World Applied Sciences Journal 17 (10): 1246-1252, 2012 ISSN 1818-4952 © IDOSI Publications, 2012

The Effect of Physical Activity on Primary Dysmenorrhea of Female University Students
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Noorbakhsh Mahvash, 1Alijani Eidy, 1Kohandel Mehdi, Mehdizadeh Toorzani Zahra, 2Mirfaizi Mani and 1Hojat Shahla

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College of Physical Education and Sport Sciences, Islamic Azad University - Karaj Branch, Iran 2 Department of Midwifery, Islamic Azad University - Karaj Branch, Iran

Abstract: Primary dysmenorrhea is one of the most common complains and gynecological problem worldwide among young females. Findings claimed that exercise may positively affect this problem. Therefore, the main purpose of this study was to examine the effect of 8 weeks physical activity on primary dysmenorrhea of female students. Based on McGill’s questionnaire 50 students having moderate to severe primary dysmenorrhea took part in this study and randomly were divided into experimental (N=25) and control (N=25) groups. The experimental group participated in a physical activity program for 8 weeks, 3 sessions a week and 90 minutes per session. The results revealed that performing a regular physical activity significantly reduced type of drugs consumed (p# 0.08), number of drugs consumed (p# 0.01), volume of bleeding (p# 0.002), rate of bleeding (p# 0.005), length of menstruation pain (p# 0.001) and total and present pain intensity (p# 0.01, p#0.05) in experimental group when comparing with control group or when comparing pre and post-test findings of experimental group. Overalls, the results of this study indicated that participating in physical activity program is likely an approach to reduce the detrimental effect of primary dysmenorrhea symptoms in young females. Key words: Physical Activity % Primary Dysmenorrhea % University Students INTRODUCTION In the past two decades, the relation between physical activity and menstrual disorders including primary dysmenorrhea has significantly been studied. Research findings have indicated that exercise can affect menstruation in many ways including inducing amenorrhea in athletes and it may decrease symptoms of premenstrual syndrome and dysmenorrhea [1]. Primary dysmenorrhea or painful menstruation, in absence of any specific pelvic diseases, is one of the most common complaints of women and is also the most common gynecological problem worldwide [2, 3]. Primary dysmenorrhea begins when young girls first experience the ovulatory cycles and its prevalence increases during adolescence (15-17 years) and reaches to its highest in 2024 years and decreases progressively thereafter [4, 5]. In primary dysmenorrhea pain begins few hours before or after the onset of menstruation and lasts for 24-48 hours. The pain is more in the first day and rarely continues to next day. Dysmenorrhea pains are felt in lower abdomin and may radiate into inner parts of thighs. In a high percentage of cases, girls may experience systematic symptoms such as backache, nausea, vomiting, diarrhea, fatigue and headache [6]. With severe pain, the suffers may be absent from school or work for one or two days [3] and it could have negative impact on academic, social and sports activities of young girls [7]. Although primary dysmenorrhea is not a real threat of life, but can impact on the quality of female life and in case of severity it may lead to disability and inefficiency [8, 9]. On the other hand, dysmenorrhea can cause psychological problems in some of the females resulting in their loneliness and inactive participation in different social activities [10]. The detrimental impact of dysmenorrhea on the lives of women has been considered by most of the researchers in this area. In many countries, primary dysmenorrhea is the leading cause of recurrent short-term school and work absenteeism in young girls and women [7, 11]. Data from few longitudinal studies

Corresponding Author:

Noorbakhsh Mahvash, College of Physical Education and Sport Sciences, Islamic Azad University, Karaj Branch, Iran, POST: 17- Shenasa Street, Valye Asr Ave, Tehran, Iran. Tel: +021-22058101, Cell: +09166148819.

