among menstrual disorders , menorrhagia , dysmenorrhea , and abnormal cycles are highly prevalent and are considered as disabling conditions among women at reproductive ages .
dysmenorrhea is defined as painful cramps in lower abdomen during menstruation without any evidence of pelvic pathologic lesions .
this condition occurs right before or during menstruation without any describable macroscopic pelvic pathology . in general ,
50% of women suffer from dysmenorrhea and 10% experience this condition for 13 days a month .
one study reported the prevalence of dysmenorrhea to be over 75% . in another study in sweden , more than 72% of 19-year - old women suffered from this condition ( 34% , 23% , and 15% of the participants had mild , moderate , and severe symptoms , respectively ) .
dysmenorrhea can reduce efficiency and production due to daily stresses and socioeconomic losses . in the us ,
at least 600 million hours and 2 billion dollars are lost due to dysmenorrhea every year .
in addition , dysmenorrhea affects young girls ' opinion about femininity and method of childbirth . for the treatment and control of dysmenorrhea
, there are many ways : common drug interventions for reduction of pain include nonsteroidal anti - inflammatory drugs ( nsaids ) and oral contraceptive pills . despite their usefulness ,
their side effects include diarrhea , stomachache , nausea , renal complications , hepatic complications , blood problems , edema , sleepiness , indigestion , and fatigue .
other treatment methods also include supplementary vegetarian diet , vitamins , minerals , nerve block , spinal manipulation , magneto - inertial fusion , percutaneous electrical nerve stimulation , acupressure , acupuncture , rest , muscle relaxation , reflexology , hand pressure , heat , aromatherapy , and physical therapy .
since the acupressure is a new therapy , the side effects of drug therapies are not readily acceptable . hence , but the rationales for using complementary and alternative medicine have been widely used for many years , and they are accepted by many people and doctors .
approximately 38.2 million adult people in america have used complementary medicine ( herbs and supplements ) in 2002 . moreover , more than half of them said that complementary medicine was important to their health and well - being , besides the points examined in this study . in reviewing the past 30 years , no article has been found .
hence , the acupressure points in this research are entirely new . according to the gate control theory of pain , cutaneous stimulation through massaging , needling , and
scratching can stimulate large fiber nerves that transfer nervous impulses to the spinal cord . in case
this stimulation is continued , it can close pain gates , eventually reducing the feeling of pain .
evidence has shown acupressure as a noninvasive , inexpensive , safe , and simple method for reduction of labor pain . in the study by wang et al . , ( 2010 )
acupressure was applied at sanyinjiao ( sp-6 ) acupoint for 20 min to assess its effect on menstrual pain and distress in young women suffering from dysmenorrhea .
the results revealed a significant decrease in pain in acupressure and self - care training groups based on short - form mcgill pain questionnaire . in another study in iran ,
acupressure at sp-6 acupoint significantly reduced the intensity of dysmenorrhea in the intervention group compared to the control group 30 min and 1 , 2 , and 3 h after the intervention ( p < 0.05 ) . in the present study ,
our aim is to perform acupressure at guan yuan ( rn-4 ) and qu gu ( rn-2 ) acupoints located on the abdominal meridian between the navel and the symphysis pubis and compare its effect to that of using ibuprofen ( control group ) .
rn-2 acupoint is also located on the midline , 5 cuns below the navel , 1 cun between the two grooves of the interphalangeal joints of the massager s middle finger .
the rationale for using self - care education to increase awareness of one s own body and the adoption of appropriate health behavior and lifestyle modification such as diet and exercise will lead to the improvement of dysmenorrheal . considering the limited interventions in this
regard and importance of complementary medicine , the present study aims to compare self - care behaviors training , acupressure at rn-4 and rn-2 acupoints , and ibuprofen consumption .
the present randomized clinical trial was conducted on 120 nonmedical students ( three groups of 40 ) living in dormitories of shiraz university shiraz , iran .
the sample size was determined based on the study by kashefi et al . and considering the loss rate of 10% .
of course , the initial sample comprised 157 patients with primary dysmenorrhea , of which 37 patients were excluded from the trial due to lack of inclusion criteria [ figure 1 ] .
consort diagram of sampling at first , five dormitories of shiraz university were selected randomly .
then , one , two , and two dormitories were randomly considered as control , self - care behaviors training , and acupressure groups , respectively .
