International Journal of Nursing Studies 84 (2018) 1–11

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Effects of aromatherapy on dysmenorrhea: A systematic review and meta- T

analysis
⁎
Ji-Ah Songa,1, Mi-kyoung Leeb,1, Eunsil Minc, Mi-Eun Kimd, Geraldine Fikee, Myung-Haeng Hurb,
a
Department of Nursing, Konyang University, 158 Gwanjeodong-ro, Seo-gu, Daejeon, 35365, Republic of Korea
b
College of Nursing, Eulji University, 77 Gyeryong-ro 771 beon-gil, Jung-gu, Daejeon, 34824, Republic of Korea
c
Department of Nursing, DaeJeon Institute of Science and Technology, 100 Hyechon-ro, Seo-gu, Daejeon, 302-715, Republic of Korea
d
Department of Nursing, Jeonju University, 303 Cheonjam-ro, Wansan-gu, Jeonju-si, Jeollabuk-do, 55069, Republic of Korea
e
Department of Nursing, California State University, San Bernardino, 5500 University Parkway, San Bernardino, CA, 92407-2393, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: Menstrual pain is not a disease, but it is a problem that periodically makes women uncomfortable
Aromatherapy during menstrual cycles. There has been a continuing effort to alleviate menstrual cramps in the medical field.
Dysmenorrhea Aromatherapy, one of the alternative complementary therapies, has been used as a way to alleviate menstrual
Oils cramps, but there is still little evidence of how to use it. Therefore, in this study, we tried to find and provide the
Volatile
evidence of relieving effects of menstrual cramps.
Stress
Design: This study involved a systematic review and meta-analysis. The study was to identify the effects of
Physiological
Systematic review aromatherapy on menstrual pain through a systematic review of the relevant literature from Korea and abroad
and a meta-analysis of the data from studies meeting our inclusion criteria.
Data sources: We obtained articles published in English from PubMed, the Cumulative Index to Nursing and
Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL), and we
also obtained articles by searching the Korean databases Research Information Service System (RISS), DBPIA,
and Korean Studies Information Service System (KISS).
Review methods: A systematic review was performed on all searchable articles published form inception to
October 17, 2016, using the international and Korean databases noted above. The search terms used was ((ar-
omatherapy OR aroma* OR essential oil) AND (dysmenorrhea OR menstrual pain)). Articles were selected for
analysis from among the retrieved articles based on the key questions and the inclusion and exclusion criteria
using a PRISMA flow diagram. The 21 articles entire texts were reviewed and qualitatively analyzed while seven
articles were quantitatively analyzed using RevMan software ver. 5.3.
Results: In a comparison between the experimental groups, which received an aromatherapy intervention, and
the control groups, which received no treatment of any kind, the dysmenorrhea score in the experimental group
decreased by 2.67 points (mean difference −2.67), showing a statistically significant difference(Z = 7.79,
p < .001, Higgins I2 = 0%). Compared to the placebo group, which received a placebo oil treatment, the
dysmenorrhea score in the experimental group decreased by 1.71 points (mean difference, −1.71), showing a
statistically significant difference (Z = 4.51, p < .001), but high heterogeneity (Higgins I2 = 81%).
Conclusions: Aromatherapy was an effective intervention for reducing dysmenorrhea. However, because the
analysis showed that the aroma intervention methods were diverse and that the basis for the intervention
methods was weak, the possibility of randomization bias was high.

What is already known about the topic? among the studies. Research methods, were also varied, and
methods of applying aromatherapy, and the oils used varied.
• A number of studies have already been conducted on aromatherapy Therefore, we conducted a systematic review and analysis of the
to relieve menstrual cramps. However, there were conflicting results various studies and meta-analysis of the results of the studies to

⁎
Corresponding author.
E-mail addresses: sjiaaah@naver.com (J.-A. Song), lmk@eulji.ac.kr (M.-k. Lee), esmin@dst.ac.kr (E. Min), mekim@jj.ac.kr (M.-E. Kim), gfike@csusb.edu (G. Fike),
mhhur@eulji.ac.kr, wowmhhur@nate.com, wowmhhur@naver.com (M.-H. Hur).
1
Equal contributors.

