Psychosocial etiology and management of chronic pelvic pain in women: a systematic review

Background Chronic Pelvic Pain (CPP) in women is a complicated disease. Psychosocial elements like stress, trauma, and mental illnesses frequently impact CPP in women. A biopsychosocial strategy emphasizing the integration of psychosocial approach for conceptualizing and managing this condition is necessary for effective management. Therefore, this systematic review was conducted to propose the psychosocial etiology and management strategies for CPP in women.

Research databases, including PubMed/MEDLINE, Embase, PsycINFO, and the Cochrane Library, were used to search for relevant articles published from 2016 to 2025. The selected studies were Cross-Sectional Studies and Randomized Controlled Trials (RCTs). Of the 32 studies, 8 were chosen according to the inclusion criteria.

The data synthesis of the selected studies found that psychological distress, unhealthy coping style, early life experiences, and emotional trauma are significant etiological factors for CPP in women. On the other hand, psychosocial therapeutic approaches including psychoeducation, Cognitive Behavior Therapy, Acceptance and Commitment Therapy, stress management techniques and coping strategies were found effective for improving the chronic pain condition.

The psychosocial etiology of CPP in women underscores the importance of a psychosocial approach to management, integrating psychological and social interventions. Addressing both the psychological and social dimensions of pain is essential for improving patient outcomes and quality of life. Trial registration This systematic review has been registered in PROSPERO with the Registration No. CRD420251179527. Similar content being viewed by others

Chronic Pelvic Pain (CPP) is a complicated condition with a minimum duration of pain being six months. Prevalence of CPP worldwide ranges from 2% to 27%, and 4% in developed countries. It has a significant negative impact on the quality of life by influencing social functioning and psychological health. The psychosocial aspects of CPP are frequently overlooked, despite the condition’s high prevalence [1,2,3]. Psychosocial factors frequently contribute to the complex etiology of CPP. Often, the etiology is unclear and can result from conditions across gynecological, gastrointestinal, urological, musculoskeletal, and psychological systems. Its complex etiology and varied symptoms pose challenges for healthcare providers. Psychosocial factors play a role in the development, maintenance, and aggravation of CPP, even though traditional medical models have focused on functional and physiological problems. Interpersonal problems, past traumas, and psychological discomfort can all play a role in the emergence and persistence of pain symptoms [4,5,6]. Chronic Pelvic Pain in women frequently calls for a treatment plan that includes psychological interventions. Maximizing the patient’s quality of life and general function is the aim of treatment, with a focus on encouraging patient self-management. Pain can arise from a variety of psychosocial processes; therefore, treating it holistically with attention to its behavioral, psychological, and sexual aspects is necessary. Proper and complete care, psychoeducation and empowerment, psychotherapy including Cognitive Behavioral Therapy, Acceptance & Commitment Therapy, mindfulness, relaxation techniques, coping strategies including stress management are all part of the psychological management that goes into the treatment plan [7,8,9]. The cultural context plays a significant role in limiting the use of a biopsychosocial approach in Pakistan. In Pakistan, the extreme stigma associated with CPP and mental health issues, along with the absence of specialized services, worsens the fundamental psychosocial etiological factors and creates significant obstacles to typical therapeutic strategies and also delays treatment seeking among women with CPP. The Pakistani-specific challenges demonstrate this essential research gap. The development and evaluation of culturally relevant, adaptable, and affordable psychological interventions that may be administered by primary care physicians or through community-based platforms is therefore urgently needed [10, 11]. The objectives of this systematic review are: to provide a clear synthesis to identify the types and strengths of relationships between psychosocial factors and CPP; to evaluate the efficacy of psychosocial management techniques by identifying significant gaps and methodological limitations in the existing evidence. There are many systematic reviews on psychological interventions for CPP and on specific conditions like endometriosis-associated pain. Previous studies lack the latest multifactorial model updates and only focus on etiology risks, such as abuse and depression, or psychological therapies alone. Still, none of them fully integrate etiology and management in a psychosocial framework. In this study, the PRISMA guidelines were followed for a systematic review, and a thorough search strategy was used to identify recent evidence. To provide a comprehensive findings, this article synthesizes the most recent research on psychosocial etiology, along with therapy techniques such as cognitive-behavioral integration.

The systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 [12]. The PRISMA 2020 checklist is provided. Protocol and registration A review protocol was established in advance to develop the research question, search approach, and analytical framework. The protocol was registered in PROSPERO with the Registration No. CRD420251179527. Eligibility criteria Studies were selected according to the PICO (Population, Intervention, Comparison, Outcome) framework. The study population consisted of adult female patients. Studies that were conducted on women with CPP, pain persisting for at least six months, studies examining psychosocial factors contributing to the development of CPP, psychosocial interventions, multidisciplinary management strategies for CPP including psychosocial management, treatment as usual or no intervention, and efficacy of intervention, outcome, or improvement in CPP intensity were included in the systematic review. Research studies that were not focusing on CPP in women, acute pain, articles not related to psychosocial factors and psychological management, review articles, and case reports were excluded. In addition, studies with surgical procedures and publications in languages other than English were also excluded. Information source and search strategy The systematic review was conducted (including the literature search and screening process) between July 2025 to October 2025. Research databases, including PubMed/MEDLINE, Embase, PsycINFO, and Cochrane Library, were used to search relevant articles published from 2016 to 2025. In accordance with systematic review standards, a comprehensive search strategy was developed and executed. The target diagnosis (Chronic Pelvic Pain), population group (Women), and multiple objectives of the review (Psychosocial etiology and Psychotherapy) were all logically combined in the search utilizing Boolean operators. Sensitivity was improved across blocks by incorporating an extensive collection of free-text keywords linked by the “OR” operator with a defined vocabulary, such as Medical Subject Headings (MeSH) terms [13]. These blocks were combined with the “AND” operator to create the final search keyword, which was applied across various databases. Primary keywords according to MeSH terms for title, abstract, and full-text articles are: “Chronic Pelvic Pain” OR “Persistent Pelvic Pain” AND “Women” OR “Female” AND “Psychosocial etiology of Chronic Pelvic Pain” OR “Psychosocial factors of Chronic Pelvic Pain” AND “Etiology of Chronic Pelvic Pain” OR “Psychological causes of Chronic Pelvic Pain” AND “Psychosocial and Behavioral management of Chronic Pelvic Pain” OR “Psychological Interventions for Chronic Pelvic Pain” AND “Psychotherapies for Chronic Pelvic Pain” OR “CBT for Chronic Pelvic Pain”. Selection process After the search was completed, studies were selected using a two-step approach. Every article was examined after the initial searches were completed, with particular attention paid to its title and abstract. Two independent reviewers subsequently carried out the screening in two separate phases. Articles were screened based on inclusion and exclusion criteria. Full-text English-language articles focusing on the psychosocial etiology and management of CPP were included in the study. The selected articles were then double-checked to ensure their eligibility. More than 437 citations were reviewed, and 85 articles were removed due to duplication after a manual check (exported search results to an Excel file, sorted by article title, and identified and removed). 320 articles that were obviously irrelevant were eliminated after titles and abstracts were compared to the eligibility criteria. The final 32 full-text articles had been retrieved and thoroughly evaluated. The following specific reasons and counts led to the exclusion of 24 articles at this full-text stage: research design not of interest (n = 10), intervention or exposure not of interest (n = 7), and publication as an abstract only with insufficient data (n = 7). Eight studies were ultimately included through this strategy, all of which were related to the research objective. The reference lists of selected articles were searched for additional articles. Details of the study selection process are in the PRISMA 2020 flow diagram (Fig. 1). Data collection process After removing duplicate studies, screening was conducted to ensure the remaining studies met eligibility criteria. Data was extracted by one reviewer and cross-checked by 2nd reviewer. By following the criteria in Table 1, 32 articles were related to this systematic review. Both reviewers independently assessed articles to minimize bias. The narrative synthesis was used for analysis because study designs and results varied widely. Regarding psychosocial etiology and management techniques, essential themes and patterns were identified and compiled. Risk of bias assessment Two reviewers used design-specific methods to independently evaluate the risk of bias for each of the eight included studies. Discrepancies and disagreements were resolved through discussion. Four selected studies with cross-sectional studies were assessed using the Johanna Briggs Institute (JBI) Critical Appraisal Checklist [14], three studies chosen with RCTs were evaluated through the Cochrane Risk of Bias (RoB 2) [15], one Case-control study was assessed through the Newcastle-Ottawa Scale (NOS) [16], and one Non-randomized Controlled Trial was evaluated using The Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) [17]. Data synthesis This systematic review’s narrative synthesis was conducted according to the Popay et al. framework to explore the psychosocial etiology of CPP in women and the impact of psychological interventions on CPP outcomes. Studies were divided into two groups: Psychosocial etiology and psychological management. A comprehensive textual relationship with the included research was developed as a next step in the analytic process. Findings are systematically extracted and coded, with descriptive labels attached to the relevant data on variables, results, and interpretations. To obtain meaning from textual data, analysis is done iteratively through coding, categorization, and theme development. Studies that “patients with CPP reported significantly higher levels of pain catastrophizing” are classified as (Etiology- Catastrophizing) and intervention that involves “restructuring negative pain-related thoughts” with the code (Management - CBT - Cognitive Restructuring). Within each domain, similar codes are grouped into broader, more significant categories. Higher-order analytical themes are developed by analyzing the relationships within and between categories. These themes provide explanations for how and why psychosocial factors affect CPP as well as potential management techniques. The last step was assessing the robustness of the conclusions. The studies which reflected high quality RCT designs and high statistical significance were considered robust as compared to studies lacking in methodology and overall significance, e.g., pilot or feasibility studies. Ethical considerations This systematic review of previously published research articles did not require ethical approval. The results will be shared with researchers, clinicians, and the public regarding the psychosocial elements of women’s CPP and practical therapeutic approaches by publishing in a peer reviewed journal.

