Stimulated by Li et al 2023.[1]
RCT – randomised controlled trial
key to acronyms
VAS – visual analogue score
This is the second moderately large (n=106) controlled trial of acupuncture in endometriosis. It is a sham controlled trial. The first was a similarly sized (n=101) cross-over trial using acupuncture at appropriate (segmental) points compared with acupuncture at mostly non-segmental points not indicated in the condition.[2] It was positive.
The other 2 controlled trials were small (n<20),[3,4] but there have been a number of comparative RCTs against drugs or herbal preparations.[5]
The paper was published in the mainstream journal Fertility and Sterility, which is the main journal of the American Society for Reproductive Medicine (ASRM) with an impact factor of 7.49.
The graphical results in the paper do not look overly impressive (see above) but note that so few patients had non-menstrual pelvic pain or dyspareunia that the baseline median VAS for both was zero.
The acupuncture protocol was relatively neat and straight-forward with 3 points on the lower abdomen (CV4 and bilateral ST30) and 3 bilateral points in the legs (SP6, LR3, KI6). Manual stimulation was applied every 10 minutes over a 30-minute session. The sham technique was a superficial (<5mm insertion) in the upper arms and shoulders at non acupuncture points. It seems familiar to the protocol used in the huge PCOS trial,[6] which I discussed on this blog in 2018, but without the electroacupuncture. There is very little other description of the sham even in the protocol.[7] So, we do not know how many needles were used. There is also no discussion of a test for blinding. I would have thought that if your acupuncture doctor in China puts needles in your shoulders and upper arms when your pain is in the pelvis that you might have some doubts or questions. None of this is discussed.
Acupuncture or sham was performed 3 times a week from 1 week prior to menstruation and every day during menstruation if there was pain. Treatment started from a week before each period and covered 12 weeks. It is not clear whether having started, the treatment continued at the same rate following each period of menstruation. My suspicion is that it did not. After the 12 weeks, during which treatment was applied, there was a further 12 weeks of follow up.
As you can see from the upper graph in the image above, there appeared to be a reasonable effect in the first 12 weeks during which acupuncture treatment was applied, but this gradually wore off over the subsequent 12 weeks follow up.
This was a positive trial demonstrating efficacy over sham and the accompanying commentary was also positive and clearly written by acupuncture advocates with a traditional influence, since they could not resist mentioning rebellious qi.
There is clearly room for some improvement in the methods and reporting. I am less impressed now than when I started reading the paper. But overall, it is a positive message in a sometimes difficult to manage condition.
Before finishing, I want to mention another paper I found whilst scouting around on the subject of endometriosis.[8] It is one of the large retrospective cohorts from Taiwan. I must have missed it when it came out in 2020. Well, there was rather a lot going on that year.
This paper took a cohort of patients diagnosed with rheumatoid arthritis (n=2407) and compared those who received at least 1 package of acupuncture (at least 6 sessions in 1 month) with a matched cohort (n=2407) who did not. Apparently, the risk of developing endometriosis is 40% higher in women with rheumatoid arthritis.
Acupuncture was associated with a reduction in risk of up to 70% in this population and more acupuncture was associated with a lower risk with a ceiling effect around 15 packages (ie 90 sessions) spread over a time period of up to 10 years.
That is certainly encouraging and together these data provide a powerful incentive for women to consider regular use of acupuncture as one choice of pain relief and also as a potential means of keeping well.
Addendum 1
During the webinar on the 10th May, one of the participants (Paul) brought to my attention the rather outdated description of endometriosis I recited, ie that it was thought to be due to retrograde menstruation. He pointed out that a recent review in the Lancet had highlighted this to be an outdated description.[9] Indeed, endometriosis is now consisted a systemic inflammatory disease with effects in many organs, including the liver, brain, spleen, lung, and adipose tissue. I am grateful to Paul for his intervention and encourage readers and listeners to continue to correct my mistakes.
Addendum 2
I am grateful to Mike Armour (one of the lead authors of a trial on endometriosis) for pointing out some errors in my original narrative, including, importantly, a trial that I, and the SR I quoted from PLOS One, completely missed. This was a moderately large cross-over trial performed by medical acupuncture colleagues from Austria,[2] several of whom I know personally, so that is a bit embarrassing.
References
1 Li P-S, Peng X-M, Niu X-X, et al. Efficacy of acupuncture for endometriosis-associated pain: A multicenter randomized single-blind placebo-controlled trial. Fertil Steril 2023;:S0015-0282(23)00072-9. doi:10.1016/j.fertnstert.2023.01.034
2 Rubi-Klein K, Kucera-Sliutz E, Nissel H, et al. Is acupuncture in addition to conventional medicine effective as pain treatment for endometriosis? A randomised controlled cross-over trial. Eur J Obstet Gynecol Reprod Biol 2010;153:90–3. doi:10.1016/j.ejogrb.2010.06.023
3 Wayne PM, Kerr CE, Schnyer RN, et al. Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. J Pediatr Adolesc Gynecol 2008;21:247–57. doi:10.1016/j.jpag.2007.07.008
4 Armour M, Cave AE, Schabrun SM, et al. Manual Acupuncture Plus Usual Care Versus Usual Care Alone in the Treatment of Endometriosis-Related Chronic Pelvic Pain: A Randomized Controlled Feasibility Study. J Altern Complement Med 2021;27:841–9. doi:10.1089/acm.2021.0004
5 Xu Y, Zhao W, Li T, et al. Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis. PloS One 2017;12:e0186616. doi:10.1371/journal.pone.0186616
6 Wu X-K, Stener-Victorin E, Kuang H-Y, et al. Effect of Acupuncture and Clomiphene in Chinese Women With Polycystic Ovary Syndrome: A Randomized Clinical Trial. JAMA 2017;317:2502–14. doi:10.1001/jama.2017.7217
7 Liang R, Li P, Peng X, et al. Efficacy of acupuncture on pelvic pain in patients with endometriosis: study protocol for a randomized, single-blind, multi-center, placebo-controlled trial. Trials 2018;19:314. doi:10.1186/s13063-018-2684-6
8 Chen W-J, Livneh H, Hsu C-H, et al. The Relationship of Acupuncture Use to the Endometriosis Risk in Females With Rheumatoid Arthritis: Real-World Evidence From Population-Based Health Claims. Front Med 2020;7:601606. doi:10.3389/fmed.2020.601606
9 Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet 2021;397:839–52. doi:10.1016/S0140-6736(21)00389-5
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