Behavioural interventions for primary and secondary dysmenorrhoea

Traditional Chinese medicine interventions based on meridian theory for pain relief in patients with primary dysmenorrhea: a systematic review and network meta-analysis

Objective

To determine the comparative effects and safety of traditional Chinese medicine (TCM) interventions based on meridian theory for pain relief in patients with primary dysmenorrhea (PD).

Methods

This is a systematic review with network meta-analysis. Randomized controlled trials (RCTs) comparing meridian-based TCM interventions with waitlist, placebo, western medicine, and conventional therapies for PD pain. A SUCRA was used to estimate the probability ranking for the effects of interventions.

Results

57 RCTs involving 3,903 participants and 15interventions were included. Thirty-two RCTs were rated as low risk of bias. A network diagram was drawn with 105 pairs of comparisons. Compared with NSAIDs and waitlist, significantly better effects were found in acupressure [SMD = -1.51, 95%CI (-2.91, -0.12)/SMD = -2.31, 95%CI (-4.61, -0.02)], warm needling [SMD = -1.43, 95%CI (-2.68, -0.18)/SMD = -2.23, 95%CI (-4.43, -0.03)], moxibustion [SMD = -1.21, 95%CI (-1.85, -0.57)/SMD = -2.10, 95%CI (-3.95, -0.07)], and acupuncture [SMD = -1.09, 95%CI (-1.62, -0.55)/SMD = -1.89, 95%CI (-3.67, -0.11)]. No adverse events were detected.

Conclusion

For PD pain, the effects of acupressure, acupuncture, warm needling, and moxibustion were superior to those of NSAIDs and waitlist. Oral contraceptive pill, electro-acupuncture, acupressure, and warm needling demonstrated higher probabilities of being better interventions. More high-quality clinical trials are needed to provide more robust evidence of this network.

Systematic review registration

PROSPERO CRD42022373312.

Dysmenorrhea, a Narrative Review of Therapeutic Options

Dysmenorrhea is the most common pathology women of childbearing age face. It is defined as painful uterine cramping associated with menstruation. Primary dysmenorrhea occurs in the absence of an organic cause, whereas secondary dysmenorrhea is pelvic pain associated with an underlying pelvic pathology. The purpose of this review is to discuss the pathophysiology of dysmenorrhea and provide a discussion of pharmacologic and non-pharmacologic treatment options. Prostaglandins play a large role in the pathophysiology of dysmenorrhea by causing myometrial contraction and vasoconstriction. The first-line treatment for dysmenorrhea is with nonsteroidal anti-inflammatory drugs due to the inhibition of cyclooxygenase enzymes, thereby blocking prostaglandin formation, as well as hormonal contraception. Other pharmacologic treatment options include Paracetamol, as well as Gonadotrophic Release Hormone Analogs, which are typically used in the treatment for endometriosis. Non-pharmacologic treatments with strong evidence include heat therapy and physical exercise. There are less evidence-based data behind other modalities for treating dysmenorrhea, such as dietary supplements, acupuncture, and transcutaneous nerve stimulation, and these methods should be used in conjunction with first-line therapy after a discussion of risks and benefits. Lastly, for women who fail medical management, surgical options include endometrial ablation, presacral neurectomy, and laparoscopic uterosacral nerve ablation. Further research is needed to measure the socioeconomic burden of dysmenorrhea on the healthcare system and to evaluate the efficacy of treatment combinations, as a multi-modal approach likely provides the most benefit for women who suffer from this condition.

The Effects of Electrode Placement on Analgesia Using Transcutaneous Electrical Nerve Stimulation for Primary Dysmenorrhea: A Single-Blind Randomized Controlled Clinical Trial

Background Primary dysmenorrhea (PD) refers to the occurrence of painful menstrual cramps without pathological involvement of the pelvic organs, with considerable morbidity and high prevalence among females of reproductive age. Objective The objective of this study is to present and test the efficacy of an innovative method of interactive transcutaneous electrical nerve stimulation (iTENS) for PD. Methods and materials This study is a single-blind controlled clinical trial. This was conducted at the outpatient clinic of the faculty of physical therapy. Females with PD (n=124) were divided into the treated group (transcutaneous electrical nerve stimulation {TENS} group {TG}, n=62) and the placebo group (PG, n=62). A single session of either iTENS or placebo intervention was used for 35 minutes. Pain, the duration of analgesia, and the use of pain medication were assessed before and after the intervention. Data from before and after the treatment were compared between groups (Student's t-test). The level of significance was set at 5%. Results A significant decrease in pain (p<0.001) was observed after the intervention for the TG, with a more long-lasting analgesia (p<0.001) and decreased need for pain medication (p<0.001). Conclusions The proposed method of transcutaneous electrical nerve stimulation (TENS) application showed positive results for pain management on females with PD, with no reported adverse effects. The new proposed TENS application takes into account the preferences of the patient regarding positioning and the number of channels needed to cause analgesia. This application was able to promote almost complete analgesia in females with primary dysmenorrhea, and the analgesia persisted for more than one menstrual cycle.

