Predictors of Psychological Outcomes and the Effectiveness and Experience of Psychological Interventions for Adult Women with Chronic Pelvic Pain: A Scoping Review

Figures & data

Table 1 Basic Overview of Population, Intervention, Comparison, Outcome (PICO) Search Strategy

Review Section	Population	Intervention	Comparison	Outcomes
Part A: Psychological interventions	Women/woman/females AND Chronic Pelvic Pain	Psychological intervention	Control group OR standard care OR placebo	Any outcomes
Part B: Predictors of mental health	Women/woman/females AND Chronic Pelvic Pain	Identification of predictors of mental health outcomes	N/A	Mental health outcomes

Table 2 Sample Search Strategy Used Within Medline Database

Search Term	Search Strategy
Women	1. Exp women/
	2. (women or woman).mp [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
	3. 1 or 2
Pelvic pain	4. Endometriosis/
	5. Exp Pelvic Pain/
	6. (persistent pain or Endometrioma* or endometrios*).mp [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
	7. Chronic Pelvic Pain
	8. 4 or 5 or 6 or 7
Psychology	9. Exp Psychotherapy/
	10. mental health/
Intervention	11. (narrative therap* or cognitive behavioural therapy psychodynamic or mindfulness or acceptance).mp [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
	12. (Psychologic* and (Therap* or interven*)).mp [mp=title, abstract, original title, name of substance word, subject heading word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
	13. or/9–12
	14. and/3, 8, 13

Abbreviations: Exp, exposure; mp, search field; therap, therapy; intervene, intervention.

Figure 1 PRISMA²⁰ diagram.

Abbreviation: n, total number of studies.

Notes: PRISMA. The PRISMA statement; 2015. Available from: http://www.prisma-statement.org/.²⁰

Table 3 Overview of Results Extracted for Psychological Interventions for the Treatment of Women with CPP

