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Research Article
Use of ginger versus stretching exercises for
the treatment of primary dysmenorrhea: a
randomized controlled trial
Marjan Ahmad Shirvani1, Narges Motahari-Tabari1, Abbas Alipour2
1. Department of Midwifery, School of Nursing & Midwifery, Mazandaran University of Medical Sciences, Sari
4816715793, Iran
2. Department of Community Medicine, School of Medicine, Mazandaran University of Medical Sciences, Sari
4847191971, Iran

ABSTRACT
BACKGROUND: Dysmenorrhea is a common gynecologic problem. In some cases, non-medical treatments
are considered to be more effective, with fewer side effects. Ginger and exercise are alternative treatments
for dysmenorrhea, but in the present study they were not combined.
OBJECTIVE: In this study, the effects of ginger and exercise on primary dysmenorrhea were compared.
DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: This randomized controlled trial was
performed in Mazandaran University of Medical Sciences, Iran. Two groups of female students were recruited
by simple random allocation. In each group, 61 students with moderate to severe primary dysmenorrhea with
regular menstrual cycles and without a history of regular exercise were assessed. The ginger group received
250 mg ginger capsules from the onset of menstruation. In the exercise group, belly and pelvic stretching
exercises were performed for 10 min, 3 times per week.
MAIN OUTCOME MEASURES: Intensity of pain was assessed according to a visual analogue scale after
the first and the second month.
RESULTS: Exercise was significantly more effective than ginger for pain relief (31.57 16.03 vs 38.19
20.47, P = 0.02), severity of dysmenorrhea (63.9% vs 44.3% mild dysmenorrhea, P = 0.02) and decrease in
menstrual duration (6.08 1.22 vs 6.67 1.24, P = 0.006), in the second cycle.
CONCLUSION: Stretching exercises, as a safe and low-cost treatment, are more effective than ginger for
pain relief in primary dysmenorrhea.
TRIAL REGISTRATION: The trial was registered in www.IRCT.ir with No. 201203118822N2.
Keywords: ginger; pain; primary dysmenorrhea; stretching exercise
Citation: Shirvani MA, Motahari-Tabari N, Alipour A. Use of ginger versus stretching exercises for the treatment
of primary dysmenorrhea: a randomized controlled trial. J Integr Med. 2017; 15(4): 295301.

http://dx.doi.org/10.1016/S2095-4964(17)60348-0
Received January 12, 2017; accepted March 31, 2017.
Correspondence: Narges Motahari-Tabari; E-mail: narges_mth@yahoo.com

