Effect of Yoga on Premenstrual Syndrome: A Systematic Review

1. Research Scholar, Faculty of Liberal Arts and Yogananda School of Spirituality and Happiness, Shoolini University, Bajhol, Solan, Himachal Pradesh, India. 2. Guide/Director, Faculty of Liberal Arts and Yogananda School of Spirituality and Happiness, Shoolini University, Bajhol, Solan, Himachal Pradesh, India.

Abstract

Introduction: Yoga takes an approach that addresses the mental and spiritual aspects, making it a powerful tool for treating medical conditions that often do not respond well to traditional methods. Researchers have a growing interest in studying the effects of yoga on chronic health issues and mental wellbeing.

Aim: To investigate and summarise the impact of yoga on premenstrual syndrome.

Materials and Methods: For this systematic review, international databases (Google Scholar, PubMed, EBSCOhost, and ScienceDirect) were systematically searched from the inception of the databases until January 31, 2024. The keywords “premenstrual syndrome” and “yoga” were employed, and “Medical Subject Headings” (MeSH) were utilised for these keywords. Two researchers independently screened articles, and consensus for inclusion was achieved through mutual discussions. All studies assessing the effect of yoga on premenstrual syndrome were extracted from the selected studies without restricting to the form or type of yogic intervention.

Results: A total of 35 studies on the subject were scrutinised, and 12 publications meeting the inclusion and exclusion criteria were incorporated in the study for evaluation. All studies indicated that yoga is effective in reducing at least one or some of the physical symptoms, such as bloating, pain, fatigue, breast tenderness, appetite changes, and psychological changes like irritability, stress, anxiety, depression, loss of interest, attention, control, and arousal during premenstrual syndrome. There is a lack of clarity regarding the effect of yoga on many other symptoms of premenstrual syndrome.

Conclusion: Yoga interventions demonstrate effectiveness in alleviating premenstrual symptoms in women with premenstrual syndrome.

Alternative therapies, Complementary therapies, Menstruation disorder, Premenstrual dysphoric disorder, Premenstrual tension

Premenstrual syndrome is a combination of psychological, physiological, and behavioural symptoms experienced by women of reproductive age during the late luteal phase of their menstrual cycle, which resolve completely after menstruation (1). The worldwide prevalence of premenstrual syndrome among women is 47.8% (2), with 28.61% reporting interference in daily life activities due to premenstrual syndrome during each cycle (3). The reported symptoms of premenstrual syndrome number around 300 (4), encompassing common behavioural, physical, and psychological symptoms such as insomnia, fatigue, dizziness, changes in appetite and libido, anger, irritability, anxiety, mood swings, tension, confusion, lack of concentration, forgetfulness, low self-esteem, headache, backache, abdominal pain, breast swelling and tenderness, weight gain, water retention, muscle, and joint pain (5). Medicinal and non medicinal treatments are widely used to alleviate premenstrual syndrome symptoms. Given the absence of a recognised treatment to date, many women seek therapeutic approaches beyond medicine (6). Various alternative and complementary techniques utilised by women for relieving premenstrual syndrome symptoms include acupuncture, the use of herbs and oil, nutritional supplements, dietary manipulation, and Mind-Body Therapies (MBTs), which encompass psychotherapy, hypnotherapy, bodywork, relaxation techniques, biofeedback, guided imagery, and yoga (7),(8). Exercise and stress-relieving techniques are considered cost-effective for treating mild premenstrual syndrome symptoms (9). Yoga, with its comprehensive approach to wellness, incorporates physical poses, movements, breathwork, relaxation, mindfulness, and meditation (10). Yoga exercise increases Alpha brain waves and decreases serum cortisol, promoting a peaceful and relaxed mental state in women suffering from premenstrual syndrome (11),(12). It enhances the quality of life and reduces premenstrual symptoms, making it a recommended approach (13). Despite numerous studies examining complementary and alternative therapies for relieving premenstrual symptoms, few directly investigate the effect of yoga on premenstrual syndrome. To address this gap, this review systematically studies freely accessible, full text literature on the impact of yoga on premenstrual syndrome.

Material and Methods

Search strategy: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (14) were utilised for this systematic review. The electronic databases were thoroughly searched from the inception of the databases to January 31, 2024. These databases included EBSCOhost, PubMed, Google Scholar, and ScienceDirect. The keywords used were “premenstrual syndrome” and “yoga”. Additionally, studies from the Google Scholar search under ‘Related Articles’ were screened and included if they met the inclusion criteria. Further details regarding the search strategies used for each database are as follows:

• EBSCOHost: “premenstrual syndrome” AND “yoga” (Title)
• Google Scholar: “premenstrual syndrome” AND “yoga” (all in title)
• PubMed: “premenstrual syndrome” (Title/Abstract) AND “yoga” (Title)
• ScienceDirect: “premenstrual syndrome” (Title/Abstract) AND “yoga” (Title)\

Inclusion criteria: All open access, clinical trials, quasi-experimental, cross-sectional, and comparative studies that investigated the impact of yoga on premenstrual syndrome. The target population comprised women of menstrual age experiencing premenstrual syndromes. All potentially relevant, free access, full text papers were assessed to determine if they met the inclusion criteria.

