closing the gap in endometriosis care

You don’t want a baby yet, though, do you?

A seemingly simple question about chronic pelvic pain symptoms resulted in more than just personal neglect; it exposed a clinical blind spot, a complete failure to recognise that pain is not just physical, but a heavy psychological burden that affects more than just fertility. Unfortunately, this experience is not unique. It reflects a reality in which there is a disconnect in understanding the complex interplay between physical conditions and their psychological impact.

One stark example of this disparity is endometriosis, a common inflammatory disease that is characterised by the growth of endometrial-like tissue outside the uterus or the presence of chronic pain (Agarwal et al., 2019). This chronic condition impacts 10% of women of reproductive age globally (WHO, 2025) and is compounded by devastating diagnostic delays, with a global diagnostic wait time of 6.6 years, rising to nearly 10 years in some Western systems (Fryer et al., 2024).

Beyond the unrelenting chronic pelvic pain, debilitating fatigue, and fertility concerns, the psychological cost is immense. The pervasive emotional burden of the disease leaves patients increasingly vulnerable to depression, anxiety, and a diminished quality of life (Skinner & Kuijer, 2025). This outcome is overwhelmingly common, with a global survey finding that 60% of endometriosis patients perceived their quality of life to be ‘poor’ or ‘very poor’ (De Graaf et al., 2013).

Despite this immense psychological burden, the understanding of protective factors is limited. Self-compassion is emerging as a promising construct, demonstrating efficacy in managing various chronic health conditions (Baxter & Sirois, 2024). To clarify the underlying mechanism, Skinner and Kuijer (2025) provide a lens through which to examine self-compassion’s role in protecting psychological well-being and health-related quality of life (HRQoL).

Methods

This prospective study followed participants in Aotearoa New Zealand over a six-month period. The researchers used validated online questionnaires, ensuring high instrument reliability, to assess self-compassion, psychological distress, and HRQoL at baseline and at six-month follow-up. A convenience sample of individuals were recruited via endometriosis organisations and social media.

Eligibility criteria included: (1) Aged between 18–45 and living in Aotearoa, New Zealand; (2) Diagnosed with endometriosis via laparoscopy or a clinical diagnosis; (3) Currently experiencing at least one common endometriosis symptom; (4) Having experienced chronic pelvic pain within the last six months; (5) Not being pregnant at either time point.

It is worth noting that while the study reported a 70% response rate at follow-up, further exclusions resulted in a final retention of 64.2% (N = 264). Readers should interpret the findings with this attrition in mind, as the loss of over one-third of the sample could obscure outcomes for those with the most severe symptoms who may have disengaged.

Results

This study (n=264) identified self-compassion as a vital resource associated with lower psychological distress and better Health-Related Quality of Life in individuals with endometriosis. The authors looked at the mechanisms supporting this relationship both immediately and over time.

Cross-sectional associations

The analysis revealed a nuance in how self-compassion impacts wellbeing immediately. While higher self-compassion was consistently linked to better outcomes, the pathways differed.

Depression and Stress (Partial Mediation): Self-compassion had both a direct benefit and an indirect benefit on depression and stress. This means that while self-compassion helped depression and stress levels by reducing pain catastrophising (the tendency to amplify pain), it also retained a significant direct benefit on these symptoms independent of pain cognition.

Anxiety and HRQoL (Full mediation): The direct effect of self-compassion on anxiety and HRQoL was not significant once mediators were included for these variables. This implies that the benefits of self-compassion for anxiety and quality of life are transmitted almost exclusively through improved coping mechanisms, specifically by lowering pain catastrophising and increasing pain willingness.

Long-term mechanisms

Longitudinal mediation analyses identified change in pain catastrophising as the sole significant mediator across all outcomes. But what does this actually mean?

Self-Compassion Reduces Catastrophising: People with higher baseline self-compassion were more likely to report a decrease in pain catastrophising (rumination, helplessness, or pain magnification) over the six-month study period.

Catastrophising Drives Outcomes: This reduction in catastrophising was directly linked to significant improvements in depression, anxiety, stress, and HRQoL after six months.

What about other coping tools?

While pain willingness, resilience and activity engagement were correlated with self-compassion at baseline, they did not mediate the prospective relationship between self-compassion and mental health outcomes over time. This suggests that reducing the tendency to catastrophise is the primary mechanism through which self-compassion enables sustained long-term benefits in endometriosis.

Conclusions

Skinner and Kuijer (2025) conclude that self-compassion serves as a vital protective factor for women with endometriosis.

Their prospective data reveals that higher baseline self-compassion predicts reduced psychological distress and improved quality of life over a six-month period.

