Relationship Between Quality of Life, Depression and Complementary and Alternative Medicine Use in Women With Chronic Pelvic Pain: A Cross-sectional Study on the Turkish Population

Relationship Between Quality of Life, Depression and Complementary and Alternative Medicine Use in Women With Chronic Pelvic Pain: A Cross-sectional Study on the Turkish Population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationship Between Quality of Life, Depression and Complementary and Alternative Medicine Use in Women With Chronic Pelvic Pain: A Cross-sectional Study on the Turkish Population SEVDE AKSU, MİNE ISLIMYE TAŞKIN, ONCU PINAR BAYIR ALBAYRAK This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8224699/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Chronic pelvic pain (CPP) is a multidimensional condition that affects women’s physical, psychological, and social well-being. This study aimed to examine the relationship between quality of life, depressive symptoms, and the use of complementary and alternative medicine (CAM) among women living with CPP. Methods: This cross-sectional study included 250 women diagnosed with CPP who were followed in the Obstetrics and Gynecology outpatient clinic of a university hospital in the Marmara region of Turkey. Data were collected using a Descriptive Information Form, the Beck Depression Inventory (BDI), and the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). Results: Uterine (49.6%) and extra-uterine gynecologic (40.0%) factors were the most common causes of CPP. Exercise (61.2%) and massage (50.4%) were the most frequently used conservative approaches, whereas acupuncture (38.0%), psychotherapy (36.0%), and sleep regulation (42.4%) were moderately used. The mean BDI score was 13.67 ± 9.94, indicating mild-to-moderate depressive symptoms. The mean WHOQOL-BREF total score was 3.26 ± 0.46. Depressive symptoms demonstrated significant negative correlations with all WHOQOL-BREF subdomains. Logistic regression analysis showed that higher WHOQOL-BREF scores significantly predicted uterine-origin pain (B = 0.714, p = 0.013), corresponding to a 2.04-fold increased likelihood (Exp(B) = 2.043). Conclusion: This study shows that gynecologic causes are the predominant etiologies of CPP in Turkish women. Conservative strategies, particularly exercise and massage, are widely adopted, while CAM awareness and use vary across modalities. Depressive symptoms were common and strongly associated with lower quality of life across all domains. These findings underscore the need for multidisciplinary approaches that integrate psychological screening, patient education, and evidence-based conservative therapies alongside conventional medical management. chronic pelvic pain quality of life depression complementary and alternative medicine women’s health Introduction Chronic pelvic pain (CPP) is defined as non-cyclic pain lasting at least six months and localized to the pelvis, lower abdomen, anterior abdominal wall, lumbosacral region, back, or buttocks, often leading to varying degrees of functional impairment (1). The International Association for the Study of Pain (IASP) emphasizes that CPP involves not only persistent pain but also behavioral and functional components, including poor response to medical treatment, marked disruption of physical functioning, vegetative symptoms of depression, and changes in family or social roles due to pain (2). Globally, CPP is estimated to affect 5.7% to 26.6% of women; however, approximately 60% of affected women do not receive a definitive diagnosis, and nearly 20% undergo no diagnostic evaluation despite persistent symptoms (3–5). CPP arises at the intersection of gynecologic, urologic, gastrointestinal, and neuromuscular etiologies and is strongly influenced by biopsychosocial factors. It is associated with reduced physical activity, social withdrawal, sexual dysfunction, impaired sleep quality, and substantial reductions in both physical and psychological well-being (3,6,7). Notably, the co-occurrence of depression and anxiety is highly prevalent in women with CPP, and this comorbidity is consistently linked to significantly lower quality-of-life scores (8–10). Large-scale data suggest that the prevalence of depression and anxiety in chronic pain populations may reach 40%, underscoring the need for routine mental health screening in CPP management (11). Despite its complex biopsychosocial burden, the evidence supporting non-pharmacological conservative treatments for CPP remains limited, and clinical guidelines continue to focus predominantly on medical and surgical interventions (13,14). Nevertheless, women with CPP frequently turn to complementary and alternative medicine (CAM) approaches, especially when symptoms become chronic and treatment response is limited. A prospective study indicated that more than half of women with CPP are likely to use non-pharmacological strategies (15). Recent systematic reviews have highlighted the potential benefits of multimodal physical therapy and have documented an increasing body of evidence for CAM approaches in endometriosis-related pelvic pain, although methodological quality and standardization vary considerably. Psychotherapeutic interventions such as somatocognitive therapy and mindfulness-based stress reduction (MBSR) have also demonstrated improvements in pain, psychological distress, and motor functioning when integrated with standard gynecologic care (12,14–18). In Turkey, the Ministry of Health formalized the regulatory framework for the use of traditional and complementary medicine (GETAT) in 2014, covering acupuncture, cupping, leech therapy, phytotherapy, hypnosis, chiropractic treatment, music therapy, osteopathy, ozone therapy, reflexology, and other modalities. Despite this progress, recent evaluations emphasize the need to strengthen practice standards and evidence-based guidance (19–21). Given their low risk profile and cost-effectiveness, these approaches are often recommended as first-line conservative options. However, the availability of high-quality, population-specific evidence to guide non-pharmacological management of CPP remains limited, and clinicians still face challenges in selecting the most appropriate interventions (22). Understanding the prevalence, determinants, and clinical implications of CAM use among women with CPP—particularly in relation to quality of life and psychological well-being—is thus of significant importance. To date, no study in Turkey has simultaneously examined quality of life, depressive symptoms, and CAM utilisation in women experiencing CPP. This study therefore aimed to (i) assess quality of life and depression levels, (ii) determine the prevalence and patterns of CAM use, and (iii) evaluate the relationships between CAM utilisation, quality of life, and depression among women living with CPP. Generating such context-specific evidence may inform the development of holistic and culturally responsive models of CPP care in Turkey and contribute to international understanding of CPP management. Methods Study design This cross-sectional study was conducted between September 2024 and December 2024 in a university hospital located in the Marmara region of Turkey. The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (see Supplementary Table 1). Sample The study population consisted of women diagnosed with chronic pelvic pain (CPP) and followed in the Obstetrics and Gynecology outpatient clinic of a university hospital in the Marmara region of Turkey. The sample size was calculated using a 95% confidence interval, 5% margin of error, and an estimated CPP prevalence of 12%, yielding a minimum required sample of 250 participants (23). A probabilistic random sampling method was used. Women were eligible if they: were aged 18–49 years, had experienced CPP for at least 3 months, had no underlying defined pathology or known chronic disease (e.g., cancer, infection), and had no diagnosed psychiatric disorder or ongoing psychiatric treatment. Women who agreed to participate and met the inclusion criteria were enrolled. Data collection Data were collected through face-to-face interviews using a Descriptive Information Form, the Beck Depression Inventory (BDI), and the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). Eligible participants were informed about the purpose and procedures of the study, and written informed consent was obtained prior to data collection. The Descriptive Information Form included questions regarding sociodemographic characteristics, CPP-related features, and the use of complementary and alternative medicine (CAM) for pain management. The BDI was developed by Beck et al. in 1961 and measures the severity of depressive symptoms (24). It contains 21 self-report items scored on a 4-point Likert scale (0–3), yielding a total score of 0–63, with higher scores indicating more severe depressive symptoms. In the present study, the Cronbach’s alpha coefficient for the BDI was 0.91. WHOQOL-BREF was developed by the World Health Organization Quality of Life Group in 1998 and consists of 26 items covering four domains: physical health, psychological health, social relationships, and environment (25). Items are rated on a 5-point Likert scale, with higher scores indicating better perceived quality of life. The Turkish validity and reliability study of the scale was conducted by Eser et al. (26). Statistical analysis Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive statistics (frequency, percentage, mean, standard deviation) were used to summarize the data. Normality of continuous variables was assessed using the Shapiro–Wilk test and by evaluating skewness and kurtosis values within the acceptable range of ±1.5. Pearson correlation analysis was used to examine relationships between continuous variables. Logistic regression analysis was applied to variables significantly associated with WHOQOL-BREF scores to determine predictive effects. A p-value of <0.05 was considered statistically significant. Ethical considerations Ethical approval was obtained from the Ethics Committee of Balikesir University (date: 06.08.2024; approval number: 2024/127) and from the administration of the hospital where the study was conducted. The study adhered to the principles of the Declaration of Helsinki. All participants voluntarily agreed to participate. They were informed about the study aims and procedures, and written informed consent was obtained. Participant confidentiality and anonymity were strictly maintained throughout the study. Results The mean age of the participants was 35.12 ± 2.14 years, and 85% had completed high school or higher education. More than half of the women were employed (62.4%), and 21.6% reported having at least one chronic medical condition. The women had been experiencing chronic pelvic pain (CPP) for an average of 2.15 ± 0.25 years. A history of gynecologic surgery was present in 17.6% of the participants, while 18.8% reported a history of abdominal surgery unrelated to gynecology. Regarding healthcare utilization, 34.8% of the women had previously sought treatment for their pain, whereas 28.0% had used non-pharmacological or non-surgical methods to relieve their symptoms. When the etiologies of CPP were examined, uterine (49.6%) and extra-uterine gynecologic (40.0%) causes were identified as the most common origins of pain. Urologic and musculoskeletal etiologies were reported at equal rates (37.2% each). In terms of conservative and complementary approaches used for pain management, the most frequently adopted methods were exercise (61.2%) and massage (50.4%). Acupuncture (38.0%), psychotherapy (36.0%), and sleep regulation (42.4%) were moderately used. Neural therapy (20.8%) and disturbance field elimination (23.2%) were the least known and least utilized methods among the participants (Table 1). The mean Beck Depression Inventory (BDI) score of the participants was 13.67 ± 9.94. The mean total score of the WHOQOL-BREF was 3.26 ± 0.46. Among the subdomains, the mean physical health score was 3.17 ± 0.50, the psychological health score was 3.30 ± 0.52, the social relationships score was 3.45 ± 0.78, and the environmental domain score was 3.27 ± 0.64 (Table 2). According to the analysis results, the Beck Depression Inventory (BDI) scores showed generally low-level correlations with the examined variables. A weak negative significant correlation was found between depressive symptoms and musculoskeletal-origin pain (r = –0.141, p < 0.05). In addition, the use of TENS (r = –0.130, p < 0.05) and massage therapy (r = –0.166, p < 0.01) was also weakly and negatively associated with BDI scores. No statistically significant correlations were observed between depressive symptoms and the remaining variables. These findings suggest