The Journal for Nurse Practitioners 16 (2020) 617e622

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Original Research

The Effects of Inhalation Lavender Aromatherapy on Postmenopausal

Women’s Depression and Anxiety: A Randomized Clinical Trial
Mozhgan Jokar, MSc, Hamed Delam, MSc, Soheila Bakhtiari, MSc, Somayeh Paki, MSc,
Aliaskar Askari, MSc, Mohammad-Rafi Bazrafshan, PhD, Nasrin Shokrpour, PhD

a b s t r a c t
Keywords: The main aim of this study was to investigate the effects of inhaled lavender aromatherapy on depression and
anxiety anxiety levels among postmenopausal women. A randomized clinical trial was performed in which 46
aromatherapy
postmenopausal women received 2% inhaled lavender essence or distilled water 20 minutes nightly before
depression
Lavandula latifolia
bedtime for 4 successive weeks. Depression and anxiety mean scores decreased in the lavender group
menopause compared with controls, providing evidence that lavender aromatherapy may be an effective noninvasive
treatment during the postmenopausal stage.
© 2020 Elsevier Inc. All rights reserved.

Introduction depression. Therefore, the clinical diagnosis and treatment of

Menopause is a physiological stage that occurs naturally within
the woman’s aging process mainly because of reduction in the
levels of the ovarian hormones, estrogen and progesterone. The
decrease in these hormone levels during menopause can lead to a
wide spectrum of physical symptoms, such as hot flushes and night
sweats, dizziness, irregular heartbeat, vaginal atrophy, bladder ir-
ritability, sleep disorders, headache, and muscle and joint pain.1
In addition to physical problems, menopause can potentially
compromise women’s psychologic health as well.2 A study of Bra-
zilian women reported the prevalence of depression during
menopause at approximately 40%,3 which is similar with the
findings (39.5%) of a Taiwanese study.4 Other studies report that the
occurrence rate of depression increases during menopause: 26% to
33% of women were estimated to experience their first episode of
depression during menopause.5 In this regard, the results of
research by Azizi et al6 showed that biological factors, such as
vasomotor symptoms, sleep disorders, and other severe meno-
pausal symptoms and lower estradiol levels had a significant
relationship with depressive symptoms.
Menopause is also associated with anxiety disorders.2 For
example, the results of the research conducted by Heidari et al7 in
2017 show that anxiety is one of the most important psychologic
complications menopausal women face8 and is therefore one of the
most important mental issues associated with depression during
menopause.7 In this regard, depression and anxiety in menopausal
women may also be associated with physical illnesses.9 The study
by Yirmiya and Bab,10 for example, showed that depression is a
significant risk factor for osteoporosis and decreased bone mass in
postmenopausal women. The results of the study by Yangın et al11
showed that sexual dysfunction in menopause is associated with
anxiety and depression symptoms during menopause are consid-
ered as an essential priority for health care providers.
In addition to clinical therapies, there are other non-
pharmacologic methods that provide complementary therapeutic
approaches available for depression and anxiety.12 Many of these
methods are widely used and have been incorporated into care
programs.13 Increased use of complementary and alternative ther-
apies indicates an increased desire by patients for this treatment.
Complementary and alternative therapy plays an important role in
health care in the 21st century. It is anticipated that this increasing
use will make complementary and alternative medical treatments
an integral part of all health care systems.14
Approximately 51% of women use complementary and alter-
native medications, and more than 60% find them effective for
menopausal symptoms. However, most women using comple-
mentary medicines do not discuss this with their health care pro-
viders but are often confused when trusting the internet as their
primary source of information about complementary medicine.15
Recent research has shown that patients often consult nurses
about complementary and alternative therapies, but only 5% of
nurses are able to answer their questions about this type of treat-
ment.13 Nurse practitioners (NPs), however, have a professional
relationship with patients, and it is important that NPs have suffi-
cient knowledge and information on the safe and effective use of
complementary and alternative medications when communicating
with the patient. Also, NPs should help their patients make
informed choices about different types of complementary and
alternative therapies for different conditions.14
Aromatherapy, as a form of complementary medicine, has has
seen rapid growth in popularity as a treatment for alleviation of
pain, stress, and anxiety.16,17 Perfume oils are believed to reduce

https://doi.org/10.1016/j.nurpra.2020.04.027
1555-4155/© 2020 Elsevier Inc. All rights reserved.
618 M. Jokar et al. / The Journal for Nurse Practitioners 16 (2020) 617e622

Assessed for eligibility (n=50)

Randomized (n = 50)

Allocation

Allocated to intervention2 (placebo) (n =23).

