Non-pharmacological that most effective to reduce of primary dysmenorrhea intensity in women childbearing age: a literature review

Abstract

One of the most common female reproductive health problems is primary dysmenorrhea. Data on the incidence of primary dysmenorrhea complained about 50-90% of women in the world. Primary dysmenorrhea data in the US is 30-70%, in Sweden is 30%, in Mexico is 64%, in Italy is 68%, in Jordan is 55.8%, in Turkey is 84.9%, and in Malaysia is 74.5%, in Indonesia is 60-70 and 15% of its, it interferes with daily activities including work. The cause of this is hypercontractility of the myometrium due to excessive secretion of prostaglandins. This study aims to explore the most effective non-pharmacological therapies in reducing the level of primary dysmenorrhea pain in women of childbearing age. The design of this study is a literature review with the PRISMA method. Database Google, Google Scholar, Research gate, Cochran Data Base, Embase, NCBI, Sciendirect, SAGE, Elsevier, Sinta. The population of this study was all full-text international journals indexed by Scopus and national journals indexed by Sinta 1-6 published in 2011-2021 including RCT amount of 114 articles. A sample of 23 articles meets the inclusion criteria and used thematic data analysis. The results of non-pharmacological therapy that effectively overcome primary dysmenorrhea pain, namely the first group with (P=0.000). The conclusions showed that Murrotal Qur'an, yoga, acupressure, counter pressure massage, effleurage massage, consume green coconut water and avocado juice combination with massage were proven to be equally effective in overcoming complaints of primary dysmenorrhea pain quickly without being accompanied by side effects.

Introduction

One of the most common female reproductive health problems is Dismenorrhea. Dysmenorrhea is a pain that occurs in the lower abdomen area or supra pubis before menstruation and occurs during the menstrual phase (1). Primary dysmenorrhea is a type of pain that occurs during the menstrual phase in the absence of disorders of the pathology of the female reproductive organs (2). Primary dysmenorrhea is a reproductive health problem in adolescent females most commonly occurring after nutritional problems. Primary dysmenorrhea usually occurs a few hours before menstruation and continues for up to 12-72 h or during menstruation and is usually felt pain accompanied by cramps in the lower abdomen (3).

Data on the incidence of primary and frequently complained dysmenorrhea is about 50-90% of women in the world and almost occur in every country (4). Data on the incidence of primary dysmenorrhea in women of childbearing age in the United States is about 30-70%, in Sweden about 30%, in Mexico about 64%, in Italy about 68%, in Jordan about 55.8%, in Turkey about 84.9%, and in Malaysia about 74.5% (5). while in Indonesia about 60-70 and 15% of them interfere with daily activities including work (6).

The contributing factor to primary dysmenorrhea is hypercontractility of myometrium due to excessive prostaglandin secretion, causing excessive pain or cramps in the lower abdomen area (7). Age factors, psychological factors, as well as other factors are nutritional factors such as eating too much salt content, animal fats, instant food, low carbohydrates, and low fiber, psychological a person and increased concentration of prostaglandins in the uterus (8).

The impact of primary dysmenorrhea is that for women who are in school, dysmenorrhea is the cause of being absent from school due to excessive pain (9). The incidence of primary dysmenorrhea that occurs in working women causes a loss of about 600 million hours of work and a loss of productivity of about 2 billion US (10).

Primary dysmenorrhea treatment is carried out pharmacologically and non-pharmacologically. Non-pharmacological restraints are known to have relatively minor side effects and even almost no side effects. Non-pharmacological therapies include yoga, pilates, acupuncture, massage, aroma therapy, giving fruit juices such as avocado, warm compressed combination with dark chocolate, deep breathing exercises, warm compresses, hypnotherapy, genupectoral positions, murrotals of the Qur'an (4,7,11).

The difference between this study and the previous study is in the non-pharmacological therapy reviewed. In this study, researchers reviewed all non-pharmacological therapies to reduce primary dysmenorrhea pain and examined which therapies were most effective to reduce primary dysmenorrhea pain quickly. The aim is to explore non-pharmacological that most effective to reduce primary dysmenorrhea intensity in women of childbearing age: A literature review.

