Systematic Review

Aromatherapy for the Management of Menopause Symptoms: An Updated Systematic Review and Meta-analysis

Introduction

Menopause is a significant milestone in a woman’s life that signifies the conclusion of her ability to reproduce.¹ The average worldwide life expectancy recorded a major increase from 66.8 years in 2000 to 73.3 years in 2019.² The World Health Organization predicts that the population of menopausal women will reach 1.2 billion by the year 2030.¹ By 2030, it is expected that 76% of the projected population will reside in developing countries.³ The health of women during menopause has become a global concern, as they typically spend approximately one-third of their lifespan at this stage.⁴ The symptoms experienced during menopause are diverse and result from a complex combination of biological, social, and psychological variables.⁵ The typical manifestations of menopause can be classified into three main groups: short-term impacts such as hot flashes, sweating, psychological issues, sleep disturbances, and joint pain; intermediate difficulties including vaginal and urinary symptoms, as well as sexual difficulties; and long-term symptoms such as osteoporosis and cardiovascular disease.^6,7 Globally, moderate-to-severe vasomotor symptoms were more common in Europe (40%) than the USA (34%), and both were greater than Japan (16%),⁸ 31% in France, and 52% in Italy.⁹ Between 13% and 87% of women experiencing menopause have at least one symptom associated with genitourinary syndrome of menopause.¹⁰

Menopause, a natural stage of the female life course that occurs as a result of aging in women, could increase the risk of health problems.¹¹ The treatment options for menopause symptoms are broadly classified into two categories: pharmacological and nonpharmacological. Long-term use of hormone replacement therapy is a pharmacological treatment that has a risk of major side effects. Consequently, during the past ten years, a large number of women have been investigating safer and more profitable alternative medicines.¹² Among the non-pharmacological, complementary, and alternative therapies available, aromatherapy is highlighted as one of the various approaches. ¹³

The results of an investigation of a study carried out in Indonesia indicate that fennel aromatherapy has a significant impact on reducing the severity of menopausal symptoms (P < 0.0001).¹⁴ The findings of Kian et al, which demonstrate that fennel can enhance menopausal women’s quality of life and reduce menopausal symptoms without having any negative side effects, further confirm this.¹⁵ Another study’s findings indicate that using Lavandula angustifolia Mill. essential oil reduces menopause symptoms.¹⁶ Additionally, according to Lucena et al the aromatherapy intervention using lavender essential oil was effective in improving the overall quality of life in postmenopausal women.¹⁷ Aromatherapy has also been shown to reduce anxiety and enhance relaxation, potentially providing relief for distressing menopausal symptoms.¹⁸

Even though several studies have found aromatherapy to be beneficial during menopause, there is presently no updated comprehensive study that consolidates and analyzes all of the effects of this alternative method on menopausal symptoms. Therefore, the present meta-analysis aimed to determine and update the impacts of aromatherapy on the management of menopausal symptoms. While previous studies have explored the benefits of specific aromatherapies such as lavender,^19,20 this updated meta-analysis is unique in its attempt to consolidate and analyze the effects of various massage and inhalation aromatherapies on menopausal symptoms. This study addresses a significant gap in the literature by providing an updated synthesis of evidence on the use of safe and effective non-pharmacological therapies for managing menopausal symptoms. Another key novelty of this study is its recency, as it provides an updated synthesis of evidence that surpasses previous reviews from at least the past four years.^21,22 This ensures the inclusion of the latest research findings, making it a timely and valuable contribution to the field of menopause management and alternative medicine. The ultimate goal of this study is to empower menopausal women to manage their symptoms autonomously and securely, enhancing their quality of life.

Material and Methods

This research project has received approval from the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Ref. No: IR.AJUMS.REC.1402.642), ensuring that the study adheres to the highest ethical standards.

Study Design

The design of this study is a systematic review and meta-analysis, which adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This approach guarantees a transparent and rigorous reporting of the study.²³

Search Strategy

We formulated an extensive search strategy to identify pertinent studies. We searched the databases of PubMed, Web of Science, Scopus, and Cochrane Library from their inception until January 20, 2024. The search terms comprised variations of “aromatherapy,” “menopause,” “symptoms,” and “randomized controlled trials.” We also manually searched the reference lists of the included studies and relevant reviews (Supplementary file 1).

