Effect of Dienogest with and without pelvic floor physiotherapy on Pain Levels in Patients with Endometriosis: A Controlled Clinical Trial

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Materials and Methods This randomized controlled clinical trial was conducted on60 patients aged20-40with endometriosis-related pelvic pain who visited the Endometriosis Outpatient Clinic at Taleghani Hospital in2024.The samples were randomly divided into intervention and control groups. The intervention group received Dienogest treatment along with pelvic floor physiotherapy12sessions,each lasting50minutes,repeated three times a week.The control group received Dienogest treatment without physiotherapy variables dysmenorrhea,dyschezia, and dyspareunia were assessed using the Visual Analogue Scale before and immediately after the intervention. Data analysis was performed using SPSS-24 with independent and paired t-tests. Findings The average age of participants in the intervention group was28.76,and in the control group, it was29.56.The average weight of participants in the intervention group was60.51,and in the control group, it was61.30.The majority of participants in both groups had a diploma education, and no significant demographic differences were observed between the two groups. There was no significant statistical difference in dyspareunia, dysmenorrhea, and dyschezia scores before the intervention between the two groups. After the intervention, these scores were significantly lower in the intervention group compared to the control group(P < 0.05). Additionally, within-group comparisons showed a significant reduction in these scores in both groups(P < 0.05). Conclusion The study results indicated that the intervention had a significant effect in reducing dyspareunia, dysmenorrhea, and dyschezia. These effects were observed both in inter-group and intra-group comparisons. Trial registration This study, identified as code A-11-38-7 at Shahid Beheshti University of Medical Sciences, was registered with the Iranian Randomized Clinical Trial Center under the code IRCT20241107063631N1on 03-12-2024. Dienogest pelvic floor physiotherapy pain endometriosis Figures Figure 1 Introduction Endometriosis is a chronic inflammatory disorder characterized by the abnormal growth of endometrial tissue outside the uterine cavity (1). It is estimated that approximately 190 million people worldwide, equivalent to about 10% of women of reproductive age, are affected by endometriosis (2). The annual incidence of endometriosis is about 1.0% among women aged 15–59 (3), with the peak age of onset between 25 and 45 years (4). The highest prevalence of endometriosis is among white women, although factors such as race, ethnicity, socioeconomic status, and gender significantly influence its diagnosis and management (5). Although the prevalence of endometriosis is reported to be higher in developing countries than in developed ones, the exact statistics in Iran are unclear (6). Approximately 30% of affected women are asymptomatic and may go undiagnosed (7), but 30–80% experience chronic pelvic pain and dysmenorrhea (3). growth of endometrial tissue outside the uterine cavity condition triggers an immune response, leading to the secretion of cytokines and chemokines within the peritoneal cavity (8). The release of inflammatory mediators enhances neurogenesis and lowers the pain threshold in affected individuals (8, 9). Chronic pain is one of the primary symptoms of endometriosis (10), with 77% of affected individuals experiencing chronic pelvic pain, 90% dysmenorrhea, 76% dyschezia, and 66% dyspareunia. In addition to physical and sexual symptoms, endometriosis is associated with psychological and social issues (8). In addition to chronic pelvic pain, individuals with endometriosis suffer from dyspareunia during or after sexual intercourse (11), pain and discomfort during defecation, or functional bowel issues, inflammation, obstruction, or neuromuscular problems in the pelvic region or dyschezia (12). Endometriosis is recognized as the leading cause of secondary dysmenorrhea worldwide (13). Various approaches have been used to manage pain caused by endometriosis, including oral melatonin before sleep (14), mindfulness-based therapies, psychotherapy, progressive muscle relaxation (15), alternative treatments such as acupuncture (16), herbal medicines (17), dietary changes (18), physical therapy (19), hormonal treatments, and non-steroidal anti-inflammatory drugs (20). pelvic physiotherapy is a remedy to alleviate chronic pelvic pain (21). Del Forno et al. (2023) demonstrated that pelvic floor muscle physiotherapy improved bowel and urinary function, dyspareunia, and chronic pelvic pain (22). Similar results were obtained in studies by Shved (2023) (23). and Wójcik in 2020 (21). In addition to physiotherapy, the use of hormonal drugs has also improved pain symptoms in endometriosis patients, as shown in a review study by Muzii (2023), where the use of dienogest was equivalent to GnRH and superior to the control group in controlling chronic pelvic pain (24). The aim of hormonal treatment for endometriosis is to prevent menstruation by suppressing the hypothalamic-pituitary-ovarian axis or inducing pseudomenopause, thereby disrupting the progression of endometrial growth (25).Some lesions do not require estrogen for growth and may even be resistant to progesterone treatment (26). Since endometriosis involves simultaneous angiogenesis and neurogenesis in ectopic endometrial tissue outside the uterus, the use of hormonal drugs is considered an alternative to anti-angiogenic factors for controlling endometriosis (27). Since no study examined the combination of dienogest with, pelvic floor physiotherapy on pain levels in endometriosis patients, in this study the effect of dienogest with and without pelvic floor physiotherapy on pain levels in endometriosis patients was assessed. Materials and Methods This study was a controlled clinical trial with a one-to-one allocation. The study population consisted of women and girls aged 20–45 with endometriosis who visited the Endometriosis Outpatient Clinic at Taleghani