{"paper_id":"f8ce6859-cc37-4b3f-8201-efaed7e3a22b","body_text":"Abstract\nBackground\nEndometriosis is associated with persistent pain and a broad symptom burden. We evaluated the effects of repeated structured exercise using published adjusted or longitudinal trial estimates where available and small-sample meta-analytic methods.\nMethods\nThis PRISMA 2020 systematic review was registered in PROSPERO (CRD420261400459). Six databases and ClinicalTrials.gov were searched through 20 August 2026 without language restriction; backward citation searching was also performed. Two reviewers independently screened records and full texts, extracted data, assessed result-level risk of bias and rated certainty; disagreements were resolved by discussion and, when required, a third reviewer. Random-effects meta-analyses used restricted maximum likelihood (REML) with Hartung–Knapp inference and alternative small-k models. GRADE used review-stage clinical decision thresholds.\nResults\nThe searches identified 3,197 database records and 68 ClinicalTrials.gov records. Eight reports from six independent trials were included, and five trials contributed quantitative data. Overall endometriosis-related pain (4 trials, N = 271) yielded SMD − 0.36 (95% CI − 0.95 to 0.24; I²=57.2%; prediction interval − 1.74 to 1.03). Psychological distress (3 trials, N = 243; SMD − 0.29, 95% CI − 1.43 to 0.85) and sexual function (3 trials, N = 144; MD − 2.23, 95% CI − 5.96 to 1.51) were also very uncertain. Statistical significance differed across random-effects specifications for five syntheses. Harms reporting was inconsistent. Certainty was very low for all key outcomes.\nConclusions\nCurrent randomised evidence does not establish a clinically important benefit of structured exercise for endometriosis-associated pain or the wider symptom burden. Point estimates generally favoured exercise, but the evidence is very uncertain because trials were few and small, confidence intervals were wide, several syntheses were method-dependent, and risk-of-bias concerns were common. Decisions to use structured exercise should be individualised according to patient preference, general physical-activity guidance, comorbidity and tolerance rather than an assumed endometriosis-specific benefit; better powered trials and systematic harms reporting are needed.\nRegistration\nPROSPERO CRD420261400459 (registered 20 May 2026; post-registration amendments are reported in the manuscript and supplementary materials).\nSimilar content being viewed by others\nAbbreviations\n- ANCOVA:\n-\nAnalysis of covariance\n- CENTRAL:\n-\nCochrane Central Register of Controlled Trials\n- CI:\n-\nConfidence interval\n- DASS-21:\n-\nDepression Anxiety Stress Scales-21\n- EHP-30:\n-\nEndometriosis Health Profile-30\n- EQ-VAS:\n-\nEuroQol visual analogue scale\n- FSFI:\n-\nFemale Sexual Function Index\n- FSI:\n-\nFatigue Symptom Inventory\n- GIQLI:\n-\nGastrointestinal Quality of Life Index\n- GRADE:\n-\nGrading of Recommendations Assessment, Development and Evaluation\n- HADS:\n-\nHospital Anxiety and Depression Scale\n- HK:\n-\nHartung-Knapp\n- HRQoL:\n-\nHealth-related quality of life\n- HSCL-5:\n-\nHopkins Symptom Checklist-5\n- KESS:\n-\nKnowles-Eccersley-Scott Symptom score\n- MD:\n-\nMean difference\n- NRS:\n-\nNumeric rating scale\n- OIS:\n-\nOptimal information size\n- PCS:\n-\nPain Catastrophizing Scale\n- PFMT:\n-\nPelvic-floor muscle training\n- PRISMA:\n-\nPreferred Reporting Items for Systematic Reviews and Meta-Analyses\n- PROSPERO:\n-\nInternational Prospective Register of Systematic Reviews\n- PSQI:\n-\nPittsburgh Sleep Quality Index\n- RCT:\n-\nRandomised controlled trial\n- REML:\n-\nRestricted maximum likelihood\n- RoB 2:\n-\nCochrane risk-of-bias tool for randomised trials\n- SE:\n-\nStandard error\n- SMD:\n-\nStandardised mean difference\n- VAS:\n-\nVisual analogue scale\n- τ²:\n-\nBetween-study variance\nAcknowledgements\nChatGPT (OpenAI) was used to assist with language editing. Responsibility for eligibility decisions, risk-of-bias and certainty judgements, numerical results and the final manuscript rests with the authors.\nFunding\nNo funding was received for this study.\nAuthor information\nAuthors and Affiliations\nCorresponding authors\nEthics declarations\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare no competing interests.\nAdditional information\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nSupplementary information\nBelow is the link to the electronic supplementary material.\nRights and permissions\nOpen Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.\nAbout this article\nCite this article\nSun, M., Zhu, Y., Wang, L. et al. Effects of structured exercise training on pain and multidimensional symptom burden in women with endometriosis: an updated systematic review and meta-analysis. BMC Psychol (2026). https://doi.org/10.1186/s40359-026-05724-7\nReceived:\nAccepted:\nPublished:\nDOI: https://doi.org/10.1186/s40359-026-05724-7","source_license":"CC0","license_restricted":false}