“It’s a Right Pain in the Pelvis!”: Post-Traumatic Stress and Post-Traumatic Growth in a Sample of Females Experiencing Chronic Pelvic Pain

Abstract

Chronic pelvic pain affects 38 per 1,000 women yearly (Daniels & Khan, 2010; Zondervan et al., 1999), accompanied by various psychological sequelae. Positive psychology may offer new approaches to pelvic pain that complement existing interventions; these include post-traumatic growth (PTG), optimism, resilience, and models of recovery. In a sample of 132 females (aged 16 to 45+), cross-sectional research revealed that participants with pelvic pain of unknown cause had the highest levels of post-traumatic stress disorder (PTSD) symptoms. A regression analysis revealed that intrusive rumination, avoidant coping, and resilience were significant predictors of PTSD symptoms, and resilience and social support were predictors of PTG. Understanding the elements of positive psychology could help create positive psychology interventions focusing on chronic pelvic pain’s impact on mental health.

Keywords:

• Chronic pelvic pain
• PTSD symptoms
• PTG
• rumination
• positive psychology

Introduction

Chronic pelvic pain is a physical ailment associated with pain concentrated in the lowest part of the abdomen; to be considered chronic, it must last for 6 months or longer (Howard, 2003; Daniels & Khan, 2010; Bryant et al., 2016; McGowan et al., 1998; Meltzer-Brody et al., 2007; Till et al., 2019; Wozniak, 2016; Zondervan et al., 1999). It is estimated that 69 conditions have the potential to cause chronic pelvic pain, with endometriosis being one of the most common (Howard, 2003; Brooks et al., 2020). In the United Kingdom (UK), however, fibroids are the most frequently reported cause (Eskenzai & Warner, 1997; Kuznetsov et al., 2017). The experience of chronic pelvic pain also affects individuals’ mental health, including but not limited to depression and anxiety (Bryant et al., 2016; Till et al., 2019) and even post-traumatic stress disorder (PTSD; Meltzer-Brody et al., 2007; Herbert, 2010). Severe chronic pelvic pain can lead to invasive gynecological procedures, including surgery (Wozniak, 2016; Meltzer-Brody et al., 2007; Till et al., 2019; Howard, 2003), and these procedures are one potential reason for the occurrence of PTSD (Tedstone & Tarrier, 2003; Oniszczenko et al., 2016).

However, as suggested by Tedeschi and Calhoun (1996), after exposure to adversity, individuals have the potential to undergo post-traumatic growth (PTG). PTG can be defined as the ability to experience self-improvement and ultimately make positive changes following a traumatic event, allowing a broader understanding of oneself and the world. It has been proposed that coping mechanisms, social support, and rumination (a form of cognitive processing), among other factors, have the potential to influence PTG (Tedeschi & Calhoun, 2004; Zhou et al., 2021). To our knowledge, PTG has never been considered in the chronic pelvic pain literature, but it has been assessed in gynecological cancer research. Zhou and colleagues (2021) reviewed a sample of 344 women with cancer and found evidence of PTG, with social support and all forms of medical coping being significant predictors, supporting Tedeschi and Calhoun’s (2004) claims regarding the variables that can influence growth. In contrast, pelvic pain, which is a much more individualized experience, influences how one behaves both socially and romantically, with research finding that relationships can be negatively affected by chronic pelvic pain (Oniszczenko et al., 2016; Gilbert et al., 2011; Jones et al., 2004; Denny, 2004; Huntington & Gilmour, 2005; Fagervold et al., 2009; Cox et al., 2003). What needs to be addressed is whether PTG exists in females experiencing chronic pelvic pain, which is one of the most common complaints in gynecological clinics (Ghaly & Chien, 2000; Herbert, 2010), while accounting for potentially influencing variables. Likewise, because of PTSD’s suggested relationship to PTG, it too needs to be studied, as up to this point it has been missing from the field’s literature. Similarly, avoidance and rumination are thought to be key factors in trauma, according to Ehlers and Clark (2000), but this has not been confirmed in a sample of women with chronic pelvic pain.