Hospital in Tehran in 2024-11-17 to 2025-02-18. Inclusion criteria, women aged 20–45 with endometriosis who had used dienogest for at least three months. They reported symptoms of pelvic pain (dyspareunia and dysmenorrhea). Exclusion criteria were pregnancy, having a pacemaker, epilepsy, cardiac arrhythmia, cancer, acute pelvic inflammatory disease, and difficulty understanding instructions. Sampling Simple random sampling was used in this study, with a sample size of 60 individuals. After obtaining approval from the ethics committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.REC.1403.430) and registration in the Iranian Clinical Trial Center (IRCT20241107063631N1), sampling was conducted randomly based on the inclusion criteria. Interested individuals were provided with detailed information about the importance and benefits of participating in the study, as well as the study procedures. After completing the informed consent form, participants filled out a demographic and fertility questionnaire. They then reported their initial dysmenorrhea, dyspareunia, and dyschezia scores using the VAS pain scale. Random sequence generation was performed using simple randomization through card shuffling. Cards were prepared for the first group, and the same number of cards was prepared for subsequent groups. The cards were shuffled, one was drawn and assigned, and then returned to the deck. This process continued until a random sequence matching the sample size was achieved. The intervention group received dienogest treatment along with pelvic physiotherapy, including, for 12 sessions, each lasting 50 minutes, repeated three times a week. The physiotherapy included 30 minutes of visceral manipulation (internal and external vaginal and abdominal) and 20 minutes of floor pelvic exercises. Participants were placed in a supine position with bent knees. Pelvic floor exercise were divided into four phases: the deep sensation phase in the first week included exercises to understand the exercises and perform fast and slow contractions; the simple phase in the second week aimed to enhance control of fast and slow contractions during simple functional activities; the advanced phase in the third week involved functional exercises with a greater range; and the strength phase in the last week aimed to increase contraction strength. Contractions were performed for both slow and fast fibers in all sessions. The control group received dienogest treatment and sham manipulation (intervention as a control intervention using sham methods). Dienogest was prescribed at a daily dose of 2 mg from Atifarm Pharmaceutical Company. Data Collection Tools Data were collected using a demographic and fertility checklist and the Visual Analogue Scale (VAS) for pain measurement. Demographic and Fertility Checklist This checklist included personal information such as age, height, weight, education, pregnancy history, infertility history, and life satisfaction. Visual Analogue Scale (VAS) The VAS, a sensitive pain scale with validity and reliability, was used to measure dysmenorrhea, dyspareunia, and dyschezia. This scale consists of a 10 cm graduated line where patients must indicate their pain level from 0 (no pain) to 10 (the most severe pain imaginable). Scores of 0 indicate no pain, 1–3 indicate mild pain, 4–6 indicate moderate pain, 7–9 indicate severe pain, and 9–10 indicate very severe pain (28). Statistical Analysis Statistical analysis was performed using SPSS version 24. The normality of quantitative data was assessed using the K-S test. Parametric tests such as the independent t-test, chi-square test, and paired t-test were used to compare variables between the two groups. Findings Out of 420 women assessed, 118 met the inclusion criteria, and 60 agreed to participate in the study. None of the participants dropped out during the study (Fig. 1 ). The study results showed that the average age of participants in the intervention group was 28.76, and in the control group, it was 29.56. The average weight of participants in the intervention group was 60.51, and in the control group, it was 61.30. The majority of participants in both groups had a high school diploma. There were no significant demographic differences between the two groups (Table 1 ). Table 1 Demographic characteristics of participants in the intervention and control groups Variable Control (N = 30) Intervention (N = 30) p Gravid 0.360 0 5 (16.7%) 2 (6.7%) 1 16 (53.3%) 15 (50.0%) 2 9 (30.0%) 13 (43.3%) Education level (edu) 0.362 Middle school 2 (6.7%) 6 (17.0%) High school 4 (13.3%) 1 (3.3%) Diploma 10 (33.3%) 8 (26.7%) University 14 (46.7%) 15 (50.0%) job 0.488 Housewife 26 (86.7%) 24 (80.0%) Employed 4 (13.3%) 6 (20.0%) Spouse education (edupartner) 0.597 Middle school 7 (23.3%) 3 (10.0%) High school 6 (20.0%) 7 (23.3%) Diploma 5 (16.7%) 8 (26.7%) University 12 (40.0%) 12 (40.0%) Spouse's occupation (job partner) 0.054 Employee 3 (10.0%) 11 (36.7%) Worker 7 (23.3%) 4 (13.3%) Shopkeeper 8 (26.7%) 3 (10.0%) Other 12 (40.0%) 12 (40.0%) Adequacy 0.400 Adequate 14 (46.7%) 18 (60.0%) Fairly adequate 11 (36.7%) 10 (33.3%) Inadequate 5 (16.7%) 2 (6.7%) Satisfaction with marital life 0.448 Completely satisfied 25 (83.3%) 27 (90.0%) Somewhat satisfied 5 (16.7%) 3 (10.0%) History of infertility 0.095 Yes 3 (10.0%) 8 (26.7%) No 27 (90.0%) 22 (73.3%) Weight 58.95 ± 10.69 63.27 ± 9.56 0.105* BMI 22.63 ± 3.51 24.03 ± 2.80 0.091* All analyses were performed with chi-square. Cases * Independent t-test The dyspareunia score before the intervention in the intervention group was 5.21 (± 0.92), which decreased to 4.10 (± 0.74) after the intervention. In the control group, the dyspareunia score was 4.89 (± 0.66) before the intervention and 4.63 (± 0.73) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P = 0.616). However, after the intervention, the dyspareunia score in the intervention group was significantly lower than in the control group (P = 0.002). In the within-group comparison, the dyspareunia score in the intervention group was significantly lower after the intervention (P = 0.001), as was the case in the control group (P = 0.045) (Table 