DE GRUYTER Journal of Complementary and Integrative Medicine.

2020; 20190229

Maryam Navaee1 / Samira Khayat1 / Zahra Ghadiri Abed1

Effect of pre-cesarean foot reflexology massage

on anxiety of primiparous women
1
Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran, E-mail: helennavaee@gmail.com,
khayatmsc@yahoo.com, z.ghadiri7373@gmail.com

Abstract:
Introduction: Anxiety is a common feeling in cesarean section and lack of attention to it is associated with
negative consequences for health of mother and child. Reflexology is a way to reduce anxiety. So far, the
effect of reflexology on pre-cesarean anxiety has not been evaluated. Therefore, we aimed to evaluate the
effect of pre-cesarean foot reflexology massage on the anxiety of women during their first pregnancy.
Materials and Methods: This study is a three-group clinical trial that was conducted in 2019. The study
sample
consisted of 90 pregnant women hospitalized for cesarean section in Zahedan who were randomly divided
into three groups of 30 women. The subjects completed the state section of Spielberger anxiety
questionnaire. The control group did not receive any intervention. For two groups, 1 h before surgery, a
group received reflexive massage, and the another group simple massage. Duration of massage for each group
was 30 min. After 30 min, the subjects completed the state section of Spielberger questionnaire again.
Statistical analysis was performed by SPSS software program, version 21.0. ANOVA and ANCOVA tests were
used to compare between groups and paired t-test was used for intra-group comparisons.
Results: The results showed that the level of anxiety was significantly reduced in the reflexology massage
group
(from 55 ± 8 to 40 ± 7) as well as simple massage group (from 51 ± 10 to 47 ± 7) (p<0.001). In the control
group, anxiety was increased (from 49 ± 9 to 56 ± 9) (p<0.001). Comparison between the three groups by
ANCOVA indicated that reflexology massage and simple massage significantly decreased anxiety scores
(p>0.001 and p>0.001,respectively). Reflexive massage significantly reduced anxiety scores (p>0.001) as
compared to simple massage.
Conclusion: The results of this study revealed the positive effect of reflexology massage on pre-cesarean
anxiety.
Because reflexology massage is an inexpensive, simple, and easy approach, the use of this non-
pharmaceutical method is recommended to reduce pre-cesarean anxiety.
Keywords: anxiety, cesarean section, massage, pregnancy, reflexology massage
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DOI: 10.1515/jcim-2019-0229
Received: August 26, 2019; Accepted: October 31, 2019

Introduction
Cesarean section is one of the most common gynecological surgeries [1]. Cesarean rates are increasing world-
wide [2]. Although the rational rate of cesarean section is 10–15% according to the World Health
Organization [3], a 2014 meta-analysis of Azami-Aghdash et al. [4] showed that cesarean rate in Iran was 48%,
namely three times that of the international standard.
Cesarean section is one of the most frightening events for the mother, which can lead to stress and anxiety
[5]. Even if the cesarean section is successful, the mother will have physical and psychological problems [6].
The study of 48 pregnant women undergoing cesarean section showed that 83.3% of them had anxiety
related to fear of fetal health, epidural anesthesia, and possible complications of cesarean section. Prior to
surgery, high levels of anxiety and moderate levels after it were reported by these women [7]. Hepp et al. [1],
in their study, showed that a majority mothers were anxious on the day of hospitalization for cesarean
section and before surgery. Although most women receive routine pre-cesarean care, negligence of
psychological compli- cations can lead to subsequent maternal discomfort [8]. Stress and anxiety have
negative effects on the health of pregnant mother and the newborn [9]. The autonomic nervous system is
stimulated by prolonged anxiety through increasing release of catecholamines such as adrenaline and
noradrenaline, which enhances the con- traction of smooth muscles such as the arterial system decreasing
oxygen supply to the uterus and increasing abnormal patterns of fetal heart rate [10, 11]. Maternal anxiety
also inhibits oxytocin secretion and reduces breastfeeding, and on the other hand, maternal stress and

1
 Navaee et al. DE GRUYTER
anxiety levels increase the likelihood of postpartum
Samira Khayat is the corresponding author.
© 2020 Walter de Gruyter GmbH, Berlin/Boston.