Author/Year/Publication Type	Setting, Methodology, Data Collection, Analysis	Participants, Size (n), Diagnoses, Age Range	Intervention	Results	Comments
Albert^Citation32 Journal article	Gynaecology outpatient clinic in Denmark. Pre-post design with 12 months follow up 1988–1997. Qualitative grounded theory, 4 pain drawings, McNemar t-test analyses.	Women with chronic pelvic pain. 18–48 years (M=30.5). Pain duration M=5.25 years. VAS pain score M=2.9. n=53 completed group therapy, n=17 drop outs.	10 x weekly 2.5 hour group, 6 participants per group. First hour physical therapy combined with relaxation, grounding exercises, visualisation. Last 1.5 hours group psychology therapy (trauma conversations, body and mind connection, pain mechanisms, pelvic anatomy, sexuality, behaviour patterns, communication).	39% pain free at 12 months follow up. VAS pain score decreased to M=0.9 (p<0.01). Analgesic unit decrease from M=8.5 to M=0.9 units per week. Benzodiazepines use decreased from 16 persons to 0. n=4 returned to work. Decreased sick leave and National Health Service use. Grounded theory identified four themes of improvement related to self-efficacy across therapy: self-knowledge, self-responsibility, self-active and self-control.	Used 2 different therapists, 6 different physiotherapists. Did not separate psychology versus physiotherapy treatment results. Potential confounding, such as other health conditions and prior treatment, were not considered.
Chao et al.^Citation39 (2015).Journal article	San Francisco hospital and California women’s health centre, USA.1 arm pilot cohort study, pre-post comparison. Measures PHQ-9, SF-36, EHP-5, SHOW-Q, pain catastrophizing scale, MYOP,/30 days health not good.	n=16 women with diagnosed CPP. Mean age 40 (range 23–63).	Monthly group 2-hour sessions based on three components of centering approach: understanding CPP, managing CPP, living with CPP Experiential exercises in pelvic floor therapy, mindfulness, guided imagery, and to provide information about anti-inflammatory diet and herbs provided. Centering Notebook that included educational material for at home.	Statistically significant improvements in EHP-5 score (p=0.01) and SF-36 sub-scales for role limitations, energy/fatigue, and social functioning (p<0.05). Number of unhealthy days reported in the previous month decreased from 24 to 18 (p=0.02). Sexual health outcomes showed statistically significant improvements (p=0.02). Women who attended 4 or more sessions had decreased severity in depressive symptoms (p< 0.05). Patients had improvements in symptom severity (p=0.01) and fewer limitations in activity (p<0.01).	Convenience sample. 61% completed study at follow up, but sample demographically comparable to larger CPP sample from geographic area. Pilot study only, hence no justification for sample size. 16 participants attended 4 or more sessions.
Farquhar^Citation35 Journal article	4 arm RCT Measures were VAS pain ratings, pain improvement rating scale, side effects noted.	CEG_A_243337n=84 women with pelvic pain for over 6 months without explanation and venogram score 5+. Age M=29.8. Groups were placebo control (n=7), psychotherapy with placebo (n=26), psychotherapy with MPA (n=26) and MPA only (n=25).	Psychotherapy with MPA and MPA only groups took 50mg of the drug daily for four months. Psychotherapy included 6 x 45 minute sessions held fortnightly. Graded exercise, behavioural analysis of pain responses, positive coping strategies, increasing activity levels. Details of cognitive components and coping skills not published. Baseline measures, then measures at follow up after treatment concluded and at 9 months post treatment.	No significant difference found between psychotherapy group in comparison to placebo group with reference to pain ratings after treatment or at nine months post intervention.	n=12 withdrew, n=7 lost at follow up. Risk of attrition bias (18%). Not blinded to psychotherapy condition Wide confidence intervals with comparison to controls indicates high potential for error.
Friggi Sebe Petreluzzi et al.^Citation33	Women’s Health Centre Brazil Within group pre-post design. Measures VAS, PSQ, SF-36, salivary cortisol.	n=26 women with Endometriosis and 7+ years of pain, mean age 32.2 (SD=1.3).	10 x weekly 2.5 hour sessions. First hour physical therapy. Psychological 1.5 hours (CBT, education (pain, stress, family, endometriosis). Coping skills, breathing exercises, techniques to manage thoughts, symptoms and feelings.	No significant improvements in SF-36 scores after MANOVA conducted. Significant difference in pre versus post treatment salivary cortisol at 8am collection only (p<0.05). Pain intensity (p<0.05) negatively correlated with physical functioning and mental health. Social functioning positively (p<0.05) mental health, role emotional, physical functioning.	Unclear if psychologists worked together or separately. Confounding with potential to influence cortisol not considered Not possible to separate impact of physical versus psychological components of therapy due to study design.
Ghaly^Citation41 Journal article	Gynaecology clinic, Scotland. Random allocation trial. Measures HADS, MPS, pain duration in months.	n=100 (n=50 scan intervention, n=50 controls) women with CPP, pain duration 6+ months, laparoscopy negative for pathology. Age M=32.2 (SD=1.6), for intervention, M=32.5 (SD=1.5) controls.	Intervention ultrasound scan, education and counselling. Controls ‘wait and see’ with treatment as usual. Re-assessment was 4–9 months post ultrasound.	Difference in results for the 2 groups was significant (p<0.01) on MPS and HADS.	No inferential statistics. n=4 scan, n=6 controls lost to follow up. No power calculation, consistency of intervention not measured. Concealed random allocation but method not specified. Confounding not considered. Performance bias potential due to study design.
