The effect of acupressure on pain, menstrual symptoms, and comfort in adolescents with primary dysmenorrhea: a single-blind randomized controlled trial

Abstract

Background

Integrative therapies, such as acupressure, may be employed for the management of primary dysmenorrhea (PD), which is a prevalent condition with a particularly high prevalence among adolescents.

Aim

This study was conducted as a single-blind randomized controlled trial to determine the effect of acupressure on pain, menstrual symptoms, and comfort in adolescents with PD.

Design

A two-arm randomized controlled trial.

Methods

A total of 56 female adolescent students were randomly assigned to either the acupressure group (n = 28) or the sham group (n = 28) using block randomization. The acupressure group applied self-acupressure to the LI4, ST36, and SP6 points, while the sham group applied self-sham acupressure to points 1.5 cm around the same points for a period of three menstrual cycles (12 weeks) for an average of 15 min, immediately after waking up and just before going to bed on the first three days of menstruation. The primary outcome was Visual Analog Scale (VAS), and the secondary outcome were Menstruation Symptom Questionnaire (MSQ) and the General Comfort Questionnaire (GCQ).

Results

A comparison of the acupressure group with the sham group revealed a statistically significant decline in VAS and MSQ scores, while GCQ scores demonstrated a notable increase at the end of the 12-week study period (p < 0.05). An intragroup comparison revealed a statistically significant decrease in the VAS scores of the acupressure group over time (p < 0.001). For both groups, there was a decrease in the MSQ scores and an increase in the scores obtained from the socio-cultural domain subscale of the GCQ over time (p < 0.05).

Conclusion

The results demonstrated that acupressure is an efficacious approach for alleviating pain and menstrual symptoms, as well as enhancing comfort. Consequently, regular acupressure may be a viable option for the management of PD in young women.

Trial registration

This randomized controlled trial was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines and registered with ClinicalTrials.gov (NCT05408611) on dated 01.06.2022.

Introduction

Primary dysmenorrhea (PD) is defined as pain caused by pathological uterine contraction that is not palpable on clinical examination. The pain is typically described as cramping and may radiate to the thighs or lower back [1]. PD affects approximately three-quarters of all women during the reproductive age, with a particularly high prevalence among young women and in early adult life [2]. Previous studies have reported a prevalence of PD ranging between 20 and 90% [3, 4]. Lower abdominal pain may be the only complaint in PD, or it can be often accompanied by additional symptoms such as nausea and vomiting, headache, diarrhea, fatigue, dizziness, and breast tenderness [1, 5]. Although the severity of pain varies individually, it often reaches a level that can significantly affect women’s daily lives and overall comfort [6, 7].

Comfort is a multidimensional and dynamic concept encompassing physical, psycho-spiritual, environmental and socio-cultural domains, and therefore goes beyond the absence of pain [8]. Kolcaba defined the concept of comfort as “the state of being strengthened through having needs for relief, ease, and transcendence met in four contexts of experience: physical, psychospiritual, environmental, and sociocultural”. She developed this concept into a nursing theory to guide holistic and patient-centred care [9, 10]. However, certain conditions such as PD can negatively affect adolescents’ comfort. PD often leads to a significant decrease in adolescents’ quality of life and reduces their daily performance. It may also impair daily academic activities such as academic achievement, productivity, concentration in class and be a reason for school absenteeism [1, 6, 7]. Furthermore, PD can be associated with increased levels of anxiety and depression, as well as interpersonal and familial conflicts [11]. A study conducted in China revealed that the majority of girls with PD altered their lifestyles to avoid triggering or exacerbating dysmenorrhea and other associated symptoms [12]. In a study examining the dysmenorrhea experiences of young girls through the lens of the comfort theory, it was found that adolescent girls with PD experienced dizziness, sleep disturbance, headache, back pain, mobility problems, absenteeism from school and classes, social isolation, and feelings of being restricted and angry [7]. These studies highlight the need to provide adolescents with coping strategies to manage dysmenorrhea.

At present, nonsteroidal anti-inflammatory drugs and hormonal contraceptives represent the best evidence-based treatment methods for PD [13]. However, these drugs are only transiently efficacious in alleviating pain and may precipitate adverse effects, addiction, and unnecessary medical expenditures. Moreover, these pharmaceutical agents must be administered repeatedly, as their concentration in the bloodstream diminishes over time [2, 14]. Integrated therapies may be regarded as nursing interventions for the alleviation of PD or the enhancement of comfort. The non-pharmacological utilization of alternative methods for the reduction of menstrual effects and the promotion of comfort is more widely accepted than pharmacological methods due to the ease of accessibility and the absence of significant adverse effects. The most well-known non-pharmacological methods include exercise, yoga, massage, aromatherapy and acupressure [15, 16].

