Comparison of the effect of Chamomile and Mefenamic Acid on primary dysmenorrhea, associated symptoms and menstrual bleeding – A randomized clinical trial study

The study was conducted on 200 female students. The inclusion criteria were as follows: single students with moderate to severe menstruation pain (score four or higher of pain intensity according to visual analog scale, age range of 18-30 years, initiation of menstruation pain before 20 years of age, regular menstruation cycles with intervals of 21-35 days, menstrual bleeding without passing clots (low and moderate bleeding), onset and duration of menstruation from a few hours before menstruation up to day 5 of bleeding. Other criteria were lack of chronic diseases, no consumption of drugs such as anticoagulants, oral contraceptives, benzodiazepines, narcotics, lack of regular exercise, abnormal vaginal discharge, history of allergy to herbs, stressors in the last two months, special dietary requirements, history of pelvic inammatory disease, myoma and pelvic tumors, history of gynecological surgery, transfer to another university and graduation within the next six months. score symptoms); score 1 (mild activities); score 2 (symptoms exist and interfere but debilitating; score 3 (symptoms are quite debilitating and severe


Results
Severe pain during two months after intervention was in 6 (6.3%) of group (B) and 6 (6.3%) in group (A) (p = 0.351, p = 0.332). Mean severity of associated symptoms two months after the treatment was( 4.93 ± 3.54) in group (B) and (5.62 ± 3.54 ) in group (A), indicating further reduction in group (B) but not signi cant (p = 0.278). Mean of bleeding was (88.71 ± 66.4 vs. 70.54 ± 53. 34) in group (B) and (A) respectively, in two months later. therefore decrease in the two groups but was not signi cant between groups(p = 0.567).

Conclusions
It seems chamomile sachet can reduce the severity of pain and bleeding similar to mefenamic acid and even further mitigate the symptoms associated with dysmenorrhea.

Trial registration:
This study was performed with the proposal approval code of 2611, ethics code of (ARAKMU.REC.1395.164) at Arak University of medical sciences and code of IRCT 2016100825031N5 on 2016.11.08.

Background
Primary dysmenorrhea is one the most common problems for young girls. It is associated with painful menstruation without a pathologic cause beginning with crampy abdominal pain shortly before menstruation and lasting up to 72 hours. However, considering the increasing secretion of prostaglandin in the rst 48 hours of menstruation, the highest intensity of pain occurs at this time (1). In studies conducted regarding the prevalence of primary dysmenorrhea in young women, varying degrees of pain (60-90%) have been reported (2); nevertheless, the severity of pain in a number of patients is so severe to interfere with daily activities, which is a leading cause of absenteeism from school and work (3,4).
NSAIDs have a special place in suppressing in ammation due to decreasing the levels of prostaglandins (19). These drugs lead to a signi cant decrease in PG concentration in endometrial uid and a decrease in uterine tone by inhibiting cyclooxygenase. Mefenamic acid is a common NSAID but cause a range of adverse effects such as diarrhea, stomachache, and nausea to serious illness such as chronic renal disease and osteoporosis (20). Nowadays, complications of chemical drugs have shifted the attention of people and researchers to complementary therapies (21,22).
Chamomile plants, namely Chamomilla recutita and Matricaria Chamomilla, have a positive effect on dysmenorrhea due to anti-in ammatory activity (23). The use of chamomile reduces abdominal and pelvic pain, fatigue, lethargy and depression during menstrual cycles (24). The ethanolic extract from the owers of this plant has anti-in ammatory, anti-spasmodic, anti-anxiety and sedative effects (25). Although US Food and Drug Administration states that chamomile has no side effects on pregnancy, lactation or on children, researchers have recommended further studies on the side effects and bene ts of complementary medicine (26-27).
There have been several studies on the e cacy of chamomile along with mefenamic acid, indicating that chamomile has been as effective as mefenamic acid in reducing pain but the effect of chamomile on menstrual bleeding has shown different results. Also, there have been few studies on symptoms associated with dysmenorrhea (28), thus the need for further studies with different forms and doses of chamomile with more people living in different places, and comparison with safe drugs is felt to con rm previous results or nd new results of chamomile effects on dysmenorrhea and its symptoms (22,(28)(29)(30)(31)(32)(33)(34).
The goal of this research is to compare the effect of chamomile sachet with mefenamic acid capsule on primary dysmenorrhea, associated symptoms and the volume of menstrual bleeding.