Hansen et al.^Citation28 Journal Article	Follow up from Kold et al.^Citation29 longitudinal study. Follow up measures of EHP-30, SF-36	n=10 women with endometriosis who participated in a study by Kold et al.^Citation29 (listed later in this table) none lost to follow up. Age M=48.0 (SD=10.0).	Follow up and measures 6 years post Kold et al.^Citation29 study conclusion.	EHP-30 four out of five scales (pain, control and powerlessness, emotional wellbeing, social support) remained significantly improved. All 8 SF-36 scales that showed significant improvement remained improved 9/10 participants still used intervention techniques particularly body scan and breathing meditation.	This study found that results from the original Kold et al.^Citation29 study were maintained at 6 year follow up, but there were no significant changes between study conclusion and 6 year results. Hypothesized changes due to changes in psychological and emotional coping rather than pain intensity changes.
Haugstad et al.^Citation36 Journal article	Female deep pelvic pain clients from a gynaecology outpatient clinic at a tertiary hospital in Norway. RCT, Mesendieck therapy with gynaecology as usual compared to gynaecology as usual controls. Movement quality assessed with the SMT test (gait, movement and posture assessment). VAS pain scale.	n=40 women with deep pelvic pain (n=20 gynaecology treatment with Mensendieck therapy, n=20 standard gynaecology treatment control group). Age M=34.3 (SD=1.97) for therapy group, M=32.30 (SD=1.43).	Mensendieck assessment test with standardized video, then randomized to groups. 10 x 1 hour Mensendieck somatocognitive therapy across 90 days, with gynaecology treatment for intervention group. Gynaecology treatment as usual for control group. Post-treatment Mensendieck test and video.	Mensendieck somatocognitive sessions significantly higher in all aspects of the Mensendieck test (p<0.05). Significant reduction in VAS scores for Mensendieck group (decreased by 48.4%). Gynaecology treatment as usual group no significant difference in SMT or VAS scores. Hypothesis diaphragm breathing assisted with lymphatic drainage.	Inferred long term effects but follow up was after a short time period. May be difficult to incorporate Mensendieck therapy into primary care settings. Confounding considered and potential confounding excluded but not allowed for in final analyses. Researchers not blinded due to study design, unclear if participants blinded. No attrition figures stated.
Haugstad et al.^Citation27 Journal article	1 year follow up of Haugstad et al.^Citation36 study. VAS and GHQ 30 item scale scores at end of treatment in comparison to 1 year post-intervention.	n=16 intervention participants and n=18 control participants, who previously participated in the Haugstad et al.^Citation36 study. n=6 lost to follow up.	VAS, SMT and GHQ-30 scales end of treatment in comparison to follow up after 1 year.	At 1 year follow up there were no significant improvements in SMT scales in comparison to follow up post treatment.	Initial power calculation from Haugstad et al.^Citation36 was for 20 participants, meaning this study was underpowered.
Kames et al.^Citation26	Women with CPP referred to pain management clinic. Case control trial. Measures MMPI, CIPI, BDI, STAI, MPQ, VAS, 3 point scale rating of social and sexual functioning (worse, same, better).	n=22 women with CPP, n=8 waitlist controls with CPP. Pain duration M=4.5 years (SD=3.9), n=2 drop out during intervention, n=6 lost to follow up.	3 phase trial; evaluation, treatment (6–8 weeks structured protocol), follow up at 6 months. Treatment group completed 2 x weekly acupuncture 1 x weekly psychotherapy sessions. Measures taken pre and post intervention and at 6 month follow up.	No significant change for waitlist controls. For treatment group, STAI, BDI, MPQ affective section, VAS, CIPI total score and activity interference significantly decreased post intervention (p<0.05). MPQ sensory no change in treatment group. At 6 month follow up changes maintained except STAI and MPQ scores, but these still remained significantly lower than pre-treatment measures.	50% also took tricyclic antidepressant medication prior to commencing the study. 1/3 treatment group prescribed opioids for pain. Psychology therapy structured but not uniform. Short term psychology intervention. Participation rate not stated, no random allocation, no allocation concealment, groups not matched. No sample size calculation reported. High program satisfaction reported.
Kold et al.^Citation29	Sample of women with endometriosis only that received treatment at Aarhus hospital Denmark. Within group pre-post comparison design. SF-36, EHP-30 measures.	n=13 women with endometriosis. Ranging from 14–37 years old (Md = 23).	5 x 1.5 hour group sessions included psycho-education, mindfulness techniques, establishing relationship, group counselling. 5 x 1.5 hour individual sessions mindfulness techniques, supportive counselling, one session with partner. Measures taken pre intervention, post intervention, 6 months and 12 months post intervention.	Significant post intervention improvements in SF-36 bodily pain (p<0.001), physical functioning (p=0.018), role-physical (p=0.019), role-emotional (p=0.005), social functioning (p=0.014), general health (p=0.023). EHP-30 pain scale (p<0.001), control and powerlessness (p<0.001), emotional well-being (p<0.001), social support (p=0.008) significant improvements. No significant different in sexual intercourse scale.	No drop outs. Principal researcher excluded from data collection and analysis. Participant forms self-report and completed at home. No control group for comparison, limits causal conclusions.
