Scenting Relief-Aromatherapy for alleviating Primary Dysmenorrhea in Adolescents and Young Women: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-4975452/v1

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Systematic Review

Scenting Relief-Aromatherapy for alleviating Primary Dysmenorrhea in Adolescents and Young Women: A systematic review and meta-analysis

https://doi.org/10.21203/rs.3.rs-4975452/v1

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Background

Primary dysmenorrhea (PD) is prevalent among adolescents and young women, significantly impacting their quality of life. Aromatherapy has emerged as a promising non-pharmacological intervention for managing PD, but its age-specific efficacy, mode of application, and type of aroma oils remain underexplored. Thus, this systematic review evaluate aromatherapy's effectiveness in alleviating PD symptoms among adolescents and young women aged 10–24.

Methods

Data were sourced from PubMed, Google Scholar, ScienceDirect, Cochrane, Bielefeld Academic Search Engine (BASE), and through cross-referencing. Results were synthesized by conducting meta-analysis using random-effects models, and assessing heterogeneity using I² statistics. Quality assessment of the included studies was also carried out.

Results

A total of 15 studies were included for meta-analysis of which 4 were RCTs and 11 were non-RCTs. Aromatherapy significantly reduced PD pain score across studies, with a standardized mean difference (SMD) of -3.19 (CI -5.09, -1.28; I² = 98%) and − 0.98 (CI-1.40, -0.57; I² = 64%) in quasi-experimental studies and RCTs, respectively. In addition, moderate to severe pain was measured categorically (RR: 0.39; CI 0.25, 0.60; I² = 36%).. Adolescents exhibited the most significant benefit (SMD: -3.64; CI -6.24, -1.03; I² 98%; RR: 0.39; CI 0.25, 0.60; I² = 36%), compared to young women (SMD: -1.04; CI -1.35, -0.72; I² 53%). Inhalation aromatherapy (SMD − 3.09; CI -5.06, -1.12; I² 98% ) showed superior efficacy over massage (SMD − 1.20; CI -1.45, -0.96; I² 7%). Rose essential oil, cinnamon, and peppermint oil demonstrated significant efficacy, while lavender and lemon oils showed varying outcomes.

Conclusion

This study supports aromatherapy's effectiveness in reducing PD symptoms, particularly among adolescents. Standardized protocols and well-designed trials are needed to optimize aromatherapy's therapeutic potential for managing menstrual pain across diverse age groups, addressing current gaps in research methodology and oil-specific efficacy.

Sexual & Reproductive Medicine

Aromatherapy

Primary dysmenorrhea

Adolescents

Young women. Menstruation

pain management

non-pharmacological interventions

and quality of life.

Primary dysmenorrhea (PD), or painful menstrual cramps, is a common issue affecting many adolescent girls and young women, often leading to missed school or work and a reduced quality of life. Aromatherapy, which uses essential oils from plants, has been suggested as a natural way to manage this pain, but it's unclear which oils work best and how they should be applied.

In this study, we reviewed and analyzed existing research to understand how effective aromatherapy is in reducing PD symptoms among girls and women aged 10 to 24. We examined 15 studies, including both randomized controlled trials (RCTs) and non-randomized studies, and found that aromatherapy significantly reduced menstrual pain. The greatest benefits were seen in younger girls, especially when using inhaled aromatherapy, compared to older women or when using massage with essential oils.

Among the oils tested, rose, cinnamon, and peppermint oils were particularly effective in easing pain, while lavender and lemon oils had mixed results. Our findings suggest that aromatherapy could be a useful addition to managing menstrual pain, especially for adolescents. However, more high-quality research is needed to develop standardized guidelines and better understand how different oils can be most effectively used.

What is already known on this topic:
Aromatherapy has been investigated as a potential treatment for primary dysmenorrhea (PD), but its effectiveness across different age groups specifically adolescents and young women of age 10-24 years and modes of application has been inconsistent.

What this study adds:
This study reveals that aromatherapy can significantly alleviate PD symptoms, with notable efficacy among adolescents. Essential oils like rose, cinnamon, and peppermint were particularly effective, with inhalation methods outperforming massage. This research highlights aromatherapy's potential as a valuable non-pharmacological treatment for menstrual pain.

How this study might affect research, practice, or policy:
The findings support the inclusion of aromatherapy in school health settings as a practical, non-pharmacological treatment for PD. They emphasize the need for standardized guidelines and policies to facilitate its use in educational environments. This approach could enhance support for adolescents experiencing menstrual pain and promote accessible, effective pain management strategies within schools.

Dysmenorrhea, commonly known as menstrual pain, involves painful uterine cramps that occur during or before menstruation (1). This pain is typically in the lower abdomen and can radiate to the back and thighs (1). It is often accompanied by systemic symptoms such as nausea, vomiting, headache, and anxiety, lasting from 1 to 3 days (2). Dysmenorrhea is a prevalent gynaecological condition affecting 60–70% women and girls worldwide, typically beginning 6 to 12 months after menarche, with peak prevalence in the late teens to early twenties (3). However, it gets better by age 30 (3). The most common form, primary dysmenorrhea, occurs without underlying conditions and accounts for approximately 90% of cases among adolescents. In contrast, secondary dysmenorrhea indicates underlying conditions such as endometriosis or pelvic inflammatory disease requiring medical attention (4, 5). The prevalence of dysmenorrhea ranges from 45–93% among women of reproductive age, with adolescents exhibiting the highest rates (6).