Study design
The present study is a double blind randomized clinical trial conducted on 200 female students fromfour universities in Arak in 2018. The city of Arak has six universities and sampling was performed by draw from four universities.

Study participants
The study was conducted on 200 female students. The inclusion criteria were as follows: single students with moderate to severe menstruation pain (score four or higher of pain intensity according to visual analog scale, age range of 18-30 years, initiation of menstruation pain before 20 years of age, regular menstruation cycles with intervals of 21-35 days, menstrual bleeding without passing clots (low and moderate bleeding), onset and duration of menstruation from a few hours before menstruation up to day 5 of bleeding. Other criteria were lack of chronic diseases, no consumption of drugs such as anticoagulants, oral contraceptives, benzodiazepines, narcotics, lack of regular exercise, abnormal vaginal discharge, history of allergy to herbs, stressors in the last two months, special dietary requirements, history of pelvic in ammatory disease, myoma and pelvic tumors, history of gynecological surgery, transfer to another university and graduation within the next six months.
The exclusion criteria were as follows: patients' desire to leave the study, having any disease requiring prolonged or continuous medication, dietary supplements and vitamins, reluctance to continue taking the drug on their own for any reason, failure to complete the pain severity table and other questionnaire items, incidence of stressful conditions over the past two months, history of contraceptive use, undergoing any surgery during the study, getting married over the study period, changing the place of residence and not consuming the drugs according to the protocol failure to complete questionnaire .

Sample size
Sample size was calculated 45 students in each group based on con dence interval of 95%, power of 80% and minimum average difference score (d) of 0.5. Due to insu cient quantity of medication and other consumables, the number of samples reached 90, and 100 participants were assigned to each group after adding a possible attrition rate of 10%.
The following formula was used to calculate the sample size:

Study procedure
After obtaining the approval of University Ethics Committee and IRCT code as well as receiving a letter from Arak University of Medical Sciences that was presented to the heads of Arak universities, , the researcher referred to the universities for sampling. Announcements were made for students with menstrual pain. By referring students, researcher, study aim and execution method fully explained. The checklist, which included demographic information, midwifery, entry and exit requirements, was given to individuals and how to ll out a checklist, especially the pain scale, was taught.After completing the checklist, students who were eligible to enter the project were randomly invited to collaborate according to the sample size.
Out of 350 participants (from a total of 1200), 200 students eligible to enter the project who were willing to cooperate were chosen after submitting written informed consent forms. The subjects were randomly divided into two groups of mefenamic acid (group A) and chamomile sachet (group B) using random blocks. The contents were enclosed in envelopes of the same shape and then the blinding was done. The willingness of the company to conduct research and keep the information con dential was emphasized for the research units.
The researcher again described the research procedure to the subjects and an emphasis was put on precise use of medication and correct completion of questionnaire(especially measuring intensity of pain, complete the table bleeding and determining the severity of associated symptoms).In addition, the address and phone number of the researcher was given to students for their follow-up.
To comply with the ethical considerations for pain relief, volunteers could use other dwellings if they did not have pain control and should record the exact type and number of dwellings accurately.
Medications for each group as well as sanitary pads with medium size from the same brand without absorbent material were given to students to measure the amount of menstrual bleeding in the preintervention cycle as well as two consecutive interventional cycles.
The sachet for the chamomile contained 5000 mg of chamomile and a spoonful of honey was consumed per serving. Due to the bitter taste of chamomile, honey was used in small amounts only as a avoring with sachet of chamomile to improve its taste. Studies show that therapeutic doses of honey can be effective in treating dysmenorrhea (35,36). The sachet contents were gently boiled in a glass of water for three minutes, ltered and dissolved in a spoonful of honey and were then ingested.
On the other hand, 250 mg mefenamic acid capsules were administered to the subjects in the mefenamic group. The two groups received the same instruction for two days before menstruation up to three days after it and three daily servings for two consecutive cycles. The researcher followed up the timely and correct consumption of medicinal plants and mefenamic acid and was also associated with students in cyberspace. In this study, ve subjects in chamomile sachet and four subjects of mefenamic acid group did not continue participation in the study ( Figure 1).

