Ideal Institute of Pharmacy, Posheri, Wada, Mumbai University.
Dysmenorrhoea, often referred to as painful menstruation, is a prevalent gynecological issue that considerably impacts women’s quality of life, productivity, and emotional health. Traditional treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives are the primary options; however, their prolonged use is frequently linked to negative effects including gastrointestinal issues, hormonal imbalances, and pain recurrence. In recent years, herbal treatments have garnered increasing interest as natural and safer alternatives for alleviating menstrual pain. This comparative study seeks to assess the effectiveness, safety, and patient satisfaction of herbal remedies in contrast to conventional treatments for primary dysmenorrhoea. A thorough review of clinical trials and observational studies was performed utilizing databases such as PubMed, Scopus, and Google Scholar, concentrating on outcomes like pain alleviation, duration of relief, side effects, and overall quality of life. Herbal remedies such as Zingiber officinale (ginger), Cinnamomum zeylanicum (cinnamon), and Foeniculum vulgare (fennel) were evaluated against conventional medications like ibuprofen and mefenamic acid. The findings indicated that herbal therapies offered comparable or superior pain relief with minimal side effects, enhanced patient tolerance, and improved adherence to treatment. In contrast, conventional medications provided quicker relief but were associated with a higher incidence of adverse reactions and increased recurrence rates. In summary, the results imply that herbal therapies represent a promising, effective, and safer option for managing dysmenorrhoea, fostering holistic well-being and sustainable menstrual health.
Dysmenorrhoea:
Lower abdominal and pelvic pain that happens during menstruation without any obvious pelvic disease is referred to as primary dysmenorrhea. About 50–90% of women who are of reproductive age are impacted. Most women with primary dysmenorrhea reported feeling less active at work or in school, which can result in both socioeconomic loss and a decline in quality of life.[1]
Types of dysmenorrhoea:
It is classified as primary dysmenorrhea, which occurs in the absence of pelvic disease and is frequently associated with elevated levels of prostaglandins, or secondary dysmenorrhea, which arises from conditions such as endometriosis or fibroids.[2]
Figure no:1 Types of dysmenorrhoea [10]
Currently, pharmacological treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives, serve as the primary approach for managing PD. While NSAIDs provide immediate pain relief, they do not demonstrate long-term effectiveness. Furthermore, prolonged use of NSAIDs may elevate the risk of adverse effects, particularly affecting the digestive and central nervous systems, leading to issues such as indigestion, headaches, drowsiness, and poor treatment adherence.[11-13] Hormonal contraceptives are frequently utilized in PD management as well, but they are often associated with side effects such as weight gain, breast discomfort, menstrual irregularities, and other negative reactions.[14,15] Moreover, it has been reported that the frequent use of these medications results in a failure rate ranging from 20% to 25%. Consequently, an increasing number of individuals are turning their attention to complementary and alternative therapies for PD.[16]
The approach to managing dysmenorrhea primarily Involves two methods: pharmacological and non-pharmacological treatments. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, and mefenamic acid are commonly prescribed for women with primary dysmenorrhea (PD). Other medications, including oral contraceptive pills (OCPs), antispasmodics, and acetaminophen, are also utilized. Nevertheless, prolonged use of NSAIDs and OCPs can result in negative side effects, such as damage to the gastrointestinal tract lining, which may cause GI discomfort. The side effects linked to these treatments have prompted women to explore complementary and alternative medicine options, including various herbs, dietary changes, or physical activity. Numerous healthcare practitioners around the globe have turned to medicinal plants like fennel, ginger, and cinnamon due to their pain-relieving properties. In addition, applying local heat, engaging in exercise, ensuring adequate rest, and limiting fatty foods have demonstrated positive effects in managing PD, with no significant negative effects recorded. While pharmacological treatments can have adverse effects, they are still regarded as the most effective and dependable options for treating dysmenorrhea.[17]
