Downloaded from http://jfprhc.bmj.com/ on May 26, 2017 - Published by group.bmj.

com

REVIEW

A review of controlled trials of acupuncture for women’s

reproductive health care
A R White, MA, BM BCh, Senior Lecturer, Complementary Medicine, Institute of Health and Social Care Research, Peninsula
Medical School, Exeter, UK

Correspondence: Dr A R White, Complementary Medicine, Institute of Health and Social Care Research, Peninsula Medical
School, 25 Victoria Park Road, Exeter EX2 4NT, UK. E-mail: [email protected]

(Accepted 4 June 2003)

Journal of Family Planning and Reproductive Health Care 2003; 29(4): 233–236

Abstract explained by the fact that the needles stimulate the nervous
Background. Acupuncture as a therapy, and acupressure system in a particular way. There is now good evidence that
as self-treatment, are increasingly widely used for acupuncture may lead to a release of neurotransmitters,
gynaecological conditions, and this study aims to review especially beta-endorphin and serotonin,6 in several parts
the scientific literature on their effectiveness. of the brain. These transmitters are involved in descending
Method. A systematic review of controlled trials of inhibitory pain control. Another possible mechanism for
acupuncture or acupressure for gynaecological conditions, pain control, but one that awaits confirmation,7 holds that
published in a European language. the needles inactivate ‘trigger points’ in muscles. Trigger
Synthesis. No studies in mastalgia, menorrhagia, pelvic points are areas of chronic hyperactivity, initially resulting
pain, premenstrual syndrome or vulvodynia met the from physical injury or microtrauma, that may continue to
inclusion criteria. Four studies, two of which were patient- cause pain for many years. Acupuncture may also produce
blinded, of acupuncture or acupressure for dysmenorrhoea effects through local changes in the tissues, e.g. stimulating
suggest that it may have an effect. Three studies of blood flow.
acupuncture given at various stages of infertility treatment There are several techniques allied to acupuncture.
are promising, but none was patient-blind. Two studies of These include acupressure (shiatsu) in which appropriate
acupuncture for menopausal symptoms showed no effect points are massaged by the fingers, thumbs or knuckles.
during the treatment period when compared with sham Acupressure may also be self-administered (for example,
acupuncture, and a third study showed no effect on using the familiar wristbands for nausea). Another
hypertension in postmenopausal women, though some technique, namely electroacupuncture, involves
improvement in symptoms was noted. stimulating the acupuncture needles by battery-powered
Conclusion. In view of the small number of studies and pulse generators. This is superficially similar to
their variable quality, doubt remains about the transcutaneous electrical nerve stimulation (TENS),
effectiveness of acupuncture for gynaecological conditions. particularly low-frequency TENS. However, there are
Acupuncture and acupressure appear promising for considerable differences, such as the effect of TENS being
dysmenorrhoea, and acupuncture for infertility, and further rarely sustained whereas the benefits of a successful course
studies are justified. of acupuncture frequently are.
It has to be admitted that acupuncture has the attributes
Key message points of a good placebo (Oriental mystique, skin penetration,
l
Acupuncture is increasingly widely used to treat gynaecological novelty). It is easy to dismiss reports of benefit as purely
conditions. due to placebo, so convincing evidence for acupuncture
l
Few rigorous studies have been performed in the use of only comes from comparing it to a placebo control. The
acupuncture in gynaecological conditions and firm conclusions placebo must appear to the patient to be like a needle, in
on effectiveness are not possible. order to have the same psychological impact. Many
l
Evidence suggests that acupuncture for dysmenorrhoea and inventive solutions have been tried,8 the commonest being
infertility is promising and further studies are justified. insertion of needles superficially and in the wrong location.
However, even this might not qualify as a totally inactive
Introduction placebo.9 Recently, a blunt needle that recoils into the
Acupuncture is widely available in the UK,1 both privately handle has been invented.10,11 It appears to enter the body
and through the National Health Service (NHS).1 It is but actually only presses on the skin. Its use should lead to
most commonly used to treat chronic pain, although there more and better evidence.
is still a lack of good evidence of its efficacy for this Gynaecological conditions are among the top six
condition.3 The evidence that acupuncture is superior to conditions for which acupuncture is used by doctors.12 This
placebo is strongest in the treatment of postoperative paper is a review of controlled trials of the effectiveness of
nausea. 4 One reason why patients and health care staff are acupuncture and acupressure in women’s reproductive
attracted to acupuncture is that it has a very low level of health excluding pregnancy.
serious adverse events when given by qualified
practitioners. 5 Methods
Many acupuncture practitioners use an approach based MEDLINE and EMBASE databases and the Cochrane
on the concepts of traditional Chinese acupuncture, and Library were searched using the terms acupuncture or
believe that the needles correct any imbalances in the flow acupressure, and dysmenorrhoea, infertility, mastalgia
of life force along meridians. In contrast, many medical, (mastodynia), menopause, menorrhagia, pelvic pain,
nursing and physiotherapy staff use a Western approach, premenstrual or vulvodynia. In addition, files in the
arguing that the effects of acupuncture can be adequately author’s office were searched. The search was restricted to