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showed that the absenteeism from school due to primary dysmenorrhea is 34 to 50 percent [12, 13]. Indeed, as reported by many studies, there is a considerable cost to both the individual and society as a result of dysmenorrhea. It is believed that symptoms of primary dysmenorrhea stem from raised concentrations of prostaglandins F2" (PGF2") resulting in uterine contractions and ischemia [14]. One likely mechanism for increasing prostaglandins is that, during premenstrual phase, progesterone decreases which results in the synthesis of prostaglandins in endometrial cells by membrane phospholipids. This process is supported by the ability of prostaglandin synthesis inhibitors in pain relief. As these inhibitors only provide pain relief in 70% to 75% of women, other factors may also be involved [1]. The results of studies carried out in North America, China, Australia, Turkey and Iran have shown that the prevalence of primary dysmenorrhea and percentage of women involved are different from society to society [1519]. Based on findings of these and other studies, dysmenorrhea is one of the most important health issues of young girls which must be considered because many researchers claimed that primary dysmenorrhea affects between 50 to 90% of general population [7, 13, 20- 25]. Due to its importance, different treatments including medical and non-medical treatment such as taking nonsteroidal anti-Inflammatory drugs (NSAIDS), herbal, dietary therapies, yoga, meditation and acupuncture have been used to reduce the effects of dysmenorrhea [18, 21, 26- 28]. Although these treatments are generally thought to reduce the discomfort associated with dysmenorrhea, it is believed that participation in regular physical activity is another positive way of dysmenorrhea treatment by which it may diminish the symptoms of dysmenorrhea in exercising young girls and women. Shavandi et al. (2009) studied the effect of 8 weeks isometric exercise on primary dysmenorrhea and reported that intensity and duration of pain-induced by primary dysmenorrhea are reduced and less medicine is taken, but it has no effect on the amount of bleeding [19]. Shahrjerdi and Sheikh Hoseini (2010) reported that the severity and length of pain due to primary dysmenorrhea in young girls following 8 weeks stretching exercises are diminished and they take significantly less medicine [29]. However, a number of studies have shown a correlation between life stress and gynecological symptoms. Similarly, women who train intensively have been found to experience fewer symptoms than women who take part in physical activities occasionally or not taking part at all [30].

In spite of the fact that many findings support the positive effect of physical activities on primary dysmenorrhea few studies results showed no effect of physical activities on primary dysmenorrhea [31, 32]. Due to the fact that dysmenorrhea has been treated successfully with stress reduction techniques [33, 34], physical activities and exercise are widely accepted as a means of moderating stress and stress- related symptoms. Exercise is known to cause the release of endorphins hormones in brain that raise the pain threshold and is shown to improve mood of exercising subjects. However, because of high prevalence of primary dysmenorrhea in different societies and the potential benefits of exercise found in treating dysmenorrhea and also existence of few studies which claimed that physical activity has no effect on primary dysmenorrhea the purpose of this study was to investigate the effects of physical activities on primary dysmenorrhea of Iranian female university students. MATERIALS AND METHODS All single and non-athlete female university students from Islamic Azad University-Karaj Branch aged 23.34 ± 2.35 years who enrolled in Physical Education Courses of the first semester of academic year of 2010-2011 (N=256) as research population took part in this semi-experimental study. Using Mc Gill’s questionnaire [35], 50 students with moderate to severe primary dysmenorrhea were selected as samples and based on their menstrual history and data obtained from this questionnaire, were randomly divided into experimental (N=25) and control (N=25) groups. After obtaining ethical clearance from University’s committee for research on human subjects all subjects participated in an introductory session. Purposes and methods of study were explained. Thereafter, all subjects completed the different parts of questionnaire. In the first part of the questionnaire demographic characteristics regarding age, mass body index and university subject were assessed. In the second part of the questionnaire menstrual characteristics including type and number of drugs consumed, volume (quality and quantity) and rate of bleeding and onset of menstruation and length of menstruation pain were evaluated. In the third part, female students were asked to quantify their menstrual characteristics including pain intensity by Pain Rate Index (PRI), Visual Analog Scale (VAS) and Present Pain Intensity (PPI) and total pain according to Mc Gill’s