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1 Introduction
Dysmenorrhea refers to the occurrence of painful
uterine cramps during menstruation.[13] It is characterized
by acute and cyclic pain in the midline of the lower
abdomen but it may be described as dull in the lumbar
area and the thighs.[4,5] Pain usually begins from a few to
several hours before the onset of menstrual bleeding, and
continues until the first or the second day of the menstrual
cycle.[35] Diarrhea, nausea and vomiting are associated
symptoms.[4,6] This pain can affect womens quality of life,
and may lead to absence from work or school, and time
spent on self-care and professional-care.[7] Between one-
third and one-half of women presenting for primary care
report moderate or severe dysmenorrhea.[1] Among Iranian
women, the prevalence of moderate to severe dysmenorrhea
is 50%.[8] Physiologically, the pain is caused by excessive
amounts of prostaglandins, which introduce abnormal
uterine contractions and reduce uterine blood flow.[7]
Medication by nonsteroidal anti-inflammatory drugs
(NSAIDs), inhibitors of cyclooxygenase enzymes and
prostaglandins, is one of the conventional treatments for
primary dysmenorrhea.[3] Current medical therapies offer
inadequate treatment, with a failure rate of 20%25%.[4] Some
women prefer not to use NSAIDs because they perceive
no benefit and have adverse side effects or for cultural
reasons.[4,9,10] Thus, alternative treatments with low toxicity,
such as traditional medicine, are recommended.[9] Several
studies have reported that ginger, an inhibitor of prostaglandin
synthesis, with a long history of use in traditional medicine,
has beneficial effects on primary dysmenorrhea.[1113] On
the other hand, physical activity stimulates the release of
-endorphin, which functions as an analgesic, and reduces
the frequency and severity of primary dysmenorrhea.[6]
Because alternative treatments may reduce some symptoms
of dysmenorrhea during the menstrual period, without the side
effects of conventional treatments, they have been considered
for the management of dysmenorrhea.[10,14,15]
Few studies have compared herbal drugs with physical
activity for the treatment of dysmenorrhea. This comparison
helps both practitioners and patients make decision about the
treatment, when several choices are available.
Although, some herbal drugs and non-pharmacological
treatments have been suggested for primary dysmenorrhea,
there is a lack of information about comparison of these
approaches. The aim of this study was to compare the
effectiveness of exercise and ginger on primary dysmenorrhea.
2 Materials and methods
2.1 Study design and subjects
This article reports some of the results of a randomized
clinical trial, with parallel design, conducted from January
July 2017, Vol. 15, No. 4 296
to May 2014. It involved female students of Mazandaran
University of Medical Sciences, Iran. The ethics
committee of this university approved the study protocol in
conformation with the Declaration of Helsinki.
Following a review of previous studies and the size
effects of physical activity (2.2 2.4) and ginger (2.3 2.8)
with = 0.05, and b = 80%, the sample size was calculated
to be 61 for each group.[3,15,16]
The participants were allocated to the groups by simple
randomization. For this reason, we provided a list of
eligible students (n = 122) with one number given to each
of them. Then they were sequentially allocated to two
groups using the random number table. One group received
training for exercise, and the other group received ginger.
The purpose and method of the study and the participants
rights (e.g., voluntary participation and ability to leave the
study) were explained in a handout. Then written informed
consent was obtained from all participants.
Inclusion criteria: students who lived in the dormitory
and were interested in participating in the study; history of
primary dysmenorrhea which had affected daily activities
in at least 50% of their cycles through the past 6 months;
and pain intensity over 40 mm, based on the 100-mm
visual analogue scale (VAS). Exclusion criteria: irregular
menstrual cycles; the use of intra-uterine devices and oral
contraceptive pills; history of regular exercise (3 times
weekly for 3045 min); diseases of the genitourinary
system (e.g., pelvic inflammatory disease and urinary tract
infections) and secondary dysmenorrhea.[6]
2.2 Measures
The participants completed a demographic form. The
primary treatment outcome was pain intensity, measured
with VAS. Pain intensity was classified as follows: 40
60 mm (moderate), more than 60 mm (severe) and under
40 mm (mild). In addition, duration of pain and some other
menstruation characteristics (e.g., length of menstruation
and menstrual cycle and change in bleeding) were assessed
as secondary outcomes. In both groups, participants were
asked to record pain intensity and other variables at the end
of the first and the second menstruation cycles.
2.3 Interventions
In one group, exercise programs were taught by two
trained instructors. First, they were trained by a qualified
sport sciences instructor. Then they performed the exercise
programs with students in the fitness hall of the dorm for
several sessions, until they were sure that all participants
could do the exercises correctly. Furthermore, pamphlets
including images and instructions for the exercises were
given to each of the participants in the exercise group. The
exercise programs included 5 min of warm-up movements
in a standing position, followed by 6 stretching exercises
for the abdomen and pelvis for 10 min. This program
was performed for 15 min, 3 times per week, for two
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consecutive menstrual cycles (8 weeks). Exercises were
not performed during menstruation.[16,17] The instructors
contacted the participants weekly to ensure that they
were following the exercise program, and to answer any
questions. In the second group, students took 250 mg ginger
capsules (Zintoma 250 mg, Goldaru Co, Iran). Capsules
were taken at the onset of menstruation and then every 6 h
until pain relief for 2 consecutive cycles.[15] The duration
of interventions was determined according to the results of
other studies.[15,16]
The students in both groups did not exercise regularly
before the interventions, and they were asked to limit any
exercise during the study period except the prescribed
stretching movements in the exercise group.
2.4 Statistical analysis
Data normality was assessed with the Kolmogorov-
Smirnov test. In addition to descriptive statistics (means,
standard deviations and frequency) and Chi-square, the
Friedman test was used for dependent variables (longitudinal
assessment in the three time periods for the same group) and
the Mann-Whitney U test was used for independent variables
(ginger and exercise groups in each period). The SPSS
version 20.0 was used for statistical analysis. The significant
level was considered less than 0.05.
3 Results
3.1 Demographic characteristics
Data were completed for 122 students, with 61 participants
in each group (Figure 1). Demographic characteristics were
not significantly different between the groups (P > 0.05,
Table 1).

