Title: Can self-compassion and mindfulness predict psychological wellbeing in individuals with
endometriosis? Findings from an online survey
Version: 4 Date: 23 Apr 2025
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
Yes - experiments and analyses were performed appropriately
S - Is the  of s in the manuscript appropriate?
Yes - appropriate al analyses have been d in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: meets best practise. good work
REQUESTED REVISIONS:
Reviewer’s comments  Author’s response My comments
The authors investigate how psychological well-being may be influenced by protective factors
such as mindfulness and self-compassion in the context of living with endometriosis. They
employed a cross-sectional study design and collected  from a large sample. While the
topic under investigation is highly relevant, my primary concern, as detailed below, is the
lack of an overall theoretical rationale for the selection of variables, which is crucial for
accurately understanding the associations between the processes of interest. Additionally, there
are concerns regarding the quality of the al analyses employed. We thank Reviewer 1 for their
insightful comments. Every effort has been made to address their concerns and improve clarity.
Satisfactory
In the background section (line 50), the authors stated that the characteristics of the painful
symptoms depend on the location of the endometriotic lesion. This statement is not entirely
accurate. Women with lesions in one organ or tissue can develop pain at a distant site
due to alteration in nociceptive processing (e.g., viscero-visceral hyperalgesia) and are not
limited to primary hyperalgesia, as the authors suggest. Please revise this phrase to avoid
misunderstandings. Yes, the statement was unclear and has been corrected according to this
suggestion. Moreover, additional material has been added to clarify the complex nature of the
pain experience in endometriosis (lines 50-57). satisfactory
When explaining mindfulness (line 111), the authors correctly described the difference between
Kabat-Zinn and Langer's conceptualizations. However, the term "mindfulness meditation" is d,
referring to Kabat-Zinn's perspective. To improve clarity, I suggest the authors elucidate the
distinction between the state of mindfulness practiced in mindfulness meditation and the trait
of one’s natural predisposition to be mindful in daily life. The latter is what is actually under
investigation in the present study. : Additional information has been provided in the Background
(see the section entitled “Mindfulness”). satisfactory
The reason for the uncommon choice of the Langerian mindfulness conceptualization, which
has much less evidence and a known theoretical scope in the biomedical literature, was not
explained (line 118). Please provide a rationale for choosing this specific approach over the
more commonly known Kabat-Zinn's perspective. This is particularly important given that,
when the authors refer to the relevance of mindfulness to women with endometriosis, they cite
only studies employing Kabat-Zinn's approach (line 123-129). The rationale for choosing the
Langerian approach was clarified in the paragraph entitled “Mindfulness”, particularly from line
169 to 173. Satisfactory
The study aims to investigate the association between mindfulness, self-compassion, and
psychological well-being. Additionally, the associations of two other variables—time since
diagnosis and pain symptoms—with the main predictors are to be explored (line 133). Why
did the authors choose to investigate the association time since diagnosis among many other
theoretically valid options? Its relevance in another cross-sectional study is not sufficient
justification, given that many other variables were also relevant. For example, the duration of
pelvic pain seems more valuable than the time since diagnosis itself, as it is unlikely that simply
carrying an endometriosis diagnosis without symptoms would be associated with mindfulness,
self-compassion, and psychological well-being—it would likely be confounded by the time
spent suffering pain. Similarly, the emphasis on age in the introduction is unclear (line 135). Is
this variable relevant enough to be highlighted? Clarifications on these points were provided in
the Background and in the Methods section. Fair
Pain symptoms were also reported as a predictor in the al section. Why test their association with
mindfulness and self-compassion? If the authors aim to explore whether pain symptoms mediate
the relationship between mindfulness, self-compassion, and psychological well-being (which
would be plausible), it would be more informative to compare different s with and without
pain as a predictor. This approach would represent a better  of hierarchical s, grounded in the
theoretical connections between the main variables, especially when a true mediation analysis
is not feasible due to the cross-sectional study design. Additional material was provided in the
Background and in the Methods section . Fair, although confusion is still present. Pls discuss
with stats expert.
