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Exercise for dysmenorrhoea (Review)
Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E
Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E.

Exercise for dysmenorrhoea.
Cochrane Database of Systematic Reviews 2019, Issue 9. Art. No.: CD004142.
DOI: 10.1002/14651858.CD004142.pub4.
www.cochranelibrary.com

Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.

Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 8
OBJECTIVES.................................................................................................................................................................................................. 8
METHODS..................................................................................................................................................................................................... 8
RESULTS........................................................................................................................................................................................................ 11
Figure 1.................................................................................................................................................................................................. 13
Figure 2.................................................................................................................................................................................................. 14
Figure 3.................................................................................................................................................................................................. 15
Figure 4.................................................................................................................................................................................................. 16
DISCUSSION.................................................................................................................................................................................................. 17
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 18
ACKNOWLEDGEMENTS................................................................................................................................................................................ 19
REFERENCES................................................................................................................................................................................................ 20
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 24
DATA AND ANALYSES.................................................................................................................................................................................... 50
Analysis 1.1. Comparison 1 Exercise versus no treatment, Outcome 1 Menstrual pain intensity..................................................... 50
Analysis 1.2. Comparison 1 Exercise versus no treatment, Outcome 2 Overall menstrual symptoms............................................. 51
Analysis 1.3. Comparison 1 Exercise versus no treatment, Outcome 3 Quality of life...................................................................... 51
Analysis 2.1. Comparison 2 Exercise versus NSAIDs, Outcome 1 Menstrual pain intensity.............................................................. 52
Analysis 2.2. Comparison 2 Exercise versus NSAIDs, Outcome 2 Use of rescue analgesic medication............................................ 52
Analysis 2.3. Comparison 2 Exercise versus NSAIDs, Outcome 3 Absence from work or school...................................................... 52
APPENDICES................................................................................................................................................................................................. 53
WHAT'S NEW................................................................................................................................................................................................. 56
HISTORY........................................................................................................................................................................................................ 57
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 57
DECLARATIONS OF INTEREST..................................................................................................................................................................... 57
SOURCES OF SUPPORT............................................................................................................................................................................... 58
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 58
NOTES........................................................................................................................................................................................................... 58
INDEX TERMS............................................................................................................................................................................................... 58
Exercise for dysmenorrhoea (Review) i

Informed decisions.

[Intervention Review]
Exercise for dysmenorrhoea
Mike Armour1, Carolyn C Ee1, Dhevaksha Naidoo1, Zahra Ayati2, K Jane Chalmers3, Kylie A Steel3, Michael J de Manincor1, Elahe Delshad4
1NICM Health Research Institute, Western Sydney University, Penrith, Australia. 2School of Pharmacy, Mashhad University of Medical
Sciences, Mashhad, Iran. 3School of Science and Health, Western Sydney University, Penrith, Australia. 4School of Persian and
Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
Contact address: Mike Armour, NICM Health Research Institute, Western Sydney University, Building J, Westmead Campus, Penrith,
NSW, 2751, Australia. m.armour@westernsydney.edu.au, 17382885@student.uws.edu.au.
Editorial group: Cochrane Gynaecology and Fertility Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 9, 2019.
Citation: Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E. Exercise for dysmenorrhoea. Cochrane
Database of Systematic Reviews 2019, Issue 9. Art. No.: CD004142. DOI: 10.1002/14651858.CD004142.pub4.
ABSTRACT
Background
Exercise has a number of health benefits and has been recommended as a treatment for primary dysmenorrhoea (period pain), but the
evidence for its effectiveness on primary dysmenorrhoea is unclear. This review examined the available evidence supporting the use of
exercise to treat primary dysmenorrhoea.
Objectives
To evaluate the effectiveness and safety of exercise for women with primary dysmenorrhoea.
Search methods
We searched the Cochrane Gynaecology and Fertility specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED and CINAHL (from
inception to July 2019). We searched two clinical trial databases (inception to March 2019) and handsearched reference lists and previous
systematic reviews.
Selection criteria
We included studies if they randomised women with moderate-to-severe primary dysmenorrhoea to receive exercise versus no treatment,
attention control, non-steroidal anti-inflammatory drugs (NSAIDs) or the oral contraceptive pill. Cross-over studies and cluster-randomised
trials were not eligible for inclusion.
Data collection and analysis

Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data from each study.
We contacted study authors for missing information. We assessed the quality of the evidence using GRADE. Our primary outcomes were
menstrual pain intensity and adverse events. Secondary outcomes included overall menstrual symptoms, usage of rescue analgesic
medication, restriction of daily life activities, absence from work or school and quality of life.
Main results
We included a total of 12 trials with 854 women in the review, with 10 trials and 754 women in the meta-analysis. Nine of the 10 studies
compared exercise with no treatment, and one study compared exercise with NSAIDs. No studies compared exercise with attention control
or with the oral contraceptive pill. Studies used low-intensity exercise (stretching, core strengthening or yoga) or high-intensity exercise
(Zumba or aerobic training); none of the included studies used resistance training.
Exercise versus no treatment

Exercise for dysmenorrhoea (Review) 1
Informed decisions.

Exercise may have a large effect on reducing menstrual pain intensity compared to no exercise (standard mean difference (SMD) -1.86, 95%
confidence interval (CI) -2.06 to -1.66; 9 randomised controlled trials (RCTs), n = 632; I2= 91%; low-quality evidence). This SMD corresponds
to a 25 mm reduction on a 100 mm visual analogue scale (VAS) and is likely to be clinically significant. We are uncertain if there is any
difference in adverse event rates between exercise and no treatment.
We are uncertain if exercise reduces overall menstrual symptoms (as measured by the Moos Menstrual Distress Questionnaire (MMDQ)),
such as back pain or fatigue compared to no treatment (mean difference (MD) -33.16, 95% CI -40.45 to -25.87; 1 RCT, n = 120; very low-
quality evidence), or improves mental quality of life (MD 4.40, 95% CI 1.59 to 7.21; 1 RCT, n = 55; very low-quality evidence) or physical
quality of life (as measured by the 12-Item Short Form Health Survey (SF-12)) compared to no exercise (MD 3.40, 95% CI -1.68 to 8.48; 1 RCT,
n = 55; very low-quality evidence) when compared to no treatment. No studies reported on any changes in restriction of daily life activities
or on absence from work or school.
Exercise versus NSAIDs
We are uncertain if exercise, when compared with mefenamic acid, reduced menstrual pain intensity (MD -7.40, 95% CI -8.36 to -6.44; 1
RCT, n = 122; very low-quality evidence), use of rescue analgesic medication (risk ratio (RR) 1.77, 95% CI 1.21 to 2.60; 1 RCT, n = 122; very
low-quality evidence) or absence from work or school (RR 1.00, 95% CI 0.49 to 2.03; 1 RCT, n = 122; very low-quality evidence). None of the
included studies reported on adverse events, overall menstrual symptoms, restriction of daily life activities or quality of life.
Authors' conclusions
The current low-quality evidence suggests that exercise, performed for about 45 to 60 minutes each time, three times per week or more,
regardless of intensity, may provide a clinically significant reduction in menstrual pain intensity of around 25 mm on a 100 mm VAS. All
studies used exercise regularly throughout the month, with some studies asking women not to exercise during menstruation. Given the
overall health benefits of exercise, and the relatively low risk of side effects reported in the general population, women may consider using
exercise, either alone or in conjunction with other modalities, such as NSAIDs, to manage menstrual pain. It is unclear if the benefits of
exercise persist after regular exercise has stopped or if they are similar in women over the age of 25. Further research is required, using
validated outcome measures, adequate blinding and suitable comparator groups reflecting current best practice or accounting for the
extra attention given during exercise.
PLAIN LANGUAGE SUMMARY
Exercise for dysmenorrhoea
Review question
Cochrane authors reviewed the evidence on the effectiveness and safety of exercise in women with primary dysmenorrhoea (period pain).
Background
We wanted to know whether using exercise was better than receiving no treatment, a treatment that gives you some attention but is not
exercise, or currently recommended pharmaceutical medications for primary dysmenorrhoea, such as the oral contraceptive pill or non-
steroidal anti-inflammatory drugs (NSAIDs).
Study characteristics
We found 12 studies including 854 women that examined the effect of exercise in women with period pain. The evidence is current to
August 2019. Two trials did not report data suitable to be included in the meta-analysis, so we included 10 trials with 754 women in our
meta-analysis. Eleven trials compared exercise with no treatment and one compared exercise with NSAIDs.
Key results
Exercise, whether low-intensity, such as yoga, or high-intensity, such as aerobics, may provide a large reduction in the intensity of period
pain, compared to not doing anything. This reduction in pain was likely to be important to women with period pain as it is over twice the
minimum amount of pain reduction we think is needed to notice a difference. Most studies asked women to exercise at least three times
per week, for about 45 to 60 minutes of exercise each time. It is unclear if exercising less frequently, or for a shorter duration would have the
same results. Exercise was performed regularly throughout the month, with some studies asking women not to perform exercise during
the period itself.
The evidence for the safety of exercise was not well reported and so we cannot draw any conclusions. Other outcomes, such as the effect
on overall menstrual symptoms or overall quality of life, were not well reported and the evidence was of very low quality, so we cannot
be sure if exercise has any effect on these outcomes. No studies reported on rates of being absent from work or school or on restrictions
of daily life activities.

Informed decisions.

There was not enough evidence to determine if there was any benefit of exercise when compared to NSAIDs, a class of medications (like
ibuprofen) commonly used to treat period pain, on menstrual pain intensity, need for additional pain-relieving medication, or absence
from work or school. No studies reported on quality of life or restriction of daily life activities
Quality of the evidence
The quality of the evidence was low to very low. The main limitations were imprecision due to small sample sizes (too few women in the
study), inconsistency (studies gave very different results) and risk of bias related to blinding (where researchers or participants knew what
treatment they were getting).

SUMMARY OF FINDINGS

Summary of findings for the main comparison. Exercise compared to no treatment for dysmenorrhoea
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Exercise compared to no treatment for dysmenorrhoea
Patient or population: young women with suspected primary dysmenorrhoea

Setting: school, university or outpatient setting
Intervention: exercise
Better health.
Informed decisions.
Trusted evidence.
Comparison: no treatment
Outcomes Anticipated absolute effects* (95% CI) Relative ef- № of partici- Quality of the Comments
fect pants evidence
Risk with no treat- Risk with exercise (95% CI) (studies) (GRADE)
ment
Menstrual pain The mean menstrual SMD 1.86 lower - 632 ⊕⊕⊝⊝ Exercise may provide a large reduction in men-
intensity, pain intensity was 6.76 (2.06 lower to 1.66 (9 RCTs) Lowab strual pain intensity compared to no treatment.
measured by var- lower)
ious outcome
measures includ-
ing VAS, MPQ and
NRS at the end of
the intervention
Lower scores
indicate less in-
tense menstrual
pain
Adverse events 0 per 1000 0 per 1000 Not estimable 36 ⊕⊝⊝⊝ Due to the very low-quality evidence, we are un-
(0 to 0) (1 RCT) Very lowcd certain whether there is any difference in risk for
adverse events between exercise and no treat-

ment control.
Overall menstrual The mean overall men- MD 33.16 lower - 120 ⊕⊝⊝⊝ Due to the very low-quality evidence, we are un-
symptoms , strual symptoms was (40.45 lower to (1 RCT) Very lowef certain whether exercise reduces overall men-
measured by the 99 25.87 lower) strual symptoms compared to a no treatment
MMDQ at the end control.
of the interven-
tion.
Lower scores
indicates lower
4

menstrual symp-
tom severity
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Use of rescue - - - - - No studies reported on this outcome.
analgesic med-
ication - not re-
ported
Restriction of dai- - - - - - No studies reported on this outcome.

ly life activities -
Better health.
Informed decisions.
Trusted evidence.
not reported
Absence from - - - - - No studies reported on this outcome.

work or school -
not reported
Quality of life, Mean postintervention Mental component: - 55 ⊕⊝⊝⊝ Due to the very low-quality evidence, we are un-
assessed with: score for the mental MD 4.40 higher (1 RCT) Very lowgh certain whether exercise improves quality of life
physical and component in the no (1.59 higher to 7.21 compared to a no treatment control.
mental compo- treatment group was higher)
nent summary 37.6
scores measured Physical compo-
by the SF-12 at Mean postintervention nent: MD 3.40 high-
the end of the in- score for the physical er
tervention component in the no (1.68 lower to 8.48
treatment group was higher)
Higher scores 44.4
indicate higher
quality of life
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; MMDQ: Moos Menstrual Distress Questionnaire; MPQ: McGil Pain Questionnaire; NRS: numeric rating scale; RCT: randomised
controlled trial; SF-12: 12-Item Short Form Health Survey; SMD: standardised mean difference; VAS: visual analogue scale

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.
aDowngraded one level for serious risk of bias: all included trials are at a high risk of bias for performance and detection bias.
bDowngraded one level for serious inconsistency: while heterogeneity is very high (I2= 91%), all effects are in the same direction, favouring exercise.
cDowngraded one level for serious risk of bias: single included trial has a high risk of performance and detection bias and this may affect the adverse event reporting.
dDowngraded two levels for very serious imprecision: very small sample size (36 participants) and rare adverse events.
5

eDowngraded two levels for very serious risk of bias: the single included study is at high risk of bias for three domains and unclear for the remainder.
fDowngraded one level for serious imprecision: one small study.
gDowngraded one level for serious risk of bias: the single included study is at high risk of bias for two domains.
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hDowngraded two levels for very serious imprecision: one small study (55 participants).

Summary of findings 2. Exercise compared to non-steroidal anti-inflammatory drugs (NSAIDs) for dysmenorrhoea
Exercise compared to non-steroidal anti-inflammatory drugs (NSAIDs) for dysmenorrhoea
Better health.
Informed decisions.
Trusted evidence.
Patient or population: young women with suspected primary dysmenorrhoea
Setting: university or school
Intervention: exercise
Comparison: NSAIDs
Outcomes Anticipated absolute effects* Relative ef- № of partici- Quality of the Comments
(95% CI) fect pants evidence
(95% CI) (studies) (GRADE)
Risk with Risk with exer-
NSAIDs cise
Menstrual pain intensity, The mean MD 7.4 low- - 122 ⊕⊝⊝⊝ Due to the very low-quality evidence,
measured by 100 mm VAS at the end of menstrual er change in (1 RCT) Very lowab we are uncertain whether exercise im-
the intervention pain intensi- VAS score from proves menstrual pain severity com-
ty was -21.3 baseline pared to NSAIDs.
Higher scores indicate greater reduc- change in VAS (8.36 lower to
tions in pain intensity from baseline score from 6.44 lower)
baseline
Adverse events - not reported - - - - - No studies reported on this outcome.
Overall menstrual symptoms - not re- - - - - - No studies reported on this outcome.

ported

Use of rescue analgesic medication 361 per 1000 638 per 1000 RR 1.77 122 ⊕⊝⊝⊝ Due to the very low-quality evidence,
(436 to 938) (1.21 to 2.60) (1 RCT) Very lowab we are uncertain whether exercise
assessed by: number of women who changes the amount of additional med-
took rescue/additional analgesics dur- ication needed compared to NSAIDs.
ing the last cycle
Greater numbers indicate more women

needed additional analgesics
Restriction of daily life activities - not - - - - - No studies reported on this outcome.

reported
6

Absence from work or school 492 per 1000 492 per 1000 OR 1.00 122 ⊕⊝⊝⊝ Due to the very low-quality evidence,
(322 to 663) (0.49 to 2.03) (1 RCT) Very lowab we are uncertain whether exercise
changes absenteeism compared to
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NSAIDs.
Quality of life - not reported - - - - - No studies reported on this outcome.
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Better health.
Informed decisions.
Trusted evidence.
CI: confidence interval; MD: mean difference; NSAID: non-steroidal anti-inflammatory drug; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; VAS: visual ana-
logue scale
GRADE Working Group grades of evidence

High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.
aDowngraded two levels for very serious risk of bias: the single included study was at high risk of bias for performance and detection bias and unclear risk of bias for all other
domains.
bDowngraded one level for serious imprecision: one small study (122 participants) reported on this outcome.


7

Informed decisions.

