Researchers find acupuncture effective for the alleviation of menstrual pain. The investigation team, finds acupuncture effective for reducing both pain intensity levels and the duration of menstrual cramping and pain on patients with chronic dysmenorrhea, due to uterine contraction. In addition, the researchers document that acupuncture reduces secondary symptoms including back pain, headaches, and nausea. Perhaps more importantly, the beneficial clinical effects were sustained for up to one year after completion of acupuncture treatments.
Western Sydney University research
The Australian research team, led by chief researcher Dr. Armor, investigated the effects of manual acupuncture and electroacupuncture on patients with chronic dysmenorrhea (menstrual related cramping and pain). All participants received a grand total of 12 acupuncture treatments. Manual acupuncture group participants received tonification (bu) or sedation (xie) methods applied to the acupuncture needles during the 20–30 minute acupuncture sessions. For electroacupuncture participants, “two distal points were selected by the practitioner and a 2Hz/100Hz square wave pulse of 200ms duration was applied between each point for 20 minutes using an ITO ES-160 electroacupuncture machine.”
The researchers conclude, “This exploratory study suggests acupuncture administered over three menstrual cycles gave both statistically and clinically significant reductions in menstrual pain compared to baseline and persisted for 12 months….” In this study, manual acupuncture slightly outperformed electroacupuncture. The researchers note, “Manual acupuncture provided the same or greater pain relief as electro-acupuncture, but with less analgesic medication required to achieve this pain reduction.”
Additional studies find acupuncture effective for the treatment of dysmenorrhea. Wenqing Wang’s research entitled Clinical Treatment of Primary Dysmenorrhea Using Acupuncture finds acupuncture more effective than ibuprofen. A total of 122 women ranging in ages from 14 to 43 were separated into an acupuncture treatment group, medication group, and a B vitamin nutritional supplement group. All groups received treatment over the course of three menstrual cycles. All groups received treatment for 5 days starting from the day prior to the expected start of menses. The acupuncture group received treatment once per day. The acupuncture points used in the study were the following:
SP6 (Sanyinjiao)
SP8 (Diji)
SP10 (Xuehai)
LI4 (Hegu)
The medication group received ibuprofen tablets 2–3 times per day and the supplement group received vitamin B supplements. The result showed that the acupuncture group had a significantly higher effective treatment rate (96.2%) compared with the ibuprofen medication group (80%) and the supplement group (13.3%).
Jiao et al. document similar findings and conclude that acupuncture plus moxibustion has a 96.8% total treatment effective rate for the treatment of dysmenorrhea, whereas ibuprofen sustained time release capsules achieved a 58.1% total treatment effective rate. The primary acupoints administered to all patients patients were the following:
Guanyuan (CV4)
Zhongji (CV3)
Sanyinjiao (SP6)
Additional acupoints were selected based on differential diagnostics. For qi and blood stasis, the following acupoints were added:
Taichong (LV3)
Xuehai (SP10)
For depressed liver qi with dampness and heat, the following acupoints were added:
Xingjian (LV2)
Yinlingquan (SP9)
For liver and kidney deficiency, the following acupoints were added:
Shenshu (BL23)
Mingmen (GV4)
For poor qi and blood circulation, the following acupoints were added:
Qihai (CV6)
Zusanli (ST36)
Manual acupuncture stimulation techniques for obtaining deqi including lifting, thrusting, and rotating were applied. Once a deqi sensation was obtained, the needles were retained and moxibustion applied to the acupoints via attachment to the needle handle. One acupuncture treatment was administered daily for 3–4 consecutive days during menstruation. Treatment was also conducted on the 2 days prior to the next menstrual cycle. The entire course of treatment comprised 3 menstrual cycles. For the ibuprofen group, patients received 300 mg of ibuprofen sustained time release capsules starting 1 – 2 days prior to menstruation. Capsules were orally administered twice per day for 2 – 3 days until the symptoms were mitigated, for a total of 3 menstrual cycles. Vitamin B was administered additionally for patients who also experienced stomach discomfort. The results tabulated, the acupuncture plus moxibustion protocol provided greater pain relief than the ibuprofen protocol.