Materials and methods

The design used systematic review by PRISMA methods. An aqualitative study was conducted with an articles year limit for literature review is 2011-2021. The literature review was conducted as preferred reporting items for systematic review by PRISMA. The database that searching included Google, Google Scholar, Research gate, Cochran Data Base, Embase, NCBI, Sciendirect, SAGE, Elsevier, and Sinta with search keywords namely the effectiveness of non-pharmacological methods (dysmenorrhea exercise, yoga, pilates, acupuncture, acupressure, massage, aroma therapy, fruit juices such as avocado, warm compressed combination with dark chocolate, deep breathing exercises, warm compresses) to reduce primary dysmenorrhea pain and check the quality of journals. For international articles, it is checked through Scimago JR, and for a national article, it is checked through the Sinta portal and uses the PICO technique for searching eligible journals.

The populations were all reputable international and national articles indexed by Sinta 1-6 on non-pharmacological therapies to reduce primary dysmenorrhea pain amount of 114 Articles. The samples were twenty-three articles that were eligible by the inclusion criteria. Sampling was used purposive sampling. The inclusion criteria were a research article in the form of a full-text article in English related to non-pharmacological therapy in reducing primary dysmenorrhea pain and proceeding full text that has been published and at least has E-ISSN and indexing by Scopus, Wos, Thompson Reuters, Sinta 1-6. The exclusion criteria were articles that were only abstract and articles not in English, and not in reputable international journals and discontinue by Scopus and national journals accredited by Sinta 1-6.

Risk of bias in this study by checking citations and for the relevant topic and various databases to avoid research bias. The data extraction was checked by our team. The data extraction process was carried out by looking for full-text articles in English, titles, years of publication, publisher and indexing, the aim, the populations, interventions, comparisons, research methods, results, and conclusions. Then, the researcher looks at the citation and H index. In addition, journals that were elligible by the inclusion criteria were sampled in this study with consideration from other research teams (Fig. 1).

A descriptive data analysis of this study synthesis was conducted in the narrative report or thematic analysis. The results are presented based on the study of journal research conducted a meta-analysis by reading the P-value of each variable and grouping the results. The results of the first group of studies are non-pharmacological therapies which have P=0.000, and the second group of non-pharmacological therapies with 0.020≤P≤0.010 and the third group with 0.030≤P≤0.05. Furthermore, the findings were carried out as a descriptive analysis as a whole. The study was conducted for ethical clearance and approved by the Ethical Committee of STIKES Hafshawaty Pesantren Zainul Hasan under the ethical code of SK: KEPK/039/Stikes-HPZH/VII/2022.

Results

The results of this literature review show that several non-­pharmacological therapies are equally effective and fast in reducing primary dysmenorrhea pain. The first group of non-pharmacological therapy is Murrotal Qur'an therapy, yoga, acupressure, counter-pressure massage, effleurage massage, consuming green coconut water, and administration of avocado juice with P=0.000 at α 0.05. Furthermore, the second group is giving dry hot compresses using glass bottles, drinking Javanese turmeric, lemon therapy aromas, lavender therapeutic aromas, hypnotherapy, longa Curcuma drinks, giving Clupeonella grimmi fish oil supplements (anchovies), relaxation techniques by taking deep breaths with 0.020≤P≤0.010. The third group is drinking ginger, aroma therapy combined with massage, physical activity, and nutrition, mat pilates exercises, physiotherapy, acupuncture, aerobic, warm compress combination dark chocolate with a value of 0.030≤P≤0.05 (Table I).

Discussion

Primary dysmenorrhea usually occurs on average in women aged <25 years old (12). The causes of primary dysmenorrhea are a lack of energy in the uterus, a decrease in the levels of the steroid hormone progesterone in the luteal phase, a condition connected to a lower level of the enzyme lysosomal and the subsequent release of endometrial phospholipase. This event causes an increase in the levels of prostaglandins responsible for the contraction of the uterus and arteries, eventually causing uterine ischemia (13).

