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From The Cochrane Library, Issue 1, 2006. Chichester, UK: John Wiley & Sons, Ltd.
Herbal medicines for treatment of irritable bowel syndrome (Cochrane Review)
Liu JP, Yang M, Liu YX, Wei ML, Grimsgaard S
Background: Traditional herbal therapies have been used for a long time to treat gastrointestinal disorders including irritable bowel syndrome, and their effectiveness from clinical research evidence needs to be systematically reviewed.
Objectives: To assess the effectiveness and safety of herbal medicines in patients with irritable bowel syndrome.
Search strategy: We searched the following electronic databases till July 2004: The Cochrane Library (CENTRAL), MEDLINE, EMBASE, AMED, LILACS, the Chinese Biomedical Database, combined with hand searches of Chinese journals and conference proceedings till end of 2003. No language restriction was used.
Selection criteria: Randomised controlled trials of herbal medicines compared with no treatment, placebo, pharmacological interventions were included.
Data collection and analysis: Data were extracted independently by two authors. The methodological quality of trials was evaluated using the components of randomisation, allocation concealment, double blinding, and inclusion of randomised participants.
Main results: Seventy-five randomised trials, involving 7957 participants with irritable bowel syndrome, met the inclusion criteria. The methodological quality of three double-blind, placebo-controlled trials was high, but the quality of remaining trials was generally low. Seventy-one different herbal medicines were tested in the included trials, in which herbal medicines were compared with placebo or conventional pharmacologic therapy. Herbal medicines were also combined with conventional therapy and compared to conventional therapy alone. Compared with placebo, a Standard Chinese herbal formula, individualised Chinese herbal medicine, STW 5 and STW 5-II, Tibetan herbal medicine Padma Lax, traditional Chinese formula Tongxie Yaofang, and Ayurvedic preparation showed significantly improvement of global symptoms. Compared with conventional therapy in 65 trials testing 51 different herbal medicines, 22 herbal medicines demonstrated a statistically significant benefit for symptom improvement, and 29 herbal medicines were not significantly different than conventional therapy. In nine trials that evaluated herbal medicine combined with conventional therapy, six tested herbal preparations showed additional benefit from the combination therapy compared with conventional monotherapy. No serious adverse events from the herbal medicines were reported.
Authors' conclusions: Some herbal medicines may improve the symptoms of irritable bowel syndrome. However, positive findings from less rigorous trials should be interpreted with caution due to inadequate methodology, small sample sizes, and lack of confirming data. Some herbal medicines deserve further examination in high-quality trials.
Citation: Liu JP, Yang M, Liu YX, Wei ML, Grimsgaard S. Herbal medicines for treatment of irritable bowel syndrome. The Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004116.pub2. DOI: 10.1002/14651858.CD004116.pub2.
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Phytomedicine. 2005 Aug;12(8):601-6.
Peppermint oil in irritable bowel syndrome.
Grigoleit HG, Grigoleit P.
In a literature search 16 clinical trials investigating 180-200 mg enteric-coated peppermint oil (PO) in irritable bowel syndrome (IBS) or recurrent abdominal pain in children (1 study) with 651 patients enrolled were identified. Nine out of 16 studies were randomized double blind cross over trials with (n = 5) or without (n = 4) run in and/or wash out periods, five had a randomized double blind parallel group design and two were open labeled studies.
Placebo served in 12 and anticholinergics in three studies as comparator. Eight out of 12 placebo controlled studies show statistically significant effects in favor of PO. Average response rates in terms of "overall success" are 58% (range 39-79%) for PO and 29% (range 10-52%) for placebo. The three studies versus smooth muscle relaxants did not show differences between treatments hinting for equivalence of treatments. Adverse events reported were generally mild and transient, but very specific. PO caused the typical GI effects like heartburn and anal/perianal burning or discomfort sensations, whereas the anticholinergics caused dry mouth and blurred vision. Anticholinergics and 5HT3/4-ant/agonists do not offer superior improvement rates, placebo responses cover the range as in PO trials.
