Virtual reality-based pain control in endometriosis: a questionnaire-based pilot study of applications for relaxation and physical activity

Purpose Virtual reality (VR) based technology may offer new avenues in the management of chronic endometriosis-related pain. Our prospective, 14-week, open, three-phase, cross-over pilot study investigated whether the use of VR technol- ogy equipped with a relaxation-inducing application (VR-R) or an activity-stimulating application (VR-A) could change endometriosis-related chronic pelvic pain levels and impairment of daily life.

23 women aged 32.7 (SD 8.2) with endometriosis-related pelvic pain were each assigned to a permutated sequence of three 4-week phases: (A) the VR-R, (B) VR-A, and (C) intervention-free control phases. Phases were separated by two interspersed 1-week washout phases. Main outcome measures included: momentary, average, and maximum pain intensities on a 0–10 numerical rating scale (NRS); the Pain Disability Index (PDI) score; the Pain Catastrophizing Scale (PCS) score; sleep quality (Medical Outcomes Study Sleep Scale (MOS-SS) score); the Depression Anxiety Stress Scales (DASS) score; and the general health-related quality-of-life score (Short Form (12) Health Survey (SF-12)).

Compared to baseline, VR-R use showed statistically significant positive effects for several scores (NRS “average pain”; PDI “total score”; PCS “total score” and the “magnification”, “rumination”, and “helplessness” subscores; MOSS-SS “index I and II”; and the DASS “depression” and “stress” subscores), whereas VR-A yielded significant positive changes only for PDI “total score”; PCS “total score” and the “helplessness” and “magnification” subscores; MOSS-SS “index II”; and DASS “depression” and “stress”. As four scale scores also showed significant improvements for control, a comparison of the effects was performed to offset a potential placebo-like effect by comparing difference from baseline against control. This analysis yielded significantly greater positive effects only for VR-R: PCS “total score” and “helplessness”; MOSS-SS “index I” and “index II”; and the three DASS subscores “depression”, “anxiety”, and “stress”. SF-12 showed no significant changes in either analysis.

VR-R and VR-A showed positive effects on several pain and quality-of-life scores, which were significant for some scores compared to baseline. For VR-R, some of these improvements were indeed significantly greater than under control conditions, while the effects with VR-A were not. Larger studies are needed to corroborate these findings. Trial registration DRKS00030189.

Chronic pain management · Benign gynecological disease · Nonpharmacological treatment · Supportive care · Immersive visual technology Abbreviations DASS Depression anxiety and stress scale MOS-SS Medical outcome study-sleep scale NRS Numerical rating scale NS Not significant PCS Pain catastrophizing scale PDI Pain disability index PRN Pro re nata (as needed) SF-12 Short form health survey SF-12 VR Virtual realty VR-A VR activity VR-R VR relaxationViktoria Pakebusch and Barbara Schlisio are joint first authors. Extended author information available on the last page of the article 1722 Archives of Gynecology and Obstetrics (2025) 311:1721–1731 What does this study add to the clinical work A cross-over pilot study of relaxation- or physical activity-inducing virtual reality technology showed improvements in endometriosis-related chronic pain and quality of life using scales to measure pain and other parameters.