BACKGROUND How the intervention might work
Description of the condition Different intensities of exercise may operate via different
mechanisms. Moderate- to high-intensity exercise may reduce pain
Dysmenorrhoea is painful uterine cramps of menstrual origin and via increasing anti-inflammatory cytokines (Febbraio 2007), and
can be classified as primary or secondary dysmenorrhoea (Proctor by reducing the overall amount of menstrual flow (Warren 2001),
2006). thereby decreasing the overall amount of prostaglandins released.
Less intense exercise, such as yoga can reduce cortisol levels
Primary dysmenorrhoea is defined as pain in the absence of an (Pascoe 2017), which in turn can reduce prostaglandin synthesis
identifiable change in the pelvis and is most common in women (Casey 1985).
under the age of 25, with pain usually starting within three years
of menarche (Coco 1999). Primary dysmenorrhoea's characteristic Why it is important to do this review
symptom is crampy, colicky spasms of pain in the suprapubic area,
occurring within eight to 72 hours of menstruation and peaking Most women manage their symptoms with primarily over the
within the first few days as menstrual flow increases (Coco 1999; counter (OTC) pain medications (e.g. ibuprofen and paracetamol/
Proctor 2006). Primary dysmenorrhoea can usually be diagnosed acetaminophen), and self-care including rest and the application
by means of a thorough history taking, as well as abdominal or of heat, rather than seeking medical advice (Armour 2019c).
pelvic examination. This applies to most patients who have typical However, one key barrier in managing menstrual pain is that the
symptoms and no risk factors for secondary causes (French 2005). intervention needs to be affordable, both in terms of time and
cost (Armour 2016). Exercise may fulfil this criteria, providing an
A recent systematic review and meta-analysis found that affordable alternative or adjunct to analgesics. Conflicting results
dysmenorrhoea is common in young women worldwide under 25, exist from population level studies examining the relationship
with 71% reporting period pain, and it is unclear whether period between exercise in general and period pain; with some studies
pain reduces with increasing age (Armour 2019b). showing no effect of exercise (Blakey 2010), some a positive effect
(Vani 2013), and some a negative effect (Metheny 1989), especially
Primary dysmenorrhoea is responsible for a decrease in quality of with regards to negative emotional symptoms, such as anxiety, that
life (Burnett 2005; Campbell 1997; Hillen 1999), absence from work can accompany menstruation (Hightower 1998).
or school (Armour 2019b; Zahradnik 2010), reduced participation in
sport and social activities (Armour 2019b; Banikarim 2000), altered OBJECTIVES
pain perception and sleeping problems (Baker 1999).
To evaluate the effectiveness and safety of exercise for women with
The largest contributing physiological factor in primary primary dysmenorrhoea.
dysmenorrhoea is increased amounts of prostaglandins present
in the menstrual fluid (Dawood 2006). Prostaglandins, especially METHODS
PGF2a, stimulate myometrial contractions, reducing uterine blood
flow and causing uterine hypoxia. This hypoxia is responsible for Criteria for considering studies for this review
the painful cramping that characterises primary dysmenorrhoea Types of studies
(Dawood 2006; Zahradnik 2010).
We included randomised controlled trials (RCTs) without restriction
Secondary dysmenorrhoea is period pain with an identifiable cause on language and publication types. We excluded non-randomised
(Proctor 2006), commonly endometriosis or uterine fibroids, and is studies (for example, studies with evidence of inadequate sequence
not the subject of this review. generation such as alternate days, patient numbers) and cluster-
RCTs. We did not include cross-over trials due to the unknown
Description of the intervention duration of the 'wash out' period for exercise.
Physical exercise has long been advocated as a non-medical Types of participants
intervention for the relief of dysmenorrhoea (Fernandez 1991;
Metheny 1989). Inclusion criteria
Exercise has often been conceptualised in the public perception as Women in the trials had to meet the following inclusion criteria for
mostly high-intensity aerobic activities, such as running, swimming the trial to be included in the review.
or cycling, or resistance training; however lower-intensity types of • Be of reproductive age (15 to 49 years).
exercise such as yoga, tai chi, Pilates and stretching are gaining
• Have suspected primary dysmenorrhoea, i.e. no identifiable
greater attention as effective alternatives to the sometimes more
pelvic pathology, as indicated by pelvic examination, ultrasound
injurious traditional forms of high-intensity exercise (Govindaraj
scans, or laparoscopy.
2016).
• Have primary dysmenorrhoea (self-reported pain) during the
For this review the American College of Sports Medicine (ACSM) majority of the menstrual cycles in the past three months.
definition of exercise as “physical activity characterized by using • Have moderate-to-severe primary dysmenorrhoea (pain is
planned and structured repetitive movements to increase or reported to affect daily activities, such as socialising, working or
maintain physical fitness” was used (ACSM 2014). This incorporates going to school, or has a high baseline score on a validated pain
both high-intensity aerobic exercise, resistance training and lower- scale (greater than 4/10 on a numeric rating scale (NRS) or 40
intensity exercise, such as tai chi and yoga. mm on a 100 mm visual analogue scale (VAS)).

Informed decisions.

Exclusion criteria Search methods for identification of studies

If participants in the trial met any of the following exclusion criteria, We conducted a comprehensive and exhaustive search strategy to
we did not include the trial in the review. identify all relevant studies regardless of language or publication
status (published, unpublished, in press, and in progress). The
• Irregular or infrequent menstrual cycles (usually outside of the search was conducted in consultation with the Gynaecology and
typical range of a 21 to 35 day cycle). Fertility Group Information Specialist.
• Diagnosed secondary dysmenorrhoea (e.g. fibroids,
endometriosis). Electronic searches
• Dysmenorrhoea resulting from use of an intrauterine device. We searched:
• Mild or infrequent dysmenorrhoea (less than 1 out of 3 three
cycles). • the Cochrane Gynaecology and Fertility specialised register, 25
July 2019 (PROCITE platform) (Appendix 1);
Types of interventions • CENTRAL, July 2019 (OVID platform) (Appendix 2);
Any randomised controlled trials (RCTs) comparing exercise (as per • MEDLINE, from 1946 to 25 July 2019 (OVID platform) (Appendix
ACSM 2014 "physical activity characterized by using planned and 3);
structured repetitive movements to increase or maintain physical • Embase, from 1980 to 25 July 2019 (Ovid platform) (Appendix 4);
fitness") to: • PsycINFO, from 1806 to 25 July 2019 (Ovid platform) (Appendix
5);
• no treatment;
• AMED, from 1985 to 25 July 2019 (Ovid platform) (Appendix 6);
• attention control (where the amount of time spent and attention
and
received from the research team are matched to the intervention
group, e.g. a lecture series on self-care for period pain); • CINAHL, from 1961 to 25 July 2019 (EBSCO platform) (Appendix
7).
• non-steroidal anti-inflammatory drugs (NSAIDs);
• oral contraceptive pill or combined oral contraceptive pill. Searching other resources
Types of outcome measures We also searched:.
Primary outcomes • trial registers for ongoing and registered trials: ClinicalTrials.gov
(www.clinicaltrials.gov) and the World Health Organization
• Menstrual pain intensity, as a continuous variable measured
preferably by VAS, NRS or other validated scales, such as (WHO) International Clinical Trials Registry Platform
McGill Pain Questionnaire (MPQ), or pain relief, measured as a (apps.who.int/trialsearch) in March 2019; and
dichotomous outcome (i.e. sufficient pain relief: yes or no) • reference lists from included articles and previous systematic
reviews.
• Adverse events, measured as rate of side effects overall and any
injuries, such as muscle sprains or strains We searched the following additional electronic resources in
Secondary outcomes English in March 2019.
• Overall menstrual symptoms (e.g. back pain, nausea, fatigue), • DARE – Database of Abstracts of Reviews of Effects (reference
measured by changes in overall symptoms of dysmenorrhoea lists from non-Cochrane reviews on similar topics).
that were either self-reported or investigator-observed, using • ProQuest Dissertations & Theses for unpublished dissertations
tools such as the Moos Menstrual Distress Questionnaire and theses.
(MMDQ). • Conference abstracts on the Web of Science.
• Use of rescue analgesic medication, measured as the proportion • OpenGrey for unpublished literature from Europe
of women requiring rescue analgesics. (www.opengrey.eu).
• Restriction of daily life activities, measured as the proportion of • LILACS database for the Portuguese and Spanish speaking world
women who reported activity restrictions. (regional.bvsalud.org).
• Absence from work or school, measured as the proportion of
women reporting absences from work or school, and also as Data collection and analysis
hours and days of absence as a more selective measure.
Selection of studies
• Quality of life, measured by a validated scale, for example the 36-
Item Short Form Health Survey (SF-36) or EuroQoL 5D (EQ-5D). Two review authors (MA and CE) screened the titles and abstracts
of English language articles and two review authors (ZA and MA)
If studies reported outcomes at different time frames, then we screened the titles and abstracts of articles in Farsi, and discarded
grouped outcomes as end of intervention, short-term (more than trials that were clearly not eligible.
1 month but less than 3 months), medium-term (4 months to 12
months) and long-term (over 12 months). The preferred time frame Two review authors (ZA and ED) translated and performed data
was the longest time since the end of intervention. extraction on Farsi language papers. MA, CE, ZA, JC, ED, KS and MdM
independently assessed whether trials met the inclusion criteria,
with disagreements resolved by discussion. If articles contained
insufficient information to make a decision about eligibility, MA,
CE or ZA attempted to contact authors of the original reports to
Informed decisions.

obtain further details. If details of randomisation were unclear in that participants will inevitably be unblinded and will be rated
the reporting, we contacted all trial authors to ascertain if the as high risk of performance bias. In the case where subjective,
study was truly randomised. We made first contact and then sent a patient-reported outcome measures were used (such as NRS) as the
reminder one month later. We documented the selection process, primary outcome, we rated detection bias as high risk of bias. If
including reasons for exclusion, in a PRISMA flow chart (Moher dropout rates were greater than 30%, or the difference in dropout
2015). rates between groups exceeded 10% and there is no explanation for
other factors, we rated attrition bias as high.
Data extraction and management
Measures of treatment effect
Following an assessment for inclusion, all review authors
independently extracted data, with two review authors extracting We performed statistical analysis in accordance with the Cochrane
data for each study. We resolved discrepancies by discussion with Handbook for Systematic Reviews of Interventions (Higgins 2011).
a third review author (CE or MA). For each included trial we We performed statistical analysis using Review Manager 5
extracted data regarding the location of the trial, the methods of software (Review Manager 2014). For dichotomous data, we
the trial (as per assessment of risk of bias), the participants (age expressed results for each study as summary risk ratios (RRs)
range, eligibility criteria), the nature of the interventions, and data with corresponding 95% confidence intervals (CIs), using the
relating to the outcomes specified above. We collected information Mantel-Haenszel method. We expressed continuous data as mean
on reported benefits and adverse events. We extracted data and differences (MDs) with 95% CIs, or as standardised mean differences
entered them onto a form sourced from the Cochrane Handbook for (SMDs) if outcomes were conceptually the same but measured in
Systematic Reviews of Interventions (Higgins 2011). MA checked and different ways in the different trials. A standard rule of thumb for
entered data into Review Manager 5 (Review Manager 2014). interpreting effect sizes is that 0.2 represents a small effect, 0.5 a
moderate effect and 0.8 a large effect.
Where studies have multiple publications, we collated multiple
reports of the same under a single study ID with multiple references. Unit of analysis issues
We corresponded with study investigators for further data on
All analyses were per woman randomised. We included trials
methods and/or results, as required.
with multiple arms and described them in the Characteristics of
Assessment of risk of bias in included studies included studies tables. If there were two similar exercise groups
(such as two low-intensity groups), we combined data from the two
Two review authors (from MA, CE, KS, ZA, JC, ED, DN and MM) treatment arms. If the exercise arms were different, such as one arm
independently assessed risks of bias for each trial, using the criteria using weight training and one using aerobics, they were analysed
described in the Cochrane Handbook for Systematic Reviews of separately and we divided the shared control group evenly between
Interventions (Higgins 2011). The tool consists of seven items, with groups as described in the Cochrane Handbook for Systematic
three potential responses: 'yes', 'no', and 'unclear'. In all cases a Reviews of Interventions (Higgins 2011). Where outcomes were
judgement of 'yes' indicates a low risk of bias and a judgement of repeated measures, we undertook analysis of outcomes at the end
'no' indicates a high risk of bias. If insufficient detail was reported, of the intervention and at any follow-up time points after the end
our judgement was usually 'unclear'. We also made a judgement of of the intervention.
'unclear' if we knew what happened in the study but the risk of bias
was unknown to us, or if an entry was not relevant to the study at Dealing with missing data
hand (particularly for assessing blinding and incomplete outcome
We analysed data on an intention-to-treat basis, as far as possible.
data, or when the outcome being assessed by the entry had not
We did not impute missing data, but we did report the proportion
been measured in the study).
lost to follow-up and analysed only the available data.
We assessed the following characteristics: sequence generation,
Assessment of heterogeneity
allocation concealment, blinding (or masking) of participants,
blinding (or masking) of outcome assessors, incomplete data We considered whether the clinical and methodological
assessment, selective outcome reporting, and other sources of characteristics of included studies were sufficiently similar for
bias. We resolved disagreements that arose at any stage by meta-analysis to provide a clinically meaningful summary. We
discussion between the review authors or with a third party, assessed statistical heterogeneity by the measure of the I2 statistic.
when necessary. We generated a 'Risk of bias' assessment table If an I2 was 50% or higher, we assumed high heterogeneity, and
for each study. We assessed other aspects of trial quality, conducted a sensitivity analysis. A high I2 statistic suggests that
including the extent of blinding (if appropriate), whether groups variations in effect estimates may be due to differences between
were comparable at baseline, the extent of losses to follow- trials rather than to chance alone (Higgins 2011).
up, non-compliance and whether the outcome assessment
was standardised according to the Cochrane Handbook for Assessment of reporting biases
Systematic Reviews of Interventions (Higgins 2011). We described all
judgements fully and present the conclusions in the 'Risk of bias' In view of the difficulty of detecting and correcting for publication
table (Characteristics of included studies). bias and other reporting biases, we aimed to minimise their
potential impact by ensuring a comprehensive search for eligible
Where protocols were available, we assessed studies for differences studies and by being alert for duplication of data. If there were 10
between study protocols and published results. Where protocols or more studies in an analysis, we used a funnel plot to explore the
were not available or details on trial registration were not provided, possibility of small-study effects (a tendency for estimates of the
we assessed the risk of bias for selective outcome reporting as intervention effect to be more beneficial in smaller studies).
unclear. Due to the nature of the exercise intervention, we expect
Informed decisions.

Data synthesis Overall quality of the body of evidence: 'Summary of findings'

tables
If the studies were sufficiently similar, we combined the data using
a fixed-effect model in the following comparisons. We used the GRADE approach as outlined in the GRADE handbook
in order to assess the quality of the body of evidence. We prepared
• Exercise versus no treatment, subgrouped by intensity of two 'Summary of findings' tables using GRADEpro and Cochrane
exercise. We pooled the data for the subgroups in this methods (GRADEpro GDT 2015). The 'Summary of findings' tables
comparison as follows. outline the overall quality of the body of evidence for the
* Low-intensity exercise (such as yoga, tai chi or stretching) main review outcomes (menstrual pain intensity, adverse events,
* High-intensity exercise (such as aerobic exercise, running, overall menstrual symptoms ,use of rescue analgesic medication,
jogging) restriction of daily life activities, absence from work or school
* Resistance exercise (such as weight lifting) and quality of life) for the review comparisons (exercise versus no
• Exercise versus attention control, subgrouped by intensity treatment and exercise versus NSAIDs).
of exercise. We pooled the data for the subgroups in this
The GRADE approach uses five considerations (study limitations,
comparison as follows.
consistency of effect, imprecision, indirectness and publication
* Low-intensity exercise (such as yoga, tai chi or stretching)
bias) to assess the quality of the body of evidence for each outcome.
* High-intensity exercise (such as aerobic exercise, running, The evidence can be downgraded from 'high quality' by one
jogging) level for serious (or by two levels for very serious) limitations,
* Resistance exercise (such as weight lifting) depending on assessments for risk of bias, indirectness of evidence,
• Exercise versus NSAIDs, subgrouped by intensity of exercise. We serious inconsistency, imprecision of effect estimates or potential
pooled the data for the subgroups in this comparison as follows. publication bias. Judgements were justified, documented, and
* Low-intensity exercise (such as yoga, tai chi or stretching) incorporated into reporting of results for each outcome.
* High-intensity exercise (such as aerobic exercise, running,
jogging)
RESULTS
* Resistance exercise (such as weight lifting) Description of studies
• Exercise versus oral contraceptive, subgrouped by intensity
of exercise. We pooled the data for the subgroups in this Study design and setting
comparison as follows. Four studies were undertaken in Iran (Fallah 2018; Motahari-
* Low-intensity exercise (such as yoga, tai chi or stretching) Tabari 2017; Nasri 2016; Saleh 2016), three in India (Arora 2014;
* High-intensity exercise (such as aerobic exercise, running, Jaibunnisha 2017; Patel 2015), one in Korea (Yang 2016), two in
jogging) Egypt (Saleh 2016; Samy 2019), one in New Zealand (Kannan 2019),
* Resistance exercise (such as weight lifting) and one in the USA (Israel 1985). Eight studies were undertaken in a
University setting, two studies in a high school setting (Fallah 2018;
We carried out statistical analysis using Review Manager 5 software Nasri 2016), and one study in an outpatient hospital setting (Saleh
(Review Manager 2014). 2016) .
Subgroup analysis and investigation of heterogeneity Participants

Where suitable studies were found, we planned to undertake a Israel 1985 recruited "college females" but did not provide any
subgroup analysis to determine if there was any effect of differing age data, Siahpour 2013 only included young women aged 20 to
intensities or types of exercise (low-intensity, high-intensity and 25, while Kannan 2019 included women with a mean age of 29
resistance) on the primary outcome of menstrual pain intensity. years. The remaining studies reported that their samples had a
mean age of under 25 years. None of the included studies reported
If we detected substantial heterogeneity, we explored possible body mass index (BMI). The majority of studies used a diagnostic
explanations in subgroup analyses (e.g. differing populations) and/ history to diagnose primary dysmenorrhoea, but it was unclear how
or sensitivity analyses (e.g. differing risk of bias). We took any secondary dysmenorrhoea and other pathologies were ruled out.
statistical heterogeneity into account when interpreting the results,
especially if there was any variation in the direction of effect. Sample size
Sensitivity analysis Sample sizes varied from 30 in Nasri 2016 and Siahpour 2013 to 126
in Saleh 2016.
We conducted sensitivity analyses (using the random-effects model
in Review Manager 5 software; Review Manager 2014) on the Type of intervention
primary outcomes if we detected a high degree of heterogeneity
Five studies used aerobic or high-intensity exercise only (Arora
(I2 ≥ 50%). We conducted a sensitivity analyses for the primary
2014; Israel 1985; Kannan 2019; Nasri 2016; Samy 2019), and one
outcomes to determine whether the removal of studies with high
used aerobic exercise or yoga (Siahpour 2013). Six studies used low-
risk of bias or a different method of analysis would have changed
intensity exercise only, with four studies using stretching exercises
the conclusions. These analyses included consideration of whether
(Fallah 2018; Jaibunnisha 2017; Motahari-Tabari 2017; Patel 2015),
the review conclusions would have differed if eligibility had been
one using yoga (Yang 2016), and one using either stretching or
restricted to studies at low risk of bias (defined as studies rated as
core strengthening (Saleh 2016). None of the included studies used
being at low risk of bias with respect to sequence generation and
resistance training.
allocation concealment).

Informed decisions.

