Effect of Propolis Administration as Levonorgestrel (LNG) Implant Adjuvant for Dysmenorrhea in Endometriosis: Focus on Clinical Improvement, Oxidative Stress Biomarkers and Inflammation
Phase: NA
Conditions: Endometriosis, Dysmenorrhea
Sponsor: Indonesia University

Health Research Ethics Committee 
FKUI-RSCM 
FKUI 
Rumah Sakit Umum Pusat 
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INFORM CONSENT FORM (ICF) and 
STUDY PROTOCOL  
 
“Effect of Propolis Administration for Dysmenorrhea in Endometriosis Patient with Levonorgestrel (LNG) 
Implant Therapy: Focus on Clinical Improvement, Oxidative Stress and Inflammatory Biomarkers” 
 
 
 
 
 
 
 
 
Principal Investigator 
 
 
Dr.drg. Dwirini Retno Gunarti, M.S 
 
 
 
 
 
 
Department of Biochemistry 
 
 
 
 
 
 
Faculty of Medicine 
 
 
 
 
 
 
University of Indonesia 
 
 
 
 
 
 
Jakarta, Indonesia 
 
 
 
 

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Rumah Sakit Umum Pusat 
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Contents 
EXPLANATION SHEET TO PROSPECTIVE SUBJECTS ........................................................................... 3 
Research Objectives ..................................................................................................................................... 3 
Participation in research ............................................................................................................................... 3 
Reasons for choosing  the participants to participate in the study ............................................................... 3 
Research procedures ..................................................................................................................................... 4 
Risks, side effects and management ............................................................................................................. 5 
Benefits ........................................................................................................................................................ 5 
Compensation ............................................................................................................................................... 5 
Financing ...................................................................................................................................................... 5 
Confidentiality .............................................................................................................................................. 5 
Research subject obligations ........................................................................................................................ 5 
Right to refuse and withdraw ....................................................................................................................... 5 
Post-trial access ............................................................................................................................................ 6 
Additional Information ................................................................................................................................. 6 
RESEARCH PARTICIPATION CONSENT SHEET ..................................................................................... 7 
STUDY PROTOCOL ...................................................................................................................................... 9 
Background .................................................................................................................................................... 10 
Objectives ....................................................................................................................................................... 10 
Design and Methods ....................................................................................................................................... 10 
Procedure ........................................................................................................................................................ 11 
Flowchart of Screening and Inclusion Process ........................................................................................... 12 
Outcomes ........................................................................................................................................................ 13 
Primary outcomes ....................................................................................................................................... 13 
Subject charateristics .................................................................................................................................. 13 
Safety outcomes ......................................................................................................................................... 13 
Analyses ......................................................................................................................................................... 13 
Primary outcome ........................................................................................................................................ 13 
Subject characteristics ................................................................................................................................ 13 
 
 
 
 

Health Research Ethics Committee 
FKUI-RSCM 
FKUI 
Rumah Sakit Umum Pusat 
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EXPLANATION SHEET TO PROSPECTIVE SUBJECTS 
 
 
I am part of a research team chaired by Dr. drg. Dwirini Retno Gunarti, M.S from the Faculty of 
Medicine, University of Indonesia.  the investigators’re conducting a research entitled “Effect of 
Propolis Administration for Dysmenorrhea in Endometriosis Patient with Levonorgestrel (LNG) 
Implant Therapy: Focus on Clinical Improvement, Oxidative Stress and Inflammatory 
Biomarkers”. 
I will provide to  the participants information about this research and then invite  the 
participants to be part of this research. 
 the participants can participate in this research by signing this form. If  the participants agree to 
participate in this research,  the participants can freely withdraw from this research at any time.  
the participants also have the right to receive the latest information from us about treatments 
being tested, if any. 
If  the participants refuse to participate or withdraw from this study, this decision will not affect  
the participantsr relationship with me and will not affect the services that apply at this hospital. 
If  the participants don't understand each statement on this form,  the participants can ask me. 
Research Objectives 
To see improvement in complaints and symptoms, as  the investigatorsll as changes in levels of 
inflammatory markers and oxidative stress in the blood, after administering propolis as adjuvant 
therapy for endometriosis patients with Levonorgestrel (LNG) implants. 
Participation in research 
Overall, this research will run for three months. If  the participants decide to participate in this 
research,  the participants must follow our schedule and ensure that  the participants can adhere 
to this schedule. This research will involve  the participants in one interview session for 1 to 2 
hours, also blood sampling at the beginning of the study, after the first month, and after the 
three month study period. 
Reasons for choosing  the participants to participate in the study 
 the investigators chose  the participants to participate in the study because  the participants met 
the criteria for this study: women aged 20-49 years and had menstruated; experienced menstrual 

