Exercise may benefit those with endometriosis: the Exercise 4 Endo trans-Tasman online survey

Exercise may benefit those with endometriosis: the Exercise 4 Endo trans-Tasman online survey | 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 Exercise may benefit those with endometriosis: the Exercise 4 Endo trans-Tasman online survey Dr Cristy Brooks, Dr Alex Semprini, Allie Eathorne, Melissa Black, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4562611/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Endometriosis affects 1 in 9 women. Current medical and surgical management strategies are not always effective and often result in significant side effects, including sub-optimal pain management. Exercise may exhibit benefits to those with endometriosis, via hormonal and/or inflammatory cytokine mediation pathways. However, previous research has provided mixed results about the impact of exercise, with some studies reporting significant adverse effects. This study aims to determine if those with endometriosis are engaging in exercise, what type(s) of exercise and what impact it has on their symptoms. A cross-sectional online survey was conducted via Qualtrics (August to October 2022). Inclusion criteria included endometriosis diagnosis, 18 + years of age and living in Australia or Aotearoa New Zealand (NZ). 424 responses were received, 63% from Australia and 37% from NZ. 73.8% exercised regularly (weekly basis), with walking the most common modality (87.8%). More than half of respondents revealed exercise was part of their endometriosis self-management strategy (51.6%). The majority of respondents exercised for mental health benefits (84.5%). Negative effects on endometriosis symptoms (e.g. pain) was the most frequently reported reason for not currently exercising (36.6%). This study showed many people with endometriosis in Australia and NZ chose to exercise regularly. Some respondents reported not currently exercising due to negative effects on symptoms, but many used exercise for symptom management, or to benefit their ongoing physical and mental health. Exercise may be a promising avenue for non-surgical treatment of endometriosis, but further research is needed to explore appropriate exercise prescription to limit symptom exacerbation. Obstetrics & Gynecology Physical Medicine & Rehab Women's studies Exercise endometriosis menstruation women’s health Introduction Endometriosis is the presence of endometrial like tissue outside the uterus [ 1 ] and is associated with low-grade systemic inflammation [ 2 , 3 ]. Endometriosis affects around 1 in 9 women and those assigned female at birth by the age of 44 in Australia [ 4 ]. Common symptoms include severe dysmenorrhea (period pain), non-cyclical pelvic pain, and fatigue [ 5 ]. Endometriosis can negatively impact all aspects of an individual’s life, including work, education, sexual and social relationships, self-identity and body image [ 5 – 8 ]. Current medical management for endometriosis is generally considered to be inadequate [ 9 ] with only 25% of those with endometriosis being satisfied with their management symptom [ 10 ]. This is often due to problematic side effects or ineffectiveness of hormonal and pain-relieving medications, leading to treatment discontinuation rates between 25–50% [ 11 ]. While laparoscopic surgery is considered the gold standard for treatment it often has significant costs and long wait times [ 9 ], in addition to substantial recurrence rates, even when performed by expert endometriosis surgeons [ 12 ]. Due, at least in part to these issues, many people with endometriosis report using self-management strategies for their symptoms [ 13 , 14 ]. Exercise was reported as a common strategy, with 42% of respondents in Australia using exercise as a self-management strategy in the last six months, however 34% reported adverse effects from exercise, most commonly increased pelvic pain or increased fatigue [ 13 ]. Despite the conflicting evidence pertaining to the use of exercise for endometriosis symptoms, the potential benefits of exercise among this population warrants further investigation. There is strong rationale for a benefit from exercise on endometriosis, as exercise is often a first-choice recommendation for other chronic pain conditions [ 15 ], and regular exercise has been found to reduce menstrual pain severity in women with primary dysmenorrhea regardless of exercise intensity [ 16 ]. Exercise has also been established as beneficial for other chronic health conditions such as polycystic ovarian syndrome, back pain, fibromyalgia, cystic fibrosis, anxiety, depression, cancer and type 2 diabetes [ 17 ]. Such exercise-associated benefits have included pain reduction, improved mobility and mood, and positive physiological adaptations [ 17 ], which highlights important potential to improve quality of life and mental health outcomes for women with endometriosis and pelvic pain [ 18 , 19 ]. Further research is needed to explore the potential for exercise-induced improvement on endometriosis symptoms. Specifically, understanding the type and intensity of exercise undertaken by those diagnosed with endometriosis and assessing the impact it has on ongoing symptoms and pain management is crucial to developing possible prescribed exercise-based interventions. There are currently mixed results among exercise-related research for endometriosis [ 20 – 24 ]. However, those studies have lacked specific detail regarding the exercise prescription, making it difficult to discern how different exercise modalities or programs may affect endometriosis-related symptoms. Therefore, this study aimed to examine the exercise habits of people with endometriosis in Australia and Aotearoa New Zealand (NZ), including the frequency, intensity, duration and type of exercise they performed on a regular basis and the reasons for their exercise-related choices. Methods Study aim, design and setting The aim of this study was to define and understand reasons for the regular exercise practices of Australian and NZ adult females with diagnosed endometriosis. This was achieved via responses collected in an online survey distributed across Australia and NZ from 24 August 2022 to 22 November 2022. The survey was conducted online using Qualtrics Software (Qualtrics, Provo, UT) and collected information from respondents regarding their exercise habits and any effects on their endometriosis symptoms. The survey content included a range of multiple choice, matrix table and open-ended text questions. Several multiple-choice questions also had an ‘other’ option where participants could specify an alternative answer in a text box. The questions included demographic information, endometriosis symptoms and current treatments and several questions pertaining to their current physical activity and exercise habits. This covered physical activity guidelines and specific aspects of exercise prescription, including type, frequency and duration of exercise sessions. The survey also asked questions regarding exercise choices such as reasons for exercising/not exercising, whether they did it alone or with others, and what impact exercise had on their endometriosis symptoms. Participants were further asked if exercise was part of their endometriosis symptom self-management plan and whether they would like to see more exercise-related treatments available for endometriosis. Participants were provided the opportunity to give further detail about their answers to the two previous questions (exercise as a self-management plan, exercise-related endometriosis treatments) via open-text entries. All questions were generated by the research team with the expertise of Accredited Exercise Physiologists. The survey took approximately 20 minutes to complete. Participant characteristics and recruitment: To be eligible for study participation, survey respondents were required to be over 18 years of age, living in Australia or NZ and have received a diagnosis of endometriosis (e.g. via laparoscopy, MRI or ultrasound imaging). Study participants were recruited via social media advertisement (Facebook, Twitter) and databases from Endometriosis Australia and the Medical Research Institute of New Zealand. Participants had an open timeframe in which to decide whether to participate, until the survey was closed. Potential participants were directed to a survey link and screened for eligibility. If a participant was under 18 years of age or not formally diagnosed with endometriosis, they were unable to continue on with the survey. The survey was anonymous, and no contact information was requested during completion of the survey. All participants provided their consent to take part in the study. Statistical methods : Categorical data are summarised by counts and proportions expressed as percentages. Continuous data are summarised by median and inter-quartile range (IQR). SAS version 9.4 was used for data descriptions. Survey answers were collated with