According to traditional Chinese medicine, dysmenorrhea is attributed to the stagnation of cold and dampness in the uterine collaterals, which can be caused by consuming cold beverages or being exposed to rain and wet conditions. The invasion of cold leads to blood coagulation, resulting in obstructed uterine collaterals, known as stagnation, which ultimately causes pain. Therefore, the treatment for dysmenorrhea should concentrate on warming the meridians, dispelling cold, and alleviating dampness. Cinnamon (Cinnamomum zeylanicum), fennel (Foeniculum vulgare), and ginger (Zingiber officinale) are widely recognized natural products that help warm meridians, dispel cold, and eliminate dampness. Cinnamon, a fragrant spice, has been utilized to address various Inflammatory conditions and chronic illnesses, including menstrual discomfort, arthritis, diabetes, and Alzheimer’s disease. Fennel, noted for its contrastimulant and analgesic properties, is regarded as an effective herbal remedy for dysmenorrhea, despite its less-than-pleasant flavor. Ginger is beneficial for alleviating discomfort linked to dysmenorrhea, rheumatoid arthritis, osteoarthritis, and gastrointestinal issues such as diarrhea, nausea, and vomiting. Some research has also indicated that ginger can aid in relieving pain for women experiencing dysmenorrhea. However, there has yet to be a comprehensive effort to compile the existing evidence that supports the effectiveness of these three herbs in treating primary dysmenorrhea.[18]
Figure no.2 Dysmenorrhoea symptoms [21]
Pathophysiology Of Dysmenorrhoea:
The exact mechanisms underlying primary dysmenorrhea remain unclear. However, it is thought that the primary cause is linked to the excessive production of prostaglandins (PGs) by the inner lining of the uterus. These prostaglandins induce pain by amplifying uterine contractions and increasing pressure within the uterus. Additionally, factors such as reduced blood flow to the uterus, ischemia, lack of oxygen, and byproducts from anaerobic metabolism may contribute to the experience of pain.[20]The elevated levels of collagenases, inflammatory cytokines, and matrix metalloproteinases in the endometrium are related to lower levels of progesterone and estradiol during menstruation. The resulting disintegration of endometrial tissue releases phospholipids, which are then transformed into arachidonic acid. This arachidonic acid is subsequently converted into prostacyclins, prostaglandins, and thromboxane-2a through the action of cyclooxygenase.[9]The substances PG F2 alpha (PGF-2α) and PG E2 (PGE2) enhance uterine tone and induce strong contractions of the uterus.[22]
Figure no:3. Pathophysiology of dysmenorrhoea [26]
During menstruation, the levels of COX-2, a type of cyclooxygenase, are notably elevated, which has led to the use of NSAIDs for treatment, as mentioned below. [9]Vasopressin has also been associated with primary dysmenorrhea, as it boosts uterine contractility and can lead to ischemic pain due to its vasoconstrictive properties.[23][25]Additionally, levels of leukotrienes C4 and D4 are increased in individuals with dysmenorrhea and seem to correlate with an upsurge in uterine contractions.[20]Moreover, uterine contractility is most pronounced in the first two days of menstruation, aligning with the peak frequency and intensity of dysmenorrhea during this time.[24]
Endometriosis and adenomyosis represent the leading causes of secondary dysmenorrhea among premenopausal women.[24]
Primary Methods:
In order to examine the efficacy and safety of herbal medications given for a minimum of ten days this study divided individuals into three groups:
Depending on group assignment, participants will receive oral DJS, GSS, or a placebo three times daily for two menstrual cycles. Each person will have a different intervention duration, which might be anything from 42 to 80 days. As a result, for each menstrual cycle, the participants will receive enough medication for 43 days of administration, taking into account a maximum of 40 days and window visit (three days). The remaining unused medication will be returned in order to increase participant adherence to the intervention guidelines. Alternative therapies for dysmenorrhea, including low frequency therapy, moxibustion, acupuncture, and infrared radiation, will not be allowed.Oral contraceptives, psychiatric medications, and herbal remedies will not be allowed, although participants may self-administer medications that are not listed in the inclusion or exclusion criteria. The Consolidated Standards of Reporting Trials (CONSORT) Extension for Chinese Herbal Medicine Formulas’ interventions item will be followed in the description of the interventions.[27]