Journal of Family Planning and Reproductive Health Care 2003: 29(4) 233
 Downloaded from http://jfprhc.bmj.com/ on May 26, 2017 - Published by group.bmj.com

Review

Table 1 Description of studies included in the review

Study Design Blinding Population Intervention n Comparison n Outcome Follow- Result

group group(s) up

Dysmenorrhoea
Helms (1987)13 RCT Patient (partial) Gynae clinic Traditional 11 Non-point 11; Menstrual 1 year NSD in scores (more
acupuncture acupuncture; 11; symptom than 50% responders
usual care; 10 score (diary) with acupuncture)
visitation

Thomas et al. RCT, No Gynae clinic Acupuncture 19 NA Menstrual pain, None Significant
(1995)14 crossover (four modes) blood loss, etc, improvement
global

Taylor et al. RCT No NS Acupressure 31 Usual care 27 Menstrual pain None Acupressure superior
(2002)16 garment and medication (p<0.05)
diary

Pouresmail and RCT Patient (partial) Schoolgirls Self-acupressure 72 Sham 72; Pain VAS; None Acupressure and
Ibrahimzadeh acupressure; 72 dysmenorrhoea ibuprofen significantly
(2002)17 ibuprofen grade superior to sham
acupressure
(p<0.0001)
Infertility
Stener-Victorin RCT No IVF centre Electro- 75 Usual 75 (Analgesia); None Acupuncture
et al. (1999)18 acupuncture alfentanil take-home significantly
analgesia baby rate superior (p<0.05)

Gerhard and Matched No Gynae clinic Auriculo- 45 Hormone Pregnancy rate 3 months NSD
Postneek (1992)19 pairs acupuncture therapy

Paulus et al. RCT No Assisted Formula 80 Usual care 80 Pregnancy rate None Acupuncture
(2002)20 reproduction acupuncture significantly superior
(p = 0.03)
Menopausal symptoms
Wyon et al. RCT Patient Gynae clinic Electro- 11 Superficial 10 Flush scores, 3 months NSD
(1995)29 acupuncture acupuncture Kupperman index

Sandberg et al. RCT Patient Gynae clinic, Electro- 15 Superficial 15 Flush scores, 6 months NSD
(2002)21 media acupuncture acupuncture well-being

Kraft et al. RCT, Patient Mild Traditional 10 Sham NA Blood pressure; 2 months BP, symptoms
(1999)22 crossover hypertension acupuncture acupuncture menopausal no difference

BP, blood pressure; gynae, gynaecological; IVF, in vitro fertilisation; NA, not applicable; NS, not stated; NSD, no significant difference; RCT, randomised
controlled trial; VAS, visual analogue score.

