Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–4 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.960823
Effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women A. El-Lithy1, A. El-Mazny1, A. Sabbour2 & A. El-Deeb2
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Departments of 1Obstetrics and Gynecology, Faculty of Medicine and 2Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Egypt
The objective of this study was to investigate the effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women. A total of 30 participants aged 16–20 years and complaining of premenstrual syndrome (PMS) were randomly assigned into two groups: a control group received vitamin B6 and Ca supplements once daily and a study group received the same medical treatment and participated in treadmill training three times per week for 3 months. A premenstrual syndrome questionnaire (MSQ), complete blood picture and hormone assays were performed for the assessment of all participants at the start and after the end of the treatment course. The study group showed a significant decrease in all post-treatment subscale symptoms, scores and total score. Haemoglobin, haematocrit, red cell count and platelet count were significantly increased, while mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and white blood cell count showed no significant differences. There was also a significant decrease in prolactin, oestradiol and progesterone levels. In conclusion, aerobic exercise increases haemoglobin, haematocrit, red cell count and platelet count, and decreases levels of prolactin, oestradiol and progesterone, resulting in improvement of fatigue, impaired concentration, confusion and most premenstrual symptoms. Keywords: Aerobic exercise, haematocrit, haemoglobin concentration, premenstrual syndrome, prolactin, steroid hormones
Introduction The menstrual cycle is a repetitive phenomenon occurring during the reproductive life of a woman that involves a patterned sequence of structural, functional and hormonal changes in the reproductive system (Farage et al. 2009). It involves complex interactions of the hypothalamus, pituitary, ovaries, uterus, prostaglandins and neuroendocrine factors (Lin et al. 2013). The cyclical process is regulated by complex changes in the concentrations of five hormones: gonadotropin-releasing hormone (GnRh); follicle stimulating hormone (FSH); luteinising hormone (LH); oestradiol (E2); and progesterone (P4). The interplay of these hormones is extremely complicated; the ovarian steroid hormones exert both negative and positive feedback effects on hypothalamic pituitary unit to influence its hormone secretion. Oestradiol produces positive feedback on LH release leading to LH surge around day 14 of the cycle. Ovulation occurs
approximately 12 h after the LH surge and P4 is secreted from the corpus luteum during the luteal phase with a peak around 8 days after LH surge (Kol and Itskovitz-Eldor 2010). Repeated cyclical haemorrhages and variations in the E2 and P4 levels in the blood during menstrual cycle may affect the blood plasma volume (Stephenson et al. 1989). There is a pronounced tendency towards an increase of haemoglobin, together with haematocrit from the early menstrual phase until the post-ovulatory period, with a subsequent decrease towards the end of the cycle (Vellar 1974). This may suspect the woman at her reproductive age to blood disorders, such as anaemia and iron deficiency, which can have negative consequences on the women, especially for neurocognitive outcomes (Coad and Conlon 2011). Abnormal fluctuations in the circulating sex hormones (E2 and P4) during the menstrual cycle may also be associated with some physical and emotional symptoms (Redei and Freeman 1995; Inoue et al. 2007; Itsekson et al. 2013). Breast tenderness, bloating, weight gain, headache, swelling of the hands or feet and pains are the main physical symptoms, while depression, angry outbursts, irritability, crying spells, anxiety, confusion, social withdrawal, poor concentration, sleep disturbance, thirst and appetite changes are common psycho-emotional and behavioural symptoms (Rapkin 2003). The cyclic recurrence of a combination of these symptoms during the luteal phase of the menstrual cycle is referred to as premenstrual syndrome (PMS) (Braverman 2007). At least, 20% of adolescents may experience moderate-tosevere premenstrual symptoms (Rapkin and Mikacich 2006). Emerging of these symptoms during the teen years complicates the process of puberty and affects social, emotional wellbeing and educational performance in a negative way, resulting in a poor self-steam, a sense of dissatisfaction and inadequacy (Rizk et al. 2006). Several studies had been conducted to show the effect of exercise on premenstrual symptoms using questionnaires (Prior et al. 1986; Prior et al. 1987; Steege and Blumenthal 1993; Aganoff and Boyle 1994; Choi and Salmon 1995; Samadi et al. 2013). To the best of our knowledge, no longitudinal studies have been conducted to investigate the effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women with PMS.
Methods A total of 30 young women aged 16–20 years and diagnosed with PMS (Rapkin 2003; Braverman 2007) were recruited from the
Correspondence: Akmal El-Mazny, Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt. E-mail: dr_akmalelmazny@ yahoo.com
J Obstet Gynaecol Downloaded from informahealthcare.com by The University of Manchester on 10/12/14 For personal use only.