Therapy to reduce primary dysmenorrhea pain in this literature review is non-pharmacological therapy. It is the type of therapy in the form of relaxation, positive thinking, herbs, a diet high in fiber, acupressure, physiotherapy, acupuncture, and other types of therapy, in addition to the administration of medical drugs (4). It works as a natural analgesic, antispasmodic, and antioxidant, decreases prostaglandin production, increases beta-endorphin levels, and facilitates uterine circulation (13).

The non-pharmacological therapy research that is most effective and grouped in the first choice of therapy is the Murrotal Qur'an. The Murrotal Qur'an is one of the music that has a positive effect on its listeners. This therapy provides a calming effect when listened to, especially when experiencing primary dysmenorrhea. This is due to the appearance of 63.11% of delta waves on the right and left forebrains and is effective in reducing primary dysmenorrhea pain if listened to for at least 15 min, especially surah Ar-Rahman (6).

Slow Murrotal Qur'an chanting can activate natural endorphin hormones which are hormonal compounds that release morphine in the body that can trigger stress and pain, increase feelings of relaxation, distract from fear, anxiety, and tension, increase metabolism so that it can reduce blood pressure and slow breathing, pulse rate, and brainwave activity. The rate of breathing to be deeper or slower is very good for producing calmness, emotional control, deep thinking, and improving the metabolism of body so that the pain due to primary dysmenorrhea can be quickly reduced (6).

Figure 1.

Flowchart of the study selection process (data extraction).

The next group of non-pharmacological therapies is yoga. Yoga is a mind-body exercise, consisting of physical posture (asana), breathing exercises (pranayama), and meditation (dhyana), which integrates the balance of body and mind. Yoga Nidra is a type of yoga with powerful meditation techniques, where the mind is still conscious during the ‘unconscious’ state associated with deep sleeping. Yoga Nidra functions to regulate thyroid-stimulating hormone levels, stimulate follicle-stimulating hormone, luteinizing hormone, and prolactin and relax muscles. This yoga is done 2 times a week with the length of each session which is 30 min for 6 months after self-tapping is done for 20 min to permanently reduce primary dysmenorrhea pain (14).

The next non-pharmacological therapy is acupressure. It is similar to acupuncture, but the difference is that acupressure does not use needles. Acupressure is based on traditional Chinese medicine and shares the main principle of opening up and harmonizing the blocked meridians by stimulating the surrounding environment below the acupressure point. The onset of pain is due to the very high levels of PGE-2 and PGF-2 Alpha in the endometrium, myometrium, and menstrual blood of women who have dysmenorrhea. Prostaglandin hormones cause increased uterine activity and pain in excitatory terminal nerve fibers. Experimental studies on acupressure have shown that acupressure effectively reduces discomfort by providing sedative and analgesic effects (15,16).

The next therapy is massage counter pressure. Counter-pressure massage is a massage that is carried out by applying continuous pressure to the patient's sacrum bone with one palm. One-hand massage uses the heel of the hand to clench in the lumbar region where the uterine sensory nerves running with the sympathetic nerves of the uterus enter the spinal cord through the thoracic nerve 10-11-12 towards the Lumbar. This massage technique can increase endorphins as physiological painkillers. Endorphins can affect the process of impulse transmission which is interpreted as a neurotransmitter that can inhibit pain. How to do a counterpressure massage is done for at least 30 min during the 1-3 days of the menstrual cycle. Therefore, this massage is effective in lowering primary dysmenorrhea pain immediately (17).

After counter pressure massage is effleurage massage. Effleurage massage is a non-pharmacological method that is considered effective in reducing pain. The most common dysmenorrhea pain that adolescents experience is stiffness or spasm in the lower abdomen. This is due to an increase in prostaglandins (PG) F2-alpha, which are cyclo oxygenases (COX-2), which produce hypertonus and vasoconstriction in the myometrium resulting in ischemia and pain in the lower abdomen. This massage is performed for 3 days with a duration of 3-5 min each time massaging is performed during primary dysmenorrhea to significantly reduce the intensity of pain quickly. This therapy will affect the motor, nervous, and cardiovascular systems, triggering the rest and relaxation phases of the body as well as an effort to restore venous and lymph flow, stimulating sensory receptors in the skin and sub-skin to reduce pain (18).