It is crucial to provide a clear theoretical rationale to avoid unnecessary multiple-association
tests. This is even more critical in a non-preregistered study to maintain transparency and avoid
suspicions of p-hacking by readers. The Reviewer is correct. In the original version of our article,
the Background section did not provide an adequate theoretical rationale. We hope that the
additional and updated material we have incorporated has improved the theoretical foundation.
Satisfactory
Please specify the time interval for which the pain symptoms were assessed—was it over one
month, one week, or another period? This information is important to convey the reliability
of the measurement. Additionally, consider whether "noncyclic pelvic pain" might be a more
precise term than "chronic pelvic pain," as the latter can encompass any form of chronic pain in
the region. Pain symptoms were assessed focusing on the past six months (see lines 208-209).
Following the reviewer’s suggestion, we decided to  the term "non-menstrual pelvic pain" rather
than "noncyclic pelvic pain." We hope the reviewer agrees with this terminology. fair
Again, a clear theoretical framework based on previous understanding of the processes involved
should be the foundation for variable selection. The authors decided to include some relevant
variables, but many other critical confounders and covariates were omitted, such as lifestyle
factors (e.g., physical activity, alcohol consumption, smoking) and mental health conditions
(e.g., anxiety, depression, personality traits like neuroticism or openness). Were these or other
important variables collected? Or were they collected and deemed less theoretically valuable
than, for example, time since diagnosis and endometriosis stage and type? These choices do
not seem theoretically justifiable. The variables indicated by the reviewer were not collected, as
these aspects were beyond the aims of our study. We hope we have clarified our methodological
choices by expanding on the theoretical background. However, we acknowledged the omission
of other important variables as a limitation in the Discussion section (lines 423-428). We also
clarified that our study did not aim at understanding processes. Fair
All independent variables are referred to as predictors, but some are more appropriately
classified as covariates or confounders, given that their predictive value is not the primary
interest. The lack of specification makes it difficult to understand the hypothesized role of each
variable. Please provide these specifications to improve comprehensibility. Yes, the reviewer is
correct. There were only two potential predictors in our study: self-compassion and mindfulness.
The other variables were included in our regression  to enhance the rigor of our analyses, as
we wanted to control for the effects of potential confounders associated with psychological
wellbeing. These specifications were provided in the Methods section (see the paragraph entitled
“al analyses”). fair
The main analysis was based on al significance (p-value less than 0.05) in univariate and
bivariate analyses. This approach is flawed, particularly given the large sample size, which can
amplify the issue (false positives). Reliance on p-values without a solid rationale can lead to
misleading conclusions and overlook the importance of effect size and practical significance.
For example, the p-values for the correlations between age and psychological well-being (r
= .132, p = 0.001) and between dysmenorrhea and psychological well-being (r = -.161, p =
0.001) were both highly significant, despite their low correlation strengths. Is it appropriate to
attribute the same importance to these variables in the decision to include them in a multiple
regression ? ally, their significance levels are almost equal, but their theoretical importance is
very different. Actually, that was not our approach. We did not merely rely on al significance. For
our main analyses (hierarchical multiple regressions), we provided the values of #R2 to specify
the change in R2 values from one  to another. For multivariate analysis of variance, we included
values of #2p. Although this was not specified in the Methods, in the Results and the Discussion
section we provided comments on the magnitude of Pearson correlations (see for example lines
366-369; see also the comments on the values of r provided in the Results). In the section focd
on al analyses, we simply clarified the pre planned level of al significance. However, additional
information has been included to avoid misunderstanding (lines 248-251). fair
Additionally, the authors categorized the variable self-compassion, an approach that results in
a loss of information, while keeping mindfulness in its original scale. Why did the authors
decide to categorize self-compassion? Clarifications were provided in the Methods section (lines
221-223). The categorical variable created according to Neff’s indications was d only in the final
set of analyses, which explored associations between self-compassion and the other variables of
interest, as done in previous endometriosis research. fair
The explanation given by the authors—"determining the distinct effects of the predictors of
interest while controlling for the effect of other variables associated with PGWB-S"—to justify
the  of significance in the univariate and bivariate analysis does not make sense. A better
approach would be to select variables based on a theoretical rationale and develop two multiple
regression s, one for each predictor of interest (SCS-Total and LMS-Total). Then, test if the
difference between the s is significant. This approach reduces the risk of Type I errors, increases
the validity of the , and enhances interpretability by ensuring that the selection of variables
is grounded in existing research. We don’t fully understand the reviewer’s statement: “[…] to
justify the  of significance.” Our intention was to adopt a more rigorous approach to examine the
associations between the two predictors and psychological wellbeing using multiple regression.