Health Research Ethics Committee 
FKUI-RSCM 
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Rumah Sakit Umum Pusat 
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pain complaints; referred to the obstetrics and gynecology polyclinic for LNG implant 
placement; willing to have LNG implants installed after receiving an explanation about 
implants; not receiving hormonal treatment for endometriosis within the last three months; and 
able to receive drops (propolis) during the study, and willing to undergo control in month one 
and month three. 
Research procedures 
During this research  the participants will undergo several stages of research procedures that 
include: 
1. The doctor will interview  the participants and inquire about  the participantsr name, age, 
educational background, current medical history, prior drug use, allergy history, smoking 
habits, and alcohol consumption patterns. 
2. The interview will also collect the data about  the participantsr food and drink 
consumption over the past month. 
3.  the participantsr height,  the investigatorsight, and overall physical condition will be 
measured and examined prior to the study. 
4.  the participants will be required to fast the night before the study, ho the investigatorsver, 
drinking water as needed is permitted. 
5. Please arrive at 7:00 AM on the day of the study's start for blood sampling. 
6. Blood will be collected three times throughout the study period, on the first day, after 1 
month, and after 3 months. Approximately 5 mL, or 1 teaspoon, of blood will be taken 
from either the left or right arm. While this procedure can result in moderate discomfort 
and may cause s the investigatorslling, redness, or infection (which typically resolves in a 
few days), it will be performed by experienced medical personnel to minimize any 
adverse effects. In case of any discomfort, assistance will be provided until recovery. 
7. The collected blood samples will be used for laboratory tests to assess levels of 
inflammatory and oxidative stress biomarkers. 
8. The blood collection will be conducted by an experienced nurse. 
9. On the first day of the study,  the participants will be given a bottle of propolis, which  
the participants should consume 2 times daily, at a dose of 1 drop per 10 kg of body  the 
investigatorsight, for a total of 3 months. 

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Rumah Sakit Umum Pusat 
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Risks, side effects and management 
Propolis is a commonly used substance with minimal side effects. Ho the investigatorsver, in 
rare cases, an allergic reaction may occur. If  the participants experience any adverse symptoms, 
it is important to immediately contact the research team or seek treatment at the Obstetrics and 
Gynecology Clinic at RSCM. Prompt action will ensure the best possible outcome. 
 
Benefits 
Participating in this study provides  the participants with a free comprehensive health check-up 
and blood tests for markers of inflammation and oxidative stress. Additionally,  the participants 
will receive information on proper propolis usage and how to maintain a healthy lifestyle to 
reduce the risk of future illnesses. Knowledge of the benefits and positive effects of propolis 
may also serve as a future alternative treatment for endometriosis. 
Compensation 
For  the participantsr participation,  the participants will receive a transportation reimbursement 
of Rp 100,000 for each of the first and third month check-ups. 
Financing 
The research will by fully funded by the researchers.  
 
Confidentiality 
All data collected during the study will be kept confidential.  the participantsr personal 
information will not be included in presentations or publications related to the research. 
Research subject obligations 
As a participant in this study,  the participants are expected to follow the instructions and 
guidelines outlined in the previous information. If  the participants have any questions or 
concerns, feel free to ask the research team.  the participants are also required to refrain from 
taking any other medications or supplements, aside from what is provided by the researchers. 
Right to refuse and withdraw 
Participation in this study is voluntary, and  the participants have the right to decline or 

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withdraw at any time. This decision will not affect the quality of care  the participants receive at 
the hospital, nor will it impact  the participantsr relationship with the medical staff. After 
hearing this information,  the participants will have the opportunity to consider  the participantsr 
decision 
 
Post-trial access 
Once the study has been completed,  the participants will continue to receive the best 
possible follow-up care for  the participantsr current condition. 
Additional Information 
 the participants are given the opportunity to ask any questions or clarify any concerns  the 
participants may have regarding this research. If  the participants experience any side effects 
or require additional information,  the participants may reach out to Dr. drg. Dwirini Retno 
Gunarti, M.S (08118382301) or Dr. dr. Eka Rusdianto Gunardi, SpOG(K), MPH (+6221-
816933301) in the Obstetrics and Gynecology Division of RSUPN Dr. Cipto 
Mangunkusumo, Jakarta.  

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Rumah Sakit Umum Pusat 
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RESEARCH PARTICIPATION CONSENT SHEET 
 
 
All of these explanations have been conveyed to me and all my questions have been ans 
the investigatorsred by the research team. I understand that if I need an explanation, I 
can ask Dr. drg. Dwirini Retno Gunarti, M.S. 
 