2 A. El-Lithy et al. Outpatient Gynecology Clinic of the Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University. The study protocol was approved by the Scientific Research Committee. Both participants, and parents of the participants 18 years, assigned written consent before starting this study and they were informed about the aims and procedures of the study. All participants experienced a regular menstrual cycle. Young women with a history of endometriosis, pelvic inflammatory diseases, any pelvic pathology, and diabetes or thyroid diseases were excluded from this study. All women did not use oral contraceptive pills or any psychotropic agents and they did not engage in any previous regular exercise programme. A full history of each participant, including age, height, weight, age at menarche and length of the menstrual cycles, was recorded. Pelvic ultrasonography was performed for each participant to exclude any pelvic pathology. Participants were randomly allocated into two equal groups, using computer-generated random numbers. The study group received medical treatment in the form of vitamin B6 (50 mg/ day) and Ca (1,200 mg/day) supplements, and were engaged in a programme of aerobic exercise for 3 months. The control group received the same medical treatment, and were instructed to avoid and report any major changes in lifestyle. A ‘modified’ Premenstrual Syndrome Questionnaire (MSQ) (Prizzorno and Murray 1999) was given to each participant at two consecutive months before starting the study to confirm the diagnosis of PMS. MSQ consists of 26 symptoms, which are categorised into subscales: •• •• •• ••
PMT-A, anxiety (behavioural changes) PMT-H, hyperhydration symptoms PMT-C, craving manifestations PMT-D, characterising depression and subscale of other symptoms.
The MSQ also measured the occurrence and severity of two menstrual pain symptoms, including cramp and backache experienced during the first 2 days of the women’ last menstrual period. Premenstrual symptoms were scaled as: mild (1); moderate (2); and severe (3). Young women with PMS should experience a premenstrual symptoms score of at least 50% greater than the postmenstrual score and rate moderate to severe impairment in one or more subscale (Vichnin et al. 2006). Also, this MSQ was filled before and after 3 months of the study course to evaluate the effect of the treatment programme. A 10 ml blood sample was taken from the antecubital vein with suitable vacutainers, with EDTA as anticoagulant. The basal venous blood samples were obtained from all the participants in the morning between 09.00 and 11.00 hours, after
Table I. Baseline characteristics of the control and study groups. Baseline characteristics
Control group (n 15)
Study group (n 15)
Age (year) BMI (kg/m2) Age at menarche (year) Menstrual length (days)
18.14 1.51 22.67 2.34 11.93 0.82 27.93 2.73
17.80 1.47 22.93 1.98 11.77 1.29 28.13 2.44
Data represented as mean SD.
12 h of overnight fasting. Three ml of each blood sample was analysed to obtain the complete blood picture: haemoglobin; red cell count; haematocrit; mean corpuscular volume (MCV); mean corpuscular haemoglobin (MCH); mean corpuscular haemoglobin concentration (MCHC); white cell count and platelet count were analysed using the UniCel DxH 800 Cellular Analysis System (Beckman Coulter, USA). Of the blood sample, 7 ml was allowed to clot and was centrifuged at 1,000 r.p.m. for 10 min to achieve separation. The serum obtained was put into aliquots in each case, labelled and stored at 220°C. The samples were analysed for hormone estimation using electrochemiluminescence immunoassay (ECLIA) (Bryant et al. 2009) on a Roche cobas e 602 immunoassay analyser (Roche, Germany). Samples from all participants were run in the same assay to reduce any variance from interassay variability. These samples were taken in the luteal phase of the menstrual cycle at day 20 of each participant before and after the treatment course. Before starting the treatment programme, each subject in the study group was informed about the benefits of the aerobic exercise to gain her motivation and cooperation during the treatment course. The women were advised to drink plenty of fluid before and after the exercise session and wear supportive, well-fitting running or walking shoes. Treadmill protocol was modified from the method used by Allor et al. (2000). The treadmill exercise programme was started with warm-up period, in which each participant walked at 80 m/min at 0.0% grade for 5 min. After the walk, the treadmill speed was increased to 147 m/min and the grade was increased gradually until it reached 25%, for 20 min. This was followed by a cool-down period, in which the treadmill speed and grade were decreased to 2.0 m.p.h. and 0.0% grade, during the cool-down period. The participants continued the treadmill exercise programme 3 days per week for 3 months. Data were represented as mean and standard deviation ( SD). Wilcoxon matched pairs and Mann–Whitney tests were used to compare within and between groups for non-parametric data, while a paired t-test and independent t-test were used to compare within and between groups for parametric data. A p value of 0.05 was considered significant. With a margin of
Table II. Comparison of PMS subscale scores and total scores at baseline and after 3 months of treatment for both groups. Control group (n 15) Symptoms Anxiety symptoms Craving symptoms Depression symptoms Hyperhydration symptoms Menstrual cramps Menstrual backache Total score
Study group (n 15)
Baseline
After 3 months
Baseline
After 3 months
8.66 2.84 6.93 1.33 9.46 2.79 9.00 1.41 2.80 0.41 2.80 0.41 52.13 7.92
9.00 2.59 6.26 1.16* 9.20 2.33 9.26 1.27 2.80 0.41 2.86 0.35 51.53 7.34
9.13 2.09 7.60 1.99 9.53 2.41 9.60 1.24 2.73 0.59 2.60 0.63 54.26 7.05
5.40 1.29** 6.13 1.30** 6.00 1.30** 6.13 1.12** 1.46 0.51** 1.60 0.50** 37.00 6.52***
Data represented as mean SD. *p 0.05; **p 0.01; ***p 0.001, as compared with baseline.