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short form questionnaire. Total pain score is equal to the total scores obtained from all dimensions of pain. Final scores calculated from the third part of questionnaire were from 0 to 60; from 0 to 45 was considered for PRI, from 0 to 10 was considered for VAS and from 0 to 5 was considered for PPI. The reliability of McGill questionnaire was confirmed (r = 0.93). Physical Activity Protocol: Experimental group took part in training program for 8 weeks, 3 sessions a week, 90 minutes in a session in two cycles under supervision of Physical Education experts. Control group only took part in ordinary class which was one session a week. Physical activity program included 5-10 minutes warm up, 30-45 minutes progressive stretching exercises specified for pelvic region, 10-15 minutes stretching exercises using partner, 10-15 minutes resistant exercises focusing on hip girdle muscles and 5-10 minutes cool down. At the end of program, the questionnaires were completed by subjects as post- test by both groups. Subjects in control group were requested not to take part in any regular exercise program except their one university session up to the end of the study. To check the normality of data Kolmogorov-Smirnov test was used in order to analyze the findings [36]. Chisquare and independent and dependent t-test at significant level of P#0.05 were also used. RESULTS Demographic Characteristics of Subjects: As shown in Table 1, there were no significant differences in the demographic characteristics between subjects of the experimental and control groups.
Table 1: Comparison of characteristics between experimental and control groups Variables Age (years, Mean±SD) Weight (Kg, Mean±SD) Height (Cm, Mean±SD) Body Mass Index (K g/m², Mean±SD) Age at onset of menstruation (years, Mean±SD) Length of menstruation cycle (days, Mean±SD) Length of menstruation phase (days, Mean±SD)

Physical Activities-Induced Changes in Primary Dysmenorrhea Symptoms: When comparing different types of drugs consumed by experimental and control group, significant difference was found between two groups (p=0.057). In pre-test Ibuprofen as a drug was used by most subjects in both groups. But when comparing the findings of post-test after 8 weeks of physical activities, no significant difference was found in experimental group (p=0.08) and type of drug consumed was changed from Ibuprofen to Acetaminophen in experimental group without change in control group (Table 2). When comparing the volume of bleeding in both groups no significant difference was found in pre-test (p=0.1) but a significant decrease was seen in post-test comparing experimental and control groups (p=0.002) (Table 2). In relation to the onset of menstruation pain, the findings showed no significant differences between two groups in pre-test (p=0.43) and post-test (p=0.27) (Table 2). When comparing the number of drugs consumed by both groups, there were no significant differences between experimental and control groups in pre-test (p=0.754) and post-test (p=0.175) (Table 3). But comparing number of drugs used by experimental group in pre and post-test, significant difference was found (p=0.01) (Table 4). When comparing the rate of bleeding based on the number of pads used, a significant difference between experimental and control groups was found (p=0.005) (Table 3).The findings also showed a significant difference between pre and post-test of experimental group (p=0.05) (Table 4).

Experimental Group N=25 22.84 ± 1.79 56.39 ± 9.05 169.26 ± 5.53 22.07 ± 3.61 13.43 ± 1.8 6.78 ± 1.27 25.87 ± 3.68

Control Group 23.8 4 ± 2.91 60.63 ± 9.27 163.86 ± 4.64 22.64 ± 3.37 12.77 ± 1.47 5.86 ± 1.28 26.54 ± 3.93

P-value N=25 W p> 0.05 p> 0.05 p> 0.05 p>0.05 p> 0.05 p> 0.05 p> 0.05

Table 2: Comparison of primary dysmenorrhea characteristics between experimental and control groups based on Chi-square analysis Variables Type of drugs consumption Volume of bleeding (quality) Onset of menstruation pain Pre-test Post-test Pre-test Post-test Pre-test Post-test K² 2.9 8.1 4.604 15.21 2.74 3.85 df 4 4 2 3 3 3 p-value 0.57 0.08 0.10 0.002 0.43 0.27

