Assessing the effectiveness of a pelvic pain management programme: does an endometriosis diagnosis influence outcome (a comparative analysis of outcomes in women with and without endometriosis)

Background Pain Management Programmes (PMPs) are recommended for chronic pain, but their effectiveness for endometriosis-associated chronic pelvic pain (CPP) remains unclear. This study evaluates outcomes from a specialised, multidisciplinary Pelvic Pain Management Programme (PPMP) for women with chronic pelvic pain. It compares results between women with and without an endometriosis diagnosis.

Validated patient-reported outcome measures (PROMs) capturing pain, physical function, and psychological wellbeing were collected at baseline (T1), post-treatment (T2), and 6-month follow-up (T3)for women completing a Pelvic PMP (September 2014 - June 2019). Outcomes were compared between women with and without endometriosis.

At T2, clinically significant change was observed across pain (distress 45%), physical function (disability 24%, activity capacity 27-31%), psychological outcomes (self-efficacy 55%, depression 42%, acceptance 53% and catastrophising 43%). At T3, gains were maintained or increased pain (distress 53%), physical function (disability 42%, activity capacity 42-44%) and psychological outcomes (self-efficacy 68%, depression 56%, acceptance 64% and catastrophising 63%). Outcomes were comparable irrespective of diagnosis across all time points.

The specialised PPMP produced meaningful improvements irrespective of diagnosis, suggesting shared central and psychosocial pain mechanisms. Findings support the need for equitable access to PPMPs and for future multicentre research evaluating long-term sustainability.

Chronic pelvic pain (CPP) describes persistent pain in the pelvic area that lasts for three months or longer, affecting 1 in 6 women [Citation1]. Whilst CPP can exist in the absence of identifiable pathology, it can be associated with abdominopelvic conditions such as endometriosis, bladder pain syndrome, vulval pain syndrome, and primary dysmenorrhoea [Citation1]. Endometriosis is the most common abdominopelvic condition associated with CPP, affecting 40%–87% of those with CPP [Citation2]. Irrespective of an associated abdominopelvic condition, CPP is, for many, a debilitating condition that has negative psychological, behavioural, cognitive and sexual consequences [Citation3] as well as being linked to bladder and bowel issues. The emotional distress of living with pain and disability significantly impacts the individual’s quality of life (QoL) [Citation4]. CPP is underpinned by interacting biopsychosocial factors rather than purely biomedical pathology [Citation5]. Biological mechanisms such as central sensitisation and altered pain modulation intersect with psychological processes, including catastrophising, low mood, and reduced self–efficacy. These factors influence pain perception by amplifying threat responses and reducing adaptive coping. Social contexts such as relationship strain, work disruption, and limited healthcare support can perpetuate stress and fear–avoidance, further reinforcing pain–related disability. Together, these interacting mechanisms sustain and exacerbate chronic pelvic pain beyond the initial biomedical pathology. In endometriosis, these challenges may be intensified by fertility concerns and delays in diagnosis. This complexity highlights the need to move beyond biomedical management alone and deliver multidisciplinary, biopsychosocial care [Citation5,Citation6]. Standard PMPs are group–based, psychologically informed multidisciplinary rehabilitation programmes that combine education, physiotherapy, psychology, and occupational therapy to target the biological, psychological, and social contributors to persistent pain. They address issues such as movement avoidance, pain beliefs, mood, and role functioning. PMPs are recommended for various chronic pain conditions to promote improved QoL, with well–established evidence [Citation5]. The National Institute for Health and Care Excellence (NICE) produces guidance for the United Kingdom (UK) National Health Service (NHS) and the wider health and care system. NICE's recent update to endometriosis guidelines states that ‘PMPs have been found effective in managing chronic pelvic pain and can improve quality of life. However, it is unclear how much of this small evidence base can be generalised to women with endometriosis’ [Citation7]. There is a need for further research that adds to the small evidence base supporting PMPs for CPP and to examine the effectiveness of PMPs for the management of endometriosis–associated pelvic pain. The Walton Centre, an NHS tertiary pain service, developed a multidisciplinary specialist PMP for women with CPP, including endometriosis–associated pelvic pain. The Pelvic PMP followed the standard multidisciplinary PMP model but was adapted through tailored content specific to women with CPP. This included sessions on pelvic floor function, flare–up management, intimacy, self–compassion, and the valued roles of parenting and family planning. The programme development has been described in detail elsewhere [Citation4]. In line with this biopsychosocial understanding, outcomes were selected to reflect psychological (e.g. catastrophising, self–efficacy, acceptance, mood), physical (e.g. disability, functional capacity), and social/occupational (e.g. performance and satisfaction with valued activities) domains of CPP. These validated patient–reported outcome measures (PROMs) are routinely collected within NHS services and are recommended as standard outcome measures for Pain Management Programmes by the British Pain Society and Faculty of Pain Medicine [Citation8]. The present study aimed to report | i) | Efficacy outcomes for all patients who have completed the Walton Centre NHS Foundation Trust specialised Pelvic PMP (PPMP). | |||| | ii) | Perform subgroup analysis to determine efficacy and comparative efficacy relative to a diagnosis of endometriosis. |