Frequency, duration and number of treatment sessions Overall menstrual symptoms

Frequency of the intervention varied significantly from once per Two studies used the Moos Menstrual Distress Questionnaire
week (Yang 2016), twice per week (Samy 2019), three times per (MMDQ) (Israel 1985; Patel 2015).
week (Fallah 2018; Israel 1985; Kannan 2019; Motahari-Tabari 2017;
Patel 2015; Siahpour 2013), three to four times per week (Saleh Use of rescue analgesic medication
2016), three to five times per week (Arora 2014), and six days per Two studies reported on analgesic medication usage (Motahari-
week (Jaibunnisha 2017). Tabari 2017; Siahpour 2013).
The duration of each session varied from 10 minutes in Jaibunnisha Absence from work or school
2017 to one hour in Yang 2016, with one study not reporting session
duration (Patel 2015). One study reported on absence from work or school (Motahari-
Tabari 2017).
The total number of sessions varied from 12 in Yang 2016 up to a
minimum of 72 in Arora 2014, with one study not reporting the total Restriction of daily life activities
number of sessions due to having an unsupervised component No studies reported on restrictions in daily life activities.
(Kannan 2019).
Quality of life
Control or comparator
One study reported on quality of life (Arora 2014), as measured by
Eleven studies used a no treatment control, while one study used a the SF-36, and one study used the SF-12 and reported both physical
NSAID control (Motahari-Tabari 2017; mefenamic acid 250 mg). and mental summary scores (Kannan 2019).
Outcome measures Funding sources and conflict of interest
All outcomes are reported as changes at the end of the intervention. Seven studies reported their funding sources. All sources of
None of the included studies provided data on short-, medium- or reported funding were internal grants from academic institutions
long-term outcomes after the end of the intervention. or professional bodies.
Menstrual pain intensity Results of the search
Ten studies used the visual analogue scale (VAS), one used the In the search for this 2019 update we retrieved 697 articles.The
numeric rating scale (NRS) (Jaibunnisha 2017), one used the McGill selection process is summarised in a PRISMA flow chart (Figure 1).
Pain Questionaaire (MPQ) (Fallah 2018). Fifty-two studies were potentially eligible and we retrieved the full
text. Eleven studies met our inclusion criteria and we excluded 28.
Adverse events
We searched clinical trial registries and categorised nine studies
Only one study reported on adverse events (Yang 2016). as 'ongoing' and four studies as 'awaiting classification' due to an
inability to contact the study authors (Azima 2015; Bustan 2018;
Sutar 2016; Vaziri 2015). See tables: Characteristics of included
studies; Characteristics of excluded studies; Characteristics of
studies awaiting classification; Characteristics of ongoing studies.


Informed decisions.

Figure 1. Study flow diagram


Informed decisions.

Figure 1. (Continued)

In the original review (Brown 2010), from the 257 records we or one group pre-post design (Chien 2013; Kannan 2015; Monori
identified, we included one study and excluded three. 2017; NCT03625375; Parkhad 2013; Rakhshaee 2011; Sarhadi 2015;
Shahr-jerdy 2012), 13 studies due to lack of a valid comparator or
Included studies control group (Aboushady 2016; Atashak 2018; Behbahani 2016;
We included a total of 12 studies with 854 women. In the meta- Chang 2018; Chaudhui 2013; Habibian 2018; Kaur 2013; Kour 2018;
analysis, we included 10 studies with 754 women. Two studies did Kumar 2017; Mahishale 2013; Padmanabhan 2018; Shirvani 2017;
not provide data in a suitable format for inclusion in the meta- Tharani 2018), six studies due to study participants not meeting the
analysis (Arora 2014; Israel 1985), and so we reported the results inclusion criteria, such as not providing details for the screening
descriptively. of primary versus secondary dysmenorrhoea (Abbaspour 2006;
Dehnavi 2018; Ortiz 2015; Pazoki 2013; Rihani 2013; Yonglitthipagon
Excluded studies 2017), and one study where the primary outcome was lower back
pain (Chen 2019).
We excluded 31 studies; 28 studies in this update and three studies
(Carpenter 1995; Hubbell 1949; Lundquist 1947), in the previous Risk of bias in included studies
version of this review (Brown 2010). We excluded eight studies
due to an inappropriate design, such as an observational study, (Figure 2; Figure 3)

Figure 2. Methodological quality graph: review authors' judgements about each methodological quality item
presented as percentages across all included studies.


Informed decisions.

Figure 3. Methodological quality summary: review authors' judgements about each methodological quality item
for each included study.

Allocation Blinding
Random sequence generation Due to the nature of the intervention and self-reported outcomes,
we rated all 12 trials at high risk of bias in both performance and
We rated five trials at low risk of selection bias for random sequence
detection bias.
generation (Fallah 2018; Kannan 2019; Saleh 2016; Samy 2019; Yang
2016), and seven at unclear risk of bias. Incomplete outcome data
Allocation concealment We rated seven trials at low risk of attrition bias, four trials at
unclear risk (Motahari-Tabari 2017; Nasri 2016; Patel 2015; Siahpour
We rated two trials at low risk of bias for allocation concealment
2013), and one trial at high risk (Saleh 2016).
(Fallah 2018; Samy 2019), and 10 trials at unclear risk.
Selective reporting
Three trials had a trial registration and we rated them at low risk
of reporting bias (Kannan 2019; Nasri 2016; Samy 2019). We rated

Informed decisions.

eight trials at unclear risk and one trial at high risk due to not findings 2 Exercise compared to non-steroidal anti-inflammatory
reporting outcomes that were outlined in the methods section drugs (NSAIDs) for dysmenorrhoea
(Patel 2015).
1 Exercise versus no treatment
Other potential sources of bias
Primary outcomes
We rated one trial at unclear risk of bias due to poor demographic
1.1 Menstrual pain intensity
reporting (Israel 1985), and 11 trials at low risk of bias.
(Analysis 1.1)(Figure 4)
Effects of interventions
See: Summary of findings for the main comparison Exercise
compared to no treatment for dysmenorrhoea; Summary of

Figure 4. Forest plot of comparison: 1 Exercise versus no treatment, outcome: 1.1 Menstrual pain intensity.

Ten studies reported on this outcome. We could not include endometriosis is 10 mm on a 100 mm VAS (Gerlinger 2010). The
one study in the meta-analysis due to reporting only pre-post difference between exercise and no treatment is approximately 2.5
change scores (Arora 2014). Arora 2014 found that high-intensity times the MCID for pelvic pain in endometriosis and is likely to be
exercise produced a greater change in menstrual pain intensity, as very clinically significant for women.
measured on a 10 cm visual analogue scale (VAS) from baseline to
end of treatment (-2.6 ± 1.5) compared to no treatment control (0.13 There was evidence that high-intensity exercise provided a greater
± 0.93). reduction in menstrual pain intensity than low-intensity exercise
(P = 0.0001). Due to the high heterogeneity we tested the effect of
Exercise may have a large effect on reducing menstrual pain using a random-effects model, which did not substantially change
intensity compared to no exercise (standardised mean difference the overall outcome (SMD -1.93, 95% CI -2.63 to -1.23; 10 RCTs, n
(SMD) -1.86, 95% confidence interval (CI) -2.06 to -1.66; 9 RCTs, n = 632; I2= 91%; low-quality evidence), but the subgroup difference
= 632; I2= 91%; low-quality evidence). This SMD corresponds to a in pain intensity between low- and high-intensity exercise was no
25 mm reduction on a 100 mm VAS. There is no minimum clinically longer significant (P = 0.29).
important difference (MCID) for menstrual pain intensity related
to primary dysmenorrhoea. The MCID for pelvic pain related to
Informed decisions.

A sensitivity analysis using only studies that were at low risk of bias 2 Exercise versus attention control
found that the findings were robust (Fallah 2018; Samy 2019), with
No studies reported data in this comparison.
the same overall direction of effect but a larger effect size (SMD
-2.52, 95% CI -3.01 to -2.03; 2 RCTs, n = 138; I2 = 97%). 3 Exercise versus non-steroidal anti-inflammatory drugs
(NSAIDs)
1.2 Adverse events
Primary outcomes
One study reported on adverse events (Yang 2016). No participants
in either group reported any adverse events, but due to the very 3.1 Menstrual pain intensity
low-quality evidence, we are uncertain if there is any difference
One study reported on this outcome (Motahari-Tabari 2017). Due to
in adverse event rates between exercise and no treatment. See
the very low-quality evidence, we are uncertain if exercise reduced
Analysis 1.2.
menstrual pain intensity compared with mefenamic acid (MD -7.40,
Secondary outcomes 95% CI -8.36 to -6.44; 1 RCT, n = 122; very low-quality evidence).
There is no minimum clinically important difference (MCID) for
1.3 Overall menstrual symptoms menstrual pain intensity related to primary dysmenorrhoea. The
Two studies reported on changes in overall menstrual symptoms MCID for pelvic pain related to endometriosis is 10 mm on a 100
via the Moos Menstrual Distress Questionnaire (MMDQ) (Israel 1985; mm VAS (Gerlinger 2010). The difference between exercise and
Patel 2015). mefenamic acid is less than 10 mm and unlikely to be clinically
relevant. See Analysis 2.1.
The data presented in Israel 1985 were not suitable for inclusion
in the meta-analysis. No standard deviations or standard errors 3.2 Adverse events
were provided in the paper and therefore the data were descriptive. No studies reported on this outcome.
The training group appeared to have significantly lower (P < 0.05)
MMDQ scores during the menstrual phase than the control group. Secondary outcomes
There was a negative linear trend in the MMDQ score over the three 3.3 Overall menstrual symptoms
observed cycles in the training group (t = 2.40, P < 0.05) and no
significant linear trend in the control group. No studies reported on this outcome.
3.4 Use of rescue analgesic medication
Patel 2015 reported on exercise and changes in menstrual
symptoms that could be included in the meta-analysis. Due to the One study reported on this outcome (Motahari-Tabari 2017). Due
very low-quality evidence, we are uncertain if exercise reduced to the very low-quality evidence, we are uncertain if women in the
menstrual symptoms compared to the no treatment control (mean exercise group were more likely to need rescue analgesics than
difference (MD) -33.16, 95% CI -40.45 to -25.87; 1 RCT, n = 120; very those in the NSAID group (risk ratio (RR) 1.77, 95% CI 1.21 to 2.60; 1
low-quality evidence) as measured by the MMDQ. See Analysis 1.2. RCT, n = 122; very low-quality evidence). See Analysis 2.2.
1.4 Use of rescue analgesic medication 3.5 Restriction of daily life activities
One study reported on this outcome (Siahpour 2013), but the data No studies reported on this outcome.
were not suitable for inclusion in the meta-analysis. Siahpour 2013 3.6 Absence from work or school
reported that the number of analgesics needed in the aerobic group
was 1.35 ± 0.48, in the yoga group 1.25 ± 0.55, and in the control One study reported on this outcome (Motahari-Tabari 2017). Due
group 2.30 ± 0.76. No details were provided for the type of analgesic. to the very low-quality evidence, we are uncertain if the rate of
absence from work or school between the exercise or NSAID groups
1.5 Absence from work or school differs (RR 1.00, 95% CI 0.49 to 2.03; 1 RCT, n = 122; very low-quality
evidence). See Analysis 2.3.
No studies reported on this outcome.
3.7 Quality of life
1.6 Restriction of daily life activities
1.7 Quality of life 4 Exercise versus oral contraceptive
We could not include Arora 2014 in the meta-analysis due to No studies reported data in this comparison.
reporting only pre-post change scores. Arora 2014 found that high-
intensity exercise produced a greater improvement in overall SF-36
DISCUSSION
scores (14.4 ± 11.3) compared to no treatment (3.0 ± 4.9).
Summary of main results
Due to the very low-quality evidence, we are uncertain if exercise We found low-quality evidence from these 12 trials, including
improves mental quality of life (as measured by the SF-12) 854 women, that exercise, undertaken regularly throughout the
compared to no exercise (mean difference (MD) 4.40, 95% CI 1.59 to month, may provide a large and clinically significant reduction in
7.21; 1 RCT, n = 55; very low-quality evidence) or physical quality of menstrual pain intensity when compared to no treatment. There
life (as measured by the SF-12) compared to no exercise (MD 3.40, was no evidence that the type of exercise (high-intensity versus low-
95% CI -1.68 to 8.48; 1 RCT, n = 55; very low-quality evidence). See intensity) provided any difference in benefit. There was insufficient
Analysis 1.3. evidence to determine whether exercise reduced menstrual pain

Informed decisions.

intensity compared to non-steroidal anti-inflammatory drugs extraction and assessed risk of bias. We are aware that some
(NSAIDs) or whether there was any difference in adverse events literature on exercise may not be published in mainstream journals
between exercise and no treatment. No trials reported on adverse and therefore, may be excluded from the main databases. Our
events when comparing NSAIDs to exercise. search was comprehensive, including searching reference lists, and
we included studies identified in languages other than English,
Overall completeness and applicability of evidence however we did not systematically search all other language
databases, for example Chinese language only databases, therefore
There were a moderate number of trials included in this review,
we cannot rule out the possibility that we may have missed some
and the type (yoga, jogging, running etc.), frequency and duration
studies.
of exercise was heterogenous. The age range of women in all
but one trial was under the age of 25, so the findings may
Agreements and disagreements with other studies or
not be applicable to women older than 25. Most trials delivered
exercise during the non-menstrual phase of the cycle, and thus
reviews
it is unclear if exercise during the menstrual period would have There have only been two systematic reviews on this topic
similar effects. All trials reported on menstrual pain intensity, published in peer reviewed journals in the past five years (Armour
but none of the included trials had follow-up periods, so it 2019a; Matthewman 2018).
is unclear if the beneficial effects found persist if exercise is
discontinued. The reporting on specific safety outcomes was Armour 2019a included only five trials concerning exercise, with
limited in some trials, either due to a lack of reporting or due one of these trials not meeting the inclusion criteria for the current
to very small sample sizes, making it difficult to detect these review. The inclusion criteria for the Armour and colleagues review
relatively rare events. Outcome reporting was inconsistent overall, was much broader than this current review, but they did not
with the majority of trials not reporting on absence from work or have access to translators, so only English language papers were
school, or use of rescue analgesic medication. No trials reported included. The authors did not use GRADE to determine the quality
on the outcome of restriction of daily life activities. No trials of the evidence. Overall, the authors found, similar to this review,
reported on comparisons with attention matched controls, or with that exercise reduced overall menstrual pain intensity.
oral contraceptive pills. While most studies used history taking
to diagnose primary dysmenorrhoea, this does not necessarily Matthewman 2018 included 11 trials in their meta-analysis,
negatively impact the real world applicability of their findings. Most with a wide range of comparator groups (including acupressure
women in a community setting will usually be given a diagnosis and menstrual education) that were not valid for this review.
of primary dysmenorrhoea unless the presence of non-menstrual Matthewman and colleagues included three studies using Kegel
symptoms (such as painful sexual intercourse) or lack of treatment exercises in their review, which did not fit the definition of exercise
response warrants other investigations, such as a laparoscopy or that we used in this review, and two trials that were described
other diagnostic measures. as cluster-randomised, but on further inspection did not meet
that criteria (Rakhshaee 2011; Shahr-jerdy 2012), and were not
Quality of the evidence included in this review. Overall there were five studies in common
between both reviews (Motahari-Tabari 2017; Nasri 2016; Saleh
The 'Risk of bias' tables show that studies on exercise for 2016; Siahpour 2013; Yang 2016). The authors made a decision
dysmenorrhoea have not generally been undertaken to a high that due to the difficulty of blinding participants, they would
methodological standard (Figure 2; Figure 3). No trials were at not downgrade the strength of the evidence based on blinding
low risk of bias across all domains. The majority of studies had issues when using GRADE. We did not make that modification and
unclear risk of bias in randomisation, allocation concealment, and therefore our GRADE quality for pain intensity was one level lower
selective reporting. In cases where it was unclear, we contacted the (low quality) than that reported by Matthewman and colleagues
authors to provide additional details, however response rates to (moderate). All included studies in the Matthewman and colleagues
these enquires were low. review used visual analogue scale (VAS) as their outcome measure,
and they found that there was a clinically significant difference
Blinding of participants was at high risk of bias in all studies,
in menstrual pain intensity when pooling all types of physical
and all studies used participant-reported outcomes, meaning all
activity compared to all controls (mean difference (MD) -2.04, 95%
assessors were unblinded and therefore, we rated them at high risk
confidence interval (CI) -2.98 to -1.10). While direct comparison
of bias. The small number of studies in most comparisons means
between this review and Matthewman et al is not possible, due
that while individual studies have had positive results, there is
to the inclusion of Kegel exercises and pooling of control groups,
currently insufficient evidence for a consistent treatment effect for
overall, the conclusions were similar, that physical activity provides
all outcomes, except for menstrual pain intensity
a significant reduction in menstrual pain intensity.
We downgraded the GRADE quality of evidence due to serious
imprecision, mostly related to small sample sizes, and very
AUTHORS' CONCLUSIONS
serious risk of bias, particularly related to participant and assessor
Implications for practice
blinding. The overall quality of evidence for GRADE was low to
very low across all outcomes (Summary of findings for the main The current low-quality evidence suggests that exercise, performed
comparison; Summary of findings 2). for about 45 to 60 minutes each time, three times per week or
more, regardless of intensity, may provide a clinically significant
Potential biases in the review process reduction in menstrual pain intensity of around 25 mm on a 100
We attempted to minimise bias during the review process. Two mm visual analogue scale (VAS). All studies used exercise regularly
review authors assessed the eligibility of studies, carried out data throughout the month, with some studies asking women not to

Informed decisions.

exercise during menstruation. Given the overall health benefits of primary dysmenorrhoea does not resolve after adolescence, future
exercise and the relatively low risk of side effects reported in the research should include women throughout their reproductive
general population, women may consider using exercise, either lifespan, rather than only in those under 25 years of age. More
alone or in conjunction with other modalities, such as non-steroidal comprehensive outcome reporting, including safety, absence from
anti-inflammatory drug (NSAIDs), to manage menstrual pain. It is work or school and changes in use of rescue medication are needed
unclear if the benefits of exercise persist after regular exercise is to provide greater understanding of the range of potential benefits
stopped or if they are similar in women over the age of 25. Further of exercise and also any potential risks.
research is required, using validated outcome measures, adequate
blinding and suitable comparator groups, reflecting current best ACKNOWLEDGEMENTS
practice or accounting for the extra attention given during exercise.
We are grateful to the editorial board of Cochrane Menstrual
Implications for research Disorders and Subfertility Group (now called Cochrane
Gynaecology and Fertility) for their methodological and language
We suggest future research include three-armed trials comparing support and assistance with searching the literature. The authors
exercise with a current gold standard treatment, such as an non- of the 2019 update acknowledge the work of the previous authors
steroidal anti-inflammatory drug (NSAID) or the oral contraceptive Julie Brown and Stephen Brown, as well as those that developed
pill, as well as with no exercise or, preferably, an attention control. the original protocol Paul Bolton, Chris Del Mar and Vivienne
Issues related to blinding may be difficult to overcome, but clearer O'Connor. The authors of the 2019 update thank Drs Jane Thomas,
reporting of randomisation and allocation concealment, as well as Rik van Eekelen and Jeppe Schroll for providing peer review
publication of clinical trial protocols will reduce the impact of poor comment on the draft.
reporting on the strength of the evidence. Given the likelihood that

Informed decisions.