2 ). Table 2 Comparison of dyspareunia, dysmenorrhea, and dyschezia scores between the intervention and control groups before and after the intervention. Variable Time Intervention) mean ± SD) Control ) mean ± SD) P-value (Independent t-test) P-value (Paired t-test) Dyspareunia Before intervention 5.21 ± 0.92 4.89 ± 0.66 0.616 < 0.001** After intervention 4.10 ± 0.74 4.63 ± 0.73 0.002 0.004* Dysmenorrhea Before intervention 5.55 ± 0.67 5.24 ± 0.65 0.082 < 0.001** After intervention 4.06 ± 0.93 4.99 ± 0.73 < 0.001 0.027* Dyschazia Before intervention 5.46 ± 0.75 5.21 ± 0.69 0.063 < 0.001** After intervention 4.26 ± 0.89 4.83 ± 0.59 0.006 0.035* * Control ** Intervention The dysmenorrhea score before the intervention in the intervention group was 5.55 (± 0.67), which decreased to 4.06 (± 0.93) after the intervention. In the control group, the dysmenorrhea score was 5.24 (± 0.65) before the intervention and 4.99 (± 0.73) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P = 0.082). However, after the intervention, the dysmenorrhea score in the intervention group was significantly lower than in the control group (P = 0.001). In the within-group comparison, the dysmenorrhea score in the intervention group was significantly lower after the intervention (P = 0.001), as was the case in the control group (P = 0.027) (Table 2 ). The dyschezia score before the intervention in the intervention group was 5.46 (± 0.75), which decreased to 4.26 (± 0.89) after the intervention. In the control group, the dyschezia score was 5.21 (± 0.69) before the intervention and 4.83 (± 0.59) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P = 0.063). However, after the intervention, the dyschezia score in the intervention group was significantly lower than in the control group (P = 0.006). In the within-group comparison, the dyschezia score in the intervention group was significantly lower after the intervention (P = 0.001), as was the case in the control group (P = 0.035) (Table 2 ). Discussion In the present study, 60 women with endometriosis participated. The results showed that the intervention group (physiotherapy with dienogest) experienced greater reductions in dyspareunia, dysmenorrhea, and dyschezia scores compared to the control group (dienogest alone). These findings highlight the importance of targeted interventions in reducing symptoms associated with gastrointestinal disorders and pain caused by clinical conditions. While the reduction in dysmenorrhea, dyspareunia, and dyschezia scores was observed in both groups, the greater reduction in the intervention group emphasizes the positive impact of combining physiotherapy with dienogest. In the intervention group, the dyspareunia score decreased from 5.21 (± 0.92) to 4.10 (± 0.74), reflecting a 21.3% reduction in pain. In contrast, the control group showed a smaller reduction, from 4.89 (± 0.66) to 4.63 (± 0.73). Khashchenko et al. (2023) reported a 10% reduction in dysmenorrhea and dyschezia after one year of dienogest use following endometriosis surgery (29). Kaya (2021) also found that dienogest reduced dysmenorrhea, dyschezia, and dyspareunia compared to routine care (30). Similarly, Gokmen et al. (2023) showed a 23% reduction in painful symptoms of endometriosis with dienogest (31), and Wu (2024) confirmed the significant impact of dienogest on reducing painful symptoms (32). The findings of the present study align with these previous research results. Additionally, the results related to physiotherapy are consistent with prior studies. Del Forno et al. (2020) demonstrated that pelvic floor physiotherapy improved dysmenorrhea in women with endometriosis (22). López-Liria, in a review study, highlighted that physiotherapy not only reduced dysmenorrhea pain but also reduced the need for non-steroidal anti-inflammatory drugs, contraceptive pills, or other medications (33). In a study by Arshiya et al., physiotherapy had an immediate effect on controlling dysmenorrhea pain in students (34). Abelló Pla (2024) confirmed the immediate impact of physiotherapy on reducing dysmenorrhea (35). Osborne suggests that physical therapy techniques, such as heat therapy, massage, and stretching exercises, can enhance blood flow to the pelvic area and uterus (36). Additionally, methods like massage, transcutaneous electrical nerve stimulation (TENS), and physical exercises that activate mechanoreceptors may reduce the transmission of pain signals, leading to a decrease in dysmenorrhea pain (37). Physiotherapy also promotes the secretion of endorphins, serotonin, and dopamine, which increases the pain tolerance threshold (38). It is possible that the combined effects of dienogest’s hormonal action and the physiological effects of pelvic physiotherapy contributed to the more significant reduction in pelvic pain in the intervention group in the present study compared to dienogest treatment alone. innovation and limitation The present study is innovative due to the simultaneous comparison of two interventions and the examination of their effects on several key indicators, including dysmenorrhea, dyspareunia, and dyschezia. Especially, no previous study directly examined the combination of dienogest and physiotherapy. This highlights the importance of the present study. Additionally, clinical trial principles such as random allocation and allocation concealment were followed in this study. However, due to the nature of the intervention, blinding was not possible. Limitations of this study include a relatively small sample size and a limited follow-up period, which may limit the generalizability of the results. It is recommended that future research examines the long-term effects of these interventions on various symptoms of endometriosis and the quality of life of patients. Declarations Authors' contributions S.S :Project administration, Conceptualization.M.H: Writing – original draft ,Formal Analysis. S.H : Writing – original draft , M.M: Writing – original draft, Formal Analysis. H.Niknam:Writing – original draft, Formal Analysis N. S : review & editing. M. N: Project Administration, Supervision. Ethics Approval and Consent to Participate This study, was approved by the ethics committees of Shahid Beheshti University of medical scinces (IR.SBMU.RETECH.REC.1403.430) in 27-10-2024 and Clinical trial number: (IRCT20241107063631N1). The ethical declaration is local, which is in line with Helsinki. Ethical considerations considered such as obtaining informed consent from participants, maintaining confidentiality, allowing participants to withdraw from the study at any time d uring the intervention, and ensuring the confidentiality of information. Our study was designed and conducted according to CONSORT guidelines. Acknowledgment The authors thank all the volunteers who participated in the study. Funding This research received no external funding. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. References García-Izquierdo L, Marín-Sánchez P, García-Peñarrubia P, Martínez-Esparza M. 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Resolving long-standing uncertainty about the clinical efficacy of transcutaneous electrical nerve stimulation (TENS) to relieve pain: a comprehensive review of factors influencing outcome. J Medicina.2021;57(4):378. Utli H. Effects of massage therapy on clinical symptoms of older people. Journal of Education Research in Nursing. 2022;18(1):103-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-6665312","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464287525,"identity":"d49eef63-e6e1-47e1-94dd-01bc312943b4","order_by":0,"name":"Saghar Salehpour","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saghar","middleName":"","lastName":"Salehpour","suffix":""},{"id":464287527,"identity":"f21ee3d2-e21f-48f2-884a-1830364751a4","order_by":1,"name":"Hoda Niknam","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hoda","middleName":"","lastName":"Niknam","suffix":""},{"id":464287529,"identity":"22488aea-a040-46d6-81ce-3b5b61833868","order_by":2,"name":"Nasrin Saharkhiz","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Nasrin","middleName":"","lastName":"Saharkhiz","suffix":""},{"id":464287530,"identity":"09e96eae-a171-49d8-ae32-499c0cddbbc9","order_by":3,"name":"Sedighe Hosseini","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sedighe","middleName":"","lastName":"Hosseini","suffix":""},{"id":464287531,"identity":"b60f56b9-1763-49f2-99ca-a513a60c9496","order_by":4,"name":"Mitra Nemati","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mitra","middleName":"","lastName":"Nemati","suffix":""},{"id":464287532,"identity":"9c6155bc-aa5a-4e21-9f41-b26dc3611a60","order_by":5,"name":"Maryam meshkat","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"","lastName":"meshkat","suffix":""},{"id":464287533,"identity":"f99e4a17-e27c-42c7-8034-2a359c639782","order_by":6,"name":"Maral Hosseinzadeh","email":"data:image/png;base64,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","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Maral","middleName":"","lastName":"Hosseinzadeh","suffix":""}],"badges":[],"createdAt":"2025-05-14 14:53:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6665312/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6665312/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83897718,"identity":"5a23d187-dd47-4574-b854-ff254d24b631","added_by":"auto","created_at":"2025-06-04 09:03:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19518,"visible":true,"origin":"","legend":"\u003cp\u003eStudy flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6665312/v1/a26bd25bf03aa4bb95a1d96b.png"},{"id":105873338,"identity":"a87cec12-3ada-42f6-9d22-878438696b43","added_by":"auto","created_at":"2026-04-01 05:11:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":673924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6665312/v1/b1ab68de-d60c-4cf6-ac28-b76e37ce0b6e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Dienogest with and without pelvic floor physiotherapy on Pain Levels in Patients with Endometriosis: A Controlled Clinical Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a chronic inflammatory disorder characterized by the abnormal growth of endometrial tissue outside the uterine cavity (1). It is estimated that approximately 190\u0026nbsp;million people worldwide, equivalent to about 10% of women of reproductive age, are affected by endometriosis (2). The annual incidence of endometriosis is about 1.0% among women aged 15\u0026ndash;59 (3), with the peak age of onset between 25 and 45 years (4). The highest prevalence of endometriosis is among white women, although factors such as race, ethnicity, socioeconomic status, and gender significantly influence its diagnosis and management (5). Although the prevalence of endometriosis is reported to be higher in developing countries than in developed ones, the exact statistics in Iran are unclear (6). Approximately 30% of affected women are asymptomatic and may go undiagnosed (7), but 30\u0026ndash;80% experience chronic pelvic pain and dysmenorrhea (3).\u003c/p\u003e \u003cp\u003egrowth of endometrial tissue outside the uterine cavity condition triggers an immune response, leading to the secretion of cytokines and chemokines within the peritoneal cavity (8). The release of inflammatory mediators enhances neurogenesis and lowers the pain threshold in affected individuals (8, 9). Chronic pain is one of the primary symptoms of endometriosis (10), with 77% of affected individuals experiencing chronic pelvic pain, 90% dysmenorrhea, 76% dyschezia, and 66% dyspareunia. In addition to physical and sexual symptoms, endometriosis is associated with psychological and social issues (8). In addition to chronic pelvic pain, individuals with endometriosis suffer from dyspareunia during or after sexual intercourse (11), pain and discomfort during defecation, or functional bowel issues, inflammation, obstruction, or neuromuscular problems in the pelvic region or dyschezia (12). Endometriosis is recognized as the leading cause of secondary dysmenorrhea worldwide (13).