Comparative Study on Ginger Supplement and Aerobic Exercise on Primary Dysmenorrhea: the Case of Debre Markos University Students, Amhara Regional State, Ethiopia

Background Primary dysmenorrhoea is a chronic cyclical pelvic pain associated with menstruation in the absence of an identiable pathological condition. Dysmenorrhea is one of the most common complaints of gynecological problem worldwide among young females. The purpose of this study was to investigate the effects of 12 week ginger supplement and aerobic exercise on primary dysmenorrhea the case of DebreMarkos university students. Methods Forty (40) female students who had the history of primary dysmenorrhea aged between 19–22 years from departments of sport science and stastics students in Debre Markos University were selected by using purposive sampling technique. The selected subjects were divided into aerobic group (20) and ginger supplement group (20). Ginger supplement group consumed ginger tea for ve days per week with once a day and aerobic group underwent aerobic exercise three days a week with in 60 minutes for 12 weeks. Pre and post test was conducted on variables such as VAS, MSQ and BMI. The data collected from subjects were analyzed by SPSS version 20.0 and the comparison of mean value results were carried out by paired sample t-test. The level of signicance was p ≤ 0.05%. Result The nding of the present study indicates that MSQ test from pre to post test showed positive signicant change for ginger supplement group. Also VAS pre to post test showed signicant change (MD,0.900) for aerobic group and (MD,1.600) for ginger supplement group and BMI pre to post test showed (MD,0.725) for aerobic group and (MD, 0.642) for ginger supplement group. The result of the study showed that ginger group was more signicant change than aerobic group in menstrual symptom questionnaires. Conclusion It was concluded that 12 week ginger supplement and aerobic exercise had positive effect on primary dysmenorrhea to reduce pain during menstruation.

Ginger tea group shows more signi cant change than aerobic exercise group on reducing pain intensity during and before menstruation.

Background
Menstrual period is a natural phenomenon which occurs throughout the reproductive years of every woman. Most females experience certain degree of pain and distress during their menstruation period. [1] Dysmenorrhea is a painful/cramping sensation in the lower abdomen often accompanied by other biological symptoms including dizziness, fatigue, sweating, backache, headache, nausea, vomiting, and diarrhea all occurring just before or during the menstruation. The term dysmenorrhea is derived from Greek words dys (di cult, painful or abnormal) mena (month) and reha ( ow). It is considered as very common gynecological problems. [2] Dysmenorrhea may be categorized into two types as primary and secondary. Primary dysmenorrhea is de ned as painful menses among females with normal pelvic anatomy, frequently beginning during adolescence. It is observed only in ovulatory cycles, frequently emerging within 6 to 12 months after menarche with no pathology or organic basis. Secondary dysmenorrhea is a menstrual pain associated with underlying pathology and its onset might be years after menarche. [3] Primary Dysmenorrhea begins when young girls rst experience the ovulatory cycles at puberty and its prevalence increases during adolescence (15-17years) and reaches to its highest in 20-24 years and decreases progressively there after. Primary Dysmenorrhea is characterized by cramping lower abdominal pain that may radiate to lower back and upper thighs and is commonly associated with nausea, headache, fatigue and diarrhea. Primary dysmenorrhea affects 60% of females, with systemic symptoms such as headache 60% lower back pain, nausea and vomiting 80% diarrhea 50% irritability 30% and adynamia 45%. [4] According to Ethiopian standard treatment guideline, dysmenorrhea occurs in about 50% of menstruating women. Dysmenorrhea in some years following menarche is usually primary, but the secondary characteristically occurs many years after menarche. [5] Ginger is known as an effective medicine in several traditional herbal remedies, such as the treatment of nausea, increasing appetite, treatment of indigestion, fever, and infections, and body cleansing. Researchers have reported that regular exercise is effective in reducing the symptoms of Premenstrual Syndrome, as well as the duration and intensity of primary dysmenorrhea pain. [6] The present study aimed to compare the effectiveness between aerobic exercise and ginger supplement over pain and menstrual symptoms in subjects with primary Dysmenorrhea.

Study Area
The study was conducted at Debre Markos University. The University is found at Debre Markos town which is located in north western part of Ethiopia. Debre Markos town is 300Km Northwest of Addis Ababa, the capital city of Ethiopia, and 265Km Southeast from Bahir Dar, the Regional capital city of Amhara regional state.

Study Design
Completely randomized comparative trial, consisting of a pre-test and post-test evaluation without control group was employed Study Population, Sampling and Sampling Technique The Study populations were 265 sport science and statistics female students of Debre Markos University.
Forty (40) volunteer students with in the age of 19-22 were selected by purposive sampling technique.

Inclusion and Exclusion Criteria
The subjects who are not taking any medicine, free from any pelvic problem and give positive response for the exercise readiness questionnaire were included. However, Subjects who havn't primary dysmenorrhea, taking home remedies for dysmenorrhea, taking oral analgesics for the dysmenorrhea, under medical treatment and age above and below the gap were excluded.

