The power of words: the role of clinician communication and language in the management of women with chronic pelvic pain through a narrative review

Chronic pelvic pain (CPP) is a highly prevalent symptom associated with significant disability. CPP disproportionately affects up to 1 in 4 women ( 1 - 3 ). It is typically defined as pain perceived to originate from the pelvic region that lasts longer than 3–6 months ( 4 , 5 ), not exclusively occurring with intercourse or menstruation, and not associated with pregnancy ( 6 ). CPP can be the consequence of one or more overlapping conditions which may include endometriosis, bladder pain syndrome or interstitial cystitis, and pelvic floor myalgia ( 6 , 7 ). CPP can result in extensive adverse physical, psychosocial and functional outcomes for the individual, irrespective of the diagnosis ( 8 , 9 ). CPP is associated with significant economic burden due to the direct and indirect healthcare costs and a decline in productivity ( 10 , 11 ). Due to the multifactorial nature of CPP, the diagnostic journey can be lengthy with multiple visits to a variety of clinicians ( 12 ). For instance, the average time to diagnosis for endometriosis, a condition associated with CPP, is estimated to be between 6 and 8 years in Australia ( 13 , 14 ). Women with CPP are commonly faced with adverse experiences of communication in healthcare which can lead to disengagement from the diagnostic journey ( 15 , 16 ). The pervasiveness of negative perceptions of healthcare was highlighted in a cross-sectional analysis (n=384) of women with endometriosis in Canada ( 15 ). In this study, 182 (47.4%) had some negative impressions and 127 (33.1%) had many negative impressions of the medical profession ( 15 ). Only 75 (19.5%) had no negative impressions ( 15 ). CPP is a burdensome experience for women with reports of poorer mental health outcomes including anxiety and depression ( 9 ). Given the high prevalence of women with CPP feeling dismissed ( 16 ), clinicians need to reform their approach to communication to adequately assess how it affects daily function and to meet their healthcare goals and needs. A clinician’s choice of language when communicating with patients is regarded as important for people who experience chronic pain by helping reduce stigmatisation and disengagement with healthcare professionals ( 17 , 18 ). The impact of language has been researched for other chronic pain conditions like back pain and migraines ( 19 - 21 ). A qualitative study of focus groups (n=66) demonstrated words like ‘chronic’ or ‘wear and tear’, commonly used by healthcare professionals when referring to back pain, can be misconstrued or have negative connotations for the participants ( 19 ). Given the potential impact of clinician communication and language on patient engagement, this narrative review aims to explore existing literature that analyses the experiences of women with CPP, including their perceptions of words, terms and phrases heard throughout the diagnostic journey. We present this article in accordance with the Narrative Review reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-72/rc ).

The narrative review was conducted through an electronic literature search of MEDLINE and Embase databases, accessed through Ovid, and with the assistance of an academic librarian. Publication dates were filtered to range from 1990 to 2025. The search was to canvass relevant studies involving women with CPP and their experience of consultations with health professionals, including their perception of clinician communication and language. Table 1 indicates the search terms and databases used and the inclusion and exclusion criteria which dictated the selection process. The selected articles underwent full-text analysis after which the quality of each study was reviewed in accordance with the Critical Appraisal Skills Programme (CASP) checklists for qualitative research and systematic reviews ( 22 , 23 ). A quality rating (low, moderate or high) was assigned to each study after considering the number of checklist items that were satisfied or not satisfied. CPP, chronic pelvic pain.

