The Effect of Exercise On Menstrual Symptoms: A Randomised Controlled Trial

The Effect of Exercise On Menstrual Symptoms: A Randomised Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Effect of Exercise On Menstrual Symptoms: A Randomised Controlled Trial Merve Koçak, Ömer Şevgin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4669670/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Aug, 2025 Read the published version in BMC Women's Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Menstrual symptoms are a prevalent and frequently encountered women's health condition. The objective of this study was to examine the impact of exercise on menstrual symptoms, sleep quality, fatigue, and physical activity levels. Methods The study was designed as a randomized controlled trial conducted between September 2023 and December 2023. The study included 54 women aged 19 to 45 years. Participants were divided into two groups: a control group and an exercise group. All participants were evaluated with the Menstrual Symptom Questionnaire (MSQ), the Menstrual Distress Questionnaire (MDQ), the Fatigue Severity Scale (FSS), the Pittsburgh Sleep Quality Index (PSQI), and the International Physical Activity Questionnaire-Short Form (IPAQ) before and after treatment. The control group did not receive an exercise program. The exercise group received an exercise program including strengthening, flexibility, and balance exercises. A moderate-intensity aerobic exercise and walking program was implemented at least three days per week. The study spanned three menstrual cycles for each woman and lasted an average of 12 weeks. Results Within-group analysis showed a significant decrease in MSQ, MDQ (menstrual), FSS, and PSQI scores after exercise. In contrast, the IPAQ score increased significantly in the exercise group. In the control group, a significant decrease was observed only in the MDQ (intermenstrual) score. A comparison of the pre-treatment and post-treatment changes in the exercise and control groups revealed a significant decrease in MSQ, MDQ (menstrual), and PSQI scores and an increase in IPAQ scores in the exercise group compared to the control group. However, the decrease in MDQ (pre-menstrual and intermenstrual) and FSS scores were not statistically different between the groups. Conclusions In conclusion, exercise had a positive effect on the severity of menstrual symptoms, sleep quality, and fatigue in women with menstrual symptoms. Women who exercised had a decrease in menstrual symptoms and an increase in sleep quality. Exercise can be employed as a non-pharmacological method to help women manage their symptoms. Trial registration: The protocol is registered with http://clinicaltrials.gov/ (17/August/2023, Clinical Trial, NCT06006507). Menstrual symptoms Physical activity Sleep Fatigue Menstrual pain Figures Figure 1 INTRODUCTION Menstrual periods may be associated with several symptoms including dysmenorrhea, migraines, and a variety of somatic symptoms (e.g. breast tenderness, abdominal bloating, swelling) and affective symptoms (e.g. depression, irritability, anxiety, confusion) ( 1 ). Menstrual symptoms are experienced by 90% of women worldwide, representing a significant public health concern. The most prevalent menstruation-related symptoms are premenstrual syndrome (PMS) and dysmenorrhea, which is defined as painful menstruation. Dysmenorrhea is characterized by the presence of cramps in the back and lower abdomen, as well as nausea, diarrhea, fatigue, and headache. PMS encompasses a range of emotional and physical symptoms that typically manifest during the luteal phase of the menstrual cycle, approximately five days before menstruation. The most severe form of premenstrual syndrome (PMS) is called premenstrual dysphoric disorder (PMDD), and it is associated with a greater prevalence of cognitive disorders ( 2 ). Women who suffer from PMS, PMDD, dysmenorrhea, or abnormal uterine bleeding have reported poor sleep quality ( 3 , 4 ). Also, in individuals with PMDD, the onset of menstruation is accompanied by a worsening of symptoms such as insomnia, fatigue, and memory impairment ( 5 ). Given that these symptoms persist until menopause, menstrual periods have a significant financial burden, including reduced work productivity, hospital visits, and medication costs ( 6 ). Despite the significant public health implications of menstrual symptoms, there is a paucity of knowledge regarding effective management strategies ( 6 ). These treatment methods can be either pharmacologic or nonpharmacologic. In light of the potential adverse effects and financial implications of pharmacological approaches, non-pharmacological methods emerge as a more viable option ( 7 ). The non-pharmacological treatments include healthy nutrition, psychosocial approaches, massage, meditation, heat application, psychotherapy, mind-body techniques, herbal supplements, acupuncture, and dance therapy ( 8 ). There is a growing body of evidence suggesting that increased physical activity and lifestyle changes may alleviate symptoms commonly experienced by women, including fatigue, and depression. Additionally, regular exercise has been shown to relieve menstrual symptoms ( 9 ). It was observed that high physical activity levels were associated with a shorter duration of menstruation, a lower dysmenorrhea and polymenorrhea incidence, and a lower premenstrual syndrome prevalence ( 10 ). Furthermore, physical exercise has been suggested to decrease the severity of premenstrual syndrome ( 8 ). However, further research is needed to confirm these potential benefits ( 2 , 3 , 5 ). It is also known that people with excessive fatigue, poor sleep quality and menstrual symptoms have a negative impact on their overall health. However, there is still no consensus on the optimal type, duration, and frequency of exercise for these individuals ( 11 ). In light of these findings, the current study aimed to investigate the effect of the treatment of physical exercise on menstrual symptoms, sleep quality, fatigue, and physical activity level. METHODS Study design The research was carried out as a single-blind, randomized controlled study, adhering to the ethical principles outlined in the Declaration of Helsinki and approved by the ethics committee. This study was conducted and reported following the Consolidated Standards of Reporting Trials (CONSORT) statement. This study was conducted between September 2023 and December 2023 after obtaining ethical approval from the Uskudar University Non-Interventional Research Ethics Committee with reference number 61351342/December 2022-67. The protocol is registered with http://clinicaltrials.gov/ (17/August/2023, Clinical Trial, NCT06006507). Determination of sample size The sample size was calculated using the G*Power Version 3.1.6 program. A total of 54 participants were required to determine the medium effect size (f = 0.25 effect) at 95% power and a 0.05 alpha significance level, given that the difference was deemed to be statistically significant. The population of the study consists of women between the ages of 18–50. The number of patients participating in the study was initially 63. However, 9 participants were excluded from the study for various reasons. Consequently, 54 participants completed the study (Fig. 1). Randomization and blinding The investigation was conducted as a single-blind randomized controlled trial following established principles of research design. The evaluator evaluated the study as single-blinded. A total of 63 participants participated in the study and were randomly assigned to the exercise group (n:32) and the control group (n:31) by simple randomization. Randomization was carried out using the sealed envelope method. A total of 69 participants were initially eligible to participate in the study. The inclusion criteria were as follows: signing the voluntary consent form, being between the ages of 18 and 50, having a menstrual cycle, having emotional or physical problems during menstruation, and having a menstrual cycle between 21 and 35 days on average. Exclusion criteria were as follows: having any chronic disease or diagnosed gynecologic disease, receiving pharmacologic treatment for menstrual symptoms, having amenorrhea, exercising regularly, and having any orthopedic or neurologic problem preventing exercise. The study was finally finalized with 54 participants. Figure 1 shows the flow of participants throughout the study. Figure 1. CONSORT flowchart. Intervention and procedure The participants were randomly allocated to two groups: an exercise group and a control group. The participants were contacted individually and their menstrual patterns were documented. The Personal Information Form, Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ) were prepared in Google Forms and sent via WhatsApp on the first day of menstruation before the study commenced. The exercise group received exercise programs via the phone application Fiziu on the first day of their menstrual periods. The application provided visual and audio support for the exercises, which were defined in personal accounts. The participants' email addresses and phone numbers were utilized to access the application, and a code was provided to the participants for the exercise program created through the application. The initial exercises were performed with the physiotherapist, and the subsequent exercises were assigned as an individual home program. A follow-up form was created to monitor the progress of the exercise group. The practicing physiotherapist met with the participants on two days per week and recorded each meeting on this form. No application was made to the control group, nor was any additional warning given. Throughout the study, participants were in regular communication with the research team. After approximately 12 weeks (on the first day of their fourth menstrual period), all questionnaires were completed, and the study was concluded. Exercise program The exercise group engaged in an exercise program that included 150 minutes of moderate-intensity walking per week and half an hour of strengthening, flexibility, and balance exercises two days per week for three months (with an average duration of 12 weeks). This program was designed following the World Health Organization's recommendations. A speech test was administered to enable individuals to self-determine the intensity of their exercise. Mild intensity is defined as a pace at which the individual can both speak and sing. Moderate intensity is defined as a pace at which the individual is unable to sing but can still speak. The most severe level of exertion is indicated by the individual being unable to speak or sing, and experiencing respiratory distress ( 12 ). The walking program was completed for a total of 150 minutes per week at a moderate intensity, distributed over at least three