Meissner et al.^Citation30	German sample. March 2010–2012, RCT design. Measures fMRI of brain connectivity, 11 point numeric pain scale, physical and mental quality of life (SF-12, FW7, HADS anxiety and depression, STAI).	n=67 women with a verified history of endometriosis and pelvic pain (n=35 intervention group, n=32 waitlist controls). Age M=35.6.	Psychotherapy with somatosensory stimulation through acupuncture points versus waitlist control. 30–60 minute psychology sessions which included mindfulness, hypnotherapy, problem solving and CBT. On average 8 (IQR =8–10) sessions of 20–60 minute acupuncture and Chinese medicine sessions attended.	Psychotherapy with somatosensory stimulation significant (p<0.05) decrease in global pain, pelvic pain, dyschezia, depression, anxiety, functional wellbeing and significant increase in quality of life (mental and physical) in comparison to controls. Moderate to large effect sizes. Held at 6 and 12 month follow up. Brain areas and scan no significant findings.	Underpowered for control group at 6 and 24 month follow up. Unusual pain scale and some pain ratings were retrospective. Participants and researchers were not blinded. Confounding not considered. Can not draw conclusions linking brain mechanisms and psychological processes from results. Session content not set. Unsure whether Chinese medicine or psychology or both lead to results.
Norman et al.^Citation37	Sample of women from USA, recruited from various pain clinics, media advertisements and through the Endometriosis Association. Prospective RCT. Measures MPQ, SIP, PANAS negative affect, AEQ, CSQ measures. Outcomes were ambivalence, catastrophizing, negative affect, mood.	n=48 with CPP (n=28 disclosure, n=20 positive control groups). Age M= 32.2 (SD=11.5). Endometriosis diagnosed in 50%. n=12 drop out.	Assessment, demographics and medical history taken. Given measures and wrote initial essays. Measures and essay at two month follow up Emotional exposure group wrote about their negative experiences with CPP, controls wrote about positive life experiences unrelated to CPP.	Initially after writing, emotional writing significantly decreased positive mood and increased negative mood, sadness, anger, guilt, fear and decreased happiness. But the disclosure group significant reduction in MPQ evaluative pain (p=0.01). Whereas control group not changed. Writing about stressful aspects of pain improved evaluative dimension of pain. Women with ambivalence to expressing emotions had the most benefit. See Norman et al.^Citation37 in Table 3 for moderators of group effects.	M=14.9 years education (11–18), 83% European. No power calculation. Participants were not blinded. 75% of participants had a history of diagnosed depression.8/12women gave reasons for drop out, feedback was it was too upsetting or too hard to think positively of their CPP. Follow up measures completed at home.
Poleshuck et al.^Citation31	Women with CPP and MDD from 2 urban obstetrics and gynaecology and family medicine clinics in the USA. RCT design. Measures SCID-IV, BDI, HDRS, MPI, IPP, CSQ, PHQ2, SF36, pain intensity and interference rating.	n=61, women with CPP and MDD diagnoses. IPT treatment group (n=34) enhanced treatment as usual (n=28). IPT age M=36.3 (SD=8.2), treatment as usual M=37.1 (SD=9.8).	IPT versus treatment as usual. IPT group 8 sessionsacross 36 weeks, Assessments completed at 12, 24, 36 weeks at home or medical clinic.	IPT participants had significantly lower adjusted depression scores, significantly lower MDD occurrence, lower interpersonal sensitivity, lower interpersonal ambivalence and lower aggression in comparison to treatment as usual group (p<0.05). No significant differences between groups for pain.	n=24 declined to participate, n=85 agreed to participate but then lost to follow up. IPT group had higher pain ratings that treatment as usual group. No power calculation reported. Medications differed across participants. Treatment as usual group treatment was not standardized. Depression could influence engagement.
Zhao et al.^Citation38	Han Chinese women with Endometriosis. Open label RCT. Measures STAI, HADS depression subscale, SF36, Health related quality of life pre and post intervention. Repeat measures	n=100 women with endometriosis. n=50 progressive muscle relaxation and gonadotrophin-releasing hormone agonist therapy group, n=50 controls who only underwent gonadotrophin-releasing hormone agonist therapy. Age range 18–40, split into 3 age groups (<25, 25–30, >30)	Progressive Muscle relaxation and gonadotrophin group did 2 x per week 40 minute group progressive muscle relaxation plus 2 at home CD recording sessions for 2 x day for 12 weeks plus one dose of depot leuprolide 11.25mg IM GnRH therapy. Controls had one dose of depot leuprolide 11.25mg IM GnRH.	Both progressive muscle relaxation and controls reported improved health related quality of life (p<0.01). Significant improvement in state anxiety (p<0.01), trait anxiety (p<0.01) and depression (p=0.01) in progressive muscle relaxation group in comparison to controls due to intervention over time.	n=67 declined to participate. n=13 drop outs. Confounding not considered. Blinding not stated. At home practice sessions self-reported. Stage III and IV endometriosis patients only. Current mental illness was excluded.