Then, group one reduces primary dysmenorrhea is consuming green coconut water. A mount of 330 ml green coconut water dose is a more effective dose to decrease primary dysmenorrhea. Green coconut water has a composition of more minerals including magnesium and calcium. Widely known that magnesium has a role in decreasing pain intensity and vasoconstriction relief. Another study about magnesium and calcium showed that both were reported to have an effective effect on pain suppression including primary dysmenorrhea. Based on it, green coconut water is effective as a non-pharmacological therapy for primary dysmenorrhea relief (19). Another study about combination massage and consuming green coconut water can relieve dysmenorrhea pain more quickly. effleurage massage technique aims to improve blood circulation, put pressure, warm the abdominal muscles, and increase physical and mental relaxation. The mechanical effect of the effleurage technique is to help the vein work and cause body heat as warming up. Massage can make patients more comfortable due to muscle relaxation and comfortable feeling. A combination of it and green coconut water can increase β-endorphin levels and overcome the pelvic flush due to muscle relaxant formation of serotonin neurotransmitter that can increase appetite, feelings of happiness, and anti-depression (20).

The last of group one on non-pharmacological therapy as the result of the literature review is the administration of avocado juice. Avocado is a type of fruit that has a high content of vegetable fats compared to other fruits. Avocado is also enriched with antioxidants and nutrients, there is the highest flavonoid content compared to other tropical fruits such as guava, pineapple, mango, papaya fruit, orange, and tamarind. The flavonoid content in avocados is used as an antioxidant due to its ability to reduce the formation of free radicals. The calcium content in avocados can relieve pain. This therapy is administered at a dose of at least 100 mg each time you drink avocado juice during the menstrual cycle (21).

Table I.

Literature review of non-pharmacological therapy in women with primary dysmenorrhea.