Effect of aerobic exercise on premenstrual symptoms 3 Table III. Comparison of haematological parameters at baseline and after 3 months of treatment for both groups. Haematological parameters Haemoglobin (g/dl) Red cell count (106/mm3) Haematocrit (vol%) MCV(fl) MCH (pg) MCHC (%) Platelet count (103/mm3)
Control group (n 15)
Study group (n 15)
Baseline
After 3 months
Baseline
After 3 months
12.01 0.49 4.13 0.34 37.29 1.94 84.40 2.89 29.33 1.39 32.40 2.16 217.30 53.57
12.02 0.44 4.24 0.46 38.07 1.66 83.73 2.55 29.40 1.29 32.87 2.10 230.70 58.27
12.15 0.72 4.19 0.30 37.82 3.63 86.13 4.58 29.67 1.91 33.93 1.10 228.90 43.91
12.40 0.48* 4.40 0.36* 38.61 3.28*
85.60 2.23 30.07 1.16 33.47 1.68 252.90 51.14*
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Data represented as mean SD. *p 0.05, as compared with baseline.
error of 4.99% and a response distribution of 50%, the confidence level was 52%, whereas with a margin of error of 9.92% and a response distribution of 50%, the confidence level was 84%.
Results As shown in Table I, there were no significant differences in baseline characteristics, including age, body mass index (BMI), menarche age and menstrual length between the control and study groups (p 0.05). After 3 months of treatment, the study group showed significant post-test decreases in anxiety (behaviour) score (p 0.001); craving symptoms score (p 0.002); depression score (p 0.001); hyperhydration symptoms score (p 0.001); menstrual cramps (p 0.001); backache (p 0.002); and total score (p 0.001). For the control group, there was a significant decrease in the craving symptoms score (p 0.02) and no significant differences in the other subscale scores: menstrual cramp, low back pain and total score (p 0.05) (Table II). Also, results showed a highly significant decrease in all post-treatment subscale symptoms scores (p 0.001) (except for craving score; p 0.05) and total score (p 0.001) of the study group when compared with the posttreatment scores of the control group. Results showed that 40% of the participants had a haemoglobin level 12 g/dl, indicating anaemia. After 3 months aerobic exercise, haemoglobin, haematocrit, red cell count and platelet count were significantly increased (p 0.02; p 0.02; p 0.02; p 0.03, respectively), while other parameters MCV, MCH, MCHC and white blood cell count showed no significant differences (p 0.05) (Table III). Only haemoglobin showed a significant difference between the control and study group after treatment (p 0.03). Prolactin level was significantly decreased by 58.92% (p 0.001) and also (E2) and (P4) decreased by 23.9% (p 0.01) and 41.2% (p 0.01), respectively, in the study group (Table IV). Results also, showed a highly significant decrease in post-treatment values of prolactin (p 0.001), P4 (p 0.001) levels, as well as a decreasing trend in (E2) without statistical significance (p 0.05) of the study group when compared with the control group after treatment.
Discussion The objective of this study was to determine the effect of 3 months of treadmill training on premenstrual symptoms, hormones that may be involved in the occurrence of these symptoms and haematological parameters in young women. The results of this study showed that B6 and Ca supplementations produced improvements in some premenstrual symptoms, such as appetite change, headache, fatigue, dizziness and palpitation. This was in agreement with Ghanbarid et al. (2009) who reported that Ca supplements showed decreased fatigability, changes in appetite and depression in women with PMS. However, these supplements did not show any change in hormone levels and haematological parameters in the control group. Exercise can significantly lower almost all premenstrual symptoms in young women. It improves anxiety and depressionrelated symptoms, carbohydrate craving symptoms and electrolyte change symptoms. This finding was consistent with the results of observational cross-sectional studies, which reported that regular exercisers had significantly lower scores on impaired concentration, negative effect, behaviour changes and pain (Aganoff and Boyle 1994), and may be protected from deterioration of mood before and during menstruation (Choi and Salmon 1995). It is also in-line with longitudinal studies, which reported reduction in premenstrual symptoms after 3 (Prior et al. 1986) and 6 (Prior et al. 1987) months of a running training programme. In addition, exercise showed a reduction in menstrual cramps and low back pain associated with the first 2 days of the menstrual period. This was in agreement with many studies, which have reported the beneficial effect of exercise on dysmenorrhea (Golub et al. 1968; Israel et al. 1985; Samadi et al. 2013). In the present study, 40% of participants had a haemoglobin level 12 g/dl, indicating that young women with PMS are at greater risk of anaemia. Low haemoglobin may be responsible for some symptoms associated with PMS, such as fatigue, dizziness, impaired concentration and confusion that may affect educational performance of the young women (Hawkins et al. 1954). Aerobic exercise showed significant improvement in haemoglobin, haematocrit, red blood cells count and platelet
Table IV. Comparison of hormonal parameters at baseline and after 3 months of treatment for both groups. Control group (n 15) Hormonal parameters
Baseline
Prolactin (ng/ml) Oestradiol (pg/dl) Progesterone (ng/ml)
29.21 15.76 107.30 39.49 10.52 5.22
After 3 months 28.73 14.00 108.70 39.22 11.10 5.03
Data represented as mean SD. *p 0.05; **p 0.01, as compared with baseline.
