Ginger in Women’s Health Care: Gynecology and Primary Care

Abstract

The well-known herb ginger, or Zingiber officinale, has been used for medicinal and culinary purposes for thousands of years throughout the world. Traditionally, ginger has been used to address a variety of ailments including nausea, vomiting, colds, arthritis, and headaches, among others. Although it is not often thought of as an herb for women’s health, there are a myriad of clinical uses for ginger to support medical conditions that are women-only as well as some that tend to impact women more often. This article seeks to highlight some of these uses of ginger beyond its antiemetic action by also discussing applications of ginger for dysmenorrhea, heavy menses, migraines, IBS, osteoarthritis, and exercise induced myalgia.

Introduction

Ginger root (Zingiber officinal Roscoe) is widely known and used as a spice and seasoning in cuisines and traditional medicine throughout the world. The nonvolatile pungent compounds have well known cardiovascular, gastrointestinal, antioxidant, analgesic, and anti-inflammatory effects (Dugasani et al 2010). Ginger has been shown to reduce pain in osteoarthritis, muscle pains and dysmenorrhea, heavy menstrual bleeding, reduce pregnancy related nausea and vomiting and chemotherapy related nausea, as well as vomiting after surgery. This short article will emphasize the recent research in using ginger for problems of great importance to women including menstrual cramps, heavy menses, nausea/vomiting of pregnancy, migraine pains, muscle pains, nausea of chemotherapy, and osteoarthritis.

Menstrual Cramps

Rather than discuss each of the studies on this topic, we were pleased to see in 2015 a systematic review and meta-analysis of randomized trials on the efficacy of ginger for primary dysmenorrhea (Daily et al 2015). In this analysis, seven randomized controlled trials met the inclusion criteria and these were used for the systematic review. Six of these trials were conducted in Iran and one in India. The meta-analysis of the data from these studies demonstrated a significant effect of ginger in reducing the pain visual analog scale (PVAS), a tool widely used to measure pain, in women having primary dysmenorrhea. In total, these randomized controlled trials showed significant efficacy for primary dysmenorrhea at doses of 750-2000mg per day during the first three to four days of the menstrual cycle.

The cause of menstrual cramps is thought to be due to an increased production of prostaglandins in the endometrium (lining of the uterus). Menstrual blood of women with primary dysmenorrhea has greater amounts of the pro-spasmodic and pro-inflammatory prostaglandins, PGE₂ and PGF₂ alpha. It is thought that the anti-inflammatory properties of ginger are due to the gingerols, which can lead to a reduction in prostaglandins, and inhibit cyclooxygenase-2, NF kappa beta and 5-lipoxygenase (Kiyama 2020).

Heavy Menstrual Bleeding

In this current study, Iranian high school students had regular menstrual cycles and a recent history of at least one heavy menstrual cycle (Kashefi et al 2015). These were girls who also had no gynecological disease, were not regularly taking hormonal medications or NSAIDS, did not have a vaginal or pelvic infection, and were not overweight or obese. Three consecutive menstrual cycles were monitored and scored for blood loss before starting the ginger or placebo. Ginger capsules contained 250mg of dried ginger, and one was given three times daily or placebo capsule three times daily starting from the day before menstrual bleeding until the third day of the menstrual period for a total of four consecutive days for the three months of menstrual cycles.

The level of menstrual blood loss dramatically decreased during the three intervention cycles in the ginger group and was significantly better than in the placebo group. The average decrease in heavy menses in the ginger group started the very first month, was even better the second month, and then a little better the third month. There were no average hemorrhage changes in the placebo group. After the intervention, the ginger group decreased in mean hemorrhage by 46.6% and the placebo group by 2.1%. Three girls had adverse events in each group: ginger=1 heart burn, 1 abdominal pain, 1 diarrhea; placebo=1 abdominal pain, 2 flatulence (Kashefi et al 2015).