2
 depression [12]. Pre-cesarean anxiety, on the other hand, can cause long-term emotional imbalances, impair
maternal mental health, and thus affect the mother-infant relationship [13]. Studies have also shown that
pre- operative anxiety can lead to decreased satisfaction and poor recovery following surgery [2]. As a result,
using assistive techniques alleviating stress and anxiety can help reduce these complications [9]. Pharmacological
and non-pharmacological approaches are used to control anxiety, which are becoming increasingly
unpopular due to the high cost, side effects, and temporary effects of pharmacological methods [14].
Complementary therapies are among the non-pharmacological ways to control anxiety, including a variety of
methods such as natural products, herbs, probiotics, vitamins and minerals, meditation, acupuncture,
relaxation techniques, yoga and massage therapy [15]. Reflexology is a type of complementary therapy used
in the treatment of diseases such as migraine headaches, problems with blood flow, pain relief and
postoperative anxiety, cancer and childbirth. This massage involves applying pressure and rubbing the reflex
points found on the hands and feet [16].
Reflexology is a simple, accessible and noninvasive technique that requires no special equipment, which is
now widely used in maternal care and can be used by people with different levels of knowledge [17].
Reflexive massage is the manipulation and pressing of parts of the foot that affect other parts of the body
[18]. Reflexive massage implies that all glands, organs, and systems of the body have points and locations in
the foot that can be affected by pressure [14]. Hassavari’s [14] study in angiographic volunteer patients
showed that anxiety score was significantly decreased immediately and half an hour after reflexology
massage. A study by Gunnarsdottir et al. [19] showed that foot reflexology massage had no effect on reducing
anxiety in patients undergoing coronary artery bypass grafting.
There have been studies regarding the effect of reflexology on anxiety in patients, which unfortunately
have only addressed the effect of this method on postoperative anxiety, whereas prenatal anxiety can have
devas- tating effects on patients. Given the importance of pre-cesarean anxiety reduction, lack of a similar
study on the efficacy of reflexology in reducing pre-cesarean anxiety, and the increasing prevalence of
cesarean section, this study aimed to investigate the effect of pre-cesarean foot reflexology massage on the
anxiety of women on their first pregnancy.

Materials and methods

This research was a randomized clinical trial with three groups of control, reflection massage and simple
mas- sage. The study was performed in 2019 on women who referred to the gynecology ward of Ali Ibn Abi
Talib Hospital in Zahedan for cesarean section of their first birth. The research project was approved by the
Ethics Committee of Zahedan University of Medical Sciences (IR.SBMU.EMRC).
Sample size was determined based on the results of a study by Razmjo et al. [20]. Pain intensity variable
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was considered 2 h after the intervention with 95% confidence interval and 80% test power, and 25 patients
in each group with 10% fall in subjects (from a total of 30) were examined in each group (90 in total).
Inclusion criteria were as follows: 18–35 years of age, physical health in the legs (especially foot), scheduled
cesarean section, complete alertness, neither drug addiction, sedation, nor alcohol, no history of foot
reflexology massage, no analgesics on the day of intervention, ability to understand and speak Persian, not
undergoing surgery in the past 6 weeks, without peripheral nephropathy, cardiac pacemaker and medical
disease, lack of labor pain and minimum score of 20 with Spielberger anxiety questionnaire. If the person did
not want to participate, they would be excluded.
After reviewing the inclusion criteria by the researcher, each participant was given a detailed explanation
of the research method and its purpose. After obtaining permission from the patient and assuring her that
the procedure was not harmful and would not cause any disruption in routine treatment, written consent was
taken from the patient who was assured that at any stage of the study she could be excluded if not willing to
continue. Patients were randomly assigned into three groups of foot reflexology, simple massage and control.
Each of the samples at the time of referral selected number one to three (i.e. 1 – intervention group, 2 –
control group, 3
– simple massage group) and was assigned to the respective group based on the chosen number. As cesarean
section is performed at 8 AM, this study was performed in the gynecological ward 1 h before the patient was
transferred to the operating room for cesarean section. This research lasted 40 min considering the preparatory
stages (completion of forms), intervention, and finally post-test.
Prior to any intervention, demographic questionnaire and the state section of Spielberger ’s anxiety question-
naire were completed by interviewing the patients. The Spielberger’s anxiety questionnaire has been
developed by Spielberger in 1984 and consists of 40 items. It measures 20 explicit and 20 hidden anxiety
questions and has 4-point Likert-type answers (1 for no anxiety and 4 for high anxiety) with a total score of
20–80. This test consists of two parts, namely State and Trait. The questionnaire has high validity and
reliability (Cronbach’s α
 DE GRUYTER Navaee et al.

