European Journal of Cardiovascular Medicine

Chronic Pelvic Pain Syndrome (CPPS) is a complex and often debilitating condition characterized by non-cyclical pain localized in the pelvic region, persisting for six months or longer, and severe enough to impair daily functioning. Distinct from pain associated with menstruation, pregnancy, trauma, or pelvic surgeries, CPPS remains a diagnostic and therapeutic challenge due to its multifactorial etiology and overlap across medical disciplines, particularly gynecology and urology. Epidemiological studies suggest that CPPS affects between 3% and 10% of the female population, highlighting a significant public health concern. [1-3]

According to the Royal College of Obstetricians and Gynecologists (RCOG), the underlying causes of CPPS can be broadly categorized into gynecological (e.g., endometriosis, adenomyosis) and extra-gynecological origins, such as urological, gastrointestinal, musculoskeletal, psychosomatic, and neurological factors. Despite extensive investigations, many cases remain idiopathic, suggesting a complex interplay between somatic, autonomic, and cognitive systems. [4-6]

Cognition and pain share overlapping neural substrates, and the relationship between the two is reciprocal—pain can impair cognitive functions, and cognitive dysfunction can influence pain perception. This is especially relevant in chronic pain syndromes, where sustained nociceptive input may interfere with executive function, working memory, and attention. Psychological comorbidities such as anxiety, depression, and perceived stress further complicate this relationship, acting as both causes and consequences of chronic pain.[6,7,8]

In this context, chronic pelvic pain presents a unique model to explore how persistent pain impacts cognitive performance in women. Given the multifactorial nature of CPPS and its potential influence on brain-body interactions, a comprehensive evaluation of cognitive function is essential for a deeper understanding of its pathophysiology and for informing more targeted interventions.

Therefore, the present study aims to assess autonomic and cognitive dysfunctions in women diagnosed with chronic pelvic pain.

By integrating physiological, psychological, and neurocognitive assessments, this research seeks to contribute to a more holistic understanding of CPPS and its broader implications on women’s health.

Study Design

This was a cross-sectional observational study conducted to evaluate cognitive dysfunction in female patients with chronic pelvic pain (CPP).

Study Setting and Duration

The study was carried out at the Department of Physiology in collaboration with Gynecology Outpatient Department (OPD) of Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, over a period of 18 months.

Study Population

A total of 200 female participants aged between 18 and 60 years were enrolled. The study group included 100 women diagnosed with chronic pelvic pain, while 100 age-matched healthy females from the community served as the control group.

Inclusion Criteria

Participants were included if they were females aged 18 to 60 years. The study group comprised subjects diagnosed with non-cyclical chronic pelvic pain of at least six months’ duration. The control group included healthy females without any history of pelvic pain or chronic illnesses. All participants had at least 12 years of formal education and scored 25 or above on the Mini Mental State Examination (MMSE).

Exclusion Criteria

The following individuals were excluded from the study:

1. Those with cyclical pelvic pain such as dysmenorrhea.
2. Subjects with pain related to malignancy.
3. Patients with chronic inflammatory bowel diseases.
4. Pregnant women and those with pain related to sexual intercourse (dyspareunia).
5. Individuals with history of stroke, dementia, major depressive disorder, psychosis, or diagnosed anxiety disorders.
6. Participants with significant hearing or visual impairment.
7. Patients with chronic illnesses known to affect cognition such as diabetes mellitus, hypertension, chronic kidney disease, or other neurological conditions.
8. Individuals with a history of cardiovascular diseases.
9. Participants on medications known to impair cognitive or autonomic function.
10. Subjects with less than 12 years of formal education or MMSE scores below 25.

Assessment of Pain

Pain was assessed using the Short-Form McGill Pain Questionnaire (SF-MPQ), a validated tool that captures both sensory and affective dimensions of pain in a structured format.