We hope we have clarified these aspects, considering the specific aims of our study. fair
To address supposed multicollinearity between pain symptom variables, the authors summarized
them into a single variable using principal component analysis (PCA). This choice is
unnecessary. Pearson correlations ranged from 0.275 to 0.538, indicating moderate correlations,
which typically do not ca significant collinearity issues. Collinearity becomes more concerning
with correlations exceeding 0.7 or 0.8. The principal components may lack direct or meaningful
interpretation in the context of the original variables, potentially obscuring the results.
Response: This choice was motivated by the fact that pain was not conceptualized as a predictor.
Therefore, we were not interested in examining associations between specific types of pain and
psychological wellbeing. Our aim was just to control for the effects of an important variable
that is strongly associated with psychological health in individuals with endometriosis. For this
reason, we chose to retain this approach.  Fair, discuss with stats expert to improve representation
of results in diff tables and figures /formats to avoid confusion.
If the authors choose to retain the PCA approach, they should include details such as the number
of principal components retained, the criteria d for their selection (e.g., eigenvalues greater
than 1, scree plot), and the component loadings to understand how each variable contributes
to the components. Additionally, they should describe any rotation methods applied, interpret
the components, and provide information on the cumulative variance explained by the retained
components. Validation methods, such as parallel analysis or cross validation, should also be
included to ensure robustness. This analysis was a straightforward one-component analysis, as
PCA—also considering the scree plot and all PCA criteria—resulted in the extraction of a single
component. Additional al details have been incorporated into the text (lines 305-307). fair
Furthermore, the results of all hierarchical s should be provided in the main text or supplementary
material. Changes made fair
The quality of the article would be enhanced if the authors were to explain more fully the value
of these concepts, how they work in relation to the disease and its symptoms, and make more of
a link with psychological well being. We hope we have been able to provide a more appropriate
theoretical background (see also our responses to Reviewer 1). fair
If the literature is lacking and the authors are taking a more exploratory approach, then it's time
to say so! (Are there aspects of the subject that the literature has not yet investigated, or that are
too superficial? Very probably, but the authors do not point out these shortcomings and merely
present the state of the art factually without criticising it). The literature review necessary for
this problematisation remains poorly documented here. Changes made fair
Why did you choose Langer's approach and not Kabat-Zinn's? Why is Langer's approach more
relevant to endometriosis? Changes made fair
The authors make several references to the cognitive and emotional representations that
patients have of them, without mentioning these concepts. It would have been interesting
to develop the representations approach, especially if this is the approach d to discuss the
results (l.277/278). The quotations reported in the Discussion were derived from qualitative
research on the psychological suffering cad by endometriosis and its symptoms, including
dyspareunia. We included those quotations beca we wanted to highlight that individuals with
endometriosis are often extremely harsh and judgmental toward themselves (i.e., the opposite
of being self compassionate), further clarifying the importance of nurturing self-compassion in
this population. Well done parts
A section of the discussion should be devoted to clinical perspectives. How can patient care be
rethought? What should we work on? And how? Clinical and research perspectives that draw
lessons from these findings are lacking, even though this is a section that readers are eagerly
awaiting. Changes made fair
ADDITIONAL REQUESTS/SUGGESTIONS:
Reviewer’s comments  Author’s response My comments
The authors investigate how psychological well-being may be influenced by protective factors
such as mindfulness and self-compassion in the context of living with endometriosis. They
employed a cross-sectional study design and collected  from a large sample. While the
topic under investigation is highly relevant, my primary concern, as detailed below, is the
lack of an overall theoretical rationale for the selection of variables, which is crucial for
accurately understanding the associations between the processes of interest. Additionally, there
are concerns regarding the quality of the al analyses employed. We thank Reviewer 1 for their
insightful comments. Every effort has been made to address their concerns and improve clarity.