Abbreviations: RCT, Randomized control trial; HPA, hypothalamic-pituitary-Adrenal; n, number of participants; SD, Standard deviation; M, Mean; HADS, Hospital Anxiety and Depression Scale; STAI, State-Trait Anxiety Index; SFHS-12, Short Form Health Survey; CNS, Central Nervous System; CBT, Cognitive Behavioural Therapy; MRI, Magnetic Resonance Imaging; p, significance statistic; PHQ-9, Patient Health Questionnaire-9 item; SF-36, Short Form Health Survey-36 item; EHP-5, Endometriosis Health Profile- 5 item; EHP-30, Endometriosis Health Profile-30 item, SHOW-Q, Sexual Health Outcomes in Women Questionnaire; MYOP, Measure Yourself Medical Outcome Profile; MPA, Medroxyprogesterone Acetate; PSQ, Perceived Stress Questionnaire; VAS, Visual Analogue Scale, MPQ, Magill Pain Questionnaire; HADS, Hospital Anxiety and Depression scale; SMT, Standardized Mensendieck Test; GHQ-30, General Health Questionnaire-30 item; MMPI, Minnesota Multiphasic Personality Inventory; CIPI, Chronic Illness Problem Inventory; BD, Beck Depression Inventory; Md; Mean Difference; fMRI, Functional Magnetic Resonance Imaging; FW-7, Functional Wellbeing 7-item; PANAS, Positive and Negative Affect Scale; AEQ, Ambivalence Over Emotional Expression Questionnaire; SIP, Sickness Impact Profile; IPT, Interpersonal Therapy; SCID-IV, Structured Clinical Interview for the Diagnostic and Statistic Manual fourth-edition; HDRS, Hamilton Rating Scale for Depression; MPI, Multidimensional Pain Inventory; IPP, Inventory of Interpersonal Problems; CSQ, Client Satisfaction Questionnaire; PHQ2, Patient Health Questionnaire 2; MDD, Major Depressive Disorder; PSI, Perceived Stress Index; MPA, medroxyprogesterone.

