Background: Premenstrual syndrome (PMS) is a common disorder among women of reproductive age. Nearly 40% of women report problems with their menstrual cycles. Exercise is one of the recommended treatments to reduce symptoms of premenstrual syndrome (PMS). The present study was conducted to determine the effect of 8 weeks aerobic exercise on severity of physical symptoms of premenstrual syndrome (PMS). Methods: This study was a randomized clinical trial (IRCT2015021721116N1) that was performed on 65 students living in student dormitories of Mashhad University of Medical Sciences in 2016, Iran. Samples were randomly assigned to control and intervention groups. The intervention group engaged in 8 weeks of aerobic exercises, three times a week, and 20 min for each session. The tools were research unit selection questionnaire, midwifery and personal particulars, temporary determination of premenstrual syndrome, Beck Depression, recorded daily symptoms of premenstrual syndrome and Borg scale. We analyzed the data using SPSS software and Mann– Whitney U test and Friedman test. Results: At the beginning of the study, both control and intervention groups were homogeneous. The results of independent t-test showed that among the physical symptoms of the premenstrual syndrome in the intervention group compared to the control group, at the end of the study, headache (p = 0.001), nausea, constipation diarrhea (p = 0.01), swollen (p = 0/001) had a significant reduction. Also, the comparison of the difference between the mean of the signs at the beginning and the end of the study, bloating (p = 0.01), Vomiting (p = 0.002), hot flashes (p =0. 04), increase in appetite (p = 0.008) were significantly decreased. Conclusion: Aerobic exercise as one of the ways to treat premenstrual syndrome can reduce the physical symptoms of the syndrome. Trial registration: Name of registry: Zahra Mohebbi Dehnavi. IRCT registration number: IRCT 2015021721116 N1. Registration date: 2015 − 08-28. Registration timing: retrospective. Keywords: Premenstrual syndrome, Aerobic exercise, Physical symptoms * Correspondence: Zahra.email@example.com Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Esfahan, University of Medical Sciences, Esfahan, Iran Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mohebbi Dehnavi et al. BMC Women's Health (2018) 18:80 Page 2 of 7 Background women with PMS for 6 weeks, The results showed that Menstrual cycle is one of the most important signs of re- symptoms of PMS were significantly decreased in mod- productive system functioning in females, but sometimes erate intensity aerobic exercise , But Silva and this phenomenon is associated with signs and symptoms Sadler’s research reported that aerobic exercise does not that cause physical and psychological problems for affect on symptoms of PMS [12, 13], While David et al. women. PMS refers to a set of repetitive symptoms that Reported that aerobic exercise had a negative effect on begins at the end of the secretion phase of the menstrual symptoms of PMS . cycle (5–7 days before menstruation) and ends in the fol- licular phase (2–4 days after menstruation) . For this Study objectives and aims syndrome, more than 150 signs have been identified, some The general objective of this study was to determine the of which are: abdominal cramps, boredom, abdominal effect of 8 weeks aerobic exercise Exercise on the sever- bloating, pain and tenderness of the breasts, acne, back ity of physical symptoms of PMS. Specifically, the study pain and headache, joint pain and muscle pain, weight aimed to: gain, energy shortages, Changes in appetite and thirst, constipation, heart rate elevation [2, 3]. Due to the high The mean of indicators of physical symptoms of prevalence of this syndrome and the role of women in the PMS in the control and intervention groups family and community, treatment is important. The preva- Comparison of the mean of physical symptoms of lence of these symptoms varies according to factors such PMS in the control and intervention groups as culture, attitude, age, exercise, nutrition, and underlying diseases . Methods Given that today, a large number of women are involved Study design and setting in the fields of occupation, education, family, and other re- The present study is a randomized clinical trial with sponsibilities. And the stress associated with these respon- IRCT 2015021721116 