Acupuncture and Women’s health Dr. Lei Gu 26 August 2013 Acupuncture and Women’s health - From menstrual concerns to infertility By : Lei Gu Bsc ND Scarborough Naturopathic Clinic 211-1585 Markham Road Scarborough, ON. M1B 2W1 www.naturopathscarborough.com Jump to: Part 1 Part 2 Part 3Part 4 Part I Menstrual concerns are common problem in women’s health, encompassing a wide range of concerns including premenstrual syndrome (PMS), painful menstruation (dysmenorrhea), and irregular or absent periods (amenorrhea). These symptoms can be a part of several medical conditions including polycystic ovary syndrome (PCOS), endometriosis, and uterine fibroids. Although not life-threatening, these health issues negatively impact the quality of a woman’s life and signal unresolved underlying problems. Conventionally, the birth control pill is often prescribed to control these symptoms. While often effective in regulating bleeding, long term use of the birth control pill is not without consequence, including the worsening of the underlying pathology (endometriosis and growth of fibroids), and potentially increased risk of cancer of the breast, uterus and ovaries.(1) It is also important to recognize that the birth control pill works by suppressing normal ovulation; thereby, it interferes with the body’s normal function while failing to address the cause of the problem in the first place. Fortunately, these conditions can be treated with success using naturopathic medical interventions such as acupuncture that help restore normal bodily function. In this article we discuss the benefits of acupuncture in the management of women’s health concerns, beginning with PMS. Premenstrual Syndrome Premenstrual syndrome (PMS) affects a large number of women of reproductive age. In fact one study determined that among college female students, over 90% experience at least two PMS symptoms.(2) PMS is a complex issue as a result of hormonal changes/imbalances beginning from mid-cycle to the start of menses. Symptoms can be both emotional as well as physical. A systematic review of the literature published in 2011 stated that although acupuncture usage is common for a wide variety of gynecological conditions, as a result of poor study design and control, more evidence is needed to support the benefit of acupuncture treatment for these concerns. However the article did report that the collective results of the individual studies examined showed a trend towards improvement in the acupuncture treatment groups, compared to control groups that either received no acupuncture treatment, or sham acupuncture.(3) Later in 2012, a small study of 11 patients demonstrated that receiving acupuncture for three consecutive menstrual cycles significantly reduced PMS symptoms including muscle pain, breast pain, and cramps. Blood levels of specific substances called nitric oxide (NO, a compound that promotes vasodilatation, thereby aids in pain relief), and glutathione (GSH, an endogenous antioxidant; antioxidant/oxidant imbalance has been correlated with PMS) were tested before and afterwards.(4) Following acupuncture treatments, NO and GSH had both increased, demonstrating clear biological change as a result of acupuncture.(5) Stay tuned for Part II, where we will discuss the impact of acupuncture on endometriosis, polycystic ovary syndrome and uterine fibroids. References 1. Zhu H, Lei X, Feng J, Wang Y. Oral contraceptive use and risk of breast cancer: a meta-analysis of prospective cohort studies. Eur J Contracept Reprod Health Care. 2012;17(6):402-14. 2. Obeidat BA, Alchalabi HA, Abdul-Razzak KK, Al-Farras MI. Premenstrual symptoms in dysmenorrheic college students: prevalence and relation to vitamin D and parathyroid hormone levels. Int J Environ Res Public Health. 2012;9(11):4210-22. 3. Kim SY, Park HJ, Lee H, Lee H. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials. BJOG. 2011 Jul;118(8):899-915 4. Duvan CI, Cumaoglu A, Turhan NO, Karasu C, Kafali H. Oxidant/antioxidant status in premenstrual syndrome. Arch Gynecol Obstet. 2011;283(2):299-304 5. Anil A, Peker T, Göktaş T, Kilic S, Erbaş D. Importance of acupuncture on premenstrual syndrome. Clin Exp Obstet Gynecol. 2012;39(2):209-13. Acupuncture and Women’s health - From menstrual concerns to infertility Part II By: Lei Gu Bsc ND Scarborough Naturopathic Clinic 211-1585 Markham Road Scarborough, ON. M1B 2W1 www.naturopathscarborough.com In Part I we reviewed the importance of treating women’s health problems in a restorative manner, rather than suppressing normal body function. We saw that acupuncture can be an effective treatment for PMS. Further research has shown that acupuncture may be effective for a host of other women’s health conditions, including conditions of painful menstruation such as endometriosis. A recent systematic review, which is a type of study summarizing all the existing data on a given topic, found that as a whole, 30 trials of acupuncture or acupuncture point stimulation through other techniques had more benefit on controlling menstrual pain compared to not receiving this therapy, or receiving medication.