THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 15, Number 3, 2009, pp. 235–242
© Mary Ann Liebert, Inc.
Effects of Auricular Acupressure on Menstrual Symptoms
and Nitric Oxide for Women with Primary Dysmenorrhea
Mei-Chuan Wang, M.N., R.N.,
Mei-Chi Hsu, Ph.D., R.N.,
Li-Wei Chien, M.D., Ph.D.,
Chien-Huei Kao, Ph.D.,
and Chi-Feng Liu, Ph.D.
Objectives: The aim of this study was to evaluate the effects of auricular acupressure on relieving menstrual
symptoms and decreasing nitric oxide (NO) for women with primary dysmenorrhea.
Design: This was a randomized clinical trial comparing the effects of auricular acupressure by seed-pressure
method and placebo adhesive patch.
Setting: Settings included colleges in northern and central Taiwan.
Subjects: Serum CA-125 testing was used as a screening test for primary dysmenorrhea (35 mg/dL). The
study included 36 college females randomized to acupressure group, 35 to control group.
Interventions: The acupressure group received auricular acupressure by seed-pressure method on liver (CO12),
kidney (CO10), and endocrine (CO18) acupoints. The control group had a plain adhesive patch placed on the
same acupoints with no seed attached. Acupressure protocol included massaging 15 times on each acupoint, 3
times a day, for a total of 20 days.
Outcome measures: Primary: Short-form Menstrual Distress Questionnaire (MDQs). Secondary: blood sample of
NO. Assessments of MDQs and NO were performed at baseline and within the first 2 days of their next menses
(after completion of 20 days of acupressure).
Results: In the acupressure group, the overall menstrual symptoms (95% confidence interval [CI] 49.8 to
6.5, effect size [ES] 0.43, p0.01) and two subscales, menstrual pain (95% CI 16.4 to 2.2, ES 0.45,
p0.01) and negative affects (95% CI 11.9–2.0, ES 0.38, p0.04), revealed that menstrual symptoms de-
creased significantly after auricular acupressure by the seed-pressure method. The ES for the MDQs were in
favor of the auricular acupressure by seed-pressure method. NO level increased in the acupressure group, al-
though this difference did not achieve statistical significance (p0.05).
Conclusions: This study supports the effects of auricular acupressure by seed-pressure method in improving
menstrual symptoms, and offers a noninvasive complementary therapy for women with primary dysmenor-
Dysmenorrhea is categorized as primary or secondary
based on the presence of known etiology or pelvic
pathology. Medically defined, primary dysmenorrhea is di-
agnosed by exclusion when painful menstruation occurs in
the absence of pathology such as endometriosis.
dysmenorrhea involves an underlying pathology acting di-
rectly or indirectly on pelvic anatomy to cause the pain
symptoms during menstrual flow. Primary dysmenorrhea is
Department of Nursing, National Taipei College of Nursing, Taipei, Taiwan, Republic of China.
Department of Nursing, I-Shou University, Taiwan, Republic of China.
Department of Obstetrics and Gynecology, Taipei Medical University and Hospital, Taipei, Taiwan.
National Taipei College of Nursing, Taipei, Taiwan, Republic of China.
Graduate Institute of Integration of Traditional Chinese Medicine with Western Nursing, National Taipei College of Nursing, Taipei,
Taiwan, Republic of China.
a common women’s health condition and health-related ex-
perience among women worldwide. Primary dysmenorrhea
includes cramping pain in the lower abdomen
ated discomfort symptoms such as fatigue, mood swing,
headache, backache, and irritability.
These symptoms are
either psychologic or physical in nature and most are rou-
tinely considered in a medical model differential diagnosis
of premenstrual syndrome or dysmenorrhea.
primary dysmenorrhea ranged from 41% to 95%.
women report experiencing cyclic pelvic pain (CPP) that sig-
nificantly impacts their quality of life. Another form of CPP
is mittelschmerz, a term used to denote midcycle pain often
associated with ovulation. This type of CPP is far less com-
mon than dysmenorrhea. The incidence of CPP is as high as
80% for women in their teens and early 20s, with half of these
women experiencing loss of time from school or work.
