Effectiveness of Pain Neuroscience Education in Women with Dysmenorrhea: A Randomized Controlled Trial

Effectiveness of Pain Neuroscience Education in Women with Dysmenorrhea: A Randomized 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 Effectiveness of Pain Neuroscience Education in Women with Dysmenorrhea: A Randomized Controlled Trial Çiğdem Inkaya¹, Osman Çoban² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8190944/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background: Dysmenorrhea is a highly prevalent gynecological condition that negatively affects menstrual pain experience, daily activities, and overall quality of life. Pain neuroscience education (PNE) is a non-pharmacological intervention designed to reshape maladaptive pain beliefs and promote a more adaptive understanding of pain mechanisms. This study aimed to examine the effects of PNE on pain beliefs, menstrual pain intensity, and the functional impact of dysmenorrhea among women with primary dysmenorrhea. Methods: This randomized controlled trial included 74 women aged ≥18 years diagnosed with primary dysmenorrhea. Participants were randomly allocated to either a PNE group (n = 37) or a control group (n = 37). The PNE group received three weekly online educational sessions, whereas the control group continued their routine activities without intervention. Outcomes were assessed before and after the intervention using the Pain Beliefs Questionnaire (PBQ), the Short-Form McGill Pain Questionnaire (SF-MPQ), and the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). All assessments were administered by evaluators blinded to group allocation. Results: The PNE group demonstrated significantly greater reductions in maladaptive pain beliefs, including both organic and psychological subscales, compared with the control group. Additionally, the PNE group showed substantial decreases in sensory, affective, and total pain scores on the SF-MPQ. Improvements in daily functioning were also evident, as reflected by significantly lower SAIDDL scores. No significant pre–post or between-group changes were identified in the control group. Conclusion: PNE effectively reduced maladaptive pain beliefs, menstrual pain intensity, and the functional impact of dysmenorrhea. These findings suggest that PNE is a low-risk, accessible, and feasible intervention that may serve as a complementary strategy in the management of primary dysmenorrhea, particularly when delivered through digital platforms. Trial Registration ClinicalTrials.gov, NCT06732778. Registered on September 12, 2024. Pain Neuroscience Education Dysmenorrhea Menstrual Pain Pain Beliefs Women’s Health Figures Figure 1 Background Dysmenorrhea, commonly referred to as menstrual pain, is one of the most frequent gynecological disorders among women of reproductive age, particularly adolescents and young adults [ 1 ]. The condition is characterized by cyclic lower abdominal pain that occurs just before or during menstruation and may persist for two to three days [ 2 ]. Epidemiological data indicate that dysmenorrhea affects approximately 50% to 90% of women of reproductive age, and about one in four experience symptoms severe enough to impair daily activities. Despite its high prevalence, dysmenorrhea was not recognized as a distinct medical condition until the 1970s [ 3 ]. It is now understood to be a substantial public health issue, contributing to decreased academic and occupational performance, absenteeism, and reduced quality of life in affected individuals [ 4 ]. The pathophysiology of dysmenorrhea involves excessive endometrial production of prostaglandins, primarily prostaglandin F₂α and E₂, which increase uterine contractility, reduce uterine blood flow, and activate pelvic nociceptors [ 5 ]. Recurrent nociceptive input may induce peripheral and central sensitization, thereby amplifying pain perception even in the absence of underlying uterine pathology [ 2 ]. In addition, neuroendocrine fluctuations and psychological stress can modulate central pain processing and exacerbate symptom severity [ 6 ]. The management of dysmenorrhea typically integrates both pharmacological and non-pharmacological strategies. Non-steroidal anti-inflammatory drugs (NSAIDs) remain the first-line treatment due to their ability to reduce prostaglandin synthesis and uterine hypercontractility [ 7 ]. Hormonal contraceptives further alleviate symptoms by regulating endometrial activity and reducing prostaglandin-mediated nociception [ 8 ]. Non-pharmacological approaches—including exercise, heat therapy, yoga, mindfulness, and transcutaneous electrical nerve stimulation (TENS)—have also demonstrated benefits by improving circulation, modulating pain pathways, and reducing emotional distress [ 9 – 11 ]. More recently, pain neuroscience education (PNE) has emerged as a complementary strategy aimed at modifying maladaptive pain cognitions and enhancing self-management in women with dysmenorrhea [ 12 ]. PNE provides a biopsychosocial framework to reinterpret menstrual pain by explaining the neurophysiological mechanisms underlying central sensitization and pain modulation. In women with dysmenorrhea, recurrent uterine nociceptive input and negative cognitive–emotional responses—such as catastrophizing and fear-avoidance—may intensify central hyperexcitability and contribute to persistent pain states [ 13 , 14 ]. By reframing pain as a modifiable neurophysiological experience, PNE aims to reduce maladaptive beliefs, enhance coping, and improve pain-related outcomes. Recent findings suggest that integrating PNE into conventional dysmenorrhea management may offer additional benefits beyond biomedical education alone [ 12 , 15 ]. Although educational strategies addressing pain mechanisms have been widely studied in individuals with chronic pain conditions, their application to dysmenorrhea remains limited. Emerging evidence indicates that women with primary dysmenorrhea exhibit features of central sensitization and maladaptive pain cognitions, including pain catastrophizing and fear of movement, which may sustain chronic pain responses [ 13 , 16 ]. These findings provide a strong rationale for incorporating PNE into dysmenorrhea management to address both neurophysiological and cognitive–emotional contributors to pain. Therefore, the present randomized controlled study, Effectiveness of Pain Neuroscience Education in Women with Dysmenorrhea , aimed to evaluate the impact of a structured PNE program on pain intensity, pain-related cognitions, and functional outcomes compared with a control group that continued their routine daily activities without additional intervention. Materials and Methods Study Design and Ethical Approval This study was designed as a randomized controlled trial and conducted online between October 1, 2024, and February 1, 2025. Ethical approval was obtained from the Üsküdar University Non-Interventional Research Ethics Committee (Meeting No: 05; Decision No: 61351342/May 2024-56; Date: May 28, 2024). The study was prospectively registered at ClinicalTrials.gov (Identifier: NCT06732778, Registration date: September 12, 2024). All participants provided electronic informed consent prior to enrollment, and all procedures were conducted in accordance with the Declaration of Helsinki. Participants and Sampling The study population consisted of women aged 18 years and older who reported experiencing dysmenorrhea. Eligible participants were required to be at least 18 years of age, to experience dysmenorrhea regularly, and to volunteer to participate in the study. Women were excluded if they were younger than 18 years, had a history of pregnancy, previously experienced pelvic infections, were using hormonal contraceptives or intrauterine devices, had menstrual durations shorter than 3 days or longer than 8 days, or had menstrual cycles outside the 21–35-day range. A total of 74 volunteers meeting these criteria were enrolled and randomly assigned to two parallel groups using a sequential allocation method: a pain neuroscience education (PNE) group (n = 37) and a control group (n = 37). Participants who met the inclusion criteria were consecutively allocated according to their order of