Those who received herbal treatment for dysmenorrhea, gave their informed consent, consented to the use of their data, comprehended the study, and filled out the surveys were eligible to participate. Serious comorbidities (such as neurological, mental, cardiovascular, or renal problems), pregnancy planning, or involvement in other clinical studies were among the exclusion criteria. Participants were drawn from general clinics that provide non-insurance-based, out-of-pocket treatments as well as clinics taking part in the nationwide pilot study for insurance coverage of herbal decoctions. Of the 135 participants who finished the trial, 72 (53.33%) were uninsured general patients, and 63 (46.67%) were enrolled through the pilot insurance program.[2]
Primary outcome:
The duration of menstrual pain, the amount of analgesics taken, and the mean change in dysmenorrhea intensity (as determined by a numerical rating scale, or NRS) were the main outcomes. At every treatment cycle, including assessments following the first and second menstruations, outcomes were evaluated. Although telephone or online surveys were used with participants’ permission, the majority of assessments were carried out in person.[2]
If the average VAS at the conclusion of the intervention (V4) differs by more than 15 mm from the baseline (V2), the intervention will be deemed successful. Endometriosis, a representative condition that causes secondary dysmenorrhea, has a minimal clinically meaningful difference (MCID) of 10 mm using VAS,[28] and Primary dysmenorrhea has improved to a slightly greater extent than secondary dysmenorrhea.[29]
Secondary outcome:
Adverse events, pleasure, and self-rated effectiveness were secondary outcomes. A 4-point scale was used to measure clinical improvement; lower values denoted more effectiveness (1 being a significant improvement and 4 being no impact). Herbal medicine and total Korean medicine treatment satisfaction were assessed separately using a 7-point rating system. Overall satisfaction was correlated with the type of intervention, although preferences for formulation type were reflected in herbal medication satisfaction. In order to evaluate the safety of herbal medicines, doctors tracked adverse events during the trial, documenting any symptoms, reactions, or treatments at each visit.[2]
ANOVA and chi-square tests were used to evaluate the demographic data, and the results were displayed as means ± SD or frequencies. Within-group changes were evaluated using paired t-tests, while between-group comparisons were evaluated using the Kruskal-Wallis test. Mann-Whitney U tests were performed post hoc when significant. A p-value of less than 0.05 was deemed significant. Missing values were imputed using the mean for continuous data and the simple for categorical data. The software SPSS 23.0 was used for the analyses.[2]
Conventional Treatment:
The primary goal of treatment for primary dysmenorrhea (PD) is to provide effective pain relief for individuals experiencing dysmenorrhea, allowing them to continue their normal activities, enhance their quality of life (QOL), and reduce absenteeism related to work or academic responsibilities.[30,31] Both pharmacological and non-pharmacological alternative therapies can serve as viable options for managing PD.[32] The initial recommended treatments for PD include nonsteroidal anti-inflammatory drugs (NSAIDs) and hormonal contraceptives, as they reduce the production of prostaglandins, which are directly linked to menstrual pain and its accompanying systemic symptoms.[30,31,33,34]
Pharmacological Therapies:
The timing of NSAID administration is a predictor of its effectiveness. To achieve optimal treatment efficacy and safety, NSAIDs ought to be started 1 to 2 days prior to the anticipated onset of menses, taken with meals to mitigate adverse gastrointestinal effects, following a consistent dosing schedule, and maintained throughout the initial 2 to 3 days of bleeding.[30,31,39]It has been determined that the administration of NSAIDs prior to the induction of the COX-2 cascade leads to a total inhibition of prostaglandin synthesis. Therefore, postponing the consumption of NSAIDs results in a gradual or partial suppression.[39]If a patient does not show improvement with a specific NSAID, replacing it with one from a different class presents an alternative treatment option [33,23]. While the majority of females tend to respond positively to NSAID therapy, it has been noted that 18% do not respond sufficiently to these medications [36]. For females who do not respond to NSAIDs, transitioning to hormone-based treatments and/or non-pharmacological therapies may be considered.[36]
Hormonal contraceptives have been demonstrated to inhibit ovulation and the proliferation of the endometrium, thereby preventing the synthesis of prostaglandins [40]. The hormonal treatments employed in the management of PD encompass options such as combined oral contraceptives (COC), transdermal contraceptive patches or vaginal rings, a levonorgestrel intrauterine device, and subcutaneous depot medroxyprogesterone acetate, proven to be effective in managing PD[41].
