Abstract
Objective:
Vitamin E and acupressure are 2 complementary and alternative therapies recommended for primary dysmenorrhea (PD). This study assessed the effect of acupressure at Spleen-10 (SP-10), compared to vitamin E on the pain severity of primary dysmenorrhea (PD).
Materials and Methods:
A quasiexperimental study was conducted on 70 eligible young female students with self-reported primary dysmenorrhea at Gonabad University of Medical Sciences, Gonabad, Iran. Participants were assigned to 2 treatment groups: acupressure or vitamin E. Interventions were implemented at the onset of menstrual pain in each patient, for 2 consecutive periods: acupressure group (n = 35) received 20 minutes of acupressure to SP-10 on both legs; and vitamin E group (n = 35) took 1 capsule of 200 international units of vitamin E. Pain severity was assessed with a visual analogue scale for pain. Data were analyzed with a response-profile analysis in R, version 3.6.1. Significance was P < 0.05.
Results:
Both treatment groups had a similar pattern of change over time. The mean level of response profiles for pain severity was the same for both groups on all occasions. The effect of time was statistically significant (P < 0.001). A decreasing trend was noted in mean severity of pain over time. Changes at the second and third measured times were significant (P < 0.001).
Conclusions:
It seems that acupressure at SP10 point is an efficient nonpharmacologic, cost-effective, easy-to-learn way to treat primary dysmenorrhea, applicable in any time or place.
Keywords: dysmenorrhea, acupressure, Spleen-10 acupoint, vitamin E
INTRODUCTION
Menstruation is an iterative process that occurs naturally during each woman's reproductive years and is usually accompanied by pain and distress.1 Dysmenorrhea is one of the most-widespread menstrual disorders, with a prevalence of 50%–70% among adolescents.2 Primary dysmenorrhea (PD) is a form of dysmenorrhea. It is a recurrent and spasmodic or contractive pain in the lower abdomen or pelvis that may extend to the lower back and thighs. It may come with symptoms, such as nausea, fatigue, bloating, and general weakness. These symptoms begin 1 or more days before menstruation and last between 1 and 3 days. PD usually happens within 6–12 months after menarche and is more prevalent in the second and third decades of a woman's life.3,4 PD is associated with certain complications, such as severe daily stress, low quality of life, disrupted social and recreational activities, and economic loss.5,6
While there is no specific scientific known cause for PD, some research traced the contractions back to the increased concentration of prostaglandin (Pg) in response to decreased menstrual progesterone.7 Currently, there are several pharmacologic therapies for PD, including analgesics, oral contraceptive pills (OCPs), and nonsteroidal anti-inflammatory drugs (NSAIDs). However, these medications only provide temporary pain relief and are associated with undesirable side-effects, dependency, and unnecessary medical costs.8,9
The effectiveness of vitamin E for treating PD has been confirmed in research.10–12 Vitamin E inhibits phospholipids peroxidation and arachidonic acid (AA) release and, therefore, prevents any increase in Pg concentration.13
Another therapeutic alternative for PD is acupressure. Traditional Chinese Medicine (TCM) believes that the body's vital energy (Qi) circulates through different meridians and the energy imbalance in Qi induces disease. Acupressure is a noninvasive technique for opening the channels, balancing body energy, and restoring health by putting physical pressure, using hands, thumbs, or other fingers on specific areas of the body.14,15 TCM theory points out that regulating Spleen energy flow through Spleen-6 (SP-6), Spleen-8 (SP-8), and Spleen-10 (SP-10) is beneficial for treating dysmenorrhea.16 Several studies have reported the effectiveness of acupressure at SP-6 for treating PD.15,17–19 However, very few studies have been conducted on the effects of acupressure at SP-8 and SP-10 and PD.17,20 Thus, this study was conducted to assess the effectiveness of acupressure at SP-10, compared to vitamin E, on pain severity of PD.
MATERIALS AND METHODS
Study Design
A quasiexperimental study was conducted on 70 female students at Gonabad University of Medical Sciences, Gonabad, Iran, from October to November 2014.