Study group (n 15) Baseline
After 3 months
30.60 18.98 123.10 39.85 9.73 5.57
12.57 4.27** 99.33 36.33* 5.65 2.44*
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4 A. El-Lithy et al. count, leading to reduction of the previous symptoms. These findings were consistent with Córdova et al. (2010), who found the maximal incremental exercise test significantly increased erythrocytes, haematocrit and blood haemoglobin levels in volleyball players, and Cho et al. (2012) who reported increased platelet counts in response to the acute effect of treadmill exercise in college male students. Some women with PMS have higher prolactin levels or may be abnormally sensitive to a normal amount of prolactin (Cho et al. 2012). In the present study, the prolactin level was significantly reduced in the exercising young women, which may lead to relief of the physical symptoms, such as breast tenderness. This was in consistent with the study which reported that prolactin-lowering agents can effectively treat premenstrual mastalgia (Peters 1992). The hypothesis of involvement of gonadal steroids in the pathophysiology of PMS is supported by the findings that symptoms are not present during non-ovulatory cycles and disappear with ovariectomy (Cunningham et al. 2009). From this hypothesis, it may be suggested that reduction in the levels of oestradiol and progesterone in response to exercise may be associated with the recovery of some premenstrual symptoms. This was consistent with Kossman et al. (2011) who reported that aerobic exercise produced reduction in both oestradiol and progesterone in premenopausal women at high risk of breast cancer. Also, a recent study on rats reported a decrease in oestradiol and progesterone in response to high intensity exercise training (Xiong et al. 2012). In conclusion, young women with PMS are at greater risk of anaemia and thus, a regular haemoglobin test is recommended for that population. Aerobic exercise has a very beneficial effect physiologically and psychologically for young women, as it relieves premenstrual symptoms, decreases prolactin, oestradiol and progesterone involved in pathophysiology of PMS and improves haemoglobin, haematocrit and red blood cell count, resulting in improvement of social, emotional wellbeing and educational performance. However, due to our relatively small sample size, further longitudinal studies are needed to confirm our findings. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Aganoff JA, Boyle GJ. 1994. Aerobic exercise, mood states and menstrual cycle symptoms. Journal of Psychosomatic Research 38:183–192. Allor K, Pivarnik J, Sam L, Perkins M. 2000. Treadmill economy in girls and women matched for height and weight. Journal of Applied Physiology 89:512–516. Braverman PK. 2007. Premenstrual syndrome and premenstrual dysphoric disorder. Journal of Pediatric and Adolescent Gynecology 20:3–12. Bryant C, Moore J, Curry TE Jr. 2009. Determination of serum oestradiol levels by radiometric and chemiluminescent techniques. Methods in Molecular Biology 590:21–32. Cho HC, Kim J, Kim S, Son YH, Lee N, Jung SH. 2012. The concentrations of serum, plasma and platelet BDNF are all increased by treadmill (VO2max) performance in healthy college men. Neuroscience Letters 519:78–83. Choi PY, Salmon P. 1995. Symptom changes across the menstrual cycle in competitive sportswomen, exercisers and sedentary women. British Journal of Clinical Psychology 34:447–460. Coad J, Conlon C. 2011. Iron deficiency in women: assessment, causes and consequences. Current Opinion in Clinical Nutrition and Metabolic Care 14:625–634. Córdova A, Sureda A, Tur JA, Pons A. 2010. Immune response to exercise in elite sportsmen during the competitive season. Journal of Physiology and Biochemistry 66:1–6.
Cunningham J, Yonkers KA, O’Brien S, Eriksson E. 2009. Update on research and treatment of premenstrual dysphoric disorder. Harvard Review of Psychiatry 17:120–137. Farage MA, Neill S, MacLean AB. 2009. Physiological changes associated with the menstrual cycle: a review. Obstetrical and Gynecological Survey 64:58–72. Ghanbarid Z, Haghollahid F, Shariata M, Foroshanib AR, Ashrafic M. 2009. Effects of calcium supplement therapy in women with premenstrual syndrome. Taiwanese Journal of Obstetrics and Gynecology 48:124–129. Golub L, Menduke H, Lang WR. 1968. Exercise and dysmenorrhea in young teenagers: a 3-year study. Obstetrics and Gynecology 32:508–511. Hawkins WW, Speck E, Leonard VG. 1954. Variation of the haemoglobin level with age and sex. Blood 9:999–1007. Inoue Y, Terao T, Iwata N, Okamoto K, Kojima H, Okamoto T et al. 2007. Fluctuating serotonergic function in premenstrual dysphoric disorder and premenstrual syndrome: findings from neuroendocrine challenge tests. Psychopharmacology (Berlin) 190:213–219. Israel RG, Sutton M, O’Brien KF. 1985. Effects of aerobic training on primary dysmenorrhea symptomatology in college females. Journal of American College Health 33:241–244. Itsekson AM, Soriano D, Zolti M, Seidman DS, Carp HJ. 2013. Intradermal sex hormone desensitization for relief of premenstrual symptoms may improve the obstetric outcome of women with recurrent pregnancy loss. Gynecological Endocrinology 29:169–172. Kol S, Itskovitz-Eldor J. 2010. Gonadotropin-releasing hormone agonist trigger: the way to eliminate ovarian hyperstimulation syndrome – a 20-year experience. Seminars in Reproductive Medicine 28:500–505. Kossman DA, Williams NI, Domchek SM, Kurzer MS, Stopfer JE, Schmitz KH. 2011. Exercise lowers estrogen and progesterone levels in premenopausal women at