Manual Acupuncture Plus Usual Care Versus Usual Care Alone in the Treatment of Endometriosis-Related Chronic Pelvic Pain: A Randomized Controlled Feasibility Study

Acupuncture and Related Therapies for Endometriosis: A Network Meta-Analysis of Randomized Controlled Trials

Background

Acupuncture and related therapies are effective and safe ways to relieve the pain, and improve the health and quality of life in women with endometriosis-related pain. However, it is still unclear which treatment is the most effective. Our study aims to summarize the evidence and determine the most effective and safe method to treat the endometriosis.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of science, China Biology Medicine, China National Knowledge Infrastructure, Wan fang Data, Chinese Scientific Journal Database and conducted manual searches of relevant papers, summarized randomized clinical trials of acupuncture-related therapies for endometriosis from database inception to 21 April 2024. After independent literature screening and data extraction that pain VAS was selected as the primary outcome measure. The quality evaluation was conducted by Review Manager 5.4. Perform network meta-analysis (NMA) used Stata 15.0 software.

Results

Forty-two eligible trials involving six acupuncture-related interventions and 3,635 participants were included in this NMA. Pairwise meta-analyses show that combination therapy was more efficacious than western medicine and Chinese herb medicine for pain VAS scores, serum CA125 level and response rate results. The NMA estimates indicated that: for pain VAS scores, acupuncture (SMD: -2.33; 95% CI: -4.37, -0.29) and combination therapy (SMD: 1.79 95% CI: 1.21, 2.41) were superior to western medicine. For serum CA125 level, acupoint application (SMD: -11.33 95% CI: -20.28, -2.97) and combination therapy (SMD: 6.20; 95% CI: 1.60, 10.75) were associated with better efficacy when considered alongside western medicine. For response rate, combination therapy (SMD: 0.20; 95% CI: 0.14, 0.29) and auricular therapy (SMD: 8.01; 95% CI: 2.08, 45.37) were more efficacious than western medicine. The comprehensive ranking results show that acupoint catgut embedding was the best performing at lowering pain VAS scores, acupoint application was identified as the most effective in reducing serum CA125 level, and auricular therapy was ranked first in improving the response rate.

Conclusion

Acupoint catgut embedding, auricular therapy, acupoint application and combination therapy may be the best solutions for the treatment of endometriosis. Additional trials are needed to develop higher-quality evidence and optimal regimens.

Acupuncture for clinical improvement of endometriosis-related pain: a systematic review and meta-analysis

BACKGROUND

Endometriosis is a common chronic gynecological condition characterized by the presence of endometrial tissue outside the uterine cavity, leading to chronic inflammation, pelvic nodules and masses, pelvic pain, and infertility. Acupuncture has been shown to improve pain associated with endometriosis by modulating abnormal levels of prostaglandins, β-endorphins, dynorphins, electrolytes, and substance P. This review aims to evaluate the clinical efficacy of acupuncture in treating endometriosis, specifically focusing on its efficacy in relieving pain associated with endometriosis.

METHODS

A comprehensive search was conducted in eight databases (PubMed, EMBASE, Cochrane, Web of Science, China National Knowledge Infrastructure (CNKI), the China Biology Medicine (CBM), Wanfang, and Weipu database) to identify randomized controlled trials (RCTs) published from database inception to December 16, 2022, which investigated the use of acupuncture for endometriosis-related pain. Two researchers independently screened articles, extracted data, and assessed methodological quality using the Cochrane Collaboration's risk of bias tool. Meta-analysis was performed using Stata statistical software.

RESULTS

A total of 1991 articles were identified, and ultimately, 14 studies involving 793 patients (387 in the acupuncture group and 359 in the control group) were included. The control interventions in the included studies included placebo, traditional Chinese medicine (TCM), and Western medicine treatments. Meta-analysis results showed that compared to the control group, acupuncture treatment for pain associated with endometriosis demonstrated significant reductions in pain severity [SMD = - 1.10, 95% CI (- 1.45, - 0.75), P < 0.001], improved response rate [RR = 1.25, 95% CI (1.09, 1.44), P = 0.02], and decreased serum CA-125 levels [SMD = - 0.62, 95% CI (- 1.15, - 0.08), P = 0.024]. Furthermore, subgroup analysis revealed that electroacupuncture and auricular acupuncture were superior to the control group in reducing pain severity, while auricular acupuncture and warm needling showed greater clinical efficacy compared to the control group. However, there were no significant differences between electroacupuncture or fire needling and the control group in terms of pain relief. The findings suggest that acupuncture is effective in improving pain associated with endometriosis.