Efficacy of individualized homeopathic medicines in primary dysmenorrhea: a double-blind, randomized, placebo-controlled, clinical trial

OBJECTIVES

Homeopathic treatment is claimed to be beneficial for primary dysmenorrhoea (PD); still, systematic research evidences remain compromised. This study was undertaken to examine the efficacy of individualized homeopathic medicines (IH) against placebo in the treatment of PD.

METHODS

A double-blind, randomized, placebo-controlled trial was conducted at the gynecology outpatient department of Mahesh Bhattacharyya Homoeopathic Medical College and Hospital, West Bengal, India. Patients were randomized to receive either IH (n=64) or identical-looking placebo (n=64). Primary and secondary outcome measures were 0-10 numeric rating scales (NRS) measuring intensity of pain of dysmenorrhea and verbal multidimensional scoring system (VMSS) respectively; all measured at baseline, and every month, up to 3 months. Group differences and effect sizes (Cohen's d) were calculated on intention-to-treat (ITT) sample.

RESULTS

Groups were comparable at baseline (all p>0.05). Attrition rate was 10.9% (IH: 7, placebo: 7). Differences between groups in both pain NRS and VMSS favoured IH over placebo at all time points (all p<0.001, unpaired t-tests and two-ways repeated measures analysis of variance) with medium to large effect sizes. Natrum muriaticum and Pulsatilla nigricans (n=20 each; 15.6%) were the most frequently prescribed medicines. No harms, serious adverse events and intercurrent illnesses were recorded in either of the groups.

CONCLUSIONS

Homeopathic medicines acted significantly better than placebo in the treatment of PD. Independent replication is warranted. Trial registration: CTRI/2018/10/016013.

Effect of Yoga on Dysmenorrhea in 6th Grade Elementary School Students at Rusunawa Health Center: A Quasi-Experimental Study

BACKGROUND: From 35 elementary school students in Marunda, 23 students (65.7%) had primary dysmenorrhea. Dysmenorrhea can interfere with student learning activities and concentration. Interventions need to be given so that students can increase their productivity and learning achievement. AIM: This study aims to analyze the effect of yoga on dysmenorrhea in 6th grade elementary school students at Rusunawa Health Center. MATERIALS AND METHODS: This study used a quasi-experimental approach with a non-equivalent control group design. The yoga group was given yoga practice for 3 months of the menstrual cycle. The sample consisted of 33 students in the yoga group and 33 students in the control group. Dysmenorrhea pain intensity was measured by Wong Baker Pain Rating Scale. Statistical tests used were Friedman test, Mann–Whitney test, and Ordinal Regression test. RESULTS: There was a significant difference in pain duration and pain intensity of dysmenorrhea in the past 3 months in the yoga group (p < 0.001). There was a significant difference in pain duration and pain intensity of dysmenorrhea between the yoga group and control group on the measurements in the 2nd month (p = 0.009; p < 0.001) and the 3rd month (p < 0.001; p < 0.001). CONCLUSIONS: Yoga had a significant effect in reducing the pain duration and pain intensity of dysmenorrhea in 6th grade elementary school students at Rusunawa Health Center. Midwives can educate elementary school students and young women in the working area of Rusunawa Health Center to use yoga as an alternative therapy to reduce dysmenorrhea.

The efficacy of eye movement desensitization and reprocessing in reducing anxiety among female university students with primary dysmenorrhea

Background

Unpleasant experiences of dysmenorrhea can lead to increased anxiety. The anxiety associated with dysmenorrhea is a pain-related anxiety which might reduce the efficacy of medication as well as enhance the perception of pain. The present study evaluated the efficacy of eye movement desensitization and reprocessing (EMDR) in reducing anxiety among female university students with primary dysmenorrhea.

Methods

In this randomized controlled trial, 88 female university students were recruited from April 2019 to February 2020. Eligible participants were selected by convenience sampling and were allocated into study groups (44 individuals in the intervention group and comparison group) using balanced block randomization. The final sample comprised 78 participants who completed the study (39 individuals in each group). Data were collected using the Spielberger State-Trait Anxiety Inventory, Subjective Units of Distress Scale, and Validity of Cognition Scale before the intervention and at the time of the first menstrual period after completion of the intervention. The intervention group received EMDR in two individual interventional sessions which lasted approximately one hour. Data analysis was performed using analysis of variance with control of covariance method at a significance level of 0.05.