European languages. The full article was retrieved for any patients provided follow-up data. There was a significant
reference that appeared from the title or abstract to report a fall in reported pain in the real acupuncture group, a
controlled trial. Predetermined trial data were extracted smaller fall in the sham acupuncture group, and smaller
into a table. falls still in the two groups who received no acupuncture
(see Table 2). The success rate was significantly higher in
Results the acupuncture group; the difference in mean pain scores
No controlled trials were located for mastalgia, was not significant, but that may be because of a type II
menorrhagia, pelvic pain (as a primary diagnosis), error.
premenstrual or vulvodynia. Results for the remaining three A second randomised controlled trial (RCT) was
clinical areas are given in Table 1 and are reviewed here. conducted at the Department of Gynaecology of the
Karolinska Hospital in Stockholm, Sweden in 31 patients
Dysmenorrhoea who had experienced dysmenorrhoea for more than 5
One small trial of acupuncture for dysmenorrhoea included years, and were unable to use analgesics for a variety of
48 women with an average age of 28 years.13 After referral reasons. 14 Nineteen patients (mean age 30 years) received
to an acupuncturist by the Gynaecology Clinic in Oakland, two treatments a few days before each of four consecutive
CA, USA, the women were randomised into four groups. menses, consisting of a different form of acupuncture
The treatment group received real acupuncture using stimulation for each cycle, in random order. Only five
traditional points on the legs and abdomen, and one point points were used, in the legs, abdomen and back. The
on the wrists, to a total of 12 needles. The acupuncture different forms of stimulation were: manual (repeated
control group were given sham acupuncture with needles rotation producing de qi), low frequency electrical, high-
placed in non-point, non-meridian sites on the legs and frequency electrical and periosteal, i.e. brief tapping of the
arms. Both these groups received treatment each week periosteum with the needle tip. Before the fifth menstrual
(except during menstruation) for 12 weeks. A second period, treatment was given according to patient
control group had no further contact with the physician. A preference. In another section of the study, 12 patients
third control group served as ‘visitation control’, and received a variety of forms of TENS, including ‘placebo’
attended the physician’s clinic three times, at monthly TENS, in a routine similar to the acupuncture. In the
intervals, for a review of symptoms and discussion. All acupuncture group there was significant improvement in
patients kept diary records of menstrual symptoms pain, analgesic intake and subjective assessment. Direct
immediately before joining the study and over the course of statistical comparisons between the treatments were not
a year. Patients were classified as ‘improved’ if their mean made. There were similar improvements in the low-
pain scores were reduced by at least 50%. A total of 43 frequency TENS group, but not the high-frequency or

234 Journal of Family Planning and Reproductive Health Care 2003: 29(4)
 Downloaded from http://jfprhc.bmj.com/ on May 26, 2017 - Published by group.bmj.com

Review

Table 2 Pain scores (combined intensity and duration) during menstruation for 1 year of a randomised controlled trial of acupuncture for dysmenorrhoea13

Real Sham Standard Visitation p

acupuncture acupuncture control control

Mean (± SE) pretreatment pain score 147 ± 38 155 ± 41 98 ± 32 118 ± 26 0.632a

Mean (± SE) posttreatment pain score 27 ± 4.8 92 ± 28.8 78 ± 24 117 ± 26 0.059a
Number improved 10/11 4/11 2/11 1/10 <0.05b

aAnalysis of variance (ANOVA). bChi-squared test, real acupuncture versus all other groups. SE, standard error.