Acupressure is defined as a form of needle-free acupuncture. The primary objective of acupressure is to stimulate the energy channels, known as meridians, and the regions associated with specific organs through the application of pressure [17]. This technique, which involves applying pressure, has been demonstrated to reduce muscle tension and promote relaxation in various bodily regions. Additionally, it has been demonstrated that acupressure stimulates the secretion of endorphins, which are neurochemicals that relieve pain, and enhances blood circulation and oxygen supply, thereby facilitating relaxation [18, 19].

The extant literature on the effects of acupressure on PD indicates that it relieves pain through sedative and analgesic effects [20–22]. The majority of these studies focus on the effects of acupressure on pain, with no attention given to its impact on comfort. However, previous studies conducted with different sample groups have shown that acupressure improves comfort by reducing postoperative pain, reducing morphine consumption, improving gastrointestinal motility, relieving nausea and vomiting, and reducing postpartum pain [23–25]. Considering that dysmenorrhea, as noted in Kolcaba’s theory, is an issue that affects the four levels of comfort needs - physical, psychospiritual, sociocultural, and environmental - it was thought that acupressure could improve comfort. Indeed, the extant literature reports that increased comfort following therapeutic interventions can facilitate recovery and rehabilitation [26, 27]. Consequently, this study sought to ascertain the impact of self-acupressure on pain level, menstruation symptoms, and general comfort level in adolescents with PD. For this purpose, the following hypotheses were developed:

H1a: There is a statistically significant difference between the pain scores of the acupressure and sham groups after the application of acupressure.

H1b: There is a statistically significant difference between the menstrual symptoms scores of the acupressure and sham groups after the application of acupressure.

H1c: There is a statistically significant difference between the comfort scores of the acupressure and sham groups after the application of acupressure.

Methods

Aim and design

The study was designed as a prospective, two-arm, single-blind randomized controlled trial to ascertain the impact of self-acupressure on pain level, menstrual symptoms, and general comfort level in adolescents with PD. This randomized controlled trial was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) guidelines and registered with ClinicalTrials.gov (NCT05408611) on dated 01.06.2022.

Participants

The study population comprised 589 female adolescent high school students in Mersin province in Turkey between April and August 2023. Sample size was calculated using G*Power version 3.1.9.2. In order to calculate the sample size, the study conducted by Wong et al. (2010) was taken as a reference [28]. A minimum of 44 patients, 22 in each group, was calculated to be required for 80% power and a maximum pairwise error of 0.05 (type 1). However, in consideration of the potential for a 25% sample loss, the sample size was set at 56. A post hoc power analysis conducted at the conclusion of the study yielded a power value of 95.3% for a total of 56 students, with a type 1 error of 0.05 and an effect size of 1.014.

The study included voluntary adolescents between the ages of 14 and 16 years, who had regular menstrual periods between 21 and 35 days, reported menstrual pain intensity of at least 40 on the Visual Analogue Scale (VAS). The study excluded adolescents use hormonal contraception, have any chronic disease and gynecological disorder, undergo any gynecological surgery and use analgesics for a minimum of six hours prior to the acupressure. The criteria for removal from the study were as follows: failure to undergo regular acupressure sessions and failure to complete the data collection forms. However, no adolescents were removed from the study.

Randomization and blinding

A list of all public high schools situated within the city center was compiled in order to identify the institution where the study would be conducted. A single high school was selected through the application of a simple random sampling method. The number of female students attending the high school was determined by the stratified sampling method, with the sample drawn according to grade.

All possible combinations were generated to ensure that each block consisted of four individuals, with two assigned to the acupressure group and two to the control group. The sample number was divided by the number of letters forming a block. The blocks were obtained by assigning random numbers from 1 to 6 in accordance with the number obtained in the division process at https://www.randomizer.org/. Given that the total number of students was 56, this process was repeated three times, with the blocks subsequently sorted in accordance with the randomly assigned number order. Subsequently, the designation of the acupressure group as “A” and the sham group as “B” was determined through the drawing of lots. An individual not involved in the study wrote the numbers from 1 to 56 on the envelope, with each number corresponding to the number of students. The group information of the adolescents was recorded inside the envelopes in accordance with the numbers, which were subsequently provided to the researchers in a sealed state. All of this was done by an independent researcher. The 56 students who were to be included in the study were assigned to the acupressure and sham groups by matching the numbers on the envelopes to their school numbers. The final sample consisted of 56 students (28 in the acupressure group and 28 in the sham group) who were evaluated over a period of three menstrual cycles, or 12 weeks.

Only the students were blinded because they were unaware of whether the points to be applied in the study were acupressure or sham points. Consequently, the study was conducted as a single-blind randomized controlled trial. The data for the acupressure and sham groups (coded as A or B) were transferred to the computer by an independent researcher and analyzed by a statistician. Figure 1 depicts the CONSORT flow diagram.