the inclusion criteria of the study were being single , being below 25 years old , having primary dysmenorrhea with pain intensity of four and above based on visual analog scale ( vas ) , having regular menstrual cycles ( 2135 days ) , having experienced dysmenorrhea in the recent six menstrual cycles ( self - report ) , not having used oral contraceptive pills , and treatment interventions ( nsaids , antiprogestins , and supplements ) since 2 months before the study , not suffering from physical ( vertebral fracture , herniated disk , acute inflammation , deep vein thrombosis , and gynecological diseases ) and mental disorders , not consuming special medications such as benzodiazepines and antidepressants , and not having experienced stress due to parents ' divorce or loss of first - degree relatives during the recent 6 months . on the other hand , the exclusion criteria of the study were having symptoms such as burn , itch , and abnormal vaginal discharges , experiencing stressors ( parents ' divorce , loss of first - degree relatives , etc . ) during the study , and not being willing to participate in the study .
all interventions and inclusion criteria carried out by the researcher , and research was done in student dormitories . before the intervention , intensity of pain was determined in all the three groups .
it should also be noted that researcher s performance of acupressure was confirmed by a specialist . in doing so
, pressure was repeatedly applied with the thumb and was controlled by a scale to equalize its amount in each application .
first group , in the acupressure group , pressure was applied on the abdominal meridian using the thumb for 20 min ( 15 s pressure , 15 s rest ) over the 1 2 days of menstruation for two cycles .
pain intensity was assessed  h , 1 h , and 2 h after application of pressure .
it should be mentioned that pain intensity was assessed by the researcher s assistant to avoid bias .
the method of compression in acupressure groups was done after obtaining confirmation from a trained researcher ( i.e. , from a specialist in physical medicine and rehabilitation ) .
after confirmation from the researcher , the intervention was conducted . in the second group ,
self - care behaviors were conducted in two parts : teaching theoretical base of using lecture , discussion , and experience sharing was performed through four sessions ( one - 6090 min session a week ) . the educational content included anatomy and physiology of the genital system , nutrition during the menstrual cycle ( based on books , articles , and a nutritionist s advice , emphasis was put on the resources that were effective in dysmenorrhea ) , the second part was practical training and includes isometric exercises during the menstrual cycle .
it should be noted that isometric exercises were educated to researcher by a master of physical education , and researcher was trained to girls in the gymnasium dormitory .
isometric exercise duration was 8 weeks , in the first 4 weeks was conducted by the researcher . in the second 4 weeks with an appropriate images of playing sports the girls were given regarding how exercise .
and the girls without researcher continued ( a total of 8 weeks ) . to ensure
the exercise was done in the dormitory to follow up , as well as phone calls , for continued exercise classes were encouraged after the 1 4 weeks .
food recommendations and other educational content have been on the books and articles . in group
three , the control group received the routine treatment for dysmenorrhea , i.e. , taking ibuprofen 400 mg three times a day for three cycles .
of course , they were provided with the educational pamphlet at the end of the study .
questionnaires were completed in the student dormitories and after the intervention ; to avoid sampling bias in research , pain assessment was conducted by a research assistant . in this study ,
intensity of pain was assessed using mcgill pain questionnaire developed by melzack , which has been introduced as a reliable instrument for the assessment of pain intensity . however , since this questionnaire takes a long time to be completed , its short form was designed and has been frequently used in persian studies .
the short form of mcgill pain questionnaire consists of 15 sensory ( 11 questions ) and emotional ( 4 questions ) items , and the patients determine the quality of their pain by selecting one of the options of none , mild , average , and severe .
the validity and reliability of this scale in the current research were based on the study performed by adelmanesh et al .
that reported cronbach s alpha coefficients of 0.951 , 0.832 , and 0.840 for sensory , emotional , and total scores , respectively .
wallis test was used to compare the three study groups . besides , paired t - test was employed to compare the means before and after the intervention . finally , qualitative variables were compared using chi - square test .
besides , written informed consents for taking part in the study were obtained from all the participants . hence , thesis number : 92 - 6900 , irct : 2013071013940n1 and ethic number : 1392 - 12 - 11 - 6900 .
the present randomized clinical trial was conducted on 120 nonmedical students ( three groups of 40 ) living in dormitories of shiraz university shiraz , iran .
the sample size was determined based on the study by kashefi et al . and considering the loss rate of 10% .
of course , the initial sample comprised 157 patients with primary dysmenorrhea , of which 37 patients were excluded from the trial due to lack of inclusion criteria [ figure 1 ] .