of 0.9) [21] and only State questionnaire was used in this study. In this research, the internal consistency of
the instrument was again tested and its Cronbach’s α was 0.87.
In the intervention group, reflexology massage was performed after soaking the sole of the foot with baby
body oil and putting the patient in a comfortable position as follows:

1. Gentle foot massage was performed with relaxation techniques for 10 min on both feet.
2. Constant or rotational pressure was applied to the solar and pituitary grid points for 15 min.
3. Finally, all parts of the foot soles were massaged to ensure the whole body massage for 5 min (30 min in total)
[22].

In the simple massage group, all the reflex points of the foot (except for anxiety points) were massaged for
30 min with less pressure than in the reflex massage group [22]. No gloves were used for massage in the two
groups.
The control group did not receive any intervention and only completed the questionnaire after 30 min.
The whole study was performed in the private rooms of patients in gynecology ward of Ali Ibn Abi Talib
Hospital in Zahedan. Only one patient together with a relative was present in the room. We did not made any
changes to the room environment.
Statistical analysis was performed using SPSS software program, version 21.0. To compare demographic
characteristics, ANOVA and chi-square tests were used. To compare anxiety scores, normal distribution of
data was evaluated by Kolmogorov–Smirnov test. Anxiety level showed normal distribution, and paired t-test
was used for intra-group comparisons of anxiety. ANOVA (with Tukey post hoc) and ANCOVA tests were used
to compare between groups and a value of p< 0.05 was considered significant in all tests.

Results
A total of 90 individuals participated in this study. To compare demographic characteristics, ANOVA and chi-
square tests were used, and the results showed that no significant difference was observed between groups in
demographic characteristics. Mean age of mothers was 25 ± 4 years in intervention group, 25 ± 3 years in simple
massage group and 26 ± 4 years in control group. The mean gestational age in all three groups was 38 weeks.
The demographic characteristics of the samples are shown in Table 1.

Table 1. The demographic characteristics of the samples.

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Sample characteristics Control group Simple massage Reflexology P value

Frequency (%) group Frequency massage group
(%) Frequency (%)
Mother’s jobs House Keeper 27 (91) 26 (86) 24 (80) 0.11
Employed 3 (9) 4 (14) 6 (20)
Husband’s job Workless 3(9) 4 (13) 5 (16) 0.18
Employed 27 (91) 26 (87) 25 (84)
Mother’s education Illiterate or 8 (27) 8 (27) 6 (20) 0.23
primary school
Guidance and 17 (57) 20 (67) 22 (74)
high school
Higher education 5 (16) 2 (6) 2 (6)
Insurance Has 28 (94) 29 (97) 28 (94) 0.76
Doesn’t have 2 (6) 1 (3) 2 (6)
Infant sex Female 17 (56) 18 (60) 15 (50) 0.34
Male 13 (44) 12 (40) 15 (50)
Cause of CS* Elective 17 (57) 15 (50) 14 (47) 0.42
Therapeutic 13 (43) 15 (50) 16 (53)

*CS, cesarean section

ANOVA test showed that there was no significant difference in anxiety level between groups before inter-
vention. However, the difference between groups was significant after intervention. As the difference in pre-

3
 intervention anxiety score between groups was close to p-value of 0.05, ANCOVA test was used to adjust the
results and pre-intervention scores were considered as covariate (Table 2).

Table 2: Comparison of mean anxiety scores of the three study groups before and after the intervention by ANOVA and
ANCOVA tests.
Anxiety scores Before intervention After the intervention
ANOVA ANCOVA
Mean ± SD P-value Mean ± SD P-value Mean ± SD P-value
Control group 49 ± 9 0.057 56 ± 9 0.001> 58 ± 0 0.001>
Simple massage group 51 ± 10 47 ± 7 48 ± 0
Reflexology massage group 55 ± 8 40 ± 7 38 ± 0

Tukey post hoc test and pairwise comparison in ANCOVA showed a significant difference between the groups
after the intervention (Table 3).

