Effects of hot temperament herbs on primary Dysmenorrhea: a systematic review.

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Effects of hot temperament herbs on primary Dysmenorrhea:
a systematic review
Farrin Rajabzadeh (1)
Seyyed Mohammadbagher Fazljou (2)
Laleh Khodaie (3)
Shamsi Abbasalizadeh (4)
Leila Sahebi (5)
(1) Department of Iranian Traditional Medicine, School of Traditional Medicine,
Tabriz University of Medical Sciences, Tabriz, IR Iran.
(2) Department of Iranian Traditional Medicine, School of Traditional Medicine,
Tabriz University of Medical Sciences, Tabriz, IR Iran.
(3) Medical Philosophy and History Research Center, Tabriz University of Medical
Sciences, Tabriz, IR Iran.
(4) Department of Obstetrics and Gynecology, Alzahra Hospital , Faculty of
Medicine, Tabriz University of Medical Sciences, Tabriz, IR Iran.
(5) Assistant Professor of Epidemiology, Maternal, Fetal and Neonatal Research
Center, Tehran University of Medical Sciences, Tehran, IR Iran.
Corresponding author:
Seyed Mohammad Bagher Fazljou,
Department of Iranian Traditional Medicine,
School of Iranian Traditional Medicine, Tabriz University of Medical Sciences,
Tabriz, IR Iran.
Tel: +98-4113379527, Fax: +98-4113379527
Received: January 30, 2018; Accepted: February 10, 2018; Published: March 1, 2018. Citation:
Rajabzadeh
F. et al.
Effects of hot temperament herbs on primar y Dysmenorrhea: a systematic review.
World Family Medicine. 2018;
16(3):257-263. DOI: 10.5742/MEWFM.2018.93338
Abstract
Context: Dysmenorrhea refers to the symptom
associated with painful menstruation which af-
fects the quality of life of a large number of fe-
males who suffer from this disorder. Dysmenor-
rhea has two categories: primary, which occurs in
the lack of pelvic pathology and secondary, from
identiable organic causes. Current treatment for
primary dysmenorrhoea has a failure rate of 20%
to 25% and may be contraindicated or not toler-
ated by some patients. Herbal medicine may be
an appropriate alternative. In this article we focus
on herbal medicine to identify the efcacy and
safety of herbs with ‘hot temperament’ for primary
dysmenorrhea compared with placebo and other
treatments.
Evidence Acquisition: This systematic review
study was designed and executed in 2017. In
this review, 128 studies were evaluated, only 18
of which were randomized clinical trials of herbal
medicines in Iran. These trials included hot tem-
perament herbs. Required data was gathered us-
ing electronic databases, such as Scopus, Pub
med, Web of science, EMBASE and Chinese sci-
entic journal database, also articles were evalu-
ated according to the JADAD scale.
Result: There is no negative result in the studies.
Most of studies showed that the effects of Ginger
are higher than other herbs in the treatment of pri-
mary dysmenorrhea. All of the mentioned studies
showed the higher effect of herbal medicines than
Ibuprofen on the treatment of dysmenorrhea.
Conclusions: The present study discusses the
use of hot temperament herbs for primary dys-
menorrhea. Effective herbal medicines can be
used as a good alternative to treat women who
do not respond well to conventional therapies or
have contraindications to use of these drugs.
Key words: herbal medicine, dysmenorrhea, ran-
domized clinical trial

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Introduction
Dysmenorrhea is dened as symptoms associated with
painful menstruation which can be divided into primary
and secondary dysmenorrhea (1). The latter is a type of
menstrual pain not a primary gynecologic disorder (2). More
than 50% of women have primary dysmenorrhea. (3). For
most women, menstrual pain tends to occur after pregnancy.
Primary dysmenorrhea is affected by unnecessary
levels of prostaglandins, hormones which make uterus
indenture during menstruation and childbirth. The pain
seems to result from uterus contractions, due to reduced
blood supply in the inner uterine lining (endometrium)
(4). Other factors which can cause the pain of primary
dysmenorrhea, include a retroverted uterus (5). Non-
steroidal anti-inammatory drugs (NSAIDs) are operative
in dismissing the pain of primary dysmenorrhea but which
has side effects of nausea, dyspepsia, peptic ulcer, and
diarrhea. (6). Hormonal birth control may progress signs
of primary dysmenorrhea (7). Recent studies have shown
that the birth control pill, comprising low doses of estrogen,
reduces pain related with dysmenorrhea. (6,8). Norplant
and Depo-Provera are also effective, since these methods
often induce amenorrhea (9). Because of side effects and
contraindication of these medicines, some peoples cannot
use chemical or hormonal drugs. That is what makes us
think of new treatments (10). Traditional medicine has
enjoyed a special status among people throughout the
past, most of which is related to medicinal herbs (11).