that musculoskeletal pain etiologies and certain treatment methods may be weakly related to depression levels among women with chronic pelvic pain (Table 3). According to the analysis results, a weak but significant positive correlation was found between WHOQOL-BREF scores and uterine gynecologic pain etiologies (r = 0.159, p < 0.05). In addition, knowledge of acupuncture was weakly and positively associated with quality-of-life scores (r = 0.125, p < 0.05). No statistically significant relationships were identified between WHOQOL-BREF scores and the remaining variables. These findings suggest that uterine gynecologic pain origins and knowledge of acupuncture may be weakly related to perceived quality of life among women with chronic pelvic pain (Table 4) Examination of the analysis results revealed negative correlations between Beck Depression Inventory (BDI) scores and all subdomains of the WHOQOL-BREF. A weak negative correlation was found between depressive symptoms and the physical health subdomain (r = –0.159, p < 0.05), while moderate negative correlations were identified with the psychological (r = –0.321, p < 0.01), social (r = –0.341, p < 0.01), and environmental (r = –0.359, p < 0.01) subdomains. A moderate negative correlation was also observed between overall WHOQOL-BREF total scores and depressive symptoms (r = –0.388, p < 0.01). These findings indicate that higher levels of depression are associated with lower perceived quality of life across all domains (Table 5). According to the logistic regression analysis, WHOQOL-BREF scores significantly predicted uterine gynecologic pain etiologies, demonstrating a positive effect within the model (B = 0.714, SE = 0.288, Wald = 6.141, p = 0.013). This indicates that an increase in quality-of-life scores is associated with approximately a 2.04-fold higher likelihood of having a uterine-origin pain etiology (Exp(B) = 2.043). No significant predictive effects of WHOQOL-BREF scores were found for urologic, musculoskeletal, or gastrointestinal pain etiologies (Table 6). Discussion This study presents a comprehensive evaluation of chronic pelvic pain (CPP) in Turkish women by simultaneously examining pain etiology, depressive symptoms, quality of life, and the use of complementary and conservative treatment strategies. This multidimensional approach offers a novel contribution to the current literature, as previous studies have typically focused on only one or two of these domains. Approximately one-fifth of the participants in our study reported a history of gynecologic or nongynecologic abdominal surgery, suggesting a potential association between CPP and prior surgical procedures. In a study comparing refugee and local women in Türkiye, the prevalence of CPP was 41% among refugee women and 19.1% among local women, with multiparity, previous pelvic surgery, and psychosocial stressors identified as factors increasing the risk of CPP (7). Similarly, Nygaard et al. (2019) found that 71% of women presenting to a multidisciplinary pain center with CPP had undergone previous pelvic or abdominal surgery (27). Given that our population more closely reflects a community-based or secondary care setting, a lower surgical burden may be expected. Nonetheless, the substantial presence of surgical history in women with CPP highlights the importance of addressing pain and adhesion management, particularly among those with prior pelvic surgery. The distribution of pain etiologies in our cohort differs from several population-based and multidisciplinary studies, in which gynecologic conditions typically account for a smaller proportion—approximately 20% of CPP cases—while gastrointestinal, urologic, and musculoskeletal disorders constitute a substantial share of the etiologic spectrum (28). Epidemiological reviews emphasize the multifactorial nature of CPP, underscoring the high prevalence of bowel disorders (particularly irritable bowel syndrome), bladder pain syndrome, and pelvic floor or musculoskeletal dysfunction, which often exceed the proportion attributed to gynecologic causes. The comparatively high rate of gynecologic etiologies (combined 90%) in our study likely reflects the characteristics of our clinical sample, which comprised women presenting to a gynecology outpatient clinic and therefore represents a more selectively gynecologic subgroup. At the same time, the relatively notable prevalence of urologic and musculoskeletal causes reinforces the well-documented concept that CPP frequently arises from overlapping multisystem pathologies rather than a single isolated cause. Collectively, these findings support the multidimensional nature of CPP and indicate that both gynecologic and non-gynecologic systems contribute substantially to symptom presentation in Turkish women. In our sample, 34.8% of women with CPP reported having previously received treatment for their pain, and 28.0% had used at least one non-pharmacological, non-surgical modality. The most commonly reported strategies were exercise (61.2%) and massage (50.4%), followed by sleep regulation (42.4%), acupuncture (38.0%), and psychotherapy (36.0%). More specialized approaches such as neural therapy (20.8%) and “disturbance field” elimination (23.2%) were the least well-known and least used. Previous studies have reported the use of conservative methods such as pelvic floor muscle training, manual therapy, acupuncture, and electrotherapy for CPP; however, methodological limitations and heterogeneity across studies preclude definitive conclusions (27–30). Our findings are broadly comparable to international reports indicating that approximately half of women with CPP use at least one complementary health approach annually, including 38.3% who use physical exercise and 8.2% acupuncture in the cohort described by Chao et al. (15). Similarly, Armour et al. found that 42% of Australian women with endometriosis used exercise and 32% used massage within the previous six months, along with other self-management strategies such as stretching, yoga/Pilates, and meditation (29). The higher rates of exercise and massage use in our study, as well as the notably greater prevalence of acupuncture and psychotherapy, may reflect cultural factors, variations in healthcare accessibility, and our broader definition of complementary and alternative medicine, which included both professionally delivered and self-directed modalities. The relatively high use of neural therapy and disturbance field elimination—approaches rarely reported in international CPP literature—suggests that our study adds novel insight into locally relevant complementary practices within a Turkish population. CPP is not solely a physiological condition; it also encompasses emotional, psychological, and cognitive components that may contribute to emotional distress. Increasing evidence indicates that women with CPP frequently experience psychological burden and depressive symptoms (5,6,7,9–12,29,31,32). Our findings are consistent with this literature, although we identified a modest negative association between depressive symptoms and musculoskeletal etiologies (r = –.141). While CPP and depression are often positively associated, recent studies emphasize that psychosocial impacts may vary depending on the underlying pain source. For example, Magariños-López et al. (2022) suggested that musculoskeletal-based components of CPP may confer a lower emotional burden, and women with pelvic floor dysfunction or other musculoskeletal etiologies may exhibit lower depressive symptom levels compared with those experiencing gynecologic or visceral pain (33). Similarly, Siqueira-Campos et al. (2022) proposed that musculoskeletal pain may be more manageable and responsive to treatment, potentially reducing psychological burden (5). Studies conducted in Türkiye have also reported that the etiology of CPP may influence depressive symptomatology (7). These findings suggest that women experiencing musculoskeletal-based pain may be relatively protected from depressive symptoms due to factors such as greater awareness, mobility, or active engagement in treatment. The modest negative associations between depression and the use of massage (r = –.166, p < .01) and TENS (r = –.130, p < .05) observed in this study indicate potential psychological benefits of non-pharmacological treatments. Malik et al. (2022) reported that women with CPP frequently utilize modalities such as massage, pelvic floor physiotherapy, and manual therapy, and that these approaches reduce not only pain but also stress and emotional burden (30). Wang et al. (2022) similarly demonstrated that physical modalities such as TENS and manual therapy may alleviate both pain severity and depressive symptoms in women with CPP (17). Mongiovi et al. (2024) emphasized the beneficial effects of massage, heat therapy, and relaxation techniques on emotional stress associated with CPP (34). Thus, our finding that massage and TENS use were inversely associated with depression aligns with existing evidence suggesting that non-pharmacological approaches may enhance psychological well-being. The absence of significant associations between depression and other complementary methods in our study is consistent with the heterogeneous findings reported in the literature. Recent systematic reviews highlight that the effects of complementary therapies on pain and depression vary depending on the specific modality, frequency of use, and individual preferences (35). The effectiveness of acupuncture and psychotherapy, for example, may depend on contextual factors, practitioner competence, and patients’ openness to treatment. Therefore, the selective associations observed in our study may reflect the complex and multidimensional nature of complementary therapy use in women with CPP. Women with CPP in our study exhibited reduced quality of life across all domains, although social domain scores were relatively higher. Consistent with this, Demirtaş et al. found that refugee and non-refugee women with CPP in Türkiye scored lower on all domains of the WHOQOL-BREF compared with women without pain. The WHOQOL-BREF is widely used in chronic pain populations, including those with CPP, and psychological functioning is frequently reported as the most impaired domain (36). Our findings align with national and international literature, demonstrating that CPP imposes substantial physical, psychological, social, and environmental burden on women’s health and daily functioning. A modest positive association between gynecologic uterine-based pain etiologies and quality of life (r = .159) in our study suggests that pain etiology may differentially influence perceived quality of life. Recent literature emphasizes that while CPP generally reduces quality of life, the degree of impairment may vary according to etiology. For example, Demirtaş et al. (2024) reported that women with identifiable gynecologic pathologies may have higher quality-of-life scores than those with unclear or complex etiologies, potentially due to greater diagnostic clarity and healthcare access (7). Magariños-López et al. (2022) similarly observed that women with uterine-based pelvic pain may report lower uncertainty and better quality-of-life outcomes in certain domains (33). Research conducted over the past five years on conditions such as endometriosis, adenomyosis, and uterine fibroids indicates that diagnostic confirmation and improved access to treatment may contribute to psychosocial improvement (37). The positive association observed in our study may therefore reflect enhanced awareness, strengthened coping strategies, and more frequent interaction with healthcare professionals among women with uterine-based pathologies. A modest positive association between acupuncture knowledge and quality of life (r = .125) suggests that knowledge about acupuncture—independent of its use—may be associated with women’s perceptions of their health and well-being. The literature indicates that greater awareness of complementary therapies may enhance perceived health, self-efficacy, coping skills, and quality of life. Malik et al. (2022) reported that women with CPP who were more aware of complementary therapies felt a greater sense of control over their pain and demonstrated higher health-related quality-of-life scores (30). Mongiovi et al. (2024) also highlighted that knowledge of acupuncture and related therapies may diversify coping strategies, thereby improving quality-of-life outcomes (34). Wang et al. (2022) noted that even knowledge about acupuncture may support psychological well-being, independent of treatment uptake (17). Thus, the association observed in our study may reflect the positive influence of health-related awareness on women’s perceptions of quality of life. Overall, the findings