Taking into account the currently available drug treatments for IBS PO (1-2 capsules t.i.d. over 24 weeks) may be the drug of first choice in IBS patients with non-serious constipation or diarrhea to alleviate general symptoms and to improve quality of life.
Publication Types:
• Review
PMID: 16121521 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16121521&query_hl=1&itool=pubmed_docsum
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J Clin Gastroenterol. 2006 Mar;40(3):270-4.
Probiotics and chronic disease.
Broekaert IJ, Walker WA.
Mucosal Immunology Laboratory, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA 02129, USA.
In today's climate, changed lifestyles and the increased use of antibiotics are significant factors that affect the preservation of a healthy intestinal microflora. The concept of probiotics is to restore and maintain a microflora advantageous to the human body. Probiotics are found in a number of fermented dairy products, infant formula, and dietary supplements. Basic research on probiotics has suggested several modes of action beneficial for the human body and clinical research has proven its preventive and curative features in different intestinal and extraintestinal diseases. Chronic diseases cause considerable disablement in patients and represent a substantial economic burden on healthcare resources. Research has demonstrated a crucial role of nutrition in the prevention of chronic disease. Thus, positive, strain-specific effects of probiotics have been shown in diarrheal diseases, inflammatory bowel diseases, irritable bowel syndrome, and Helicobacter pylori-induced gastritis, and in atopic diseases and in the prevention of cancer. As the majority of probiotics naturally inhabit the human intestinal microflora, their use has been regarded as very safe. However, in view of the range of potential benefits on health that might be achieved by the use of some probiotic bacteria, major and thorough evaluation is still necessary. In conclusion, probiotics act as an adjuvant in the prevention and treatment of a wide variety of chronic diseases.
PMID: 16633135 [PubMed - in process]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16633135&query_hl=7&itool=pubmed_DocSum
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Evidence-Based Medicine 2002; 7:20
© 2002 Evidence-Based Medicine
Dietary fibre supplementation with psyllium or Acacia (gum arabic) reduced faecal incontinence in community-living adults
Bliss DZ, Jung HJ, Savik K, et al. Supplementation with dietary fiber improves fecal incontinence. Nurs Res 2001 Jul–Aug;50:203–13
QUESTION: In community-living adults with incontinence of loose or liquid stools, does dietary fibre supplementation with psyllium or gum arabic reduce faecal incontinence?
Design
Randomised {allocation concealed*}, blinded {clinicians, participants, and statisticians},* placebo controlled trial with 8 day post-intervention comparison.
Setting
Colorectal surgical practice and community in Minneapolis, Minnesota, USA.
Participants
42 adults (mean age 61 y) with at least weekly faecal incontinence of loose or liquid stools. Exclusion criteria were rectal prolapse, colon cancer, rectal fistula, ulcerative colitis, or removal of some portion of the gastrointestinal tract. No participant had biofeedback training for pelvic muscle exercises. Follow up was 93%.
Intervention
Participants were allocated to receive 31 days of dietary fibre supplementation with psyllium 7.1 g/day (n=13); gum arabic 25 g/day (n=13); or placebo given as pectin 0.25 g/day (n=13). Supplements were mixed into fruit juice and divided into 2 servings for consumption during the morning and evening meals. Participants were instructed to maintain their usual diet. Those who were taking antidiarrhoeal medication were advised not to alter the type and amount during the study.
Main outcome measures
Daily self reported stool characteristics, including rate of incontinent stools, stool consistency, stool frequency, and stool weight.
Main results
The rates of incontinent stools for the psyllium and gum arabic groups were lower than for the placebo group (table). The psyllium and gum arabic groups had lower rates of loose and unformed or liquid stools than did those in the placebo group (2(6)=20.8, p=0.002). No difference existed between the 3 groups for stool frequency, wet weight of stool, or weight of total stool solids.