Serum levels of prostaglandin E2 and prostacyclin are higher in women with heavy menstrual bleeding, which results in the vasodilatation and local platelet accumulation in addition to lower amounts of prostaglandin F2alpha which is responsible for vasoconstriction. Women with heavy menstrual bleeding also have more PGE2 receptors (Kiyama 2020). It would be logical then that herbs and/or foods and/or medications that inhibit prostaglandin synthesis and leukotriene formation may provide the needed anti-inflammatory effect to decrease heavy menstrual blood loss.

Heavy menstrual bleeding is one of the more common gynecological reasons why women come to their health care provider. It can affect quality of life and cause iron deficiency anemia. Not only can this result in mild to severe fatigue, but changes in cognition, exercise tolerance, dyspnea, and heart palpitations can occur. The bigger picture is determining what is causing the heavy menstrual bleeding, defined as greater than 80ml per menstrual cycle. Causes of heavy menstrual bleeding can include a simple anovulatory cycle due to stress or perimenopause, thyroid disorders, uterine polyps, uterine fibroids, adenomyosis, uterine pre-cancer, uterine cancer, and von Willebrand syndrome. While some common herbs and medicines can be used to treat a particular episode of heavy menstrual flow, treating the underlying condition is particular to each of the causes mentioned.

Migraine Headaches

Migraine headaches are one of the most common causes of pain and can vary from a minimal impact on activities of daily living to incapacitating. An effective herbal intervention for acute pain relief would be a welcome addition to the list of options.

This double-blind randomized controlled clinical trial compared the efficacy of ginger to sumatriptan, a standard conventional prescription treatment, in the treatment of common migraine (Maghbooli et al 2014). Study subjects with common migraines, in Iran, were randomly provided either one ginger capsule of 250mg upon onset of headache or 50mg of sumatriptan. Women comprised 68% of the sumatriptan group vs 74% of the ginger group. Both sumatriptan and ginger powder decreased the mean severity of common migraine attacks within two hours of use. No significant difference existed between the two treatments, which is impressive for the ginger. Before taking the medication, 22% of the sumatriptan group and 20% of the ginger group had severe headaches. The mean headache severity at two hours after sumatriptan or ginger use demonstrated similar effectiveness for both groups. There was 4.7-unit reduction in the headache severity in the sumatriptan group and a 4.6-unit reduction in the ginger group. Favorable relief was achieved in 70% of the sumatriptan-treated headache individuals and 64% of the ginger-treated patients at two hours following intake. There were more side effects from sumatriptan use including dizziness, sedation, vertigo, and heartburn. The only clinical adverse effect of ginger was dyspepsia.

In a previous study in 2005 using ginger with feverfew in sublingual tablets for acute migraine pain, 32% of participants were pain-free at two hours in those receiving the medication vs 16% receiving placebo. In total, at two hours, 63% receiving medication were either pain-free or had only mild pain vs 39% for placebo (Cady et al 2005).

And in another fever/ginger study for acute migraine treatment in the early pain phase, an open-label study enrolling 30 subjects, male and female, 48% were pain-free after two hours with 34% reporting a headache of only mild severity and 29% having a recurrence within 24 hours (Cady et al 2011).

Ginger and Nausea/Vomiting of Pregnancy

Nausea and vomiting are the most common unpleasant symptoms during pregnancy. Fifty percent to 90% of women experience these complications. In the most recent study on this topic, a single-blind controlled randomized clinical trial was conducted in women up to 20 weeks of pregnancy in Iran (Ozgoli et al 2009). Thirty-two women received ginger and 35 received placebo. One ginger (250mg) or placebo capsule four times per day was given over the course of four days. Nausea intensity improved in 84% of those who used the ginger and in 56% of the women in the control group. The incidence of vomiting in the control group was decreased 9%, while the ginger group experienced a 50% decrease.

At least four previous published studies have shown success in the use of ginger for nausea and vomiting of pregnancy (Chittumma et al 2007, Haji et al 2013, Mohammadbeigi et al 2011, Thomson et al 2014). Doses of 1000mg to 1500mg per day have been used previously. The current study showed not only a positive effect, but women were satisfied with that effect and no complications were observed during the treatment period.