registration. An a priori power analysis was conducted using G*Power software (version 3.1.9.7; Universität Düsseldorf, Germany) to determine the required sample size. Previous studies have demonstrated moderate-to-large associations between dysmenorrhea, activity limitations, and quality-of-life impairments in women [ 17 ]. Based on this evidence, a medium effect size (Cohen’s d = 0.50) was selected to estimate the expected between-group difference in the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL), the primary outcome measure of the study. Assuming a statistical power of 0.80, a two-tailed α = 0.05, and a 90% confidence level, the minimum required sample size was calculated as 74 participants. Accordingly, 74 eligible women were recruited and equally randomized into the PNE (n = 37) and control (n = 37) groups in a 1:1 allocation ratio. The flow of participants throughout the study is presented in Fig. 1 . Intervention Procedures Participants in the intervention group received a structured PNE program delivered online by the researcher. The program consisted of three consecutive weekly sessions, each lasting approximately 30 minutes. The educational content aimed to improve participants’ understanding of the neurophysiological mechanisms underlying dysmenorrhea. Topics included the neurophysiology of pain, central sensitization, the interaction between cognitive–emotional processes and pain perception, and evidence-based self-management strategies. Visual materials, metaphors (e.g., the nervous system as an “overprotective alarm system”), and interactive discussions were used to enhance engagement and comprehension [ 18 , 19 ]. Sessions emphasized that pain is a protective output of the nervous system and may be amplified through increased neural sensitivity, even in the absence of tissue damage [ 20 ]. Dysmenorrhea mechanisms—such as prostaglandin-related uterine contractions, inflammatory mediators, and transient hypoxia—were explained as physiological rather than harmful. Psychological contributors including stress, catastrophizing, and negative menstrual beliefs were discussed as factors that modulate central processing and intensify pain [ 21 ]. Participants were introduced to practical self-management strategies such as diaphragmatic breathing, relaxation exercises, gentle aerobic activity, yoga-based movements, heat application, and general lifestyle regulation. Misconceptions surrounding dysmenorrhea were addressed, and pain-related beliefs were reframed using contemporary pain science principles to support adaptive coping. Participants in the control group did not receive any educational or therapeutic intervention and were instructed to continue their usual daily routines. This passive control design allowed for comparison of PNE effects with the natural course of dysmenorrhea and typical coping behaviors. Outcome Assessments Outcome measures were obtained twice for all participants—before and after one menstrual cycle—by independent assessors blinded to group allocation. Pain intensity was measured using the Short-Form McGill Pain Questionnaire (SF-MPQ), while the impact of dysmenorrhea on daily living was evaluated with the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). Pain-related beliefs were assessed using the Pain Beliefs Questionnaire (PBQ). All assessments were administered via secure online forms to ensure consistency, participant privacy, and data reliability. Short-Form McGill Pain Questionnaire (SF-MPQ) Pain intensity was assessed using the SF-MPQ, a widely validated instrument for evaluating sensory and affective pain components [ 22 ]. The SF-MPQ includes 15 descriptors (11 sensory and 4 affective), each rated on a 0–3 scale (0 = none, 3 = severe), producing sensory, affective, and total pain scores. It also contains a global pain intensity item with five verbal categories. In this study, the first two sections of the SF-MPQ were used to assess pre- and post-intervention pain levels. Pain Beliefs Questionnaire (PBQ) Pain-related beliefs were evaluated using the PBQ, a validated instrument developed to measure individuals’ cognitive interpretations of pain. The PBQ includes two subscales: Organic Beliefs (8 items) and Psychological Beliefs (4 items). Items are rated on a 6-point Likert scale ranging from “never” to “always.” Subscale scores are calculated by averaging item responses, yielding Organic, Psychological, and Total PBQ scores [ 23 ]. Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL) Functional impact was measured using a 0–10 numerical interference scale adapted from the conceptual structure of the Visual Analogue Scale (VAS), a widely accepted instrument for evaluating subjective symptom intensity [ 24 ]. Participants rated how much dysmenorrhea affected their daily activities on the third day of their menstrual cycle, with 0 representing “no impact” and 10 indicating “complete disruption.” Although this tool has not yet undergone formal psychometric validation, its scoring logic and symptom-focused format align with VAS-based pain interference assessments and provide a practical indicator of functional impact. Statistical Analysis All statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS, version 25.0; IBM Corp., Armonk, NY, USA). Descriptive data were summarized as mean ± standard deviation. The normality of variable distributions was verified using the Shapiro–Wilk test, supporting the use of parametric procedures. Between-group comparisons at baseline and post-intervention were performed using independent-samples t-tests, whereas within-group (pre–post) differences were analyzed using paired-samples t-tests. To examine the combined influence of time and group, a two-way repeated-measures ANOVA (Time × Group) was conducted for each outcome variable. Effect sizes were calculated using eta squared (η²) and categorized as small (0.01), medium (0.06), or large (≥ 0.14). All analyses were two-tailed, and statistical significance was set at p < 0.05. Reporting Standards This randomized controlled trial was designed, conducted, and reported in accordance with the CONSORT 2010 guidelines. A completed CONSORT checklist is provided as an additional file with the revised manuscript. Results Baseline demographic variables were examined to ensure comparability between groups prior to the intervention. No statistically significant differences were found between the pain neuroscience education (PNE) and control groups regarding age, body mass index (BMI), menstrual cycle length, or duration of menstrual pain (p > 0.05). Detailed demographic characteristics are presented in Table 1. Table 2 presents the comparisons of Short-Form McGill Pain Questionnaire (SF-MPQ) scores. Baseline values did not differ significantly between groups (p > 0.05). Following the intervention, the PNE group demonstrated significantly greater reductions in sensory (F=88.32, p < 0.001, η²=0.55), affective (F=46.63, p < 0.001, η²=0.39), and total (F=90.65, p < 0.001, η²=0.56) pain scores compared with the control group. These findings suggest that PNE effectively reduced both sensory and affective components of dysmenorrhea-related pain. Table 3 summarizes the within- and between-group comparisons of the Pain Beliefs Questionnaire (PBQ). Participants in the PNE group exhibited significantly greater improvements than those in the control group. Specifically, the intervention led to reductions in the organic (F=34.27, p < 0.001, η²=0.32) and psychological (F=97.83, p < 0.001, η²=0.58) subscales, as well as in total PBQ scores (F=4.21, p = 0.04, η²=0.06), indicating that PNE reduced maladaptive pain-related beliefs. Table 4 displays within- and between-group analyses of the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). At baseline, there were no significant differences between groups (p > 0.05). Post-intervention analyses showed a marked improvement in the PNE group, reflected by significantly greater reductions in SAIDDL scores compared with the control group (F=126.55, p < 0.001, η²=0.64). Within-group analyses revealed a significant pre–post improvement in the PNE group (t=11.25, p < 0.001), whereas the control group showed no significant change. These results indicate