CONCLUSIONS

In conclusion, acupuncture is effective in alleviating dysmenorrhea and pelvic pain associated with endometriosis, reducing serum CA-125 levels, decreasing the size of nodules, improving patients' quality of life, and lowering the recurrence rate. However, it should be noted that the current evidence is limited by the design and quality flaws of the original studies, as well as a lack of research specifically focusing on subtypes of acupuncture. Therefore, caution should be exercised when interpreting the results.

An overview and comprehensive analysis of interdisciplinary clinical research in endometriosis based on trial registry

Endometriosis is a chronic multisystem disease associated with immunological, genetic, hormonal, psychological, and neuroscientific factors, leading to a significant socioeconomic impact worldwide. Though multidisciplinary management is the ideal approach, there remains a scarcity of published interdisciplinary clinical trials at present. Here, we have conducted a comprehensive analysis of the characteristics and issues of interdisciplinary trials on endometriosis based on the clinical registration database ClinicalTrials.gov. Among all 387 endometriosis trials, 30% (116) were identified as interdisciplinary, mostly conducted in Europe and North America, and fully funded by non-industrial sources. We documented growth in both patient-centered multidisciplinary comprehensive management and collaboration between fundamental biomedical science and applied medicine. However, compared to traditional obstetric-gynecological trials, interdisciplinary studies exhibited negative characteristics such as less likely to be randomized and less likely to report results. Our study provides insights for future trial investigators and may contribute to fostering greater collaboration in medical research.

Effects and mechanisms of acupuncture on women related health

Globally, public health interventions have resulted in a 30-year increase in women's life expectancy. However, women's health has not increased when socioeconomic status is ignored. Women's health has become a major public health concern, for those women from developing countries are still struggling with infectious and labor-related diseases, and their counterparts in developed countries are suffering from physical and psychological disorders. In recent years, complementary and alternative medicine has attracted wide attentions with regards to maintaining women's health. Acupuncture, a crucial component of traditional Chinese medicine, has been used to treat many obstetric and gynecological diseases for thousands of years due to its analgesic and anti-inflammatory effects and its effects on stimulating the sympathetic/parasympathetic nervous system. To fully understand the mechanism through which acupuncture exerts its effects in these diseases would significantly extend the list of available interventions and would allow for more reasonable advice to be given to general practitioners. Therefore, by searching PubMed and CNKI regarding the use of acupuncture in treating obstetric and gynecological diseases, we aimed to summarize the proven evidence of using acupuncture in maintaining women's health by considering both its effectiveness and the underlying mechanisms behind its effects.

Acupuncture for endometriosis: A systematic review and meta-analysis

Background

Current endometriosis treatments do not always provide symptom relief, with many using complementary approaches. This study examined the effectiveness of acupuncture on pain and quality of life in people with endometriosis.

Methods

Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Allied and Complementary Medicine Database (AMED) and Embase (Ovid), Epistemonikos, and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOhost) on 20 March 2023. Trials were included if they used penetrating acupuncture. Risk of bias was assessed with Cochrane RoB2 and GRADE for overall evidence certainty. Random-effects meta-analyses were undertaken, using Hedges' g or mean difference (MD) both with 95 % confidence intervals (CI).

Results

Six studies involving a total of 331 participants were included. Evidence for benefit was found for acupuncture compared to non-specific acupuncture on overall pelvic pain (g = 1.54, 95 % CI 0.92 to 2.16, 3 RCTs, n = 231, low certainty evidence, p<0.001), menstrual pain (g = 1.67, 95 % CI 1.23 to 2.12, 1 RCT, n = 106, moderate certainty evidence, p<0.001), and non-specified pelvic pain (MD -2.77, 95 % CI 2.15 to 3.38, 2 RCTs, n = 125, low certainty evidence, p<0.001), and compared to usual care on menstrual pain (g = 0.9, 95 % CI 0.15 to 1.64, 1 RCT, n = 19, very low certainty evidence, p = 0.02). Most studies reported low rates of adverse events.