Critical assessment The McMaster Critical Review Form – Quantitative Studies [18] was used to assess methodological quality. This tool was selected because it is a validated, specifically developed tool for evaluating various quantitative study designs. It provides a uniform evaluation of important methodological domains, including study objective, sampling, evaluation of results, bias, and analytic rigor. Its systematic checklist provides a comprehensive assessment of key components necessary for understanding the results on psychosocial factors and interventions. Overall, 85% of quantitative studies answered “yes” to the McMaster criteria for purpose, design, and results. The consistent finding of a significant relationship between CPP and psychosocial characteristics across many research contexts is a primary strength of the selected studies. However, cross-sectional studies [19, 21, 22] and case-control study [20] designs provide the majority of the evidence for etiology. Although these studies correctly calculate odds ratios and identify correlations, their designs make it difficult to draw causal conclusions. The internal validity of the interventional studies is mixed. Although they have certain drawbacks, the two RCTs [23, 24] have the best designs. Performance bias is introduced because it is impossible to blind participants and therapists to psychological therapies. Brunahl et al.’s feasibility trial, although helpful in evaluating the intervention’s practicality, lacked randomization and a control group, so its observed pre-post improvements cannot be definitively linked to the intervention itself [25]. The survey provides valuable insight into gaps in therapeutic practice and reflects medical health professional perceptions rather than actual patient outcomes [26]. Studies used a variety of instruments to evaluate psychological factors, which makes comparisons and meta-synthesis more difficult. In intervention studies, small sample sizes and recruitment from specialist clinic settings may not be representative of the larger community-based population of women with CPP. Table 2 shows the critical appraisal of selected studies. General characteristics of the studies All eight studies were conducted on women. Participants ranged in age from 18 to 70 years. The mean age of participants was 32.5 ± 43.8 years (Mean ± Standard Deviation), and the weighted mean was 37.4 ± 10.8 years. All the selected studies were published between 2016 and 2025. The sample sizes differed significantly. These studies cover a range of study designs to investigate the psychosocial factors contributing to women’s CPP. Three selected studies on psychosocial etiology were cross-sectional, and one was a case-control study. In psychological management, two selected studies were Randomized Controlled Trials (RCTs), one study was a Non-Randomized Controlled Trial, and one study was a cross-sectional study using a survey method. Synthesis of the results To summarize the psychosocial etiology and management for CPP in women, the included studies were divided into two categories: psychosocial etiology and psychological management. Table 3 summarizes the outcomes of the selected articles. Psychosocial etiology In four selected studies on the psychosocial etiology of CPP [19,20,21,22], a clear link between psychosocial factors and CPP was found. Psychological distress, unhealthy coping style, early life experiences, and emotional trauma are significant etiological factors for CPP in women. Rocha et al. reported substantial correlations between pain intensity, disability, and psychosocial factors [19]. Osorio et al. found associations between CPP and early emotional traumas [20]. Magarinos Lopez et al. identified distinct psychological profiles in women with CPP [21]. Demirtas et al. highlighted that the refugee status independently contributes to the risk of developing CPP; they are more vulnerable to developing CPP due to difficulties in living conditions, health services, and social and psychological stress [22]. Psychological management In four studies of psychological management [23,24,25,26], psychosocial approaches including psychoeducation, Cognitive Behavior Therapy, stress management techniques and coping strategies were found to be effective and valuable in improving CPP. Donatti et al. demonstrated CBT’s efficacy in reducing both physical and psychological symptoms in women with CPP [23]. Wang et al. noted that the effectiveness of psychological intervention can improve the psychological status and sexual function in CPP [24]. Brunahl et al. conducted a feasibility trial that emphasized introducing CBT for pain management is a promising approach for managing psychological aspects of pain [25]. Brooks et al. highlighted the importance of psychological interventions in the management of CPP [26]. Reporting biases Overall, the synthesis shows a consistent observational relationship between psychosocial distress and CPP. None of the studies identified in the search reported completely neutral findings, suggesting a high risk of publication bias. In contrast, interventional studies indicate that psychologically informed treatments may be beneficial components of management, despite their small number and methodological heterogeneity. Diverse groups and populations, a wide range of study designs, and small-to-moderate sample sizes in RCTs characterize the evidence base. As a whole, the body of evidence suggests that the efficacy and reliability of psychosocial relationships and interventions for CPP may be overemphasized.