Endometriosis is a common benign but chronic disease in women of reproductive age, in which endometrial cells grow outside the uterine cavity, forming lesions within the uterine wall (adenomyosis) and in extrauterine sites, such as the ovaries, fallopian tubes, and abdominal tissues, including the bladder, intestines, peritoneum, and diaphragm [1 –5]. Symptoms, if present, vary greatly from patient to patient [6, 7] and typically include chronic pelvic pain with or without lower back or abdominal pain, dysmenorrhea, dyspareunia, dysuria, dyschezia, ovulation pain (mittelschmerz), and pain during physical activity. As symptoms tend to be unspecific, endometriosis often remains undiagnosed for many months and even up to years [1 , 3, 8–10]. Endometriosis-related chronic pain is often severe and can significantly affect the daily life of patients. The resulting medical costs and loss of productivity are also of considerable economic importance due to the frequency of the disease [11– 14]. Furthermore, endometriosis can cause infertility [15, 16] and patients with endometriosis often suffer from depression, anxiety and sleep disorders [17]. Treatment options typically include analgesics, surgery, hormonal therapy, and complementary medical treatments [1–3, 18– 21]. Nonpharmacologic and nonsurgical approaches to the management of chronic pain include psychotherapy, distraction techniques, and physical activity [22]. With the advent of virtual reality (VR) based technology in recent years, new avenues are currently also being explored in the management of chronic endometriosis pain [23, 24]. More generally, VR has been shown to be effective in the treatment of chronic pain associated with other diseases, or in the treatment of comorbidities such as anxiety and depression, as recent meta-analyses have shown [25, 26]. Against this backdrop, we sought to investigate the potential beneficial effects of using VR headsets equipped with relaxation (HypnoVR ®) and activity (SyncVR Fit®) applications on self-reported endometriosis-related chronic pain, pain-related disability in everyday life, health-related and overall quality of life, and the general well-being of endometriosis patients.

Study population Eligible for inclusion were women aged at least 18 years with a histologically confirmed diagnosis of endometriosis, reporting endometriosis-related severe pelvic pain with pre- study baseline ratings of at least 5 points on visual numerical rating scale (NRS). Recruitment occurred during routine outpatient visits to our university level-3 endometriosis center. Baseline ratings were derived from patient-reported NRS ratings for the preceding four weeks. Further eligibility criteria included the willingness not to have surgery or begin a new drug or nondrug treatment (opioid or nonopioid analgesic, acupuncture, behavioral therapy, massages, etc.) during study participation. Inclusion also required an adequate knowledge of German and the assurance that the study devices would be used according to manufacturers’ instructions. Exclusion criteria included serious mental illness (e.g., psychosis, schizophrenia, or bipolar disorder) and major depression based on screening with the aid of the study questionnaires and the Depression Anxiety Stress Scales (DASS). Starting regular use of opioid analgesics within seven days preceding study entry was also an exclusion criterion. Study objectives The aim of this study was to investigate whether the use of VR technology with a relaxation application (HypnoVR®) or an activity application (SyncVR Fit®) had an effect on the reported pain level and endometriosis pain-related impairment of daily life. Primarily, we investigated momentary, average, and maximum pain intensity per day. Secondary objectives included recording (1) pain-related disability as measured using the Pain Disability Index (PDI); (2) sleep quality as measured using the Medical Outcome Study–Sleep Scale (MOS-SS); and (3) general health-related quality of life as measured using the 12-item Short Form (12) Health Survey (SF-12). Study design, devices, and interventions Study design. This study was a prospective, 14-week, open, three-phase, cross-over pilot study with 1-week washout periods interspersed between phases. Each participant sequentially completed a four-week intervention phase with 1723Archives of Gynecology and Obstetrics (2025) 311:1721–1731 each of the two study devices, and a four-week intervention- free control phase. The sequence of the two intervention phases and the control phase was permutated, yielding an allocation plan with six different sequences. Participants were consecutively included and assigned to one of the six predetermined intervention/control sequences in accordance with the allocation plan. Questionnaires were completed at baseline and after each study phase. Additionally, participants were provided with a paper-based pain diary for daily completion (see