View this table:
[in this window]
[in a new window]
Psyllium, gum arabic, and placebo for faecal incontinence at 8 days
Conclusion
In adults living in the community, dietary fibre supplementation with psyllium or gum arabic reduced the rate of incontinent stools and improved stool consistency.
Footnotes
Sources of funding: National Institute of Nursing Research; National Institutes of Health; American Federation for Aging Research; Sigma Theta Tau Zeta Chapter; University of Minnesota
http://ebm.bmjjournals.com/cgi/content/full/7/1/20
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Beneficial Bacteria Protect the Gut from Stress
By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Robert Jasmer, MD; Assistant Professor of Medicine, University of California, San Francisco
April 25, 2006
Also covered by: BBC News
MedPage Today Action Points
Explain to interested patients that this study suggests that probiotics may help to protect the gut against stress-induced intestinal disease.
Caution patients that this study was conducted only in animal models.
Review
TORONTO, April 24 — Probiotics can help protect the gut against harmful bacteria and symptoms brought on by long-term stress, according to researchers here.
In a study of rats subjected to stress, those who were pretreated with either of two Lactobacillus strains had less adhesion to intestinal walls of harmful bacteria, said Philip M. Sherman, M.D., and colleagues at the Hospital for Sick Children here.
What's more, pretreatment with the probiotics prevented translocation of the harmful bacteria to the mesenteric lymph nodes, indicating a protective effect, they reported in the early online issue of Gut.
Although the study focused on stressed-out rodents, the findings have implications for the treatment of inflammatory bowel disease and irritable bowel syndrome in humans, the authors wrote.
"Enhanced bacterial uptake following exposure to chronic stress may lead to an increased antigen load in the intestinal mucosa," Dr. Sherman and colleagues wrote. "Thus local inflammation could be initiated, which eventually leads to more diffuse intestinal inflammation… In addition, these findings indicate that probiotics may provide a novel approach for the management of stress induced intestinal dysfunction."
Dr. Sherman and colleagues looked at the ability of probiotics to prevent intestinal pathophysiology precipitated by stress. In this case, the stress was induced by a water avoidance stress test, in which the animals were placed for one hour per day for 10 days on a small platform surrounded by warm water in a plastic container. Controls were subjected to "sham stress," in which they were placed on an identical platform in an empty plastic container.
The animals had been fed either a standard diet or the same diet with probiotics (Lactobacillis helveticus and L. rhamnosus strains) added to the water for seven days before the start of the induced stress and continuing for the duration of the study.
"We have previously shown that probiotics survive and transiently colonize the gut when administered to mice via addition to sterile drinking water," the authors noted.
Four hours after the last real or sham stress session, the rats were killed and their tissues, including mesenteric lymph nodes and intestinal segments, were examined for studies of bacterial translocation, and morphological and functional analysis.
The authors found that the chronic stress caused by water-avoidance induced excess ion secretion and intestinal mucosal barrier dysfunction in both the ileum and the colon, and that these effects were associated with increased bacterial adhesion and penetration into surface epithelial cells.
They also saw that about 70% of the rats subjected to the water avoidance stress had bacterial penetration of the gut endothelium and translocation of the bacteria to mesenteric lymph nodes.
However, pretreatment with probiotics reduced the number of adherent bacteria, prevented bacterial translocation to mesenteric lymph nodes, and inhibited chronic stress-induced elevated intestinal ion secretion, but not increased permeability, the authors found.
"These findings indicate that probiotics can prevent chronic stress induced intestinal abnormalities and, thereby, exert beneficial effects in the intestinal tract," they wrote.