The reporting of this study conforms to the STROBE statement. Outcome data were accessed from the Pain Management Registry, an ethically approved database of PPMP outcomes since 2014 (IRAS ID (339716) REC ref (24/NW/0068)). The project was approved by the NHS trust audit department. This study utilised a practice–based audit design that compared pre–treatment baseline (T1), post–treatment (T2) and 6-month post–treatment completion (T3) outcomes. Intervention T1. All patients received a medical screen by a pain consultant and underwent an assessment with a Clinical Psychologist, Occupational Therapist and Physiotherapist to determine PMP suitability, identify additional support needs, and obtain baseline outcomes. T2. The PPMP comprised ~40 hours delivered as one full day per week across seven consecutive weeks, underpinned by psychologically informed (CBT–based) rehabilitation and co–facilitated by physiotherapists, clinical psychologists, occupational therapists, and pain consultants. Physiotherapy sessions included graded exercise and movement, pelvic floor education and exercises, flare–up management, and strategies for sustaining activity. Psychology content addressed the biopsychosocial impact of chronic pain, values and acceptance, relationships and intimacy, mood states and emotions, and self–compassion. Occupational therapy delivered mindfulness–based pain sessions, activity management with value–driven targets, communication skills and work and employment support. Medical teaching covered pain mechanisms, relevant bodily systems and diagnosis pain education (co–delivered with physiotherapy). Content is consistent with PMP guidelines [Citation8] (themes described in the Appendix ). Post–treatment outcomes are collected in the final week of the programme. T3. All patients are invited to a half–day follow–up at six months post–treatment, and further outcomes are collected. Participants All patients who completed the PPMP and provided outcome data between 11th September 2014 (programme inception) and 17th June 2019 (when services were paused during COVID). Patients were considered eligible if they were female, aged 18 or over, and experiencing chronic pelvic pain for ≥3 months. Suitability for the PPMP was determined through multidisciplinary assessment (medical, psychological, physiotherapy, occupational therapy) to ensure patients could engage in a group programme, had no acute medical or psychiatric instability, and were motivated to adopt self–management strategies. Although referral criteria for the PPMP did not specifically require patients to have received prior hormonal or surgical treatments, most referrals to this tertiary pain service occurred after these standard management options had been explored in secondary care. As part of the multidisciplinary assessment process (medical, psychological, physiotherapy, and occupational therapy), treatment history was routinely discussed to ensure that no further active medical or surgical interventions were planned before participation. However, detailed treatment histories were not systematically recorded within the registry dataset. Patients deemed unsuitable for the PPMP (e.g. due to ongoing investigations or the need for mental health support prior to self–management) were considered not appropriate for the programme. These patients were either discharged or referred on to alternative care pathways by the MDT; however, their outcomes were not routinely followed up and are therefore beyond the scope of this study. Outcomes The outcome measures were not selected specifically for this study but are routinely collected within NHS pain management services as part of standardised audit procedures. They reflect the core outcome domains for chronic pain management (pain intensity, emotional functioning, and physical and social role functioning) as recommended by IMMPACT [Citation9], and endorsed by the British Pain Society and Faculty of Pain Medicine [Citation8]. These measures are sensitive to the biopsychosocial changes targeted within Pain Management Programmes and capture meaningful aspects of the pain experience. Pain: ‘Pain intensity’ is rated from 0 (no pain), to 10 (most intense pain imaginable) over the last week. ‘Pain distress’ is rated from 0 (no distress) to 10 (extremely distressed) over the last week9. Widely used in chronic pain assessment; test–retest reliability r = 0.80–0.90 [Citation10]. Psychometric outcomes: The Pain Catastrophising Scale (PCS) [Citation11], is a 13-item questionnaire (score 0-52) designed to assess catastrophic thoughts or feelings accompanying the experience of pain, with higher scores indicating higher levels of catastrophising, scores of ≥ 30 is considered clinically significant for chronic pain. High internal consistency (Cronbach’s α = 0.95) and test–retest reliability r = 0.70 over 8–12 weeks [Citation11]. The Pain Self–Efficacy Questionnaire (PSEQ) [Citation12]; is a 10-item questionnaire (score 0-60), that assesses the confidence that people with pain have in performing activities, with lower scores indicating low self–efficacy. Cutoff points of the PSEQ scores are low (ranging from 0 to 11), medium (ranging from 12 to 32), and high (ranging from 33 to 60) [Citation13]. High internal consistency (α = 0.92) and test–retest reliability r = 0.73 [Citation14]. The Chronic Pain Acceptance Questionnaire (CPAQ) [Citation15] is a 20-item questionnaire (score 0-120), with higher scores representing greater psychological flexibility and acceptance of pain. A low score has been suggested as Low 46.8; however, there are no established cut–offs [Citation16]. Adequate internal consistency (α = 0.85) with good construct validity [Citation15]. The Beck Depression Inventory II (BDI–II) [Citation17], is a 21-item questionnaire (score 0-63), with higher scores indicating higher levels of depression. A score of 20-28 is associated with moderate depression. Excellent internal consistency (α = 0.92) and test–retest reliability r = 0.93 [Citation17]. Physical function/disability: The Rolland and Morris Disability Questionnaire (RMQ) [Citation18] is a 24-item disability questionnaire with higher scores indicating higher levels of disability; a score of > 7 is associated with disability/impairment. Internal consistency α = 0.84 and test–retest reliability r = 0.91 [Citation19]. The sit to stand (STS) test is a performance measure to evaluate physical function by counting the number of times a person can stand up from a chair in one minute [Citation20]. The median number of repetitions ranged from 50/min (25–75th percentile 41–57/min) in young men and 47/min (39–55/min) in young women aged 20–24 years to 30/min (25–37/min) in older men and 27/min (22–30/min) in older women aged 75–79 years [Citation21]. The ‘Five Minute Walk’ Test 20determines how far a person can walk in five minutes. Normative values indicate 333-583 metres for 25–50-year–olds [Citation22]. High test–retest reliability (r > 0.80) and clinical utility for chronic pain assessment [Citation23]. Occupational performance: The Canadian Occupational Performance Measure (COPM) asks participants to identify 5 activities where they encounter problems. Each activity is scored (1 low-10 high) on separate scales of performance and satisfaction. A change of 2 points or more (on performance or satisfaction) is considered a clinically important difference (CID/MCID) [Citation24,Citation25]. High test–retest reliability (r > 0.80) and established content and construct validity [Citation26] Bias To minimise bias, only patients with complete baseline and post–treatment data were included in analyses, with complete case data used at follow–up and no imputation applied. As outcomes were collected routinely within the NHS registry, selection bias was reduced. However, registry data did not capture certain potentially influential variables such as prior treatments or comorbid conditions, which we note as limitations. Analyses Analysis was computed using SPSS (Statistical Package for the Social Sciences v.16.0, SPSS Inc., Chicago, IL, USA). Descriptive statistics were calculated for demographic data, including age and pain duration. PPMP mean outcomes were calculated at all time points. Post–PPMP and follow–up changes were determined using effect size (ES, Cohen's d) and Clinically Significant Change (CSC). Patients were excluded if they did not complete the PPMP or if baseline outcome data were incomplete. Analyses at T2 and T3 were conducted using complete case data. Effect sizes with 95% confidence intervals are reported to convey the precision of estimates. ES was compared to the established minimum benchmark for clinically beneficial treatment effects, as shown in a randomised controlled trial [Citation27]. Effect sizes equal to or larger than these benchmarks indicate clinical benefit however this is limited to pain intensity, PCS, BDI and STS domains only [Citation27]. Changes within 0.2 to two standard deviations of the baseline group mean can be used to determine CSC [Citation28,Citation29]. For the purposes of this study, CSC was positive if pre–post improvement was more than one standard deviation of the baseline group mean. T–tests were used to identify any significant differences in demographics and efficacy relative to a diagnosis of endometriosis and CPP not associated with endometriosis (non–endometriosis). In addition, within–group t–tests of difference comparing T1 with T2 and T3 were conducted to enhance transparency, recognising that the study was designed as a service evaluation audit rather than a hypothesis–driven trial. Mean change in outcomes T2-T1 and T3-T1 were also statistically compared per group. Data distribution was normal for all outcomes apart from COPM satisfaction and STS therefore Wilcoxon signed–rank test and Friedman test was used for within and between groups respectively.