below). Participants had four interviews, one at the initial visit (eligibility assessment and baseline data collection) and one after completing each study phase. The study protocol received prior approval from the ethics committee of the medical faculty of Tübingen University Hospital, Tübingen, Germany (approval number 893/2021B01) in accordance with the ICH-GCP guidelines, the Declaration of Helsinki, and all relevant laws and regulations. All participants gave their prior written informed consent. Study devices. Two virtual reality (VR) headsets were used as study devices: the Pico G2 4 K (Pico Technology Co., Ltd, Beijing, China) with the pre-installed HypnoVR ® (HypnoVR SAS, Lampertheim, France, www. hypno vr. io/ en) application and the Pico Neo 3 Pro with the pre-installed SyncVR Fit® (Amersfoort, The Netherlands, www. syncv rmedi cal. com) application. Virtual experiences with the HypnoVR® included, e.g., a journey through space and a deep-sea dive for virtual reality-induced relaxation (VR-R), whereas the SyncVR Fit® offered virtual reality-induced activity (VR-A) by motivating participants to be physically active and, e.g., perform guided body movements or play soccer in a virtual stadium. Examples of the 3D-immersive VR environments provided by the VR-R and VR-A applica- tions are shown in Figs.  1 and 2. Study interventions. These consisted in using the assigned VR device for 15–20 min three times a week, completing the relevant online questionnaires described below, and documenting the experience in an electronic pain diary online. In addition, pro re nata (PRN, as needed) use was permitted, but needed to be recorded. During the control phase, participants were required to complete the questionnaires and keep their pain diary. Data collection Questionnaires. Table  1 lists the questionnaires used to record basic demographic and medication-related data as well as three pain-related questionnaires and three questionnaires pertaining to quality of sleep, quality of life, and mental health. Participants were requested to complete the questionnaires at the same time of day (7 pm, if possible). Participants used a secure web-based survey platform (Unipark®, Tivian XI GmbH, Cologne, Germany; www. unipa rk. com) hosting the NRS, PDI, PCS, MOS-SS, DASS, and SF-12 questionnaires to record their pain ratings, additional self-assessments, and use of pain medication. No personal data were stored on the Unipark® platform. Pain diary. Participants were instructed to keep a purpose- designed, paper-based pain diary throughout the study duration (including washout periods), detailing momentary pain at rest, average pain, and maximum pain intensity at the same time of day (7 pm, if possible). They were also requested to provide information on their medication Fig. 1 Examples of 3D-immersive virtual reality environments for relaxation (VR-R): a winter day (top), an ocean beach (middle), and an underwater landscape (bottom) (reproduced with kind permission from the rights owner) 1724 Archives of Gynecology and Obstetrics (2025) 311:1721–1731 requirements, including PRN medication, and their menstrual cycle, including typical cycle duration, duration of menstruation, and whether they had experienced menstrual bleeding or spotting within the last 24 h. Data analysis Statistical analysis was performed using R, Version 4.2.2. Descriptive statistics used numbers and percentages and means and standard deviations (SD). The difference to baseline was assessed by paired Wilcoxon–Mann–Whitney rank test. To investigate the effects of treatments, the differences to baseline Δ B for VR-R and VR-A were compared versus the Δ B for control. A linear model for PRN medication depending on the presence or absence of menstrual bleeding was formulated with participant as random factor. A significance level of 5% was chosen in all statistical tests.

Study population The study was conducted between 10/2022 and 02/2023. Out of 25 eligible candidates meeting the inclusion criteria, 2 discontinued study participation after completing the baseline visit and the baseline questionnaire and were therefore excluded from the study. Table  2 summarizes the 23 participants’ baseline demographic and clinical characteristics. Participants stated their occupations as: homemaker (1/23), student or apprentice (6/23), job seeker (1/23), full-time worker (10/23), or part-time worker (5/23). None indicated being unable to work. Endometriosis-related pain had persisted for 1 to more than 5 years in all participants at study initiation, with 11 of 23 (48%) participants reporting comorbidities. Single instances of other complaints reported by 12 of 23 (52%) included cold symptoms, hormone fluctuations, exhaustion/fatigue, gastrointestinal complaints (bloating, pain, food intolerance), headaches, sleep disorders, fears, palpitations, leg cramps, frequent urge to urinate, back pain, dyspareunia, and hypothermia, amongst others. Treatment with