Effects of Pilates and Yoga on Pain Intensity, Absenteeism, Quality of Life, and Sleep Quality among Primary Dysmenorrhea School Students

Abstract

Dysmenorrhea, a common issue among female student community, often leads to severe cramping and absenteeism during menstruation. This study compares Pilates and yoga’s effectiveness in managing pain, absenteeism, and sleep quality. This is an experimental study in which 28 participants aged 14 to 17 were selected through purposive sampling. The participants were randomly divided into three groups: Pilates (n = 10), Yoga (n = 9), and Control (n = 9) groups. Pre- and post-test measures included VAS, PSQI, EQ-5D-5L, and an absenteeism questionnaire. Significant improvements were observed in pain intensity, quality of life, sleep quality, and absenteeism in the Pilates, Yoga, and Control groups (P < 0.001). Pilates and yoga groups showed sustained benefits over 3 months, with notable reductions in pain intensity, absenteeism, and enhancements in quality of life and sleep quality. Pilates and yoga effectively alleviate dysmenorrhea symptoms, reduce absenteeism, and enhance overall wellbeing among adolescent females. Integrating these practices may offer valuable benefits in the community for young individuals experiencing menstrual pain.

INTRODUCTION

Menarche triggers hormonal changes, leading to irregular and often anovulatory cycles for 2–5 years, with up to 20% remaining anovulatory for 5 years. Dysmenorrhea, initially rare, becomes more common as ovulatory cycles establish during adolescence.[1] Dysmenorrhea, caused by prostaglandin-induced uterine contractions, leads to pelvic cramping before menstruation.[2] Risk factors include age, smoking, higher BMI, early menarche, nulliparity, heavy flow, and family history. Oral contraceptives can help, while stress and depression worsen symptoms. The impact of education, marital status, employment, alcohol, and exercise varies.[3] In India, studies report that 66–79% of adolescent girls experience dysmenorrhea, with a significant number reporting moderate to severe pain that interferes with daily activities, including school attendance.[4,5]

Dysmenorrhea is classified as primary or secondary. Primary involves severe lower abdominal cramping before/during menstruation, lasting 8–72 hours, peaking on the first or second day. Secondary is linked to conditions like endometriosis, adenomyosis, fibroids, or pelvic inflammatory disease.[6] Dysmenorrhea severity varies widely, causing mild to extreme pain and significant impacts on emotions, social life, and physical wellbeing. It often leads to school absenteeism among young women, with substantial social, economic, and health costs.[7,8] Approximately 50% of students with dysmenorrhea report missing classes or experiencing reduced concentration during menstruation.[4] Despite its high prevalence and significant impact, dysmenorrhea remains underreported and undertreated, often due to cultural taboos and lack of awareness. Pain-related sleep disruption is common, influenced by estrogen and progesterone receptors’ effects on the sleep–wake cycle.[9]

The endometrium releases molecules essential for pregnancy and immune suppression, including prostaglandins, which, in high levels, cause uterine contractions and ischemia, worsening primary dysmenorrhea symptoms.[10,11] NSAIDs and contraceptives, common treatments, suppress ovulation and prostaglandin production but may have side effects.[12,13] Stretching and aerobic exercise are also beneficial.[14] Rising demand for complementary therapies alongside conventional medicine includes physical therapy techniques and nonpharmacological self-care like massage, acupressure, yoga, Pilates, heat therapy, aromatherapy, and meditation.[15,16,17] Yoga, a mind–body practice, enhances both mental and physical wellbeing. It alleviates dysmenorrhea by reducing stress, decreasing prostaglandin synthesis, and improving uterine blood flow, thereby lessening pain and discomfort during menstruation.[18] Yoga combines physical activity, meditation, and deep breathing to build strength, flexibility, and endurance while reducing stress and improving mood through changes in β-endorphins and neurotransmitters like serotonin and dopamine. Yoga, through asanas, pranayama, and meditation, reduces dysmenorrhea pain and stress and enhances wellbeing.[19,20]