In the past, a verity of studies have been conducted for
treatment of dysmenorrhea (12). There are inadequate
data to commend the use of herbal supplements for the
treatment of dysmenorrhea such as melatonin, vitamin E,
and fennel (13). Supplementary research is recommended
to follow up strong evidence of advantage of ginger,
valerian, zinc sulphate, sh oil, and vitamin B1(14).
Traditional Chinese herbal medicines are a method for
the treatment of dysmenorrhea, some of which were not
accepted in Iranian Culture (15). Traditional Iranian books
are a rich source of medicinal herbs for dysmenorrhea.
Some of these herbs have undergone clinical trials and
have had effective results (16).
The functional mechanism of herbal medicines is still not
understood but some of them have anti-inammatory
and anti-spasmodic effects (17). However, a variety of
studies have focused on herbal medicines. In addition, a
lot of studies have shown the effect of herbal medicines
on dysmenorrhea in Iran. Because of dysmenorrheal
etiology which is prostaglandin F 2 α (PG-F2α) effects
stimulate the uterine muscles and cause severe vascular
contraction (18). For this reason, one of the effective
treatments for primary dysmenorrhea is the administration
of prostaglandin-medications. Some women cannot use
herbal medicines with ‘cold temperament’, so the present
study focused on hot temperament herbs to nd the efcacy
of ‘hot temperament’ herbs on primary dysmenorrhea.
Methods
Study design and search strategy
In this systematic review which was performed in
2017, the required data was gathered using electronic
databases, such as Scopus, Pubmed, Web of Science,
EMBASE and Chinese scientic journal database. The
key words used in the present study were dysmenorrhea,
primary dysmenorrhea, herbal medicines, medicinal
plants, hot temperament. All randomized controlled trails
(RTCs) had to be included in this study. Observational,
cohort, qualitative, and laboratory studies were excluded.
Women of reproductive age with primary dysmenorrhea
and no identiable pelvic pathology, ultrasound scan
and laparoscopy examination and self reporting women
were included in this study. Exclusion criteria consisted
of dysmenorrhea resulting from use of intra uterine
contraceptive devices and patients with a diagnosis of
pregnancy, stroke, and organic disease; in addition, cold
temperament herbs were excluded from the study.
Article evaluation
The selected papers extracted from the databases
were assessed by two investigators using Jadad scale.
Discrepancies between the two raters were referred to the
third investigator. In this balance, the maximum mark is
5 and the papers with marks of 3 were examined in this
study.
Results
In this review, 128 studies were identied, only 18 of which
were clinical trials of herbal medicines in Iran. These trials
include hot temperament herbs (Figure 1 & Table 1).
Ginger (Zingiber ofcinale Rosc)
Ginger is one of the main hot temperament herbal inhibitors
of prostaglandins, which has been traditionally used for the
treatment of dysmenorrhea, arthritis, and colic (19). Ginger
is grown in more countries such as India, China, Nigeria, and
Thailand (20). The main effects of Ginger are anti-nausea,
blood clotting, antibacterial, antioxidants, anti cough, anti-
liver poisons, anti-inammatory, urinating, reduced spasm,
anti-atulence. In Iranian traditional medicine ginger
was used with a mix of candy and buckthorn to prevent
atulence of premature fruit (21). Also Ginger can secrete
cortisol and manage kidney transplantation (22). Blood
cholesterol lowering Oleoresin and essential oil are also
produced from ginger (23). Ginger can be boiled in water
and drinking the solution can reduce the pain. Ozgoli et al.,
in a double-blinded clinical trial study, showed that ginger
has the same effect of mefenamic acid or ibuprofen in
pain reduction. Their study had 3 groups, including Ginger
(64%), ibuprofen (66%) and mefenamic acid (58%). The
mechanism of Ginger is to inhibit cyclooxygenase and
lipooxygenase pathways in prostaglandin, which is the
main effect of ginger on menstrual pain (24).
Chamomile (Matricaria Chamomilla)
This ower is a traditional herbal medicine whose extract
shows both anti-inammatory and anti-spasmodic effects.