high risk of breast cancer. Journal of Applied Physiology 111:1687–1693. Lin IM, Tsai YC, Peper E, Yen CF. 2013. Depressive mood and frontal alpha asymmetry during the luteal phase in premenstrual dysphoric disorder. Journal of Obstetrics and Gynaecology Research 39:998–1006. Peters F. 1992. Multicentre study of gestrinone in cyclical breast pain. Lancet 339:205–208. Prior JC, Vigna Y, Alojada N. 1986. Conditioning exercise decreases premenstrual symptoms. A prospective controlled three month trial. European Journal of Applied Physiology and Occupational Physiology 55:349–355. Prior JC, Vigna Y, Sciarretta D, Alojado N, Schulzer M. 1987. Conditioning exercise decreases premenstrual symptoms: a prospective, controlled 6-month trial. Fertility and Sterility 47:402–408. Prizzorno JR, Murray MT. 1999. Textbook of natural medicine. New York: Churchill Livingstone. p. 330–331. Rapkin A. 2003. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology 28:39–53. Rapkin AJ, Mikacich JA. 2006. Premenstrual syndrome in adolescents: diagnosis and treatment. Pediatric Endocrinology Reviews 3:132–137. Redei E, Freeman EW. 1995. Daily plasma oestradiol and progesterone levels over the menstrual cycle and their relation to premenstrual symptoms. Psychoneuroendocrinology 20:259–267. Rizk DE, Mosallam M, Alyan S, Nagelkerke N. 2006. Prevalence and impact of premenstrual syndrome in adolescent schoolgirls in the United Arab Emirates. Acta Obstetricia et Gynecologica Scandinavica 85:589–598. Samadi Z, Taghian F, Valiani M. 2013. The effects of 8 weeks of regular aerobic exercise on the symptoms of premenstrual syndrome in non-athlete girls. Iranian Journal of Nursing and Midwifery Research 18:14–19. Steege JF, Blumenthal JA. 1993. The effects of aerobic exercise on premenstrual symptoms in middle-aged women: a preliminary study. Journal of Psychosomatic Research 37:127–133. Stephenson LA, Kolka MA, Francesconi R, Gonzalez RR. 1989. Circadian variations in plasma renin activity, catecholamines and aldosterone during exercise in women. European Journal of Applied Physiology and Occupational Physiology 58:756–764. Vellar OD. 1974. Changes in haemoglobin concentration and haematocrit during the menstrual cycle: A Cross-sectional Study. Acta Obstetricia et Gynecologica Scandinavica 53:243–246. Vichnin M, Freeman EW, Lin H, Hillman J, Bui S. 2006. Premenstrual syndrome (PMS) in adolescents: severity and impairment. Journal of Pediatric and Adolescent Gynecology 19:397–402. Xiong R, Ren X, Wang G, Chen G, Yang H, Yuan Q et al. 2012. High intensity training induces alteration of the ubiquitin-proteasome system gene expression profile and structural changes in the ovaries. Molecular Medicine Reports 5:1352–1356.
Effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women A. El-Lithy1, A. El-Mazny1, A. Sabbour2 & A. El-Deeb2
J Obstet Gynaecol Downloaded from informahealthcare.com by The University of Manchester on 10/12/14 For personal use only.
Departments of 1Obstetrics and Gynecology, Faculty of Medicine and 2Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Egypt
The objective of this study was to investigate the effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women. A total of 30 participants aged 16–20 years and complaining of premenstrual syndrome (PMS) were randomly assigned into two groups: a control group received vitamin B6 and Ca supplements once daily and a study group received the same medical treatment and participated in treadmill training three times per week for 3 months. A premenstrual syndrome questionnaire (MSQ), complete blood picture and hormone assays were performed for the assessment of all participants at the start and after the end of the treatment course. The study group showed a significant decrease in all post-treatment subscale symptoms, scores and total score. Haemoglobin, haematocrit, red cell count and platelet count were significantly increased, while mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), mean corpuscular haemoglobin concentration (MCHC) and white blood cell count showed no significant differences. There was also a significant decrease in prolactin, oestradiol and progesterone levels. In conclusion, aerobic exercise increases haemoglobin, haematocrit, red cell count and platelet count, and decreases levels of prolactin, oestradiol and progesterone, resulting in improvement of fatigue, impaired concentration, confusion and most premenstrual symptoms. Keywords: Aerobic exercise, haematocrit, haemoglobin concentration, premenstrual syndrome, prolactin, steroid hormones
Introduction The menstrual cycle is a repetitive phenomenon occurring during the reproductive life of a woman that involves a patterned sequence of structural, functional and hormonal changes in the reproductive system (Farage et al. 2009). It involves complex interactions of the hypothalamus, pituitary, ovaries, uterus, prostaglandins and neuroendocrine factors (Lin et al. 2013). The cyclical process is regulated by complex changes in the concentrations of five hormones: gonadotropin-releasing hormone (GnRh); follicle stimulating hormone (FSH); luteinising hormone (LH); oestradiol (E2); and progesterone (P4). The interplay of these hormones is extremely complicated; the ovarian steroid hormones exert both negative and positive feedback effects on hypothalamic pituitary unit to influence its hormone secretion. Oestradiol produces positive feedback on LH release leading to LH surge around day 14 of the cycle. Ovulation occurs