Fig. 1.

The CONSORT flow diagram

Outcome measures

The primary outcome of the study is the effect of acupressure on the pain intensity and menstruation-related symptoms experienced by adolescents. The secondary outcome is the effect of acupressure on general comfort. Data were collected using the descriptive information form, Visual Analog Scale (VAS), the Menstruation Symptom Questionnaire (MSQ), and the General Comfort Questionary (GCQ).

Descriptive information form

The form was developed by the researchers in accordance with existing literature and comprises questions pertaining to the sociodemographic and menstrual characteristics of women [21, 22, 28].

Measurement of menstrual pain intensity

The intensity of pain was quantified using the VAS. The VAS is a self-report instrument developed by Price et al. (1983) as a simple method for measuring the severity of pain [29]. Aydın et al. (2011) adapted the VAS and Affect Grid into Turkish and proposed that the VAS may be employed to assess other subjective experiences, such as anxiety and satisfaction [30]. The adolescents were requested to quantify the intensity of the pain on a 100 mm vertical or horizontal scale. The obtained values were evaluated on a scale from 0 to 100.

Measurement of the severity of menstrual symptoms

The Menstrual Symptom Questionnaire was initially developed by Chesney and Tasto (1975) for the assessment of menstrual pain and associated symptoms [31]. The questionnaire was modified by Negriff (2009) and subsequently adapted into Turkish by Güvenç et al. (2014) [32, 33]. The MSQ is composed of 22 items in three subscales. The MSQ is composed of 22 items distributed across three subscales. Each item is scored on a Likert scale from 1 (never) to 5 (always), with higher composite scores indicating an increase in the severity of menstrual symptoms. The Cronbach’s alpha value of the MSQ was calculated as 0.92, while in our study, the Cronbach’s alpha value of the MSQ was 0.88.

Measurement of the general comfort

The General Comfort Questionnaire was initially developed by Kolcaba (2003) and subsequently adapted into Turkish by Kuğuoğlu and Karabacak (2018) [34, 35]. The scale comprises 48 items, which are scored on a four-point Likert scale. The 48 items belonging to the four contexts considered by Kolcaba (physical, psycho-spiritual, socio-cultural, and environmental) are grouped into three factors: relief, ease, and transcendence. Total scores range from 48 to 192. The mean score is calculated by dividing the total score by the number of items, with a result varying from 1 to 4. Lower scores indicate poor comfort levels. The Cronbach’s alpha of value of the GCQ was calculated as 0.88, while in our study, the Cronbach’s alpha value of the MSQ was 0.74.

Data collection procedures

The adolescents who met the inclusion criteria were informed about the study during a designated lunch period in the conference hall of the school. The researchers utilized a form, prepared by themselves, to ascertain whether the adolescents met the inclusion criteria. The researchers obtained informed consent forms from both the adolescents who met the inclusion criteria and their legal guardians. The students received instruction in acupressure application in an empty classroom at the high school. Subsequently, the adolescents were instructed to perform three cycles of acupressure at home independently. This was due to the fact that the optimal time for the students to practice was immediately following waking and prior to sleep. The initial and second (4 weeks later) measurements were conducted by the researchers during face-to-face interviews on weekdays, when the students were not engaged in academic pursuits. The third (8 weeks later) and fourth (12 weeks later) measurements were conducted online, as the students were on summer vacation. Both groups completed the VAS, MSQ and the GCQ before their first session of acupressure and at the end of the first, second and third menstrual cycles.

Interventions

The students in both groups received training in acupressure from two researchers who held internationally recognized certificates. In accordance with the recommendations of an existing study, the adolescents were instructed to perform self-acupressure for an average of 15 min immediately following waking and just before bedtime on the first three days of their menstrual cycle for three cycles (12 weeks) [28].

Acupressure group procedures

The acupoints Hegu (LI4), Zusanli (ST36), and Sanyinjiao (SP6) were selected for the application of acupressure. Acupressure was applied to the aforementioned points in a specific order, in accordance with the direction of the meridian. The participating students were instructed to assume either a semi-seated or supine position, as appropriate, in order to ensure their comfort and to facilitate the researchers’ access to the acupressure points. The adolescents were instructed to assume a 45-degree flexion of the knees while applying pressure to the ST36 and SP6 points. Each step was explained in detail, with particular attention paid to the appropriate intensity and duration of pressure. Given the inherent variability in individual responses, the level of pressure was adjusted on a case-by-case basis to account for the sensitivity of the individual. The pressure was applied manually by the researchers, who informed the students that each successive pressure should last two minutes (ten seconds of pressure, two seconds of rest-10 times) and that a total of 12 min would be required for three points bilaterally (approximately 15 min with preparation). Moreover, the researchers emphasized that the successive pressures should be applied at a frequency that does not disturb the individual, does not cause pain, and has a calming effect. The students were then instructed to perform self-acupressure in a step-by-step manner to evaluate their ability to perform acupressure independently. In the event that an incorrect application was identified, the student was instructed to repeat it until it was performed correctly.