Results

The results of the study showed that EMDR did not have a statistically significant effect on State-Trait Anxiety of patients with dysmenorrhea (p > 0.05). Based on the Cohen’s d effect size of 0.06 for state-anxiety, -0.01 for trait-anxiety, and partial eta square less than 0.059 for both uncorrected and corrected models, the intervention was within a trivial effect.

Conclusion

EMDR intervention did not have a statistically and clinically significant effect on State-Trait Anxiety of patients with dysmenorrhea. Therefore, the efficacy of EMDR in treating dysmenorrhea-related anxiety remains inconclusive.

Trial registration IRCT20180823040851N2 on 2019-02-09.

Treatment of endometriosis: a review with comparison of 8 guidelines

Background

Endometriosis, the presence of endometrial-like tissue outside the uterus, is a common clinical entity between women of reproductive age, with a prevalence of about 10%. Due to the variety of endometriosis-associated symptoms, a great variety of treatments have been implemented. The aim of this review is to give an overview on therapeutical approaches of eight national and international widely used guidelines.

Methods

Six national (College National des Gynecologues et Obstetriciens Francais, National German Guideline (S2k), Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians (ACOG) and Gynecologists, American Society for Reproductive Medicine (ASRM) and National Institute for Health and Care (NICE) and two international (World Endometriosis Society, European Society of Human Reproduction and Embryology) guidelines are included in this review.

Conclusion

All the above-mentioned guidelines agree that the combined oral contraceptive pill, progestogens are therapies recommended for endometriosis associated pain. Concerning infertility, there is no clear consensus about surgical treatment. Discrepancies are also found on recommendation of the second- and third-line treatments.

An Open Trial of a Mind-Body Intervention for Young Women with Moderate to Severe Primary Dysmenorrhea

OBJECTIVE

To evaluate the feasibility, acceptability, and preliminary efficacy of a mind-body intervention for moderate to severe primary dysmenorrhea (PD).

DESIGN

Open trial (single arm).

SETTING

Academic medical school.

SUBJECTS

A total of 20 young adult women with moderate to severe primary dysmenorrhea were included across four separate intervention groups.

METHODS

All participants received five 90-minute sessions of a mind-body intervention and completed self-report measures of menstrual pain, depression, anxiety, somatization, and pain catastrophizing at baseline, post-treatment, and at one-, two-, three-, and 12-month follow-up. Self-report of medication use and use of skills learned during the intervention were also collected at all follow-up points.

RESULTS

Participants reported significantly lower menstrual pain over time compared with baseline. No changes in anxiety, depression, or somatization were observed, although pain catastrophizing improved over time. Changes in menstrual pain were not associated with changes in medication use or reported use of skills.

CONCLUSIONS

A mind-body intervention is a promising nondrug intervention for primary dysmenorrhea, and future research should focus on testing the intervention further as part of a randomized clinical trial.

Integrating Lifestyle Focused Approaches into the Management of Primary Dysmenorrhea: Impact on Quality of Life

OBJECTIVE

This narrative review aims to identify alternative ways to improve the symptoms of primary dysmenorrhea (PD).

BACKGROUND

PD refers to endometrial painful cramps during the premenstrual period. This condition affects a lot of women worldwide and is accompanied with absenteeism and high economic costs, thus, risk-free, and effective therapeutic approaches are needed. Pharmacological agents such as non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs), which are widely prescribed for these women, demonstrate adequate efficacy in alleviating pain and discomfort. The long natural course of the disease dictates remedies that focus on lifestyle changes and on improvement of Quality-of-Life (QoL) for women suffering with PD.

MATERIALS AND METHODS

Five major search engines, namely MEDLINE, PubMed, EMBASE, and Cochrane Library were searched for articles published prior to October 2020 focused in PD. A total of 74 paper were included.

DISCUSSION

Physical activity, for instance yoga, aromatherapy massage, and other forms of relaxation, vitamins and dietary changes, acupressure and acupuncture,a and some psychological interventions are just few of the proposed health behavior targeted approaches in cases of PD. This review focuses on lifestyle changes and alternative methods that could potentially result in minimizing symptoms of PD and in improving overall QoL for these patients, by providing current scientific evidence on their efficacy.

CONCLUSION

Complementary and alternative medicine practices (CAM) are widely accepted by women. International literature provides controversial scientific evidence, thus further studies need to be conducted in order to prove or disregard their efficacy in cases of PD.