that PNE improved participants’ ability to manage daily activities during menstruation. Discussion This study examined the effects of pain neuroscience education (PNE) on pain intensity, pain-related beliefs, and daily functioning in women with dysmenorrhea. The findings demonstrated that PNE significantly improved all targeted outcomes, indicating that educational interventions addressing pain mechanisms can meaningfully contribute to the management of menstrual pain. By incorporating metaphors, visual explanations, and interactive discussions, the program encouraged participants to reinterpret dysmenorrhea from a threatening, biomedical-oriented experience to a modifiable and manageable neurophysiological process. The successful online delivery of PNE further underscores the feasibility of digital education models, which may help overcome common barriers to accessing non-pharmacological pain management strategies. PNE is grounded in contemporary pain science, emphasizing the dynamic interplay between peripheral nociception, central modulation, cognitive–emotional processes, and environmental influences [ 25 ]. It challenges traditional biomedical assumptions that attribute pain solely to tissue damage, instead promoting an understanding of pain as an output of the nervous system that is shaped by a wide range of factors. Prior research has shown that PNE can reduce symptoms, alter maladaptive beliefs, decrease catastrophizing, and improve function in individuals with chronic musculoskeletal, neuropathic, and postoperative pain [ 18 , 26 , 27 ]. The present study extends these findings to dysmenorrhea, illustrating that similar mechanisms may operate in menstrual pain. Given that women with primary dysmenorrhea frequently exhibit heightened central sensitization, increased nociceptor responsiveness, and negative cognitive–emotional reactions, educational approaches that target these processes may offer substantial benefits. A wide range of treatments exists for dysmenorrhea, including NSAIDs, hormonal contraceptives, heat therapy, transcutaneous electrical nerve stimulation (TENS), exercise, and mind–body practices. Although pharmacological agents—particularly NSAIDs—remain a first-line intervention due to their prostaglandin-inhibiting effects, long-term use may be constrained by gastrointestinal, renal, and cardiovascular risks [ 28 ]. In recent years, growing attention has shifted toward complementary and non-pharmacological interventions that provide symptom relief without medication-related adverse effects. Evidence from network meta-analyses suggests that interventions such as acupressure, exercise, mind–body techniques, and thermal therapies can reduce menstrual pain with favorable safety profiles [ 10 , 16 ]. The present study's results align with this trend, suggesting that PNE may offer an additional non-pharmacological modality capable of improving symptom severity and functional capacity. Several studies support the potential of alternative interventions in dysmenorrhea management. Shah et al. [ 29 ] demonstrated that hypnosis produced sustained reductions in menstrual pain, outperforming NSAID therapy and highlighting the value of approaches that influence pain perception and cognitive-emotional processing. The present study mirrors these findings, showing that PNE contributed to reductions in pain and improvements in daily functioning, likely through its effects on maladaptive cognitions such as fear-avoidance and catastrophizing. Thermal interventions, such as topical heat therapy, have also been shown to improve dysmenorrhea symptoms by increasing blood flow, relaxing uterine musculature, and reducing nociceptor sensitivity. Jo and Choi [ 30 ] reported that heat application was superior to placebo and comparable to certain pharmacological agents in reducing pain intensity. Although the mechanism differs from that of PNE, both interventions promote symptom relief through non-invasive, accessible means. In the present study, PNE similarly improved pain outcomes and daily functioning, suggesting that educational interventions may play a complementary role alongside traditional symptom-relief methods. Transcutaneous electrical nerve stimulation (TENS) is another non-pharmacological modality with demonstrated efficacy. Manisha et al. [ 31 ] showed that high-frequency TENS produced rapid reductions in lower abdominal and referred pain among adolescent girls. Although TENS acts primarily through peripheral gating mechanisms, and PNE through central cognitive–affective modulation, both approaches aim to alter pain processing pathways. The present findings suggest that PNE may contribute to improved menstrual experiences through enhanced understanding of pain physiology and better coping strategies. Exercise-based interventions have similarly shown positive effects in dysmenorrhea. Dehnavi et al. [ 32 ] and Arora et al. [ 33 ] found that aerobic exercise reduced pain intensity, improved quality of life, and decreased functional limitations. Exercise may influence menstrual pain through mechanisms involving endorphin release, improved circulation, stress reduction, and enhanced physical conditioning. While PNE does not directly induce physiological changes in tissue or musculature, it may facilitate greater willingness to engage in physical activity, thereby indirectly supporting improved menstrual health. The present study’s findings—which showed improved daily functioning—support this interpretation. Mind–body practices and manual therapies have also shown promise. Rakhshaee [ 34 ] demonstrated that yoga reduced both the intensity and duration of dysmenorrhea, while Kim et al. [ 35 ] reported improvements following abdominal meridian massage. These interventions may exert their effects through muscle relaxation, autonomic regulation, stress reduction, or improved pelvic mobility. The improvements associated with PNE in the current study suggest that educational strategies may operate synergistically with such practices by reducing fear, increasing body awareness, and promoting self-regulation. Dietary interventions, including omega-3 fatty acids and vitamin E, have been shown to reduce pain severity and decrease reliance on rescue medication [ 36 , 37 ]. These approaches target inflammatory pathways associated with menstrual pain. In contrast, PNE targets cognitive and neurophysiological components of pain processing. The present findings suggest that combining nutritional strategies with educational approaches may yield multidimensional benefits, although this requires future investigation. Collectively, the present study supports the integration of educational interventions into dysmenorrhea management. By addressing the cognitive and neurophysiological contributors to menstrual pain, PNE may reduce symptom burden, improve functional performance, and promote long-term self-management skills. As PNE carries no medication-related risks, is easily delivered online, and is cost-effective, it represents a sustainable option in settings with limited healthcare access or high prevalence of dysmenorrhea-related disability. Further research is needed to identify optimal delivery formats, examine long-term outcomes, and explore synergistic effects when combined with other non-pharmacological or pharmacological therapies. Conclusions This study demonstrates that pain neuroscience education (PNE) is an effective, safe, and accessible non-pharmacological approach for managing dysmenorrhea. By enhancing understanding of pain mechanisms and modifying maladaptive pain-related beliefs, PNE led to reductions in pain intensity and improvements in daily functioning. These findings highlight the importance of addressing cognitive and neurophysiological contributors to menstrual pain, alongside traditional symptom-management strategies. PNE may serve as a valuable standalone or complementary intervention in dysmenorrhea management. Future research should explore long-term outcomes, the integration of PNE with other therapeutic modalities, and applicability across diverse populations and clinical contexts. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Üsküdar University Non-Interventional Research Ethics Committee (Meeting No: 05; Decision No: 61351342/May 2024-56; Date: May 28, 2024). All participants were informed about the study procedures, and written informed consent was obtained prior to participation. Consent for publication Not applicable. The manuscript does not contain any individual person’s data. Consent to Participate Written informed consent was obtained from all participants prior to their enrollment in the study. Clinical trial registration Clinical trial number: NCT06732778. Registration date: September 12, 2024. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors’ contributions Ç.İ. conceived and designed the study, conducted the intervention, collected the data, and performed the initial statistical analysis. O.Ç. contributed to the literature review, data interpretation, methodological development, and advanced statistical analysis. All authors reviewed, revised, and approved the final version of the manuscript. Acknowledgements The authors thank all participants for their valuable contributions to this study. This study was conducted as part of the master’s thesis of Çiğdem Inkaya at Üsküdar University, Institute of Health Sciences. References Nagy H, Carlson K, Khan MA. Dysmenorrhea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Itani R, Arabi R, Badro DA, et al. Primary dysmenorrhea: Pathophysiology, diagnosis, and treatment updates. Korean J Fam Med. 2022;43(2):101–106. 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Supplementary Files tablorevize.docx CONSORTChecklistpdf.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Mar, 2026 Reviews received at journal 24 Mar, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviews received at journal 02 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 04 Dec, 2025 Editor invited by journal 03 Dec, 2025 Submission checks completed at journal 02 Dec, 2025 First submitted to journal 02 Dec, 2025 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. 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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-8190944","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582049835,"identity":"0dc801db-753a-4a37-bdfc-107542ed2b42","order_by":0,"name":"Çiğdem Inkaya¹","email":"","orcid":"","institution":"Üsküdar University","correspondingAuthor":false,"prefix":"","firstName":"Çiğdem","middleName":"","lastName":"Inkaya¹","suffix":""},{"id":582049837,"identity":"37c78a7f-0153-4d64-a649-9954594438d2","order_by":1,"name":"Osman Çoban²","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYJACZiCW42dvAFIGFsRrMZbsOQDSIkG8lsQNNxJAbCK08PMffvi4oOYO48yZz69u+FEgwcDf3p2AV4vkjDRj4xnHnjHzS+eU3ewBOkzizNkNeLUY3OBhk+ZhO8wmOTsn7QYPUIuBRC4BLefPALX8O8xjcPNM2s0/RGk5kMMmzdt2WMLgBvux20TZAvbLzL7DBpI9OWy3ZQwkeAj6BRJi3w7X97Mff3bzzR8bOf72XvxakACPAZgkVjkIsD8gRfUoGAWjYBSMIAAAJy9GVrXuEiEAAAAASUVORK5CYII=","orcid":"","institution":"Üsküdar University","correspondingAuthor":true,"prefix":"","firstName":"Osman","middleName":"","lastName":"Çoban²","suffix":""}],"badges":[],"createdAt":"2025-11-24 08:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8190944/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8190944/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101845409,"identity":"3af312ae-71a3-4619-9dad-c83e8b504aac","added_by":"auto","created_at":"2026-02-04 09:12:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":230488,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT 2010 Flow Diagram of Participant Enrollment, Allocation, Follow-up, and Analysis\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8190944/v1/8e6f650d439bbf371cbedb00.png"},{"id":101845454,"identity":"6e76625c-f84e-4592-84d1-8a651edf5109","added_by":"auto","created_at":"2026-02-04 09:12:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":792782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8190944/v1/f9227e02-ca1a-4f12-85f0-7330ee3bb26b.pdf"},{"id":101845411,"identity":"dfb9fb00-c57e-4c07-b197-19f5bdbbc7b9","added_by":"auto","created_at":"2026-02-04 09:12:38","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":34032,"visible":true,"origin":"","legend":"","description":"","filename":"tablorevize.docx","url":"https://assets-eu.researchsquare.com/files/rs-8190944/v1/44179f1350f54cea96e14bcd.docx"},{"id":101845434,"identity":"43241767-13aa-409e-9d3c-c3d2aefbb77e","added_by":"auto","created_at":"2026-02-04 09:12:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30194,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORTChecklistpdf.docx","url":"https://assets-eu.researchsquare.com/files/rs-8190944/v1/98070df1ca82e7252593f755.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffectiveness of Pain Neuroscience Education in Women with Dysmenorrhea: A Randomized Controlled Trial\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDysmenorrhea, commonly referred to as menstrual pain, is one of the most frequent gynecological disorders among women of reproductive age, particularly adolescents and young adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The condition is characterized by cyclic lower abdominal pain that occurs just before or during menstruation and may persist for two to three days [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Epidemiological data indicate that dysmenorrhea affects approximately 50% to 90% of women of reproductive age, and about one in four experience symptoms severe enough to impair daily activities. Despite its high prevalence, dysmenorrhea was not recognized as a distinct medical condition until the 1970s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is now understood to be a substantial public health issue, contributing to decreased academic and occupational performance, absenteeism, and reduced quality of life in affected individuals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of dysmenorrhea involves excessive endometrial production of prostaglandins, primarily prostaglandin F₂α and E₂, which increase uterine contractility, reduce uterine blood flow, and activate pelvic nociceptors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Recurrent nociceptive input may induce peripheral and central sensitization, thereby amplifying pain perception even in the absence of underlying uterine pathology [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition, neuroendocrine fluctuations and psychological stress can modulate central pain processing and exacerbate symptom severity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe management of dysmenorrhea typically integrates both pharmacological and non-pharmacological strategies. Non-steroidal anti-inflammatory drugs (NSAIDs) remain the first-line treatment due to their ability to reduce prostaglandin synthesis and uterine hypercontractility [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Hormonal contraceptives further alleviate symptoms by regulating endometrial activity and reducing prostaglandin-mediated nociception [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Non-pharmacological approaches\u0026mdash;including exercise, heat therapy, yoga, mindfulness, and transcutaneous electrical nerve stimulation (TENS)\u0026mdash;have also demonstrated benefits by improving circulation, modulating pain pathways, and reducing emotional distress [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. More recently, pain neuroscience education (PNE) has emerged as a complementary strategy aimed at modifying maladaptive pain cognitions and enhancing self-management in women with dysmenorrhea [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePNE provides a biopsychosocial framework to reinterpret menstrual pain by explaining the neurophysiological mechanisms underlying central sensitization and pain modulation. In women with dysmenorrhea, recurrent uterine nociceptive input and negative cognitive\u0026ndash;emotional responses\u0026mdash;such as catastrophizing and fear-avoidance\u0026mdash;may intensify central hyperexcitability and contribute to persistent pain states [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By reframing pain as a modifiable neurophysiological experience, PNE aims to reduce maladaptive beliefs, enhance coping, and improve pain-related