\u003c/p\u003e \u003cp\u003eVarious approaches have been used to manage pain caused by endometriosis, including oral melatonin before sleep (14), mindfulness-based therapies, psychotherapy, progressive muscle relaxation (15), alternative treatments such as acupuncture (16), herbal medicines (17), dietary changes (18), physical therapy (19), hormonal treatments, and non-steroidal anti-inflammatory drugs (20). pelvic physiotherapy is a remedy to alleviate chronic pelvic pain (21). Del Forno et al. (2023) demonstrated that pelvic floor muscle physiotherapy improved bowel and urinary function, dyspareunia, and chronic pelvic pain (22). Similar results were obtained in studies by Shved (2023) (23). and W\u0026oacute;jcik in 2020 (21). In addition to physiotherapy, the use of hormonal drugs has also improved pain symptoms in endometriosis patients, as shown in a review study by Muzii (2023), where the use of dienogest was equivalent to GnRH and superior to the control group in controlling chronic pelvic pain (24). The aim of hormonal treatment for endometriosis is to prevent menstruation by suppressing the hypothalamic-pituitary-ovarian axis or inducing pseudomenopause, thereby disrupting the progression of endometrial growth (25).Some lesions do not require estrogen for growth and may even be resistant to progesterone treatment (26). Since endometriosis involves simultaneous angiogenesis and neurogenesis in ectopic endometrial tissue outside the uterus, the use of hormonal drugs is considered an alternative to anti-angiogenic factors for controlling endometriosis (27). Since no study examined the combination of dienogest with, pelvic floor physiotherapy on pain levels in endometriosis patients, in this study the effect of dienogest with and without pelvic floor physiotherapy on pain levels in endometriosis patients was assessed.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study was a controlled clinical trial with a one-to-one allocation. The study population consisted of women and girls aged 20\u0026ndash;45 with endometriosis who visited the Endometriosis Outpatient Clinic at Taleghani Hospital in Tehran in 2024-11-17 to 2025-02-18.\u003c/p\u003e \u003cp\u003eInclusion criteria, women aged 20\u0026ndash;45 with endometriosis who had used dienogest for at least three months. They reported symptoms of pelvic pain (dyspareunia and dysmenorrhea). Exclusion criteria were pregnancy, having a pacemaker, epilepsy, cardiac arrhythmia, cancer, acute pelvic inflammatory disease, and difficulty understanding instructions.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSampling\u003c/h2\u003e \u003cp\u003eSimple random sampling was used in this study, with a sample size of 60 individuals. After obtaining approval from the ethics committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.RETECH.REC.1403.430) and registration in the Iranian Clinical Trial Center (IRCT20241107063631N1), sampling was conducted randomly based on the inclusion criteria. Interested individuals were provided with detailed information about the importance and benefits of participating in the study, as well as the study procedures. After completing the informed consent form, participants filled out a demographic and fertility questionnaire. They then reported their initial dysmenorrhea, dyspareunia, and dyschezia scores using the VAS pain scale.\u003c/p\u003e \u003cp\u003eRandom sequence generation was performed using simple randomization through card shuffling. Cards were prepared for the first group, and the same number of cards was prepared for subsequent groups. The cards were shuffled, one was drawn and assigned, and then returned to the deck. This process continued until a random sequence matching the sample size was achieved.\u003c/p\u003e \u003cp\u003eThe intervention group received dienogest treatment along with pelvic physiotherapy, including, for 12 sessions, each lasting 50 minutes, repeated three times a week. The physiotherapy included 30 minutes of visceral manipulation (internal and external vaginal and abdominal) and 20 minutes of floor pelvic exercises. Participants were placed in a supine position with bent knees. Pelvic floor exercise were divided into four phases: the deep sensation phase in the first week included exercises to understand the exercises and perform fast and slow contractions; the simple phase in the second week aimed to enhance control of fast and slow contractions during simple functional activities; the advanced phase in the third week involved functional exercises with a greater range; and the strength phase in the last week aimed to increase contraction strength. Contractions were performed for both slow and fast fibers in all sessions. The control group received dienogest treatment and sham manipulation (intervention as a control intervention using sham methods). Dienogest was prescribed at a daily dose of 2 mg from Atifarm Pharmaceutical Company.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eData were collected using a demographic and fertility checklist and the Visual Analogue Scale (VAS) for pain measurement.\u003c/p\u003e\n\u003ch3\u003eDemographic and Fertility Checklist\u003c/h3\u003e\n\u003cp\u003eThis checklist included personal information such as age, height, weight, education, pregnancy history, infertility history, and life satisfaction.\u003c/p\u003e\n\u003ch3\u003eVisual Analogue Scale (VAS)\u003c/h3\u003e\n\u003cp\u003eThe VAS, a sensitive pain scale with validity and reliability, was used to measure dysmenorrhea, dyspareunia, and dyschezia. This scale consists of a 10 cm graduated line where patients must indicate their pain level from 0 (no pain) to 10 (the most severe pain imaginable). Scores of 0 indicate no pain, 1\u0026ndash;3 indicate mild pain, 4\u0026ndash;6 indicate moderate pain, 7\u0026ndash;9 indicate severe pain, and 9\u0026ndash;10 indicate very severe pain (28).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS version 24. The normality of quantitative data was assessed using the K-S test. Parametric tests such as the independent t-test, chi-square test, and paired t-test were used to compare variables between the two groups.