This systematic review highlights the complex role of psychological and social factors that result in CPP experience in women. According to the systematic evaluation, the origin and worsening of CPP are significantly influenced by psychological factors [1]. One systematic review concluded that women with CPP are affected mainly by psychosocial factors, which may aggravate perceptions of pain and maintenance through reciprocal interactions with biological factors. According to the review, there was insufficient high-quality data to draw definite conclusions about the efficacy of psychological treatments for CPP; however, the efficacy of these interventions indicate that these interventions have potential for improvement [27]. There has been a significant correlation between psychological issues, the degree or severity of pain, and disability that patients suffer [6]. Higher anxiety and depression levels in women are associated with greater pain and disability, which may indicate that psychological distress aggravates physical symptoms. Higher pain intensity and functional impairment were seen in women who reported poorer coping mechanisms and lower social support [19]. Patients with CPP frequently have coexisting psychosocial disorders, which are linked to worsening the quality of life. Psychosocial environment and stressors also contribute towards the experience of CPP in women such as refugee status. Refugee women face problems such as housing issues, low income, social and psychological stress, poor quality of life, lack of health services, post-traumatic stress, and other mental health issues. They are most vulnerable to severe CPP compared with non-refugee women. The study results showed significantly higher pain intensity and lower quality of life compared with non-refugee women [22]. According to other studies, CPP was 1.8 times higher among those with low income than among those with moderate income. In addition, emotional stress, post-traumatic stress disorder, maladaptive coping strategies, and poor quality of life can be causes of CPP in women [28, 29]. Similarly, early psychological traumas, abuse and childhood neglect can have long-term effects on pain perceptions and can increase vulnerability to CPP [20]. One study result indicates that sexual abuse is unlikely to be a distinct etiological component in specific populations when it comes to the development of CPP [30]. One Systematic review found a strong association between childhood experiences and chronic pain in adulthood [31], and according to another review, childhood trauma may be associated with pain sensitivity in adulthood [32]. Moreover, the psychological traits, including poor emotional regulation and maladaptive coping, are integral to understanding the persistence of CPP [21]. The women with CPP frequently display unhealthy coping mechanisms and elevated emotional discomfort, which could make their pain worse. One systematic review explored that there is an association between emotional regulation and chronic pain. Maladaptive response to emotions may be an essential risk factor in the development and maintenance of chronic pain [33]. The cognitive behavior therapy (CBT) is promoted as an effective psychological strategy that helps patients reframe unfavorable thought patterns and develop more constructive coping strategies. The study by Donatti et al. described dramatic decrease in pain and enhanced psychosocial results, perception of pain, coping strategies, alleviating stress and depression, and improving the quality of life in women with CPP who received CBT [23]. The Behavior therapy component of CBT teaches patients more productive ways to behave, and cognitive therapy component focuses on fixing incorrect thought patterns [34]. The CBT has been found effective in relieving symptoms of CPP [23], though, psychotherapy combined with drug therapy was found more effective than drug therapy alone in patients with CPP. The combined therapy group showed significant improvement in both pain management and psychological symptoms (e.g., depression, anxiety) compared to the drug-only group [24]. Cognitive Behavior Therapy focuses on the psychological and emotional dimensions of chronic pain and improves quality of life, while drug therapy addresses the physical symptoms only. This integrative approach not only reduces pain but also empowers patients by fostering a sense of control over their condition, ultimately leading to better outcomes in terms of both pain management and overall wellbeing [1, 35, 36]. One previous review surveyed mindfulness technique with mixed results but ignored psychosocial etiology [35]. In contrast, the current review synthesis emphasizes psychological etiology and psychosocial interventions to improve outcomes. Another study further discussed the effectiveness of CBT combined with physiotherapy for women with CPP. The combined intervention group showed significant improvements in pain intensity and psychological distress, along with better functional outcomes. Pain reduction also significantly decreased the level of anxiety and depression. The combination of physiotherapy and CBT proved to be a promising approach for managing both the physical and psychological aspects of CPP [25]. The CBT helps patients identify and modify thought patterns and behaviors that worsen their pain experience. When combined, these treatments can help women with CPP better manage their pain, improve function, and increase overall quality of life [7, 37]. Several previous studies advise to use interventions like psychoeducation, CBT, and mindfulness, which are effective in the psychological management of CPP [26, 34]. Similarly, another study reported the efficacy of Acceptance and Commitment Therapy (ACT) in bringing relief in chronic pain symptoms. ACT, on the other hand, is based on the model of psychological flexibility [38] and uses the psychological techniques of acceptance, mindfulness and living with one’s values to achieve effective pain management. ACT does not aim at eliminating pain perception rather it fosters psychological flexibility and helps individuals improve their functioning with chronic pain condition instead of eliminating or replacing it [39]. A more comprehensive and patient-centered approach must be combined, in which mental health services play a critical role in reducing pain severity, treating psychological issues, and improving patients’ general health [10, 11].