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Table 3: Comparison of primary dysmenorrhea characteristics of experimental and control groups based on independent t-test analysis Variables Number of drugs consumed Rate of bleeding Length of menstruation pain Volume of bleeding(quantity) Pre-test Post-test Pre-test Post-test Pre-test Post-test Pre-test Post-test Mean Diff. 0.16 0.73 0.96 1.92 0.17 1.74 0.18 0.50 df 48 48 48 48 48 48 48 48 t 0.315 1.315 1.58 4.18 -0.39 3.28 0.33 -0.35 p-value 0.754 0.175 0.12 0.005 0.69 0.001 0. 75 0.72

Table 4: Comparison of primary dysmenorrhea characteristics between pre and post-test of experimental group based on dependent t-test analysis Variables Number of drugs consumed Rate of bleeding Length of menstruation pain(days) Volume of bleeding(quantity/CC) Mean diff. 1.040 0.84 0.6 2 df 24 24 24 24 t 2.68 3.05 2.05 2.87 p-value 0.01 0.005 0.05 0.008

Table 5: Comparison of primary dysmenorrheal pain between experimental and control groups assessed by Mc Gill’s questionnaire based on independent t-test analysis Variables Pain Rate Index (PRI) Visual Analog Scale(VAS) Present Pain Intensity (PPI) Total Pain Mean diff. -6.56 -0.84 -1.04 8.37 df 48 48 48 48 t -6.56 -1.97 -4.9 -9.21 p-value 0.01 0.05 0.05 0.01

When comparing the length of menstruation pain it was found that this item is significantly decreased in experimental group (p=0.05) (Table 4). The results also showed that the difference between the length of menstruation pain of experimental and control groups was significant (p=0.001) (Table 3). When comparing the volume of bleeding, there was no significant difference between data of control group in pre and post-test (p=0.22), but this difference was significant in experimental group (p=0.008) (Table 4). When the findings of two groups regarding the volume of bleeding was compared, no significant difference was observed (p=0.72) (Table 3). In regard to Pain Rate Index (PRI), the findings showed no significant difference in pre and post-test of control group (p=0.14), but this difference was significant comparing pre and post-test of experimental group (p=0.01). PRI was also significantly different between experimental and control groups (p=0.01) (Table 5). Findings from Visual Analog Scale (VAS) and the Present Pain Intensity (PPI) which assess the total and present intensity of pain, showed that significant reduction was found between experimental and control groups (p=0.05) in both cases in favor of experimental group (Table 5).

The results of the study also showed that the total amount of pain reduction was significantly more in experimental group (p=0.01) in comparison with control group (Table 5). DISCUSSION AND CONCLUSION The main findings of this study indicated that physical activity had a positive impact on the most of primary dysmenorrhea symptoms in such a way that type of drugs consumption changed from Ibuprofen to Acetaminophen (p#0.05). Volume and rate of bleeding decreased (p#0.002, p#0.05). Length of menstruation pain reduced (p#0.05), number of drugs consumed reduced, but not significantly and finally Pain Rate Index and Total and Present Pain Intensity reduced (p#0.01, p#0.05). Regarding type of drugs used by subjects prior to study, it was found that experimental group participating in physical activity protocol replaced Acetaminophen with Ibuprofen which is a strong pain relief meaning that physical activity resulted in more tolerable menstruation thereafter. This finding is in line with Thirza et al. [17]. Due to the fact that painful menstruation may limit social activities and may also lead to school missing [15, 17, 18, 21, 37] young girls try to use strong drugs such as Ibuprofen to prevent these problems.