REFERENCES

References to studies included in this review a randomized controlled trial. Journal of Pediatric & Adolescent
Gynecology 2019;11:11.
Arora 2014 {published data only}
Arora A, Yardi S, Gopal S. Effect of 12 weeks of aerobic exercise Siahpour 2013 {published data only}
on primary dysmenorrhea. Indian Journal of Physiotherapy & Siahpour T, Nikbakht M, Rahimi E, Rabiee MA. The effect of 8
Occupational Therapy 2014;8(3):130-5. weeks aerobic exercise and yoga on primary dysmenorrhea.
Armaghane Danesh 2013;18(6):475-83.
Fallah 2018 {published data only}
Fallah F, Mirfeizi M. How is the quality and quantity of primary Yang 2016 {published data only}
dysmenorrhea affected by physical exercises? A study among Yang NY, Kim SD. Effects of a yoga program on menstrual
Iranian students. International Journal of Women's Health and cramps and menstrual distress in undergraduate students with
Reproduction Sciences 2018;6(1):60-6. primary dysmenorrhea: a single-blind, randomized controlled
trial. Journal of Alternative and Complementary Medicine
Israel 1985 {published data only}
2016;22(9):732-8.
Israel R, Sutton M, O'Brien K. Effects of aerobic training on
primary dysmenorrhoea symptomology in college females.
Journal of the American College of Health 1985;33:241-4. References to studies excluded from this review
Jaibunnisha 2017 {published data only} Abbaspour 2006 {published data only}
Jaibunnisha, Gomathi B, Goerge U. Effect of selected muscle Abbaspour Z, Rostami M, Najjar S. The effect of exercise on
stretching exercises on primary dysmenorrhoea among primary dysmenorrhea. Journal of Research in Health Sciences
student nurses. International Journal of Nursing Education 2006;6(1):26-31.
2017;9(3):69-74.
Aboushady 2016 {published data only}
Kannan 2019 {published data only} Aboushady R. Effect of home-based stretching exercises and
Kannan P, Chapple CM, Miller D, Claydon-Mueller L, Baxter GD. menstrual care on primary dysmenorrhea and premenstrual
Effectiveness of a treadmill-based aerobic exercise intervention symptoms among adolescent girls. IOSR Journal of Nursing and
on pain, daily functioning, and quality of life in women Health Science 2016;5:47-57.
with primary dysmenorrhea: A randomized controlled trial.
Atashak 2018 {published data only}
Contemporary Clinical Trials 2019;81:80-6.
Atashak S, Rashidi S. Effect of eight-week high-intensity interval
Motahari-Tabari 2017 {published data only} training and ginger supplementation on primary dysmenorrhea
Motahari-Tabari N, Shirvani MA, Alipour A. Comparison of in nonathletic female students. Iranian Journal of Obstetrics,
the effect of stretching exercises and mefenamic acid on the Gynecology and Infertility 2018;20(12):23-31.
reduction of pain and menstruation characteristics in primary
Behbahani 2016 {published data only}
dysmenorrhea: a randomized clinical trial. Oman Medical
Journal 2017;32(1):47-53. Behbahani BM, Ansaripour L, Akbarzadeh M, Zare N,
Hadianfard MJ. Comparison of the effects of acupressure
Nasri 2016 {published data only} and self-care behaviors training on the intensity of primary
Nasri M, Barati AH, Ramezani AR. Comparison of aerobic dysmenorrhea based on McGill pain questionnaire among
training and pelvic floor muscle exercise on primary Shiraz University students. Journal of Research in Medical
dysmenorrhea in adolescent girls. Journal of Clinical Nursing Sciences 2016;21:104.
and Midwifery 2016;5(3):53-61.
Carpenter 1995 {published data only}
Patel 2015 {published data only} Carpenter S, Tjaden B, Rock J, Kimball A. The effect of regular
Patel NS, Tanna T, Bhatt S. Effect of active stretching exercises exercise on women receiving danazol for the treatment of
on primary dysmenorrhea in college going female students. endometriosis. International Journal of Gynaecology and
Indian Journal of Physiotherapy and Occupational Therapy Obstetrics 1995;49:299-304.
2015;9(3):72-6.
Chang 2018 {published data only}
Saleh 2016 {published data only} Chang EA, Koo IS, Choi JH. The effect of pilates stabilization
Saleh H, Mowafy H, El Hameid A. Stretching or core exercise and kinesio taping on the dysmenorrhea and
strengthening exercises for managing primary dysmenorrhea. prostaglandin f2α of female university students. Journal
Journal of Womens Health Care 2016;5(1):1-6. of International Academy of Physical Therapy Research
2018;9(3):1558-63.
Samy 2019 {published data only}
Chaudhui 2013 {published data only}
Samy A, Zaki SS, Metwally AA, Mahmoud DS, Elzahaby IM,
Amin AH, et al. The effect of Zumba exercise on reducing Chaudhuri A, Singh A, Dhaliwal L. A randomised controlled
menstrual pain in young women with primary dysmenorrhea: trial of exercise and hot water bottle in the management of

Informed decisions.

dysmenorrhoea in school girls of Chandigarh, India. Indian trial. Indian Journal of Physiotherapy and Occupational Therapy
Journal of Physiology & Pharmacology 2013;57(2):114-22. 2013;7(3):40-4.
Chen 2019 {published data only} Monori 2017 {published data only}
Chen H-M, Hu H-M. Randomized trial of modified stretching Monori A, Csakvari T, Karacsony I, Ferenczy M, Fusz K, Olah A, et
exercise program for menstrual low back pain. Western Journal al. Comparing the effect of progressive relaxation and perineal
of Nursing Research 2019;41(2):238-57. strengthening interval exercises among women with primary
dysmenorrhoea to reduce menstrual cramps. Value in Health
Chien 2013 {published data only} 2017;20(9):A519.
Chien LW, Chang HC, Liu CF. Effect of yoga on serum
homocysteine and nitric oxide levels in adolescent women NCT03625375 {published data only}
with and without dysmenorrhea. Journal of Alternative and NCT03625375. Effects of combined exercises on primary
Complementary Medicine 2013;19(1):20-3. dysmenorrhea. clinicaltrials.gov/ct2/show/NCT03625375 (first
received 10 August 2018).
Dehnavi 2018 {published data only}
Dehnavi ZM, Jafarnejad F, Kamali Z. The effect of aerobic Ortiz 2015 {published data only}
exercise on primary dysmenorrhea: a clinical trial study. Journal Ortiz MI, Cortes-Marquez SK, Romero-Quezada LC, Murguia-
of Education & Health Promotion 2018;7:3. Canovas G, Jaramillo-Diaz AP. Effect of a physiotherapy
program in women with primary dysmenorrhea. European
Habibian 2018 {published data only} Journal of Obstetrics & Gynecology and Reproductive Biology
Habibian Masoumeh, Safarzadeh Zeynan. Comparison of the 2015;194:24-9.
effectiveness of walking associated with stretching exercises
and cinnamon In take on the primary dysmenorrhea. Razi Padmanabhan 2018 {published data only}
Journal of Medical Sciences 2018;25(6):11-9. Padmanabhan K, Selvaraj S, Aravind S, Kumar CR Praveen,
Monika S. Efficacy of yoga asana and gym ball exercises in the
Hubbell 1949 {published data only} management of primary dysmenorrhea: a single-blind, two
Hubbell J. Specific and non-specific exercises for the relief of group, pretest-posttest, randomized controlled trial. CHRISMED
dysmenorrhoea. Research Quarterly 1949;20:378-86. Journal of Health and Research 2018;5(2):118.
Kannan 2015 {published data only} Parkhad 2013 {published data only}
Kannan P, Claydon LS, Miller D, Chapple CM. Vigorous exercises Parkhad SB, Palve SB, Latti RG, Kulkarni NB. Effect of yoga on
in the management of primary dysmenorrhea: a feasibility premenstrual and menstrual cycle disorders in adolescent girls.
study. Disability Rehabilitation 2015;37(15):1334-9. Biomedicine (India) 2013;33(2):170-5.
Kaur 2013 {published data only} Pazoki 2013 {published data only}
Kaur A, Saxene G, Dhakshinamoorty P. Comparison of effect Pazoki H, Bolouri G, Farokhi F, Azarbayjani M A. Comparing the
of fast and slow Kegels exercises in reducing pain in primary effects of aerobic exercise and fennel (foeniculum vulgare)
dysmenorrhea: experimental design. Physiotherapy and on pre-menstrual syndrome(PMS) in high school young girls.
Occupational Therapy Journal 2013;6(3):135. Middle East Fertility Society Journal 2013;21:61-4.
Kour 2018 {published data only} Rakhshaee 2011 {published data only}
Kour G, Kaur J, Kaur R. The effect of exercises in primary Rakhshaee Z. Effect of three yoga poses (cobra, cat and fish
dysmenorrhea among young females of Adesh University. poses) in women with primary dysmenorrhea: a randomized
Indian Journal of Physiotherapy & Occupational Therapy clinical trial. Journal of Pediatric and Adolescent Gynecology
2018;12(3):112-6. 2011;24(4):192-6.
Kumar 2017 {published data only} Rihani 2013 {published data only}
Kumar Y, Lalita C, Srivastava R. Role of walnut consumption, Rihani T, Jafarnejad F, Vshany HR, Mahmoud AM. Effect of
aerobic exercises and meditation in relieving symptoms fast walking on primary dysmenorrhoea in female students.
of dysmenorrhoea in young healthy medical students. Iranian Journal of Obstetrics, Gynecology and Infertility
International Journal of Current Advanced Research 2013;16(46):14-9.
2017;6(12):8242-5.
Sarhadi 2015 {published data only}
Lundquist 1947 {published data only} Sarhadi S, Ramezani A, Gholami M, Taheri H. The effect of an
Lundquist C. Use of the Billig exercise for dysmenorrhoea for aerobic training cycle in the morning and evening on primary
college women. Research Quarterly 1945;18:44-53. dysmenorrhea and some physiological variables in matured
girls. Iranian Journal of Obstetrics, Gynecology and Infertility
Mahishale 2013 {published data only} 2015;18:162.
Mahishale A, Mascarenhas D, Patted S. Effect of knee chest
position in primary dysmenorrhea- a randomized controlled

Informed decisions.

Shahr-jerdy 2012 {published data only} IRCT20120215009014N245 {published data only}

Shahr-jerdy S, Hosseini RS, Gh ME. Effects of stretching exercises IRCT20120215009014N245. Effect of 8 weeks of aqua
on primary dysmenorrhea in adolescent girls. Biomedical yoga versus no training on pain severity and duration of
Human Kinetics 2012;4(1):127-32. menstruation in girl students with primary dysmenorrhea
[Effect of 8 weeks of aqua yoga versus no training on pain
Shirvani 2017 {published data only} severity and duration of menstruation in girl students with
Shirvani MA, Motahari-Tabari N, Alipour A. Use of ginger versus primary dysmenorrhea: a randomized clinical trial]. en.irct.ir/
stretching exercises for the treatment of primary dysmenorrhea: trial/34350 (first received 21 October 2018).
a randomized controlled trial. Journal of Integrative Medicine
2017;15(4):295-301. IRCT20130812014333N111 {published data only}
IRCT20130812014333N111. Comparison of the effect of
Tharani 2018 {published data only} stretching exercises and a combination of massage - stretching
Tharani G, Dharshini E, Rajalaxmi V, Kamatchi K, Vaishnavi G. To exercises on primary dysmenorrheal [The comparison of
compare the effects of stretching exercise versus aerobic dance the effect of stretching exercises and a combination of
in primary dysmenorrhea among collegiates. Drug Invention massage - stretching exercises on primary dysmenorrheal of
Today 2018;10(Special Issue 1):2844-2848. female students of RAZI University of Kermanshah]. en.irct.ir/
trial/35378 (first received 6 January 2019).
Yonglitthipagon 2017 {published data only}
Yonglitthipagon P, Muansiangsai S, Wongkhumngern W, IRCT20140519017756N41 {published data only}
Donpunha W, Chanavirut R, Siritaratiwat W, et al. Effect of IRCT20140519017756N41. Effects of aerobic training with
yoga on the menstrual pain, physical fitness, and quality of cumin supplementation on serum β-endorphin levels and
life of young women with primary dysmenorrhea. Journal of pain intensity [The effect of an aerobic training course with
Bodywork and Movement Therapies 2017;21(4):840-6. and without cumin supplementation on serum β-endorphin
levels and pain intensity in non-athlete girls with primary
dysmenorrhea]. en.irct.ir/trial/30035 (first received 23 March
References to studies awaiting assessment 2018). [IRCT20140519017756N41]
Azima 2015 {published data only} IRCT2016103119024N2 {published data only}
Azima S, Bakhshayesh HR, Kaviani M, Abbasnia K, Sayadi M. IRCT2016103119024N2. The effect of exercise on primary
Comparison of the effect of massage therapy and isometric dysmenorrhea [The effect of a core stability exercise program
exercises on primary dysmenorrhea: a randomized controlled on the primary dysmenorrhea in young adult females- a
clinical trial. Journal of Pediatric & Adolescent Gynecology randomized controlled trial]. en.irct.ir/trial/17119 (first received
2015;28(6):486-91. 13 November 2016).
Bustan 2018 {published data only} IRCT201708309014N179 {published data only}
Bustan MN, Seweng A. Abdominal stretching exercise in IRCT201708309014N179. Effects of exercises program versus
decreasing pain of dysmenorrhea among nursing students. no exercise on duration and severity of dysmenorrhea among
Journal of Physics: Conference Series. IOP Publishing, 2018; Vol. students with primary dysmenorrhea [Effects of exercises
1028:012103. program versus no exercise on duration and severity of
dysmenorrhea among students with primary dysmenorrhea: a
Sutar 2016 {published data only}
randomized clinical trial]. en.irct.ir/trial/9617 (first received 30
Sutar A, Paldhikar S, Shikalgar N, Ghodey S. Effect of aerobic September 2017).
exercises on primary dysmenorrhoea in college students. IOSR
Journal of Nursing and Health Science 2016;5:20-4. IRCT20181212041948N1 {published data only}
IRCT20181212041948N1. Comparison of the effect of stretching
Vaziri 2015 {published data only}
exercises and massaging of connective tissue with the control
Vaziri F, Hoseini A, Kamali F, Abdali K, Hadianfard M, Sayadi M. group on dysmenorrhea [Comparison of the effect of tensile
Comparing the effects of aerobic and stretching exercises connective tissue massage and sports with the control group on
on the intensity of primary dysmenorrhea in the students of primary dysmenorrhea]. en.irct.ir/trial/35989 (first received 10
universities of bushehr. Journal of Family & Reproductive Health January 2019).
2015;9(1):23-8.
NCT03821207 {published data only}

NCT03821207. The Effect of Abdominal Massage and Exercise
References to ongoing studies
on Primary Dysmenorrhea in University Students [The Effect
CTRI/2018/09/015617 {published data only} of Abdominal Massage and Exercise on Primary Dysmenorrhea
* CTRI/2018/09/015617. To compare the effect of drawing in University Students: A Randomised Controlled Study].
in maneuver exercises versus core strengthening exercises clinicaltrials.gov/ct2/show/record/NCT03821207 (first received
on primary dysmenorrhea. ctri.nic.in/Clinicaltrials/ 30 December 2018).
pmaindet2.php?trialid=27444&EncHid=&userName=015617
(first received 6 September 2018).

Informed decisions.