approximately 12 h after the LH surge and P4 is secreted from the corpus luteum during the luteal phase with a peak around 8 days after LH surge (Kol and Itskovitz-Eldor 2010). Repeated cyclical haemorrhages and variations in the E2 and P4 levels in the blood during menstrual cycle may affect the blood plasma volume (Stephenson et al. 1989). There is a pronounced tendency towards an increase of haemoglobin, together with haematocrit from the early menstrual phase until the post-ovulatory period, with a subsequent decrease towards the end of the cycle (Vellar 1974). This may suspect the woman at her reproductive age to blood disorders, such as anaemia and iron deficiency, which can have negative consequences on the women, especially for neurocognitive outcomes (Coad and Conlon 2011). Abnormal fluctuations in the circulating sex hormones (E2 and P4) during the menstrual cycle may also be associated with some physical and emotional symptoms (Redei and Freeman 1995; Inoue et al. 2007; Itsekson et al. 2013). Breast tenderness, bloating, weight gain, headache, swelling of the hands or feet and pains are the main physical symptoms, while depression, angry outbursts, irritability, crying spells, anxiety, confusion, social withdrawal, poor concentration, sleep disturbance, thirst and appetite changes are common psycho-emotional and behavioural symptoms (Rapkin 2003). The cyclic recurrence of a combination of these symptoms during the luteal phase of the menstrual cycle is referred to as premenstrual syndrome (PMS) (Braverman 2007). At least, 20% of adolescents may experience moderate-tosevere premenstrual symptoms (Rapkin and Mikacich 2006). Emerging of these symptoms during the teen years complicates the process of puberty and affects social, emotional wellbeing and educational performance in a negative way, resulting in a poor self-steam, a sense of dissatisfaction and inadequacy (Rizk et al. 2006). Several studies had been conducted to show the effect of exercise on premenstrual symptoms using questionnaires (Prior et al. 1986; Prior et al. 1987; Steege and Blumenthal 1993; Aganoff and Boyle 1994; Choi and Salmon 1995; Samadi et al. 2013). To the best of our knowledge, no longitudinal studies have been conducted to investigate the effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women with PMS.
Methods A total of 30 young women aged 16–20 years and diagnosed with PMS (Rapkin 2003; Braverman 2007) were recruited from the
Correspondence: Akmal El-Mazny, Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt. E-mail: dr_akmalelmazny@ yahoo.com
J Obstet Gynaecol Downloaded from informahealthcare.com by The University of Manchester on 10/12/14 For personal use only.
2 A. El-Lithy et al. Outpatient Gynecology Clinic of the Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University. The study protocol was approved by the Scientific Research Committee. Both participants, and parents of the participants 18 years, assigned written consent before starting this study and they were informed about the aims and procedures of the study. All participants experienced a regular menstrual cycle. Young women with a history of endometriosis, pelvic inflammatory diseases, any pelvic pathology, and diabetes or thyroid diseases were excluded from this study. All women did not use oral contraceptive pills or any psychotropic agents and they did not engage in any previous regular exercise programme. A full history of each participant, including age, height, weight, age at menarche and length of the menstrual cycles, was recorded. Pelvic ultrasonography was performed for each participant to exclude any pelvic pathology. Participants were randomly allocated into two equal groups, using computer-generated random numbers. The study group received medical treatment in the form of vitamin B6 (50 mg/ day) and Ca (1,200 mg/day) supplements, and were engaged in a programme of aerobic exercise for 3 months. The control group received the same medical treatment, and were instructed to avoid and report any major changes in lifestyle. A ‘modified’ Premenstrual Syndrome Questionnaire (MSQ) (Prizzorno and Murray 1999) was given to each participant at two consecutive months before starting the study to confirm the diagnosis of PMS. MSQ consists of 26 symptoms, which are categorised into subscales: •• •• •• ••
PMT-A, anxiety (behavioural changes) PMT-H, hyperhydration symptoms PMT-C, craving manifestations PMT-D, characterising depression and subscale of other symptoms.
The MSQ also measured the occurrence and severity of two menstrual pain symptoms, including cramp and backache experienced during the first 2 days of the women’ last menstrual period. Premenstrual symptoms were scaled as: mild (1); moderate (2); and severe (3). Young women with PMS should experience a premenstrual symptoms score of at least 50% greater than the postmenstrual score and rate moderate to severe impairment in one or more subscale (Vichnin et al. 2006). Also, this MSQ was filled before and after 3 months of the study course to evaluate the effect of the treatment programme. A 10 ml blood sample was taken from the antecubital vein with suitable vacutainers, with EDTA as anticoagulant. The basal venous blood samples were obtained from all the participants in the morning between 09.00 and 11.00 hours, after
Table I. Baseline characteristics of the control and study groups. Baseline characteristics
Control group (n 15)
Study group (n 15)
Age (year) BMI (kg/m2) Age at menarche (year) Menstrual length (days)
18.14 1.51 22.67 2.34 11.93 0.82 27.93 2.73
17.80 1.47 22.93 1.98 11.77 1.29 28.13 2.44
Data represented as mean SD.