days of the week, with a minimum of 10 minutes per session. A program comprising whole-body strengthening, flexibility, and balance exercises was developed. The exercise program comprised a series of strengthening, flexibility, and balance exercises. The following exercises were prescribed for strengthening the muscles: squats, planks, bridges, sit-ups, scissors, prone back extensions, and modified push-ups. The following flexibility exercises were employed: shoulder roll, child's pose, adductor stretch, hamstring stretch, gastroc-soleus stretch, and cat camel exercise. A variety of postures on one leg were demonstrated as examples of balance exercises. The strengthening and flexibility exercises were planned as three sets of eight repetitions, while the balance exercises were planned for one minute. Outcome measurements The following demographic information was recorded in the demographic information form: age, height, weight, body mass index (BMI), employment status, education level, exercise habits, marital status, pregnancy status, number of pregnancies, smoking and alcohol habits. Furthermore, the age at menarche, menstrual pattern (regular-irregular), cycle duration, number of days of the menstrual period, and use of painkillers during menstruation were also recorded to ascertain the menstrual history and menstrual period characteristics. Menstrual Symptom Questionnaire (MSQ) It is a 5-point Likert-type scale and consists of 24 items with three sub-parameters: 'negative effects/somatic effects', 'menstrual pain', and 'coping methods'. Respondents select one of the following options for the symptoms they experience: "never, rarely, sometimes, often, and always". Never: 1, Rarely: 2, Sometimes: 3, Frequently: 4, Always: 5 points. The MSQ score is obtained by averaging the points given. A higher score indicates more severe menstrual symptoms. Turkish validity and reliability were developed by Güvenç et al. ( 13 ). Menstrual Distress Questionnaire (MDQ) The Menstrual Distress Questionnaire is comprised of eight subgroups, namely pain, water retention, autonomic reaction, negative affect, impaired concentration, behavioral changes, revitalization, and control, in addition to increased appetite. The scale comprises 47 items and is of the Likert-type. It evaluates premenstrual syndrome symptoms separately for the menstrual, premenstrual, and intermenstrual periods. Each item is scored from 0 to 4, with the maximum score that can be obtained from the scale being 184 for each period. The Menstrual Distress Complaint List was translated into Turkish and its validity and reliability were evaluated by Kızılkaya ( 14 ). Fatigue Severity Scale (FSS) The FSS is comprised of nine items in total. Each item on the scale is evaluated according to a Likert-type scale, with scores ranging from 1 to 7. The scale score is calculated by taking the mean of the nine items. A higher score on the scale indicates a greater degree of fatigue. A score of 4 or above is indicative of severe fatigue ( 15 ). The Turkish validity and reliability study was conducted by Armutlu et al. ( 16 ). Pittsburgh Sleep Quality Index (PSQI) The Pittsburgh Sleep Quality Index (PSQI) was developed as a means of assessing sleep quality. The test comprises 24 questions distributed across 10 main headings and is designed to assess sleep quality over the past month. The PSQI comprises seven sub-headings, as follows: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, sleep medication use, and daytime dysfunction. Each component is evaluated on a 0–3 point scale, with a total of 21 points. A score greater than 5 indicates poor sleep quality ( 17 ). Ağargün et al. conducted Turkish validity and reliability studies ( 18 ). International Physical Activity Questionnaire-Short Form (IPAQ) The International Physical Activity Questionnaire (IPAQ) was developed to assess the duration of various forms of physical activity, including vigorous exercise (e.g., soccer, volleyball, high-speed running, weight lifting), moderate exercise (e.g., light weight-bearing, cycling at moderate speed, dancing, table tennis), walking, and time spent sitting during the day. The short version of the questionnaire assesses the subject's activities over the past seven days. The validity and reliability study of the questionnaire in our country was conducted by Öztürk et al. ( 19 ). To calculate the total score from the questionnaire, the total days and minutes of walking, moderate physical activity, and vigorous physical activity are calculated. The questions in the questionnaire cover a minimum of 10 minutes of activity. The duration of walking, moderate-intensity physical activity, and vigorous physical activity are converted into METs (metabolic equivalents) corresponding to basal metabolic rate to calculate the total physical activity score (MET-min/week). According to the questionnaire, the physical activity score in a category is obtained by multiplying the total minutes and days of activity by the MET equivalent of that activity. These MET values are based on the metabolic rate of a 60-kilogram individual. One MET equals approximately 3.5 O2/kg/min ( 19 ). Data Analysis The data were analyzed using SPSS 15.0 (IBM SPSS Statistics for Windows, Version 15.0. Armonk, NY: IBM Corp) software. To compare the scale scores, parametric methods were employed. Normality was assessed using the Shapiro-Wilk normality test. Independent t-tests were employed for normally distributed measurements, while paired t-tests were utilized to compare pre-and post-treatment measurements within each group. For measurements that exhibited non-normal distributions in both groups, the Mann-Whitney U test was employed as a nonparametric alternative to the independent group t-test, and the Wilcoxon signed-rank test was utilized as an alternative to the dependent group t-test. The chi-square test was utilized to compare the relationship between the groups. All statistical analyses were conducted with a significance level of p < 0.05. RESULTS This was a randomized clinical study with 54 participants with menstrual symptoms conducted between September 2023 and December 2023. After the group allocation, 5 people in the exercise group and 4 participants in the control were excluded from the study because they did not complete the exercises or were unwilling to participate. At the end of the study, demographic data of the exercise (n: 27) and control (n:27) groups are as shown in Table 1. The sociodemographic information indicates that the groups exhibited statistically similar characteristics. Except for the number of pregnancies and age at menarche (p 0.05). Table 1. Demographic characteristics of the participants. Variable Exercise (n:27) Control (n:27) p* X ±SD X ±SD Age 30,3±6,3 32,7±6,6 0,100 Height (cm) 164,3±5,0 163,7±5,5 0,761 Weight (kg) 60,1±6,3 59,3±8,1 0,843 BMI (kg/m 2 ) 22,2±2,3 22,1±2,4 0,749 Number of Birth 0,3±0,8 0,6±0,8 0,060 Number of Pregnancy 0,4±1,2 0,7±1,1 0,049 Age at first period 13,4±1,0 12,6±1,1 0,016 Duration of menstrual period (days) 6,6±1,5 6,3±1,6 0,460 Duration of the menstrual cycle (days) 28,5±4,5 29,0±1,9 0,380 Employment Status n (%) n (%) Working 24 (88,9) 23 (85,2) 1,000 Not working 3 (11,1) 4 (14,8) Education Status Primary school 0 (0,0) 1 (3,7) 0,105 High school 0 (0,0) 3 (11,1) University 27 (100) 23 (85,2) Marital Status Single 18 (66,7) 12 (44,4) 0,100 Married 9 (33,3) 15 (55,6) Use of Painkillers During Period Sometimes 14 (51,9) 7 (25,9) 0,145 Every time 5 (18,5) 7 (25,9) No 8 (29,6) 13 (48,1) Exercise Habits Yes 13 (48,1) 7 (25,9) 0,091 No 14 (51,9) 20 (74,1) Smoking No 20 (74,1) 21 (77,8) 0,750 Yes 7 (25,9) 6 (22,2) Alcohol Use No 20 (74,1) 20 (74,1) 1,000 Yes 7 (25,9) 7 (25,9) *p<0.05. X: Mean, SD: Standard Deviation, BMI: Body Mass Index. Table 2 . Comparison difference of Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ) measures before and after the exercise treatment therapy. The change in the scores was calculated by subtracting post-treatment scores from pre-treatment scores. Rating Scale Exercise Group (n:27) X ± SD Control Group (n:27) X ± SD P 1 value Exercise Group Change X ± SD Control Group Change X ± SD P 2 value MSQ Pre-treatment 3,0±0,6 2,8±0,8 0,189 0,35±0,30 -0,06±0,46 0,001 Post-treatment 2,7±0,5 2,8±0,8 0,437 p time 0,001 0,532 MDQ (pre-menstrual) Pre-treatment 40,3±23,5 44,2±31,9 0,615 5,19±20,72 2,63±17,28 0,626 Post-treatment 36,0±28,4 41,6±33,1 0,593 p time 0,213 0,475 MDQ (menstrual) Pre-treatment 53,4±28,0 48,6±32,2 0,320 11,88±17,81 0,63±17,19 0,023 Post-treatment 41,5±27,0 48,0±29,5 0,408 p time 0,002 0,976 MDQ (inter-menstrual) Pre-treatment 14,9±13,1 26,1±25,0 0,169 -0,24±11,08 6,33±16,29 0,348 Post-treatment 16,1±12,9 19,8±22,0 0,927 p time 0,915 0,026 FSS Pre-treatment 4,6±1,2 4,0±1,5 0,134 0,55±0,89 -0,01±1,50 0,102 Post-treatment 4,1±1,3 4,1±1,3 0,980 p time 0,003 0,986 PSQI Pre-treatment 8,1±3,9 5,6±2,7 0,014 2,56±2,26 0,22±2,39 0,001 Post-treatment 5,6±3,4 5,4±3,1 0,701 p time 0,001 0,633 IPAQ-Short form Pre-treatment 1192,8±549,2 814,5±442,0 0,007 -571,8±435,4 -35,4±404,3 0,001 Post-treatment 1764,6±685,1 849,9±509,1 0,001 p time 0,001 0,653 p<0.05. X: Mean, SD: Standard Deviation. p time : Within-group treatment difference (p), P 1 value: Inter-group comparison of post and pre-treatment values (p), P 2 value: Inter-group treatment difference (p). Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ). The comparison differences of the assessments among the groups are presented in Table 2. Within-group analysis showed a significant decrease in MSQ, MDQ (menstrual), FSS, and PSQI scores after exercise. In contrast, the IPAQ score increased significantly in the exercise group (p < 0.05). In the control group, a significant decrease was observed only in the MDQ (intermenstrual) score (p < 0.05). No significant difference was observed between the exercise and the control group in the pre-treatment MSI, MDQ, and FSS scores. However, the exercise group exhibited statistically higher values than the control group in the PSQI and IPAQ scores (p < 0.05). There was no significant difference between the exercise group and the control group in terms of MSQ, MDQ, and PSQI scores after treatment, whereas the values of the exercise group were statistically higher than the control group in the IPAQ score (p<0.05). A comparison of the pre-treatment and post-treatment changes in the exercise and control groups revealed a significant decrease in MSQ, MDQ (menstrual), and PSQI scores and an increase in IPAQ scores in the exercise group compared to the control group (p < 0.05). However, the decrease in MDQ (pre-menstrual and intermenstrual) and FSS scores were not statistically different between the groups. DISCUSSION Our study was the first to investigate the effects of whole-body strengthening, flexibility, balance, and aerobic exercises on menstrual symptom severity, sleep quality, fatigue severity, and physical activity level in people with menstrual symptoms. The primary outcome was menstrual symptom severity. The secondary outcomes included sleep quality, fatigue severity, and physical activity level. The main results of the present study were: (i) The exercise group exhibited a marked reduction in MSQ, MDQ (menstrual), FSS, and PSQI scores, accompanied by an increase in IPAQ scores in post-treatment; (ii) Compared with the control group, decrease in MSQ, MDQ (menstrual), and PSQI scores were significantly higher in exercise group; (ii) The participants receiving exercise treatment showed a significant increase in IPAQ score in comparison to non-exercising women with the menstrual syndrome. It has been posited that the early age of menarche is associated with the early onset of ovarian function and the fluctuation of steroid hormones in individuals who lack physical and psychological maturity ( 6 ). In another study, it was stated that the early age of menarche increased the complaints of dysmenorrhea ( 20 ). Furthermore, a reduction in the number of pregnancies has been linked to an elevated risk of developing more severe PMS symptoms ( 21 ). In our study, the exercise and control groups were distributed heterogeneously concerning age at menarche and number of pregnancies. The mean age at menarche was lower and the mean number of pregnancies was higher in the control group. Given that no differences were observed between the groups in the pre-treatment evaluation of the MSQ and MDQ questionnaires, it can be concluded that the heterogeneity of the number of pregnancies and menarche age did not exert any influence on the course of the study. It has been demonstrated that aerobic exercise is an efficacious intervention for alleviating physical symptoms associated with premenstrual syndrome (PMS) and dysmenorrhea, including bloating, vomiting, hot flashes, and increased appetite ( 22 ). Another study demonstrated that aerobic exercise was an effective intervention for reducing both physical and psychological symptoms in individuals with PMS and PMDD ( 23 ). Vaghela et al. demonstrated that yoga and physical exercise can alleviate the pain severity and premenstrual symptoms after four weeks however; the yoga group exhibited greater improvements than the aerobic exercise group ( 24 ). In women with menstrual abnormalities, regular exercise has been demonstrated to reduce menstrual irregularities ( 25 ). In another study, functional exercise programs have been shown to be effective on the MSQ, PSQI, and low back and abdominal pain of dysmenorrhea patients ( 26 ). Core exercise programs have been shown to improve the pain level and quality of life of people with dysmenorrhea ( 27 ). Another meta-analysis study stated that menstrual pain can be reduced with aerobic exercise, strengthening, and flexibility exercises ( 28 ). In this study, whole-body strengthening, flexibility, balance, and aerobic exercises were applied in combination and alleviated symptoms such as menstrual pain and negative somatic effects. Therefore, the notable decline in MSQ scores among the exercise group is consistent with the findings of previous studies. Menstruation-related bleeding, pain, fatigue, and mood changes, collectively referred to as menstrual distress, have a profound impact on a woman's physical, social, and emotional well-being ( 29 ). Previous research has demonstrated that menstruation affects mood and cognitive function, potentially resulting in negative experiences that give rise to menstrual-related concerns and difficulties in coping with them ( 30 ). PMS and PMDD are thought to occur during the luteal phase of the menstrual cycle, approximately one week before menstruation. It is reported that these conditions resolve with the onset of menstruation ( 3 , 5 ). In this study, the data related to the pre-menstrual period were based on 1 week before menstruation. There were no significant changes in the MDQ (pre-menstrual) scores before and after treatment in the distress scores of the exercise and control groups. Accordingly, the absence of a reduction in the MDQ score for the menstrual period is inconsistent with the existing literature. This may be related to psychosocial factors or life stressors beyond the control of the current study. The prevalence of symptoms among women with PMS and PMDD is higher during the luteal phase. However, these women also report experiencing insomnia, inattention, fatigue, and memory problems during the follicular phase. The existing literature emphasizes the importance of physical activity in managing PMS and PMDD ( 5 ). The findings of this study support the association between exercise and menstrual symptoms. Many factors can affect women's menstrual symptoms such as poor eating habits, inactive lifestyle, alcohol and smoking habits, anxiety, and stress ( 5 , 31 ). In this study, the MDQ score of the inter-menstrual period decreased significantly in the control group despite the absence of any intervention. The observed change in the control group did not result in a significant difference among groups. This suggests that the observed differences may be attributed to potential changes in the participants’ lifestyles. Fatigue is one of the most common menstrual symptoms ( 32 ). In women with heavy menstrual bleeding, it was found that ferritin levels and physical functions decreased and fatigue increased in parallel with the increase in the duration of menstruation ( 33 ). People with moderate levels of physical activity showed an effective reduction in PMS symptoms such as sleepiness, fatigue, pain, and increased appetite ( 31 ) Although there was no significance between the groups, the decrease in fatigue severity in the exercise group is in parallel with the literature. Given that circadian rhythms are irregular in individuals with sleep disorders, the release of gonadotropin-releasing hormone from the pituitary gland is inhibited, which in turn increases the severity of menstrual symptoms ( 3 ). A correlation has been identified between increased sleepiness, decreased sleep quality, and short sleep duration with the onset of dysmenorrhea, PMS, and irregular menstruation ( 3 ). It has been reported that 12-week Pilates exercises improved sleep quality in women with dysmenorrhea ( 34 ). In our study, although the exercise group had significantly worse sleep quality than the control group before treatment, the improvement in sleep quality after exercise was significant compared to the control group. This may be supported by studies suggesting that exercise improves sleep quality ( 35 , 36 ). In particular, studies have demonstrated that moderate-intensity exercise programs conducted three days a week for 12 weeks to six months have the greatest impact on sleep quality. Several studies have shown that even low levels of physical activity, such as walking, are associated with improved sleep quality, with this effect being more pronounced in women than in men ( 37 ). The existing literature indicates that high levels of physical activity are associated with a reduction in the average duration of menstruation, the incidence of dysmenorrhea and polymenorrhea, and premenstrual syndrome ( 10 ). Another study found a significant increase in dysmenorrhea complaints due to decreased physical activity level during the pandemic period ( 38 ). Therefore, the increased level of physical activity in the exercise group in this study may also be associated with reduced symptoms in this group. This research is the first to evaluate the efficacy of whole-body strengthening, flexibility, balance, and aerobic exercises in women with menstrual syndromes and to examine their functional and patient-reported outcomes. However, it is important to consider the limitations. Firstly, the study relied on self-report data, which may have resulted in social acceptability and recall biases. Secondly, the assessment of heart rate and other objective indicators of exercise, in addition to the use of standard instruments for self-reported physical activity, were not included in the study design. In addition, the investigation failed to explore the lasting effects of the intervention, regarding the sustainability of the outcomes. Lastly, the study population was selected from individuals presenting with any one or more of the symptoms associated with the menstrual cycle. Consequently, the relationship between the exercise method and specific symptoms such as PMS or PMDD was not investigated. Such information should be clarified in future research. CONCLUSIONS In the present study, we have demonstrated that enhanced muscle awareness, correct muscle usage, and strengthening through prescribed exercise programs may be effective in relieving menstrual symptoms. The study indicated that these approaches can be safely self-administered and serve as a convenient, cost-effective, and non-invasive alternative that does not require any intrusive procedures. The whole-body strengthening, flexibility, balance, and aerobic exercises has been demonstrated to be an effective measure in reducing menstrual symptoms in terms of both functional outcomes and sleep quality. Abbreviations MSQ: Menstrual Symptom Questionnaire MDQ: Menstrual Distress Questionnaire FSS: Fatigue Severity Scale PSQI: Pittsburgh Sleep Quality Index IPAQ: International Physical Activity Questionnaire Declarations Ethics approval and consent to participate: This study was conducted after obtaining ethical approval from the Uskudar University Non-Interventional Research Ethics Committee with reference number 61351342/December 2022-67. Informed consent was obtained from all participants. Consent for publication: Informed consent was obtained from all participants. Availability of data and materials: Data sets generated during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Not applicable. Authors' contributions: MK and ÖŞ analyzed and interpreted the patient data. ÖŞ was a major contributor to writing the manuscript. All authors read and approved the final manuscript. Acknowledgments: Not applicable. References Ferrero S, Abbamonte LH, Giordano M, Alessandri F, Anserini P, Remorgida V, et al. What is the desired menstrual frequency of women without menstruation-related symptoms? Contraception. 2006;73(5). Gudipally PR, Sharma GK. Premenstrual Syndrome - StatPearls - NCBI Bookshelf. StatPearls. 2023; Jeon B, Baek J. Menstrual disturbances and its association with sleep disturbances: a systematic review. BMC Womens Health. 2023;23(1). Li Y, Kang B, Zhao X, Cui X, Chen J, Wang L. 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The fatigue severity scale: Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46(10). Armutlu K, Cetisli Korkmaz N, Keser I, Sumbuloglu V, Irem Akbiyik D, Guney Z, et al. The validity and reliability of the Fatigue Severity Scale in Turkish multiple sclerosis patients. International Journal of Rehabilitation Research. 