Illness perception, pain coping, and self-compassion: a cross-sectional study of Polish women with endometriosis

Introduction: Endometriosis is a  chronic inflammatory gynecological dis- ease, one of whose main symptoms is chronic pain. Generally, negative per - ceptions of the disease as an obstacle/loss, harm, or threat are linked to poorer adjustment, whereas positive perceptions of illness as a challenge, value, or profit show the opposite pattern. The study aimed to investigate whether pain-coping strategies and self-compassion in women with endo- metriosis were associated with the perception of their disease in terms of obstacle/loss, threat, harm, value, challenge, and profit.

The study group consisted of 265 Polish women with a diagnosis of endometriosis. The online survey included three measures: the Self-Compassion Scale (SCS-PL), the Coping Strategies Questionnaire (CSQ), and the Disease-Related Appraisals Scale (DRAS).

Perceiving illness in negative terms – as an obstacle/loss, threat, or harm – was associated with catastrophizing about pain. Threat and harm categories were also inversely related to self-compassion. Perceptions of endometriosis in terms of value or profit were positively associated with the strategy of reinterpreting pain sensations and by self-compassion. The profit category was also negatively associated with coping self-statements, whereas viewing illness as value or challenge was associated with the pray- ing and hoping strategy.

Higher self-compassion and greater use of reinterpreting pain sensations were associated with more positive perceptions of endometri- osis, whereas catastrophizing was associated with more negative percep- tions. These findings may help inform psychological interventions sup- porting women with endometriosis, although longitudinal or intervention studies are needed to determine whether modifying these factors changes illness perceptions and improves functioning or quality of life. Key words: endometriosis, perception of illness, self-compassion, pain- coping strategies, chronic pain.

Endometriosis is a chronic inflammatory disease in which endometri- al cells are found outside the uterine cavity [1]. It affects around 10% of women worldwide [2]. The most common symptoms include chronic pel- vic pain, painful and heavy menstruation, dyspareunia, and difficulties conceiving [3]. Endometriosis, accompanied by long-lasting pain, fatigue, Małgorzata Puchalska-Wasyl, Katarzyna Wikiera 2 Arch Med Sci and daily limitations, significantly disrupts wom- en’s psychosocial functioning and reduces their quality of life, as well as physical and psychologi- cal well-being [2, 4]. Low mood, depression, anxi- ety, feelings of guilt, shame, and low self-esteem are typical of women with endometriosis [5–7]. Additionally, lack of understanding from close family members may result in feelings of loneli- ness and social withdrawal [8, 9]. According to Lazarus and Folkman [10], stress experienced during illness is influenced both by its physical consequences and by the meaning that patients assign to it (i.e., their subjective in- terpretation). Lipowski [11] distinguished sever - al categories that people commonly attribute to their condition. Categories with positive meaning include: challenge – seeing illness as a chance for mobilization or growth; profit – perceiving sec- ondary gains such as receiving care or reduced duties; and value – attributing deeper significance to the illness and seeing it as an opportunity for life reflection. Categories with negative meaning include: obstacle/loss – viewing illness as blocking goals and causing loss of health or independence; threat – experiencing it as dangerous and unpre- dictable; and harm – interpreting it through guilt or a sense of being wronged. Extensive research shows that perception of one’s illness plays a key role in patient adaptation, psychosocial functioning, and emotional respons- es. For example, women with endometriosis often hold negative beliefs about the consequences, chronicity, and controllability of their condition, which are associated with higher stress and low- er quality of life [12, 13]. At the same time, their personal narratives emphasize emotional burden, disrupted life plans, and challenges to self-identity [14]. In this article, we do not aim to focus on the consequences of illness