The MEDLINE and Embase database searches identified 628 articles using the MeSH terms in Table 1 . The duplicate articles (n=44) were removed. The screening of the 584 articles took place in two steps. The first screening step involved reviewing the titles. Articles (n=562) were excluded because there was no reference in the title to ‘chronic pelvic pain’, ‘endometriosis’, ‘interstitial cystitis’ or a ‘pelvic floor’ condition causing CPP, and/or no reference to patient experiences of clinician interaction, communication or language. The second screening step involved reading the abstract of the remaining articles (n=22) while considering the inclusion and exclusion criteria in Table 1 . Articles (n=15) were excluded for the following reasons: not a qualitative study (n=8), study findings did not explore participant experiences of clinician encounters/communication/language (n=3), irrelevant inclusion criteria (n=1), insufficient sample size (n=1), not written in English (n=1) and withdrawn from journal (n=1). The process resulted in 7 articles being deemed suitable for full-text review. The reference lists of the 7 articles were screened to find other relevant articles in a cascade approach. This resulted in an additional 7 articles which met the inclusion and exclusion criteria, contributing to a total of 14 articles ( 24 - 37 ) that were selected as suitable for full text review and analysis ( Table 2 ). Upon critical appraisal using the CASP checklists, we deemed 9 out of 14 (64%) ‘high’ quality and 5 out of 14 (36%) ‘moderate’ quality. CPP, chronic pelvic pain; IC/BPS, interstitial cystitis/bladder pain syndrome; n/a, not available. There were no studies that adequately targeted perceptions of clinician language including analysis of specific words, terms and phrases. The 14 studies tended to explore women with CPP’s general experiences of clinical encounters and how they were made to feel ( 24 - 37 ). There were incidental mentions of specific clinician language, but no targeted questioning of it. Negative impressions of clinician encounters were pervasive, characterised by dismissal of pain, a sense of marginalisation, and a failure to adopt a patient-centred approach ( 24 - 34 ). The review revealed 5 common themes surrounding clinician communication more generally which are summarised below. A common theme amongst 12 out of 14 of the studies was patients’ aversions toward CPP being normalised, such as being referred to as ‘normal’, ‘just period pain’ or a ‘part of being a woman’ ( 24 - 29 , 31 - 36 ). Women desired clinician communication that made them feel like they were taken seriously and heard, irrespective of the presence of a physical pathology ( 25 , 27 ). Discrepancies in understanding were evident when clinicians trivialised the pain or described it as ‘normal’ despite being highly impactful to the daily life of the patient ( 26 ). Women expressed how they made a conscious effort to convey how the pain was a detriment to quality of life, including school, work, relationships, sexual intercourse and other life activities ( 25 , 34 , 36 ). Two qualitative studies showcased how women with CPP preferred the use of emphatic descriptors to describe their experiences of pain ( 24 , 28 ). To adequately convey severity of endometriosis symptoms women used violent metaphors like ‘stabbing me with a large knife’, ‘knitting needles being pushed through your abdomen’, ‘hot poker planted inside your stomach’ and ‘a knife going into each ovary’ ( 24 , 28 ). The studies, however, did not provide comprehensive lists of words, terms and phrases that women would like to hear in response from clinicians during these encounters ( 24 , 28 ). It appears the use of such metaphors was an attempt to differentiate their symptoms from what they feared may be deemed ‘normal’, a fear voiced in several studies( 24 - 28 , 31 - 34 , 36 ). There is an evident mismatch between how women with CPP communicate their pain and how clinicians understand the extent of the patient experience. A finding common to all studies was that women with CPP feeling that clinicians believed the pain was exaggerated, fabricated or ‘all in your head’ ( 24 - 37 ). The subjective nature of CPP was challenging for patients when trying to communicate with clinicians: ‘how do you explain a pain that can’t be seen?’ ( 27 ). Women frequently were made to believe they were ‘hysterical’, ‘professional patients’ and ‘difficult patients’ ( 35 ). The comment ‘low pain threshold’ was met with strong dissatisfaction in 2 studies ( 31 , 34 ), creating the insinuation that psychological factors played a major part in their pain. The immediate dismissal of pain as ‘psychological’ significantly contributed to negative perceptions of clinical encounters. Remarks that women with CPP heard included ‘hypochondriac’, ‘psychological problem’, ‘mental’, ‘psychosomatic’, ‘all in your head’, ‘anxiety’, ‘depression’ and ‘think happy thoughts’ ( 25 , 29 , 32 , 36 ). This infers that their condition simply requires strengthening of the mind. The thematic analysis of surveys (n=1,038) of women with endometriosis demonstrated how clinicians invalidated the degree of patient suffering by suggesting it was a mental battle to overcome ( 36 ). Clinicians encouraged self-efficacy to ‘treat’ the condition by recommending that patients ‘live with it’, ‘toughen up’, ‘deal with it’, ‘get over it’, ‘get used to it’, ‘get on with life’, ‘move on’, ‘put up with it’, ‘grin and bear it’ and ‘accept it’ ( 36 ). Pressure to silently manage CPP by improving one’s mental strength contributes to significant feelings of loneliness and isolation, with flow-on effects to interpersonal relationships and work ( 37 ). Conversely, patients appreciated when clinicians validated their experience and did not imply they were fabricating or exaggerating their symptoms ( 35 ). There needs to be further exploration of clinician language that is perceived as validating