suggest that variables such as uterine-based pain etiologies and acupuncture knowledge are associated with quality of life, highlighting that CPP is shaped not only by biological factors but also by diagnostic clarity, treatment awareness, and psychosocial processes. In our study, depressive symptoms were negatively associated with all quality-of-life domains, including physical, psychological, social, and environmental functioning. This indicates that the psychosocial burden of CPP is extensive. Magariños-López et al. (2022) similarly reported that depressive and anxiety symptoms adversely affect all quality-of-life domains in women with CPP, underscoring the central role of psychological factors in pain management (33). Demirtaş et al. (2024) likewise found that CPP substantially reduced physical, social, and environmental functioning in Turkish women, suggesting that depression may act as a mediating factor (7). Siqueira-Campos et al. (2022) reported that CPP significantly impacts social participation, daily activities, functionality, and environmental adaptation, with greater impairment in the presence of psychological distress (5). These findings align with our study, in which depression was more strongly associated with social and environmental quality-of-life domains. Mongiovi et al. (2024) also demonstrated that depression exacerbates the social consequences of CPP, including interpersonal relationships, employment challenges, and community engagement (34). The reciprocal relationship between depression and quality of life is well-documented: chronic pain may trigger depressive symptoms, whereas depression negatively affects pain perception, coping behaviors, and treatment adherence. Wang et al. (2022) noted that depression may increase pain severity and hinder pain control, indirectly worsening quality of life (17). Our results support the existing evidence that depression should be a primary clinical target in the management of CPP. Finally, our logistic regression findings demonstrated that higher quality-of-life scores significantly predicted uterine-based pain etiologies, doubling the likelihood of having a uterine source of pain. Demirtaş et al. (2024) reported that women with gynecologic pathologies in Türkiye had higher rates of healthcare access and diagnostic confirmation, which may contribute to better quality-of-life outcomes (7). Our findings similarly suggest that enhanced diagnostic clarity, greater access to treatment, and more frequent contact with healthcare systems may explain this association. Magariños-López et al. (2022) likewise emphasized that different etiologies of CPP are characterized by distinct psychological and quality-of-life profiles, with diagnosed gynecologic conditions associated with reduced uncertainty and relatively better quality-of-life outcomes (33). Accordingly, our findings are consistent with descriptive patterns reported in the literature. Quality of life did not predict urologic, musculoskeletal, or gastrointestinal pain etiologies in our study. Given the multidisciplinary nature of CPP, this result is not unexpected, as these etiologies often involve diagnostic complexity, multisystem interactions, and variable access to treatment, limiting the direct association between etiology and quality of life. Siqueira-Campos et al. (2022) noted that the impact of CPP etiologies on quality of life differs depending on diagnostic clarity and treatment response, with musculoskeletal and urologic etiologies often characterized by greater uncertainty (5). Wang et al. (2022) similarly reported that quality of life in women with non-gynecologic CPP was more strongly related to pain severity, treatment duration, and psychological well-being rather than etiology (17). Our findings collectively suggest that quality-of-life assessments may contribute valuable insights in evaluating the biopsychosocial dimensions of CPP, particularly among women with uterine-based pain etiologies, in whom quality-of-life scores appeared to be meaningful predictors. Conclusion In this study of Turkish women living with chronic pelvic pain (CPP), uterine and non-uterine gynecologic conditions emerged as the most common etiologies, followed by urologic and musculoskeletal origins. Participants had been experiencing pain for an average of two years; however, only one-third had previously sought treatment, and fewer than one-third had used any non-pharmacological or non-surgical modality. This indicates a potential gap in care and suggests substantial unmet healthcare needs among women with CPP. Exercise and massage were the most frequently adopted conservative strategies, while acupuncture, psychotherapy, and sleep regulation showed moderate levels of use. Less familiar approaches, such as neural therapy and disturbance-field elimination, were used by a smaller subgroup of women. These findings highlight a widespread reliance on complementary and alternative strategies and underscore the importance of understanding patient-driven coping mechanisms in CPP management. Depressive symptoms were prevalent at mild to moderate levels and demonstrated significant negative associations with all quality-of-life domains, particularly psychological, social, and environmental functioning. These results emphasize the considerable psychosocial burden associated with CPP. Logistic regression analyses further revealed that higher quality-of-life scores significantly predicted the likelihood of reporting uterine-based pain, whereas no such associations were found for urologic, musculoskeletal, or gastrointestinal etiologies. Collectively, these findings support the necessity of a multidisciplinary (gynecology, urology, physiotherapy, psychiatry/psychology) and multimodal (pharmacological, surgical, complementary and integrative therapies, and lifestyle interventions) approach to CPP. The results underscore the importance of holistic care models that incorporate psychological assessment, patient education, and evidence-based conservative therapies alongside conventional medical management. Strengths and Limitations This study provides one of the most comprehensive evaluations to date of chronic pelvic pain (CPP) among women in Türkiye, simultaneously examining pain etiology, depressive symptoms, quality of life, and the use of complementary and conservative treatment strategies. By assessing both the utilization and the awareness of complementary and alternative therapies (CAT), the study offers a novel contribution to the global CPP literature. In particular, it documents less commonly investigated practices—such as neural therapy and disturbance-field elimination—which are rarely quantified in international research and therefore add meaningful contextual insight. Several limitations should be acknowledged. The cross-sectional design precludes causal inferences regarding the relationships among depression, quality of life, and pain etiology. Self-reported data on CAT use and knowledge may be subject to recall bias or social desirability bias. Additionally, conservative and CAT approaches were not differentiated in terms of frequency, duration, or level of professional guidance, limiting the interpretation of treatment intensity and exposure. Future prospective and multicenter studies are needed to confirm and further elaborate on these findings. Declarations Acknowledgements The authors thank the nurse managers who participated in this study fortheir valuable time, insights, and contributions. Conflict of Interest The authors declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article Funding No funding. Author Contributions S.A and M.I.T. designed the study, and S.A. and OPBA provided the data. S.A conducted data analyses and prepared tables. S.A and M.I.T. edited the manuscript and provided valuable comments. All authors wrote the mainmanuscript text and reviewed and approved the manuscript. Data Availability Statement The data that support the findings of this study are available on requestfrom the corresponding author. The data are not publicly available due toprivacy or ethical restrictions Ethics Statement Permission for the research was obtained from the Balikesir University Ethics Committee (date: 06.08.2024; approval number: 2024/127) and the Chief Physician of the hospital where the research was conducted. The study was carried out in accordance with the principles of the Declaration of Helsinki. References American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Chronic pelvic pain: ACOG Practice Bulletin No. 218. Obstet Gynecol. 2020;135:e98–e109. Merskey H, Bogduk N, editors. Classification of pelvic pain. In: IASP Task Force on Taxonomy. 2nd ed. Seattle (WA): IASP Press; 1994. p. 209–14. Pinto L, Soutinho M, Coutinho Fernandes M, Táboas MI, Leal J, Tomé S, et al. Chronic primary pelvic pain syndromes in women: a comprehensive review. Cureus. 2024;16(12):e74918. doi:10.7759/cureus.74918 Peinado-Molina RA, Hernández-Martínez A, Martínez-Vázquez S, Rodríguez-Almagro J, Martínez-Galiano JM. Pelvic floor dysfunction: prevalence and associated factors. BMC Public Health. 2023;23:2005. doi:10.1186/s12889-023-16901-3 Siqueira-Campos VM, de Deus MS, Poli-Neto OB, Rosa-e-Silva JC, de Deus JM, Conde DM. Current challenges in the management of chronic pelvic pain in women: from bench to bedside. Int J Womens Health. 2022;14:225–44. doi:10.2147/IJWH.S224891 Vargas-Costales JA, Rosero CYLMV, Mazin SC, et al. Prevalence of chronic pelvic pain and associated factors among indigenous women of reproductive age in Ecuador. BMC Womens Health. 2024;24:388. Demirtaş Z, Arslantaş D, Ünsal A, Çalışkan F, İnan F. Examining the risk factors of chronic pelvic pain and its effect on the quality of life in refugee and non-refugee women. BMC Womens Health. 2024;24:503. doi:10.1186/s12905-024-03348-7 Ghiasi M, Chang C, Shafrir AL, Vitonis AF, Sasamoto N, Vazquez AI, et al. Subgroups of pelvic pain are differentially associated with endometriosis and inflammatory comorbidities: a latent class analysis. Pain. 2024;165(9):2119–29. doi:10.1097/j.pain.0000000000003218 Neto JN, Brito AIC, Nogueira MB, Lira LLF, Gomes LMRS, Leal PC, Moura ECR. Prevalence of depression and anxiety in women with chronic pelvic pain: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2025;305:312–7. Peinado Molina RA, Martínez Vázquez S, Martínez Galiano JM, Rivera Izquierdo M, Khan KS, Cano-Ibáñez N. Prevalence of depression and anxiety in women with pelvic floor dysfunctions: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2024;167(2):507–28. doi:10.1002/ijgo.15719 Aaron RV, Ravyts SG, Carnahan ND, et al. Prevalence of depression and anxiety among adults with chronic pain: a systematic review and meta-analysis. JAMA Netw Open. 2025;8(3):e250268. doi:10.1001/jamanetworkopen.2025.0268 Starzec-Proserpio M, Frawley H, Bø K, Morin M. Effectiveness of non-pharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;232(1):42–71. doi:10.1016/j.ajog.2024.08.006 Mardon AK, Leake HB, Szeto K, et al. Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines. BJOG. 2022;129:1248–60. Ghai V, Subramanian V, Jan H, Loganathan J, Doumouchtsis SK. Evaluation of clinical practice guidelines for the management of female chronic pelvic pain using the AGREE II instrument. Int Urogynecol J. 2021;32:2899–912. Chao MT, Abercrombie PD, Nakagawa S, et al. Prevalence and use of complementary health approaches among women with chronic pelvic pain: a prospective cohort study. Pain Med. 2015;16:328–40. Mazur-Bialy A, Tim S, Pępek A, et al. Holistic approaches in endometriosis as an effective method of supporting traditional treatment: a systematic search and narrative review. Reprod Sci. 2024;31:3257–74. doi:10.1007/s43032-024-01660-2 Wang X, Ding N, Sun Y, Chen Y, Shi H, Zhu L, et al. Non-pharmacological therapies for treating chronic pelvic pain in women: a review. Medicine (Baltimore). 2022;101(49):e31932. doi:10.1097/MD.0000000000031932 Li L, Lou K, Chu A, O’Brien E, Molina A, Riley K. Complementary therapy for endometriosis-related pelvic pain. J Endometr Pelvic Pain Disord. 2023;15(1):34–43. Durmaz A, Gun Kakasci C. Pregnant women’s attitudes towards complementary and alternative medicine and the use of phytotherapy during the COVID-19 pandemic: a cross-sectional study. PLoS One. 2024;19(1):e0296435. doi:10.1371/journal.pone.0296435 Akalın B, İrban A, Özargun G. Türkiye’de geleneksel ve tamamlayıcı tıp uygulamalarının mevcut standartları ve iyileştirme önerileri. Sağlık Proj Arş Derg. 2023;5(1):49–69. doi:10.57224/jhpr.1230794 Yorgancı A, Öztürk UK, Evliyaoğlu Bozkurt Ö, Akyol M, Pay RE, Engin-Ustun Y. Complementary and alternative medicine attitudes of gynecologic patients: experience in a tertiary clinic. Rev Bras Ginecol Obstet. 