(1) Endometriosis is a common cause of severe menstrual pain and can also be successfully managed using acupuncture.(2, 3) Specifically, in a Japanese study, acupuncture treatment for four weeks resulted in significantly decreased pelvic pain among women with endometriosis.(4) A condition which can cause menstrual irregularity is polycystic ovarian syndrome, or PCOS. PCOS presents with a number of signs and symptoms that can include increased levels of androgen hormones such as testosterone, irregular menses, increased body hair, and acne.(5) Numerous studies have demonstrated the effectiveness of acupuncture as a treatment option for PCOS. One of these compared the results of using electric stimulated acupuncture, or physical exercise, or no intervention for a group of 87 women with PCOS. Hormone levels, menstrual frequency, and severity of acne breakouts were assessed. Both intervention groups (acupuncture and exercise) showed significant improvements in all outcomes measured compared to the group receiving no intervention; however, the group that underwent acupuncture treatment had best results.(6) Furthermore, in addition to physical symptoms relief, patients have reported that acupuncture treatments help to improve their mood and provide a sense of hope and control in managing PCOS.(7) A third condition afflicting women and leading to dysfunctional bleeding is uterine fibroids. Uterine fibroids are benign tumors that form inside the uterine wall. The most common symptom of this condition is heavy menstrual bleeding, which over the long term can lead to other issues including iron-deficiency anemia as a result of the blood loss. A Chinese study conducted in 1994 found very positive results on uterine fibroids with use of acupuncture: 98% of the patients responded favorably, and 73% of patients were completely cured.(8) More recently, in 2011, a case study reported that acupuncture treatments decreased symptoms of uterine fibroids, based on the number of sanitary pads used as well as blood flow measured through Doppler ultrasound technology.(9) Many acknowledge the effectiveness of acupuncture but struggle to understand how it works. Although the mechanisms by which acupuncture works are likely multifaceted, it is hypothesized that both the central and peripheral nervous systems are affected by needle insertion near specific nerve pathways and/ or organs, thereby changing brain’s regulation of hormones centrally. More specifically, in women’s health concerns, it is theorized that insertion of the needles into acupuncture points in the pelvic area for instance, could be triggering nerve signals to the ovaries.(10) Overall, acupuncture is a safe, non-invasive and effective treatment option for women’s health concerns. Stay tuned for Part III and IV discussing the role of acupuncture in infertility. References 1. Chung YC, Chen HH, Yeh ML. Acupoint stimulation intervention for people with primary dysmenorrhea: Systematic review and meta-analysis of randomized trials. Complement Ther Med. 2012;20(5):353-63. 2. Zhou J, Qu F. Treating gynaecological disorders with Traditional Chinese Medicine: a review. Afr J Tradit Complement Altern Med. 2009; 6(4): 494–517. 3. Rubi-Klein K, Kucera-Sliutz E, Nissel H, Bijak M, Stockenhuber D, Fink M, 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(1):90-3. 4. Wayne PM, Kerr CE, Schnyer RN, Legedza AT, Savetsky-German J, Shields MH 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(5):247-57. 5. Sheehan D. Polycystic ovarian syndrome: diagnosis and management. Clin Med Res. 2004; 2(1): 13–27. 6. Jedel E, Labrie F, Odén A, Holm G, Nilsson L, Janson PO, et al. Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. Am J Physiol Endocrinol Metab. 2011;300(1):E37-45. 7. Billhult A, Stener-Victorin E. Acupuncture with manual and low frequency electrical stimulation as experienced by women with polycystic ovary syndrome: a qualitative study. BMC Complement Altern Med. 2012;12:32. 8. Yan H, Wang J. The clinical study on hysteromyoma treated with acupuncture. Zhen Ci Yan Jiu. 1994;19(2):14-6. 9. Cakmak YÖ, Akpınar IN, Yoldemir T, Cavdar S. Decreasing bleeding due to uterine fibroid with electroacupuncture. Fertil Steril. 2011;96(1):e13-5. 10. Raja-Khan N, Stener-Victorin E, Wu X, Legro RS. The physiological basis of complementary and alternative medicines for polycystic ovary syndrome. Am J Physiol Endocrinol Metab. 2011;301(1):E1-E10. Acupuncture and Women’s health - From menstrual concerns to infertility Part III By: Lei Gu Bsc ND Scarborough Naturopathic Clinic 211-1585 Markham Road Scarborough, ON. M1B 2W1 www.naturopathscarborough.com According to a 2012 study published in Human Reproduction, infertility affects 16% of heterosexual couples in Canada.