By Alex Jennings
Editor’s Note: Painful periods, or dysmenorrhea, are common, but they should not be accepted as the norm. Patients’ quality of life often suffers due to painful periods; consequently, patients often seek management options from their healthcare professionals. While non-steroidal anti-inflammatory drugs (NSAIDs) are the standard of care, exercise as treatment is a valid option, as demonstrated in the meta-analysis “Exercise for dysmenorrhea,” summarized here by Alex Jennings during the FACTS Elective. To learn more about the effect of exercise on cycle health and fertility, from Part O of the FACTS CME course.
Introduction
Primary dysmenorrhea is a condition characterized by pain with menstruation that is not caused by another condition. If that pain is caused by another condition such as endometriosis, fibroids, endometritis, etc., the condition is termed “secondary dysmenorrhea.” First onset of symptoms from primary dysmenorrhea typically occurs within 6 to 24 months of menarche, which can be a helpful distinguishing factor between primary and secondary dysmenorrhea. [1]
Primary dysmenorrhea is one of the most common gynecological conditions, with a prevalence cited at 71% worldwide, according to a 2022 meta-analysis from Armour et al. [2] This condition significantly reduces quality of life and is a commonly quoted reason for women to miss days of school or work. The significant impact of this condition on women worldwide necessitates effective treatment, but tragically, primary dysmenorrhea is frequently disregarded and undertreated. Currently, the leading treatment strategy is NSAID use or which carries its own risks.
“Primary dysmenorrhea is one of the most common gynecological conditions, with a prevalence cited at 71% worldwide.”
The meta-analysis “Exercise for dysmenorrhea” by Armour et al. looked at exercise as a potential treatment and prevention strategy for primary dysmenorrhea. [3] The proposed mechanism for this intervention was that anti-inflammatory cytokines produced from intense exercise, such as running or biking, could combat the prostaglandins produced during menstruation that cause painful uterine contractions. A secondary mechanism of decreased cortisol, found with lower intensity exercise, was proposed as well.
Methodology
For this study, only randomized control trials (RCTs) were included. The inclusion criteria incorporated women of childbearing age with self-reported, moderate-to-severe primary dysmenorrhea, but trials that included women with irregular cycles or secondary dysmenorrhea were excluded. Overall, 12 RCTs were utilized for qualitative synthesis and 10 RCTs were utilized for the meta-analysis. Nine of the ten studies compared exercise with no treatment, and one study compared exercise with NSAIDs. The average amount of exercise prescribed in the study was 45-60 minute sessions three times per week. Intensity varied across the studies between low-intensity, such as yoga, and high-intensity, such as running. [3] The CDC guidelines for adult Americans promote 150 minutes per week of moderate intensity exercise or 75 minutes of vigorous intensity with two days of resistance training, which correlates well with the study parameters. [4]
Results
The study concluded that exercise may have a large impact on reducing menstrual pain intensity compared to no exercise. On a pain rating scale of 10, the mean menstrual pain intensity was 6.76 with a mean difference of -1.86 (95% CI of -2.06 to -1.66) between the exercise treatment groups and the controls. They also found that high intensity exercise proved more impactful with a pain difference from baseline to end of treatment of -2.6 ± 1.5 compared to no treatment control pain difference of 0.13 ± 0.93. [3]
“Exercise may have a large effect on reducing menstrual pain intensity compared to no exercise.”
Only one trial compared the efficacy of exercise for pain reduction against NSAID use. This study determined that there was uncertain evidence for improvement of menstrual pain with exercise over NSAID use. On a visual analogue scale of 100mm, the mean menstrual pain intensity reduction was 7.4mm more (95% CI of 8.36mm to 6.44mm) in the exercise group than the NSAID group. Utilizing a minimally clinically important difference (MCID) of 10mm on the visual pain scale that is used in endometriosis studies, a reduction of 7.4mm was determined not to be clinically significant. [3]
Discussion
The conclusion that exercise could have a large impact on reducing menstrual pain intensity when compared to no treatment could be practice changing. As primary care physicians, exercise counseling is already a part of routine annual visits and chronic disease management, but now reductions in menstrual pain intensity in those with primary dysmenorrhea could be added to the list of exercise benefits. The MCID for pelvic pain in endometriosis is 10mm, and the difference in pain intensity found between exercise and no exercise in this study was 2.5 times the MCID, indicating that these findings are likely very clinically significant for patients. [3] The current recommended treatment for primary dysmenorrhea is NSAIDs, which carry with them their own significant risks, including gastrointestinal and kidney complications. Adding an exercise regimen to a multi-modal approach to dysmenorrhea could potentially decrease someone’s usage of pain medication and allow them to continue normal living throughout their menstrual cycle.