Study procedure
After obtaining the approval of University Ethics Committee and IRCT code as well as receiving a letter from Arak University of Medical Sciences that was presented to the heads of Arak universities, , the researcher referred to the universities for sampling. Announcements were made for students with menstrual pain. By referring students, researcher, study aim and execution method fully explained. The checklist, which included demographic information, midwifery, entry and exit requirements, was given to individuals and how to ll out a checklist, especially the pain scale, was taught.After completing the checklist, students who were eligible to enter the project were randomly invited to collaborate according to the sample size.
Out of 350 participants (from a total of 1200), 200 students eligible to enter the project who were willing to cooperate were chosen after submitting written informed consent forms. The subjects were randomly divided into two groups of mefenamic acid (group A) and chamomile sachet (group B) using random blocks. The contents were enclosed in envelopes of the same shape and then the blinding was done. The willingness of the company to conduct research and keep the information con dential was emphasized for the research units.
The researcher again described the research procedure to the subjects and an emphasis was put on precise use of medication and correct completion of questionnaire(especially measuring intensity of pain, complete the table bleeding and determining the severity of associated symptoms).In addition, the address and phone number of the researcher was given to students for their follow-up.
To comply with the ethical considerations for pain relief, volunteers could use other dwellings if they did not have pain control and should record the exact type and number of dwellings accurately.
Medications for each group as well as sanitary pads with medium size from the same brand without absorbent material were given to students to measure the amount of menstrual bleeding in the preintervention cycle as well as two consecutive interventional cycles.
The sachet for the chamomile contained 5000 mg of chamomile and a spoonful of honey was consumed per serving. Due to the bitter taste of chamomile, honey was used in small amounts only as a avoring with sachet of chamomile to improve its taste. Studies show that therapeutic doses of honey can be effective in treating dysmenorrhea (35,36). The sachet contents were gently boiled in a glass of water for three minutes, ltered and dissolved in a spoonful of honey and were then ingested.
On the other hand, 250 mg mefenamic acid capsules were administered to the subjects in the mefenamic group. The two groups received the same instruction for two days before menstruation up to three days after it and three daily servings for two consecutive cycles. The researcher followed up the timely and correct consumption of medicinal plants and mefenamic acid and was also associated with students in cyberspace. In this study, ve subjects in chamomile sachet and four subjects of mefenamic acid group did not continue participation in the study (Figure 1).

Data collection tools
Data collection was done by a questionnaire in three times. Questionnaire No. 1 ,2 and 3 were completed by research units before intervention, one and two months after the intervention, respectively. The questionnaire consisted of demographic information, investigating pain intensity and duration using pain ruler, menstrual blood loss was evaluated using a pictorial chart and accompanying symptoms of dysmenorrhea were assessed using the Andersch-Milsom verbal scale.
The intensity of dysmenorrhea pain was assessed by Visual Analog Scale (VAS) and 8-10, 4-7, and 1-3 scores represented severe, moderate, and mild pain, respectively. Pictorial Bleeding Assessment Loss Chart (PBAC) was employed to determine the extent of bleeding, indicating an estimate of the blood loss through menstruation with mild (score 1), moderate (score 5), and severe (score 20) criteria on a sanitary pad. In this chart, small quantity of blood on sanitary pads was given score 1, the large ones score 5, and impregnation with blood score 20. The chart also rated small and large clots. Small clots scored 1, large clots 5, and ow of blood scored 10. A score <50 indicated mild bleeding, 51-100 moderate bleeding, and >100 hypermenorrhea during menstruation. The scores were summed up to calculate the overall score. The symptoms related with dysmenorrhea were measured based on Andersch-Milsom Verbal Multidimensional Scoring System. Four grades have been mentioned in this scale for the severity of dysmenorrhea symptoms as follows: score 0 (no symptoms); score 1 (mild symptoms are present but do not interfere with daily activities); score 2 (symptoms exist and interfere with daily tasks but are moderate and not debilitating; score 3 (symptoms are quite debilitating and severe (15).
Isolation of essential oil 500 g of chamomile ower was hydro distilled for 12 h in a Clevenger type apparatus to isolate the essential oils Thenwere stored in dark conditions at -4°C for GC/Mass analyses.

Statistical analysis
Analysis of collected data was done using SPSS software through descriptive statistics of percentage and mean as well as analytical statistics including Mann-Whitney U, Wilcoxon, repeated measure ANOVA and X2 tests.

Ethical consideration
This study was performed with the proposal approval code of 2611, ethics code of (ARAKMU.REC.1395.164) at Arak University of medical sciences and code of IRCT 2016100825031N5. All the ethics principles of the Helsinki Charter were observed in the study. After submitting a letter to the research institution and the participants, the researcher obtained written consent from the volunteer participants.