Among adolescents, the pain and discomfort associated with dysmenorrhea can have debilitating effects on physical, emotional, and social well-being, interfering with daily activities such as schooling and social engagements (7). This can lead to feelings of isolation, anxiety, depressive symptoms, and a reduced overall quality of life (QoL). Studies indicate that dysmenorrhea disrupts the daily lives of 20–50% of affected young women and girls, with around 20% of students experiencing school absenteeism (7). This issue is more pronounced in Low-Middle-Income Countries (LMICs) at 26%, compared to 12% in High-Income Countries (HICs), with more than 40% of students reporting adverse effects on concentration while studying, consistent across both LMICs and HICs (8).

In managing primary dysmenorrhea, many women consult healthcare professionals and use analgesic drugs such as non-steroidal anti-inflammatory drugs (NSAIDs) to alleviate pain (9). However, these pharmacological interventions can lead to side effects like drowsiness, dizziness, and indigestion, and long-term use can result in drug dependency, further impacting daily performance (9). Due to the adverse effects, non-pharmacological and complementary therapies are gaining attention. These include respiratory relaxation, essential oils, aromatherapy, music therapy, exercise therapy, acupuncture, and acupressure, which can reduce pain and improve QoL (10).

Among various complementary therapies, aromatherapy has been historically used in multiple forms, such as massage, inhalation, and bathing. Aromatherapy oils provide therapeutic effects and can be easily used in public settings (11). They are known to increase user satisfaction and improve psychological stability by alleviating depression, anxiety, and stress and influencing the endocrine and circulatory systems (11). Aromatherapy promotes physical functions like pain reduction, memory enhancement, stress reduction, and attention improvement. Besides, many types of essential oils used in aromatherapy have demonstrated antiviral, antimicrobial, and anti-inflammatory properties (12). Despite its potential benefits, the application of aromatherapy in clinical settings faces challenges due to the variety of essential oils, mixture combinations, and differing intervention methods and durations in studies (13).

Despite these benefits, existing studies predominantly focus on adult women, overlooking adolescents and young women aged 10–24 years who are particularly affected by this condition. This systematic review aims to address this gap by evaluating the effectiveness of aromatherapy specifically for primary dysmenorrhea in this age group. In addition to providing a comprehensive analysis, this review includes novel subgroup analyses based on age, methods of aromatherapy administration (inhalation vs. massage), and types of essential oils used. By consolidating and analyzing this data, we seek to inform clinical practice and improve the QoL for young individuals. Additionally, this review will explore the mechanisms of action and consider placebo effects, offering a thorough understanding of aromatherapy's therapeutic potential and clinical significance.

Aromatherapy has emerged as a promising complementary therapy for alleviating primary dysmenorrhea, a common menstrual disorder affecting adolescent girls and young women (12, 14). The practice involves the therapeutic use of essential oils extracted from plants through inhalation, massage, or topical application (13). Essential oils are believed to interact with olfactory and skin receptors, triggering physiological responses such as muscle relaxation and anti-inflammatory effects. Concurrently, aromatherapy is hypothesized to exert psychological benefits, including stress reduction and mood enhancement, which may modify pain perception and tolerance during menstruation (15).

In examining the effectiveness of aromatherapy, several factors play pivotal roles in shaping treatment outcomes. These factors can impact hormonal fluctuations, pain sensitivity, and the individual response to aromatherapy interventions. Additionally, mediating factors, such as psychological responses (e.g., stress reduction) and physiological effects (e.g., muscle relaxation), mediate the relationship between aromatherapy and primary dysmenorrhea outcomes (15). However, it is essential to account for confounding variables, including socioeconomic status (SES), concurrent use of other pain management techniques, and variability in menstrual cycle characteristics, which can obscure or exaggerate the observed effects of aromatherapy (16). The graphical representation of these factors has been shown through a theoretical framework (Fig. 1).

Information sources

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (17). The study was exempt from ethical review approval. Before initiating the review, it was registered with PROSPERO (CRD42024552178). The review adhered mainly to the registered protocol, with few modifications: the meta-analysis on different time points, QoL, Body Mass Index (BMI), type of sanitary napkins, and complications for aromatherapy were not conducted due to insufficient evidence.

Eligibility criteria

Key eligibility criteria were established for including research studies in this systematic review. The studies focused on adolescents and young girls aged 10–24 years who experienced primary dysmenorrhea. We included studies that compared the effects of aromatherapy with other interventions, control groups with no treatment, or placebo groups using placebo oil.

Studies were excluded if they involved participants who were married, had any obstetric or gynaecological diseases, chronic conditions, or mental illnesses, or had known hypersensitivity to aromatherapy. Additionally, studies that did not separately report outcomes for the age group of 10–24 years were excluded. However, if the exact ages of participants were not mentioned, studies were included if the mean age of the participants fell within the 10–24 years range. Research focusing on secondary dysmenorrhea or other types of menstrual disorders was also excluded.

Given the focus on primary dysmenorrhea, studies reporting on different outcomes or unrelated conditions were not included. Only studies published or available in English were considered for inclusion. No geographical restrictions were applied, ensuring a comprehensive global perspective. There were no limitations on the year of publication or study design, except that systematic reviews, observational studies, case reports, and case series were excluded from this review. Refer to the Population, Intervention, Comparator, Outcome (PICO) criteria mentioned in Table 1.

Table 1

PICO Strategy
Population	The populations (patients) in this study consisted of adolescents and young girls aged 10–24 years who experienced menstrual pain. The study excluded participants who were married and had any obstetric or gynecological diseases, chronic conditions, or mental illnesses, as well as those with known hypersensitivity to aromatherapy.
Intervention	For this study, the selected aromatherapy intervention studies included either inhalation or massage therapy with single or blended essential oils. There were no limitations on the types, volumes, or forms of the aromatherapy oils used in these interventions.
Comparison	For the comparators, studies were included in this review if they met the criteria of comparing other interventions with aromatherapy, utilized a control group with no treatment, or employed a placebo group using placebo oil.
Outcome	Studies were included in this review if they assessed the effects of aromatherapy on menstrual pain. Menstrual pain was represented by subjective pain measurements using tools such as the visual analog scale (VAS), numeric rating scale (NRS) or categorically as mild (0–3), moderate (4–6) or severe (> 7 to 10).