Author	The title research	The aim	The population/sample	Methods	Finding	Conclution	(Refs.)
Septianingrum	The effect of	To know the effect	32 students then divided	Pre post test design	The listening of Murrotal	The provision of	(6)
et al 2019	Murrotal Qur'an on	of Murottal Qur'an	into two groups, 16 into		Qur'an therapy showed	Murrotal Qur'an of
	Menstrual Pain in	on menstrual pain	intervention group;		that effective in reducing	Surah Ar-Rahman in
	Nursing Student of	in nursing students	16 into control group		primary dysmenorrhea	15 min on students
	Universitas Nahdlatul				pain (P=0.000)	can decrease primary
	Ulama Surabaya					dismenorhea.
Ulaa et al 2017	Application of Mind	To know	88 people and divided	Quasy experiment	Yoga can effectively	Yoga interventions	(22)
	Body Practice:	effectiveness of	into 47 intervention	with nonequivalent	reduce long pain in	effective to reduce
	Yoga for reducing	yoga towards long	gorup; 41 into control	pretest-posttest	primary dysmenorrhea	long pain in primary
	long pain primary	pain of primary	group	control group	(P=0.000)	dysmen orrhea.
	dismenorrhea	dysmenorrhea		design			Mirbagher-
	The effects of	To evaluate the	Student divided into	An RCT with	Scores of dysmenorrhea	Acupressure on the	(15)
Ajorpaz et al	acupressure on	effect of	15 intervention gorup;	pre and post-test	between the two groups	SP6 meridian can
2011	primary	acupressure on	15 into control group	design	after treatment (P=0.004)	be an effective non-
	dysmenorrhea:	primary			and also 3 h after	invasive intervention
	A randomized	dysmenorrhea in			treatment (P=0.000)	to reduce primary
	controlled trial	Iranian medical				dysmenorrhea and
		sciences students				its effects last for 3 h
						post-treatment.
Santiasari &	Counterpressure	To analyze the	n=30	Quasy	There is a difference	This techniques can	(17)
Christianingsih,	for dysmenorrhea	effect of counter-		experimental	between before and	decrease dysmenor
2019	pain in teenagers	pressure massage		(one group	after the intervention,	rhea pain at students.
		on dysmenorrhea		pre-posttest	P=0.000
		pain in high school		design)
		students.
Sholihah &	The Effect of	To describe the	N=58	Quasy-	There was a significant	Efflurage massage	(18)
Azizah, 2020	effleurage massage	effect of effleurage	(29 intervention group;	experimental with	difference after being	gives the effect of
	on primary	massage on	29 control group)	pre and post-test	given an efflurage	reducing
	dysmenorrhea in	the primary		two-group design	massage between	dysmenorrhea.
	female adolescent	dysmenorrhea of			3-5 min for 3 days of
	students	teens in boarding			the menstrual cycle,
		house of Jenderal			P=0.000
		Achmad Yani
		University,
		Yogyakarta
Nugroho et al	Non-pharmacological	To obtain the opti-	N=21 young women,	Randomized	Giving 100 ml of green	Consume green	(19)
2020	Randomised control	mal dose of green	divided into 3 group,	control trial	coconut water evary	coconut routinely
	Trial: Green Coconut	coconut water	each group with n=7		4 h at least 330 ml	every menstruation
	(Cocos nucifera L.)	as a magnesium	young women		during menstrual cycle	cycle showed it can
	Water to Reduce	source for reducing			(P=0.000)	relieve of primary
	Dysmenorrhea Pain	dysmenorrhea pain.				dysmenorrhea.
Tompunuh et al	Effect of Avocado	To know about	N=98 women student	Pre experimental	Giving 100 ml of	The administration	(21)
2021	Juice administration	the effect of	and n=30 women	design one group	avocado juice every	of avocado juice
	on Dismenhorrhea	avocado juice	student	pretest postest	time you drink and	has been shown to
	Reduction in Young	administration on			during the menstrual	reduce the scale of
	Women in Junior	the reduction of			cycle can reduce	dismenorhea pain.
	High School 1 Bone	dysmenorrhea pain			dysmenorrhea pain
	Bolango.	in adolescents in			(P=0.000)
		Junior High School
		1 Bone Bolango.
Thabet et al	Effects of two	To assess the	N=90 women student,	Quasy-	There is a high signifi-	Dry hot compress	(23)
2020	Non-pharmacological	effect of two non-	divided into 3 group	experimental	cation of the difference	more effective than
	Pain Relief	pharmacological	(30 dry hot compress	research design.	between before and after	genupectoral