hormones as contraceptives or endometriosis medications was reported by 12 out of 23 (52%). Reports of nonpharmacologic treatments for pain included physiotherapy (5 of 23 patients), psychotherapy (3 of 23), and acupuncture and relaxation techniques (5 of 23). Fig. 2 Examples of 3D-immersive virtual reality environments induc- ing physical activity (VR-A): throwing rings into a pyramid (top), catching fireflies (middle), and throwing soccer balls (bottom) (repro- duced with kind permission from the rights owner) 1725Archives of Gynecology and Obstetrics (2025) 311:1721–1731 Completeness of data sets Two participants did not complete the baseline question- naire. One participant discontinued after the first phase and another after the second phase. Pain diaries were missing for two other participants. Due to the small number of par - ticipants and since this was a pilot study, these participants were not excluded. Pain diary Pain diary. Complete pain diaries were obtained from 21 out of 23 (91%) participants. Scatter diagram analysis of the questionnaire and pain diary recordings of average and maximum pain matched well (with respective Pearson correlation coefficients of rP = 0.84 and rP = 0.90). VR-A and VR-R phases were not associated with any significant differences in diary-recorded pain scores averaged per participant when compared against control or each other. Menstrual bleeding. Momentary pain at rest, average pain, and maximum pain averaged per participant were all significantly greater with menstrual bleeding than without (p = 0.027, p = 0.011, and p = 0.008, respectively). PRN medication. There was no significant difference in PRN medication averaged per participant in the presence or absence of menstrual bleeding (p = 0.114). A linear model for PRN medication depending on the presence or absence of bleeding with participant as random factor showed a significant difference (p < 0.001). These results demonstrate the importance of collecting menstrual cycle data. Figure  3 shows an example of the time course of pain rat- ings as reported by one participant during the study. Gener- ally, pain ratings in all three pain categories increased with the onset of menstruation, accompanied by increased con- sumption of PRN medication. Table 1 Study questionnaires Decreases in scores indicate improvement except with SF-12, where increases indicate improvement PRN pro re nata (as needed) Questionnaire Purpose Basic questionnaire Collection of demographic data, including age, weight, height, previous and current analgesic (long-term or PRN) medication Numerical rating scale (NRS) for pain Subjective assessment of pain intensity on a 0–10 rating scale Pain disability index (PDI) Self-assessment of chronic pain-related disruption of everyday life activities to measure subjective pain-related disability Pain catastrophizing scale (PCS) Measurement of exaggerated negative perception of pain, comprising 3 subscales (“magnification”, “rumination”, and “helplessness”) Medical Outcome Study–Sleep Scale (MOS-SS) Assessment of the quality and possible impairment of night sleep Depression Anxiety and Stress Scale (DASS) Determination of the probability of the presence of depressive disorder or anxiety disorder Short Form (12) Health Survey (SF-12) 12-item self-reported survey of general health-related quality of life Table 2 Baseline demographic and clinical characteristics of the study population (n = 23) SD standard deviation *Age is given as patient-reported full years Mean (SD) or number | percentage Demographics  Age at baseline*, years 32.7 (8.2)  Body mass index, kg/m 2 22.6 (4.4) Endometriosis  Duration of endometriosis-related pain, years    5 16 |70%  Comorbidities (multiple entries possible)   Anxiety disorder 0|0%   Chronic lower back pain 2|9%   Chronic headaches 3|13%   Depression 3|13%   Other pain disorders 7|30%   No comorbidities 12|52% Pain medication  Opioids 3|13%  Before study entry 3|13%  After study entry 3|13%  Nonopioids 21|91%  Daily use 3|13%  Occasional use 18|78% Hormone treatment 12|52%  Oral contraceptive 9|39%  Hormonal intrauterine device 2|9%  Vaginal ring 1|4% 1726 Archives of Gynecology and Obstetrics (2025) 311:1721–1731 Questionnaires Pain numerical rating scale The pain NRS questionnaire measures momentary pain severity and average and maximum pain during the pre- ceding 4 weeks. Figure  4 shows that for average pain, the mean NRS value of 3.3 exhibited a significant difference versus baseline (4.4) for VR-R (p = 0.033), whereas VR-A (3.6) and control (3.8) did not. No significant differences in NRS scores versus baseline were observed for momentary pain and maximum pain (data not shown). Comparisons of differences from baseline Δ B yielded no statistically significant effects for momentary, average, and maximum pain on the NRS scale observed with either VR-A and VR-R versus control (Table  3). Pain disability index (PDI) The 7-item Pain Disability Index (PDI) questionnaire measures self-reported pain-related impairment [ 27]. PDI scores were significantly lower than baseline for VR-A, VR-R, and control (p = 0.008, p = 0.003, and p = 0.008, respectively). Testing Δ B values of VR-A and VR-R versus control yielded no statistically significant differences (p = 0.270 and p = 0.457, respectively). Fig. 3 Example of a time course of participant-reported pain ratings in the diary throughout the study. Solid black line = maximum pain; dashed line = average pain; solid grey line = momentary pain; red dashes = days with menstrual bleeding; circles = PRN medications Fig. 4 Average pain on the NRS scale as reported for baseline, virtual reality-guided activity (VR-A) and relaxation (VR-R), and control 1727Archives of Gynecology and Obstetrics (2025) 311:1721–1731 Pain catastrophizing scale (PCS) The 13-item Pain Catastrophizing Scale (PCS) measures the extent of pain catastrophizing, distinguishing 3 subscales: “rumination”, “magnification,” and “helplessness” [28, 29]. PCS total scores and all three PCS subscores for both VR applications differed significantly from baseline, as did the control, with the exception of the “helplessness” subscore for the control and the “rumination” subscore for VR-A. However, comparison of the differences from baseline (Δ B values) for the PCS total score and the PCS subscores of VR-A and VR-R against control showed no statistically significant effects, except for the PCS total score (p = 0.043) and the PCS “helplessness” subscore (p = 0.023) observed with VR-R versus control. Medical outcomes study sleep scale (MOS‑SS) The 12-item MOS-SS questionnaire measures sleep qual- ity during the 4 weeks before questioning [30]. MOS-SS questionnaire items are detailed in Supplementary Table 1 online (based on [31]). MOS-SS scores for sleep disturbance differed significantly from baseline for VR-A, VR-R, and control. For VR-R, the scores for somnolence, index I, and index II also differed significantly from baseline; for VR-A, the index II score differed significantly from baseline. Test- ing Δ B values of VR-A and VR-R versus control yielded significant effects only for the index I and index II scores (p = 0.019 and p = 0.003, respectively). Depression anxiety stress scale (DASS) The 21-item DASS self-report questionnaire comprises 7 questions per subscale to assess signs of depression (DASS-D), anxiety (DASS-A), and stress (DASS-S) over the past week [32, 33]. DASS -D and DASS-S subscores were statistically significantly different from baseline for both VR applications but not for control, whereas the DASS-A subscores were not significantly different. By contrast, testing differences from baseline (Δ B values) VR-R versus control yielded significant effects for all 3 subscores (p = 0.014 for DASS-D, p = 0.033 for DASS-A, and p = 0.004 for DASS-S). Table 3 Qualitative summary of questionnaire results for virtual reality interventions and control versus baseline, and changes from baseline Δ B for virtual reality interventions versus control NS not significant, NRS numerical rating scale, PDI pain disability index, PCS pain catastrophizing scale, MOSS-SS medical outcome study – sleep scale, DASS depression anxiety and stress scale, SF-12 short form (12) health survey SF-12, VR-R VR relaxation, VR-A VR activity *Significant increase or decrease in measured scores VR-R vs. baseline n = 22 VR-A vs. baseline n = 21 Control vs. baseline n = 23 Change from baseline Δ B VR-R vs. control n = 22 VR-A vs. control n = 21 Pain on NRS scale (↓ = improvement)  Momentary pain ↓ ↓ ↓ NS NS  Average pain ↓* ↓ ↓ NS NS  Maximum pain ↓ → ↓ NS NS PDI (↓ = improvement)  Total score ↓* ↓* ↓* NS NS PCS (↓ = improvement)  Total score ↓* ↓* ↓* Significant NS  Helplessness ↓* ↓* ↓ Significant NS  Magnification ↓* ↓* ↓* NS NS  Rumination ↓* ↓ ↓* NS NS MOSS-SS (↓ = improvement)  (Sleep) Index I ↓* ↓ ↓ Significant NS  (Sleep) Index II ↓* ↓* ↓ Significant NS DASS (↓ is improvement)  Depression ↓* ↓* ↓ Significant NS  Anxiety ↓ ↓ ↑ Significant NS  Stress ↓* ↓* ↓ Significant NS SF-12 (↑ = improvement)  Physical health ↑ ↑ ↑ NS NS  Mental health ↑ ↑ ↓ NS NS 1728 Archives of Gynecology and Obstetrics (2025) 311:1721–1731 SF‑12 health survey The Short Form (12) Health Survey is a 12-item, self- reported health survey that provides physical health and mental health scores [34]. In our study, neither VR application yielded statistically significant results, whether comparisons were performed as scores versus baseline or Δ B versus control. Summary of results Overall, the results of our 14-week VR-based intervention study of pain disability; sleep; depression, anxiety, and stress; and physical and mental health demonstrates that, compared versus baseline, both VR applications showed statistically significant reductions in some of the scores for the respective rating scales employed. Significant differences were also seen for the control phase and baseline (Table  3).

