Clinical Epidemiology and Global Health 18 (2022) 101152

Contents lists available at ScienceDirect

Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Effectiveness of Zingiber Officinale(ginger) compared with non-steroidal

anti-inflammatory drugs and complementary therapy in primary
dysmenorrhoea: A systematic review
Ashmita Gurung a, b, Bhushan Khatiwada a, b, Babita Kayastha c, Shradha Parsekar d,
Sabuj Kanti Mistry e, Uday Narayan Yadav a, b, e, f, *
a
Torrens University, Sydney, Australia
b
Centre for Research Policy and Implementation (CRPIN), Biratnagar, Nepal
c
Scheer Memorial Adventist Hospital Medical Institute, Kavre, Nepal
d
Department of Community Medicine, Kasturba Medical College, Manipal, Karnataka, India
e
Centre for Primary Health Care and Equity, UNSW, Sydney, Australia
f
National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Problem considered: The empirical evidence suggested the usage of ginger (zingiber officinale), complementary
Complementary therapy therapies and Non-steroidal anti-inflammatory drugs (NSAIDs) for dysmenorrhoea compared to self-
Dysmenorrhoea administration of NSAIDs alone in alleviating the symptoms of dysmenorrhoea. However, there is a need for
Ginger
strong evidence to compare the effectiveness of ginger to that of complementary therapies like exercise, herbs
Non-steroidal anti-inflammatory drugs
(other than ginger) and NSAIDs. Thus, this systematic review aimed to compare the effectiveness of ginger with
NSAIDs and other complementary therapies and suggests an effective dose of ginger in oral form that can be
taken during dysmenorrhoea.
Methods: A systematic literature search was conducted using electronic databases, namely MEDLINE via PubMed,
Cochrane central, Scopus, CINHAL, EBSCOhost, ProQuest Central, and Google Scholar search engine. The search
terms were combined keywords related to menstrual pain, complementary therapy, NSAIDs, and ginger. Ran­
domized or quasi-randomized controlled trials that included ginger as a comparator to assess the effect on pri­
mary dysmenorrhea were included in this systematic review. Data were extracted, and the findings were
narratively synthesised.
Result: An initial search from the electronic database identified 394 studies, of which eleven studies met the
eligibility criteria, where seven were randomised controlled trials, and four were quasi-experimental studies.
There was no significant difference between ginger and NSAIDs in decreasing pain intensity during menstruation.
Ginger and exercises like muscle relaxation techniques, stretching, and sub-maximal aerobic exercise effectively
reduce pain when combined. Dill seeds (Anethum graveolens, an aromatic herb used for flavouring and medical
purposes) and ginger alone were effective in dysmenorrhoea, but no effect of valerian, peppermint and cumin
(spices) seeds were observed. The effect of ginger was inclusive compared to placebo.
Conclusion: The usage of ginger up to two grams per day in divided doses of powder or dietary form for three days
from the first day of the menstrual cycle can be used safely for primary dysmenorrhoea. Ginger can be combined
with complementary therapies like exercise for increased effectiveness in relieving menstrual pain. The alter­
native therapy can reduce dependency on synthetic drugs for controlling dysmenorrhoea. However, there is a
need to carry out rigorous randomized controlled trials of longer duration to evaluate the effectiveness of ginger
and auxiliary therapies other than ginger in controlling menstrual pain.

* Corresponding author. National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia.
E-mail address: [email protected] (U.N. Yadav).

https://doi.org/10.1016/j.cegh.2022.101152
Received 5 June 2022; Received in revised form 7 September 2022; Accepted 16 September 2022
Available online 18 October 2022
2213-3984/© 2022 The Authors. Published by Elsevier B.V. on behalf of INDIACLEN. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