For 10%–20% of women, CPP is severe.
Young women in
their teens and early 20s experience menstrual pain most of-
ten, with the onset occurring within 3 years of menarche.
This leads to expenses for self-care, over-the-counter treat-
ments, and visits to health care professionals.
The cause of primary dysmenorrhea is unknown, but a num-
ber of influencing factors, for example, uterine hyperactiv-
ity, prostaglandins, leukotrienes, and antidiuretic hormone,
have been implicated. Combined oral contraceptives and non-
steroidal anti-inflammatory drugs (NSAIDs) or NSAIDs used
alone are widely used for prevention or treatment of peri-
menstrual pain. Both medications are effective in about 70%–
90% women with primary dysmenorrhea.
cine may not be entirely effective and has side-effects for some
Nonresponse to drug treatment is estimated to occur
in about 10% of patients with primary dysmenorrhea.
ever, women and girls with primary dysmenorrhea may not
wish to take medications and show resistance or unwillingness
to take any treatment. Thus, there is a need to develop easy
and effective methods to ease many forms of their discomfort,
so their quality of life can be improved.
Acupressure is a long-standing treatment in Traditional
Chinese Medicine technique and may be a valuable treat-
ment in improving menstrual symptoms.
The effects of
acupressure have been demonstrated to be comparable to
ibuprofen (a type of NSAID) in treating dysmenorrhea.
use of acupressure as a complementary therapy for more se-
vere cases of dysmenorrhea is also supported.
In Chinese medicine, menstrual symptoms are caused by
either the lack of blood in the body or stagnant qi or Blood.
The general treatment principles of Chinese medicine for
dysmenorrhea are to tonify the Kidney Deficiency, clear the
accumulation of Liver Fire, dissipate Cold, expel Wind, and
move qi and Blood. Acupressure involves the stimulation of
acupuncture points and meridians without the use of nee-
dles. Moreover, acupressure has been found to be safe and
effective for improving anxiety and stress-related ail-
reducing tension, promoting wellness, maintain-
ing the normal bodily functions, and providing comfort.
Particularly, in Chinese medicine theory, auricular acupres-
sure can activate and regulate the flow of qi and Blood. It
brings relief of symptoms by rebalancing Yin and Yang sta-
tus of internal organs and qi. Stimulating acupoints with
pressure triggers the production of a morphine-like natural
painkiller in the body called endorphins.
promotes the secretion of neurotransmitters that lead to pain
Dysmenorrhea may be related to nitric oxide (NO). Nitric
oxide is a potent vasodilator produced by endothelial and
other cells, which helps to control blood pressure, platelet
aggregation, and cytotoxicity.
The uterine muscle stabil-
ity is associated with a higher concentration of serum NO
level. NO activity has influences in the severity of dysmen-
orrhea symptoms and affects the homocysteine metabolic
pathway in dysmenorrhea symptoms.
NO level caused more frequent muscular and vascular con-
tractibility of the uterus.
There has been little evidence-based research to support
the effects of auricular acupressure for the management of
primary dysmenorrhea. Moreover, most of existing studies
does not include any physiologic indices to confirm the ef-
fect of acupressure in their research. Reports regarding the
role of auricular acupressure on NO changes in reducing
menstrual symptoms are scanty. No studies compared the
differences of auricular acupressure by seed-pressure
method and placebo adhesive patch for primary dysmenor-
rhea. Therefore, the present study was undertaken to evalu-
ate the effects of auricular acupressure on menstrual symp-
toms and serum level of NO in women with primary
Materials and Methods
This double-blinded, randomized clinical trial was con-
ducted in Taiwan. All participants met the following crite-
ria: (1) they were between 18 and 28 years old; (2) they had
no prior internal and gynecologic diseases, or secondary dys-
menorrhea affecting the progress of their menstrual period,
or underlying medical illness that causes primary dysmen-
orrhea; (3) a serum CA-125 level less than 35mg/dL was con-
firmed; (4) the initial onset of primary dysmenorrhea oc-
curred shortly after 6 months following menarche; (5) they
had complains of menstrual pain at least three times in the
past 6 months; (6) they had no smoking or drinking history;
(7) they were not taking over-the-counter analgesics (e.g.,
NSAIDs or other painkillers) during the study period; and
(8) they were able to speak Chinese or Taiwanese.