perception for patients’ adaptive functioning. Rather, we seek to deter - mine how illness perception is shaped in women with endometriosis – specifically, whether it can be predicted based on pain-coping strategies and self-compassion. This raises an important ques- tion: why these particular predictors? Coping strategies for pain are acquired early in life [15]. Thus, the ways individuals have pre- viously learned to cope with pain may shape their perception of endometriosis – a disease in which pain is a core symptom. Coping with pain involves cognitive (i.e., reinterpreting pain sensations, ig- noring pain sensations, coping self-statements, and catastrophizing) and behavioral strategies (i.e., increased behavioral activity, diverting at- tention, and praying and hoping) aimed at re- ducing discomfort [16]. Studies based on the Common-Sense Model [17] have primarily con- ceptualized illness perception as an antecedent of coping and health outcomes, with evidence link- ing it to general coping strategies and psychologi- cal adjustment in chronic illness and pain [18–20]. In research on illness perception, pain-specific coping strategies are less frequently investigated compared to general coping, and when examined, both illness perception and pain-specific coping are typically treated as predictors of the same psy- chological or functional outcomes, such as depres- sive symptoms, anxiety, or quality of life [21, 22]. However, the potential role of pain-specific coping strategies as predictors of illness perception re- mains underexplored, although a recent study has shown that a  pain catastrophizing strategy can predict an accepting attitude toward illness [23]. The present research addresses this gap by ex- amining whether different pain-coping strategies predict distinct categories of illness perception in women with endometriosis. In the context of pain coping and illness per - ception, self-compassion may also play an import- ant role. It is defined as an attitude of kindness and understanding toward oneself in the face of suffering, acceptance of one’s flaws and failures, mindful awareness of one’s emotions, and the recognition that suffering is a part of the human condition [24]. The existing literature has not di- rectly examined the relationship between levels of self-compassion and specific categories of illness perception. However, research shows that higher self-compassion in individuals with chronic con- ditions is associated with better pain adaptation, lower distress, improved quality of life [25, 26], ill- ness acceptance, greater resilience, and construc- tive coping with problems [27–30]. Although pain coping strategies and self-com- passion have been studied in relation to pain intensity, emotional distress, and quality of life in chronic illness populations [16, 31–33], their combined role in illness perception – particularly in women with endometriosis – remains under - studied. Our study adds to the existing body of research by emphasizing the meaning of illness rather than solely symptom severity, while high- lighting pain-coping strategies and self-compas- sion as potentially modifiable factors associated with illness perception and potentially relevant to patient quality of life and adaptation to the illness.

Participants The study group consisted of 265 Polish wom- en with a diagnosis of endometriosis. The subjects were in early and middle adulthood; the age range was 20–52 years (M = 31.3; SD = 7.28). Most of them (N = 73, 27.5%) lived in a city with a popula- tion of up to 150,000, 70 (26.4%) respondents lived Illness perception, pain coping, and self-compassion: a cross-sectional study of Polish women with endometriosis Arch Med Sci 3 in a city with a population of more than 500,000, 64 (24.2%) participants lived in a city with a popu- lation of 150,000 to 500,000, and the fewest lived in a  rural area (N = 58, 21.9%). The majority of women had a university degree (N = 165, 62.3%), 56 of them (21.1%) had a high school education, 34 participants (12.8%) were in college, while the fewest respondents had vocational education (N = 8, 3%) or primary education (N = 2, 0.8%). The vast majority of women (N = 203, 76.6%) were in a relationship at the time of the survey, 52 (19.6%) described their status as single, while the fewest women declared their marital status as divorced (N = 