de-identified information collected from other survey respondents. ‘Other’ text responses were collated and analysed quantitatively. The two open text questions were “Please provide a reason for your answer to Q26 (Is exercise part of your self-management plan for your endometriosis) if you would like to” and “Please provide more detail about your answer to Q28 (Would you like to see more exercise-related treatments available for endometriosis) if you would like to.” These two questions were analysed using content analysis to initially code participant answers, which were then put into categories that represented reasons why exercise was part of a self-management strategy or more exercise-related treatments were desired respectively. Once completed, these codes were reported as percentages in line with the other findings. Results 424 respondents completed the survey. The most common age of respondents was 31–38 years of age. Two-thirds of respondents resided in Australia, with Australian and European ethnicity most common. Demographic information is presented in Table 1 . Table 1 Demographic Information of Respondents (n = 424) N (%) Age, years 18–24 73 (17.2) 25–30 111 (26.2) 31–38 128 (30.2) 39+ 112 (26.4) Country of Residence Australia 267 (63.0) Aotearoa New Zealand 157 (37.0) Ethnicity (Australian residents) African 4 (1.5) American 2 (0.7) Asian 11 (4.1) Australian 195 (73.0) European 33 (12.4) Middle Eastern 3 (1.1) New Zealander 8 (3.0) Pacific Islander 1 (0.4) Other 10 (3.7) Aboriginal and/or Torres Strait Islander origin Yes 7 (2.6) Ethnicity (NZ residents) Asian 4 (2.5) European 123 (78.3) Māori 17 (10.8) Middle Eastern / Latin American / African 1 (0.6) Pacific Peoples 1 (0.6) Other 11 (7.0) The endometriosis characteristics of respondents are presented in Table 2 . The most common symptoms currently experienced were dysmenorrhea (86.8%), chronic pelvic pain (84.4%), abdominal distension (87.7%), bowel symptoms (83.0%) and fatigue (84.2%). Non-opioid pain relief (86.3%) and heat (87.0%) were the most frequently reported treatments used for endometriosis symptoms. Table 2 Endometriosis Characteristics of Respondents (n = 423) N (%) How did you get your most recent endometriosis diagnosis? Clinical diagnosis (e.g doctor) 26 (6.1) Surgery (e.g laparoscopy) 362 (85.6) Ultrasound scan or MRI 35 (8.3) What are your endometriosis symptoms? Period pain (dysmenorrhea) 367 (86.8) Heavy menstrual bleeding 265 (62.6) Chronic pelvic pain (pain below your belly button not associated with menstrual bleeding) 357 (84.4) Abdominal distension (bloating) 371 (87.7) Bowel symptoms 351 (83.0) Bladder symptoms 197 (46.6) Fatigue 356 (84.2) Nausea 234 (55.3) Low Back Pain 340 (80.4) Headache or migraine 232 (54.8) Anxiety or depression 250 (59.1) Difficulties with sleep 207 (48.9) Painful sex (dyspareunia) 285 (67.4) Other 59 (13.9) What treatments and medications do you routinely use to treat your endometriosis symptoms? Non-opioid pain relief (e.g. ibuprofen, paracetamol/ acetaminophen) 365 (86.3) Opioid-based pain relief (e.g. codeine, oxycontin, morphine, fentanyl) 159 (37.7) Hormonal treatment (e.g. the oral contraceptive pill, dienogest/Visanne, Mirena, Lupron, elagolix/Orilissa, goserelin acetate/Zoladex) 245 (57.9) Neuroleptics (e.g. Lyrica/pregabalin or gabapentin) 38 (9.0) Physiotherapy/pelvic exercises 155 (36.6) Heat (e.g. heat packs) 368 (87.0) Cardio/aerobic exercise (e.g. walking, running, cycling, swimming) 199 (47.0) Strength/resistance (e.g. lifting weights) 108 (25.5) Combined or High-intensity exercise (e.g. CrossFit, HIIT training) 43 (10.2) Yoga or Pilates 152 (35.9) Psychological treatment (e.g. speaking with a psychologist, mindfulness or meditation) 123 (29.1) Acupuncture 65 (15.4) Cannabis 45 (10.6) Herbal Medicine (e.g. Chinese herbal medicine – not including cannabis) 51 (12.1) Other 71 (16.9) 80.6% of respondents considered themselves to be physically active each week (Table 3 ), with 57.0% believing they meet the moderate-vigorous physical activity (MPVA) guidelines. 56.3% of respondents performed muscle-strengthening activities at least twice per week. Most respondents (73.8%) exercised on a regular weekly basis. Table 3 Physical Activity Characteristics of Respondents (n = 423) N (%) Do you consider yourself to be physically active each week? Yes 341 (80.6) No 69 (16.3) Unsure 13 (3.1) Do you think you meet these [MVPA] guidelines in a typical week? Yes 241 (57.0) Do you believe you perform muscle-strengthening activities at least twice per week on a typical week? Yes 238 (56.3) Are you currently exercising regularly (on a weekly basis)? Yes 312 (73.8) No 101 (23.9) Unsure 10 (2.4) Table 4 presents the exercise characteristics of survey respondents. Walking was the most frequently reported type of exercise (87.8%), followed by resistance/weight training (51.6%), going to the gym (potentially multimodal exercise regime) (38.8%), home-based exercise (38.8%) and yoga (34.9%). The most common frequency of exercise was 2–3 times per week (42.0%), closely followed by 4–6 times per week (38.8%), and then daily (15.1%). Typical durations for exercise sessions were 45 min – 1 hour (45.5%), and 30–45 minutes (25.6%). Slightly over half of respondents exercised alone (51.6%), or a combination of alone and with others (29.5%). Nearly all respondents said their current exercise choices were their own (85.6%) rather than from the advice or recommendation of others. The two most frequently reported reasons for exercising were for mental health (84.5%) and to improve overall health (80.9%), although a variety of other reasons were also common (Table 4 ). Approximately half (51.6%) of respondents considered exercise to be a part of their self-management plan for their endometriosis. The most frequently reported reason for not exercising was due to negative effects on symptoms (36.6%), followed by other reasons (28.7%). The majority (81.1%) of respondents were in support of increasing the availability of exercise-related treatments for endometriosis. Table 4 Exercise Characteristics of Respondents N (%) What type of exercise do you do? Walking 274 (87.8) Running 86 (27.6) Yoga 109 (34.9) Pilates 80 (25.6) Resistance/weight training 161 (51.6) CrossFit 11 (3.5) Zumba / Dancing 30 (9.6) Sport 41 (13.1) High-Intensity Interval Training (HIIT) 70 (22.4) Go to the gym 121 (38.8) Home-based exercise 121 (38.8) Other 57 (18.3) How often do you exercise? Daily 47 (15.1) 4–6 times a week 121 (38.8) 2–3 times a week 131 (42.0) Once a week 12 (3.8) A few times a month 1 (0.3) How long do you exercise for? (in a typical exercise session) > 2 hours 8 (2.6) 1–2 hours 34 (10.9) 45 mins − 1 hour 142 (45.5) 30–45 mins 80 (25.6) 20–30 mins 38 (12.2) Less than 20 mins 10 (3.2) On a typical week, do you do this exercise alone or with others? By myself 161 (51.6) With a training partner 20 (6.4) With a coach/trainer 18 (5.8) Combination 92 (29.5) Other 21 (6.7) Are your current exercise choices your own or based on recommendations/advice from another person? My choice / personal preference 267 (85.6) Recommendation / advice 45 (14.4) What is your reason/s for exercising? (n = 309) Improves endometriosis symptoms 111 (35.9) Increase energy / combat fatigue 180 (58.3) Pain reduction 87 (28.2) Digestive benefit (e.g reduce bloating or other gastrointestinal symptoms) 115 (37.2) Mental health (e.g positive impact on anxiety and/or depression) 261 (84.5) Gain or maintain cardiovascular fitness 174 (56.3) Improve muscle strength, size or endurance 165 (53.4) Weight reduction or maintenance 197 (63.8) Improve overall health 250 (80.9) Personal enjoyment 191 (61.8) Sporting performance 33 (10.7) Is exercise part of your self-management plan for your endometriosis? (n = 228) Yes 118 (51.6) No 75 (32.9) Maybe 35 (15.4) Do you have a particular reason for not exercising at the moment? (n = 101) Has a negative effect on my endometriosis symptoms (e.g. causes pain) 37 (36.6) Not considered a priority 4 (4.0) Not motivated/ interested 9 (8.9) Too busy 22 (21.8) Other 29 (28.7) Would you like to see more exercise-related treatments available for endometriosis? (n = 227) Yes 184 (81.1) No 11 (4.8) Unsure 32 (14.1) Other types of exercise listed in text responses (18.3%) included barre, boxing, cycling, hiking, pole dancing, swimming and assorted others. Of the exercise choices based upon recommendation or advice (14.4%) health professionals were most referenced. The most highly reported were physiotherapist, pelvic physiotherapist, personal trainer, doctor and gynaecologist (Supplementary Table 1). Those that reported ‘Other’ reasons for not exercising (28.7%) included pain, fatigue, endo symptoms and other illnesses/disease (Supplementary Table 1). 29.7% of respondents suggested exercise programs tailored towards people with endometriosis (and/or endometriosis symptoms) or different times of the menstrual cycle, and 20.0% of responses recommended the use of exercise prescription to better manage symptoms. 