Demographic characteristics
The demographic and midwifery characteristics of subjects evaluated by Kruskal-Wallis test )age, menarche, age of dysmenorrhea onset), Fisher's exact test and chi-square test (education level, menstruation cycle, length of menstruation bleeding per day, and regular menstruation) are shown in Table 1.

Symptoms of dysmenorrhea
The results of Friedman test showed a signi cant decrease in the severity of pain one and two months after treatment in group A (p = 0.001) and in group B (p = 0.001) and Fisher's exact test results indicated that the frequency distribution of pain intensity within one (p = 0.351) and two months (p = 0.332) of treatment was no signi cantly different in the two groups (P = 0.001) ( Table 2). test showed that changes in scores of associated symptoms in both groups were signi cant up to one month after the intervention ( Table 3).
Results of between-group repeated measure test with control for confounding effects (age of dysmenorrhea) showed that there was no signi cant difference in mean score of the number of pain days (p = 0.248, F = 1.371), the mean score of associated symptoms (p = 0.278, F = 1.183) and score of Hingham with confounding effect (Hingham score in baseline and age of dysmenorrhea) (p = 0.567, F = 0.329) ( Table 3). Comparison of each of the associated symptoms in detail using Friedman test revealed that although the mean severity of associated symptoms in chamomile sachet group was reduced to a higher extent than the mefenamic acid group, no signi cant statistical relationship was found in this difference one and two months after the treatment (p = 0.262 and p = 0.131, respectively). Symptoms such as headache, back pain, diarrhea, dizziness, fatigue and anorexia in sachet of chamomile group showed a higher reduction in average intensity (p = 0.001). Moreover, the mean intensity of symptoms such as vomiting, fainting and mood changes had a higher reduction in the mefenamic acid group but was not signi cant (Table 4). Overall, the reported side effects of mefenamic acid users included gastrointestinal complications (n = 9) and the complaint in the chamomile group was bitter taste and vomiting (n = 5).