9, 3.4%) or widowed (N = 1, 0.4%). In the study group, 79 (29.8%) women had at least one child, while 186 (70.2%) women were child- less. The range of years of experiencing symptoms of the disease ranged from one to thirty years (M = 9.92; SD = 7.05), while the mean pain in- tensity score assessed on a scale of 1 to 10 was M = 6.75 (SD = 2.84). Procedure The research was conducted online using con- venience sampling. From November 2024 to March 2025, the survey link was posted on Facebook groups and portals for women with endometriosis. Participation was voluntary and anonymous. Wom- en aged 18 or older with a physician-diagnosed en- dometriosis, who gave informed consent, complet- ed the survey. It included three questionnaires and seven sociodemographic items (see Participants). Completion took approximately 20–25 min. Measures The online survey included three measures, de- scribed below. Table I shows internal consistency coefficients for all the analyzed variables. Self-Compassion Scale (SCS-PL) Based on Neff’s original scale (2003) [34], the Polish adaptation [35] consists of 26 items rated on a 5-point scale (1 = “almost never” to 5 = “al- most always”). Items correspond to six subscales (self-kindness, self-judgment, common humanity, isolation, mindfulness, over-identification), but only the total mean score was used in this study. A higher score reflects greater self-compassion (see Introduction). Coping Strategies Questionnaire (CSQ) Rosenstiel and Keefe’s (1983) scale [16] in the Polish adaptation by Juczyński (2001) [36] was used. It contains 42 items across seven coping strategies (see Introduction). Respondents answer using a  7-point scale (0 = “I  never do this”; 3 = “I sometimes do this”; 6 = “I always do this”) to indicate how often they use each strategy when in pain. For each strategy, we calculated the mean score. A higher score reflects more frequent use of that coping strategy. The Disease-Related Appraisals Scale (DRAS) Janowski, Steuden, Kuryłowicz, and Nieśpia- łowska-Steuden’s (2009) scale [37] assesses Table I. Correlations (Pearson’s r) and internal consistency coefficients of the analyzed variables Variables 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 1. SelfComp – 2. DivAtten 0.29*** – 3. ReinPaSen 0.30*** 0.49*** – 4. Catastr 0.44*** –0.10 –0.17** – 5. IgnoPaSen 0.22*** 0.38*** 0.61*** –0.31*** – 6. PrayHop 0.09 0.48*** 0.21*** 0.24*** 0.09 – 7. CopSState 0.28*** 0.44*** 0.44*** –0.31*** 0.70*** 0.16** – 8. InBehActiv 0.20*** 0.59*** 0.45*** –0.23*** 0.55*** 0.21*** 0.62*** – 9. Obst/Loss –0.26*** –0.07 –0.03 0.47*** –0.09 0.03 0.21*** –0.16** – 10. Threat –0.36*** –0.11 –0.12 0.49*** –0.01* 0.14* –0.22*** –0.14* 0.77*** – 11. Harm –0.36*** –0.01 –0.06 0.48*** 0.08 0.16** –0.10 –0.09 0.59*** 0.63*** – 12. Value 0.24*** 0.31*** 0.27*** –0.02 0.13* 0.31*** 0.14* 0.18** 0.10 0.08 0.02 – 13. Challen 0.20*** 0.28*** 0.23*** –0.01 0.12* 0.37*** 0.21*** 0.21*** 0.17** 0.25*** 0.16* 0.54*** – 14. Profit 0.14* 0.10 0.18** 0.05 0.01 0.12* –0.09 –0.00 0.26*** 0.17** 0.19** 0.53** 0.30*** – 15. Import –0.25*** –0.11 –0.19** 0.44*** –0.23*** 0.09 –0.18** –0.12 0.52*** 0.65*** 0.46*** –0.08 0.15* –0.06 – α 0.93 0.82 0.82 0.86 0.82 0.73 0.85 0.70 0.92 0.88 0.86 0.82 0.60 0.72 0.76 SelfComp – Self-compassion, DivAtten – Diverting Attention, ReinPaSen – Reinterpreting Pain Sensations, Catastr – Catastrophizing, IgnoPaSen – Ignoring Pain Sensations, PrayHop – Praying and Hoping, CopSState – Coping Self-Statements, InBehActiv – Increased Behavioral Activity, Obst/Loss – Obstacle/Loss, Challen – Challenge, Import – Importance; *p < 0.05; **p < 0.01; ***p < 0.001. Małgorzata Puchalska-Wasyl, Katarzyna Wikiera 4 Arch Med Sci ways of perceiving one’s illness. It draws on Lazarus and Folkman’s [10] transactional stress model and Lipowski’s [11] concept of illness per - ception (see Introduction). It contains 47 items rated on a  5-point scale (“Yes”; “Rather yes”; “Don’t know”; “Rather no”; “No”). The DRAS in- cludes six subscales (obstacle/loss, threat, harm, value, challenge, profit) and a  control scale of Importance, which reflects whether the illness disturbs life balance or is seen as minor. In this study, the mean Importance score was 4.26 (SD = 0.74). Subscale scores were computed as mean values, with higher scores indicating stronger perceptions of endometriosis in that category.