Pilates is a kind of physical exercise that emphasizes breathing, posture correction, muscle control, flexibility training, and muscular strengthening.[21] The effect of Pilates training is said to promote the abdominal muscles’ activation during physical activity or daily tasks. Pilates emphasizes core strength while also focusing on muscular development, control of the body, and range of motion.[21,22] The fundamental principles of Pilates include breathing, centering, attention, control, and precision.[23] Both Yoga and Pilates offer specialized exercises and mindfulness techniques essential for managing menstrual pain and improving overall wellbeing. Existing literature supports their benefits, showing reductions in pain intensity and improvements in quality of life. However, their impact on school absenteeism due to dysmenorrhea has been less explored. This study aims to fill that gap by examining how yoga and Pilates affect absenteeism among students with primary dysmenorrhea, comparing their effectiveness on these factors.

MATERIALS AND METHODS

The study was conducted in a higher secondary school in Chennai. Initially, ten schools were contacted to inquire about participation; of these, only two schools provided consent to conduct the research. Permission was obtained from the school authorities prior to recruiting participants. The Institutional Scientific Review Board has approved this study (ISRB number: 01/009/2023/ISRB/SR/SCPT). The study was conducted from November 2023 to February 2024. It is an experimental study that was carried out in female school students with primary dysmenorrhea. The study included female school students aged 14–17 years with primary dysmenorrhea, who were absent from school for 1 or 2 days due to dysmenorrhea and had WaLIDD (working ability, location, intensity, days of pain, dysmenorrhea) scores between 5 and 12.[24] Exclusion criteria consist of individuals with known diagnoses of Polycystic Ovary Syndrome (PCOS), Endometriosis, and Pelvic Inflammatory Disease (PID). Before the commencement of the study, the participants were informed about the procedure of the study and an informed assent was obtained from the participants and their parent. Based on a G * Power analysis to detect an effect size of 0.25, the sample size for this study was estimated at 33 participants to achieve 80% power at an alpha level of 0.05, including a 10% attrition rate. The study screened a total of 55 participants; 43 scored between 5 and 12 on the WALIDD scale, and 28 subjects took leave from school due to dysmenorrhea and met the study criteria. Ultimately, these 28 participants were randomly allocated to the three groups: Pilates group, Yoga group, and Control group. Participants from each group were asked to fill the Visual Analog Scale (VAS), absenteeism question, Euro QoL 5D-5L questionnaire (EQ 5D-5L), and Pittsburgh Sleep Quality Index (PSQI) on the 2^nd day of their menstruation to estimate the baseline scores. The study was conducted for 3 months with three sessions/week of 40 minutes. An introduction session was conducted where they were explained about the procedure in detail after which the follow-up sessions were conducted via video conference. The intervention was given to all the participants after the end of their first menstruation in the period of the study and was ended before the beginning of their 4^th consecutive menstrual cycle. The participants were asked to fill the same questionnaires in the beginning of their 4^th consecutive menstrual cycle, that is, the end of the study period, and the results were compared.

Randomization and allocation

Participants were randomly assigned to either the Pilates and Yoga group using a computer-generated randomization method, whereas the participants who choose not willing to take exercise were allocated in the control group.

Intervention

Participants were instructed to avoid wearing watches or bracelets to prevent skin injury and to dress comfortably to avoid constriction or restricted circulation. They were also advised to refrain from performing exercises during their menstrual cycle.

Pilates regimen

• Exercises: Pelvic Bridge, Adductor Ball Squeeze, Double Leg Stretch, and Roll Like a Ball [Table S1].

• Duration and Repetitions: Each exercise was performed for 5 repetitions, with rest as needed. Each session lasted approximately 40 minutes.

• Instructor Adherence Monitoring: The study was conducted over 3 months, with three sessions per week. An introductory session was conducted to explain the procedure in detail. All follow-up sessions were conducted via video conference, during which certified instructors monitored participants to ensure correct posture, technique, and safety. Attendance and adherence were recorded for each session.

Table S1.