RBR-9vqhg7 {published data only} Burnett 2005

RBR-9vqhg7. TENS effect and exercises in menstrual pain Burnett MA, Antao V, Black A, Feldman K, Grenville A, Lea R, et
[TENS effect in Primary Dysmenorrhea and its influence on al. Prevalence of primary dysmenorrhea in Canada. Journal of
central sensitization pre and post exercise: randomized clinical Obstetrics & Gynaecology Canada 2005;27(8):765-70.
trial]. ensaiosclinicos.gov.br/rg/RBR-9vqhg7/ (first received 3
December 2017). Campbell 1997
Campbell MA, McGrath PJ. Use of medication by adolescents for
the management of menstrual discomfort. Archives of Pediatrics
Additional references and Adolescent Medicine 1997;151(9):905-13.
ACSM 2014
Casey 1985
American College of Sports Medicine. ACSM's Guidelines for
Casey M, MacDonald P, Mitchell, M D. Despite a massive increase
Exercise Testing and Prescription. Philadelphia: Wolters Kluwer/
in cortisol secretion in women during parturition, there is
Lippincott Williams & Wilkins Health, 2014.
an equally massive increase in prostaglandin synthesis. A
Armour 2016 paradox?. Journal of Clinical Investigation 1985;75(6):1852-7.
Armour M, Dahlen HG, Smith CA. More than needles: the Coco 1999
importance of explanations and self-care advice in treating
Coco AS. Primary dysmenorrhea. American Family Physician
primary dysmenorrhea with acupuncture. Evidence-Based
1999;60(2):489-96.
Complementary and Alternative Medicine 2016;2016:3467067.
Dawood 2006
Armour 2019a
Dawood MY. Primary dysmenorrhea: advances in pathogenesis
Armour M, Smith CA, Steel KA, Macmillan F. The effectiveness of
and management. Obstetrics & Gynecology 2006;108(2):428-41.
self-care and lifestyle interventions in primary dysmenorrhea: a
systematic review and meta-analysis. BMC Complementary and Febbraio 2007
Alternative Medicine 2019;19(1):22.
Febbraio MA. Exercise and inflammation. Journal of Applied
Armour 2019b Physiology 2007;103(1):376-7.
Armour M, Parry K, Manohar N, Holmes K, Ferfolja T, Curry C, et Fernandez 1991
al. The prevalence and academic impact of dysmenorrhea in
Fernandez E, Turk D. Sensory and affective components
21,573 young women: a systematic review and meta-analysis.
of pain: Separation and synthesis. Psychological Bulletin
Journal of Women's Health 2019;28(8):1161-71. [DOI: 10.1089/
1991;112:205-17.
jwh.2018.7615]
French 2005
Armour 2019c
French L. Dysmenorrhea. American Family Physician
Armour M, Parry K, Al-Dabbas MA, Curry C, Holmes K,
2005;71(2):285-91.
MacMillan F, et al. Self-care strategies and sources of
knowledge on menstruation in 12,526 young women with Gerlinger 2010
dysmenorrhea: A systematic review and meta-analysis. PLOS
One 2019;14(7):e0220103. [DOI: 10.1371/journal.pone.0220103] Gerlinger C, Schumacher U, Faustmann T, Colligs A, Schmitz H,
Seitz C. Defining a minimal clinically important difference for
Baker 1999 endometriosis-associated pelvic pain measured on a visual
analog scale: analyses of two placebo-controlled, randomized
Baker FC, Driver HS, Rogers GG, Paiker J, Mitchell D. High
trials. Health and Quality of Life Outcomes 2010;8:138.
nocturnal body temperatures and disturbed sleep in women
with primary dysmenorrhea. American Journal of Physiology Govindaraj 2016
1999;277(6 Pt 1):E1013-21.
Govindaraj R, Karmani S, Varambally S, Gangadhar BN. Yoga
Banikarim 2000 and physical exercise – a review and comparison. International
Review of Psychiatry 2016;28(3):242-53.
Banikarim C, Chacko MR, Kelder SH. Prevalence and impact
of dysmenorrhea on Hispanic female adolescents. Archives of GRADEpro GDT 2015 [Computer program]
Pediatrics and Adolescent Medicine 2000;154(12):1226-9.
GRADE Working Group, McMaster University. GRADEpro GDT.
Blakey 2010 Version accessed 4 Febuary 2018. Hamilton (ON): GRADE
Working Group, McMaster University, 2015.
Blakey H, Chisholm C, Dear F, Harris B, Hartwell R, Daley AJ,
et al. Is exercise associated with primary dysmenorrhoea in Higgins 2011
young women?. BJOG International Journal of Obstetrics &
Gynaecology 2010;117(2):222-4. Higgins JP, Green S, editor(s). Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 (updated
March 2011). The Cochrane Collaboration, 2011. Available from
handbook.cochrane.org.

Informed decisions.

Hightower 1998 Review Manager 2014 [Computer program]

Hightower M. Effects of exercise participation on menstrual pain Nordic Cochrane Centre, The Cochrane Collaboration. Review
and symptoms. Women & Health 1998;26(4):15-27. Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic
Cochrane Centre, The Cochrane Collaboration, 2014.
Hillen 1999
Hillen TI, Grbavac SL, Johnston PJ, Straton JA, Keogh JM. Vani 2013
Primary dysmenorrhea in young Western Australian women: Vani KR, Veena KS, Subitha L, Kumar VR, Bupathy A. Menstrual
prevalence, impact, and knowledge of treatment. Journal abnormalities in school going girls - are they related to dietary
of Adolescent Health: official publication of the Society for and exercise pattern?. Journal of Clinical and Diagnostic
Adolescent Medicine 1999;25(1):40-5. Research 2013;7(11):2537-40.
Matthewman 2018 Warren 2001

Matthewman G, Lee A, Kaur JG, Daley AJ. Physical activity Warren MP, Perlroth NE. The effects of intense exercise on
for primary dysmenorrhea: a systematic review and meta- the female reproductive system. Journal of Endocrinology
analysis of randomized controlled trials. American Journal 2001;170(1):3-11.
of Obstetrics and Gynecology 2018;219(3):255.e1-255.e20.
[PUBMED: 29630882] Zahradnik 2010
Zahradnik HP, Hanjalic-Beck A, Groth K. Nonsteroidal anti-
Metheny 1989 inflammatory drugs and hormonal contraceptives for pain relief
Metheny WP, Smith RP. The relationship among exercise, stress from dysmenorrhea: a review. Contraception 2010;81(3):185-96.
and primary dysmenorrhoea. Journal of Behavioural Medicine
1989;12(6):569-86.
References to other published versions of this review
Moher 2015
Brown 2009
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A,
Bolton PJ, Del Mar C, O'Connor V, Dean LM, Jarrett MS. Exercise
Petticrew M, et al. Preferred reporting items for systematic
for primary dysmenorrhoea. Cochrane Database of Systematic
review and meta-analysis protocols (PRISMA-P) 2015 statement.
Reviews 2009, Issue 1. [DOI: 10.1002/14651858.CD004142]
Systematic reviews 2015;4(1):1-9.
Brown 2010
Pascoe 2017
Brown J, Brown S. Exercise for dysmenorrhoea. Cochrane
Pascoe MC, Thompson DR, Ski CF. Yoga, mindfulness-based
Database of Systematic Reviews 2010, Issue 2. [DOI:
stress reduction and stress-related physiological measures: a
10.1002/14651858.CD004142.pub2]
meta-analysis. Psychoneuroendocrinology 2017;86:152-68.

Proctor 2006
* Indicates the major publication for the study
Proctor M, Farquhar C. Diagnosis and management of
dysmenorrhoea. BMJ 2006;332(7550):1134-8.

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Arora 2014
Methods Randomised controlled trial of aerobic exercise versus no treatment control
Participants Country: India
Setting: Department of Physiotherapy, Dr DY Patil University, Nerul, Navi Mumbai
Participants: 60 young female students 19 to 24 years who met the inclusion criteria were randomly al-
located 30 each to the control and the experiment group
Incusion: young females 19 to 24 years, diagnosed with primary dysmenorrhoea (as per the question-
naire) and who conceded to a written informed consent
Exclusion: known organic cause of dysmenorrhoea, having received herb or acupuncture therapy with-
in one month prior to enrolment, poor compliance to investigator's advice

Informed decisions.

Arora 2014 (Continued)
Interventions Aerobic Exercise group: 3 to 5 times per week for 12 weeks. Each session consisted of a warm–up
phase (10 minutes), aerobic phase (treadmill walking with the target heart rate in the range of 74% to
84% heart rate max for more than 30 minutes) and cool-down phase (10 minutes)
Control group: no treatment
Outcomes Primary outcome: pain severity, measured by VAS. Verbal multidimensional score also provided, but
not used in this analysis
Secondary outcome: quality of life (SF-36)
Notes Funding: not reported

Conflict of interest: no known conflict of interest reported
Date study was conducted: not reported
Trial registration: CTRI/2009/ 091/001005
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence genera- Unclear risk Quote: "A group of 60 subjects were randomly selected and allocated 30 each
tion (selection bias) randomly to the Control and the Experiment group" (p. 132).
Comment: not described
Allocation concealment Unclear risk Concealment not described

(selection bias)
Blinding of participants High risk Participants not blinded to group allocation

and personnel (perfor-
mance bias)
All outcomes
Blinding of outcome as- High risk Pain scores are self-reported, and are likely to be affected by lack of blinding
sessment (detection bias)
All outcomes
Incomplete outcome data Low risk No missing data

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk The study protocol is not available
porting bias)
Other bias Low risk None noted

Fallah 2018
Methods Double-blind randomised clinical trial comparing stretch, massage, combination and control
Participants Country: Iran
Participants: 70 female students aged 15 to 18 years with primary dysmenorrhoea randomly assigned
to 4 different groups: stretch group (n = 19), massage group (n = 19), combined group (n = 21), and con-
trol group (n = 19)
Setting: Atot and Fagher schools in 14th district of Tehran and Tehran sports club

Informed decisions.

Fallah 2018 (Continued)
Inclusion: single, 15 to 18 years old; no history of musculoskeletal disease, or chronic diseases, such as
diabetes, hypertension, or coronary vascular disease; not professional athletes; no history of any med-
ications or herbal medicine use during 3 menstrual cycles before trial; not suffering from a gynaecology
or pelvic disease, such as endometriosis, fibromyoma, ovarian cyst, or other related problems
Exclusion: absent for > 2 sessions of exercise in the study and attending extra classes during 3 months
prior to the start of the project, history of secondary dysmenorrhoea
Interventions Stretching group: treatment was applied as 8 weeks of physical activity, 3 sessions per week, 20 min-
utes, twice per day. All exercises were taught to the participants by a trainer in Tehran's sports club on
the first day of menstrual cycle. The participants performed 6 stretch exercises in the abdomen, pelvis
and groin. The stretch consisted of 5 minutes warm-up, 15-minute progressive stretch exercise specific
for pelvic, groin, abdomen, and hip girdle muscles then cool-down. An extra 1 minute was added to the
exercise every week
Control: no treatment
We did not include the massage group and combined group (massage plus stretching) in this review.
Outcomes Primary outcomes: pain severity, measured by MPQ
Notes Funding: thesis grant, Faculty of Physical Education and Sports Sciences, Department of Sports Medi-
cine and Health, Islamic Azad University
Conflict of interest: authors declare no conflicts of interest
Date study was conducted: 2014 to 2015
Ethics approved by the Ethics Committee of Islamic Azad University (No. 0061)
Risk of bias
Random sequence genera- Low risk Random number tables (quote): "All selected participants were randomly as-
tion (selection bias) signed into a control, a massage, a stretch, and a combined group using a ran-
domized number chart" (p. 61)
Allocation concealment Low risk Central randomisation (quote): "The allocation sequence was concealed and it
(selection bias) was generated using a table of random numbers" (p. 61)

mance bias)
All outcomes
All outcomes

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk Study protocol is not available

porting bias)


Informed decisions.

Israel 1985
Methods Randomised trial of training versus control in women with primary dysmenorrhoea
Participants County: USA
Participants: 40 women responding positively to a prerecruitment dysmenorrhoea questionnaire. Four

were subsequently excluded for having a diagnosis of secondary dysmenorrhoea.
Setting: college
Inclusion: clinically diagnosed primary dysmenorrhoea
Exclusion: secondary dysmenorrhoea, confirmed by pelvic exam
Interventions Aerobic group (walking or jogging): 12-week walk or jog training programme at an intensity of 70%
to 85% of heart rate range. Training was for 3 days per week and the duration of the aerobic phase was
30 minutes with 15 minute warm-up and cool-down periods. All participants were pretested two weeks
prior to the start of the study to determine baseline levels of cardiorespiratory endurance using a tread-
mill with a steady incline until volitional fatigue was reached. ECG was recorded.
Control: asked not to exercise during the experimental period
Outcomes Primary outcome: not reported

Secondary outcome: overall menstrual symptoms (MMDQ)

Conflict of interest: not reported
Additional: protocol adherence to training was 80%
Risk of bias
Random sequence genera- Unclear risk Quote: "Randomly assigned"

tion (selection bias)
Allocation concealment Unclear risk No details in paper

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Details and reasons for losses to follow-up provided. Three women from the
(attrition bias) control group were ill and unavailable for post-testing and seven dropped out
All outcomes of the training group due to illness, injuries or stringent dietary regimens; none
of these were caused by the training.
Selective reporting (re- Unclear risk No study protocol available

porting bias)
Other bias Unclear risk Not enough detail in paper to determine if groups were matched at baseline

Informed decisions.


Jaibunnisha 2017
Methods Randomised controlled trial of stretching exercises and no treatment
Participants: 67 student nurses with primary dysmenorrhoea were selected and randomly assigned in-
to experimental group (n = 33) and control group (n = 34)
Setting: Himalayan College of Nursing Hostel
Inclusion: regular menstrual cycle with primary dysmenorrhoea
Exclusion: history of any systematic diseases, traumatic injury, any other gynaecological diseases
Interventions Stretching group: muscle stretching exercises taught to the experimental group and practiced for 8
weeks (6 days/week, for 10 minutes daily). Stretching exercises included exercises in the abdomen,
pelvic and groin region. The subjects were requested to perform the exercise at hostel regularly. Fur-
thermore they were instructed to avoid performing stretching exercises during their periods.
• Forward bending from the hip joint; duration: 5 seconds; repetition: 10 times
• Heel raise (bilateral) alternatively; repetition: 20 times
• Half squatting position; duration: 5 seconds; then raised body; repetition: 10 times
• Bend and touch left ankle with right hand and right ankle with left hand; repetition: 10 times for each
side
• Knee to chest bending and reach to chin; repetition: 10 times
• Abdominal contraction for 10 seconds; repetition: 10 times
Control group: was requested not to take part in any exercise programme up to the end of the study
Outcomes Primary outcome: menstrual pain intensity (NRS)
Notes Funding: self-funded by researcher

Conflict of interest: nil
Date study was conducted: 2014 to 2015
Risk of bias
Random sequence genera- Unclear risk Quote: "…randomly assigned into two experimental (35) and control groups
tion (selection bias) (35)."
Comment: not described
Allocation concealment Unclear risk Not described

(selection bias)

mance bias)
All outcomes
All outcomes

Informed decisions.

Jaibunnisha 2017 (Continued)
Incomplete outcome data Low risk Missing outcome data balanced in numbers across intervention groups, with
(attrition bias) similar reasons for missing data across groups; final analysis (experimental 33,
All outcomes control 34)
Selective reporting (re- Unclear risk Study protocol is not available

porting bias)

Kannan 2019
Methods A randomised controlled trial of aerobic exercise on a treadmill versus usual care
Participants County: New Zealand
Participants: 70 women from the community with primary dysmenorrhoea, randomised to exercise (n
= 35) or control (n = 35)
Setting: University of Otago
Inclusion: primary dysmenorrhoea was confirmed based on information about the onset of primary
dysmenorrhoea, pain, and a history of analgesics use. Participants were eligible if they were in the age
group 18 to 43 years; were not pregnant; were having regular menstrual cycles; and reported moder-
ate-to-severe primary dysmenorrhoea-associated pain, indicated by a score of ≥ 4 on a NRS ranging
from ‘no pain’ (0) to ‘unbearable pain’ (10) for at least two previous consecutive menstrual periods
Exclusion: pregnancy, irregular menstrual cycles, menstrual cycles > 35 days, use of the oral contra-
ceptive pill, hormonal therapy or IUD and women who did not respond to over the counter analgesics
Interventions Exercise group: 7 months of exercise intervention in total; 1 month supervised and the remaining six
months unsupervised at home. During the supervised period, exercise was performed on a treadmill for
50 minutes in total; 10 minutes warm-up, 30 minutes of vigorous aerobics at 70% to 85% of their maxi-
mum heart rate, followed by a 10 minute cool-down phase. This was performed three times per week.
Exercise was not undertaken during the menstrual period. While participants were on the treadmill,
Borg's RPE scale between 6 and 20 was used to regulate the exercise intensity on the treadmill. Based
on the participants' feedback, the intensity of exercise was adjusted by speeding up or slowing down
the treadmill in order to maintain their level of exertion between RPE 14 to 16, which is considered as
vigorous intensity. Additionally heart rate was monitored while on treadmill to ensure it did not exceed
an intensity of 85% of age-adjusted maximum heart rate. Heart rate was recorded every 10 min while
participants were on the treadmill.
During the six-month unsupervised period, participants were encouraged to continue with a similar ex-
ercise programme, either using a treadmill or engaging in walking or jogging.
Control group: were asked to continue to manage their pain as usual, e.g. with analgesics
Both groups could use analgesics as needed.
Outcomes Primary outcome: short-form MPQ reported as pain quality, measured with the Pain Rating Index; pain
intensity, measured with the 0 to 100 mm VAS; and the 'present pain' measured with Present Pain Index
Secondary outcomes: SF-12, Women's Health Initiative Insomnia Rating Scale, Patient Global Impres-
sion of Change scale, exercise adherence
Notes Funding: supported by Dunedin School of Medicine Grant in aid; School of Physiotherapy Research
Budget; and Physiotherapy New Zealand Scholarship Trust Fund
Date study was conducted: May 2014 to August 2015

Informed decisions.

Kannan 2019 (Continued)
Trial registration: ACTRN12613001195741
Risk of bias
Random sequence genera- Low risk Quote: “Women with primary dysmenorrhea were randomly allocated to un-
tion (selection bias) dertake regular aerobic exercise (experimental group) or usual care (control
group) by a clinical research administrator using simple randomisation (gener-
ated using a random numbers list)” (p. 81)
Allocation concealment Unclear risk Quote: “(generated using a random numbers list) with allocation concealment
(selection bias) using opaque sealed envelopes [given by clinical research administrator]. The
clinical research administrator was an independent person with no other in-
volvement in the study.” (p. 81)
Comment: unclear if sealed envelopes were sequentially numbered

mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Dropout rate was higher (21%) than anticipated (15%) but the authors note
(attrition bias) (quote): “Reasons for dropping out of study is not known, it is unlikely that it
All outcomes could be related to intervention parameters because our feasibility study iden-
tified good acceptance towards the intervention and intensity of training.” (p.
85)
Selective reporting (re- Low risk Both study protocol published and trial prospectively registered
porting bias)

Motahari-Tabari 2017
Methods Randomised controlled trial of stretching exercises versus mefanamic acid
Participants: 122 participants
Setting: Mazandran University of Medical Sciences Dormitory
Inclusion: students living in the university dormitory who had moderate-to-severe primary dysmenor-
rhoea for more than 50% of menstrual cycles lasting for at least one day and affected their daily activ-
ities. The diagnosis of primary dysmenorrhoea was made based on having characteristics of pain and
ruling our any history of pelvic disorders.
Exclusion: participants were excluded if they had irregular menstrual cycles, used an IUD or oral con-
traceptive pill, undertook regular exercise, had a history of physical or psychological problems, and
known secondary dysmenorrhoea

Informed decisions.

