Exercise for dysmenorrhoea

Mike Armour; Carolyn C Ee; Dhevaksha Naidoo; Zahra Ayati; K Jane Chalmers; Kylie A Steel; Michael J de Manincor; Elahe Delshad

doi:10.1002/14651858.CD004142.pub4

. 2019 Sep 20;2019(9):CD004142. doi: 10.1002/14651858.CD004142.pub4

Exercise for dysmenorrhoea

Mike Armour ^1,^✉, Carolyn C Ee ¹, Dhevaksha Naidoo ¹, Zahra Ayati ², K Jane Chalmers ³, Kylie A Steel ³, Michael J de Manincor ¹, Elahe Delshad ⁴

Editor: Cochrane Gynaecology and Fertility Group

PMCID: PMC6753056 PMID: 31538328

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 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.

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

Background

Description of the condition

Dysmenorrhoea is painful uterine cramps of menstrual origin and can be classified as primary or secondary dysmenorrhoea (Proctor 2006).

Primary dysmenorrhoea is defined as pain in the absence of an identifiable change in the pelvis and is most common in women under the age of 25, with pain usually starting within three years of menarche (Coco 1999). Primary dysmenorrhoea's characteristic symptom is crampy, colicky spasms of pain in the suprapubic area, occurring within eight to 72 hours of menstruation and peaking within the first few days as menstrual flow increases (Coco 1999; Proctor 2006). Primary dysmenorrhoea can usually be diagnosed by means of a thorough history taking, as well as abdominal or pelvic examination. This applies to most patients who have typical symptoms and no risk factors for secondary causes (French 2005).

A recent systematic review and meta‐analysis found that dysmenorrhoea is common in young women worldwide under 25, with 71% reporting period pain, and it is unclear whether period pain reduces with increasing age (Armour 2019b).

Primary dysmenorrhoea is responsible for a decrease in quality of life (Burnett 2005; Campbell 1997; Hillen 1999), absence from work or school (Armour 2019b; Zahradnik 2010), reduced participation in sport and social activities (Armour 2019b; Banikarim 2000), altered pain perception and sleeping problems (Baker 1999).

The largest contributing physiological factor in primary dysmenorrhoea is increased amounts of prostaglandins present in the menstrual fluid (Dawood 2006). Prostaglandins, especially PGF2_a, stimulate myometrial contractions, reducing uterine blood flow and causing uterine hypoxia. This hypoxia is responsible for the painful cramping that characterises primary dysmenorrhoea (Dawood 2006; Zahradnik 2010).

Secondary dysmenorrhoea is period pain with an identifiable cause (Proctor 2006), commonly endometriosis or uterine fibroids, and is not the subject of this review.

Description of the intervention

Physical exercise has long been advocated as a non‐medical intervention for the relief of dysmenorrhoea (Fernandez 1991; Metheny 1989).

Exercise has often been conceptualised in the public perception as mostly high‐intensity aerobic activities, such as running, swimming or cycling, or resistance training; however lower‐intensity types of exercise such as yoga, tai chi, Pilates and stretching are gaining greater attention as effective alternatives to the sometimes more injurious traditional forms of high‐intensity exercise (Govindaraj 2016).

For this review the American College of Sports Medicine (ACSM) definition of exercise as “physical activity characterized by using planned and structured repetitive movements to increase or maintain physical fitness” was used (ACSM 2014). This incorporates both high‐intensity aerobic exercise, resistance training and lower‐intensity exercise, such as tai chi and yoga.

How the intervention might work

Different intensities of exercise may operate via different mechanisms. Moderate‐ to high‐intensity exercise may reduce pain via increasing anti‐inflammatory cytokines (Febbraio 2007), and by reducing the overall amount of menstrual flow (Warren 2001), thereby decreasing the overall amount of prostaglandins released. Less intense exercise, such as yoga can reduce cortisol levels (Pascoe 2017), which in turn can reduce prostaglandin synthesis (Casey 1985).

Why it is important to do this review

Most women manage their symptoms with primarily over the counter (OTC) pain medications (e.g. ibuprofen and paracetamol/acetaminophen), and self‐care including rest and the application of heat, rather than seeking medical advice (Armour 2019c). However, one key barrier in managing menstrual pain is that the intervention needs to be affordable, both in terms of time and cost (Armour 2016). Exercise may fulfil this criteria, providing an affordable alternative or adjunct to analgesics. Conflicting results exist from population level studies examining the relationship between exercise in general and period pain; with some studies showing no effect of exercise (Blakey 2010), some a positive effect (Vani 2013), and some a negative effect (Metheny 1989), especially with regards to negative emotional symptoms, such as anxiety, that can accompany menstruation (Hightower 1998).

Objectives

To evaluate the effectiveness and safety of exercise for women with primary dysmenorrhoea.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs) without restriction on language and publication types. We excluded non‐randomised studies (for example, studies with evidence of inadequate sequence generation such as alternate days, patient numbers) and cluster‐RCTs. We did not include cross‐over trials due to the unknown duration of the 'wash out' period for exercise.

Types of participants

Inclusion criteria

Women in the trials had to meet the following inclusion criteria for the trial to be included in the review.

Be of reproductive age (15 to 49 years).
Have suspected primary dysmenorrhoea, i.e. no identifiable pelvic pathology, as indicated by pelvic examination, ultrasound scans, or laparoscopy.
Have primary dysmenorrhoea (self‐reported pain) during the majority of the menstrual cycles in the past three months.
Have moderate‐to‐severe primary dysmenorrhoea (pain is reported to affect daily activities, such as socialising, working or going to school, or has a high baseline score on a validated pain scale (greater than 4/10 on a numeric rating scale (NRS) or 40 mm on a 100 mm visual analogue scale (VAS)).

Exclusion criteria

If participants in the trial met any of the following exclusion criteria, we did not include the trial in the review.

Irregular or infrequent menstrual cycles (usually outside of the typical range of a 21 to 35 day cycle).
Diagnosed secondary dysmenorrhoea (e.g. fibroids, endometriosis).
Dysmenorrhoea resulting from use of an intrauterine device.
Mild or infrequent dysmenorrhoea (less than 1 out of 3 three cycles).

Types of interventions

Any randomised controlled trials (RCTs) comparing exercise (as per ACSM 2014 "physical activity characterized by using planned and structured repetitive movements to increase or maintain physical fitness") to:

no treatment;
attention control (where the amount of time spent and attention received from the research team are matched to the intervention group, e.g. a lecture series on self‐care for period pain);
non‐steroidal anti‐inflammatory drugs (NSAIDs);
oral contraceptive pill or combined oral contraceptive pill.

Types of outcome measures

Primary outcomes

Menstrual pain intensity, as a continuous variable measured preferably by VAS, NRS or other validated scales, such as McGill Pain Questionnaire (MPQ), or pain relief, measured as a dichotomous outcome (i.e. sufficient pain relief: yes or no)
Adverse events, measured as rate of side effects overall and any injuries, such as muscle sprains or strains

Secondary outcomes

Overall menstrual symptoms (e.g. back pain, nausea, fatigue), measured by changes in overall symptoms of dysmenorrhoea that were either self‐reported or investigator‐observed, using tools such as the Moos Menstrual Distress Questionnaire (MMDQ).
Use of rescue analgesic medication, measured as the proportion of women requiring rescue analgesics.
Restriction of daily life activities, measured as the proportion of women who reported activity restrictions.
Absence from work or school, measured as the proportion of women reporting absences from work or school, and also as hours and days of absence as a more selective measure.
Quality of life, measured by a validated scale, for example the 36‐Item Short Form Health Survey (SF‐36) or EuroQoL 5D (EQ‐5D).

If studies reported outcomes at different time frames, then we grouped outcomes as end of intervention, short‐term (more than 1 month but less than 3 months), medium‐term (4 months to 12 months) and long‐term (over 12 months). The preferred time frame was the longest time since the end of intervention.

Search methods for identification of studies

We conducted a comprehensive and exhaustive search strategy to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress). The search was conducted in consultation with the Gynaecology and Fertility Group Information Specialist.

Electronic searches

We searched:

the Cochrane Gynaecology and Fertility specialised register, 25 July 2019 (PROCITE platform) (Appendix 1);
CENTRAL, July 2019 (OVID platform) (Appendix 2);
MEDLINE, from 1946 to 25 July 2019 (OVID platform) (Appendix 3);
Embase, from 1980 to 25 July 2019 (Ovid platform) (Appendix 4);
PsycINFO, from 1806 to 25 July 2019 (Ovid platform) (Appendix 5);
AMED, from 1985 to 25 July 2019 (Ovid platform) (Appendix 6); and
CINAHL, from 1961 to 25 July 2019 (EBSCO platform) (Appendix 7).

Searching other resources

We also searched:.

trial registers for ongoing and registered trials: ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (apps.who.int/trialsearch) in March 2019; and
reference lists from included articles and previous systematic reviews.

We searched the following additional electronic resources in English in March 2019.

DARE – Database of Abstracts of Reviews of Effects (reference lists from non‐Cochrane reviews on similar topics).
ProQuest Dissertations & Theses for unpublished dissertations and theses.
Conference abstracts on the Web of Science.
OpenGrey for unpublished literature from Europe (www.opengrey.eu).
LILACS database for the Portuguese and Spanish speaking world (regional.bvsalud.org).

Data collection and analysis

Selection of studies

Two review authors (MA and CE) screened the titles and abstracts of English language articles and two review authors (ZA and MA) screened the titles and abstracts of articles in Farsi, and discarded trials that were clearly not eligible.

Two review authors (ZA and ED) translated and performed data 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 obtain further details. If details of randomisation were unclear in the reporting, we contacted all trial authors to ascertain if the study was truly randomised. We made first contact and then sent a reminder one month later. We documented the selection process, including reasons for exclusion, in a PRISMA flow chart (Moher 2015).

Data extraction and management

Following an assessment for inclusion, all review authors independently extracted data, with two review authors extracting data for each study. We resolved discrepancies by discussion with a third review author (CE or MA). For each included trial we extracted data regarding the location of the trial, the methods of the trial (as per assessment of risk of bias), the participants (age range, eligibility criteria), the nature of the interventions, and data relating to the outcomes specified above. We collected information on reported benefits and adverse events. We extracted data and entered them onto a form sourced from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). MA checked and entered data into Review Manager 5 (Review Manager 2014).

Where studies have multiple publications, we collated multiple reports of the same under a single study ID with multiple references. We corresponded with study investigators for further data on methods and/or results, as required.

Assessment of risk of bias in included studies

Two review authors (from MA, CE, KS, ZA, JC, ED, DN and MM) independently assessed risks of bias for each trial, using the criteria described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The tool consists of seven items, with three potential responses: 'yes', 'no', and 'unclear'. In all cases a judgement of 'yes' indicates a low risk of bias and a judgement of 'no' indicates a high risk of bias. If insufficient detail was reported, our judgement was usually 'unclear'. We also made a judgement of '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 hand (particularly for assessing blinding and incomplete outcome data, or when the outcome being assessed by the entry had not been measured in the study).

We assessed the following characteristics: sequence generation, allocation concealment, blinding (or masking) of participants, blinding (or masking) of outcome assessors, incomplete data assessment, selective outcome reporting, and other sources of bias. We resolved disagreements that arose at any stage by discussion between the review authors or with a third party, when necessary. We generated a 'Risk of bias' assessment table for each study. We assessed other aspects of trial quality, including the extent of blinding (if appropriate), whether groups were comparable at baseline, the extent of losses to follow‐up, non‐compliance and whether the outcome assessment was standardised according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We described all judgements fully and present the conclusions in the 'Risk of bias' table (Characteristics of included studies).

Where protocols were available, we assessed studies for differences between study protocols and published results. Where protocols were not available or details on trial registration were not provided, we assessed the risk of bias for selective outcome reporting as unclear. Due to the nature of the exercise intervention, we expect that participants will inevitably be unblinded and will be rated as high risk of performance bias. In the case where subjective, patient‐reported outcome measures were used (such as NRS) as the primary outcome, we rated detection bias as high risk of bias. If dropout rates were greater than 30%, or the difference in dropout rates between groups exceeded 10% and there is no explanation for other factors, we rated attrition bias as high.

Measures of treatment effect

We performed statistical analysis in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We performed statistical analysis using Review Manager 5 software (Review Manager 2014). For dichotomous data, we expressed results for each study as summary risk ratios (RRs) with corresponding 95% confidence intervals (CIs), using the Mantel‐Haenszel method. We expressed continuous data as mean differences (MDs) with 95% CIs, or as standardised mean differences (SMDs) if outcomes were conceptually the same but measured in different ways in the different trials. A standard rule of thumb for interpreting effect sizes is that 0.2 represents a small effect, 0.5 a moderate effect and 0.8 a large effect.

Unit of analysis issues

All analyses were per woman randomised. We included trials with multiple arms and described them in the Characteristics of included studies tables. If there were two similar exercise groups (such as two low‐intensity groups), we combined data from the two treatment arms. If the exercise arms were different, such as one arm using weight training and one using aerobics, they were analysed separately and we divided the shared control group evenly between groups as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Where outcomes were repeated measures, we undertook analysis of outcomes at the end of the intervention and at any follow‐up time points after the end of the intervention.

Dealing with missing data

We analysed data on an intention‐to‐treat basis, as far as possible. We did not impute missing data, but we did report the proportion lost to follow‐up and analysed only the available data.

Assessment of heterogeneity

We considered whether the clinical and methodological characteristics of included studies were sufficiently similar for meta‐analysis to provide a clinically meaningful summary. We assessed statistical heterogeneity by the measure of the I² statistic. If an I² was 50% or higher, we assumed high heterogeneity, and conducted a sensitivity analysis. A high I² statistic suggests that variations in effect estimates may be due to differences between trials rather than to chance alone (Higgins 2011).

Assessment of reporting biases

In view of the difficulty of detecting and correcting for publication bias and other reporting biases, we aimed to minimise their potential impact by ensuring a comprehensive search for eligible studies and by being alert for duplication of data. If there were 10 or more studies in an analysis, we used a funnel plot to explore the possibility of small‐study effects (a tendency for estimates of the intervention effect to be more beneficial in smaller studies).

Data synthesis

If the studies were sufficiently similar, we combined the data using a fixed‐effect model in the following comparisons.

Exercise versus no treatment, subgrouped by intensity of exercise. We pooled the data for the subgroups in this comparison as follows.
- Low‐intensity exercise (such as yoga, tai chi or stretching)
- High‐intensity exercise (such as aerobic exercise, running, jogging)
- Resistance exercise (such as weight lifting)
Exercise versus attention control, subgrouped by intensity of exercise. We pooled the data for the subgroups in this comparison as follows.
- Low‐intensity exercise (such as yoga, tai chi or stretching)
- High‐intensity exercise (such as aerobic exercise, running, jogging)
- Resistance exercise (such as weight lifting)
Exercise versus NSAIDs, subgrouped by intensity of exercise. We pooled the data for the subgroups in this comparison as follows.
- Low‐intensity exercise (such as yoga, tai chi or stretching)
- High‐intensity exercise (such as aerobic exercise, running, jogging)
- Resistance exercise (such as weight lifting)
Exercise versus oral contraceptive, subgrouped by intensity of exercise. We pooled the data for the subgroups in this comparison as follows.
- Low‐intensity exercise (such as yoga, tai chi or stretching)
- High‐intensity exercise (such as aerobic exercise, running, jogging)
- Resistance exercise (such as weight lifting)

We carried out statistical analysis using Review Manager 5 software (Review Manager 2014).

Subgroup analysis and investigation of heterogeneity

Where suitable studies were found, we planned to undertake a subgroup analysis to determine if there was any effect of differing intensities or types of exercise (low‐intensity, high‐intensity and resistance) on the primary outcome of menstrual pain intensity.

If we detected substantial heterogeneity, we explored possible explanations in subgroup analyses (e.g. differing populations) and/or sensitivity analyses (e.g. differing risk of bias). We took any statistical heterogeneity into account when interpreting the results, especially if there was any variation in the direction of effect.

Sensitivity analysis

We conducted sensitivity analyses (using the random‐effects model in Review Manager 5 software; Review Manager 2014) on the primary outcomes if we detected a high degree of heterogeneity (I² ≥ 50%). We conducted a sensitivity analyses for the primary outcomes to determine whether the removal of studies with high risk of bias or a different method of analysis would have changed the conclusions. These analyses included consideration of whether the review conclusions would have differed if eligibility had been restricted to studies at low risk of bias (defined as studies rated as being at low risk of bias with respect to sequence generation and allocation concealment).

Overall quality of the body of evidence: 'Summary of findings' tables

We used the GRADE approach as outlined in the GRADE handbook in order to assess the quality of the body of evidence. We prepared two 'Summary of findings' tables using GRADEpro and Cochrane methods (GRADEpro GDT 2015). The 'Summary of findings' tables outline the overall quality of the body of evidence for the main review outcomes (menstrual pain intensity, adverse events, overall menstrual symptoms ,use of rescue analgesic medication, restriction of daily life activities, absence from work or school and quality of life) for the review comparisons (exercise versus no treatment and exercise versus NSAIDs).

The GRADE approach uses five considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of the body of evidence for each outcome. The evidence can be downgraded from 'high quality' by one level for serious (or by two levels for very serious) limitations, depending on assessments for risk of bias, indirectness of evidence, serious inconsistency, imprecision of effect estimates or potential publication bias. Judgements were justified, documented, and incorporated into reporting of results for each outcome.

Results

Description of studies

Study design and setting

Four studies were undertaken in Iran (Fallah 2018; Motahari‐Tabari 2017; Nasri 2016; Saleh 2016), three in India (Arora 2014; Jaibunnisha 2017; Patel 2015), one in Korea (Yang 2016), two in Egypt (Saleh 2016; Samy 2019), one in New Zealand (Kannan 2019), and one in the USA (Israel 1985). Eight studies were undertaken in a University setting, two studies in a high school setting (Fallah 2018; Nasri 2016), and one study in an outpatient hospital setting (Saleh 2016) .

Participants

Israel 1985 recruited "college females" but did not provide any age data, Siahpour 2013 only included young women aged 20 to 25, while Kannan 2019 included women with a mean age of 29 years. The remaining studies reported that their samples had a mean age of under 25 years. None of the included studies reported body mass index (BMI). The majority of studies used a diagnostic history to diagnose primary dysmenorrhoea, but it was unclear how secondary dysmenorrhoea and other pathologies were ruled out.

Sample size

Sample sizes varied from 30 in Nasri 2016 and Siahpour 2013 to 126 in Saleh 2016.

Type of intervention

Five studies used aerobic or high‐intensity exercise only (Arora 2014; Israel 1985; Kannan 2019; Nasri 2016; Samy 2019), and one used aerobic exercise or yoga (Siahpour 2013). Six studies used low‐intensity exercise only, with four studies using stretching exercises (Fallah 2018; Jaibunnisha 2017; Motahari‐Tabari 2017; Patel 2015), one using yoga (Yang 2016), and one using either stretching or core strengthening (Saleh 2016). None of the included studies used resistance training.

Frequency, duration and number of treatment sessions

Frequency of the intervention varied significantly from once per week (Yang 2016), twice per week (Samy 2019), three times per week (Fallah 2018; Israel 1985; Kannan 2019; Motahari‐Tabari 2017; Patel 2015; Siahpour 2013), three to four times per week (Saleh 2016), three to five times per week (Arora 2014), and six days per week (Jaibunnisha 2017).

The duration of each session varied from 10 minutes in Jaibunnisha 2017 to one hour in Yang 2016, with one study not reporting session duration (Patel 2015).

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 number of sessions due to having an unsupervised component (Kannan 2019).

Control or comparator

Eleven studies used a no treatment control, while one study used a NSAID control (Motahari‐Tabari 2017; mefenamic acid 250 mg).

Outcome measures

All outcomes are reported as changes at the end of the intervention. None of the included studies provided data on short‐, medium‐ or long‐term outcomes after the end of the intervention.

Menstrual pain intensity

Ten studies used the visual analogue scale (VAS), one used the numeric rating scale (NRS) (Jaibunnisha 2017), one used the McGill Pain Questionaaire (MPQ) (Fallah 2018).

Adverse events

Only one study reported on adverse events (Yang 2016).

Overall menstrual symptoms

Two studies used the Moos Menstrual Distress Questionnaire (MMDQ) (Israel 1985; Patel 2015).

Use of rescue analgesic medication

Two studies reported on analgesic medication usage (Motahari‐Tabari 2017; Siahpour 2013).

Absence from work or school

One study reported on absence from work or school (Motahari‐Tabari 2017).

Restriction of daily life activities

No studies reported on restrictions in daily life activities.

Quality of life

One study reported on quality of life (Arora 2014), as measured by the SF‐36, and one study used the SF‐12 and reported both physical and mental summary scores (Kannan 2019).

Funding sources and conflict of interest

Seven studies reported their funding sources. All sources of reported funding were internal grants from academic institutions or professional bodies.

Results of the search

In the search for this 2019 update we retrieved 697 articles.The selection process is summarised in a PRISMA flow chart (Figure 1). Fifty‐two studies were potentially eligible and we retrieved the full text. Eleven studies met our inclusion criteria and we excluded 28. We searched clinical trial registries and categorised nine studies 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.

In the original review (Brown 2010), from the 257 records we identified, we included one study and excluded three.

Included studies

We included a total of 12 studies with 854 women. In the meta‐analysis, we included 10 studies with 754 women. Two studies did not provide data in a suitable format for inclusion in the meta‐analysis (Arora 2014; Israel 1985), and so we reported the results descriptively.

Excluded studies

We excluded 31 studies; 28 studies in this update and three studies (Carpenter 1995; Hubbell 1949; Lundquist 1947), in the previous version of this review (Brown 2010). We excluded eight studies due to an inappropriate design, such as an observational study, or one group pre‐post design (Chien 2013; Kannan 2015; Monori 2017; NCT03625375; Parkhad 2013; Rakhshaee 2011; Sarhadi 2015; Shahr‐jerdy 2012), 13 studies due to lack of a valid comparator or control group (Aboushady 2016; Atashak 2018; Behbahani 2016; Chang 2018; Chaudhui 2013; Habibian 2018; Kaur 2013; Kour 2018; Kumar 2017; Mahishale 2013; Padmanabhan 2018; Shirvani 2017; Tharani 2018), six studies due to study participants not meeting the inclusion criteria, such as not providing details for the screening of primary versus secondary dysmenorrhoea (Abbaspour 2006; Dehnavi 2018; Ortiz 2015; Pazoki 2013; Rihani 2013; Yonglitthipagon 2017), and one study where the primary outcome was lower back pain (Chen 2019).

Risk of bias in included studies

(Figure 2; Figure 3)

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

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

Allocation

Random sequence generation

We rated five trials at low risk of selection bias for random sequence generation (Fallah 2018; Kannan 2019; Saleh 2016; Samy 2019; Yang 2016), and seven at unclear risk of bias.

Allocation concealment

We rated two trials at low risk of bias for allocation concealment (Fallah 2018; Samy 2019), and 10 trials at unclear risk.

Blinding

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 detection bias.

Incomplete outcome data

We rated seven trials at low risk of attrition bias, four trials at unclear risk (Motahari‐Tabari 2017; Nasri 2016; Patel 2015; Siahpour 2013), and one trial at high risk (Saleh 2016).

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 eight trials at unclear risk and one trial at high risk due to not reporting outcomes that were outlined in the methods section (Patel 2015).

Other potential sources of bias

We rated one trial at unclear risk of bias due to poor demographic reporting (Israel 1985), and 11 trials at low risk of bias.

Effects of interventions

See: Table 1; Table 2

Summary of findings for the main comparison. Exercise compared to no treatment for dysmenorrhoea.

Exercise compared to no treatment for dysmenorrhoea
Patient or population: young women with suspected primary dysmenorrhoea  Setting: school, university or outpatient setting  Intervention: exercise  Comparison: no treatment
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Quality of the evidence  (GRADE)	Comments
Outcomes	Risk with no treatment	Risk with exercise	Relative effect  (95% CI)	№ of participants  (studies)	Quality of the evidence  (GRADE)	Comments
Menstrual pain intensity,  measured by various outcome measures including VAS, MPQ and NRS at the end of the intervention    Lower scores indicate less intense menstrual pain	The mean menstrual pain intensity was 6.76	SMD 1.86 lower  (2.06 lower to 1.66 lower)	‐	632  (9 RCTs)	⊕⊕⊝⊝  Low^ab	Exercise may provide a large reduction in menstrual pain intensity compared to no treatment.
Adverse events	0 per 1000	0 per 1000  (0 to 0)	Not estimable	36  (1 RCT)	⊕⊝⊝⊝  Very low^cd	Due to the very low‐quality evidence, we are uncertain whether there is any difference in risk for adverse events between exercise and no treatment control.
Overall menstrual symptoms ,  measured by the MMDQ at the end of the intervention.    Lower scores indicates lower menstrual symptom severity	The mean overall menstrual symptoms was 99	MD 33.16 lower  (40.45 lower to 25.87 lower)	‐	120  (1 RCT)	⊕⊝⊝⊝  Very low^ef	Due to the very low‐quality evidence, we are uncertain whether exercise reduces overall menstrual symptoms compared to a no treatment control.
Use of rescue analgesic medication ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Restriction of daily life activities ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Absence from work or school ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Quality of life,  assessed with: physical and mental component summary scores measured by the SF‐12 at the end of the intervention Higher scores indicate higher quality of life	Mean postintervention score for the mental component in the no treatment group was 37.6 Mean postintervention score for the physical component in the no treatment group was 44.4	Mental component: MD 4.40 higher  (1.59 higher to 7.21 higher) Physical component: MD 3.40 higher  (1.68 lower to 8.48 higher)	‐	55  (1 RCT)	⊕⊝⊝⊝  Very low^gh	Due to the very low‐quality evidence, we are uncertain whether exercise improves quality of life compared to a no treatment control.
*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.

Exercise compared to non‐steroidal anti‐inflammatory drugs (NSAIDs) for dysmenorrhoea
Patient or population: young women with suspected primary dysmenorrhoea  Setting: university or school  Intervention: exercise  Comparison: NSAIDs
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Quality of the evidence  (GRADE)	Comments
Outcomes	Risk with NSAIDs	Risk with exercise	Relative effect  (95% CI)	№ of participants  (studies)	Quality of the evidence  (GRADE)	Comments
Menstrual pain intensity,  measured by 100 mm VAS at the end of the intervention    Higher scores indicate greater reductions in pain intensity from baseline	The mean menstrual pain intensity was ‐21.3 change in VAS score from baseline	MD 7.4 lower change in VAS score from baseline  (8.36 lower to 6.44 lower)	‐	122  (1 RCT)	⊕⊝⊝⊝  Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise improves menstrual pain severity compared to NSAIDs.
Adverse events ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Overall menstrual symptoms ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Use of rescue analgesic medication assessed by: number of women who took rescue/additional analgesics during the last cycle Greater numbers indicate more women needed additional analgesics	361 per 1000	638 per 1000  (436 to 938)	RR 1.77  (1.21 to 2.60)	122  (1 RCT)	⊕⊝⊝⊝  Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise changes the amount of additional medication needed compared to NSAIDs.
Restriction of daily life activities ‐ not reported	‐	‐	‐	‐	‐	No studies reported on this outcome.
Absence from work or school	492 per 1000	492 per 1000  (322 to 663)	OR 1.00  (0.49 to 2.03)	122  (1 RCT)	⊕⊝⊝⊝  Very low^ab	Due to the very low‐quality evidence, we are uncertain whether exercise changes absenteeism compared to 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).    CI: confidence interval; MD: mean difference; NSAID: non‐steroidal anti‐inflammatory drug; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; 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.

Date	Event	Description
27 August 2019	New citation required and conclusions have changed	Conclusions changed from previous review: 11 new studies included: 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

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 review 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 changes	Substantive amendment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
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]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
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]

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 allocated 30 each to the control and the experiment group Incusion: young females 19 to 24 years, diagnosed with primary dysmenorrhoea (as per the questionnaire) and who conceded to a written informed consent Exclusion: known organic cause of dysmenorrhoea, having received herb or acupuncture therapy within one month prior to enrolment, poor compliance to investigator's advice
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 generation (selection bias)	Unclear risk	Quote: "A group of 60 subjects were randomly selected and allocated 30 each randomly to the Control and the Experiment group" (p. 132). Comment: not described
Allocation concealment (selection bias)	Unclear risk	Concealment not described
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No missing data
Selective reporting (reporting bias)	Unclear risk	The study protocol is not available
Other bias	Low risk	None noted

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 control group (n = 19) Setting: Atot and Fagher schools in 14th district of Tehran and Tehran sports club 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 medications 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 minutes, 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 Medicine 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*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random number tables (quote): "All selected participants were randomly assigned into a control, a massage, a stretch, and a combined group using a randomized number chart" (p. 61)
Allocation concealment (selection bias)	Low risk	Central randomisation (quote): "The allocation sequence was concealed and it was generated using a table of random numbers" (p. 61)
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No missing data
Selective reporting (reporting bias)	Unclear risk	Study protocol is not available
Other bias	Low risk	None noted

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 treadmill 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)
Notes	Funding: not reported  Conflict of interest: not reported  Date study was conducted: not reported Additional: protocol adherence to training was 80%
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "Randomly assigned"
Allocation concealment (selection bias)	Unclear risk	No details in paper
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Details and reasons for losses to follow‐up provided. Three women from the control group were ill and unavailable for post‐testing and seven dropped out of the training group due to illness, injuries or stringent dietary regimens; none of these were caused by the training.
Selective reporting (reporting bias)	Unclear risk	No study protocol available
Other bias	Unclear risk	Not enough detail in paper to determine if groups were matched at baseline

Methods	Randomised controlled trial of stretching exercises and no treatment
Participants	Country: India Participants: 67 student nurses with primary dysmenorrhoea were selected and randomly assigned into 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. Furthermore 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*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Quote: "…randomly assigned into two experimental (35) and control groups (35)." Comment: not described
Allocation concealment (selection bias)	Unclear risk	Not described
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups; final analysis (experimental 33, control 34)
Selective reporting (reporting bias)	Unclear risk	Study protocol is not available
Other bias	Low risk	None noted

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 moderate‐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 contraceptive 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 maximum 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 exercise 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 Impression 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  Conflict of interest: nil  Date study was conducted: May 2014 to August 2015  Trial registration: ACTRN12613001195741
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “Women with primary dysmenorrhea were randomly allocated to undertake regular aerobic exercise (experimental group) or usual care (control group) by a clinical research administrator using simple randomisation (generated using a random numbers list)” (p. 81)
Allocation concealment (selection bias)	Unclear risk	Quote: “(generated using a random numbers list) with allocation concealment using opaque sealed envelopes [given by clinical research administrator]. The clinical research administrator was an independent person with no other involvement in the study.” (p. 81) Comment: unclear if sealed envelopes were sequentially numbered
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Dropout rate was higher (21%) than anticipated (15%) but the authors note (quote): “Reasons for dropping out of study is not known, it is unlikely that it could be related to intervention parameters because our feasibility study identified good acceptance towards the intervention and intensity of training.” (p. 85)
Selective reporting (reporting bias)	Low risk	Both study protocol published and trial prospectively registered
Other bias	Low risk	None noted

Methods	Randomised controlled trial of aerobic training versus kegel exercises versus no exercise
Participants	Country: Iran 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 Exclusion: history of any gynaecology or urethra disease, history of coronary vascular, liver or kidney 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% maximum heart rate and duration of 45 minutes. The intensity of exercises was 5% less during menstruation. All exercises were supervised by a trainer. Control: no treatment Kegel exercises (arm not eligible for inclusion)
Outcomes	Primary outcome: menstrual pain intensity (VAS)
Notes	Funding: Shahid Rajaee teacher training university Tehran  Conflict of interest: not reported  Date study was conducted: April to June 2013 Trial registration: IRCT 2014042017362N1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Page 55 states allocation was random, but no further details given
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	Dropouts not reported
Selective reporting (reporting bias)	Low risk	Trial registration shows study reported on all predefined outcomes
Other bias	Low risk	None noted

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 menstrual 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
Outcomes	Primary outcome: menstrual pain intensity (VAS)
Notes	Funding: not reported  Conflict of interest: not reported  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*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: "Samples were selected through convenience sampling and were then assigned to an intervention and control groups by permuted block randomization" (p. 2)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	High risk	Dropouts uneven between groups; 12 in control group (24%) and 6 in each intervention group
Selective reporting (reporting bias)	Unclear risk	No study protocol was published
Other bias	Low risk	None noted

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 following conditions: pregnancy, known genitourinary system diseases (e.g. pelvic inflammatory disease and urinary tract infections), secondary dysmenorrhoea, and chronic illnesses that might contraindicate 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. Classes 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 consisted of continuous dance movements to Latin music with changing intensity level all through the sessions. Low‐intensity movements were initiated for the first 5 minutes of each session, followed by an increasing 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 offered weekly 10‐minute telephone follow‐ups to provide support and for addressing dropout prevention
Outcomes	Primary outcome: menstrual pain intensity (VAS)  Secondary outcomes: duration of pain (in hours)
Notes	Funding: not reported  Conflict of interest: nil  Date study was conducted: May 2018 to September 2018  Trial registration: NCT03561493
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “They were randomly assigned to the Zumba or the control group (49 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 (selection bias)	Low risk	Quote: “Assignments were enclosed in sequentially numbered, sealed opaque envelopes and stored by a research assistant who was independent to the trial team.” (p. 2)
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Quote: “…Limitation of the study… lack of blinding of participants and outcome assessors” (p. 5)
Blinding of outcome assessment (detection bias)   All outcomes	High risk	“…Limitation of the study… lack of blinding of participants and outcome assessors” (p. 5)
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No missing data
Selective reporting (reporting bias)	Low risk	Trial prospectively registered and all specified outcomes reported
Other bias	Low risk	None noted