Study Selection

Two independent reviewers conducted a screening of the titles and abstracts of the articles retrieved to identify studies that could potentially be relevant. We then evaluated the full texts of the chosen articles for eligibility based on pre-established inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

The studies that were considered for inclusion were randomized controlled trials (RCTs) that compared the impact of aromatherapy with a control group in managing symptoms of menopause. Secondary outcomes included menopausal women’s sleep quality and sexual function. We excluded studies that were not RCTs, did not involve menopausal patients, or did not report relevant outcomes.

Data Extraction

Two independent reviewers performed data extraction using a standardized form. The extracted information from each study included study characteristics (author, year of publication), randomization, blindness, participant characteristics, intervention details, control or comparison, outcomes assessed, tools, and findings.

Assessment of Risk of Bias

The Cochrane Risk of Bias 2 (RoB2) tool²¹was used to assess the methodological quality of the included studies. This standardized tool is used for assessing the risk of bias in RCTs included in systematic reviews and meta-analyses. The RoB2 tool evaluates bias in five key domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome, and bias in the selection of the reported result. For each domain, the RoB2 tool provides specific signaling questions that guide reviewers in assessing the risk of bias. These questions help reviewers evaluate the adequacy of randomization, blinding, handling of missing data, and other factors that could affect the validity of study results. Based on individual domains, we assessed the overall risk of bias for each included study. The assessment rated the studies as either high, with some concerns, or low quality.²⁴

Data Synthesis

In our quantitative analysis, the mean difference (MD) was calculated as the primary effect size for continuous outcomes measured on the same scale across all trials, with results reported as MD and 95% CI. For outcomes assessed using different scales in the included studies, the standardized mean difference (SMD) was used instead.²⁵ Forest plots were utilized to make a graph of the estimated data for the effect size and a P value of 0.05 was determined to be statistically significant. The I² value, which calculates the amount of overall variance that may be attributed to heterogeneity, was used to assess heterogeneity. The fixed effects model was selected for pooling the results of the studies if the values were less than 50%. We used a random effects model if it was greater than 50%. Publication bias was assessed using funnel plots. The RevMan 5.1 software (Cochrane Collaboration, Oxford) was used for all analyses. Findings that could not be meta-analyzed were reported qualitatively.

Evidence Certainty Assessment

To determine the quality of evidence for outcomes, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. This tool categorizes systematic reviews or meta-analyses into four groups: ‘high’, ‘moderate,’ ‘low,’ and ‘very low’. We started with a ‘high’ grade and downgraded it if we found bias, inconsistency (I-squared statistics > 50%), indirectness (intervention differences), imprecision (95% CI includes 1.0), or publication bias. Conversely, we raised the rating to 25 if there was a significant intervention effect or if all reasonable biases would reduce the amount of the intervention’s effect in the event of a dose-response association.²⁶Two researchers independently performed the GRADE assessment and resolved any discrepancies through discussion.

Ethical Considerations

We conducted this meta-analysis strictly adhering to ethical standards in research. Existing studies were the primary data sources, and as a result, no direct human or animal subjects were included in our analysis. However, we ensured that all included studies had obtained appropriate ethical approval from their respective institutional review boards or ethics committees.

Results

Study Selection

The selection process is depicted in Figure 1. Initially, a total of 250 records were found from the database search. After the removal of duplicates, we were left with 162 studies. Upon reviewing the titles and abstracts, 98 studies were excluded. During the full-text review, an additional 46 studies were excluded. Consequently, 15 studies with a total of 1217 participants were included in the systematic review, and out of these, 13 RCTs were considered for the meta-analysis.

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Figure 1.

PRISMA 2020 Flow Diagram For Systematic Reviews

Figure 1.

PRISMA 2020 Flow Diagram For Systematic Reviews

Included Studies Characteristics

The characteristics of the included studies are shown in Table 1. The included studies were conducted in Iran (n = 13), South Korea (n = 1), Turkey (n = 1), and Brazil (n = 1). The included RCTs were published between 2012²⁷and 2023.^28,29Two studies were published in Farsi^30,31 and others in English. Four studies were designed as a three-arm RCT^27,28,32,33 and one was four-arm trial.³⁴ The remaining ten had two arms. In seven trials, lavender oil was used for aromatherapy,^30,35-40two studies used Citrus aurantium^41,42and one study used officinalis.²⁹ In Döner et al’s study, lemon and peppermint oils were compared with placebo.²⁸Four RCTs used combined aroma oils.^27,31,32,34 Massage aromatherapy was used in three studies^27,28,32and inhalation aromatherapy was used in other studies.

