|Year : 2020 | Volume
| Issue : 3 | Page : 312-319
Acupuncture in polycystic ovary syndrom
Nadia M Gazar1, Maher F Mahmoud2, Mona E Alkafrawy1, Mai I Hafez1
1 Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Egypt
2 Department of Anesthesia, ICU and Pain Management, Faculty of Medicine, Cairo University, Cairo, Egypt
|Date of Submission||25-Sep-2019|
|Date of Decision||15-Nov-2019|
|Date of Acceptance||17-Nov-2019|
|Date of Web Publication||2-Oct-2020|
MB, BCH Mai I Hafez
Department of Obstetrics and Gynecology, Resident of Obestetrics and Gynecology Nasr City Health Insurance Hospital, 11865
Source of Support: None, Conflict of Interest: None
Introduction Polycystic ovarian syndrome (PCOS) is characterized by the clinical signs of oligomenorrhoea, infertility, and hirsutism. Biochemically, women with PCOS often show signs of hyperandrogenism (excessive production of androgen).
Aim The aim was to evaluate the use of acupuncture to prevent and reduce symptoms related to PCOS in patients with infertility.
Patients and methods This study was carried out on 32 women with PCOS of reproductive age (20–35 years) who presented with infertility. The diagnostic criteria of PCOS applied in this study were based on the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine consensus in Rotterdam, 2003.
Results A total of 15 (46.9%) women experienced a good effect. Women with good effect from acupuncture had significantly lower BMI (from 27.68±3.36 to 26.97±3.34; P=0.006), but there was no significant change in waist-to-hip circumference (from 0.85±0.14 to 0.84±0.14; P=0.188). There was a significant decrease in mean serum concentration of luteinizing hormone (LH) (from 13.81±3.91 to 10.30±5.14), LH/follicle stimulating hormone ratio (from 2.32±0.81 to1.69±0.90), serum testosterone (from 1.26±0.68 to 1.08±0.75), and fasting insulin (from 31.32±9.90 to 27.53±7.67); a decrease in mean and SD for serum concentration of LH (from 13.81±3.91 to 10.30±5.14), LH/follicle stimulating hormone ratio (from 2.32±0.81 to 1.69±0.90), serum testosterone (from 1.26±0.68 to 1.08±0.75), and fasting insulin (from 31.32±9.90 to 27.53±7.67); and a significant increase in serum E2 (from 34.23±15.32 to 49.02±26.08).
Conclusion Acupuncture is a safe and effective treatment of PCOS, as the adverse effect of pharmacologic interventions are not present in patients with PCOS who use acupuncture. Acupuncture therapy increases the blood flow to the ovaries, reducing ovarian volume and the number of ovarian cysts. Reducing serum testosterone, increasing insulin sensitivity, and decreasing insulin level also assist in weight loss.
Keywords: acupuncture, polycystic ovarian syndrome, ultrasound
|How to cite this article:|
Gazar NM, Mahmoud MF, Alkafrawy ME, Hafez MI. Acupuncture in polycystic ovary syndrom. Sci J Al-Azhar Med Fac Girls 2020;4:312-9
| Introduction|| |
Polycystic ovarian syndrome (PCOS) is characterized by the clinical signs of oligo-menorrhoea, infertility, and hirsutism. Biochemically, women with PCOS often show signs of hyperandrogenism. In addition, they often have anovulatory infertility and metabolic disorders (e.g. diabetes mellitus).
The etiology of PCOS is incompletely understood, despite the high prevalence of the syndrome; morbidity from its metabolic, reproductive, and hyperandrogenic features; and the associated cardiovascular risk. The most consistent endocrine feature is hyperandrogenemia from a predominantly ovarian source, which likely plays a key etiological role .
Insulin sensitivity is decreased by 30–40% in women with PCOS, predominantly in overweight women, and the compensatory hyperinsulinemia increases ovarian androgen production and further exacerbates symptoms of PCOS .
Adiposity is also important in the pathogenesis of PCOS as shown by improved menstrual regularity after weight reduction .