2007;30(1). Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2). Ağargün MY, Kara H AÖ. The validity and reliability of the Pittsburgh Sleep Quality Index. Turkish journal of psychiatry. 1996;7. Öztürk M. Üniversitede Eğitim-Öğretim Gören Öğrencilerde Uluslararası Fiziksel Aktivite Anketinin Geçerliliği Ve Güvenirliği Ve Fiziksel Aktivite Düzeylerinin Belirlenmesi. Yüksek Lisans Tezi, Hacettepe Üniversitesi Sağlık Bilimleri Enstitüsü, Ankara. 2005; Tuğçe Sönmez, Ayla Çapık, Merve Akkaş. Evaluation Of Symptoms Related To Menstruation Period İn Midwifery Students. Anadolu Hemşirelik Ve Sağlık Bilim Dergisi. 2019;22(1):25–32. Burcu Önal. Premenstrual Sendromda Risk Faktörleri Ve Tedavi Arama Davranışının Araştırılması. [İzmir]: Dokuz Eylül Üniversitesi Tıp Fakültesi Aile Hekimliği Anabilim Dalı; 2011. Dehnavi Z, Jafarnejad F, Kamali Z. The Effect Of Aerobic Exercise On Primary Dysmenorrhea: A Clinical Trial Study. J Educ Health Promot. 2018;7(1). Liguori F, Saraiello E, Calella P. Premenstrual Syndrome And Premenstrual Dysphoric Disorder’s Impact On Quality Of Life, And The Role Of Physical Activity. Vol. 59, Medicina (Lithuania). 2023. Vaghela N, Mishra D, Sheth M, Dani Vb. To Compare The Effects Of Aerobic Exercise And Yoga On Premenstrual Syndrome. J Educ Health Promot. 2019;8(1). İmamoğlu Pao. Kardiyo Bosu Egzersizinin Sedanter Kadınlarda Menstruasyon, Stres Ve Depresyon Üzerine Etkileri. Journal Of Turkish Studies. 2019;Volume 14 Issue 6(Volume 14 Issue 6). Kirmizigil B, Demiralp C. Effectiveness Of Functional Exercises On Pain And Sleep Quality İn Patients With Primary Dysmenorrhea: A Randomized Clinical Trial. Arch Gynecol Obstet. 2020;302(1). Sinem Bağcı. The Effect Of Core Exercises On Pain And Quality Of Life İn Young People With Primary Dysmenorrhea: A Non-Randomized Study . [Konya]: Necmettin Erbakan Üniversitesi; 2021. Carroquino-Garcia P, Jiménez-Rejano Jj, Medrano-Sanchez E, De La Casa-Almeida M, Diaz-Mohedo E, Suarez-Serrano C. Therapeutic Exercise İn The Treatment Of Primary Dysmenorrhea: A Systematic Review And Meta-Analysis. Vol. 99, Physical Therapy. 2019. Matteson Ka, Zaluski Km. Menstrual Health As A Part Of Preventive Health Care. Vol. 46, Obstetrics And Gynecology Clinics Of North America. 2019. Vannuccini S, Rossi E, Cassioli E, Cirone D, Castellini G, Ricca V, Et Al. Menstrual Distress Questionnaire (Medı-Q): A New Tool To Assess Menstruation-Related Distress. Reprod Biomed Online. 2021;43(6). Kawabe R, Chen Cy, Morino S, Mukaiyama K, Shinohara Y, Kato M, Et Al. The Relationship Between High Physical Activity And Premenstrual Syndrome İn Japanese Female College Students. Bmc Sports Sci Med Rehabil. 2022;14(1). Fernández-Martínez E, Onieva-Zafra Md, Abreu-Sánchez A, Fernández-Muñóz Jj, Parra-Fernández Ml. Absenteeism During Menstruation Among Nursing Students İn Spain. Int J Environ Res Public Health. 2020;17(1). Kocaoz S, Cirpan R, Degirmencioglu Az. The Prevalence And İmpacts Heavy Menstrual Bleeding On Anemia, Fatigue And Quality Of Life İn Women Of Reproductive Age. Pak J Med Sci. 2019;35(2). Song Bh, Kim J. Effects Of Pilates On Pain, Physical Function, Sleep Quality, And Psychological Factors İn Young Women With Dysmenorrhea: A Preliminary Randomized Controlled Study. Healthcare (Switzerland). 2023;11(14). Ayşenur Tuncer, Fatih Enzin, Sevgi Gamze Felek İri, Elif Dinler, Zerrin Pelin, Kezban Bayramlar. The Importance Of Exercise Therapy İn Disorders. . Zeugma Sağlık Araştırmaları Dergisi. 2020;2(2). Vanderlinden J, Boen F, Van Uffelen Jgz. Effects Of Physical Activity Programs On Sleep Outcomes İn Older Adults: A Systematic Review. Vol. 17, International Journal Of Behavioral Nutrition And Physical Activity. 2020. Sullivan Bisson An, Robinson Sa, Lachman Me. Walk To A Better Night Of Sleep: Testing The Relationship Between Physical Activity And Sleep. Sleep Health. 2019;5(5). Ayhan T, Yıldız A, Bektaş G, Büyükturan B, Büyükturan Ö, Varol S. Pandeminin Fiziksel Aktivite Ve Dismenoreye Etkisinin Birlikte İncelenmesi. Turkısh Journal Of Health And Sport (Tjhs). 2023;Tjhs Vol:4 Issue:1(Tjhs Vol:4 Issue:1). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Aug, 2025 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 03 Jul, 2024 Editor assigned by journal 03 Jul, 2024 Submission checks completed at journal 03 Jul, 2024 First submitted to journal 01 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4669670","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":322264163,"identity":"d6195881-ad47-4534-8a4b-4d0268c42ddd","order_by":0,"name":"Merve Koçak","email":"","orcid":"","institution":"Bahçeşehir University","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"Koçak","suffix":""},{"id":322264164,"identity":"95d2e514-ba7a-469d-a157-a511c9a39d12","order_by":1,"name":"Ömer Şevgin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYFADZgbGBwwMCQwMB0A8NuK0MBugaOEhQhObBFFa+MUOH/vA8Mcmcb4777Fqnj9piX3Hzz5g+FB2mMFe+gBWLZKz05JnMLalJW48zJd2m7ctJ3HmmXQDxhnnDjPw8CVg1WJwO8eYgbHhsLFhM4/Zbd6GisQNB9IYmHnbgFpwuMzgdv5nBoY//8Fainn+ALWcf8bA/BevlhxmoGcPyMkz85gx87DlJG64AbSFEY8WoF+MGRLbkuUMmHmMJee2pRnPvPGM4WDPuXQenjM4Qkw6+THDhz92PPL9Zww/vPmTLNt3Po3xwY8yazn2HuxawAAUMgYHkARAbMIxKd9AUMkoGAWjYBSMVAAAxLNXxADZUZoAAAAASUVORK5CYII=","orcid":"","institution":"Üsküdar University","correspondingAuthor":true,"prefix":"","firstName":"Ömer","middleName":"","lastName":"Şevgin","suffix":""}],"badges":[],"createdAt":"2024-07-01 17:39:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4669670/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4669670/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-025-03940-8","type":"published","date":"2025-08-23T15:56:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61197061,"identity":"ca4d94fa-0ecd-4acd-b383-80609b93873d","added_by":"auto","created_at":"2024-07-27 00:30:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136730,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flowchart.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4669670/v1/6a3e05d0482e912350d992e9.png"},{"id":89847100,"identity":"0101a18d-4632-473f-b7cd-be5e597d18b5","added_by":"auto","created_at":"2025-08-25 16:39:48","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1104683,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4669670/v1/9dce4be7-c71d-4efd-ac08-c3de6fb634ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Effect of Exercise On Menstrual Symptoms: A Randomised Controlled Trial","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMenstrual periods may be associated with several symptoms including dysmenorrhea, migraines, and a variety of somatic symptoms (e.g. breast tenderness, abdominal bloating, swelling) and affective symptoms (e.g. depression, irritability, anxiety, confusion) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Menstrual symptoms are experienced by 90% of women worldwide, representing a significant public health concern. The most prevalent menstruation-related symptoms are premenstrual syndrome (PMS) and dysmenorrhea, which is defined as painful menstruation. Dysmenorrhea is characterized by the presence of cramps in the back and lower abdomen, as well as nausea, diarrhea, fatigue, and headache. PMS encompasses a range of emotional and physical symptoms that typically manifest during the luteal phase of the menstrual cycle, approximately five days before menstruation. The most severe form of premenstrual syndrome (PMS) is called premenstrual dysphoric disorder (PMDD), and it is associated with a greater prevalence of cognitive disorders (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Women who suffer from PMS, PMDD, dysmenorrhea, or abnormal uterine bleeding have reported poor sleep quality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Also, in individuals with PMDD, the onset of menstruation is accompanied by a worsening of symptoms such as insomnia, fatigue, and memory impairment (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven that these symptoms persist until menopause, menstrual periods have a significant financial burden, including reduced work productivity, hospital visits, and medication costs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite the significant public health implications of menstrual symptoms, there is a paucity of knowledge regarding effective management strategies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These treatment methods can be either pharmacologic or nonpharmacologic. In light of the potential adverse effects and financial implications of pharmacological approaches, non-pharmacological methods emerge as a more viable option (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The non-pharmacological treatments include healthy nutrition, psychosocial approaches, massage, meditation, heat application, psychotherapy, mind-body techniques, herbal supplements, acupuncture, and dance therapy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). There is a growing body of evidence suggesting that increased physical activity and lifestyle changes may alleviate symptoms commonly experienced by women, including fatigue, and depression. Additionally, regular exercise has been shown to relieve menstrual symptoms (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It was observed that high physical activity levels were associated with a shorter duration of menstruation, a lower dysmenorrhea and polymenorrhea incidence, and a lower premenstrual syndrome prevalence (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, physical exercise has been suggested to decrease the severity of premenstrual syndrome (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, further research is needed to confirm these potential benefits (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). It is also known that people with excessive fatigue, poor sleep quality and menstrual symptoms have a negative impact on their overall health. However, there is still no consensus on the optimal type, duration, and frequency of exercise for these individuals (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn light of these findings, the current study aimed to investigate the effect of the treatment of physical exercise on menstrual symptoms, sleep quality, fatigue, and physical activity level.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e The research was carried out as a single-blind, randomized controlled study, adhering to the ethical principles outlined in the Declaration of Helsinki and approved by the ethics committee. This study was conducted and reported following the Consolidated Standards of Reporting Trials (CONSORT) statement. This study was conducted between September 2023 and December 2023 after obtaining ethical approval from the Uskudar University Non-Interventional Research Ethics Committee with reference number 61351342/December 2022-67. The protocol is registered with \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://clinicaltrials.gov/\u003c/span\u003e\u003cspan address=\"http://clinicaltrials.gov/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (17/August/2023, Clinical Trial, NCT06006507).