Power analysis by using SSize software (version 2.0; for
Windows; ECHIP, Inc.) was used to calculate the sample size.
A significance level of 0.05, power of the test of 0.8, propor-
tion of group 1 of 0.9, and proportion of group 2 of 0.6
showed that 32 women were needed in each group.
The pilot study. A convenience sample of 32 eligible par-
ticipants was sought for the pilot study. An issue arose from
this pilot study was that the adhesive acupressure patch
could not consistently stick well on acupoints after shower-
ing. However, this problem was solved after the provision
of education related to protection in the area of the acu-
The recruitment of the participants. A total of 90 college
women were recruited. A team staff not involved in the trial
organized and held the randomization list and numbered en-
velopes. The team staff passed envelopes to one of the two
researchers after demonstrating that the college student was
eligible and had consented to the trial. The researcher opened
WANG ET AL.236
envelopes to reveal study treatment allocation and then ad-
ministered the acupressure protocol. Another researcher was
only responsible for evaluating outcome measures.
All potential participants were screened using the Health
Examination Survey for any internal and gynecologic dis-
eases. No health problems listed were found. They also com-
pleted Short-form Menstrual Distress Questionnaire (MDQs)
and collection of CA-125 blood samples. CA-125 is a bio-
AURICULAR ACUPRESSURE ON PRIMARY DYSMENORRHEA 237
FIG. 1. Flow diagram of the progress of all data collection procedures. MDQs, Menstrual Distress Questionnaires.
chemical marker that was used to monitor benign disease
such as endometriosis and ovarian disease. Thus, CA-125 as-
say was selected as a screening test for determination of pri-
mary or secondary dysmenorrhea. Six (6) participants in the
experimental and control groups, respectively, were identi-
fied and excluded from the study as having CA-125 test re-
sults of greater than 35mg/dL. The blood sample was then
collected from the other 74 eligible participants in order to
determine their serum NO levels prior to acupressure ther-
apy just 0–2 days before menstrual period. The progress of
all procedures is outlined in Figure 1.
Auricular acupressure protocol
All participants were given a detailed description of the
auricular acupressure protocol. To control the reliability and
validity of auricular acupressure, the protocol was devel-
oped and set up as follows:
1. The acupressure protocol was developed based on the lit-
erature and the consultation with 3 physicians and experts
in Chinese medicine. Three (3) auricular acupressure
points—Liver (CO12), Kidney (CO10), and Endocrine
(CO18) —were selected for the study.
2. In the acupressure group (n37), auricular acupressure
was performed by using acupressure seeds named Semen
vaccariae. The seeds were kept in place by a piece of
opaque adhesive patch and fixed onto the three acupoints
3. Members of the control group (n37) had a plain adhe-
sive patch placed on the same points with no seed at-
tached. Both groups had acupressure.
4. Participants were instructed by one of the researchers on
(1) how to apply auricular acupressure, for example, the
procedure, duration, and intensity of auricular acupres-
sure by manually pressing lightly on every acupressure
point; (2) how to check and keep acupressure patches in
the right place and how to protect them; and (3) how to
record the time of application of acupressure and any pos-
sible side-effects in a diary after each session.
5. The next step in the application of acupressure included
massaging 15 times on each point of a sequence of three
acupressure meridian points, three times a day, for a to-
tal of 20 days.
6. To both enhance and ascertain the accuracy of timing for
a follow-up test, the anticipated time of the next menstrual
period was monitored.
7. For optimal treatment outcome and better hygiene, the
adhesive patch with/without the ear seed was renewed
and recorded every 5 days by the researcher.
8. Assessments of MDQs and NO level were performed
again starting within the first 2 days of their next menses.