2021;43(11):853–61. doi:10.1055/s-0041-1739462 Nicklas L, Albiston M, Dunbar M, et al. A systematic review of economic analyses of psychological interventions and therapies in health-related settings. BMC Health Serv Res. 2022;22:1131. Özdemir K, Özerdoğan N, Ünsal A. Assessment of chronic pelvic pain and quality of life among women of childbearing age. Osmangazi J Med. 2015;37(3):13–22. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71. Ohaeri JU, Awadalla AW. The reliability and validity of the short version of the WHO Quality of Life instrument in an Arab general population. Ann Saudi Med. 2009;29(2):98–104. doi:10.4103/0256-4947.51790 Eser E, Fidaner H, Fidaner C, Eser SY, Elbi H, Göker E. WHOQOL-100 ve WHOQOL-BREF’in psikometrik özellikleri. 3P Derg. 1999;7(Suppl 2):23–40. Nygaard A, Stedenfeldt M, Øian P, Haugstad GK. Characteristics of women with chronic pelvic pain referred to physiotherapy after multidisciplinary assessment: a cross-sectional study. Scand J Pain. 2019;19(2):355–64. doi:10.1515/sjpain-2018-0308 Dydyk AM, Singh C, Gupta N. Chronic pelvic pain. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554585/ Armour M, Sinclair J, Chalmers KJ, et al. Self-management strategies among Australian women with endometriosis: a national online survey. BMC Complement Altern Med. 2019;19:17. Malik A, Sinclair J, Ng CHM, et al. Allied health and complementary therapy usage in Australian women with chronic pelvic pain: a cross-sectional study. BMC Womens Health. 2022;22:37. Özcan H, Çuvadar A, Uzun S. The effect of psychotherapeutic interventions on pain and quality of life in endometriosis: a systematic review and meta-analysis. Ir J Med Sci. 2025;194:1391–400. Klotz SGR, Kolbe C, Rueß M, Brünahl CA. The role of psychosocial factors in the interprofessional management of women with chronic pelvic pain: a systematic review. Acta Obstet Gynecol Scand. 2024;103(2):199–209. Magariños-López M, et al. Psychological profile in women with chronic pelvic pain. J Clin Med. 2022;11:6345. Mongiovi JM, et al. Complementary and alternative methods among women managing acyclic pelvic pain. Front Reprod Health. 2024;3:1140857. Aydin T, et al. Non-pharmacological interventions in chronic pelvic pain: effectiveness and challenges. Womens Health Rep. 2021;3:1. Manu A, Poenaru E, Duica F, et al. Quality of life assessment and clinical implications for women with endometriosis through validated tools: a narrative review. Medicina. 2025;61:1729. González-Echevarría AM, et al. Impact of endometriosis on quality of life: updates from recent clinical evidence. Womens Health (Lond). 2021;17:1–13. Tables Table 1. Characteristics of Women with Chronic Pelvic Pain (n = 250) Characteristics N % History of Gynecologic Surgery Yes 44 17.6 No 206 82.4 History of Abdominal Surgery (Non-gynecologic) Yes 47 18.8 No 203 81.2 Previous Treatment for Pain Complaint Yes 87 34.8 No 163 65.2 Use of Non-pharmacological or Non-surgical Pain Relief Methods Yes 70 28.0 No 180 72.0 Causes of Chronic Pelvic Pain Extra-uterine gynecologic 100 40.0 Uterine gynecologic 124 49.6 Urologic 93 37.2 Musculoskeletal 93 37.2 Gastrointestinal 76 30.4 Other 86 34.4 Knowledge of Conservative / CAM Methods Neural therapy 52 20.8 Local pain therapy 63 25.2 Manual therapy 80 32.0 Acupuncture 95 38.0 Disturbance field elimination 58 23.2 Psychotherapy 90 36.0 Electrotherapy 68 27.2 TENS 75 30.0 Exercise 153 61.2 Massage 126 50.4 Hydrotherapy 83 33.2 Healthy and balanced diet 118 47.2 Breathing techniques 119 47.6 Hypnosis 74 29.6 Sleep regulation 106 42.4 Detox 75 30.0 Table 2. Mean Scores of BDI and WHOQOL-BREF Scale Min Max Mean SD Skewness Kurtosis Beck Depression Inventory 0.00 44.00 13.67 9.94 0.683 –0.281 WHOQOL-BREF Physical 1.57 4.57 3.17 0.50 –0.139 0.242 WHOQOL-BREF Psychological 1.67 4.50 3.30 0.52 –0.083 0.511 WHOQOL-BREF Social 1.67 5.00 3.45 0.78 0.121 –0.354 WHOQOL-BREF Environment 1.50 4.88 3.27 0.64 –0.121 –0.100 WHOQOL-BREF Total 2.00 4.35 3.26 0.46 –0.031 0.252 Table 3. Pearson Correlation Between BDI Scores and Study Variables Variable BDI Score (r) Gynecologic surgery history 0.113 Abdominal surgery history 0.080 Previous treatment for pain –0.012 Use of non-pharmacological methods –0.100 Pain Etiology Extra-uterine gynecologic 0.038 Uterine gynecologic –0.119 Urologic –0.045 Musculoskeletal –0.141* Gastrointestinal –0.022 Other –0.077 Knowledge of CAM / Conservative Methods Neural therapy 0.060 Local pain therapy 0.043 Manual therapy –0.003 Acupuncture –0.076 Disturbance field elimination 0.078 Psychotherapy 0.017 Electrotherapy –0.085 TENS –0.130* Exercise –0.110 Massage –0.166** Hydrotherapy –0.058 Healthy diet –0.053 Breathing techniques –0.053 Hypnosis 0.069 Sleep regulation –0.065 Detox 0.114 **p<.01 *p<.05* Table 4. Pearson Correlation Between WHOQOL-BREF and Study Variables Variable WHOQOL-BREF Total (r) Gynecologic surgery history –0.058 Abdominal surgery history –0.081 Previous treatment for pain –0.043 Use of non-pharmacological methods –0.049 Pain Etiology Extra-uterine gynecologic 0.055 Uterine gynecologic 0.159* Urologic 0.122 Musculoskeletal 0.051 Gastrointestinal 0.084 Other 0.013 Knowledge of CAM / Conservative Methods Neural therapy 0.023 Local pain therapy –0.032 Manual therapy 0.043 Acupuncture 0.125* Disturbance field elimination 0.042 Psychotherapy –0.005 Electrotherapy 0.038 TENS 0.102 Exercise 0.075 Massage 0.114 Hydrotherapy 0.007 Healthy diet 0.015 Breathing techniques –0.033 Hypnosis 0.025 Sleep regulation –0.006 Detox –0.075 **p<.01 *p<.05* Table 5. Pearson Correlation Between BDI and WHOQOL-BREF Subdomains WHOQOL-BREF Subdomain BDI Score (r) Physical health –0.159* Psychological health –0.321** Social relationships –0.341** Environmental health –0.359** WHOQOL-BREF Total –0.388** Table 6. Logistic Regression Analysis of WHOQOL-BREF Scores Predicting CPP Etiologies Dependent Variable B SE Wald df p Exp(B) Uterine gynecologic 0.714 0.288 6.141 1 0.013 2.043 Constant –2.314 0.949 5.948 1 0.015 0.099 Urologic 0.559 0.293 3.643 1 0.056 1.749 Constant –1.292 0.956 1.825 1 0.177 0.275 Musculoskeletal 0.233 0.287 0.659 1 0.417 1.263 Constant –0.236 0.943 0.062 1 0.803 0.790 Gastrointestinal 0.404 0.304 1.768 1 0.184 1.498 Constant –0.483 0.991 0.238 1 0.626 0.617 B = Beta katsayısı, SE = Standart hata, Exp(B) = Odds oranı. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 13 May, 2026 Reviewers agreed at journal 10 May, 2026 Reviewers invited by journal 16 Apr, 2026 Editor invited by journal 20 Jan, 2026 Editor assigned by journal 01 Dec, 2025 Submission checks completed at journal 01 Dec, 2025 First submitted to journal 27 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8224699","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":624470267,"identity":"20eb17eb-f67f-415d-9d67-ba59050351a3","order_by":0,"name":"SEVDE AKSU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie3RMWrDMBSA4ScMzqJkNhiiKygYSkMHX0XGoC4idAoeCqUEksVt13TKFXyEGIG7qJlVsnjqVvBUPKSlEnTI4DoZO+hfJB588JAAXK5/WgDAAAY5QE3NxbMz/xyClTmOCT5JAmEP9jvrIWSVT3Rzy2P69lE27IaPyWpYQzOXEIfbTkKViqbrSiTFfpYGjIqIygFF650EPGLdJOA8xH7G6F5QQ7Kk8HzwhktD/tiMbN55ePjOzGIqag252ywM+eohoL0qREuBCo0v7GIMpCGoh1CVyunDI0+e1YxfMsonhSFlvrvG9tW7X6y81+1nGo9eXqVuDikhTxWq2/nV2P7t+W2h/yddLpfLdaIfeA5aLEYyDw0AAAAASUVORK5CYII=","orcid":"","institution":"Balıkesir University","correspondingAuthor":true,"prefix":"","firstName":"SEVDE","middleName":"","lastName":"AKSU","suffix":""},{"id":624470268,"identity":"ddb7acca-794c-46b9-85de-3d55962227e1","order_by":1,"name":"MİNE ISLIMYE TAŞKIN","email":"","orcid":"","institution":"Balıkesir University","correspondingAuthor":false,"prefix":"","firstName":"MİNE","middleName":"ISLIMYE","lastName":"TAŞKIN","suffix":""},{"id":624470269,"identity":"8b9c2580-3df7-40eb-a4c1-e962c8d015f0","order_by":2,"name":"ONCU PINAR BAYIR ALBAYRAK","email":"","orcid":"","institution":"Balıkesir University","correspondingAuthor":false,"prefix":"","firstName":"ONCU","middleName":"PINAR BAYIR","lastName":"ALBAYRAK","suffix":""}],"badges":[],"createdAt":"2025-11-27 19:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8224699/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8224699/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107707972,"identity":"5cdfcd0b-fccb-4914-a587-869c2133a45b","added_by":"auto","created_at":"2026-04-24 09:21:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":403535,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8224699/v1/2892ee67-4fae-48e6-b302-8fec375a5cb4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRelationship Between Quality of Life, Depression and Complementary and Alternative Medicine Use in Women With Chronic Pelvic Pain: A Cross-sectional Study on the Turkish Population\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic pelvic pain (CPP) is defined as non-cyclic pain lasting at least six months and localized to the pelvis, lower abdomen, anterior abdominal wall, lumbosacral region, back, or buttocks, often leading to varying degrees of functional impairment (1). The International Association for the Study of Pain (IASP) emphasizes that CPP involves not only persistent pain but also behavioral and functional components, including poor response to medical treatment, marked disruption of physical functioning, vegetative symptoms of depression, and changes in family or social roles due to pain (2). Globally, CPP is estimated to affect 5.7% to 26.6% of women; however, approximately 60% of affected women do not receive a definitive diagnosis, and nearly 20% undergo no diagnostic evaluation despite persistent symptoms (3–5). CPP arises at the intersection of gynecologic, urologic, gastrointestinal, and neuromuscular etiologies and is strongly influenced by biopsychosocial factors. It is associated with reduced physical activity, social withdrawal, sexual dysfunction, impaired sleep quality, and substantial reductions in both physical and psychological well-being (3,6,7). Notably, the co-occurrence of depression and anxiety is highly prevalent in women with CPP, and this comorbidity is consistently linked to significantly lower quality-of-life scores (8–10). Large-scale data suggest that the prevalence of depression and anxiety in chronic pain populations may reach 40%, underscoring the need for routine mental health screening in CPP management (11). Despite its complex biopsychosocial burden, the evidence supporting non-pharmacological conservative treatments for CPP remains limited, and clinical guidelines continue to focus predominantly on medical and surgical interventions (13,14). Nevertheless, women with CPP frequently turn to complementary and alternative medicine (CAM) approaches, especially when symptoms become chronic and treatment response is limited. A prospective study indicated that more than half of women with CPP are likely to use non-pharmacological strategies (15). Recent systematic reviews have highlighted the potential benefits of multimodal physical therapy and have documented an increasing body of evidence for CAM approaches in endometriosis-related pelvic pain, although methodological quality and standardization vary considerably. Psychotherapeutic interventions such as somatocognitive therapy and mindfulness-based stress reduction (MBSR) have also demonstrated improvements in pain, psychological distress, and motor functioning when integrated with standard gynecologic care (12,14–18). In Turkey, the Ministry of Health formalized the regulatory framework for the use of traditional and complementary medicine (GETAT) in 2014, covering acupuncture, cupping, leech therapy, phytotherapy, hypnosis, chiropractic treatment, music therapy, osteopathy, ozone therapy, reflexology, and other modalities. Despite this progress, recent evaluations emphasize the need to strengthen practice standards and evidence-based guidance (19–21). Given their low risk profile and cost-effectiveness, these approaches are often recommended as first-line conservative options. However, the availability of high-quality, population-specific evidence to guide non-pharmacological management of CPP remains limited, and clinicians still face challenges in selecting the most appropriate interventions (22). Understanding the prevalence, determinants, and clinical implications of CAM use among women with CPP—particularly in relation to quality of life and psychological well-being—is thus of significant importance. To date, no study in Turkey has simultaneously examined quality of life, depressive symptoms, and CAM utilisation in women experiencing CPP. This study therefore aimed to (i) assess quality of life and depression levels, (ii) determine the prevalence and patterns of CAM use, and (iii) evaluate the relationships between CAM utilisation, quality of life, and depression among women living with CPP. Generating such context-specific evidence may inform the development of holistic and culturally responsive models of CPP care in Turkey and contribute to international understanding of CPP management.