Primary source: Gut
Source reference:
Zareie M et al. "Probiotics prevent bacterial translocation and improve intestinal barrier function in rats following chronic psychological stress." Gut 2006;000:1-8. doi: 10.1136/gut.2005.080739
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The pathogenesis of constipation remains to be completely defined, although the condition is commonly categorized as normal-transit constipation, pelvic floor dysfunction, and slow-transit constipation. The role of bacteria in the generation of constipation symptoms has begun to receive considerable attention, and one report has shown an association between excess methane production and slow colonic transit. In an interesting study involving 22 patients with slow-transit constipation documented by radio-opaque markers, Schlieger and colleagues randomized subjects to receive either Lactobacillus casei (6.5 x 109 colony forming units/day) or placebo for 4 weeks. Measurement of colonic transit time was repeated after 4 weeks. Patients in the Lactobacillus group had an objective improvement in colonic transit time from 95.6 hours to 77 hours (P < .05), primarily due to more rapid transit through the rectosigmoid colon. Patients in the placebo group noted a slight reduction in transit time as well (from 93.7 hours to 87.1 hours), although this was not statistically significant.
The study authors did not report symptom response and did not report whether colonic transit time worsened after Lactobacillus treatment had stopped. Future studies are needed to verify this finding and determine the relationship between probiotic use and colonic transit.
Pimentel M, Mayer AG, Park S, Chow EJ, Hasan A, Kong Y. Methane production during lactulose breath test is associated with gastrointestinal disease presentation. Dig Dis Sci. 2003;48:86-92. Abstract
Schlieger F, Krammer H, Franke A, Harder H, Wagner I, Singer MV. Effect of lactobacillus casei shirota on colonic transit time in patients with slow-transit constipation. Gastroenterology. 2006;130:A-289. [#S1938]
http://www.medscape.com/viewarticle/536306?src=mp
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Phytother Res. 2006 Jun 12;
A review of the bioactivity and potential health benefits of peppermint tea (Mentha piperita L.).
McKay DL, Blumberg JB.
USDA Human Nutrition Research Center on Aging at Tufts University, 711 Washington St., Boston, MA 02111, USA.
Peppermint (Mentha piperita L.) is one of the most widely consumed single ingredient herbal teas, or tisanes. Peppermint tea, brewed from the plant leaves, and the essential oil of peppermint are used in traditional medicines. Evidence-based research regarding the bioactivity of this herb is reviewed. The phenolic constituents of the leaves include rosmarinic acid and several flavonoids, primarily eriocitrin, luteolin and hesperidin. The main volatile components of the essential oil are menthol and menthone. In vitro, peppermint has significant antimicrobial and antiviral activities, strong antioxidant and antitumor actions, and some antiallergenic potential. Animal model studies demonstrate a relaxation effect on gastrointestinal (GI) tissue, analgesic and anesthetic effects in the central and peripheral nervous system, immunomodulating actions and chemopreventive potential. Human studies on the GI, respiratory tract and analgesic effects of peppermint oil and its constituents have been reported. Several clinical trials examining the effects of peppermint oil on irritable bowel syndrome (IBS) symptoms have been conducted. Adverse reactions to peppermint tea have not been reported, although caution has been urged for peppermint oil therapy in patients with GI reflux, hiatal hernia or kidney stones. Copyright (c) 2006 John Wiley & Sons, Ltd.
PMID: 16767798 [PubMed - as supplied by publisher]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16767798&query_hl=15&itool=pubmed_docsum
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Probiotics
The data on these agents originally suffered from poor study design, limits on generalizability and commercial bias: true 'junk science'. Reviews mentioning them still grossly outnumber studies with primary data, but the application of better study design supports their use. Thus far, there are more data for probiotic use in ulcerative colitis than in Crohn's disease. VSL#3 is a combination of probiotic strains that has been shown to maintain remission and decrease the incidence of pouchitis. Recent open-label data suggest that it may have utility for the induction of remission in patients with ulcerative colitis.[24] In this small study of 34 patients with moderately active ulcerative colitis, there was a 77% response rate, indicating that the VSL#3 probiotic mixture induces remission in patients with active ulcerative colitis. A German study[25] found equivalent efficacy of Escherichia coli Nissle 1917 and mesalazine in maintaining remission in ulcerative colitis. Although interesting, these must be considered grade III data and require more extensive exploration and validation in large-scale clinical trials.
http://www.medscape.com/viewarticle/536494_4
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From Nature Clinical Practice Gastroenterology & Hepatology
Are Probiotics Effective for Treating Clostridium Difficile Disease and Antibiotic-Associated Diarrhea?