Allocated to intervention1 (n = 23) ♦ Received allocated intervention (n =23).
□ Received allocated intervention (n =23) ♦ No received allocated intervention (n =0).
□ No received allocated intervention (n =0)

Follow Up

Lost to follow-up (discharged) (n= 2)

Lost to follow-up (discharged) (n=1) Discontinued intervention (n= 0)
Discontinued intervention (n=1)

Analysis

Analyzed (n=23) Analyzed (n=23)

♦ Excluded from analysis (n=0) ♦ Excluded from analysis (n=0)

Figure 1. A flow diagram of the study protocol.

anxiety and increase relaxation, which may be helpful in Materials and Methods
relieving the stressful symptoms of menopause. Researchers who
study of the effect of aromatherapy18-20 have shown that Study Design
aromatherapy is effective in reducing physical and psychologic
symptoms. However, there is insufficient evidence to support The current study was a single-blind, placebo-controlled clinical
aromatherapy as an independent treatment to reduce meno- trial.
pausal psychiatric symptoms.
One of the most common aromatic herbal oils applied in
aromatherapy is from the Lavandula latifolia plant, a small aromatic
evergreen shrub that belongs to the mint family. The essential or Sample and Setting
volatile oil of lavender is an extract from this plant. This root-
generating medicinal herb has long been used in traditional Parallel to another similar study,26 the sample number was set
medicine.16 at 46 individuals using the statistical formula with a test power of
Lavender medicinal properties have been investigated in the 90% and a significance level of 5%.
treatment of depression in many different cases.21 As examples,
lavender has been used in practice and demonstrated effectiveness
for mental health in a number of specific areas, including pregnant
women with stress and depression,22 patients on hemodyalysis Randomization
suffering depression and stress,17 women in first-stage labor having
anxiety,23 postpartum mothers suffering fatigue, depression, and Samples were randomly selected from community health cen-
mother-infant attachment with sleep disorder,24 patients with ters. First, a list of all postmenopausal women referred to care
preoperative anxiety or recovering from heart surgery,25 and centers for follow-up examinations who met the inclusion criteria
women with insomnia.24 With regard to the breadth and depth of was prepared. Each person was then given a reference number. The
these studies, the general positive effects and practicability of lav- allocated numbers were recorded on small cards, which were put
ender for psychologic symptoms are easily noticeable and worth into a box. A card was randomly taken out, and its number was
taking into more seriously. recorded. This process continued until the desired sample numbers
Although evidence for positive effects of lavender on physical were obtained.
and mental health status has been reported and demonstrated in
treating and curing a broad variety of patients and disorders, the
Table 1
potential benefits of lavender aromatherapy in reducing depression Beck Depression Inventory Categories
and anxiety in postmenopausal women are less clear, and further
Normal Mild Borderline Moderate Severe Extreme
research and experiments are required. We therefore initiated the
Depression Clinical Depression Depression Depression
current study to investigate the effects of lavender aromatherapy Depression
on postmenopausal women’s depression and anxiety via
0-10 11-16 17-20 21-30 31-40 >40
inhalation.
 M. Jokar et al. / The Journal for Nurse Practitioners 16 (2020) 617e622 619

Table 2
Spielberger Anxiety Inventory Categories

Anxiety Type Mild Mild-Moderate Moderate-High Relatively Severe Severe Highly Severe