placebo TENS groups. Changes in the acupuncture and on pregnancy rate could have been psychologically
low-frequency TENS groups persisted for 3 months. mediated since no placebo acupuncture was used in the
A Cochrane Review summarised these studies, saying controls.
they ‘suggest benefit for this modality’ but concluding that
the evidence was insufficient.15 The same review included Menopausal symptoms
studies of TENS, and concluded that high-frequency TENS Twenty-four menopausal women received either genuine
was effective for the treatment of dysmenorrhoea, though electroacupuncture or superficial needling at incorrect
the number of trials was still small. points, and were followed up for 5 months. Scores for
In one study of acupressure, 61 women were flushes by daily diary improved by 50% in both groups
randomised to either a control group who had usual care, or during the 12 weeks’ treatment, but remained improved
an experimental group who wore a specially designed only in the acupuncture group, being better than the
cotton Lycra panty brief (‘Relief Brief’) with 10 latex foam controls during this time though not significantly. The
pads fixed over lower abdominal and lower back Kupperman index also improved, but there was no
acupressure points that are used in treating measurable effect on sleep dysfunction. Urinary secretion
dysmenorrhoea. 16 The acupressure garment was worn on of calcitonin gene-related peptide, a potent vasodilator,
the first 3 days of menstruation, for two cycles, for as long increased in both groups during treatment but tended to
as possible without discomfort. The mean duration worn return to normal afterwards.
over the 3 days was 29 hours, and four patients found the The same research group21 repeated the study in 30
discomfort so great that they did not use it in the second women with vasomotor symptoms. This time the
cycle. Patients wearing the garment recorded highly acupuncture group showed no greater improvement than
significantly lower mean scores for ‘worst’ menstrual pain the controls for menopausal symptom scores or
and for menstrual symptoms than the control group. More psychological well-being throughout the 6-month study.
than two-thirds of the women wearing the garment reported There was a significant superiority in mood scale scores
at least 50% reduction in pain. during the first 12 weeks only.
In a second acupressure study, 216 schoolgirls aged Ten menopausal women with mild hypertension were
14–18 years were either given ibuprofen regularly, or included in a placebo-controlled, crossover study. 22
taught real or placebo (wrong points) acupressure, before Menopausal complaints and well-being significantly
each of three consecutive cycles. 17 The severity of improved during treatment but this effect did not last for
dysmenorrhoea was graded (on a four-point scale) at the more than 2 months. No effect was seen on hypertension or
end of therapy: 50% of the acupressure group reported zero on serum lipids, though there was a reduction in the
grade, compared with 36% of the ibuprofen group and 18% secretion of noradrenaline in the acupuncture group.
of the sham acupressure group.
It is interesting to note that acupuncture was not shown Discussion
to have any effect on menstrual blood flow in the one The number of controlled studies of acupuncture in
study 14 in which it was estimated. There is no evidence gynaecological disorders is small, and their quality is
from other published controlled trials that acupuncture has limited. Particular weaknesses are small sample sizes
any effect on menorrhagia. (particularly for studies in the menopause) and lack of
observer blinding. Patient blinding was designed into some
Infertility trials though it was not verified. Practitioner blinding is
Stener-Victorin compared electroacupuncture analgesia difficult, though not impossible, in acupuncture studies. In
with standard alfentanil analgesia during oocyte contrast, some of these studies show interesting features:
aspiration.18 Although the effect on fertility was not the Helms13 included a visitation control group in an attempt to
primary objective of the study, and so this finding must be control for the attention of the practitioner, Pouresmail and
viewed with caution, the electroacupuncture group were Ibrahimzadeh17 recruited a large number of schoolgirls
found to have a significantly higher chance of implantation from several schools of different socio-economic status,
and take-home baby rates (28/75 compared with 19/74 in and Taylor et al.16 tested a novel garment designed to offer
the control group). sustained pressure on the relevant acupuncture points.
Two gynaecologists in Germany frequently used ear In the absence of conclusive evidence for or against
acupuncture for treatment of infertility over 4 years. (The effectiveness for any of these conditions, it is worth
ear has been found to be useful site for giving acupuncture, considering possible mechanisms of action of acupuncture.
which may be related to its vagal innervation.) The results The potential mechanisms of acupuncture for treatment of
of treatment for 45 infertile women were reviewed and dysmenorrhoea are its central analgesic effect6 and its
compared with matched pairs who received standard reflex effects on the tissues, such as changes in blood
hormonal therapy.19 The overall pregnancy rate was about flow.23 For hormonal problems, laboratory studies have
50%, with no difference between the groups. shown that acupuncture stimulates the release of opioid
In a recent study involving 160 women undergoing in peptides (such as beta-endorphin) in the arcuate nucleus of
vitro fertilisation, 20 two sessions of acupuncture the hypothalamus.24 Since this is also the site for the
immediately before and after embryo transfer resulted in a gonadotrophin pulse generator,25 it is not unreasonable to
significantly higher pregnancy rate (42.5%) than in the explore whether acupuncture may have some effect on
control group who had no acupuncture (26.3%). The effect gonadotrophin-releasing hormone release and therefore