Posted 11/09/2006
Mario Guslandi
Background
Antibiotic-associated diarrhea (AAD) and Clostridium difficile disease (CDD) are common conditions linked to the use of antibiotics. Studies evaluating the efficacy of probiotics for the treatment of these two conditions have produced contradictory results.
Objectives
To determine the efficacy and safety of probiotics for the prevention of AAD and CDD.
Design and Intervention
The databases of PubMed, MEDLINE, Google Scholar, metaRegister, the NIH registry of clinical trials, and the Cochrane Central Register of Controlled Trials were searched to identify studies suitable for inclusion in the meta-analysis. In addition, reference lists, commentaries, books, and meeting abstracts were examined. Keywords, including "probiotics", "Clostridium difficile", "antibiotics", "diarrhea", "Saccharomyces", and "Lactobacilli" were used to carry out the search. Studies were eligible for inclusion if they were published between 1977 and 2005 in peer-reviewed publications, used human subjects, and were randomized controlled trials (RCTs) that examined efficacy. Exclusion criteria included case reports, Phase I safety studies, and trials that used unspecified probiotics. Diarrhea was defined as loose stools within 24 h for 2 days, or loose stools within 48 h. AAD was defined as diarrhea within 2 months of exposure to antibiotics. CDD was defined as diarrhea associated with a positive Clostridium difficile culture or toxin within a month of exposure to antibiotics. The quality of suitable studies was assessed according to a number of factors, including study design, sample size, and outcome measures. A quality grade was given to each study: 1 = poor, 2 = fair, 3 = good.
Outcome Measure
The main outcome measure was identification of studies suitable for inclusion in the meta-analysis.
Results
In total, 31 RCTs were included in the meta-analysis, and all were rated fair or good quality. Of these, 25 featured patients with AAD, and collectively contained the data of 2,810 patients, and 6 featured patients with CDD, and collectively contained data on 354 patients. Meta-analysis revealed that probiotics had a significant protective effect for the development of AAD (relative risk [RR] 0.43, 95% CI 0.31-0.58, P <0.001). In a further meta-analysis by probiotic strain, Saccharomyces boulardii (S. boulardii), Lactobacillus rhamnosus GG (L. rhamnosus GG), and a mixture of two strains of Lactobacilli showed significant efficacy for treating AAD (RR 0.34, 95% CI 0.26-0.52; P <0.0001; RR 0.31, 95% CI 0.13-0.72; P = 0.006; and RR 0.51, 95% CI 0.38-0.68; P <0.0001, respectively). Meta-analysis also revealed that probiotics had a significant protective effect for the development of CDD (RR =0.59, 95% CI 0.41-0.85; P = 0.005). S.boulardii was the only probiotic that showed a significant reduction in the recurrence of CDD. Overall, 24 trials reported no adverse events, and those that did reported minor adverse events, including thirst and constipation.
Conclusion
S. boulardii, L. rhamnosus GG, and probiotic mixtures significantly reduced the development of AAD. S. boulardii significantly reduced the development of CDD.