Exclusion criteria: Review articles, non English publications, non full text articles, case histories, and those requiring paid access were excluded from the study. The intervention of interest was yoga, and the outcome of interest was premenstrual syndrome (Table/Fig 1).

As no primary data was collected, ethical approval was not required for this study. The flowchart below represents the study selection process (Table/Fig 2).

Quality and risk of bias assessment: The authors assessed the quality and risk of bias for each study included in the review using a modified version of the Downs SH and Black N Checklist (15).

Selection of eligible studies: The research included in the systematic review was conducted from the inception of the databases to January 2024. There was no limitation in terms of the years covered while reviewing the literature. The full text of the research, which were published in English and had free/open access, were included in the study. All studies were included without limitation of the type/form of yoga and symptom type. The titles of full articles were reviewed against the inclusion and exclusion criteria; any uncertainty regarding the eligibility of the study was resolved through discussion among the first and second authors.

Results

Study selection: A total of 26 articles were retrieved from the databases: 10 from Google Scholar, nine from PubMed, four from ScienceDirect, and three from EBSCOHost. Out of the 19 non duplicated studies, full articles of 10 studies were unavailable, and one study was found to be a qualitative review, while one was a literature review. The remaining seven were accessed for full articles. Nine unduplicated articles were shortlisted from the ‘Related articles’ search in Google Scholar, which matched the inclusion/exclusion criteria for selection and were accessed for full articles. One study was a case study and was, therefore, excluded. Two studies were related to yoga but did not have ‘yoga’ in the title and were, therefore, excluded. One study did not have ‘syndrome’ in the title and hence was excluded (Table/Fig 2).

Study characteristics: A total of 703 women were part of 12 studies included in this research. (Table/Fig 3) represents the findings in terms of authors, research purpose, sample, measurement tools used, type and duration of yoga intervention, and the type of research (11),(16),(17),(18),(19),(20),(21),(22),(23),(24),(25),(26).

Types of yoga intervention and procedures: A well-defined yoga protocol/intervention was applied in seven studies (11),(16),(19),(20),(21),(25), and one study used a Digital Video Disc (DVD) for the application of the intervention (26).

The yoga protocol was evaluated for four weeks in two studies (20),(23), six weeks in one study (11), 10 weeks in five studies (18),(19),(21),(22),(25), and 12 weeks in three studies (16),(17),(26). In one study, the duration was not specified (24). The repetition of the yoga intervention each week varied: every day in one study (25), six times in one study (19), five times in one study (17), three times in five studies [18,20-22,26], and two times in three studies (11),(16),(23). In one study (24), it was not clear or specified. The duration of each intervention session varied between 30 minutes in one study (26), 40 minutes in another study (20), 45 minutes in three studies (19),(23),(25), 50 minutes in two studies (11),(16), and 60 minutes in four studies (17),(18),(19),(22).

Effect of yoga on premenstrual syndrome: For the purpose of this review, the premenstrual symptoms encountered in 12 studies have been grouped into two categories: Psychological (including emotional) and Physical (including physiological) Symptoms. (Table/Fig 4) summarises the effect of yoga on the Psychological (including Emotional) symptoms of premenstrual syndrome. (Table/Fig 5) shows the relationship between yoga and physical (including physiological) symptoms of yoga.

The 12 studies included in this systematic review investigate the effect of yoga/yoga intervention, commonly comprising yogic practices like Sookshvyayama, Asanas, Pranayama, Meditation, and Shavasana, on common symptoms as well as premenstrual syndrome as a whole.

Yoga was found to have a positive effect on physical symptoms (n=2) (17),(20), physical functions (n=1) (16), and autonomic responses (n=2) (22),(25) without separate evaluation in these studies. Yoga was found to be effective in improving physical symptoms like abdominal swelling/bloating (n=3) (16),(19),(25), breast tenderness (n=1) (16), fatigue (n=1) (26), cold sweats (n=1) (16), weight gain (n=1) (16), pain (n=5) (16),(19),(20),(24),(25), overeating/food cravings (n=2) (18),(26), and pulse rate (n=1) (17). In one study by Tsai SY (n=1) (16), yoga was found to be ineffective on the following physical symptoms: muscle stiffness, dizziness, backache, headache, skin allergies, nausea/vomiting, diarrhea, constipation, weight loss, and fatigue.

Yoga has been found to have a positive effect on improving psychological symptoms like irritability/anger (n=2) (18),(26), depression/hopelessness (n=3) (18),(22),(26), crying/sensitivity (n=2) (18),(26), tension/stress/anxiety (n=3) (7),(22),(23), loss of interest (n=2) (18),(26), concentration/attention (n=5) (11),(18),(19),(25),(26), arousal (n=1) (25), control (n=2) (19),(26), sleep problem (n=2) (18),(21), quality of sleep (n=2) (21),(23).