Preliminary analyses First, descriptive statistics were calculated and the assumption of normality was tested using the Shapiro-Wilk test. The results indicat- ed that only the self-compassion score met the assumption of normality. Therefore, skewness and kurtosis were further examined. The scores for catastrophizing (CSQ subscale) and four subscales of the DRAS – obstacle/loss, threat, harm, and challenge – were slightly negative- ly skewed (from –0.20 to –0.86). The remain- ing subscales exhibited slight positive skew- ness (from 0.13 to 1.12). All skewness values fell within the acceptable range of –2 to +2, as recommended by George and Mallery [38], con- firming the suitability of parametric tests for the subsequent analyses. Similarly, although we found statistically significant deviations from the normality of residuals, the low skew- ness and kurtosis values, as well as the Q–Q plot analysis, suggested that these deviations were subtle and did not substantially affect the model’s conclusions. Second, Pearson’s bivariate correlations and in- ternal consistency indices were also computed for all measured variables (Table I). Regression analyses The next step involved conducting linear re- gression analyses using the enter method, which is employed for exploratory purposes [39]. The overall self-compassion score and seven pain cop- ing strategies were simultaneously entered as pre- dictors, while the categories of perceived illness (obstacle/loss, threat, harm, value, challenge, and profit) were sequentially analyzed as dependent variables. The results are presented in Table II. The assumption of no multicollinearity among the predictors was verified. The highest variance inflation factor (VIF) was 2.672, and the lowest tolerance value was 0.374, both corresponding to the pair of variables: ignoring pain sensations and the dependent variable (obstacle/loss, threat, harm, value, challenge, and profit). Regression analyses revealed the extent to which self-compassion and pain coping strategies were associated with distinct categories of illness perception. The explained variance in the study group ranged from 7% for profit to 26% for threat. All models showed a good fit. Perception of illness as obstacle/loss was pos- itively associated with the catastrophizing strate- gy, explaining 24% of the variance. A similar pat- tern was found for threat (26%) and harm (25%). These two categories were positively associated with catastrophizing and inversely related to self-compassion. This demonstrates that negative illness perception is preceded by intense unpleas- ant emotions, a  sense of helplessness in coping with pain (catastrophizing), and, in some cases, an inability to engage in self-care in the face of illness (self-compassion). Positive perceptions of illness were associated with more adaptive strategies. Viewing illness as value was positively associated with self-compas- sion, reinterpreting pain sensations, and pray- ing and hoping, explaining 15% of the variance. Similarly, self-compassion and reinterpreting pain sensations were positively associated with, while Table II. Predicting illness perceptions from self-compassion and coping strategies for pain: a linear regression analysis Variable B SE β t P-value Obstacle/Loss F(8;256) = 11.22; p < 0.001; R2 adj. = 0.236 (Constant) 2.72 0.407 6.69 < 0.001 Self-compassion –0.88 0.103 –0.055 –0.86 0.393 Diverting Attention 0.05 0.071 0.055 0.70 0.487 Reinterpreting Pain Sensations 0.07 0.082 0.062 0.84 0.404 Catastrophizing 0.38 0.053 0.473 7.01 < 0.001 Ignoring Pain Sensations 0.15 0.081 0.166 1.88 0.061 Praying and Hoping –0.08 0.056 –0.090 –1.39 0.167 Coping Self-Statements –0.13 0.072 –0.152 –1.82 0.071 Increased Behavioral Activity –0.08 0.083 –0.080 –1.02 0.309 Illness perception, pain coping, and self-compassion: a cross-sectional study of Polish women with endometriosis Arch Med Sci 5 Variable B SE β t P-value Threat F(8;256) = 12.53; p < 0.001; R2 adj. = 0.259 (Constant) 3.61 0.320 11.26 < 0.001 Self-compassion –0.21 0.081 –0.167 –2.64 0.009 Diverting Attention –0.05 0.056 –0.068 –0.88 0.381 Reinterpreting Pain Sensations –0.03 0.07 –0.034 –0.46 0.646 Catastrophizing 0.24 0.042 0.379 5.78 < 0.001 Ignoring Pain Sensations 0.12 0.064 0.155 1.79 0.074 Praying and Hoping 0.08 0.044 0.112 1.74 0.083 Coping Self-Statements –0.11 0.057 –0.152 –1.84 0.066 Increased Behavioral Activity 0.02 0.065 0.024 0.31 0.757 Harm F(8;256) = 11.77; p < 0.001; R 2 adj. = 0.246 (Constant) 2.87 0.374 7.69 < 0.001 Self-compassion –0.34 0.095 –0.225 –3.53 < 0.001 Diverting Attention 0.05 0.065 0.059 0.75 0.455 Reinterpreting Pain Sensations 0.01 0.075 0.012 0.16 0.876 Catastrophizing 0.28 0.049 0.384 5.81 < 0.001 Ignoring Pain Sensations 0.06 0.075 0.066 0.76 0.451 Praying and Hoping 0.05 0.052 0.059 0.91 0.363 Coping Self-Statements 0.03 0.066 0.037 0.44 0.660 Increased Behavioral Activity –0.07 0.076 –0.073 –0.94 0.348 Value F(8;256) = 6.83; p < 0.001; R 2 adj. = 0.150 (Constant) 0.98 0.338 2.91 0.004 Self-compassion 0.21 0.086 0.168 2.49 0.014 Diverting Attention 0.07 0.059 0.097 1.16 0.246 Reinterpreting Pain Sensations 0.15 0.068 0.167 2.13 0.034 Catastrophizing 0.02 0.044 0.027 0.39 0.698 Ignoring Pain Sensations –0.04 0.068 –0.048 –0.52 0.605 Praying and Hoping 0.15 0.047 0.214 3.12 0.002 Coping Self-Statements –0.02 0.060 –0.022 –0.25 0.805 Increased Behavioral Activity 0.01 0.069 0.015 0.19 0.852 Challenge F(8;256) = 7.38; p < 0.001; R 2 adj. = 0.162 (Constant) 2.30 0.266 8.64 < 0.001 Self-compassion 0.12 0.067 0.122 1.81 0.071 Diverting Attention –0.01 0.046 –0.010 –0.125 0.901 Reinterpreting Pain Sensations 0.08 0.054 0.121 1.55 0.122 Catastrophizing 0.01 0.035 0.009 0.13 0.897 Ignoring Pain Sensations –0.08 0.053 –0.129 –1.41 0.161 Praying and Hoping 0.17 0.037 0.308 4.50 < 0.001 Coping Self-Statements 0.07 0.047 0.134 1.53 0.126 Increased Behavioral Activity 0.04 0.054 0.065 0.79 0.431 Profit F(8;256) = 3.50; p < 0.001; R 2 adj. = 0.070 (Constant) 1.53 0.258 5.94 < 0.001 Self-compassion 0.15 0.066 0.157 2.22 0.027 Diverting Attention 0.01 0.045 0.019 0.22 0.830 Reinterpreting Pain Sensations 0.14 0.052 0.218 2.66 0.008 Catastrophizing 0.03 0.034 0.063 0.86 0.392 Ignoring Pain Sensations 0.01 0.052 0.016 0.17 0.868 Praying and Hoping 0.04 0.036 0.076 1.06 0.291 Coping Self-Statements –0.12 0.046 –0.242 –2.63 0.009 Increased Behavioral Activity –0.00 0.052 –0.005 –0.06 0.953 B – unstandardized regression coefficient, SE – standard error, β – standardized regression coefficient, t – result of the t-test, F – result of the analysis of variance, R²adj. – adjusted R-squared. Table II. Cont. Małgorzata Puchalska-Wasyl, Katarzyna Wikiera 6 Arch Med Sci coping self-statements were negatively associated with, the perception of illness as profit, explaining 7% of the variance. The first two predictors over - lap in the perception of illness as value and profit, suggesting that the perception of benefits from ill- ness may be related to positive reinterpretation of pain sensations and understanding one’s suffer - ing as a communal experience. Additionally, pray- ing and hoping was associated with the percep- tion of illness as value. Finally, interpreting illness as a  challenge was associated with the praying and hoping strategy (R² = 16%).