Sham group procedures

Sham acupressure was applied to three points situated at a distance of approximately 1.5 cm from the Hegu (LI4), Zusanli (ST36), and Sanyinjiao (SP6) points. To prepare the points for acupressure, the tissue sensitivity was reduced by rubbing the points for approximately 20 s without applying direct pressure. Subsequently, acupressure was applied to the aforementioned points with the thumb for a period of two minutes, though with less pressure than that which would be required. Similar to the acupressure group, the preparation and application of acupressure for each patient took approximately 15 min in total. The students were instructed to perform sham acupressure in a step-by-step manner, thereby ensuring the accuracy and consistency of the technique. In the event of an incorrect application, the procedure was repeated until the student demonstrated proficiency.

In the present study, a checklist was utilized to ensure the consistent implementation of the acupressure intervention by both groups, with a duration of 15 min. Adolescents were requested to complete this form for three cycles, documenting the day and time of the acupressure or sham acupressure sessions, in addition to the duration and technique of the application. Furthermore, the researchers made contact with the adolescents to provide reminders regarding the correct timing and implementation of the intervention, as well as to emphasize the utilization of the prescribed technique. This approach was adopted to ensure the consistency and standardization of the intervention to the greatest extent possible. However, due to the self-administered nature of the intervention in the home setting, it was not possible to ascertain with absolute certainty that the intervention was always performed in strict accordance with the recommended protocol.

Figures 2 and 3 illustrate the locations of the acupressure and sham acupressure points, respectively.

Fig. 2.

Acupressure group application points

Fig. 3.

Sham group application points

Statistical analysis

All data were evaluated using the SPSS (Statistical Package for Social Science) version 25.0 software (IBM, Armonk, NY, USA). Normality checking of the continuous measurements in the research was performed with the Shapiro Wilk test. Per-protocol analysis was used to evaluate the data. Student t test is only used to determine the age difference between groups. Mann Whitney U test was used test the difference between the groups for scale scores; Friedman test was used for differences between repeated measurements. For differences between categoric variables, Likelihood Ratio Chi-square, Yates’ Test (continuity corrected chi-square test) and Fisher’s Exact Chi-square Test were used. Data were presented with percentages, mean, standard deviation, median, and interquartil range. Statistical significance was taken as p < 0.05. In addition to, it was calculated the Cohen’s d for each primary and secondary outcome in the 4th measurements.

Ethics approval and consent to participate

Ethical approval

was obtained from the Clinical Research Ethics Committee of Mersin University (No. 645; dated 28.09.2022) and institutional permission was obtained from Mersin Provincial Directorate of National Education (No. 73752739; dated 04.04.2023). An informed consent forms were obtained from all adolescents and their legal guardians. The study was conducted in accordance with the ethical standards set forth in the Declaration of Helsinki. In this context, adolescents were informed that if they did not respond to the treatments they had previously used or to the acupressure applied in our study, their parents would be notified and advised to consult a specialist to manage dysmenorrhea. This approach was considered important both from an ethical perspective and in terms of ensuring adolescents’ comfort.

Results

Participants’ sociodemographic characteristics

The mean age of the acupressure group and sham group was 15.04 ± 0.84 and 15.04 ± 0.74, respectively, and there was no significant difference (t = 0.000; p = 1.000). In addition there was no significant difference between the two groups in terms of class (X² = 0.417; p = 0.812) and income status (X² = 0.146; 0.705).

Participants’ menstrual characteristics and body mass index (BMI)

Comparison of students menstrual characteristics and BMI were presented in Table 1. Accordingly, there was no statistically significant difference between the acupressure and sham groups in term of menstrual characteristics and BMI.

Table 1.