Ginger Extract on Nausea due to Chemotherapy

Nausea can be a significant side effect of numerous chemotherapy medications and preventing and treating chemotherapy induced nausea and vomiting (CINV) is a priority in oncology patients. There are indeed some important and often effective conventional medications, but even then, nausea and vomiting can occur in 30-60% of cancer patients (Rao and Faso 2012). Nausea and vomiting are, at best, unpleasant symptoms, but can significantly affect quality of life, cause insufficient nutrition, and can even result in chemotherapy treatment delays or reduction in desired dosing.

Ginger has been studied for nausea due to other causes such as pregnancy and post-operative nausea and vomiting. There is also a literature review published in 2013 on ginger and chemotherapy induced nausea and vomiting (Marx et al 2013). However, there are some research methodology problems in the previous studies, which might be preventing common use of ginger in these patients in the oncology setting.

The primary objective of this double-blind, randomized placebo-controlled trial (Marx et al 2017) was to address those methodology issues and assess ginger compared to placebo in patients receiving chemotherapy agents that are moderatey to highly associated with causing nausea and vomiting.

Patients were randomly assigned to receive 300mg capsules four times daily of standardized ginger extract or placebo in conjunction with the standard medications for nausea/vomiting for the first three cycles of chemotherapy. Ginger or placebo was given with meals, starting on the day of the chemotherapy and for a total of five days, for each cycle. Over three consecutive chemotherapy cycles, nausea was more prevalent than vomiting. In cycle one, those who received ginger reported significantly better quality of life in terms of chemotherapy induced nausea, nausea/vomiting, as well as less fatigue than placebo. There were no significant results in cycle two. In cycle three, quality of life and fatigue were significantly better in the ginger compared to placebo group (Marx et al 2017).

Ginger and Nausea Associated with Antiretroviral Medication and Postoperative Nausea

Given the evidence showing ginger can reduce nausea related to pregnancy, chemotherapy, and other situations, one might deduce that ginger’s antiemetic properties could be extended to other instances when nausea is present. Indeed, one study concluded that a dose of 500mg of Zingiber officinale taken by mouth twice daily 30 minutes prior to each dose of antiretroviral medication seems to be effective in treating nausea and vomiting associated with these drugs. Mild, moderate, and severe nausea among study participants was reduced compared with the placebo group (p=0.01) (Dabaghzadeh et al 2014). There may also be opportunity for clinical application of ginger to address post-operative nausea. One study found that ginger effectively reduced nausea and vomiting in participants who underwent open nephrectomy as well as laparoscopic nephrectomy. Participants of this study were either given a ginger essence or placebo and severity of nausea was assessed using a visual scale (Hosseini and Adib-Hajbaghery 2015). Another study investigating post-operative use of ginger concluded ginger reduced incidence of nausea and vomiting after various surgical procedures, but these reductions were not statistically significant (Montazeri et al 2013).

Gastrointestinal Motility, Irritable Bowel Syndrome, Inflammatory Bowel Disease

While the antiemetic effect of ginger has been well-established, there is also evidence this herb may be useful in supporting gastric emptying and proper GI motility. A very small study (n=11) sought to determine if ginger had an impact on gastric motility and functional dyspepsia by administering a total of 1200mg of ginger in capsule form one hour prior to having participants eat a 500ml low-nutrient soup. Results showed gastric emptying was faster after ginger compared with placebo, but unfortunately did not result in reduction in gastrointestinal symptoms (Hu et al 2011).

Since ginger contains anti-inflammatory constituents and its antiemetic properties are well documented, there is the notion that ginger may be helpful for IBS. Unfortunately, the evidence on ginger and IBS is underwhelming. One double-blind randomized controlled pilot study on ginger and IBS did not find any statistically significant difference between participants with IBS who received placebo, 1g, or 2g of ginger daily for 28 days (van Tilburg et al 2014). One possible limitation of this study was the small size of 45 total participants.

Research currently underway is aiming to establish if there is a role for ginger in inflammatory bowel disease.