Principal findings Endometriosis is often associated with severe chronic pain. Patients with chronic pain tend to feel helpless and dependent on others, which in turn may trigger, inter alia, depression and anxiety [17]. Current guideline- based standard pain treatments involving analgesics, hormone therapy, and surgery are frequently inadequate and may entail specific risks and considerable side effects. Supportive care also provides only limited relief and is often unsatisfactory [22]. Hence there is a need for new methods that are readily available, have few side effects, and will help to restore patients’ sense of self-efficacy. With the advent of VR technology, which immerses the user in an alternative audio-visual reality, VR-based distraction, relaxation, and physical activity interventions have been found to be effective in the treatment of chronic pain of various etiologies [25, 26]. The present study investigated the use of virtual reality applications in endometriosis patients with regard to pain, sleep quality, mental health, and quality of life. To our knowledge, our study was the first to compare the effects of two different VR applications, i.e., relaxation (VR-R) and activity (VR-A), against a VR intervention-free control phase in a cross-over design. Moreover, it was also the first study to run over a longer period of 14 weeks in total to investigate medium- term effects on the above-mentioned areas investigated. Our study showed that the use of VR-R led to significant improvements in several pain and quality-of-life scores. As improvements were also seen in the control phase, in contrast to other studies [23, 24], we performed further analyses which took into account the change from baseline Δ B in order to determine as precisely as possible the effect of the intervention as such, so as to differentiate the effect of the VR intervention from the effect of study participation (potential placebo-like effect in the control). With VR-R, changes that were significantly greater than control were thus observed for the PCS (“Total score” and the “helplessness” subscore), MOSS-SS (“index I” and “index II”), and DASS (“depression”, “anxiety”, and “stress”) scores. Positive effects were also observed for “average pain”, PDI “total score”, and the PCS “magnification” and “rumination” subscores, although these were not significant when compared to the changes in the control. With VR-A, improvements from baseline were noted for the PDI (“total score”), PCS (“total score”, “helplessness”, and “magnification”), MOSS-SS (“index II”), DASS (“depression” and “stress”) scores, but these were not significantly greater than the effects in the control. A comparison of the present study with previously published data reveals clear differences. In 2022, Merlot et al. [23] published the results of a randomized controlled trial in 45 women with endometriosis-related chronic pelvic pain. They investigated a single immersion-based VR intervention for pain treatment, followed by 6 pain recordings over a period of 4 h. By contrast, we recorded 84 pain scores and quality-of-life data items per participant in a crossover design over a 14-week study period. A second study by Merlot et  al. published in 2023 [24] revisited the topic, expanding the study to 102 participants treated with immersive VR technology after repeated use of VR, but again limited to 2–5 days starting from menstruation. The total of 4 measurements of pain perception were also only taken around the intervention on the same day. Of particular note, the authors did not account for the potential placebo-like effect in the control group, which in contrast to our study was a “control group” with intervention but without immersive technology. Nevertheless, the authors speak of a significant improvement in pain perception through the use of VR with immersive technology. By contrast, our present study attempted to analyze the efficacy of both VR-R and VR-A as precisely as possible by addressing the potential influence of mere participation in the study. Strengths and limitations Several strengths and limitations of our study should be considered when interpreting our results. One strength is that this was the first study to compare the effects of 4-week periods of VR-based relaxation and VR-based exercise therapy on pain and quality-of-life related parameters with a 4-week VR intervention-free control phase. Also, the crossover design enabled us to conduct this pilot study with 1729Archives of Gynecology and Obstetrics (2025) 311:1721–1731 a comparatively small number of participants. Furthermore, although treatment allocation was not randomized in the strict sense, the preestablished allocation table eliminated arbitrary assignment of consecutive patients to a specific treatment sequence. Carry-over effects were minimized by 1-week