Data Collection Procedures
Ethical clearance was obtained from concerning body and meets the participants of the study, during the familiarization session; participants were informed of all procedures and familiarized with all measurement techniques before conducting the study. Next to this before the participants were going to aerobic exercise and ginger supplement work outs the pre general history towards primary dysmenorrhea test was taken and recorded by the help of data recorders. Subjects were included in the study and grouped in to two groups' aerobic exercise group which are sport science students and ginger consumption groups which are statistics departments. The training program of aerobic exercise was given for 12 weeks, three days a week and the duration was 60 minutes in a day and also ginger consumption was given for 12 weeks, ve days in a week. Ginger was consumed in the dose of 2 g of ginger and 2 g of tea is boiled with 100ml of water for 10 minutes and cooled. Add brown sugar to ginger tea then, the amounts of ginger tea is 100 ml was taken one times a day totally ve times a week. The study was recorded data by the help of assistant data recorder.

Instruments
Visual Analogue Scale (VAS) Questionnaires A Visual Analogue Scale (VAS) is a measurement instrument that tries to measure a characteristic or attitude believed to range across a continuum of values and cannot easily be directly measured. For example, the amount of pain that a patient feels ranges across a continuum from none to an extreme amount of pain. From the patient's perspective this spectrum appears continuous ± their pain does not take discrete jumps, as a categorization of none, mild, moderate and severe would suggest. It was to capture this idea of an underlying continuum that the VAS was devised. [7] Assess the severity of menstrual Pain by using numerical pain rating scale. No pain 0, mild pain 1-3, moderate pain 4-7, severe pain 8-10. Based on the response it has been scored as No symptoms (1), Mild symptoms (2), Moderate symptoms (3), severe symptoms (4). The VAS score is determined by measuring in millimeters from the left hand end of the line to the point that the patient marks.
Body Mass Index BMI is calculated by taking a person's weight and dividing by their height squared.

Statistical Analysis Method
The data collected through questionnaire, visual analogue scale and body mass index were analyzed and interpreted in to amending full idea using computer to compare aerobic exercise and ginger consumption on the mean value by using paired T-test and SPSS version 20.0 Soft ware at level of signi cance p ≤ 0.05%.

Ethical Issue
The study was going in such a way that ethical issues are properly addressed. Privacy of the subjects protected and con dentiality was strictly observed and maintained throughout the study. Generally this research was conducted based on the research ethics of Debre Markos University. The protocol was approved by the university guidelines. The subjects were informed earlier with a written consent/ agreement letter.

Results And Discussion
The purpose of this study was to compare the effects of 12 weeks aerobic exercise and ginger supplement on primary dysmenorrehea the case of Debre Markos University. Forty subjects were selected from department of sport science and Stastics students. They were randomly assigned in to two groups of aerobic group and ginger supplement group with 20 subjects for each group. Pre and posttest were conducted on variables such as VAS, MSQ and BMI. The data collected from subjects were analyzed by SPSS version 20.0 and the comparison of mean value results were carried out by paired sample t-test. Research suggests that compounds found in ginger may help to protect against the increases in in ammation, by inhibiting the body's production of prostaglandins (a class of pro-in ammatory chemicals involved in triggering the muscle contractions that help the uterus shed its lining). Because the onset of menstrual cramps appears to be linked to excessive production of prostaglandins, it's thought that consuming ginger in dietary supplement or tea form can help reduce menstrual pain.

Mean Value of Pre and Post Test Result of Menstrual Symptom Questionnaire
Many ndings support the fact that exercise has positive effect on dysmenorrhea. Studies have shown that physical exercise is bene cial to adolescents with primary dysmenorrhoea. Exercise causes to delay the start of prostaglandins gathering and to increase the rate of accumulation of waste from the body. It reduced the menstrual pain by increasing endorphins and reducing stress and sympathetic nervous activity, and also by increasing the blood ow to the pelvic.  Finally the result indicates that ginger was more signi cant on nausea and vomiting than aerobic exercise. In addition, [9] studied the effectiveness of dietary ginger v/s active exercise on primary dysmenorrhea among adolescent girls. The results showed that active exercise increased the blood ow and metabolism of the uterus during exercise which may be effective in the reduction of dysmenorrhea symptoms. Moreover, the study observed that dietary ginger is more effective than active exercise among adolescent girls in Primary Dysmenorrhea. and improve mood and behavior. [10] Primary dysmenorrhea (PD) is a very common and serious problem that can often directly affect the quality of life for women, interfering in activities such as working or studying. [10]  The result shows that both groups were a signi cant change between pre and post test results after 12