23.2% of respondents expressed interest in increasing education and awareness around exercise as a possible treatment for endometriosis. 15.1% of respondents highlighted a need for more research and evidence for exercising with endometriosis, 11.9% further knowledge around exercise types and 11.9% suggested guidelines for exercise prescription among those with endometriosis. Financial barriers, scepticism of exercise benefits, and negative opinions about exercise were also expressed. Free text responses stratified by country and ethnicity are available in Supplementary Tables 2–3. Discussion This study found that people with endometriosis are commonly leading active lifestyles, with nearly three-quarters of respondents engaging in regular exercise sessions (2–6 times per week). Walking was the preferred modality, but a range of other aerobic and/or strength-based exercise modalities were also common, with sessions typically lasting 45 minutes to an hour. The level of exercise reported in the current study is in line with previous work [ 13 ], with over half of respondents reporting that exercise was a part of their self-management strategy for endometriosis. Regular exercise habits were typically based on individual choice or preference, rather than recommendation or advice. The main reason for not exercising was symptom exacerbation, consistent with previous findings [ 13 ]. The present study found that people with endometriosis may often have multiple reasons for their exercise choices. Aside from improvements in symptoms such as pain, digestive comfort and fatigue, respondents also reported exercising for personal enjoyment, weight-related factors, or physiological parameters such as cardiovascular and/or muscular fitness. Moreover, the two most frequently reported reasons for exercising were positive impacts on their overall health and mental health. This supports previous research that regular exercise may provide multifaceted benefits for those with endometriosis, such as positive impacts on overall health and wellbeing [ 18 , 19 ]. Thus, just as the disease itself is complex and multifactorial, so are the exercise-related outcomes, with a lack of a “one-size fits all” approach and likely to require trial and error to determine the benefits of different types of exercise on an individual. While it is important to consider the potential benefits of exercise on the lives of women with endometriosis, the balance between symptom improvement and symptom exacerbation must be considered. Nevertheless, the findings of the present study contribute to the increasing evidence of positive exercise impacts on mental health in those with endometriosis [ 25 ] and adds to the existing evidence base for exercise-related benefits on anxiety and depression [ 26 – 28 ]. Therefore, it is plausible to consider that the benefits of exercise may extend beyond improvements in pain symptoms to overall physical and mental health. Despite the potential benefits of exercise for endometriosis and the existence of multiple reviews on the effects of physical activity and/or exercise on the disease, the heterogeneity of studies has largely led to inconclusive results [ 20 – 24 ]. Moreover, the individualistic nature of endometriosis symptoms, in addition to low data quality and high or non-reported drop-out rates making comparisons difficult [ 21 ]. A further possible contributor to the inconclusive evidence topic to-date is the notion that disease impacts may reduce treatment efficacy. For instance, previous research suggests that biopsychosocial impairments induced from the disease may compromise treatment modalities, and therefore a holistic approach is warranted to improve overall quality of life among this chronic population [ 22 ]. The complexity of the disease itself may be an additional consideration, since those with endometriosis often have an array of symptoms. In the present study, the most common symptoms reported were chronic pelvic pain, bloating, bowel symptoms, fatigue and low back pain, followed by a number of other debilitating symptoms, aligning with previous evidence [ 24 ]. Despite the previous lack of conclusive data and individualistic nature of the disease presenting an array of possible challenges for symptom management, the potential exercise-induced benefits on endometriosis still remains. Previous research shows that exercise works to improve pain severity and physical function in those with chronic pain conditions [ 15 ]. Furthermore, exercise-based treatments are more likely to be more effective than standard medical care or receiving no care in some populations [ 29 ]. For example, exercise benefits have been observed in chronic low back pain [ 30 – 32 ], fibromyalgia [ 33 ] and rheumatoid arthritis [ 34 – 36 ]. In addition, there is growing evidence to suggest that graded exercise or ‘activity pacing’ may benefit those with chronic fatigue syndrome [ 37 ], or chronic conditions that are commonly associated with fatigue symptoms [ 38 ]. What remains unknown is the specific conditions by which such exercise-induced benefits may be experienced by those with endometriosis. For instance, there is a possibility that while one person may benefit from a particular exercise program, another may not. Therefore, the optimum type, intensity, duration and frequency of exercise to limit symptom exacerbation may differ between individuals. Although the paucity of research exploring the effect of specific exercise prescription (modality, duration, frequency, intensity) on endometriosis symptoms means this notion is currently unverified, it has been previously suggested that the type and intensity of exercise may play a role in exercise-related effects on endometriosis [ 20 , 24 ]. This coincides with the finding from the present study that more exercise-related treatments are strongly desired among those with endometriosis. However, improving our understanding of exercise prescription for endometriosis is vital for women to achieve exercise-related benefits while also limiting symptom exacerbation. Therefore, there is also a clear need for exercise-related guidance for people with endometriosis and the health practitioners treating them. To do this, future research needs to explore those aspects the multifaceted benefits in an endometriosis population, alongside changes in pain or other symptoms such as fatigue possibly instigated by exercise. To the best of the authors’ knowledge, this is the first study to survey specific exercise habits of people with endometriosis in Australia and NZ. While our findings are limited to the trans-Tasman locality and cannot be generalised for all people with endometriosis on a global scale, the benefits of exercise indicated in this study provide a promising avenue for non-surgical treatment to better help people with endometriosis manage their symptoms. This study has provided encouraging evidence to suggest that this population can benefit from exercise despite chronic and often debilitating symptoms. Conclusions The results of this study have revealed most people with endometriosis are exercising or want to exercise, despite their ongoing symptoms. It is plausible that exercise may make living with this disease more manageable, as a potential coping mechanism both physically and mentally. This study indicates that exercise may be a promising option for ongoing symptom management in those with endometriosis, highlighting the need for future research to help define exercise prescription for endometriosis. Abbreviations MVPA moderate-vigorous physical activity NZ Aotearoa New Zealand SD standard deviation Declarations Competing interests The authors declare that they have no competing interests. Funding No funding was received for this work. Compliance with Ethical Standards Disclosure of potential conflicts of interest None to declare. Research involving Human Participants and/or Animals This study has ethical approval from the Human Research Ethics Committee at Western Sydney University (approval number H15028). Participants were provided with a Participant Information Sheet via an online link prior to commencing the survey. Possible adverse events associated with survey questions were acknowledged and all potential participants were provided with opportunities to speak to the research team. Informed consent Online consent to have their data collected for research prior to being able to access the survey was required by all survey respondents. Participation was on a voluntary basis and all respondents had the right to withdraw their consent at any time. Consent for publication Not applicable Availability of data and materials Results of text variables from survey responses is available via the supplementary file. Author contributions Cristy Brooks and Mike Armour were responsible for study conception and design. All authors contributed to survey design. Data collection was performed by Cristy Brooks. Data analysis was performed by Allie Eathorne. The first draft of the manuscript was written by Cristy Brooks. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements Nicola Marshall for study promotion. References Johnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS et al (2017) World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32(2):315–324 Mikhaleva LM, Radzinsky VE, Orazov MR, Khovanskaya TN, Sorokina AV, Mikhalev SA et al (2021) Current Knowledge on Endometriosis Etiology: A Systematic Review of Literature. 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Front Immunol 13:1089621 Metsios GS, Stavropoulos-Kalinoglou A, Kitas GD (2015) The role of exercise in the management of rheumatoid arthritis. Expert Rev Clin Immunol 11(10):1121–1130 Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H (2017) Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med 51(14):1065–1072 Casson S, Jones MD, Cassar J, Kwai N, Lloyd AR, Barry BK et al (2023) The effectiveness of activity pacing interventions for people with chronic fatigue syndrome: a systematic review and meta-analysis. Disabil Rehabil 45(23):3788–3802 Abonie US, Sandercock GRH, Heesterbeek M, Hettinga FJ (2020) Effects of activity pacing in patients with chronic conditions associated with fatigue complaints: a meta-analysis. Disabil Rehabil 42(5):613–622 Additional Declarations The authors declare no competing interests. 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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-4562611","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313043108,"identity":"cbd69556-983e-4472-afd9-671ae18dbf28","order_by":0,"name":"Dr Cristy Brooks","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-1022-0747","institution":"Western Sydney University","correspondingAuthor":true,"prefix":"Dr","firstName":"Cristy","middleName":"","lastName":"Brooks","suffix":""},{"id":313043109,"identity":"eac68013-f03c-46ab-be20-69112ccf8072","order_by":1,"name":"Dr Alex Semprini","email":"","orcid":"","institution":"Medical Research Institute of New Zealand","correspondingAuthor":false,"prefix":"Dr","firstName":"Alex","middleName":"","lastName":"Semprini","suffix":""},{"id":313043110,"identity":"318a17ec-ba7e-46c9-8535-38e720f35d08","order_by":2,"name":"Allie Eathorne","email":"","orcid":"","institution":"Medical Research Institute of New Zealand","correspondingAuthor":false,"prefix":"","firstName":"Allie","middleName":"","lastName":"Eathorne","suffix":""},{"id":313043111,"identity":"d16e8684-fbc1-4f86-bf8e-0cf8cb58a1be","order_by":3,"name":"Melissa Black","email":"","orcid":"","institution":"Medical Research Institute of New Zealand","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"","lastName":"Black","suffix":""},{"id":313043112,"identity":"d63f0dda-943c-403f-bab5-9723926357b9","order_by":4,"name":"Michaela Walton","email":"","orcid":"","institution":"Medical Research Institute of New Zealand","correspondingAuthor":false,"prefix":"","firstName":"Michaela","middleName":"","lastName":"Walton","suffix":""},{"id":313043113,"identity":"dc750ba8-4cc8-4c00-a67a-4a1cdeeb8fb3","order_by":5,"name":"Associate Professor Mike Armour","email":"","orcid":"","institution":"NICM Health Research Institute, Western Sydney University","correspondingAuthor":false,"prefix":"","firstName":"Associate","middleName":"Professor Mike","lastName":"Armour","suffix":""}],"badges":[],"createdAt":"2024-06-11 08:48:07","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4562611/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4562611/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58186619,"identity":"52ffc1d7-c653-489b-958a-d898ca57bfae","added_by":"auto","created_at":"2024-06-12 07:23:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":549035,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4562611/v1/ec6965ef-7035-4328-aabc-dd85162eb39d.pdf"},{"id":58185988,"identity":"82f8c1c7-34be-4985-a1a2-ee6d5813204b","added_by":"auto","created_at":"2024-06-12 07:15:47","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":40301,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4562611/v1/23121dac44185e24aad9de63.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eExercise may benefit those with endometriosis: the Exercise 4 Endo trans-Tasman online survey\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is the presence of endometrial like tissue outside the uterus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and is associated with low-grade systemic inflammation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Endometriosis affects around 1 in 9 women and those assigned female at birth by the age of 44 in Australia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Common symptoms include severe dysmenorrhea (period pain), non-cyclical pelvic pain, and fatigue [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Endometriosis can negatively impact all aspects of an individual\u0026rsquo;s life, including work, education, sexual and social relationships, self-identity and body image [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Current medical management for endometriosis is generally considered to be inadequate [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] with only 25% of those with endometriosis being satisfied with their management symptom [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This is often due to problematic side effects or ineffectiveness of hormonal and pain-relieving medications, leading to treatment discontinuation rates between 25\u0026ndash;50% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. While laparoscopic surgery is considered the gold standard for treatment it often has significant costs and long wait times [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], in addition to substantial recurrence rates, even when performed by expert endometriosis surgeons [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Due, at least in part to these issues, many people with endometriosis report using self-management strategies for their symptoms [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Exercise was reported as a common strategy, with 42% of respondents in Australia using exercise as a self-management strategy in the last six months, however 34% reported adverse effects from exercise, most commonly increased pelvic pain or increased fatigue [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the conflicting evidence pertaining to the use of exercise for endometriosis symptoms, the potential benefits of exercise among this population warrants further investigation. There is strong rationale for a benefit from exercise on endometriosis, as exercise is often a first-choice recommendation for other chronic pain conditions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and regular exercise has been found to reduce menstrual pain severity in women with primary dysmenorrhea regardless of exercise intensity [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Exercise has also been established as beneficial for other chronic health conditions such as polycystic ovarian syndrome, back pain, fibromyalgia, cystic fibrosis, anxiety, depression, cancer and type 2 diabetes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Such exercise-associated benefits have included pain reduction, improved mobility and mood, and positive physiological adaptations [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], which highlights important potential to improve quality of life and mental health outcomes for women with endometriosis and pelvic pain [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurther research is needed to explore the potential for exercise-induced improvement on endometriosis symptoms. Specifically, understanding the type and intensity of exercise undertaken by those diagnosed with endometriosis and assessing the impact it has on ongoing symptoms and pain management is crucial to developing possible prescribed exercise-based interventions. There are currently mixed results among exercise-related research for endometriosis [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, those studies have lacked specific detail regarding the exercise prescription, making it difficult to discern how different exercise modalities or programs may affect endometriosis-related symptoms. Therefore, this study aimed to examine the exercise habits of people with endometriosis in Australia and Aotearoa New Zealand (NZ), including the frequency, intensity, duration and type of exercise they performed on a regular basis and the reasons for their exercise-related choices.