The disturbances in PCOS have been attributed to defects in different organ systems. These include androgen synthesis defects that enhance ovarian androgen production and alter cortisol metabolism, resulting in enhanced adrenal androgen production, neuroendocrine defects with exaggerated luteinizing hormone (LH) pulsatility, and defects in insulin action and secretion leading to hyperinsulinaemia and insulin resistance .
First-line therapy in PCOS is often oral contraceptives, which reduce hirsutism and acne but adversely affect glucose tolerance, coagulability, and fertility. Therefore, treatment strategies such as acupuncture need to be evaluated in PCOS .
Acupuncture, a treatment that dates back 3000–5000 years, is an integral part of traditional Chinese medicine and has become more established in Western medicine as a complement or alternative to conventional therapies. The physiological basis for using acupuncture in PCOS is intramuscular needle insertion causes a particular pattern of afferent activity in peripheral nerves. Depending on the intensity, stimulation of the acupuncture needles activate muscle afferents to the spinal cord and the central nervous system .
β-endorphin is produced and released from hypothalamic nucleus, the nucleus arcuatus, and the nucleus tractus solitarius in the brainstem when acupuncture is done. This central hypothalamic β-endorphin system appears to be a key mediator of changes in autonomic functions after acupuncture. These changes are probably caused by inhibition of the vasomotor center, which decreases sympathetic tone and blood pressure .
β-endorphin is also released into peripheral blood from the hypothalamus via the anterior pituitary, a process regulated by corticotrophin-releasing factor, which is secreted from the para venricular nucleus of the hypothalamus .
Acupuncture affects the hypothalamic–pituitary–adrenal axis by decreasing cortisol concentrations and the hypothalamic–pituitary–gonadal axis by modulating central and peripheral β-endorphin production and secretion, thereby influencing the release of hypothalamic GnRH and pituitary secretion of gonadotropin .
Acupuncture modulates spinal reflexes, so needles were placed in the abdomen and hind limb, which have the same somatic innervation as the ovaries and uterus .
Clearly, manual acupuncture and low-frequency electroacupuncture affect PCOS symptoms via modulation of endogenous regulatory systems, including the sympathetic nervous system, the endocrine system, and the neuroendocrine system. The changes are most likely meditated via the endogenous opioid system .
| Aim|| |
The present study is designed to evaluate the use of acupuncture to prevent and reduce symptoms related with PCOS in patients with infertility.
| Patients and methods|| |
This study was carried out on women of reproductive age (20–35 years) with PCOS who presented with infertility. This study was done after approval of the Ethical Committee of the Department of obestetrics and gynecology, faculty of medicine, Al zahraa university hospital. Informed consent was taken from all participants and thier husbands.
The diagnostic criteria of PCOS applied in this study are based on the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine consensus in Rotterdam, 2003 .
Patients were recruited from the outpatient clinics of the Department of Gynecology at El Zahraa University Hospital and Nasr City Health Insurance Hospital after taking written informed consent.
Type of the study
This was an interventional, longitudinal, and prospective study. This study included 32 women according to the study inclusion and exclusion criteria. Sample size was calculated using Epi info 7.0 version is a suite of free data managment, analysis, and visualization tools, software tool, internet, USA, setting the power at 0.8 and the two-sided confidence level at 0.95.
Calculation according to these value produces a minimal sample size of 29 women. Assuming a dropout rate of 10%, a minimal sample size of 32 women was needed.
Women were aged from 30–35 years with PCOS presenting with infertility, amenorrhea or oligomenorrhea, typical ultrasonographic presentation of PCO (multiple subcapsular follicles and thickened ovarian stroma) and hormonal profile [increased LH, decreased follicle stimulating hormone (FSH), LH/FSH ratio ≥2 : 1, decreased E2, high insulin level, and elevated testosterone level] were included in the study.
Women with hyperandrogenism (androgen secreting tumor), women with hyperprolactinemia, women with Cushing syndrome, women with congenital adrenal hyperplasia, women with thyroid disease, patients with BMI more than 35 (as they are very resistant to treatment), and patients on hormonal therapy were excluded from the study.