Conclusion

Acupuncture treatment for endometriosis demonstrated clinically relevant improvements in pelvic pain and should be considered as a potential treatment intervention.

Study registration

PROSPERO ID: CRD42023408700.

Research Trends of Acupuncture Therapy on Chronic Pelvic Pain Syndrome from 2000 to 2022: A Bibliometric Analysis

Background

Acupuncture is considered an important means of analgesic, which has been widely used in chronic pelvic pain syndrome (CPPS) management and treatment in recent years, published a large number of related documents. However, the relevant literature in this field has not been summarized and quantitatively analyzed. Therefore, this study aims to analyze the hotspots and predicting future research trends of acupuncture on pelvic pain syndrome.

Methods

Search for the relevant publications of the web of science database from 2000 to 2022 about the treatment of acupuncture on chronic pelvic pain syndrome. The Citespace software and VosViewer software are used to analyze the visualization of the countries, institutions, authors, keywords and references and references in the literature.

Results

A total of 173 publications were included. The annual number of essays gradually showed an overall growth trend over time. Medicine magazine is the most published journal in this field. J UROLOGY and Acupunct Med are the most cited journals and the most influential magazines; The most active and influential country is China, and the most produced institutions are Beijing University of Chinese Medicine; The most produced authors are Liu Zhishun. The most cited and most influential authors are Nickel JC and Armour M; keywords and cited reference analysis show that the quality of life, mechanism research, alternative medicine and electro-acupuncture will be the scientific hotspot of acupuncture treatment for chronic pelvic pain syndrome.

Conclusion

This study shows that acupuncture on CPPS is increasingly valued and recognized. The future research hotspots will focus on the effects and mechanisms. In the future, more high-quality animal basic research will be required to explore the exact mechanism of acupuncture on CPPS. In addition, different parameters of acupuncture such as electric-acupuncture, stimulating frequency, duration and strength are also the focus of future research. More clinical trials are required to verify its safety and effectiveness.

Transcutaneous electrical acupoint stimulation versus dexamethasone for prophylaxis of postoperative nausea and vomiting in breast surgery: A non-inferiority randomized controlled trial

BACKGROUND

Transcutaneous electrical acupoint stimulation and dexamethasone can reduce postoperative nausea and/or vomiting. In this noninferiority study, we compared the effects of Neiguan acupoint (PC6) transcutaneous electrical acupoint stimulation with dexamethasone to prevent postoperative nausea and/or vomiting in female patients undergoing breast surgery.

METHODS

In total, 280 patients were randomized into the following 2 groups: transcutaneous electrical acupoint stimulation (n = 140) and dexamethasone (n = 140). Transcutaneous electrical acupoint stimulation was performed 0.5 hours before anesthesia induction, immediately after entering the post-anesthesia care unit, and every 3 hours after leaving the post-anesthesia care unit. In the postoperative ward, the anesthetist instructed the patient's family members to assist the patient with PC6 patient-controlled transcutaneous electrical acupoint stimulation. Patients in the dexamethasone group were given 8 mg dexamethasone (intravenously) at 0.5 hours before induction of anesthesia. The incidence of nausea, vomiting, need for rescue antiemetics, patient satisfaction score, and the feasibility results of PC6 patient-controlled transcutaneous electrical acupoint stimulation were recorded 24 hours after surgery.

RESULT

Within 0 to 24 hours after surgery, the incidence of postoperative nausea and/or vomiting in the transcutaneous electrical acupoint stimulation group was not inferior to the dexamethasone group (31.1% vs 27.9%, per protocol risk difference 3.2; 95% confidence interval -7.7 to 14.0). The results of the intention-to-treat analysis (30.7% vs 27.1%, risk difference 3.6; 95% confidence interval -7.0 to 14.2) agreed with the per protocol analysis. Patient satisfaction score in the transcutaneous electrical acupoint stimulation group was higher than that in the dexamethasone group (3.9 ± 0.1 vs 3.6 ± 0.1, P = .003). The scheme of preventing postoperative nausea and/or vomiting by PC6 patient-controlled transcutaneous electrical acupoint stimulation was feasible.