1. Introduction necrosis factor alpha (TNF alpha).19,32,33Various components of ginger

like Gingerol, Shogaol, Paradol, Zingerones, and Gingerdione have
Menstruation represents a sign of a healthy body in women, which anti-inflammatory pharmacological actions and act as a potent inhibitor
starts after puberty and signifies balance.1 Menarche is the milestone of of cyclooxygenase (COX-2), resulting in the inhibition of prostaglandins
a female adolescent, usually starting from 11 years of age, and it ends at and leukotriene biosynthesis.31,34–37 The ginger component efficiently
menopause, between the late forties and mid-fifties.2,3 During the inhibits the synthesis of inflammatory cytokines at the site of inflam­
menstruation cycle, women may experience pain known as dysmenor­ mation.31,34,35 Thus, it can produce analgesic and anti-inflammatory
rhoea with/without symptoms of abdominal cramps, nausea, fatigue, effects during pain. In addition, the shogalos component of ginger acts
headache, backache, general discomfort and emotional and psycholog­ as an agonist of transient receptors potential cation channel subfamily
ical effects.2 Dysmenorrhoea is derived from the Greek words dys, Vanilliod member 1 (TRPV1), which is responsible for transmitting
meaning painful/difficult/abnormal; meno means month, and rrhea physical and chemical stimuli. Hence, prolonged exposure to shogaols
means flow.4 Dysmenorrhoea is of two types; primary dysmenorrhoea is TRPV1 is desensitized, resulting in relief from pain.19,32,38
the pain of the lower abdomen with spasmodic cramping without Ginger is used for relieving pain from osteoarthritis, rheumatoid
organic disease, which starts before or at the start of menstruation with a arthritis, menstrual pain, migraine, relieving nausea from pregnancy
fixed pattern lasting from eight to 72 hrs. Secondary dysmenorrhoea has and chemotherapy and has a vital role in cardiovascular disease,
no fixed pattern of pain associated with pathological diseases such as metabolic disorder and Diabetes Type II as it has anti-oxidative prop­
pelvic inflammatory diseases, endometriosis, adenomysis, and fi­ erties.19,33,39 Before the scientific evidence supported ginger’s proper­
broids.1,5,6 Dysmenorrhoea can be explained with the help of a scientific ties, ginger has been used as traditional medicinal herbs in Chinese and
theory; it is caused due to disruption in endometrial cells leading to the Asian-Indian for various purposes.19,40 Various studies have compared
release of prostaglandin, F2alpha stimulant. F2alpha stimulates myo­ ginger’s analgesic effectiveness with different doses of ginger with
metrium for contraction and vasoconstriction. When the stimulant is paracetamol, mefenamic acid, and transdermal iron chip and found it to
prolonged, myometrium contraction is protected, further decreasing produce the same analgesic effect as drugs with the rare side-effect for
blood flow and creating hypoxia in cells of the uterus, resulting in pain.7 primary dysmenorrhoea.27,28,41–43 The empirical evidence suggested the
Dysmenorrhea usually lasts 48–72 h of mensuration, experienced usage of ginger and complementary therapies for dysmenorrhoea over
mainly by half of the young women.4,7 Dysmenorrhoea-related factors self-administration of NSAIDs27,28 but the amount of ginger to be taken
are early age of menarche, smoking, low body mass index, duration of during dysmenorrhoea remained unclear.
blood flow, family history, null parity, and stress.4,8–12 There are existing published systematic reviews that reported the
Many studies have shown variation in the prevalence of dysmenor­ effectiveness of ginger in alleviating pain in general and primary dys­
rhoea in different parts of the world, dysmenorrhoea among adolescents menorrhoea. However, the last search dates of the reviews were older
was reported to have a high prevalence (50%–70%).10,13–15 A systematic than six years.19,33,44,45 Additionally, a review by Xu et al. assessed the
review and meta-analysis conducted by including studies across the effectiveness of ginger for primary dysmenorrhoea but combined all the