Motahari-Tabari 2017 (Continued)
Interventions Stretching group: exercise programme included a 5-minute warm-up in standing position and then 6
belly and pelvic stretching exercises for 10 minutes. This programme was performed for 15 minutes, 3
times per week in 2 menstrual cycles (8 weeks). Exercise was not performed during menstruation.
Control group: students received mefanamic acid (250 mg) capsules every 8 hours from the onset of
menstruation until pain relief, also for 2 cycles
Outcomes Primary outcome: menstrual pain intensity (VAS)
Notes Funding: VC for Research, Mazandaran University of Medical Sciences (grant number: H-92-24)
Conflict of interest: authors declare no conflicts of interest
Date study was conducted: 2014 (over 5 months)
Trial registration number: 201203118822N2
Risk of bias
Random sequence genera- Unclear risk Quote: “Eligible students were determined via a convenience sampling using a
tion (selection bias) checklist based on the inclusion and exclusion criteria and were then random-
ly divided into two interventional groups” (p. 48)
Allocation concealment Unclear risk "We used a list for allocation"

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk No missing data reported, but study missing CONSORT flow diagram
(attrition bias)
All outcomes
Selective reporting (re- Unclear risk The study protocol is not available
porting bias)

Nasri 2016
Methods Randomised controlled trial of aerobic training versus kegel exercises versus no exercise
Participants: 45 participants total (30 participants in eligible arms)
Setting: 2 schools in the city of Salehabad (Hamadan Province)
Inclusion: single healthy teenagers (10 to 18 years); not being professional athletes (limited to sport at
school); normal menstrual cycles (22 to 35 days), normal menstruation period (3 to 10 days), normal
bleeding volume

Informed decisions.

Nasri 2016 (Continued)
Exclusion: history of any gynaecology or urethra disease, history of coronary vascular, liver or kid-
ney disease, diabetes, asthma, any mental disease like depression, hypothyroidism. Using analgesics.
Smoking. Currently doing routine and regular exercise.
Interventions Aerobic training: 8 weeks aerobic exercise, 3 sessions per week with intensity of 65% to 70% maxi-
mum heart rate and duration of 45 minutes. The intensity of exercises was 5% less during menstrua-
tion. All exercises were supervised by a trainer.
Control: no treatment
Kegel exercises (arm not eligible for inclusion)
Notes Funding: Shahid Rajaee teacher training university Tehran

Date study was conducted: April to June 2013
Trial registration: IRCT 2014042017362N1
Risk of bias
Random sequence genera- Unclear risk Page 55 states allocation was random, but no further details given
Allocation concealment Unclear risk Not reported

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Dropouts not reported

(attrition bias)
All outcomes
Selective reporting (re- Low risk Trial registration shows study reported on all predefined outcomes
porting bias)

Patel 2015
Methods Randomised controlled trial of stretching exercises versus no treatment
Participants: 120 participants
Setting: Shree BG Patel College of Physiotherapy, Anand and Shree Jalaramgirls hostel, VV Nagar

Informed decisions.

Patel 2015 (Continued)
Inclusion: all participants experiencing moderate-to-severe primary dysmenorrhoea and with a regular
menstrual cycle
Exclusion: history of specific disease, compulsory use of special drug, symptoms such as tingling, itch-
ing, discharge, irregular menstruation cycle or subjects with regular exercise history
Interventions Stretching group: 6 types of active stretching exercise were performed:
• The subject was asked to stand behind a chair, bend trunk forward from the hip joint so that the shoul-
ders and back were positioned in a straight line and the upper body was placed parallel to the floor.
Duration of holding time was 5 seconds. Repetition was 10 times.
• The subject was requested to stand 20 cm behind a chair, then raise one heel off the floor, then repeat
the exercise with the other heel alternatively. The exercise was performed 20 times.
• The subject was asked to spread their feet shoulder width, place trunk and hands in forward stretch-
ing mode, then completely bend her knees and maintain a semi-squatting position. Duration of this
position was 5 seconds; the subject then raised her body and repeated the same movement 10 times.
• The subject was asked to spread her feet wider than shoulder width and was asked to bend and touch
left ankle with her right hand while putting her left hand in a stretched position above her head, so that
the head was in the middle and her head was turned and looked for her left hand. This was repeated
for the opposite foot. The exercise was repeated alternatively 10 times for each side of the body.
• The subject was asked to lie down in the supine position so that the shoulders, back, and feet were
kept on the floor. In this position the knees were bent with the help of her hands and pulled to her
chin. The repetition frequency was 10 times.
• The subject was asked to stand against a wall and put her hands behind her head and elbows touching
the wall, then without bending the vertebral column, the abdominal muscle wall was contracted for
10 seconds.
All exercises were done for 3 days per week and 2 times per day, for 8 weeks (48 sessions total)
Control group: did not perform any type of exercise
Secondary outcomes: overall menstrual symptoms (MMDQ)
Notes Funding: nil

Risk of bias
Random sequence genera- Unclear risk Quote: "participants were randomly divided into 2 groups: an experimental
tion (selection bias) group (n = 60) and a control group (n = 60)" (p. 72)
Allocation concealment Unclear risk Insufficient information

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Not reported

(attrition bias)
Informed decisions.

Patel 2015 (Continued)
All outcomes
Selective reporting (re- High risk Not all of the study's prespecified primary outcomes have been reported; VAS
porting bias) scores at 4 weeks not reported

Saleh 2016
Methods Three-armed randomised controlled trial comparing stretching, core strengthening and no treatment
Participants Country: Egypt
Participants: 150 participants with primary dysmenorrhoea randomised, 126 completed the study
Setting: outpatient clinic at Zagazig university hospital
Inclusion: diagnosis of primary dysmenorrhoea after a thorough history and clinical examination, pain
intensity of 5 or above in VAS
Exclusion: pharmacological or non-pharmacological methods for pain relief during the study, suffering
from systemic diseases or diseases in the genital organs abnormal vaginal bleeding and irregular men-
strual cycles, any history of regular exercises 3 days/week
Interventions Stretching group: performed for 8 weeks (3 days per week and 3 times per day for 10 minutes) at
home. They were asked to avoid performing stretching exercises during the period itself.
• First stretching exercise: the subjects were asked to stand and bend trunk forward from the hip joint so
that the shoulders and back were positioned in a straight line and the upper body was placed parallel
to the floor for 5 seconds; repetition 10 times
• Second stretching exercise: the subjects were requested to stand then raise 1 heel off the floor, then
repeat the exercise with the other heel alternatively. The exercise was performed 20 times
• Third stretching exercise: the subjects were asked to spread their feet shoulder width, place trunk
and hands in forward stretching mode, then completely bend her knees and maintain a squatting
position, duration of this position was 5 seconds, the subject then raised her body and repeated the
same movements 10 times
• Fourth stretching exercise: the subjects were asked to spread her feet wider than shoulder width. Then
the subject was asked to bend and touch left ankle with her right hand while putting her left hand
in a stretched position above her head so that the head was in the middle and her head was turned,
looking at her left hand; this exercise was repeated for the opposite foot. The exercises were repeated
alternatively 10 times for each side of the body
Core strengthening group: 4 core strengthening exercises performed 4 days per week, three times
each day for 20 min in total per day for 8 weeks
• Pelvic bridging: the subjects were asked to lie supine, with knees flexed and pelvis raised off the floor;
position held for 5 sec with 10 repetitions
• Plank: the subjects were requested to lie prone with weight on elbows and toes, lifting the body off
the floor; position held for 5 sec with 5 repetitions
• Cat and camel: the subjects were requested to prone kneel and then take a deep breath from nose
while making a hump in the back (cat) and breathe out from mouth while curving the spine (camel);
position held for 5 sec with 10 repetitions
• Curl up: the subjects were requested to lie supine with mild knee flexion, clasping both hands behind
the head and moving the body towards the knee; position held for 5 sec with 10 repetitions
Control group: no exercise or stretching performed
For the meta-analysis, we combined the stretching group and core strengthening group

Informed decisions.

Saleh 2016 (Continued)

Date study was conducted: December 2012 to April 2014
Ethics approval: protocol approved by Research Ethics Committee of the Zagazig University Hospitals
Risk of bias
Random sequence genera- Low risk Quote: "Samples were selected through convenience sampling and were then
tion (selection bias) assigned to an intervention and control groups by permuted block randomiza-
tion" (p. 2)

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data High risk Dropouts uneven between groups; 12 in control group (24%) and 6 in each in-
(attrition bias) tervention group
All outcomes
Selective reporting (re- Unclear risk No study protocol was published

porting bias)

Samy 2019
Methods Randomised controlled trial of Zumba versus no treatment
Participants Country: Egypt
Participants: 98 women with primary dysmenorrhoea recruited from the community and randomised
to Zumba (n = 49) or no treatment (n = 49)
Setting: Bahgat gym and fitness centre in Egypt
Inclusion: women aged 18 to 25 years with regular menstrual cycles (30 to 35 days) and menstrual
bleeding of 3 to 10 days who had suspected primary dysmenorrhoea with menstrual pain scores over
4 cm, on the 10-point VAS. Women were screened with an ultrasound scan by a gynaecologist at Cairo
University.
Exclusion: previous practice of Zumba fitness, irregular menstrual cycles, the usage of contraceptive
methods such as intrauterine contraceptive devices, and oral contraceptive pills and any of the follow-
ing conditions: pregnancy, known genitourinary system diseases (e.g. pelvic inflammatory disease and
urinary tract infections), secondary dysmenorrhoea, and chronic illnesses that might contraindicate

Informed decisions.

Samy 2019 (Continued)
physical exercise (cardiac, respiratory, renal diseases, asthma, diabetes, epilepsy, migraine, thyroid,
anaemia, nervous disorders, and musculoskeletal injuries)
Interventions Zumba group: Zumba classes were undertaken twice per week for 8 weeks, 16 sessions in total. Class-
es started from the 3rd day of the menstrual cycle. Classes were one hour long, and at least 48 hours
elapsed between classes. Zumba sessions were conducted at Bahgat gym and fitness centre and con-
sisted of continuous dance movements to Latin music with changing intensity level all through the ses-
sions. Low-intensity movements were initiated for the first 5 minutes of each session, followed by an in-
creasing intensity during the workout. The intensity of the workouts gradually decreased at the end of
the training session.
Control group: participants in the control group did not get any intervention. Participants were also of-
fered weekly 10-minute telephone follow-ups to provide support and for addressing dropout preven-
tion

Secondary outcomes: duration of pain (in hours)

Date study was conducted: May 2018 to September 2018
Trial registration: NCT03561493
Risk of bias
Random sequence genera- Low risk Quote: “They were randomly assigned to the Zumba or the control group (49
tion (selection bias) participants in each group), using simple randomization. The randomization
sequence was generated using Stata 10.0 (Stata Corp, College Station, TX).” (p.
2)
Allocation concealment Low risk Quote: “Assignments were enclosed in sequentially numbered, sealed opaque
(selection bias) envelopes and stored by a research assistant who was independent to the trial
team.” (p. 2)
Blinding of participants High risk Quote: “…Limitation of the study… lack of blinding of participants and out-
and personnel (perfor- come assessors” (p. 5)
mance bias)
All outcomes
Blinding of outcome as- High risk “…Limitation of the study… lack of blinding of participants and outcome as-
sessment (detection bias) sessors” (p. 5)
All outcomes

(attrition bias)
All outcomes
Selective reporting (re- Low risk Trial prospectively registered and all specified outcomes reported
porting bias)


Informed decisions.

Siahpour 2013
Methods Three-armed trial comparing yoga, aerobic exercise and no treatment
Participants: 60 participants aged 20 to 25 with primary dysmenorrhoea
Setting: university
Inclusion
• Participants between 20 to 25 years old

• Single participants
• Regular and painful menstrual cycle
• Not taking regular exercise
• Participants who are not taking any hormone medications
• Participants who had not have any pelvic structural damage
Exclusion
• History of any particular (chronic) disease

• Taking medication
• Irregular menstrual cycle
• Taking regular exercise
Interventions Yoga group: Yoga performed 3 times per week for 60 minutes each time.
Participants were asked to perform the following poses: Marjariasana (cat stretch pose for spine),
Asana (bend forward), Asana (while sitting and lying down), Supta prasana, Matsyasana (Fish pose),
Ardha matsyendrasana, move forward wide-legged, Savasana (relaxing asana)
Aerobic group: three aerobic exercise sessions performed per week for 60 minutes each time. No de-
tails on the exercise provided.
Control group: no exercise or yoga performed
Outcomes Menstrual pain intensity (VAS), use of analgesic medication
Notes Funding: Islamic Azad University Fars Science and Research Branch, Yasuj
Date study was conducted: April 2012 to July 2012
Trial registration: IRCT2013091014611N1
Risk of bias
Random sequence genera- Unclear risk Page 477 states that it is 'random' but does not provide details

(selection bias)

mance bias)
All outcomes

Informed decisions.

Siahpour 2013 (Continued)
All outcomes
Incomplete outcome data Unclear risk No dropouts reported in text, but no CONSORT figure, so unclear if not report-
(attrition bias) ed or did not occur
All outcomes
Selective reporting (re- Unclear risk No study protocol is published

porting bias)

Yang 2016
Methods Randomised controlled trial of yoga and no treatment
Participants Country: Korea
Participants: 40 respondents were randomly assigned to yoga exercise (n = 20) or control (n = 20)
groups and completed the entire study
Setting: Nursing college near Daejeon metropolitan area, Konyang University Continuing Education
Centre
Inclusion
• Age 18 to 25 years
• Menstrual cramp pain score above 6 points on the 10-point VAS for pain
• Menstrual cycle duration between 20 and 40 days
• BMI 18 kg/m2 to 25 kg/m2
Exclusion
• Diagnosis of pelvic or gynaecologic diseases or secondary dysmenorrhoea

• Surgery related to pelvic or gynaecologic diseases
• Use of contraceptives
• Experience with yoga exercises
Interventions Yoga group: integrated yoga programme consisting of three parts (surya namaskara 15 mins, three yo-
ga poses 10 mins, and yoga nidra 30 mins) was used. Surya namaskara, or "sun salutations" consists
of 12 postures and breathing exercises. The three yoga poses were cobra, cat, and fish. Yoga nidra, is
a specific yogic relaxation and meditation practice. The programme was conducted for about 1 hour
once per week for 12 weeks (12 sessions for 60 minutes per session over 12 weeks)
Control group: did not practice this yoga programme
Outcomes • Menstrual pain intensity (VAS)

• Menstrual pain duration
SF and MMDQ responses were measured before initiation of the 12-week yoga programme and after
programme completion
Notes Funding: Kangwon National University

Date study was conducted: 2015

Informed decisions.

Yang 2016 (Continued)
Study procedure approval: Institutional review board of Kangwon National University
(KWNUIRB-2015-02-002-001)
Risk of bias
Random sequence genera- Low risk Quote: “random permuted block design using a random-number table
tion (selection bias) through the Excel random-numbers function” (p. 733)

(selection bias)

mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk No dropouts reported (Figure 1, pg 734)

(attrition bias)
All outcomes
Selective reporting (re- Unclear risk No study protocol was published

porting bias)
ECG: electrocardiograph
IUD: intrauterine device
MPQ: McGil Pain Questionnaire
MMDQ: Moos Menstrual Distress Questionnaire
NRS: numeric rating scale
RPE: rate of perceived exertion
SF-12: 12-Item Short Form Health Survey
VAS: visual analogue scale

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Abbaspour 2006 No details on screening for primary dysmenorrhoea, or menstrual cycle details (e.g. regularity of
cycle)
Aboushady 2016 No valid control group (menstrual care instructions)
Atashak 2018 No valid intervention group (exercise + ginger)
Behbahani 2016 Active intervention combined exercise with education
Carpenter 1995 Included a treatment with medical intervention, therefore wrong control group

Informed decisions.

Study Reason for exclusion
Chang 2018 No valid control (taping)
Chaudhui 2013 No valid control (hot water bottle)
Chen 2019 Primary outcome was menstrual pain in the lower back
Chien 2013 Observational study
Dehnavi 2018 No details of dysmenorrhoea severity, frequency or duration
Habibian 2018 No valid control (all groups consumed either cinnamon or placebo)
Hubbell 1949 Controlled clinical trial, not randomised
Kannan 2015 Quasi-experimental design
Kaur 2013 No valid intervention group (combined heat and exercise) and no valid control group (heat)
Kour 2018 No valid control (thermotherapy)
Kumar 2017 No valid control (meditation or walnut consumption)
Lundquist 1947 Controlled clinical trial, not randomised
Mahishale 2013 No valid control (thermotherapy)
Monori 2017 Observational study
NCT03625375 Non randomised trial
Ortiz 2015 Included high proportion of women with irregular cycles
Padmanabhan 2018 No valid control (yoga versus gym ball)
Parkhad 2013 Observational study
Pazoki 2013 Does not screen for primary dysmenorrhoea, primary outcome premenstrual syndrome-related
Rakhshaee 2011 Cluster-randomised trial
Rihani 2013 No details provided on severity of dysmenorrhoea or any effect on daily activities
Sarhadi 2015 Pre- and post interventional study with no control group
Shahr-jerdy 2012 Cluster-randomised trial
Shirvani 2017 No valid control (ginger)
Tharani 2018 No valid control group (comparing two types of exercise)
Yonglitthipagon 2017 No details on screening or diagnosis for primary or secondary dysmenorrhoea

Informed decisions.