Search Engines

The databases searched included PubMed, Google Scholar, ScienceDirect, BASE, and Cochrane. The search strategy was developed in collaboration with a librarian. Additionally, cross-referencing was performed to identify articles that might have been missed in the database searches. This involved reviewing the reference lists of identified articles and relevant systematic reviews to ensure a comprehensive examination of the available evidence and to uncover additional studies that may not have been captured through the initial searches, thereby enhancing the inclusivity and thoroughness of this review (18).

Search terms and strategy

This systematic review utilized a comprehensive search strategy to identify relevant studies. The search terms were carefully constructed using a combination of medical subject headings (MeSH) terms and text terms, connected by Boolean operators, and designed according to the PICO framework. This approach ensures the search is reproducible, allowing others to obtain the same results independently.

This study identified relevant studies using the specified search terms, and the screening process is detailed in Table 2. Three reviewers conducted searches across the various databases from the commencement of the research study, with the final search conducted on 14 May 2024. The detailed search terms for the systematic literature review, encompassing the PICO framework, were as follows:

Table 2

Search strategy
SNO	Key terms
1	Aromatherapy
2	Oils, Volatile
3	essential oils
4	aromatic therapy
5	aroma inhalation
6	lavender oil
7	rose-oxide
8	Rose oil
9	1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8
10	primary dysmenorrhea
11	Dysmenorrhea
12	menstrual pain
13	period pain
14	menstrual cramps
15	Menstruation Disturbances
16	Menstruation Disorders
17	menstrual disorder
18	Pelvic Pain
19	painful menstruation
20	painful period
21	10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20
22	Adolescent
23	adolescent girls
24	teenage girls
25	teenage females
26	teenage women
27	Youth
28	Youth girls
29	Youth female
30	Youth Women
31	Young women
32	Young girls
33	Young female
34	22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33
35	9 AND 21 AND 34
36	Filter: clinical trials and English
*Means to include all words that begin with aroma

Data Collection and Extraction

Once eligibility was determined and the literature was extracted from the search engines, the relevant studies were imported into Rayyan as the primary screening and data extraction tool. Three reviewers independently screened the studies for potential inclusion in the systematic review. Each article underwent screening by two reviewers from the team. The third reviewer resolved disagreements during the title, abstract, and full-text screening stages. Studies selected for inclusion proceeded to the final stage of data extraction, quality assessment, and synthesis for meta-analysis. Data extraction was conducted independently by three reviewers to ensure accuracy and reliability. Information extracted included the primary author's name and publication year, study design, sample size, blinding, participant characteristics such as age, intervention group, type of aroma oil, control group, primary outcome measures (scale), results significant or insignificant, and key findings (Table 3).

Table 3

Data extracted from individual studies in the systematic review
Data
Name of the first author
Year of publication
Study design and sample size
Type of blinding (if applicable)
Age (years) of study population: age range or mean ± SD
intervention group (regime)
Type of aroma oil used
Control group regime
Main outcome measures (scale),
Overall result significant/insignificant
Key findings

Risk of bias assessment

For randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) included in this systematic review, two standardized tools were employed to assess the risk of bias: the Cochrane Risk of Bias Tool (ROB II) for RCTs and the ROBINS-I tool for non-randomized studies (19, 20). Methodological assessors critically analyzed each study to identify and mitigate potential biases arising from confounding variables, intervention allocation and outcome assessment. This systematic approach helped ascertain the level of bias in each study, ensuring rigorous evaluation and interpretation of the findings (19). Three authors evaluated each article to evaluate the risk of bias further; an expert from the team resolved any discrepancies.

Synthesis of results

The data were synthesized through qualitative analysis, with quantitative analysis performed using meta-analysis techniques where appropriate. Meta-analytical techniques were employed using Review Manager version 5.4 to combine findings from RCTs and non-RCTs, considering their distinct study designs.

Standardized Mean Differences (SMD) were calculated for continuous outcomes measuring pain severity due to variations in scale measurements across studies. For categorical outcomes, specifically the prevalence of moderate to severe pain (≥ 4 on a scale of 10), risk ratios (RR) were used to quantify associations. A random-effects model was applied to accommodate potential heterogeneity among studies, assessed using the I2 statistic and visual inspection of forest plots. Funnel plots were employed to detect and evaluate potential publication bias.

Subgroup analyses were performed to explore the influence of key factors such as age group (adolescents aged 10–19 vs. young women aged 20–24), type of aromatherapy oil used, and mode of application (massage vs. inhalation). These analyses aimed to elucidate how these variables might modify the effects of aromatherapy on pain outcomes in different demographic and treatment subgroups.

A total of 106 records were obtained from initial hits, and seven papers were obtained from cross-referencing. After removing duplicates, 49 studies were subjected to title and abstract screening, and 22 reached the full-text screening stage after removing 27 irrelevant studies. Five full-text studies were excluded (Fig. 2), and 15 studies were ultimately included in this review and meta-analysis. A PRISMA flow diagram explains the process of including the studies in the systematic review.

Study Characteristics

Among the 15 included studies, four were randomized controlled trials (RCTs) (21–24) and 11 were quasi-experimental designs, all published between 2000 and 2024 (25–35)(Table 4). These studies primarily investigated the effectiveness of aromatherapy in managing dysmenorrhea, focusing on adolescents aged 10–19 years (n = 10) and young adults aged 20–24 years (n = 5) across the globe regardless of geographical location.