https://doi.org/10.1016/j.ijnurstu.2018.01.016
Received 7 April 2017; Received in revised form 30 January 2018; Accepted 30 January 2018
0020-7489/ © 2018 Published by Elsevier Ltd.
J.-A. Song et al.
provide a strong basis for their effects.
What this paper adds
• As a result, the aroma massage group and placebo group were ef-
fective in decreasing menstrual cramps. These results suggest that
the massage itself has the effect of relieving menstrual cramps, but
using aroma oils is more effective in reducing pain. Meta-analysis
also confirmed that aroma inhalation methods are effective in re-
ducing menstrual cramps.
• When the research studies were qualitatively or quantitatively
synthesized, the research methodology in the systematic literature
review did not sufficiently study the Randomized Controlled Trials,
but the research showed that aromatherapy was effective in miti-
gating menstrual pain, and massage or inhalation application
methods were all effective. Especially, the most used essential oil
was lavender, and it was effective when lavender was used alone or
mixed.
• In conclusion, the systematic review of the literature has shown that
massages are mainly used to alleviate menstrual pain. Lavender
essential oils are mainly used and the effect of mixed essential oils is
limited.
1. Introduction
Menstrual pain that occurs in women of child-bearing age with
regular ovulation refers to pain that appears before or at the start of
menstruation (Deligeoroglou, 2000). Dysmenorrhea refers to men-
struation accompanied by pain, and it can be classified into pPrimary
dysmenorrhea: no organic pelvic lesions, and secondary dysmenorrhea:
accompanied by organic lesions. Primary dysmenorrhea is caused by
the production of prostaglandin that induces uterine contractions in the
endometrium (Deligeoroglou, 2000), and appears in over 50% of
women of child-bearing age (Dawood, 2006). A study in Korea reported
that 82.7% of adolescent female students experienced dysmenorrhea,
with 29.8% having severe dysmenorrhea symptoms (Jung and Kim,
2004). The symptoms primarily occur at the start of menstruation and
persist for several days, while the pain that feels like inward tightening
has the characteristic pattern of radiating from the lower abdomen
(Ohde et al., 2008). This menstrual pain usually appears up to 48 or
72 h from the start of menstruation (Rees, 2001). Primary dysmenor-
rhea is not life-threatening, but it can become a cause of absence from
school and affects quality of life. When women with severe dysme-
norrhea were compared to those without dysmenorrhea, higher levels
of depressive symptoms, suicidal ideation, and anxiety appeared in
women with severe dysmenorrhea, and their subjective view of their
own health was poorer (Ambresin et al., 2012). Moreover, because
economic losses may occur from increased levels of serious stress in
daily living and decreased productivity, creativity, and job performance
in these women, proper intervention and treatment for dysmenorrhea
are needed (Chawla et al., 2002).
As a treatment for dysmenorrhea, medical drug intervention has
been provided, but drug therapy can cause indigestion, headache, and
drowsiness, while long-term use may lead to adverse effects such as
drug dependency (Proctor and Farquhar, 2006). In addition, various
nursing interventions are also provided, including essential fatty acid
therapy, vitamins, acupuncture, oriental medicine, aromatherapy, re-
flexology, finger-pressure therapy, massage therapy, and exercise
therapy (Chen et al., 2011; Kim et al., 2011; Lee, 2011, Mirbagher-
Ajorpaz et al., 2011; Onur et al., 2012).
Among the various complementary and alternative therapies, ar-
omatherapy has historically been used for various purposes and in
various forms, such as massage, inhalation, and bathing. Moreover,
aromatherapy oils provide positive effects to the user since they can be
easily used in public by anyone and have potential therapeutic effects
(Battaglia, 2003). It has been claimed that aromatherapy increases the
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International Journal of Nursing Studies 84 (2018) 1–11
satisfaction of the subjects and improves psychological stability such as
depression, anxiety, stress relief, and affects the hormones, the endo-
crine glands, and the circulatory system. And also the aromatherapy
promotes physical functions such as pain reduction, memory and at-
tention. Many types of aroma essential oils used in aromatherapy have
the healing functions physically, mentally and spiritually and the ef-
fectiveness of the aromatherapy has been shown regarding antiviral,
antimicrobial and anti-inflammatory (Ali et al., 2015). Therefore, the
importance of aromatherapy has emerged. For these reasons, there have
been many studies on the use of aromatherapy oils with various tech-
niques to measure their efficacy on a variety of health issues, including
reducing effects of dysmenorrhea (Kim et al., 2011; Lee, 2011). How-
ever, there is a wide variety of aromatherapy oils such as oils that are
frequently mixed together, and intervention methods and durations
vary by study. Consequently, there are some limitations in applying the
aromatherapy oils in the actual clinical settings.
A number of studies have already been conducted on aromatherapy
to relieve menstrual cramps. However, there were conflicting results
among the studies. Research methods were also varied, and methods of
applying aromatherapy and the oils used varied. Therefore, we con-
ducted a systematic review and analysis of the various studies and
meta-analysis of the results of the studies to provide a strong basis for
their effects. Accordingly, this systematic literature review aimed to
identify the effect size and to determine the effects of aromatherapy for
dysmenorrhea according to intervention methods and durations in
order to establish a basis for nursing practice.
2. Objective
The objective of the study was to identify the effects of ar-
omatherapy on menstrual pain through a systematic review of studies
from Korea and abroad that applied aromatherapy to examine its effects
on menstrual pain. Detailed objectives were as follows: First, to sum-
marize the effects of aromatherapy interventions on menstrual pain
through a systematic literature review; second, to identify the elements
aromatherapy that affected menstrual pain; and third, to identify the
methods of aromatherapy that affected menstrual pain.
3. Methods
3.1. Study design
The study was a systematic review of experimental articles that
analyzed the effects of aromatherapy on menstrual pain.
3.2. Searching terms
This study is a systematic review. In a systematic review, searching
terms are used as a searching strategy in data collection. A searching
term is a set of Mesh term and text term using the Boolean operator,
which includes populations, intervention, comparator, outcome (PICO).
Anyone using the searching term will be able to get the same results
when they search again.
In this study, studies were extracted using this searching term for
data collection, and the screening process was described in the Table 1.
Data were presented through qualitative analysis and meta-analysis was
used for quantitative analysis.
Detailed searching terms for the systematic literature review and
patients, intervention, comparator, and outcome (PICO) were as fol-
lows:
3.2.1. Populations (patients)
The populations (patients) in the study consisted of girls and women
who experienced menstrual pain, excluding those with any genital,
chronic, or mental diseases, as well as those with hypersensitivity to
aromatherapy.
J.-A. Song et al.
Table 1
Searching strategy.
No. Searching term
1 Aromatherapy [MeSH]
2 Aroma*
3 Essential oil
4 1 or 2 or 3
5 Dysmenorrhea [MeSH]
6 Menstrual pain
7 5 OR 6
8 4 AND 7
*Means to include all words that begin with aroma.
3.2.2. Intervention
For the study, the aromatherapy intervention studies selected con-
sisted of those that applied inhalation or massage therapy using single
or mixed aromatherapy oils without any restrictions on the types, vo-
lume, or forms of aromatherapy oils used.
3.2.3. Comparators
For the comparators, studies included in this review when they met
these criteria that compared other interventions with aromatherapy,