N1 registration code. This study sibilities is related to health issues, such as PMS, lifestyle was performed on 65 female students that living in changes, membership in supportive groups, the use of dormitories of Mashhad University of Medical Sciences stress control methods along with supplementary drugs in 2016. and vitamins may help relieve the symptoms of the disease Initially, Sample size According to El-Lithy’s study But information on the complete treatment of this disease , 30 people in each group were estimated, with Con- is currently very limited . Several possible causes have sidering sample loss, 35 people were estimated in each been reported for the syndrome, including: estrogen, pro- group. At first, randomly and according to the table, two gesterone, fluid retention, hyperprolactinemia, vitamin B6 hostels were randomly selected and in order to avoid deficiency, hypoglycemia, prostaglandin deficiency, andro- any interference in the sampling, a dormitory was con- gen hormones allergy, psychosomatic problems, increased sidered as the control group and one was considered as activity of aldosterone and renin plasma, thyroid disorders the control group. Then, in dormitories of the Mashhad and lack of serotonin [5–7]. Since precise pathophysiology University of Medical Sciences, people with symptoms of PMS is not known, there is no definitive treatment for of PMS were requested to attend a meeting in the dor- it, and most of the symptom is being treated. Generally, mitory’s residence According to the date announced. treatments can be arranged in three groups: Surgical treat- Then, the research objectives were explained to the par- ment, drug treatment (such as hormonal use, antidepres- ticipants and they were asked to complete written con- sant and analgesic drugs) and non-drug therapies (such as sent if they wished to participate in the study. The lifestyle changes and exercise) . inclusion criteria included: regular menstrual cycles (cy- Considering the side effects of drug and surgical treat- cles of 21-35 days with a bleeding time of 3–10 days), ments, non-drug treatments, especially physical activity, PMS (according to the interim screening questionnaire, have attracted the attention of specialists and women having 4 of 11 The question mark) and Score below 40 with the disease . Physical activity is a suitable from Beck Depression questionnaire was entered into method for the treatment of PMS and is the best the study. The exclusion criteria at the beginning of the method for all women to reduce pressure and balance in study included pregnancy, participation in other sports the brain’s chemical secretions. It seems that physical ac- programs, continuous use of medication, chronic dis- tivity by increasing endorphins and reducing adrenal ease, Women with neurological, psychological disorders, cortisol leads to improvement of symptoms of PMS, in- women under hormonal treatment, women with endo- creased pain tolerance, decreased anxiety, depression crinological diseases, women with local lesions causing and other problems . pain as PID, severe depression (according to the depres- Vishnupriya et al. Examined the effect of aerobic exer- sion questionnaire having a score above 40), the incidence cise with different severity (low, moderate, severe) on 61 of adverse events in the last 3 months. All research units Mohebbi Dehnavi et al. BMC Women's Health (2018) 18:80 Page 3 of 7 were assured that each stage of the study could be ex- questionnaire was routinely completed by research units. cluded from the study and referring to the specialist if Twice a week, the researcher made phone calls to the re- there were any problems that prevented them from search units and encouraged them to do the exercises and studying. Exclusion criteria during the study included: complete the questionnaires. Once every 2 weeks, the re- dissatisfaction with the continuation of the research, preg- searcher visited the volunteers to check the situation of ex- nancy during the study, Exit the menstrual cycle from the ercise activities in the intervention group by recording their normal order during the study, the failure to complete the pulse rates after exercise and the Borg scale performance, questionnaire (3 consecutive days and 5 days interrupted) i.e. after exercise the heart rate should be in the range of and the adverse and stressful during the study. In the 120–150 and the Borg scale in the range of 12–15. next step, the questionnaires were completed by the The control group during the same 8-week period re- research units. corded their daily activities without having any exercise The instruments used included: The questionnaires of programs and were encouraged to complete the ques- temporary determination of PMS (set temporary PMS) tionnaire on a regular basis twice per week through (the validity of this questionnaire was confirmed in 2013 phone calls made by the researcher. The information by Shakeri et al.)  