Interventions primarily involved aromatherapy using essential oils such as lavender, cinnamon, rose, lemon, and peppermint. Eight studies utilized inhalation methods, where participants inhaled oils applied to gauze, palms, or through a necklace, with inhalation durations ranging from 5 to 20 minutes (22, 25, 28, 30–32, 34, 35). Aromatherapy massage was featured in six studies, predominantly using lavender oil (n = 6), either alone or combined with oils like clary sage and rose (21, 23, 24, 27, 29, 33). Massage techniques included effleurage, which is characterized by gentle, rhythmic strokes on the abdomen (effleurage) that last 10 to 15 minutes per session and are applied daily or intermittently around menstruation.

Table 4: Characteristics of the included studies

Author’s first name	Study design (sample size)	Type of blinding	Age range (years)	Intervention group (regime)	Aroma oils	Control group (regime)	Main outcome measures (scale)	Significant or insignificant	Key findings
Serap (2012)(33)	Quasi-experimental study (n-44)	NA	*20.31±1.09	aromatherapy massage (efflurage) at a fixed time of the day by the same massager for 15 mins on the abdomen in a special quiet room where the temperature was between 23 C and 25 C (73.4 F and 77 F).	Lavender	placebo massage (effleurage) with odorless liquid petrolatum (soft paraffin) at a fixed time of the day by the same massager for 15 mins on abdomen in a special quiet room where the temperature was between 23 C and 25 C (73.4 F and 77 F).	VAS	P<0.001	Aromatherapy massage with lavender oil was more effective in reducing dysmenorrhea compared to placebo massage.
Niasty et al (2021)(28)	Quasi experimental design (n=44)	NA	15-18	All students who received aromatherapy via inhalation for 15 minutes while experiencing dysmenorrhea.	Cinnamon (Cinnamomum burmanii)	No treatment or therapy was provided in preintervention phase	Pain scale with categories like "very annoying pain", "slight pain", and "very bothersome pain"	P<0.001	The key findings are: 1) Primary dysmenorrhea pain was experienced by the majority of students before the intervention, with most reporting "disturbing pain". 2) After the intervention of cinnamon aromatherapy, the majority of students reported experiencing "a bit of pain", indicating a significant reduction in pain. 3) The statistical analysis showed a significant effect of the cinnamon aromatherapy on reducing primary dysmenorrhea pain.
Husnul et al (2021)(27)	Quasi Experimental Design (n=60)	NA	Adolescents (age not mentioned)	The intervention group received acupressure therapy using lemon essential oil aromatherapy at points LI 11, LI 4, and ST 36 on days 1-2 of menstruation.	Lemon essential oil aromatherapy	The control group (preintervention) received acupressure therapy without using aromatherapy.	Numerical visual analog scale (VAS) with a pain intensity scale ranging from 0-10	p<0.001	Acupressure using aromatherapy is effective in reducing dysmenorrhea (menstrual pain) in teenage students, and is more effective than acupressure alone.
Yuni et al (2018)(29)	Quasi-experimental, time series method (n=40)	NA	15-18	Effleurage massage using lavender aromatherapy, where the lavender essential oil was diluted in olive oil, and the massage was performed for 10 minutes, repeated after 6 hours (n=22)	a mixture of lavender essential oil and olive oil	The control group did not take any action (n=22).	Numerical rating scale: 0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-9 = severe pain, 10 = very severe pain	p<0.001	The use of lavender aromatherapy combined with effleurage massage was effective in reducing menstrual pain (dysmenorrhea) in high school students, as shown by a significant reduction in pain levels compared to control groups.
Dwi et al (2021)(25)	Quasi experimental, n= 22	NA	14-17	Inhalation aromatherapy to reduce dysmenorrhea (menstrual pain) in teenage girls.	Lavender oil	No intervention	Lavender aromatherapy questionnaire, the dysmenorrhea scale	P<0.01	Lavender aromatherapy was effective in reducing dysmenorrhea (menstrual pain) in teenage girls.
Yeti et al (2022)(30)	Quasi experimental using two groups (n=30)	NA	18-19	Aromatherapy for 1 hour	Lavender essential oil	Warm compression for 1 hour	Numeric Rating Scale (NRS)	P<0.001	Both warm compresses and lavender aromatherapy were effective in reducing dysmenorrhea pain, with no significant difference between the two interventions.
Froozan et al (2015)(21)	RCT (crossover design)	Not mentioned	18-24	Aromatherapy massage with rotation movements using both hands without creating pressure on the abdomen for 15 min.	Lavender essential oil	Placebo massage with rotation movements using both hands without creating pressure on the abdomen for 15 min.	VAS with 10 point ruler	P<0.001	Massage with lavender essential oil resulted in a significantly greater reduction in the severity of dysmenorrhea compared to placebo massage alone, and lavender oil appears to have a more important role in reducing pain severity than other essential oils.
Rahayu et al (2019)(32)	Quasi Experimental Design (n=34)	NA	Teenage girls of grade X and XI (age not mentioned)	Inhalation aromatherapy for 20 minutes, using 3 drops of lavender essential oil mixed with 20 ml of water	Lavender oil	No treatment in pre intervention phase	Menstrual pain scale (10 points)	P<0.001	Lavender aromatherapy is effective in reducing the level of dysmenorrhea (menstrual pain) in adolescent girls.
Lika et al (2022)(31)	Quasi experimental study (n=30)	NA	15-17	Inhalation aromatherapy	Cinnamon aromatherapy	No treatment in preintervention phase	Menstrual pain or dysmenorrhea, measured on a scale from 0 to 3, with 0 indicating no pain and 3 indicating severe pain.	NS	Cinnamon aromatherapy intervention significantly reduced the intensity of primary dysmenorrhea in the study participants, with the average pain score decreasing from 6.067 before the intervention to 3.100 after the intervention. The paired t-test showed a significant difference in anxiety levels before and after the intervention, with a p-value of 0.000.
Selda et al (2023)(22)	RCT	Open label	*21.51 ± 1.63	The intervention group (group R) received both standard analgesic treatment (diclofenac sodium 50 mg enteric film tablets) and inhalation aromatherapy with rose oil (Rosa damascena Mill.)	essential rose oil (Rosa damascena Mill.)	The control group (group C) only used standard analgesics (50 mg diclofenac sodium enteric film tablets).	pre-treatment (VAS-0) and post-treatment (VAS- 60)	P<0.05	Inhalation of rose oil (Rosa damascena Mill.) in addition to standard NSAID treatment for primary dysmenorrhea led to lower pain scores and lower total analgesic consumption compared to NSAID treatment alone. Rose oil aromatherapy by inhalation can be a good self-treatment option for primary dysmenorrhea, either alone or as an additional method to avoid excessive NSAID use and side effects.
Farida et al (2023)(26)	Quasi experimental design (n=30)	NA	15-16	Cinnamon aromatherapy for 15 minutes when experiencing menstrual pain.	Cinnamon aromatherapy	No treatment during preintervention phase	Numeric rating scale using categorization into mild (1-3), moderate (4-6), severe (>7)	P<0.001	cinnamon aromatherapy had a significant effect in reducing the intensity of primary menstrual pain among the female students. After the treatment, the majority of students (63.3%) experienced mild pain, compared to 46.7% experiencing moderate pain before the treatment. The statistical analysis showed a significant difference in pain levels before and after the treatment.
Leza et al (2024)(24)	RCT (n=40) Intervention (n=20) Control (n=20)	Open label	18-24	3% peppermint lotion 3 times a day for 3 days,	Peppermint oil lotion	The control group received a placebo lotion, administered 3 times per day for 3 days.	Pain intensity (Numeric Rating Scale) and cortisol levels (blood serum)	P<0.05	Administration of peppermint lotion for 3 days reduced pain intensity and cortisol levels in adolescents with primary dysmenorrhea, with statistically significant differences between the intervention and control groups.
Sun-Hee et al (2006)(23)	RCT (n=67) Intervention (n=25) Control (n=20)	Double	*20.6 ± 1.27	15-minute abdominal massage using a blend of lavender, clary sage, and rose essential oils (2:1:1 ratio) diluted in almond oil at a 3% concentration, applied daily starting one week before the start of menstruation and continuing until the first day of menstruation.	A blend of lavender, clary sage, and rose essential oils diluted in almond oil at a 2:1:1 ratio and 3% concentration	The control group received no treatment and continued their daily routine.	The main outcome measures were: 1) Intensity of menstrual cramps, measured using a 10-point Visual Analogue Scale (VAS) 2) Severity of dysmenorrhea, measured using a verbal multidimensional scoring system with 4 grades (1 = none, 2 = mild, 3 = moderate, 4 = severe)	P<0.001	Aromatherapy using a blend of lavender, clary sage, and rose essential oils significantly reduced menstrual cramps and the severity of dysmenorrhea compared to placebo and control groups.
Thenmozhi et al (2020)(35)	Quasi experimental study (n=60)	NA	17-19	Aromatherapy was administered by inhalation method in alternate days from 7th day of menstrual cycle for two consecutive menstrual cycles. It was administered by sprinkled few drops of lavender essential oil onto a clean and sterile tissue and instructed the participants to inhale its aroma.	Lavender essential oil	No therapy before intervention	The main outcome measure was a 27-item primary dysmenorrhea symptom assessment questionnaire that covered physiological and psychological symptoms, as well as a numerical pain rating scale.	P<0.001	Aromatherapy using lavender oil was effective in reducing menstrual distress, including physical symptoms like nausea and back ache, as well as improving concentration and sleep, in adolescent girls with primary dysmenorrhea. The therapy was also inexpensive, easy to administer, safe, and affordable, making it a recommended treatment in both clinical and community settings.
Sri Sat et al (2019)(34)	Quasi experimental study (n=16)	NA	16-17	Lavender aromatherapy, where 3-5 drops of lavender essential oil were inhaled for 5 minutes	Lavender essential oil	NA	NRS (Numeric Rating Scale)	P<0.001	Lavender aromatherapy was effective in reducing menstrual pain in female teenagers, with a significant decrease in pain score from 3.69 to 2.06 after the intervention.

