Our study was the first to investigate the effects of whole-body strengthening, flexibility, balance, and aerobic exercises on menstrual symptom severity, sleep quality, fatigue severity, and physical activity level in people with menstrual symptoms. The primary outcome was menstrual symptom severity. The secondary outcomes included sleep quality, fatigue severity, and physical activity level. The main results of the present study were: (i) The exercise group exhibited a marked reduction in MSQ, MDQ (menstrual), FSS, and PSQI scores, accompanied by an increase in IPAQ scores in post-treatment; (ii) Compared with the control group, decrease in MSQ, MDQ (menstrual), and PSQI scores were significantly higher in exercise group; (ii) The participants receiving exercise treatment showed a significant increase in IPAQ score in comparison to non-exercising women with the menstrual syndrome.
It has been posited that the early age of menarche is associated with the early onset of ovarian function and the fluctuation of steroid hormones in individuals who lack physical and psychological maturity (6). In another study, it was stated that the early age of menarche increased the complaints of dysmenorrhea (20). Furthermore, a reduction in the number of pregnancies has been linked to an elevated risk of developing more severe PMS symptoms (21). In our study, the exercise and control groups were distributed heterogeneously concerning age at menarche and number of pregnancies. The mean age at menarche was lower and the mean number of pregnancies was higher in the control group. Given that no differences were observed between the groups in the pre-treatment evaluation of the MSQ and MDQ questionnaires, it can be concluded that the heterogeneity of the number of pregnancies and menarche age did not exert any influence on the course of the study.
It has been demonstrated that aerobic exercise is an efficacious intervention for alleviating physical symptoms associated with premenstrual syndrome (PMS) and dysmenorrhea, including bloating, vomiting, hot flashes, and increased appetite (22). Another study demonstrated that aerobic exercise was an effective intervention for reducing both physical and psychological symptoms in individuals with PMS and PMDD (23). Vaghela et al. demonstrated that yoga and physical exercise can alleviate the pain severity and premenstrual symptoms after four weeks however; the yoga group exhibited greater improvements than the aerobic exercise group (24). In women with menstrual abnormalities, regular exercise has been demonstrated to reduce menstrual irregularities (25). In another study, functional exercise programs have been shown to be effective on the MSQ, PSQI, and low back and abdominal pain of dysmenorrhea patients (26). Core exercise programs have been shown to improve the pain level and quality of life of people with dysmenorrhea (27). Another meta-analysis study stated that menstrual pain can be reduced with aerobic exercise, strengthening, and flexibility exercises (28). In this study, whole-body strengthening, flexibility, balance, and aerobic exercises were applied in combination and alleviated symptoms such as menstrual pain and negative somatic effects. Therefore, the notable decline in MSQ scores among the exercise group is consistent with the findings of previous studies.
Menstruation-related bleeding, pain, fatigue, and mood changes, collectively referred to as menstrual distress, have a profound impact on a woman's physical, social, and emotional well-being (29). Previous research has demonstrated that menstruation affects mood and cognitive function, potentially resulting in negative experiences that give rise to menstrual-related concerns and difficulties in coping with them (30). PMS and PMDD are thought to occur during the luteal phase of the menstrual cycle, approximately one week before menstruation. It is reported that these conditions resolve with the onset of menstruation (3, 5). In this study, the data related to the pre-menstrual period were based on 1 week before menstruation. There were no significant changes in the MDQ (pre-menstrual) scores before and after treatment in the distress scores of the exercise and control groups. Accordingly, the absence of a reduction in the MDQ score for the menstrual period is inconsistent with the existing literature. This may be related to psychosocial factors or life stressors beyond the control of the current study. The prevalence of symptoms among women with PMS and PMDD is higher during the luteal phase. However, these women also report experiencing insomnia, inattention, fatigue, and memory problems during the follicular phase. The existing literature emphasizes the importance of physical activity in managing PMS and PMDD (5). The findings of this study support the association between exercise and menstrual symptoms. Many factors can affect women's menstrual symptoms such as poor eating habits, inactive lifestyle, alcohol and smoking habits, anxiety, and stress (5, 31). In this study, the MDQ score of the inter-menstrual period decreased significantly in the control group despite the absence of any intervention. The observed change in the control group did not result in a significant difference among groups. This suggests that the observed differences may be attributed to potential changes in the participants’ lifestyles.
Fatigue is one of the most common menstrual symptoms (32). In women with heavy menstrual bleeding, it was found that ferritin levels and physical functions decreased and fatigue increased in parallel with the increase in the duration of menstruation (33). People with moderate levels of physical activity showed an effective reduction in PMS symptoms such as sleepiness, fatigue, pain, and increased appetite (31) Although there was no significance between the groups, the decrease in fatigue severity in the exercise group is in parallel with the literature.
Given that circadian rhythms are irregular in individuals with sleep disorders, the release of gonadotropin-releasing hormone from the pituitary gland is inhibited, which in turn increases the severity of menstrual symptoms (3). A correlation has been identified between increased sleepiness, decreased sleep quality, and short sleep duration with the onset of dysmenorrhea, PMS, and irregular menstruation (3). It has been reported that 12-week Pilates exercises improved sleep quality in women with dysmenorrhea (34). In our study, although the exercise group had significantly worse sleep quality than the control group before treatment, the improvement in sleep quality after exercise was significant compared to the control group. This may be supported by studies suggesting that exercise improves sleep quality (35, 36). In particular, studies have demonstrated that moderate-intensity exercise programs conducted three days a week for 12 weeks to six months have the greatest impact on sleep quality. Several studies have shown that even low levels of physical activity, such as walking, are associated with improved sleep quality, with this effect being more pronounced in women than in men (37).
The existing literature indicates that high levels of physical activity are associated with a reduction in the average duration of menstruation, the incidence of dysmenorrhea and polymenorrhea, and premenstrual syndrome (10). Another study found a significant increase in dysmenorrhea complaints due to decreased physical activity level during the pandemic period (38). Therefore, the increased level of physical activity in the exercise group in this study may also be associated with reduced symptoms in this group.
This research is the first to evaluate the efficacy of whole-body strengthening, flexibility, balance, and aerobic exercises in women with menstrual syndromes and to examine their functional and patient-reported outcomes. However, it is important to consider the limitations. Firstly, the study relied on self-report data, which may have resulted in social acceptability and recall biases. Secondly, the assessment of heart rate and other objective indicators of exercise, in addition to the use of standard instruments for self-reported physical activity, were not included in the study design. In addition, the investigation failed to explore the lasting effects of the intervention, regarding the sustainability of the outcomes. Lastly, the study population was selected from individuals presenting with any one or more of the symptoms associated with the menstrual cycle. Consequently, the relationship between the exercise method and specific symptoms such as PMS or PMDD was not investigated. Such information should be clarified in future research.