Effects of structured exercise training on pain and multidimensional symptom burden in women with endometriosis: an updated systematic review and meta-analysis
Systematic review / meta-analysis
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A systematic review and meta-analysis found that current randomized evidence does not establish a clinically important benefit of structured exercise for endometriosis-associated pain or symptom burden due to very low certainty.
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This systematic review and meta-analysis evaluated the impact of structured exercise training on pain and multidimensional symptom burden in women with endometriosis. The authors analyzed data from six independent trials involving small sample sizes, assessing outcomes such as endometriosis-related pain, psychological distress, and sexual function using random-effects models. Although point estimates generally favored exercise, the evidence was rated as very low certainty due to wide confidence intervals, method-dependent statistical significance, and common risk-of-bias concerns. This paper is centrally about endometriosis — specifically investigating whether structured exercise provides clinically important benefits for associated pain and symptom burden.
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Abstract
Endometriosis is associated with persistent pain and a broad symptom burden. We evaluated the effects of repeated structured exercise using published adjusted or longitudinal trial estimates where available and small-sample meta-analytic methods. This PRISMA 2020 systematic review was registered in PROSPERO (CRD420261400459). Six databases and ClinicalTrials.gov were searched through 20 August 2026 without language restriction; backward citation searching was also performed. Two reviewers independently screened records and full texts, extracted data, assessed result-level risk of bias and rated certainty; disagreements were resolved by discussion and, when required, a third reviewer. Random-effects meta-analyses used restricted maximum likelihood (REML) with Hartung–Knapp inference and alternative small-k models. GRADE used review-stage clinical decision thresholds. The searches identified 3,197 database records and 68 ClinicalTrials.gov records. Eight reports from six independent trials were included, and five trials contributed quantitative data. Overall endometriosis-related pain (4 trials, N = 271) yielded SMD − 0.36 (95% CI − 0.95 to 0.24; I²=57.2%; prediction interval − 1.74 to 1.03). Psychological distress (3 trials, N = 243; SMD − 0.29, 95% CI − 1.43 to 0.85) and sexual function (3 trials, N = 144; MD − 2.23, 95% CI − 5.96 to 1.51) were also very uncertain. Statistical significance differed across random-effects specifications for five syntheses. Harms reporting was inconsistent. Certainty was very low for all key outcomes. Current randomised evidence does not establish a clinically important benefit of structured exercise for endometriosis-associated pain or the wider symptom burden. Point estimates generally favoured exercise, but the evidence is very uncertain because trials were few and small, confidence intervals were wide, several syntheses were method-dependent, and risk-of-bias concerns were common. Decisions to use structured exercise should be individualised according to patient preference, general physical-activity guidance, comorbidity and tolerance rather than an assumed endometriosis-specific benefit; better powered trials and systematic harms reporting are needed. PROSPERO CRD420261400459 (registered 20 May 2026; post-registration amendments are reported in the manuscript and supplementary materials).
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Abstract
Background
Endometriosis is associated with persistent pain and a broad symptom burden. We evaluated the effects of repeated structured exercise using published adjusted or longitudinal trial estimates where available and small-sample meta-analytic methods.
Methods
This PRISMA 2020 systematic review was registered in PROSPERO (CRD420261400459). Six databases and ClinicalTrials.gov were searched through 20 August 2026 without language restriction; backward citation searching was also performed. Two reviewers independently screened records and full texts, extracted data, assessed result-level risk of bias and rated certainty; disagreements were resolved by discussion and, when required, a third reviewer. Random-effects meta-analyses used restricted maximum likelihood (REML) with Hartung–Knapp inference and alternative small-k models. GRADE used review-stage clinical decision thresholds.
Results
The searches identified 3,197 database records and 68 ClinicalTrials.gov records. Eight reports from six independent trials were included, and five trials contributed quantitative data. Overall endometriosis-related pain (4 trials, N = 271) yielded SMD − 0.36 (95% CI − 0.95 to 0.24; I²=57.2%; prediction interval − 1.74 to 1.03). Psychological distress (3 trials, N = 243; SMD − 0.29, 95% CI − 1.43 to 0.85) and sexual function (3 trials, N = 144; MD − 2.23, 95% CI − 5.96 to 1.51) were also very uncertain. Statistical significance differed across random-effects specifications for five syntheses. Harms reporting was inconsistent. Certainty was very low for all key outcomes.
Conclusions
Current randomised evidence does not establish a clinically important benefit of structured exercise for endometriosis-associated pain or the wider symptom burden. Point estimates generally favoured exercise, but the evidence is very uncertain because trials were few and small, confidence intervals were wide, several syntheses were method-dependent, and risk-of-bias concerns were common. Decisions to use structured exercise should be individualised according to patient preference, general physical-activity guidance, comorbidity and tolerance rather than an assumed endometriosis-specific benefit; better powered trials and systematic harms reporting are needed.
Registration
PROSPERO CRD420261400459 (registered 20 May 2026; post-registration amendments are reported in the manuscript and supplementary materials).
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Abbreviations
- ANCOVA:
-
Analysis of covariance
- CENTRAL:
-
Cochrane Central Register of Controlled Trials
- CI:
-
Confidence interval
- DASS-21:
-
Depression Anxiety Stress Scales-21
- EHP-30:
-
Endometriosis Health Profile-30
- EQ-VAS:
-
EuroQol visual analogue scale
- FSFI:
-
Female Sexual Function Index
- FSI:
-
Fatigue Symptom Inventory
- GIQLI:
-
Gastrointestinal Quality of Life Index
- GRADE:
-
Grading of Recommendations Assessment, Development and Evaluation
- HADS:
-
Hospital Anxiety and Depression Scale
- HK:
-
Hartung-Knapp
- HRQoL:
-
Health-related quality of life
- HSCL-5:
-
Hopkins Symptom Checklist-5
- KESS:
-
Knowles-Eccersley-Scott Symptom score
- MD:
-
Mean difference
- NRS:
-
Numeric rating scale
- OIS:
-
Optimal information size
- PCS:
-
Pain Catastrophizing Scale
- PFMT:
-
Pelvic-floor muscle training
- PRISMA:
-
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PROSPERO:
-
International Prospective Register of Systematic Reviews
- PSQI:
-
Pittsburgh Sleep Quality Index
- RCT:
-
Randomised controlled trial
- REML:
-
Restricted maximum likelihood
- RoB 2:
-
Cochrane risk-of-bias tool for randomised trials
- SE:
-
Standard error
- SMD:
-
Standardised mean difference
- VAS:
-
Visual analogue scale
- τ²:
-
Between-study variance
Acknowledgements
ChatGPT (OpenAI) was used to assist with language editing. Responsibility for eligibility decisions, risk-of-bias and certainty judgements, numerical results and the final manuscript rests with the authors.
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Sun, M., Zhu, Y., Wang, L. et al. Effects of structured exercise training on pain and multidimensional symptom burden in women with endometriosis: an updated systematic review and meta-analysis. BMC Psychol (2026). https://doi.org/10.1186/s40359-026-05724-7
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DOI: https://doi.org/10.1186/s40359-026-05724-7
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