Assessed for eligibility (N = 227)

Enrollment

Excluded (n = 105)
Not meeting inclusion criteria (n = 37)
Use of another drug (n = 61)
Declined to participate (n = 7)

Randomized (n = 122)
Allocation

Allocated to ginger group (n = 61) Allocated to exercise group (n = 61)

Received allocated intervention Received allocated intervention
Analysis

Analysed (n = 61) Analysed (n = 61)

Figure 1 Flowchart of participants enrollment in the study

Table 1 Demographic characteristics of students with dysmenorrhea in the study groups

Ginger group Exercise group
Variable P value
(n = 61) (n = 61)
Age (mean standard deviation, years) 21.60 2.14 21.32 1.96 0.45
BMI (mean standard deviation, kg/m2) 21.65 3.08 22.56 3.56 0.13
Year level in the university (n (%))
1st & 2nd 33 (54.1) 24 (39.3)
0.07
3rd 28 (45.9) 37 (60.7)
Family history of dysmenorrhea (n (%))
Yes 39 (63.9) 34 (55.7)
No 14 (23.0) 20 (32.8) 0.48
Unknown 8 (13.1) 7 (11.5)
BMI: body mass index.

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3.2 Pain and menstruation characteristics
As shown in Table 2, decrease in pain intensity was
significant within both groups (P < 0.001). However, the
reduction of pain was more significant in the exercise
group than in the ginger group in the second month of
intervention (P = 0.02). Pain duration was not significantly
different between the groups during the study, though it
decreased significantly in the exercise group (P = 0.02).
The length of the menstrual cycle was not significantly
different between the groups, but it increased in the
ginger group during the study (P = 0.02). There was a
significant reduction in the duration of menstruation in
the exercise group during the study (P < 0.001). This
reduction was more than the ginger group in the second
month (P = 0.006).
3.3 Menstruation outcomes
Although there were no cases of mild dysmenorrhea
at the beginning of the study, some cases appeared after
the first month, as participant symptoms improved. No
case of severe dysmenorrhea was seen at the end of the
second month. The occurrence of mild dysmenorrhea
was significantly higher in the exercise group in the
second month (Table 3). The change in bleeding was not
significantly different between groups during the study
(Table 3).
4 Discussion
Currently, various medical and non-medical treatments
are suggested for the treatment of primary dysmenorrhea.
Although the use of NSAIDs is common,[3] because of
some reports of poor efficacy and side effects, alternative
approaches, such as herbal drugs and physical activities,
are recommended.[1,3,6,1820]
The results of this study showed that the stretching
exercises had a greater effect than ginger in treatment
of primary dysmenorrhea after two months. Although
no case of severe dysmenorrhea was seen in either