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted between September 2024 and December 2024 in a university hospital located in the Marmara region of Turkey. The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (see Supplementary Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population consisted of women diagnosed with chronic pelvic pain (CPP) and followed in the Obstetrics and Gynecology outpatient clinic of a university hospital in the Marmara region of Turkey. The sample size was calculated using a 95% confidence interval, 5% margin of error, and an estimated CPP prevalence of 12%, yielding a minimum required sample of 250 participants (23). A probabilistic random sampling method was used.\u003c/p\u003e\n\u003cp\u003eWomen were eligible if they:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ewere aged 18–49 years,\u003c/li\u003e\n \u003cli\u003ehad experienced CPP for at least 3 months,\u003c/li\u003e\n \u003cli\u003ehad no underlying defined pathology or known chronic disease (e.g., cancer, infection), and\u003c/li\u003e\n \u003cli\u003ehad no diagnosed psychiatric disorder or ongoing psychiatric treatment.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWomen who agreed to participate and met the inclusion criteria were enrolled.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through face-to-face interviews using a Descriptive Information Form, the Beck Depression Inventory (BDI), and the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). Eligible participants were informed about the purpose and procedures of the study, and written informed consent was obtained prior to data collection.\u003c/p\u003e\n\u003cp\u003eThe Descriptive Information Form included questions regarding sociodemographic characteristics, CPP-related features, and the use of complementary and alternative medicine (CAM) for pain management.\u003c/p\u003e\n\u003cp\u003eThe BDI was developed by Beck et al. in 1961 and measures the severity of depressive symptoms (24). It contains 21 self-report items scored on a 4-point Likert scale (0–3), yielding a total score of 0–63, with higher scores indicating more severe depressive symptoms. In the present study, the Cronbach’s alpha coefficient for the BDI was 0.91.\u003c/p\u003e\n\u003cp\u003eWHOQOL-BREF was developed by the World Health Organization Quality of Life Group in 1998 and consists of 26 items covering four domains: physical health, psychological health, social relationships, and environment (25). Items are rated on a 5-point Likert scale, with higher scores indicating better perceived quality of life. The Turkish validity and reliability study of the scale was conducted by Eser et al. (26).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25.0. Descriptive statistics (frequency, percentage, mean, standard deviation) were used to summarize the data. Normality of continuous variables was assessed using the Shapiro–Wilk test and by evaluating skewness and kurtosis values within the acceptable range of ±1.5. Pearson correlation analysis was used to examine relationships between continuous variables. Logistic regression analysis was applied to variables significantly associated with WHOQOL-BREF scores to determine predictive effects. A p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of Balikesir University (date: 06.08.2024; approval number: 2024/127) and from the administration of the hospital where the study was conducted. The study adhered to the principles of the Declaration of Helsinki. All participants voluntarily agreed to participate. They were informed about the study aims and procedures, and written informed consent was obtained. Participant confidentiality and anonymity were strictly maintained throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean age of the participants was 35.12 ± 2.14 years, and 85% had completed high school or higher education. More than half of the women were employed (62.4%), and 21.6% reported having at least one chronic medical condition. The women had been experiencing chronic pelvic pain (CPP) for an average of 2.15 ± 0.25 years. A history of gynecologic surgery was present in 17.6% of the participants, while 18.8% reported a history of abdominal surgery unrelated to gynecology. Regarding healthcare utilization, 34.8% of the women had previously sought treatment for their pain, whereas 28.0% had used non-pharmacological or non-surgical methods to relieve their symptoms. When the etiologies of CPP were examined, uterine (49.6%) and extra-uterine gynecologic (40.0%) causes were identified as the most common origins of pain. Urologic and musculoskeletal etiologies were reported at equal rates (37.2% each). In terms of conservative and complementary approaches used for pain management, the most frequently adopted methods were exercise (61.2%) and massage (50.4%). Acupuncture (38.0%), psychotherapy (36.0%), and sleep regulation (42.4%) were moderately used. Neural therapy (20.8%) and disturbance field elimination (23.2%) were the least known and least utilized methods among the participants (Table 1).\u003c/p\u003e\n\u003cp\u003eThe mean Beck Depression Inventory (BDI) score of the participants was 13.67 ± 9.94. The mean total score of the WHOQOL-BREF was 3.26 ± 0.46. Among the subdomains, the mean physical health score was 3.17 ± 0.50, the psychological health score was 3.30 ± 0.52, the social relationships score was 3.45 ± 0.78, and the environmental domain score was 3.27 ± 0.64 (Table 2).\u003c/p\u003e\n\u003cp\u003eAccording to the analysis results, the Beck Depression Inventory (BDI) scores showed generally low-level correlations with the examined variables. A weak negative significant correlation was found between depressive symptoms and musculoskeletal-origin pain (r = –0.141, p \u0026lt; 0.05). In addition, the use of TENS (r = –0.130, p \u0026lt; 0.05) and massage therapy (r = –0.166, p \u0026lt; 0.01) was also weakly and negatively associated with BDI scores. No statistically significant correlations were observed between depressive symptoms and the remaining variables. These findings suggest that musculoskeletal pain etiologies and certain treatment methods may be weakly related to depression levels among women with chronic pelvic pain (Table 3).\u003c/p\u003e\n\u003cp\u003eAccording to the analysis results, a weak but significant positive correlation was found between WHOQOL-BREF scores and uterine gynecologic pain etiologies (r = 0.159, p \u0026lt; 0.05). In addition, knowledge of acupuncture was weakly and positively associated with quality-of-life scores (r = 0.125, p \u0026lt; 0.05). No statistically significant relationships were identified between WHOQOL-BREF scores and the remaining variables. These findings suggest that uterine gynecologic pain origins and knowledge of acupuncture may be weakly related to perceived quality of life among women with chronic pelvic pain (Table 4)\u003c/p\u003e\n\u003cp\u003eExamination of the analysis results revealed negative correlations between Beck Depression Inventory (BDI) scores and all subdomains of the WHOQOL-BREF. A weak negative correlation was found between depressive symptoms and the physical health subdomain (r = –0.159, p \u0026lt; 0.05), while moderate negative correlations were identified with the psychological (r = –0.321, p \u0026lt; 0.01), social (r = –0.341, p \u0026lt; 0.01), and environmental (r = –0.359, p \u0026lt; 0.01) subdomains. A moderate negative correlation was also observed between overall WHOQOL-BREF total scores and depressive symptoms (r = –0.388, p \u0026lt; 0.01). These findings indicate that higher levels of depression are associated with lower perceived quality of life across all domains (Table 5).\u003c/p\u003e\n\u003cp\u003eAccording to the logistic regression analysis, WHOQOL-BREF scores significantly predicted uterine gynecologic pain etiologies, demonstrating a positive effect within the model (B = 0.714, SE = 0.288, Wald = 6.141, p = 0.013). This indicates that an increase in quality-of-life scores is associated with approximately a 2.04-fold higher likelihood of having a uterine-origin pain etiology (Exp(B) = 2.043). No significant predictive effects of WHOQOL-BREF scores were found for urologic, musculoskeletal, or gastrointestinal pain etiologies (Table 6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study presents a comprehensive evaluation of chronic pelvic pain (CPP) in Turkish women by simultaneously examining pain etiology, depressive symptoms, quality of life, and the use of complementary and conservative treatment strategies. This multidimensional approach offers a novel contribution to the current literature, as previous studies have typically focused on only one or two of these domains.\u003c/p\u003e\n\u003cp\u003eApproximately one-fifth of the participants in our study reported a history of gynecologic or nongynecologic abdominal surgery, suggesting a potential association between CPP and prior surgical procedures. In a study comparing refugee and local women in Türkiye, the prevalence of CPP was 41% among refugee women and 19.1% among local women, with multiparity, previous pelvic surgery, and psychosocial stressors identified as factors increasing the risk of CPP (7). Similarly, Nygaard et al. (2019) found that 71% of women presenting to a multidisciplinary pain center with CPP had undergone previous pelvic or abdominal surgery (27). Given that our population more closely reflects a community-based or secondary care setting, a lower surgical burden may be expected. Nonetheless, the substantial presence of surgical history in women with CPP highlights the importance of addressing pain and adhesion management, particularly among those with prior pelvic surgery.\u003c/p\u003e\n\u003cp\u003eThe distribution of pain etiologies in our cohort differs from several population-based and multidisciplinary studies, in which gynecologic conditions typically account for a smaller proportion—approximately 20% of CPP cases—while gastrointestinal, urologic, and musculoskeletal disorders constitute a substantial share of the etiologic spectrum (28). Epidemiological reviews emphasize the multifactorial nature of CPP, underscoring the high prevalence of bowel disorders (particularly irritable bowel syndrome), bladder pain syndrome, and pelvic floor or musculoskeletal dysfunction, which often exceed the proportion attributed to gynecologic causes. The comparatively high rate of gynecologic etiologies (combined 90%) in our study likely reflects the characteristics of our clinical sample, which comprised women presenting to a gynecology outpatient clinic and therefore represents a more selectively gynecologic subgroup. At the same time, the relatively notable prevalence of urologic and musculoskeletal causes reinforces the well-documented concept that CPP frequently arises from overlapping multisystem pathologies rather than a single isolated cause. Collectively, these findings support the multidimensional nature of CPP and indicate that both gynecologic and non-gynecologic systems contribute substantially to symptom presentation in Turkish women.\u003c/p\u003e\n\u003cp\u003eIn our sample, 34.8% of women with CPP reported having previously received treatment for their pain, and 28.0% had used at least one non-pharmacological, non-surgical modality. The most commonly reported strategies were exercise (61.2%) and massage (50.4%), followed by sleep regulation (42.4%), acupuncture (38.0%), and psychotherapy (36.0%). More specialized approaches such as neural therapy (20.8%) and “disturbance field” elimination (23.2%) were the least well-known and least used. Previous studies have reported the use of conservative methods such as pelvic floor muscle training, manual therapy, acupuncture, and electrotherapy for CPP; however, methodological limitations and heterogeneity across studies preclude definitive conclusions (27–30). Our findings are broadly comparable to international reports indicating that approximately half of women with CPP use at least one complementary health approach annually, including 38.3% who use physical exercise and 8.2% acupuncture in the cohort described by Chao et al. (15). Similarly, Armour et al. found that 42% of Australian women with endometriosis used exercise and 32% used massage within the previous six months, along with other self-management strategies such as stretching, yoga/Pilates, and meditation (29). The higher rates of exercise and massage use in our study, as well as the notably greater prevalence of acupuncture and psychotherapy, may reflect cultural factors, variations in healthcare accessibility, and our broader definition of complementary and alternative medicine, which included both professionally delivered and self-directed modalities. The relatively high use of neural therapy and disturbance field elimination—approaches rarely reported in international CPP literature—suggests that our study adds novel insight into locally relevant complementary practices within a Turkish population.