Table 4 Predictors of Mental Health Outcomes in Women with CPP

Author/Year	Setting, Methodology, Data Source	Participants, Size (n), Diagnoses, Age.	Results	Comments
Allaire et. al.^Citation45	Women with CPP from an interdisciplinary pain clinic including counselling intervention in British Columbia. 1 year prospective cohort study design. EHP-30, service access reports, VAS pain ratings.	n=296 women with CPP. Age M=34.3 (SD=7.6).	Multi-disciplinary treatment in a team including psychology improved median pain severity and decreased emergency and physician visits after 1 year. Quality of life on the EHP-30 pain subscale improved. Higher chronic pain severity at 1 year associated with higher pain catastrophizing score at baseline. Counselling intervention included mindfulness skills (body scan, breathing, progressive muscle relaxation) and CBT to challenge thinking and beliefs.	57% response rate at 1 year follow up. May not be generalizable to other cohorts. Did not consider potential moderators of catastrophizing at baseline. Participants were reported to have 2 visits to counselling.
Donatti et al.^Citation48	Brazilian sample of women with Endometriosis. Prospective explorative within group design. COPE, BDI, LISS measures.	n=171 women with endometriosis. Age M= 39.5 (SD=5.6) years of age.	Higher depression scores predicted higher maladaptive strategies in solving daily life problems. Increased CPP severity predicted increased stress and increased depression scores. Participants who used positive coping strategies had lower depression scores and adapted better to stress.	Statistics appeared to be correlational than inferential and were not well described. Not reflective of population as a whole. No inferential statistics. Confounding not considered. Withdrawal participants not described.
Facchin et al.^Citation72	Women with endometriosis from an Italian obstetrics and gynaecology department sample recruited 2012–2014. Cross-sectional study, between groups comparisons. Investigated whether endometriosis predicted personality factors on the TCI-R 240 item scale.	n=133 split into 3 groups: endometriosis with pain (n=58), endometriosis no pain (n=24) and controls no endometriosis or pain (n=51).	Women with pain and endometriosis had lower novelty seeking, lower exploratory excitability, higher harm avoidance, lower responsibility and higher fatigability in comparison to pain free endometriosis and control groups. Higher CPP severity predicted higher harm avoidance and lower self-directedness.	Small control sample, groups not matched. May not be generalizable to other cohorts. Included pain with sex and periods associated with endometriosis diagnoses. Model of personality related to Cloningers’ model (1998).
Facchin et al.^Citation46	Italian women with endometriosis from a gynaecology department, recruited 2015–2017. Cross sectional study, within group design. Measures HADS, RRS for mental health outcomes. Rosenburg self-esteem scale, emotional self-efficacy scale.	n=210 endometriosis patients. Age M=36.7 (SD=7).	Being in a stable relationship was associated with decreased rumination on the RRS. Pelvic pain severity predicted anxiety, depression and rumination. Greater self-esteem, body esteem and emotional self-efficacy were associated with less anxiety, depression and rumination.	Potential confounding (eg Fertility, pregnancy, sexual concerns, beliefs about gender, cultural differences) was not considered.
Facchin et al.^Citation47	Italian women with Endometriosis recruited from an endometriosis service 2014–2015. Grounded theory based interviews looking at how endometriosis affects mental health. Textual analysis of transcripts. Qualitative study.	n=74 women with Endometriosis. Age M= 36.44 (SD=6.9).	Women with high distress reported regular life disruption as a theme, where those without distress did not. Life disruption and continuity of care were affected by: pathway to diagnoses, quality of doctor-patient relationship, support (intimate and financial), female identity (body impact, fertility, sexuality), meaning of life with endometriosis.	One institution limits generalizability of results. Cultural and gender factors not considered.
Kaya et al.^Citation54	Women with PP from Inonu University Medical Facility in Turkey, collected January – April 2000. Cross-sectional survey, quasi-experimental case control design. Measures BDI, BAI, STAI, GRIS.	n=19 women with CPP. Age M= 34.1 (SD=9.3), n=25 healthy controls, age M=30.6 (SD=7.3).	Avoidance, dissatisfaction and non-sensuality subscales of the GRIS positive correlation with depression and anxiety scores. Linked anxiety, depression and sexual dysfunction in women with CPP.	Underpowered. Non-parametric statistics. Statistical investigation stopped at correlations for some associations.
Low et al.^Citation52	Women with CPP who presented to a UK gynaecology clinic with concerns related to CPP, infertility or both. Between groups comparison. EPQ, BDI, GHQ-30, STAI, GRIMS, MPQ-SF short form measures.	3 groups of women separated by referral reason. n=61 CPP referral group, n=12 infertility referral group, n=15 CPP and infertility referral group. Measures completed 2 weeks pre-treatment and 13 months post-treatment.	Concluded anxiety associated with pain not fertility. Less psychopathy associated with less pain.	Small group sizes and no power calculation noted. Confounding not considered. n=58 had prior treatment, n=50 had prior surgical treatment. Pre and post assessments in different settings. CPP higher anxiety pre and post treatment in comparison to infertility group.