Abbreviations: VAS: Visual Analogue Scale, NRS: Numeric Rating Scale, RCT: Randomized Controlled Trial, NA: Not Applicable, NSAID: Non-Steroidal Anti-Inflammatory Drug

^aAge: mean±SD

Among the RCTs, blinding procedures were noted, ensuring participants and/or assessors were unaware of the treatment allocation to minimize bias. For instance, Han et al. (2006) used a double-blind method in their study involving a blend of lavender, clary sage, and rose essential oils, diluted in almond oil, demonstrating significant reductions in menstrual cramps and dysmenorrhea severity (23). Meliya et al. (2024) utilized an open-label approach for young females (24). Additionally, one study by Khotimah et al. (2021) integrated acupressure therapy with lemon essential oil aromatherapy, focusing on adolescents, though specific age ranges were not always specified.(27)

Control groups in these studies received no treatment, placebo massages using odorless oils, or standard analgesic treatments. Outcome measures included pain intensity assessed via scales like the Visual Analogue Scale (VAS) (36), Numeric Rating Scale (NRS) (37), and specific dysmenorrhea questionnaires (38). Most studies reported substantial decreases in pain scores post-intervention, affirming the efficacy of aromatherapy in managing dysmenorrhea symptoms. The duration and frequency of interventions varied, with consistent findings indicating that aromatherapy, particularly with lavender oil, provides a promising non-invasive approach for alleviating menstrual pain.