The National Institute of Complementary Medicine at Western Sydney University in Australia
Over half of all women experience primary dysmenorrhea, including menstrual pain and other pre-menstrual symptoms. In the occident, acupuncture has recently gained popularity for women's reproductive health conditions, especially infertility. Nevertheless, women do not seek acupuncture to treat their dysmenorrhea; in some cases, it is only after seeking out acupuncture for other conditions that women are educated in its potential to treat their menstrual pain.
Researchers at The National Institute of Complementary Medicine at Western Sydney University in Australia conducted a study to compare the efficacy of manual acupuncture and electro-acupuncture, at two timing intervals, for the treatment of primary dysmenorrhea. The researchers found that, in all cases, acupuncture leads to a significant reduction in the intensity and duration of menstrual pain after three months of treatment, and the results were sustained one year after trial entry. [1]
Primary dysmenorrhea is menstrual pain that has no identified organic cause; women with endometriosis, or other biomedically defined uterine conditions, may have menstrual pain, but that pain is considered secondary dysmenorrhea since the etiology is known. Primary dysmenorrhea is most common in young women under the age of 25. The characteristic symptoms are cramps — colicky spasms of pain in the suprapubic area — occurring within 8–72 hours of menstruation, and the pain usually peaks with the increase in menstrual flow. "In addition to painful cramps, many women experience other symptoms, including back pain, headaches, diarrhea, nausea and vomiting." [2] Iacovides et al. note that prevalence estimates vary between 45 and 95% of menstruating women, with very severe primary dysmenorrhea estimated to affect 10–25% of women of reproductive age. As such, dysmenorrhea appears to be the most common gynecological disorder in women irrespective of nationality and age. [3]
Amongst women, dysmenorrhea is the most common cause of absenteeism from school and work, and it may also lead to "a reduction in academic performance, reduced participation in sport and social activities and an overall significant decrease in women's quality of life. The most commonly prescribed treatments by doctors for primary dysmenorrhea are non-steroidal anti-inflammatories (NSAIDs) and the combined oral contraceptive (COC) pill.
In Traditional Chinese Medicine (TCM), dysmenorrhea refers to recurrent abdominal or lumbosacral pain experienced before, during, or after menstruation. According to TCM theory, there are three primary etiologies, each manifesting according to its root cause:
liver qi stagnation,
cold accumulation and
qi and blood deficiency.
Liver qi stagnation
Liver qi stagnation causes distending pain in the lower abdomen, which may refer to the waist and back; when qi stagnation leads to blood stasis, there may be spells of sharp, stabbing pain, which is relieved by the passing of small clots of menstrual blood. Stagnated liver qi can also cause the irritability and emotional issues associated with PMS.
Cold accumulation
Similarly, cold accumulation will slow and coagulate the blood, causing blood stasis; this pattern causes the sharp, stabbing pain associated with blood stasis, as well as the cramping or contracting of the uterine muscles due to cold accumulation.
Qi and blood deficiency
Alternatively, deficient qi and blood fail to nourish the uterus, leading to dull, aching pain that may occur during or after menstruation.
Moxibustion
Both the excess cold and qi and blood deficiency patterns can be alleviated by warmth, and thus moxibustion — the burning of mugwort at acupoints or around the area of pain — is indicated for both of these etiologies.
Studies
According to scientific studies, dysmenorrhea is linked to an increase in both the tension and contraction frequency of the uterine muscles, as well as a discord in the rhythm of shrinkage; the uterine muscles contract and do not relax fully between contractions. These abnormalities cause a disorder in uterine micro-circulation that leads to ischemia and hypoxia.
The prevailing theory is that the changes in uterine micro-circulation and contractility associated with dysmenorrhea are related to the disordered production of endometrial prostaglandins (PGs), endogenous hormone-like lipid compounds. During the luteal phase, women have increased levels of PGs. However, women with dysmenorrhea have notably higher levels of circulating PGs than eumenorrheic women, especially during the first 48 hours of their menses, when their symptoms peak. Furthermore, "the severity of menstrual pain and associated symptoms of dysmenorrhea are directly proportional to the amount of PGs released," [11] confirming that altered PG levels are the likely cause of pain.