Setting and Sample
To estimate the minimum sample size, a power analysis was performed according to a similar study by Ezadi et al.,20 with a power of 80% and a confidence interval of 99%. The estimated ample size was 32 individuals per group, which was increased to 39 with a potential attrition rate of 20%. Female students with PD symptoms were invited to participate in the study. Purposive sampling was used to select the sample. Inclusion criteria were: a PD score of 4 or higher based on a visual analogue scale for pain (VAS); being single; being between ages 18 and 26; having a regular menstrual period of 21–35 days; being in good general health; and not having genital-tract disease. Exclusion criteria were: taking other medicines such as analgesics, OCPs, or NSAIDs 2 weeks before or during the menstrual period; experiencing stressful events; and an unwillingness or inability to participate until the end of the study. Eligible participants were assigned consecutively to either a vitamin E or an acupressure group (Fig. 1).
FIG. 1.
CONSORT [Consolidated Standards of Reporting Trials] diagram of sampling.
Instruments
Information on each participant's age and menstrual characteristics—including length of bleeding during each menstrual period, onset of PD after menarche, and duration of pain during each menstrual period—was collected, using a questionnaire. A VAS was also used as an acceptable, valid, and reliable self-administered instrument to measure the severity of each participant's pain.21,22 The VAS uses a graded straight line from 0 (no pain) to 10 (extreme severe pain).
Interventions
The interventions were performed for 2 consecutive menstrual periods in both treatment groups.
Vitamin E group
Patients in the vitamin E–recipient group were also asked to determine their pain severity, using the VAS at the onset of pain and before the intervention. Then, they were asked to take 1 capsule of 200 international units (IU) of vitamin E and determine the severity of dysmenorrhea again after 1 hour.
Acupressure group
An introduction to acupressure and its applications was provided for participants. The participants' skills were evaluated and confirmed after the required training by an expert on locating and massaging SP-10. According to Yang and Monti, this is “when the knee is flexed, the point is 2 cun above the mediosuperior border of the patella, on the bulge of the medial portion of the quadriceps femoris.”23 The participants were asked to put pressure on the SP-10 point on 1 leg (6 seconds of pressure and 2 seconds rest) and then change to the other leg every 5 minutes. Total intervention time was 20 minutes on both legs. The participants assessed their pain-severity levels before the intervention (at the onset of pain) and immediately after the intervention by using the VAS.
Ethical Considerations
Ethical considerations in the present study included obtaining approval from the ethics committee of Gonabad University of Medical Sciences (#GMU.REC.1393.60), clarifying the purpose of the study and process to the participants, and obtaining written informed consents from all participants.
Data Analysis
All statistical analyses were performed using free software (R3.6.1). Continuous and categorical variables were summarized as mean (standard deviation [SD]) and frequency (%). A Mann–Whitney U-test, a test, and a response-profile analysis approach were used to compare age, menstrual characteristics, and repeated measures of pain severity between the 2 groups. Analysis of response profiles for longitudinal data has certain robustness because there is no assumption about the patterns in the mean response over time and the covariance of the responses. Therefore, the potential risks of bias due to mis-specification of the models for the mean and covariance are minimal when this method is used.24 Significance level was P < 0.05.
RESULTS
Participants' Ages and Menstrual Characteristics
Both groups were homogeneous in terms of their menstrual characteristics, including the duration of bleeding during each menstrual period, onset of PD after menarche, and the duration of pain during each menstrual period (P > 0.05). However, the mean ages of the 2 groups were significantly different (P < 0.001). See Table 1.
Table 1.