This systematic review provides evidence that the experience and intensity of CPP in women are consistently and significantly associated with psychosocial factors. All selected articles highlight the relationship between psychosocial factors and CPP. Psychosocial factors such as stress, anxiety, early life experiences, any emotional traumas, and childhood abuse or neglect are strongly associated with the development of CPP. Regarding management, research demonstrates the effectiveness of psychological interventions whether administered solely or in combination with other therapies. Such approaches may improve quality of life and decrease the impact of pain. Implications of the study In the clinical implications, integration of psychosocial models is crucial for the better conceptualization and management of CPP. The findings suggest the need for community awareness campaigns, comprehensive screening tools, and specific culturally sensitive education for healthcare providers to improve outcomes and reduce diagnostic delays across susceptible populations.

and recommendations This systematic review has some limitations and recommendations. In this review, only 8 studies were included, all conducted in the last 9 years. Due to the small sample size and inconsistent methodological quality of the eight studies that make up the evidence base, this systematic review is limited. Due to the potential for confounding and recall bias, cross-sectional and case-control designs are typically used, which limit the causal inference about psychosocial causation. Conclusions about long-term efficacy are limited by the few RCTs and short follow-ups (less than 6 months), despite these studies offering more substantial evidence for management strategies. While a focus on women only improves specificity, it limits generalizability to other genders. It is recommended that, in future reviews, use a larger sample, increase the number of RCTs, and adopt a more rigorous study design. A heterogeneous population can increase generalizability. Research on the long-term psychosocial effects and pain management techniques associated with CPP in women is also needed. An understanding of their long-term impacts can influence improved patient support and management strategies. Further systematic reviews should be conducted using meta-analysis. In future research, studies should be performed over an extended period with Pakistani sample. Data availability The supporting data related to the findings of this study is available publicly and can be viewed or downloaded through this link: [**https://doi.org/10.17605/OSF.IO/4DJVP**].

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Author information Authors and Affiliations Contributions Conception and design: N. U. H. A., and (A) B., Acquisition of data: (B) A., and S. A., Analysis and interpretation of data: B. A., and S. A., Drafting the article: B. A., and S. A., Revising the article for intellectual content: N. U. H. A., and A. B., Final approval: N. U. H. A., (A) B., (B) A., and S. A. Corresponding author Ethics declarations Ethics approval and consent to participate The human ethics and consent to participate did not apply to this systematic review. Consent for publication Not Applicable. Competing interests The authors declare no competing interests. Additional information Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 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To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/. About this article Cite this article Abbasi, N.u.H., Bilal, A., Akram, B. et al. Psychosocial etiology and management of chronic pelvic pain in women: a systematic review. BMC Psychol 14, 1022 (2026). https://doi.org/10.1186/s40359-026-04854-2 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1186/s40359-026-04854-2