Satisfactory
In the background section (line 50), the authors stated that the characteristics of the painful
symptoms depend on the location of the endometriotic lesion. This statement is not entirely
accurate. Women with lesions in one organ or tissue can develop pain at a distant site
due to alteration in nociceptive processing (e.g., viscero-visceral hyperalgesia) and are not
limited to primary hyperalgesia, as the authors suggest. Please revise this phrase to avoid
misunderstandings. Yes, the statement was unclear and has been corrected according to this
suggestion. Moreover, additional material has been added to clarify the complex nature of the
pain experience in endometriosis (lines 50-57). satisfactory
When explaining mindfulness (line 111), the authors correctly described the difference between
Kabat-Zinn and Langer's conceptualizations. However, the term "mindfulness meditation" is d,
referring to Kabat-Zinn's perspective. To improve clarity, I suggest the authors elucidate the
distinction between the state of mindfulness practiced in mindfulness meditation and the trait
of one’s natural predisposition to be mindful in daily life. The latter is what is actually under
investigation in the present study. : Additional information has been provided in the Background
(see the section entitled “Mindfulness”). satisfactory
The reason for the uncommon choice of the Langerian mindfulness conceptualization, which
has much less evidence and a known theoretical scope in the biomedical literature, was not
explained (line 118). Please provide a rationale for choosing this specific approach over the
more commonly known Kabat-Zinn's perspective. This is particularly important given that,
when the authors refer to the relevance of mindfulness to women with endometriosis, they cite
only studies employing Kabat-Zinn's approach (line 123-129). The rationale for choosing the
Langerian approach was clarified in the paragraph entitled “Mindfulness”, particularly from line
169 to 173. Satisfactory
The study aims to investigate the association between mindfulness, self-compassion, and
psychological well-being. Additionally, the associations of two other variables—time since
diagnosis and pain symptoms—with the main predictors are to be explored (line 133). Why
did the authors choose to investigate the association time since diagnosis among many other
theoretically valid options? Its relevance in another cross-sectional study is not sufficient
justification, given that many other variables were also relevant. For example, the duration of
pelvic pain seems more valuable than the time since diagnosis itself, as it is unlikely that simply
carrying an endometriosis diagnosis without symptoms would be associated with mindfulness,
self-compassion, and psychological well-being—it would likely be confounded by the time
spent suffering pain. Similarly, the emphasis on age in the introduction is unclear (line 135). Is
this variable relevant enough to be highlighted? Clarifications on these points were provided in
the Background and in the Methods section. Fair
Pain symptoms were also reported as a predictor in the al section. Why test their association with
mindfulness and self-compassion? If the authors aim to explore whether pain symptoms mediate
the relationship between mindfulness, self-compassion, and psychological well-being (which
would be plausible), it would be more informative to compare different s with and without
pain as a predictor. This approach would represent a better  of hierarchical s, grounded in the
theoretical connections between the main variables, especially when a true mediation analysis
is not feasible due to the cross-sectional study design. Additional material was provided in the
Background and in the Methods section . Fair, although confusion is still present. Pls discuss
with stats expert.