Comparison of students’ menstrual characteristics and BMI according to groups (n = 56)

		Acupressure (n = 28)		Sham (n = 28)		Test valuea (p)
		±SS	Median [IQR]	±SS	Median [IQR]
Age at onset of menstruation (years)		12.60 ± 0.83	12.50 [1.00]	12.61 ± 0.92	13.00 [1.00]	0.000 (1.000)
Menstrual cycle length (days)		28.99 ± 2.33	29.00 [2.88]	29.48 ± 1.12	29.50 [1.00]	-0.277 (0.782)
Menstrual cycle duration (days)		7.54 ± 1.55	7.00 [2.75]	7.32 ± 1.12	7.00 [1.00]	-0.385 (0.700)
Time of onset of first dysmenorrhea following menarche (months)		8.91 ± 9.76	5.50 [8.00]	9.98 ± 9.85	6.00 [7.75]	-0.605 (0.545)
Duration of dysmenorrhea (days)		2.68 ± 0.72	3.00 [1.00]	2.71 ± 0.76	3.00 [1.00]	-0.137 (0.891)
BMI		19.86 ± 2.66	19.32 [4.14]	19.75 ± 2.63	19.16 [3.62]	-0.386 (0.700)
		n	%	n	%	Test value b (p)
Experiencing bowel changes during menstruation	Evet	13	46.4	13	46.4	0.000
	Hayır	15	53.4	15	53.4	(1.000)
Absence from school due to dysmenorrhea	Evet	19	67.9	20	71.4	0.000
	Hayır	9	32.1	8	28.6	(1.000)
Prevention of social activities due to dysmenorrhea	Evet	27	96.4	27	96.4	0.000
	Hayır	1	3.6	1	3.6	(1.000)
Avoidance of social interactions due to dysmenorrhea	Evet	17	60.7	19	67.9	0.078
	Hayır	11	39.3	9	32.1	(0.780)
Family history of dysmenorrhea	Evet	22	78.6	23	82.1	0.000
	Hayır	6	21.4	5	17.9	(1.000)

Significant at the level of p < 0.05

^a Mann Whitney U test

^b Chi square test

Menstrual pain intensity

As shown on Table 2, the VAS pain score decreased significantly in the acupressure group compared to the sham group at week 12 (p < 0.001; Cohen d: 1.014, 95% CI) (Table 2).

Table 2.

Comparison of students’ VAS scores (n = 56)

	Group	1st measurement		2nd measurement		3rd measurement		4th measurement		Test valueb (p)
		±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]
VAS	Acupressure	71.61 ± 21.69	72.50 [28.75]	62.50 ± 14.81	60.00 [15.00]	55.89 ± 13.54	55.00 [20.00]	43.04 ± 10.21	40.00 [13.75]	64.089 (< 0.001)
	Sham	72.68 ± 18.53	70.00 [32.50]	63.21 ± 22.45	60.00 [30.00]	59.14 ± 26.20	60.00 [32.50]	60.53 ± 22.13	55.00 [20.00]	4.649 (0.199)
	Test value a (p)	0.016 (0.987)		0.380 (0.704)		-1.495 (0.135)		3.806 (< 0.001)

Significant at the level of p < 0.05

^a Mann Whitney U test ^b Friedman test

Severity of menstrual symptoms

MSQ, menstrual pain symptoms and coping methods scores of the acupressure group in the 3rd and 4th measurements were lower and significantly different compared to the sham group (all p value < 0.05; Cohen d: 1.442, 1.637, 1.484 respectively, 95% CI). Negative effects/somatic complaints score of the acupressure group was lower than the sham group only in the 4th measurement (p < 0.001; Cohen d: 1.090, 95% CI) (Table 3).

Table 3.

Comparison of students’ menstrual symptom questionnaire and sub-dimension scores (n = 56)

	Group	1st measurement		2nd measurement		3rd measurement		4th measurement		Test valueb (p)
		±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]
Total score	Acupressure	3.51 ± 0.73	3.40 [0.90]	3.66 ± 1.18	3.39 [1.45]	2.68 ± 0.63	2.50 [0.80]	1.92 ± 0.62	1.95 [0.84]	66.358 (< 0.001)
	Sham	3.29 ± 0.78	3.14 [1.03]	3.33 ± 0.84	3.14 [1.13]	3.25 ± 0.73	3.23 [1.13]	3.01 ± 0.87	3.05 [1.49]	33.920 (0.005)
	Test value a (p)	-0.821 (0.412)		-0.665 (0.506)		-3.017 (0.003)		-4.576 (< 0.001)
Negative affect/somatic complaints	Acupressure	3.43 ± 0.82	3.35 [1.27]	3.73 ± 1.71	3.35 [1.60]	2.54 ± 0.45	2.54 [0.75]	2.03 ± 0.72	2.00 [0.90]	56.977 (< 0.001)
	Sham	3.12 ± 0.85	3.19 [1.25]	3.17 ± 0.87	3.12 [1.50]	3.13 ± 0.73	3.04 [1.06]	2.90 ± 0.87	2.65 [1.31]	17.828 (< 0.001)
	Test value a (p)	-1.231 (0.218)		-0.879 (0.380)		-0.879 (0.380)		-3.815 (< 0.001)
Menstrual pain	Acupressure	3.86 ± 0.76	3.83 [1.29]	3.77 ± 0.83	3.75 [1.38]	2.78 ± 0.74	2.50 [1.00]	1.89 ± 0.65	2.00 [0.62]	61.040 (< 0.001)
	Sham	3.67 ± 0.91	3.88 [1.00]	3.40 ± 0.80	3.50 [0.90]	3.44 ± 0.88	3.58 [1.13]	3.29 ± 1.02	3.42 [1.33]	20.676 (< 0.001)
	Test value a (p)	-0.569 (0.569)		-0.140 (0.888)		-2.983 (0.003)		4.881 (< 0.001)
Methods of coping with menstrual pain	Acupressure	3.14 ± 1.12	3.00 [1.83]	3.17 ± 1.28	2.67 [2.25]	2.19 ± 1.06	2.00 [1.50]	1.46 ± 0.47	1.33 [0.92]	45.155 (< 0.001)
	Sham	3.31 ± 1.23	3.33 [2.25]	3.30 ± 1.27	3.50 [2.00]	3.21 ± 1.27	3.17 [2.58]	2.96 ± 1.35	2.67 [2.50]	11.250 (0.010)
	Test value a (p)	-0.543 (0.587)		0.363 (0.717)		-3.101 (0.002)		-4.412 (< 0.001)