Significant Increase in Depression in Women With Primary Dysmenorrhea: A Systematic Review and Cumulative Analysis

Women with primary dysmenorrhea are vulnerable to develop a depressive disorder, which is a common form of psycho-disturbance. However, clinical findings are inconsistent across studies, and the evidence has not been previously synthesized. This study aims to investigate whether primary dysmenorrhea is associated with a higher risk of depression via a cumulative analysis. Four electronic databases were systematically searched for the eligible studies. The combined effect was assessed by analyzing the relative risk (RR) and standard mean differences (SMD) with a 95% confidence interval (CI). This cumulative analysis was registered on the PROSPERO (ID: CRD42020169601). Of 972 publications, a total of 10 studies involving 4,691 participants were included. Pooled results from six included studies showed that primary dysmenorrhea was associated with a significant depressive disorder (RR = 1.72, 95%CI: 1.44 to 2.0, P < 0.001; heterogeneity: I ² = 0%, P = 0.544). In addition, synthesis results from two studies provided the BDI scores suggested that dysmenorrhea had significantly higher scores when compared to non-dysmenorrhea (SMD = 0.47, 95% CI: 0.31-0.62, P < 0.001; heterogeneity: I ² = 0%, P = 0.518). However, in the two studies providing the PROMIS T-Score, the pooled result showed that there was no significant difference between women with dysmenorrhea and those without dysmenorrhea (P = 0.466). The overall quality of the evidence in our study was judged to MODERATE. The present study has confirmed the positive relationship between primary dysmenorrhea and depression. Social supports and medical help from pain management physicians or psychologists are important interventions for women with dysmenorrhea-suffering depressive disorder.

Efficacy of herbal medicine (cinnamon/fennel/ginger) for primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To assess the efficacy of herbal medicine (cinnamon/fennel/ginger) for treating primary dysmenorrhea.

METHODS

Relevant studies were searched in multiple databases. The weighted mean difference (WMD) was used as the effect indicator for measurement data, and each effect size was given estimates and 95% confidence intervals (CIs).

RESULTS

Nine studies with 647 patients were selected. Compared with the results in the control group, pain intensity was significantly relieved in the trial group when assessed by the intervention (cinnamon vs. placebo: WMD = 1.815, 95% CI = 1.330-2.301; fennel vs. placebo: WMD = 0.528, 95% CI = 0.119-6.829; ginger vs. placebo: WMD = 2.902, 95% CI = 2.039-3.765), observation period (one cycle: WMD = 2.061, 95% CI = 0.815-3.307; one cycles: WMD = 1.831, 95% CI = 0.973-2.690), and study quality (high quality: WMD = 2.224, 95% CI = 1.488-2.960). Pain duration was significantly shorter in the trial group (cinnamon vs. placebo: WMD = 16.200, 95% CI = 15.271-17.129). No publication bias was observed for either outcome.

CONCLUSIONS

For primary dysmenorrhea, cinnamon/fennel/ginger effectively reduced pain intensity, and cinnamon shortened the duration of pain. Further studies are needed to confirm our results.

Personal perception and body awareness of dysmenorrhea and the effects of rhythmical massage therapy and heart rate variability biofeedback-A qualitative study in the context of a randomized controlled trail

OBJECTIVE

The purpose was to involve women's personal experiences of daily life with primary dysmenorrhea (PD) and their body perceptions of the dysmenorrhea-related symptoms in relation to the treatment procedure and to explore the perception of Heart Rate Variability Biofeedback (HRV-BF) or Rhythmical Massage (RM) according to Ita Wegman as a therapeutic intervention within the framework of Anthroposophic Medicine (AM).

DESIGN

From 60 women who participated in our randomized controlled trial analyzing the effects of HRV-BF or RM, we examined 14 women to get an in-depth understanding of this prevalent disease, using a qualitative design. The women drew their body image before and after the 3-month-intervention on body silhouette diagrams and described their body-perceptions. Semi-structured interviews were conducted and analyzed using content analysis.

RESULTS

Women perceive dysmenorrhea as a disturbance of their daily lives. The body images showed the variations of experience, from misbalances of body perception to overwhelming attacks of pain hindering a normal life for several days per month. Perception of therapeutic interventions range from relaxing without effects on complaints to important changes and benefits on the physical, emotional, and/or social level. Both therapies can support stronger self-awareness through enabling a more differentiated sense of body-awareness, sometimes resulting in women experiencing fewer limitations in their daily lives. Effects may be influenced by the readiness to resonate with the therapeutic process. Qualitative interviews and body images can serve as tools to integrate individuality and help to integrate embodied more or less conscious aspects of complaints.

CONCLUSIONS

The body silhouette diagram could be used systematically to include reflections of embodiment in the therapeutic and research settings and help to diagnose in advance the ability of participants to resonate with interventions. RM and HRV-BF influence self-awareness and may enable salutogenic and self-management capacities. For more effective treatment it may be helpful to make treatment suggestions based on an integrative individual history that includes preferences, expectations and a body silhouette diagram.