However, 1 participant in the acupressure group and 2 in
the control group were dropped from the study because of
prolonged time between two menstrual periods and time
Short-form MDQs. The primary outcome measure was
The MDQs were used comprehensively to
screen women and identify those suffering from premen-
strual or menstrual distress on both psychologic and physi-
cal aspects. The original questionnaire has been shown pre-
viously to have split half reliabilities of 0.74–0.98,
internal consistency (Cronbach 0.83–0.84). The MDQs
were composed of 22 items from the full MDQ scale, which
were grouped into 4 categories, namely, pain, water reten-
tion, autonomic reactions, and negative affect. Participants
were asked to rate the presence of menstrual symptoms ex-
perienced during their most recent menstrual period on a 4-
point Likert-type scale, ranging from 1 (no experience of the
symptom) to 4 (severe or partially disabling symptoms).
Higher scores are indicative of increasing symptom distress.
Serum NO level. The secondary outcome was assays of
serum NO level. It was performed by utilizing the enzyme-
liked immunosorbent assay (ELISA) kit (Cayman Chemical
Company, Ann Arbor, MI) and ELISA reader (Immuno Bi-
ological Laboratories, IBL, Minneapolis, MN) according to
the manufacturer’s instructions for measurement. The incu-
bation time of the substrate reaction in the laboratory was
carefully controlled and ensured. Absorbance was deter-
mined by ELISA reader at 540 nm in a micro ELISA reader.
Values were presented as mean standard deviation
(SD). Mann-Whitney Utests and independent t-tests were
used for the analysis of menstrual symptoms. The 95% con-
fidence interval (95% CI) for the difference in the outcome
measures between groups was calculated. An effect size (ES)
analysis was computed to compare the mean of the acu-
pressure group with the mean of the control group. ES was
measured as the standardized difference between two post-
The mean age of the participants was 22.4 years (range:
19–28 years; Table 1). The average age of menarche was 12.5
years (range: 10–15 years). The average menstrual cycle was
29.2 days. More than half the participants (52%, n37) had
their initial onset of menstrual pain 6 months to 2 years fol-
lowing menarche. At baseline, mean serum CA-125 level for
all participants was 13.4 0.9 mg/dL (range: 0.5–33.2). No
baseline differences existed for demographics or assessments
between acupressure/control groups.
Primary outcome measure
Pain (61.9 14.6) and water retention (69.2 18.7) were
commonly reported categories for menstrual symptoms dur-
ing the menstrual period. Figure 2 presents the differences
at baseline and after application of acupressure among
groups. The 10 most frequently reported symptoms experi-
enced during participants’ most recent menstrual period are
presented in Table 2.
The global score of the MDQs showed that the mean post-
test scores of both the experimental and control groups de-
creased compared with that of the pretest scores. This indi-
cated that improvements in menstrual symptoms were
observed in both groups (Table 3). Moreover, the overall
menstrual symptoms (95% CI 49.8 to 6.5, ES 0.43, p
WANG ET AL.238
0.01) and the categories of pain (95% CI 16.4 to 2.2, ES
0.45, p0.01), and negative affect (95% CI 11.9–2.0, ES
0.38, p0.04) of the acupressure group revealed that men-
strual symptoms of the acupressure group decreased signif-
icantly after auricular acupressure by the seed-pressure
method, in comparison with that of the control group. How-
ever, the ES for the four categories of the MDQs were in fa-
vor of the auricular acupressure by the seed-pressure
AURICULAR ACUPRESSURE ON PRIMARY DYSMENORRHEA 239
Acupressure group Control group
Mean (SD) n(%) Mean (SD) n(%) p value
Age 22.3 (2.4) 22.6 (2.6) 0.82
Age at menarche (years) 12.6 (1.2) 12.4 (1.1) 0.77
Menstrual cycle (days) 28.8 (3.6) 29.7 (3.5) 0.20
The initial onset of 0.30
Within 6–24 months 22 (61.1) 15 (42.9)
After 24 months of 9 (25) 12 (34.3)
Cannot remember 5 (13.9) 8 (22.9)
Times of menstrual 4.9 (1.5) 5.3 (1.2) 0.39
Pain 60.9 (11.1) 62.9 (17.5) 0.57
Water retention 68.5 (18.2) 69.9 (19.4) 0.60
Autonomic reactions 58.7 (18.3) 58.7 (19.9) 0.73
Negative affect 54.9 (13.2) 58.6 (18.8) 0.54
Total scores 242.97 (44.9) 250.1 (57.4) 0.56
CA-125 11.7 (6.8) 15.3 (8.8) 0.07
Nitric oxide 0.353 (0.12) 0.340 (0.16) 0.72
MDQs, Menstrual Distress Questionnaires, SD, standard deviation.