Discussion
The present study showed that chamomile and mefenamic acid both reduced pain intensity, duration of pain and bleeding equally, chamomile appears to be more successful in alleviating the symptoms associated with dysmenorrhea.
Research shows that α-Bisabolol and its oxides in the owers of chamomile have therapeutic value. Chamomile has antispasmodic, anti-in ammatory, antihistamine, antioxidant, and anti-anxiety properties.
Due to the presence of avonoids and alkaloids with direct effect in the reduction of prostaglandins, active ingredients such as spiroether, namely a strong antispasmodic agent ,also having the ability to block the calcium channel, chamomile can relieve the pain during the menstruation and prevent premature delivery.
Other studies have reported the reduced amount bleeding of chamomile same to other drugs such as mefenamic acid, ginger and fennel, and the decrease of bleeding between chamomile and the drugs mentioned did not differ signi cantly (43,25); however, no information is available on its mechanism of action (44).
one of the most likely factors causing severe menstrual bleeding has been reported to be an increase in the production of uterine prostaglandins. PGE2 and PGF2α increase blood ow to the uterus and E2 prostaglandins are vasodilators, thus elevating the risk of menstrual bleeding. Several researches have shown that the inhibition of prostaglandin synthesis can decrease the amount of menstrual bleeding in women. Since chamomile has anti-prostaglandin properties, it inhibits cyclooxygenase and stops the production of prostaglandins and leukotrienes . (28,31) According to traditional medicine, dysmenorrhea occurs due to the cold and the concentration of substances in the uterus, which requires a drug that is warm and able to relieve the cold as well as eliminating the concentration of substances (45,46). Chamomile has a hot and dry temperament and is able to relieve uterine coldness; moreover,, it is soluble and can alleviate the concentration and help relieve dysmenorrhea and its associated bleeding (47). Karimian et al. performed a clinical trial on 90 female students with primary dysmenorrhea. In this study, one group received 250 mg chamomile capsules and the other group took mefenamic acid capsules 250 mg every 8 hours from 48 hours before menstruation to 24 hours after it, which was administered in two cycles.The results showed that chamomile is as effective as mefenamic acid in relieving dysmenorrhea and that the amount of bleeding decreased in the two groups (33). Study of Radfard showed that chamomile reduced the severity and duration of pain during menstruation similar to yarrow (37) and in Modarres study, severity of pain and mean hemorrhage score decreased with chamomile that considerably alleviated pain (28).
Results of Naja 's study comparing bleeding amount between chamomile capsules or placebo using Higham chart showed the average bleeding in the chamomile group decreased after its consumption (31).
Abedian showed that the bleeding was reduced in both groups of chamomile and mefenamic acid (44).
The results of the present study using chamomile as a sachet before the onset of menstruation (Due to chamomile is more effective on relieving dysmenorrhea if it is used before pain begins) (25) are consistent with other studies with capsule, drop, tea, and different amounts of chamomile (25,48,22). In a study to compare the effects of chamomile extract and mefenamic acid on PMS, Shari reported complications of chamomile increasing bleeding, that may be due to the type and concentration of active ingredients in chamomile in different places of cultivation and different seasons of the year and needs more study.
Examination of changes in symptoms associated with primary dysmenorrhea in this study showed that the mean severity of signs such as back pain, diarrhea, dizziness, headache, anorexia and fatigue was further decreased in chamomile group, and the difference was signi cant in relation to the headache symptom.
Studies show that chamomile in addition to antispasmodic and anti-in ammatory properties, is a stimulant factor of central nervous system. Apigenin, glycine, luteolin and avonoids found in chamomile bind benzodiazepine receptors and have anxiolytic and sedative effects and are effective for stress and anxiety relief (37,38,49,50). It seems that chamomile can be used to treat nightmares and other sleep disorders (50). Dysmenorrhea is associated with neurological symptoms and it is predicted that the consumption of chamomile will improve the quality of sleep and reduce fatigue.
In addition, due to the sedative effects of chamomile, a person's mental state as well as mood disorders such as irritability is likely to improve (51)(52)(53). In the study of Janabi on primary dysmenorrhea, menstrual pain, anxiety and emotions in the chamomile tea group had a signi cant difference from the control group (25). Yazdani showed that the consumption of fennel and chamomile had a signi cant effect on dysmenorrhea and on the three symptoms of premenstrual syndrome abdominal and pelvic pain, fatigue, lethargy, and depression with anger. Chamomile has been shown to be more effective in relieving abdominal and pelvic pain, depression, anger, and fennel is more effective in reducing fatigue and lethargy (48). Dadfar showed that chamomile extract reduced the severity of PMS anxiety, depressive symptoms and retention symptoms; however, it had no effect on physical and emotional symptoms (49). In another study, the physical symptoms were decreased to the same degree by chamomile extract and mefenamic acid and the decrease in psychological symptoms by chamomile was more pronounced than mefenamic acid. It was concluded that avonoids, apigenin and luteolin in chamomile have anti-anxiety and sedative effects, while mefenamic acid has anti-prostaglandin effects (34). The reason for the difference in the results as previously mentioned, could be due to the difference in the method of preparation of the drug and its effect on the active ingredients.In this research, gastrointestinal complications occurred in those taking mefenamic acid and although other studies show improved gastrointestinal complications using chamomile, it caused vomiting symptoms in our study. It seems that bitter taste of chamomile sachet leads to low digestive tolerance and vomiting in these individuals.Researchers suggest the combination of chamomile and honey for treatment of dysmenorrhea and further studies and long-term trial studies with a larger number of participants are necessary to ensure the de nitive effectiveness of herbal remedies.

Conclusions
The results of the study showed that chamomile sachet was effective in reducing pain and symptoms associated with primary dysmenorrhea and menstrual bleeding similar to mefenamic acid capsules. It is recommended that midwives and reproductive health professionals use complimentary methods in clinical elds and suggest them as treatment options according to the needs of women.
Limitation A limitation of this study was self-assessment. The method of completing the questionnaire was fully explained to the subjects and in all stages of the study, the researcher was in contact with the research units. Also, it was not possible to completely simulate plant compounds with mefenamic acid. Attempts were made to minimize the effects of disruptive factors such as immeasurable stress and consumption of tea, coffee, and salt through randomization. Appropriate sample size was used to reduce the selection error, and blinding was performed to reduce the error of data interpretation.

Consent for publication
Written and informed consent has been obtained from all the students.

Availability of data and materials
The source of data and materials will not be shared because we are working on another related research topic and are preparing to publish it.

Competing interests
There was no con ict of interest between the authors as well as with Traditional Medicine School of Tehran University providing the combined sachet.

Funding
This study was funded with the proposal approval code No. 2611 at Arak University of Medical Sciences in Iran.

Authors' contributions
Sh F, NB F, BM, and B S designed the study. Sh F,N F and VC conducted the study and Sh F, NB F,N F,BM and VC analyzed and interpreted results and wrote and approved the nal manuscript. Sh F, NB F supervised the project. All authors read and approved the nal manuscript.
NB F, agrees to be held accountable for all aspects of this work. Consort Flow Diagram