Acupuncture and the menopause

Acupuncture is increasingly used for many different conditions, but one that may not at first be obvious if that of menopausal symptoms, where acupuncture has been shown in studies to be of benefit. Here I will present information on acupuncture for hot flushes, and other menopausal symptoms of sleep quality, mood and anxiety, memory and cognition and general quality of life.

I’ll also discuss theories and scientific studies showing how acupuncture may be achieving these effects.

I will also touch on hot flushes of other causes, in males and females after cancer-treatment using hormonal drugs these can also cause “vasomotor symptoms”, also known as hot flushes.

I’ll discuss how research shows acupuncture to affect the hormonal system, and finally I’ll leave you with some information and links to follow up for the references and bibliography relating to this area.

Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.

Hot flushes, also known as “vasomotor symptoms”

Hot flushes are experienced by a high number of women in the menopause, Gjelsvik at al, 2011 state that 36% of women experienced them at least daily.

Acupuncture has been shown to significantly reduce the number and severity of hot flushes in menopausal women (Wyon et al, 1995; Boroud et al, 2009; Chiu, 2015; Park et al, 2009)

Recently, studies have been looking at the role of Calcitonin gene-related peptide (CGRP), which has been found to be elevated in menopausal women experiencing hot flushes (Sharma et al, 2010). Acupuncture has been shown to decrease the urinary secretion of this same substance, (Wyon et al,1995; Zijlstra et al, 2003), suggesting acupuncture may have a regulatory effect on the calcitonin system.

Studies have repeatedly shown that acupuncture has effects on the autonomic nervous system; in particular the body’s natural opioids (Li et al, 2013) it is theorised that this is part of acupuncture’s mechanism of action in improvements in menopausal hot flushes is due to the fact that changes in central opioid activity have been implicated in hot flushes (Wyon et al, 1995).

“We suggest that acupuncture is a viable alternative treatment of vasomotor symptoms in postmenopausal women”. Wyon et al, 2004.

A recent systematic review of 23 RCTs (n=2302), and meta-analysis of 10 the these found acupuncture to reduce the frequency and severity of hot flushes, and improve quality of life.  The researchers recommended that more high-quality RCTs should be performed (Jo et al, 2021).    

Sleep

Studies have shown acupuncture to be beneficial to sleep in menopausal women (Wyon et al, 2003, Cohen et al, 2003; Chiu et al 2016)

“Acupuncture using menopausal-specific sites holds promise for non-hormonal relief of hot flushes and sleep disturbances.” Cohen et al, 2003.

“Acupuncture is associated with a significant reduction in sleep disturbances in women experiencing menopause-related sleep disturbances”. Chiu et al, 2016.

Quality of life

Studies have also looked at rating quality of life, and found improvements in this for acupuncture in relation to menopausal symptoms, for example anxiety, mood and energy, (Avis et al; Chu et al 2015, Kim et al, 2020).

“Conclusions: This meta-analysis confirms that acupuncture improves hot flush [sic] frequency and severity, menopause-related symptoms, and quality of life (in the vasomotor domain) in women experiencing natural menopause.” Chiu et al, 2015.

Memory and cognition

There is a well-known link between the hormone oestrogen, and memory and cognition.

“Increased levels of oestrogen are associated with increased dendritic spine and synapse density in the hippocampus, a brain area important for learning and memory” Daniel, 2006

Oestrogen is lowered in menopause, and this may be the reason for memory and concentration problems reported by menopausal women.

Studies have shown acupuncture may help improve memory in menopausal women, (Tang et al 2013). This is thought to be due to the fact acupuncture can raise oestrogen levels in the blood (specifically serum estradiol levels) e.g. Shen et al, 2005. Studies in animals support this theory – acupuncture has also been shown to improve learning and memory by increasing brain oestrogen levels in rats (Tang et al,) 2013.

Acupuncture in iatrogenic non-menopausal hot flushes after oncology treatment

This is an increasingly researched area, that oncologists are beginning to suggest acupuncture for. A useful resource in this area is Cancer Research UK Hot Flushes under the “complementary therapies” section 3/4 of the way down the page.  Acupuncture has been shown to also be helpful for men suffering hot flushes as a side-effect of prostate cancer treatment (Beer et al, 2010; Ashmala et al, 2010), and to women suffering hot flushes as a result of breast cancer treatment (Deng et al, 2007; Lesi et al, 2016)

Overall mechanisms of action: hormones

Blood measures before and after a course of acupuncture showed increase estraiol (an oestrogen) and decreased follicle stimulating hormone and luteotrophic hormone (LH), (rises in which are responsible for menopausal symptoms). (Chiu et al, 2016; Xia et al, 2008; Qin, 2013). In menopause, the FSH rises and the oestrogen falls, a combination of which gives rise to the symptoms. Acupuncture may therefore be said to be mediating these hormones to give symptomatic relief.