We measured the reliability of this was provided to the participants. questionnaire according to the re-test method and the Spearman–Brown correlation coefficient as 0.79). Beck Community engagement and ethical considerations Depression questionnaires (This questionnaire with re- Initially written consent was obtained from all partici- gard to the study by Jafarnejad et al. is a valid and reli- pants in the research. Participants could withdraw at any able tool. A study by Jafarnejad et al. has mentioned that stage of the research. This study did not endanger the Beck et al. in 1996 obtained the credibility coefficient of participants’ health. During the research, the participants the test, re-test, in a weekly interval as 0.93. A study by were referred to relevant specialists in the presence of Ahmadi Tahoor in 2009 confirmed its content validity severe PMS and severe depression according to the . Recorded daily symptoms of PMS-(The validity of questionnaires. The information obtained from the par- this questionnaire was confirmed in 2013 by jafarnejad ticipants was confidential. The information obtained et al.) . The reliability of this questionnaire was by from the study was presented to the participants at the Cronbach’s alpha Internal consistency, and the reliability end of the study. This research was approved by the coefficient was calculated as 0.77). Borg scale-(It has the Vice-Chancellor of Ethics Committee of Mashhad Uni- sufficient validity. Moreover, the validity of this question- versity of Medical Sciences (with the code 931232). The naire was confirmed by Azhary et al. in 2004. The reli- clinical trial code is IRCT 2015021721116 N1. ability of the questionnaire was confirmed) . We conducted this study in two stages, a stage prior to intervention (2 months) and the next stage after the Data management and statistical analyses intervention (2 months). Information was encrypted and entered into SPSS (Ver- The intervention consisted of aerobic exercise training, sion 23) software (IBM, SPSS Inc., Chicago, Illinois, USA). which was taught to intervention units at a meeting face Then, descriptive statistics Independent t-test tests were to face. At the end of the session, CDs and educational used to analyze the data. P < 0.05 was considered statisti- posters containing all the exercises were provided to the cally significant. units of the intervention group and they were asked to perform aerobic training for 8 weeks, 3 times a week Results and 30 min each time. Each exercise cession included At the beginning of the study, 70 individuals entered the warming up movements for the first 5 min (including study and 65 followed through to the end of the study head movements, stretching and rotation of the shoul- and 5 individuals were excluded from the study. ders and maintaining balance), cooling down for the last 5 min (movements in sitting and lying-down position to return to the initial state) and in the time between the two, aerobic exercises (kinetic movements including ro- tating and stretching the arms, rotating the upper body, standing-in-place movements). The two groups were homogeneous for demographic The research units, at the end of each exercise session, characteristics (Tables 1 and 2). The mean age of partici- had to check their pulse rate and record it in the Borg pants in the study in the control group was 24/06 ± 4/ questionnaire. Also, they were asked to record the intensity 71 and in the intervention group was 25/22 ± 4/41. of the exercises according to the Borg scale. Moreover, Menstrual intervals in the control group were 7/33 ± 1/ during the 8-week period, the recorded daily symptoms 34 and in the intervention group were 6/6 ± 1/41. Mohebbi Dehnavi et al. BMC Women's Health (2018) 18:80 Page 4 of 7 Table 1 Average and homogeneity