Description of the intervention
Consent was taken from all patients, and the treatment was started after general and local examination. The treatment period was 16 weeks, and the women received in total 14 treatment sessions: twice a week during the first 2 weeks, once a week during next 8 weeks, and thereafter every 2 weeks till 14 treatment sessions. No hormonal treatment was given for 3 months before the start of the study or throughout the entire study period.
The type of needles was Hegu:Hegu AB Landsbro (South of Sweden), with size 36 gauge (0.2 mm in diameter) and length 2.5 inches. Needles were inserted intramuscularly to a depth of 15–40 mm in acupuncture points selected in somatic segments common to the innervation of the ovary and uterus (Th12-L2, S2-S4) ); four needles were inserted at the thoracolumbar and sacral level and four needles in the calf muscles. Manually stimulated needles were rotated five times during each treatment session (duration of whole session 30 min). The needles were inserted and rotated to evoke ‘needle sensation’ for activation of muscle–nerve afferents.
Follow-up of the patients
- The skin temperature was measured with a digital infrared thermometer (Beurer GmbH, 89077ulm, Germany); the recording site was at the forehead. The measurements were made during the first, fifth, and tenth acupuncture treatments. The first measurement was after 10-min rest and just before acupuncture. These are the ‘baseline’ values. Thereafter, further measurements were made every seventh minute during acupuncture. The room temperature was constant during the three experimental sessions.
- Measurements of BMI and waist-to-hip circumference (WHR) measured with a soft tape, at the level of the umbilicus and the spina iliaca anterior superior with the women in the standing position, were made before the acupuncture treatments and after the study period.
- Blood samples were drawn from an antecubital vein on three occasions: within 1 week before the first acupuncture treatment, 1 week after the last acupuncture treatment, and 3 months later. Serial sampling for LH, FSH, serum testosterone, serum estradiol, and basal serum insulin was done.
- Clinical pregnancy rate: the number of women who get pregnant on this study.
All data were collected and statistically analyzed.
| Results|| |
Results are presented in [Table 1] and [Table 2].
|Table 2 Comparison between the studied groups (before and after acupuncture) regarding BMI and waist to hip ratio|
Click here to view
A total of 15 (46.9%) women experienced a good effect. Women with good effect from acupuncture had significantly lower BMI (from 27.68±3.36 to 26.97±3.34; P=0.006), but there was no significant change in waist-to-hip circumference (from 0.85±0.14 to 0.84±0.14; P=0.188). There was a significant decrease in mean serum concentration of luteinizing hormone (LH) (from 13.81±3.91 to 10.30±5.14), LH/follicle stimulating hormone ratio (from 2.32±0.81 to1.69±0.90), serum testosterone (from 1.26±0.68 to 1.08±0.75), and fasting insulin (from 31.32±9.90 to 27.53±7.67); a decrease in mean and SD for serum concentration of LH (from 13.81±3.91 to 10.30±5.14), LH/follicle stimulating hormone ratio (from 2.32±0.81 to 1.69±0.90), serum testosterone (from 1.26±0.68 to 1.08±0.75), and fasting insulin (from 31.32±9.90 to 27.53±7.67); and a significant increase in serum E2 (from 34.23±15.32 to 49.02±26.08).
| Discussion|| |
In this study, the mean age, BMI, and WHR were 27.94±3.35 years, 27.68±3.36 kg/m2, and 0.85±0.14, respectively. Primary infertility was 40.6% (13 women), and the secondary infertility was 59.4% (19 women).
Mean values of hormonal profile (FSH, LH, serum E2, and serum testosterone) of patients in the study were 6.15±1.32, 13.813.91, 34.2315.32, and (1.26±0.68, respectively, and also the mean value of fasting insulin was 31.32±9.90, and the temperature of the forehead was 36.86±0.23.
This study shows significant decrease in BMI (from 27.68±3.36 to 26.97±3.34; P=0.006), but no significant change in WHR (from 0.85±0.14 to 0.84±0.14; P=0.188).
This study is in agreement with Stener-Victorin et al.  who conducted a nonrandomized, longitudinal, prospective study on 26 women, in whom electroacupuncture was done (10–14 sessions), and BMI and WHR were measured before and after treatment. The study showed significant decrease in BMI (32.02±5.37 vs 22.67±2.64; P<0.001) and WHR (0.89±0.007 vs 0.81±0.006; P=0.0058).