Significant at the level of p < 0.05

^a Mann Whitney U test ^b Friedman test

Comfort

As can be seen on Table 4, the scores of the acupressure group on the GCQ and socioculturel dimension scores increased significantly compared to the sham group in the 3rd and 4th measurements (all p value < 0.05, Cohen d: 1.123, 1.168 respectively, 95% CI). Physical dimension score of the acupressure group in the 2nd, 3rd and 4th measurements were higher and significantly different compared to the sham group (all p value < 0.05; Cohen d:1.412, 95% CI). Psychospiritual dimension score of the acupressure group in the only 4th measurements were higher and significantly different compared to the sham group (all p value < 0.05; Cohen d: 0.925, 95% CI).

Table 4.

Comparison of students’ general comfort questionnaire and sub-dimension scores (n = 56)

	Group	1st measurement		2nd measurement		3rd measurement		4th measurement		Test valueb (p)
		±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]	±SS	Median [IQR]
Total score	Acupressure	2.84 ± 0.44	2.85 [0.68]	2.90 ± 0.46	2.88 [0.83]	2.99 ± 0.48	2.98 [0.56]	3.16 ± 0.40	3.32 [0.52]	6.727 (0.081)
	Sham	2.76 ± 0.55	2.78 [0.88]	2.76 ± 0.50	2.72 [0.85]	2.74 ± 0.53	2.63 [0.82]	2.67 ± 0.47	2.60 [0.65]	4.477 (0.214)
	Test value a (p)	-0.550 (0.583)		-0.795 (0.427)		-2.124 (0.034)		-3.540 (< 0.001)
Physical	Acupressure	2.53 ± 0.42	2.58 [0.69]	2.78 ± 0.50	2.78 [0.83]	2.86 ± 0.52	3.00 [0.88]	3.26 ± 0.59	3.46 [0.79]	24.109 (< 0.001)
	Sham	2.46 ± 0.46	2.46 [0.79]	2.48 ± 0.54	2.48 [0.67]	2.49 ± 0.46	2.58 [0.77]	2.42 ± 0.60	2.38 [0.65]	16.626 (0.001)
	Test value a (p)	-0.551 (0.582)		-2.134 (0.033)		-2.756 (0.006)		4.251 (< 0.001)
Psychospiritual	Acupressure	2.99 ± 0.72	2.92 [0.69]	2.98 ± 0.57	3.12 [1.02]	3.10 ± 0.65	3.12 [0.85]	3.26 ± 0.47	3.26 [0.65]	7.524 (0.057)
	Sham	2.93 ± 0.84	2.92 [0.90]	2.88 ± 0.84	2.88 [0.85]	2.86 ± 0.80	2.81 [0.77]	2.73 ± 0.66	2.73 [0.73]	7.104 (0.069)
	Test value a (p)	-0.312 (0.755)		-0.919 (0.358)		-1.725 (0.085)		-3.142 (0.002)
Environmental	Acupressure	2.95 ± 0.83	2.88 [0.50]	2.93 ± 0.81	2.96 [0.54]	2.97 ± 0.55	3.00 [0.62]	3.03 ± 0.40	3.08 [0.44]	6.258 (0.100)
	Sham	2.86 ± 0.92	2.77 [0.96]	2.85 ± 0.58	2.85 [0.96]	2.88 ± 0.92	2.77 [0.90]	2.89 ± 0.42	2.88 [0.69]	2.927 (0.403)
	Test value a (p)	-0.436 (0.663)		-0.263 (0.793)		-1.414 (0.157)		-1.404 (0.160)
Sociocultural	Acupressure	2.61 ± 0.42	2.60 [0.60]	2.89 ± 0.45	2.90 [0.88]	3.03 ± 0.42	3.10 [0.60]	3.14 ± 0.41	3.20 [0.58]	34.043 (< 0.001)
	Sham	2.54 ± 0.50	2.60 [0.75]	2.83 ± 0.54	2.90 [0.80]	2.70 ± 0.54	2.65 [0.85]	2.58 ± 0.54	2.45 [0.80]	30.506 (< 0.001)
	Test value a (p)	-0.537 (0.591)		-0.347 (0.729)		-2.361 (0.018)		-3.774 (< 0.001)

