acupressure and massage therapy are effective non - pharmacologic therapies and can be effective in reducing menstrual pain . the body 's vital energy , called chi in chinese medicine , moves in the body pathways known as meridians . the increase or decrease of energy in each meridian can affect the health of specific organs . there are many points in meridians that are used to apply acupressure in traditional chinese medicine . acupressure relieves symptoms of dysmenorrhea , such as pain , depression , anxiety , and stress . but in another study , no significant relationship was found between painful menstruation and anxiety . one of the energy - consuming organs of the liver meridian is genitalia , and acupressure on the liv3 can treat dysmenorrhea . although no study has been conducted about any change in anxiety occurring after acupressure on liv3 point , anxiety is associated with pain and pain relief may lead to an anxiety reduction . some studies have reported that acupressure can reduce dysmenorrhea and the anxiety caused by dysmenorrhea . but there are studies reporting that anxiety did not decrease on applying acupressure by the research unit or the researcher . considering that each meridian can affect the health of specific organs , the insufficient data about the effectiveness of acupressure at liv3 on dysmenorrhea , the lack of reports about its effectiveness on anxiety caused by dysmenorrhea , contradictory reports about the relationship between acupressure and anxiety caused by dysmenorrhea , the importance of applying acupressure by the research unit , and the simplicity and accessibility of acupressure , this study intends to determine the effect of acupressure at the liv3 point on anxiety level in patients with primary dysmenorrhea . it has been approved by the ethics committee of kashan university of medical sciences ( kaums ) with the number /29/5/1/3613 and registered in iranian registry of clinical trials ( irct ) with the number irct201201308869n1 . acupressure was performed on the treatment and placebo points . in the control group ( group a ) , acupressure was given in placebo point that was located 2 cun above the distance between the third and fourth fingers ( this point is not located on the path of meridians [ figure 1 ] . in treatment group ( group b ) , acupressure was given on the liv3 point located 2 cun ( width of three fingers ) above the distance between the first and second metatarsal bones . the study was performed at dormitory of kaums between march and june 2012 for three menstrual cycles . inclusion criteria were self - reported , including living at dormitory ; being single ; having regular menstrual periods ; pain starting with menstrual bleeding onset ; duration of bleeding between 3 and 8 days and menstrual interval between 21 and 35 days ; dysmenorrhea with pain intensity equal to or higher than 4 based on visual analog scale ( vas ) for pain intensity ; lack of anemia , high blood pressure , or known systemic or genital disease , and severe psychological stress in the past 6 months ( students were asked whether or not they have had severe emotional stress such as the death of relatives , surgeries , marriage , or divorce of parents in the past 6 months ) . exclusion criteria were self - reported , including use of heat for pain relief ; use of oral contraceptives , non - steroidal anti - inflammatory drugs , analgesics , or prostaglandin synthesis inhibitors from 4 h before to 4 h after acupressure ; and not cooperating until the end of the third period of the menstrual cycle . sample size was estimated as 27 students per group based on a pilot study . considering 80% power and 95% confidence level , inclusion and exclusion criteria , and the possible loss of samples , public invitation was extended to 500 dormitory living students . liv3 and placebo points block randomization was done with 1:1 allocation ratio based on pain intensity . at first , the researcher learned the technique of acupressure from a traditional chinese medicine professor and applied it on the subjects . she was in constant contact with the students face to face , by telephone , or via post . also , spielberg ( stai ) anxiety questionnaire was completed by the students before and after intervention . on the first day of the first cycle , pain intensity was measured without intervention at the start of bleeding and after 0.5 , 1 , 2 , 3 , and 4 h. dysmenorrhea was assessed according to vas for pain intensity . subjects with pain score equal to or greater than 4 were selected . at this time students were taught to find the exact location of acupoints and to apply acupressure technique . at first , acupressure was applied by the researcher in a clockwise rotation . pressure was continued until the students reported de chi ( feeling the symptoms of heat , cold , or tingling ) . students were asked to apply the same pressure and pay attention to their nail color change . in the second and third cycles , students applied pressure by themselves at the bleeding onset . it was stopped with feeling de chi ; otherwise , it was continued for 2 min and resumed on the other foot after a 2 min rest . pressure was applied twice on each leg and a total of four times ( 16 min ) in clockwise rotation . pain was measured at the start of bleeding and after 