State 20-31 32-42 43-53 54-64 65-75 >76

Trait 20-31 32-42 43-52 53-62 63-72 >73

Allocation or a control group. The Consolidated Standards of Reporting Trials

All the medicines used (lavender essential oil and distilled wa-
ter) and were packaged and coded by Barij Essence in similar jars
(23 codes for 2% lavender essential oil and 23 codes for distilled
water). One member of the research team was responsible for
taking notes for each code, put it in an envelope, and sealed it.
Corresponding to each code, there was a can containing the
medication and the recorded code was on it. All the cans were
designed in a similar size to prevent leakage of oil. To balance the
number of samples assigned to each study group, we used the block
randomization method. The envelopes were shuffled several times
before distribution in the research units on the first visit. Re-
searchers unsealed the envelopes, and corresponding medicine
was delivered to each participant according to the code.
Blinding
This study was designed as a single blind study. The evaluator,
who was a member of the research team who interviewed each of
the participants and completed the depression and anxiety ques-
tionnaires, was not informed of the type of medication the partic-
ipant received. Only the Barij Essence pharmacist was aware of the
nature of the codes (A ¼ lavender; B ¼ distilled water), and the
nature of the codes were undercover until the data of the final
participant in the study were analyzed.
Participants
The participants in the present study were postmenopausal
women at the Larestan Health Community Centre, in Iran in 2019. NPs
work collaboratively at the center with other health care professionals
to promote women’s health by counselling, providing health educa-
tion, and doing research. Participants who met the inclusion criteria
and provided written consent were randomly assigned to a treatment
flow diagram of the study is displayed in Figure 1.
Inclusion criteria were women aged older than 45 years,
absence of menstrual periods for at least 12 months and post-
menopausal for a maximum of 5 years, and a depression score
greater than 10 on the Beck Depression Inventory.
Exclusion criteria were presence of diabetes, heart, kidney,
respiratory, or skin disease; history of reaction or allergy to herbal
medicines; hormonal therapy use during the last 6 months; olfac-
tory disorder, or the participant’s data were not analyzed if treat-
ment was missed for more than 3 nights during the month on a
complete case basis
Intervention
Participants received instructions on how to use the application
guidance: 2 drops on a 4  6-inch handkerchief using a dropper.
The handkerchief was attached to their collar with a pin 8 inches
from the nose allowing inhalation, which was removed after 20
minutes. Treatments continued for 4 weeks, nightly before sleep.
During the intervention, the investigator contacted and sent
messages twice a week to ensure the regular use of the essence by
participants. After each weekly call, the participants were asked about
the negative side effects of inhalation of lavender, such as dyspnea.
The interviewer who completed the instruments, the researcher who
administrated the treatments, and those who analyzed the results
were unaware of the allocation of the interventions.
Consequences
To follow symptoms of anxiety and depression, all participants
were asked to attend the health center, and Beck Depression In-
ventory and Spiegel Anxiety Questionnaires, based on the in-
terviews and participants’ answers, were completed by the
evaluator at the end of week 4 (end of the intervention).

Table 3
Baseline Comparison of Demographic Characteristics Between Treatment and Control Groups

Variable Treatment Group Control Group Test

Mean (SD) Mean (SD)

Length of menopause, y 3.78 (1.53) 3.26 (1) t ¼ 1.361, P ¼ .180

Children, No. 2.39 (2.18) 3.30 (0.97) t ¼ 1.827, P ¼ .074
Height, cm 160.65 (7.79) 159.04 (6.77) t ¼ 0.747, P ¼ .459
Weight, kg 70.82 (10.41) 70.34 (8.51) t ¼ 0.171, P ¼ .865
Body mass index, kg/m2 27.49 (3.88) 27.76 (2.57) t ¼  0.279, P ¼ .782
Age, y 55.95 (5.70) 53.56 (2.67) t ¼ 1.819, P ¼ .076
No. (%) No. (%) Fisher Exact Test Statistics
Marital status
Single 1 (4.35) 0 c2 ¼ 3.209
Married 20 (86.96) 23 (100) P ¼ .201
Widow 2 (8.69) 0
Occupation
Housewife 21 (91.30) 22 (95.65) c2 ¼ 0.357
Employee 2(8.70) 1(4.35) P ¼ .550
Educational Level
Illiterate 1 (4.35) 3 (13.04) c2 ¼ 1.410
Elementary school 9 (39.13) 9 (39.13) P ¼ .842
Middle school 4 (17.39) 4 (17.39)
Diploma 7 (30.43) 6 (26.09)
Higher degree 2 (8.70) 1 (4.35)
620 M. Jokar et al. / The Journal for Nurse Practitioners 16 (2020) 617e622