Consent Sertification 
I have read all the explanations about this 
research. I have been given the opportunity 
to ask questions and all my questions have 
been ans the investigatorsred clearly. I agree 
to participate in this research study 
voluntarily. 
 
 
 Name of subject/guardian 
 
Signature of study participants 
 
Date 
 
date/month/year 
I confirm that participants have been 
given the opportunity to ask questions 
about this study, and that all questions 
have been ans the investigatorsred 
correctly. I confirm that consent was 
voluntarily given. 
 
Name of researcher/approval requester 
 
Signature of researcher/approval 
requester 
Date 
 
date/month/year 

Health Research Ethics Committee 
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Rumah Sakit Umum Pusat 
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About researcher: 
Lead researcher: 
Dr. Drg. Dwirini Retno Gunarti, M.S) 
Jl. Batu Pancawarna no. 5 Rt. 001 Rw. 011 
Kayu Putih Pulogadung Jakarta 13210] 
(08118382301/rinairet@gmail.com) 
 
Researcher 
: 
Eka Rusdianto Gunardi, Dr, dr, SpOG(K),MPH 
Komplek Hankam Cidodol no. 33 Rt. 004 Rw. 011 Kelurahan Grogol 
selatan Kecamatan Kebayoran Lama Jakarta Selatan 12220 
(+62-21-72791866/eka.dhikita@yahoo.co.id) 
 
 
KEPK FKUI-RSCM: Jalan Salemba 6, Jakarta Pusat, 10430 
Phone no: 021 3157008 
Email: ec_fkui@yahoo.com 
 
 

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STUDY PROTOCOL 
 
“Effect of Propolis Administration for Dysmenorrhea in Endometriosis Patient with Levonorgestrel (LNG) 
Implant Therapy: Focus on Clinical Improvement, Oxidative Stress and Inflammatory Biomarkers” 
 
 
 
 
 
 
 
 
Principal Investigator 
 
 
Dr.drg. Dwirini Retno Gunarti, M.S 
 
 
 
 
 
 
Department of Biochemistry 
 
 
 
 
 
 
Faculty of Medicine 
 
 
 
 
 
 
University of Indonesia 
 
 
 
 
 
 
Jakarta, Indonesia 
 
 

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Background 
Endometriosis is a benign gynecological disease which is defined as the presence of endometrial 
tissue located in places other than the uterine cavity. The incidence of endometriosis is estimated 
to be around 3-10% of all women of reproductive age, 2-5% of postmenopausal women, and 25-
80% of the infertile group. In Indonesia, data on patients with endometriosis are not known with 
certainty because there are no comprehensive epidemiologic studies. One of the clinical problems 
of endometriosis is the high rate of recurrence and cannot be prevented, so it often requires repeat 
surgery. In addition, endometriosis can spread to various organs near the uterus, such as the 
rectum, vagina and cervix. Besides having the ability to spread, endometriosis also has the ability 
to attach, destroy and invade other tissues, so that it is similar to the characteristics of cancer. On 
studies at Cipto Mangunkusumo Hospital Jakarta, in 2010, it was stated that endometriosis 
accounted for 42.62% of all benign gynecological disorders.  
 
The typical symptom of endometriosis is severe pain during menstruation (dysmenorrhea) that 
interferes with physical activity. Besides pain, another thing that is more important is the impact of 
endometriosis on fertility status. Indonesian Obstetrics and Gynecology Association states that 
pain felt by endometriosis patients can be chronic and often relapses even though operative 
measures have been taken. The American Society for Reproductive Medicine in studies in several 
countries found that 35-50% of patients with infertility have a history of endometriosis. Chronic 
conditions such as endometriosis can trigger oxidative stress in the body which causes an 
imbalance of antioxidants with reactive oxygen species (ROS). a bee product that is rich in 
phenolic compounds as bioactive components that have antioxidant effects which have been 
proven to have a positive effect on reducing ROS levels in the human body. Jasprica et al  looked 
at the effect of propolis administration on oxidative stress parameters in the form of 
malondialdehyde (MDA) and endogenous antioxidant, namely superoxide dismutase (SOD) in 
healthy adults for 30 days. the result is that there is a decrease in MDA of 23.2% for 15 days and a 
significant increase in SOD of 20.9% 
 
Objectives 
To see improvement in complaints and symptoms, as  the investigatorsll as changes in levels of 
inflammatory markers and oxidative stress in the blood, after administering propolis as adjuvant 
therapy for endometriosis patients with Levonorgestrel (LNG) implants 
 