(1) Of these couples, many seek out complementary or alternative solutions, one of which is acupuncture treatment. Couples have reported a wide range of benefits when they do incorporate acupuncture into their fertility treatment. While the culprit of infertility in couples can be due to either male or female factor problems, this article focuses on the discussion of the efficacy of acupuncture and infertility when acupuncture treatments are administered to women. Unlike male factor infertility, female factor infertility can be due to a number of problems. First, there can be ovulatory problems. This includes poor quality ovulation, and can include missed or irregular of ovulation. Second, there can be cervical factors, such as insufficient, poor quality, or hostile cervical mucus – this mucus is essential to allowing sperm to travel toward the egg for fertilization. Third, there can be scarring or blockages of the Fallopian tubes leading to the ovaries. If this is the case, sperm will not be able to reach the egg. Fourth, there can be implantation problems, such as an insufficient or hostile uterine lining, insufficient progesterone levels, or the presence of fibroids. Needless to say, all of these factors are influenced by female hormones. Acupuncture works to restore and optimize normal body function. For instance, when pathologies that affect ovulation, such as PCOS, are successfully treated, the chances of achieving pregnancy also improve. Similarly, improving egg quality results in improved chances of successful pregnancy. Acupuncture can regulate hormone balance, improve ovulation and egg quality, increase blood flow to the reproductive organs, and promote a suitable uterine environment for implantation.(2, 3) Acupuncture has been shown to help regulate cortisol and prolactin levels in the woman’s body, both of which can interfere with normal ovulation.(4) In addition, when compared to conventional interventions, acupuncture treatment resulted in normalized hormone levels for a longer period of time post treatment.(5) In patients with PCOS, acupuncture twice weekly for 10-13 weeks resulted in more frequent ovulation and significant improvements in sex hormones compared to women receiving no treatment;(6) while in another study, women who were undergoing IVF, acupuncture treatment beforehand resulted in better quality eggs/ oocytes.(7) Another study found that acupuncture improved blood blow to reproductive organs.(8) When infertile women were treated with acupuncture twice weekly for four weeks, there was a significant reduction in their uterine artery blood flow impedance, indicating better blood delivery to the uterus. Unfortunately, successful treatment of these pathologies does not always lead to successful conception in every case, and certainly not all pathologies can be cured. As a result, many infertile couples choose to undergo assisted reproductive procedures. In Part IV we discuss the adjunctive role of acupuncture in optimizing the outcomes of IVF. References 1. Bushnik T, Cook J, Yuzpe A, Tough S, Collins J. Estimating the prevalence of infertility in Canada Hum. Reprod. 2012;27:738–746 2. Gerhard I, Postneek F. Auricular acupuncture in the treatment of female infertility. Gynecol Endocrinol. 1992;6(3):171-81. 3. Lyttleton J. Treatment of Infertility with Chinese Medicine, 1st edition. Churchill Livingstone, 2004. 4. Magarelli PC, Cridennda DK, Cohen M. Changes in serum cortisol and prolactin associated with acupuncture during controlled ovarian hyperstimulation in women undergoing in vitro fertilization-embryo transfer treatment. Fertil Steril. 2009;92(6):1870-9. 5. Chen D, Chen SR, Shi XL, Guo FL, Zhu YK, Li S, et al. [Clinical study on needle-pricking therapy for treatment of polycystic ovarial syndrome]. Zhongguo Zhen Jiu. 2007;27(2):99-102. 6. Johansson J, Redman L, Veldhuis PP, Sazonova A, Labrie F, Holm G, et al. Acupuncture for ovulation induction in polycystic ovary syndrome: A randomized controlled trial. Am J Physiol Endocrinol Metab. 2013 [Epub ahead of print] 7. Rashidi BH, Tehrani ES, Hamedani NA, Pirzadeh L. Effects of acupuncture on the outcome of in vitro fertilisation and intracytoplasmic sperm injection in women with polycystic ovarian syndrome. Acupunct Med. 2013. [Epub ahead of print] 8. Stener-Victorin E, Waldenström U, Andersson SA, Wikland M. Reduction of blood flow impedance in the uterine arteries of infertile women with electro-acupuncture. Hum Reprod. 1996;11(6):1314-7. Acupuncture and Women’s health - From menstrual concerns to infertility Part IV By: Lei Gu Bsc ND Scarborough Naturopathic Clinic 211-1585 Markham Road Scarborough, ON. M1B 2W1 www.naturopathscarborough.com In-vitro fertilization (IVF) is by far the most expensive and the most invasive method of assisted reproduction and it is often a couple’s last resort. The success rate of IVF however is only estimated to be around 33%.