Significant at the level of p < 0.05

^a Mann Whitney U test ^b Friedman test

Discussion

A total of 56 patients were evaluated in this research, with 28 individuals assigned to the acupressure group, and 28 to the sham group. In this study, no adverse events were reported by any adolescent. The findings were then discussed in the context of existing literature on the subject.

Following a 12-week period of self-acupressure application, the VAS scores of the acupressure group decreased significantly compared to the sham group. The therapeutic effect on pain observed in our study is comparable to the findings reported by researchers in other studies where acupressure was the predominant intervention. In a study conducted by Abd El-azeem et al. (2020) on a cohort of Egyptian women between the ages of 18 and 25, self-acupressure was observed to reduce pain, with the SP6 point demonstrating particular efficacy [23]. Atef Osman et al. (2024) found that self-acupressure applied to the SP6 point was an effective method for alleviating menstrual pain in university students with dysmenorrhea [36]. Disilva et al. (2024) reported that acupressure reduced pain in a sample of 60 adolescent girls with dysmenorrhea [37]. The meta-analysis conducted by Rahmawati et al. (2022) on nine studies indicated that acupressure had a pain-relieving effect in women with dysmenorrhea [38]. The extant evidence suggests that acupressure increases the release of endogenous opioids, such as β-endorphin and enkephalin, and neurotransmitters, including serotonin, by stimulating free nerve endings. This, in turn, provides an analgesic and sedative effect [39, 40]. However, another study revealed that acupressure had no significant impact on menstrual distress and pain, although a reduction in both parameters was observed over the three-day period [41]. As seen, there are studies that report findings contrary to ours. In order to determine the effectiveness of acupressure on pain, it is crucial to appropriately adjust the stimulus dose, including the frequency, duration, and intensity of the application.

In the present study, the severity of menstrual symptoms of the acupressure group decreased significantly in the 3rd and 4th measurements compared to the sham group. However, the severity of menstrual symptoms decreased significantly after 12 weeks of self-acupressure in both groups, but the decrease in the acupressure group was greater than in the sham group. A systematic review indicated that self-acupressure applied to women with dysmenorrhea can alleviate dysmenorrhea symptoms experienced in subsequent cycles if performed regularly [42]. Our findings corroborate those of previous studies in this regard. On the other hand, the reduction in menstrual symptom severity in the sham group can be explained not only by the placebo effect but also by the adolescents’ increased awareness of their bodies. Since adolescents in the sham group performed acupressure on themselves, it is likely that focusing on their bodies, dedicating time to themselves, and becoming more conscious of their menstrual cycles contributed to this outcome. Such attentional focus and heightened internal awareness may alter the way pain is perceived [43]. Furthermore, expectations regarding the ‘therapeutic’ effects of the intervention may have triggered a placebo effect, leading to a subjective sense of symptom improvement [44]. Therefore, the reduction observed in the sham group can be explained not only by physiological processes but also by psychological and cognitive factors. Additionally, several limitations should be considered in interpreting the findings of our study. In particular, individual differences such as physical activity level, dietary habits, and stress levels are potential confounding factors that could influence pain perception and menstrual symptoms. These variables were not directly measured or controlled in our study. Therefore, the effect of acupressure may not be fully independent of these factors.

The MSQ comprises three sub-dimensions: menstrual pain symptoms, the negative effects/somatic complaints, and coping methods. In our study, the negative effects/somatic complaints sub-dimension scores of the acupressure group were significantly lower than the sham group only in the 4th measurement. In this regard, the findings of our study indicated that the influence of acupressure on negative affect and somatic complaints became evident at a subsequent point in time. In a study conducted by Solt and Dolgun (2022), acupressure was applied to the LI4 and SP6 points for a single menstrual cycle in a sample of university students. The results of the study indicated that there was no statistically significant difference between the scores of the acupressure and control groups in the relevant sub-dimension [45]. Consequently, as in this study, our study demonstrated that acupressure applied in a single cycle was not an effective intervention for reducing somatic complaints in girls with PD.