45.64 ± 1.53**
60.86 ± 1.85 62.89 ± 2.97
57.00 ± 2.25**
52.97 ± 2.13**
68.50 ± 3.03 69.94 ± 3.27
60.69 ± 2.34*
47.28 ± 1.58**
58.67 ± 3.04
58.69 ± 3.37
55.14 ± 2.43
42.19 ± 1.37*
54.94 ± 2.20 58.63 ± 3.18
50.83 ± 2.04*
FIG. 2. Comparisons of Menstral Distress Questionaires in acupressure and control groups at baseline and after applica-
tion of acupressure. * p0.05; ** p0.01
method. This suggested that overall menstrual symptoms in
the acupressure group significantly improved more than in
the control group (Table 3).
Secondary outcome measure
Mean serum NO level at baseline for the acupressure
group was 0.353 (SD 0.12) and 0.340 (SD 0.16) for the
control group (Table 3). There was no statistically significant
difference in serum NO levels when the acupressure group
was compared with the control group (p0.46).
Women experience menstrual distress and related dis-
comforts during the menstrual period that result in impaired
quality of life, fatigue, irritability, and depression. These lead
to negative impacts on the emotional health, performance,
and functioning of women.
The auricular points
including endocrine, uterus, shenmen, brain, liver, spleen,
kidney, etc. have often been used for dysmenorrhea. Three
selected auricular acupressure points—liver, kidney, and en-
docrine in the present study—are considered to encircle the
reproductive organs, simultaneously activate the endocrine
system, store blood, and ensure the smooth flow and direc-
tion of Qi movement in the body. Although the applied acu-
pressure points and ways of doing acupressure in the pres-
ent study differed from those used in other studies,
reported effects of acupressure are generally similar to those
of previous studies in the same area. The effect of acupres-
sure on the management of primary dysmenorrhea has been
Furthermore, acupressure is effective in reduc-
ing low back pain,
and pain relief for pa-
tients with sickle cell disease.
Thus, acupressure, with no
complications, appears to be effective for pain management
and the decrease of the severity of primary dysmenorrhea.
Actual differences or improvements in outcome measures
between the two groups are significantly obvious, and thus
may be clinically meaningful. In the present study, there
were greater improvements in negative affect and pain. This
may suggest that acupressure may also induce the relaxation
response. This was further supported by the improvement
of mood swings, irritability, and anxiety in this study. Such
findings are comparable to acupressure studies that found
that acupressure treatment is effective in decreasing anx-
parental preoperative anx-
and improvements in quality of life.
This study design is unique in the comparison of the ef-
fects of auricular acupressure using S. vaccariae seeds and
acupressure without seed attachment. Females college stu-
dents undergoing auricular acupressure treatment by the
seed-pressure method experienced a statistically significant
and overall improvement in menstrual symptoms as com-
pared to those who received acupressure without seed at-
tachment to the points. There is a possible reason for such a
WANG ET AL.240
Category Mean (SD) Menstrual symptom Mean (SD) Rank
Pain 61.9 (14.6) Fatigue 1.6 (0.95) 2
Backache 1.5 (0.96) 5
Cramp 1.2 (0.96) 8
General aches and pains 0.9 (0.95) 9
Water retention 69.2 (18.7) Abdominal swelling 1.7 (1.08) 1
Tender breasts, breast swelling 1.3 (1.10) 6
Skin disorders 1.2 (0.92) 7
Negative affect 56.8 (16.2) Mood swings 1.6 (1.06) 3
Irritability 1.5 (1.10) 4
Restlessness 0.8 (0.86) 10
SD, standard deviation.
