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Menopause Live - IMS Updates
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Date of release: 31 August, 2009

Acupuncture for vasomotor menopausal symptoms


Almost two-thirds of postmenopausal women experience hot flushes; 10–20% of these find it very distressing [1]. Symptoms may last for up to 5 years after natural menopause, and, in at least 20% of women, flushes may persist for up to 15 years. Hormone replacement therapy (HRT) is the most efficacious treatment. However, alternatives are needed for women who have a contraindication against HRT or desire a non-hormonal treatment for personal reasons. One of these alternative complementary methods becoming increasingly popular is acupuncture. 


 


Until now, no large, solid, randomized, controlled trials (RCTs) have shown that acupuncture is efficient in Western women suffering from menopausal hot flushes. Therefore, the recent RCT published by a Norwegian group [2] merits our interest. It shows an overall reduction in hot flush frequency of 48% among women who received acupuncture, compared with a 28% reduction in the control group. This multicenter, pragmatic RCT with two parallel arms was intended to compare the effectiveness of individualized acupuncture plus self-care vs. self-care alone on hot flushes and health-related quality of life in postmenopausal women. The primary endpoint was a change in mean hot flush frequency from baseline to 12 weeks. The secondary endpoint was a change in health-related quality of life measured by the Women’s Health Questionnaire. Exclusion criteria were surgical menopause, history of cancer within the past 5 years (including use of tamoxifen), an uncontrolled chronic disease and drug or alcohol dependency. Use of systemic HRT and selective serotonin reuptake inhibitors/serotonin norepinephrine reuptake inhibitors required a washout period of 8 weeks and use of local prescription estrogens for 4 weeks. 


A total of 267 women were randomized to the study and 248 were analyzed. Women randomized to receive acupuncture were referred to a local study acupuncturist. Before the treatment started, the acupuncturists met and discussed the expected traditional Chinese medicine diagnoses and the recommended acupuncture point selection. They were free to diagnose and to individualize the acupuncture treatment for each participant. Moxibustion (heated needles) could be added if indicated, but no other treatments, for example herbs, were given. De Qi (a characteristic dull and numb sensation) was obtained if possible, and needle manipulation with even, reducing, or reinforcing methods was used. 


The acupuncture group of women received ten acupuncture treatment sessions and advice on self-care. Point location was not standardized in the study but was left to the acupuncturists to decide. The participants in the control group were not prescribed any medical treatment for menopausal symptoms within the study. They were free to use any over-the-counter medication and self-provided non-pharmaceutical interventions, guided by the self-care information leaflet given to them after randomization.


The results showed a significant decrease of hot flush frequency by 5.8 per 24 h in the acupuncture group (n = 134) and 3.7 per 24 h in the control group (n = 133), a difference of 2.1 (p < 0.001). Hot flush intensity decreased by 3.2 units in the acupuncture group and 1.8 units in the control group, a difference of 1.4 (p < 0.001). The acupuncture group experienced statistically significant improvements in the vasomotor, sleep and somatic symptom dimensions of the Women’s Health Questionnaire compared with the control group. The overall reduction in hot flush frequency was 48% among women who received acupuncture, compared with a 28% reduction in the control group. Nineteen women (7%) dropped out (16 in the control group and three in the acupuncture group). No participants withdrew because of adverse effects.


These results suggest that a policy of use of acupuncture plus self-care can reduce hot flush frequency by 50% or more in half of the postmenopausal women experiencing frequent hot flushes. The authors conclude that acupuncture plus self-care can contribute to a clinically relevant reduction in hot flushes and increased health-related quality of life in postmenopausal women [2].

Comment

The trial published by Borud and colleagues [2] is the first large, RCT to study the effect of acupuncture on hot flushes in a Western cultural setting. However, it has several limitations. It tested acupuncture as a complete treatment package on a generic level. No placebo treatment was given in the control group. As is well known, patient expectations can have a measurable impact on clinical outcomes. This may lead to an overestimation of the acupuncture treatment effect. Therefore, the authors stress that their study does not allow an estimation of what proportion of the clinical benefit was due to the effects of the needling itself and what was due to other factors, such as the patient–provider interaction [2]. 
The efficiency of acupuncture for the treatment of climacteric hot flushes has not been confirmed by two recent meta-analyses [3,4]. Both reviews, published this year, were intended to assess whether acupuncture therapy reduces vasomotor menopausal symptoms. For both meta-analyses, only RCTs were selected, without any language restrictions. Women with breast cancer were excluded in both reviews. One of the two meta-analyses included 11 trials [3], the other six [4]. The smaller meta-analysis [4] included only RCTs comparing acupuncture vs. sham acupuncture. The largest of these six studies included 103 women, the others had a sample size between 24 and 56 participants [4]. The 11 RCTs of the less restrictive meta-analysis included a total of 764 individual cases. Five of these 11 studies [3] reported a reduced frequency of hot flushes within groups. Only one small study, comparing acupuncture to sham acupuncture [5], found a significant difference in the severity outcomes of hot flushes between groups (mean difference, 0.48; 95% confidence interval, 0.05–0.91). However, this study was too small to generate reliable findings.
In conclusion, acupuncture is said to be an efficient tool to treat vasomotor symptoms in a classical, traditional Asian cultural and social environment. In spite of the new Norwegian data from Borud and colleagues [2] suggesting that acupuncture is a viable option for treating menopausal symptoms, there is no sufficiently convincing evidence from reliable RCTs that acupuncture, in comparison to sham acupuncture or oral treatments, is effective in reducing menopausal hot flushes in a Western cultural setting. Therefore, further evaluation of the effects of acupuncture on vasomotor menopausal symptoms, based on well-controlled placebo trials, is still warranted.

Comentario

Martin Birkhäuser
Professor Emeritus, Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics & Gynecology, University of Berne, Switzerland

    References

  1. Stearns V, Ullmer L, Lopez JF, Smith Y, Isaacs C, Hayes D. Hot flushes. Lancet 2002;360:1851-61.
    http://www.ncbi.nlm.nih.gov/pubmed/12480376

  2. Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial. Menopause 2009;16:484-93. Published May/June 2009.
    http://www.ncbi.nlm.nih.gov/pubmed/19423996

  3. Cho SH, Whang WW. Acupuncture for vasomotor menopausal symptoms: a systematic review. Menopause 2009; May 6. E-pub ahead of print.
    http://www.ncbi.nlm.nih.gov/pubmed/19424092

  4. Lee MS, Shin B-C, Ernst E. Acupuncture for treating menopausal hot flushes: a systematic review. Climacteric 2009;12:16-25.
    http://www.ncbi.nlm.nih.gov/pubmed/19116803

  5. Nir Y, Huang MI, Schnyer R, Chen B, Manber R. Acupuncture for postmenopausal hot flashes. Maturitas 2007;56:383-95.
    http://www.ncbi.nlm.nih.gov/pubmed/17182200