	Interventions on	pain relief	group, 30 genupectoral		the intervention during	position.
	the Severity of Pain	interventions on	position group,		the menstrual cycle and
	among Adolescent	the severity of pain	30 control group)		the second menstrual
	Girls Complaining	among adolescent			cycle, P=<0.001 in a dry
	from Primary	girls complaining			hot compress using a
	Dysmenorrhea	of primary			glass bottle and
		dysmenorrhea			genupectoral position
Ria et al 2021	The Difference of	To analyze	Female students	Quasy-	Gingger warm compress	Consuming turmeric	(5)
	Effectiveness of	differences of	experiencing primary	experimental type	for 20 min	tamarind regularly
	Ginger Warm	effectiveness of	dysmenorrhea;	two group pre post	(P=0.004), while	can be used in
	Compress and	ginger warm	30 in gingger	test design	consumption of acidic	primary
	Consumption of	compresses and	compress group; 30 in		turmeric for 2 days	dysmenorrhea pain
	Acidic Turmeric	consumption	consumtion of acidic		menstrual cycle	therapy as a non
	on Decreasing	turmeric tamarind	turmeric		(P=<0.001)	pharmacological
	Primary Menstrual	in reducing primary				therapy.
	Pain Scale	menstrual pain
		scale
Widarti et al	Effectiveness of	To find out the	37 young women	Pre-Experiment	Young women who	Warm water	(24)
2021	warm water compress	effectiveness of		with One Group	are given warm water	compress and lemon
	with lemon aroma-	warm water com-		Pre-Post-test	compresses, lemon and	aromatherapy with
	therapy and lavender	presses and lemon		design	lavender aroma therapy	warm water
	aromatherapy	aromatherapy			can reduce	compress and
	against primary	with lavender			dysmenorrhea pain,	lavender
	dysmenorrhea pain	aromatherapy			P=0.001	aromatherapy are
	levels	against the level				effective against
		of primary				decreased
		dysmenorrhea pain				dysmenorrhea pain
		in young women				in young women.
Laili et al 2021	The Effect of	To determine	N=117, n=20 female	Pre-experimental	Hypnotherapy provides	Hypnotherapy can be	(25)
	hypnotherapy	the effect of	student with primary	with one group	a permanent effect	non pharmacological
	to reduce	hypnotherapy on	dysmenorrhea	pre-test post-test.	in lowering primary	therapy to reduce
	dysmenorrhea pain	dysmenorrhoea			dysmenorrhea pain	primary
		in high school			(P=0,001)	dysmenorrhea.
		students
Moghadamnia	Effect of	To investigate-	N=female student	Randomized	There was a significant	It proved significant	(26)
et al 2011	Clupeonella grimmi	therole of dietary	amount of 1200. n=38	control trial	difference after 3 months	in reducing ibu
	(anchovy/kilka)	supplementation	(18-22 y.o) in Babol		of supplementation with	profen when using
	fish oil on	with C. grimmi oil	University of Medical		fish oil (visual analog	fish oil as a primary
	dysmenorrhoea	on symptoms of	Sciences.		scale score of 20.9	dysmenorrhea
		dysmenorrhoea in			compared to 61.8 for	therapy.
		young girls.			placebo (P=0.001)
Hidayatunnafiah	The Effect of	To analyze effect	Teenager (11-24 years	A literature review	Deep breathing	Relaxation by deep	(11)
et al 2022	relaxation	of deep respiratory	old), the publication		relaxation can help	breathing can be used
	techniques	relaxation	period of the journal in		reduce dysmenorrhea in	to reduce primary
	in reducing	techniques on	2010-2020 was 5 full		adolescents, P=0.001	dysmenorrhea pain.
	dysmenorrhea in	the reduction of	text articles.			Changes can be seen
	adolescents	dysmenorrhea in				when this technique
		teens				is put into practice
						for 5-30 min.
Utami et al	The Effectiveness	The use of	Female with 15-18 y.o	Experiments	Curcuma Longa	Curcuma longa can	(27)
2020	of curcuma longa	Curcuma longa	amount of 32 and	with pre-test and	drink can reduce	be used as a non-
	drink in decreasing	drinks to reduce	stay in Dormitory	post-test research	dysmenorrhea pain	pharmacological
	the intensity of	the pain of	Pontianak, divided into	designs	in teenager, P≤0.001	therapy to reduce
	dysmenorrhea	dysmenorrhea by	the Curcuma longa			primary
		comparing the	home industry drink			dysmenorrhea pain
		home industry and	group and the Curcuma			both home industry
		researched	longa drink group by			and concoctions.
		concoctions	researchers
Daily et al 2015	Efficacy of Ginger	This systematic	N=29 articles from	Systematic review	This data meta-analysis	Collectively	(10)
	for Alleviating the	review is to	12 electronic data base	evaluates	shows significant effect	these RCTs
	symptoms of primary	review evidence			of ginger in reducing	provide evidence
	Dysmenorrhea: A	of ginger's			PVAS in subjects having	that drinking
	Systematic Review	effectiveness in			primary dysmenorrhea,	750-2,000 mg ginger
	and Meta-analysis of	treating primary			P=0.0003	powder for the first
	Randomized Clinical	dysmenorrhea pain				3-4 days of the
	Trials					menstrual cycle
						may lower primary
						dysmenorrhea pain.
Marzouk et al	The Effect of	To investigate	Group 1 (n=48)	A randomized	Aroma therapy	Aroma therapy	(28)
2013	Aromatherapy	the effects of	receive Aromatherapy	blind clinical trial	abdominal massage can	(cinnamon, clove,
	Abdominal Massage	aromatherapy	Abdominal Massage	of crossover design	lower the level and	rose, and lavender) is
	on Alleviating	massage in a	once daily for seven		duration of menstrual	effective in relieves
	Menstrual Pain in	group of nursing	days prior to		pain as well as the	menstrual pain,
	Nursing Students:	students suffering	menstruation using		amount of bleeding,	its duration and
	A Prospective	from primary	the essential oils		P=0.007	excessive menstrual
	Randomized	dysmenorrhea	(cinnamon, clove, rose,			bleeding.
	Cross-Over Study		and lavender); group 2
			(n=47), receive placebo
			(almond oil) Kelompok
			1 (n=48)
Abadi Bavil	A comparison of	To investigate	N=250 students with	Comparative	Average score nutrition	Healthier nutritional	(8)
et al 2018	physical activity and	the relationship	and without primary	descriptive study	was 57.91 in the group	patterns and regular
	nutrition in young	between physical	dysmenorrhea		with dysmenorrhea	physical exertion can
	women with and	activity and nutri			and 61.68 in the group	reduce the severity
	without primary	tion with primary			without dysmenorrhea,	of dysmenorrhea in
	dysmenorrhea	dysmenorrhea			while the average	teens. However, the
		in students at			intensity of physical	nutritional patterns is
		Mazandaran			activity was 5,518.75	more effective than
		University of			metrics in groups with	physical activity.
		Medical Sciences			dysmenorrhea and
					4,666.42 metrics in
					groups without
					dysmenorrhea.
					Physical activity is
					calculated on a MET
					scale (minutes/week).
					P nutrition=0.008;
					P physical activity=0.011
Nikjou et al	The Effect of	Investigating the	n=200 female student	Triple-blind	There was a significant	Lavender	(29)
2016	Lavender aroma-	effects of lavender	in Ardabil University of	randomized	difference in the average	aromatherapy uses
	therapy on the pain	aromatherapy on	Medical Sciences, Iran	clinical trial	pain severity between	for 2 months proved
	severity of primary	the severity of			the intervention and	effective in reducing
	dysmenorrhea:	pain in primary			control groups and less	the severity of
	A Triple-blind	dysmenorrhea			pain felt after the	primary
	randomized clinical				intervention for 2 months	dysmenorrhea
	trial				(P<0.01)	pain.
Cahyanto et al	The effect of exercise	To strengthen the	n=52, divide into two	Eksperimental	There was a difference	Pilates can be	(30)
2021	mat pilates on pain	theory of the	group; group 1=got	pre tets post test	in the pain and anxiety	an alternative to
	scale, anxiety, heart	relationship	pilates exercise	control group	scale scores with a	complementary care
	rate frequency in	between pilates	treatment 2x a week for	design	mean of 4.15 and 27.7,	in young women
	adolescent principle	exercise and	4 weeks; group 2=only		P=0.010	who experience
	with primary	dysmenorrhea	got informational			menstrual anxiety
	dysmenorrhea in	symptoms	support only.			and pain.
	Surakarta
Kannan &	Some physiotherapy	Effects of	The search yielded	Sistematic review	Acupuncture (weighted	Physiotherapists	(7)
Claydon, 2014	treatments may	physiotherapy	222 citations. Of	of randomised	mean difference 2.3,	could consider using
	relieve menstrual	interventions	these, 11 were eligible	trials with	95% CI 1.6 to 2.9) and	heat, transcutaneous
	pain in women	compared to	randomised trials and	meta-analysis	acupressure (weighted	electrical nerve