Cognitive Function Assessment

Cognitive functions were assessed using a standardized neuropsychological battery to evaluate multiple domains such as memory, executive function, attention, and visuospatial skills. The following tools were used:

• Mini Mental State Examination (MMSE) for global cognitive screening.
• Perceived Stress Scale (PSS) to evaluate psychological stress.
• Hamilton Anxiety Rating Scale (HAM-A) for anxiety assessment.
• Beck Depression Inventory-II (BDI-II) to evaluate depressive symptoms.
• Rey Auditory Verbal Learning Test (RAVLT) to assess verbal memory and learning.
• Rey–Osterrieth Complex Figure Test (CFT) for visual memory and visuospatial abilities.
• Victoria version of the Colour-Word Stroop Test to assess executive function and cognitive flexibility.

All assessments were conducted in a quiet clinical setting by trained professionals under standardized conditions.

Ethical Considerations

The study protocol was approved by the Institutional Ethics Committee (IEC) of IGIMS, Patna. Written informed consent was obtained from all participants before enrolment. Participation was entirely voluntary, and subjects were allowed to withdraw at any point during the study without any consequences.

Statistical Analysis

Data were expressed as mean ± standard deviation (SD). Differences between the study and control groups were analyzed using independent t-tests. A p-value of less than 0.05 was considered statistically significant. Data analysis was performed using SPSS software (version to be specified).

The following tables present the results of the cross-sectional observational study conducted at the Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, evaluating cognitive dysfunction in women with chronic pelvic pain (CPP) compared to healthy controls.

Table 1 presents the demographic characteristics of the study participants, comparing the chronic pelvic pain (CPP) group with the control group. The two groups were comparable in terms of age, educational background, body mass index (BMI), and Mini Mental State Examination (MMSE) scores. There were no statistically significant differences observed in any of these baseline characteristics, with p-values well above the 0.05 threshold. This suggests that the two groups were appropriately matched and that any differences observed in cognitive function can more reliably be attributed to the presence of chronic pelvic pain rather than demographic confounders.

Table 1: Demographic Characteristics of Study Participants

Table 2 details the pain characteristics among participants in the CPP group. The total pain score, as assessed by the Short-Form McGill Pain Questionnaire (SF-MPQ), averaged 22.4 with a range from 10 to 35, indicating moderate to severe levels of perceived pain. Sensory pain scores were higher than affective pain scores, suggesting that the pain experienced was primarily somatic in nature. The mean pain duration was 18.3 months, with a wide range from 6 to 48 months, reflecting the chronic nature of the condition and the potential for long-term impact on psychological and physiological health.

Table 2: Pain Characteristics in the CPP Group

Table 3 outlines the cognitive performance outcomes in both groups. Although there was no significant difference in MMSE scores, more sensitive neuropsychological assessments revealed that the CPP group performed significantly worse across all domains. In the Rey Auditory Verbal Learning Test (RAVLT), both immediate and delayed recall scores were significantly lower in the CPP group, indicating deficits in verbal memory. Similarly, in the Rey–Osterrieth Complex Figure Test (CFT), both copy and delayed recall scores were significantly impaired, suggesting reduced visuospatial processing and visual memory. The CPP group also showed poorer performance in the Stroop interference task, with significantly longer response times, reflecting deficits in attention and executive function.

Table 3: Cognitive Function Assessment

Table 4 focuses on the psychological status and perceived stress levels of the study participants. The CPP group had significantly higher scores on all psychological scales. The Perceived Stress Scale (PSS) scores were notably elevated, indicating heightened stress perception. Scores on the Hamilton Anxiety Rating Scale (HAM-A) and the Beck Depression Inventory-II (BDI-II) were also significantly higher in the CPP group compared to controls, suggesting a greater burden of anxiety and depressive symptoms. These findings underscore the strong psychological component associated with chronic pelvic pain and its potential role in mediating cognitive dysfunctions.