globe reported a high (71%) prevalence rate of dysmenorrhoea.16 comparators together.46 Therefore, rigorous and up-to-date systematic
Moreover, studies have reflected that dysmenorrhoea not only causes reviews are needed to compare the effectiveness of ginger to that of
physical and emotional distress, but it also affects daily activities and complementary therapies like exercise, herbs (other than ginger) and
quality of life during the menstrual cycle every month. A cross-sectional NSAIDs in alleviating dysmenorrhoea symptoms and decreasing the
study done in Sweden among 600 women of nineteen year olds identi­ intake of over-the-counter drugs to relieve menstrual pain. The purpose
fied that more than fifty per cent of the women were absent from school of this systematic review was to compare the effectiveness of ginger with
or work due to dysmenorrhoea.4 It was reported that 13 to 51% of NSAIDs and other complementary therapies and suggests an effective
women were absent from school or university, negatively impacting dose of ginger in oral form that can be taken during dysmenorrhoea.
their academics or work. About 14% of women with dysmenorrhoea had
severe symptoms, subsequently affecting their quality of life and well­ 2. Materials and methods
being.6,16 There is a direct association between dysmenorrhoea severity,
interference in daily activity, and sleep quality. Women with moderate 2.1. Protocol and registration
to severe dysmenorrhoea had low sleep efficiency and less quality sleep
than women with mild dysmenorrhoea.17 Furthermore, dysmenorrhoea We used the guidelines and criteria set by Preferred Reporting Items
alters emotion and interaction in the social life of women, decreases for Systematic Review and Meta-Analysis (PRISMA) for reporting sys­
appetite, the perception of regret being a woman, and the misconception tematic reviews.47 The proposal was registered with the International
of not having a child in the future.17,18 Prospective Register of Systematic Review (PROSPERO) registration no
To relieve dysmenorrhoea, women use Non-steroidal anti-inflam­ CRD42021227887.
matory drugs (NSAIDs). NSAIDs provide aanalgesic effect by inhibiting
cyclo-oxygenase enzymes (COX-2) and decreasing prostaglandin syn­ 2.2. Inclusion and exclusion criteria
thesis. As a result, it relives pain during menturation.19 There is also a
high chance of NSAIDs failure rate of 20–25% if frequently used for a The studies included in this review had to meet pre-defined Popu­
prolonged time.19Nevertheless, NSAIDs have side effects such as lation, Intervention, Comparison, and Outcome (PICO) study criteria
gastrointestinal disorders, peptic ulcers, and kidney failure, and there is described in Table 1. Due to resource constraints, we restricted the
a risk for cardiac and renal failure on prolonged use. Most women are studies to English peer-reviewed journal publications.
unaware of these side effects and consume NSAIDs without a physician’s
prescription.19–24 2.3. Search strategy and identification of the studies
On the other hand, complementary therapies such as exercise and
herbal medicine, including zingiber officinale (commonly known as A comprehensive search was undertaken in electronic databases such
ginger), are known to relieve pain and symptoms during the menstrual as MEDLINE via PubMed, Cochrane central, Scopus, CINHAL, EBSCO­
cycle.7,25–30 Ginger is an indigenous perennial climbing plant found in host and ProQuest central to identify any potential studies between the
South Asian countries, which is used as a dry or fresh herb.31 Ginger has 01st of January 2010 and March 2022. A search engine, Google scholar,
more than forty components that possess anti-inflammatory actions; it was also searched. The timeframe was decided based on evidence that
inhibits leukoterine synthesis, cyclooxygenase enzymes (COX-1 and the chance of losing primary studies is minimum while performing
COX-2), helps in the production of interlukines (Il-1 and Il-2) and tumor searches from the last twelve years.48 Additionally, the team extensively