consort diagram of sampling at first , five dormitories of shiraz university were selected randomly .
then , one , two , and two dormitories were randomly considered as control , self - care behaviors training , and acupressure groups , respectively .
the inclusion criteria of the study were being single , being below 25 years old , having primary dysmenorrhea with pain intensity of four and above based on visual analog scale ( vas ) , having regular menstrual cycles ( 2135 days ) , having experienced dysmenorrhea in the recent six menstrual cycles ( self - report ) , not having used oral contraceptive pills , and treatment interventions ( nsaids , antiprogestins , and supplements ) since 2 months before the study , not suffering from physical ( vertebral fracture , herniated disk , acute inflammation , deep vein thrombosis , and gynecological diseases ) and mental disorders , not consuming special medications such as benzodiazepines and antidepressants , and not having experienced stress due to parents ' divorce or loss of first - degree relatives during the recent 6 months . on the other hand , the exclusion criteria of the study were having symptoms such as burn , itch , and abnormal vaginal discharges , experiencing stressors ( parents ' divorce , loss of first - degree relatives , etc . ) during the study , and not being willing to participate in the study .
all interventions and inclusion criteria carried out by the researcher , and research was done in student dormitories .
before the intervention , intensity of pain was determined in all the three groups . it should also be noted that researcher s performance of acupressure was confirmed by a specialist . in doing so
, pressure was repeatedly applied with the thumb and was controlled by a scale to equalize its amount in each application .
first group , in the acupressure group , pressure was applied on the abdominal meridian using the thumb for 20 min ( 15 s pressure , 15 s rest ) over the 1 2 days of menstruation for two cycles .
pain intensity was assessed  h , 1 h , and 2 h after application of pressure .
it should be mentioned that pain intensity was assessed by the researcher s assistant to avoid bias .
the method of compression in acupressure groups was done after obtaining confirmation from a trained researcher ( i.e. , from a specialist in physical medicine and rehabilitation ) .
after confirmation from the researcher , the intervention was conducted . in the second group ,
self - care behaviors were conducted in two parts : teaching theoretical base of using lecture , discussion , and experience sharing was performed through four sessions ( one - 6090 min session a week ) . the educational content included anatomy and physiology of the genital system , nutrition during the menstrual cycle ( based on books , articles , and a nutritionist s advice , emphasis was put on the resources that were effective in dysmenorrhea ) , the second part was practical training and includes isometric exercises during the menstrual cycle .
it should be noted that isometric exercises were educated to researcher by a master of physical education , and researcher was trained to girls in the gymnasium dormitory .
isometric exercise duration was 8 weeks , in the first 4 weeks was conducted by the researcher . in the second 4 weeks with an appropriate images of playing sports the girls were given regarding how exercise .
and the girls without researcher continued ( a total of 8 weeks ) . to ensure the exercise
was done in the dormitory to follow up , as well as phone calls , for continued exercise classes were encouraged after the 1 4 weeks .
food recommendations and other educational content have been on the books and articles . in group
three , the control group received the routine treatment for dysmenorrhea , i.e. , taking ibuprofen 400 mg three times a day for three cycles .
of course , they were provided with the educational pamphlet at the end of the study .
questionnaires were completed in the student dormitories and after the intervention ; to avoid sampling bias in research , pain assessment was conducted by a research assistant . in this study ,
intensity of pain was assessed using mcgill pain questionnaire developed by melzack , which has been introduced as a reliable instrument for the assessment of pain intensity . however , since this questionnaire takes a long time to be completed , its short form was designed and has been frequently used in persian studies .
the short form of mcgill pain questionnaire consists of 15 sensory ( 11 questions ) and emotional ( 4 questions ) items , and the patients determine the quality of their pain by selecting one of the options of none , mild , average , and severe . the validity and reliability of this scale in the current research
that reported cronbach s alpha coefficients of 0.951 , 0.832 , and 0.840 for sensory , emotional , and total scores , respectively .
wallis test was used to compare the three study groups . besides , paired t - test was employed to compare the means before and after the intervention . finally , qualitative variables were compared using chi - square test .
this study was approved by the ethics committee of shiraz university of medical sciences . besides , written informed consents for taking part in the study were obtained from all the participants . hence , thesis number : 92 - 6900 , irct : 2013071013940n1 and ethic number : 1392 - 12 - 11 - 6900 .