Investigating the effect of Eye Movement Desensitization and Reprocessing on pain intensity in patients with primary dysmenorrhea: a protocol for a randomized controlled trial

Background

Unpleasant experience with the previous menstruation can increase the sensitivity to pain which may lead to moderate to severe pain in patients with dysmenorrhea. Eye movement desensitization and reprocessing (EMDR) is a psychological method to alleviate the distress from unpleasant memories and related events and can be used for other conditions such as anxiety, depression, and chronic pain. This protocol was designed to investigate the effect of EMDR therapy on pain intensity in patients with dysmenorrhea.

Methods/Design

A randomized clinical trial was designed in compliance with the Consolidated Standards of Reporting Trials (CONSORT). Female students who have moderate to severe primary dysmenorrhea (based on a visual analogue scale [VAS] score of at least 4 for two consecutive months) and who live in dormitories at Qazvin University of Medical Sciences in Qazvin, Iran will be invited to participate in the study. The total sample size will be 88 girls, who will be randomly assigned to intervention (N = 44) and control (N = 44) groups. EMDR therapy will be performed for the intervention group, while the control group can use sedative or other pain relife methods as their routin... There will be six treatment sessions, which will be held twice a week. The duration of each session is 30–90 min, according to the convenience of each participant. The data will be collected using the demographic characteristics questionnaire, the VAS, the Subjective Units of Anxiety or Distress Scale (SUD), and the Validity of Cognition Scale (VOC). The data on pain intensity due to primary dysmenorrhea in both groups will be collected at 1 and 2 months before the intervention (to identify eligible participants) and 1 and 2 months after the intervention (follow-ups). Data will be analyzed by using SPSS version 25 software and analysis of variance (ANOVA) with repeated measures with appropriate post hoc tests. A P value of less than 0.05 will be considered significant.

Discussion

The results are expected to provide the information on the efficacy of EMDR therapy to manage moderate to severe pain in patients with primary dysmenorrhea.

Ethics and dissemination

The research proposal is approved by the human ethics committee of Qazvin University of Medical Sciences (IR.QUMS.REC.1397.100). The results of this trial will be submitted for publication in a peer-reviewed research journal.

Trial registration

IRCT20180823040851N1. Registered on 6, October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3507-0) contains supplementary material, which is available to authorized users.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews

BACKGROUND

Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure.

OBJECTIVES

To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions.

METHODS

We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively.

MAIN RESULTS

We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance.

AUTHORS' CONCLUSIONS

The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.

Beliefs About Dysmenorrhea and Their Relationship to Self-Management

Dysmenorrhea is highly prevalent and is the leading cause of work and school absences among women of reproductive age. However, self-management of dysmenorrhea is not well understood in the US, and little evidence is available on factors that influence dysmenorrhea self-management. Guided by the Common Sense Model, we examined women's representations of dysmenorrhea (beliefs about causes, symptoms, consequences, timeline, controllability, coherence, and emotional responses), described their dysmenorrhea self-management behaviors, and investigated the relationship between representations and self-management behaviors. We conducted a cross-sectional, web-based survey of 762 adult women who had dysmenorrhea symptoms in the last six months. Participants had varied beliefs about the causes of their dysmenorrhea symptoms, which were perceived as a normal part of life. Dysmenorrhea symptoms were reported as moderately severe, with consequences that moderately affected daily life. Women believed they understood their symptoms moderately well and perceived them as moderately controllable but them to continue through menopause. Most women did not seek professional care but rather used a variety of pharmacologic and complementary health approaches. Care-seeking and use of self-management strategies were associated with common sense beliefs about dysmenorrhea cause, consequences, timeline, and controllability. The findings may inform development and testing of self-management interventions that address dysmenorrhea representations and facilitate evidence-based management. © 2016 Wiley Periodicals, Inc.

Nonsteroidal anti-inflammatory drugs for dysmenorrhoea

BACKGROUND

Dysmenorrhoea is a common gynaecological problem consisting of painful cramps accompanying menstruation, which in the absence of any underlying abnormality is known as primary dysmenorrhoea. Research has shown that women with dysmenorrhoea have high levels of prostaglandins, hormones known to cause cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that act by blocking prostaglandin production. They inhibit the action of cyclooxygenase (COX), an enzyme responsible for the formation of prostaglandins. The COX enzyme exists in two forms, COX-1 and COX-2. Traditional NSAIDs are considered 'non-selective' because they inhibit both COX-1 and COX-2 enzymes. More selective NSAIDs that solely target COX-2 enzymes (COX-2-specific inhibitors) were launched in 1999 with the aim of reducing side effects commonly reported in association with NSAIDs, such as indigestion, headaches and drowsiness.

OBJECTIVES

To determine the effectiveness and safety of NSAIDs in the treatment of primary dysmenorrhoea.