Table 3: Tukey posttest and pairwise comparison results of comparison between the three study groups.
Groups Groups P-value
ANOVA ANCOVA
Control group Intervention group 0.001> 0.001>
Simple massage group 0.001 0.001>
Simple massage group Intervention group 0.003 0.001>
Control group 0.001 0.001>
Reflexology massage group Simple massage group 0.003 0.001>
Control group 0.001> 0.001>

Paired t-test indicated that the level of anxiety significantly decreased after the intervention in massage group
and the treatment group (p<0.001) but it increased significantly in the control group (p<0.001) (Figure 1).
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Figure 1: Changes in stress scores in the three groups before and after the intervention.
 Discussion
The findings of this study showed that massage in both groups of reflexology and simple massage could sig-
nificantly reduce anxiety, but reflexology massage reduced anxiety more effectively than simple foot massage.
Massage involves soft-tissue manipulation [18], which restores the metabolic balance of tissues and dimin-
ishes stress by stimulating the hypothalamus, leading to parasympathetic effects and reduced metabolism,
blood pressure, heart rate, respiratory rate as well as oxygen consumption that result in relaxation [14]. The
findings of a study by Maryami et al. [23] also showed that foot massage alleviates anxiety in hysterectomy pa-
tients. Consistent with the results of this research, a study on drug addicted women in Isfahan prison showed
that massage played a role in reducing anxiety and depression in these women [24]. Albert’s [25] study, how-
ever, showed that massage had no effect on depression and anxiety in patients undergoing postoperative car-
diac surgery. Moreover, an investigation by Chang et al. [26] on Taiwanese women in the labor process
revealed that massage was useful in reducing labor anxiety and pain. The type of illness, conditions and stress
associated
with heart disease, different medical conditions, and post-cardiac may have caused this difference.
A study on women undergoing abdominal hysterectomy showed that postoperative reflexology signifi-
cantly reduced anxiety and pain [27]. Furthermore, Razmjoo et al. [20] research indicated that reflexology did
not significantly reduce anxiety after cesarean section. In his investigation, Razmjoo used a visual scale to
mea- sure postoperative anxiety. Perhaps the differences in data collection tools and time have led to
differences in results.
Foot reflexology massage affects the function of target organs, increasing relaxation and recovery
response. As a result, it can improve a wide range of symptoms [28]. In reflexology, massage stimulates the
secretion of enkephalins and endorphins, which can relieve anxiety and pain and create a sense of well-being
and health. Furthermore, reflexology techniques block the neural transmission of pain signals to the brain
[29]. Studies showed that reflexology leads to reduced stress and increased local blood perfusion [30]. In
addition, reflexol- ogy reduces systolic and diastolic blood pressure [31]. However, the mechanism of
reflexology’s effect is not fully understood.
Nowadays, due to the side effects of chemical drugs and the increasing costs of health care, the use of
traditional and alternative medicine is becoming more and more popular [32]. Complementary medicine is
commonly used in the treatment of many conditions such as menopausal symptoms, PMS, and
dysmenorrhea [33, 34]. The results of this research also showed that complementary medicine is useful in
reducing anxiety of pre-cesarean section.
The findings of this study indicate that without intervention, anxiety increases with approaching to
surgical time. In other words, lack of proper intervention leads to increased anxiety. For unknown
reasons, anxiety is the most common feeling before surgery. Studies show that on the day of surgery,
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preoperative steps and concerns about the consequences of surgery cause anxiety. Preoperative anxiety can
be due to a variety of causes, including fear because of delayed surgery, losing control, anesthesia, pain,
unconsciousness or death. Anxiety can lead to complications in the patient; for example, it delays wound
healing [23]. Due to growing anxiety of mothers in case of lack of intervention, the probability of
complications may increase, which justifies interventions to reduce anxiety.
The limitation of our study was that it was performed in the one hospital and that only one massage
session was performed.