Mean Value of Pre and Post Test Result of BMI of Primary Dysmenorrhea
week ginger supplement and aerobic exercise. Active ingredients in ginger are known to speed up the metabolism, speci cally due to their thermogenic qualities. [11] This can increase your body's level of passive fat-burning and aid weight loss efforts; ginger is also known to suppress the appetite, which can further help you shed those pounds. In order to maintain your weight after weight loss, experts recommend that you do 60 to 90 minutes of daily moderate-intensity physical activity while continuing to eat nutritious foods that do not exceed your calorie requirements. Studies show that physical activities are very important to successful long term weight control. Studies have shown that women who experience higher levels of pain have higher levels of in ammatory prostaglandins or hormone-like substances in their bodies. High levels of prostaglandins can promote painful uterine contractions, decreased blood ow to the uterus, and pain. So in many cases, the solution for menstrual cramps is to avoid foods that increase in ammation, and emphasize foods that decrease in ammation. So ginger was used for anti-in ammatory purpose to reduce pain level. The antiin ammatory properties of ginger have been known and valued for centuries. [12] 4.4. Mean Difference and Signi cance of Aerobic and Ginger Group Ginger supplement and aerobic exercise shows positive effect on menstrual symptom of primary dysmenorrhea. But when comparing ginger supplement group and aerobic group, ginger supplement was more signi cance than aerobic exercise. Evidence suggests that aerobic exercise reduces negative effect on women who exercise regularly exhibit lower levels of negative effect and physical symptoms across the menstrual. [10], [ 13]    The above table indicates that both groups aerobic and ginger supplement was a positive effect on body mass index. When we compare ginger supplement group and aerobic group, ginger supplement group was a signi cant change than aerobic group. The relation between dysmenorrhea and BMI was found to be highly signi cant with increased prevalence of dysmenorrhea in low and high BMI group. Overweight, especially BMI was over 35 it was likely that are not getting regular periods and also the intensity of pain was severe because of increased fat mass or adipose tissue produces extra estrogen that was partly responsible for problems on ovulation and missed periods. Also underweight was not getting regular periods. Finally overweight and underweight on the body that causes hormonal changes that interfere with ovulation. This also causes Avery low estrogen level, which is especially bad for bone health.

Mean Value of Pre and Post Test Result of VAS of Primary Dysmenorrhea
4.6. Mean Difference and Signi cance of Aerobic and Ginger Group of VAS on Primary Dysmenorrhea So the result of 12 week treatment was a signi cant change in order to reduce pain during menstruation.
The nding of the current study showed that both aerobic exercise and ginger supplement were effective in reducing the intensity of pain during menstruation. But ginger supplement was more signi cant change than aerobic exercise to reduce pain intensity during menstruation. So students can use either of them depending of their condition and interest.
Laboratory studies suggest that ginger has some compounds that inhibit lipoxygenase and cyclooxygenase pathway and has effects on the arachidonic acid metabolism which is a precursor of prostaglandins production. Ginger has possibly anti-in ammatory and antioxidant effects by inhibiting the production of prostaglandins and leukotriene, prostaglandins during menstruation period. [14] A lack of exercise can increase the severity and duration of symptoms associated with dysmenorrhea. In addition to a regular physical exercise regimen, a good moving meditation can help balance the emotions, reduce stress, strengthen the organs, and regulate menstruation. Regular exercise, including exercise right before and during your menstrual cycle can and will help lessen the severity of menstrual cramping. [15] Conclusions Based on the major nding of this study the following points were stated as conclusions.
12 weeks ginger supplement and aerobic exercise signi cantly reduce intensity and duration of pain during and before menstruation. But ginger was more signi cant change than aerobic exercise on reducing pain intensity during and before menstruation.
Ginger supplement was a positive effect on menstrual symptom of primary dysmenorrha when comparing with aerobic exercise.
Both Aerobic and Ginger supplement groups were had a positive effect on BMI and VAS.

Recommendations
Health care providers can recommend these ginger remedies to women's for management of dysmenorrhea. However, well-designed studies about roles, doses, and side effects of ginger remedies should be conducted.
Students use ginger because ginger preparation was an easily available and effective home remedy which has signi cant effect in relieving primary dysmenorrhea. So, it is important to enhance the usage of natural and home remedies for management of dysmenorrhea with less expensive, less side effects and easily available methods.

Declarations
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Authors' contributions EJ contributes in the design of the study, analysis and write up of the manuscript. DK made the data analysis, drafting, interpretation and edition of the data, monitoring the study and edition of the manuscript. Both authors critically revised the manuscript and have approved the nal manuscript.
Ethics approval and consent to participate Ethical clearance was obtained from the Institutional Review Board (IRB) of Debre Markos University, College of computational and natural sciences. A written informed consent was obtained from the participants. All participants got the right to opt out of the research. This was done by explaining the objective and importance of the study as it would be bene cial for quality service delivery for future encounters. Neither the case records nor the data extracted was used for any other purpose. The con dentiality and privacy of participants were assured throughout by removing identi ers from data collection tools using different codes.

Consent for publication
Not applicable.