Commentary
Probiotics feature in a number of commercially successful products and dietary supplements, which are widely available in pharmacies, drugstores, and even supermarkets. Many people consider probiotics to be natural, beneficial agents that can exert favorable effects on health. The intestinal tract is the main target of the action of probiotics, and probiotics are perceived to be especially effective in treating diarrhea. Scientists, however, are more cautious about this claim, mainly because of the plethora of probiotic-containing products that are available. In addition, some products do not even seem to contain what they claim.[1]
AAD is an important indication for probiotics, which can re-establish the unbalanced composition of intestinal microflora, enhance immune response, and clear pathogens from the host. Published studies in this setting vary greatly in terms of trial design, type and dose of probiotic, and duration of treatment and therefore sometimes yield contradictory and inconclusive results. The lack of definitive evidence about the efficacy and the safety of probiotics has hampered their acceptance and use as a treatment for AAD and CDD. Previous meta-analyses[2,3] have examined only a limited number of trials, and failed to emphasize possible publication bias or data heterogeneity.
In this article, McFarland reports an exhaustive meta-analysis of 31 carefully selected, good-quality trials involving 2,810 patients with AAD, and 354 patients with CDD, who were treated with probiotics. Two single probiotic strains—S. boulardii and L. rhamnosus GG—as well as mixtures of different types of Lactobacilli, showed significant efficacy in AAD. Only S. boulardii, however, proved to be effective in preventing recurrences of CDD.
The first take-home message from this paper is that probiotics do exert the therapeutic effects on AAD in clinical practice that were anticipated from a theoretical point of view. This is extremely important because clinicians now have scientific evidence of a therapeutic indication that had, so far, remained controversial. The second, equally important message is that, once again, probiotics are an extremely heterogeneous group of micro-organisms that are endowed with different properties and modes of action. The assumption that the therapeutic effects of a particular probiotic agent might be attributed to other similar strains, or to the whole probiotic family, is totally wrong. Each agent must be tested and evaluated separately; admittedly, this is a time-consuming process, but it is the only way to obtain scientific evidence. Similarly, the efficacy of a probiotic in a specific disorder (e.g. AAD) does not automatically mean that the particular product will also be beneficial in other intestinal conditions (e.g. IBD or IBS), and vice versa. Finally, physicians must bear in mind that probiotics do not consist of only or mainly Lactobacilli. One of the few probiotic agents that have been proved to be effective in AAD, and the only one able to prevent CDD recurrence, is S. boulardii. This probiotic is a nonpathogenic yeast that, incidentally, has shown promising preliminary results as a supportive measure in the treatment of IBD.[4,5]
Practice point
Probiotics are effective for treating antibiotic-associated diarrhea and Clostridum difficile disease; Lactobacillus rhamnosus GG is effective for antibiotic-associated diarrhea, Saccharomyces boulardii is effective for both
The synopsis was written by Rachel Jones, Associate Editor, Nature Clinical Practice.
Hepatogastroenterology Unit, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy.
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Mario Guslandi is Head of the Clinical Hepatogastroenterology Unit and adjunct professor at the San Raffaele University Hospital in Milan, Italy.
Nat Clin Pract Gastroenterol Hepatol. 2006;3(11):606-607. ©2006 Nature Publishing Group
http://www.medscape.com/viewarticle/546934_1
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East Mediterr Health J. 2006 May-Jul;12(3-4):423-7.
Comparison of the effectiveness of fennel and the non-steroidal anti-inflammatory drug mefenamic acid on pain intensity in dysmenorrhoea.
Modaress Nejad V, Asadipour M.
Department of Obstetrics and Gynaecology, Kerman University of Medial Sciences and Health Services, Kerman, Islamic Republic of Iran.
A study in Kerman, Islamic Republic of Iran in 2002 compared the effectiveness of fennel and mefenamic acid on pain relief in primary dysmenorrhoea. Two groups of high-school girls (mean age 13 years) suffering dysmenorrhoea were randomized to receive fennel extract (n = 55) or mefenamic acid (n = 55) for 2 months. In the fennel group, 80% of girls and in the mefenamic acid group, 73% of girls showed complete pain relief or pain decrease, while 80% in the fennel group and 62% in the mefenamic acid group no longer needed to rest. There was no significant difference between the 2 groups in the level of pain relief.
PMID: 17037712 [PubMed - in process]
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17037712&query_hl=15&itool=pubmed_docsum
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