Intervention and their descriptions

Pilates exercises	Descriptions	Yoga poses	Descriptions
Pelvic bridge	Lie on your back with knees bent, feet hip-width apart. Lift your hips off the mat, squeezing your glutes, then lower back down.	Child’s pose (Balasana)	Participants start on their knees, then slowly bend forward, bringing thighs toward the chest until their head touches the ground. Arms are extended forward with palms facing downward.
Adductor ball squeeze	Sit with knees bent, feet flat, and a ball between knees. Squeeze the pillow/ball gently, engaging inner thigh muscles, then release.	Cobra pose (Bhujangasana)	Participants lie on their bellies, feet hip-distance apart, hands beside ribs. They lift their head and chest, rolling shoulders back while keeping the back of the neck long, avoiding excessive tilting of the head or lifting the chin.
Double leg stretch	Lie on your back, legs bent, and arms by your sides. Lift legs to a 90-degree angle, then extend arms and legs out, circle arms back to hips while bringing knees back to starting position.	Cat pose (Marjaryasana)	Participants start in Tabletop position, round their spine towards the ceiling on an exhale while engaging the lower belly. They return to a neutral spine position to conclude the pose.
Roll like a ball	Sit on the mat, knees bent, holding ankles. Lift feet off the mat, balance on sit bones, and roll backward, aiming for shoulders. Return to seated position using core muscles.	Fish pose (Matsyasana)	Participants sit with legs extended; hands flat on the mat under buttocks. They arch their back, lifting their chest upward until the crown of their head rests on the mat.
		Boat pose (Navasana)	Participants sit on the mat with legs extended, hands beside hips. They gradually lift legs off the mat, aiming to create a strong “V” shape with their body, arms parallel to the ground.

Yoga regimen

• Asanas: Child’s Pose (Balasana), Cobra Pose (Bhujangasana), Cat Pose (Marjaryasana), Fish Pose (Matsyasana), and Boat Pose (Navasana) [Table S1].

• Duration and Repetitions: Each pose was held for 60 seconds, performed for 5 repetitions, with a 20-second interval between poses. Each session lasted approximately 40 minutes.

• Instructor Adherence Monitoring: As with Pilates, an initial introduction session explained the procedure in detail. Follow-up sessions were conducted via video conference, with certified instructors monitoring alignment, posture, and breathing.

Session attendance and adherence to prescribed holds and repetitions were recorded.

Control group

There were participants in the control group, who did not receive any intervention and only completed questionnaires for data collection. This pragmatic approach resembles a partially randomized patient preference design, which has been described as a valid method to improve adherence and reduce dropout in behavioral intervention trials (Walter and Turner[25]; King et al.[26]).

Statistical analysis

The data were evaluated using descriptive and inferential statistics. Mean and standard deviation were calculated, and normality was checked with the Shapiro–Wilk test, which showed a non-normal distribution. Friedman’s Two-Way ANOVA identified differences between months, with post hoc tests for within-group comparisons. The Kruskal–Wallis’s test, along with the Bonferroni adjustment, was used for multiple comparisons, and the effect size was estimated with Eta-Squared. Pairwise differences were assessed with the Mann–Whitney U Test, considering P < 0.05 as statistically significant.

RESULTS

The 28 participants in the study were in the mean age of 16 ± 0.93. Other factors such as height, weight, and BMI are shown in Table 1. Post hoc analyses revealed significant shifts within groups, particularly in pain intensity, quality of life, and sleep quality from baseline to the end of the second and third months. Of note, the yoga group demonstrated a significant reduction in pain intensity from the first to the third month, highlighting the potential benefits of sustained yoga practice in pain management. Additionally, both quality of life and sleep quality showed significant improvements from the end of the first month to the end of the third month in both the Pilates and yoga groups. Table 2a provides the outcomes of Friedman’s test, examining the changes in pain intensity (PI), quality of life (QoL), and sleep quality (SQ) over time within the Pilates, yoga, and control groups. Significant improvements were observed in pain intensity, quality of life, and sleep quality within the groups, with notable reductions in pain intensity and enhancements in quality of life and sleep quality from baseline to subsequent months (P < 0.001). Further examination in Table 2b unveiled significant differences between groups, notably showcasing the superiority of yoga and Pilates interventions over the control group in managing dysmenorrhea symptoms and enhancing overall wellbeing throughout the study period. In terms of pain intensity, significant differences were observed between the Pilates group and the yoga group at the end of the first month with large effects as shown in Table 2b. Moreover, there was a consistent and significant distinction noted between the Pilates group and the control group across all three months of the study. The yoga group exhibited notable disparities compared to the control group by the end of the third month, particularly in pain intensity, underscoring the prolonged benefits of yoga practice in mitigating dysmenorrhea symptoms. Significant differences in both quality of life and sleep quality were evident between the Pilates group and the yoga group, as well as between the Pilates and the control group, consistently observed over the 3-month study period with large effect sizes [Table 2b].