Methodological Quality

The risk of bias judgment for included studies is depicted in Table 2 and Figure 2 shows the review authors’ judgments about each risk of bias domain presented as percentages across all included RCTs. Seven trials were judged to be at low risk of bias for all domains. However, four studies were rated as having some concerns.^30,34,37,38These concerns could be related to randomization, deviations from the intended interventions, and missing outcome data. Additionally, four studies^27,31,32,40were judged to be at high risk of bias. The high risk of bias in these studies could be due to several factors such as randomization, blinding, selective outcome reporting, or incomplete outcome data.

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Figure 2.

Risk of bias graph: review authors’ judgments about each risk of bias domain presented as percentages across all included RCTs

Figure 2.

Risk of bias graph: review authors’ judgments about each risk of bias domain presented as percentages across all included RCTs

While the presence of a high risk of bias or some concerns does not necessarily invalidate the results of these studies, it does suggest that we should interpret the findings with caution. The potential impact of these biases on the overall results of our meta-analysis was carefully considered in our interpretation and conclusions. Throughout the process, the authors observed no disagreement, indicating a consensus in evaluating the risk of bias in the included studies. This consensus strengthens the reliability of our bias assessment and, consequently, the validity of our meta-analysis findings.

The findings of the Meta-analysis

Effect of Aromatherapy on Menopause Symptoms

Figure 3 illustrates the impact of aromatherapy on the various symptoms associated with menopause. A meta-analysis of four RCTs with a total of 259 women who have undergone menopause, indicates a notable decrease in physical menopausal symptoms for those who received aromatherapy compared to the control group (SMD -0.93, 95% CI -1.19 to -0.67, P < 0.0001) (Figure 3A). The low heterogeneity among the studies warranted the use of a fixed effect model (χ² = 4.70, I² = 36%, P = 0.19), and the limited number of studies meant that publication bias was not assessed for this outcome.

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Figure 3.

Forest plot of the effect of aromatherapy on physical (A), psychological (B), and overall symptoms (C) of menopause

Figure 3.

Forest plot of the effect of aromatherapy on physical (A), psychological (B), and overall symptoms (C) of menopause

Furthermore, the study found a considerable alleviation of psychological symptoms in postmenopausal women who underwent aromatherapy when compared to the control group (SMD -0.83, 95% CI -1.13 to -0.54, P < 0.00001) (Figure 3B). The presence of heterogeneity led to the adoption of a random effect model (χ² = 18.39, I² = 56%, P = 0.02). Subgroup analysis further demonstrated that both inhalation (SMD -0.64, 95% CI -0.89 to -0.39, P <0.00001) and massage (SMD -1.09, 95% CI -1.71 to -0.47, P =0.0006) methods of aromatherapy significantly lessened psychological symptoms of menopause. The presence of heterogeneity led to the adoption of a random effect model for massage aromatherapy (χ² = 12.35, I² = 76%, P =0.006). No heterogeneity was found in the inhalation subgroup (χ² = 1.06, I² = 0%, P =0.90). Figure 4 presents the funnel plot illustrating the effect of aromatherapy on the psychological symptoms of menopause. A visual inspection of the plot reveals noticeable asymmetry, which may indicate the presence of publication bias. However, the reliability of this observation is limited due to the small number of included studies. Additionally, the observed asymmetry could be influenced by other factors, such as heterogeneity in intervention effects.

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Figure 4.

Funnel plot of the effect of aromatherapy on the psychological symptoms of menopause

Figure 4.

Funnel plot of the effect of aromatherapy on the psychological symptoms of menopause

In terms of overall menopausal symptoms, the intervention group experienced a substantial reduction (SMD -1.51, 95% CI -2.11 to -0.90, P < 0.0001) (Figure 3C). However, subgroup analysis revealed that while inhalation aromatherapy did contribute to a decrease in overall symptoms, the change was not statistically significant (P = 0.05). Conversely, massage aromatherapy did result in a significant diminution of these symptoms (P < 0.0001). Owing to notable heterogeneity (χ² = 25.35, I² = 80%, P = 0.0001), a random effect model was applied, and similar to the physical symptoms, the small number of studies precluded the evaluation of publication bias for overall symptoms.

