Accepted Manuscript

Effects of lavender scent on patients' anxiety and pain levels during gynecological
examination

Nilufer Tugut, RN, PhD, Assistant Professor, Gulbahtiyar Demirel, RN, PhD, Assistant
Professor, Muruvvet Baser, RN, Ph.D, Professor Doctor, Elvan E. Ata, RN, PhD,
Assistant Professor, Savas Karakus, MD, Assistant Professor
PII: S1744-3881(17)30120-2
DOI: 10.1016/j.ctcp.2017.05.006
Reference: CTCP 728

To appear in: Complementary Therapies in Clinical Practice

Received Date: 22 March 2017

Accepted Date: 12 May 2017

Please cite this article as: Tugut N, Demirel G, Baser M, Ata EE, Karakus S, Effects of lavender scent on
patients' anxiety and pain levels during gynecological examination, Complementary Therapies in Clinical
Practice (2017), doi: 10.1016/j.ctcp.2017.05.006.

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 ACCEPTED MANUSCRIPT

Title: Effects of lavender scent on patients’ anxiety and pain levels during

gynecological examination

Nilufer Tuguta, Gulbahtiyar Demirelb,*, Muruvvet Baserc, Elvan E. Atad, Savas

Karakuse

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Nilufer Tugut

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Assistant Professor, RN, PhD,

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E-mail: nlfrtugut@gmail.com

Adresses: aDepartment of Nursing, Faculty of Health Sciences, Cumhuriyet University,

58140 Sivas, Turkey

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Gulbahtiyar Demirel (Corresponding author)

Assistant Professor. RN, PhD.

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E mail: gulbahtiyar_doganer@hotmail.com
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Adresses: b,*Department of Midwifery, Faculty of Health Sciences, Cumhuriyet

University, 58140 Sivas, Turkey

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Fax: +90 3462191261

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Muruvvet Baser

Professor Doctor, RN, Ph.D,

E mail: mbaser@erciyes.edu.tr

Adresses: cDepartment of Nursing, Faculty of Health Sciences, Erciyes University,

Kayseri, Turkey.
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Elvan E. Ata

Assistant Professor. RN, PhD.

E mail: elvanhenden@gmail.com

Adresses: dDepartment of Nursing, Faculty of Health Sciences, Giresun University,

Turkey.

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Savas Karakus

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Assistant Professor, MD
E-mail: karakussavas@yahoo.com.tr

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Adresses: eDepartment of Obstetrics and Gynecology, Faculty of Medicine, Cumhuriyet
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University, 58140 Sivas, Turkey
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1. Introduction

Although gynecological examinations take a shorter time than do many other examinations,

they evoke negative feelings in many women. Of all medical interventions, gynecological

examinations are the most common cause of anxiety [1-4]. However, gynecological

examinations have a very important place in the protection of women's health as they ensure

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the early diagnosis of sexually transmitted infections, genital cancers and ill-health [5]. A

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woman’s negative experiences of gynecological examination discourage her from having

another one. Therefore, the aim of protecting women's health with regular gynecological

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controls may not always be realized, which can result in the deterioration of women's health.

Thus, gynecological examinations should be conducted in such a way that they do not cause

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anxiety and women can treat them as they would any other medical examination. In many
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studies it is reported that women suffer physical and emotional discomfort during
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gynecological examinations and thus they avoid them [1-3,5]. On the other hand, some

studies report that the use of techniques such as relaxation exercises and listening to music
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before and during examination offers a more positive experience for women [1-6].
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Aromatherapy is widely seen as an alternative relaxation method. In several studies, EEG

results have demonstrated that different aromatic fragrances affect the electrical activity of the
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brain differently. It has been reported that essential oils such as lavender can raise the level of

the happiness hormone, endorphin, in the brain eight to ten-fold and provide mental and
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physical relaxation a few minutes after exposure [7]. Studies have revealed that lavender is

useful and can be applied safely [8-10]. In Turkey, although the use of lavender scent as one

supportive approach has been reported, there is not enough research on its effect in the field of

gynecology. This study aimed at determining the effect of lavender scent on anxiety suffered

during gynecological examination.

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2. Materials and methods

2.1. Design

This study was designed as a randomized controlled trial.

2.2. Location of the study

The study was conducted in the gynecology and obstetrics outpatient clinic of a university

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hospital.