	with primary	controls (either	were included in the		mean difference 1.4,	stimulation, and yoga
	dysmenorrhe: a	no treatment or	review		95% CI 0.8 to 1.9), when	in the management
	systematic review	placebo) on pain			compared to a control	of primary
		and quality of life			group receiving no	dysmenorrhea.
		of women with			treatment. However,
		primary			these are likely to be
		dysmenorrhea pain			placebo effects because
					when the control groups
					in acupuncture/
					acupressure trials
					received a sham instead
					of no treatment, pain
					severity did not
					significantly differ
					between the groups.
					Significant reductions in
					pain intensity on a 0-10
					scale were noted in
					individual trials of heat
					(by 1.8, 95% CI 0.9 to
					2.7), transcutaneous
					electrical nerve
					stimulation (2.3, 95% CI
					0.03 to 4.2), and yoga
					(3.2, 95% CI 2.2 to 4.2).
Smith et al 2011	Acupuncture to	To check the	Female 14-25 y.o	A randomized	Follow-up at 6 months	Although	(31)
	treat primary	effectiveness of	with primary	controlled trial	found a significant	acupuncture
	dysmenorrhea	acupuncture to	dismenorhea=92		reduction in the	improved menstrual
	in Women: A	reduce the severity	divided into acupunture		duration of menstrual	mood symptoms in
	randomized	and intensity of	group=46, control		pain in the acupuncture	women with primary
	controlled trial	primary	group=46.		group compared with	dysmenorrhea
		dysmenorrhea			the control group, mean	during the treatment
					difference-9.6,	phase, the trend in
					95% CI-18.9 to -0.3,	the improvement of
					P=0.040	symptoms during
						the active phase of
						treatment, and at
						6 and 12 months was
						non-significant,
						indicating that a
						small treatment
						effect from
						acupuncture on
						dysmenorrhea may
						exist.
Dehnavi et al	The Effect of aerobic	To determine the	N=70 female	A randomized	The intervention group	Doing aerobic	(32)
2018	exercise on primary	effect of 8 weeks	student with primary	clinical trial	showed significant	exercise can lower
	dysmenorrhe: A	of aerobic exercise	dismenorhea		changes compared to	primary
	clinical trial study	on the severity of			control group after	dysmenorrhea pain.
		primary			8 weeks of aerobic
		dysmenorrhea			exercise (P=0.041)
Satriawati et al	The Influence of	To find out the	N=54, divided into	Quasy	There is an effect of	The combination	(33)
2020	Combination of	effect of the	two group (group 1=27,	Eksperimental	combination of warm	of warm
	Warm Compression	combination of	group 2=27)	with control time	compression and	compression and
	and Chocolate	warm compresses		series design	chocolate to reduction	chocolate has been
	Against Menstrual	and chocolate on			of menstrual pain	shown to be effective
	Pain Reduction	the reduction of			(P-value 0.050).	to reduction pain of
	(Dysmenorrhea) in	mestruating pain			In addition, there are	primery dismenorhea
	Teens Junior High	(dysmenorrhea) in			other factors that affect	although there is
	School 1st Bangkalan	teenager in Junior			the decrease in menstrual	another factor that
		High School 1st			pain, namely BMI	affects it which is
		Bangkalan			(P-value 0.032)	BMI.

Limitation

The weakness of this study does not consider the results of research that uses other languages and other data base search besides Google, Google scholar, Research gate, Cochran Data Base, Embase, NCBI, Sciendirect, SAGE, Elsevier, Sinta so that it has the potential to cause bias.

Conclusions

In the literature review research of all scientific journals containing the most important determinants in non-pharmacological therapies. The results of the literature review of non-pharmacological therapies that are most effective in reducing the intensity of primary dysmenorrhea pain in women of childbearing age are non-pharmacological therapies that are classified as in the first group. It is murrotal therapy of Qur'an, yoga, acupressure, counter pressure massage, effleurage massage, consuming green coconut water and consume of avocado juice have been proven to be equally the most effective to treat complaints of dysmenorrhea pain quickly.

Funding Statement

Funding: ITSK RS Dr. Soepraoen Kesdam V/Brawijaya funded this research.