Effect of physical activity and exercise on symptoms associated with endometriosis: a systematic review | BMC Women’s Health


Selection of studies

This study identified 1879 citations (Fig. 1). After removing the duplicates, the remaining 1,045 citations were selected for eligibility based on title and abstract. Seventeen publications were assessed for further inclusion by reading the full versions of the articles, and four publications were included for quality assessment. [25,26,27,28]. We identified four studies that described an intervention incorporating PA and / or exercise: two were RCTs [27, 28] and two were pre-post studies without a control group [25, 26] (Tables 1, 2).

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) flow diagram for identification, selection, eligibility and inclusion of relevant articles

Table 1 Assessment of the quality of controlled intervention studies
Table 2 Quality assessment of before-after (pre-post) studies without a control group

Assessment of the quality, risk of bias and assessment of the exercise intervention

One study was rated as fair [27], while three were judged to be of poor quality [25, 26, 28]. The detailed assessment, including the signaling questions, is presented in Tables 1 and 2. The RCT of Carpenter et al. [27] was rated as of fair quality (Table 1). The main limitation of this RCT for the purposes of this review was that the participants were treated with danazol, which is a potent drug to treat endometriosis. Despite having a control group, the study was not powerful enough to determine if exercise had an additional effect on danazol. However, since the study was designed to find out whether exercise could alleviate the side effects of danazol, it was not inherently wrong. In addition, the sample was too small to allow comparisons of individual side effects, important secondary outcomes (pelvic pain, dysmenorrhea, and dyspareunia) were not reported, and methods of randomization and assessment of patients. results have not been reported.

The RCT of Gonçalves et al. [28] was judged to be of poor quality due to significant differences in baseline characteristics between the intervention and control groups (Table 1). The intervention group had a higher level of education, a higher percentage of housewives, and a lower employment rate, confusing quality of life ratings. In addition, one of the inclusion criteria was the presence of treatment-resistant CPP, which is a possible confounding factor for symptoms associated with endometriosis. In addition, the control group also received physiotherapy. Finally, the dropout rate in the intervention group was very high, at 30% (vs. 0% in the control group).

The study by Friggi Sebe Petrelluzzi et al. [25] was rated as of fair quality (Table 2). As in Gonçalves et al. [28] only women with treatment-resistant endometriosis and CPD were included, which is a confounding factor. In addition, no sample size calculations were reported and there was no control group. The intervention involved not only PA and exercise, but also a range of modalities, including cognitive behavioral therapy, which confuses the contribution of PA and exercise to symptom improvement.

The study by Awad et al. [26] was found to be of poor quality (Table 2). It was ultimately excluded from the synthesis because its design was fatally flawed by initiating medroxyprogesterone acetate, an effective hormone treatment for endometriosis, at the same time as the intervention but without including a control group. In addition, no sample size calculation was provided and the inclusion and exclusion criteria appeared to be clinically random.

Individual scores for articles based on the CERT Checklist (Supplementary File 3) ranged from 7 to 14. None of the articles provided a description of exercise progress. [25,26,27,28], and only one included a description of personalized exercises [27]. Exercise adherence was adequately measured in a study [27], just like motivational strategies [25]. The level of exercise was only described for two studies [27, 28].

Populations studied

The total study sample consisted of 109 participants [25, 27, 28] (Table 3). Two studies included women with surgically confirmed endometriosis [25, 27], while it was not specified how endometriosis was diagnosed by Gonçalves et al. [28]. The stage of endometriosis was not reported for any of the studies. The age of the women included was provided for two studies [25, 28]. All women in two studies [25, 28] also had the CPP. Details of previous hormonal or surgical treatments were not provided for any of the studies.

Table 3 Characteristics of the included studies


The interventions performed are listed in Table 1. No follow-up studies have been carried out after the end of the intervention. Confounding interventions on PA and exercise were identified in all studies, as explained above. The limits in reporting exercise interventions (according to CERT) are also explained above.

Primary and secondary outcome measures

Primary and secondary outcomes for all studies are shown in Table 3. Only one study had “pain” as primary outcome. [25]. Results reporting were incomplete for all studies.

Effect of intervention on pain

Gonçalves et al. [28] reported that the degree of daily pain was significantly lower in the intervention group than in the control group, although the difference in mean scores on a visual analog scale (VAS) was not provided (pHealth Profile-30 (EHP-30) were significantly lower in the yoga group than in the control group after the intervention (32.39 ± 21.95 vs. 55 , 05 ± 21.49, p

Friggi Sebe Petrelluzzi et al. [25] did not find significant improvement in pain intensity (variation in VAS score from pre-treatment to post-treatment: 4.00 ± 0.56 to 3.30 ± 0.65, p> 0.05). Carpenter et al. [27] found that pelvic pain was reduced in both the intervention and control groups, with medical treatment using danazol providing no additional effect compared to that obtained with PA and exercise. However, the exact results and the level of significance were not reported, leaving it uncertain whether a Type II error was present due to the too small sample size.

Effects of the intervention on aspects of mental health and well-being

The study by Friggi Sebe Petrelluzzi et al. [25] measured stress levels using the Perceived Stress Questionnaire (PSQ), salivary cortisol levels and the 36-point Short-Form Health Survey (SF-36). The PSQ was developed as an outcome measure in psychosomatic research and has been validated for use in Brazil [29]. Perceived stress was significantly lower at pretreatment (0.62 ± 0.02) than after treatment (0.56 ± 0.02, ppp= 0.04), but this was not correlated with perceived stress as measured with PSQ. Gonçalves et al. [28] found significant improvements in some elements of EHP-30 (control and helplessness, emotional well-being and self-image) in the intervention group compared to the control group (p

Effect of the procedure on pelvic floor dysfunction

The study by Carpenter et al. [27] evaluated how exercise during treatment with danazol could improve pelvic floor symptoms such as dyspareunia and dysmenorrhea. These authors reported that symptoms improved in both groups, but values ​​and significance levels were not provided. Gonçalves et al. [28] found that the sexual intercourse domain of EHP-30 was lower after 8 weeks of Hatha yoga in the intervention and control groups, but the result did not reach inter- or intra-group significance.


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