Moreover, Lai et al.  showed that BMI and WHR were reduced significantly in both medication groups (250 mg/time tid metformin in first week then 500 mg/time tid thereafter for 6 months) and abdominal acupuncture groups (abdominal acupuncture once daily for 6 months, P<0.05), and the effects of abdominal acupuncture group were significantly superior to those of medication group in downregulating BMI and WHR (P<0.05).
In addition, Zheng et al.  studied 86 women with PCOS (BMI≥25 kg/m2) who were randomly assigned to receive 6 months of abdominal acupuncture (once a day) or oral metformin (250 mg three times daily in the first week, followed by 500 mg three times daily thereafter), and according to the results at baseline and 6 months, BMI and WHR were reduced significantly (P<0.05) in the two groups.
This study disagrees with Johansson et al.  who conducted a prospective, randomized, controlled clinical trial in which 32 women with PCO were randomized to receive either acupuncture with manual and low-frequency electrical stimulation (acupuncture group) or meeting with a physical therapist (attention control group) twice a week for 10–13 weeks. The study shows that weight, BMI, waist circumference, and WHR decreased in the attention control group, and waist circumference decreased in acupuncture group.
Acupuncture activates peripheral nerve terminal to release several neuropeptides that give immediate local reaction with an increase in microcirculation resulting in elevation of skin temperature .In the current study, there is increase in skin temperature of forehead region in all women during first, fifth, and tenth session of acupuncture, with statistically significant difference (P≥0.000) ([Table 3],[Table 4],[Table 5],[Table 6]).
|Table 6 Mean of hormonal profile (follicle stimulating hormone, luteinizing hormone, serum E2, serum testosterone, and fasting insulin) of studied group before, within 1 week, and 3 months after last acupuncture|
Click here to view
This study is in agreement with Stener-Victorin et al. , who conducted a nonrandomized, longitudinal, prospective study on 26 women in whom electroacupuncture was done (10–14 sessions). Skin temperature measurements were made at first, fifth, and tenth session. Serial measurements were done at each session. Recording sites were between applied acupuncture needles in the sacrum and in the forehead. The study showed significant increase in the skin temperature in the forehead during all three experimental sessions.
This study shows decrease in mean and SD for serum concentration of LH (from 13.81±3.91 to 10.30±5.14), LH/FSH ratio (from 2.32±0.81 to 1.69±0.90), serum testosterone (from 1.26±0.68 to 1.08±0.75), and fasting insulin (from 31.32±9.90 to 27.53±7.67) and increase in serum E2 (from 34.23±15.32 to 49.02±26.08), with a statistically significance change (P=0.000, 0.001, 0.003, 0.006, and 0.000, respectively) after acupuncture treatment. However, FSH showed no significant change (from 6.15±1.32 to 6.34±1.19; P=0.168) after treatment.
This study is in agreement with Pastore et al.  who showed an improvement in the ratio of LH to FSH during the 8 weeks of intervention (P<0.04), and this persisted for the 3 months of follow-up in the acupuncture arm (P=0.001). There was no change in the FSH levels across time in either intervention arm (P>0.11). LH declined during the intervention phase in both arms, although only significantly so in the sham arm (P=0.04), and LH declined over the entire 5-month study time frame in both arms (P<0.05). Lower free testosterone (P<0.10) and lower fasting insulin were highly correlated with a higher ovulation rate within the true acupuncture group.
Moreover, Stener-Victorin et al.  conducted a single-arm study of 24 women with PCOS, all of whom had 2 months of acupuncture (same acupuncture points as in this RCT) and 3 months of posttreatment follow-up. They reported significant decrease in mean LH/FSH ratio (from 1.7 to 1.47; P=0.042) and mean testosterone concentration (P=0.016).
In addition, Zheng et al.  showed that luteotrophic hormone, ratio of luteotrophic hormone to FSH, testosterone, fasting blood glucose, 2-h postprandial blood glucose, fasting insulin, 2-h postprandial blood insulin, and HOMA-IR were reduced significantly (P<0.05); FSH also increased, but the change was not significant (P>0.05)
Furthermore, Lai et al.  reported that reproductive hormones (serum LH, LH/FSH, and T levels) in the two groups decreased significantly (P<0.05), and the effect of abdominal acupuncture was superior to that of medication group in reducing serum testosterone level.