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDetermination of sample size\u003c/h2\u003e \u003cp\u003eThe sample size was calculated using the G*Power Version 3.1.6 program. A total of 54 participants were required to determine the medium effect size (f\u0026thinsp;=\u0026thinsp;0.25 effect) at 95% power and a 0.05 alpha significance level, given that the difference was deemed to be statistically significant. The population of the study consists of women between the ages of 18\u0026ndash;50. The number of patients participating in the study was initially 63. However, 9 participants were excluded from the study for various reasons. Consequently, 54 participants completed the study (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRandomization and blinding\u003c/h2\u003e \u003cp\u003eThe investigation was conducted as a single-blind randomized controlled trial following established principles of research design. The evaluator evaluated the study as single-blinded. A total of 63 participants participated in the study and were randomly assigned to the exercise group (n:32) and the control group (n:31) by simple randomization. Randomization was carried out using the sealed envelope method. A total of 69 participants were initially eligible to participate in the study. The inclusion criteria were as follows: signing the voluntary consent form, being between the ages of 18 and 50, having a menstrual cycle, having emotional or physical problems during menstruation, and having a menstrual cycle between 21 and 35 days on average. Exclusion criteria were as follows: having any chronic disease or diagnosed gynecologic disease, receiving pharmacologic treatment for menstrual symptoms, having amenorrhea, exercising regularly, and having any orthopedic or neurologic problem preventing exercise. The study was finally finalized with 54 participants. Figure\u0026nbsp;1 shows the flow of participants throughout the study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1.\u003c/b\u003e CONSORT flowchart.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIntervention and procedure\u003c/h2\u003e \u003cp\u003eThe participants were randomly allocated to two groups: an exercise group and a control group. The participants were contacted individually and their menstrual patterns were documented. The Personal Information Form, Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ) were prepared in Google Forms and sent via WhatsApp on the first day of menstruation before the study commenced. The exercise group received exercise programs via the phone application Fiziu on the first day of their menstrual periods. The application provided visual and audio support for the exercises, which were defined in personal accounts. The participants' email addresses and phone numbers were utilized to access the application, and a code was provided to the participants for the exercise program created through the application. The initial exercises were performed with the physiotherapist, and the subsequent exercises were assigned as an individual home program. A follow-up form was created to monitor the progress of the exercise group. The practicing physiotherapist met with the participants on two days per week and recorded each meeting on this form. No application was made to the control group, nor was any additional warning given. Throughout the study, participants were in regular communication with the research team. After approximately 12 weeks (on the first day of their fourth menstrual period), all questionnaires were completed, and the study was concluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eExercise program\u003c/h2\u003e \u003cp\u003eThe exercise group engaged in an exercise program that included 150 minutes of moderate-intensity walking per week and half an hour of strengthening, flexibility, and balance exercises two days per week for three months (with an average duration of 12 weeks). This program was designed following the World Health Organization's recommendations. A speech test was administered to enable individuals to self-determine the intensity of their exercise. Mild intensity is defined as a pace at which the individual can both speak and sing. Moderate intensity is defined as a pace at which the individual is unable to sing but can still speak. The most severe level of exertion is indicated by the individual being unable to speak or sing, and experiencing respiratory distress (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The walking program was completed for a total of 150 minutes per week at a moderate intensity, distributed over at least three days of the week, with a minimum of 10 minutes per session. A program comprising whole-body strengthening, flexibility, and balance exercises was developed. The exercise program comprised a series of strengthening, flexibility, and balance exercises. The following exercises were prescribed for strengthening the muscles: squats, planks, bridges, sit-ups, scissors, prone back extensions, and modified push-ups. The following flexibility exercises were employed: shoulder roll, child's pose, adductor stretch, hamstring stretch, gastroc-soleus stretch, and cat camel exercise. A variety of postures on one leg were demonstrated as examples of balance exercises. The strengthening and flexibility exercises were planned as three sets of eight repetitions, while the balance exercises were planned for one minute.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measurements\u003c/h2\u003e \u003cp\u003eThe following demographic information was recorded in the demographic information form: age, height, weight, body mass index (BMI), employment status, education level, exercise habits, marital status, pregnancy status, number of pregnancies, smoking and alcohol habits. Furthermore, the age at menarche, menstrual pattern (regular-irregular), cycle duration, number of days of the menstrual period, and use of painkillers during menstruation were also recorded to ascertain the menstrual history and menstrual period characteristics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMenstrual Symptom Questionnaire (MSQ)\u003c/h2\u003e \u003cp\u003eIt is a 5-point Likert-type scale and consists of 24 items with three sub-parameters: 'negative effects/somatic effects', 'menstrual pain', and 'coping methods'. Respondents select one of the following options for the symptoms they experience: \"never, rarely, sometimes, often, and always\". Never: 1, Rarely: 2, Sometimes: 3, Frequently: 4, Always: 5 points. The MSQ score is obtained by averaging the points given. A higher score indicates more severe menstrual symptoms. Turkish validity and reliability were developed by G\u0026uuml;ven\u0026ccedil; et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eMenstrual Distress Questionnaire (MDQ)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Menstrual Distress Questionnaire is comprised of eight subgroups, namely pain, water retention, autonomic reaction, negative affect, impaired concentration, behavioral changes, revitalization, and control, in addition to increased appetite. The scale comprises 47 items and is of the Likert-type. It evaluates premenstrual syndrome symptoms separately for the menstrual, premenstrual, and intermenstrual periods. Each item is scored from 0 to 4, with the maximum score that can be obtained from the scale being 184 for each period. The Menstrual Distress Complaint List was translated into Turkish and its validity and reliability were evaluated by Kızılkaya (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eFatigue Severity Scale (FSS)\u003c/h2\u003e \u003cp\u003eThe FSS is comprised of nine items in total. Each item on the scale is evaluated according to a Likert-type scale, with scores ranging from 1 to 7. The scale score is calculated by taking the mean of the nine items. A higher score on the scale indicates a greater degree of fatigue. A score of 4 or above is indicative of severe fatigue (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Turkish validity and reliability study was conducted by Armutlu et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePittsburgh Sleep Quality Index (PSQI)\u003c/h2\u003e \u003cp\u003eThe Pittsburgh Sleep Quality Index (PSQI) was developed as a means of assessing sleep quality. The test comprises 24 questions distributed across 10 main headings and is designed to assess sleep quality over the past month. The PSQI comprises seven sub-headings, as follows: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, sleep medication use, and daytime dysfunction. Each component is evaluated on a 0\u0026ndash;3 point scale, with a total of 21 points. A score greater than 5 indicates poor sleep quality (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Ağarg\u0026uuml;n et al. conducted Turkish validity and reliability studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInternational Physical Activity Questionnaire-Short Form (IPAQ)\u003c/h2\u003e \u003cp\u003eThe International Physical Activity Questionnaire (IPAQ) was developed to assess the duration of various forms of physical activity, including vigorous exercise (e.g., soccer, volleyball, high-speed running, weight lifting), moderate exercise (e.g., light weight-bearing, cycling at moderate speed, dancing, table tennis), walking, and time spent sitting during the day. The short version of the questionnaire assesses the subject's activities over the past seven days. The validity and reliability study of the questionnaire in our country was conducted by \u0026Ouml;zt\u0026uuml;rk et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). To calculate the total score from the questionnaire, the total days and minutes of walking, moderate physical activity, and vigorous physical activity are calculated. The questions in the questionnaire cover a minimum of 10 minutes of activity. The duration of walking, moderate-intensity physical activity, and vigorous physical activity are converted into METs (metabolic equivalents) corresponding to basal metabolic rate to calculate the total physical activity score (MET-min/week). According to the questionnaire, the physical activity score in a category is obtained by multiplying the total minutes and days of activity by the MET equivalent of that activity. These MET values are based on the metabolic rate of a 60-kilogram individual. One MET equals approximately 3.5 O2/kg/min (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using SPSS 15.0 (IBM SPSS Statistics for Windows, Version 15.0. Armonk, NY: IBM Corp) software. To compare the scale scores, parametric methods were employed. Normality was assessed using the Shapiro-Wilk normality test. Independent t-tests were employed for normally distributed measurements, while paired t-tests were utilized to compare pre-and post-treatment measurements within each group. For measurements that exhibited non-normal distributions in both groups, the Mann-Whitney U test was employed as a nonparametric alternative to the independent group t-test, and the Wilcoxon signed-rank test was utilized as an alternative to the dependent group t-test. The chi-square test was utilized to compare the relationship between the groups. All statistical analyses were conducted with a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis was a randomized clinical study with 54 participants with menstrual symptoms conducted between September 2023 and December 2023. After the group allocation, 5 people in the exercise group and 4 participants in the control were excluded from the study because they did not complete the exercises or were unwilling to participate. At the end of the study, demographic data of the exercise (n: 27) and control (n:27) groups are as shown in Table 1. The sociodemographic information indicates that the groups exhibited statistically similar characteristics. Except for the number of pregnancies and age at menarche (p \u0026lt; 0.05), no statistically significant differences were observed in women\u0026apos;s health-related data, socio-demographic characteristics, menstruation, and lifestyle patterns (p \u0026gt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographic characteristics of the participants.