Journal of Family Planning and Reproductive Health Care 2003: 29(4) 235
 Downloaded from http://jfprhc.bmj.com/ on May 26, 2017 - Published by group.bmj.com

Review

may modify polycystic ovarian syndrome (PCOS). This 18 Stener-Victorin E, Waldenstrom U, Nilsson L, et al. A prospective
possibility has received some support from laboratory randomized study of electro-acupuncture versus alfentanil as
anaesthesia during oocyte aspiration in in-vitro fertilization. Hum
experiments: EA stimulation prevented the expected rise in Reprod 1999; 14: 2480–2484.
corticotrophin-releasing factor26 and nerve growth factor27 19 Gerhard I, Postneek F. Auricular acupuncture in the treatment of
concentrations in the ovaries of a rat PCOS model female infertility. Gynecol Endocrinol 1992; 6: 171–181.
produced by oestradiol injection. Chen reported that 6/13 20 Paulus WE, Zhang M, Strehler E, et al. Influence of acupuncture on
the pregnancy rate in patients who undergo assisted reproduction
anovulatory cycles in women responded to acupuncture, therapy. Fertil Steril 2002; 77: 721–724.
and were accompanied by autonomic effects as measured 21 Sandberg M, Wijma K, Wyon Y, et al. Effects of electro-acupuncture
by skin temperature changes. 28 By a similar mechanism on psychological distress in postmenopausal women. Complement
one might expect a response in menopausal symptoms.29 Ther Med 2002; 10: 161–169.
22 Kraft K, Coulon S, Wong AMK, et al. Der Einfluss einer
Pointing to another possible mechanism of action, standardisierten Akupunkturbehandlung auf Beschwerden, Blutdruck
electroacupuncture was shown to be associated with a und Serumlipide hypertensiver, postmenopausaler Frauen. Forsch
reduction of blood flow impedance (measured by Komplementarmed 1999; 6: 74–79.
pulsatility index) in the uterine arteries which may improve 23 Jansen G, Lundeberg T, Kjartansson J, et al. Acupuncture and sensory
neuropeptides increase cutaneous blood flow in rats. Neurosci Lett
endometrial receptivity in preparation for embryo 1989; 97: 305–309.
transfer.30 24 Takeshige C, Oka K, Mizuno T, et al. The acupuncture point and its
It is concluded that, within the stated limitations, the connecting central pathway for producing acupuncture analgesia.
evidence suggests that acupressure has a specific effect in Brain Res Bull 1993; 30: 53–67.
dysmenorrhoea but acupuncture is equivocal; that 25 Chang R, Chung PH, Rosenwaks Z. Role of acupuncture in the
treatment of female infertility. Fertil Steril 2002; 78: 1149–1153.
acupuncture is promising for infertility and was not shown 26 Stener-Victorin E, Lundeberg T, Waldenstrom U, et al. Effects of
to be inferior to standard hormonal therapy; and that electro-acupuncture on corticotropin-releasing factor in rats with
acupuncture has not been shown to be effective for experimentally-induced polycystic ovaries. Neuropeptides 2001; 35:
dysmenorrhoea but the trials are very small. In view of the 227–231.
27 Stener-Victorin E, Lundeberg T, Waldenstrom U, et al. Effects of
theoretical basis of possible mechanisms, further research electro-acupuncture on nerve growth factor and ovarian morphology
is justified in all these areas. in rats with experimentally induced polycystic ovaries. Biol Reprod
2000; 63: 1497–1503.
Statements on funding and competing interests 28 Chen BY, Yu J. Relationship between blood radioimmunoreactive
Funding. This project was partially funded by a Health Action Zone beta-endorphin and hand skin temperature during the electro-
(HAZ) fellowship. acupuncture induction of ovulation. Acupunct Electrother Res 1991;