Table 2 Comparison of pain and menstruation characteristics within and between the ginger and exercise groups
Ginger group (n = 61) Exercise group (n = 61)
Variable
Mean SD P value Mean SD P value
Pain intensity (VAS score)
Baseline 58.01 15.16 60.26 14.45
1st month 43.49 19.99 < 0.001 45.42 19.21 < 0.001
2nd month 38.19 20.47 31.57 16.03
Comparing changes between baseline and 1st month (intergroup) P = 0.95
Comparing changes between baseline and 2nd month (intergroup) P = 0.02
Pain duration (d)
Baseline 1.62 0.85 1.78 0.70
1st month 1.60 0.80 0.69 1.59 0.78 0.02
2nd month 1.49 0.78 1.50 0.72
Comparing changes between baseline and 1st month (intergroup) P = 0.12
Comparing changes between baseline and 2nd month (intergroup) P = 0.16
Menstrual cycle duration (d)
Baseline 27.44 3.15 29.16 3.47
1st month 28.85 2.92 0.02 29.01 4.29 0.47
2nd month 28.95 2.67 29.16 2.88
Comparing changes between baseline and 1st month (intergroup) P = 0.23
Comparing changes between baseline and 2nd month (intergroup) P = 0.07
Duration of menstruation (d)
Baseline 6.70 1.22 6.77 1.30
1st month 6.50 1.19 0.35 6.50 1.14 < 0.001
2nd month 6.67 1.24 6.08 1.22
Comparing changes between baseline and 1st month (intergroup) P = 0.78
Comparing changes between baseline and 2nd month (intergroup) P = 0.006
VAS: visual analogue scale. SD: standard diviation

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Table 3 Comparison of menstruation outcomes between the ginger and the exercise groups
Menstruation outcomes (n (%)) Ginger group (n = 61) Exercise group (n = 61) P value
Severity of dysmenorrhea
Baseline
Moderate 40 (65.6) 39 (63.9) 0.50
Severe 21 (34.4) 22 (36.1)
1st month
Mild 19 ( 31.1) 20 (32.8) 0.95
Moderate 33 (54.1) 33 (54.1)
Severe 9 (14.8) 8 (13.1)
2nd month
Mild 27 (44.3) 39 (63.9) 0.02
Moderate 34 (55.7) 22 (36.1)
Bleeding
1st month
Increase 8 (13.1) 6 (9.8) 0.39
Decrease 10 (16.4) 16 (26.2)
No change 43 (70.5) 39 (63.9)
2nd month
Increase 9 (14.8) 9 (14.8) 0.10
Decrease 11 (18.0) 21 (34.4)
No change 41 (67.2) 31 (50.8)

group by the second month, mild dysmenorrhea was
significantly more prevalent in the exercise group. Pain
reduction in the ginger group was also considerable.
Traditionally, ginger has been used for the treatment of
pain[13] and has been introduced as an effective treatment
for dysmenorrhea. [21,22] Recently, authors reported the
effects of various dosages of ginger on pain relief in
dysmenorrhea. [11,12,15,23,24] Also, the effects of various
types of exercise, such as stretching movements, on
dysmenorrhea have been confirmed.[7,16,17,25] In a study
comparing active exercise with a combination of active
exercise and dietary ginger, Gupta et al.[9] reported that
the efficacy of combined ginger and exercise was higher
than that of exercise alone for the relief of pain from
primary dysmenorrhea. In the current study, we did not
compare the combination of ginger and exercise, but the
effect of exercise was higher than that of ginger alone.
Thus, for increasing the effect of ginger, taking it in
combining with an exercise program may be effective.
Similar to the study by Gupta et al., [9] in the present
study, though pain intensity decreased in both groups
in the first month, the difference was not significant.
Those authors concluded that the effect of exercise on
dysmenorrhea increased over time. Shahr-jerdy et al.[16]
reported the effectiveness of 8 weeks of stretching
exercises on pain reduction in primary dysmenorrhea.
Other researchers showed the effects of prolonged
exercise protocols on pain relief in dysmenorrhea.[17,26,27]
Additionally, it has been reported that regular exercise
is more effective than occasional exercise.[28] Further,
greater than one hour of daily physical activity was
associated with lower prevalence of dysmenorrhea.[29] In
the current study, pain duration decreased in the exercise
group during the study, but the difference was not
significant between the groups. There are some reports
of reduced pain duration with exercise, which may cause
a more rapid transfer of prostaglandins.[16,17,30,31] Rahnama
and co-workers[12] reported a decrease in pain duration
when ginger was prescribed from 2 d before menstruation.
Thus, a lack of significant reduction in pain duration in
the ginger group compared with the exercise group in our
study may be due to the later prescription of ginger.
Some of the mechanisms of pain relief in dysmenorrhea
are common between ginger and exercise. Exercise
improves pelvic blood circulation, which prevents
prostaglandins aggregation. [7,28] Also, ginger has the
same effect via decreasing endothelin-1 and increasing
nitrous oxide, which lead to expansion of vessels
and, as a result, improvement of blood circulation.[32]
Prostaglandins stimulate myometrium contractions
and are important factors in the induction of primary
dysmenorrhea.[7] In addition, ginger activates endorphin
receptors by the inhibition of thromboxane synthesis
and suppresses hyperactivity of neuroadrenergics; [33]