SEARCH METHODS

We searched the following databases in January 2015: Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, November 2014 issue), MEDLINE, EMBASE and Web of Science. We also searched clinical trials registers (ClinicalTrials.gov and ICTRP). We checked the abstracts of major scientific meetings and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised controlled trial (RCT) comparisons of NSAIDs versus placebo, other NSAIDs or paracetamol, when used to treat primary dysmenorrhoea.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed their risk of bias and extracted data, calculating odds ratios (ORs) for dichotomous outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs). We used inverse variance methods to combine data. We assessed the overall quality of the evidence using GRADE methods.

MAIN RESULTS

We included 80 randomised controlled trials (5820 women). They compared 20 different NSAIDs (18 non-selective and two COX-2-specific) versus placebo, paracetamol or each other. NSAIDs versus placeboAmong women with primary dysmenorrhoea, NSAIDs were more effective for pain relief than placebo (OR 4.37, 95% CI 3.76 to 5.09; 35 RCTs, I(2) = 53%, low quality evidence). This suggests that if 18% of women taking placebo achieve moderate or excellent pain relief, between 45% and 53% taking NSAIDs will do so.However, NSAIDs were associated with more adverse effects (overall adverse effects: OR 1.29, 95% CI 1.11 to 1.51, 25 RCTs, I(2) = 0%, low quality evidence; gastrointestinal adverse effects: OR 1.58, 95% CI 1.12 to 2.23, 14 RCTs, I(2) = 30%; neurological adverse effects: OR 2.74, 95% CI 1.66 to 4.53, seven RCTs, I(2) = 0%, low quality evidence). The evidence suggests that if 10% of women taking placebo experience side effects, between 11% and 14% of women taking NSAIDs will do so. NSAIDs versus other NSAIDsWhen NSAIDs were compared with each other there was little evidence of the superiority of any individual NSAID for either pain relief or safety. However, the available evidence had little power to detect such differences, as most individual comparisons were based on very few small trials. Non-selective NSAIDs versus COX-2-specific selectorsOnly two of the included studies utilised COX-2-specific inhibitors (etoricoxib and celecoxib). There was no evidence that COX-2-specific inhibitors were more effective or tolerable for the treatment of dysmenorrhoea than traditional NSAIDs; however data were very scanty. NSAIDs versus paracetamolNSAIDs appeared to be more effective for pain relief than paracetamol (OR 1.89, 95% CI 1.05 to 3.43, three RCTs, I(2) = 0%, low quality evidence). There was no evidence of a difference with regard to adverse effects, though data were very scanty.Most of the studies were commercially funded (59%); a further 31% failed to state their source of funding.

AUTHORS' CONCLUSIONS

NSAIDs appear to be a very effective treatment for dysmenorrhoea, though women using them need to be aware of the substantial risk of adverse effects. There is insufficient evidence to determine which (if any) individual NSAID is the safest and most effective for the treatment of dysmenorrhoea. We rated the quality of the evidence as low for most comparisons, mainly due to poor reporting of study methods.

Evaluation of a group based cognitive behavioural therapy programme for menstrual pain management in young women with intellectual disabilities: protocol for a mixed methods controlled clinical trial

BACKGROUND

Menstrual pain which is severe enough to impact on daily activities is very common amongst menstruating females. Research suggests that menstrual pain which impacts on daily functioning may be even more prevalent amongst those with intellectual disabilities. Despite this, little research attention has focused on pain management programmes for those with intellectual disabilities.The aims of this pilot study were to develop and evaluate a theory-based cognitive behavioural therapy (CBT) programme for menstrual pain management in young women with intellectual disabilities.

METHODS/DESIGN

The study utilised a mixed methods controlled clinical trial to evaluate elements from a CBT programme called Feeling Better (McGuire & McManus, 2010). The Feeling Better programme is a modular, manualised intervention designed for people with an intellectual disability and their carers. The programme was delivered to 36 young women aged 12-30 years who have a Mild-Moderate Intellectual Disability, split between two conditions. The treatment group received the Feeling Better intervention and the control group received treatment as usual. To evaluate the effectiveness of the programme, measures were taken of key pain variables including impact, knowledge, self-efficacy and coping. Process evaluation was conducted to examine which elements of the programme were most successful in promoting change.

DISCUSSION

Participants in the intervention group were expected to report the use of a greater number of coping strategies and have greater knowledge of pain management strategies following participation in the intervention and at three month follow-up, when compared to control group participants. A significant advantage of the study was the use of mixed methods and inclusion of process evaluation to determine which elements of a cognitive behavioural therapy programme work best for individuals with intellectual disabilities.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN75567759.

A preliminary pilot randomized crossover study of uzara (Xysmalobium undulatum) versus ibuprofen in the treatment of primary dysmenorrhea

OBJECTIVE

Preliminary evaluation of efficacy and safety of uzara use in treatment of moderate and severe primary dysmenorrhea in comparison to ibuprofen.