Endometriosis patients with chronic pelvic pain experience difficulty coping. In particular, rumination has been found to be a negative coping mechanism, ultimately increasing the experienced pain (Martin et al., 2011; McPeak et al., 2018; Till et al., 2019). Other forms of negative coping strategies relating specifically to avoidance behaviors were found to influence the levels of stress experienced by women diagnosed with endometriosis (Donatti et al., 2017). This suggests that thinking continuously about the pain increases its intensity. It is posited that moving the attentional focus away from the pain, such as by being more optimistic, can decrease the level of pain experienced (Geers et al., 2008; Goodin, Glover et al., 2013; Carver & Scheier, 2014). Furthermore, resilience can play a significant role, as research has found that the evolution of endometriosis over time was positively related to resilience (Lubián-López et al., 2021). It could be argued that due to long waiting times for treatment (6 months to 2 years or more, according to a recent survey by Endometriosis UK (2022)), women have no alternative but to build resilience and learn to cope with their condition. It is possible that adopting a positive mind-set supports the idea that life goes on after adversity (Tedeschi & Calhoun, 2004). Yet women’s pelvic pain experiences are often negative, with many women feeling dismissed or misunderstood (Till et al., 2019; Bryant et al., 2016), given the societal view that they should be able to cope as well as any other woman (Denny, 2004). This is evidenced by Facchin et al. (2018), who found that, even when experiencing their worst pain, women often chose not to visit a health care worker (HCW). Another review suggests that poor relations with HCWs can prompt the development of PTSD (Tedstone & Tarrier, 2003). It is entirely plausible that women’s experiences are still influenced by the concept of “hysteria,” as suggested by research into the treatment of endometriosis (Guidone, 2018).

It is vital that chronic pelvic pain not be viewed as a single entity; rather, it is an entity that can be caused by multiple conditions (Till et al., 2019), and some individuals experience pelvic pain with no known cause (McGowan et al., 1998; Thomas et al., 2006). Several implications are worth considering, but one key issue ignored in the literature is whether the causes of pelvic pain are related to the experience of PTSD. It could be argued that not having a definitive diagnosis negatively influences a woman’s mental health, which could be an important concept when considering trauma. Therefore, the aim of this research was to establish whether the cause of pelvic pain influences the level of PTSD symptoms. Due to the nature of the chronic pain experience, it is possible that pain becomes a component of the individual’s identity, known as event centrality, which in turn could predict the likelihood of experiencing either trauma or growth. This has not been considered in previous pelvic pain research, so our study assessed potential predictors for both PTSD symptoms and PTG. Coinciding with the nature of the sample and the participants’ continually reoccurring pain, and in line with Tedeschi and Calhoun’s (2004) research, potential growth-promoting variables were selected to provide a broader understanding of the pain experience from different perspectives in an understudied sample. This generated two research questions:

1. Are there differences among the various chronic pelvic pain conditions with regard to the presence of PTSD symptoms?

2. What are the key variables predicting PTSD symptoms and PTG in a chronic pelvic pain sample?

Methods

Design

A cross-sectional design was selected for the study. To obtain the required sample, a purposive sampling technique was used. This technique was chosen because it allowed the deliberate selection of the sample to ensure that the participants had the relevant experiences to answer the research questions. We focused on social media groups aimed at individuals with chronic pelvic pain with strict criteria for joining. Potential members were asked a series of questions about their conditions and experiences, and their responses were evaluated before being either accepted or rejected by the group.

The predictor variables included social support, event centrality, intrusive rumination, deliberate rumination, resilience, avoidant and approach coping, and optimism. Both PTSD symptoms and PTG were considered the outcome variables. In addition, causes of pelvic pain, not included in the predictive models, was an independent variable. To establish this variable, three categories were created: pelvic pain with unknown cause, pelvic pain with one cause, and pelvic pain with multiple causes. Before data collection, ethical approval was obtained from the Psychology Department at the University of Bolton, in line with British Psychological Society (BPS) guidelines (see BPS, 2018).

Participants

The majority of the sample consisted of females (cisgender) aged 16 to 44 years. Initially, the sample comprised 136 participants, but 4 males (cisgender) were removed for being unrepresentative of that gender type. As such, the final sample consisted of 132 females, most of whom were British, had no religion, and were married (Table 1). For information on the participants’ experiences of chronic pelvic pain, diagnosis, and most common causes of pelvic pain, see Table 2.

Table 1. Participants’ demographic information.

Variable	N	%
Age:
16–44 years	115	87.12
45–65+ years	17	12.90
Ethnicity:
British	86	65.65
Other	45	34.40
Religion:
Atheist	72	55.00
Christian	32	24.43
Catholic	14	10.70
Islam	2	1.53
Hindu	2	1.53
Other	9	6.90
Marital status:
Married	46	35.40
Single	22	16.92
In a relationship	16	12.31
Living with a partner	41	31.54
Divorced	5	3.85

Table 2. Most common responses to chronic pelvic pain–related questions.