for women with CPP to help guide future recommendations. Women with CPP voiced concerns of stigmatisation by some health professionals, bearing a sense of blame and shame for their ongoing struggle ( 29 , 31 , 33 , 36 ). Given its invisible nature, they were met with phrases like ‘you look fine’ ( 29 ) and belittlement through suggestions they were merely an ‘attention-seeker’ ( 27 ) or ‘drug-seeker’ ( 33 ). When clinicians emphasised lifestyle factors for women with endometriosis, they were perceived as invalidating and made women feel like their symptoms were their fault ( 31 , 36 ). Sometimes the only solutions that were communicated were that they should start exercising ( 31 ) or lose weight, drink water, relax, meditate or use heat pads ( 36 ). Such suggestions further contribute to the normalisation of CPP and continue to undermine its impact on daily life. Sighs, avoidance of eye contact, tapping fingers, monotonous responses and the use of specialist jargon conveyed a clear sense of disinterest toward women with CPP ( 31 , 34 ). Clinicians exhibiting nonchalance and accusatory tone in their communication added to the sense of shame felt by women with CPP and the belief that they were lacking in self-efficacy. Clinician communication that is pessimistic in nature negatively affected women with CPP by implying there is no hope for their future. There was dismay with words and terms like ‘unlucky’ and ‘bad luck’ suggesting attempts to find solutions were feeble and they had to continue to deal with the situation they were presented with ( 31 , 34 ). Qualitative analysis of interviews (n=9) demonstrated that women with endometriosis disliked when clinicians placed the burden back on them by saying ‘how do you want me to help you’ or ‘there is no plan’, leaving them feeling helpless, marginalised and in despair ( 31 ). Alternatively, reassurance for women with CPP could be provided by clinicians emphasising treatability versus curability in the instance of interstitial cystitis ( 37 ) and ensuring simple recognition as opposed to just focusing on a medical diagnosis for CPP ( 27 ). The literature demonstrated that women with CPP have a strong desire for tailored discussions with their clinician, emphasising the need for individualised care ( 25 , 31 , 33 ). Women want to communicate how CPP affects them personally throughout all facets of life. In a thematic analysis of interviews (n=26) exploring how women with endometriosis negotiate power in medical encounters, clinicians were urged to value a patient’s knowledge of their own body and their recognition ‘when something isn’t right’ ( 33 ). A participant voiced their relief when a clinician stated, ‘I want to hear everything, tell me from the beginning’, being the first time a doctor had delved into their personal journey ( 33 ). A qualitative meta-analysis of studies (n=14) concerning the healthcare encounters of women with endometriosis described the offensiveness of comments not tailored to the individual, for instance, recommending pregnancy as a treatment option even if they were infertile ( 34 ). This flippant display of disregard for patient circumstances shows how individualised care is not prioritised for women with CPP. Clinician language can be better shaped to ensure patients feel like they are an individual and not a statistic and without an assumption that all women with CPP have uniform experiences.

This is the first review of the literature attempting to determine the role, preferences and aversions of clinician language as perceived by women with CPP. Although studies explored clinician communication, our findings did not find a single study that addressed clinician language. There is an absence of frameworks for clinical language that would help foster therapeutic relationships during a protracted diagnostic timeline ( 13 , 14 ). Clinicians have provided their viewpoint of consultations with women with CPP ( 28 , 38 , 39 ), describing the challenges of achieving effective communication in primary care with short time frames and varying sociocultural factors ( 40 ). Given the highly individualised experience of CPP and its impact across all aspects of life ( 8 - 11 ), there should be a more in-depth exploration beyond a simple symptom checklist. A qualitative analysis (n=142) of interviews with primary care physicians (n=11) and patients (n=131) showed a mutual dissatisfaction specifically with the use of the Numerical Rating Scale due to its lack of meaningful enquiry into the impact of endometriosis-related CPP on daily life ( 28 ). There seems to be hesitancy amongst clinicians to commit to diagnostic labels for some women, with a qualitative analysis of interviews with primary care physicians (n=42) showcasing the challenges of managing a possible endometriosis diagnosis ( 38 ). There was a theme of caution surrounding the use of the label ‘endometriosis’ for the potential patient distress and anxiety that could be precipitated due to fertility concerns and the need for invasive procedures ( 38 ). Some could see the benefit of a diagnostic label; however acknowledged the considerable uncertainties and variability of women’s experiences ( 38 ). There was discomfort with the term ‘chronic pelvic pain’ in a qualitative analysis of interviews of primary care physicians (n=21) and practice nurses (n=20) ( 39 ). CPP was viewed as a difficult term to use because it was often in the absence of physical pathology and they perceived it as a last resort label with a sense of therapeutic nihilism surrounding it ( 39 ). Despite this concern, there is a movement to expand recognition of CPP as a condition in itself, in order to address its extensive physical, emotional and social impact ( 11 ). This concept aligns with the definition from the International Association for the Study of Pain (IASP) which includes those with CPP without a well-defined classical pathology ( 41 ). A 2025 consensus-based