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise (n:27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n:27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50.450450450450454%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49.549549549549546%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e30,3\u0026plusmn;6,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e32,7\u0026plusmn;6,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeight (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e164,3\u0026plusmn;5,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e163,7\u0026plusmn;5,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,761\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight (kg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e60,1\u0026plusmn;6,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e59,3\u0026plusmn;8,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,843\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e22,2\u0026plusmn;2,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e22,1\u0026plusmn;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e0,3\u0026plusmn;0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e0,6\u0026plusmn;0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,060\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e0,4\u0026plusmn;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e0,7\u0026plusmn;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge at first period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e13,4\u0026plusmn;1,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e12,6\u0026plusmn;1,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of menstrual period (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e6,6\u0026plusmn;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e6,3\u0026plusmn;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,460\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of the menstrual cycle (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e28,5\u0026plusmn;4,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e29,0\u0026plusmn;1,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e0,380\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003eWorking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e24 (88,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e23 (85,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eNot working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e3 (11,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e4 (14,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0,105\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0,0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e3 (11,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e27 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e23 (85,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSingle\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e18 (66,7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e12 (44,4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMarried\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e9 (33,3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e15 (55,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUse of Painkillers During Period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e14 (51,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e0,145\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eEvery time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e5 (18,5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e8 (29,6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e13 (48,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise Habits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e13 (48,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,091\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e14 (51,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e20 (74,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e20 (74,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e21 (77,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,750\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e6 (22,2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol Use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.22222222222222%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.444444444444443%\" valign=\"top\"\u003e\n \u003cp\u003e20 (74,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.09722222222222%\" valign=\"top\"\u003e\n \u003cp\u003e20 (74,1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.23611111111111%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1,000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"55.06072874493927%\" valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.672064777327936%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.267206477732792%\" valign=\"top\"\u003e\n \u003cp\u003e7 (25,9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e*p\u0026lt;0.05. X: Mean, SD: Standard Deviation, BMI: Body Mass Index.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Comparison difference of Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ) measures before and after the exercise treatment therapy. The change in the scores was calculated by subtracting post-treatment scores from pre-treatment scores.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRating Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n:27)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group (n:27)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003csup\u003e1\u0026nbsp;\u003c/sup\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eExercise Group Change\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group Change\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eX \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003csup\u003e2\u003c/sup\u003e value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMSQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e3,0\u0026plusmn;0,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e2,8\u0026plusmn;0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,35\u0026plusmn;0,30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0,06\u0026plusmn;0,46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e2,7\u0026plusmn;0,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e2,8\u0026plusmn;0,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,437\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,532\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMDQ (pre-menstrual)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e40,3\u0026plusmn;23,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e44,2\u0026plusmn;31,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5,19\u0026plusmn;20,72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2,63\u0026plusmn;17,28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,626\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e36,0\u0026plusmn;28,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e41,6\u0026plusmn;33,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,593\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,475\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMDQ (menstrual)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e53,4\u0026plusmn;28,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e48,6\u0026plusmn;32,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e11,88\u0026plusmn;17,81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,63\u0026plusmn;17,19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e41,5\u0026plusmn;27,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e48,0\u0026plusmn;29,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,976\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMDQ (inter-menstrual)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e14,9\u0026plusmn;13,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e26,1\u0026plusmn;25,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0,24\u0026plusmn;11,08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6,33\u0026plusmn;16,29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,348\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e16,1\u0026plusmn;12,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e19,8\u0026plusmn;22,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,927\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e4,6\u0026plusmn;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e4,0\u0026plusmn;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,55\u0026plusmn;0,89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0,01\u0026plusmn;1,50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e4,1\u0026plusmn;1,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e4,1\u0026plusmn;1,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,980\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSQI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e8,1\u0026plusmn;3,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e5,6\u0026plusmn;2,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2,56\u0026plusmn;2,26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,22\u0026plusmn;2,39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e5,6\u0026plusmn;3,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e5,4\u0026plusmn;3,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,701\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,633\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"7\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIPAQ-Short