Acupuncture needles are placed and stimulated in the same somatic innervation as the sympathetic innervation of the ovary. This leads to decrease in the sympathetic nerve activity, leading to decreased secretion and the release of ovarian androgens, so ovulation, menstrual frequency, and hypomenorrhea are enhanced .
In the present study, we demonstrate that repeated manual acupuncture treatments in lean/overweight women with PCOS results in improvement of hypomenorrhea (31.3%), oligomenorrhea (25%), and regulation of cycle (25%) during and after the treatment period ([Table 7], [Figure 2]).
This study is in agreement with Johansson et al.  who reported that ovulation frequency was higher in the acupuncture group than in the attention control group (0.76±0.27 vs 0.41±0.28 ovulations per month; P=0.002) ([Figure 1],[Figure 2],[Figure 3]).
|Figure 1 The mean values of skin temperature changes in the forehead region in all women during first, fifth, and tenth acupuncture session.|
Click here to view
Moreover, Pastore et al.  studied a RCT of acupuncture in oligo-ovulatory and an ovulatory untreated, adult female patients with PCOS and revealed that mean rate of ovulation over the 5-month protocol was 0.37 (95% confidence interval: 0.29–0.46) in the true acupuncture group and 0.40 (95% confidence interval: 0.32–0.49) in the sham acupuncture arm (P=0.64).In addition, Jedel et al.  conducted a three-arm RCT (16 weeks of low-frequency electroacupuncture vs 16 weeks of physical exercise vs an observation-only arm). They reported an increase in the monthly ovulation rate from 28% at baseline to 69% after treatment and menstrual frequency increased to 0.69/month from 0.28/month at baseline in EA group.
Furthermore, Stener-Victorin et al.  showed an ovulation rate (9 out of 24) of 38%, and this group of nine women displayed a total of four ovulations in the period of 3 months before electro acupuncture (0.15 ovulation/woman and month). This increased to 31 ovulations in period during and after electroacupuncture (0.66 ovulations/women and month). The difference was significant (P=0.004).
Moreover, in the study done by Zheng et al.  on 86 women with PCOS (BMI≥25 kg/m2) who were randomly assigned to receive 6 months of abdominal acupuncture (once a day) or oral metformin (250 mg three times daily in the first week, followed by 500 mg three times daily thereafter), according to the results at baseline and 6 months, menstrual frequency (P<0.05) increased significantly in both groups.
This study showed pregnancy rate (3 out of 32) of 9.4%.
In agreement with our study, Lim and collegaues conducted RCTs including 191 women. They compared true acupuncture with sham acupuncture (2RCTs). No study reported live birth, and two studies reported clinical pregnancy and found no evidence of difference between true (60 per 1000 women) and sham acupuncture (148 per 1000 women).
Moreover, in agreement with our study, a study done by Gerhard and Postneek  compared the results of 45 infertile women who were treated with acupuncture with those of 45 women who received hormonal treatment, and the acupuncture group had 22 pregnancies: 11 after acupuncture, four spontaneously and seven after appropriate medication. Women treated with hormone had 20 pregnancies: five spontaneously and 15 after treatment.
| Conclusion|| |
Acupuncture is a safe and effective treatment to PCOS as the adverse effect of pharmacologic interventions are not expected by women with PCOS. Acupuncture therapy has a role in PCOS by increasing the blood flow to the ovaries and reducing ovarian volume and the number of ovarian cysts. Reducing serum testosterone, increasing insulin sensitivity, and decreasing insulin level also assist in weight loss.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wild S, Pierpoint T, Jacobs H, McKeigue P. Long-term consequences of polycystic ovary syndrome: Results of a 31year follow-up study. Hum Fertil 2000; 3:101–105.
Gilling-Smith C, Willis DS, Beard RW, Franks S. Hyper secretion of androstenedione by isolated thecal cells from polycystic ovaries. J Clin Endocrinol Metab 1994; 79:1158–1165.