used a control group with no treatment of any kind, or used a placebo
group that used placebo oil.
3.2.4. Outcome
Studies included in this review when they identified the effects of
aromatherapy on menstrual pain, with menstrual pain represented by
subjective pain measured using a visual analog scale (VAS) or numeric
rating scale (NRS).
3.3. Literature review, data collection, and screening procedures
3.3.1. Literature review
Eligible studies included all searchable articles published from in-
ception to October 17, 2016. The international databases used for the
search included PubMed, CINAHL, CENTRAL, Korean databases: RISS,
DBPIA, and KISS. To increase the sensitivity of the literature search,
gray literature was searched manually using Google Scholar. The search
queries used Medical Subject Headings terminology and text words
with AND/OR, as well as truncated searches (Table 1).
3.3.2. Data collection and screening
The inclusion criteria for the articles to be systematically reviewed
were: (1) interventional studies using aromatherapy for menstrual pain,
(2) randomized controlled trials (RCTs) and non-randomized controlled
clinical trials (CCTs), and (3) journal articles. The exclusion criteria
were: (1) animal studies or pre-clinical trial studies, (2) studies that
were not published in Korean or English, (3) unpublished thesis papers,
and (4) non-experimental studies, such as observational studies or re-
views.
The selected data were screened based on the searching terms and
the inclusion and exclusion criteria, while a PRISMA flow diagram was
used to describe in detail the stepwise article selection process. A total
of 135 articles were found from the search, and after removing 33
duplicate articles, the titles and abstracts of 102 articles were reviewed
independently by two researchers. Subsequently, a total of 41 eligible
articles were selected from the preliminary screening after removing 61
articles that were unrelated to the aromatherapy and dysmenorrhea or
did not meet the study design or inclusion criteria. In the secondary
screening, the full texts of the 41 articles selected from the preliminary
screening were reviewed using the same criteria and process, and as a
result, a total of 21 articles were selected after removing five studies
that did not match the dependent variable: one study that did not use a
placebo or control group for comparison, two studies that used
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International Journal of Nursing Studies 84 (2018) 1–11
acupuncture or moxibustion as the intervention method, eight studies
that did not match the study design, three studies that were not pub-
lished in Korean or English, and one study with unclear study results
(Fig. 1).
3.4. Quality assessment of articles
The study used Cochrane’s risk of bias tool to perform a critical
review of the articles. The study conducted a critical review of the lit-
erature using the Cochrane Risk Assessment Tool. The quality assess-
ment was conducted independently of the two researchers after the
final selection of the finalized paper. The discrepancies have resulted in
the three researchers being fully discussed and derived as a result.
There was no disagreement in this study.
3.5. Data analysis
3.5.1. Data extraction
After analyzing the characteristics of the 21 articles selected for the
systematic review, the articles were codified and organized. The coding
table consisted of author(s), publication year, study design, sample size,
intervention group(regime), aroma oils, control group(regime), main
outcome measures, intergroup differences, and authors’ conclusions
(Table 2).
3.5.2. Selection of the analysis model
The 21 articles entire texts were reviewed and qualitatively ana-
lyzed while seven articles were quantitatively analyzed using RevMan
software ver. 5.3 (Computer Program). The study used a random-effects
model for analysis, because, based on the data extraction results, we
determined that heterogeneity may exist in intervention methods,
durations, and periods used in each study. The random-effects model is
based on the premise that the true effect value may vary significantly
depending on the sample and study, and it also assumes that any dif-
ference in effect size is attributable to sampling error and variance
between studies. Therefore, this model is used when there is evidence of
unexplained heterogeneity between studies and even if heterogeneity is
found to be low, it is still used if the studies cannot be assumed to be
homogenous. The fixed effect model can be used when the results of
these studies are considered to be parameters extracted from the same
population (Higgns and Green, 2011). Therefore, in this study, random
effect model was used instead of fixed effects model.
3.5.3. Effect size calculation
The effect size in the study was analyzed by means and standard
deviations since the outcome was a continuous variable that used the
same measurement tool on the same intervention outcomes. The effect
of each outcome variable and 95% CIs were analyzed using an inverse
variance method.
3.5.4. Heterogeneity test
Heterogeneity refers to the differences that appear as variability
among individual studies being compiled for meta-analysis. In the
study, heterogeneity was assessed via the Higgins I2-statistic with I2
values of ≤25%, 50%, and ≥75% deemed to represent low, medium,
and high heterogeneity, respectively.
3.5.5. Publication bias test
In the study, publication bias was determined visually via a funnel
plot. If the funnel plot was visually symmetric, then the possibility of
publication bias decreased, whereas if the funnel plot was asymmetric,
it suggested an increased possibility of publication bias (Higgns and
Green, 2011).
J.-A. Song et al.
Fig. 1. Study flow diagram of a systematic review.
4. Results
4.1. General characteristics of systematically reviewed articles
The total number of studies included in the systematic literature
review based on our data selection criteria was 21 studies (Table 2),
with the data selection process being as follows (Fig. 1). The studies
included in the analysis were all from articles published after 2000,
consisting of nine RCTs and 12 CCTs. The subjects in these studies were
women with moderate to severe dysmenorrhea, and all studies used a
VAS to measure dysmenorrhea. The intervention in a total of five ar-
ticles was aromatherapy oil inhalation and the study included a total of
fifteen articles on aroma oil massage. And one article using aroma oil
inhalation and massage. All of the studies used a single oil, with la-
vender being used most often (n = 5), along with Thymus vulgaris
(n = 1), and rose (n = 1) oil. The method of inhalation in three studies
used a necklace, and three studies used the method of inhaling the oil
dropped onto gauze or the palm. The intervention period varied from a
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International Journal of Nursing Studies 84 (2018) 1–11
single application to a regimen lasting 2 weeks with intervention time
per session varying from 5, 30, to 360 min. A total of 16 studies used
aromatherapy oil massage as the intervention of which six studies used
a single oil and 10 studies used a mixture of various oils. Lavender and
rose were used as single oil sources while a total of 14 oils, including
lavender, rose, rose geranium, marjoram, and clary sage, were used in
mixed oils. Massage was administered as abdominal massage with each
session lasting 10 to 15 min. With respect to the intervention period,
eight studies applied the intervention from one week prior to the ex-
pected menstruation date and eight studies applied the intervention
from the start of menstruation, when dysmenorrhea also began, to two
to three days later.
4.2. Quality assessment of articles
The outcomes from the quality assessment of articles were input
into RevMan software ver 5.3 according to quality assessment judgment
criteria, and results were as noted on Fig. 2. The quality assessment tool
 Table 2
Summary of RCTs and CCTs Examining Aromatherapy and Menstrual Pain.
First author Study design (Sample Intervention group(regime) Aroma oils Control group(regime) Main outcome Intergroup Author’s conclusion
J.-A. Song et al.