Norman et al.^Citation37	US obstetrics and gynaecology sample of women with CPP. Prospective RCT. Demographics, medical history taken at assessment. Measures essays, MPQ, SIP, PANAS negative affect, AEQ, CSQ at assessment and two month follow up.	n=48 (n=28 disclosure, n=20 control groups). 18–64 (M=38.2, SD= 11.5) years old. n=12 drop out. For written emotional exposure, CPP group wrote about their negative experiences with CPP, controls wrote about positive life experiences unrelated to CPP	Baseline catastrophizing, negative affect and ambivalence were found to predict daily disability. However, baseline catastrophizing was no longer a significant moderator of daily disability over and above negative affect and baseline ambivalence.	No power calculation and high drop-out rate. Participants predominantly Caucasian. 75% of women reported previous depression diagnoses which may have influenced negative affect and ambivalence.
Oniszczenko et al.^Citation58	Sample of women hospitalized for gynaecological reasons in Polish hospital. Cross-sectional study. PTSD-FVIT, FCB-TI, MSI, GHQ-28.	n=136 women with CPP, 18–60 (M=34.60, SD=9.92) years old. n=10 drop outs.	Emotional reactivity, anxiety and lovability explained 8%, 34% and 6% of the variance in PTSD FVIT scores respectively, 48% of total variance. Suggested esteem has a protective role in trauma for women with CPP.	No power calculation. Participants were not blinded. 75% of participants had a history of diagnosed depression. 8/12 women gave reasons for drop out, feedback was it was too upsetting or too hard to think positively of their CPP. Multiple diagnoses included. Follow up measures were completed at home.
Petreluzzi et al.^Citation51	Women with CPP recruited from Brazilian Women’s Health Centre for endometriosis group, Between groups comparison. PSQ, HRQOL- SF-36, HPA axis activity from salivary cortisol, VAS for pain scores measures.	n=93 women with endometriosis and CPP non responsive to surgical or pharmacological treatment, n=82 controls made up of university staff and student volunteers. Endometriosis diagnosed by laparoscopy or laparotomy. Age endometriosis group M=33.85 (SD=1.04) controls M=30.9 (SD=0.92).	PSQ stress score higher for women with constant versus intermittent pain, pain intensity did not differ between groups.	Mental health conditions such as anxiety and depression can influence salivary cortisol. Antidepressants can be used to manage CPP in women and may influence cortisol concentrations. Participants had different levels of endometriosis. Did not consider many confounding variables.
Spinhoven et al.^Citation57	Women with CPP recruited from gynaecology departments of two academic hospitals in the Netherlands. Cohort study, correlational design. CPP sample was one of four samples in this study. SDQ-20 and self-report measures.	n=52 women who had CPP for over six months. Age M= 37.8 (SD=9.7) years.	Positive association between self-reported physical abuse and SDQ-20 scores for somatoform dissociation remained after general psychopathy removed as a mediating factor. Suggested considering dissociation in physical abuse history.	Physical abuse was self-reported.
Toomey et al.^Citation55	Women with CPP from a hospital based CPP clinic in North Carolina. Between groups design. Abuse history questionnaire, MPQ, MPI, FIS, SLC-90 measures.	n=36 women with CPP, n=19 reported abuse history, n=17 reported no abuse history. VAS pain M=4.91 (SD=5.95), age M=30.31 (SD=9.56) years.	19/36 participants reported prior abuse. Abuse group reported less perceived control, greater punishing responses to pain, high somatization, higher global distress in comparison to non-abuse group.	t-test only for statistical analyses and no consideration of potential confounding.
Vannuccini et al.^Citation49	Italian sample of women with endometriosis. Observational cross-sectional design. PHQ measure.	Women with endometriosis n=134. Age M= 34.8 (SD=6.3) years, BMI M=22.0 (SD=3.7).	Having a mental health condition was highly correlated with pain symptoms. Pain positively correlated with incidence of multiple psychiatric disorders, pain and somatoform disorders were positively correlated.	Chronic pain often diagnosed as somatoform disorder hence high association pain and somatoform disorder diagnoses. Response rate 89.3%.
Weijenborg et al.^Citation50	Women with CPP who attended gynaecology outpatient clinic at Leiden University in the Netherlands, between July 2001-January 2006. Retrospective cohort study. Intervention was hospital team treatment. Rand-36, HADS. PCCL, McGill VAS on MPQ Dutch version.	n=84 women with CPP completed pre and post measures. Age M= 40.2 (SD=11.3) years.	Reduction in pain intensity and catastrophizing, as well as improvements to depressive symptoms and SF-36 physical scores at follow up in comparison to baseline. Baseline PCCL internal pain control subscale score was associated in changes in depression scores and baseline pain intensity. PCCL catastrophizing and internal pain control subscales were negatively correlated.	64% response rate that completed baseline and follow up measures. Correlation analyses.