Conclusion
Mean pre-intervention anxiety score was not significantly different in the three groups, but both types of
inter- ventions significantly reduced anxiety. Reflection massage was more effective than simple massage,
whereas anxiety was increased without intervention. Based on the results of present study, it can be
recommend to use reflexology as a non-invasive, inexpensive, and easy approach to reduce pre-cesarean
anxiety, and to make the maternal process more pleasant during the cesarean delivery. Given the increasing
trend of cesarean delivery around the world, it is advisable to use non-pharmacological anxiety reduction
methods.

Acknowledgments

This paper is taken from the research project approved by Zahedan University of Medical Sciences, code
6985, and has been registered with the Iranian Clinical Trial Center under IRCT2015122723370N3. The
researchers
 sincerely appreciate the Vice-Chancellor for Research and Technology of Zahedan University of Medical Sci-
ences, the gynecology ward staff of Ali Ibn Abi Talib Hospital, and the mothers who participated in the
project.

Author contributions: All the authors have accepted responsibility for the entire content of this submitted
manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection,
analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for
publication.

References
[1] Hepp P, Hagenbeck C, Burghardt B, Jaeger B, Wolf OT, Fehm T, et al. Measuring the course of anxiety in women giving birth by
caesarean section: a prospective study. Bmc Pregnancy Childb 2016;16:113.
[2] Hobson JA, Slade P, Wrench IJ, Power L. Preoperative anxiety and postoperative satisfaction in women undergoing elective
caesarean section. Int J Obstet Anesth 2006;15:18–23.
[3] Mylonas I, Friese K. Indications for and risks of elective cesarean section. Dtsch Arztebl Int 2015;112:489–95.
[4] Azami-Aghdash S, Ghojazadeh M, Dehdilani N, Mohammadi M, Asl Amin Abad R. Prevalence and causes of cesarean section
in Iran: systematic review and meta-analysis. Iran J Public Health 2014;43:545–55.
[5] Hepp P, Hagenbeck C, Gilles J, Wolf OT, Goertz W, Janni W, et al. Effects of music intervention during caesarean delivery on
anxiety and stress of the mother a controlled, randomised study. Bmc Pregnancy Childb 2018;18:435.
[6] Puia D. First-time mothers’ experiences of a planned cesarean birth. J Perinat Educ 2018;27:50–60.
[7] Bluml V, Stammler-Safar M, Reitinger AK, Resch I, Naderer A, Leithner K. A qualitative approach to examine women’s
experience of planned cesarean. J Obstetric Gynecologic Neonatal Nurs: JOGNN 2012;41:E82–90.
[8] Edwards GJ, Davies NJ. Elective caesarean section–the patient’s choice? J Obstetrics Gynaecology: J Ins Obstetrics
Gynaecology 2001;21:128–9.
[9] Wulff V, Hepp P, Fehm T, Schaal NK. Music in obstetrics: an intervention option to reduce tension, pain and stress. Geburtshilfe
Frauen- heilkd 2017;77:967–75.
[10] Pillitteri A. Maternal & child health nursing: care of the childbearing & childrearing family. Philadelphia: Wolters Kluwer
Automatically generated rough PDF by ProofCheck from River Valley Technologies Ltd

Health/Lippin- cott Williams & Wilkins, 2010.