It is also helpful for women with constipation, leading to

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Figure 1: Flowchart showing the trial selection process for the study investigating hot temperament plants on
primary dysmenorrhea
pain reduction with sedative and anti-anxiety effects
(25-27). Chamomile is used for a sore stomach, bowel
syndrome, and gentle sleep aid. It is also affected as a
mild laxative and is anti-inammatory and bactericidal
(28). Chamomile is a little bitter herb that effects to soothe
nerves, increase mental awareness, settle the stomach
and promote digestion (29). Its formal use is tea to calm
hyperactive children, menstrual cramps, and asthma.
Chamomile is useful for the liver and lungs and helps
reduce jaundice, relieve chest pain, eliminate infection,
swelling, and ease withdrawal from drugs (30-34, 35). For
treating the sore stomach can take a cup not accompanied
by food for three months. Chamomile assists healing of
wounds in animals. It also showed some benet in an
animal model of diabetes (36). Essential oil of chamomile
is an important antiviral agent against herpes simplex virus
type 2 (HSV-2) in vitro (37). The methanol extract of M.
recutita showed effective anti allergic activity by reserve of
histamine release from mast cells in cell-mediated allergic
models (38). A variety of studies have examined the effect
of Chamomile on primary dysmenorrhea. A study carried
out by Bani et.al. showed that prescription of Chamomile
tea to a study group was signicantly different from control
groups after one month’s drinking (39). Another study
showed that the Chamomile was more effective than
mefenamic acid in pain reduction.
Mint ( Mentha Longifolia):
This medicine is another hot temperament herb which has
been used to treat stomach disorders, nausea, vomiting,
and dysmenorrhea (40). Mint has a common use for
alleviation of stomach pain, as a blood diluent and is effective
in strengthening the stomach. Mint contains phenolic
compounds such as Rosmarin Acid and Flavonoids and
has antimicrobial, antiviral, antioxidant and analgesic
properties. It has been shown in laboratory studies that the
menthol content of mint oil acts as an antagonist of calcium
channels and has the property of muscle relaxation (41).
This herbal medicine can be used as a tea. In a study
conducted by Xu Huaxi et al., no signicant difference was
found between Mint and nonsteroidal anti-inammatory
drugs (NSAIDs)(42). Zataria Multiora is a member of
the mint family and its oil is thymol and carvacrol. Some
studies showed that Zataria is useful to treat respiratory
diseases and dysmenorrhea(43). Antispasmodic effects of
smooth muscles are a common property of Multiora. This
herb can inhibit contractions caused by cell depolarization
and block calcium channels. Amoueeroknabad. divided
these herbs randomly into 3 groups, including placebo,
1% of the multiora oil and 2% of the multiora oil. The
study showed that multiora leads to pain reduction in a
third group (44).
Valeriana ofcinalis:
This has been a sedative drug since the 11th century
(45). The main effects of valeriana are strengthening
the brain, reducing infections and strengthening the liver
and stomach to treat icterus (jaundice). It is also useful
for uterine inammation and kidney pain (46). It can
reduce chest pain (47). Valerian has a function similar
to benzodiazepines; however, as a substitute of binding
to the gamma subunit like a benzodiazepine, it seems to
bind to the beta subunit on the GABA-A receptor instead
(48). Valerian can decrease the removal or metabolism of
GABA, thereby allowing GABA to stay around longer (49).
Valeriana roots and rhizomes have essential oil which
contain valepotriates. Three studies have been conducted
on Valeriana which associated the consequence of its
root with placebo, mefnamic acid and other NSAIDs,
respectively. The rst study showed that Valeriana was
most effective in pain reduction, as compared with placebo
(50). In the second and third studies, it was found that
valeriana has the same effect as mefnamic acid and other
NSAIDs. Recent studies have shown that systematic
symptoms of dysmenorrhea were reduced after taking
Valeriana (51).

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Table 1.summary of included trials

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Cramp Bark and Black Haw:
Cramp Bark and Black Haw are most effective herbs to
reduce uterine cramps and relieve pains and uterine
muscle contractions (36, 52). The suitable dose of cramp
bark depends on user’s age, health, and several other
conditions. There is no study to regulate a suitable range
of doses for cramp bark. (32, 53-55). A study carried out by
Su Zhaoilaiang et al. showed that these herbs are safe for
use for several days to prevent painful cramps. In that study,
the herbs were compared with ibuprofen, and their results
showed that there is no signicant difference between the
herbs and chemical effects. However, ibuprofen exhibits
more side effects as compared with Cramp (28, 33, 56-58).