Acupressure group (n36) Control group (n35)
Pre-test Post-test Mean Pre-test Post-test Mean
Mean (SD) Mean (SD) difference Mean (SD) Mean (SD) difference 95% CI p-value ES
Pain 60.9 (11.1) 45.6 (9.19) 15.2 62.9 (17.5) 57.0 (13.3) 5.9 16.4–2.2 0.01** 0.45
Water retention 68.5 (18.2) 52.9 (12.8) 15.5 69.9 (19.4) 60.7 (13.8) 9.2 14.6–2.1 0.14 0.28
Autonomic reactions 58.7 (18.3) 47.3 (9.5) 11.4 58.7 (19.9) 55.1 (14.4) 3.6 16.4–0.7 0.19 0.31
Negative affect 54.9 (13.2) 42.2 (8.2) 12.7 58.6 (18.8) 50.8 (12.1) 7.8 11.9–2.0 0.04* 0.38
Total score 242.97 (44.9) 188.08 (30.1) 54.8 250.1 (57.4) 223.7 (43.6) 26.4 49.8–6.5 0.01** 0.43
Serum NO level 0.353 (0.12) 0.366 (0.24) 0.340 (0.16) 0.321 (0.22) 0.01–0.1 0.46 0.45
The ES represents effect sizes of the post-test between both groups. The 95% CI is the confidence interval for differences.
MDQs, Menstrual Distress Questionnaires; SD, standard deviation; CI, confidence interval; ES, effect sizes.
difference in relieving menstrual symptoms (i.e., the effect
of seed-embedded acupressure to the applied points). Au-
ricular acupressure is thought to promote wellness and op-
timize overall health.
There is often a clear sensation of qi
when the seed is applied. Auricular acupressure by seed-
pressure method facilitates the movement of qi and Blood
through the channels. This method has a synergistic effect
compared with auricular acupressure with no seed placed.
It is possible that seeds could deeply stimulate the acupres-
sure points and work at a higher energy level. Thus, auric-
ular acupressure with the seed-pressure method may be
more effective to deal with menstrual symptoms than acu-
pressure with no seed-attachment method. Prior research has
not consistently identified the role S. vaccariae plays to
achieve a better therapeutic effect, but does indicate the con-
sistent use of S. vaccariae as a popular method for seed-press-
A possible mechanism of NO in response to the improve-
ment of menstrual distress was presented by a current
They suggest that the NO pathway may be involved
in the pathophysiologic mechanism responsible for the dam-
aging effects of homocysteine on women with dysmenor-
rhea. An effect on NO level was expected after using acu-
pressure. Measurement of NO level increased slightly over
the study period (not significant) in the acupressure group
and decreased in the control group. However, there was also
no significant difference in serum NO level between the two
groups. This indicated that further research may be needed
to determine whether there is indeed an effect of auricular
acupressure as designed in the present study on NO level.
Limitations in this study must be considered when re-
viewing the results. The use of serum CA-125 testing may
have limited clinical value as a screening test for endome-
triosis and in evaluating women with dysmenorrhea. The
limitations also included the short time frame. The short time
frame made it unlikely that measurable changes in NO lev-
els would be evident.
Auricular acupressure by seed-pressure method effec-
tively improved menstrual symptoms of women. An ex-
pected effect of auricular acupressure on NO level was not
found. However, findings from this study have implications
for health care providers to consider incorporating auricular
acupressure in their clinical practice when caring for women
with menstrual symptoms. It is also important for women to
consider administering auricular acupressure technique for
themselves through appropriate training and find relief
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Address reprint requests to:
Chi-Feng Liu, Ph.D.
Graduate Institute of Integration of Traditional Chinese
Medicine with Western Nursing
National Taipei College of Nursing
No. 365, Ming-Te Road
Taipei City, Taiwan
Republic of China
WANG ET AL.242