Risk of bias assessment

Regarding study quality assessment, the included randomized controlled trials (RCTs) were rated as high quality due to their low risk of bias (21–24). These studies employed rigorous methodologies such as randomization and blinding, enhancing the reliability of their results. On the other hand, the quasi-experimental studies were deemed low quality overall, with a majority categorized as having serious risk of bias. Specifically, two of these quasi-experimental studies were assessed to have a critical risk of bias (32,33). This rating reflects potential methodological limitations in study design.

Figure 3a and b illustrates the risk of bias graph and summary plot for the RCTs, highlighting their methodological strengths. Conversely, Figure 4a and b depicts these assessments for the quasi-experimental studies, emphasizing the variability and lower quality of their methodological approaches.

Findings from Meta-analysis:

Randomized controlled trials

RCT meta-analysis included four studies and used menstrual pain as a continuous variable (Figure 5) (21–24). Given the significant heterogeneity among the studies (I² = 64), a random-effects model was applied. The pooled SMD was -0.98 (95% CI: -1.40, -0.57), indicating a moderate reduction in menstrual pain among participants who received aromatherapy compared to the control group. These results demonstrate that aromatherapy significantly alleviates primary dysmenorrhea, with the findings being statistically significant (p < 0.001).

The funnel plot for the RCTs included in the meta-analysis (Figure 6) demonstrates the relationship between each study's standard error and SMD. The plot is symmetrical, indicating no significant publication bias among the included studies. The scatter of the points around the vertical dashed line at zero suggests that the effect sizes from individual studies are evenly distributed on both sides, further supporting the absence of bias. However, the plot does show some variability in the standard errors, which is expected given the differences in study sample sizes and methodologies.

Quasi-experimental studies

Among the 11 quasi-experimental studies, we conducted a meta-analysis using two different approaches: continuous and categorical data. Six studies reported menstrual pain as a continuous variable with mean scores(30–35). For these studies, we calculated the standardized mean difference (SMD) (Figure 7a). Given the high heterogeneity (I² of 98%), a random effects model was applied, yielding a pooled SMD of -3.19 (95% CI: -5.09 to -1.28) with a p-value of 0.001. This result indicates a significant reduction in menstrual pain with aromatherapy. On the other hand, five studies reported pain categorically, focusing on the prevalence of moderate to severe menstrual pain (Figure 7b) (25–29). Using a random effects model, the relative risk (RR) was found to be 0.39 (95% CI: 0.25-0.60) with an I² of 36%. This result was also statistically significant with a p-value of <0.001, further supporting the efficacy of aromatherapy in relieving menstrual pain.

Funnel plot

Funnel plots with 95% confidence intervals (CIs) for quasi-experimental studies on the effect of aromatherapy on menstrual pain relief are shown in Figure 8. The plot in Figure 8a depicts the Standardized Mean Differences (SMDs) for continuous data, with the SMDs (x-axis) plotted against their standard errors (SEs) (y-axis). The plot in Figure 8b shows the Risk Ratios (RRs) for categorical data, with the log-scale RRs (x-axis) plotted against their standard errors (SEs) (y-axis). The visual inspection of these plots suggests some asymmetry, indicating potential publication bias or heterogeneity in the study outcomes.

Subgroup Analysis

We conducted subgroup analyses to evaluate the overall effect of aromatherapy on menstrual pain across age groups (adolescents and young adults), modes of aromatherapy application, and types of aroma oils (Figure 9). Adolescents showed a significant reduction in pain risk (RR 0.39; CI 0.25, 0.60; I² 36) and a substantial decrease in pain intensity (SMD -3.64; CI -6.24, -1.03; I² 98) ((25–29,31,32,34) (26,30). Young adults exhibited moderate pain reduction (SMD: -1.04, CI -1.35,-0.72; I² 53) (21–24,33). Massage also moderately reduced pain intensity (SMD: -1.20, CI -1.45, -0.96; I2 7 ; RR: 0.58, CI 0.34,0.99; I² 0), while inhalation had a more substantial effect (SMD: -3.09, CI -5.06, -1.12; I² 98; RR 0.20; CI 0.10, 0.39; I² 0%). Peppermint rose and cinnamon oils appeared most effective in alleviating menstrual pain, showing modest to moderate reductions in pain intensity (22,24,26,28,31). Lemon oil showed no significant effect (RR:0.60; CI 0.25,1.44) (27), while lavender did not significantly reduce moderate to severe pain (SMD:-2.85; CI -4.28,-1.41; I² 97; RR 0.38; CI 0.11,1.32; I² 45) (21,23,29,30,32–35).

Other outcomes

Aromatherapy impacts various aspects of menstrual health beyond pain relief. Analgesic consumption was significantly lower in participants receiving aromatherapy compared to controls (50 mg [50–100] vs. 100 mg [50–100]; p = 0.003). Mean pain scores measured during the second and third cycles showed no significant differences, indicating that time did not affect menstrual pain among those receiving the intervention or control (21). One study reported a significant reduction in cortisol levels in the intervention group (MD 2.64) compared to the control group (MD 0.94; p = 0.010) after aromatherapy administration (24). Additionally, primary dysmenorrhea-related parameters were assessed, revealing that 59% of adolescent girls with dysmenorrhea were stressed, only 12% sought medical advice, and only 12% were prescribed treatment therapy (25,35). Furthermore, 88% of adolescents with dysmenorrhea skipped meals (35). There was also a statistically significant association between the duration of the menstrual cycle and the pre-intervention level of menstrual distress among adolescent girls with primary dysmenorrhea (p < 0.05) (35). Overall, QoL was not measured in any of the studies.

