Daily Pain and Activity Interference Trajectories Following Primary Motor Cortex rTMS for Endometriosis-Associated Chronic Pelvic Pain: A Prospective Real-World Cohort Study

Pelvic pain may persist despite guideline-concordant endometriosis care. Evidence for primary motor cortex repetitive transcranial magnetic stimulation (M1-rTMS) in this population is limited. We assessed daily pain and activity interference, treatment delivery and safety after clinically indicated M1-rTMS. A prospective, single-centre observational cohort enrolled women with confirmed endometriosis and chronic pelvic pain. Ten left M1-rTMS sessions were scheduled over two weeks (10 Hz, 80% resting motor threshold, 1500 pulses/session). Daily diaries recorded pelvic pain and activity interference during pre-treatment, treatment, and post-treatment days 1-28 and week 8. Changes were estimated using linear mixed-effects models. Forty-two participants were enrolled and 40 initiated treatment; analyses included 37 for pain and 35 for interference. Model-based marginal mean pain decreased from 5.69 to 4.69 (change, -1.00; 95% CI, -1.46 to -0.55; p < 0.001), and interference from 6.03 to 4.63 (change, -1.39; 95% CI, -1.84 to -0.95; p < 0.001). Both remained below pre-treatment at week 8. Ten of 34 evaluable participants achieved ≥30% pain reduction and three achieved ≥50%. Of the 400 planned sessions, 386 were delivered; a total of 33/40 participants attended all ten and 38/40 at least eight. Twenty-eight participants reported 47 treatment-emergent adverse events; one was severe, none was serious, and all were resolved. M1-rTMS was feasible to deliver with high protocol fidelity and acceptable tolerability. Modest reductions in pain and activity interference were observed, although clinically important pain relief occurred in a minority; without a sham, usual-care, or untreated comparator, these changes cannot be attributed causally to rTMS. Controlled trials are required to determine efficacy and optimal dosing.