Table 4 : Psychological and Stress Assessments

This study aimed to evaluate the cognitive dysfunction in women diagnosed with chronic pelvic pain (CPP). The findings revealed significant alterations in cognitive domain among CPP patients when compared to age-matched healthy controls, offering deeper insight into the pathophysiological complexity of chronic pelvic pain.

The demographic characteristics between the CPP and control groups were statistically comparable, ruling out the influence of confounding baseline variables such as age, education, BMI, and global cognitive screening via MMSE. This confirms that the observed differences in cognitive outcomes can be attributed to the chronic pain condition rather than demographic disparities.

In line with prior research, the CPP group reported moderate to severe pain levels, as indicated by elevated total SF-MPQ scores. The sensory component of pain was more pronounced than the affective component, which aligns with earlier findings by Melzack [9], emphasizing the predominance of somatic over emotional pain descriptors in chronic non-cyclical pelvic pain.

Cognitive testing revealed significant deficits in verbal memory, visuospatial processing, and executive function in the CPP group. While MMSE scores did not differ significantly, more sensitive domain-specific neuropsychological assessments uncovered meaningful impairments. In particular, the RAVLT scores demonstrated reduced immediate and delayed recall, echoing the findings of Till et al. [5], who noted similar deficits in women with chronic pelvic pain. Likewise, diminished performance on the CFT and Stroop tasks is consistent with the view that chronic pain interferes with both memory consolidation and executive control mechanisms, potentially due to overlapping neural networks that mediate pain perception and cognitive processing [6].

The psychological assessments further illuminated the burden of CPP, with significantly higher levels of perceived stress, anxiety, and depression in the study group. These psychological disturbances may not only exacerbate the perception of pain but also contribute independently to cognitive dysfunction. Cohen et al.’s Perceived Stress Scale [9] and the Hamilton Anxiety and Beck Depression scales [10,11] were sensitive in detecting these differences. These findings affirm the biopsychosocial model of chronic pain, which recognizes psychological comorbidities as integral to the experience and outcomes of pain syndromes.[12-14]

These associations highlight a dynamic interplay between physiological and cognitive domains and support the notion posited by Urits et al. [6] that therapies targeting cognitive pathways—such as cognitive behavioral therapy and mindfulness-based stress reduction—may offer dual benefits for this population.

These findings contributes to the growing literature on the systemic effects of chronic pain. The overlap between our results and those of studies by Loerbroks et al. [4] and Till et al. [5] further reinforces the robustness of the observed relationships between pain and cognition.

Strengths and Limitations

One of the key strengths of this study was the comprehensive approach involving psychological and cognitive assessments under standardized conditions. The relatively large sample size and rigorous inclusion/exclusion criteria improved internal validity. However, the cross-sectional nature of the study limits the ability to infer causality. Longitudinal studies would be valuable in determining the directionality and progression of these impairments. Moreover, hormonal factors, sleep disturbances, and medication history, though partly controlled for, could have subtle effects not captured in this design.

Implications for Clinical Practice

These findings underscore the importance of a multidisciplinary approach in managing CPP. Beyond gynecological evaluation and pain management, there is a clear need for routine assessment of cognitive status in this population. Interventions aimed at cognitive rehabilitation and psychological counseling, may hold promise in improving quality of life for these patients.

The present study highlights a significant association between chronic pelvic pain and alterations in cognitive functions among women. Women with CPP exhibited notable impairments in memory, visuospatial ability, and executive function. These findings were further compounded by elevated levels of stress, anxiety, and depression, underscoring the multifaceted impact of chronic pain on overall well-being. Importantly, the observed correlations suggest a shared neurophysiological basis, reinforcing the need for integrative diagnostic and therapeutic strategies. Addressing psychological distress alongside conventional gynecological care may offer a more holistic and effective approach to managing CPP. Future longitudinal and interventional studies are warranted to explore causal relationships and to evaluate the efficacy of targeted therapies aimed at improving both neural function in this patient population.

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