Mahitab M. Yosri, Hamada A. Hamada, Amel M. Yousef | Year 2022

Effect of visceral manipulation on menstrual complaints in women with polycystic ovarian syndrome


Gynecological and obstetric disorders

Type of study:

Pilot randomized controlled trial

Date of publication of the study’:



Purpose of the study

  • Objective: to evaluate the effects of visceral manipulation on premenstrual and menstrual disorders in women with polycystic ovary syndrome
  • Measured outcomes:
    • Primario: evaluation of menstrual and premenstrual problems through the corresponding items of the Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ).
    • Secondary: body weight and body mass index (BMI) assessment using a weight–height scale..


  • Number: 30 women
  • Criteria of inclusion: women, between 20 and 34 years of age, BMI between 25 and 30, hip-waist ratio 0.8, diagnosis of polycystic ovary syndrome confirmed by the referring gynaecologist, based on Rotterdam PCOS Diagnostic Criteria, irregular menstrual cycles (less than 8 cycles a year or more than 35 days between one cycle and the next), painful menstruation and premenstrual symptoms (abdominal swelling and headache)
  • Criteria of exclusion: presence of cardiovascular diseases, hypertension, diabetes, malignancy, endocrine disorders (eg, hypothyroidism, hyperprolactinemia), abnormalities in the adrenal glands, acute pelvic inflammation, endometrial pathologies (eg, endometriosis), prolapse of the pelvic organs, pelvic masses; use of intrauterine devices; hormonal treatment in the 3 months preceding the study; medical treatment directed to polycystic ovary syndrome; women receiving manipulative treatments at the same time of the study
  • Groups of study: 2 groups obtained by randomization
    • Group 1: low-calorie diet with visceral manipulation, 15 women (mean age 26.2 years)
    • Group 2: low-calorie diet, 15 women (average age 27.5 years)

Interventions and evaluations

  • At the beginning of the study and 3 months after the end of the treatments: evaluation of body weight and BMI using a weight–height scale. and of menstrual and premenstrual problems through the corresponding items of the PCOSQ
  • Evaluation of hirsutism through PCOSQ
  • Collection of data regarding the patients’ menstrual history (frequency, duration, quantity, regularity), pregnancies, medical or hormonal treatments in the last 6 months
  • 8 visceral manipulation sessions over 3 months (1 each week for the first month and 1 every two weeks for the second and third month)
    • the patients have been requested to evacuate the bladder before any treatment
  • Low calorie diet: customized for each participant and designed to reduce the calorie intake by at least 500kcal per day, thus favoring a weight loss of 0.5kg per week
    • the diet was made up by 55% low to medium glycemic index carbohydrates, 15% protein and 30% fat
    • foods banned: high glycemic index carbohydrates, fast-food or foods with high-salt content
    • recommended foods: whole grains, fibrous vegetables, lean meat and low-fat dairy products
    • weekly counseling visits with a dietitian
  • Visceral manipulation: treatment directed to the pelvic organs and related structures, customized on the basis of the evaluation carried out by the practitioner
    • evaluation of mobility and motility of the pelvic organs, in relation to breathing, and following treatment according to the methods described by Hebgen, Barral, Mercier, Lason and Peeters
    • at the beginning of each treatment, muscle decongestion maneuvers to reduce pelvic congestion and improve circulation i case of abnormal tensions or adhesions, stretching of these adhesions by pressure sustained for 6 seconds and repeated until the patient no longer felt the tension
    • in case of abnormal tensions or adhesions, stretching of these adhesions by applying pressure, sustained for 6 seconds and repeated until the patient no longer felt the tension
  • Treatment carried out by a qualified physiotherapist who, for the study, received further training on osteopathic manipulation and nutrition



  • Primary outcomes: In both groups, the clinical condition measured by PCOSQ improved statistically significantly. The group with visceral manipulation, however, showed a markedly greater increase than the group with low-calorie diet alone (1.7 points vs 0.5), thus exceeding the minimal clinically important difference (MCID).
  • Secondary outcomes: with regard to both weight and BMI, both groups showed a statistically significant decrease compared to the study start values. However, there was no difference between the groups, thus indicating that the decrease occurred equally.
  • Further analysis: most of the women in the group with visceral manipulation showed uterine adhesions and restrictions in uterine, ovarian and broad ligament mobility.

Compared to the beginning of the study, both groups experienced a decrease in symptoms considered severe and an increase in symptoms considered mild or rare. These changes were most noticeable in the group with visceral manipulation.

A woman in the group with visceral manipulation who suffered from secondary infertility became pregnant at the end of the study. Nevertheless, she had not followed any specific therapy in the last 3 months and, indeed, had already tried several therapies without any success.

No adverse events were reported.


In both study groups the treated women saw a decrease in weight, BMI, and the severity of menstrual and premenstrual symptoms. However, the group that received visceral manipulation showed a remarkably improved symptomatology of polycystic ovary syndrome, with a result that among other things indicated a great improvement in the quality of life perceived by the patients.

These findings are in line with previous studies that have stressed the importance of a lifestyle-based approach, which should be the primary approach in case of polycystic ovary syndrome – such an approach tends in fact to improve multiple parameters -, and the possible usefulness of OMT, visceral manipulation or connective massage to improve premenstrual and menstrual symptomatology in case of alterations.

Potentially, the results obtained can derive from having acted, through the diet, on the metabolism, in particular on the glycemic and insulin regulation and, through the visceral manipulation, on the improvement of the circulation and organ mobility.

The increased likelihood of becoming pregnant, as happened to a patient treated with visceral manipulation within the study, is also in line with previous studies on the use of OMT for infertility. Potentially, the manual stimulation given to the pelvic organs both favors their better mechanical adaptation during pregnancy, and induces an ovarian “excitement” that helps the normal course of the menstrual cycle.

The detection of many adhesions at the pelvic level was interesting, as polycystic ovary syndrome is not considered capable of causing such alterations. Therefore, their presence indicates other underlying causal factors (eg, chronic pelvic inflammation, caesarean sections, miscarriages) that may predispose to alter both pelvic structure and pelvic function.

Future studies will need to evaluate appropriate follow-ups to see if these results are maintained over time. In addition, evaluating more complex manipulations (such as OMT) or recruiting non-overweight women could lead to better results.

The review of Osteopedia

By Marco Chiera

Strengths: accurate description of methods and materials; calculation of the sample number (how many people to recruit) based on a small pilot study in order to determine the effect size (the extent of the effectiveness of the intervention); interesting the report of the evaluation that a woman became pregnant at the end of the experimental protocol; accurate discussion of the results.

Limits: it could have been specified better how adverse effects were assessed; lack of follow-ups

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