(1) Given the high cost and limited success rate of the procedure, any adjunctive therapy that can increase the success of IVF would be beneficial. Acupuncture is a treatment option that is increasingly being sought out by women undergoing IVF and is increasingly recommended by their fertility specialists. In 2008, two meta–analyses (powerful studies that combine the data from all earlier studies) were published, both indicating that acupuncture increases the pregnancy rate in women undergoing IVF treatment. More specifically, the first study (including 7 studies and 1366 patients) concluded that when acupuncture is administered around the time of embryo transfer, both pregnancy and live birth rates are significantly improved. The second study (including 10 studies and 2003 patients) found similar results, especially when acupuncture treatment is given on the same day as embryo transfer. In 2012, a newer meta-analysis that included many more studies (33 trials, and a patient pool of 5598) concluded that acupuncture treatment yielded a significant increase in both pregnancy and live birth rates when administered in conjunction with IVF procedure.(3) Finally, another study involving 97 cases found that the use of both Chinese herbal medicine and acupuncture compared to no treatment resulted in higher egg/ oocyte quality as well as significantly higher pregnancy rates.(1) Undergoing IVF, an expensive and last-resort treatment option, can bring about a great deal of stress for the couple. In fact, pre-treatment anxiety has been found to be significantly higher in women who did not successfully become pregnant following IVF procedure compared to those who did, leading to the conclusion that anxiety itself inhibits the success of IVF.(4) On the other hand, treatment which can help decrease anxiety in women receiving IVF treatment could potentially increase their success rates. Since acupuncture has been found to significantly decrease anxiety level in these patients,(5) it is yet another reason to incorporate acupuncture treatment as an adjunct to assisted reproductive procedures such as IVF. In summary, acupuncture has been found to be a safe and effective treatment option for women’s infertility. It can successfully treat the underlying pathologies causing fertility challenges, and it also increases the success rate of IVF procedure when administered shortly before and after the procedure.(6) It has been found that acupuncture statistically significantly improves egg quality.(7) Overall, acupuncture is a safe treatment option that improves the rate of pregnancies and live births compared to control groups.(8) Additionally, it also reduces pain from the egg retrieval procedure more effectively compared to conventional medication.(9) Therefore, acupuncture is certainly a worthwhile treatment for adjunctive use alongside IVF in order to maximize success rates.(10) As demonstrated through this four-part series, acupuncture represents an effective therapy for the treatment of many women’s health concerns, ranging from various menstrual issues to infertility. References 1. Zheng CH, Zhang MM, Huang GY, Wang W. The role of acupuncture in assisted reproductive technology. Evid Based Complement Alternat Med. 2012; 2012: 543924. 2. Manheimer E. Selecting a control for in vitro fertilization and acupuncture randomized controlled trials (RCTs): how sham controls may unnecessarily complicate the RCT evidence base. Fertil Steril. 2011;95(8):2456-61. 3. Guo J, Wang LN, Li D. Exploring the effects of Chinese medicine in improving uterine endometrial blood flow for increasing the successful rate of in vitro fertilization and embryo transfer. Zhong Xi Yi Jie He Xue Bao. 2011;9(12):1301 4. Koryntová D, Síbrtová K, Kloucková E, Cepický P, Rezábek K, Zivný J. Effect of psychological factors on success of in vitro fertilization. Ceska Gynekol. 2001;66(4):264-9. 5. Isoyama D, Cordts EB, de Souza van Niewegen AM, de Almeida Pereira de Carvalho W, Matsumura ST, Barbosa CP. Effect of acupuncture on symptoms of anxiety in women undergoing in vitro fertilisation: a prospective randomised controlled study. Acupunct Med. 2012;30(2):85-8. 6. Isoyama D, Cordts EB, de Souza van Niewegen AM, de Almeida Pereira de Carvalho W, Matsumura ST, Barbosa CP. Effect of acupuncture on symptoms of anxiety in women undergoing in vitro fertilisation: a prospective randomised controlled study. Acupunct Med. 2012;30(2):85-8. 7. Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril. 2002;77(4):721-4. 8. Cui W, Li J, Sun W, Wen J. Effect of electroacupuncture on oocyte quality and pregnancy for patients with PCOS undergoing in vitro fertilization and embryo transfervitro fertilization and embryo transfer. Zhongguo Zhen Jiu. 2011;31(8):687-91. 9. Stener-Victorin E, Humaidan P. Use of acupuncture in female infertility and a summary of recent acupuncture studies related to embryo transfer. Acupunct Med. 2006;24(4):157-63. 10. Humaidan P, Stener-Victorin E. Pain relief during oocyte retrieval with a new short duration electro-acupuncture technique--an alternative to conventional analgesic methods. Hum Reprod. 2004;19(6):1367-72.