of quantitative variables of this study showed that among the physical symptoms of participants’ demographics the PMS in the intervention group compared to the con- Variable Control Intervention P-Value trol group, at the end of the study, headache (p =0.001), X SD X SD nausea, constipation diarrhea (p =0.01), swollen (p =0/001) Age 24/06 ± 4/71 25/22 ± 4/41 0/2 had a significant reduction. Also, comparison of the differ- ence between the mean of symptoms at the beginning Monthly bleeding intervals 27/63 ± 3/39 28/34 ± 3/69 0/42 and the end of the study showed that among the physical duration of menstrual bleeding 7/33 ± 1/34 6/6 ± 1/41 0/37 signs of PMS, Bloating (p =0.01), Swollen (p =0.002), intensity of Dysmenorrhea 3/80 ± 2/85 4/02 ± 3/52 0/77 flushing (p = 0.04), increase in appetite (p =0.008), had a P < 0.05 was considered statistically significant ** significant decrease. Although other symptoms also significant decreased, this was not significant. The results of this study showed that among the Also, the results of Vishnupriya study showed that physical symptoms of the PMS in the intervention exercise can reduce symptoms of premenstrual syn- groupcomparedto the controlgroup,atthe endofthe drome , But Aimee and colleagues reported that study, headache (p = 0.001), nausea, constipation diar- there is no significant relationship between exercise and rhea (p = 0.01), swollen (p = 0/001) had a significant premenstrual syndrome . In 2004, Lustik and col- decrease (Table 3). leagues conducted a research on stress, quality of life, Also, the comparison of the difference between the physical activity, and symptoms of premenstrual syn- mean of symptoms at the beginning and the end of the drome. This study was performed on 114 women aged study showed that among the physical symptoms of the 18-33 years old and divided into 2 severe and weak PMS, Bloating (is any abnormal gas swollen, or increase groups in terms of symptoms of premenstrual syndrome. in diameter of the abdominal area) (p = 0.01), Swollen in Studies have shown that people who exercise at times Breast (p = 0.002), flushing (p = 0.04), increase in appetite experience more severe symptoms than those who often (p = 0.008) were significantly decreased (Table 3). exercise [17, 18]. In the study of Maged et al., reported highly significant Discussion difference between the study and control groups weak Today, solving women’sproblemsisone of themost coordination, confusion, headache, tiredness, pains, ten- important health and research priorities. PMS is one of derness of the breast, and cramps . the most common problems of women, which can inter- In the study of El-Lithy et al., the study group showed a fere with everyday life in women. In this study (8 weeks of significant decrease in all post-treatment subscale symp- aerobic exercise), there was a significant decrease in phys- toms, scores and total score. Haemoglobin, haematocrit, ical symptoms of premenstrual syndrome. The results of red cell count and platelet count were significantly in- creased, while mean corpuscular volume (MCV), mean Table 2 Qualitative variables of participants’ demographics corpuscular haemoglobin (MCH), mean corpuscular Variable Control Intervention P-Value haemoglobin concentration (MCHC) and white blood cell Number Number count showed no significant differences. There was also a (percent) (percent) significant decrease in prolactin, oestradiol and progester- History of absence from the 9 (30%) 13 (37/1%) 0/54 one levels. In conclusion, aerobic exercise increases workplace or university haemoglobin, haematocrit, red cell count and platelet History of the use of treatment 10 (33/3%) 16 (45/7%) 0/31 count, and decreases levels of prolactin, oestradiol and before the study progesterone, resulting in improvement of fatigue, im- The Impact of Pre-Study 8 (26/7%) 11 (31/4%) 0/49 paired concentration, confusion and most premenstrual Therapeutic Therapy symptoms . Marital status 0/13 In the study of Azhary et al., reported a significant Married 18 (60%) 27 (77/1%) reduction in low back pain (p = 0.001), abdominal pain Single 12 (40%) 8 (22/9%) (p = 0.001) and Swollen (p = 0.05) . Contrary to the Number of pregnancies results of this study, In the study of Prior, bloating in married people (p = 0.025) decreased significantly . In the study of 0 9 (50%) 13 (48/14%) 0/26 Fatoukian , bloating (p = 0.05) showed