\u003c/p\u003e\n\u003cp\u003eCPP is not solely a physiological condition; it also encompasses emotional, psychological, and cognitive components that may contribute to emotional distress. Increasing evidence indicates that women with CPP frequently experience psychological burden and depressive symptoms (5,6,7,9–12,29,31,32). Our findings are consistent with this literature, although we identified a modest negative association between depressive symptoms and musculoskeletal etiologies (r = –.141). While CPP and depression are often positively associated, recent studies emphasize that psychosocial impacts may vary depending on the underlying pain source. For example, Magariños-López et al. (2022) suggested that musculoskeletal-based components of CPP may confer a lower emotional burden, and women with pelvic floor dysfunction or other musculoskeletal etiologies may exhibit lower depressive symptom levels compared with those experiencing gynecologic or visceral pain (33). Similarly, Siqueira-Campos et al. (2022) proposed that musculoskeletal pain may be more manageable and responsive to treatment, potentially reducing psychological burden (5). Studies conducted in Türkiye have also reported that the etiology of CPP may influence depressive symptomatology (7). These findings suggest that women experiencing musculoskeletal-based pain may be relatively protected from depressive symptoms due to factors such as greater awareness, mobility, or active engagement in treatment.\u003c/p\u003e\n\u003cp\u003eThe modest negative associations between depression and the use of massage (r = –.166, p \u0026lt; .01) and TENS (r = –.130, p \u0026lt; .05) observed in this study indicate potential psychological benefits of non-pharmacological treatments. Malik et al. (2022) reported that women with CPP frequently utilize modalities such as massage, pelvic floor physiotherapy, and manual therapy, and that these approaches reduce not only pain but also stress and emotional burden (30). Wang et al. (2022) similarly demonstrated that physical modalities such as TENS and manual therapy may alleviate both pain severity and depressive symptoms in women with CPP (17). Mongiovi et al. (2024) emphasized the beneficial effects of massage, heat therapy, and relaxation techniques on emotional stress associated with CPP (34). Thus, our finding that massage and TENS use were inversely associated with depression aligns with existing evidence suggesting that non-pharmacological approaches may enhance psychological well-being. The absence of significant associations between depression and other complementary methods in our study is consistent with the heterogeneous findings reported in the literature. Recent systematic reviews highlight that the effects of complementary therapies on pain and depression vary depending on the specific modality, frequency of use, and individual preferences (35). The effectiveness of acupuncture and psychotherapy, for example, may depend on contextual factors, practitioner competence, and patients’ openness to treatment. Therefore, the selective associations observed in our study may reflect the complex and multidimensional nature of complementary therapy use in women with CPP.\u003c/p\u003e\n\u003cp\u003eWomen with CPP in our study exhibited reduced quality of life across all domains, although social domain scores were relatively higher. Consistent with this, Demirtaş et al. found that refugee and non-refugee women with CPP in Türkiye scored lower on all domains of the WHOQOL-BREF compared with women without pain. The WHOQOL-BREF is widely used in chronic pain populations, including those with CPP, and psychological functioning is frequently reported as the most impaired domain (36). Our findings align with national and international literature, demonstrating that CPP imposes substantial physical, psychological, social, and environmental burden on women’s health and daily functioning. A modest positive association between gynecologic uterine-based pain etiologies and quality of life (r = .159) in our study suggests that pain etiology may differentially influence perceived quality of life. Recent literature emphasizes that while CPP generally reduces quality of life, the degree of impairment may vary according to etiology. For example, Demirtaş et al. (2024) reported that women with identifiable gynecologic pathologies may have higher quality-of-life scores than those with unclear or complex etiologies, potentially due to greater diagnostic clarity and healthcare access (7). Magariños-López et al. (2022) similarly observed that women with uterine-based pelvic pain may report lower uncertainty and better quality-of-life outcomes in certain domains (33). Research conducted over the past five years on conditions such as endometriosis, adenomyosis, and uterine fibroids indicates that diagnostic confirmation and improved access to treatment may contribute to psychosocial improvement (37). The positive association observed in our study may therefore reflect enhanced awareness, strengthened coping strategies, and more frequent interaction with healthcare professionals among women with uterine-based pathologies.\u003c/p\u003e\n\u003cp\u003eA modest positive association between acupuncture knowledge and quality of life (r = .125) suggests that knowledge about acupuncture—independent of its use—may be associated with women’s perceptions of their health and well-being. The literature indicates that greater awareness of complementary therapies may enhance perceived health, self-efficacy, coping skills, and quality of life. Malik et al. (2022) reported that women with CPP who were more aware of complementary therapies felt a greater sense of control over their pain and demonstrated higher health-related quality-of-life scores (30). Mongiovi et al. (2024) also highlighted that knowledge of acupuncture and related therapies may diversify coping strategies, thereby improving quality-of-life outcomes (34). Wang et al. (2022) noted that even knowledge about acupuncture may support psychological well-being, independent of treatment uptake (17). Thus, the association observed in our study may reflect the positive influence of health-related awareness on women’s perceptions of quality of life. Overall, the findings suggest that variables such as uterine-based pain etiologies and acupuncture knowledge are associated with quality of life, highlighting that CPP is shaped not only by biological factors but also by diagnostic clarity, treatment awareness, and psychosocial processes.\u003c/p\u003e\n\u003cp\u003eIn our study, depressive symptoms were negatively associated with all quality-of-life domains, including physical, psychological, social, and environmental functioning. This indicates that the psychosocial burden of CPP is extensive. Magariños-López et al. (2022) similarly reported that depressive and anxiety symptoms adversely affect all quality-of-life domains in women with CPP, underscoring the central role of psychological factors in pain management (33). Demirtaş et al. (2024) likewise found that CPP substantially reduced physical, social, and environmental functioning in Turkish women, suggesting that depression may act as a mediating factor (7). Siqueira-Campos et al. (2022) reported that CPP significantly impacts social participation, daily activities, functionality, and environmental adaptation, with greater impairment in the presence of psychological distress (5). These findings align with our study, in which depression was more strongly associated with social and environmental quality-of-life domains. Mongiovi et al. (2024) also demonstrated that depression exacerbates the social consequences of CPP, including interpersonal relationships, employment challenges, and community engagement (34). The reciprocal relationship between depression and quality of life is well-documented: chronic pain may trigger depressive symptoms, whereas depression negatively affects pain perception, coping behaviors, and treatment adherence. Wang et al. (2022) noted that depression may increase pain severity and hinder pain control, indirectly worsening quality of life (17). Our results support the existing evidence that depression should be a primary clinical target in the management of CPP.\u003c/p\u003e\n\u003cp\u003eFinally, our logistic regression findings demonstrated that higher quality-of-life scores significantly predicted uterine-based pain etiologies, doubling the likelihood of having a uterine source of pain. Demirtaş et al. (2024) reported that women with gynecologic pathologies in Türkiye had higher rates of healthcare access and diagnostic confirmation, which may contribute to better quality-of-life outcomes (7). Our findings similarly suggest that enhanced diagnostic clarity, greater access to treatment, and more frequent contact with healthcare systems may explain this association. Magariños-López et al. (2022) likewise emphasized that different etiologies of CPP are characterized by distinct psychological and quality-of-life profiles, with diagnosed gynecologic conditions associated with reduced uncertainty and relatively better quality-of-life outcomes (33). Accordingly, our findings are consistent with descriptive patterns reported in the literature.\u003c/p\u003e\n\u003cp\u003eQuality of life did not predict urologic, musculoskeletal, or gastrointestinal pain etiologies in our study. Given the multidisciplinary nature of CPP, this result is not unexpected, as these etiologies often involve diagnostic complexity, multisystem interactions, and variable access to treatment, limiting the direct association between etiology and quality of life. Siqueira-Campos et al. (2022) noted that the impact of CPP etiologies on quality of life differs depending on diagnostic clarity and treatment response, with musculoskeletal and urologic etiologies often characterized by greater uncertainty (5). Wang et al. (2022) similarly reported that quality of life in women with non-gynecologic CPP was more strongly related to pain severity, treatment duration, and psychological well-being rather than etiology (17). Our findings collectively suggest that quality-of-life assessments may contribute valuable insights in evaluating the biopsychosocial dimensions of CPP, particularly among women with uterine-based pain etiologies, in whom quality-of-life scores appeared to be meaningful predictors.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study of Turkish women living with chronic pelvic pain (CPP), uterine and non-uterine gynecologic conditions emerged as the most common etiologies, followed by urologic and musculoskeletal origins. Participants had been experiencing pain for an average of two years; however, only one-third had previously sought treatment, and fewer than one-third had used any non-pharmacological or non-surgical modality. This indicates a potential gap in care and suggests substantial unmet healthcare needs among women with CPP. Exercise and massage were the most frequently adopted conservative strategies, while acupuncture, psychotherapy, and sleep regulation showed moderate levels of use. Less familiar approaches, such as neural therapy and disturbance-field elimination, were used by a smaller subgroup of women. These findings highlight a widespread reliance on complementary and alternative strategies and underscore the importance of understanding patient-driven coping mechanisms in CPP management. Depressive symptoms were prevalent at mild to moderate levels and demonstrated significant negative associations with all quality-of-life domains, particularly psychological, social, and environmental functioning. These results emphasize the considerable psychosocial burden associated with CPP. Logistic regression analyses further revealed that higher quality-of-life scores significantly predicted the likelihood of reporting uterine-based pain, whereas no such associations were found for urologic, musculoskeletal, or gastrointestinal etiologies. Collectively, these findings support the necessity of a multidisciplinary (gynecology, urology, physiotherapy, psychiatry/psychology) and multimodal (pharmacological, surgical, complementary and integrative therapies, and lifestyle interventions) approach to CPP. The results underscore the importance of holistic care models that incorporate psychological assessment, patient education, and evidence-based conservative therapies alongside conventional medical management.