Abbreviations: BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory; CPP, chronic pelvic pain; COPE, Brief Coping Orientation to Problems Experienced; EHP-30, Endometriosis Health Profile 30- item; GRIS, Golombok-Rust Inventory of Sexual Satisfaction; HADS, Hospital Anxiety and Depression Scale; n, sample size; LISS, Lipps Stress Symptom Inventory for Adults; M Mean; SD, standard deviation, RCT, randomized control trial; RRS, Ruminative Response Scale; STAI, Speilberger State Trait Anxiety Index; VAS, Visual Analogue Scale; EPQ, Eysenck Personality Questionnaire; GHQ-30, General Health Questionnaire 30-item; GRIMS, Golombok-Rust Inventory of Marital State; MPQ-SF, Mcgill Pain Questionnaire- short form; MPQ, Mcgill Pain Questionnaire; PTSD, Post-Traumatic Stress Disorder; PTSD-FVIT, Post-Traumatic Stress Disorder Factorial Version Inventory; FCB-TI, Formal Characteristics of Behaviour Temperament Inventory; MSI, Multi-dimensional Self-esteem Inventory; PSQ, Perceived Stress Index; HRQOL, Health Related Quality of Life; SF-36, Short Form Survey 36-item; SDQ-20, Somatoform Dissociation Questionnaire; PHQ, Patient Health Questionnaire; PCCL, Pain Appraisal and Pain Coping Scale; GHQ-28, General Health Questionnaire 28-item; FIS; Functional Interference Scale; SCL-90, Symptom Checklist 90 item; HPA, Hypothalamic-Pituitary-Adrenal; TCI-R, Temperament and Character Inventory –Revised; SIP, Sickness Impact Profile; PANAS, Positive and Negative Affect Schedule; AEQ, Achievement Emotions Questionnaire; CSQ, Client Satisfaction Questionnaire; PCOS, Polycystic Ovary Syndrome.

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