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2.3. Population and sample

Women who were admitted to the gynecology and obstetrics outpatient clinic of a training

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and research hospital and who met the inclusion criteria listed below comprised the

population of the study. The inclusion criteria were as follows:

- being in the 19-65 age group

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- being at least a primary school graduate
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- being non-pregnant

- not having any chronic health problems including asthma / allergic asthma, chronic
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lung disease
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- not being allergic to any scent

- not having any mental health problems such as anxiety, depression, panic attacks,
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bipolar affective disorder or schizophrenia

- volunteering to participate in the study

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The sample size of the study was based on Braden and colleagues’ study [11], using the

NCSS-PASS 2008 (Statistics, Graphics, Power Analysis & Sample Size Program) program

(Type I error of 0.05 and Type II error of 0.20 were assumed). After this calculation, the

sample size was estimated to include at least 156 participants.

The study sample consisted of 156 women who met the inclusion criteria and voluntarily

gave their informed consent to participate in the study. The participants who met the inclusion
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criteria were randomly assigned into two groups with an equal chance by means of the

random sampling method. After the women were given numbers, they were selected from the

random number table, and then 78 women assigned to the intervention group and 78 to the

control group. The first person was assigned to the intervention and the second person to the

control group, and so on.

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2.4. Data collection

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In this present study, three forms were used to collect the data.

Sociodemographic Characteristics Questionnaire: the questionnaire was developed from the

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literature and aimed to determine sociodemographic characteristics, obstetric history and the

examination room-related thoughts of the women who presented for gynecological

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examination. The questionnaire consisted of 10 closed-end and open-end questions.
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State Anxiety Inventory (STAI): in order to determine the participating women's anxiety levels
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during gynecological examination, the State Anxiety Inventory developed by Spielberger [12]

and translated into Turkish by Oner and Le Compte [13] was used. The cronbach alpha value
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of State Anxiety Inventory ranged between 0.94 and 0.96, In the present study, Cronbach's
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alpha value was 0.91 for the State Anxiety Inventory. The scale has reverse-scored and direct-

scored items. The total scores of reverse-scored and direct-scored items are separately
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calculated. The total score obtained from the reversed items is subtracted from that of the non-

reversed items. A predetermined constant value is added to this value. This predetermined
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constant value is 50 for the State Anxiety Inventory. The final value obtained is the

individual's anxiety score. Total score obtained from the scale vary between 20 and 80.

Higher scores indicate higher anxiety levels, while lower scores indicate low levels of anxiety.

The mean scores determined during implementations varied between 36 and 41. Spielberger

reported that scores between zero and 19 obtained from the scale indicate that the person has

"no anxiety," between 20 and 39 indicates that the person’s anxiety level is “mild,” between
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40 and 59 indicates that the person’s anxiety level is "moderate," and between 60 and 79

indicates that the person’s anxiety level is "severe," and that those whose score is 60 or higher

need professional help.

Visual Analog Scale (VAS): in order to determine the severity of pain and emotional distress

suffered by women in the intervention and the control groups during gynecological

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examination, the VAS was used [14]. The VAS is used to convert values which cannot be

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measured numerically into numerical values. The scale is widely used for pain assessment. In

the VAS assessment, zero refers to no pain, 1-4=mild pain, 5-6=moderate pain and 7-10=

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severe pain.

2.5. Implementation of the study

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To perform the study, written approvals were obtained from Erciyes University Clinical
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Research Ethics Board (dated and numbered 2014/568) and the hospital where the study was
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conducted. Before the women who presented for gynecological examination were enrolled in

the study, it was determined whether they met the inclusion criteria or not. Those who did
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meet the inclusion criteria were informed of the purpose and content of the study and then
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their written informed consent was obtained. The women were divided into two groups by the

random sampling method. In order to obtain accurate data, the participating women were told
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not to write any personally identifiable information but to use a pseudonym on all documents

other than the consent form. They were also told that all the data obtained would remain
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confidential. While the sociodemographic characteristics of the participants in the waiting

room were determined with the relevant questionnaire, their anxiety levels during

gynecological examination were determined with the State Anxiety Scale. The participants

were given an average of 10 to 15 minutes to fill in the questionnaires. Then the lavender

scent prepared by the researchers was put into the examination room. As suggested in other

studies, 10% lavender oil was prepared and put into a lamp [3,4]. Lavender oil has been
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reported to be effective in reducing anxiety 3 to 15 minutes after it is inhaled [1-5].