outcomes. Recent findings suggest that integrating PNE into conventional dysmenorrhea management may offer additional benefits beyond biomedical education alone [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough educational strategies addressing pain mechanisms have been widely studied in individuals with chronic pain conditions, their application to dysmenorrhea remains limited. Emerging evidence indicates that women with primary dysmenorrhea exhibit features of central sensitization and maladaptive pain cognitions, including pain catastrophizing and fear of movement, which may sustain chronic pain responses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. These findings provide a strong rationale for incorporating PNE into dysmenorrhea management to address both neurophysiological and cognitive\u0026ndash;emotional contributors to pain. Therefore, the present randomized controlled study, \u003cem\u003eEffectiveness of Pain Neuroscience Education in Women with Dysmenorrhea\u003c/em\u003e, aimed to evaluate the impact of a structured PNE program on pain intensity, pain-related cognitions, and functional outcomes compared with a control group that continued their routine daily activities without additional intervention.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Ethical Approval\u003c/h2\u003e \u003cp\u003eThis study was designed as a randomized controlled trial and conducted online between October 1, 2024, and February 1, 2025. Ethical approval was obtained from the \u0026Uuml;sk\u0026uuml;dar University Non-Interventional Research Ethics Committee (Meeting No: 05; Decision No: 61351342/May 2024-56; Date: May 28, 2024). The study was prospectively registered at ClinicalTrials.gov (Identifier: NCT06732778, Registration date: September 12, 2024). All participants provided electronic informed consent prior to enrollment, and all procedures were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Sampling\u003c/h3\u003e\n\u003cp\u003eThe study population consisted of women aged 18 years and older who reported experiencing dysmenorrhea. Eligible participants were required to be at least 18 years of age, to experience dysmenorrhea regularly, and to volunteer to participate in the study. Women were excluded if they were younger than 18 years, had a history of pregnancy, previously experienced pelvic infections, were using hormonal contraceptives or intrauterine devices, had menstrual durations shorter than 3 days or longer than 8 days, or had menstrual cycles outside the 21\u0026ndash;35-day range. A total of 74 volunteers meeting these criteria were enrolled and randomly assigned to two parallel groups using a sequential allocation method: a pain neuroscience education (PNE) group (n\u0026thinsp;=\u0026thinsp;37) and a control group (n\u0026thinsp;=\u0026thinsp;37). Participants who met the inclusion criteria were consecutively allocated according to their order of registration.\u003c/p\u003e \u003cp\u003eAn a priori power analysis was conducted using G*Power software (version 3.1.9.7; Universit\u0026auml;t D\u0026uuml;sseldorf, Germany) to determine the required sample size. Previous studies have demonstrated moderate-to-large associations between dysmenorrhea, activity limitations, and quality-of-life impairments in women [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Based on this evidence, a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.50) was selected to estimate the expected between-group difference in the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL), the primary outcome measure of the study. Assuming a statistical power of 0.80, a two-tailed α\u0026thinsp;=\u0026thinsp;0.05, and a 90% confidence level, the minimum required sample size was calculated as 74 participants. Accordingly, 74 eligible women were recruited and equally randomized into the PNE (n\u0026thinsp;=\u0026thinsp;37) and control (n\u0026thinsp;=\u0026thinsp;37) groups in a 1:1 allocation ratio.\u003c/p\u003e \u003cp\u003eThe flow of participants throughout the study is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eIntervention Procedures\u003c/h3\u003e\n\u003cp\u003eParticipants in the intervention group received a structured PNE program delivered online by the researcher. The program consisted of three consecutive weekly sessions, each lasting approximately 30 minutes.\u003c/p\u003e \u003cp\u003eThe educational content aimed to improve participants\u0026rsquo; understanding of the neurophysiological mechanisms underlying dysmenorrhea. Topics included the neurophysiology of pain, central sensitization, the interaction between cognitive\u0026ndash;emotional processes and pain perception, and evidence-based self-management strategies. Visual materials, metaphors (e.g., the nervous system as an \u0026ldquo;overprotective alarm system\u0026rdquo;), and interactive discussions were used to enhance engagement and comprehension [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSessions emphasized that pain is a protective output of the nervous system and may be amplified through increased neural sensitivity, even in the absence of tissue damage [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Dysmenorrhea mechanisms\u0026mdash;such as prostaglandin-related uterine contractions, inflammatory mediators, and transient hypoxia\u0026mdash;were explained as physiological rather than harmful. Psychological contributors including stress, catastrophizing, and negative menstrual beliefs were discussed as factors that modulate central processing and intensify pain [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants were introduced to practical self-management strategies such as diaphragmatic breathing, relaxation exercises, gentle aerobic activity, yoga-based movements, heat application, and general lifestyle regulation. Misconceptions surrounding dysmenorrhea were addressed, and pain-related beliefs were reframed using contemporary pain science principles to support adaptive coping.\u003c/p\u003e \u003cp\u003eParticipants in the control group did not receive any educational or therapeutic intervention and were instructed to continue their usual daily routines. This passive control design allowed for comparison of PNE effects with the natural course of dysmenorrhea and typical coping behaviors.\u003c/p\u003e\n\u003ch3\u003eOutcome Assessments\u003c/h3\u003e\n\u003cp\u003eOutcome measures were obtained twice for all participants\u0026mdash;before and after one menstrual cycle\u0026mdash;by independent assessors blinded to group allocation. Pain intensity was measured using the Short-Form McGill Pain Questionnaire (SF-MPQ), while the impact of dysmenorrhea on daily living was evaluated with the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). Pain-related beliefs were assessed using the Pain Beliefs Questionnaire (PBQ). All assessments were administered via secure online forms to ensure consistency, participant privacy, and data reliability.\u003c/p\u003e\n\u003ch3\u003eShort-Form McGill Pain Questionnaire (SF-MPQ)\u003c/h3\u003e\n\u003cp\u003ePain intensity was assessed using the SF-MPQ, a widely validated instrument for evaluating sensory and affective pain components [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The SF-MPQ includes 15 descriptors (11 sensory and 4 affective), each rated on a 0\u0026ndash;3 scale (0\u0026thinsp;=\u0026thinsp;none, 3\u0026thinsp;=\u0026thinsp;severe), producing sensory, affective, and total pain scores. It also contains a global pain intensity item with five verbal categories. In this study, the first two sections of the SF-MPQ were used to assess pre- and post-intervention pain levels.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePain Beliefs Questionnaire (PBQ)\u003c/h2\u003e \u003cp\u003ePain-related beliefs were evaluated using the PBQ, a validated instrument developed to measure individuals\u0026rsquo; cognitive interpretations of pain. The PBQ includes two subscales: Organic Beliefs (8 items) and Psychological Beliefs (4 items). Items are rated on a 6-point Likert scale ranging from \u0026ldquo;never\u0026rdquo; to \u0026ldquo;always.