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exercise leads to hormonal changes in the uterus and
activates endorphins, [7,16,17] which can relieve pain.
However, exercise may affect dysmenorrhea by some
additional mechanisms. Psychological conditions
influence dysmenorrhea and its severity.[3436] There is a
correlation between dysmenorrhea and stress levels. [16]
Stress increases uterine contractions, with an effect on
the nervous system.[36,37] Exercise has a positive effect
on dysmenorrhea by decreasing stress and improving
mood.[7,38,39] Also, exercise decreases spasms and pressure
on the nerves.[1,18,25]
Although the duration of the menstrual cycle was
shorter in the ginger group, the difference in cycle length
between groups was not significant during the study. The
duration of menstruation was reduced in the exercise
group during the study and was significantly lower than
that of the ginger group in the second month. In addition,
during the study, more women in the exercise group
reported decreased bleeding compared to the ginger
group, but the difference was not significant. Similarly,
Shavandi et al.[31] reported no change in bleeding with
8 weeks of exercise. In contrast, reduction in bleeding
was reported by Abbaspour et al.[17] in the 4th cycle after
initiation of exercise, and by Mahvash et al.[30] 8 weeks
after beginning a program of stretching plus resistance
exercise for 90 min 3 times per week. Thus, it seems
that the effect of exercise on bleeding may be increased
with prolonged duration and higher-intensity exercise
programs, probably because of hormonal changes.[30]
In this study, we compared two alternative treatments,
ginger and exercise, for primary dysmenorrhea. To the
best of our knowledge, this has not been considered
previously. Because primary dysmenorrhea usually affects
young women and this study included a young population
of female students, these findings are especially
relevant for young women with primary dysmenorrhea.
Limitations of the study included: no comparison with
control or placebo groups; no investigation of the role of
timing of ginger dose with the onset of menstruation or
the dose effect of ginger supplements; and no exploration
of the role of intensity, duration and type of exercise on
improvement of symptoms.
5 Conclusions
It appears that stretching exercises, as a safe and low-
cost approach, are more effective than ginger for the
reduction of pain and menstrual duration in primary
dysmenorrhea.
6 Funding
This study has been supported by a grant from the
July 2017, Vol. 15, No. 4 300
Research Deputy of Mazandaran University of Medical
Sciences (grant number: H-92-24), Iran.
7 Acknowledgements
We thank the vice-Chancellor for Research of Mazandaran
University of Medical Sciences for supporting this project
(grant number: H-92-24). We also appreciate all the
students who participated in this study.
8 Conflicts of interest
There is no conflict of interest.
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