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy aim, design and setting\u003c/h2\u003e \u003cp\u003eThe aim of this study was to define and understand reasons for the regular exercise practices of Australian and NZ adult females with diagnosed endometriosis. This was achieved via responses collected in an online survey distributed across Australia and NZ from 24 August 2022 to 22 November 2022. The survey was conducted online using Qualtrics Software (Qualtrics, Provo, UT) and collected information from respondents regarding their exercise habits and any effects on their endometriosis symptoms. The survey content included a range of multiple choice, matrix table and open-ended text questions. Several multiple-choice questions also had an \u0026lsquo;other\u0026rsquo; option where participants could specify an alternative answer in a text box. The questions included demographic information, endometriosis symptoms and current treatments and several questions pertaining to their current physical activity and exercise habits. This covered physical activity guidelines and specific aspects of exercise prescription, including type, frequency and duration of exercise sessions. The survey also asked questions regarding exercise choices such as reasons for exercising/not exercising, whether they did it alone or with others, and what impact exercise had on their endometriosis symptoms. Participants were further asked if exercise was part of their endometriosis symptom self-management plan and whether they would like to see more exercise-related treatments available for endometriosis. Participants were provided the opportunity to give further detail about their answers to the two previous questions (exercise as a self-management plan, exercise-related endometriosis treatments) via open-text entries. All questions were generated by the research team with the expertise of Accredited Exercise Physiologists. The survey took approximately 20 minutes to complete.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics and recruitment:\u003c/h2\u003e \u003cp\u003eTo be eligible for study participation, survey respondents were required to be over 18 years of age, living in Australia or NZ and have received a diagnosis of endometriosis (e.g. via laparoscopy, MRI or ultrasound imaging). Study participants were recruited via social media advertisement (Facebook, Twitter) and databases from Endometriosis Australia and the Medical Research Institute of New Zealand. Participants had an open timeframe in which to decide whether to participate, until the survey was closed. Potential participants were directed to a survey link and screened for eligibility. If a participant was under 18 years of age or not formally diagnosed with endometriosis, they were unable to continue on with the survey. The survey was anonymous, and no contact information was requested during completion of the survey. All participants provided their consent to take part in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStatistical methods\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003eCategorical data are summarised by counts and proportions expressed as percentages. Continuous data are summarised by median and inter-quartile range (IQR). SAS version 9.4 was used for data descriptions. Survey answers were collated with de-identified information collected from other survey respondents. \u0026lsquo;Other\u0026rsquo; text responses were collated and analysed quantitatively. The two open text questions were \u0026ldquo;Please provide a reason for your answer to Q26 (Is exercise part of your self-management plan for your endometriosis) if you would like to\u0026rdquo; and \u0026ldquo;Please provide more detail about your answer to Q28 (Would you like to see more exercise-related treatments available for endometriosis) if you would like to.\u0026rdquo; These two questions were analysed using content analysis to initially code participant answers, which were then put into categories that represented reasons why exercise was part of a self-management strategy or more exercise-related treatments were desired respectively. Once completed, these codes were reported as percentages in line with the other findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e424 respondents completed the survey. The most common age of respondents was 31\u0026ndash;38 years of age. Two-thirds of respondents resided in Australia, with Australian and European ethnicity most common. Demographic information is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Information of Respondents (n\u0026thinsp;=\u0026thinsp;424)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (26.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e128 (30.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCountry of Residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e267 (63.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAotearoa New Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157 (37.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e \u003cp\u003eEthnicity (Australian residents)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfrican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmerican\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAustralian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195 (73.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEuropean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (12.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle Eastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew Zealander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAboriginal and/or Torres Strait Islander origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eEthnicity (NZ residents)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEuropean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e123 (78.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMāori\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (10.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle Eastern / Latin American / African\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePacific Peoples\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (7.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe endometriosis characteristics of respondents are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The most common symptoms currently experienced were dysmenorrhea (86.8%), chronic pelvic pain (84.4%), abdominal distension (87.7%), bowel symptoms (83.0%) and fatigue (84.2%). Non-opioid pain relief (86.3%) and heat (87.0%) were the most frequently reported treatments used for endometriosis symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEndometriosis Characteristics of Respondents (n\u0026thinsp;=\u0026thinsp;423)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHow did you get your most recent endometriosis diagnosis?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical diagnosis (e.g doctor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery (e.g laparoscopy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e362 (85.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasound scan or MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"13\" rowspan=\"14\"\u003e \u003cp\u003eWhat are your endometriosis symptoms?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePeriod pain (dysmenorrhea)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e367 (86.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeavy menstrual bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e265 (62.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronic pelvic pain (pain below your belly button not associated with menstrual bleeding)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e357 (84.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbdominal distension (bloating)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e371 (87.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBowel symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e351 (83.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBladder symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197 (46.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e356 (84.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234 (55.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow Back Pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e340 (80.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeadache or migraine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e232 (54.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnxiety or depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e250 (59.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDifficulties with sleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e207 (48.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePainful sex (dyspareunia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e285 (67.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (13.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"14\" rowspan=\"15\"\u003e \u003cp\u003eWhat treatments and medications do you routinely use to treat your endometriosis symptoms?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-opioid pain relief (e.g. ibuprofen, paracetamol/ acetaminophen)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e365 (86.