CONCLUSION

Transcutaneous electrical acupoint stimulation was noninferior to dexamethasone in preventing postoperative nausea and/or vomiting within 24 hours after breast surgery. Neiguan acupoint patient-controlled transcutaneous electrical acupoint stimulation was feasible to prevent postoperative nausea and/or vomiting.

Unmet Needs of Australians in Endometriosis Research: A Qualitative Study of Research Priorities, Drivers, and Barriers to Participation in People with Endometriosis

Background and Objectives: Endometriosis causes significant personal and societal burden. Despite this, research funding lags behind other chronic conditions. Determining where to prioritise these limited funds is therefore vital. Research priorities may also differ between individuals with endometriosis and clinicians/researchers. The aim of this research project is to explore research priorities and factors shaping participation in endometriosis research from the perspective of people with endometriosis in Australia. Materials and Methods: Four focus groups involving 30 people with endometriosis were conducted and analysed using qualitative inductive content analysis. Results: Two categories were developed from the data: unmet research needs and motivators and barriers to participation in endometriosis research. Participants expressed interest in developing non-invasive diagnostic tools and a more multidisciplinary or holistic approach to treatment. Participants urgently desired research on treatment options for symptom management, with many prioritising non-hormonal treatments, including medicinal cannabis and complementary medicine. Others prioritised research on the causes of endometriosis over research on treatments to assist with prevention and eventual cure of the disease. The main drivers for participating in endometriosis research were hope for symptom improvement and a reduction in time to diagnosis. Research design features that were important in supporting participation included ease of access to testing centres (e.g., for blood tests) and sharing test results and automated data collection reminders, with simple stra-tegies to record data measurements. Research incentives for younger people with endometriosis and a broad dissemination of information about research projects was considered likely to increase participant numbers. Barriers included time commitments, a lack of flexibility around research appointments for data collection, travel or work commitments, concerns about the safety of some products, and trying to conceive a child. Conclusions: People with endometriosis were open to participating in research they felt aligned with their needs, with a significant focus on diagnostic tools and symptom relief. However, researchers must co-design approaches to ensure convenience and flexibility for research participation.

Acupuncture and moxibustion for endometriosis: A systematic review and analysis

OBJECTIVES

This study aimed to examine the effect of acupuncture on symptoms and health-related quality of life in patients with endometriosis.

METHODS

Nine biomedical databases were searched to April 2022 to identify randomized controlled trials of acupuncture and/or moxibustion used alone or as adjunct to guideline-recommended pharmacotherapy for the treatment of endometriosis. One reviewer extracted data and another verified the data. A random effects model was used to calculate mean differences.

RESULTS

Fifteen trials involving 1018 patients met the inclusion criteria, but diversity in comparisons and outcome measures prevented meta-analysis. Compared to sham acupuncture, manual acupuncture was more effective at reducing dysmenorrhea VAS pain score (mean difference [MD] - 2.40, 95 % CI [- 2.80, - 2.00]; moderate certainty evidence), pelvic pain VAS score (MD - 2.65, 95 % CI [- 3.40, - 1.90]; high certainty evidence) and dyspareunia VAS scores (MD - 2.88, [- 3.83, - 1.93]), lessened the size of ovarian cyst (MD - 3.88, 95 % CI [- 7.06, - 0.70]), and improved quality of life. Compared to conventional therapy, manual acupuncture plus conventional therapy and warm needle alone resulted in greater improvements in quality of life than conventional therapy. Among the six studies that reported safety, fewer adverse events were reported in participants who received acupuncture or moxibustion.

CONCLUSIONS

Low to moderate certainty evidence from single studies showed that manual acupuncture may improve pain-related symptoms and quality of life; however, there is insufficient evidence on the overall effectiveness of acupuncture and moxibustion for endometriosis.

Non-response to first-line hormonal treatment for symptomatic endometriosis: overcoming tunnel vision. A narrative review

One-fourth to one-third of women with endometriosis receiving first-line hormonal treatment lacks an adequate response in terms of resolution of painful symptoms. This phenomenon has been ascribed to "progesterone resistance", an entity that was theorized to explain the gap between the ubiquity of retrograde menstruation and the 10% prevalence of endometriosis among women of reproductive age.Nevertheless, the hypothesis of progesterone resistance is not free of controversies. As our understanding of endometriosis is increasing, authors are starting to set aside the traditionally accepted tunnel vision of endometriosis as a strictly pelvic disease, opening to a more comprehensive perspective of the condition. The question is: are patients not responding to first-line treatment because they have an altered signaling pathway for such treatment, or have we been overlooking a series of other pain contributors which may not be resolved by hormonal therapy?Finding an answer to this question is evermore impelling, for two reasons mainly. Firstly, because not recognizing the presence of further pain contributors adds a delay in treatment to the already existing delay in diagnosis of endometriosis. This may lead to chronicity of the untreated pain contributors as well as causing adverse consequences on quality of life and psychological health. Secondly, misinterpreting the consequences of untreated pain contributors as a non-response to standard first-line treatment may imply the adoption of second-line medical therapies or of surgery, which may entail non-negligible side effects and may not be free of physical, psychological and socioeconomic repercussions.The current narrative review aims at providing an overview of all the possible pain contributors in endometriosis, ranging from those strictly organic to those with a greater neuro-psychological component. Including these aspects in a broader psychobiological approach may provide useful suggestions for treating those patients who report persistent pain symptoms despite receiving first-line hormonal medical treatment.

Complementary therapy for endometriosis related pelvic pain

In the setting of a global pandemic, it is vastly important now more than ever that patients have agency and control over pain management when living with a debilitating chronic pain disease such as endometriosis. We present a review of the available literature on the most popular and easily accessible complementary pain management therapies for endometriosis including Transcutaneous Electrical Nerve stimulator (TENS) units, diets, Cannabidiol (CBD), turmeric, meditation, yoga, and acupuncture. These are worthwhile recommendations; however, the data for each is limited and more research is needed to further support each of its use.

Frontocentral delta-beta amplitude coupling in endometriosis-related chronic pelvic pain

OBJECTIVE

Endometriosis is associated with neuroplastic changes in cognitive control and pain processing networks. This was the first study to assess eyes-closed resting electroencephalogram (EEG) oscillatory amplitudes in women with endometriosis compared to healthy controls, and explore the relationship with chronic pelvic pain.

METHODS

Women with endometriosis-related chronic pelvic pain and individually age-matched pain-free controls (N = 20 per group) documented pelvic pain for 28 days before having continuous EEG recorded during a 2 min eyes closed resting state. Natural frequency components were extracted for each group using frequency principal components analysis. Corresponding components were assessed for group differences and correlated with pain scores.

RESULTS

Relative to controls, the endometriosis group had greater component amplitudes in delta (0.5 Hz) and beta (∼28 Hz), and reduced alpha (∼10 Hz). Delta and beta amplitudes were positively associated with pain severity, but only beta maintained this association after delta-beta amplitude coupling was controlled.

CONCLUSIONS

Enhanced resting delta and beta amplitudes were seen in women with endometriosis experiencing chronic pelvic pain. This delta-beta coupling varied with pelvic pain severity, perhaps reflecting altered cholinergic tone and/or stress reactivity.

SIGNIFICANCE

Endometriosis-related changes in central pain processing demonstrate a distinct neuronal oscillatory signature detectable at rest.

Feasibility and acceptability of an adapted environmental enrichment intervention for endometriosis: A pilot study

Introduction

We have previously shown that Environmental Enrichment (EE)-consisting of social support, novelty, and open spaces-decreased disease progression and anxiety in a rat model of endometriosis. We developed a novel EE intervention to be tested in a pilot randomized clinical trial (RCT) in patients with endometriosis, a painful, stressful disease.

Objective

To translate and evaluate the feasibility and acceptability of an adapted EE intervention as an adjuvant to standard-of-care for endometriosis patients.

Methods

Feasibility was assessed through recruitment, enrollment, and adherence rates. Acceptability was evaluated through a post-intervention survey and focus group discussion 3-months after the end of the intervention.