\u003c/p\u003e \u003c/div\u003e "},{"header":"Findings","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003cp\u003eOut of 420 women assessed, 118 met the inclusion criteria, and 60 agreed to participate in the study. None of the participants dropped out during the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe study results showed that the average age of participants in the intervention group was 28.76, and in the control group, it was 29.56. The average weight of participants in the intervention group was 60.51, and in the control group, it was 61.30. The majority of participants in both groups had a high school diploma. There were no significant demographic differences between the two groups (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 characteristics of participants in the intervention and control groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (53.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (30.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation level (edu)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ejob\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (86.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (80.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpouse education (edupartner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (20.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpouse's occupation (job partner)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (23.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (13.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShopkeeper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (46.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (60.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFairly adequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (36.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInadequate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (6.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with marital life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompletely satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of infertility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.095\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (90.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (73.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58.95\u0026thinsp;\u0026plusmn;\u0026thinsp;10.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.27\u0026thinsp;\u0026plusmn;\u0026thinsp;9.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.105*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.63\u0026thinsp;\u0026plusmn;\u0026thinsp;3.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.03\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.091*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAll analyses were performed with chi-square. Cases * Independent t-test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe dyspareunia score before the intervention in the intervention group was 5.21 (\u0026plusmn;\u0026thinsp;0.92), which decreased to 4.10 (\u0026plusmn;\u0026thinsp;0.74) after the intervention. In the control group, the dyspareunia score was 4.89 (\u0026plusmn;\u0026thinsp;0.66) before the intervention and 4.63 (\u0026plusmn;\u0026thinsp;0.73) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P\u0026thinsp;=\u0026thinsp;0.616). However, after the intervention, the dyspareunia score in the intervention group was significantly lower than in the control group (P\u0026thinsp;=\u0026thinsp;0.002). In the within-group comparison, the dyspareunia score in the intervention group was significantly lower after the intervention (P\u0026thinsp;=\u0026thinsp;0.001), as was the case in the control group (P\u0026thinsp;=\u0026thinsp;0.045) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eComparison of dyspareunia, dysmenorrhea, and dyschezia scores between the intervention and control groups before and after the intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl ) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value (Independent t-test)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value (Paired t-test)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDyspareunia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.616\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDysmenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.027*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDyschazia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e5.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAfter intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.26\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.035*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Control ** Intervention\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe dysmenorrhea score before the intervention in the intervention group was 5.55 (\u0026plusmn;\u0026thinsp;0.67), which decreased to 4.06 (\u0026plusmn;\u0026thinsp;0.93) after the intervention. In the control group, the dysmenorrhea score was 5.24 (\u0026plusmn;\u0026thinsp;0.65) before the intervention and 4.99 (\u0026plusmn;\u0026thinsp;0.73) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P\u0026thinsp;=\u0026thinsp;0.082). However, after the intervention, the dysmenorrhea score in the intervention group was significantly lower than in the control group (P\u0026thinsp;=\u0026thinsp;0.001). In the within-group comparison, the dysmenorrhea score in the intervention group was significantly lower after the intervention (P\u0026thinsp;=\u0026thinsp;0.001), as was the case in the control group (P\u0026thinsp;=\u0026thinsp;0.027) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe dyschezia score before the intervention in the intervention group was 5.46 (\u0026plusmn;\u0026thinsp;0.75), which decreased to 4.26 (\u0026plusmn;\u0026thinsp;0.89) after the intervention. In the control group, the dyschezia score was 5.21 (\u0026plusmn;\u0026thinsp;0.69) before the intervention and 4.83 (\u0026plusmn;\u0026thinsp;0.59) after the intervention. The independent t-test showed no significant difference between the two groups before the intervention (P\u0026thinsp;=\u0026thinsp;0.063). However, after the intervention, the dyschezia score in the intervention group was significantly lower than in the control group (P\u0026thinsp;=\u0026thinsp;0.006). In the within-group comparison, the dyschezia score in the intervention group was significantly lower after the intervention (P\u0026thinsp;=\u0026thinsp;0.001), as was the case in the control group (P\u0026thinsp;=\u0026thinsp;0.035) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, 60 women with endometriosis participated. The results showed that the intervention group (physiotherapy with dienogest) experienced greater reductions in dyspareunia, dysmenorrhea, and dyschezia scores compared to the control group (dienogest alone). These findings highlight the importance of targeted interventions in reducing symptoms associated with gastrointestinal disorders and pain caused by clinical conditions. While the reduction in dysmenorrhea, dyspareunia, and dyschezia scores was observed in both groups, the greater reduction in the intervention group emphasizes the positive impact of combining physiotherapy with dienogest.\u003c/p\u003e \u003cp\u003eIn the intervention group, the dyspareunia score decreased from 5.21 (\u0026plusmn;\u0026thinsp;0.92) to 4.10 (\u0026plusmn;\u0026thinsp;0.74), reflecting a 21.3% reduction in pain. In contrast, the control group showed a smaller reduction, from 4.89 (\u0026plusmn;\u0026thinsp;0.66) to 4.63 (\u0026plusmn;\u0026thinsp;0.73).\u003c/p\u003e \u003cp\u003eKhashchenko et al. (2023) reported a 10% reduction in dysmenorrhea and dyschezia after one year of dienogest use following endometriosis surgery (29). Kaya (2021) also found that dienogest reduced dysmenorrhea, dyschezia, and dyspareunia compared to routine care (30). Similarly, Gokmen et al. (2023) showed a 23% reduction in painful symptoms of endometriosis with dienogest (31), and Wu (2024) confirmed the significant impact of dienogest on reducing painful symptoms (32). The findings of the present study align with these previous research results.\u003c/p\u003e \u003cp\u003eAdditionally, the results related to physiotherapy are consistent with prior studies. Del Forno et al. (2020) demonstrated that pelvic floor physiotherapy improved dysmenorrhea in women with endometriosis (22). L\u0026oacute;pez-Liria, in a review study, highlighted that physiotherapy not only reduced dysmenorrhea pain but also reduced the need for non-steroidal anti-inflammatory drugs, contraceptive pills, or other medications (33). In a study by Arshiya et al., physiotherapy had an immediate effect on controlling dysmenorrhea pain in students (34). Abell\u0026oacute; Pla (2024) confirmed the immediate impact of physiotherapy on reducing dysmenorrhea (35). Osborne suggests that physical therapy techniques, such as heat therapy, massage, and stretching exercises, can enhance blood flow to the pelvic area and uterus (36). Additionally, methods like massage, transcutaneous electrical nerve stimulation (TENS), and physical exercises that activate mechanoreceptors may reduce the transmission of pain signals, leading to a decrease in dysmenorrhea pain (37). Physiotherapy also promotes the secretion of endorphins, serotonin, and dopamine, which increases the pain tolerance threshold (38).\u003c/p\u003e \u003cp\u003eIt is possible that the combined effects of dienogest\u0026rsquo;s hormonal action and the physiological effects of pelvic physiotherapy contributed to the more significant reduction in pelvic pain in the intervention group in the present study compared to dienogest treatment alone.\u003c/p\u003e\n\u003ch3\u003einnovation and limitation\u003c/h3\u003e\n\u003cp\u003eThe present study is innovative due to the simultaneous comparison of two interventions and the examination of their effects on several key indicators, including dysmenorrhea, dyspareunia, and dyschezia. Especially, no previous study directly examined the combination of dienogest and physiotherapy. This highlights the importance of the present study. Additionally, clinical trial principles such as random allocation and allocation concealment were followed in this study. However, due to the nature of the intervention, blinding was not possible. Limitations of this study include a relatively small sample size and a limited follow-up period, which may limit the generalizability of the results. It is recommended that future research examines the long-term effects of these interventions on various symptoms of endometriosis and the quality of life of patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.S :Project administration, Conceptualization.M.H: Writing \u0026ndash; original draft ,Formal Analysis. S.H : Writing \u0026ndash; original draft , M.M: Writing \u0026ndash; original draft, Formal Analysis. H.Niknam:Writing \u0026ndash; original draft, Formal Analysis \u0026nbsp;N. S : review \u0026amp; editing. M. N: Project Administration, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study, was approved by the ethics committees of Shahid Beheshti University of medical scinces (IR.SBMU.RETECH.REC.1403.430) in 27-10-2024 and Clinical trial number: (IRCT20241107063631N1). The ethical declaration is local, which is in line with Helsinki. Ethical considerations considered such as obtaining informed consent from participants, maintaining confidentiality, allowing participants to withdraw from the study at any time d uring the intervention, and ensuring the confidentiality of information.\u0026nbsp;Our study was designed and conducted according to CONSORT guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the volunteers who participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\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\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003c/span\u003eGarc\u0026iacute;a-Izquierdo L, Mar\u0026iacute;n-S\u0026aacute;nchez P, Garc\u0026iacute;a-Pe\u0026ntilde;arrubia P, Mart\u0026iacute;nez-Esparza M. 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Pathogenesis based diagnosis and treatment of endometriosis. Frontiers in endocrinology. 2021;12:745548.\u003c/li\u003e\n\u003cli\u003eDiVasta AD, Stamoulis C, Gallagher JS, Laufer MR, Anchan R, Hornstein MD. Nonhormonal therapy for endometriosis: a randomized, placebo-controlled, pilot study of cabergoline versus norethindrone acetate. J F S Reports. 