\u0026rdquo; Subscale scores are calculated by averaging item responses, yielding Organic, Psychological, and Total PBQ scores [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eScale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL)\u003c/h3\u003e\n\u003cp\u003eFunctional impact was measured using a 0\u0026ndash;10 numerical interference scale adapted from the conceptual structure of the Visual Analogue Scale (VAS), a widely accepted instrument for evaluating subjective symptom intensity [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Participants rated how much dysmenorrhea affected their daily activities on the third day of their menstrual cycle, with 0 representing \u0026ldquo;no impact\u0026rdquo; and 10 indicating \u0026ldquo;complete disruption.\u0026rdquo; Although this tool has not yet undergone formal psychometric validation, its scoring logic and symptom-focused format align with VAS-based pain interference assessments and provide a practical indicator of functional impact.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS, version 25.0; IBM Corp., Armonk, NY, USA). Descriptive data were summarized as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. The normality of variable distributions was verified using the Shapiro\u0026ndash;Wilk test, supporting the use of parametric procedures. Between-group comparisons at baseline and post-intervention were performed using independent-samples t-tests, whereas within-group (pre\u0026ndash;post) differences were analyzed using paired-samples t-tests. To examine the combined influence of time and group, a two-way repeated-measures ANOVA (Time \u0026times; Group) was conducted for each outcome variable. Effect sizes were calculated using eta squared (η\u0026sup2;) and categorized as small (0.01), medium (0.06), or large (\u0026ge;\u0026thinsp;0.14). All analyses were two-tailed, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eReporting Standards\u003c/p\u003e \u003cp\u003e This randomized controlled trial was designed, conducted, and reported in accordance with the CONSORT 2010 guidelines. A completed CONSORT checklist is provided as an additional file with the revised manuscript.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline demographic variables were examined to ensure comparability between groups prior to the intervention. No statistically significant differences were found between the pain neuroscience education (PNE) and control groups regarding age, body mass index (BMI), menstrual cycle length, or duration of menstrual pain (p \u0026gt; 0.05). Detailed demographic characteristics are presented in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 2 presents the comparisons of Short-Form McGill Pain Questionnaire (SF-MPQ) scores. Baseline values did not differ significantly between groups (p \u0026gt; 0.05). Following the intervention, the PNE group demonstrated significantly greater reductions in sensory (F=88.32, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.55), affective (F=46.63, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.39), and total (F=90.65, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.56) pain scores compared with the control group. These findings suggest that PNE effectively reduced both sensory and affective components of dysmenorrhea-related pain.\u003c/p\u003e\n\u003cp\u003eTable 3 summarizes the within- and between-group comparisons of the Pain Beliefs Questionnaire (PBQ). Participants in the PNE group exhibited significantly greater improvements than those in the control group. Specifically, the intervention led to reductions in the organic (F=34.27, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.32) and psychological (F=97.83, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.58) subscales, as well as in total PBQ scores (F=4.21, p = 0.04, \u0026eta;\u0026sup2;=0.06), indicating that PNE reduced maladaptive pain-related beliefs.\u003c/p\u003e\n\u003cp\u003eTable 4 displays within- and between-group analyses of the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). At baseline, there were no significant differences between groups (p \u0026gt; 0.05). Post-intervention analyses showed a marked improvement in the PNE group, reflected by significantly greater reductions in SAIDDL scores compared with the control group (F=126.55, p \u0026lt; 0.001, \u0026eta;\u0026sup2;=0.64). Within-group analyses revealed a significant pre\u0026ndash;post improvement in the PNE group (t=11.25, p \u0026lt; 0.001), whereas the control group showed no significant change. These results indicate that PNE improved participants\u0026rsquo; ability to manage daily activities during menstruation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the effects of pain neuroscience education (PNE) on pain intensity, pain-related beliefs, and daily functioning in women with dysmenorrhea. The findings demonstrated that PNE significantly improved all targeted outcomes, indicating that educational interventions addressing pain mechanisms can meaningfully contribute to the management of menstrual pain. By incorporating metaphors, visual explanations, and interactive discussions, the program encouraged participants to reinterpret dysmenorrhea from a threatening, biomedical-oriented experience to a modifiable and manageable neurophysiological process. The successful online delivery of PNE further underscores the feasibility of digital education models, which may help overcome common barriers to accessing non-pharmacological pain management strategies.\u003c/p\u003e \u003cp\u003ePNE is grounded in contemporary pain science, emphasizing the dynamic interplay between peripheral nociception, central modulation, cognitive\u0026ndash;emotional processes, and environmental influences [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. It challenges traditional biomedical assumptions that attribute pain solely to tissue damage, instead promoting an understanding of pain as an output of the nervous system that is shaped by a wide range of factors. Prior research has shown that PNE can reduce symptoms, alter maladaptive beliefs, decrease catastrophizing, and improve function in individuals with chronic musculoskeletal, neuropathic, and postoperative pain [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The present study extends these findings to dysmenorrhea, illustrating that similar mechanisms may operate in menstrual pain. Given that women with primary dysmenorrhea frequently exhibit heightened central sensitization, increased nociceptor responsiveness, and negative cognitive\u0026ndash;emotional reactions, educational approaches that target these processes may offer substantial benefits.\u003c/p\u003e \u003cp\u003eA wide range of treatments exists for dysmenorrhea, including NSAIDs, hormonal contraceptives, heat therapy, transcutaneous electrical nerve stimulation (TENS), exercise, and mind\u0026ndash;body practices. Although pharmacological agents\u0026mdash;particularly NSAIDs\u0026mdash;remain a first-line intervention due to their prostaglandin-inhibiting effects, long-term use may be constrained by gastrointestinal, renal, and cardiovascular risks [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In recent years, growing attention has shifted toward complementary and non-pharmacological interventions that provide symptom relief without medication-related adverse effects. Evidence from network meta-analyses suggests that interventions such as acupressure, exercise, mind\u0026ndash;body techniques, and thermal therapies can reduce menstrual pain with favorable safety profiles [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The present study's results align with this trend, suggesting that PNE may offer an additional non-pharmacological modality capable of improving symptom severity and functional capacity.\u003c/p\u003e \u003cp\u003eSeveral studies support the potential of alternative interventions in dysmenorrhea management. Shah et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] demonstrated that hypnosis produced sustained reductions in menstrual pain, outperforming NSAID therapy and highlighting the value of approaches that influence pain perception and cognitive-emotional processing. The present study mirrors these findings, showing that PNE contributed to reductions in pain and improvements in daily functioning, likely through its effects on maladaptive cognitions such as fear-avoidance and catastrophizing.