Effect of Aromatherapy on the Sexual Function of Menopausal Women

Figure 5 shows a forest plot of the effect of aromatherapy on menopausal women’s sexual function. The overall effect size and the test for overall effect suggest that aromatherapy is beneficial for improving sexual function in menopausal women when compared to a control group (MD 5.58, 95% CI 0.98 to 10.17, P = 0.02). The high I² value indicates substantial heterogeneity among the studies (χ² = 68.32, I² = 97%, P < 0.00001). We did not assess the publication bias for this outcome due to the limited number of studies.

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Figure 5.

Forest plot of the effect of aromatherapy on the sexual function of menopausal women

Figure 5.

Forest plot of the effect of aromatherapy on the sexual function of menopausal women

Effect of Aromatherapy on Sleep Quality of Menopausal Women

Based on Figure 6, which is about the impact of aromatherapy and sleep quality of menopausal women, the meta-analysis of 3 studies on 181 women showed that aromatherapy caused a significant improvement in the sleep quality of menopausal women compared to the control group (MD -4.51, 95% CI -7.45 to -1.57, P = 0.003). The random effect model was used because significant heterogeneity was found (χ² = 46.49, I² = 96%, P < 0.00001). The publication bias was not calculated.

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Figure 6.

Forest plot of the effect of aromatherapy on sleep quality of menopausal women

Figure 6.

Forest plot of the effect of aromatherapy on sleep quality of menopausal women

Certainty of the Evidence

Table 3 shows the GRADE evidence profiles for outcomes among the trials included in the systematic review. The evidence grading for physical symptoms of menopause was considered moderate, having received one downgrade due to serious imprecision. The evidence grading for the sleep quality was low. Serious inconsistency, imprecision, and a serious risk of bias led to their downgrading. Ultimately, the grading of the evidence for overall symptoms of menopause, psychological symptoms of menopausal women, and sexual function was very low due to downgrades caused by a serious risk of bias, serious inconsistency, publication bias, or very serious imprecision.

Discussion

This meta-analysis indicates that aromatherapy significantly reduces physical and overall symptoms of menopause. This aligns with earlier systematic reviews which also found aromatherapy to be beneficial in easing physical symptoms associated with menopause.^19,20,21

The potential influence of aromatherapy on physical symptoms could stem from the engagement of the autonomic nervous system when essential oils are inhaled. For instance, the compound linalool found in lavender might regulate the parasympathetic nervous system via the hypothalamus, which is linked to the senses of touch and smell.⁴³ Theoretically, inhaling or massaging with essential oils could trigger the release of neurotransmitters like serotonin, dopamine, and endorphins. Nevertheless, further foundational research is necessary to fully comprehend how aromatherapy acts to alleviate menopausal symptoms.

Both massage and inhalation as methods of aromatherapy have been found to significantly reduce the psychological symptoms associated with menopause. Echoing recent findings, other meta-analyses have also indicated that groups receiving aromatherapy massage and inhalation experienced significantly fewer psychological issues like depression compared to control those.⁴⁴The beneficial effects of aromatherapy massage on depression may be attributed to enhanced blood circulation in the brain’s frontal cortex, stimulation of the body’s soft tissues leading to metabolic equilibrium, and the creation of a nurturing environment that conveys care and affection to the patient.⁴⁵ This study rated the quality of evidence for aromatherapy’s impact on physical menopausal symptoms as moderate while rating it low for psychological symptoms and very low for overall symptoms.

It is important to note, however, that the studies reviewed primarily document the short-term benefits of aromatherapy on psychological symptoms, leaving the long-term effects uncertain. Additionally, the researchers’ emotional support during aromatherapy, which did not extend to the control group, could have influenced the outcomes.