2021;2(4):454-61.\u003c/li\u003e\n\u003cli\u003eMelzack R. The short-form McGill pain questionnaire. Pain. 1987;30(2)191-7\u003c/li\u003e\n\u003cli\u003eKhashchenko EP, Uvarova EV, Chuprynin VD, Pustynnikova MY, Fatkhudinov TK, Elchaninov AV, et al. Pelvic Pain, Mental Health and Quality of Life in Adolescents with Endometriosis after Surgery and Dienogest Treatment. Journal of Clinical Medicine. 2023;12(6):2400\u003c/li\u003e\n\u003cli\u003eKaya C, Alay İ, Cengiz H, Bah\u0026ccedil;eci E, Ekin M, Yaşar L. Short-term efficacy of dienogest in improving pain in patients with endometriosis: a singlecenter experience. J Eur Arch Med Res.2021;37:4-11\u003c/li\u003e\n\u003cli\u003eGokmen BS, Selcuki NFT, Aydın A,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003eBahat PY, Ak\u0026ccedil;a A. Effects of Dienogest Therapy on Endometriosis-Related Dysmenorrhea, Dyspareunia, and Endometrioma Size. J Cureus.2023;15(1).\u003c/li\u003e\n\u003cli\u003eWu H, Liu J-J, Ye S-T, Liu J, Li N. Efficacy and safety of dienogest in the treatment of deep infiltrating endometriosis: A meta-analysis. European Journal of Obstetrics Gynecology Reproductive Biology. 2024;297:40-9.\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez-Liria R, Torres-\u0026Aacute;lamo L, Vega-Ram\u0026iacute;rez FA, Garc\u0026iacute;a-Luengo AV, Aguilar-Parra JM, Trigueros-Ramos R, et al. Efficacy of physiotherapy treatment in primary dysmenorrhea: a systematic review and meta-analysis. International journal of environmental research public health.2021;18(15):7832\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eArshiya DY. Immediate Effect of Physiotherapy Intervention in Subjects with primary dysmenorrhea:\u003cspan dir=\"RTL\"\u003e \u003c/span\u003eA Quasi-Experimental Study. International Journal for Multidisciplinary Research.2023;5(5):1-10.\u003c/li\u003e\n\u003cli\u003eAbell\u0026oacute; Pla A, Andreu-Povar A, Fabbi L, Esquirol-Caussa J, Lleberia-Juan\u0026oacute;s J, Gil-Moreno A, et al. Capacitive Resistive Monopolar Radiofrequency Combined with Manual Physiotherapy to Treat Dyspareunia in Young Women. J Women\u0026apos;s Health Reports.2024;5(1):889-96.\u003c/li\u003e\n\u003cli\u003eOsborne C, Kolakowski M, Lobenstine D. Pre-And Perinatal Massage Therapy: A Comprehensive Guide to Prenatal, Labor and Postpartum Practice: Jessica Kingsley Publishers; 2021.\u003c/li\u003e\n\u003cli\u003eJohnson MI. Resolving long-standing uncertainty about the clinical efficacy of transcutaneous electrical nerve stimulation (TENS) to relieve pain: a comprehensive review of factors influencing outcome. J Medicina.2021;57(4):378.\u003c/li\u003e\n\u003cli\u003eUtli H. Effects of massage therapy on clinical symptoms of older people. Journal of Education Research in Nursing. 2022;18(1):103-7.\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","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":"Dienogest, pelvic floor physiotherapy, pain, endometriosis","lastPublishedDoi":"10.21203/rs.3.rs-6665312/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6665312/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEndometriosis is a chronic inflammatory disorder where chronic pain is one of its main symptoms.This study aims to evaluate the effect of Dienogest with and without pelvic floor physiotherapy on pain levels in patients with endometriosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis randomized controlled clinical trial was conducted on60 patients aged20-40with endometriosis-related pelvic pain who visited the Endometriosis Outpatient Clinic at Taleghani Hospital in2024.The samples were randomly divided into intervention and control groups. The intervention group received Dienogest treatment along with pelvic floor physiotherapy12sessions,each lasting50minutes,repeated three times a week.The control group received Dienogest treatment without physiotherapy variables dysmenorrhea,dyschezia, and dyspareunia were assessed using the Visual Analogue Scale before and immediately after the intervention. Data analysis was performed using SPSS-24 with independent and paired t-tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average age of participants in the intervention group was28.76,and in the control group, it was29.56.The average weight of participants in the intervention group was60.51,and in the control group, it was61.30.The majority of participants in both groups had a diploma education, and no significant demographic differences were observed between the two groups. There was no significant statistical difference in dyspareunia, dysmenorrhea, and dyschezia scores before the intervention between the two groups. After the intervention, these scores were significantly lower in the intervention group compared to the control group(P \u0026lt; 0.05). Additionally, within-group comparisons showed a significant reduction in these scores in both groups(P \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study results indicated that the intervention had a significant effect in reducing dyspareunia, dysmenorrhea, and dyschezia. These effects were observed both in inter-group and intra-group comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study, identified as code A-11-38-7 at Shahid Beheshti University of Medical Sciences, was registered with the Iranian Randomized Clinical Trial Center under the code IRCT20241107063631N1on 03-12-2024.\u003c/p\u003e","manuscriptTitle":"Effect of Dienogest with and without pelvic floor physiotherapy on Pain Levels in Patients with Endometriosis: A Controlled Clinical Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-04 09:03:10","doi":"10.21203/rs.3.rs-6665312/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":"0da5812e-acd1-4453-af68-5c4464666005","owner":[],"postedDate":"June 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T05:10:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-04 09:03:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6665312","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6665312","identity":"rs-6665312","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}