\u003c/p\u003e \u003cp\u003eThermal interventions, such as topical heat therapy, have also been shown to improve dysmenorrhea symptoms by increasing blood flow, relaxing uterine musculature, and reducing nociceptor sensitivity. Jo and Choi [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] reported that heat application was superior to placebo and comparable to certain pharmacological agents in reducing pain intensity. Although the mechanism differs from that of PNE, both interventions promote symptom relief through non-invasive, accessible means. In the present study, PNE similarly improved pain outcomes and daily functioning, suggesting that educational interventions may play a complementary role alongside traditional symptom-relief methods.\u003c/p\u003e \u003cp\u003eTranscutaneous electrical nerve stimulation (TENS) is another non-pharmacological modality with demonstrated efficacy. Manisha et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] showed that high-frequency TENS produced rapid reductions in lower abdominal and referred pain among adolescent girls. Although TENS acts primarily through peripheral gating mechanisms, and PNE through central cognitive\u0026ndash;affective modulation, both approaches aim to alter pain processing pathways. The present findings suggest that PNE may contribute to improved menstrual experiences through enhanced understanding of pain physiology and better coping strategies.\u003c/p\u003e \u003cp\u003eExercise-based interventions have similarly shown positive effects in dysmenorrhea. Dehnavi et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and Arora et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] found that aerobic exercise reduced pain intensity, improved quality of life, and decreased functional limitations. Exercise may influence menstrual pain through mechanisms involving endorphin release, improved circulation, stress reduction, and enhanced physical conditioning. While PNE does not directly induce physiological changes in tissue or musculature, it may facilitate greater willingness to engage in physical activity, thereby indirectly supporting improved menstrual health. The present study\u0026rsquo;s findings\u0026mdash;which showed improved daily functioning\u0026mdash;support this interpretation.\u003c/p\u003e \u003cp\u003eMind\u0026ndash;body practices and manual therapies have also shown promise. Rakhshaee [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] demonstrated that yoga reduced both the intensity and duration of dysmenorrhea, while Kim et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] reported improvements following abdominal meridian massage. These interventions may exert their effects through muscle relaxation, autonomic regulation, stress reduction, or improved pelvic mobility. The improvements associated with PNE in the current study suggest that educational strategies may operate synergistically with such practices by reducing fear, increasing body awareness, and promoting self-regulation.\u003c/p\u003e \u003cp\u003eDietary interventions, including omega-3 fatty acids and vitamin E, have been shown to reduce pain severity and decrease reliance on rescue medication [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These approaches target inflammatory pathways associated with menstrual pain. In contrast, PNE targets cognitive and neurophysiological components of pain processing. The present findings suggest that combining nutritional strategies with educational approaches may yield multidimensional benefits, although this requires future investigation.\u003c/p\u003e \u003cp\u003eCollectively, the present study supports the integration of educational interventions into dysmenorrhea management. By addressing the cognitive and neurophysiological contributors to menstrual pain, PNE may reduce symptom burden, improve functional performance, and promote long-term self-management skills. As PNE carries no medication-related risks, is easily delivered online, and is cost-effective, it represents a sustainable option in settings with limited healthcare access or high prevalence of dysmenorrhea-related disability. Further research is needed to identify optimal delivery formats, examine long-term outcomes, and explore synergistic effects when combined with other non-pharmacological or pharmacological therapies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that pain neuroscience education (PNE) is an effective, safe, and accessible non-pharmacological approach for managing dysmenorrhea. By enhancing understanding of pain mechanisms and modifying maladaptive pain-related beliefs, PNE led to reductions in pain intensity and improvements in daily functioning. These findings highlight the importance of addressing cognitive and neurophysiological contributors to menstrual pain, alongside traditional symptom-management strategies. PNE may serve as a valuable standalone or complementary intervention in dysmenorrhea management. Future research should explore long-term outcomes, the integration of PNE with other therapeutic modalities, and applicability across diverse populations and clinical contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the \u0026Uuml;sk\u0026uuml;dar University Non-Interventional Research Ethics Committee (Meeting No: 05; Decision No: 61351342/May 2024-56; Date: May 28, 2024). All participants were informed about the study procedures, and written informed consent was obtained prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to their enrollment in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: NCT06732778. Registration date: September 12, 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026Ccedil;.İ. conceived and designed the study, conducted the intervention, collected the data, and performed the initial statistical analysis.\u003c/p\u003e\n\u003cp\u003eO.\u0026Ccedil;. contributed to the literature review, data interpretation, methodological development, and advanced statistical analysis.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed, revised, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all participants for their valuable contributions to this study. This study was conducted as part of the master\u0026rsquo;s thesis of \u0026Ccedil;iğdem Inkaya at \u0026Uuml;sk\u0026uuml;dar University, Institute of Health Sciences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNagy H, Carlson K, Khan MA. Dysmenorrhea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.\u003c/li\u003e\n\u003cli\u003eItani R, Arabi R, Badro DA, et al. Primary dysmenorrhea: Pathophysiology, diagnosis, and treatment updates. Korean J Fam Med. 2022;43(2):101\u0026ndash;106.\u003c/li\u003e\n\u003cli\u003eFrancavilla R, Loizzi V, Cicinelli E, et al. Dysmenorrhea: Epidemiology, causes and treatment. Clin Exp Obstet Gynecol. 2023;50(12):274\u0026ndash;279.\u003c/li\u003e\n\u003cli\u003eIacovides S. What we know about primary dysmenorrhea today: A critical review. 2015.\u003c/li\u003e\n\u003cli\u003eJin P, Duan G, Li X, et al. Central pain hypersensitivity in primary dysmenorrhea: Neuroimaging evidence. Quant Imaging Med Surg. 2024;14(4):3075\u0026ndash;3087.\u003c/li\u003e\n\u003cli\u003eFort\u0026uacute;n-Rabad\u0026aacute;n R, Quartana L, Clauw DJ, et al. Central pain mechanisms across the menstrual cycle. J Pain. 2023;24(9):1541\u0026ndash;1554.\u003c/li\u003e\n\u003cli\u003eChristensen K. Dysmenorrhoea: Primary healthcare management. Aust J Gen Pract. 2024;53(1\u0026ndash;2):19\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eKirsch E, Bajaj P, Shoskes A, et al. Dysmenorrhea: Therapeutic options. J Pain Res. 2024;17:2657\u0026ndash;2666.\u003c/li\u003e\n\u003cli\u003eLi X, Wang H, Zhao H, et al. Manual therapy in primary dysmenorrhea: Meta-analysis. J Pain Res. 2024;17:1663\u0026ndash;1681.\u003c/li\u003e\n\u003cli\u003eLi X, Wang H, Zhao H, et al. Non-pharmacological interventions for dysmenorrhoea. BMJ Evid Based Med. 2024;29(3):162\u0026ndash;170.