It is crucial to provide a clear theoretical rationale to avoid unnecessary multiple-association
tests. This is even more critical in a non-preregistered study to maintain transparency and avoid
suspicions of p-hacking by readers. The Reviewer is correct. In the original version of our article,
the Background section did not provide an adequate theoretical rationale. We hope that the
additional and updated material we have incorporated has improved the theoretical foundation.
Satisfactory
Please specify the time interval for which the pain symptoms were assessed—was it over one
month, one week, or another period? This information is important to convey the reliability
of the measurement. Additionally, consider whether "noncyclic pelvic pain" might be a more
precise term than "chronic pelvic pain," as the latter can encompass any form of chronic pain in
the region. Pain symptoms were assessed focusing on the past six months (see lines 208-209).
Following the reviewer’s suggestion, we decided to  the term "non-menstrual pelvic pain" rather
than "noncyclic pelvic pain." We hope the reviewer agrees with this terminology. fair
Again, a clear theoretical framework based on previous understanding of the processes involved
should be the foundation for variable selection. The authors decided to include some relevant
variables, but many other critical confounders and covariates were omitted, such as lifestyle
factors (e.g., physical activity, alcohol consumption, smoking) and mental health conditions
(e.g., anxiety, depression, personality traits like neuroticism or openness). Were these or other
important variables collected? Or were they collected and deemed less theoretically valuable
than, for example, time since diagnosis and endometriosis stage and type? These choices do
not seem theoretically justifiable. The variables indicated by the reviewer were not collected, as
these aspects were beyond the aims of our study. We hope we have clarified our methodological
choices by expanding on the theoretical background. However, we acknowledged the omission
of other important variables as a limitation in the Discussion section (lines 423-428). We also
clarified that our study did not aim at understanding processes. Fair
All independent variables are referred to as predictors, but some are more appropriately
classified as covariates or confounders, given that their predictive value is not the primary
interest. The lack of specification makes it difficult to understand the hypothesized role of each
variable. Please provide these specifications to improve comprehensibility. Yes, the reviewer is
correct. There were only two potential predictors in our study: self-compassion and mindfulness.
The other variables were included in our regression  to enhance the rigor of our analyses, as
we wanted to control for the effects of potential confounders associated with psychological
wellbeing. These specifications were provided in the Methods section (see the paragraph entitled
“al analyses”). fair
The main analysis was based on al significance (p-value less than 0.05) in univariate and
bivariate analyses. This approach is flawed, particularly given the large sample size, which can
amplify the issue (false positives). Reliance on p-values without a solid rationale can lead to
misleading conclusions and overlook the importance of effect size and practical significance.
For example, the p-values for the correlations between age and psychological well-being (r
= .132, p = 0.001) and between dysmenorrhea and psychological well-being (r = -.161, p =
0.001) were both highly significant, despite their low correlation strengths. Is it appropriate to
attribute the same importance to these variables in the decision to include them in a multiple
regression ? ally, their significance levels are almost equal, but their theoretical importance is
very different. Actually, that was not our approach. We did not merely rely on al significance. For
our main analyses (hierarchical multiple regressions), we provided the values of #R2 to specify
the change in R2 values from one  to another. For multivariate analysis of variance, we included
values of #2p. Although this was not specified in the Methods, in the Results and the Discussion
section we provided comments on the magnitude of Pearson correlations (see for example lines
366-369; see also the comments on the values of r provided in the Results). In the section focd
on al analyses, we simply clarified the pre planned level of al significance. However, additional
information has been included to avoid misunderstanding (lines 248-251). fair
Additionally, the authors categorized the variable self-compassion, an approach that results in
a loss of information, while keeping mindfulness in its original scale. Why did the authors
decide to categorize self-compassion? Clarifications were provided in the Methods section (lines
221-223). The categorical variable created according to Neff’s indications was d only in the final
set of analyses, which explored associations between self-compassion and the other variables of
interest, as done in previous endometriosis research. fair
The explanation given by the authors—"determining the distinct effects of the predictors of
interest while controlling for the effect of other variables associated with PGWB-S"—to justify
the  of significance in the univariate and bivariate analysis does not make sense. A better
approach would be to select variables based on a theoretical rationale and develop two multiple
regression s, one for each predictor of interest (SCS-Total and LMS-Total). Then, test if the
difference between the s is significant. This approach reduces the risk of Type I errors, increases
the validity of the , and enhances interpretability by ensuring that the selection of variables
is grounded in existing research. We don’t fully understand the reviewer’s statement: “[…] to
justify the  of significance.” Our intention was to adopt a more rigorous approach to examine the
associations between the two predictors and psychological wellbeing using multiple regression.