Table 4
Scores of State Anxiety, Trait Anxiety, and Depression for the Control and Treatment Groups at Baseline and Postintervention

Variable Time point Score, mean (SD) t Test P value

Treatment (n ¼ 31) Control (n ¼ 31)

State anxiety Baseline 47.34 (5.83) 48.34 (6.04) 0.571 .571

Postintervention 43.17 (5.24) 48.65 (5.51) 3.452 .001
Trait anxiety Baseline 47.82 (4.20) 48.65 (4.69) 0.628 .533
Postintervention 47.17 (4.58) 48.65 (4.12) 1.148 .257
Depression Baseline 20.08 (9.34) 22.52 (10.31) 0.839 .406
Postintervention 16 (8.84) 22.56 (10.13) 2.34 .024

Ethical Considerations (independent-sample t test, Mann-Whitney, c2, and the Wilcoxon

signed rank test) were used to analyze the data at a significance
The Larestan University of Medical Sciences Ethics Committee level of 0.05.
approved the study (IR.LARUMS.REC.1398.013). Details of the study
were explained to all participants, and their questions were
answered. The participants provided written consent before the
intervention, according to the Declaration of Helsinki.
Results

Data Collection
Of the 50 participants in this study, 46 women completed the
study (23 for each treatment or control group; Figure 1). No sta-
A demographic questionnaire consisting of several items,
tistically significant differences were found at baseline between the
including the length of menopause, number of children, marital
treatment and control groups in demographic characteristics
status, occupation, educational degree, weight, height, and body
(Table 3), trait anxiety, state anxiety, and depression (Table 4). The
mass index was completed at baseline. The Persian versions of the
clinical categories of anxiety or depression were similar at baseline
Beck Depression Inventory27 and Spielberger State-Trait Anxiety
(Table 4).
Inventory (STAI)26 were administered at baseline and at completion
The results after the intervention demonstrated that the mean
of the study.
score of state anxiety was less in the treatment group compared
The Beck Depression Inventory contained 21 questions on a 4-
with the control group (mean difference, 5.48; P ¼ .001). Although
point Likert scale. Scores on the inventory indicated 1 of 6
no significant difference was observed between the 2 groups in the
depression categories (Table 1). Test-retest reliability of this scale
mean score of trait anxiety, the mean score of depression was
was reported from 48.0% to 86.0%.27
significantly less in the treatment group than in the control group
The STAI included 40 statements, and for each state and trait
(mean difference, 6.56; P ¼ .024; Table 4).
anxiety scale, there were 20 statements. The answers were rated on
Tables 5 and 6 report the clinical categories for depression and
a 4-point Likert scale (very low, low, high, and very high). The
anxiety. There was a significant difference in depression categories
scores of each of the 2 scales varied from 20 to 80 (Table 2). Scores
in the treatment group compared with the controls (P ¼ .010). After
of 20 on both scales indicated low anxiety and 80 indicated high
the intervention, there was also a significant difference in the state
anxiety.28 The validity and reliability of the STAI have previously
anxiety categories in the treatment group compared with the
been investigated in many studies. The reliability of the STAI was
control group (P < .001). However, no significant difference was
reported at 88% in a study by Shahinfar et al,26 but was 83% in the
found between the 2 groups in the trait anxiety categories.
current study.
Results showed that there was a significant difference in the
mean score of anxiety and depression in the treatment group be-
Data Analysis tween before and after the intervention. The anxiety and depres-
sion score decreased significantly after the intervention in the
Statistical analysis was performed using SPSS 25 software (IBM treatment group (P < .05); however, no significant differences were
Corp). Descriptive statistics (mean and SD) and inferential statistics observed in the control group (P > .05) (Table 7).