(years) size) measures difference

Inhalation
Seo and Kim Cross-over design 20 (A) Aroma inhalation (n = 20) 2 weeks(1 Lavender • placebo inhalation (n = 20) 2 weeks(1 (1) Menstrual pain (1) NS ‘The menstrual pain, anxiety
(2008) female students week before menstruation ∼ menstrual week before menstruation ∼ menstrual (10 cm-VAS) (2) NS and depression significantly
(VAS ≥ 5.96) period) necklace period) (2) Dysmenorrhea (3) NS improved after the aroma
(Han & Hur scale) (4) NS treatment. However not
(3) Anxiety (SAI) significantly different from
(4) Depression (CES- those after the placebo
D) treatment…’

Choi and Seo Nonequivalent (A) Aroma inhalation (n = 21) 2 weeks(1 Lavender • placebo inhalation (n = 17) 2 weeks(1 (1) Menstrual pain (1) NS ‘Aroma inhalationmay not be
(2010) control group posttest week before menstruation ∼ menstrual week before menstruation ∼ menstrual (10 cm-VAS) (2) NS effective inmanaging
design 38 female period) necklace period) (2) Dysmenorrhea dysmenorrhea and menstrual
students (Han & Hur scale) pain. In order to further clarify
(VAS ≥ 5.96) the efficiency of research design
Cross-over design 20 • Aroma inhalation (n = 20) 2 weeks(1 Lavender • placebo inhalation (n = 20) 2 weeks(1 (1) Menstrual pain (1) NS and the effect of aromatherapy
female students week before menstruation ∼ menstrual week before menstruation ∼ menstrual (10 cm-VAS) (2) NS on discomfort during
(VAS ≥ 5.96) period) necklace period) (2) Dysmenorrhea menstruation, replication
(Han & Hur scale) studies are necessary…’

Raisi Dehkordi RCT 96 female (A) Aroma inhalation (n = 48) Lavender • Placebo inhalation (n = 48) 1 time, 5 min (1) Menstrual pain (1) p < .001 ‘Inhalation of lavender relieves
et al. students (4 score ≥ 2) menstruation ∼ menstrual 3rd day) 1 (1–4score) the severity of primary
(2014) time, 5 min dysmenorrhea symptoms…’

Salmalian RCT 84 students (A) Aroma inhalation + placebo drug Thymus vulgaris • Placebo inhalation + ibuprofen (n = 28) 2 (1) Menstrual pain (1) A vs B NS ‘Thymus vulgaris as well as
et al. (≥moderate pain) (n = 28) 2 cycle menstruation every 6 h cycle menstruation every 6 h (10 cm-VAS) (1) A vs C ibuprofen can be effective in

5
(2014) • Placebo inhalation + placebo drug (2) Menstruation p < .001 reducing the severity of pain
(n = 28) 2 cycle menstruation every 6 h hemorrhage (2) NS and spasm in primary
(PBAC) dysmenorrhea.’