Ginger May Reduce Exercise-induced Muscle Pain and Soreness

This systematic review evaluated the use of ginger as an analgesic and ergogenic aid for exercise-induced pain (Wilson 2015). Other studies have explored ginger as an analgesic, for example with acute migraines and dysmenorrhea. However, this is the first review of ginger as an analgesic and ergogenic aid (an exogenous substance that enhances athletic performance) for exercise training and athletics.

Casual exercisers, serious athletes, and professional athletes all commonly use NSAIDS to prevent and manage pain and as many as 50-70% of athletes take NSAIDS regularly. With known potential side effects, including suppression of muscle protein synthesis, muscle degeneration after exercise, and adverse effects on cartilage repair, NSAIDS are actually counter-productive for active individuals in particular.

PubMed was searched in April 2015 for randomized, controlled trials (RCTs) assessing ginger as an analgesic or ergogenic aid for athletes. Any studies in which ginger was used in combination with other ingredients were excluded. A total of nine publications were identified; seven studies evaluated ginger as an analgesic for athletes, and nine studies evaluated ginger as an ergogenic aid (Wilson 2015).

Studies on the analgesic effects evaluated acute single-dose uses of ginger and longer duration effects of 11 days to six weeks in doses ranging from 2-4g/day. In two RCTs, the acute doses of 2g/day of dried ginger had no significant analgesic effects. The longer duration studies evaluated different forms of ginger including raw, heat treated, and powdered and were taken before and after exercise. In four RCTs, there were modest benefits (Wilson 2015).

Ginger had no clear benefits in the ergogenic studies. One study found that 4 g/d ginger may accelerate upper body strength recovery after resistance exercise. Daily use of ginger may reduce the inflammatory response to cardiorespiratory exercise (Wilson 2015).

While the studies in this review have some design and reporting flaws and different ginger preparations, we think this before and after exercise use of ginger for reducing muscle pain and soreness has merit. An ideal scenario might be 2 g/day for five to 14 days before an endurance event and then 4g after to accelerate recovery of muscle strength. Acute doses of 2g of ginger appear to provide no analgesic benefit.

Osteoarthritis and Ginger

The evidence demonstrating the efficacy of ginger for osteoarthritis-associated pain is mixed. While some studies did conclude oral ginger reduced pain in participants with osteoarthritis, other trials found ginger to be an ineffective means of pain management. This is especially true of topical ginger preparation. One meta-analysis found taking ginger orally at a dose of 500 to 1000mg daily with trial duration ranging from 3 to 12 weeks resulted in positive outcomes including statistically significant pain reduction in ginger groups compared with placebo. Adverse events were characterized as mild and limited to complaints of dyspepsia and “bad taste” (Bartels et al 2015). On the contrary, a different meta-analysis concluded approximately 500 to 1000mg of ginger taken daily for 6 to 12 weeks did not yield sufficient evidence to support the use of ginger to reduce pain or improve function (Araya-Quintanilla et al 2020). Despite some conflicting data on ginger as a standalone therapy for osteoarthritis, a recent study investigating treatment of mild osteoarthritis found a combination product called Tregocel®, which contains curcuminoid extracts of herbs including Harpagophytum procumbens, Boswellia serrata, Apium graveolens, and Zingiber officinale, to be efficacious for pain reduction compared with standard osteoarthritis therapy (Zegota et al 2021).

Cautions, Contraindications, and Adverse Reactions

As with all supplements and botanical medicines, it is important to discuss initiation of anything new with a doctor or other licensed health care provider. Although supplements are often viewed by the public as relatively innocuous, there are many potential interactions between herbs, pharmaceuticals, and nutrients to be aware of. Caution is advised in the combination of ginger with anticoagulant and antiplatelet drugs since ginger may slow clotting and thus increase chances of bleeding or bruising with certain medications (Abebe 2002, Marx et al 2015). There are some animal studies showing theoretical interactions between ginger and calcium channel blockers, cyclosporine, losartan, metronidazole, and antidiabetic drugs. Overall, ginger is typically well-tolerated. However, especially when taken at higher doses, some patients endorse GI symptoms including dyspepsia, diarrhea, heartburn, belching, and unpleasant taste. For topical applications, burning sensation or contact dermatitis may occur.

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