\u003c/li\u003e\n\u003cli\u003eOzturk N, Ger\u0026ccedil;ek \u0026Ouml;ter E, K\u0026uuml;rek Eken M. Abdominal massage \u0026amp; stretching for dysmenorrhea. Health Care Women Int. 2023;44(5):621\u0026ndash;638.\u003c/li\u003e\n\u003cli\u003eErol BN, Balci NS, Yildirim G, et al. PNE vs biomedical education in dysmenorrhea. Healthcare. 2025;13(1):xx\u0026ndash;xx.\u003c/li\u003e\n\u003cli\u003ede Arruda GT, Mendes A, Almeida A. Menstrual symptoms \u0026amp; central sensitization. Eur J Pain. 2022;26(8):1759\u0026ndash;1767.\u003c/li\u003e\n\u003cli\u003eRogers S, Smith A, Patel R, et al. Dysmenorrhea severity \u0026amp; induced pain. Front Pain Res. 2024;5:1365193.\u003c/li\u003e\n\u003cli\u003eWatson JA, Ryan CG, Cooper L, et al. PNE for chronic pain: Systematic review. J Pain. 2019;20(10):1140.e1\u0026ndash;1140.e22.\u003c/li\u003e\n\u003cli\u003eLiu N, Li J, Liu Q, et al. Brain structure changes in dysmenorrhea. Quant Imaging Med Surg. 2022;13(2):1071\u0026ndash;1083.\u003c/li\u003e\n\u003cli\u003eAmza M, Nguyen T, Salah M, et al. Dysmenorrhea \u0026amp; quality of life. J Clin Med. 2024;13(19):5660.\u003c/li\u003e\n\u003cli\u003eMoseley GL, Butler DS. Explaining pain: 15-year update. J Pain. 2015;16(9):807\u0026ndash;813.\u003c/li\u003e\n\u003cli\u003eMoseley GL. Reconceptualising pain. Phys Ther Rev. 2007;12(3):169\u0026ndash;178.\u003c/li\u003e\n\u003cli\u003eLouw A, Diener I, Butler DS, et al. PNE efficacy on musculoskeletal pain. Physiother Theory Pract. 2016;32(5):332\u0026ndash;355.\u003c/li\u003e\n\u003cli\u003eNijs J, van Wilgen CP, et al. Explaining central sensitization. Man Ther. 2011;16(5):413\u0026ndash;418.\u003c/li\u003e\n\u003cli\u003eCan E, \u0026Ouml;zt\u0026uuml;rk GT, Candan E, et al. Turkish SF-MPQ-2 validation. Arch Rheumatol. 2025;40(2):249\u0026ndash;256.\u003c/li\u003e\n\u003cli\u003eIrmak B, Sarı H, Yılmaz F, et al. Pain beliefs among nursing students. Agri. 2025;37(1):24\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eModarresi S, Kim JH, Nicassio PM, et al. Psychometric properties of NPRS \u0026amp; VAS. Clin J Pain. 2022;38(2):132\u0026ndash;148.\u003c/li\u003e\n\u003cli\u003eLouw A, Puentedura EJ, Zimney K, et al. Neuroscience education effects. Arch Phys Med Rehabil. 2011;92(12):2041\u0026ndash;2056.\u003c/li\u003e\n\u003cli\u003eTurk DC, Okifuji A. Psychological factors in chronic pain. J Consult Clin Psychol. 2002;70(3):678\u0026ndash;690.\u003c/li\u003e\n\u003cli\u003eApkarian AV, Baliki MN, Geha PY. Theory of chronic pain. Prog Neurobiol. 2009;87(2):81\u0026ndash;97.\u003c/li\u003e\n\u003cli\u003eIacovides S, Avidon I, Baker FC. Primary dysmenorrhea: Critical review. Hum Reprod Update. 2015;21(6):762\u0026ndash;778.\u003c/li\u003e\n\u003cli\u003eShah M, Anwar K, Bhatia A, et al. Hypnosis for dysmenorrhea. CHRISMED J Health Res. 2016;3(3):197\u0026ndash;202.\u003c/li\u003e\n\u003cli\u003eJo J, Lee SH. Heat therapy for dysmenorrhea. Sci Rep. 2018;8(1):16252.\u003c/li\u003e\n\u003cli\u003eManisha U, Anuradha L. High-frequency TENS for dysmenorrhea. J Bodyw Mov Ther. 2021;26:108\u0026ndash;112.\u003c/li\u003e\n\u003cli\u003eDehnavi ZM, Jafarnejad F, Kamali Z. Aerobic exercise for dysmenorrhea. J Educ Health Promot. 2018;7:3.\u003c/li\u003e\n\u003cli\u003eArora A, Yardi S, Gopal S. Aerobic exercise \u0026amp; dysmenorrhea. Indian J Physiother Occup Ther. 2014;8(3):130\u0026ndash;135.\u003c/li\u003e\n\u003cli\u003eRakhshaee Z. Yoga poses for dysmenorrhea. J Pediatr Adolesc Gynecol. 2011;24(4):192\u0026ndash;196.\u003c/li\u003e\n\u003cli\u003eKim JS, Jo YJ, Hwang SK. Abdominal meridian massage. J Korean Acad Nurs. 2005;35(7):1325\u0026ndash;1332.\u003c/li\u003e\n\u003cli\u003eRahbar N, Asgharzadeh N, Ghorbani R. Omega-3 for dysmenorrhea. Int J Gynaecol Obstet. 2012;117(1):45\u0026ndash;47.\u003c/li\u003e\n\u003cli\u003eZiaei S, Zakeri M, Kazemnejad A. Vitamin E for dysmenorrhea. BJOG. 2005;112(4):466\u0026ndash;469.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\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":"Pain Neuroscience Education, Dysmenorrhea, Menstrual Pain, Pain Beliefs, Women’s Health","lastPublishedDoi":"10.21203/rs.3.rs-8190944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8190944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Dysmenorrhea is a highly prevalent gynecological condition that negatively affects menstrual pain experience, daily activities, and overall quality of life. Pain neuroscience education (PNE) is a non-pharmacological intervention designed to reshape maladaptive pain beliefs and promote a more adaptive understanding of pain mechanisms. This study aimed to examine the effects of PNE on pain beliefs, menstrual pain intensity, and the functional impact of dysmenorrhea among women with primary dysmenorrhea.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This randomized controlled trial included 74 women aged ≥18 years diagnosed with primary dysmenorrhea. Participants were randomly allocated to either a PNE group (n = 37) or a control group (n = 37). The PNE group received three weekly online educational sessions, whereas the control group continued their routine activities without intervention. Outcomes were assessed before and after the intervention using the Pain Beliefs Questionnaire (PBQ), the Short-Form McGill Pain Questionnaire (SF-MPQ), and the Scale for Assessing the Impact of Dysmenorrhea on Daily Life (SAIDDL). All assessments were administered by evaluators blinded to group allocation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The PNE group demonstrated significantly greater reductions in maladaptive pain beliefs, including both organic and psychological subscales, compared with the control group. Additionally, the PNE group showed substantial decreases in sensory, affective, and total pain scores on the SF-MPQ. Improvements in daily functioning were also evident, as reflected by significantly lower SAIDDL scores. No significant pre–post or between-group changes were identified in the control group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e PNE effectively reduced maladaptive pain beliefs, menstrual pain intensity, and the functional impact of dysmenorrhea. These findings suggest that PNE is a low-risk, accessible, and feasible intervention that may serve as a complementary strategy in the management of primary dysmenorrhea, particularly when delivered through digital platforms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinicalTrials.gov, NCT06732778. Registered on September 12, 2024.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Pain Neuroscience Education in Women with Dysmenorrhea: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 09:11:32","doi":"10.21203/rs.3.rs-8190944/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-25T10:51:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T20:41:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317656353380630990432857003374659956947","date":"2026-02-27T14:55:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139376844379108974949905888496966745565","date":"2026-02-27T13:24:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T17:21:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48567823977845712750593081304548172430","date":"2026-02-05T11:47:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55090662829208665415485631191430682171","date":"2026-02-03T03:35:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-03T01:53:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140076319707377503700812904886479442813","date":"2026-02-03T01:28:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-28T17:32:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-04T13:35:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-03T05:31:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-02T11:33:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-12-02T11:02:11+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":"1d68edbf-b048-4eae-a21a-64a11d1e275c","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T09:10:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-04 09:11:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8190944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8190944","identity":"rs-8190944","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}