The study aimed to investigate whether self-compassion and pain-coping strategies were associated with distinct categories of illness per - ception in women with endometriosis. Regression

showed that self-care and emotional and cognitive responses to pain were significantly associated with how the illness is perceived, in both negative and positive terms. In addition to self-compassion, the pain-coping strategies asso- ciated with illness perception included reinterpret- ing pain sensations, praying and hoping, coping self-statements, and catastrophizing. This is con- sistent with previous studies [29, 40, 41] suggest- ing that women with endometriosis employ both adaptive and maladaptive coping strategies in their daily lives. Perceiving illness in negative terms – as an ob- stacle/loss, threat, or harm – was associated with a catastrophizing strategy. This finding can be in- terpreted within the Fear-Avoidance Model, which focuses on the impact of cognitive interpretations of pain on patients’ emotional and behavioral re- sponses [42]. According to this model, catastrophic interpretations of pain – including negative beliefs about its intensity, duration, and lack of control over the suffering experienced – may contribute to increased fear of pain. As a result, pain begins to be perceived as a signal of danger and poten- tial damage to the body, which can contribute to feelings of helplessness and ineffectiveness [43]. Consequently, fear of pain may trigger avoidance strategies and lead to reduced physical activity, while also reinforcing excessive focus on somatic symptoms, creating a vicious circle of increasing pain and dysfunction [44]. This may lead individu- als to avoid pain stimuli and focus excessively on them, potentially triggering greater stress. Empir - ical research has shown that catastrophizing, fear of pain, and pain vigilance are associated with negative affect, anxiety, depression, pain-related disability, and pain intensity in patients with vari- ous chronic pain conditions [45]. In the case of en- dometriosis, which is commonly associated with chronic pain, this mechanism contributes to per - ceiving the disease as an obstacle/loss, a threat, or harm – that is, as an illness that may be perceived as highly debilitating for everyday functioning. Poor control over thoughts, dichotomous thinking, and impaired emotion regulation may contribute to elevated stress and reduced quality of life [44]. Women may become preoccupied with the losses and limitations imposed by the illness, which may reinforce beliefs about its negative impact on their activities and socio-professional life. This way of interpreting health experiences hinders the pro- cess of adaptation to and acceptance of the dis- ease and may lead to denial of its significance in the patient’s life. Negative perceptions of illness, such as threat and harm, were also linked to lower levels of self-compassion, which is defined as kindness and understanding toward oneself and acceptance of difficult experiences [46]. Self-compassion may be beneficial for individuals facing illness by poten- tially facilitating stress management, enhancing quality of life in chronic conditions [26], and im- proving emotion regulation in chronic pain, there- by being associated with reductions in depressive and anxiety symptoms as well as catastrophic thinking [25]. Thus, it is conceivable that self-com- passion may also be positively associated with both the primary and secondary appraisal of ill- ness, in line with the transactional model of stress and coping [10]. Therefore, self-compassion may represent a potentially relevant target for further therapeutic research aimed at helping patients reframe their experiences and reduce the psycho- logical burden of chronic illness. Women may perceive endometriosis not only negatively but also positively, in terms of value (re- ferring to intangible and spiritual aspects) or profit (referring to material or social gains). In such cas- es, self-compassion, combined with cognitive re- appraisal of pain experiences, may be associated with more adaptive functioning. Recent research demonstrates that higher levels of self-compas- sion and mindfulness are associated with better psychological well-being, lower psychological dis- tress, and improved quality of life among women with endometriosis [47, 48]. In the context of findings highlighting the neg- ative role of catastrophizing and the positive role of self-compassion and strategies involving the reinterpretation of pain sensations, Acceptance and Commitment Therapy (ACT) appears to pro- vide a  theoretical framework that may be rele- vant to promoting adaptive functioning in women experiencing chronic pain due to endometriosis. Within this approach, self-compassion may play an important role by facilitating the acceptance of pain-related thoughts and emotions without