Crucially, the study identified the mechanism driving this benefit: self-compassion works by significantly reducing pain catastrophising. Ultimately, self-compassion interrupts the negative spiral of amplifying pain, offering a tangible, psychological pathway to better wellbeing.

Strengths and limitations

This prospective study offers a welcome advancement in endometriosis research, highlighting the condition’s significant impact on psychological wellbeing over time.

A key strength is the study’s methodological rigour. The authors applied strict eligibility criteria, requiring confirmed clinical diagnoses and excluding pregnancy. By minimising confounding variables, we can be confident that the protective link found between self-compassion and mental wellbeing is genuinely accurate for this specific group. Furthermore, the study boasted adequate statistical power, with a moderate sample size (n=264) capable of detecting meaningful effects and excellent internal reliability (α > .90) across measures.

While the authors attempted to minimise confounders, a striking 85% of the participants reported being diagnosed with at least one other health condition. While this reflects the reality that endometriosis rarely exists in isolation, it introduces a significant confounder that the authors did not statistically control for. This makes it difficult to disentangle the source of the participants’ distress. Are the high levels of pain catastrophising and anxiety driven specifically by endometriosis, or are they the cumulative result of living with multiple chronic illnesses? By not adjusting for comorbidity load, the study may be attributing general health-related distress specifically to endometriosis, potentially obscuring the true relationship between endometriosis and self-compassion.

Moreover, the findings are constrained by significant selection bias. Recruitment via online support organisations resulted in a remarkably homogenous cohort: 81% European ethnicity and 76% educated beyond secondary school. This represents a “WEIRD” (Western, Educated, Industrialised, Rich and Demographic) sample and this demographic skew likely reflects individuals with the resources to navigate complex healthcare systems. Consequently, the study suffers from limited external generalisability. While the data are high-quality, it leaves us in the dark about how self-compassion functions for those facing systemic barriers, lower health literacy, or those unable to access a diagnosis. While the internal validity is strong, these results may not represent the broader, more diverse endometriosis community.

Furthermore, as stated by the authors, while prospective, the two-wave design means change in mediators and outcomes were measured simultaneously (Skinner & Kuijer.,, 2025). Without a third timepoint to establish temporal precedence, we cannot definitively conclude that reduced catastrophising causes improved wellbeing, rather than merely occurring alongside it.

Implications

Despite these constraints, this study highlights the pivotal role of self-compassion in managing both the physical pain and psychological correlates of endometriosis. These findings align with the wider literature on positive affect and health (Pressman et al., 2019), but critically, they add specific nuance by highlighting exactly how self-compassion works: by reducing pain catastrophising.

Consequently, these insights translate into actionable healthcare outcomes. By shedding light on the specific psychological burden of the disease, we can prompt constructive dialogue and help dispel prevailing stigmas that often dismiss the patient’s experience. Practically, this means moving toward holistic support systems that integrate mental health into standard endometriosis care. We must create environments that validate the patient’s reality, as acknowledging pain is a prerequisite for reducing the helplessness associated with catastrophising (Petrini & Arendt-Nielsen, 2020). This support should encompass a variety of resources, such as access to Compassion-Based Interventions, as well as educational support that teaches patients specifically how to disentangle the physical pain from the psychological distress.

Currently, NICE guidelines prioritise Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT) as primary treatments for chronic pain (NICE, 2021). However, the findings of this study suggest we must broaden this approach. Skinner and Kuijer (2025) demonstrated that self-compassion improves wellbeing specifically by dismantling pain catastrophising. This is critical for policy because, as the authors highlight, recent evidence suggests that self-compassion can be more effective than standard CBT at changing these specific pain-related cognitions (Torrijos-Zarcero et al., 2021). Therefore, clinical guidelines should formally recommend Compassion-Based Therapies (such as CFT) not just as an alternative, but as a mechanistically precise intervention for patients who are stuck in cycles of negative thinking.

Future research in this domain will derive considerable advantage by addressing selection bias and recruiting diverse cohorts to understand if these protective mechanisms hold true for those facing systemic racism, lower health literacy, and diagnostic delays.

Personally, I find these results instil a deep sense of hope. Too often, women’s pain is dismissed, leading to a cycle of helplessness. This evidence puts power back in the patients’ hands. While we wait for future medical advancements and faster diagnoses, knowing that we can actively protect our mental health through the learnable skill of self-compassion offers a vital sense of agency in a condition that often feels uncontrollable.

Statement of Interest

Aoife Coyle has no conflicts of interest to report.

Edited by

Dr Dafni Katsampa.

Links

Primary paper

Chelsea Skinner, Roeline Kuijer (2025). The role of self-compassion in protecting psychological wellbeing and health-related quality of life in those with endometriosis: A prospective study. Journal of Psychosomatic Research, 196, 112322.

Other references