Variable	N	%
Chronic pelvic pain experience:
Experienced chronic pelvic pain for the last 6 months	126	95.50
Had previous experience of chronic pelvic pain for 6 months or more	6	4.55
Diagnosis:
Officially diagnosed	103	78.03
No diagnosis	20	15.20
Cause of pelvic pain:
No condition	30	58.33
One condition	25	18.94
Multiple causes	77	58.33

Measures

Impact of Event Scale-Revised (IES-R; Weiss & Marmar, 1997)

The IES-R scale was used to measure PTSD symptoms, with a focus on participants’ experiences with chronic pelvic pain, including any treatments, operations, or appointments. The IES-R contains 22 questions measured on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). No specific cutoff score was provided with the original scale, but research suggests that a score of 33 or higher is cause for concern (Creamer et al., 2003). Therefore, the higher the score, the more severe the level of PTSD symptoms experienced. The overall scale reliability in our study based on Cronbach’s α was .94.

Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al., 1988)

The MSPSS measures the perceived level of social support provided by family, friends, and romantic partners (significant others). Overall, the scale consists of 12 items measured on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). The higher the score, the more positively the participants perceived their social support. In our study, the reliability based on Cronbach’s α was .91.

Brief COPE Scale (Carver, 1997)

The Brief COPE (Coping Orientation to Problems Experienced) Scale contains 28 items and is a shorter version of the original COPE Scale (Carver, Scheier & Weintraub, 1989). Responses are measured on a 4-point Likert scale ranging from 1 (I haven’t been doing this at all) to 4 (I’ve been doing this a lot). Previous research has furthered the understanding of this scale and divided it into approach and avoidant coping (Eisenberg et al., 2012). The following subscales were found to be related to approach coping: active coping, emotional and instrumental support, positive reframing, planning, and acceptance. Self-distraction, denial, substance use, behavioral disengagement, venting, and self-blame were found to be related to avoidant coping. In our study, Cronbach’s α was .83 for approach coping and .73 for avoidant coping.

Connor-Davidson Resilience Scale (CD-RISC 10; Connor & Davidson, 2003)

The CD-RISC 10 focuses on participants’ levels of resilience measured on a 5-point Likert scale ranging from 0 (not true at all) to 4 (true nearly all the time). Scores range from 0 to 40, with higher scores indicating higher levels of resilience. Cronbach’s α was .89 in our study.

Life Orientation Test-Revised (LOT-R; Scheier, Carver & Bridges, 1994)

The LOT-R measures an individual’s level of optimism. Overall, there are 10 questions measured on a 5-point Likert scale from 0 (I agree a lot) to 4 (I disagree a lot). Items 3, 7, and 9 are reverse-coded prior to obtaining the total score by adding the scores for those items to the scores for items 1, 4, and 10. The remaining items 2, 5, 6, and 8 are fillers to prevent the participants from discovering the real purpose of the test (Scheier et al., 1994). Higher scores are associated with higher levels of optimism. The overall scale reliability for our study was .76.

Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996)

The 21-item PTGI measures individuals’ level of growth after experiencing trauma—in this case, chronic pelvic pain. The PTGI consists of a 6-point Likert scale ranging from 0 to 5. To conform to our study, the responses for questions 0 and 5 were altered. For 0, the response was changed to “I did not experience this change as a result of my chronic pelvic pain,” and 5 was replaced with “A very great degree as a result of my chronic pelvic pain.” These were the only two response options that required adaptation. Higher scores on the PTGI indicate higher levels of growth. A cutoff score of 45 was selected, based on previous research (Mazor et al., 2016). Cronbach’s α was .90 for our study.

Centrality of Event Scale (CES; Berntsen & Rubin, 2006)

The CES assesses how influential a traumatic event is in determining how one sees oneself and the surrounding world, referred to as event centrality. There are two versions of the CES—a 20-item and a 7-item scale. For this study, the 7-item version was selected for ease of use and was rated on a scale from 1 (totally disagree) to 5 (totally agree). A higher score indicates a higher level of event centrality. The overall scale reliability in our study based on Cronbach’s α was .90.

Event Related Rumination Inventory (ERRI; Cann et al., 2011)

The ERRI contains 20 items—the first 10 rate intrusive rumination, and the final 10 rate deliberate rumination. The higher the score, the higher the level of rumination; this is true of both intrusive and deliberate rumination. In our study, reliability based on Cronbach’s α was .96 for intrusive rumination and .86 for deliberate rumination.