Characteristics of studies awaiting assessment [ordered by study ID]

Azima 2015
Methods Randomised controlled trial of stretching exercises versus massage versus no treatment
Participants: 120 students residing in dormitories of Shiraz University, who were majoring in non-
medical fields
Setting: college dormitories
Inclusion criteria
• Participants studying in non-medical fields

• Primary dysmenorrhoea (diagnosed with the demographic questionnaire and a gynaecologist's
confirmation) with pain intensity of 5 or higher according to the VAS
• No routine use of any pharmacologic or nonpharmacologic analgesic agents
• Nulliparous
• Not taking oral contraceptive pills
• Not having a systemic or a reproductive system disease
• No limitation when performing isometric exercises, such as a cardiovascular disease
Exclusion criteria
• Not willing to co-operate in the study

• Using other treatments during the study
• Being allergic to lavender oil
• Taking any medications
• Having any disease
• Having any physical or psychiatric problem
Interventions Excerise group: isometric exercises from the third day of the menstrual cycle 5 days per week, 2
sessions per day, and 10 times per session for 8 weeks. These exercises included 7 stages, which
were modified and confirmed by a specialised rehabilitation consultant
Massage group: not included
Outcomes Pain intensity (VAS)
Notes Data as reported in manuscript appears incorrect. All standard deviations are several orders of
magnitude larger than means. Contacted authors twice for clarification but no reply as of April
2019.

Bustan 2018
Methods A quasi-experimental study
Participants 96 nursing students
Interventions Abdominal stretching was given for 15 minutes, two times per week, for three weeks
Control group: unclear

Informed decisions.

Bustan 2018 (Continued)
Outcomes Pain scale (unclear)
Notes Conference abstract only: authors contacted April 2019

Sutar 2016
Methods Randomised controlled trial of aerobic exercise versus no treatment
Participants: 100 undergraduate medical students (aged 17 to 23) received the intervention, un-
clear if there were any dropouts
Setting: not reported
Inclusion: regular menstrual cycle, diagnosis of primary dysmenorrhoea given by gynaecologist
Exclusion: regular exercise, pelvic pathology
Interventions Exercise group: eight weeks of structured aerobic training undertaken three days per week for 45
minutes each session. Exercise was not performed during the menstrual cycle. The session consist-
ed of 10 minutes of warm-up exercises, 25 minutes of aerobic dance performed at 70% to 80% of
maximum heart rate, then 10 minutes cool-down
Outcomes Pain scores as measured by VAS, health-related quality of life (SF-36)
Notes Unclear what the severity of the dysmenorrhoea was at baseline, so unclear if eligible for inclusion.
Additionally no means or standard deviations given for outcome data, only graphical representa-
tion. Contacted authors twice for clarification, but no reply as of April 2019

Vaziri 2015
Methods Randomised controlled trial of aerobic or stretching exercise and no treatment
Participants: 100 participants received the intervention, 98 were analysed
Setting: Universities of Bushehr Medical Sciences sports club
Inclusion
• Single
• 18 to 30 years old
• No history of mental or physical diseases
• No history of joint, motion, muscle, or bone diseases that reduce their abilities to exercise
• Not a professional athlete
• Not taking any medications or vitamin and mineral supplements during three menstrual cycles
before the trial
• Not having done leisure time exercises leading to sweating or increasing heart rate (using Godin's
questionnaire) in the past three months
• Not passing their physical education course
• Not suffering from pelvic diseases, such as endometriosis, myoma, and ovarian cyst
Informed decisions.

Vaziri 2015 (Continued)
• BMI 19 kg/m2 to 29 kg/m2
• Regular menstrual cycles of 24 to 35 days
• Individuals who had menstruation cramps of at least 3 to 5 in intensity (classed as moderate to
very severe) as measured by a modified menstrual symptom questionnaire were entered into the
study
Exclusion
• Being absent for more than two sessions of exercise in both menstrual cycles
• Starting any type of exercise in the control group
• Starting any additional exercises in the intervention groups
• Unable to tolerate physical exercise
• Occurrence of any unexpected events, such as death of relatives or marriage
Interventions Aerobic exercise group: aerobic exercises were performed on a treadmill device for 20 min (four
5-min stages). The exercises started with low-intensity and their intensity was increased in the sec-
ond and third stages. In the fourth stage, the intensity of the exercises was reduced again; thus, the
intensity of exercises was the same in the first and fourth stages. Each participant performed these
exercises three times per week for two menstrual cycles.
Stretching exercise group: 10 stretching exercises in abdomen, pelvis, and groin that were per-
formed 3 days per week for two menstrual cycle. Each exercise started at 10 seconds in the first
session and 1 second was added to it every session. Each movement was repeated 5 times (24 ses-
sions for 20 minutes per session over 8 weeks).
Control group: did not do any exercises and did not take any chemical or herbal drugs or supple-
ments to prevent their dysmenorrhoea during their menstrual cycles
Outcomes Secondary: overall menstrual pain intensity (modified version of a menstrual symptom question-
naire)
Notes Funding: Shiraz Univeristy of Medical Sciences

Date study was conducted: 2012-2013
No details provided on the initial sample size for each group. Dropouts reported but not which
group they came from. No CONSORT diagram. Contacted authors twice for clarification, but no re-
ply as of April 2019
BMI: body mass index


Characteristics of ongoing studies [ordered by study ID]

CTRI/2018/09/015617
Trial name or title To compare the effect of drawing in maneuver exercises versus core strengthening exercises on pri-
mary dysmenorrhoea
Methods Randomised controlled trial comparing abdominal drawing in exercise versus core strengthening
exercise
Participants Inclusion criteria
• Females between 18 to 25 years of age

• Regular menstrual cycle (30 to 35 days)
• Pain intensity more than or equal to 5 on numerical pain rating scale

Informed decisions.

CTRI/2018/09/015617 (Continued)
• Willing to participate in the study
Exclusion criteria
• Irregular menstruation
• Abnormal vaginal bleeding
• Medications: analgesics and oral contraceptive pills
• History of gynaecological disease
Interventions Group 1: abdominal drawing in exercise
Group 2: core strengthening exercise
Outcomes Menstrual pain intensity (NRS), Overall menstrual symptoms (Menstrual Distress Questionnaire)
Starting date September 2018
Contact information Hitiksha Dedania shweta.rakholiya@rku.ac.in
Notes

IRCT20120215009014N245
Trial name or title Effect of 8 weeks of aqua yoga versus no training on pain severity and duration of menstruation in
girl students with primary dysmenorrhoea: a randomized clinical trial
Methods Randomised controlled trial comparing aqua yoga + usual care versus usual care
• Aged 18 to 26 years
• Primary dysmenorrhoea
• Single
Exclusion criteria
• A history of secondary dysmenorrhoea

• Regular physical activity of sessions per week or more
• Physical and motor problems
Interventions Intervention: usual care + aqua yoga 1 hr twice per week for 8 weeks
Control: usual care for dysmenorrhoea
Outcomes Pain duration and severity of dysmenorrhoea at 8 weeks by "standard questionnaire"
Contact information Farid Babakhani farideh_babakhani@yahoo.com
Notes


Informed decisions.

IRCT20130812014333N111
Trial name or title The comparison of the effect of stretching exercises and a combination of massage - stretching ex-
ercises on primary dysmenorrhoea of female students of RAZI University of Kermanshah
Methods Randomised controlled 3-armed trial comparing stretching exercises versus stretching + massage
versus no intervention
Participants No age limit
Inclusion criteria
• Regular and painful menstruation

• Lack of severe stress, such as the death of a family member
Exclusion criteria
• Known physical or mental illness

• Surgery in the last three months
• Non-use of pain relief medication during trial period
• Record of being married
Interventions Group 1: stretching exercises (abdominal, pelvic and groin stretching exercises), 4 days per week,
15 minutes each time for 8 weeks
Group 2: massage and stretching exercises 4 days per week, 15 mins at a time, for 8 weeks
Group 3: no intervention
Outcomes "dysmenorrhea" measured by McGill Pain Questionnaire
Starting date January 2019
Contact information Leila Farhadi khalily1267@yahoo.com
Notes

IRCT20140519017756N41
Trial name or title The effect of an aerobic training course with and without cumin supplementation on serum ß-en-
dorphin levels and pain intensity in non-athlete girls with primary dysmenorrhoea
Methods Randomised controlled trial comparing aerobic training with cumin versus aerobic training with
placebo capsules
• Moderate-to-severe dysmenorrhoea (pain intensity score from 4 to 10)
• Single girl
• Non-athlete
• Regular monthly cycles of more than 21 days and less than 35 days
• Pain during menstruation
Exclusion criteria
• Consumption of hormonal medications and any type of herbal or chemical tranquillisers affecting
menstrual bleeding from 48 hours before menstruation to the end of the research project
• Cardiovascular, hepatic and renal disease

Informed decisions.

IRCT20140519017756N41 (Continued)
• Genital tract infection
• Pelvic damage
• Secondary dysmenorrhoea
Interventions Group 1: cumin capsules (300 milligrams every 8 hours) on the first 3 days plus 28 days of aerobic
exercise from the fourth day
Group 2: starch capsules (300 milligrams every 8 hours) on the first 3 days plus 28 days of aerobic
exercise from the fourth day
Outcomes Menstrual pain severity (VAS)
Serum beta endorphin
Starting date May 2017
Contact information Mohadese Eidy Kakhky M.eidykakhky1993@gmail.com
Notes

IRCT2016103119024N2
Trial name or title The effect of a core stability exercise program on the primary dysmenorrhoea in young adult fe-
males- a randomized controlled trial
Methods Randomised controlled trial comparing core stability exercises versus no intervention
Participants Major inclusion criteria
• Young adult females, 18 to 25 years old who lived in Arak, Iran

• Persistent primary dysmenorrhoea of more than 6 months with regular menstruation cycles
• No history of pregnancy; low back pain; diabetes; polycystic ovary disease; pelvic infection or
pelvic pain with no relation to dysmenorrhoea
Major exclusion criteria
• No tolerance to exercise
• Any additional physical activity
• Taking any medications or vitamin and mineral supplements
Interventions Group 1: 8-week (3 sessions per week) core stability exercise programme
Group 2: no intervention
Outcomes • Painkiller use

• Duration of pain (hours)
• Pain severity (numeric rating scale)
Starting date November 2016
Contact information Fahime Mahmoudi Fahime.mahmoudi@yahoo.com
Notes

Informed decisions.

IRCT201708309014N179
Trial name or title Effects of exercises program versus no exercise on duration and severity of dysmenorrhoea among
students with primary dysmenorrhoea: a randomized clinical trial
Methods Randomised controlled trial comparing usual care + physical activity versus usual care alone
• Single
• Mild or moderate dysmenorrhoea
• Regular cycles with 21 to 35 days interval
Exclusion criteria
• Chronic diseases
• Genital organ diseases
• Physical disability
• Educated in midwifery
• Regular physical activity in control group
• Resident of dormitory
Interventions Group 1: physical activity one hour per day, 3 times per week plus usual care
Group 2: usual care
Outcomes • Duration of dysmenorrhoea

• Severity of dysmenorrhoea (McGill Pain ruler)
Contact information Elahe Abdolmaleki Elaheabdolmaleki.95@ gmail.com
Notes

IRCT20181212041948N1
Trial name or title Comparison of the effect of stretching exercises and massaging of connective tissue with the con-
trol group on dysmenorrhoea
Methods Randomised controlled 3-armed trial comparing stretching exercises versus connective tissue mas-
sage versus no intervention
• Desire to participate in the study

• Single
• Being a student
• No systemic disease or disease in reproductive organs
• Aged between 18 to 25 years
• Regular inactivity
• Intensity of menstrual pain more than 5 VAS criteria
• Lack of limits exercise and massage
• Non-use of oral contraceptive pills and drug and complementary therapies for the treatment of
dysmenorrhoea during the study

Informed decisions.

IRCT20181212041948N1 (Continued)
Interventions Group 1: stretching for 8 weeks, 3 times per week, 10 minutes duration. No stretching during the
period of menstruation
Group 2: connective tissue massage, every week for 8 weeks and the massage protocol is per-
formed twice. No massage during the period of menstruation
Group 3 (control): no intervention
Outcomes Primary: Menstrual pain severity (VAS) at 8 weeks
Starting date January 2019
Contact information Somaieh Ramy s_rahimy@ymail.com
Notes

NCT03821207
Trial name or title The effect of abdominal massage and exercise on primary dysmenorrhoea in university students
Methods Randomised cross-over 3-armed trial of exercise, abdominal massage or control (no treatment)
Participants Inclusion
• 18 to 20 year old women with regular menstrual cycles

• Recording > 6 points on VAS in the first 3 days on at least 2 of the last 3 menstrual cycles
• Not using analgesics during the study period
Exclusion
• Endometriosis
• Pelvic inflammatory disease
• Ovarian cyst
• Myoma
• Chronic pelvic pain
• Urinary system infection
• Menometrorrhagia
• Obstructive vaginal or uterine congenital anomalies
• Secondary dysmenorrhoea
• History of major abdominal or pelvic surgery in the last 3 months
• Hormonal treatment in the last 6 months
Interventions Exercise: stretching exercises including the pelvic and lumbar regions 3 times per day for the first 3
days of the menstrual cycle
Abdominal massage: group instructed to massage the abdomen for 10 minutes a day on the first 3
days of the menstrual cycle. The massage is to be applied as effleurage (light touch) clockwise over
the abdomen.
Control: no exercise or massage
Outcomes Primary: Menstrual pain intensity (VAS) during 3 menstrual cycles,
Starting date December 2018

Informed decisions.

NCT03821207 (Continued)
Contact information Meryem Kurek Eken, meryemkurekeken@gmail.com
Notes

RBR-9vqhg7
Trial name or title TENS effect in primary dysmenorrhoea and its influence on central sensitization pre and post exer-
cise: randomized clinical trial
Methods Randomised controlled trial comparing TENS and core training versus placebo TENS and core
training
• Women aged between 11 and 35 years

• Pelvic pain lasting 8 to 72 hours during the menstrual period
• Intensity equal to or greater than 3 on the numeric scale
• Nulliparous
Exclusion criteria
• Use of contraceptives during the study period

• Frequent use of analgesics or anti-inflammatories during treatment
• Presence of pelvic disease
• Pregnant
• History of abortion
• Musculoskeletal damage or excessive pain in any joint that may limit participation in an exercise
programme or evaluation of functional parameters
• Psychiatric disorder, cognitive decline or dementia influencing the communication process
• Under physiotherapeutic treatment during the study
• Presence of contraindications for the use of TENS, such as ulceration or allergy to electrode ma-
terial
• Prior use of TENS
• Chronic use of opioids or antidepressants
• Reduced sensitivity in the places where the electrodes will be placed
• History of previous surgery in the uterus
• Presence of chronic decompensated diseases
Interventions Intervention: TENS in the active form, duration of 30 minutes, 2 first days of the menstrual cycle,
during 3 menstrual cycles. Afterwards, core training exercises will be performed, lasting 30 min-
utes, 2 times per week, over another 3 menstrual cycles.
Control: TENS in the placebo form, duration of 30 minutes, 2 first days of the menstrual cycle, dur-
ing 3 menstrual cycles. Afterards, core training exercises will be performed, lasting 30 minutes, 2
times per week, over another 3 menstrual cycles.
Outcomes • Menstrual pain intensity (NRS)

• Pressure algometer
• Conditioned pain modulation test
• Temporal summation test
• Pain catastrophic scale
• McGil Pain Questionnaire

Informed decisions.

RBR-9vqhg7 (Continued)
Starting date March 2017
Contact information Josimari Melo Santana desantanajm@gmail.com
Notes
TENS: transcutaneous electric nerve stimulation


DATA AND ANALYSES

Comparison 1. Exercise versus no treatment
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Menstrual pain intensity 9 632 Std. Mean Difference (IV, Fixed, 95% CI) -1.86 [-2.06, -1.66]
1.1 High-intensity exercise 4 213 Std. Mean Difference (IV, Fixed, 95% CI) -2.51 [-2.89, -2.13]
1.2 Low-intensity Exercise 6 419 Std. Mean Difference (IV, Fixed, 95% CI) -1.62 [-1.85, -1.38]
2 Overall menstrual symptoms 1 120 Mean Difference (IV, Fixed, 95% CI) -33.16 [-40.45, -25.87]
3 Quality of life 1 110 Mean Difference (IV, Fixed, 95% CI) 4.17 [1.71, 6.62]
3.1 Mental 1 55 Mean Difference (IV, Fixed, 95% CI) 4.40 [1.59, 7.21]
3.2 Physical 1 55 Mean Difference (IV, Fixed, 95% CI) 3.40 [-1.68, 8.48]

Analysis 1.1. Comparison 1 Exercise versus no treatment, Outcome 1 Menstrual pain intensity.
Study or subgroup Exercise No treatment Std. Mean Difference Weight Std. Mean Difference
N Mean(SD) N Mean(SD) Fixed, 95% CI Fixed, 95% CI
1.1.1 High-intensity exercise
Kannan 2019 27 38.1 (6.8) 28 58.9 (10.7) 8.48% -2.28[-2.97,-1.59]
Nasri 2016 15 4.2 (1.4) 15 5.9 (1.8) 6.8% -1.04[-1.81,-0.27]
Samy 2019 49 3.1 (0.7) 49 6.9 (1.1) 7.98% -4.13[-4.84,-3.42]
Siahpour 2013 20 3.5 (1.7) 10 7.1 (1.1) 4.2% -2.28[-3.26,-1.3]
Subtotal *** 111 102 27.46% -2.51[-2.89,-2.13]
Heterogeneity: Tau2=0; Chi2=34.52, df=3(P<0.0001); I2=91.31%
Test for overall effect: Z=12.84(P<0.0001)

1.1.2 Low-intensity Exercise
Fallah 2018 19 4 (2.4) 21 6.5 (2.1) 8.98% -1.09[-1.76,-0.42]
Jaibunnisha 2017 33 4.3 (1.3) 34 5.2 (1) 16.32% -0.75[-1.25,-0.26]
Patel 2015 60 3 (1) 60 7.2 (1.4) 12.34% -3.46[-4.03,-2.89]
Saleh 2016 88 4.8 (1.9) 38 7.7 (1.4) 21.54% -1.64[-2.07,-1.2]
Favours exercise -5 -2.5 0 2.5 5 Favours no treatment

Informed decisions.