Uysal et al. RCT 100 patients (A) Aroma inhalation + diclofenac (n = 50) 1 Rose • Placebo inhalation + diclofenac (n = 50) (1) Menstrual pain (1) p = .019 ‘The present study suggests that
(2016) (VAS ≥ 5) time, 30 min 1 time, 30 min (10 cm-VAS) aromatherapy with rose
essential oil, may be beneficial
for pain relief in individuals
with primary dysmenorrhea.’
Inhalation + Massage
Choi (2009)a Nonequivalent quasi- (A) Aroma oil abd. massage (n = 24) 1 week Lavender • Placebo oil abd. massage (n = 17) 1 week (1) Menstrual pain (1) NS ‘Lavender abdominal massage
experimental gesign before menstruation ∼ menstruation before menstruation ∼ menstruation (10 cm-VAS) (2) NS and inhalation could be
74 college female period 1 time/day, 10 min period 1 time/day, 10 min (2) Dysmenorrhea (3) NS effective methods to reduce
students (VAS ≥ 7) (Han & Hur scale) (4) NS dysmenorrhea…’
(3) Anxiety (SAI)
(4) Depression (CES-
D)
• Aroma inhalation (n = 18) 1 week before Lavender • Placebo inhalation (n = 18) 1 week before (1) Menstrual pain (1) p < .001
menstruation ∼ menstruation period menstruation ∼ menstruation period (10 cm-VAS) (2) NS
daytime, necklace daytime, necklace (2) Dysmenorrhea (3) NS
(Han & Hur scale) (4) NS
(3) Anxiety (SAI)
(4) Depression (CES-
D)
Massage
Han et al. Nonequivalent (A) Aroma oil abd. massage (n = 25) 8 days (1 Lavender, clary • Almond oil abd. massage (n = 20) 8 days (1) Menstrual pain (1) P < .001 ‘Aromatherapy could be applied
(2001) control group posttest week before menstruation ∼ menstrual 1st sage, rose (1 week before menstruation ∼ menstrual (10 cm-VAS) (2) p = .004 to women suffering with
design 45 college day) 1 time/day, 15 min 1st day) 1 time/day, 15 min (2) Dysmenorrhea menstrual cramps,
female students (Han & Hur scale) dysmenorrheal…’
(VAS ≥ 6)
International Journal of Nursing Studies 84 (2018) 1–11

(continued on next page)

 Table 2 (continued)

First author Study design (Sample Intervention group(regime) Aroma oils Control group(regime) Main outcome Intergroup Author’s conclusion
(years) size) measures difference
J.-A. Song et al.

Hyun and Hur Nonequivalent (A) Aroma oil abd. massage (n = 26) 8 days (1 Lavender, clary • No treatment (n = 20) (1) Menstrual pain (1) p < .001 ‘Aromatherapy could be applied
(2004)a control group posttest week before menstruation ∼ menstrual 1st sage, marjoram, (10 cm-VAS) (2) NS to as a nursing treatment for
design 46 cadet day) 1 time/day, 10 min rose (2) Dysmenorrhea cadet women suffering with
women (Han & Hur scale) menstrual pains…’

Lee et al. Nonequivalent (A) Aroma oil abd. massage (n = 24) 6 days Clary sage, • placebo oil abd. massage (n = 23) 6 days (1) Menstrual pain (1) NS ‘Abdominal massage using an
(2006)a control group posttest (4 days before menstruation ∼ menstrual marjoram, (4 days before menstruation ∼ menstrual (100mm-VAS) (2) NS ordinary oil and an aroma oil
design 47 female 2nd day) 1 time/day, 7–10 min chamomile 2st day) 1 time/day, 7–10 min (2) Dysmenorrhea can be relived a menstrual pain
nurses (VAS ≥ 6) (MMDQ) and a dysmenorrhea…’

Han et al. RCT 67 college (A) Aroma oil abd. massage (n = 25) 8 days (1 Lavender, clary • Almond oil abd. massage (n = 20) 8 days (1) Menstrual pain (1) p < .01 ‘Aromatherapy is effective in
(2006) female students week before menstruation ∼ menstrual 1st sage, rose (1 week before menstruation ∼ menstrual (10 cm-VAS) (2) P < .05 decreasing the severity of
(VAS ≥ 6) day) 1 time/day, 15 min 1st day) 1 time/day, 15 min (2) Dysmenorrhea (%) menstrual cramps…’
• No treatment (n = 22)
Kim et al. RCT 53 women (A) Aroma oil abd. massage (n = 18) 2 days Rose geranium, • No treatment (n = 17) (1) Menstrual pain (1) Significant ‘The study showed that aroma
(2008)a (VAS ≥ 5) (menstrual 1st ∼ 2nd day) 1 time/day, clary sage, (10 cm-VAS) different therapy can be relived a
10 min cypress, juniper (p = ?) menstrual pain…’
(B) Aroma lotion abd. massage (n = 18) berry,
2 days (menstrual 1st ∼ 2nd day) 1 time/ chamomile,
day, 10 min ginger

Kim et al. Nonequivalent (A) Aroma oil abd. massage (n = 26) 2 days Rose, rose otto, • Almond oil abd. massage (n = 18) 2 days (1) Menstrual pain (1) p < .05 ‘Self-aromatherapy massage
(2011)a control group posttest (menstrual 1st, 2nd day) 1 time/day, clary sage, rose (menstrual 1st, 2nd day) 1 time/day, (10 cm-VAS) (2) P < .05 may be effective treatment that
design 63 female 10 min geranium, ginger 10 min (2) Anxiety (10 cm- decreases menstrual pain…’
nurses • No treatment (n = 19) VAS)

6
Lee (2011) Nonequivalent (A) Aroma oil leg massage + foot reflex Lavender • No treatment (n = 24) (1) Menstrual pain (1) p < .001 ‘aroma-foot-reflexology is an
control group posttest (n = 37) 3 days (1 week before (10 cm-VAS) (2) p < .001 effective nursing intervention in
design 61 college menstruation) 3times/week, 35 min (2) premenstrual (3) p < .005 reducing premenstrual
female students syndrome (Hur syndrome and dysmenorrhea…’
(VAS ≥ 6) scale)
(3) low abd. skin
temperature (°C)