Table 5
Frequency Distribution of Depression Rate Before and After the Intervention

Variable Depression Category Treatment Group Control Group Mann-Whitney Test

No. (%) No. (%) Z P

Before the intervention Normal 0 (0) 0 (0) 0.811 .417

Mild 11 (47.80) 9 (39.10)
Borderline 3 (13) 3 (13)
Moderate 6 (26.10) 5 (21.70)
Severe 2 (8.70) 5 (21.70)
Extreme 1 (4.30) 1 (4.30)
After the intervention Normal 8 (34.80) 0 (0) 2.580 .010
Mild 7 (30.40) 9 (39.1)
Borderline 3 (13) 3 (13)
Moderate 3 (13) 6 (26.10)
Severe 1 (4.30) 4 (17.40)
Extreme 1 (4.30) 1 (4.30)
 M. Jokar et al. / The Journal for Nurse Practitioners 16 (2020) 617e622 621

Table 6
Frequency Distribution of State and Trait Anxiety Before and After the Intervention

Variable Clinical Category Treatment Group Control Group Mann-Whitney Test

No. (%) No. (%) P Z

Trait anxiety baseline Low to Moderate 3 (13) 1 (4.30) .542 0.610

Moderate to high 17 (73.90) 19 (82.60)
Relatively severe 3 (13) 3(13)
Trait anxiety postintervention Low to Moderate to low 6 (26.1) 3(13) .559 0.584
Moderate to high 14 (60.90) 18 (78.30)
Relatively severe 3 (13) 2 (8.70)
Wilcoxon test Z 1.342 1.732
P .180 .083
State anxiety baseline Mild 0 (0) 0 (0) .989 0.014
Moderate to low 4 (17.4) 3 (13)
Moderate to high 16 (69.60) 18 (78.30)
Relatively severe 3(13) 2 (8.17)
State anxiety postintervention Mild 0 (0) 0 (0) >.001 3.686
Moderate to low 12 (52.20) 1 (4.30)
Moderate to high 11 (47.80) 20 (87)
Relatively severe 0 (0) 2(8.70)
Wilcoxon Z 3.317 1.414
P .001 .157