Study or subgroup Exercise No treatment Std. Mean Difference Weight Std. Mean Difference
Siahpour 2013 20 4.5 (2) 10 7.1 (1.1) 5.48% -1.47[-2.32,-0.61]
Yang 2016 18 5.9 (0.7) 18 6.9 (0.8) 7.87% -1.19[-1.9,-0.47]
Subtotal *** 238 181 72.54% -1.62[-1.85,-1.38]

Total *** 349 283 100% -1.86[-2.06,-1.66]
Test for subgroup differences: Chi2=15.06, df=1 (P=0), I2=93.36%
Favours exercise -5 -2.5 0 2.5 5 Favours no treatment

Analysis 1.2. Comparison 1 Exercise versus no treatment, Outcome 2 Overall menstrual symptoms.
Study or subgroup Exercise No treatment Mean Difference Weight Mean Difference
Patel 2015 60 65.9 (12.5) 60 99.1 (26) 100% -33.16[-40.45,-25.87]

Total *** 60 60 100% -33.16[-40.45,-25.87]
Heterogeneity: Not applicable
Favours exercise -100 -50 0 50 100 Favours no treatment

Analysis 1.3. Comparison 1 Exercise versus no treatment, Outcome 3 Quality of life.
Study or subgroup Exercise No treatment Mean Difference Weight Mean Difference
1.3.1 Mental
Kannan 2019 27 42 (6) 28 37.6 (4.5) 76.54% 4.4[1.59,7.21]
Subtotal *** 27 28 76.54% 4.4[1.59,7.21]
Test for overall effect: Z=3.07(P=0)

1.3.2 Physical
Kannan 2019 27 47.8 (9.7) 28 44.4 (9.5) 23.46% 3.4[-1.68,8.48]
Subtotal *** 27 28 23.46% 3.4[-1.68,8.48]
Test for overall effect: Z=1.31(P=0.19)

Total *** 54 56 100% 4.17[1.71,6.62]
Heterogeneity: Tau2=0; Chi2=0.11, df=1(P=0.74); I2=0%
Test for subgroup differences: Chi2=0.11, df=1 (P=0.74), I2=0%
Favours no treatment -100 -50 0 50 100 Favours exercise


Informed decisions.

Comparison 2. Exercise versus NSAIDs
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Menstrual pain intensity 1 122 Mean Difference (IV, Fixed, 95% CI) -7.40 [-8.36, -6.44]
2 Use of rescue analgesic medication 1 122 Risk Ratio (M-H, Fixed, 95% CI) 1.77 [1.21, 2.60]
3 Absence from work or school 1 122 Odds Ratio (M-H, Fixed, 95% CI) 1.0 [0.49, 2.03]

Analysis 2.1. Comparison 2 Exercise versus NSAIDs, Outcome 1 Menstrual pain intensity.
Study or subgroup Exercise NSAID Mean Difference Weight Mean Difference
Motahari-Tabari 2017 61 -28.7 (2.5) 61 -21.3 (2.9) 100% -7.4[-8.36,-6.44]

Total *** 61 61 100% -7.4[-8.36,-6.44]
Favours exercise -50 -25 0 25 50 Favours NSAID

Analysis 2.2. Comparison 2 Exercise versus NSAIDs, Outcome 2 Use of rescue analgesic medication.
Study or subgroup Exercise NSAID Risk Ratio Weight Risk Ratio
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Motahari-Tabari 2017 39/61 22/61 100% 1.77[1.21,2.6]

Total (95% CI) 61 61 100% 1.77[1.21,2.6]
Total events: 39 (Exercise), 22 (NSAID)
Favours exercise 0.01 0.1 1 10 100 Favours NSAID

Analysis 2.3. Comparison 2 Exercise versus NSAIDs, Outcome 3 Absence from work or school.
Study or subgroup Exercise NSAIDs Odds Ratio Weight Odds Ratio
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Motahari-Tabari 2017 30/61 30/61 100% 1[0.49,2.03]

Total (95% CI) 61 61 100% 1[0.49,2.03]
Total events: 30 (Exercise), 30 (NSAIDs)
Test for overall effect: Not applicable
Favours exercise 0.01 0.1 1 10 100 Favours NSAIDs

Informed decisions.


APPENDICES
Appendix 1. Cochrane Gynaecology and Fertility specialised register search strategy

PROCITE platform
Searched 25 July 2019
Keywords CONTAINS "exercise" or "Exercise Therapy" or "activity scheduling" or "fitness" or "aerobic exercise" or "Athletic Support" or
"aerobic exercises" or "aerobic training" or "yoga" or "walking" or "Athletes" or "physical condition" or "physical exercise" or "physical
performance" or "physical well being" or Title CONTAINS "exercise" or "Exercise Therapy" or "activity scheduling" or "fitness" or "aerobic
exercise" or "Athletic Support" or "aerobic exercises" or "aerobic training" or "yoga" or "walking" or "Athletes "or "physical condition" or
"physical exercise" or "physical performance" or "physical well being"
AND
Keywords CONTAINS "dysmenorrh" or "pelvic pain" or "menstrual cramps" or "menstrual pain" or "pain-dysmenorrhea" or "pain-
dyspareunia" or "menstrual distress" or "Dysmenorrhea-Symptoms" or "dyamenorrhea" or "cramping" or Title CONTAINS "dysmenorrh"
or "pelvic pain" or "menstrual cramps" or "menstrual pain" or "pain-dysmenorrhea" or "pain-dyspareunia" or "menstrual distress" or
"Dysmenorrhea-Symptoms" or "dyamenorrhea" or" cramping"
(85 records)
Appendix 2. CENTRAL search strategy

OVID platform
Searched July 2019
1 exp Dysmenorrhea/ (547)

2 Dysmenorrh$.tw. (1734)
3 (pain$ adj5 menstruat$).tw. (190)
4 (period$ adj5 pain$).tw. (4955)
5 (menstrua$ adj3 cramp$).tw. (80)
6 or/1-5 (6709)
7 exp exercise/ or exp exercise therapy/ (28270)
8 exercise$.tw. (76646)
9 aerobic$.tw. (11822)
10 (yoga or walk$ or gym or crossfit or circuit).tw. (29866)
11 (swim$ or jog$ or run$).tw. (19547)
12 (athlet$ or train$).tw. (88719)
13 conditioning.tw. (4484)
14 (physical$ adj5 activ$).tw. (25921)
15 (fitness or isometric$).tw. (11818)
16 or/7-15 (187349)
17 6 and 16 (808)
Appendix 3. MEDLINE search strategy

OVID Platform
Searched from 1946 to 25 July 2019

6 or/1-5 (13279)
7 exp exercise/ or exp exercise therapy/ (210978)
Informed decisions.


16 or/7-15 (1346427)
17 randomized controlled trial.pt. (485992)
18 controlled clinical trial.pt. (93178)
19 randomized.ab. (449872)
20 placebo.tw. (204927)
21 clinical trials as topic.sh. (187740)
22 randomly.ab. (315157)
23 trial.ti. (202189)
24 (crossover or cross-over or cross over).tw. (81073)
25 or/17-24 (1257911)
26 (animals not (humans and animals)).sh. (4568770)
27 25 not 26 (1155731)
28 6 and 16 and 27 (232)
Appendix 4. Embase search strategy

OVID Platform

4 pelv$ pain$.tw. (14153)
7 or/1-6 (28293)
16 exercise/ or anaerobic exercise/ or aerobic exercise/ or aquatic exercise/ (261748)
17 or/8-16 (1690321)
18 Clinical Trial/ (951050)
19 Randomized Controlled Trial/ (555816)
20 exp randomization/ (83333)
21 Single Blind Procedure/ (35823)
22 Double Blind Procedure/ (159939)
23 Crossover Procedure/ (59832)
24 Placebo/ (324185)
25 Randomi?ed controlled trial$.tw. (206826)
26 Rct.tw. (33071)
27 random allocation.tw. (1891)
28 randomly allocated.tw. (32780)
29 allocated randomly.tw. (2451)
30 (allocated adj2 random).tw. (807)
31 Single blind$.tw. (22978)
32 Double blind$.tw. (192840)
33 ((treble or triple) adj blind$).tw. (966)
34 placebo$.tw. (286864)
35 prospective study/ (534007)
36 or/18-35 (2050161)
37 case study/ (62471)
38 case report.tw. (376332)
39 abstract report/ or letter/ (1064724)
40 or/37-39 (1493745)
41 36 not 40 (1999101)
Informed decisions.

42 7 and 17 and 41 (420)
Appendix 5. PsycINFO search strategy

OVID Platform
1 exp DYSMENORRHEA/ (211)

4 period$ pain$.tw. (47)
5 menstrua$ cramp$.tw. (21)
6 or/1-5 (516)
7 exp EXERCISE/ or exp AEROBIC EXERCISE/ (24859)
15 or/7-14 (508660)
16 6 and 15 (61)
17 random.tw. (55673)
18 control.tw. (427474)
19 double-blind.tw. (22226)
20 clinical trials/ (11368)
21 placebo/ (5283)
22 exp Treatment/ (1007827)
23 or/17-22 (1390122)
24 16 and 23 (41)
Appendix 6. AMED search strategy

OVID Platform

4 period$ pain$.tw. (32)
5 pelv$ pain$.tw. (146)
7 or/1-6 (425)
8 exp Physical fitness/ or exp Exercise/ (11191)
16 or/8-15 (56410)
17 7 and 16 (40)
18 randomized controlled trials/ (2210)
19 randomized controlled trial.pt. (4614)
20 controlled clinical trial.pt. (70)
21 placebo.ab. (2711)
22 random*.ti,ab. (18733)
23 trial.ti,ab. (11000)
24 groups.ab. (23369)
25 or/18-24 (39001)
Informed decisions.

26 17 and 25 (14)
Appendix 7. CINAHL search strategy

EBSCO Platform
S29 S16 AND S28 73

S28 S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 1,336,827
S27 TX allocat* random* 10,395
S26 (MH "Quantitative Studies") 22,987
S25 (MH "Placebos") 11,373
S24 TX placebo* 57,547
S23 TX random* allocat* 10,395
S22 (MH "Random Assignment") 55,792
S21 TX randomi* control* trial* 171,682
S20 TX ( (singl* n1 blind*) or (singl* n1 mask*) ) or TX ( (doubl* n1 blind*) or (doubl* n1 mask*) ) or TX ( (tripl* n1 blind*) or (tripl* n1 mask*) )
or TX ( (trebl* n1 blind*) or (trebl* n1 mask*) ) 1,024,076
S19 TX clinic* n1 trial* 246,457
S18 PT Clinical trial 86,798
S17 (MH "Clinical Trials+") 262,630
S16 S5 AND S15 221
S15 S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 613,475
S14 TX (fitness or isometric*) 48,027
S13 TX (physical* N5 activ*) 79,420
S12 TX conditioning 15,000
S11 TX (athlet* or train*) 313,747
S10 TX (swim* or jog* or run*) 63,354
S9 TX (yoga or walk* or gym or crossfit or circuit) 88,019
S8 TX aerobic* 18,705
S7 TX exercis* 192,218
S6 (MM "Exercise+") OR (MM "Resistance Training") OR (MM "Abdominal Exercises") OR (MM "Therapeutic Exercise+") OR (MM "Group
Exercise") 76,523
S5 S1 OR S2 OR S3 OR S4 2,109
S4 TX menstrua* N3 cramp* 119
S3 TX pain* N5 menstruat* 172
S2 TX Dysmenorrh* 1,970
S1 (MM "Dysmenorrhea") 831
Appendix 8. Clinical trials registry search strategy

Web platform
Searched 25 July 2019
Keywords used:
(dysmenorrhoea OR dysmenorrhoea) AND (exercise OR physical activity OR yoga OR resistance OR fitness OR aerobic OR stretching)
WHAT'S NEW

Date Event Description
27 August 2019 New citation required and conclusions Conclusions changed from previous review: 11 new studies in-
have changed cluded: Arora 2014; Fallah 2018; Jaibunnisha 2017; Kannan 2019;
Motahari-Tabari 2017; Nasri 2016; Patel 2015; Saleh 2016; Samy
2019; Siahpour 2013; Yang 2016
1 December 2018 New search has been performed New authors added and review updated

Informed decisions.


HISTORY
Protocol first published: Issue 2, 2003
Review first published: Issue 2, 2010

Date Event Description
14 February 2017 Amended Current authors have withdrawn from this review
18 March 2014 New search has been performed Search rerun and four new trials entered
31 August 2009 Amended New authors assigned to review. Changed from protocol to re-
view status. Search strategies run and one new trial identified
8 April 2008 Amended Converted to new review format
19 February 2003 New citation required and major Substantive amendment

changes

CONTRIBUTIONS OF AUTHORS
Mike Armour: performed the screening of the searches, ran the additional Google Scholar and PubMed searches, entered the data,
performed the meta-analysis and interpretation, generated the GRADE tables, and took the lead in writing the review.
Carolyn Ee: searched the trial registries, assisted MA with screening, performed data extraction, and commented on each draft of the review.
Dhevaksha Naidoo: performed data extraction, assisted with entering the data for the meta-analysis and commented on the final version
of the review.
Zahra Ayati: screened Farsi papers, translated papers from Farsi, performed data extraction and commented on the final version of the
review.
Jane Chalmers: performed data extraction and commented on the final version of the review.
Kylie Steel: performed data extraction and commented on the final version of the review.
Michael de Manincor: performed data extraction and commented on the final version of the review.
Elahe Delshad: translated papers from Farsi, performed data extraction and commented on the final version of the review.
DECLARATIONS OF INTEREST
MA, DN, CE and MdM: as a medical research institute, NICM receives research grants and donations from foundations, universities,
government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of
the Institute. No funding was received for this review.
CE: is the Programme Lead for an academic integrative healthcare centre that provides yoga services.
MdM: is a practising psychologist and yoga therapist, Director of a yoga teacher training centre, and Director of a charity that provides yoga
to the underserved.
ZA: none noted
JC: none noted
KS: none noted
ED: none noted

Informed decisions.

SOURCES OF SUPPORT
Internal sources
• none, Other.
External sources
• none, Other.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
• We included additional valid control groups (versus attention control, versus non-steroidal anti-inflammatory drug (NSAIDs) and versus
oral contraceptive).
• For dichotomous outcomes, we used risk ratios (RRs) instead of odds ratios (ORs). When there are a small number of included studies,
RRs tend to be more intuitive to understand for non-statisticians, and ORs do not offer any benefit to outweigh this.
• We excluded cluster-randomised trials.
NOTES
The previous authors withdrew from this review in February 2017.
INDEX TERMS
Medical Subject Headings (MeSH)

Dysmenorrhea [*therapy]; Exercise [*physiology]; Fatigue [therapy]; Menstruation; Quality of Life; Randomized Controlled Trials as
Topic
MeSH check words

Female; Humans


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Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E.

Exercise for dysmenorrhoea (Review) i

Exercise for dysmenorrhoea

Editorial group: Cochrane Gynaecology and Fertility Group.

Data collection and analysis

Exercise versus no treatment

Exercise versus NSAIDs

Exercise for dysmenorrhoea

Exercise for dysmenorrhoea (Review) 2

Quality of the evidence

Exercise for dysmenorrhoea (Review) 3

Patient or population: young women with suspected primary dysmenorrhoea

Cochrane Database of Systematic Reviews

Restriction of dai- - - - - - No studies reported on this outcome.

Absence from - - - - - No studies reported on this outcome.

Cochrane Database of Systematic Reviews

Exercise compared to non-steroidal anti-inflammatory drugs (NSAIDs) for dysmenorrhoea

Adverse events - not reported - - - - - No studies reported on this outcome.

Overall menstrual symptoms - not re- - - - - - No studies reported on this outcome.

Cochrane Database of Systematic Reviews

Greater numbers indicate more women

Restriction of daily life activities - not - - - - - No studies reported on this outcome.

Quality of life - not reported - - - - - No studies reported on this outcome.

GRADE Working Group grades of evidence

Cochrane Database of Systematic Reviews

BACKGROUND How the intervention might work

Exercise for dysmenorrhoea (Review) 8

Exclusion criteria Search methods for identification of studies

Types of outcome measures We also searched:.

Data synthesis Overall quality of the body of evidence: 'Summary of findings'

Subgroup analysis and investigation of heterogeneity Participants

Exercise for dysmenorrhoea (Review) 11

Frequency, duration and number of treatment sessions Overall menstrual symptoms

Exercise for dysmenorrhoea (Review) 12

Figure 1. Study flow diagram

Exercise for dysmenorrhoea (Review) 13

Exercise for dysmenorrhoea (Review) 14

Exercise for dysmenorrhoea (Review) 15

1.7 Quality of life 4 Exercise versus oral contraceptive

Exercise for dysmenorrhoea (Review) 17

Exercise for dysmenorrhoea (Review) 18

Exercise for dysmenorrhoea (Review) 19

Exercise for dysmenorrhoea (Review) 20

Exercise for dysmenorrhoea (Review) 21

Shahr-jerdy 2012 {published data only} IRCT20120215009014N245 {published data only}

Exercise for dysmenorrhoea (Review) 22

RBR-9vqhg7 {published data only} Burnett 2005

Exercise for dysmenorrhoea (Review) 23

Hightower 1998 Review Manager 2014 [Computer program]

Matthewman 2018 Warren 2001

Characteristics of included studies [ordered by study ID]

Participants Country: India

Setting: Department of Physiotherapy, Dr DY Patil University, Nerul, Navi Mumbai

Exercise for dysmenorrhoea (Review) 24

Control group: no treatment

Notes Funding: not reported

Trial registration: CTRI/2009/ 091/001005

Bias Authors' judgement Support for judgement

Comment: not described

Allocation concealment Unclear risk Concealment not described

Blinding of participants High risk Participants not blinded to group allocation

Incomplete outcome data Low risk No missing data

Other bias Low risk None noted