0.5 , 1 , 2 , 3 , and 4 h. after the third menstrual cycle , anxiety questionnaire was completed by the participants for the second time . students were informed that they might be placed in control or intervention groups and they could discontinue cooperating in the study at any time they wanted . we used a digital glass scale ( gs46 ) with 100 g accuracy that was made in germany for measuring the weight and a single non - elastic tape for measuring the height . pressure exerted by the fingers of the researcher and the student was determined by a force gauge device . vas pain scale is a ruler used by the research units to rate their pain . distance between the beginning of the ruler to the marked point will be the numerical pain score of the unit . spielberg anxiety questionnaire has 40 questions in two areas ; each area has 20 questions . each question has four options and a rating between 1 and 4 . in apparent anxiety , a score of 4 indicates too high , 3 means high , 2 indicates low , and 1 means very low . in hidden anxiety , a score of 4 means almost always , 3 means often , 2 indicates almost never , and 1 means never . anxiety score from 40 up to 80 is considered as low , 81 - 120 as moderate , and 121 - 160 as high . additionally the internal consistency reliability of the measure has been supported in this study achieving an alpha value of .85 . in this questionnaire , some phrases indicate absence of distress and are weighted inversely , including 1 , 2 , 5 , 8 , 10 , 11 , 15 , 16 , 19 , 20 for apparent anxiety and 21 , 23 , 26 , 27 , 30 , 33 , 34 , 36 39 for hidden anxiety . confounding variables were matched between groups , including painful menstrual history in first - degree relatives , age at menarche , interval between menarche and onset of dysmenorrhea , menstrual duration , and body mass index ( bmi ) . results were reported as mean [ standard deviation ( sd ) ] or frequency ( % ) for qualitative variables and mean ( min .- max . ) for quantitative variables . to check the consistency of underlying variables , t - test or chi - square test was used according to the nature of variables . mann - whitney was used to compare the pain intensity between groups in the first cycle . to compare the anxiety scores between groups in the first cycle , t - test was used . to compare the anxiety scores before and after intervention , paired sample t - test was used . also , in the third cycle , univariate analysis of variance with adjustment of the baseline values in the first cycle was used to compare the anxiety scores between groups . , the researcher learned the technique of acupressure from a traditional chinese medicine professor and applied it on the subjects . she was in constant contact with the students face to face , by telephone , or via post . also , spielberg ( stai ) anxiety questionnaire was completed by the students before and after intervention . on the first day of the first cycle , pain intensity was measured without intervention at the start of bleeding and after 0.5 , 1 , 2 , 3 , and 4 h. dysmenorrhea was assessed according to vas for pain intensity . subjects with pain score equal to or greater than 4 were selected . at this time , 67 remaining students were randomly divided into two groups . students were taught to find the exact location of acupoints and to apply acupressure technique . at first , acupressure was applied by the researcher in a clockwise rotation . pressure was continued until the students reported de chi ( feeling the symptoms of heat , cold , or tingling ) . students were asked to apply the same pressure and pay attention to their nail color change . in the second and third cycles , students applied pressure by themselves at the bleeding onset . it was stopped with feeling de chi ; otherwise , it was continued for 2 min and resumed on the other foot after a 2 min rest . pressure was applied twice on each leg and a total of four times ( 16 min ) in clockwise rotation . pain was measured at the start of bleeding and after 0.5 , 1 , 2 , 3 , and 4 h. after the third menstrual cycle , anxiety questionnaire was completed by the participants for the second time . students were informed that they might be placed in control or intervention groups and they could discontinue cooperating in the study at any time they wanted . we used a digital glass scale ( gs46 ) with 100 g accuracy that was made in germany for measuring the weight and a single non - elastic tape for measuring the height . pressure exerted by the fingers of the researcher and the student was determined by a force gauge device . vas pain scale is a ruler used by the research units to rate their pain . distance between the beginning of the ruler to the marked point will be the numerical pain score of the unit . spielberg anxiety questionnaire has 40 questions in two areas ; each area has 20 questions . each question has four options and a rating between 1 and 4 . in apparent anxiety , a score of 4 indicates too high , 3 means high , 2 indicates low , and 1 means very low . in hidden anxiety , a score of 4 means almost always , 3 means often , 2 indicates almost never , and 1 means never . anxiety score from 40 up to 80 is considered as low , 81 - 120 as moderate , and 121 - 160 as high . reliability and validity of this questionnaire additionally the internal consistency reliability of the measure has been supported in this study achieving an alpha value of .85 . in this questionnaire , some phrases indicate absence of distress and are weighted inversely , including 1 , 2 , 5 , 8 , 10 , 11 , 15 , 16 , 19 , 20 for apparent anxiety and 21 , 23 , 26 , 27 , 30 , 33 , 34 , 36 39 for hidden anxiety . confounding variables were matched between groups , including painful menstrual history in first - degree relatives , age at menarche , interval between menarche and onset of dysmenorrhea , menstrual duration , and body mass index ( bmi ) . results were reported as mean [ standard deviation ( sd ) ] or frequency ( % ) for qualitative variables and mean ( min .