The generalizability of this study geographically is fairly robust as the meta-analysis included studies from different parts of the world, including the USA, Iran, India, Egypt, and New Zealand. However, most of the studies had average ages below 25 and were conducted in school settings, skewing generalization toward younger populations. Other limitations of the study include the low quality of the evidence produced by the included RCTs. Since exercise was the intervention, it is almost impossible to blind the patients and the physicians to the intervention. Furthermore, the methods for screening patients for secondary dysmenorrhea or determining what was appropriate exercise were unclear at times.
“Adding an exercise regimen to a multi-modal approach to dysmenorrhea could potentially decrease someone’s usage of pain medication and allow them to continue normal living throughout their menstrual cycle.”
Considerations for future research in this area could include higher quality studies exploring exercise as a treatment option compared to the standard of care of NSAIDs. Analyzing the effects of exercise on quality of life in patients with dysmenorrhea by studying additional endpoints such as days of school or work missed or restrictions on daily activities could also be beneficial. The authors were interested in these types of endpoints as well but could not find sufficient trials or evidence to determine a conclusion. Additionally, it would be interesting to interpret how timing of exercise in relation to the menstrual cycle might affect these results or if exercise timed closely before or during menstruation would have greater impacts on perceived pain reduction.
As with most gynecological conditions, familiarity with one’s own body and being able to track ovulatory-menstrual cycles and symptoms is crucial in the understanding and diagnosis of dysmenorrhea. Historically, it has been very difficult to determine the root cause of menstrual and pelvic pain. With conditions such as endometriosis commonly causing secondary dysmenorrhea and potential infertility, it is important for patients to take note of new or worsening symptoms and communicate with their physicians. This is critical so symptoms that may indicate other significant conditions are not mislabeled or dismissed as primary dysmenorrhea. And for those with true primary dysmenorrhea, patients should work with their physicians to determine a multi-modal approach to reduce their pain and improve their quality of life.
References
[1] Itani R, Soubra L, Karout S, Rahme D, Karout L, Khojah HMJ. Primary Dysmenorrhea: Pathophysiology, Diagnosis, and Treatment Updates. Korean J Fam Med. 2022 Mar;43(2):101-108. doi: 10.4082/kjfm.21.0103. Epub 2022 Mar 17. PMID: 35320895; PMCID: PMC8943241.
[2] Armour M, Parry K, Al-Dabbas MA, Curry C, Holmes K, MacMillan F, et al. Self-care strategies and sources of knowledge on menstruation in 12,526 young women with dysmenorrhea: A systematic review and meta-analysis. PLOS One 2019;14(7):e0220103. DOI: 10.1371/journal.pone.0220103
[3] Armour M, Ee CC, Naidoo D, Ayati Z, Chalmers KJ, Steel KA, de Manincor MJ, Delshad E. Exercise for dysmenorrhea. Cochrane Database Syst Rev. 2019 Sep 20;9(9):CD004142. doi: 10.1002/14651858.CD004142.pub4. PMID: 31538328; PMCID: PMC6753056.
[4] Centers for Disease Control and Prevention. Adult activity: an overview. Updated December 20, 2023. Accessed January 19, 2026. https://www.cdc.gov/physical-activity-basics/guidelines/adults.html
ABOUT THE AUTHOR
Alex Jennings is a fourth-year medical student at Wake Forest University School of Medicine in Winston-Salem, NC. She completed her undergraduate education at Miami University in Oxford, OH. She plans to pursue residency in family medicine and is interested in mother-baby dyad care, lifestyle medicine, and education. She enrolled in the FACTS elective to gain a better understanding of fertility awareness-based methods so that she can begin to utilize an approach of restorative reproductive medicine with her future patients to help them reach their health goals.
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