the mean age of the participants was 20.02  1.44 , 20.12  1.50 , and 20.37  1.54 years in the acupressure , training , and control groups , respectively ( p = 0.569 ) . besides , the mean time of beginning of pain after menarche was 1.80  0.82 years in the acupressure group , 1.90  0.77 years in the training group , and 1.87  0.79 years in the control group ( p = 0.844 ) . according to the results of kruskal 
wallis test , the three groups were homogeneous regarding these two variables [ table 1 ] .
comparison of the age of in three groups ( acupressure - education of self - care behaviors and control ) in the training group , the mean intensity of pain was 16.90  7.43 before the intervention and 10.56  5.71 after the intervention , and the results of paired t - test showed that the difference was statistically significant ( p < 0.001 ) . in the acupressure group also , the mean intensity of pain was 20.25  6.93 before the intervention , and the results showed a significant difference in this regard before and 1 and 2 months after the intervention ( p < 0.001 ) [ table 2 ] .
comparison of the intensity of pain after and before the acupressure and educational groups based on the mcgill questionnaire in the control group , the mean intensity of pain was 31.77  6.36 before the intervention , 23.52  5.55 1 month after the intervention ( p < 0.001 ) , 9  5.99 2 months after the intervention ( p < 0.001 ) , and 14.57  6.40 3 months after that ( p
comparison of the intensity of pain after and before the acupressure and educational and control groups based on the mcgill questionnaire based on mcgill pain questionnaire , the mean intensity of pain was 10.65  5.71 in the training group , 19  5.41 in the control group , and 14.40  6.87 in the acupressure group after the intervention .
wallis test , showed that these differences were statistically significant , and both interventions were more effective compared to the control group [ table 4 ] .
comparison of the difference mean scores severity of pain of in three groups ( acupressure - education of self - care behaviors and control of the mcgill questionnaire
according to the present study results , discussion is on three main axes : in our study , the mean intensity of pain significantly decreased in the self - care training group . chang and chuang conducted a study to introduce the effective factors in dysmenorrhea . in that study , the participants with moderate dysmenorrhea received self - care behaviors training , and the results showed that training self - care behaviors at schools were one of the effective methods in reduction of dysmenorrhea .
chen et al . also carried out a research on self - care behaviors using herbal medicines and complementary medicine in primary dysmenorrhea among taiwanese adolescents .
the results of the study by chen et al . revealed the necessity to educate individuals regarding the effect of food diet and effective herbal medications on the treatment of dysmenorrhea . in that study , the participants mentioned the reduction of physical activities as a self - care behavior , but the researchers modified this opinion and trained individuals regarding aerobic exercises as a self - care behavior to decrease their pain .
, who investigated the effect of heavy exercises on the treatment of dysmenorrhea using mcgill pain questionnaire .
the results of that study demonstrated that exercising was effective in reduction of pain without any side effects .
in contrast , shafaie - sehati et al . found no significant difference between athletic and nonathletic groups with respect to the frequency of dysmenorrhea . in the present study ,
self - care behaviors training resulted in a reduction of pain and exercising was among the bases of this training .
exercising enters the body in the state of hypoxia where beta - endorphin levels increase .
therefore , hypoxia and acidosis stimulate production of beta - endorphins , and the relationship between breathing and beta - endorphin production can be associated with the effect of acidosis on the two through different mechanisms .
reduction of pain after self - care training can also be attributed to the control of prostaglandins .
in fact , aerobic exercises empty the uterus from waste materials and prostaglandins , which are the main cause of pain , eventually reducing the duration of pain through the menstrual cycle . in another survey exercise after 6 weeks
is created flexibility in the hamstring , back and hip muscles , and reduces pain .
the current study at the second part findings showed a significant difference in the acupressure group s pain intensity before and after the intervention .
considering the limited number of studies conducted on rn-4 and rn-2 acupoints , the results of performance of acupressure at other points have been discussed in this section . in the study by yeh et al .