Hur et al. Nonequivalent (A) Aroma oil abd. massage (n = 32) 1 time, Clary sage, • Acetaminophen (n = 23) (1) Menstrual pain (1) p < .001 ‘Aromatherapy massage may be
(2012) control group posttest 10 min marjoram, (10 cm-VAS) an effective treatment for
design 55 high school cinnamon, menstrual pain…’
girls ginger, geranium
Apay (2012) Quasi-experimental (A) Aroma oil abd. massage (n = 44) 1 day lavender • Placebo oil abd. massage (n = 44) 1 day (1) Menstrual pain (1) p < .001 ‘Massage was effective in
cross-over design 44 (menstruation 1st day), 1 time, 15 min (menstruation 1st day), 1 time, 15 min (100 mm-VAS) reducing dysmenorrhea. In
female students addition aromatherapy massage
on pain was higher than that of
placebo massage…’

Ou et al. RCT 48 outpatients (A) Aroma cream abd. massage (n = 24) 3 Lavender, clary • Placebo cream abd. massage (n = 24) 3 (1) Menstrual pain (1) NS ‘Aroma oil massage provided
(2012)a (VAS ≥ 5) weeks (end of the sage, marjoram weeks (end of the (10 cm-VAS) (2) NS relief for outpatients with
menstruation ∼ beginning of the next menstruation ∼ beginning of the next (2) Menstrual pain primary dysmenorrhea and
menstruation) 1 time/day, none menstruation) 1 time/day, none (6score-VRS) reduced the duration of
menstrual pain…’

Cheon and Lim RCT 30 women (A) Aroma oil abd. massage (n = 15) 2 weeks Nutmeg, fennel, • Placebo oil abd. massage (n = 15) 2 weeks (1) Menstrual pain (1) p < .01 ‘aromatherapy using nutmeg,
(2013) (VAS ≥ 6) (14 days after the beginning of marjoram (14 days after the beginning of (10 cm-VAS) (2) NS fennel and marjoram was
menstruation. ∼ beginning of the next menstruation ∼ beginning of the next (2) Dysmenorrhea (3) p < .05 proved to be effective and could
menstruation) 1 time/day, 10 min menstruation) 1 time/day, 10 min (Han & Hur scale) be used as effective intervention
(3) low abd. skin methods in menstrual cramps
temperature (°C) and dysmenorrhea.’

(continued on next page)

International Journal of Nursing Studies 84 (2018) 1–11
 J.-A. Song et al. International Journal of Nursing Studies 84 (2018) 1–11

is intended to assess the risk of random sequence generation, allocation

‘Lavender oil massage decreases

were effective in reducing some

reduces the severity of primary

‘Lavender oil massage therapy

dysmenorrhea, in comparison
‘Aromatherapy is effective in
alleviating menstrual pain…’
concealment, blinding of participants and researchers, blinding of

symptoms of dysmenorrhea.’

‘Massage with aromatherapy

with massage therapy alone’

primary dysmenorrhea…’
outcome assessment, incomplete outcome data, selective reporting, and
other bias. In response, the risks are assessed in response to low, high
Author’s conclusion

and unclear risks.

Random sequence generation is assessed as an area where random
assignment is adequate and the allocation concealment is adequately
covered is highly evaluated in this study. Low risk was incomplete
outcome data and selective reporting. Incomplete outcome data refers
to the data being dropped or excluded during the study, and the se-
lective reporting is selected selectively missing some results or selec-
(1) p < .001
(2) p < .001

(1) p < .001

(2) p < .001

tively reporting some data (Higgns and Green, 2011).
(1) p < .05

(2) p < .05

Intergroup
difference

(3) NS

(1) NS
4.3. Effect size estimation

Among the 21 articles analyzed, seven articles reporting results

(1st cycle) (10 cm-

from RCTs with data described as means and standard deviations were
(1) Menstrual pain

(1) Menstrual pain

(1) Menstrual pain

(1) Menstrual pain

(2) Menstrual pain

(2) Pain duration

(2) Pain duration

(3) Anxiety (SAI)

(10 cm-VAS)

(10 cm-VAS)

(10 cm-VAS)

(10 cm-VAS)
(2nd cycle) selected for the meta-analysis of the effect size of aromatherapy on
Main outcome

dysmenorrhea (Fig. 3).

(hours)

(hours)
measures

VAS)

When the homogeneity of the articles was examined, experimental

treatments applied were not homogenous (Higgins I2 = 81%), and as a
result, a random-effects model was used to analyze the effect size.
Compared to the placebo group that received placebo oil treatment,
(menstruation period) 1 time/day, 10 min

oil abd. Massage (n = 25) 1 day

oil abd. massage (n = 80) 1 day
Aroma oil abd. massage (n = 47) 7 days

(menstruation 1st day), 1 time, 15 min

(menstruation 1st day), 1 time, 15 min

dysmenorrhea showed a decreasing effect of 1.71 points (mean differ-

ence, −1.71; 95% CI, −2.46 to −0.97), with the effect size between
Placebo oil abd. massage (n = 47)

the experimental and placebo groups showing a statistically significant

difference (Z = 4.51, p < .001) but high heterogeneity (Higgins
I2 = 81%). In the subgroup analysis, applying aromatherapy showed a
• No treatment (n = 34)

• No treatment (n = 25)

decreasing effect of 1.77 points (mean difference, −1.77; 95% CI,

Control group(regime)