Competing interests. None identified. 16: 1–5.
29 Wyon Y, Lindgren R, Lundeberg T, et al. Effects of acupuncture on
References climacteric vasomotor symptoms, quality of life, and urinary
1 Thomas KJ, Nicholl JP, Coleman P. Use and expenditure on excretion of neuropeptides among postmenopausal women.
complementary medicine in England: a population based survey. Menopause 1995; 2: 3–12.
Complement Ther Med 2001; 9: 2–11. 30 Stener-Victorin E, Waldenstrom U, Andersson SA, et al. Reduction of
2 Thomas K, Fall M, Parry G, et al. National survey of access to blood flow impedance in the uterine arteries of infertile women with
complementary health care via general practice. Sheffield: MCRU, electro-acupuncture. Hum Reprod 1996; 11: 1314–1317.
1995. Copies available from Medical Care Research Unit, Regent
Court, 30 Regent Street, Sheffield S1 4DA, UK.
3 Ezzo J, Berman B, Hadhazy V, et al. Is acupuncture effective for the
treatment of chronic pain? A systematic review. Pain 2000; 86:
217–225.
4 Lee A, Done ML. The use of nonpharmacologic techniques to prevent
postoperative nausea and vomiting: a meta-analysis. Anesth Analg
1999; 88: 1362–1369.
5 White A, Hayhoe S, Hart A, et al. Adverse events following
acupuncture: prospective survey of 32 000 consultations with doctors
and physiotherapists. BMJ 2001; 323: 485–486.
6 Han J, Terenius L. Neurochemical basis of acupuncture analgesia.
Annu Rev Pharmacol Toxicol 1982; 22: 193–220.
7 Cummings TM, White AR. Needling therapies in the management of
myofascial trigger point pain: a systematic review. Arch Phys Med
Rehabil 2001; 82: 986–992.
8 White A, Park J. Protocols for clinical trials of acupuncture. Acupunct
Med 1999; 17: 54–58.
9 Le Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory
controls (DNIC). 1. Effects on dorsal horn convergent neurones in the
rat. Pain 1979; 6: 283–304.
10 Streitberger K, Kleinhenz J. Introducing a placebo needle into
acupuncture research. Lancet 1998; 352: 364–365.
11 Park J, White A, Stevinson C, et al. Validating a new non-penetrating
sham acupuncture device: two randomised controlled trials. Acupunct
Med 2002; 20: 168–174.
12 Hayhoe S, Box H. A questionnaire on medical acupuncture practice.
Acupunct Med 1997; 15: 96–99.
13 Helms JM. Acupuncture for the management of primary
dysmenorrhea. Obstet Gynecol 1987; 69: 51–56.
14 Thomas M, Lundeberg T, Björk G, et al. Pain and discomfort in
primary dysmenorrhoea is reduced by preemptive acupuncture or low
frequency TENS. Eur J Phys Med Rehabil 1995; 4: 71–76.
15 Proctor ML, Smith CA, Farquhar CM, et al. Transcutaneous electrical
nerve stimulation and acupuncture for primary dysmenorrhoea
(Cochrane Review). Cochrane Database Syst Rev 2002; CD002123.
16 Taylor D, Miaskowski C, Kohn J. A randomized clinical trial of the
effectiveness of an acupressure device (relief brief) for managing
symptoms of dysmenorrhea. J Altern Complement Med 2002; 8:
357–370.
17 Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen
on the severity of primary dysmenorrhea. J Tradit Chin Med 2002;
22: 205–210.

236 Journal of Family Planning and Reproductive Health Care 2003: 29(4)
 Downloaded from http://jfprhc.bmj.com/ on May 26, 2017 - Published by group.bmj.com

A review of controlled trials of acupuncture

for women's reproductive health care
A R White

J Fam Plann Reprod Health Care 2003 29: 233-236

doi: 10.1783/147118903101197863

Updated information and services can be found at:

http://jfprhc.bmj.com/content/29/4/233

These include:

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/