A recent systematic review of 15 studies, (n=1376) comparing acupuncture and hormone therapy, looking at clinical effects as well as blood measures of FSH, LH and estradiol:  concluding acupuncture to be a safe and effective approach (He et al, 2021).

Recently, Ebrahimi et al (2020) examined a number of complementary approaches for menopause, including 18 for acupuncture in their systematic review, concluding that acupuncture “improved sleep quality, decreased vasomotor symptoms, reduced symptoms of depression and anxiety, improved dry eye and sleep disturbances, improved metabolic syndrome, reduced irritability and hot flashes, enhanced quality of life, and reduced menopausal symptoms.”

A note on research:

When reading health research, it is important to know that Systematic Reviews or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms.  The next best level of evidence is the individual Randomised Controlled Study (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment).  In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.

The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control).  Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.

References for the research used are below.  When reading a research article, the n= figure tells you how many people were participants in the study.  Usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. When you are reading a trial/study, the “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.

References

Avis NE, Legault C, Coeytaux RR, Pian-Smith M, Shifren JL, Chen W, Valaskatgis P. A randomized, controlled pilot study of acupuncture treatment for menopausal hot flashes. Menopause2008; 15: 1070-8

Avis, Nancy E. PhD; Coeytaux, Remy R. MD, PhD; Isom, Scott MS; Prevette, Kristen BA; Morgan, Timothy PhD Acupuncture in Menopause (AIM) study: a pragmatic, randomized controlled trial. Menopause: Published Ahead-of-Print 

Ashamalla H, Jiang ML, Guirguis A, Peluso F, Ashamalla M Acupuncture for the alleviation of hot flashes in men treated with androgen ablation therapy. Int J Radiat Oncol Biol Phys. 2011 Apr 1;79(5):1358-63.. Epub 2010 Jun 3.

Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, Garzotto M, Donovan D, Katovic N, Reeder C, Eilers K. Acupuncture for hot flashes in patients with prostate cancer. Urology. 2010 Nov;76(5):1182-8. Epub 2010 May 21.

Borud E, White A. A review of acupuncture for menopausal problems. Maturitas 2010; 66: 131-4.

Borud EK, Alraek T, White A, Grimsgaard S. The acupuncture on hot flashes among menopausal women study: Observational follow-up results at 6 and 12 months. Menopause 2010; 17: 262-8.

Borud, Einar Kristian MD, MPH; Alraek, Terje PhD; White, Adrian MD, PhD; Fonnebo, Vinjar MD, MSc, PhD; Eggen, Anne Elise PhD; Hammar, Mats MD, PhD; Lotta Lindh RN; Theodorsson, Elvar MD, PhD; Grimsgaard, Sameline MD, MPH, PhD  The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial  May/June 2009 – Volume 16 Issue 3.

Cho SH, Whang WW. Acupuncture for vasomotor menopausal symptoms: A systematic review. Menopause 2009; 16: 1065-73.  A systematic review, including 11 randomised controlled trials with a total of 764 patients 

Chiu, Hsiao-Yean RN, PhD; Pan, Chieh-Hsin RN, MSN; Shyu, Yuh-Kae RN, PhD; Han, Bor-Cheng PhD Tsai, Pei-Shan RN, PhD Effects of acupuncture on menopause-related symptoms and quality of life in women in natural menopause: a meta-analysis of randomized controlled trials Menopause: February 2015 – Volume 22 – Issue 2 – p 234-244

Chiu, Hsiao-Yean RN, PhD; Hsieh, Yu-Jung RN, MSN; Tsai, Pei-Shan RN, PhD Acupuncture to Reduce Sleep Disturbances in Perimenopausal and Postmenopausal Women: A Systematic Review and Meta-analysis Obstetrics & Gynecology: March 2016 – Volume 127 – Issue 3 – p 507-515

Cohen, Susan M. DSN, C-FNP; Rousseau, Mary Ellen MS, CNM; Carey, Bonnie L. OMD, LAc, RN Can Acupuncture Ease the Symptoms of Menopause? Holistic Nursing Practice: November/December 2003 – Volume 17 – Issue 6 – p 295-299

Daniel, JM Effects of oestrogen on cognition: what have we learned from basic research? J Neuroendocrinol. 2006 Oct;18(10):787-95.

Deng, G Andrew J. Vickers, K. Simon Yeung, Gabriella M. D’Andrea, Han Xiao, Alexandra S. Heerdt, Steven Sugarman, Tiffany Troso-Sandoval, Andrew D. Seidman, Clifford A. Hudis and Barrie R. Cassileth Randomized, Controlled Trial of Acupuncture for the Treatment of Hot Flashes in Breast Cancer Patients Journal of Clinical Oncology JCO December 10, 2007 vol. 25 no. 35 5584-5590

Ebrahimi, A., Tayebi, N., Fatemeh, A. and Akbarzadeh, M., 2020. Investigation of the role of herbal medicine, acupressure, and acupuncture in the menopausal symptoms: an evidence-based systematic review study. Journal of family medicine and primary care, 9(6), p.2638.

