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The Effect of Physical Activity on Primary

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Article in World Applied Sciences Journal January 2012

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World Applied Sciences Journal 17 (10): 1246-1252, 2012
ISSN 1818-4952
IDOSI Publications, 2012

The Effect of Physical Activity on Primary Dysmenorrhea

of Female University Students
1
Noorbakhsh Mahvash, 1Alijani Eidy, 1Kohandel Mehdi,
2
Mehdizadeh Toorzani Zahra, 2Mirfaizi Mani and 1Hojat Shahla

1
College of Physical Education and Sport Sciences, Islamic Azad University - Karaj Branch, Iran
2
Department of Midwifery, Islamic Azad University - Karaj Branch, Iran

Abstract: Primary dysmenorrhea is one of the most common complains and gynecological problem worldwide
among young females. Findings claimed that exercise may positively affect this problem. Therefore, the main
purpose of this study was to examine the effect of 8 weeks physical activity on primary dysmenorrhea of female
students. Based on McGills questionnaire 50 students having moderate to severe primary dysmenorrhea took
part in this study and randomly were divided into experimental (N=25) and control (N=25) groups. The
experimental group participated in a physical activity program for 8 weeks, 3 sessions a week and 90 minutes
per session. The results revealed that performing a regular physical activity significantly reduced type of drugs
consumed (p# 0.08), number of drugs consumed (p# 0.01), volume of bleeding (p# 0.002), rate of bleeding (p#
0.005), length of menstruation pain (p# 0.001) and total and present pain intensity (p# 0.01, p#0.05) in
experimental group when comparing with control group or when comparing pre and post-test findings of
experimental group. Overalls, the results of this study indicated that participating in physical activity program
is likely an approach to reduce the detrimental effect of primary dysmenorrhea symptoms in young females.

Key words: Physical Activity % Primary Dysmenorrhea % University Students

INTRODUCTION next day. Dysmenorrhea pains are felt in lower abdomin

In the past two decades, the relation between
physical activity and menstrual disorders including
primary dysmenorrhea has significantly been studied.
Research findings have indicated that exercise can affect
menstruation in many ways including inducing
amenorrhea in athletes and it may decrease symptoms of
premenstrual syndrome and dysmenorrhea [1]. Primary
dysmenorrhea or painful menstruation, in absence of any
specific pelvic diseases, is one of the most common
complaints of women and is also the most common
gynecological problem worldwide [2, 3]. Primary
dysmenorrhea begins when young girls first experience
the ovulatory cycles and its prevalence increases during
adolescence (15-17 years) and reaches to its highest in 20-
24 years and decreases progressively thereafter [4, 5]. In
primary dysmenorrhea pain begins few hours before or
after the onset of menstruation and lasts for 24-48 hours.
The pain is more in the first day and rarely continues to
and may radiate into inner parts of thighs. In a high
percentage of cases, girls may experience systematic
symptoms such as backache, nausea, vomiting, diarrhea,
fatigue and headache [6]. With severe pain, the suffers
may be absent from school or work for one or two days [3]
and it could have negative impact on academic, social and
sports activities of young girls [7].
Although primary dysmenorrhea is not a real threat
of life, but can impact on the quality of female life and in
case of severity it may lead to disability and inefficiency
[8, 9]. On the other hand, dysmenorrhea can cause
psychological problems in some of the females resulting
in their loneliness and inactive participation in different
social activities [10]. The detrimental impact of
dysmenorrhea on the lives of women has been considered
by most of the researchers in this area. In many countries,
primary dysmenorrhea is the leading cause of recurrent
short-term school and work absenteeism in young girls
and women [7, 11]. Data from few longitudinal studies