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpioid-based pain relief (e.g. codeine, oxycontin, morphine, fentanyl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e159 (37.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHormonal treatment (e.g. the oral contraceptive pill, dienogest/Visanne, Mirena, Lupron, elagolix/Orilissa, goserelin acetate/Zoladex)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e245 (57.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeuroleptics (e.g. Lyrica/pregabalin or gabapentin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysiotherapy/pelvic exercises\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e155 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeat (e.g. heat packs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e368 (87.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardio/aerobic exercise (e.g. walking, running, cycling, swimming)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e199 (47.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrength/resistance (e.g. lifting weights)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined or High-intensity exercise (e.g. CrossFit, HIIT training)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43 (10.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoga or Pilates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e152 (35.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychological treatment (e.g. speaking with a psychologist, mindfulness or meditation)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e123 (29.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcupuncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (15.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCannabis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHerbal Medicine (e.g. Chinese herbal medicine \u0026ndash; not including cannabis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71 (16.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e80.6% of respondents considered themselves to be physically active each week (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), with 57.0% believing they meet the moderate-vigorous physical activity (MPVA) guidelines. 56.3% of respondents performed muscle-strengthening activities at least twice per week. Most respondents (73.8%) exercised on a regular weekly basis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePhysical Activity Characteristics of Respondents (n\u0026thinsp;=\u0026thinsp;423)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDo you consider yourself to be physically active each week?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e341 (80.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (16.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think you meet these [MVPA] guidelines in a typical week?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e241 (57.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you believe you perform muscle-strengthening activities at least twice per week on a typical week?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e238 (56.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAre you currently exercising regularly (on a weekly basis)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e312 (73.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101 (23.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the exercise characteristics of survey respondents. Walking was the most frequently reported type of exercise (87.8%), followed by resistance/weight training (51.6%), going to the gym (potentially multimodal exercise regime) (38.8%), home-based exercise (38.8%) and yoga (34.9%). The most common frequency of exercise was 2\u0026ndash;3 times per week (42.0%), closely followed by 4\u0026ndash;6 times per week (38.8%), and then daily (15.1%). Typical durations for exercise sessions were 45 min \u0026ndash; 1 hour (45.5%), and 30\u0026ndash;45 minutes (25.6%). Slightly over half of respondents exercised alone (51.6%), or a combination of alone and with others (29.5%). Nearly all respondents said their current exercise choices were their own (85.6%) rather than from the advice or recommendation of others.\u003c/p\u003e \u003cp\u003eThe two most frequently reported reasons for exercising were for mental health (84.5%) and to improve overall health (80.9%), although a variety of other reasons were also common (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Approximately half (51.6%) of respondents considered exercise to be a part of their self-management plan for their endometriosis. The most frequently reported reason for not exercising was due to negative effects on symptoms (36.6%), followed by other reasons (28.7%). The majority (81.1%) of respondents were in support of increasing the availability of exercise-related treatments for endometriosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExercise Characteristics of Respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003eWhat type of exercise do you do?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWalking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e274 (87.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRunning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86 (27.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYoga\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e109 (34.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePilates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80 (25.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResistance/weight training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161 (51.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCrossFit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (3.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZumba / Dancing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSport\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh-Intensity Interval Training (HIIT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGo to the gym\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome-based exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57 (18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eHow often do you exercise?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;6 times a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121 (38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3 times a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131 (42.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOnce a week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA few times a month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eHow long do you exercise for? (in a typical exercise session)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (2.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 mins \u0026minus;\u0026thinsp;1 hour\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e142 (45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;45 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80 (25.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;30 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (12.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than 20 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eOn a typical week, do you do this exercise alone or with others?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBy myself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161 (51.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith a training partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (6.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith a coach/trainer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (5.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e92 (29.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (6.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAre your current exercise choices your own or based on recommendations/advice from another person?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMy choice / personal preference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e267 (85.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecommendation / advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (14.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"10\" rowspan=\"11\"\u003e \u003cp\u003eWhat is your reason/s for exercising? (n\u0026thinsp;=\u0026thinsp;309)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImproves endometriosis symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111 (35.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncrease energy / combat fatigue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e180 (58.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePain reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (28.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDigestive benefit (e.g reduce bloating or other gastrointestinal symptoms)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115 (37.