This review focuses on studies that assessed the impact of aromatherapy on menstrual pain relief among adolescents and young girls aged 10-24 years. The pooled estimates showed a significant reduction in menstrual pain severity, with inhalation demonstrating the most effective mode of application. Among the essential oils studied, cinnamon and peppermint oils were found to be the most effective, while lavender oil showed mixed results, and lemon oil was insignificant in providing pain relief. A significant difference was observed in pain relief outcomes based on the mode of application and the type of essential oil used. The quality of the studies varied, with some exhibiting a high risk of bias and others demonstrating more robust methodologies. There was also considerable heterogeneity across studies, likely due to differences in study design, population characteristics, and intervention protocols. Despite these issues, the evidence suggests that aromatherapy, particularly using cinnamon and peppermint oils through inhalation, may be a valuable non-pharmacological approach for managing menstrual pain in this demographic.

Aromatherapy exerts pain-relieving effects via the olfactory-hippocampal pathway, stimulating GABAergic neurons and influencing acetylcholine release (41). Inhalation of essential oils activates olfactory receptors, transmitting signals that impact memory, emotions, and pain perception (42). This process can trigger the secretion of endorphins and enkephalins, potentially alleviating anxiety and pain (41). Beyond dysmenorrhea, aromatherapy has shown positive effects on various women's health issues, including premenstrual syndrome (43), gestational hyperemesis (44), labor pain (45), postpartum depression (46), breast milk production (47) and management of menopausal physical, sexual, and psychological symptoms (48). However, limited research has focused on the impact of aromatherapy on sexual and reproductive health among adolescents (49).

Our findings are consistent with a systematic review by Soo Lee et al. (2018), which focused on randomized controlled trials (RCTs) involving women aged 18 to 30 years. This review reported an overall standardized mean difference (SMD) for menstrual pain of -0.91 (95% CI −1.17 to −0.64) among those who received aromatherapy (40). Another meta-analysis among adult women with dysmenorrhea indicated that the use of mixed aroma oils (SMD -0.88) compared to unmixed oils (SMD -0.75) showed a slight but insignificant difference in effectiveness in pain relief. (50). Consistent with these findings, our study also demonstrated significant relief in primary dysmenorrhea (PD) among adolescents and young adults following aromatherapy use. These results underscore the potential of aromatherapy as an effective non-pharmacological intervention for menstrual pain relief across various age groups.

To determine the age-specific efficacy of aromatherapy, we explored if there is any difference in alleviating dysmenorrhea among adolescents and younger girls. This finding aligns with several quasi-experimental studies indicating that following aromatherapy intervention, only 15% of participants reported severe pain, contrasting sharply with the 48% reported before intervention (28). However, the absence of a systematic review hampers our ability to provide pooled estimates for its effectiveness. In addition, none of the systematic reviews on this age group is currently available to identify the pooled estimates for its overall effectiveness.

The mode of application significantly influences treatment outcomes. A meta-analysis of 10 studies comparing aromatherapy massage versus placebo massage revealed a significant reduction in pain among those receiving aromatherapy massage (50). Conversely, in their study, Choi (2006) reported no significant difference in pain relief between aromatherapy massage recipients and controls (51). However, Lee et al. (2006) demonstrated the efficacy of plain massage with regular oil in reducing menstrual pain (51). When comparing massage-based aromatherapy versus inhalation aromatherapy, studies have indicated inhalation to be more effective (51,52). Notably, these studies primarily involved women aged 18-40, underscoring the need for further research to explore comparative effectiveness among younger age groups.

For the aromatherapy essential oils, a total of 7 different oils were used, including lavender, rose (Rosa damascena Mill), lemon, Cinnamon (Cinnamomum burmanii), clary sage, almond oil and peppermint oils. From these, clary sage and almond oil are mainly used as a carrier oil to help with dilution. Lavender (mostly mixed form) was the most commonly used among them. Studies suggest that applying rose oil and peppermint via abdominal massage significantly reduces the duration and severity of menstrual pain (53,54). In contrast, cinnamon oil inhalation is effective in this regard (55). Lavender oil aromatherapy is most popularly reported for its pain-relieving mechanism; however, its effectiveness in younger age groups is still questionable.

Other than pain and discomfort management, aromatherapy plays a significant role in improving QoL. Evidence from multiple systematic reviews suggests that aromatherapy can significantly reduce stress, anxiety, and cortisol levels, thereby enhancing overall well-being. For instance, systematic reviews have found consistent reductions in stress and improvements in sleep quality among women with reproductive health issues following aromatherapy interventions (56). Similarly, the use of essential oils like lavender and rosemary has been systematically reviewed and shown to significantly lower cortisol levels, indicating reduced stress and anxiety (57). However, it is important to note that while these benefits are well-documented in general populations, there is a notable lack of studies specifically measuring QoL outcomes for girls with primary dysmenorrhea (PD). Our review identified only one study that measured stress and cortisol levels in this group, highlighting a critical gap in the research. Future studies should aim to fill this gap by investigating the impact of aromatherapy on QoL for girls with PD, including comprehensive measures of stress and hormonal changes.

In our meta-analysis, heterogeneity among these studies was significantly high due to the larger age group of the population, difference in study designs, intervention variability, duration and frequency of aromatherapy application, use of different tools to assess PD, geography and cultural differences. When applying aromatherapy, future studies must compare geographical locations, cultural aspects, periods, and durations.