Corresponding Author: Noorbakhsh Mahvash, College of Physical Education and Sport Sciences,
Islamic Azad University, Karaj Branch, Iran, POST: 17- Shenasa Street, Valye Asr Ave, Tehran, Iran.
Tel: +021-22058101, Cell: +09166148819, E-mail: mahvashnoorbakhsh@yahoo.com.
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 World Appl. Sci. J., 17 (10): 1246-1252, 2012
showed that the absenteeism from school due to primary
dysmenorrhea is 34 to 50 percent [12, 13]. Indeed, as
reported by many studies, there is a considerable cost to
both the individual and society as a result of
dysmenorrhea.
It is believed that symptoms of primary dysmenorrhea
stem from raised concentrations of prostaglandins F2"
(PGF2") resulting in uterine contractions and ischemia
[14]. One likely mechanism for increasing prostaglandins
is that, during premenstrual phase, progesterone
decreases which results in the synthesis of
prostaglandins in endometrial cells by membrane
phospholipids. This process is supported by the ability of
prostaglandin synthesis inhibitors in pain relief. As these
inhibitors only provide pain relief in 70% to 75% of
women, other factors may also be involved [1]. The
results of studies carried out in North America, China,
Australia, Turkey and Iran have shown that the
prevalence of primary dysmenorrhea and percentage of
women involved are different from society to society [15-
19]. Based on findings of these and other studies,
dysmenorrhea is one of the most important health issues
of young girls which must be considered because many
researchers claimed that primary dysmenorrhea affects
between 50 to 90% of general population [7, 13, 20- 25].
Due to its importance, different treatments including
medical and non-medical treatment such as taking non-
steroidal anti-Inflammatory drugs (NSAIDS), herbal,
dietary therapies, yoga, meditation and acupuncture have
been used to reduce the effects of dysmenorrhea [18, 21,
26- 28].
Although these treatments are generally thought to
reduce the discomfort associated with dysmenorrhea, it is
believed that participation in regular physical activity is
another positive way of dysmenorrhea treatment by which
it may diminish the symptoms of dysmenorrhea in
exercising young girls and women. Shavandi et al. (2009)
studied the effect of 8 weeks isometric exercise on primary
dysmenorrhea and reported that intensity and duration of
pain-induced by primary dysmenorrhea are reduced and
less medicine is taken, but it has no effect on the amount
of bleeding [19]. Shahrjerdi and Sheikh Hoseini (2010)
reported that the severity and length of pain due to
primary dysmenorrhea in young girls following 8 weeks
stretching exercises are diminished and they take
significantly less medicine [29]. However, a number of
studies have shown a correlation between life stress and
gynecological symptoms. Similarly, women who train
intensively have been found to experience fewer
symptoms than women who take part in physical activities
occasionally or not taking part at all [30].
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In spite of the fact that many findings
support the positive effect of physical activities on
primary dysmenorrhea few studies results showed no
effect of physical activities on primary dysmenorrhea
[31, 32].
Due to the fact that dysmenorrhea has been treated
successfully with stress reduction techniques [33, 34],
physical activities and exercise are widely accepted as
a means of moderating stress and stress- related
symptoms. Exercise is known to cause the release of
endorphins hormones in brain that raise the pain
threshold and is shown to improve mood of
exercising subjects. However, because of high
prevalence of primary dysmenorrhea in different
societies and the potential benefits of exercise found
in treating dysmenorrhea and also existence of few
studies which claimed that physical activity has no
effect on primary dysmenorrhea the purpose of this
study was to investigate the effects of physical activities
on primary dysmenorrhea of Iranian female university
students.
MATERIALS AND METHODS
All single and non-athlete female university students
from Islamic Azad University-Karaj Branch aged 23.34
2.35 years who enrolled in Physical Education Courses of
the first semester of academic year of 2010-2011 (N=256)
as research population took part in this semi-experimental
study. Using Mc Gills questionnaire [35], 50 students
with moderate to severe primary dysmenorrhea were
selected as samples and based on their menstrual history
and data obtained from this questionnaire, were randomly
divided into experimental (N=25) and control (N=25)
groups. After obtaining ethical clearance from
Universitys committee for research on human subjects all
subjects participated in an introductory session. Purposes
and methods of study were explained. Thereafter, all
subjects completed the different parts of questionnaire. In
the first part of the questionnaire demographic
characteristics regarding age, mass body index and
university subject were assessed. In the second part of
the questionnaire menstrual characteristics including type
and number of drugs consumed, volume (quality and
quantity) and rate of bleeding and onset of menstruation
and length of menstruation pain were evaluated. In the
third part, female students were asked to quantify their
menstrual characteristics including pain intensity by Pain
Rate Index (PRI), Visual Analog Scale (VAS) and Present
Pain Intensity (PPI) and total pain according to Mc Gills
 World Appl. Sci. J., 17 (10): 1246-1252, 2012