Procedure

The survey provided to participants contained questions about demographics, pelvic pain diagnosis, and measures of the variables provided above. The questionnaire was created via Qualtrics software (March 2021version; copyright 2020) and distributed online through various social media platforms (Facebook, Twitter, LinkedIn), with a focus on groups relevant to individuals experiencing chronic pelvic pain. An informational sheet was provided to potential participants, informing them about the study, explaining what they would need to do, and notifying them that by clicking “submit” at the end of the survey, they consented to the use of their responses in the study.

Data were analyzed using SPSS, with PTSD symptoms and PTG entered as the dependent variables. The cause of chronic pelvic pain was added as an independent variable for the Kruskal-Wallis H tests only, looking for differences among the three categories. The remaining variables were added as predictors for the regression analyses for both PTSD symptoms and PTG.

Results

For the predictors and outcomes, means (M) and standard deviations (SD) were reported alongside median (Med) scores (Table 3).

Table 3. Descriptive statistics for all independent and dependent variables.

Variable	N	Mean / Median	SD
PTSD symptoms	128	55.16 / 54.00	16.51
PTG	129	45.68 / 46.00	19.91
Intrusive rumination	130	19.48 / 20.00	7.33
Deliberate rumination	130	18.62 / 18.00	5.49
Event centrality	131	13.34 / 12.00	5.82
Resilience	130	25.50 / 25.00	7.06
Optimism	132	14.11 / 14.00	5.41
Social support	131	33.91 / 32.17	14.65
Approach coping	131	26.31 / 25.00	6.80
Avoidant coping	131	32.35 / 32.00	6.16

A Kruskal-Wallis H test was conducted to confirm that the cause of pelvic pain influences the level of PTSD symptoms experienced. The analysis revealed that pelvic pain with an unknown cause had the highest mean (M = 60.52, SD = 17.61) compared to pelvic pain with one cause (M = 58.65, SD = 16.50) and pelvic pain with multiple causes (M = 52.05, SD = 15.53). This difference was significant (Kruskal-Wallis H = 8.14, p = .017). Therefore, individuals with no known cause for their pelvic pain experienced higher levels of PTSD symptoms. In contrast, having only one causative condition was associated with higher levels of PTG (M = 50.40, SD = 21.01), but the difference was not significant (Kruskal-Wallis H = 3.04, p > .001). After completing Kruskal-Wallis H tests on the remaining predictor variables, the only variable with a significant difference was optimism (Kruskal-Wallis H = 8.38, p < .05), revealing that women with multiple causes of their pain experienced higher levels of optimism (M = 14.92, SD = 4.75).

To establish a predictive model for PTSD symptoms and PTG, regression analysis was performed. For PTSD symptoms, intrusive and deliberate rumination, event centrality, approach and avoidant coping, social support, optimism, and resilience were inputted as predictors. The same was done for PTG, with the added element of PTSD symptoms. Using the enter method, a significant model was found (F (8, 117) = 41.29, p < .001) that explained 72.1% of the variance in PTSD symptoms, but only intrusive rumination, avoidant coping, and resilience were found to be significant predictors (Table 4).

Table 4. Regression analysis for PTSD symptoms.

Variable	Unstandardized B	SE	t
Intrusive rumination	1.526	.147	10.371**
Avoidant coping	.569	.153	3.899**
Resilience	.267	.131	2.043*
Deliberate rumination	−.014	.195	−.074
Event centrality	.259	.184	1.405
Approach coping	.059	.136	.437
Optimism	−.073	.180	−.409
Social support	−.091	.057	−1.587

Adjusted R² = .721; predictor = PTSD symptoms; ** <.001 * <.05.

The same process was completed for PTG. In this case, a significant model was found (F (9, 115) = 6.05, p < .001), but it explained only 26.8% of the variance, with resilience and social support being the only significant predictors (Table 5).

Table 5. Regression analysis for PTG.

Variable	Unstandardized B	SE	t
Resilience	−.584	.261	−.2.238*
Social support	−.461	.113	−4.063**
Event centrality	−.265	.364	−.729
Intrusive rumination	−.061	.399	−.152
Deliberate rumination	−.499	.383	−1.303
Avoidant coping	−.378	.318	1.189
Approach coping	−.413	.266	−1.554
Optimism	.106	.352	.300
PTSD symptoms	−.177	.181	−.979

Adjusted R² = .268; predictor = PTG; ** <.001; * <.05.