We hope we have clarified these aspects, considering the specific aims of our study. fair
To address supposed multicollinearity between pain symptom variables, the authors summarized
them into a single variable using principal component analysis (PCA). This choice is
unnecessary. Pearson correlations ranged from 0.275 to 0.538, indicating moderate correlations,
which typically do not ca significant collinearity issues. Collinearity becomes more concerning
with correlations exceeding 0.7 or 0.8. The principal components may lack direct or meaningful
interpretation in the context of the original variables, potentially obscuring the results.
Response: This choice was motivated by the fact that pain was not conceptualized as a predictor.
Therefore, we were not interested in examining associations between specific types of pain and
psychological wellbeing. Our aim was just to control for the effects of an important variable
that is strongly associated with psychological health in individuals with endometriosis. For this
reason, we chose to retain this approach.  Fair, discuss with stats expert to improve representation
of results in diff tables and figures /formats to avoid confusion.
If the authors choose to retain the PCA approach, they should include details such as the number
of principal components retained, the criteria d for their selection (e.g., eigenvalues greater
than 1, scree plot), and the component loadings to understand how each variable contributes
to the components. Additionally, they should describe any rotation methods applied, interpret
the components, and provide information on the cumulative variance explained by the retained
components. Validation methods, such as parallel analysis or cross validation, should also be
included to ensure robustness. This analysis was a straightforward one-component analysis, as
PCA—also considering the scree plot and all PCA criteria—resulted in the extraction of a single
component. Additional al details have been incorporated into the text (lines 305-307). fair
Furthermore, the results of all hierarchical s should be provided in the main text or supplementary
material. Changes made fair
The quality of the article would be enhanced if the authors were to explain more fully the value
of these concepts, how they work in relation to the disease and its symptoms, and make more of
a link with psychological well being. We hope we have been able to provide a more appropriate
theoretical background (see also our responses to Reviewer 1). fair
If the literature is lacking and the authors are taking a more exploratory approach, then it's time
to say so! (Are there aspects of the subject that the literature has not yet investigated, or that are
too superficial? Very probably, but the authors do not point out these shortcomings and merely
present the state of the art factually without criticising it). The literature review necessary for
this problematisation remains poorly documented here. Changes made fair
Why did you choose Langer's approach and not Kabat-Zinn's? Why is Langer's approach more
relevant to endometriosis? Changes made fair
The authors make several references to the cognitive and emotional representations that
patients have of them, without mentioning these concepts. It would have been interesting
to develop the representations approach, especially if this is the approach d to discuss the
results (l.277/278). The quotations reported in the Discussion were derived from qualitative
research on the psychological suffering cad by endometriosis and its symptoms, including
dyspareunia. We included those quotations beca we wanted to highlight that individuals with
endometriosis are often extremely harsh and judgmental toward themselves (i.e., the opposite
of being self compassionate), further clarifying the importance of nurturing self-compassion in
this population. Well done parts
A section of the discussion should be devoted to clinical perspectives. How can patient care be
rethought? What should we work on? And how? Clinical and research perspectives that draw
lessons from these findings are lacking, even though this is a section that readers are eagerly
awaiting. Changes made fair