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A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

Table 1 assessed against described eligibility criteria. Any confusion that arose
Eligibility criteria. between the researchers while screening the articles was solved through
Population The population were women of reproductive age group (menarche to discussion, and the consensus was reached on the inclusion or exclusion
menopause but less than 50 years) experiencing primary of the study. Discrepancies that could not be solved were discussed with
dysmenorrhoea. Primary dysmenorrhoea is defined as menstrual the senior team member for the final decision. Some studies initially
pain and is not related to any other pathological diseases conditions.
found to be relevant were subsequently excluded with reason. During
The pain during menstrual period before intervention needed to be
described and assessment of dysmenorrhoea after intervention must the screening process, 34 articles were assessed for eligibility. Finally, 11
be included in the study. The studies that included other than human studies with full text met the eligibility criteria for the review as indi­
participants were excluded. The studies that included secondary cated in the PRISMA 2020 flow diagram (Fig. 1).
dysmenorrhoea were excluded from the study.
Study design The experimental studies having at least one interventional and a
control group were included. Randomized control trials and quasi- 3.2. Characteristics of included studies
experimental studies were selected for the review. The included
studies could have either two-arm parallel or three-arm parallel
Of the eleven included studies, seven studies were conducted in
designs. Non randomized trials, observational studies, reviews, and
case studies were excluded. The review excluded systematic reviews,
Iran,30,42,50–54 three studies were conducted in India25,55,56 and one
conference papers, opinions, letters to the editors, newspaper study was conducted in Pakistan.57 Fifty per cent of the studies included
articles, unpublished thesis studies, and studies with only abstracts. were published between 2010 to 2015,25,51–55 and the remaining after
Intervention The intervention was Zingiber officinale (ginger root or ginger) in 2015.30,42,50,56,57 Most of the studies (7/11) were randomised control
oral form administrated to women during menstruation. The
trials (RCTs),30,42,50,51,53,54,56 whilst four studies were
intervention should have provided orally in any form (e.g. dried
powder, fresh juice or capsule) during the start of menstruation at quasi-experimental studies.25,52,55,57 All the eleven studies included fe­
least once a day. The studies that assessed effects of ginger remedies male participants who had their menarch and were suffering from pri­
other than oral forms such as oil or aroma were excluded. Besides, the mary dysmenorrhoea and were studying in high school51 and
articles that studied the effects of a mixture of oral ginger with other
university.25,30,42,50,52–57 A total sample size of eleven included studies
substances to relieve dysmenorrhoea were excluded. However, if the
co-intervention was equally distributed in the control group (ginger),
consisted of 1206 samples in studies ranging from 40 participants52 to
the study was eligible to be included. There was no restriction on the 168 participants.42 All included studies used ginger either in powder,25
dose, frequency and duration of the oral intake of ginger. Ginger dietary55 or capsule form.30,42,50–54,56,57 The dose of ginger ranged from
could be consumed in concentrated juice or diluted. 250 mg to 2 gm in one session of the intake starting from the onset of
Comparison The control group could be placebo, no intervention, NSAID’s,
mensturation till three days. Four studies included exercise25,30,52,55
complementary therapies like massage or exercise techniques and
other herbal/traditional meditation besides ginger. whereas two studies included NSAIDs,42,54 three studies included
Outcome The primary study outcome was the severity of pain in herbs,50,56,57 and two studies included placebo51,53 along with ginger to
dysmenorrhoea. There was no restriction on the outcome measure. see the effect on reliving dysmenorrhoea pain. The characteristics of the
The severity of pain could have been measured through the use of the
included studies are described in Tables 2–5.
Pain Visual Analogue Scale (PVAS), Numerical pain score or either
the Likert scale having various parameters of the severity of pain.
3.3. Quality assessment

searched the reference list of the included studies. The search was per­
The methodological quality assessment of the included studies was
formed using combinations of different keywords related to “menstrual
done using a critical appraisal tool developed by Joanna Briggs Institute
pain”, “primary dysmenorrhoea”, “complementary therapy”, “non-ste­
(JBI) for RCTs and quasi-experimental studies.58,59 The study evidence
roidal anti-inflammatory drugs (NSAIDs)”, and “ginger “with Boolean
had shown this tool as a valid approach for assessing the methodological
operators (“AND” & “OR”). The search strategy and keywords used for
quality of the studies in systematic reviews.60,61 The primary purpose of
searching PubMed are in supplementary file 1. The PubMed search was
the quality analysis was to determine the extent to which the selected
customised to be used for other databases. The retrieved records from
studies had addressed the probability of bias while designing conducting
the database search were imported to Endnote X9.49
and a thorough analysis of the data. The answers to the question of the
critical appraisal tool were carefully recorded. RCTs and a
2.4. Data extraction and management quasi-experimental studies checklist were used for the included studies.
The domain assessed in the RCTs were treatment group, concealment,
Data extraction was done for the included studies into an excel blinding, randomisation, reliability and use of statistical analysis. The
spreadsheet, and descriptive characteristics were recorded. The data domain assessed for quasi-experimental studies were variable clarity,
extraction form was pilot tested initially. The data extraction form comparison, intervention control group and outcome reliability. Two
included details such as the title of the study, study design, participant reviewers (AG and BK) appraised the articles independently. In case of
details (e.g. mean, age), intervention, outcome, follow-up and main conflict, all the reviewer members solved it by discussion. The quality of
findings. The studies were carefully examined for any missing infor­ evidence was verified by the supervisory author(UNY). Out of eleven
mation. Two reviewers (AG and BK) completed the data extraction, and studies, eight were high-quality studies, and three met the criteria for
the supervisory author (UNY) checked the extracted data. Any discrep­ moderate-quality studies. The results of the assessment are presented in
ancies between the reviewers on extracted data were resolved by dis­ Table 6.
cussion and reaching a consensus.
3.4. Study outcomes
3. Results
Two studies have reported effectiveness of ginger51,53 alone in
3.1. Identification of the studies reliving dysmenorrhoea were the comparators were placebo. Ginger
produced the same analgesic effect as NSAIDs42,54 during menstural
The literature search identified 394 studies, of which relevant po­ pain. Ginger effectiveness was increased for reliving dysmenorrhoea
tential titles and abstracts were screened after removing the duplicates when combined with exercise.25,30,52,55 Ginger was compared with
(n = 81). The title and abstract were screened by three reviewers other herbs and spices56,57 it was found effective in releving dysme­
independently. The relevant studies were searched for the full text and norrhoea. But one (1/11, 9%)study reported ginger was ineffective in
retrieved. The retrieved full texts were independently screened and reliving dysmenorrhoea.50