form\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePre-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e1192,8\u0026plusmn;549,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e814,5\u0026plusmn;442,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e0,007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-571,8\u0026plusmn;435,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-35,4\u0026plusmn;404,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.26448362720403%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ePost-treatment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.700251889168765%\" valign=\"top\"\u003e\n \u003cp\u003e1764,6\u0026plusmn;685,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.19647355163728%\" valign=\"top\"\u003e\n \u003cp\u003e849,9\u0026plusmn;509,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.838790931989925%\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.102310231023104%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003csub\u003etime\u003c/sub\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.49174917491749%\" valign=\"top\"\u003e\n \u003cp\u003e0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.16171617161716%\" valign=\"top\"\u003e\n \u003cp\u003e0,653\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.755775577557756%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.026402640264026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.211221122112212%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.250825082508252%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep\u0026lt;0.05. X: Mean, SD: Standard Deviation.\u0026nbsp;p\u003csub\u003etime\u003c/sub\u003e:\u0026nbsp;Within-group treatment difference (p), P\u003csup\u003e1\u003c/sup\u003e value: Inter-group comparison of post and pre-treatment values (p), P\u003csup\u003e2\u003c/sup\u003e value: Inter-group treatment difference (p). Menstrual Symptom Questionnaire (MSQ), Menstrual Distress Questionnaire (MDQ), Fatigue Severity Scale (FSS), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire-Short From (IPAQ).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; The comparison differences of the assessments among the groups are presented in Table 2. Within-group analysis showed a significant decrease in MSQ, MDQ (menstrual), FSS, and PSQI scores after exercise. In contrast, the IPAQ score increased significantly in the exercise group (p \u0026lt; 0.05). In the control group, a significant decrease was observed only in the MDQ (intermenstrual) score (p \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eNo significant difference was observed between the exercise and the control group in the pre-treatment MSI, MDQ, and FSS scores. However, the exercise group exhibited statistically higher values than the control group in the PSQI and IPAQ scores (p \u0026lt; 0.05). \u0026nbsp;There was no significant difference between the exercise group and the control group in terms of MSQ, MDQ, and PSQI scores after treatment, whereas the values of the exercise group were statistically higher than the control group in the IPAQ score (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003eA comparison of the pre-treatment and post-treatment changes in the exercise and control groups revealed a significant decrease in MSQ, MDQ (menstrual), and PSQI scores and an increase in IPAQ scores in the exercise group compared to the control group (p \u0026lt; 0.05). However, the decrease in MDQ (pre-menstrual and intermenstrual) and FSS scores were not statistically different between the groups.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study was the first to investigate the effects of whole-body strengthening, flexibility, balance, and aerobic exercises on menstrual symptom severity, sleep quality, fatigue severity, and physical activity level in people with menstrual symptoms. The primary outcome was menstrual symptom severity. The secondary outcomes included sleep quality, fatigue severity, and physical activity level. The main results of the present study were: (i) The exercise group exhibited a marked reduction in MSQ, MDQ (menstrual), FSS, and PSQI scores, accompanied by an increase in IPAQ scores in post-treatment; (ii) Compared with the control group, decrease in MSQ, MDQ (menstrual), and PSQI scores were significantly higher in exercise group; (ii) The participants receiving exercise treatment showed a significant increase in IPAQ score in comparison to non-exercising women with the menstrual syndrome.\u003c/p\u003e \u003cp\u003eIt has been posited that the early age of menarche is associated with the early onset of ovarian function and the fluctuation of steroid hormones in individuals who lack physical and psychological maturity (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In another study, it was stated that the early age of menarche increased the complaints of dysmenorrhea (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Furthermore, a reduction in the number of pregnancies has been linked to an elevated risk of developing more severe PMS symptoms (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In our study, the exercise and control groups were distributed heterogeneously concerning age at menarche and number of pregnancies. The mean age at menarche was lower and the mean number of pregnancies was higher in the control group. Given that no differences were observed between the groups in the pre-treatment evaluation of the MSQ and MDQ questionnaires, it can be concluded that the heterogeneity of the number of pregnancies and menarche age did not exert any influence on the course of the study.\u003c/p\u003e \u003cp\u003eIt has been demonstrated that aerobic exercise is an efficacious intervention for alleviating physical symptoms associated with premenstrual syndrome (PMS) and dysmenorrhea, including bloating, vomiting, hot flashes, and increased appetite (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study demonstrated that aerobic exercise was an effective intervention for reducing both physical and psychological symptoms in individuals with PMS and PMDD (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Vaghela et al. demonstrated that yoga and physical exercise can alleviate the pain severity and premenstrual symptoms after four weeks however; the yoga group exhibited greater improvements than the aerobic exercise group (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In women with menstrual abnormalities, regular exercise has been demonstrated to reduce menstrual irregularities (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In another study, functional exercise programs have been shown to be effective on the MSQ, PSQI, and low back and abdominal pain of dysmenorrhea patients (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Core exercise programs have been shown to improve the pain level and quality of life of people with dysmenorrhea (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Another meta-analysis study stated that menstrual pain can be reduced with aerobic exercise, strengthening, and flexibility exercises (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In this study, whole-body strengthening, flexibility, balance, and aerobic exercises were applied in combination and alleviated symptoms such as menstrual pain and negative somatic effects. Therefore, the notable decline in MSQ scores among the exercise group is consistent with the findings of previous studies.\u003c/p\u003e \u003cp\u003eMenstruation-related bleeding, pain, fatigue, and mood changes, collectively referred to as menstrual distress, have a profound impact on a woman's physical, social, and emotional well-being (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Previous research has demonstrated that menstruation affects mood and cognitive function, potentially resulting in negative experiences that give rise to menstrual-related concerns and difficulties in coping with them (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). PMS and PMDD are thought to occur during the luteal phase of the menstrual cycle, approximately one week before menstruation. It is reported that these conditions resolve with the onset of menstruation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In this study, the data related to the pre-menstrual period were based on 1 week before menstruation. There were no significant changes in the MDQ (pre-menstrual) scores before and after treatment in the distress scores of the exercise and control groups. Accordingly, the absence of a reduction in the MDQ score for the menstrual period is inconsistent with the existing literature. This may be related to psychosocial factors or life stressors beyond the control of the current study. The prevalence of symptoms among women with PMS and PMDD is higher during the luteal phase. However, these women also report experiencing insomnia, inattention, fatigue, and memory problems during the follicular phase. The existing literature emphasizes the importance of physical activity in managing PMS and PMDD (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The findings of this study support the association between exercise and menstrual symptoms. Many factors can affect women's menstrual symptoms such as poor eating habits, inactive lifestyle, alcohol and smoking habits, anxiety, and stress (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In this study, the MDQ score of the inter-menstrual period decreased significantly in the control group despite the absence of any intervention. The observed change in the control group did not result in a significant difference among groups. This suggests that the observed differences may be attributed to potential changes in the participants\u0026rsquo; lifestyles.\u003c/p\u003e \u003cp\u003eFatigue is one of the most common menstrual symptoms (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In women with heavy menstrual bleeding, it was found that ferritin levels and physical functions decreased and fatigue increased in parallel with the increase in the duration of menstruation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). People with moderate levels of physical activity showed an effective reduction in PMS symptoms such as sleepiness, fatigue, pain, and increased appetite (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) Although there was no significance between the groups, the decrease in fatigue severity in the exercise group is in parallel with the literature.