Grand Rounds

Cochrane Review: Is Exercise an Effective Treatment for Primary Dysmenorrhea?

BACKGROUND AND PURPOSE:

In this Cochrane review, Armour et al. (Cochrane Database of Systematic Reviews, 2019) evaluated the effectiveness and safety of exercise for primary dysmenorrhea

Systematic review and meta-analysis
Data sources
- Cochrane Gynaecology and Fertility specialized register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED and CINAHL (from inception to July 2019)
- Two clinical trial databases (ClinicalTrials.gov and WHO Trials Registry) and hand-searched reference lists and previous systematic reviews
Inclusion criteria
- RCTs that included women with moderate-to-severe primary dysmenorrhea, randomized to exercise vs
  - No treatment | Attention control (“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”) | NSAIDs| OCPs
Exercise definition: “Physical activity characterized by using planned and structured repetitive movements to increase or maintain physical fitness”
- Most studies included asked women to exercise three times per week, for about 45 to 60 minutes, throughout the month
Data synthesis and analysis
- Two reviewers independently selected the studies, assessed bias, and extracted data
- Study authors were contacted for missing information
- GRADE criteria used for study quality assessment
Primary outcomes
- Menstrual pain intensity
- Adverse events
Secondary outcomes
- Overall menstrual symptoms | Usage of rescue analgesic medications | Restriction of daily life activities | Absence from work or school and quality of life

Meta-analysis: 10 trials 754 women
- 9 of the 10 studies compared exercise with no treatment, and 1 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 may have a ‘large’ effect on reducing menstrual pain intensity compared to no exercise (low- quality evidence)
- Standard mean difference (SMD) -1.86 (95% CI -2.06 to -1.66; n = 632)
- Clinically significant difference (Corresponds to a 25 mm reduction on a 100 mm visual analogue scale [VAS])
Adverse events: Uncertain if there is any difference in adverse events between treatment and control
For other outcomes, uncertain if exercise is of benefit for the following due to very low-quality evidence
- Overall menstrual symptoms (e.g., back pain or fatigue)
- Improvement in mental quality of life
- Improvement in physical quality of life
No studies reported on changes in daily life activities or absence from work/school

Uncertain if exercise, when compared with mefenamic acid, was of benefit due to very low-quality evidence for the following
- Menstrual pain intensity
- Use of rescue analgesic medication
- Absence from work or school
Studies did not report
- Adverse events | Overall menstrual symptoms | Restriction of daily life activities | Quality of life

Exercise may relieve pain intensity associated with dysmenorrhea
- Reduction is likely clinically significant
Unclear whether exercising for less time or less frequently would have the same effect as that described in most studies (45 to 60 minutes, 3 times per week)
Insufficient evidence to determine if exercise provides benefit vs NSAIDs

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