Table 1 Characteristics of included studies

Akin 2004

USA / 344 women

Active heat wrap (40 degrees C) for eight hours

Oral acetaminophen (paracetamol) 500 mg 4 times per day for one day

1 day, starting on the first day of moderate or greater menstrual pain

Pain relief (categorical 0–5 score, 0 = no pain relief, 5 = complete pain relief) during the eight hours

Adverse events

Heat was superior to oral acetaminophen in reducing menstrual pain. One mild AE in the heat group (pink skin)

Akin 2001

USA / 81 women

Heat patch (180cm², 38.9 °C) for 12 h each day, plus placebo pills.

3 comparator groups:

1- Heat patch (180 cm2, 38.9 °C) plus ibuprofen 400 mg, 3 times per day

2- Unheated patch (180 cm2) plus ibuprofen 400 mg, 3 times per day

3- Unheated patch plus placebo pills

2 days – from onset of menstrual pain

Pain relief (categorical 0–5 score, 0 = no pain relief, 5 = complete pain relief) during the 12 h

Adverse events

Heated patch plus ibuprofen, heated patch plus placebo pills and unheated patch plus ibuprofen all showed similar pain reductions. The time to onset of pain reduction was shorter in the heated patch plus ibuprofen group compared to the unheated patch plus ibuprofen. No adverse events reported

Potur 2014

Turkey / 193 women

Heat patch (180cm², 38.9 °C, 8 h)

2 comparator groups:

1. Self-medication group (SMG) – single dose of analgesics of participants choice

2. Control group – no medication but could use single dose of oral analgesic if pain was unbearable.

1 day, first day of menses

Pain intensity (VAS) at 4 h and 8 h after starting treatment

Quasi-randomised based on presentation order. The group receiving the heat patch reported the greatest pain reduction at 4 h and at 8 h after the start of the intervention.

Rigi 2012

Iran / 150 women

Heat patch (84 cm², 40 °C, 8 h)

Ibuprofen (400 mg) every 8 h as needed

1 Day. First day of menses, once menstrual bleeding started

SF-MPQ at 24 h after starting treatment.

Total pain score as measured by SF-MPQ was not significantly different between groups at 24 h after onset of menses. There was no pre-post comparison. Fchar

Aghamiri 2005

Iran / 100 women

Acupressure at unspecified points on the abdomen, near the waist and in the leg. 15 min pressure, 15 min rest, then 15 min pressure

Sham acupressure: Same as active group but using ‘off channel’ points.

Frequency and timing of treatment not reported

Pain intensity (VAS) at 180 min following treatment.

Article translated from Farsi. Acupressure group had significantly lower pain scores at 180 min post treatment than sham.

Behbahani 2016

Iran / 120 women

Acupressure at CV4 and CV2. Pressure was applied for 15 s and then 15 s of rest for a total of 20 min.

Two comparator groups:

1. Self-care behaviours. Four 60–90 min sessions, once per week. Isometric exercises were also taught.

2. Ibuprofen group: 400 mg, three times per day.

Acupressure applied over the first two days of menses for two cycles.

Comparator groups: Unclear about timing in relation to menses.

McGill pain questionnaire (MPQ) at the end of the 2 month intervention.

Both training and acupressure groups had greater reductions in pain than the ibuprofen group, however no between group comparisons were performed.

Bazarganipour 2010

Iran / 194 women

Acupressure at LR3. Two minutes of firm pressure then two minutes of ‘massage’ on the point. Twenty minutes in total per session. Unclear if alternating sides were used.

Sham Acupressure. Point located at the same level as LR3 but between the 3rd and 4th toes.

Starting three to seven days before menses, for two menstrual cycles.

Andersch and Milsom Scale (0 = no inhibition by pain 3 = work clearly inhibited by pain) during the first menstrual cycle post intervention.

Pain scores decreased in both groups from baseline but the reduction was significantly greater in the acupressure group

Charandabi 2011

Iran / 72 women

Acupressure at SP6. Four seconds of pressure and two seconds without pressure, for five minutes. After five minutes the alternate leg was used, for a total of 20 min per day (4 × 5 min cycles).

Ibuprofen (400 mg) every 6 h as needed

Starting from onset of menstrual pain for two menstrual cycles.

Menstrual symptom severity (5 point Likert scale) for eight symptoms (cramp, headache, back pain, leg pain, depression, irritability, general pain and abdominal pain)

Ibuprofen consumption

Menstrual symptom severity had a greater reduction in the acupressure group compared to the ibuprofen group.