short form questionnaire. Total pain score is equal to the
total scores obtained from all dimensions of pain. Final
scores calculated from the third part of questionnaire were
from 0 to 60; from 0 to 45 was considered for PRI, from 0
to 10 was considered for VAS and from 0 to 5 was
considered for PPI. The reliability of McGill questionnaire
was confirmed (r = 0.93).
Physical Activity Protocol: Experimental group took part
in training program for 8 weeks, 3 sessions a week, 90
minutes in a session in two cycles under supervision of
Physical Education experts. Control group only took part
in ordinary class which was one session a week. Physical
activity program included 5-10 minutes warm up, 30-45
minutes progressive stretching exercises specified for
pelvic region, 10-15 minutes stretching exercises using
partner, 10-15 minutes resistant exercises focusing on hip
girdle muscles and 5-10 minutes cool down. At the end of
program, the questionnaires were completed by subjects
as post- test by both groups. Subjects in control group
were requested not to take part in any regular exercise
program except their one university session up to the end
of the study.
To check the normality of data Kolmogorov-Smirnov
test was used in order to analyze the findings [36]. Chi-
square and independent and dependent t-test at
significant level of P#0.05 were also used.
RESULTS
Demographic Characteristics of Subjects: As shown in
Table 1, there were no significant differences in the
demographic characteristics between subjects of the
experimental and control groups.
Physical Activities-Induced Changes in Primary
Dysmenorrhea Symptoms: When comparing different
types of drugs consumed by experimental and control
group, significant difference was found between two
groups (p=0.057). In pre-test Ibuprofen as a drug was
used by most subjects in both groups. But when
comparing the findings of post-test after 8 weeks of
physical activities, no significant difference was found in
experimental group (p=0.08) and type of drug consumed
was changed from Ibuprofen to Acetaminophen in
experimental group without change in control group
(Table 2).
When comparing the volume of bleeding in both
groups no significant difference was found in pre-test
(p=0.1) but a significant decrease was seen in post-test
comparing experimental and control groups (p=0.002)
(Table 2).
In relation to the onset of menstruation pain, the
findings showed no significant differences between two
groups in pre-test (p=0.43) and post-test (p=0.27)
(Table 2).
When comparing the number of drugs consumed by
both groups, there were no significant differences
between experimental and control groups in pre-test
(p=0.754) and post-test (p=0.175) (Table 3).
But comparing number of drugs used by experimental
group in pre and post-test, significant difference was
found (p=0.01) (Table 4).
When comparing the rate of bleeding based on the
number of pads used, a significant difference between
experimental and control groups was found (p=0.005)
(Table 3).The findings also showed a significant
difference between pre and post-test of experimental
group (p=0.05) (Table 4).

Table 1: Comparison of characteristics between experimental and control groups

Variables Experimental Group N=25 Control Group P-value N=25 W
Age (years, MeanSD) 22.84 1.79 23.8 4 2.91 p> 0.05
Weight (Kg, MeanSD) 56.39 9.05 60.63 9.27 p> 0.05
Height (Cm, MeanSD) 169.26 5.53 163.86 4.64 p> 0.05
Body Mass Index (K g/m, MeanSD) 22.07 3.61 22.64 3.37 p>0.05
Age at onset of menstruation (years, MeanSD) 13.43 1.8 12.77 1.47 p> 0.05
Length of menstruation cycle (days, MeanSD) 6.78 1.27 5.86 1.28 p> 0.05
Length of menstruation phase (days, MeanSD) 25.87 3.68 26.54 3.93 p> 0.05