a significant 1 3 (16/6%) 6 (22/22%) decrease. Karimian et al. Reported that exercise had a 2 5 (27/7%) 6 (22/22%) significant effect on abdominal pain (p = 0.001) and joint pain (p = 0.008) . Contrary to the results of this 3 1 (5/5%) 2 (7/4%) * study, Karimian et al. Reported Bloating and sensitivity P < 0.05 was considered statistically significant ** significant of breast (p ≤ 0.05) had not recovered after exercise , Mohebbi Dehnavi et al. BMC Women's Health (2018) 18:80 Page 5 of 7 Table 3 The mean of indicators of physical symptoms of premenstrual syndrome in the control and intervention groups before and after the intervention Group Control Intervention P value Independent X SD X SD Physical symptoms t-test Acne Before 1/9 ± 1/37 1/85 ± 1/26 0/89 After 1/26 ± 1/08 1/11 ± 0/9 0/09 Difference − 0/66 ± 0/92 − 0/82 ± 1/04 0/5 Bloating Before 1/34 ± 0/66 1/34 ± 0/88 0/5 After 0/89 ± 0/43 0/53 ± 0/32 0/08 ** Difference -0/26 ± 0/63 −0/54 ± 0/88 0/01 Breast sensitivity Before 2/56 ± 0/81 2/74 ± 0/65 0/33 After 1/90 ± 0/95 1/80 ± 0/93 0/7 Difference −0/7 ± 0/98 −1/05 ± 0/9 0/13 Dizziness Before 2/23 ± 1/19 1/44 ± 1/57 0/06 After 1/7 ± 1/16 1/20 ± 1/25 0/06 Difference −0/4 ± 0/77 −0/4 ± 0/73 0/7 Fatigue Before 1/56 ± 1/4 1/51 ± 1/37 0/88 After 1/16 ± 1/17 1/14 ± 1/16 0/8 Difference −0/3 ± 0/74 −0/6 ± 0/84 0/13 Headache Before 1/93 ± 1/36 1/48 ± 1/50 0/21 ** After 1/6 ± 1/3 0/85 ± 0/74 0/001 Difference −0/5 ± 0/82 −0/42 ± 0/69 0/7 Flushing Before 2/02 ± 1/21 1/77 ± 1/37 0/42 After 1/83 ± 1/17 1/31 ± 1/20 0/08 ** Difference −0/36 ± 0/71 −0/8 ± 0/99 0/04 Nausea, diarrhea, constipation Before 1/90 ± 1/39 1/68 ± 1/45 0/54 ** After 1/6 ± 1/24 1/01 ± 0/91 0/01 Difference −0/43 ± 0/89 −0/45 ± 0/78 0/9 *** heart beat (Palpitations) Before 1/8 ± 1/27 1/08 ± 2/34 0/17 After 1/4 ± 1/1 1/4 ± 0/97 0/09 Difference −0/5 ± 1/00 −0/91 ± 0/98 0/12 Swollen in Breast Before 1/56 ± 1/38 1/42 ± 1/31 0/68 ** After 1/36 ± 1/32 0/98 ± 0/97 0/001 ** Difference −0/33 ± 0/71 −1/00 ± 0/71 0/002 Increased appetite Before 2/00 ± 1/25 1/97 ± 1/36 0/93 After 1/7 ± 1/05 1/34 ± 0/99 0/1 ** Difference −0/36 ± 0/71 −0/91 ± 0/88 0/008 P < 0.05 was considered statistically significant ** significant *** Palpitations are the perceived abnormality of the heartbeat characterized by awareness of cardiac muscle contractions in the chest: hard, fast and/or irregular beats also, Azhary et al. Reported that breast tenderness reported that exercise has no effect on the physical increased after 8 weeks of aerobic exercise . In con- symptoms of PMS [12, 13, 27, 28]. firmation of the results of this study, Abedi and Nik- Considering that in this study, the severity of symptoms bakht (2007), Moqadasi et al. (2009), Dehghan Manshadi decreased at the end of the study, but this was not signifi- et al. (2008), Samadi et al. (2012) indicate positive effects cant and only some of the physical symptoms decreased of exercise on reducing the Physical symptoms of PMS significantly. Due to the difference in the results of this [8, 23–26]. While the study of Beackvid et al. (2000) and study and other studies, this difference can be attributed to Gharakhanlu et al. (2000), Sadler (2010) and Silva (2006) the difference in the duration and intensity of the exercises, Mohebbi Dehnavi et al. BMC Women's Health (2018) 18:80 Page 6 of 7 the pattern of sleep and nutrition of individuals and their Conclusion living environment. In fact, the occurrence of electrolyte Regarding the results of this study, performing 8 weeks symptoms such as bloating and swollen may be due to an of regular aerobic exercise in people with PMS causes a increase in serum aldosterone, an increase in prostaglandin significant decrease in some of the physical symptoms of E2, and a deficiency of vitamin B6 and magnesium. Conse- the syndrome, For this reason, having a regular exercise quently, given the positive effect of aerobic training on the program is recommended to all women of reproductive reduction of serum aldosterone, the results are justifiable age, especially those with PMS. [20, 29]. Aerobic exercise lowers renin levels, increases es- Abbreviation trogen, progesterone, and reduces serum aldosterone levels, PMS: Pre Menstrual Syndrome resulting in improved symptoms . Aganoffy considers Acknowledgments aerobic exercise ineffective in water retention in athletic The authors would like to acknowledge all the study