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health (e.g positive impact on anxiety and/or depression)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e261 (84.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGain or maintain cardiovascular fitness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e174 (56.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImprove muscle strength, size or endurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e165 (53.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight reduction or maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197 (63.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImprove overall health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e250 (80.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersonal enjoyment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191 (61.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSporting performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eIs exercise part of your self-management plan for your endometriosis? (n\u0026thinsp;=\u0026thinsp;228)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e118 (51.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75 (32.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaybe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (15.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eDo you have a particular reason for not exercising at the moment? (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHas a negative effect on my endometriosis symptoms (e.g. causes pain)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (36.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot considered a priority\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot motivated/ interested\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eToo busy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (21.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (28.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWould you like to see more exercise-related treatments available for endometriosis? (n\u0026thinsp;=\u0026thinsp;227)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e184 (81.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOther types of exercise listed in text responses (18.3%) included barre, boxing, cycling, hiking, pole dancing, swimming and assorted others. Of the exercise choices based upon recommendation or advice (14.4%) health professionals were most referenced. The most highly reported were physiotherapist, pelvic physiotherapist, personal trainer, doctor and gynaecologist (Supplementary Table\u0026nbsp;1). Those that reported \u0026lsquo;Other\u0026rsquo; reasons for not exercising (28.7%) included pain, fatigue, endo symptoms and other illnesses/disease (Supplementary Table\u0026nbsp;1). 29.7% of respondents suggested exercise programs tailored towards people with endometriosis (and/or endometriosis symptoms) or different times of the menstrual cycle, and 20.0% of responses recommended the use of exercise prescription to better manage symptoms. 23.2% of respondents expressed interest in increasing education and awareness around exercise as a possible treatment for endometriosis. 15.1% of respondents highlighted a need for more research and evidence for exercising with endometriosis, 11.9% further knowledge around exercise types and 11.9% suggested guidelines for exercise prescription among those with endometriosis. Financial barriers, scepticism of exercise benefits, and negative opinions about exercise were also expressed. Free text responses stratified by country and ethnicity are available in Supplementary Tables\u0026nbsp;2\u0026ndash;3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that people with endometriosis are commonly leading active lifestyles, with nearly three-quarters of respondents engaging in regular exercise sessions (2\u0026ndash;6 times per week). Walking was the preferred modality, but a range of other aerobic and/or strength-based exercise modalities were also common, with sessions typically lasting 45 minutes to an hour. The level of exercise reported in the current study is in line with previous work [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], with over half of respondents reporting that exercise was a part of their self-management strategy for endometriosis. Regular exercise habits were typically based on individual choice or preference, rather than recommendation or advice. The main reason for not exercising was symptom exacerbation, consistent with previous findings [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study found that people with endometriosis may often have multiple reasons for their exercise choices. Aside from improvements in symptoms such as pain, digestive comfort and fatigue, respondents also reported exercising for personal enjoyment, weight-related factors, or physiological parameters such as cardiovascular and/or muscular fitness. Moreover, the two most frequently reported reasons for exercising were positive impacts on their overall health and mental health. This supports previous research that regular exercise may provide multifaceted benefits for those with endometriosis, such as positive impacts on overall health and wellbeing [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Thus, just as the disease itself is complex and multifactorial, so are the exercise-related outcomes, with a lack of a \u0026ldquo;one-size fits all\u0026rdquo; approach and likely to require trial and error to determine the benefits of different types of exercise on an individual. While it is important to consider the potential benefits of exercise on the lives of women with endometriosis, the balance between symptom improvement and symptom exacerbation must be considered. Nevertheless, the findings of the present study contribute to the increasing evidence of positive exercise impacts on mental health in those with endometriosis [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and adds to the existing evidence base for exercise-related benefits on anxiety and depression [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, it is plausible to consider that the benefits of exercise may extend beyond improvements in pain symptoms to overall physical and mental health.\u003c/p\u003e \u003cp\u003eDespite the potential benefits of exercise for endometriosis and the existence of multiple reviews on the effects of physical activity and/or exercise on the disease, the heterogeneity of studies has largely led to inconclusive results [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Moreover, the individualistic nature of endometriosis symptoms, in addition to low data quality and high or non-reported drop-out rates making comparisons difficult [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A further possible contributor to the inconclusive evidence topic to-date is the notion that disease impacts may reduce treatment efficacy. For instance, previous research suggests that biopsychosocial impairments induced from the disease may compromise treatment modalities, and therefore a holistic approach is warranted to improve overall quality of life among this chronic population [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The complexity of the disease itself may be an additional consideration, since those with endometriosis often have an array of symptoms. In the present study, the most common symptoms reported were chronic pelvic pain, bloating, bowel symptoms, fatigue and low back pain, followed by a number of other debilitating symptoms, aligning with previous evidence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the previous lack of conclusive data and individualistic nature of the disease presenting an array of possible challenges for symptom management, the potential exercise-induced benefits on endometriosis still remains. Previous research shows that exercise works to improve pain severity and physical function in those with chronic pain conditions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, exercise-based treatments are more likely to be more effective than standard medical care or receiving no care in some populations [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. For example, exercise benefits have been observed in chronic low back pain [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], fibromyalgia [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and rheumatoid arthritis [\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In addition, there is growing evidence to suggest that graded exercise or \u0026lsquo;activity pacing\u0026rsquo; may benefit those with chronic fatigue syndrome [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], or chronic conditions that are commonly associated with fatigue symptoms [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. What remains unknown is the specific conditions by which such exercise-induced benefits may be experienced by those with endometriosis. For instance, there is a possibility that while one person may benefit from a particular exercise program, another may not. Therefore, the optimum type, intensity, duration and frequency of exercise to limit symptom exacerbation may differ between individuals. Although the paucity of research exploring the effect of specific exercise prescription (modality, duration, frequency, intensity) on endometriosis symptoms means this notion is currently unverified, it has been previously suggested that the type and intensity of exercise may play a role in exercise-related effects on endometriosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This coincides with the finding from the present study that more exercise-related treatments are strongly desired among those with endometriosis. However, improving our understanding of exercise prescription for endometriosis is vital for women to achieve exercise-related benefits while also limiting symptom exacerbation. Therefore, there is also a clear need for exercise-related guidance for people with endometriosis and the health practitioners treating them. To do this, future research needs to explore those aspects the multifaceted benefits in an endometriosis population, alongside changes in pain or other symptoms such as fatigue possibly instigated by exercise. To the best of the authors\u0026rsquo; knowledge, this is the first study to survey specific exercise habits of people with endometriosis in Australia and NZ. While our findings are limited to the trans-Tasman locality and cannot be generalised for all people with endometriosis on a global scale, the benefits of exercise indicated in this study provide a promising avenue for non-surgical treatment to better help people with endometriosis manage their symptoms. This study has provided encouraging evidence to suggest that this population can benefit from exercise despite chronic and often debilitating symptoms.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of this study have revealed most people with endometriosis are exercising or want to exercise, despite their ongoing symptoms. It is plausible that exercise may make living with this disease more manageable, as a potential coping mechanism both physically and mentally. This study indicates that exercise may be a promising option for ongoing symptom management in those with endometriosis, highlighting the need for future research to help define exercise prescription for endometriosis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMVPA\u0026nbsp; \u0026nbsp;moderate-vigorous physical activity\u003c/p\u003e\n\u003cp\u003eNZ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Aotearoa New Zealand\u003c/p\u003e\n\u003cp\u003eSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; standard deviation\u003c/p\u003e"},{"header":"Declarations","content":"\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\u003eNo funding was received for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving Human Participants and/or Animals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has ethical approval from the Human Research Ethics Committee at Western Sydney University (approval number H15028). Participants were provided with a Participant Information Sheet via an online link prior to commencing the survey. Possible adverse events associated with survey questions were acknowledged and all potential participants were provided with opportunities to speak to the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline consent to have their data collected for research prior to being able to access the survey was required by all survey respondents. Participation was on a voluntary basis and all respondents had the right to withdraw their consent at any time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults of text variables from survey responses is available via the supplementary file.\u003c/p\u003e\n\u003cp\u003e\u003cb\u003eAuthor contributions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCristy Brooks and Mike Armour were responsible for study conception and design. All authors contributed to survey design. Data collection was performed by Cristy Brooks. Data analysis was performed by Allie Eathorne. The first draft of the manuscript was written by Cristy Brooks. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNicola Marshall for study promotion.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJohnson NP, Hummelshoj L, Adamson GD, Keckstein J, Taylor HS, Abrao MS et al (2017) World Endometriosis Society consensus on the classification of endometriosis. Hum Reprod 32(2):315\u0026ndash;324\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikhaleva LM, Radzinsky VE, Orazov MR, Khovanskaya TN, Sorokina AV, Mikhalev SA et al (2021) Current Knowledge on Endometriosis Etiology: A Systematic Review of Literature. Int J Womens Health 13:525\u0026ndash;537\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmolarz B, Szyłło K, Romanowicz H, Endometriosis (2021) Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature). 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Expert Rev Clin Immunol 11(10):1121\u0026ndash;1130\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSveaas SH, Smedslund G, Hagen KB, Dagfinrud H (2017) Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med 51(14):1065\u0026ndash;1072\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasson S, Jones MD, Cassar J, Kwai N, Lloyd AR, Barry BK et al (2023) The effectiveness of activity pacing interventions for people with chronic fatigue syndrome: a systematic review and meta-analysis. Disabil Rehabil 45(23):3788\u0026ndash;3802\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbonie US, Sandercock GRH, Heesterbeek M, Hettinga FJ (2020) Effects of activity pacing in patients with chronic conditions associated with fatigue complaints: a meta-analysis. Disabil Rehabil 42(5):613\u0026ndash;622\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Western Sydney University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Exercise, endometriosis, menstruation, women’s health","lastPublishedDoi":"10.21203/rs.3.rs-4562611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4562611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEndometriosis affects 1 in 9 women. Current medical and surgical management strategies are not always effective and often result in significant side effects, including sub-optimal pain management. Exercise may exhibit benefits to those with endometriosis, via hormonal and/or inflammatory cytokine mediation pathways. However, previous research has provided mixed results about the impact of exercise, with some studies reporting significant adverse effects. This study aims to determine if those with endometriosis are engaging in exercise, what type(s) of exercise and what impact it has on their symptoms. A cross-sectional online survey was conducted via Qualtrics (August to October 2022). Inclusion criteria included endometriosis diagnosis, 18\u0026thinsp;+\u0026thinsp;years of age and living in Australia or Aotearoa New Zealand (NZ). 424 responses were received, 63% from Australia and 37% from NZ. 73.8% exercised regularly (weekly basis), with walking the most common modality (87.8%). More than half of respondents revealed exercise was part of their endometriosis self-management strategy (51.6%). The majority of respondents exercised for mental health benefits (84.5%). Negative effects on endometriosis symptoms (e.g. pain) was the most frequently reported reason for not currently exercising (36.6%). This study showed many people with endometriosis in Australia and NZ chose to exercise regularly. Some respondents reported not currently exercising due to negative effects on symptoms, but many used exercise for symptom management, or to benefit their ongoing physical and mental health. Exercise may be a promising avenue for non-surgical treatment of endometriosis, but further research is needed to explore appropriate exercise prescription to limit symptom exacerbation.\u003c/p\u003e","manuscriptTitle":"Exercise may benefit those with endometriosis: the Exercise 4 Endo trans-Tasman online survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-12 07:15:43","doi":"10.21203/rs.3.rs-4562611/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f2d3da68-6520-4fff-b2b5-31e910b4e1a4","owner":[],"postedDate":"June 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33092817,"name":"Obstetrics \u0026 Gynecology"},{"id":33092818,"name":"Physical Medicine \u0026 Rehab"},{"id":33092819,"name":"Women's studies"}],"tags":[],"updatedAt":"2024-06-12T07:15:43+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-12 07:15:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4562611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4562611","identity":"rs-4562611","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}