Chen 2004

Taiwan / 69 women

Acupressure at SP6. Alternate legs used, two five minute cycles of pressure on each leg (20 min total).

Rest: Participants rested in the school health centre for 20 min.

Once during menses when participants were experiencing cramping

Pain intensity (VAS) at the end of the intervention

No significant difference in pain intensity scores between groups.

Chen 2010

Taiwan / 134 women

Acupressure at LI4 + SP6. Six seconds of pressure, then two seconds without pressure for five minutes per cycle. Two cycles per acupressure point for four cycles (20 min) in total.

Three comparator groups:

1. Acupressure at LI4:

Same as active intervention but on LI4 point only.

2. Acupressure at ST36:

Same as active intervention but on LI4 point only.

3. Rest: Participants rested in the school health centre for 20 min.

Every day, for the first three days of menses for six menstrual cycles.

Pain intensity (VAS) at the end of the six month follow up period.

Menstrual symptoms and distress as measured by the Moos MDQ at the end of the six month follow up period

Active group (LI4 + SP6) vs rest was included in the meta-analysis.

LI4 + SP6 group had the greatest reduction in pain intensity and menstrual distress compared to all three comparator groups.

Chen 2015

Taiwan / 129 women

Acupressure at SP6, BL32 and LR3. Four seconds of pressure, then two seconds without pressure, repeated 10 times per minute. After five minutes the alternate side of the body was used for another five minutes. Two five-minute cycles per point, for 30 min in total.

Education control:

Education on the use of supplements and dietary therapy for dysmenorrhea.

Three times per week for twelve months.

Pain intensity (VAS) at the end of the 12 month follow up period.

Menstrual symptoms and distress as measured by the Moos MDQ at the end of the 12 month follow up period

The acupressure group had greater reductions in pain intensity and menstrual distress compared to the education only group.

Kashefi 2010

Iran / 86 women

Acupressure at SP6 for 30 min, once per cycle.

Sham acupressure: Same as active group but using an ‘off channel’ points.

Frequency and timing of treatment not reported

Pain intensity (VAS) at 180 min following treatment.

Article translated from Farsi. Acupressure group had significantly lower pain scores at 180 min post treatment than sham.

Mirbagher-Ajorpaz 2011

Iran / 30 women

Acupressure at SP6. Eight seconds of pressure and two seconds for rest for twenty minutes in total.

Sham acupressure at SP6 (“light touch”), where no pressure was applied to SP6.

Once during menses, timing unclear.

Pain intensity (VAS), at end of intervention, 1,2 and 3 h post intervention.

Acupressure caused a much greater reduction in pain scores from baseline than sham acupressure.

Pouresmail 2002

Iran / 216 women

Acupressure at SP6, LR3, LI4, SP16, ST36. Pressure for two minutes for each point. Total number of minutes unclear.

Two comparator groups:

1. Sham acupressure at two locations on the arms and two on the legs

(exact locations not given). Pressure for two minutes for each point.

2. Ibuprofen (400 mg) three times per day for three days.

Starting 24 h before onset of menses for one cycle.

Andersch and Milsom Scale (0 = no inhibition by pain 3 = work clearly inhibited by pain) at end of intervention

Pain intensity (VAS), at end of intervention

Pain measured on both VAS and Andersch and Milsom Scale decreased in all groups after intervention, however ibuprofen and acupressure had the greatest reduction.

Wang 2009

Taiwan / 74 women

Auricular acupressure at Liver (CO12), Kidney (CO10) and Endocrine (CO18) points using acupressure seeds under adhesive patch. Points were stimulated 15 times, three times per day.

Sham adhesive patch: Patches placed on same points as active group but no acupressure seed. Points were stimulated 15 times, three times per day in same manner as active group.

20 days.

Moos MDQ at end of intervention (20 days)

Auricular acupressure group had lower MDQ scores at the end of intervention compared to sham.

Wong 2010

Hong Kong / 40 women

Acupressure at SP6. 15 s of pressure followed by 15 s of rest. Repeated 10 times, totalling five minutes per cycle. Two cycles per leg for a total of 20 min per treatment. Performed twice per day upon waking and at bedtime

No treatment – participants were told to rest for 20 min upon waking and at bedtime.

First three days of menses, for three menstrual cycles.