Participants 150 patients were assessed as suitable for PPMP (T1). Of these, 100 patients completed the PPMP, with 96 complete data sets included in the efficacy analysis (T2). Additionally, 58 of these patients attended a 6-month follow–up (T3) (). Demographic characteristics The average age of patients was 37.6 years (range 19-66) with an average pain duration of 8.2 years (range 1-35) (). Pain duration was 0.9 years longer in the non–endometriosis group. Age differences between the endometriosis and non–endometriosis group reached statistical significance (t (58) = 4.88; p = < 0.001), whereas pain duration did not (t(89) = 0.53; p = 0.60). Outcomes data No statistically significant differences were observed between groups for baseline outcomes (). Clinically significant change (CSC) At T2, CSC proportions were as follows: PSEQ 55% overall (60% endometriosis; 49% non–endometriosis); CPAQ 53% overall (53% in both groups); PCS 43% overall (53% endometriosis; 30% non–endometriosis); and BDI 42% overall (43% endometriosis; 40% non–endometriosis). For functional outcomes, CSC was achieved by 24% on the RMQ (26% endometriosis; 21% non–endometriosis), 27% on the Sit–to–Stand (28% endometriosis; 26% non–endometriosis), and 31% on the five–minute walk (34% endometriosis; 28% non–endometriosis). The highest CSC rates were observed for the COPM, with 73% on COPM-P and 79% on COPM–S across groups.At T3, CSC was maintained or increased for several outcomes: PSEQ 68% overall (73% endometriosis; 63% non–endometriosis); CPAQ 65% overall (73% endometriosis; 56% non–endometriosis); PCS 63% overall (63% in both groups); and BDI 56% overall (53% endometriosis; 59% non–endometriosis). CSC for physical function measures ranged from 33–44% across groups, while COPM remained high (51%–58%). and provide a visual summary of these data. Effect size (ES) At T2, large effect sizes (Cohen’s D) calculations (d ≥ 0.8) were observed for most outcomes, including PCS, PSEQ, CPAQ, BDI, Sit–to–Stand, Walking, and both COPM scales. Medium effect sizes (d ≥ 0.5 and < 0.8) were found for Pain Distress, Roland Morris Disability Questionnaire, and Pain Intensity. At T3, large effect sizes were maintained across most outcomes, except for Pain Intensity and RMQ, which showed medium effect sizes (). The ES for pain intensity, PCS, BDI, and STS suppose the minimum benchmark for treatment efficacy as expected in a PMP RCT [Citation27]. For further transparency, within group tests of difference comparing baseline (T1) with T2 and T3, revealed significant changes at p < 0.001 across all outcomes for those with and without endometriosis. Subgroup analysis Between–group analysis confirmed that PD was the only outcome showing significant differences, with greater improvements in the endometriosis group at T2 and T3 (p < 0.05).