washout periods in between study phases. Of note, compliance with study requirements was very high across all participants, which was reflected not least in the high quality of the data. Moreover, the pain diary entries matched closely with the questionnaire responses. In addition, while favoring VR-based relaxation, all participants stated they had subjectively benefited from the study. Last, our study population was balanced with regard to hormone therapy, with half of participants (52%) receiving hormones. A specific, and likely the most important limitation of the study was its small sample size of 23 participants, which may have impacted the significance of the results and therefore warrants special consideration in future, larger studies. However, this was a pilot study with a cross-over design, which allowed us to keep the sample size to a minimum. Further sample-size considerations included the logistics of exchanging the high-cost devices between participants in the midst of the ongoing COVID-19 pandemic. In this context it is remarkable that only two of the 23 participants discontinued their participation. Due to the small sample size, it was not possible to take the sequence of study phases into account in the analysis. However, our findings show the importance of varying the sequence of study phases, ideally to use all possible permutations equally often in the absence of randomization.

VR-R was shown to have positive effects on a number of pain and quality-of-life scores, which were significant for several scores when compared to baseline, and some of these effects were even shown to be significantly larger than those observed in the control. Moreover, VR-A showed significant positive effects compared to baseline; however, in our small sample, these effects were not significantly greater than those in the control. We conclude that VR-R may have a greater impact than VR-A but concede that both VR options need to be further explored in larger studies. Supplementary Information The online version contains supplemen- tary material available at https:// doi. org/ 10. 1007/ s00404- 025- 08000-y.

We are grateful to HypnoVR and SyncVR Medi- cal, who provided the headsets and software applications for the pur - poses of the present study. While both companies provided instructions and advice on the use of the study equipment, neither company had a role in the design or conduct of the study, data analysis, data inter - pretation, or manuscript writing. The authors retained full control of manuscript content at all times. The present data and results are part of VP’s doctoral thesis, which at the time of writing was at the finalization stage and unpublished. VP is the principal author and has given consent to publish the data reported in this article. Author contributions V Pakebusch: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/ editing; B Schlisio: Protocol/project development, Manuscript writing/editing; B Schönfisch: Protocol/project development, Data analysis, Manuscript writing/editing; SY Brucker: Manuscript writing/editing; B Krämer: Manuscript writing/editing; J Andress: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing. The first draft of the manuscript was written by Viktoria Pakebusch and Jürgen Andress. All authors commented on earlier manuscript versions, and read and approved the final manuscript. Funding Open Access funding enabled and organized by Projekt DEAL. This research received no external funding. Data availability No datasets were generated or analysed during the current study. Declarations Conflict of interest The authors have no relevant financial or non-fi- nancial interests to disclose. Ethical approval The study protocol received prior approval from the ethics committee of the medical faculty of Tübingen University Hospi- tal, Tübingen, Germany (approval number 893/2021B01) in accordance with the ICH-GCP guidelines, the Declaration of Helsinki, and all relevant laws and regulations. All participants gave their prior written informed consent to participate in the present study. Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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Hogrefe Verlag, Göttingen Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 1731Archives of Gynecology and Obstetrics (2025) 311:1721–1731 Authors and Affiliations Viktoria Pakebusch1  · Barbara Schlisio2  · Birgitt Schönfisch1  · Sara Y . Brucker1  · Bernhard Krämer1  · Jürgen Andress1 * Jürgen Andress [email protected] Viktoria Pakebusch [email protected] Barbara Schlisio [email protected] Birgitt Schönfisch [email protected] Sara Y. Brucker [email protected] Bernhard Krämer [email protected] 1 Department of Obstetrics and Gynecology, University of Tübingen, Calwerstr. 7, 72076 Tübingen, Germany 2 Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany