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Am Fam Physician. 2021;103(9):525-526

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is exercise a safe and effective treatment for primary dysmenorrhea?

Evidence-Based Answer

Low-intensity exercise, such as stretching or core strengthening, and high-intensity exercise, such as Zumba or aerobic training, improve menstrual pain intensity compared with no exercise (standardized mean difference [SMD] = −1.86; 95% CI, −2.06 to −1.66; nine randomized controlled trials [RCTs]; n = 632).1 (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) It is unclear whether any one type of exercise is superior to another at improving overall menstrual symptoms, mental quality of life, or physical quality of life. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) The evidence is insufficient to draw any conclusions about adverse effects. Also, there is not enough evidence to determine the benefit or harm of exercise compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Primary dysmenorrhea is defined as menstrual pain without known pelvic pathology. It is the most commonly reported menstrual symptom among young women, occurring in about 71% of those younger than 25 years, typically beginning six to 12 months following menarche.1,2 Allopathic treatment options include NSAIDs, none of which have been shown to be superior to another. Combined hormonal, implantable, injectable, or hormone-releasing intrauterine contraceptives are also effective options. Exercise has long been recommended as a low-risk adjunct, and this review evaluated the effectiveness of exercise for treating primary dysmenorrhea.3

This Cochrane review included 12 trials with 854 patients in the subjective review and 10 trials with 754 women in the meta-analysis; participants had regular menses and a diagnosis of primary dysmenorrhea.1 Women 18 to 43 years of age (mean age = 25 years) participated. Nine RCTs evaluated exercise compared with no exercise. Studies were varied and included either low-intensity exercise (e.g., yoga, stretching, core exercises) or high-intensity exercise (e.g., Zumba, aerobic training). Studies were performed in the United States, India, Iran, New Zealand, Egypt, and Korea. They lasted eight or 12 weeks, with the exception of one study that lasted seven months, and included both supervised and unsupervised training programs. Resistance training was not examined in any of the studies. Limitations included risk of performance bias and detection bias as well as lack of blinding and limited generalizability. Eight studies included in the meta-analysis used a visual analog scale (VAS); the McGill Pain Questionnaire and a numeric rating scale were each used in one study, necessitating the use of the SMD as a primary outcome. A VAS is used to subjectively measure a participant's level of agreement with a statement on a continuous line between two points. Previous studies comparing changes on a VAS have determined 10 mm to be a clinically significant change in pain after surgery.4

Results from this review suggest a clinically significant reduction in menstrual pain intensity (SMD = −1.86; 95% CI, −2.06 to −1.66; nine RCTs; n = 632) corresponding to a 25-mm decrease on a 100-mm VAS. Data on the effect of exercise on overall menstrual symptoms, mental quality of life, or physical quality of life were inconclusive. Only one RCT compared abdominal stretching plus mefenamic acid vs. mefenamic acid alone and found an additional VAS reduction in the abdominal stretching plus mefenamic acid group (mean difference = −7.40; 95% CI, −8.36 to −6.44; n = 122).

Adverse effects and safety of exercise were not reported well enough in the reviewed studies to draw conclusions, although exercise can be considered safe provided adequate consideration is made for recovery, nutritional support, and surveillance for injury. None of the studies compared exercise with any type of contraceptive.

These results are consistent with another 2019 systematic review that concluded that exercise is an effective and safe form of lifestyle intervention to decrease symptoms of dysmenorrhea.5 Clinical guidelines from the American College of Obstetricians and Gynecologists recommend encouraging patients to exercise for the treatment of dysmenorrhea.2

The practice recommendations in this activity are available at http://www.cochrane.org/CD004142.

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