Interpretation of findings Clinically significant improvements in psychometric and functional outcomes were observed among patients who completed a specialised PPMP for women with CPP. These improvements exceeded effect sizes for chronic pain management and were sustained six months post–treatment. Subgroup analysis revealed comparable outcome efficacy between women with and without a diagnosis of endometriosis. Our findings contribute to the growing body of evidence supporting the effectiveness of specialised PMPs for CPP [Citation7]. While the primary aim of PMPs is to address the cognitive, behavioural, and emotional consequences of pain rather than directly reduce pain intensity [Citation30], improvements in pain levels were also observed. Pain intensity showed a medium effect size across all groups at six months. Improvements in pain and psychological outcomes are consistent with evidence from systematic reviews of psychological interventions for chronic pain,which demonstrate sustained benefits across pain intensity,mood,and function [Citation31]. They also align with recent evidence specific to CPP, which has shown that biopsychosocial interventions can improve quality of life and function in women with pelvic pain [Citation32]. Interestingly, improvements in physical and psychological function were greater at six months post–treatment than immediately following treatment. This may reflect the time required for patients to integrate and internalise strategies, allowing for sustained behavioural and cognitive changes [Citation33]. Additionally, neuroplasticity and central pain modulation mechanisms may take time to develop, leading to progressive improvements over an extended period. The findings reinforce the importance of long–term follow–up in assessing treatment efficacy and reinforce the value of sustained engagement with self–management strategies beyond the programme itself. Clinical implications Patients with CPP often report needs that extend beyond generic pain management, including support with intimacy, fertility, menstruation, pregnancy, and childbirth [Citation34]. Mardon et al. (2023) found that while general pain education is a crucial part of pain management, patients with CPP benefit from interventions that address both the physical and psychosocial complexities of their condition, including validation, self–management, and QoL improvement [Citation35]. A specialised PPMP provides a supportive environment where these sensitive topics and pain complexities can be openly explored, facilitating a comprehensive approach to managing CPP. They integrate multidisciplinary expertise, combining physiotherapy, psychology and occupational therapy to address physical, psychological and social factors [Citation4]. This comprehensive approach is in line with national guidelines that emphasise the importance of interdisciplinary assessment and management for CPP [Citation3,Citation36]. Given the complexity of CPP, the delivery of a PPMP requires service considerations such as the mix of staff, skills, and expertise to provide effective rehabilitation for people living with chronic pain [Citation4]. Pain services are well–positioned to offer consistent, high–quality programmes that address both the general and specific needs of patients with CPP, including the integration of pelvic floor physiotherapy, psychological support, and education on pain mechanisms [Citation3,Citation4]. Although recent policy has prioritised endometriosis [Citation37,Citation38], our findings suggest that women without a diagnosis of endometriosis achieve similar benefits. This suggests that PPMPS address shared mechanisms,such as central sensitisation,altered descending pain modulation,and overlapping psychosocial contributors,which are known to drive persistent pelvic pain irrespective of underlying diagnosis [Citation1,Citation5]. Over–reliance on diagnosis risks delaying access to effective care, particularly given the well–documented delays in confirming endometriosis [Citation37]. Strengths & limitations The strengths of this study lie in its sample characteristics and the comprehensiveness of the outcome measures used. Most patients referred to the PPMP had previously undergone standard medical (e.g. hormonal) and/or surgical treatments for pelvic pain, with ongoing symptoms despite these interventions. Although this treatment history was typically explored during multidisciplinary assessment to confirm suitability for self–management, it was not systematically captured within the registry data. The sample consisted of a broad age range and did not exclude postmenopausal patients [Citation39]. This enhances the generalisability of the findings across different age groups. A comprehensive set of outcomes captured domains relevant to patients and overall QoL, ensuring a patient–centred evaluation.