2nd treatment phase

1st treatment phase

−2.74 to −0.79) when applied as massage and 1.58 points (mean

difference, −1.58; 95% CI, −2.97 to −0.19) when applied by in-
halation.
• Placebo

• Placebo

Compared to the control group that did not receive any type of
treatment, dysmenorrhea showed a decreasing effect of 2.67 points
•
•

(mean difference, −2.67; 95% CI, −3.34 to −1.99), with the effect size
between the experimental and control group showing a statistically
Cinnamon, clove,

significant difference (Z = 7.79, p < .001) without heterogeneity

rose, lavender,

(Higgins I2 = 0%).
Aroma oils

Lavender

Lavender

Rose

4.4. Publication bias test

(menstruation period) 1 time/day, 10 min

Publication bias for articles evaluated in the study was visually

(a) Placebo oil abd. Massage (n = 48) 7 days

(A) Aroma oil abd. Massage (n = 25) 1 day

(A) Aroma oil abd. massage (n = 38) 2 day

(A) Aroma oil abd. massage (n = 80) 1 day

(B) Exercise (n = 30) 5 day (menstruation)

(menstruation 1st day), 1 time, 15 min

(menstruation 1st day), 1 time, 15 min

determined through a funnel plot (Fig. 4) of the 7 published articles.

(menstruation 1st, 2nd day), 1 time,

Fewer than 10 studies were included in the meta-analysis of this study.

(A) Aroma oil abd. massage (n = 48)

Therefore, it was not possible to determine whether or not the funnel

plot was symmetrical.
Intervention group(regime)

5. Discussion
2nd treatment phase
1st treatment phase

A number of studies have already been conducted on aromatherapy

to relieve menstrual cramps. However, there were conflicting results
15 min

2time

among the studies. Research methods were also varied, and methods of
applying aromatherapy and the oils used varied. Therefore, we con-
ducted a systematic review and analysis of the various studies and
meta-analysis of the results of the studies to provide a strong basis for
Randomly cross- over

Randomly cross- over

Study design (Sample

students (VAS ≥ 6)

their effects.
design 95 nursing

design 80 female
RCT 102 women

RCT 75 students

The subjects in the 21 studies that were included in the systematic

review consisted of women with moderate to severe menstrual pain,
(VAS ≥ 5)

(VAS ≥ 5)
students

and with respect to the intervention method, massage intervention was

most common (15 studies), followed by five studies using the inhalation
size)
Table 2 (continued)

method and one study using co-administration of massage and inhala-

Self-massage.

tion.
Marzouk et al.

Sadeghi Aval
Azima et al.

(2015)a
First author

Bakhtshirin
(2013)

(2015)

(2015)

The meta-analysis was performed on seven RCTs that used a VAS to

Shahr
et al.

et al.

measure menstrual pain, and the outcome variables were described as

(years)

means and standard deviations. Compared to studies that applied pla-

a

cebo treatment or no treatment of any kind, menstrual pain decreased

7
J.-A. Song et al.
significantly in the experimental groups that received aromatherapy.
The aromatherapy oils in the meta-analysis included lavender, rose,
clary sage, marjoram, and cinnamon, which were used alone or as a
mixture.
Among the methods used to apply the aromatherapy, massage
therapy may have some benefits from the massage itself, and as such, an
analysis was performed on five studies that used a placebo group to
distinguish the effects of aromatherapy oil from those of massage. The
results showed that there was a significant difference in menstrual pain
between the experimental and placebo groups. Moreover, the inhala-
tion method was also found to have an effect on reducing menstrual
pain. However, a study that compared the degree of menstrual pain
between a group that received abdominal massage with lavender oil
and a group that received massage showed no significant difference
between the two groups with respect to reduction in menstrual pain
(Choi, 2009), while applying a plain massage with regular oil was also
effective in reducing menstrual pain (Lee et al., 2006). Moreover, a
previous study also reported that applying massage therapy is more
effective than aromatherapy is for alleviating dysmenorrhea (Kim et al.,
2001). These results are consistent with those of other studies that have
shown aromatherapy to be effective for reducing dysmenorrhea and
menstrual pain (Cheon and Lim, 2013; Choi, 2009), but validation on
whether aromatherapy is the optimal method is still lacking.
Heterogeneity among the studies appeared to be high, which may be
attributable to these studies applying different periods and durations of
aromatherapy. Therefore, it is deemed necessary for future studies to
compare the optimal application methods, periods, and durations when
applying aromatherapy.
With respect to the aromatherapy essential oils, a total of 14 oils
were used, including lavender, Thymus vulgaris, rose, rose geranium,
and marjoram. Among them, lavender was the most commonly used,
being used on its own in 10 studies and as a part of mixed oil in five
studies. In addition, clary sage was used in eight studies and rose in
seven studies as a part of mixed oils. This was consistent with various
previous studies reporting that in oil form, clary sage, lavender, cha-
momile, and rose have a positive effect on alleviating menstrual pain
(Keville and Green, 1995). Among these, lavender having anti-
spasmodic and analgesic effects (Battaglia, 2003), which was supported
by a study by Han et al. (2001). Moreover, clary sage and rose have also
been reported to have antispasmodic effects, which is beneficial for
menstrual pain and dysmenorrhea (Hyun and Hur, 2004). In other
words, lavender, clary sage, and rose oils can be viewed as being ef-
fective in reducing menstrual pain. However, the effects of
Fig. 2. Risk of bias for included study.
8
International Journal of Nursing Studies 84 (2018) 1–11
aromatherapy essential oils, may vary depending on how they are
mixed, and by mixing the oils together, synergistic effects may be
gained as well (Lee et al., 2006). Therefore, it is necessary to determine
a standardized protocol through studies with bases for selecting the oils,
the mixture ratio of the oils, and the application method and period.
The significance of this study is that it analyzed the results of studies
that reported the effects of aromatherapy on menstrual pain in a more
comprehensive and scientific manner. However, because the study also
included non-randomized CCTs, there was a high risk of randomization
bias with respect to the quality of articles. Moreover, the number of
studies used in the meta-analysis was small, which can be viewed as a
limitation of the study, while also indicating the need for more stringent
experimental studies in the future. Furthermore, while conducting the
study, it was found that the type and amount of oil, mixing method and
period of experimental treatment are applied to aromatherapy in var-
ious ways. It is important that such intervention protocols not being
standardized could be a handicapping factor in applying it as an ef-
fective nursing intervention in clinical settings, despite many studies
reporting its positive effects. Therefore, it is necessary for future studies
to be stringent, meaning RCTs, that apply a standardized protocol
proposed through repeated studies on oils used in the intervention and
experimental treatment duration, as well as repeated studies with rig-
orous control over exogenous variables and study design, to be strin-
gent so that the standard for such evidence can be raised.
As a result, when the research studies were qualitatively or quan-
titatively synthesized, the research methodology in the systematic lit-
erature review did not sufficiently study the RCT, but the research
showed that aromatherapy was effective in mitigating menstrual pain,
and massage or inhalation application methods were all effective.
Especially, the most used essential oil was lavender, and it was effective
when lavender was used alone or mixed. Also, the application time of
aromatherapy was effective when used for 1–2 days after menstruation,
and it was not effective for longer than 3 days.
6. Conclusions
Aromatherapy was an effective intervention for reducing dysme-
norrhea. However, because the analysis showed that the aroma inter-
vention methods were diverse and that the basis for the intervention
methods was weak, the possibility of randomization bias was high.
Therefore, it is necessary to conduct repeated studies in the future based
on strict control of the research design.
J.-A. Song et al. International Journal of Nursing Studies 84 (2018) 1–11