Considering the time determined in the aforementioned studies and the time needed for the

gynecological examination, the participants were given an average of 10 to 15 minutes to

inhale the lavender scent. The concentrated lavender oil was placed at a distance of 15 cm

from the gynecological examination table and the room temperature was set at between 21

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and 24 C°. Gynecological examination of the participants in the intervention group was

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performed by the same physician.

After the examination, each woman in the intervention group was taken to the waiting room

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and administered the State Anxiety Inventory to determine the level of anxiety experienced

during the gynecological examination and the VAS to determine the severity of pain and

emotional discomfort after the examination.

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After the women in the control group filled out the questionnaires, they were taken to the
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examination room where there was no lavender scent, and their gynecological examination

was performed by the same physician. After the examination, each woman in the control
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group was taken to the waiting room and administered the State Anxiety Inventory to
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determine the level of anxiety experienced during gynecological examination and the VAS to

determine the severity of pain and emotional discomfort after the examination.
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2.6. Analysis of the data

The study data were analyzed with the SPSS 16 software package. The sociodemographic
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characteristics of the participants were given as numbers, mean values and standard deviation

in the tables, and the groups were compared using the Chi-square test and Fisher's exact test.

While the scores obtained from the scales at the pre-test and post-test were compared with the

independent sample t-test, the mean scores of participants in the intervention and control

groups at pre-test and post-test were compared using the paired t test. For the significance

level of the statistical results, p<0.05 was used.

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3. Results

Table 1 provides some of the sociodemographic characteristics of the participants in the

intervention and control groups. Some 48.7% in the intervention group and 57.7% in the

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control group were under 35 years of age. The participants in both groups had similar

characteristics in terms of their mean age, marital status, educational status, place of residence

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and employment status (p>0.05). Forty-one percent in the intervention group and 25.6% in the

control group had a good level of income. The difference between the two groups was

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statistically significant (p<0.05). Thirty-four percent in the intervention group, and 33.3% in

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the control group were admitted to the hospital complaining of bleeding. The reasons why
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participants in both groups presented to the hospital were similar (p>0.05).
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Table 1

Distribution of some of the sociodemographic characteristics of the participants in the

intervention and control groups.

Characteristics Intervention (n= 78) Control (n= 78)

n(%) n (%) p

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Age
<35 years 38(48.7) 45(57.7) 0.336

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≥35 years 40(51.3) 33(42.3)

Mean age (X±SD) 35.0± 9.7 33.5 ±12.4 0.264

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Marital status
Married 74(94.9) 74(94.9) 1.000

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Unmarried 4(5.1) 4(5.1)
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Education
Primary school 30(38.6) 21(26.9) 0.148
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Junior high school 24(30.8) 22(28.2)

Senior high school 13(16.7) 13(16.7)
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University 11(14.1) 22(28.2)

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Place of residence
Province 49(62.8) 54(69.2) 0.179
District 14(17.9) 17(21.8)
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Town / village 15(19.2) 7(9.0)

Employment status
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Employed 15(19.2) 13(16.7) 0.835

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Unemployed 63(80.8) 65(83.3)

Reason for admission to hospital

Vaginal discharge 7(9.0) 10(12.8) 0.935
Bleeding 27(34.6) 26(33.3)
Pelvic pain 14(17.9) 14(17.9)
Menopause 8(10.3) 9(11.5)
Control 22(28.2) 19(24.4)
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Table 2 shows that the mean scores the participants in the intervention and control groups

obtained from the State Anxiety Scale before the application were 39.8±5.4 and 38.1±6.0

respectively. The pre-application mean scores the participants in the intervention and control

groups obtained from the state anxiety scale was similar (p>0.05). The post-application mean

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scores of the participants in the intervention and control groups obtained from the State

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Anxiety Scale were 37.0±5.2 and 46.8±3.2 respectively. The difference between the mean

scores of the two groups was statistically significant (p<0.05).

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Table 2 indicates that the mean pre- and post-application state anxiety scores of the

participants in the intervention group were 39.8±5.4 and 37.0±5.2 respectively, and the

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difference between the mean scores was statistically significant (p<0.05). The mean pre- and
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post-application state anxiety scores of the participants in the control group were 38.1±6.0 and
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46.8±3.2 respectively, and the difference between the mean scores was statistically significant

(p<0.05).
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Table 2
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Distribution of the mean scores the participants in the intervention and control groups
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obtained from the State Anxiety Scale before and after the application.