included the absence of a control group (e.g. waitlist or alternative treatment) is acknowledged as a potential limitation. However, as an observational clinical study conducted in a real–world setting, this design was chosen to be pragmatic and ethically appropriate, avoiding withholding treatment from eligible patients. While a waitlist control could have been considered, fluctuations and changes within such groups may limit the validity of comparisons. The chosen approach, therefore, reflects the realities and priorities of delivering clinical care in this environment. No a priori sample size or power calculation was undertaken because this was a retrospective audit, and no primary outcome was prespecified. In line with best practice for observational studies, we have not included a post hoc power calculation; instead, we report effect sizes with 95% confidence intervals to reflect the precision of our estimates. Future prospective, multi–centre studies will prespecify primary outcomes and be powered accordingly. Whilst we found no differences between outcomes based on diagnosis, we did not explicitly explore diagnosis–specific factors (e.g. perceived severity, association with disease, prior treatments, diagnostic delays, and co–morbid pain conditions). These variables are not collected in the PMP registry. These factors may influence outcomes and warrant systematic collection in future research to better understand their impact. Additionally, the non–endometriosis group encompassed a range of diagnoses, which may dilute specific effects related to any one condition. This heterogeneity should be considered when interpreting subgroup comparisons. Further work in this area may be useful to advance personalised care and meet patients' needs. Attendance at the six–month follow–up was lower, which may have influenced the long–term outcome data. Further exploration of the reasons for non–attendance and the ongoing needs of patients is necessary to better understand follow–up observations and support sustained change. The study sample lacked diversity, as ethnicity, socioeconomic status, and parity history were not collected for this study. As a clinical team, we recognise this as a limitation and have now implemented the collection of these demographic variables to ensure that future work can offer greater generalisability. The study was conducted at a single centre, which may restrict the applicability of the results to other settings. Finally, accessibility of treatment remains a challenge, as the programme requires patients to attend sessions once per week, which may pose time commitments and logistical barriers for some individuals. Future research Future research should use multi–centre, prospective studies with longer–term follow–up to evaluate the sustainability of effects and improve generalisability by recruiting larger, ethnically and socioeconomically diverse samples. With larger samples, multivariate approaches (e.g. regression or mixed models) could be used to control for potential confounders such as age and to explore interrelationships among outcomes over time. In the present study, the relatively small subgroup sizes and retrospective design limited the feasibility and statistical power for such analyses, so they were not undertaken. Additionally, investigating the specific mechanisms underlying the observed improvements in function and psychometric outcomes, particularly the delayed benefits, could provide valuable insights into the optimal timing and components of such interventions.