In a study conducted by Yang et al. to investigate the efficacy of moxibustion at the acupoints:
CV4 (Guanyuan)
CV8 (Shenque)
SP6 (Sanyinjiao)
The researchers found that pain levels decreased over the three month trial, and that the therapeutic effect of moxibustion was sustained in the three months after the trial ended. Through blood tests, the researchers also found that moxibustion decreased levels of both PGF2 and PGE2, which allows for increased blood flow and decreased contractility of the uterus. [17] Heat is also well understood to regulate menstrual pain — and was found to be as effective as ibuprofen, and more effective than acetaminophen in relieving dysmenorrheic pain" [18] — and thus, the heat from moxa over the abdomen, would be similarly effective for inducing vessel dilation and increasing blood flow to decrease pain. [19] The acupoint SP6 (Sanyinjiao) is effective for the treatment of dysmenorrhea, likely due to the fact that SP6 is segmental to the uterus… This segmental activation at the sacral spinal nerve 2 (S2) may lead to reflex sympathetic inhibition of the uterus resulting in increased uterine blood flow." [20]
In the exploratory study conducted by Armour et al., the researchers used a 2x2 factorial design "to test the individual and combined effects of changing 1) treatment timing, and 2) mode of stimulation. [21] Each patient was given acupuncture by one of two modalities: manual acupuncture (MA) or electro-acupuncture (EA). Manual acupuncture, after the insertion of the needles, in this trial, were stimulated again 10–15 minutes after insertion; [22] electro-acupuncture uses the same points but adds electrical stimulation to the points. An ITO ES-160 electro-acupuncture machine with a 2Hz / 100Hz square wave pulse of 200ms for 20 minutes was employed. [23] DeQi was obtained at all acupoints. [23a] For the patient, DeQi feels like soreness, pressure, or heaviness at the site of insertion; for the practitioner, it is an indication that the qi has begun to flow at the acupoint, accessing the unique energy of the point to heal.
Treatment timing was tested by separating the participants into high and low frequency test groups. "All women in the study were scheduled to receive 12 treatments over the course of three menstrual cycles. Women in the high frequency (HF) group received three treatments in the seven days prior to the estimated day one of the menstrual cycle. Women in the low frequency (LF) group received three treatments in the time between menses, approximately every seven to ten days' dependent on cycle length.
Treatment was based on the principles of TCM and the practitioners had the flexibility with their point selection to address the diagnosed pattern of disharmony, [25] Up to two concurrent patterns of disharmony were supported by this trial, distinguished into primary (root) and secondary (branch) patterns. [26] No more than 7 unique acupoints were chosen for each patient, according to the diagnosis, and all points were needled bilaterally. [27] Indirect moxa was administered via smokeless moxa stick for 5–10 minutes on one of the selected acupuncture points. Each patient was given a diet and lifestyle advice sheet during their first treatment session. These were grounded in TCM theory." [28]
The primary outcome of this study was the decrease in peak menstrual pain one year after trial entry. [29] All groups showed a significant reduction in peak pain and duration of pain over time, and neither the mode nor frequency of treatment showed a stronger effect by the one-year follow-up. However, manual acupuncture provided more immediate pain reduction.
The researchers also compared health related quality of life (HRQoL), supplementary analgesic use, and secondary symptoms. HRQoL measures subjective physical and mental well-being, by collecting participant data on factors including body pain, vitality, social function, and mental health. Decreased nonsteroidal anti-inflammatory drug (NSAID) use, measured in mean doses per day, [31] is thought to be another way of measuring pain relief, since patients will only take medications once their pain meets their personal threshold. Secondary symptoms may vary between women, but common symptoms include mood changes, bloating, and breast tenderness. [32] The results indicate that high frequency and manual treatments show better results for these factors. "Health related quality of life increased significantly in six domains in groups having high frequency of treatment compared to two domains in low frequency groups. Manual acupuncture groups required less analgesic medication than electro-acupuncture groups." [33] More specifically, manual acupuncture provides the same — or greater — pain relief, while simultaneously decreasing the analgesic medication required. [34] The use of moxa for indicated conditions, which was found by Yang et al. to regulate PGF2 and PGE2 levels, [37] may have also contributed to the lasting effects of the course of treatment.