Discussion mild to moderate depression levels. Matsumoto et al30 also sug-

gested that short-term inhalation for 10 minutes of lavender
The findings of this study demonstrated that inhalation essential oil could alleviate the symptoms of premenstrual syn-
aromatherapy with 2% lavender essential oil per night for 20 mi- drome, such as anxiety, depression, irritability, fatigue, and dizzi-
nutes over a 4-week period reduced state anxiety in post- ness, with a significant difference in reducing depression in the
menopausal women. However, no significant difference was intervention group compared with the control group. Conrad et al31
observed in the mean scores of trait anxiety after the intervention reported that weekly lavender inhalation and massage for 15 mi-
between the 2 groups (Table 4), which concurred with the findings nutes for 4 consecutive weeks resulted in reduction of anxiety and
of Tafazoli et al,23 where a significant difference in anxiety was seen depression levels for postpartum women.
among the study participants during the first stage of labor and in Comparatively, the current study supported similar findings as
the first pregnancy experience with inhalation of lavender essential those of Kianpour et al32 who showed that inhaling 3 drops of
oil for 15 minutes. lavender essential oil 3 times a day for 4 weeks was effective in
The present study also found a significant reduction in clinical reducing stress, anxiety, and depression in a period of 3 months
state anxiety severity categories taking lavender inhalation before postpartum.
compared with the placebo, which means the observed reduction The results of the present study investigating the effect of
in state anxiety holds clinical significance and requires more inhaling aromatherapy on anxiety and depression in post-
experimental studies. However, we should mention that the menopausal women may increase the NP’s knowledge of comple-
severity of anxiety was not reduced to mild or normal for any mentary or alternative therapies. Results showed that
women in the treatment or control groups, where the highest approximately 9 of 10 NPs would recommended complementary
frequency of anxiety degree remained at a moderate or low level alternative therapies for patients but did not have sufficient infor-
after the intervention. mation in this area and their information had not been obtained
In addition, inhalation aromatherapy with 2% lavender essential from their professional education.33
oil for 20 minutes over a 4-week period proved to be effective for Also, the results of the present study reveal that all participants
depression, with a significant reduction in depressive symptoms inhaled lavender essential oil completely for 1 month each night.
after the intervention. The greater reduction in clinical depression This shows an appropriate therapeutic relationship between the
severity categories for the treatment group demonstrated the practitioner and patients. Therefore, NPs with strong patient re-
clinical significance of the treatment effects on depression. lationships and extensive knowledge about complementary and
Kamalifard et al29 reported that oral administration of lavender alternative treatment are in an ideal position to maximize the
for 8 weeks significantly decreased depression measured by the benefits of such treatments.34
Beck Depression Scale in postmenopausal women with a range of
Limitations
Table 7
Comparison the Mean Score of State and Trait Anxiety and Depression at Baseline The present study observed the effects of inhaling aromatherapy
and Postintervention for anxiety and depression in postmenopausal women in a short-
Variable Time Point Score Mean (SD) P Valuea term period; hence, long-term periods of inhalation were not
evaluated. We recommend that further studies should be con-
Baseline Postintervention
ducted to examine the long-term effects of inhaling lavender
State anxiety Treatment 47.34 (5.83) 43.17 (5.24) <.001
essence with other methods of aromatherapy on anxiety and
Control 48.35 (6.04) 48.65 (5.51) .296
Trait anxiety Treatment 47.82 (4.20) 47.17 (4.58) .010 depression.
Control 48.65 (4.69) 48.65 (4.12) >.99 The results of other research studies show a decrease in the
Depression Treatment 20.08 (9.34) 16.00 (8.84) <.001 physiological effects of menopause after inhaling lavender essential
Control 22.52 (10.31) 22.56 (10.13) .803 oil,35 but the present study did not evaluate other effects of
a
Paired t test. menopause that could lead to or exacerbate depression in
622 M. Jokar et al. / The Journal for Nurse Practitioners 16 (2020) 617e622
postmenopausal women. We therefore suggest that future studies
investigate the effect of lavender essential oil on other physiological
complications of menopause and assess the relationship between
its severity and the level of depression and anxiety in post-
menopausal women.
Conclusion
The results of the current study indicate that lavender inhalation
aromatherapy could be effective in reducing state anxiety and
depression levels in postmenopausal women. Therefore, we sug-
gest that NPs should consider lavender aromatherapy as a safe,
noninvasive, simple, and complementary therapy in reduction of
psychosocial complications during menopause.
Acknowledgement
The present study is the result of a research project approved by
the Vice Chancellor for Education, Research and Cultural Student
Affairs of Larestan University of Medical Sciences, NO. 1398-004
and it was funded by this department. Therefore, Larestan Uni-
versity of Medical Sciences is gratefully acknowledged for its
financial support.
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Mozhagan Jokar, MSc, is at the Department of Nursing, Khomein University of Medical
Sciences Khomein, Iran. Hamed Delam, MSc of Epidemiology, Student Research
Committee, Larestan University of Medical Sciences, Larestan, Iran. Soheila Bakhtiari,
MSc, is a PhD candidate at the Faculty of Nursing and Midwifery, Shiraz University of
Medical Sciences, Shiraz, Iran, and Nursing and Midwifery Care Research Center,
Isfahan University of Medical Sciences, Isfahan, Iran. Somayeh Paki, MSc, is at the
Department of Community Health Nursing, Social Security Organization, Isfahan,
Iran. Aliaskar Askari, MSc, is at the Larestan University of Medical Sciences, Larestan,
Iran. Mohammad-Rafi Bazrafshan, PhD, is at the Department of Nursing, School of
Nursing, Larestan University of Medical Sciences, Larestan, Iran, and can be contacted
at m.bazrafshan@larums.ac.ir. Nasrin Shokrpour, PhD, is a professor at the English
Department, Shiraz University of Medical Sciences, Shiraz, Iran. This study was
supported by Larestan University of Medical Sciences, Larestan, Iran.
In compliance with national ethical guidelines, the authors report no relationships
with business or industry that would pose a conflict of interest.
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