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003eThis study provides one of the most comprehensive evaluations to date of chronic pelvic pain (CPP) among women in Türkiye, simultaneously examining pain etiology, depressive symptoms, quality of life, and the use of complementary and conservative treatment strategies. By assessing both the utilization and the awareness of complementary and alternative therapies (CAT), the study offers a novel contribution to the global CPP literature. In particular, it documents less commonly investigated practices—such as neural therapy and disturbance-field elimination—which are rarely quantified in international research and therefore add meaningful contextual insight.\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be acknowledged. The cross-sectional design precludes causal inferences regarding the relationships among depression, quality of life, and pain etiology. Self-reported data on CAT use and knowledge may be subject to recall bias or social desirability bias. Additionally, conservative and CAT approaches were not differentiated in terms of frequency, duration, or level of professional guidance, limiting the interpretation of treatment intensity and exposure. Future prospective and multicenter studies are needed to confirm and further elaborate on these findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the nurse managers who participated in this study fortheir valuable time, insights, and contributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.A and M.I.T. designed the study, and S.A. and OPBA provided the data. S.A conducted data analyses and prepared tables. S.A and M.I.T. edited the manuscript and provided valuable comments. All authors wrote the mainmanuscript text and reviewed and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on requestfrom the corresponding author. The data are not publicly available due toprivacy or ethical restrictions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePermission for the research was obtained from the Balikesir University Ethics Committee \u0026nbsp;(date: 06.08.2024; approval number: 2024/127) and the Chief Physician of the hospital where the research was conducted. The study was carried out in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists\u0026rsquo; Committee on Practice Bulletins\u0026ndash;Gynecology. Chronic pelvic pain: ACOG Practice Bulletin No. 218. Obstet Gynecol. 2020;135:e98\u0026ndash;e109.\u003c/li\u003e\n\u003cli\u003eMerskey H, Bogduk N, editors. Classification of pelvic pain. In: IASP Task Force on Taxonomy. 2nd ed. Seattle (WA): IASP Press; 1994. p. 209\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003ePinto L, Soutinho M, Coutinho Fernandes M, T\u0026aacute;boas MI, Leal J, Tom\u0026eacute; S, et al. Chronic primary pelvic pain syndromes in women: a comprehensive review. Cureus. 2024;16(12):e74918. doi:10.7759/cureus.74918\u003c/li\u003e\n\u003cli\u003ePeinado-Molina RA, Hern\u0026aacute;ndez-Mart\u0026iacute;nez A, Mart\u0026iacute;nez-V\u0026aacute;zquez S, Rodr\u0026iacute;guez-Almagro J, Mart\u0026iacute;nez-Galiano JM. Pelvic floor dysfunction: prevalence and associated factors. BMC Public Health. 2023;23:2005. doi:10.1186/s12889-023-16901-3\u003c/li\u003e\n\u003cli\u003eSiqueira-Campos VM, de Deus MS, Poli-Neto OB, Rosa-e-Silva JC, de Deus JM, Conde DM. Current challenges in the management of chronic pelvic pain in women: from bench to bedside. Int J Womens Health. 2022;14:225\u0026ndash;44. doi:10.2147/IJWH.S224891\u003c/li\u003e\n\u003cli\u003eVargas-Costales JA, Rosero CYLMV, Mazin SC, et al. Prevalence of chronic pelvic pain and associated factors among indigenous women of reproductive age in Ecuador. BMC Womens Health. 2024;24:388.\u003c/li\u003e\n\u003cli\u003eDemirtaş Z, Arslantaş D, \u0026Uuml;nsal A, \u0026Ccedil;alışkan F, İnan F. Examining the risk factors of chronic pelvic pain and its effect on the quality of life in refugee and non-refugee women. BMC Womens Health. 2024;24:503. doi:10.1186/s12905-024-03348-7\u003c/li\u003e\n\u003cli\u003eGhiasi M, Chang C, Shafrir AL, Vitonis AF, Sasamoto N, Vazquez AI, et al. Subgroups of pelvic pain are differentially associated with endometriosis and inflammatory comorbidities: a latent class analysis. Pain. 2024;165(9):2119\u0026ndash;29. doi:10.1097/j.pain.0000000000003218\u003c/li\u003e\n\u003cli\u003eNeto JN, Brito AIC, Nogueira MB, Lira LLF, Gomes LMRS, Leal PC, Moura ECR. Prevalence of depression and anxiety in women with chronic pelvic pain: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2025;305:312\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003ePeinado Molina RA, Mart\u0026iacute;nez V\u0026aacute;zquez S, Mart\u0026iacute;nez Galiano JM, Rivera Izquierdo M, Khan KS, Cano-Ib\u0026aacute;\u0026ntilde;ez N. Prevalence of depression and anxiety in women with pelvic floor dysfunctions: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2024;167(2):507\u0026ndash;28. doi:10.1002/ijgo.15719\u003c/li\u003e\n\u003cli\u003eAaron RV, Ravyts SG, Carnahan ND, et al. Prevalence of depression and anxiety among adults with chronic pain: a systematic review and meta-analysis. JAMA Netw Open. 2025;8(3):e250268. doi:10.1001/jamanetworkopen.2025.0268\u003c/li\u003e\n\u003cli\u003eStarzec-Proserpio M, Frawley H, B\u0026oslash; K, Morin M. Effectiveness of non-pharmacological conservative therapies for chronic pelvic pain in women: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;232(1):42\u0026ndash;71. doi:10.1016/j.ajog.2024.08.006\u003c/li\u003e\n\u003cli\u003eMardon AK, Leake HB, Szeto K, et al. Treatment recommendations for the management of persistent pelvic pain: a systematic review of international clinical practice guidelines. BJOG. 2022;129:1248\u0026ndash;60.\u003c/li\u003e\n\u003cli\u003eGhai V, Subramanian V, Jan H, Loganathan J, Doumouchtsis SK. Evaluation of clinical practice guidelines for the management of female chronic pelvic pain using the AGREE II instrument. Int Urogynecol J. 2021;32:2899\u0026ndash;912.\u003c/li\u003e\n\u003cli\u003eChao MT, Abercrombie PD, Nakagawa S, et al. Prevalence and use of complementary health approaches among women with chronic pelvic pain: a prospective cohort study. Pain Med. 2015;16:328\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eMazur-Bialy A, Tim S, Pępek A, et al. Holistic approaches in endometriosis as an effective method of supporting traditional treatment: a systematic search and narrative review. Reprod Sci. 2024;31:3257\u0026ndash;74. doi:10.1007/s43032-024-01660-2\u003c/li\u003e\n\u003cli\u003eWang X, Ding N, Sun Y, Chen Y, Shi H, Zhu L, et al. Non-pharmacological therapies for treating chronic pelvic pain in women: a review. Medicine (Baltimore). 2022;101(49):e31932. doi:10.1097/MD.0000000000031932\u003c/li\u003e\n\u003cli\u003eLi L, Lou K, Chu A, O\u0026rsquo;Brien E, Molina A, Riley K. Complementary therapy for endometriosis-related pelvic pain. J Endometr Pelvic Pain Disord. 2023;15(1):34\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eDurmaz A, Gun Kakasci C. Pregnant women\u0026rsquo;s attitudes towards complementary and alternative medicine and the use of phytotherapy during the COVID-19 pandemic: a cross-sectional study. PLoS One. 2024;19(1):e0296435. doi:10.1371/journal.pone.0296435\u003c/li\u003e\n\u003cli\u003eAkalın B, İrban A, \u0026Ouml;zargun G. T\u0026uuml;rkiye\u0026rsquo;de geleneksel ve tamamlayıcı tıp uygulamalarının mevcut standartları ve iyileştirme \u0026ouml;nerileri. Sağlık Proj Arş Derg. 2023;5(1):49\u0026ndash;69. doi:10.57224/jhpr.1230794\u003c/li\u003e\n\u003cli\u003eYorgancı A, \u0026Ouml;zt\u0026uuml;rk UK, Evliyaoğlu Bozkurt \u0026Ouml;, Akyol M, Pay RE, Engin-Ustun Y. Complementary and alternative medicine attitudes of gynecologic patients: experience in a tertiary clinic. Rev Bras Ginecol Obstet. 2021;43(11):853\u0026ndash;61. doi:10.1055/s-0041-1739462\u003c/li\u003e\n\u003cli\u003eNicklas L, Albiston M, Dunbar M, et al. A systematic review of economic analyses of psychological interventions and therapies in health-related settings. BMC Health Serv Res. 2022;22:1131.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zdemir K, \u0026Ouml;zerdoğan N, \u0026Uuml;nsal A. Assessment of chronic pelvic pain and quality of life among women of childbearing age. Osmangazi J Med. 2015;37(3):13\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eBeck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eOhaeri JU, Awadalla AW. The reliability and validity of the short version of the WHO Quality of Life instrument in an Arab general population. Ann Saudi Med. 2009;29(2):98\u0026ndash;104. doi:10.4103/0256-4947.51790\u003c/li\u003e\n\u003cli\u003eEser E, Fidaner H, Fidaner C, Eser SY, Elbi H, G\u0026ouml;ker E. WHOQOL-100 ve WHOQOL-BREF\u0026rsquo;in psikometrik \u0026ouml;zellikleri. 3P Derg. 1999;7(Suppl 2):23\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eNygaard A, Stedenfeldt M, \u0026Oslash;ian P, Haugstad GK. Characteristics of women with chronic pelvic pain referred to physiotherapy after multidisciplinary assessment: a cross-sectional study. Scand J Pain. 2019;19(2):355\u0026ndash;64. doi:10.1515/sjpain-2018-0308\u003c/li\u003e\n\u003cli\u003eDydyk AM, Singh C, Gupta N. Chronic pelvic pain. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: \u003cu\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK554585/\u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eArmour M, Sinclair J, Chalmers KJ, et al. Self-management strategies among Australian women with endometriosis: a national online survey. BMC Complement Altern Med. 2019;19:17.\u003c/li\u003e\n\u003cli\u003eMalik A, Sinclair J, Ng CHM, et al. Allied health and complementary therapy usage in Australian women with chronic pelvic pain: a cross-sectional study. BMC Womens Health. 2022;22:37.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zcan H, \u0026Ccedil;uvadar A, Uzun S. The effect of psychotherapeutic interventions on pain and quality of life in endometriosis: a systematic review and meta-analysis. Ir J Med Sci. 2025;194:1391\u0026ndash;400.\u003c/li\u003e\n\u003cli\u003eKlotz SGR, Kolbe C, Rue\u0026szlig; M, Br\u0026uuml;nahl CA. The role of psychosocial factors in the interprofessional management of women with chronic pelvic pain: a systematic review. Acta Obstet Gynecol Scand. 2024;103(2):199\u0026ndash;209.\u003c/li\u003e\n\u003cli\u003eMagari\u0026ntilde;os-L\u0026oacute;pez M, et al. Psychological profile in women with chronic pelvic pain. J Clin Med. 2022;11:6345.\u003c/li\u003e\n\u003cli\u003eMongiovi JM, et al. Complementary and alternative methods among women managing acyclic pelvic pain. Front Reprod Health. 2024;3:1140857.\u003c/li\u003e\n\u003cli\u003eAydin T, et al. Non-pharmacological interventions in chronic pelvic pain: effectiveness and challenges. Womens Health Rep. 2021;3:1.\u003c/li\u003e\n\u003cli\u003eManu A, Poenaru E, Duica F, et al. Quality of life assessment and clinical implications for women with endometriosis through validated tools: a narrative review. Medicina. 2025;61:1729.\u003c/li\u003e\n\u003cli\u003eGonz\u0026aacute;lez-Echevarr\u0026iacute;a AM, et al. Impact of endometriosis on quality of life: updates from recent clinical evidence. Womens Health (Lond). 2021;17:1\u0026ndash;13.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Characteristics of Women with Chronic Pelvic Pain (n = 250)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Gynecologic Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of Abdominal Surgery (Non-gynecologic)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Treatment for Pain Complaint\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eUse of Non-pharmacological or Non-surgical Pain Relief Methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCauses of Chronic Pelvic Pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExtra-uterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMusculoskeletal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of Conservative / CAM Methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeural therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLocal pain therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eManual therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcupuncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDisturbance field elimination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eElectrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTENS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e153\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMassage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHydrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealthy and balanced diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBreathing techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e47.