Foeniculum vulgare
Fennel is a herb that has been used for many years in
traditional Iranian medicine as an anti-inammatory and
analgesic pain in cats. The herb has a warm and dry
effect and is used to strengthen the stomach and remove
its inammation. In addition, it is a diuretic and leads to an
increase in menstrual blood and assists in breastfeeding.
According to Iranian medical documents, due to its warm
and dry nature, it is useful in removing biliary obstruction
(59). This herbal medicine has numbing effects in uterus
by constraining reductions induced by oxytocin and
prostaglandins. (59). Khorshidi et al. showed that F.
vulgare essential oil was benecial in reducing pain and
systemic symptoms of primary dysmenorrhea compared
with placebo (60), but the study of Zahrani et al., showed no
affect on systemic symptoms (61). Jahromi et al. compared
F. vulgare and mefenamic acid in their study. (62). In the
study of Zeraati et al F.vulgare and Vitex are more effective
than mefenamic acid in reducing dysmenorrhea. (63) F.
vulgare has been active in reducing of dysmenorrhea in all
studies which compare with placebo.(64,65).
Cumminum cyminum
In a randomized clinical trial, the effect of C. cyminum
on primary dysmenorrhea compared to placebo and
mefenamic acid, demonstrated that treatment with C.
cyminum was equal to treatment with mefenamic acid
(66). Cumin has a warm and dry nature and is useful in
the treatment of epistaxis and is useful for embroidery,
anti-aking and sweating, it causes weight loss. Due to
its nature, it makes it easy to reduce blood pressure and
reduce menstrual pain.
Cinnamomum zeylanicum
Cinnamon is warm and dry, it is mentioned in Iranian
medical texts and has been used as an antibiotic, for
anesthetizing, diuretic and regulating, enhancing the libido,
strengthening the stomach and liver. It is also used to treat
‘cough Prodotti’. Cinnamon oil has been used to relieve
uterine pains. Some studies reported that C. zeylanicum
has an antispasmodic effect. Eugenol can also prevent
biosynthesis of prostaglandins and affect inammation
(67). A study where C. zeylanicum capsule was compared
with placebo showed the effect of C. zeylanicum on severity
of dysmenorrhea was more than effect of placebo(68). C.
zeylanicum has anti-microbial, anti-parasitic, anti-oxidant
and free radical scavenging properties. In addition C.
zeylanicum reduced blood glucose, serum cholesterol
and blood pressure, so it can be useful in treatment of
cardiovascular diseases. (69)
Melissa ofcinalis (Lemon Balm)
It is warm and dry, and it is a central nervous system
augmentator. It is useful in the treatment of neurological
diseases. It is used in the treatment of sleep disorders and
also has a sedative effect. It is also helpful in relieving pain.
Melissa ofcinalis can be used for pain relief and treatment
of some diseases. One study showed that Melissa was
more operative than mefenamic acid in release of pain on
primary dysmenorrhea (70).
Discussion
This study was conducted to evaluate the effect of
medicinal plants on the treatment of primary dysmenorrhea
in Iran. The aforementioned articles had a great deal
of variation in the type of plant studied, which requires
more studies with more stringent methodology to apply to
many of these plants. It also examined hot temperament
herbal medicine on the intensity of primary dysmenorrhea.
Studies conducted on Ginger found it to be more useful
than those conducted on other herbs. Eight trials received
score 4 from Jadad. (29). There is no negative result in
the studies. Most of the studies showed that the effects
of Ginger are higher than other herbs in the treatment of
primary dysmenorrhea. However, only one study presented
that the effect of Mint herbs is higher than Ginger (30).
Collectively, all of the above-mentioned studies showed
the higher effect of herbal medicines than Ibuprofen on
the treatment of dysmenorrhea (41). In addition, some
publications discussed ‘cold temperament’ herbal medicine
such as Coriander to reduce dysmenorrhea. Some studies
focused on Cramp and multiora, showing positive results
and on their ability to reduce dysmenorrhea. The present
study demonstrated the higher effect of herbal medicines
as compared with NSAIDs; in addition, Ginger may be a
real and safe therapy for pain relief in women with primary
dysmenorrhea if administered during the days prior to
menstruation. Conclusion of this study is focus on those hot
temperament herbs which passed the clinical trials studies
and are common in Iranian traditional medicine. Effective
herbal medicines can be used as a good alternative to treat
patients who do not respond well to conventional therapies
or have contraindications to use these drugs.
Acknowledgements
The authors gratefully acknowledge the nancial support
for this work that was provided by Tabriz University of
Medical Sciences. This research presented as a PhD
thesis at School of Iranian Traditional Medicine, Tabriz
University of Medical Sciences.
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