[11] Fassoulaki A, Paraskeva A, Kostopanagiotou G, Tsakalozou E, Markantonis S. Acupressure on the extra 1 acupoint: the effect on
bispectral index, serum melatonin, plasma β-endorphin, and stress. Anesth Analg 2007;104:312–17.
[12] Speroff L, Fritz MA. Clinical gynecologic endocrinology and infertility. Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins, 2005.
[13] Procelli DE. Effects of music therapy and relaxation prior to breastfeeding on the anxiety of new mothers and the behavior
state of their infants during feeding 2005.
[14] Hasavari F, Paryad E, Khorsandfard M, KazemnejadLeili E. The effect of foot reflexive massage on anxiety in patients
undergoing coro- nary angiography. cmja 2018;7:2100–14.
[15] Smith CA, Shewamene Z, Galbally M, Schmied V, Dahlen H. The effect of complementary medicines and therapies on
maternal anxiety and depression in pregnancy: A systematic review and meta-analysis. J Affect Disord 2019;245:428–39.
[16] Tsay S-L, Chen H-L, Chen S-C, Lin H-R, Lin K-C. Effects of reflexotherapy on acute postoperative pain and anxiety among
patients with digestive cancer. Cancer Nurs 2008;31:109–15.
[17] Mirzaei F, Kaviani M, Jafari P. Effect of foot reflexology on duration of labor and severity of first-stage labor pain. IJOGI 2010;13:27–
32.
[18] Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for
pain manage- ment in labour. Cochrane Database Syst Rev 2018;3:1–78.
[19] Gunnarsdottir TJ, Jonsdottir H. Does the experimental design capture the effects of complementary therapy? A study using
reflexology for patients undergoing coronary artery bypass graft surgery. J Clin Nurs 2007;16:777–85.
[20] Razmjoo N, Yousefi F, Esmaeeli H, Azizi H, Lotfalizadeh M. Effect of foot reflexology on pain and anxiety in women
following elective cesarean section. IJOGI 2012;15:8–16.
[21] Bavafa A, Akbar Foroughi A, Khaledi-Paveh B, Abbas Taheri A, Fehrest F, Amiri S. The comparison of effects of state and trait
anxiety on the components of sleep quality. JSS 2018;3:95–101.
[22] Embong NH, Soh YC, Ming LC, Wong TW. Revisiting reflexology: Concept, evidence, current practice, and practitioner
training. J Trad Complement Med 2015;5:197–206.
[23] Maryami Z, Modarres M, Taavoni S, Rahimi Foroushani A. Effect of foot massage on pre- and post hysterectomy
anxiety. Hayat 2013;19:65–75.
[24] Vafamand E, Kargarfard M, Salehi M, Ghasemi G. Effect of massage therapy on decreasing anxiety and depression in addicted
women of Isfahan central prison. Iran J Res Behav Sci 2013;11:81–9.
 [25] Albert NM, Gillinov AM, Lytle BW, Feng J, Cwynar R, Blackstone EH. A randomized trial of massage therapy after heart
surgery. Heart Lung 2009;38:480–90.
[26] Chang MY, Wang SY, Chen CH. Effects of massage on pain and anxiety during labour: a randomized controlled trial in Taiwan.
J Adv Nurs 2002;38:68–73.
[27] Öztürk R, Ü S, Sargin A, Yücebilgin MS. The effects of reflexology on anxiety and pain in patients after abdominal
hysterectomy: A ran- domised controlled trial. Complement Ther Med 2018;36:107–12.
[28] Jones J, Thomson P, Lauder W, Howie K, Leslie SJ. Reflexology has an acute (immediate) haemodynamic effect in healthy
volunteers: a double-blind randomised controlled trial. Complement Ther Clin Pract 2012;18:204–11.
[29] Valiani M, Shiran E, Kianpour M, Hasanpour M. Reviewing the effect of reflexology on the pain and certain features and
outcomes of the labor on the primiparous women. Iran J Nurs Midwifery Res 2010;15:302–10.
[30] Molavi Vardanjani M, Masoudi Alavi N, Razavi NS, Aghajani M, Azizi-Fini E, Vaghefi SM. A randomized-controlled trial
examining the effects of reflexology on anxiety of patients undergoing coronary angiography. Nurs Midwifery Stud 2013;2:3–9.
[31] Hughes CM, Krirsnakriengkrai S, Kumar S, McDonough SM. The effect of reflexology on the autonomic nervous system in
healthy adults: a feasibility study. Altern Ther Health Med 2011;17:32–7.
[32] Fanaei H, Behboodi Moghadam Z, Kasaeiyan A. Comparison the effects of ginger and curcumin in treatment of premenstrual
syndrome. ISMJ 2015;18:575–86.
[33] Khayat S, Kheirkhah M, Behboodi Moghadam Z, Fanaei H, Kasaeian A, Javadimehr M. Effect of treatment with ginger on the
severity of premenstrual syndrome symptoms. ISRN Obstet Gynecol 2014;2014:1–5.
[34] Khayat S, Fanaei H, Kheirkhah M, Moghadam ZB, Kasaeian A, Javadimehr M. Curcumin attenuates severity of premenstrual
syndrome symptoms: A randomized, double-blind, placebo-controlled trial. Complement Ther Med 2015;23:318–24.
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