classification system “R U MOVVING SOMe” developed by the International Federation of Gynaecology and Obstetrics (FIGO) in combination with the International Pelvic Pain Society (IPPS) provided a framework for working up patients with CPP. It suggested acknowledging CPP as a pain condition in itself to help validate the healthcare journeys of patients irrespective of cause ( 4 ). The literature is dominated by experiences of primary care physicians and the input of other health care professionals involved in the care of CPP would be valuable in future research. Clinicians acknowledge the importance of building a rapport and enduring relations with women with CPP but feel challenged by communicating in an effective and meaningful way ( 28 , 38 - 40 ). Negative experiences of dismissive and invalidating clinician communication cause women with CPP to withdraw from care, leaving them feeling disempowered and their pain unaddressed ( 15 , 16 , 27 , 29 , 42 ). A systematic review (n=86) representing more than 20,000 women indicated that clinician factors like dismissal of symptoms and the normalisation of symptoms were key barriers to seeking care ( 16 ). Examining the causes for delays in diagnosis, a cross-sectional survey of women with endometriosis (n=506) in Australia, found that an overwhelming 85% (n=340) of participants believed doctor dismissal/disbelief was a reason for the delay ( 42 ). Given the time to diagnosis for endometriosis is between 6 and 8 years ( 13 , 14 ), the barriers to care arising from ineffective clinician communication need to be adequately addressed. Addressing the barriers to care faced by women with CPP is a part of a wider movement toward improving women’s health outcomes. There has been an observed gender pain gap which describes society’s tendency to under-recognise women’s pain and perceive it as an emotional construct, despite chronic pain conditions being more prevalent in women ( 43 - 46 ). Medical misogyny and dismissal of women’s health concerns is a topical area currently being reviewed in political spaces such as Australia’s National Women’s Health Advisory Council ( 47 ). Their report summarised findings from online surveys (n=2,570) and revealed around 67% (n=1,713) of women had personal experiences of gender bias while seeking healthcare and around 38% (n=977) experienced the bias in the context of persistent pain ( 47 ). These women reported feeling dismissed, disbelieved and dehumanised in the setting of a consultation with a healthcare professional ( 47 ). The Australian Victorian Government has recently released The Inquiry into Women’s Pain Report 2025 titled ‘Bridging the Gender Pain Gap’ which involved surveys (n=12,792) of a diverse range of girls, women, healthcare professionals and key stakeholders ( 48 ). Around 90% (n=10,621 out of 11,801) had experienced pain lasting greater than 1 year, 71% (n=5,943 out of 8,370) voiced that widespread dismissal by healthcare professionals was a primary challenge when seeking help, and 89% (n=10,467 out of 11,767) cited that pain had impacted their mental health ( 48 ). One of the key recommendations that came from the report was a focus on improving education and training for health services in order to facilitate patient-centred, empathetic and trauma-informed communication ( 48 ). Clinician language remains a key element of communication that can be examined in future studies to help propagate better outcomes for women with CPP. Future research on experiences of clinician language should encompass the diverse experiences of women with CPP, especially if recommendations are to be formulated. This includes women of different ages, socioeconomic statuses and education levels, indigenous and refugee populations, and those with varying gender identities, such as transgender or non-binary. Different populations face unique challenges, including access to healthcare, financial burdens, social norms and experiences of trauma ( 49 - 52 ). A biopsychosocial approach, where physical, psychological and social factors affecting the patient are addressed alongside diagnosis and management, is integral to the understanding and holistic management of CPP ( 53 - 55 ). There is growing momentum for changes in the approach to the management of women with CPP ( 11 ) and this narrative review has drawn attention to a key area of reform—clinician communication and language. The findings indicate the prevalence of clinical encounters characterised by feelings of invalidation, dismissal and lack of individualisation for women with CPP. To improve their clinical journey, there needs to be further research into the role of language and a policy-driven commitment to educating an array of clinicians on the power of language. Efforts to improve clinician language would align with the six ‘call to action priorities’ of FIGO-IPPS for women with CPP, including ‘empower women and reduce stigma’ and ‘enhance education and awareness’ ( 11 ). By empowering women with CPP and educating others, it could reduce the high rates of withdrawal from care, encourage advocacy and drive research agenda.

The existing literature describes the negative healthcare experiences of women with CPP in which they consistently feel disregarded and not adequately heard. Clinicians have expressed feeling ill-equipped during their efforts to communicate with and address the individualised needs of these patients. However, there is a paucity of qualitative data focused on women with CPP’s perception of clinician language, including their preferences and aversions. A possible research question could target validating versus invalidating communication, especially given the pervasiveness of symptom dismissal. Future research should aim to guide clinicians to effectively communicate with women with CPP, contributing to greater support and engagement during their healthcare journey.

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