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A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

Fig. 1. Prisma 2020 flow diagram.

Table 2
Result for ginger compared with NSAIDS.
Study design Author Intervention Comparator Participant detail Follow Outcome Findings
up

Randomised Rad HA, Basirat Z, Ginger capsule: Novafen: 200 Mean age: 21.86 ± Two Compare the effect of Ginger was as effective
crossover Bakouei F, 200 mg every mg every 6hr, 2.25years. months ginger and Novofen on as Novafen.
trial Moghadamnia AA, 6hr, for 48hr for 48hr Setting: Babol decreasing pain intensity
Khafri S, Kotenaei ZF university during dysmenorrhea on
et al. (42) Sample size: 168 visual analogue scale.
Randomised Shirvani MA, Ginger capsule: Mefenamic acid Mean age: 21.62 ± 2.0 Two Compare the effect of The result showed that
controlled Motahari-Tabari N, 250 mg × 6hr 250 mg × 8hr and 21.60 ± 2.14 years months ginger and mefenamic acid ginger and mefenamic
trial Alipour A. (54) until pain relief until pain relief in mefenamic and on decreasing pain acid effectively
ginger, respectively. intensity during minimise pain intensity.
Sample size: 122 dysmenorrhea by visual Ginger did not have an
analogue scale adverse effect

3.5. Effectiveness of ginger compared with non-steroidal anti- exercise programs (three times a week for 15 min) with oral ginger.30
inflammatory drugs (NSAIDs) The Visual Analogue Scale (VAS) showed a decrease in pain intensity in
both groups; however, the pain reduction was much more significant in
Two studies compared ginger with NSAIDs mefenamic acid and the exercise group than the ginger group in the second month of the
Novafen for dysmenorrhoea.42,54 The researchers found no significant intervention. A quasi-experimental study comparing oral ginger with
difference in intensity and severity of pain from dysmenorrhoea be­ exercise (Jacobson’s progressive muscle relaxation technique) found the
tween ginger and NSAIDs. There was no statistically significant differ­ superior effect of ginger powder than muscle relaxation technique in
ence between ginger and Novafen42 or mefenamic acid.54 Although the treating symptoms of dysmenorrhoea.25 Two studies compared the ef­
difference was not statistically significant, the effectiveness of ginger fect of combined therapy (ginger and exercise) with exercise alone and
was equal to novafen and mefenamic acid in decreasing the intensity of with ginger or exercise.52,55 Both of these studies found the higher effect
pain. It was concluded that ginger is safe to be used for dysmennorhea of combined therapy (ginger and exercise) in reducing the severity of
over NSAIDs because of its non-synthetic and natural way of treating dysmenorrhoea. Gupta et al. used Numerical Rating Pain Score (NRS)
dysmenorrhoea with no adverse effects.42,54 and Menstrual distress questionnaire (MDQ) to measure pain and found
muscle strengthening and stretching (for 20 min/2 times a day except on
the day of menstruation) combined with oral ginger were effective in
3.6. Effectiveness of ginger compared with exercise reducing pain than exercise alone. Yeknami et al. used the VAS to
measure the intensity of dysmenorrhoea. They found sub-maximal aer­
Four studies compared oral ginger with active exercise, Jacob’s obic exercise along with oral ginger was more effective in reducing pain
muscle relaxation technique, stretching exercise, and sub-maximal aer­ than oral ginger or exercise alone. It can be concluded that ginger
obic exercise for menstrual pain,25,30,52,55 of which three were combined with exercise has a higher effect in reducing pain during
quasi-experimental studies25,52,55 and one RCT.30 An RCT compared

4
 Table 3
Result for ginger compared with exercise.
A. Gurung et al.

Study design Author Intervention Comparator Participant detail Follow up Outcome Findings