Non- Pharmacological Interventions:
The application of non-pharmacological interventions is prevalent among females experiencing dysmenorrhea. A recent meta-analysis involving 12,526 dysmenorrheic females indicated that 51.8% utilized various non-pharmacological strategies to alleviate their menstrual discomfort [47]. To address dysmenorrhea, numerous non-pharmacological interventions have been suggested, which can be used independently as an alternative treatment or in conjunction with NSAIDs or COCs as a supplementary therapy [38,33,30,31].These interventions were proposed to alleviate menstrual pain through various mechanisms, such as enhancing pelvic blood flow, suppressing uterine contractions, promoting the release of endorphins and serotonin, and modifying the capacity to receive and interpret pain signals [50,47,51,52].
The application of heating pads and consistent physical activity, whether as a substitute or an adjunct therapy, ought to be promoted due to their demonstrated effectiveness, rare adverse effects, and affordability [30,31]. However, there is a lack of adequate evidence regarding the effectiveness of dietary supplements (including vitamins B, D, and E, as well as omega-3 fatty acids), acupuncture, yoga, massage, and herbal treatments in the treatment of PD [47,33,30,31,53].
Its analgesic effect is facilitated through two distinct mechanisms. The first mechanism entails raising the sensory threshold for uterine pain by relaying a sequence of afferent electrical signals through large-diameter sensory fibers, which leads to a diminished perception of pain associated with uterine hypercontractility during menstruation. In contrast, the second mechanism pertains to the stimulation of endorphin release by peripheral nerves, which contributes to pain relief [54-56].
Surgical Interventions:
In exceptional cases, surgical procedures have been suggested for individuals suffering from severe dysmenorrhea who do not respond to standard treatment options. These surgical procedures encompass laparoscopic uterosacral nerve ablation (LUNA), presacral neurectomy (PSN), and hysterectomy [57,30,31]. Both LUNA and PSN entail the disruption of cervical sensory pain fibers by severing afferent nerve fibers located in the uterosacral ligaments or pelvis. Nevertheless, due to a lack of sufficient evidence to validate the effectiveness and safety of these procedures, they are unlikely to be endorsed for the management of PD [57,58]. Furthermore, hysterectomy is regarded as a last resort in cases of severe refractory dysmenorrhea, but it should be avoided in adolescents, young women, and those who wish to become pregnant [59].
Figure no:4 Dysmenorrhoea Treatments [60]
Herbal Remedies:
Figure no:5 Ginger [71]
Figure no:6 Fennel [72]
Figure no:7 Chamomile [73]
Figure no:8 Pycnogenol [74]
Figure no:9 Cinnamon [75]
Figure no: 10 Peppermint [76]
Differential Diagnosis:
The differential diagnosis of dysmenorrhea encompasses a wide range of conditions. It can be divided into gynecological and non-gynecological categories: [77]
Pertinent Studies and Ongoing Trials:
Different phenotypes of dysmenorrhea probably exist; each associated with distinct underlying causes. The implementation of breakthrough pain management in treating dysmenorrhea, along with monitoring this in conjunction with menstrual pain, may prove beneficial in the future as relevant studies on NSAID-resistant treatments for dysmenorrhea develop.[9]
Prognosis:
An initial medical treatment procedure is initiated and maintained for a duration of 2 to 3 months prior to conducting a reassessment of the symptoms.Should there be an improvement in symptoms, yet they persist, an additional treatment method may be introduced.If there is little to no positive response observed, a modification of the treatment plan with the cessation of the initial approach might be proposed.Patients are to continue with the treatment for a further 3 months before undergoing another assessment.In the event that an adequate response is not achieved, an evaluation for a potential underlying cause of secondary dysmenorrhea may be commenced. Moreover, a comprehensive assessment of pelvic pain that includes contributions from physical therapy may also be taken into consideration.