ex- cessive self-criticism, potentially allowing individ- uals to disengage from experiential avoidance and Illness perception, pain coping, and self-compassion: a cross-sectional study of Polish women with endometriosis Arch Med Sci 7 pain catastrophizing. Moreover, ACT emphasizes cognitive reappraisal of pain sensations, helping patients reinterpret them as transient internal ex- periences rather than threats. This combination of acceptance, self-compassion, and reinterpre- tation enables engagement in valued life activi- ties despite ongoing symptoms [49, 50]. Such an ACT-consistent approach may be particularly rel- evant for women with endometriosis, for whom complete elimination of pain is often unattainable. In a positive perception of illness, the strategy of praying and hoping also appears to be relevant. When the illness is perceived as a value, personal prayer may be associated with inner peace, reflec- tion on life’s meaning, and a sense of value in suf- fering. When the disease is seen as a challenge, prayer may also promote hope and provide sup- port through the belief that God has control over one’s illness [51]. Moreover, frequent prayer and placing hope in God may reflect viewing the ill- ness not only as a challenge to one’s coping capa- bilities but also as a test of faith – one believed to be surmountable through prayer and trust in God. Understanding the determinants of illness per- ception, such as self-compassion and pain-coping strategies, can help clarify factors associated with a  more positive perception of endometriosis. In particular, developing self-compassion and replac- ing catastrophizing with cognitive reinterpretation of pain sensations may be relevant to therapeutic interventions aimed at supporting women in cop- ing with their chronic condition. The findings have important implications for the comprehensive care of women with endome- triosis. Given the interconnections between illness perception, pain-coping strategies, self-compas- sion, and psychological well-being, routine psy- chological assessment may be a useful component of treatment. Regular screening for maladaptive illness beliefs, pain catastrophizing, and anxiety may facilitate early identification of patients at risk of psychological distress and reduced quality of life, potentially supporting timely intervention. Furthermore, access to psychological counsel- ing may be beneficial for women with endome- triosis. Interventions based on cognitive-behav- ioral therapy, acceptance-based approaches, and compassion-focused therapy have been asso- ciated with reductions in pain catastrophizing, better emotional regulation, and more adaptive coping in patients with chronic pain [46, 52, 53]. For women with endometriosis, interventions promoting self-compassion and cognitive rein- terpretation of pain, instead of catastrophizing, may be relevant to addressing maladaptive illness perceptions, psychological distress, and resilience [5]. Integrating psychological support into stan- dard gynecological care may contribute to more patient-centered care and potentially better long- term outcomes [54]. The study has several limitations that may affect the interpretation of the results. First, its online design limited control over the reliability of responses, and the considerable number of re- flective questions may have reduced participants’ attentiveness. Future research should monitor completion time or include attention-check ques- tions. Second, the cross-sectional design makes it difficult to draw causal conclusions. The observed associations may be bidirectional, highlighting the need for replication in longitudinal studies to bet- ter understand the mechanisms underlying illness perception and coping. Third, for some regression models, such as the one for profit, R 2 values were relatively low, indicating limited explained vari- ance. Combined with a relatively large number of predictors, this may increase the risk of overfitting. Consequently, these results should be interpreted with caution, considering the limited statistical power and potential risk of Type I errors. Fourth, clinical variables such as pain intensity, disease duration, and parental status were not included in the analyses, although they may be associat- ed with pain-coping strategies, illness perception, and adaptation. Additionally, the lack of data on the mental health history of participants and their families (e.g., previous therapies, hospitalizations) limits a full understanding of the relationships un- der study. Therefore, future research should take these factors into account. Funding No external funding. Ethical approval The procedure was approved by the Research Ethics Committee at the first author’s university (approval no. KEBN_20/2025). Conflict of interest The authors declare no conflict of interest.

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