respondents, Deputy of and non-athlete women . While Stoddard et al. Showed Research of Mashhad University of Medical Sciences, University dormitory positive effects of aerobic exercise on the clinical symptoms officials, Staff of the Faculty of Nursing and Midwifery and Participants in the study. Finally, we would also like to acknowledge the Deputy of Research of of PMS, such as pain and water retention . It is said that Mashhad University of Medical Sciences for providing the necessary resources prolactin levels increase in the end of luteal phase is one of to conduct this study. the causes of pain and swollen in the breast. Occurrence of physical symptoms such as swollen, weight gain, headache, Funding Funding for this study was provided by the Research Deputy of Mashhad breast pain may be related to increased activity in the University of Medical Sciences. The funding body have no further input into system of aldesterone renin-angiotensin, prolactin, prosta- the collection, analysis and interpretation of the data or in manuscript glandin, deficiency of vitamin B6, E2 and magnesium. Pros- preparation. taglandin E2 is one of the risk factors for developing Availability of data and materials physical symptoms. The repeated muscle contraction in The datasets used and/or analyzed during the current study are available from physical activity helps to reverse vein and increases the the corresponding author on reasonable request. movement of prostaglandin and other substances and Authors’ contributions prevents their accumulation in the pelvis and reduces ZMD and FJ conceptualized the idea for this study. ZMD supervised field the back pain and abdominal discomfort . Khademi data collection activities. FJ analyzed the data and prepared the first draft of the manuscript. ZMD, FJ and SSG assisted with interpreting the data. ZMD, et al. Also considered 8 weeks of swimming sport as FJ and SSG revised the manuscript for proper intellectual content. All authors one of the aerobic exercises that can be used to reduce read and approved the final manuscript. physical symptoms such as headache, swollen of the breast, and low back pain . The beta-androgen level Ethics approval and consent to participate Ethical approval for the study was obtained from the Research Ethics at the end of the luteal phase decreases due to changes Committee of the Mashhad University (with the code 931232). The clinical in sex hormones, aerobic exercise results in increased trial code is IRCT 2015021721116 N1. All participants provided written levels of beta-endorphin and increases pain tolerance in informed consent. individuals, thereby improving the body’ssymptoms Competing interests that are due to decreased beta-endorphin . Increas- The authors declare that they have no competing interests. ing renin-angiotogenic activity and decreasing estrogen and progesterone levels have been reported as an effect- Publisher’sNote ive factor in increasing the serum level of aldesterone Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. in the late phases of the luteal phase. Increasing the serum level of aldesterol leads to increased sodium and Author details water reabsorption and thus causes edema and physical Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Esfahan, University of Medical Sciences, Esfahan, Iran. Faculty of symptoms . Nursing and Midwifery, Mashhad, Iran. Faculty of Nursing and Midwifery, Since this syndrome can have negative effects on the Mashhad University of Medical Science, Mashhad, Iran. efficiency and presence of women in their employment Received: 11 January 2018 Accepted: 16 May 2018 centers, the existence of this syndrome also has a dam- aging effect on the economic aspect. With the emphasis on the results of the research, exercise can be combined References with other therapies to reduce the symptoms of this 1. Hasani N, Kazemi M, Karimi Afshar H, Kazemi M, Tavakoli M. Comparison of the effects of relaxation and vitamin B6 on emotional and physical syndrome. symptoms in premenstrual syndrome. Evid Based Care J. 2015;5(15):75–83. The lack of control of nutrition, sleep, and unequal 2. Mohebbi Dehnavi Z, Jafarnejad F, Mojahedy M, Shakeri M, Sardar M. The motivation of subjects during exercise is a limitation of relationship between temperament warm and cold with symptoms of premenstrual syndrome. 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