Evaluation of brain pain centers in endometriosis‐associated chronic pelvic pain: Retrospective insights into central sensitization using a novel magnetic resonance imaging technique

OBJECTIVE: To investigate alterations in brain pain-processing networks using resting-state functional magnetic resonance imaging (rs-fMRI) in women with endometriosis-associated chronic pelvic pain and to evaluate neurobiological evidence of central sensitization relevant to clinical management. METHODS: This retrospective study included 30 women aged 18-45 years: 10 with deep infiltrating endometriosis (DIE) and chronic pelvic pain, 10 with ovarian endometriomas without pain, and 10 healthy controls. rs-fMRI data were analyzed using the SPM12 and the CONN toolbox. Seed-to-voxel functional connectivity analyses focused on predefined pain-related brain regions. Between-group differences were assessed using two-sample t tests with family-wise error (FWE) correction. RESULTS: Compared with controls, women with DIE and chronic pelvic pain demonstrated significantly increased connectivity between the amygdala and the right frontal pole (FWE-corrected P = 0.012 and 0.044), left paracingulate gyrus (FWE-corrected P = 0.036), right frontal operculum cortex (FWE-corrected P = 0.040), and anterior cingulate gyrus (FWE-corrected P = 0.044). Increased con was also observed between the posterior cingulate gyrus and the precuneus cortex (FWE-corrected P = 0.002), whereas decreased connectivity was detected between the anterior cingulate gyrus and the posterior left middle temporal gyrus (FWE-corrected P = 0.002). No significant differences were found in patients with ovarian endometriomas without pain. CONCLUSION: Endometriosis-associated chronic pelvic pain is associated with altered connectivity within key pain modulation networks, supporting central sensitization. Persistent pelvic pain may therefore reflect maladaptive central pain processing in addition to peripheral pathology. Recognition of these neurofunctional alterations may improve understanding of treatment-resistant pain and support earlier multidisciplinary and individualized management strategies.