Fig. 2. (continued)

9
J.-A. Song et al. International Journal of Nursing Studies 84 (2018) 1–11

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 aroma massage
Bakhtshirin, 2015 3.54 2.42 80 6.48 1.68 80 16.1% -2.94 [-3.59, -2.29]
Han, 2006 4.26 2.36 25 7.04 1.74 20 12.4% -2.78 [-3.98, -1.58]
Marzouk, 2013 5.8 2.1 48 6.8 1.7 47 15.3% -1.00 [-1.77, -0.23]
Ou, 2012 3.92 2.39 24 4.33 2.55 24 11.1% -0.41 [-1.81, 0.99]
Sadeghi 2015 4.84 1.51 22 6.32 1.49 24 14.7% -1.48 [-2.35, -0.61]
Subtotal (95% CI) 199 195 69.7% -1.77 [-2.74, -0.79]
Heterogeneity: Tau² = 0.98; Chi² = 22.54, df = 4 (P = 0.0002); I² = 82%
Test for overall effect: Z = 3.57 (P = 0.0004)

1.1.2 aroma inhalation

Salmalian, 2014 1.21 1.06 28 3.54 2.26 28 14.3% -2.33 [-3.25, -1.41]
Uysal, 2016 2.09 1.45 50 3 1.86 50 16.1% -0.91 [-1.56, -0.26]
Subtotal (95% CI) 78 78 30.3% -1.58 [-2.97, -0.19]
Heterogeneity: Tau² = 0.84; Chi² = 6.04, df = 1 (P = 0.01); I² = 83%
Test for overall effect: Z = 2.23 (P = 0.03)

Total (95% CI) 277 273 100.0% -1.71 [-2.46, -0.97]

Heterogeneity: Tau² = 0.79; Chi² = 31.31, df = 6 (P < 0.0001); I² = 81%
-10 -5 0 5 10
Test for overall effect: Z = 4.51 (P < 0.00001)
aromatherapy placebo treatment
Test for subgroup differences: Chi² = 0.05, df = 1 (P = 0.83), I² = 0%

aroma massage no treatment Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Han, 2006 4.26 2.36 25 6.59 2.02 22 28.7% -2.33 [-3.58, -1.08]
Sadeghi 2015 4.84 1.51 22 7.64 1.18 23 71.3% -2.80 [-3.59, -2.01]

Total (95% CI) 47 45 100.0% -2.67 [-3.34, -1.99]

Heterogeneity: Tau² = 0.00; Chi² = 0.39, df = 1 (P = 0.53); I² = 0%
-10 -5 0 5 10

Fig. 3. Forest plot.

Fig. 4. Funnel plot of comparison: aromatherapy versus placebo, outcome.

10
J.-A. Song et al.
Conflicts of interest
None.
Author contributions
Ji-Ah Song, Mi-kyoung Lee – Data collection, analysis and inter-
pretation, final approval.
Eun Sil Min, Mi-Eun Kim – Data collection, analysis, and inter-
pretation.
Geraldine Fike – Revising the article, (especially discussion).
Myung-Haeng Hur – The conception and design of the study, data
analysis, final approval.
Acknowledgements
This research was supported by the Basic Science Research Program
through the National Research Foundation of Korea (NRF), funded by
the Ministry of Science, ICT & Future Planning (NRF-
2015R1A1A3A04001441).
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