRIBUTING FACTORS AND IMPACTS OF PELVIC PAIN 7\nthe classroom (Eryilmaz et  al. 2010, Armour et  al. 2020), poor \nschool functioning (Nur Azurah et  al. 2013), missed exams \nand poor exams performance (Eryilmaz et  al.  2010, \nGonzalez-Echevarria et  al. 2019, Armour et  al. 2020).\nLimitations\nThis review was limited by several factors. First, the defini -\ntion of pelvic pain varied throughout the studies, with \nsome reporting pain severity and others using a dichoto -\nmic approach (presence versus absence of pain). This vari -\nation was compounded by a lack of consistency in \nclassifying the severity or presence of dysmenorrhoea. Pain \nseverity was measured using a Visual Analogue Scale (VAS), \nother scales from moderate to severe or a Numerical Rating \nScale (NRS) from 0 to 10, McGill Pain Questionnaire, Verbal \nMultidimensional Scoring (VMS) and sometimes impact on \ndaily activities was accounted for in its definition. Some \nstudies described rates of ‘self-reported’ dysmenorrhoea by \nparticipants, but did not mention how dysmenorrhoea was \ndefined or whether its severity was assessed. Second, there \nwas a large heterogeneity in tools used for some factors, \nsuch as HRQOL, making comparison between studies chal -\nlenging. In addition, some of the tools (such as SF-12 and \nSF-36) were not validated in the age group of study partic -\nipants, making the results interpretation difficult. Third, \nsome authors used only a few items from a scale, which \ndid not correspond to the complete and validated score. \nFourth, this review did not use a systematic approach, lim -\niting the generalisability of our findings. In addition, \nincluded studies were not formally assessed for quality, \nalthough this was accounted for when interpreting the \nresults.\nConclusion\nThis review has established that the assessment of pelvic pain \nin adolescents requires a multi-factorial approach both in \nexploring its contributing factors as well as measuring its out -\ncome impact. Pelvic pain assessment in adolescents should \ninclude an assessment of pain severity, ACEs, coping strate -\ngies, HRQOL, mental health and sleep through validated \nscores that are age appropriate. Future research should focus \non the development of consensus amongst researchers as \nwell as input from young women themselves to establish a \nstandardised international approach to clinical trials involving \nthe investigation and reporting of pelvic pain in adolescents \nwith a view to improving the care and long-term outcomes \nin these patients.\nAuthor contributions\nDM contributed to acquisition and analysis of data, interpretation of data \nand drafted the manuscript. OG contributed to the design of the study, \nacquired and interpreted the data, and drafted the manuscript. SG con -\ntributed to the design of the study, acquired and analysed the data, and \nreviewed the manuscript critically for important intellectual content. All \nauthors approved the final version to be published and agree to be \naccountable for all aspects of the work in ensuring that questions related \nto the accuracy or integrity of any part of the work are appropriately \ninvestigated and resolved.\nDisclosure statement\nNo potential conflict of interest was reported by the author(s).\nFunding\nDehlia Moussaoui was supported by a grant from the Fonds de \nPerfectionnement, Geneva University Hospitals, Geneva, Switzerland, and \nthe Swiss National Science Foundation (Postdoc. Mobility grand number \nP400PM_199338).\nData availability statement\nThe data that support the findings of this study are available on request \nfrom the corresponding author.\nReferences\nAl-Jefout, M., et  al., 2015. Dysmenorrhea: prevalence and impact on qual -\nity of life among young adult Jordanian females. Journal of Pediatric \nand Adolescent Gynecology , 28 (3), 1–9.\nAlok, R., et  al., 2014. 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