Quasi- Gupta R, Kaur S, Dietary ginger 500 mg twice a Active exercise only twice a day Mean age: 17–19 years Two months Decrease in pain by assessment Ginger with active exercise is
experimental Singh A. (55) day for three days during except on mensuration days Setting: two nursing in numerical pain score in effective than exercise alone.
menstruation + college response to the treatment
Active exercise twice a day except Sample size: 64
on mensuration days
Quasi- Halder A. (25) Ginger powder 1 gms twice a day Jacobson’s Muscles relaxation Mean age: Reproductive Within one Decrease in dysmenorrhea. Ginger is more effective than Muscles
experimental for three days during technique once a day for three age group. month (pre-test Symptoms on Likert scale relaxation technique statically
menstruation days during menstruation Setting: Nursing College, and post-test) significant
Pune
Sample size: 75
Randomized Shirvani MA, Ginger capsule: 250 mg every Stretching exercise only for 15 Mean age: 21.60 ± Two months A decrease in pain intensity of Stretching exercise was more
controlled Motahari-Tabari N, 6hrly till pain relief with the start min for three times per week 2.14/21.32 ± 1.96. dysmenorrhea on visual analog effective in reducing pain than ginger
trial Alipour A. (30) of the menstrual cycle 2 days. except during menstruation Setting: Mazandaran scale
University of Medical
Sciences, Iran
Sample size: 122
Quasi- Nazari Yeknami F, Ginger capsule: 250 mg for three Submaximal exercise for Mean age: 21.40 ± 1.42 Two months Reduction in pain intensity in Submaximal aerobic exercise along
experimental Nasri M, Shahidi F, days, four times a day during 40min, two times a week and years. Visual analog scale with ginger capsule was effective in
Kashef M. (52) menstruation ginger along with exercise Setting: Shahid Rajaei alleviating pain in dysmenorrheal
University
Sample size: 40

5
Table 4
Result for ginger compared with herbs.
Study design Author Intervention Comparator Participant detail Follow Outcome Findings
up

Randomised Abadi MD, Vakilian K, Ginger capsule: 250 mg every Capsuled valerian: 350 mg Mean age: 20.36 ± 1.28 Two Decrease in pain by Ginger and valerian at suggested doses in this
clinical trial Aghdam NSZ, 8hr for three days of every 8hr for three days of and 21.16 ± 0.91 in months producing the analgesic study failed to produce an analgesic effect and
Ranjbaran M. (50) menstruation periods valerian and ginger group effect by Ginger and thus could not decrease the symptom of
resp. valerian dysmenorrhea.
Setting: college students
Sample size: 210
Randomised Omidvar S, Nasiri-Amiri Ginger capsule: 1 gm/day, Dill seeds capsule: 3 gm/day, Mean age: 23.3 ± 2.1. Three Decrease in pain in a Dill seeds were most effective in reducing
Clinical trial F, Bakhtiari A, Begum K. divided in three capsules per divided in six capsules per day, Setting: University of months numerical pain rating dysmenorrhea, followed by ginger, whereas
(56) day, three days from menstrual three days from menstrual Mysore scale cumin showed no effect.
pain. pain. Sample size: 45
Cumin seed: 3 gm/day, divided
in two dose per day, three days
from menstrual pain
Quasi- Sultan S, Ahmed Z, Ginger capsule: Peppermint capsule: 250 mg × Mean age: 16.8 ± 2.2. One Decrease in menstural The Ginger capsule was most effective in
experimental Afreen A, Rashid F, 250 mg × 3 times a day for five 3 times a day for five days Setting: Rawalpindi district month pain on pain grading reducing dysmenorrhea, followed by the
Majeed F, Khalid, et al. days Lactose capsule: 250 mg × 3 school and college scale peppermint capsule.
(57) times a day for five days Sample size: 90
Clinical Epidemiology and Global Health 18 (2022) 101152
A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

Table 5
Result for ginger compared with placebo.
Study design Author Intervention Comparator Participant Follow Outcome Findings
detail up