, pressure was applied for 1 min four times a day for 2 days , which is different from our study .
the results showed a significant difference in each group s pain intensity before and after the intervention . in the present study , however , the study groups ' pain intensity was significantly different only based on mcgill pain questionnaire .
other researches have also revealed the effectiveness of acupressure in treatment of dysmenorrhea and relaxation . in a review study
about efficacy of self - acupressure showed several studies ( eight rcts and two quasi - rcts ) have a positive effect and effective on primary dysmenorrhea . in another study concluded that enough evidence not exists for the effectiveness of acupressure or acupuncture and rct larger studies are needed .
the analgesic effect of acupressure can be due to release of endorphins and glucocorticoids that block pain gates .
acupressure , in fact , refers to the touch technique for balancing human body s energy flow or qi .
this method leads to the release of various neurotransmitters , which cut the nervous signals transferred by the nervous system .
it also inhibits secretion of prostaglandins , reduces stimulation of cerebral cortex , and regulates secretion of endocrine hormones .
based on mcgill pain questionnaire scores , the control group s pain intensity scores were significantly different before and after the intervention . similarly , the results of the studies by zafari and witt et al . indicated the effectiveness of ibuprofen . however , the results obtained by salmalian were on the contrary to those of the present study .
in general , nsaids are the first - line treatment , but their side effects , including gastrointestinal problems , make patients choose alternative therapies .
overall , the results of the current study showed a significant difference among the three groups regarding the intensity of pain , and that training and acupressure were more effective compared to consumption of ibuprofen . in this study ,
new and effective acupoints were employed , whereas the previous studies had not used such a combination of effective points .
one of the limitations of our study was the difficulty in obtaining the required permissions from dormitories and performing the procedures privately .
hence , probable physiological tolerance of pain in each people is different , so feel pain is different , as well as contrast to the reactions and feelings of loss pain after pain relief methods will be different , which is beyond the control of the researcher .
another limitation was to assess the severity of pain after intervention . in order to solve the problem and avoid bias in sampling ,
finally , due to the different time periods , research conducted at the same time for all units is not possible .
future studies are recommended to compare the effects of acupressure at other acupoints and common chemical and herbal drugs on primary dysmenorrhea in larger populations .
suggestions for future research : ( 1 ) comparison the effect of other point of acupressure on severity of primary dysmenorrhea with the rn-2 , rn-4 points .
( 2 ) the application of educational models such as basnef models on knowledge and attitudes of people with primary dysmenorrhea .
according to the current study results , the most effective method in reduction of dysmenorrhea was self - care behaviors training followed by acupressure at rn-4 and rn-2 acupoints and consumption of ibuprofen .
considering the side effects of consuming ibuprofen drug , training and acupressure as nonpharmacological , easy , safe , and inexpensive methods can be incorporated into the curricula of girls ' high schools . considering the effectiveness of acupressure in reducing dysmenorrheal ,
obstetricians , gynecologists , and midwives have recommended acupressure not only in the treatment of dysmenorrhea but also in reducing labor pain and pain control . the effective nondrug method that is the responsibility of the midwifery , and in clinics and delivery room applications and
this study is funded by the shiraz university of medical sciences , shiraz , iran .
this study is funded by the shiraz university of medical sciences , shiraz , iran .
all authors contributed to the conception of the work , conducting the study , revising the draft , approval of the final version of the manuscript , and agreed for all aspects of the work .
 background : dysmenorrhea is one of the common problems during reproductive ages , with prevalence rate of 6090% . 
 this study aimed to compare the effects of acupressure at guan yuan ( rn-4 ) and qu gu ( rn-2 ) acupoints , self - care behaviors training , and ibuprofen on the intensity of primary dysmenorrhea based on mcgill pain questionnaire.materials and methods : in the randomized clinical trial , 120 females , aged between 18 and 25 years , with primary dysmenorrhea , randomly selected from five dormitories of shiraz university , shiraz , iran were screened and randomized into acupressure group , in that pressure was applied for 20 min over the 1st 2 days of menstruation for two cycles . in the second group , 
 the training group took part in four educational sessions each lasting for 6090 min and control group received ibuprofen 400 mg . 
 the intensity of pain before and after the intervention was measured using short - form mcgill pain questionnaire . 
 the data were entered into the spss statistical software ( version 16 ) and analyzed using kruskal  
 wallis test , paired t - test , and chi - square test.results:a significant difference was found in the mean intensity of pain before and after the intervention in all the three study groups . 
 the mean score of pain intensity was 10.65  5.71 in the training group , 19  5.41 in the control group , and 14.40  6.87 in the acupressure group after the intervention . 
 the results of kruskal  wallis test revealed that both interventions were more effective compared to consumption of ibuprofen.conclusion:training and acupressure were more effective than ibuprofen in the reduction of dysmenorrhea . 
 thus , they can be considered as trainable methods without side effects in adolescent girls . 