Table 2: Comparison of primary dysmenorrhea characteristics between experimental and control groups based on Chi-square analysis
Variables K df p-value
Type of drugs consumption Pre-test 2.9 4 0.57
Post-test 8.1 4 0.08
Volume of bleeding (quality) Pre-test 4.604 2 0.10
Post-test 15.21 3 0.002
Onset of menstruation pain Pre-test 2.74 3 0.43
Post-test 3.85 3 0.27

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 World Appl. Sci. J., 17 (10): 1246-1252, 2012

Table 3: Comparison of primary dysmenorrhea characteristics of experimental and control groups based on independent t-test analysis
Variables Mean Diff. df t p-value
Number of drugs consumed Pre-test 0.16 48 0.315 0.754
Post-test 0.73 48 1.315 0.175
Rate of bleeding Pre-test 0.96 48 1.58 0.12
Post-test 1.92 48 4.18 0.005
Length of menstruation pain Pre-test 0.17 48 -0.39 0.69
Post-test 1.74 48 3.28 0.001
Volume of bleeding(quantity) Pre-test 0.18 48 0.33 0. 75
Post-test 0.50 48 -0.35 0.72

Table 4: Comparison of primary dysmenorrhea characteristics between pre and post-test of experimental group based on dependent t-test analysis
Variables Mean diff. df t p-value
Number of drugs consumed 1.040 24 2.68 0.01
Rate of bleeding 0.84 24 3.05 0.005
Length of menstruation pain(days) 0.6 24 2.05 0.05
Volume of bleeding(quantity/CC) 2 24 2.87 0.008

Table 5: Comparison of primary dysmenorrheal pain between experimental and control groups assessed by Mc Gills questionnaire based on independent
t-test analysis
Variables Mean diff. df t p-value
Pain Rate Index (PRI) -6.56 48 -6.56 0.01
Visual Analog Scale(VAS) -0.84 48 -1.97 0.05
Present Pain Intensity (PPI) -1.04 48 -4.9 0.05
Total Pain 8.37 48 -9.21 0.01

When comparing the length of menstruation pain it
was found that this item is significantly decreased in
experimental group (p=0.05) (Table 4).
The results also showed that the difference
between the length of menstruation pain of
experimental and control groups was significant (p=0.001)
(Table 3).
When comparing the volume of bleeding, there was
no significant difference between data of control group in
pre and post-test (p=0.22), but this difference was
significant in experimental group (p=0.008) (Table 4).
When the findings of two groups regarding the volume of
bleeding was compared, no significant difference was
observed (p=0.72) (Table 3).
In regard to Pain Rate Index (PRI), the findings
showed no significant difference in pre and post-test of
control group (p=0.14), but this difference was significant
comparing pre and post-test of experimental group
(p=0.01). PRI was also significantly different between
experimental and control groups (p=0.01) (Table 5).
Findings from Visual Analog Scale (VAS) and the
Present Pain Intensity (PPI) which assess the total and
present intensity of pain, showed that significant
reduction was found between experimental and control
groups (p=0.05) in both cases in favor of experimental
group (Table 5).
The results of the study also showed that the total
amount of pain reduction was significantly more in
experimental group (p=0.01) in comparison with control
group (Table 5).
DISCUSSION AND CONCLUSION
The main findings of this study indicated that
physical activity had a positive impact on the most of
primary dysmenorrhea symptoms in such a way that type
of drugs consumption changed from Ibuprofen to
Acetaminophen (p#0.05). Volume and rate of bleeding
decreased (p#0.002, p#0.05). Length of menstruation pain
reduced (p#0.05), number of drugs consumed reduced,
but not significantly and finally Pain Rate Index and Total
and Present Pain Intensity reduced (p#0.01, p#0.05).
Regarding type of drugs used by subjects prior to
study, it was found that experimental group participating
in physical activity protocol replaced Acetaminophen
with Ibuprofen which is a strong pain relief meaning that
physical activity resulted in more tolerable menstruation
thereafter. This finding is in line with Thirza et al. [17].
Due to the fact that painful menstruation may limit
social activities and may also lead to school missing
[15, 17, 18, 21, 37] young girls try to use strong drugs
such as Ibuprofen to prevent these problems.