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Our findings also showed that the number of drugs consumed by experimental group decreased comparing pre and post-test data. This result is in agreement with Shavandi et al. [19], Abbaspour et al. [38] and Shahrjerdi and Sheikh Hoseini [29]. The reasons for this reduction might be due to that when menstruation is very painful, the suffers use more drugs and prefer to take antiinflammatory type such as Ibuprophen or other strong drugs. When volume of bleeding was studied, our results indicated that volume of bleeding was significantly lowered in post- exercise group. In addition to the evidence that experimental group had lower volume of bleeding after 8 weeks of physical activity, it is suggested that physical activity might reduce, in some degree, the magnitude of bleeding, because it may lead to a better hormonal balance. On the other hand, evidence shows that anti diuretic hormone is active during physical activity and the vasoconstriction action of this hormone and variations in pelvic blood flow may influence the synthesis or breakdown of prostaglandins [1]. This finding is not in line with the results obtained from Shavandi et al. [19] which indicated that there is no change in the volume of bleeding in post-exercise young girls. Our results also depicted that rate of bleeding based on the number of pads changed per day, was reduced significantly in experimental group. This finding supports the notion that doing exercise may reduce the volume of bleeding and suggested that exercise may actually be associated with higher level of menstrual discomfort. Regarding the length of menstruation pain, the finding of this study showed that the length of menstruation pain was reduced significantly in our experimental group after 8 weeks training. This finding is supported by previous studies carried out by Shavandi et al. [19], Iorno et al. [28] and Shahrjerdi and Sheikh Hoseini [29]. One likely mechanism for reducing the length of menstruation pain in post-exercise group is that physical activity may help a faster transfer of vast products and prostaglandins as a root of menstruation pain from uterine muscle. This result is not in agreement with Kermanshahi et al. [39] which might be due to age of subjects and training conditions. Our findings in association with intensity of primary dysmenorrhea pain obtained from McGill’s questionnaire using Pain Rate Index and Visual Analog Scale for assessing the total and present pain intensity revealed that the intensity of pain was reduced in experimental group after completing training protocol. Even though, a

number of studies have failed to find any relation between intensity of primary dysmenorrhea pain and physical activity [31, 32], other studies such as Smith et al. [27], Iorno et al. [28], Abbaspour et al. [38], Shahrjerdi and Sheikh Hoseini [29] and Izzo and Labriola [30] support our results. One possible mechanism explaining the positive effect of physical activity on intensity of primary dysmenorrhea pain is associated with stress. It has been accepted that exercise is used as a mean of moderating stress. Menstrual pain may be resulted from increased contraction of uterine muscle which is innervated by the sympathetic nervous system. Stress is supposed to increase the sympathetic activity which may lead to the increase of menstrual pain by enhancing the intensity of uterine contraction. So, due to the fact that exercise reduce and moderate stress, the sympathetic activity may be decreased. Thereby, intensity of menstrual pain and other related symptoms may be reduced as well. Another possible dilemma in this respect is that, because doing physical activity leads to the release of endorphins which are produced by brain may enhance the pain threshold. In conclusion, the results of the present study suggested that performing regular physical activity reduced the primary dysmenorrhea symptoms. As a factor it has been accepted that in developing countries such as Iran, participating in regular physical activity programs are limited by social, cultural and religious factors. Therefore, because of high potential benefits of physical activity and exercise in reducing the detrimental effects of primary dysmenorrhea symptoms, young girls are recommended to take part in such physical activity programs in order to help them to decrease the negative impact of these symptoms on their academic, social and even personal life. REFERENCES 1. Warren, M.P. and J. Locke Rebecca, 1999. What is the effect of exercise on primary dysmenorrheal? WJSM, 33: 227. Kennedy, S., 1997. Primary dysmenorrhea. Lancet, 19: 1116. Harel, Z., 2006. Dysmenorrhea in adolescents and young adults: etiology and management Journal of pediatr adolesc gynecology, 19: 363-371. Chantler, I., D. Mitchell and A. Fuller, 2008. The effect of three cyclo-oxygenase inhibitors on intensity of primary dysmenorrhoeic pain. Clinical Journal of Pain, 24: 39-44.

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