Dysmenorrhea can considerably affect the daily lives of patients. This effect is evident in the levels of absenteeism from educational institutions or workplaces. Additionally, dysmenorrhea may restrict a patient's involvement in athletic activities or social gatherings. Moreover, there are emotional stressors linked to dysmenorrhea. In the United States, it is estimated that dysmenorrhea accounts for approximately 140 million hours of work lost annually, representing a public health issue with substantial economic consequences.[79]
The outlook for primary dysmenorrhea is typically favorable when recommended treatment options are utilized. Mild to moderate dysmenorrhea generally shows a positive response to NSAIDs. Although severe dysmenorrhea may also respond to NSAIDs, it might necessitate higher dosages or the use of combination/adjuvant therapies. In instances of persistent dysmenorrhea, it is essential to explore secondary causes. The prognosis for secondary dysmenorrhea is contingent upon the underlying etiology, type, location, and severity of the condition.
Complications:
The complications associated with primary dysmenorrhea can be characterized by the severity of the pain and its impact on the patient’s overall well-being, as well as its interference with daily activities. Given that primary dysmenorrhea is not associated with any underlying pathology or disease, there are no further known complications.
Conversely, the complications of secondary dysmenorrhea differ based on the underlying cause. These complications may encompass infertility, pelvic organ prolapse, excessive bleeding, and anemia, among others.[24][80]
Deterrence And Patient Education:
A balanced and nutritious diet, along with consistent physical activity, can alleviate the intensity of dysmenorrhea.[81] It is crucial to inform and raise awareness among young individuals about the significance of maintaining a well-balanced diet to mitigate the discomfort associated with dysmenorrhea. Certain vitamins and healthy dietary changes have been linked to a decrease in menstrual pain.[82][83][84]
Engaging in regular exercise has proven to be beneficial in lessening dysmenorrhea. Physical activity serves as a non-specific pain reliever by enhancing pelvic blood flow and promoting the release of β-endorphins.
The main objective of treatment is to alleviate pain and enhance the quality of life for individuals experiencing dysmenorrhea. Medical and procedural interventions should be utilized judiciously to enable affected individuals to carry out their daily activities without significant interruptions to their education or employment. Patients are encouraged to consult their healthcare provider if dysmenorrheic symptoms become troublesome and are not adequately managed.
Enhancing Healthcare Team Outcomes:
In the management of dysmenorrhea, it is crucial to adopt a multifaceted approach that involves a diverse team of healthcare professionals to guarantee patient-centered care and achieve optimal outcomes.Healthcare experts, including physicians, advanced care practitioners, nurses, pharmacists, and pelvic physical therapists, must have a comprehensive skill set that encompasses a profound understanding of gynecological health and pain management.
The strategy of the interprofessional team should focus on evidence-based, personalized treatment plans that cater to the distinct needs and preferences of each patient, while also adhering to ethical guidelines that uphold patient autonomy and informed consent. Patients ought to receive appropriate counseling regarding the treatment options available for dysmenorrhea, as well as the potential complications linked to secondary dysmenorrhea. The management of dysmenorrhea in a patient is contingent upon the severity of symptoms and the effectiveness of the treatment. The ultimate goal is to achieve improved outcomes with minimal disruption to daily activities.