Considering the effectiveness of aromatherapy for PD, Healthcare providers can integrate aromatherapy into treatment plans, considering safety, patient preferences, and feasibility. Essential oils, such as lavender and cinnamon, should be diluted to prevent irritation, and inhalation methods offer a non-invasive option. Patient involvement in choosing scents can enhance adherence and satisfaction. Aromatherapy is cost-effective and easily implemented in various healthcare settings, including use by school health nurses for girls with primary dysmenorrhea (PD). This complementary approach offers a promising addition to clinical practice for managing menstrual pain among young female population (58–62).

To the best of our knowledge, this is the first systematic review to comprehensively examine the use of aromatherapy for primary dysmenorrhea (PD) and to compare the benefits of individual essential oils. Our findings provide valuable insights into the potential of aromatherapy as a non-pharmacological treatment for menstrual pain. However, several limitations should be considered. First, most of the quasi-experimental studies included in our review had a serious risk of bias, which may affect the reliability of the results. The sample sizes of the included studies, especially for the subgroup analysis of aroma oils, were relatively small, and the study durations varied, potentially impacting the generalizability of our findings. Additionally, there was considerable heterogeneity among the studies regarding intervention protocols, types of essential oils used, and outcome measures. This variability might have influenced the pooled results and limited the ability to draw definitive conclusions about the most effective aromatherapy interventions.

Future research should address these limitations by conducting larger, well-designed, randomized controlled trials with standardized intervention protocols and outcome measures. Investigating the optimal dosage regimens and long-term effects of aromatherapy for PD would provide more robust evidence for its clinical application. Comparative effectiveness studies comparing aromatherapy with conventional treatments, such as NSAIDs, could also help determine its relative benefits and potential role in comprehensive pain management strategies (51). Additionally, research exploring the mechanisms of action of different essential oils could contribute to understanding their therapeutic effects and enhance their targeted use in clinical practice. Furthermore, school health nurse-based trials should be conducted to provide evidence for the use of aromatherapy in school settings for girls with PD, thereby offering a practical and accessible nurse-led non-pharmacological intervention. Other outcomes, such as QoL, stress, and hormone levels, must also be considered (50). Notably, none of the randomized controlled trials have specifically targeted adolescent populations, highlighting the need for robust studies in this age group to better understand the efficacy and safety of aromatherapy for PD among adolescents (49).

Besides, policymakers and healthcare organizations should consider integrating aromatherapy into menstrual pain management strategies for adolescent girls and young women. Aromatherapy has demonstrated efficacy in reducing menstrual pain and improving well-being. Yet, gaps include the lack of standardized protocols or guidelines for its safe and effective use, particularly concerning monitoring and managing adverse effects. Standardized protocols outlining dosage, application methods, and treatment duration should be developed, accompanied by training programs for healthcare providers, including school health nurses (59). Research initiatives should focus on long-term effects, optimal dosages, and comparative effectiveness against NSAIDs, specifically conducting trials in school settings to evaluate feasibility and benefits(63). Establishing evidence-based guidelines will facilitate the integration of aromatherapy into clinical practice, offering a non-pharmacological option for menstrual pain relief (59).

Our systematic review provides compelling evidence of aromatherapy's effectiveness in alleviating primary dysmenorrhea (PD), particularly among adolescent girls. This review highlights a significant reduction in moderate to severe menstrual pain following aromatherapy interventions, supported by quasi-experimental evidence specifically in adolescents. This study addresses a crucial gap by systematically exploring aromatherapy's impact across different age groups for PD. However, limitations such as serious risk of bias in quasi-experimental studies and significant heterogeneity were identified. Future research should prioritize rigorous randomized controlled trials to establish robust estimates, optimize treatment protocols, and compare aromatherapy's effectiveness with conventional treatments. Addressing these gaps will enhance our understanding of aromatherapy's potential in PD management and inform evidence-based practices.

PD: Primary Dysmenorrhea
BMI: Body Mass Index
QoL: Quality of Life
LMICs: Low- and Middle-Income Countries
HICs: High-Income Countries
NSAIDs: Non-steroidal anti-inflammatory Drugs
SES: Socioeconomic Status
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
PROSPERO: International Prospective Register of Systematic Reviews
MeSH: Medical Subject Headings
PICO: Population, Intervention, Comparison, Outcome
VAS: Visual Analog Scale
NRS: Numerical Rating Scale
RCTs: Randomized Controlled Trials
nRCTs: Non-Randomized Controlled Trials
ROBIN-I: Risk of Bias in Non-randomized Studies of Interventions
SMD: Standardized Mean Difference
RR: Risk Ratio
CI: Confidence Interval
NA: Not Applicable
MD: Mean Difference
SEs: Standard Errors
logRRs: Logarithm of Risk Ratios
GABAergic: Gamma-Aminobutyric Acidergic

Acknowledgement

The authors would like to thank the Deanship of Scientific Research at Shaqra University for supporting this work.

Ethics approval and consent to participate:

Not applicable. This study is a systematic review and meta-analysis of previously published studies and does not involve the direct participation of human subjects.

Consent for publication

Not applicable. This study does not contain any person's data.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Competing Interest

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contribution

HNT and NR conceived the study, developed the protocol, and managed the PROSPERO registration. NR, MT, and HNT conducted the comprehensive literature search and designed the search strategies. NR, NA, MSA performed the screening and data extraction. HNT, IZ, YA performed risk of bias. HNT, NA, MT, IZ conducted the meta-analysis and MSA, NEEM performed statistical evaluations. HNT, NR and MT performed subgroup analysis. NR, IZ, YA contributed to drafting and revising the manuscript. HNT, NEEM and NA finalized the manuscript. All authors approved the final manuscript and are accountable for all aspects of the work.

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The authors declare no competing interests.

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Scenting Relief-Aromatherapy for alleviating Primary Dysmenorrhea in Adolescents and Young Women: A systematic review and meta-analysis

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