\u003c/p\u003e \u003cp\u003eGiven that circadian rhythms are irregular in individuals with sleep disorders, the release of gonadotropin-releasing hormone from the pituitary gland is inhibited, which in turn increases the severity of menstrual symptoms (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A correlation has been identified between increased sleepiness, decreased sleep quality, and short sleep duration with the onset of dysmenorrhea, PMS, and irregular menstruation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It has been reported that 12-week Pilates exercises improved sleep quality in women with dysmenorrhea (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). In our study, although the exercise group had significantly worse sleep quality than the control group before treatment, the improvement in sleep quality after exercise was significant compared to the control group. This may be supported by studies suggesting that exercise improves sleep quality (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In particular, studies have demonstrated that moderate-intensity exercise programs conducted three days a week for 12 weeks to six months have the greatest impact on sleep quality. Several studies have shown that even low levels of physical activity, such as walking, are associated with improved sleep quality, with this effect being more pronounced in women than in men (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe existing literature indicates that high levels of physical activity are associated with a reduction in the average duration of menstruation, the incidence of dysmenorrhea and polymenorrhea, and premenstrual syndrome (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another study found a significant increase in dysmenorrhea complaints due to decreased physical activity level during the pandemic period (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Therefore, the increased level of physical activity in the exercise group in this study may also be associated with reduced symptoms in this group.\u003c/p\u003e \u003cp\u003eThis research is the first to evaluate the efficacy of whole-body strengthening, flexibility, balance, and aerobic exercises in women with menstrual syndromes and to examine their functional and patient-reported outcomes. However, it is important to consider the limitations. Firstly, the study relied on self-report data, which may have resulted in social acceptability and recall biases. Secondly, the assessment of heart rate and other objective indicators of exercise, in addition to the use of standard instruments for self-reported physical activity, were not included in the study design. In addition, the investigation failed to explore the lasting effects of the intervention, regarding the sustainability of the outcomes. Lastly, the study population was selected from individuals presenting with any one or more of the symptoms associated with the menstrual cycle. Consequently, the relationship between the exercise method and specific symptoms such as PMS or PMDD was not investigated. Such information should be clarified in future research.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eIn the present study, we have demonstrated that enhanced muscle awareness, correct muscle usage, and strengthening through prescribed exercise programs may be effective in relieving menstrual symptoms. The study indicated that these approaches can be safely self-administered and serve as a convenient, cost-effective, and non-invasive alternative that does not require any intrusive procedures. The whole-body strengthening, flexibility, balance, and aerobic exercises has been demonstrated to be an effective measure in reducing menstrual symptoms in terms of both functional outcomes and sleep quality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMSQ: Menstrual Symptom Questionnaire\u003c/p\u003e\n\u003cp\u003eMDQ: Menstrual Distress Questionnaire\u003c/p\u003e\n\u003cp\u003eFSS: Fatigue Severity Scale\u003c/p\u003e\n\u003cp\u003ePSQI: Pittsburgh Sleep Quality Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPAQ: International Physical Activity Questionnaire\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was conducted after obtaining ethical approval from the Uskudar University Non-Interventional Research Ethics Committee with reference number 61351342/December 2022-67. Informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Informed consent was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eData sets generated during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e MK and \u0026Ouml;Ş analyzed and interpreted the patient data. \u0026Ouml;Ş was a major contributor to writing the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerrero S, Abbamonte LH, Giordano M, Alessandri F, Anserini P, Remorgida V, et al. What is the desired menstrual frequency of women without menstruation-related symptoms? Contraception. 2006;73(5). \u003c/li\u003e\n\u003cli\u003eGudipally PR, Sharma GK. Premenstrual Syndrome - StatPearls - NCBI Bookshelf. StatPearls. 2023; \u003c/li\u003e\n\u003cli\u003eJeon B, Baek J. Menstrual disturbances and its association with sleep disturbances: a systematic review. BMC Womens Health. 2023;23(1). \u003c/li\u003e\n\u003cli\u003eLi Y, Kang B, Zhao X, Cui X, Chen J, Wang L. Association between depression and dysmenorrhea among adolescent girls: multiple mediating effects of binge eating and sleep quality. 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The Prevalence And İmpacts Heavy Menstrual Bleeding On Anemia, Fatigue And Quality Of Life İn Women Of Reproductive Age. Pak J Med Sci. 2019;35(2). \u003c/li\u003e\n\u003cli\u003eSong Bh, Kim J. Effects Of Pilates On Pain, Physical Function, Sleep Quality, And Psychological Factors İn Young Women With Dysmenorrhea: A Preliminary Randomized Controlled Study. Healthcare (Switzerland). 2023;11(14). \u003c/li\u003e\n\u003cli\u003eAyşenur Tuncer, Fatih Enzin, Sevgi Gamze Felek İri, Elif Dinler, Zerrin Pelin, Kezban Bayramlar. The Importance Of Exercise Therapy İn Disorders. . Zeugma Sağlık Araştırmaları Dergisi. 2020;2(2). \u003c/li\u003e\n\u003cli\u003eVanderlinden J, Boen F, Van Uffelen Jgz. Effects Of Physical Activity Programs On Sleep Outcomes İn Older Adults: A Systematic Review. Vol. 17, International Journal Of Behavioral Nutrition And Physical Activity. 2020. \u003c/li\u003e\n\u003cli\u003eSullivan Bisson An, Robinson Sa, Lachman Me. Walk To A Better Night Of Sleep: Testing The Relationship Between Physical Activity And Sleep. Sleep Health. 2019;5(5). \u003c/li\u003e\n\u003cli\u003eAyhan T, Yıldız A, Bektaş G, B\u0026uuml;y\u0026uuml;kturan B, B\u0026uuml;y\u0026uuml;kturan \u0026Ouml;, Varol S. Pandeminin Fiziksel Aktivite Ve Dismenoreye Etkisinin Birlikte İncelenmesi. Turkısh Journal Of Health And Sport (Tjhs). 2023;Tjhs Vol:4 Issue:1(Tjhs Vol:4 Issue:1). \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Menstrual symptoms, Physical activity, Sleep, Fatigue, Menstrual pain","lastPublishedDoi":"10.21203/rs.3.rs-4669670/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4669670/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMenstrual symptoms are a prevalent and frequently encountered women's health condition. The objective of this study was to examine the impact of exercise on menstrual symptoms, sleep quality, fatigue, and physical activity levels.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was designed as a randomized controlled trial conducted between September 2023 and December 2023. The study included 54 women aged 19 to 45 years. Participants were divided into two groups: a control group and an exercise group. All participants were evaluated with the Menstrual Symptom Questionnaire (MSQ), the Menstrual Distress Questionnaire (MDQ), the Fatigue Severity Scale (FSS), the Pittsburgh Sleep Quality Index (PSQI), and the International Physical Activity Questionnaire-Short Form (IPAQ) before and after treatment. The control group did not receive an exercise program. The exercise group received an exercise program including strengthening, flexibility, and balance exercises. A moderate-intensity aerobic exercise and walking program was implemented at least three days per week. The study spanned three menstrual cycles for each woman and lasted an average of 12 weeks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWithin-group analysis showed a significant decrease in MSQ, MDQ (menstrual), FSS, and PSQI scores after exercise. In contrast, the IPAQ score increased significantly in the exercise group. In the control group, a significant decrease was observed only in the MDQ (intermenstrual) score. A comparison of the pre-treatment and post-treatment changes in the exercise and control groups revealed a significant decrease in MSQ, MDQ (menstrual), and PSQI scores and an increase in IPAQ scores in the exercise group compared to the control group. However, the decrease in MDQ (pre-menstrual and intermenstrual) and FSS scores were not statistically different between the groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn conclusion, exercise had a positive effect on the severity of menstrual symptoms, sleep quality, and fatigue in women with menstrual symptoms. Women who exercised had a decrease in menstrual symptoms and an increase in sleep quality. Exercise can be employed as a non-pharmacological method to help women manage their symptoms.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe protocol is registered with \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://clinicaltrials.gov/\u003c/span\u003e\u003cspan address=\"http://clinicaltrials.gov/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (17/August/2023, Clinical Trial, NCT06006507).\u003c/p\u003e","manuscriptTitle":"The Effect of Exercise On Menstrual Symptoms: A Randomised Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-27 00:30:00","doi":"10.21203/rs.3.rs-4669670/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-03T13:40:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-03T05:06:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-03T05:06:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2024-07-01T17:38:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55d44817-969a-4650-b27d-9cca731abad3","owner":[],"postedDate":"July 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:30:28+00:00","versionOfRecord":{"articleIdentity":"rs-4669670","link":"https://doi.org/10.1186/s12905-025-03940-8","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2025-08-23 15:56:55","publishedOnDateReadable":"August 23rd, 2025"},"versionCreatedAt":"2024-07-27 00:30:00","video":"","vorDoi":"10.1186/s12905-025-03940-8","vorDoiUrl":"https://doi.org/10.1186/s12905-025-03940-8","workflowStages":[]},"version":"v1","identity":"rs-4669670","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4669670","identity":"rs-4669670","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}