Table 1.

Baseline characteristics of school children with primary dysmenorrhea

Characteristic	All participants		Pilates group (n=10)		Yoga group (n=9)		Control group (n=9)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Age	16.10	0.93	16.30	1.00	15.88	0.99	16.11	0.73
Height	157.10	5.49	160.10	4.48	154.55	6.76	156.33	2.94
Weight	51.39	6.47	53.10	5.02	50.77	8.07	50.11	5.64
BMI	20.79	2.23	20.72	2.01	21.14	2.35	20.50	2.30

Table 2a.

Comparison of mean and standard deviation for pain intensity, quality of life, and sleep quality within the group

Outcome measure	Pilates group (n=10)				Yoga group (n=9)				Control group (n=9)				Friedman’s P
	Baseline	E1M	E2M	E3M	Baseline	*E1M	*E2M	*E3M	Baseline	*E1M	*E2M	E3M
*PI	6.90±1.19	3.20±0.78	2.20±0.63	2.00±0.66	6.77±0.97	4.55±0.88	3.44±0.88	2.77±1.09	6.88±0.927	5.44±0.88	4.88±0.92	4.66±1.11	<0.001
*QoL	15.50±1.84	6.50±1.26	3.70±1.15	3.00±0.81	17.00±1.41	12.22±2.16	10.66±2.12	9.44±1.66	14.88±1.05	13.44±1.13	12.66±0.70	12.22±0.97	<0.001
*SQ	15.20±1.31	6.90±0.99	4.30±0.67	3.20±0.78	15.66±1.80	10.33±2.00	8.33±1.87	7.55±2.00	14.88±1.37	13.44±1.13	12.66±1.00	12.33±0.86	<0.001

*PI: Pain intensity, QoL: Quality of life, SQ: Sleep quality, E1M: End of-1 month, E2M: End of-2 month, E3M: End of-3 month

Table 2b.

Between group comparison for pain intensity, quality of life, and sleep quality

Outcome Measures	Time points	Pilates group	Yoga group	Control group	Kruskal–Wallis	Eta square	Between groups	Post-hoc E1M	Post-hoc E2M	Post-hoc E3M
		(n=10)	(n=9)	(n=9)	P			P
		Mean±SD	Mean±SD	Mean±SD
*PI	*BL	6.90±1.19	6.77±0.97	6.88±0.927	<0.001
	*E1M	3.20±0.78	4.55±0.88	5.44±0.88		0.575	Pilates vs. yoga	0.043	0.079	0.514
	*E2M	2.20±0.63	3.44±0.88	4.88±0.92		0.672	Yoga vs. control	0.399	0.111	0.034
	*E3M	2.00±0.66	2.77±1.09	4.66±1.11		0.599	Pilates vs. control	<0.001	<0.001	<0.001
*QoL	*BL	15.50±1.84	17.00±1.41	14.88±1.05	<0.001
	*E1M	6.50±1.26	12.22±2.16	13.44±1.13		0.809	Pilates vs. yoga	0.003	0.006	0.020
	*E2M	3.70±1.15	10.66±2.12	12.66±0.70		0.891	Yoga vs. control	1.000	0.609	0.139
	*E3M	3.00±0.81	9.44±1.66	12.22±0.97		0.923	Pilates vs. control	<0.001	<0.001	<0.001
*SQ	*BL	15.20±1.31	15.66±1.80	14.88±1.37	<0.001
	*E1M	6.90±0.99	10.33±2.00	13.44±1.13		0.799	Pilates vs. yoga	0.028	0.033	0.033
	*E2M	4.30±0.67	8.33±1.87	12.66±1.00		0.892	Yoga vs. control	0.149	0.063	0.063
	*E3M	4.30±0.67	7.55±2.00	12.33±0.86		0.900	Pilates vs. control	<0.001	<0.001	<0.001