Design and Methods 
This is a double-blind clinical trial study which using propolis and placebo. The population of the 
study is all of women with endometriosis in Obstetrics gynecology clinic at Cipto Mangunkusumo 
Hospital Jakarta.sampling methods of this study is consecutive sampling with randomization 
blocks to divide the subjects into two groups, namely the propolis and placebo groups. Propolis 
and placebo  the investigatorsre administered 2 times a day, namely in the morning before 
breakfast and at night before going to bed, with a dose of 1 drop/10 kg body  the investigatorsight. 
clinical examination in the form of body mass index (BMI) and visual analogue scale (VAS) as  
the investigatorsll as laboratory tests in the form of biomarkers of inflammation TNFα and IL-6, 
oxidative stress biomarker; MDA, SOD, Glutathione, and 8-OhdG. 
 

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Procedure 
- 
The nutritionist will interview  the participants and inquire about  the participantsr 
name, age, educational background, current medical history, prior drug use, allergy 
history, smoking habits, and alcohol consumption patterns and also collect the data 
about food and drink consumption over the past month. height,  the investigatorsight, 
and overall physical condition will be measured and examined prior to the study. 
- 
Blood will be collected three times throughout the study period, on the first day, after 
1 month, and after 3 months. Approximately 5 mL, or 1 teaspoon, of blood will be 
taken from either the left or right arm. The collected blood samples will be used for 
laboratory tests to assess levels of inflammatory and oxidative stress biomarkers. The 
blood collection will be conducted by an experienced nurse. 
- 
On the first day of the study, the subjects will be given a bottle of propolis, which 
should consume 2 times daily, at a dose of 1 drop per 10 kg of body  the 
investigatorsight, for a total of 3 months. 
- 
Evaluation will be held everyday by the certified nutritionist. 
 
 

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Flowchart of Screening and Inclusion Process 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 and 3-Month 
Follow Up 
Allocation 
Population 
screening 
Confirmation of eligibility 
Inform consent signature 
Baseline measurements 
Dietary assessment: Physical examination, 24 
hours food recall and semi quantitavie food 
frequency  questionnaire (SQ-FFQ) 
 
Collect blood sample 
Screening criteria  
Women with endometriosis 
 Intervention 
1 drop/10 kgBW 2 
times  daily 
Placebo  
1 drop/10 kgBW 2 
times  daily 
Follow-up Measurements 
Dietary assessment: Physical examination, 24 
hours food recall and semi quantitavie food 
frequency  questionnaire (SQ-FFQ) 
 
Collect blood sample 
Excluded 
Endometriosis with 
hormonal therapy 
-Not reached 
-Not interested 
-excluded 
Ineligible 
Bee products intolerance 
BMI >25 kg/m2 
On therapy of 
degenerative disease 
(hyoertension, diabetes 
mellitus, cancer, fatty 
liver) 
Total estimated drop 
out in both arms: 10% 
Enrollment 

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Outcomes 
Primary outcomes 
 
Visual analogue scale (VAS), Inflammation and stress oxidative biomarker. It will be measured at 
baseline, 1 month and 3 months 
 
Subject charateristics 
- 
 Age, marital status. And education level 
- 
 Body Mass Index (kg/m2) 
- 
carbohydrate intake (g/day) 
- 
Protein intake (g/day) 
- 
Fat intake (g/day) 
- 
Calorie intake (kkal/day) 
- 
Total flavonoid intake (mg/day) 
 
Safety outcomes 
Adverse events 
Adverse events are reported at each nutritionist visit 
 
Concomitant medications 
Usage of medications during study periode will be recorded  
Analyses 
 
- 
All randomized study subjects will be analysed with Intention-to-treat (ITT) method. This 
will be seen as the primary population for the analysis. 
- 
All outcomes will be presented using descriptive statistics; normally distributed data by 
the mean and standard deviation (SD) and ske the investigatorsd distributions by the 
median and interquartile range (IQR). Binary and categorical variables will be presented 
using counts and percentages. SPSS for Windows version 26 will be used for all statistical 
analysis. 
Primary outcome 
 
The primary analysis will compare intervention groups (propolis vs placebo treatment) on their 
mean change in visual analogue scale, inflammatory and oxidative stress biomarker bet the 
investigatorsen baseline,1 month and 3 months using a linear mixed model. Difference in visual 
analogue scale and biomarkers from baseline to time points where it is measured during the study 
(1 and 3 months) will be the dependent variable. Baseline value will be included as a covariate. 
The estimated difference in mean change from baseline to 3 months and the corresponding 95 % 
confidence interval (CI) will be presented. 
Subject characteristics 
The characteristics will describe analyses in addition to the descriptive statistics