12 h of overnight fasting. Three ml of each blood sample was analysed to obtain the complete blood picture: haemoglobin; red cell count; haematocrit; mean corpuscular volume (MCV); mean corpuscular haemoglobin (MCH); mean corpuscular haemoglobin concentration (MCHC); white cell count and platelet count were analysed using the UniCel DxH 800 Cellular Analysis System (Beckman Coulter, USA). Of the blood sample, 7 ml was allowed to clot and was centrifuged at 1,000 r.p.m. for 10 min to achieve separation. The serum obtained was put into aliquots in each case, labelled and stored at 220°C. The samples were analysed for hormone estimation using electrochemiluminescence immunoassay (ECLIA) (Bryant et al. 2009) on a Roche cobas e 602 immunoassay analyser (Roche, Germany). Samples from all participants were run in the same assay to reduce any variance from interassay variability. These samples were taken in the luteal phase of the menstrual cycle at day 20 of each participant before and after the treatment course. Before starting the treatment programme, each subject in the study group was informed about the benefits of the aerobic exercise to gain her motivation and cooperation during the treatment course. The women were advised to drink plenty of fluid before and after the exercise session and wear supportive, well-fitting running or walking shoes. Treadmill protocol was modified from the method used by Allor et al. (2000). The treadmill exercise programme was started with warm-up period, in which each participant walked at 80 m/min at 0.0% grade for 5 min. After the walk, the treadmill speed was increased to 147 m/min and the grade was increased gradually until it reached 25%, for 20 min. This was followed by a cool-down period, in which the treadmill speed and grade were decreased to 2.0 m.p.h. and 0.0% grade, during the cool-down period. The participants continued the treadmill exercise programme 3 days per week for 3 months. Data were represented as mean and standard deviation ( SD). Wilcoxon matched pairs and Mann–Whitney tests were used to compare within and between groups for non-parametric data, while a paired t-test and independent t-test were used to compare within and between groups for parametric data. A p value of 0.05 was considered significant. With a margin of
Table II. Comparison of PMS subscale scores and total scores at baseline and after 3 months of treatment for both groups. Control group (n 15) Symptoms Anxiety symptoms Craving symptoms Depression symptoms Hyperhydration symptoms Menstrual cramps Menstrual backache Total score
Study group (n 15)
Baseline
After 3 months
Baseline
After 3 months
8.66 2.84 6.93 1.33 9.46 2.79 9.00 1.41 2.80 0.41 2.80 0.41 52.13 7.92
9.00 2.59 6.26 1.16* 9.20 2.33 9.26 1.27 2.80 0.41 2.86 0.35 51.53 7.34
9.13 2.09 7.60 1.99 9.53 2.41 9.60 1.24 2.73 0.59 2.60 0.63 54.26 7.05
5.40 1.29** 6.13 1.30** 6.00 1.30** 6.13 1.12** 1.46 0.51** 1.60 0.50** 37.00 6.52***
Data represented as mean SD. *p 0.05; **p 0.01; ***p 0.001, as compared with baseline.
Effect of aerobic exercise on premenstrual symptoms 3 Table III. Comparison of haematological parameters at baseline and after 3 months of treatment for both groups. Haematological parameters Haemoglobin (g/dl) Red cell count (106/mm3) Haematocrit (vol%) MCV(fl) MCH (pg) MCHC (%) Platelet count (103/mm3)
Control group (n 15)
Study group (n 15)
Baseline
After 3 months
Baseline
After 3 months
12.01 0.49 4.13 0.34 37.29 1.94 84.40 2.89 29.33 1.39 32.40 2.16 217.30 53.57
12.02 0.44 4.24 0.46 38.07 1.66 83.73 2.55 29.40 1.29 32.87 2.10 230.70 58.27
12.15 0.72 4.19 0.30 37.82 3.63 86.13 4.58 29.67 1.91 33.93 1.10 228.90 43.91
12.40 0.48* 4.40 0.36* 38.61 3.28*
85.60 2.23 30.07 1.16 33.47 1.68 252.90 51.14*
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Data represented as mean SD. *p 0.05, as compared with baseline.
error of 4.99% and a response distribution of 50%, the confidence level was 52%, whereas with a margin of error of 9.92% and a response distribution of 50%, the confidence level was 84%.