Gjelsvik B, Rosvold EO, Straand J, Dalen I, Hunskaar S. Symptom prevalence during menopause and factors associated with symptoms and menopausal age. Results from the Norwegian Hordaland Women’s Cohort study. Maturitas. 2011 Dec;70(4):383-90. 

He, Q.D., Zhong, Z.H., Liu, M.N., Tong, Z.Y., Wu, Q.B. and Chen, M., 2021. Efficacy and safety of acupuncture vs. hormone therapy for menopausal syndrome: a systematic review and meta-analysis. The American Journal of Chinese Medicine, 49(08), pp.1793-1812.

Li, Q; Shi, G-X; Xu, Q; Wang, J; Liu, C-Z; and Wang, L-P Acupuncture Effect and Central Autonomic Regulation Evid Based Complement Alternat Med. 2013; 2013: 267959. Published online 2013 May 26. 

Jo, H.R., Choi, S.K., Sung, W.S., Kim, E.J., Choi, S.J., Kim, D.I. and Noh, E.J., 2021. Efficacy Comparison of Different Acupuncture Treatments for Hot Flashes: A Systematic Review with Network Meta-Analysis. 

Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot flushes: a systematic review. Climacteric. 2009; 12: 16-25.

Kim KH, Kang KW, Kim DI, Kim HJ, Yoon HM, Lee JM, Jeong JC, Lee MS, Jung HJ, Choi SM..Effects of acupuncture on hot flashes in perimenopausal and postmenopausal women-a multicenter randomized clinical trial. Menopause 2010; 17: 269-80.

Lesi, G; Giorgia Razzini, Muriel Assunta Musti, Elisa Stivanello, Chiara Petrucci, Benedetta Benedetti, Ermanno Rondini, Maria Bernadette Ligabue, Laura Scaltriti, Alberto Botti, Fabrizio Artioli, Pamela Mancuso, Francesco Cardini and Paolo Pandolfi Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT) Published online before print March 28, 2016,  JCO March 28, 2016

Park JE, Lee MS, Jung S, Kim A, Kang K, Choi J, Park J, Choi SM. Moxibustion for treating menopausal hot flashes: a randomized clinical trial. Menopause 2009; 16: 660-5

Qin, Y; Jing He, Lu Xia, Hua Guo, Chengqi He Effects of electro-acupuncture on oestrogen levels, body weight, articular cartilage histology and MMP-13 expression in ovariectomised rabbits Acupunct Med 2013;31:214-221 

Sharma, S; Annil Mahajan, and Vishal R. Tandon Calcitonin gene-related peptide and menopause J Midlife Health. 2010 Jan-Jun; 1(1): 5-8. 

Shen, X., Du, Y., Yan, L., Xia, Y., Yan, H., Han, G., Guo, Y. and Shi, X., 2005. Acupuncture for treatment of climacteric syndrome–a report of 35 cases. Journal of traditional Chinese medicine= Chung i tsa chih ying wen pan, 25(1), pp.3-6.

Tang, C.L. Tang, H.W. Xie, Y.E. Song Electroacupuncture improves learning-memory of rats with low estrogen-induced cognitive impairment Sheng Li Xue Bao, 65 (2013), pp. 26-32

Venzke L, Calvert JF Jr, Gilbertson B. A randomized trial of acupuncture for vasomotor symptoms in post-menopausal women. Complementary Therapies in Medicine 2010; 18:  59-66.

Wyon, Y.; Lindgren, R.; Lundeberg, T.; Hammar, M. Effects of Acupuncture on Climacteric Vasomotor Symptoms, Quality of Life, and Urinary Excretion of Neuropeptides among Postmenopausal Women. Menopause: 1995 – Volume 2 – Issue 1 

Wyona, Y; K Wijmaa, E Nedstranda & M Hammara A comparison of acupuncture and oral estradiol treatment of vasomotor symptoms in postmenopausal women Climacteric Volume 7, Issue 2, 2004 pages 153-164 

Xia XH et al. Multicentral randomized controlled clinical trials about treatment of perimenopausal syndrome with electroacupuncture of sanyinjiao (SP 6) [Article in Chinese] . Zhen Ci Yan Jiu. 2008 Aug;33(4):262-6

Xiao, X., Zhang, J., Jin, Y., Wang, Y. and Zhang, Q., 2020. Effectiveness and safety of acupuncture for perimenopausal depression: a systematic review and meta-analysis of randomized controlled trials. Evidence-based Complementary and Alternative Medicine, 2020, pp.1-13.

Zijlstra, FJ; Ineke van den Berg-de Lange, Frank J P M Huygen, and Jan Klein Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003;12: 59-69.