Positive effects of yoga on negative effects (n=2) [19,25], mental health (n=1) (16), and behavioural changes (n=2) (19),(25) of premenstrual syndrome were observed when symptoms were not evaluated separately. Yoga positively affected the impaired personal, social, and workplace functioning in a study (n=1) (26), whereas in another study (n=1) (16), yoga was found ineffective on the following symptoms of premenstrual syndrome: irritability/anger, depression/hopelessness, crying/sensitivity, tension/stress/anxiety, and emotional stability.

Discussion

A total of 12 studies were reviewed, which included 703 women. The studies evaluated the effect of yoga on premenstrual syndrome. The results of this review indicate that yoga is effective in relieving premenstrual symptoms in women. Even the two comparative studies included in this systematic review concluded that yoga is more effective than administering oral calcium (17) or doing aerobic exercises (20). Although yoga is effective in improving many physical and psychological symptoms, its efficacy on all premenstrual symptoms is not proven. The yoga modules used as an intervention by each researcher were different in all eight studies (11),(16),(19),(20),(21),(25),(26); therefore, it is difficult to conclude which module is best suited for premenstrual syndrome. Not all studies have mentioned the type of yoga or module incorporated in their research; hence, it cannot be concluded which form or module of yoga practice works better in dealing with premenstrual syndrome. Duration and repetitions of yoga intervention also differed in these studies, but all 12 studies have reported success in improving at least one or more symptoms of PMS. No results of research included in this review reported to have completely failed in improving the symptoms of premenstrual syndrome.

Health-related quality of life is negatively affected due to the prevalence of physical premenstrual symptoms (abdominal swelling, fatigue, backache, and abdominal cramps), resulting in decreased occupational productivity. Relief from premenstrual pain (24) has been reported in the literature, which resulted in the enhancement of most dimensions of the Short Form 36-Item (SF), such as physical functions, bodily pain, general health perception, vitality/energy, social function, and mental health (16). Yoga provides a moderate degree of exercise or toning to the body and can be adopted as a healthy lifestyle adjunct. Physical distress can cause absenteeism from college in young girls. The wellbeing of female students by encouraging them to engage in yoga can improve their work efficiency (17). Slowly stretched muscles decrease muscle pain during premenstrual syndrome, and yoga strengthens these muscles and increases their flexibility (18).

The literature mentions the regulation of Leptin during the menstrual cycle, which increases during premenstrual syndrome and is responsible for controlling emotional behaviour. High levels of Leptin in circulation are associated with the psychological symptoms of premenstrual syndrome. Exercise is known to reduce blood Leptin levels. Physical exercises and yoga movements have many similarities and differences. In most outcomes, yoga movements are equal or superior to physical exercises. Yoga exercise was reported to be better than aerobic exercise in relieving PMS symptoms (20).

Practicing yoga has a significant beneficial effect on the quality of sleep (21),(23). The hormones affecting sleep include Serotonin, norepinephrine, L-tryptophan, and acetylcholine. A drop in estrogenic levels during the luteal phase decreases serotonin levels, affecting the quality of sleep during premenstrual syndrome (23). A woman’s body tolerates hormonal fluctuations during the menstrual cycle, which results in physical, emotional, and behavioural symptoms. Levels of Gamma-aminobutyric Acid (GABA) play a critical role in managing anxiety, and yoga increases the level of GABA, respective factors, which are aggression and anxiety (22),(23). Yoga was found to improve anxiety scores negatively with no effect on vital signs (22).

Limitation(s)

The studies included in this review had heterogeneous study designs and yoga intervention characteristics, such as the type and form of yoga and duration. Due to these differences, the findings from these studies might be biased. While every effort was made to obtain all relevant data, the authors were unable to access articles that were not in English, whose full text was not available, or were not free to access. Therefore, the possibility of publication bias cannot be excluded.

Conclusion

Regardless of the differences in the intervention plan, yoga can be considered effective in improving physical and psychological symptoms. Further studies are required to investigate the effects of yoga on women suffering from premenstrual syndrome, given the limited number of articles in this area. Evaluating premenstrual symptoms separately using appropriate tools will lead to more accurate and specific outcomes. Additionally, it is recommended that further studies be conducted to evaluate the impact of different forms of yoga on PMS. Standardisation of yoga protocols related to specific symptoms and severity of premenstrual symptoms is suggested so that they can be easily prescribed to women.

Acknowledgement

The authors are grateful to Dr. Hina Sharma, Clinical Professor, Pacific Medical College and Hospital, Udaipur, Rajasthan, for all her help and assistance in doing this research.

DOI and Others

DOI: 10.7860/JCDR/2024/69959.19375

Date of Submission: Feb 08, 2024
Date of Peer Review: Mar 02, 2024
Date of Acceptance: Apr 02, 2024
Date of Publishing: May 01, 2024

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS: [Jain H et al.]
• Plagiarism X-checker: Feb 08, 2024
• Manual Googling: Mar 28, 2024
• iThenticate Software: Mar 20, 2024 (11%)

ETYMOLOGY: Author Origin

EMENDATIONS: 6