Comparison of Age and Menstrual Characteristics Between Vitamin E and Acupressure Groups
| |
|
|
Group |
Test statistics |
|
|---|---|---|---|---|---|
| Variable | Duration | SD, IQR, or % | Vitamin E | Acupressure | & P-value |
| Age (yrs) | Mean (SD) | 21.8 (0.8) | 20.7 (1.1) | U = 227.00, | |
| Median (IQR) | 22.0 (1.0) | 21.0 (1.0 | P < 0.001 † | ||
| Length of bleeding within each menstrual period (d) | Mean (SD) | 6.9 (1.1) | 6.6 (0.9) | U = 495.00 | |
| Median (IQR) | 7.0 (0.0) | 7.0 (1.0) | P = 0.13* | ||
| Onset of PD after menarche (yrs) | < 1 | n (%) | 14.0 (40.0) | 12.0 (34.3 | 0.9 |
| 1–2 | n (%) | 8.0 (22.9) | 10.0 (28.6) | P = 0.80† | |
| 2–3 | n (%) | 6.0 (17.1) | 8.0 (22.9) | ||
| > 3 | n (%) | 7.0 (20.0) | 5.0 (14.3 | ||
| Length of pain in each menstrual period (hrs) | 24 | n (%) | 23.0 (65.7) | 19.0 (54.3 | 1.66, |
| 25–48 | n (%) | 5.0 (14.3) | 12.0 (34.3) | P = 0.13† | |
| 49–72 | n (%) | 7.0 (20.0) | 4.0 (11.4 | ||
Mann–Whitney-U test; † test.
Bolding denotes statistical significance.
yrs, years; d, day; hrs, hours; PD, primary dysmenorrhea; SD, standard deviation; IQR, interquartile range; U, probability distribution.
Severity of Pain Before and After Interventions
Table 2 shows the mean of pain Severity after intervention in two groups of vitamin E and acupressure decreased in 2 menstrual cycles.
Table 2.
Severity of Pain Before and After the Intervention in 2 Menstrual Cycles in Vitamin E and Acupressure Groups
| Time of measurement | Group |
|
|---|---|---|
| Vitamin E |
Acupressure |
|
| Mean (SD) | Mean (SD) | |
| Before the intervention, 1st mo (Time 0) | 6.14 (1.80) | 6.17 (1.38) |
| After the intervention, 1st mo (Time 1) | 5.83 (1.71) | 5.48 (1.44) |
| Before the intervention, 2nd mo (Time 2) | 4.14 (2.09) | 4.00 (2.06) |
| After the intervention, 2nd mo (Time 3) | 3.80 (2.07) | 3.89 (2.08) |
SD, standard deviation; mo, month.
Response-Profile Analysis
The results of the response-profile analysis for fixed effects tests and the estimated regression coefficients and standard errors are shown in Tables 3 and 4, respectively.
Table 3.
Tests of Fixed Effects Based on Analysis of Response Profiles of Pain Severity
| Variable | F | df* | P-value |
|---|---|---|---|
| Treatment group | 0.114 | 1 | 0.736 |
| Time | 41.035 | 3 | 0.001 |
| Time treatment group | 2.286 | 3 | 0.079 |
| Age | 0.297 | 1 | 0.586 |
The degree of freedom (df) for the denominator (residuals) is 272.
Bolding denotes statistical significance.
Table 4.
Estimated Regression Coefficients and Standard Errors Based on Analysis of Response Profiles of Pain Severity
| Variable | Group | Time | Estimate | SE | Z | P-value |
|---|---|---|---|---|---|---|
| Intercept | 8.44 | 4.22 | 2.00 | 0.046 | ||
| Treatment | Acupressure at SP-10 | –0.09 | 0.44 | −0.200 | 0.841 | |
| Age | –0.11 | 0.19 | –0.55 | 0.586 | ||
| Time | 1 | –0.31 | 0.20 | –1.59 | 0.113 | |
| 2 | –2.00 | 0.29 | –6.99 | <0.001 | ||
| 3 | –2.34 | 0.32 | –7.30 | <0.001 | ||
| Group time | Acupressure at SP-10 | 1 | –0.37 | 0.28 | –1.33 | 0.185 |
| Acupressure at SP-10 | 2 | –0.17 | 0.40 | –0.42 | 0.672 | |
| Acupressure at SP-10 | 3 | 0.06 | 0.45 | 0.13 | 0.899 |
Bolding denotes statistical significance.