Results As shown in Table I, there were no significant differences in baseline characteristics, including age, body mass index (BMI), menarche age and menstrual length between the control and study groups (p 0.05). After 3 months of treatment, the study group showed significant post-test decreases in anxiety (behaviour) score (p 0.001); craving symptoms score (p 0.002); depression score (p 0.001); hyperhydration symptoms score (p 0.001); menstrual cramps (p 0.001); backache (p 0.002); and total score (p 0.001). For the control group, there was a significant decrease in the craving symptoms score (p 0.02) and no significant differences in the other subscale scores: menstrual cramp, low back pain and total score (p 0.05) (Table II). Also, results showed a highly significant decrease in all post-treatment subscale symptoms scores (p 0.001) (except for craving score; p 0.05) and total score (p 0.001) of the study group when compared with the posttreatment scores of the control group. Results showed that 40% of the participants had a haemoglobin level 12 g/dl, indicating anaemia. After 3 months aerobic exercise, haemoglobin, haematocrit, red cell count and platelet count were significantly increased (p 0.02; p 0.02; p 0.02; p 0.03, respectively), while other parameters MCV, MCH, MCHC and white blood cell count showed no significant differences (p 0.05) (Table III). Only haemoglobin showed a significant difference between the control and study group after treatment (p 0.03). Prolactin level was significantly decreased by 58.92% (p 0.001) and also (E2) and (P4) decreased by 23.9% (p 0.01) and 41.2% (p 0.01), respectively, in the study group (Table IV). Results also, showed a highly significant decrease in post-treatment values of prolactin (p 0.001), P4 (p 0.001) levels, as well as a decreasing trend in (E2) without statistical significance (p 0.05) of the study group when compared with the control group after treatment.
Discussion The objective of this study was to determine the effect of 3 months of treadmill training on premenstrual symptoms, hormones that may be involved in the occurrence of these symptoms and haematological parameters in young women. The results of this study showed that B6 and Ca supplementations produced improvements in some premenstrual symptoms, such as appetite change, headache, fatigue, dizziness and palpitation. This was in agreement with Ghanbarid et al. (2009) who reported that Ca supplements showed decreased fatigability, changes in appetite and depression in women with PMS. However, these supplements did not show any change in hormone levels and haematological parameters in the control group. Exercise can significantly lower almost all premenstrual symptoms in young women. It improves anxiety and depressionrelated symptoms, carbohydrate craving symptoms and electrolyte change symptoms. This finding was consistent with the results of observational cross-sectional studies, which reported that regular exercisers had significantly lower scores on impaired concentration, negative effect, behaviour changes and pain (Aganoff and Boyle 1994), and may be protected from deterioration of mood before and during menstruation (Choi and Salmon 1995). It is also in-line with longitudinal studies, which reported reduction in premenstrual symptoms after 3 (Prior et al. 1986) and 6 (Prior et al. 1987) months of a running training programme. In addition, exercise showed a reduction in menstrual cramps and low back pain associated with the first 2 days of the menstrual period. This was in agreement with many studies, which have reported the beneficial effect of exercise on dysmenorrhea (Golub et al. 1968; Israel et al. 1985; Samadi et al. 2013). In the present study, 40% of participants had a haemoglobin level 12 g/dl, indicating that young women with PMS are at greater risk of anaemia. Low haemoglobin may be responsible for some symptoms associated with PMS, such as fatigue, dizziness, impaired concentration and confusion that may affect educational performance of the young women (Hawkins et al. 1954). Aerobic exercise showed significant improvement in haemoglobin, haematocrit, red blood cells count and platelet
Table IV. Comparison of hormonal parameters at baseline and after 3 months of treatment for both groups. Control group (n 15) Hormonal parameters
Baseline
Prolactin (ng/ml) Oestradiol (pg/dl) Progesterone (ng/ml)
29.21 15.76 107.30 39.49 10.52 5.22
After 3 months 28.73 14.00 108.70 39.22 11.10 5.03
Data represented as mean SD. *p 0.05; **p 0.01, as compared with baseline.
Study group (n 15) Baseline
After 3 months
30.60 18.98 123.10 39.85 9.73 5.57
12.57 4.27** 99.33 36.33* 5.65 2.44*
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4 A. El-Lithy et al. count, leading to reduction of the previous symptoms. These findings were consistent with Córdova et al. (2010), who found the maximal incremental exercise test significantly increased erythrocytes, haematocrit and blood haemoglobin levels in volleyball players, and Cho et al. (2012) who reported increased platelet counts in response to the acute effect of treadmill exercise in college male students. Some women with PMS have higher prolactin levels or may be abnormally sensitive to a normal amount of prolactin (Cho et al. 2012). In the present study, the prolactin level was significantly reduced in the exercising young women, which may lead to relief of the physical symptoms, such as breast tenderness. This was in consistent with the study which reported that prolactin-lowering agents can effectively treat premenstrual mastalgia (Peters 1992). The hypothesis of involvement of gonadal steroids in the pathophysiology of PMS is supported by the findings that symptoms are not present during non-ovulatory cycles and disappear with ovariectomy (Cunningham et al. 2009). From this hypothesis, it may be suggested that reduction in the levels of oestradiol and progesterone in response to exercise may be associated with the recovery of some premenstrual symptoms. This was consistent with Kossman et al. (2011) who reported that aerobic exercise produced reduction in both oestradiol and progesterone in premenopausal women at high risk of breast cancer. Also, a recent study on rats reported a decrease in oestradiol and progesterone in response to high intensity exercise training (Xiong et al. 2012). In conclusion, young women with PMS are at greater risk of anaemia and thus, a regular haemoglobin test is recommended for that population. Aerobic exercise has a very beneficial effect physiologically and psychologically for young women, as it relieves premenstrual symptoms, decreases prolactin, oestradiol and progesterone involved in pathophysiology of PMS and improves haemoglobin, haematocrit and red blood cell count, resulting in improvement of social, emotional wellbeing and educational performance. However, due to our relatively small sample size, further longitudinal studies are needed to confirm our findings. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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