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e29.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSleep regulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDetox\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Mean Scores of BDI and WHOQOL-BREF\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSkewness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKurtosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBeck Depression Inventory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.281\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHOQOL-BREF Physical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.242\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHOQOL-BREF Psychological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.083\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHOQOL-BREF Social\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHOQOL-BREF Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWHOQOL-BREF Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.252\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Pearson Correlation Between BDI Scores and Study Variables\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBDI Score (r)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGynecologic surgery history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal surgery history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrevious treatment for pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUse of non-pharmacological methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePain Etiology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExtra-uterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.119\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMusculoskeletal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.141*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.077\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of CAM / Conservative Methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeural therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLocal pain therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eManual therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcupuncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.076\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDisturbance field elimination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.078\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eElectrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTENS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.130*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMassage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.166**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHydrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealthy diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBreathing techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSleep regulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDetox\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e**p\u0026lt;.01 *p\u0026lt;.05*\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Pearson Correlation Between WHOQOL-BREF and Study Variables\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eWHOQOL-BREF Total (r)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGynecologic surgery history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAbdominal surgery history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePrevious treatment for pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUse of non-pharmacological methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePain Etiology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExtra-uterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUterine gynecologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.159*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrologic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMusculoskeletal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.084\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of CAM / Conservative Methods\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeural therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLocal pain therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eManual therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcupuncture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.125*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDisturbance field elimination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePsychotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eElectrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTENS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eExercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMassage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHydrotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHealthy diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBreathing techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHypnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSleep regulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDetox\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026ndash;0.075\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e**p\u0026lt;.01 *p\u0026lt;.05*\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Pearson Correlation Between BDI and WHOQOL-BREF Subdomains\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHOQOL-BREF Subdomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI Score (r)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003ePhysical health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026ndash;0.159*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003ePsychological health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026ndash;0.321**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003eSocial relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026ndash;0.341**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003eEnvironmental health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026ndash;0.359**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 233px;\"\u003e\n \u003cp\u003eWHOQOL-BREF Total\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026ndash;0.388**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6. Logistic Regression Analysis of WHOQOL-BREF Scores Predicting CPP Etiologies\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\" width=\"604\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDependent Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWald\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExp(B)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUterine gynecologic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e6.141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e2.043\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026ndash;2.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.949\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e5.948\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrologic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.559\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e3.643\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e1.749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026ndash;1.292\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.825\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMusculoskeletal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.659\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e1.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026ndash;0.236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.943\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.790\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrointestinal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.404\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e1.768\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e1.498\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026ndash;0.483\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e0.991\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 45px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003e0.626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 120px;\"\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eB = Beta katsayısı, SE = Standart hata, Exp(B) = Odds oranı.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"chronic pelvic pain, quality of life, depression, complementary and alternative medicine, women’s health","lastPublishedDoi":"10.21203/rs.3.rs-8224699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8224699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Chronic pelvic pain (CPP) is a multidimensional condition that affects women’s physical, psychological, and social well-being. This study aimed to examine the relationship between quality of life, depressive symptoms, and the use of complementary and alternative medicine (CAM) among women living with CPP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This cross-sectional study included 250 women diagnosed with CPP who were followed in the Obstetrics and Gynecology outpatient clinic of a university hospital in the Marmara region of Turkey. Data were collected using a Descriptive Information Form, the Beck Depression Inventory (BDI), and the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Uterine (49.6%) and extra-uterine gynecologic (40.0%) factors were the most common causes of CPP. Exercise (61.2%) and massage (50.4%) were the most frequently used conservative approaches, whereas acupuncture (38.0%), psychotherapy (36.0%), and sleep regulation (42.4%) were moderately used. The mean BDI score was 13.67 ± 9.94, indicating mild-to-moderate depressive symptoms. The mean WHOQOL-BREF total score was 3.26 ± 0.46. Depressive symptoms demonstrated significant negative correlations with all WHOQOL-BREF subdomains. Logistic regression analysis showed that higher WHOQOL-BREF scores significantly predicted uterine-origin pain (B = 0.714, p = 0.013), corresponding to a 2.04-fold increased likelihood (Exp(B) = 2.043).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This study shows that gynecologic causes are the predominant etiologies of CPP in Turkish women. Conservative strategies, particularly exercise and massage, are widely adopted, while CAM awareness and use vary across modalities. Depressive symptoms were common and strongly associated with lower quality of life across all domains. These findings underscore the need for multidisciplinary approaches that integrate psychological screening, patient education, and evidence-based conservative therapies alongside conventional medical management.\u003c/p\u003e","manuscriptTitle":"Relationship Between Quality of Life, Depression and Complementary and Alternative Medicine Use in Women With Chronic Pelvic Pain: A Cross-sectional Study on the Turkish Population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 05:51:36","doi":"10.21203/rs.3.rs-8224699/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"107362292327081005028589629124537434125","date":"2026-05-13T16:33:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16449785281938439035451471442006742086","date":"2026-05-10T20:25:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T16:24:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T16:38:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-01T05:43:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-01T05:40:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Complementary Medicine and Therapies","date":"2025-11-27T19:17:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-complementary-medicine-and-therapies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcam","sideBox":"Learn more about [BMC Complementary Medicine and Therapies](https://bmccomplementmedtherapies.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Complementary Medicine and Therapies","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8d91a251-48cb-4cb2-8fa0-41d870ceec39","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"107362292327081005028589629124537434125","date":"2026-05-13T16:33:08+00:00","index":51,"fulltext":""},{"type":"reviewerAgreed","content":"16449785281938439035451471442006742086","date":"2026-05-10T20:25:30+00:00","index":50,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T05:51:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 05:51:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8224699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8224699","identity":"rs-8224699","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}