The present research findings demonstrate the beneficial effects of aromatherapy on improving sexual function in menopausal women. The meta-analysis conducted by Khadivzadeh et al revealed that aromatherapy, whether with neroli oil or lavender (used individually) or a combination of lavender, fennel, geranium, and rose oils, had a significant positive impact on human sexual function. However, they did not observe significant alterations in the serum estrogen level.²² Another meta-analysis demonstrated the efficacy of lavender, administered either as a capsule or through aromatherapy, in enhancing the sexual desire of menopausal women. However, the authors cautioned that we should interpret these findings cautiously, given the study’s limitations.²⁰ Aromatherapy employs herbal essential oils in various ways, such as inhaling the odor molecules, stimulating the sense of smell, and sending impulses to the olfactory part of the brain. This part of the brain interacts with various control systems, including emotions, memory, hormones, sexual sensations, and heart rate. This interaction results in the release of hormones capable of stimulating, incubating, calming, or euphoria absorption, as well as the skin absorption of volatile oils and their subsequent penetration into the bloodstream. The grading of the evidence for sexual function was very low, primarily due to the significant risk of bias, serious inconsistency, and severe imprecision. Given the limitations of this review, including a lack of standardized instruments, a small number of studies, and short-term follow-up, it is important to present these findings with caution.

Aromatherapy caused a significant improvement in the sleep quality of postmenopausal women compared to the control group, which is consistent with the results of Lin et al, who supported aromatherapy in effectively improving sleep quality in other populations.⁴⁶ Previous meta-analyses of menopausal women also align with this result.¹⁹ This result suggests that the reduction of physical symptoms and improvement of psychological problems will enhance the quality of sleep for these women.^20,30,47 The evidence grading for menopausal women’s sleep quality was low, indicating that the current research may not provide a robust or reliable basis for concluding the impact of the intervention on sleep quality in this population. This underscores the need for further high-quality studies to better understand and address the effect of aromatherapy on sleep disturbances in menopausal women. In future research, it is also important to consider individual differences and other potential confounding factors.

Strengths and Limitations

The following are the study’s key strengths: We implemented a thorough search strategy that encompassed a broad spectrum of databases and search terms, thereby enhancing the probability of identifying all included studies. One of our study’s strengths is that it included articles in both Persian and English, enhancing the diversity and comprehensiveness of the research incorporated in our analysis. This bilingual approach broadens the scope of the study and allows for a more inclusive examination of the subject matter. The exclusive inclusion of RCTs, considered the gold standard in clinical research due to their ability to minimize bias and confounding factors, further strengthened the meta-analysis. The GRADE framework’s application to assess the quality of evidence bolstered the study’s rigor. GRADE is a systematic and transparent approach used to describe the quality of evidence and the strength of recommendations in healthcare.⁴⁸

However, the study also had several limitations. We observed notable heterogeneity among the included studies, potentially due to variations in study design, population characteristics, intervention protocols, and the type and dosage of essential oils used for aromatherapy. This could limit the applicability of the findings. Additionally, some of the included trials assessed a high risk of bias, potentially impacting the results of the meta-analysis. Moreover, the quality of evidence for some comparisons was very low, which undermines confidence in the effect estimates. These strengths and limitations should be considered when interpreting the findings of this study. Further, high-quality studies are required to validate these results and provide more robust evidence.

Conclusion

Few studies have thoroughly assessed how aromatherapy impacts symptoms experienced during menopause. These inquiries predominantly utilized lavender for aromatherapy. Findings suggest that using lavender or other herbs for aromatherapy, as mentioned in these RCTs, could potentially alleviate a range of menopausal symptoms, including physical, psychological, and sexual function, when compared to a control group. However, we recommend conducting additional research on different types of essential oils. The conclusions drawn from these studies are tentative due to the small number of studies, the small sample size, and the indeterminate risk of bias. Therefore, we should exercise caution when generalizing these results due to potential heterogeneity in the essential oil composition and the countries where the experiments took place.

Acknowledgments

We would like to express our appreciation to the Ahvaz Jundishapur University of Medical Sciences for their approval and support in the development of this study

Mona Larki^2,3,

Competing Interests

There is nothing to declare.

Data Availability Statement

The datasets are available from the corresponding author upon reasonable request.

Ethical Approval

The Ahvaz Jundishapur University of Medical Sciences ethics committee provided the research’s ethics code (Ref. No: IR.AJUMS.REC.1402.642). Consent to participate is not applicable.

Supplementary file 1

Research Highlights

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