1249
 World Appl. Sci. J., 17 (10): 1246-1252, 2012
Our findings also showed that the number of drugs
consumed by experimental group decreased comparing
pre and post-test data. This result is in agreement with
Shavandi et al. [19], Abbaspour et al. [38] and Shahrjerdi
and Sheikh Hoseini [29]. The reasons for this reduction
might be due to that when menstruation is very
painful, the suffers use more drugs and prefer to take anti-
inflammatory type such as Ibuprophen or other strong
drugs.
When volume of bleeding was studied, our results
indicated that volume of bleeding was significantly
lowered in post- exercise group. In addition to the
evidence that experimental group had lower volume of
bleeding after 8 weeks of physical activity, it is suggested
that physical activity might reduce, in some degree, the
magnitude of bleeding, because it may lead to a better
hormonal balance. On the other hand, evidence shows
that anti diuretic hormone is active during physical
activity and the vasoconstriction action of this hormone
and variations in pelvic blood flow may influence the
synthesis or breakdown of prostaglandins [1]. This
finding is not in line with the results obtained from
Shavandi et al. [19] which indicated that there is no
change in the volume of bleeding in post-exercise young
girls.
Our results also depicted that rate of bleeding based
on the number of pads changed per day, was reduced
significantly in experimental group. This finding supports
the notion that doing exercise may reduce the volume of
bleeding and suggested that exercise may actually be
associated with higher level of menstrual discomfort.
Regarding the length of menstruation pain, the
finding of this study showed that the length of
menstruation pain was reduced significantly in our
experimental group after 8 weeks training. This
finding is supported by previous studies carried out by
Shavandi et al. [19], Iorno et al. [28] and Shahrjerdi and
Sheikh Hoseini [29]. One likely mechanism for reducing
the length of menstruation pain in post-exercise group is
that physical activity may help a faster transfer of vast
products and prostaglandins as a root of menstruation
pain from uterine muscle. This result is not in agreement
with Kermanshahi et al. [39] which might be due to age of
subjects and training conditions.
Our findings in association with intensity of primary
dysmenorrhea pain obtained from McGills questionnaire
using Pain Rate Index and Visual Analog Scale for
assessing the total and present pain intensity revealed
that the intensity of pain was reduced in experimental
group after completing training protocol. Even though, a
1250
number of studies have failed to find any relation between
intensity of primary dysmenorrhea pain and physical
activity [31, 32], other studies such as Smith et al. [27],
Iorno et al. [28], Abbaspour et al. [38], Shahrjerdi and
Sheikh Hoseini [29] and Izzo and Labriola [30] support our
results. One possible mechanism explaining the positive
effect of physical activity on intensity of primary
dysmenorrhea pain is associated with stress. It has been
accepted that exercise is used as a mean of moderating
stress. Menstrual pain may be resulted from increased
contraction of uterine muscle which is innervated by the
sympathetic nervous system. Stress is supposed to
increase the sympathetic activity which may lead to the
increase of menstrual pain by enhancing the intensity of
uterine contraction. So, due to the fact that exercise
reduce and moderate stress, the sympathetic activity
may be decreased. Thereby, intensity of menstrual pain
and other related symptoms may be reduced as well.
Another possible dilemma in this respect is that, because
doing physical activity leads to the release of endorphins
which are produced by brain may enhance the pain
threshold.
In conclusion, the results of the present study
suggested that performing regular physical activity
reduced the primary dysmenorrhea symptoms. As a factor
it has been accepted that in developing countries such as
Iran, participating in regular physical activity programs
are limited by social, cultural and religious factors.
Therefore, because of high potential benefits of physical
activity and exercise in reducing the detrimental effects of
primary dysmenorrhea symptoms, young girls are
recommended to take part in such physical activity
programs in order to help them to decrease the negative
impact of these symptoms on their academic, social and
even personal life.
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