In our study, menstrual pain symptoms and coping methods sub-dimensions scores of the acupressure group decreased significantly compared to the control group in the 3rd and 4th measurements. Regular application of self-acupressure in this study may have mitigated the pain experienced by adolescents and diminished their reliance on coping strategies. The analysis of the coping methods subscale of the scale indicates that the items are predominantly related to the utilization of analgesics. In light of these findings, it can be posited that regular self-acupressure may serve to diminish the reliance on pharmacological interventions by reducing perceived pain. A review of the literature reveals that acupressure has been demonstrated to be an efficacious intervention for the reduction of menstrual pain in women with PD [23, 46, 47]. Nevertheless, the Cochrane review highlights the need for further large-scale studies to confirm the efficacy of acupressure in the management of dysmenorrhea [48].

The concept of comfort can be defined as the ease that facilitates daily life. The level of comfort is reduced in individuals experiencing pain and stress [26]. The total score obtained by the acupressure group from the GCQ in the third and fourth measurements demonstrated a statistically significant increase in comparison to the sham group. This result is consistent with the proposed hypothesis (H1c), which posits that there is a statistically significant difference between the comfort scores of the acupressure and sham groups after the application of acupressure. A review of the literature revealed no studies that have evaluated the effect of acupressure or self-acupressure on the level of comfort in female students with PD. It is anticipated that our study will contribute to the existing literature on this topic, as menstrual pain has the potential to impede the ability to engage in daily physical activities. Our findings are corroborated by a number of studies on university students. Aktaş (2015) found that the general comfort levels of university students with dysmenorrhea were not at the desired level (2.57 ± 0.25) [6]. In a qualitative study conducted with university students, Yaşar et al. (2021) found that dysmenorrhea had a detrimental impact on comfort across all domains, including physical, sociocultural, psychospiritual, and environmental [7]. Therefore, the current research demonstrates that non-pharmacological methods such as acupressure can be employed as a means of coping with PD.

Strengths and limitations

In the context of existing literature, this is the inaugural single-blind randomized controlled trial that investigates the impact of self-acupressure applied at three distinct points (LI4, ST36, SP6) over three menstrual cycles on pain, menstrual symptoms, and comfort in adolescents with PD. In this regard, the present study contributes to the extant literature by addressing the question of how acupressure affects comfort, thereby filling an existing gap. However, the study is subject to several limitations. Firstly, the study was conducted at a single center, which precludes the possibility of generalizing the results to all adolescents. Secondly, due to adolescents performing acupressure/sham acupressure on themselves, it could not be guaranteed that the intervention was always carried out exactly as recommended. Thirdly, although adolescents were instructed not to use analgesic medication for six hours prior to the intervention to assess the effectiveness of acupressure independently of pharmacological effects, there was a lack of information regarding the use of analgesics and other treatment methods during the intervention. Additionally, the pressure force applied during each session may have varied across individuals, which was beyond control as it could not be measured with a device. Finally, it is worth mentioning that the sample size in this study was relatively small. In future studies, it will be important to expand the sample size and follow-up period to obtain more comprehensive and objective evidence.

Conclusion

The findings of this study indicate that self-acupressure applied to three distinct points for a period of three menstrual cycles results in a reduction in pain and menstrual symptoms, as well as an enhancement in comfort levels. Therefore, self-acupressure, when employed on a regular basis, may be regarded as a potential non-pharmacological intervention for managing PD and improving overall well-being. However, further randomized controlled trials are required to assess the impact of acupressure on comfort in women with PD.

Abbreviations

PD

Primary dysmenorrhea

VAS

Visual Analog Scale

MSQ

Menstruation Symptom Questionnaire

GCQ

General Comfort Questionnaire

CONSORT

Consolidated Standards of Reporting Trials

SPSS

Statistical Package for Social Science

BMI

Body mass index

Author contributions

All authors contributed to conceptualization and methodology of the study. Formal analysis, data curation and analysis were performed by A.A.C., A.B. Investigation, writing - original draft, writing was caried out by A.A.C., A.A. The supervision, reading and approval of the final version of the article were carried out by all authors.

Funding

The study has no funding to report.

Data availability

Data from this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Clinical Research Ethics Committee of Mersin University (No. 645; dated 28.09.2022) and institutional permission was obtained from Mersin Provincial Directorate of National Education (No. 73752739; dated 04.04.2023). An informed consent forms were obtained from all adolescents and their legal guardians. The study was conducted in accordance with the ethical standards set forth in the Declaration of Helsinki. In this context, adolescents were informed that if they did not respond to the treatments they had previously used or to the acupressure applied in our study, their parents would be notified and advised to consult a specialist to manage dysmenorrhea. This approach was considered important both from an ethical perspective and in terms of ensuring adolescents’ comfort.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.