Randomised Rahnama P, Montazeri Ginger capsule: 500 placebo (toast Mean age: 21.4/ Two The severity of pain Ginger is an effective and
controlled A, Huseini HF, mg three times a day powder) capsules 21.3 for ginger months intensity was safe therapy for relieving
trial Kianbakht S, Naseri M. First cycle: two days three times a day and placebo assessed by a visual pain in dysmenorrhea.
(53) before menstruation group resp. analogue scale
and then for three Setting: Shahed
days of bleeding University
Second cycle: only in Sample size: 120
the first three days of
periods
Randomised Kashefi F, Khajehei M, Ginger capsule: 250 Zinc sulphate: 220 Mean age: 17 ± Two The severity of Ginger and zinc sulphate
controlled Tabatabaeichehr M, mg three times a day mg three times a day 4.3. months dysmenorrhea was was effective in
trial Alavinia M, Asili J. for four days from the for four days from the Setting: three measured by a pain alleviating
(51) start of menstruation start of menstruation. high schools in visual analogue scale dysmenorrhea when
AND Placebo Bojnurd compared with the
(lactose): Sample size: 150 placebo group
Three times a day for
four days from the
start of menstruation

Table 6
Quality appraisal of the studies using Joanna Briggs Institute Critical appraisal tool.

dysmenorrhoea than with ginger or exercise alone. Omidvar et al. found that dill seeds were the most effective in treating
dysmenorrhoea, followed by ginger among three spices, whereas no
effect of cumin was observed in relieving pain. However, cumin signif­
3.7. Effectiveness of ginger compared with other herbs
icantly reduced systemic responses like cold sweats, backache, fatigue
and cramps.56 Dill seeds were also effective in reliving dysmenorrhoea.
Three studies have compared the effectiveness of ginger with her­
This effect was believed to be because of two significant components,
baccous and aromatic herbs viz. valerian (Valeriana officinalis),50 dill
anethol and tannin, in dill seeds that have sedative effects.56 In a study
seeds (Anethum graveolens) and cumin seeds (Cuminum cyminum),56 and
conducted by Abadi et al., the duration of pain was significantly shorter
peppermint (Mentha)57 for menstrual pain. A study conducted by

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A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