Discussion

This research found that individuals with no identified cause of their pelvic pain were more inclined to experience higher levels of PTSD symptoms. This is in line with previous findings (Meltzer-Brody et al., 2007; Herbert, 2010) and suggests that an absence of a diagnosis is associated with higher levels of PTSD symptoms. Furthermore, many individuals with chronic pelvic pain undergo various procedures, including surgery (Wozniak, 2016; Meltzer-Brody et al., 2007; Till et al., 2019; Howard, 2003). It could be argued that these invasive procedures contribute to the development of PTSD, especially if they are performed in an attempt to establish a diagnosis. These procedures are often exploratory, undertaken in the hope of finding a cause for the pain, which helps explain why pelvic pain with an unknown cause is more likely to result in PTSD symptoms. In addition, HCWs have been implicated in the occurrence of PTSD (Tedstone & Tarrier, 2003). Individuals with an unknown cause of pain may have more contact with HCWs while undergoing investigations to identify a cause. Due to the continued presence of hysteria in conceptualizations of women’s health (Guidone, 2018), it is not surprising that women with symptoms indicative of trauma are dismissed and misunderstood by health care professionals (Till et al., 2019; Bryant et al., 2016). Through the ages, any type of ill health among women has been either viewed as a reason for mental health problems and related behaviors or totally ignored (Hudson, 2022). Invalidation of pain and other symptoms is relevant to gynecological conditions such as endometriosis, fibroids, and polycystic ovary syndrome. This explains why women struggle not only to be diagnosed but also to be believed and have their symptoms acknowledged. More attention to female-related conditions is required from the health care system. To support this, future research could assess investigative procedures and their influence on PTSD. Meanwhile, relevant government bodies should provide HCWs with training to recognize trauma and ensure a better understanding of female-related conditions.

Our research adds to the existing literature by focusing on rumination as two distinct variables. The fact that intrusive rumination was found to predict PTSD symptoms supports previous research suggesting that rumination as a single construct can be considered a negative coping mechanism (Martin et al., 2011; McPeak et al., 2018; Till et al., 2019). Such mechanisms often incorporate avoidance behaviors, which affect levels of stress (Donatti et al., 2017) or, in our study, PTSD symptoms. Our findings support Ehlers and Clark’s (2000) model, which considers avoidance and rumination key components of trauma. Consequently, we add to the current literature by confirming the relevance of this model more than two decades after its creation on a previously unstudied sample. Because resilience was a positive predictor of PTSD symptoms, it could be argued that it is a double-edged sword, given its relationship to PTG. It is possible that individuals’ experiences with HCWs fuel their resilience and trauma simultaneously.

It has been established that relationships can be affected by chronic pelvic pain (Oniszczenko et al., 2016; Gilbert et al., 2011; Jones et al., 2004; Denny, 2004; Huntington & Gilmour, 2005; Fagervold et al., 2009; Cox et al., 2003), yet our research found perceived social support to be a key predictor of PTG, corroborating previous research (Zhou et al., 2021). We expand on the current literature by accounting for all individuals with chronic pelvic pain and not just those with a specific diagnosis, while incorporating positive psychology concepts. Our findings suggest that irrespective of their chronic pelvic pain, individuals perceive their social support networks to be reliable, which facilitates their ability to experience PTG. It could be suggested that the amount of support available is not as important as how useful they find that support. This can only be theorized, as our study did not include a measure of actual support received. Thus, future research should consider comparing received and perceived social support. Our research provides evidence of the potential mental strength of women with chronic pelvic pain, as resilience predicted PTG. Societal views suggesting that these women should be able to cope as well as other women (Denny, 2004), along with the difficulties of obtaining a diagnosis, might explain the relevance of resilience and PTG. A “stiff upper lip” attitude coinciding with positive psychological change might have been the women’s only option when told their pain is not real or that they should just cope better. Perhaps internalized belief systems regarding how women should behave in society, linked to the idea that they should just “get on with it,” also played a role. Ultimately, these women faced adversity and learned how to deal with it directly. These findings expand on the current literature on chronic pelvic pain, but more attention should be paid to the influence of positive psychology factors.

Our research adds to the understanding of what influences PTSD symptoms in those with chronic pelvic pain, but we still have minimal understanding of what influences PTG. This might be explained by the fact that chronic pelvic pain is a continuous event, with no definitive end point. Our findings provide clinicians with an understanding of how women’s experiences related to chronic pelvic pain affect them both positively and negatively. This knowledge could lead to the creation of an intervention focusing on their trauma and including those elements found to be most beneficial. It would also be helpful to conduct future research based on group discussions with chronic pelvic pain sufferers to establish their views and opinions, as well as what they need to ensure their mental well-being.

Acknowledgements

Part of this research study was presented at the British Psychological Society Postgraduate Affairs Group Conference 2022.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author [CLW], upon reasonable request.

Additional information

Funding

No funding was obtained for this research.