Healthcare professionals are tasked with delivering compassionate and culturally aware care that enhances patient safety while reducing the risk of adverse effects or complications. Efficient interprofessional communication is essential to facilitate a smooth exchange of information and coordinated care, allowing the team to collaboratively customize treatments and interventions for each patient. By combining their expertise, strategies, ethical considerations, responsibilities, and communication efforts, the interprofessional team can improve patient-centered care, enhance outcomes, increase patient safety, and optimize team performance in the management of dysmenorrhea.[85]
Approaches To Treatment:
Alternative and conservative methods of care Following the initial evaluation, patients are frequently reassured that primary dysmenorrhea is a recognized disorder and that the disease is improbable. When patients show up early, the anomaly usually goes away over time. (After five years, prevalence drops from 72 to 67 percent in 19-year-olds, from 15 to 10 percent in those with daily activity limitations, and from 51 to 34 percent in work absenteeism.) Dysmenorrhea also usually gets better after giving delivery. One should not undervalue the therapeutic value of a patient’s relationship with her physician. Patients report feeling more relieved and satisfied with their care when their medical professionals communicate with them and involve them in decision-making. Exercise may alleviate dysmenorrhea, although observational investigations have yielded inconsistent results, and controlled trials have been limited and of low quality. There are plausible ways that exercise could be beneficial, and since it improves overall health and well-being, patients should be encouraged to engage in it. Although it is unknown if changing these factors can lessen symptoms, patients should be advised that smoking, obesity, stress, and alcohol usage are linked to more severe dysmenorrhea. The benefits of dietary supplements have not been demonstrated. However, since the intervention frequently has a large placebo effect, it is prudent to encourage women to use alternative or herbal therapies when there are strong cultural beliefs in them and where danger is improbable and the cost is not exorbitant. Numerous modest trials have shown the effectiveness of high-frequency transcutaneous electrical nerve stimulation (TENS), which is a good substitute for women who want to take less medications. According to current systematic reviews, there is inadequate evidence to support either acupuncture or behavioral therapy because most trials have small sample sizes and poor methodological quality.[86]
Prevention:
Dysmenorrhea has been treated in an outpatient setting using a variety of strategies, such as the following: Changing one’s lifestyle seems to be beneficial. Given that smoking may increase the likelihood of dysmenorrhea, quitting should be urged [87, 89]. Although the exact mechanism is unclear, exercise has been demonstrated to reduce dysmenorrhea symptoms [88, 90]. Relaxation techniques and other behavioral therapies may be useful in treating primary and secondary dysmenorrhea, according to a Cochrane review of five randomized controlled studies. [88] Relaxation exercise proved to be the most successful exercise strategy for reducing discomfort related to primary dysmenorrhea, according to a meta-analysis that looked at strength training, aerobic activity, yoga, combined exercise, relaxation exercise, and the Kegel maneuver. [91]
CONCLUSION:
The comparative examination of herbal and conventional treatments for dysmenorrhoea underscores the increasing significance of merging traditional knowledge with contemporary medicine. Although conventional therapies, including NSAIDs and hormonal treatments, deliver swift and effective pain relief, they frequently come with adverse effects and restricted long-term tolerance. Conversely, herbal solutions—such as Zingiber officinale (ginger), Cinnamomum zeylanicum (cinnamon), Foeniculum vulgare (fennel), and Curcuma longa (turmeric)—provide a safer, more comprehensive approach by addressing the root inflammatory and hormonal imbalances with minimal side effects.
In summary, herbal treatments not only relieve menstrual discomfort but also promote overall health and menstrual regularity, positioning them as a promising complementary or alternative option. Nevertheless, the necessity for standardized formulations, thorough clinical trials, and explicit dosage guidelines is essential to validate their efficacy and safety in comparison to conventional therapies. The future of managing dysmenorrhoea may indeed reside in an evidence-based fusion of herbal and conventional methods, ensuring effective, safe, and patient-centered care.
REFERENCES
Harshada Dhak, Prerana Vairag*, Dr. Sonali Uppalwar, A Comparative Study of Herbal Vs Conventional Therapies in Dysmenorrhoea Management, Int. J. of Pharm. Sci., 2025, Vol 3, Issue 11, 2561-2580 https://doi.org/10.5281/zenodo.17637625
10.5281/zenodo.17637625