SE, standard error.
As shown in Table 3, after adjusting for age, the group × time–interaction effect and treatment–group effect were not statistically significant (P = 0.079 and P = 0.758, respectively). Thus, there was a similar pattern of change during the interventions and the same mean level of response profiles for pain severity on all occasions for the 2 groups. The effect of time was statistically significant (P < 0.001; Table 3), and the estimated regression coefficients (shown in Table 4) indicated a decreasing trend of change in the levels of pain over time, which was significant for Times 2 and 3. So after two months and three months after the intervention began, pain decreased in both groups significantly (P < 0.001).
DISCUSSION
Acupressure therapy leads to a relaxed feeling and perceived lower pain via release of specific peptides, which act as analgesics and sedatives.25 TCM suggests that acupressure at SP-6, SP-8, and SP-10 points could be used to treat dysmenorrhea.16 Alternatively, a number of researchers have proposed vitamin E as an effective method for treating PD.10–12 Restraining the AA spread and its conversion to Pg and increasing internal opioids can explain the effect of vitamin E for relieving pain.13 This study investigated the effectiveness of SP-10 acupressure relative to vitamin E for treating pain severity in patients with PD .
A significant decrease was found in pain severity in the SP-10 acupressure group, which is consistent with the findings of Ezadi et al.20
Vitamin E induced a significant decrease in severity of pain in patients with PD, which is in line with previous studies. Several trials have indicated that taking various doses (200, 400, and 500 IU) of vitamin E for 5 days, from 2 days before menstruation addresses PD after the first or second month of the intervention.10,11,26,27 Bostani Khaleesi et al. assessed the effect of taking 200 IU of vitamin E on PD, when the vitamin was taken at the onset of pain, and confirmed the vitamin's beneficial effect 1 hour after ingestion.12
Another study also reported that intramuscular vitamin E (2.0 mL of a 50% solution) could decrease pain 15 minutes after injection in patients who have PD.28 In the current study, 200 IU of vitamin E was administered at the onset of pain, and the finding was consistent with that finding reported by Bostani Khaleesi et al.12
There was no statistically significant difference in reducing pain between vitamin E and acupressure groups at SP-10 in the present study. Bostani Khaleesi et al. investigated PD.12 and found that acupressure at Sanyinjiao (SP-6) was more effective for decreasing pain than vitamin E.
The current study pioneered in examining SP-10 acupressure's effect on PD, compared to vitamin E. The participants were in their second or third reproductive decade and were more likely to experience more severe PD.
There were several limitations in this study. First, assigning the participants to the treatment groups was not performed randomly. Second, only the VAS measurement was used to evaluate pain severity without any additional different measurement methods. Third, this study was conducted in a self-administered, self-assessment, and self-reporting manner, which may be a potential source of bias. Further research would be worthwhile—in particular, a randomized multimeasurement (hour-to-hour) trial during each menstrual period using other measurements in addition to a VAS to assess the effect of acupressure at SP-10 on pain. It is suggested to compare the effect of acupressure at SP-10 and the combined effect of acupressure at SP-10 and vitamin E on the during of pain and the rate of bleeding in patients with PD.
CONCLUSIONS
It seems that acupressure at SP-10 is an efficient nonpharmacologic, cost-effective, easy-to-learn approach to treat PD that is applicable at any time or place. Further research is needed with more-accurate study designs, such as randomized clinical trials to confirm this study's findings.
ACKNOWLEDGMENTS
The abstract of the study was previously presented at the International Congress on Complementary and Alternative Medicine, held on October, 7–9 2015, and published.29 The research team would like to thank the individuals who devoted their time generously to this research project and cooperated with the research team.
AUTHOR DISCLOSURE STATEMENT
No financial conflicts of interest exist.
FUNDING INFORMATION
This study was approved (# IR.GMU.SRC.1392.68) and financially supported by the Student Research Committee of Gonabad University of Medical Sciences, in Gonabad, Iran.
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