MATERIALS AND METHODS

This randomized, comparative two way cross-over study comprised 60 single female students at Faculty of Medicine, Ain Shams University, Egypt, aged 19-28 years with moderate (n = 46) or severe (n = 14) primary dysmenorrhea. Participants were randomized to take either uzara (80 mg/8 hours for two doses, then 40 mg/8 hours) then ibuprofen (400 mg/6 hours) in two subsequent cycles or vice versa. The pain intensity, using VAS, was recorded immediately before taking the medication (0 hour) and after 4, 12, 24, 48-60, 96-120 hours. Main outcome measures included effectiveness of pain relief defined as drop of VAS to 3 or less, patient's global evaluation of the drug, absence from school, the use of a rescue medication, and, in those who continued the treatment, the pain intensity difference (PID) at different points after start of medication and its sum (SPID).

RESULTS

Uzara was comparably effective to ibuprofen (78.3% vs. 86.7% of cycles; respectively), with comparable rates of effectiveness on global evaluation (being around 50% for either drug), and rates of school absences (11.7% vs. 13.3%; respectively). The need for rescue medication was different (18.3% and 10%; respectively), albeit with no statistical significance. The means of PID at different time points and SPID were comparable, with significantly lower average mean of VAS scores compared to that felt with no medication (1.6 vs. 6.8, p<0.001). Side effects were less with uzara than ibuprofen (0% vs. 8.3%, p<0.05).

CONCLUSIONS

Uzara might be as effective as ibuprofen in management of primary dysmenorrhea but with less side effects. These findings need to be confirmed by a properly designed trial with a larger sample size.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN25618258.

Complementary and Alternative Medicine in the Treatment of Chronic Pelvic Pain in Women: What Is the Evidence?

Chronic pelvic pain (CPP) is defined as pain of at least 6 months' duration that occurs in the lower abdomen or below the umbilicus and has resulted in functional or psychological disability or required intervention and treatment. Therapeutic interventions center around the treatment of CPP as a diagnosis in and of itself, and treatment of specific disorders that may be related to CPP. A multidisciplinary approach for diagnosis and treatment seems to be most effective for symptomatic relief. This paper reviews the evidence for such interventions as psychological treatments including the use of complementary and alternative medicine techniques for CPP in women. Unfortunately, finding the best evidence in this setting is difficult as only very few randomized controlled trials are available. A combination of treatments is usually required over time for the treatment of refractory CPP. The multifactorial nature of CPP needs to be discussed with the patient and a good rapport as well as a partnership needs to be developed to plan a management program with regular followup. Promotion of a multidisciplinary approach which includes complementary and alternative medicine techniques in managing CPP in women seems to yield the best results.

The effect of aromatherapy abdominal massage on alleviating menstrual pain in nursing students: a prospective randomized cross-over study

Dysmenorrhea is a common cause of sickness absenteeism from both classes and work. This study investigated the effect of aromatherapy massage on a group of nursing students who are suffering of primary dysmenorrhea. A randomized blind clinical trial of crossover design was used. In the first treatment phase, group 1 (n = 48) received aromatherapy abdominal massage once daily for seven days prior to menstruation using the essential oils (cinnamon, clove, rose, and lavender in a base of almond oil). Group 2 (n = 47) received the same intervention but with placebo oil (almond oil). In the second treatment phase, the two groups switched to alternate regimen. Level and duration of pain and the amount of menstrual bleeding were evaluated at the baseline and after each treatment phase. During both treatment phases, the level and duration of menstrual pain and the amount of menstrual bleeding were significantly lower in the aromatherapy group than in the placebo group. These results suggests that aromatherapy is effective in alleviating menstrual pain, its duration and excessive menstrual bleeding. Aromatherapy can be provided as a nonpharmacological pain relief measure and as a part of nursing care given to girls suffering of dysmenorrhea, or excessive menstrual bleeding.

Oral fennel (Foeniculum vulgare) drop effect on primary dysmenorrhea: Effectiveness of herbal drug

BACKGROUND

Primary dysmenorrhea refers to the occurrence of painful menstrual cramps of uterus and is considered as a gynecological complaint. The common treatment for this problem is medical therapy such as mefenamic acid [non-steroidal anti-inflammatory drugs (NSAIDs)] and oral contraceptive pills, both of which work by reducing myometrial activity. Fennel contains an antispasmodic and anethol agents and may be helpful for management of primary dysmenorrhea.

MATERIAL AND METHODS

The aim of this study was to evaluate the effects of oral fennel drop for treating primary dysmenorrhea. Sixty college students suffering from primary dysmenorrhea were randomly assigned to two groups and followed up for two cycles. Statistical analysis was performed using SPSS version 16. P < 0.05 was considered to be statistically significant. Parametric and non-parametric tests were adopted.