*PI: Pain intensity, QoL: Quality of life, SQ: Sleep quality, BL: Baseline, E1M: End of-1 month, E2M: End of-2 month, E3M: End of-3 month

In terms of absenteeism, by the End of-1 month (E1M), there was a reduction seen across all groups. At the End of-2 month (E2M), differences emerged in absenteeism percentages among the groups. Notably, the Pilates group demonstrated a 30% absenteeism rate, the yoga group showed a 33.3% absenteeism rate, and the control group displayed an absenteeism rate of 88.8%. By the End of-3 month (E3M), further fluctuations occurred, with the Pilates group experiencing a 10% absenteeism rate, the yoga group with a 22.2% absenteeism rate, and the control group at 77.7% [Table 3].

Table 3.

Comparison of pretest and post-test absenteeism reports

	Baseline	*E1M		*E2M		*E3M
	Absenteeism n (%)	Absenteeism n (%)	No absenteeism n (%)	Absenteeism n (%)	No absenteeism n (%)	Absenteeism n (%)	No absenteeism n (%)
Pilates group	10 (100%)	4 (40%)	6 (60%)	3(30%)	7(70%)	1(10%)	9(90%)
Yoga group	9 (100%)	5 (55.5%)	4 (44.4%)	3(33.3%)	6(66.6%)	2(22.2%)	7(77.7%)
Control group	9 (100%)	8 (88.8%)	1 (11.1%)	8(88.8%)	1(11.1%)	7(77.7%)	2(22.2%)

*E1M: End of-1 month, E2M: End of-2 month, E3M: End of-3 month

DISCUSSION

In our study, we aimed to assess the effectiveness of Pilates and yoga interventions in alleviating pain, improving quality of life, enhancing sleep, and reducing absenteeism in school children with primary dysmenorrhea. Our results provide valuable insights into the potential advantages of integrating these mind–body techniques into the care of menstrual pain and overall health among adolescents.

Pilates, focusing on controlled movement and mindful breathing, improves pain levels and quality of life by enhancing flexibility and strength, as supported by Paithankar and Hande.[23] Yoga also significantly reduces pain by targeting brain pain centers and inducing relaxation, with specific poses like child’s pose and cobra pose being particularly effective, according to Rakhshaee.[19] The link between dysmenorrhea and sleep quality, emphasized by Sahin et al.[9] and Kirmizigil and Demiralp,[15] shows that regular exercise alleviates pain and improves sleep quality. The study also emphasized the broader implications of dysmenorrhea on students’ working ability and quality of life. Ouda et al.[11] and Fernández-Martínez et al.[16] stressed the importance of managing dysmenorrhea to improve social and intellectual functioning. Nag and Kodali[20] demonstrated a reduction in college absenteeism following a yoga program, suggesting that Pilates and yoga can improve attendance and academic performance. Integrating these practices into school health programs can help manage dysmenorrhea and its negative effects on education. One of the study’s main limitations is the limited sample size. The smaller sample size limits statistical power and may have an impact on the findings’ generalizability, despite the favorable intervention patterns. Future research should involve larger, more diverse samples and combine both therapies to further explore their benefits. The study demonstrates moderate internal validity, supported by standardized interventions, session monitoring, and validated outcome measures. However, partial randomization and a small sample size may introduce bias and limit statistical power. External validity is limited as the study was conducted in a single school, and findings may not be generalizable to other regions, school types, or populations. Consequently, results should be interpreted cautiously and confirmed in larger, multicenter trials.

CONCLUSION

In conclusion, our study highlights the effectiveness of Pilates and yoga in reducing absenteeism and enhancing wellbeing among adolescents with dysmenorrhea in the community. Over 3 months, both interventions significantly lowered absenteeism and improved pain intensity, quality of life, and sleep quality compared to the control group. These results suggest that integrating mind–body practices like Pilates and yoga can be a valuable approach in managing menstrual pain and supporting adolescent health.

Conflict of interest

The authors declare no conflict of interest.

Funding Statement

No specific grant was given for this research by public, private or nonprofit funding organizations.