Pain intensity (VAS) at end of intervention

McGill pain questionnaire (SF-MPQ) at end of intervention

Moos MDQ (MMDQ) at end of intervention

The acupressure group had a significantly greater reduction from baseline in pain intensity, SF-MPQ and MMDQ scores at the end of the three month intervention.

Yeh 2013

Taiwan / 113 women

Auricular acupressure at Shenmen, Liver, Kidney, Internal Genital, Central Rim and Endocrine acupressure seeds under adhesive patch. Points were stimulated for 1 min each point, four times per day

Sham acupressure:

Six auricular acupressure points with no expected effects on dysmenorrhea (wind stream, tonsils, trachea, esophagus, internal nose, pharynx and larynx) using acupressure seeds under adhesive patch. Points were stimulated for 1 min each point, four times per day

2 days from onset of menstrual pain

Pain intensity (VAS) at the end of the intervention

Moos MDQ at end of intervention

Auricular acupressure group had greater reductions in both pain and MDQ scores from baseline than sham.

Zafari 2011

Iran / 296 women

Acupressure at SP6. Four seconds of pressure and two seconds without pressure, for five minutes. After five minutes the alternate leg was used, for a total of 20 min per day (4 × 5 min cycles).

Ibuprofen (400 mg) at onset of pain and taken every eight hours if needed .

From onset of menstrual pain, number of days per cycle unclear. Two menstrual cycles.

Pain intensity (self-reported), scale unclear.

Both acupressure and ibuprofen groups had reductions in pain from baseline and there was no between group differences.

Abbaspour 2006

Iran / 150 women

Stretching exercises:

1- Lie face up with legs and knees bent perform

abdominal breathing about 10 times.

2- Stand holding backs of chair; lift one heel off

the floor, then the other, repeat 20 times.

3- Stand holding back of chair then does 5 deep

knee bends.

4- While lying on back lift and bring knees to

touch chin, 10 times. Performed

twice a day for 20 min. Exercise was not performed during menstruation

No treatment

Two menstrual cycles

Pain intensity (VAS), at end of intervention

Pain duration (hours) at end of intervention

Both severity and duration of pain decreased significantly from baseline in the stretching group. No change in the control group.

Motahari-Tabari 2017

Iran / 122 women

Stretching exercises:

included a five-minute warm up in a standing position and then six belly and pelvic stretching exercise for 10 min. This program was performed for 15 min, three times a week. Exercise was not performed during menstruation

Mefenamic acid (250 mg) every eight hours when in pain.

Two menstrual cycles (8 weeks)

Pain intensity (VAS), at end of intervention

Pain duration (days) at end of intervention

Pain intensity and duration significantly decreased in both groups from baseline, with no differences between groups.

Rakhshaee 2011

Iran / 92 women

Yoga postures:

Cobra, Cat and Fish postures, one 20 min session per day,

No treatment

Luteal phase of menstrual cycle (14 days) for two menstrual cycles

Andersch and Milsom Scale (0 = no inhibition by pain 3 = work clearly inhibited by pain) at end of intervention

Pain duration (hours) at end of intervention

Quasi-randomised based on location Pain severity and duration decreased significantly from baseline in the Yoga group, and this was significantly different to the no treatment group.

Shahr-Jerdy 2012

Iran / 179 women

Stretching exercises: Six exercises in the abdominal, pelvic and groin region. Three days per week and two times per day for 10 min. Exercise was not performed during menstruation

No treatment

Two menstrual cycles (8 weeks)

Pain intensity (VAS), at end of intervention

Pain duration (hours) at end of intervention

Analgesic usage (number of tablets) at end of intervention

Quasi-randomised based on location. Stretching exercise group pain intensity, duration and analgesic usage decreased significantly from baseline and this was significantly different to the no treatment group.

Yang 2016

Korea / 40 women

Yoga postures:

10 cycles of surya namaskara for 15 min and then performed shavasana for 5 min of relaxation. Next, five cycles of cat, cobra, and fish yoga poses were performed for 10 min. Finally, the participants performed yoga nidra for 30 min. Yoga nidra was performed in shavasana. This was done for 1 h once a week.

No treatment

12 weeks

Pain intensity (VAS), at end of intervention

Pain duration (hours) at end of intervention

Moos Menstrual Distress Questionnaire (MMDQ) at the end of the intervention.

Adverse events

Menstrual pain intensity and distress decreased significantly in the yoga group compared to the no-treatment group. No participant reported adverse events.