Inspired by Zhou et al 2022.
PMD – perimenopausal depressionkey to acronyms
MA – manual acupuncture
EA – electroacupuncture
HAM-D – Hamilton Depression Rating Scale
HAMD-17 – the sum of the first 17 items on the HAM-D
MENQOL – Menopause-specific Quality of Life Questionnaire
FSH – follicle stimulating hormone
LH – luteinising hormone
RCT – randomised controlled trial
This paper is essentially a relatively large trial (n=242) of MA plus EA versus escitalopram in perimenopausal depression, but it has some novelty in the analysis of outcomes.
I struggled with the title for a while…
The Role of Acupuncture in Hormonal Shock-Induced Cognitive-Related Symptoms in Perimenopausal Depression
…in particular the hormonal shock.
I guessed it must refer to a drop in oestrogen rather in the same way as blood pressure drops in hypovolemic, cardiogenic, anaphylactic or septic shock.
Whilst oestrogen fluctuates and then drops from perimenopause to post menopause, other hormones, such as FSH and LH, go up. So, I’m not sure the term hormonal shock is the best. Indeed, this may be the first use of the term in PubMed and may have been facilitated by both authors and reviewers being Chinese. Perhaps there is a translation that makes sense and is in common use in Chinese.
The research is from Guangzhou, a huge sprawling port city on the Pearl river north of Hong Kong. The population of the provincial area is almost the same as that of the entire UK. Patients were recruited with PMD from 6 different hospitals in the area. To be eligible they had to score between 8 and 22 on the HAM-D. This range include all severities of depression apart from the most severe cases. They were randomised to 12 weeks of treatment with either acupuncture or escitalopram at a dose of 10mg per day.
The acupuncture was performed 3 times a week for the 12 weeks, so that is a lot of treatment, and follow up was continued until 24 weeks with HAMD-17 and MENQOL. Serum hormone levels of oestradiol, FSH and LH were taken on day 2–5 of the menstrual cycle at week 0 and week 12.
The acupuncture protocol included both MA and EA. MA was applied at LI4, CV4, SP6, and LR3. EA was applied between GV20 and Yintang, across ST25, and across Zigong (an extra point 3cun lateral to CV3). EA was applied at 50Hz and 0.5 to 10mA. It was described as ‘sparse and density wave stimulation’ which I take to mean a form of frequency modulation, so the frequency may have varied from low to high frequency at the extremes.
So far it all seems like a relatively straightforward parallel arm comparative RCT, but then we are introduced to the construction of a structural equation model and a latent profile analysis. The former measures correlations between the different outcome measures over time and links them all together in a structural equation, and the latter was applied to the different subscales of the HAM-D (somatisation, cognition, block and sleep) but is entirely unintelligible to me I’m afraid.
Over the course of the 12 weeks of treatment with either acupuncture or escitalopram, there was a gradual improvement (drop) in both HAMD-17 and MENQOL scores with a trend in favour of acupuncture, but there was no significant difference between groups. From 12 to 24 weeks in the follow up period after treatment was stopped, the acupuncture group continued a downward trend, and the escitalopram group maintained the level at the end of the treatment phase. The difference between groups became significant at 16 weeks for the HAMD-17 and at 20 weeks for the MENQOL.
FSH and LH levels correlated with MENQOL but not with HAMD-17. Oestradiol levels did not correlate with either. This is when they created a structural equation model using the hormones (FSH and LH), MENQOL and HAMD-17, which indicated that MENQOL was a statistically significant mediating variable between hormones and the HAMD-17.
They went on to analyse the subscales of HAM-D in a latent profile analysis and apparently cognitive impairment was the main manifestation of perimenopausal depression.
Thus, the change in perimenopausal depression was mediated by the effect of hormone fluctuations on menopausal symptoms and the key abnormality identified was in cognitive function. Whilst antidepressants can improve cognitive function when improving depression, acupuncture can also improve menopausal symptoms. In this way acupuncture may have a superior effect by improving the individual’s embodied experience through its strong somatosensory properties.
In simple terms, antidepressants improve depression via neurotransmitters in the brain, but acupuncture, as well as affecting the brain directly, also improves menopausal symptoms, which appear to be the key factor in the path from hormone shock (fluctuations) to perimenopausal depression.
1 Zhou J-H, Zhang D-L, Ning B-L, et al. The Role of Acupuncture in Hormonal Shock-Induced Cognitive-Related Symptoms in Perimenopausal Depression: A Randomized Clinical Controlled Trial. Front Psychiatry 2021;12:772523. doi:10.3389/fpsyt.2021.772523