Mean Scores of Scale Intervention Group (n= 78) Control Group (n= 78)
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X±SD X±SD t/ p
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Before the examination

State anxiety 39.8±5.4 38.1±6.0 -1.883/0.062

After the examination

State anxiety 37.0±5.2 46.8±3.2 14.214/0.000

t/p t=4.739, p=0.000 t=-13.597, p=0.000

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Table 3 presents the levels of the gynecological examination-related pain suffered by the

participating women. While the mean VAS score of the intervention group who stated that

they suffered pain during the gynecological examination was 1.5±0.9, it was 5.6±1.8 for their

counterparts in the control group. The difference between the VAS scores was statistically

significant (p<0.05).

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Table 3

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Distribution of the gynecological examination-related mean VAS scores of the participants in

the intervention and control groups.

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VAS Scores Intervention Group (n= 35) Control Group (n= 51)

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X±SD X±SD t/ p
1.5±0.9 5.6±1.8 11.805/0.000
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The correlation between the mean scores obtained by the women participating in the study

from the VAS and the State Anxiety Scale after the gynecological examination is given in
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Table 4. The correlation between the mean scores obtained by the participants in the
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intervention group was moderate, positive and significant.

Table 4
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Correlation between the mean scores obtained by the women participating in the study from
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the VAS and the State Anxiety Scale after gynecological examination.
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Groups State anxiety

r p
Intervention Group (n=35) VAS 0.464 0.005

Control Group (n=51) VAS 0.176 0.237

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4. Discussion

Gynecological examination is a process causing anxiety for women [2,3]. In this present

study, the state anxiety levels of the women in the intervention and control groups before the

gynecological examination were similar and mild (p<0.05). In studies conducted by Demiray

and colleagues [15], Kocabas and Khorshid [6] and Erbil and colleagues [16], women’s

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anxiety levels before gynecological examinations were moderate. The results of the studies

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indicate that although the gynecological examination takes a short time, it leads to negative

feelings at different levels in many women. A woman’s negative experience might prevent

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her from having a further examination. In order to protect women’s health, it is essential to

perform gynecological examinations without causing discomfort and to ensure that women

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treat gynecological examinations like any other examinations. Therefore, to reduce the
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participants’ anxiety, different methods such as playing music, special clothing, relaxation
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techniques have been implemented and these methods have been determined to reduce

women’s anxiety levels [6,17-20]. Aromatherapy is seen as an alternative relaxation method.

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In the present study, the lavender scent used during gynecological examination reduced
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anxiety.

The use of lavender scent during a gynecological examination helps women undergo a
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more positive examination process. On the other hand, the state anxiety level of the

participants in the control group was mild before the examination but increased to moderate
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after the examination. In many studies, women reported moderate levels of anxiety owed to

negative feelings and physical discomfort suffered during gynecological examination

[2,3,16,21,22]. The results of those studies are consistent with those of the present study.

In different studies, lavender scent has been found to have positive effects on anxiety, pain

and depression levels [7,11,23-37]. Lavender scent and/or oil was used by Itai and colleagues

[27] for anxiety disorders, by Graham and colleagues [34] before radiotherapy, by Louis and
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Kowalski [33] for pain, anxiety and depression in hospitalized patients, by Buckle [23] and

Braden and colleagues [11] prior to surgery, by Hoya and colleagues [28] prior to gastroscopy

and by Lehrner and colleagues [35] in a dental clinic, and they all reported that it reduced

anxiety levels.

In the present study, it was found that the pain suffered by the participants in the control

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group during examination (5.5±1.8) was about three times greater than that suffered by the

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participants in the intervention group (1.5±0.9), and that lavender scent was effective on pain.

In the intervention group, as the state anxiety score decreased so did the VAS score. State

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anxiety is a temporary emotional state characterized by subjective tension, feelings of anxiety

or arousal of the autonomic nervous system [38]. Gynecological examination is a medical

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intervention which takes place at a particular time, during which different feelings are
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experienced, the result of the present study supports this theoretical knowledge.
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5. Conclusion
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Given the result of this study that lavender scent reduced anxiety and pain suffered during
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gynecological examination, it can be recommended that lavender scent be routinely used

before and during such examination.

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Authors' contribution
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Nilufer Tugut: Study design, data analysis, data interpretation and drafting of the manuscript.
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Gulbahtiyar Demirel: Study design, data collection, data interpretation, critical revision of the

manuscript and manuscript editing.

Muruvvet Baser: Study design, data analysis and interpretation.

Elvan E. Ata: Study design and data analysis.

Savas Karakus: Study design and data collection.

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Conflict of interest

The authors declare that there is no conflict of interest.

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