- max . ) for quantitative variables . to check the consistency of underlying variables , t - test or chi - square test was used according to the nature of variables . mann - whitney was used to compare the pain intensity between groups in the first cycle . to compare the anxiety scores between groups in the first cycle , t - test was used . to compare the anxiety scores before and after intervention , also , in the third cycle , univariate analysis of variance with adjustment of the baseline values in the first cycle was used to compare the anxiety scores between groups . in the liv3 group , 33 students and in the control group , 34 students were enrolled and included in the study . of these , 11 students in the liv3 group and 20 students in the control group were kept for analysis because of the possibility of losing the samples . the mean ( sd ) for age , bmi , menarche , bleeding duration , menstrual intervals , family history of dysmenorrhea , pain intensity , use of painkillers , heat , and massage did not have a significant difference between groups . also , anxiety level in the first cycle had no difference between groups . mean ( sd ) values for apparent anxiety in the control and liv3 groups are shown in table 1 . this table indicates that acupressure on liv3 point caused decrease in apparent anxiety ( p < 0.05 ) . moreover , there was no significant difference for hidden anxiety in any of the groups . univariate analysis of variance did not show a significant difference for apparent ( p = 0.337 ) and hidden anxiety ( p = 0.438 ) between groups , when adjustment for baseline values in the first cycle was done . this study was done to determine the effect of acupressure at liv3 and placebo points on the anxiety level in patients with primary dysmenorrhea . in this study , this is the first report of the relationship between anxiety reduction and acupressure on liv3 acupoint . we did not find any study that evaluated the effect of acupressure at liv3 on anxiety . there are also some reports of reduction in dysmenorrhea on applying acupressure on sp6 acupoint . since pain is associated with anxiety , pain relief can decrease anxiety , and this issue can confirm our result . chen et al . ( 2004 ) studied the effect of acupressure at sp6 point on the level of anxiety . they showed a decrease in anxiety after acupressure ; but they used vas anxiety and studied persons with a pain score of 5 or more according to vas pain intensity , whereas we assessed anxiety with spielberg questionnaire and studied students with a pain score of 4 or more according to vas pain intensity . 's study is that the pressure was applied by the research units . in their study , acupressure on sp6 was firstly done by a researcher , which caused decrease in dysmenorrhea and anxiety . but when acupressure was done by the research units , it just caused decrease in dysmenorrhea and not anxiety . lee et al . ( 2003 ) reported that acupressure on the sp6 point can reduce anxiety during labor without having adverse effects on the mother and baby . also , in the study of charandabi ( 2011 ) , reduction of menstrual symptoms severity scores after treatment was significantly more in the intervention group ( acupressure on sp6 acupoint ) as compared with the control group . ( 2012 ) did not show any decrease in anxiety on applying acupressure on the sp6 point . it may be due to applying pressure on more than one acupoint resulting in decrease in duration of pressure on each point . . showed decrease in hidden anxiety on applying pressure on p6 point . in this study , acupressure on the placebo point was not effective on the anxiety level . although some studies reported the effectiveness of acupressure on the placebo point , this effect was more in the intervention group . chen et al . 's ( 2004 ) study confirms our study . in their study , the intervention group received 20 min of pressure on sp6 point and the control group had 20 min break ; reduction of anxiety was not seen in the control group . but the control group in our study received the same acupressure in the placebo point . another important point to be noted in our study is that the researcher was not present when the pressure was applied , whereas the presence of a researcher along with the patient can reduce the anxiety level . this is the first report that has shown reduction of anxiety associated with dysmenorrhea after applying acupressure on the liv3 acupoint . also , successful self - treatment by the participants indicates that this approach can help women to reduce their anxiety without seeking any help from someone else .