in the ginger group compared to the valerian and placebo groups. minimal side-effects of ginger, as well as various medicinal herbs like
However, no analgesic effects of ginger were observed.50 Peppermint dill seeds and cumin, along with complementary therapies like yoga and
was not found as effective as ginger in decreasing menstrual pain and its exercises, may be a companion treatment for dysmenorrhoea. However,
related symptoms.57 the majority of the included studies were limited only up to the first
instance of a decrease in the severity of pain due to dysmenorrhoea.
3.8. Effectiveness of ginger compared with placebo Therefore, more rigorous randomised controlled trials are needed that
could generate promising results in decreasing the intensity of dysme­
Two studies compared the effectiveness of oral ginger with placebo norrhoea for a longer time duration in several periods of menstruation.
on pain relief in dysmenorrhoea using a VAS.51,53 Kashefi et al. reported
the significant relief of dysmenorrhoea by using either ginger or zinc
sulphate compared to placebo; however, no significant difference was 4.1. Strengths and limitations
observed while comparing ginger to zinc sulphate.51 A significant dif­
ference was seen between ginger and placebo groups in reducing Strengths of the present study include, the use of the electronic
severity as well as the duration of pain.53 database, use of standard guidelines for the review process, and use of
widely used quality appraisal tool.58,59
4. Discussion Although the search was comprehensive, it was not reviewed by the
information scientists, review restricted the studies to peer-reviewed
This review has summarised the effectiveness of ginger on dysme­ journal publications and articles published in the English language,
norrhoea, and it has shown a promising effect in decreasing the symp­ which limits the scope of the review and affects the generalizability of
toms of dysmenorrhoea, which has been found as effective as NSAIDs. the findings. Also, the review did not search subject-specific databases as
The result also showed that oral ginger could be combined with other these were not accessible at the time of searching. Due to the mentioned
complementary therapies like exercise, and massage, which signifi­ restrictions, various trials with potential data might have been excluded
cantly relieves primary dysmenorrhoea significantly.55 However, some in this systematic review. The included studies show no significant dif­
studies showed that ginger is not only a medicinal herb that can be used ference between NSAIDs and ginger; author has exemplified the superior
for dysmenorrhoea, but various other medicinal herbs like dill seeds, usage of ginger to NSAIDs because of its natural properties and common
Curcuma longa, and cinnamon can produce a better analgesic effect than side effects. Further research with good quality RCTs are required to
ginger.51,53 The findings were interpreted with great caution due to a critically analyse and promote ginger as well as medicinal herbs and
smaller number of suitable studies for our research. Further, these complementary therapies as an adjunct treatment in primary dysme­
studies included small sample size and had shorter follow-up period. norrhoea. Although we critically appraised included studies using JBI
NSAIDs drugs are used as the first-line drugs with known side-effect tool, we refrained drawing conclusion based on study quality as all the
of the gastrointestinal tract as well as heart complications.62 The result studies were either moderate or high quality. However, we are aware
of the review shows that ginger can be as effective as analgesic drugs in that RCTs as a methodological approach are not comparable to quasi
relieving menstrual pain.42,54 A review by Lakhan, Ford, & Tepper experimental studies.
(2015) concluded that ginger has hypo analgesic property and a better
safety profile than NSAIDs.45 Our review shows that ginger solely is safe
4.2. Recommendation for research and practice
in reducing the pain of dysmenorrhoea.25,53 A meta-analysis has sup­
ported the result of ginger having a positive effect on reducing menstural
The researcher suggests for future researchers that comparative
pain.37,63–65
studies on effectiveness of ginger with other pharmacological and non-
Our review also identified the combining effects of exercise with
pharmacological can be carried out in the same studies and to have a
ginger and found it to be beneficial in providing relief from dysmenor­
longer follow-up to see long-term effect. The research studies should also
rhoea.52,55 Various studies have suggested the low-intensity exercises
focus on assessing quality of life and general wellbeing and cost-
like yoga and pilates in reducing the intensity and duration of pain
effectiveness of using herbal products. Future systematic reviews
during menstruation; these exercises may help to increase the produc­
should statistically pool the result and use Grading of Recommenda­
tion of anti-inflammatory cytokines, increase the blood flow around the
tions, Assessment, Development and Evaluations (GRADE) approach to
uterus and decrease the release and synthesis of prostaglandin.66–68
draw the conclusion.
People consider herbal medicines as the safest methods to consume,
and research has shown that there is a widespread usage of herbs by
women for dysmenorrhoea.69 Our result showed that some of the herbs 5. Conclusion
like dill seeds; cumin are capable of producing an analgesic effect for
menstrual symptoms.56 A review conducted by Xu et al. suggested using This research suggests that the usage of ginger up to two grams per
herbs like ginger and cinnamon, also known as warm medicines, for day in divided dosage in powder, or dietary form can be used for man­
dysmenorrhoea.46 In addition, a systematic review done to analyse the aging dysmenorrhoea for three days from the start of menstrual cycle.
efficacy of medicinal plants use in primary dysmenorrhoea found Furthermore, the consumption of ginger, along with complementary
various medicinal plants like Zingiber officinale, Mentha piperita, Cin­ therapies like yoga, massage and light exercise, are safe in controlling
namomum zeylanicum, Mellisa officinalis, Thymus vulgaris, Tecrium the pain during menstruation. The studies related to the use of alter­
polium were safe in reliving menstrual pain.69 Prior researchers have native therapies to NSAIDs enables women to use cost-effective, natural
found that substances like gingerol, protein, and free fatty acid present products with no or minimal effect and reduces the dependence on the
in ginger have properties similar to NSAIDs, which inhibits the biosyn­ high synthetic drug to control dysmenorrhoea. Therefore, further
thesis of components inducing pain like leukotrienes and prostaglandins research analysing both the beneficial and negative role of the utiliza­
through inhibition of cyclooxygenase (COX).34–36 tion of ginger, medicinal herbs and exercise for a longer duration of time
The current review has shown the potential effectiveness of ginger, is needed to evaluate the effectiveness of auxiliary therapies to control
various medicinal herbs and complementary therapies like massage and painful menstruation.
exercises to reduce pain in menstruation. The present analysis shows
compelling proof that besides synthetic NSAIDs, there are various ways Source of funding
and measures to reduce the intensity and duration of pain due to dys­
menorrhoea. Based on the prior studies, a higher safety profile and The authors did not receive any funding for conducting this review.

7
A. Gurung et al. Clinical Epidemiology and Global Health 18 (2022) 101152

Author’s contribution 22 O’Connell K, Davis AR, Westhoff C. Self-treatment patterns among adolescent girls
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26 Kannan P, Claydon LS. Some physiotherapy treatments may relieve menstrual pain in
The authors declare that no conflict of interest exists. women with primary dysmenorrhea: a systematic review. J Physiother. 2014 Mar 1;
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