Results

Of the 103 subjects recruited, 64 were randomized to the intervention group and 39 to the control group. At the start of the intervention, the study groups consisted of 29 (intervention) and 27 (control) subjects. Enrollment rates were 45.3% and 69.2%, and adherence rates were 41.4% and 100% for the intervention and control groups, respectively. Delays resulting from natural events (earthquakes, the COVID-19 pandemic) impacted enrollment and adherence rates. The most common reasons for missing an intervention were period pain (39.1%) and work-study (34.8%). There was high acceptability (>80%) of the intervention's logistics. The majority (82.4%) of subjects would continue participating in support groups regularly, and 95.7% would recommend the intervention to other patients.

Conclusions

We showed that EE could be translated into an acceptable integrative multi-modal therapy perceived as valuable among participants who completed the intervention. High attrition/low adherence indicates that additional refinements would be needed to improve feasibility. Acceptability data indicate that EE has the potential to be integrated into the clinical management of patients with endometriosis and other inflammatory, painful disorders. Studies are ongoing to assess the efficacy of EE in improving pain symptoms, mental health, and quality of life (QoL).

Non-pharmacological therapies for treating chronic pelvic pain in women: A review

Chronic pelvic pain (CPP) is an intricate condition with multiple etiologies that lead to indefinite pain mechanisms. Physicians and researchers are challenged in its treatment, and the combined therapy of pharmacologic and non-pharmacologic treatment has been recognized as a multidisciplinary approach cited by guidelines and adopted in clinical practice. As an alternative therapy for CPP, non-pharmacologic therapies benefit patients and deserve further study. This study reviews the literature published from January 1991 to April 2022 on non-pharmacologic therapies for CPP in adult women. Based on a survey, this review found that the most commonly used non-pharmacological therapies for CPP include pelvic floor physical therapy, psychotherapy, acupuncture, neuromodulation, and dietary therapy. By evaluating the efficacy and safety of each therapy, this study concluded that non-pharmacological therapies should be included in the initial treatment plan because of their high degree of safety and low rate of side effects. To fill the lack of data on non-pharmacologic therapies for CPP, this study provides evidence that may guide treatment and pain management.

What is the evidence of effectiveness of non-pharmaceutical, non-surgical, biopsychosocial interventions for body image and pain management in individuals with endometriosis? A systematic review

Aim:

To identify and review the success of non-pharmaceutical, non-surgical biopsychosocial interventions in individuals with endometriosis, in managing pain and improving body image.

Methods:

Cochrane, EBSCO, IBSS, NICE, Open Grey, OVID, Proquest, Scopus and Science Direct were searched in April 2021, using inclusion and exclusion criteria.

Data collection and analysis:

Five randomised control trials, and one controlled clinical trial resulted from the search. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. Studies were synthesised by intervention type, into physical only, and physical and psychological.

Results:

Across the six papers, 323 participants were recruited, through medical records or self-referral, and treatments largely administered by specialist practitioners. From the EPHPP quality assessment,2 weak quality papers, and four moderate quality papers found improvements to pain, with large effect sizes in four papers. No studies used established body image measures to examine intervention effects on body image, and all lacked health psychology theoretical basis. There were common issues in selection bias, confounders and blinding.

Conclusion:

Without gold-standard methodology, evidence of effectiveness cannot be concluded. However, there is promising rationale if these issues are addressed.

Effect of Antioxidant Supplementation on Endometriosis-Related Pain: A Systematic Review

PURPOSE OF REVIEW

This study was conducted to determine the effects of antioxidant supplementation on endometriosis-related chronic pelvic pain, dysmenorrhea, and dyspareunia.

METHODS

PubMed/MEDLINE, Scopus, and Cochrane Library databases and the Google Scholar search engine were searched from early 2012 to 2022 using appropriate keywords for clinical trials receiving antioxidant supplements and reporting endometriosis-related pelvic pain (PROSPERO registration number CRD42022318924). The qualities of the included studies were evaluated using the Joanna Briggs Institute (JBI) Checklists Critical Appraisal Tools and the National Institutes of Health (NIH) quality assessment tool for before-after (Pre-Post) study with no control group. This systematic review was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline.

RESULTS

In this systematic review, 8 studies (5 RCTs and 3 non-comparative trials) published in 2012-2022 were included.

CONCLUSIONS

The studies we included showed promising results in the use of antioxidants in endometriosis-related pain. However, many scientific studies are needed for clear statements.