RESULTS

Comparison of pain intensity in the two groups showed that there was no significant difference in pain relief between the two groups. Comparison of bleeding severity in the study group before and after intervention was demonstrated from the first day to the fifth day (PV on first day, second day, third day, fourth day, and fifth day 0.948, 0.330, 0.508, 0.583, 0.890, respectively).

CONCLUSION

It seems that fennel can be effective in reducing the severity of dysmenorrhea, but it has an unpleasant taste in view of most of the volunteers.

Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials

Chronic pelvic pain (CPP), a common cause of disability in women, is a condition best viewed in the biopsychosocial framework. Psychological interventions are frequently considered alongside medical and surgical treatments. Our objective was to evaluate the effectiveness of psychological therapies for the treatment of CPP. Electronic literature searches were conducted in Medline, Embase, PsycInfo and DARE databases from database inception to April 2010. Reference lists of selected articles were searched for further articles. The studies selected were randomized controlled trials of psychological therapies in patients with CPP compared with no treatment, standard gynecological treatment or another form of psychological therapy. Two reviewers independently selected articles without language restrictions and extracted data covering study characteristics, study quality and results. Reduction in pain, measured using visual analog scales or other measurements, was the main outcome measure. Of the 107 citations identified, four studies satisfied the inclusion criteria. Compared with no psychological intervention, therapy produced a standardized mean pain score of -3.27 [95% confidence interval (CI) -4.52 to -2.02] and 1.11 (95% CI -0.05 to 2.27) at 3 months and -3.95 (95% CI -5.35 to -2.55) and 0.54 (95% CI -0.78 to 1.86) at 6 months and greater, based on a visual analog scale score of 0-10. The current evidence does not allow us to conclude whether psychological interventions have an effect on self-reported pain scores in women with CPP.

Effect of three yoga poses (cobra, cat and fish poses) in women with primary dysmenorrhea: a randomized clinical trial

OBJECTIVE

We have evaluated the clinical efficacy of yoga for primary dysmenorrhea. Primary dysmenorrhea occurs in 50% of female adolescents and is a common problem in women of reproductive age. We have assessed whether three yoga poses (Cobra, Cat, and Fish Poses) are able to reduce severity and duration of primary dysmenorrhea.

METHODS

To determine the effectiveness of yoga in adolescents with primary dysmenorrhea, 92 girl students,18-22 years old, were randomly assigned to an experimental group (n = 50) and a control group (n = 42). The Visual Analog Scale for Pain was used to assess intensity of pain and the pain duration was calculated in terms of hours. Each group was evaluated for three menstrual cycles. At first cycle no method was presented; the participants only were asked to complete the questionnaire of menstrual characteristics during their menstrual. Then the participants were asked by the experimental group to do yoga poses at luteal phase, and also to complete the menstrual characteristics questionnaire in during of menstruation. The control group did not receive any intervention except to complete menstrual characteristics questionnaire in during of menstruation.

RESULTS

There was a significant difference in the pain intensity and pain duration in the post-tests compared with the pretest in yoga group (P < 0.05). The results showed that compared with the Control group, there was a significant difference in the pain intensity and pain duration in the experimental group (P < 0.05).

CONCLUSION

Yoga reduced the severity and duration of primary dysmenorrhea. The findings suggest that yoga poses are safe and simple treatment for primary dysmenorrhea.

Women's health: selected topics

Complementary and alternative medicine (CAM) therapies have become increasingly popular for the treatment of a variety of conditions. The World Health Organization has recognized the value of traditional healing techniques, which are classified as CAM, for 30 years. In the United States nearly 50% of women use CAM for common medical conditions, significantly more than men. This pattern is frequently seen in the treatment of women's health conditions such as infertility, premenstrual syndrome, and menopause. This article provides an integrative approach for conditions commonly encountered in the primary care setting among women, discusses alternative therapies used to treat these health conditions, and provides an evidence-based summary of recommendations based on a review of the literature.

Dysmenorrhea

Primary dysmenorrhea is commonly a straightforward diagnosis that can be made accurately with an attentive history. In young women who have classic symptoms and no specific indication, a pelvic examination is often unnecessary in the initial evaluation. The opportunity for primary care practitioners to support women in unearthing the best approach to this chronic recurrent discomfort to minimize adverse life impact is significant and valuable. Identification of patients who are incapacitated by their symptoms or have symptoms that represent underlying pathology is a critical component of a careful history. The wide range of treatments available for primary dysmenorrhea virtually ensures that all females troubled by the symptoms can find relief with safe and inexpensive treatments while limiting negative side effects.