This study reinforces the importance of integrative, multidisciplinary care models that address the multifaceted needs of individuals with CPP and support broad access to PPMPs for all eligible patients. The comparable outcomes between patients with and without endometriosis suggest that PPMP targets shared mechanisms underlying CPP, supporting broad access irrespective of diagnosis. Given diagnostic delays, this highlights the value of providing timely biopsychosocial support and holistic management to all individuals with CPP. Author contributions Conceptualisation; SJ, NL, KH and AB, Data Curation; KH, CD and ML, Formal analysis; KH & SJ, Project administration; SJ, KH, NL and AB, Investigation; CD, ML, Writing; SJ and AB, Writing, review and editing; KH, NL, CD.

Selina Johnson research hours at time of publication were supported by University of Liverpool Research budget support monies and Walton Centre research capacity funding, no further financial support was received for the research, authorship, and/or publication of this article. Disclosure statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Data availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Additional information Funding Notes on contributors Selina Johnson Dr Selina Johnson: Clinical Research Fellow and Pain Specialist Physiotherapist. Clinical focus of research is improving the management of persistent pain, including pelvic pain. She is exploring patient–centred approaches for the management of persistent pelvic pain to improve treatment efficiency of how people access appropriate treatment, and quality of life outcomes to support people to live better with chronic pain. Mathew Liptrot Catriona Drew and Mathew Liptrot: Clinical pain psychology assistants. Both support the investigation and data curation of numerous projects within the pain service. Catriona Drew Catriona Drew and Mathew Liptrot: Clinical pain psychology assistants. Both support the investigation and data curation of numerous projects within the pain service. Alison Bradshaw Ms Alison Bradshaw: Pain specialist Occupational Therapist and NIHR internship fellow. Clinical work focuses on supporting and promotion of occupational performance for persons with chronic pain. Within her research role she supports PMP themed projects within the pain service, and research outcomes that explore work and employment issues. Natalie Lane Dr Natalie Lane: Consultant Clinical Psychologist and service lead for the pelvic pain service at The Walton Centre. Dr Lanes research interests are psychologically informed approaches to management of chronic pain. Katie Herron Dr Katie Herron: Consultant Clinical Psychologist and Research Lead for Pain Management Programmes. In addition to her clinical work, she is PMP Research Lead with a key agenda to drive PMP themed projects within the service well as establish external collaborations across academic institutions and other NHS departments.

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