Methods	Three‐armed trial comparing yoga, aerobic exercise and no treatment
Participants	Country: Iran 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 details 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  Conflict of interest: not reported  Date study was conducted: April 2012 to July 2012 Trial registration: IRCT2013091014611N1
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Page 477 states that it is 'random' but does not provide details
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Unclear risk	No dropouts reported in text, but no CONSORT figure, so unclear if not reported or did not occur
Selective reporting (reporting bias)	Unclear risk	No study protocol is published
Other bias	Low risk	None noted

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 yoga 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  Conflict of interest: not reported  Date study was conducted: 2015 Study procedure approval: Institutional review board of Kangwon National University (KWNUIRB‐2015‐02‐002‐001)
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote: “random permuted block design using a random‐number table through the Excel random‐numbers function” (p. 733)
Allocation concealment (selection bias)	Unclear risk	Not reported
Blinding of participants and personnel (performance bias)   All outcomes	High risk	Participants not blinded to group allocation
Blinding of outcome assessment (detection bias)   All outcomes	High risk	Pain scores are self‐reported, and are likely to be affected by lack of blinding
Incomplete outcome data (attrition bias)   All outcomes	Low risk	No dropouts reported (Figure 1, pg 734)
Selective reporting (reporting bias)	Unclear risk	No study protocol was published
Other bias	Low risk	None noted

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
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

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

Methods	Randomised controlled trial of aerobic or stretching exercise and no treatment
Participants	Country: Iran 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 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 second 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 performed 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 sessions 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 supplements to prevent their dysmenorrhoea during their menstrual cycles
Outcomes	Secondary: overall menstrual pain intensity (modified version of a menstrual symptom questionnaire)
Notes	Funding: Shiraz Univeristy of Medical Sciences  Conflict of interest: not reported  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 reply as of April 2019

Trial name or title	To compare the effect of drawing in maneuver exercises versus core strengthening exercises on primary 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 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

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
Participants	Inclusion criteria 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"
Starting date	September 2018
Contact information	Farid Babakhani farideh_babakhani@yahoo.com
Notes

PERMALINK

Exercise for dysmenorrhoea

Mike Armour

Carolyn C Ee

Dhevaksha Naidoo

Zahra Ayati

K Jane Chalmers

Kylie A Steel

Michael J de Manincor

Elahe Delshad

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Inclusion criteria

Exclusion criteria

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Overall quality of the body of evidence: 'Summary of findings' tables

Results

Description of studies

Study design and setting

Participants

Sample size

Type of intervention

Frequency, duration and number of treatment sessions

Control or comparator

Outcome measures

Menstrual pain intensity

Adverse events

Overall menstrual symptoms

Use of rescue analgesic medication

Absence from work or school

Restriction of daily life activities

Quality of life

Funding sources and conflict of interest

Results of the search

1.

Included studies

Excluded studies

Risk of bias in included studies

2.

3.

Allocation

Random sequence generation

Allocation concealment

Blinding

Trial name or title	The comparison of the effect of stretching exercises and a combination of massage ‐ stretching exercises 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

Trial name or title	The effect of an aerobic training course with and without cumin supplementation on serum ß‐endorphin 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
Participants	Inclusion criteria Aged 18 to 25 years 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 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

Trial name or title	The effect of a core stability exercise program on the primary dysmenorrhoea in young adult females‐ 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

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
Participants	Inclusion criteria Aged 18 to 25 years 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)
Starting date	September 2017
Contact information	Elahe Abdolmaleki Elaheabdolmaleki.95@ gmail.com
Notes

Trial name or title	Comparison of the effect of stretching exercises and massaging of connective tissue with the control group on dysmenorrhoea
Methods	Randomised controlled 3‐armed trial comparing stretching exercises versus connective tissue massage versus no intervention
Participants	Inclusion criteria 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
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 performed 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

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
Contact information	Meryem Kurek Eken, meryemkurekeken@gmail.com
Notes

Trial name or title	TENS effect in primary dysmenorrhoea and its influence on central sensitization pre and post exercise: randomized clinical trial
Methods	Randomised controlled trial comparing TENS and core training versus placebo TENS and core training
Participants	Inclusion criteria 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 material 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 minutes, 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, during 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
Starting date	March 2017
Contact information	Josimari Melo Santana desantanajm@gmail.com
Notes