Predicting daily sleep outcomes from continuous HRV in female chronic pelvic pain disorders

Background: Female chronic pelvic pain disorders (CPPDs) are highly prevalent and frequently accompanied by sleep disturbance and autonomic nervous system (ANS) dysregulation. Heart rate variability (HRV), a non-invasive index of ANS function, may provide an objective, physiological correlate of sleep health and can be monitored using wearable devices, enabling a continuous, scalable approach. Objectives: This study examined whether wearable-derived daily HRV metrics are associated with self-reported sleep disturbance in women with CPPD(s) compared with healthy controls, using epoch-level data and generalized additive models. Methods: We conducted a retrospective observational study using up to 90 days of data from a mobile health research app. Participants were 128 women with CPPD(s) and 63 demographically matched healthy controls, who completed a daily PROMIS-based 3-item sleep disturbance questionnaire and wore Fitbit devices that provided 5-minute HRV epochs. Primary predictors were high frequency (HF) and low frequency (LF) power and root mean square of successive differences (RMSSD), with group (CPPD vs control), daily pain severity, and menstrual status as covariates. We fit separate generalized additive mixed models (GAMMs) for each HRV metric with a nonlinear smooth term and an HRV x Group interaction. Results: Higher HF and RMSSD were associated with lower sleep disturbance scores, and these associations were stronger in controls than in the CPPD group (HF x group B {approx} -1.59, p < 0.00010; RMSSD x group B {approx} -0.58, p < 0.0001). LF showed a more complex pattern but also differed by group (B {approx} -0.531, p < 0.0001). HRV smooth terms were highly nonlinear, and models explained ~8-9% of deviance in sleep disturbances. Pain severity and menstrual bleeding were strongly associated with worse sleep. Conclusion: These findings indicate small but consistent associations between wearable-derived HRV metrics and daily sleep disturbances in women with CPPD(s) and healthy controls, with weaker associations in CPPD(s). Integrating continuous HRV with symptom tracking could support low-burden and multimodal monitoring of sleep health in chronic pelvic pain, but prospective validation is needed before HRV can be used for diagnostic or treatment response decision making.