Dunaif A, Thomas A. Current concepts in the polycystic ovary syndrome. Annu Rev Med 2001; 52:401–419.
Barber TM, McCarthy MI, Wass JA, Franks S. Obesity and polycystic ovary syndrome. Clin Endocrinol (Oxf) 2006; 65:137–145.
Tsilchorozidou T, Overton C, Conway GS. The pathophysiology of polycystic ovary syndrome. Clin Endocrinol (Oxf) 2004; 60:1–17.
Lanham MS, Lebovic DI, Domino SE. Contemporary medical therapy for polycystic ovary syndrome. Int J Gynaecol Obstet 2006; 95:236–241.
Kagitani F, Uchida S, Hotta H, Aikawa Y. Manual acupuncture needle stimulation of the rat hindlimb activates groups I, II, III and IV single afferent nerve fibers in the dorsal spinal roots. Japanese J Physiol 2005; 55:149–155.
Andersson S, Lundeberg T. Acupuncture from empiricism to science functional background to acupuncture effects in pain and disease. Med Hypotheses 1995; 45:271–281.
Crine P, Gianoulakis C, Seidah NG. Biosynthesis of beta-endorphin from beta-lipotropin and a larger molecular weight precursor in rat pars intermedia. Proc Natl Acad Sci USA 1978; 75:4719–4723.
Harbach H, Moll B, Boedeker RH, Vigelius‐Rauch U, Otto H, Muehling J et al.
Minimal immunoreactive plasma beta‐endorphin and decrease of cortisol at standard analgesia or different acupuncture techniques. Eu J Anaesthesiol 2007; 24:370–376.
Stener-Victorin S, Fujisawa F, Kurosawa M. Ovarian blood flowresponses to electroacupuncture stimulation depend on estrous cycle and on site and frequency of stimulation in anesthetized rats. J Appl Physiol 2006; 101:84–91.
Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004; 19:41–47.
Pastore LM, Williams CD, Jenkins J, Patrie JT. True and shamacupuncture produced similar frequency of ovulation and improved LH to FSH ratios in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2011; 96:3143–3150.
Bonica J. The Management of Pain. 2nd ed. Philadelphia, London: Lea & Febiger 1990.
Sato A, Sato Y, Shimura M, Uchida S. Calcitonin gene-related peptide produces skeletal muscle vasodilation following antidromic stimulation of unmyelinated afferents in the dorsal root in rats. Neurosci Lett 2000; 283:137–140.
Stener‐Victorin E, Lindholm C. Immunity and beta‐endorphin concentrations in hypothalamus and plasma in rats with steroid‐induced polycystic ovaries: effect of low‐frequency electroacupuncture. Biol Reprod 2004; 70:329–333.
Lai MH, Ma HX, Yao H, Liu H, Song XH, Huang WY, Wu XK. Effect of abdominal acupuncture therapy on the endocrine and metabolism in obesity-type polycystic ovarian syndrome patients. Acupuncture Res 2010; 35:298–302.
Johansson J, Leanne R, Paula PV, Antonina S, Fernard L, Stener-Victorin E. Polycystic ovary syndrome: effect and mechanisms of acupuncture for ovulation induction. Evid Based Complement Alternat Med 2013; 13:762615.
Zheng YH, Wang X, Lai MH, Yao H, Liu H, Ma HX. Effectiveness of abdominal acupuncture for patients with obesity type Pco. J Altern Complement Med 2013; 19:740–745.
Stener-Victorin U, Waldenstrom U, Tagnfors T, Lundeberg G, Lindstedt G, Janson PO. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstetricia Gynecol Scandinavica 2000; 79:180–188.
Jedel E, Labrie F, Oden A, Holm G, Nilsson L, Janson PO et al.
Impact of electro acupuncture and exercise on hyperandrogenism and oligo-amenorrhea in women with polycystic ovary syndrome: a randomised controlled trial. Am J Physiol Endocrinol Metab 2011; 300:E37–E45.
Gerhard F, Postneek F. Auricular acupuncture in the treatment of female infertility. Gynecol Endocrinol 1992; 6:171–181.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]