The treatment before the onset of menses produced greater pain reductions than treatment during menstruation. [39] Zhao et al. found that SP6 (Sanyinjiao) is the most commonly used acupoint to treat primary dysmenorrhea, inducing significant analgesic effects [40] especially for those patients with the specific TCM diagnosis of cold and dampness stagnation. [41] Hsu et al. found similar results, showing that acupuncture at SP6 with DeQi significantly increased microvascular uterine blood velocity as compared with the model control group that received the same treatment without DeQi. [42]
Self-care advice may also play an important role in TCM treatment. [44] Women responded well to the advice regarding diet and lifestyle choices. [45] Additionally, TCM practitioners tend to spend more time talking and listening to their patients, allowing practitioners to better understand the life-world of the client and provide explanations and self-care advice that was appropriate and achievable. [46] The women interviewed overwhelmingly confirmed that the explanations about menstrual physiology, as well as the advice on self-care, increased their self-efficacy. [49]
The most important result of this study, and others like it, is that menstrual pain is not inevitable. Many women may feel that medications — either NSAIDs or oral contraceptives — are their only option for treating their monthly symptoms, but acupuncture has been shown to be equally effective, and its effects last long after the course of treatment. Additionally, TCM practitioners provide individualized advice. Acupuncture can provide a safe and effective alternative to medications. This study shows that the abdominal pain and emotional symptoms of primary dysmenorrhea can be addressed with TCM, and it will hopefully empower women to address their menstrual pain holistically and efficiently.
References:
[1] [2] [21] [22] [23] [25] [26] [27] [28] [29] [31] [32] [33] [34] Armour, Mike, Hannah G. Dahlen, Xiaoshu Zhu, Cindy Farquhar, and Caroline A. Smith. "The role of treatment timing and mode of stimulation in the treatment of primary dysmenorrhea with acupuncture: An exploratory randomised controlled trial." Plos One 12, no. 7 (2017).[3] [11] [18] Iacovides, Stella, Ingrid Avidon, and Fiona C. Baker. "What we know about primary dysmenorrhea today: a critical review." Human Reproduction Update vol 21, no 6, (2015);
Wenqing Wang (2007). Clinical Treatment of Primary Dysmenorrhea using Acupuncture. Hubei TCM Magazine, 2007. 29(6): 57.
Liangxi Zhi (2007). Treatment of Primary Dysmenorrhea using Fu’s subcutaneous needle. Chinese Acupuncture, 2007. 27(1): 18-21.
Jiao FL, Liang YC & He M. (2014). Therapeutic Observation of Acupuncture-moxibustion for Primary Dysmenorrhea. Shanghai Journal of Acupuncture and Moxibustion. 33(5).
[17] [19] [37] Yang, M., Chen, X., Bo, L., Lao, L., Chen, J., Yu, S., Liang, F. (n.d.). Moxibustion for pain relief in patients with primary dysmenorrhea: A randomized controlled trial.
[20] [39] Armour, M., & Smith, C. A. (2016). Treating primary dysmenorrhoea with acupuncture: a narrative review of the relationship between acupuncture ‘dose' and menstrual pain outcomes. Acupuncture in Medicine, 34(6).
23a Xing-Yue Yang, Guang-Xia Shi, Qian-Qian Li, Zhen-Hua Zhang, Qian Xu, and Cun-Zhi Liu, “Characterization of Deqi Sensation and Acupuncture Effect,” Evidence-Based Complementary and Alternative Medicine, vol. 2013, Article ID 319734, 2013.
[40] [41] Zhao, M., Zhang, P., Li, J., Wang, L., Zhou, W., Wang, Y. Zhu, J. (2017). Influence of de qi on the immediate analgesic effect of SP6 acupuncture in patients with primary dysmenorrhoea and cold and dampness stagnation: a multicentre randomised controlled trial. Acupuncture in Medicine.
42 Hsu, Wing-Sze, Xiao-Yu Shen, Jia-Min Yang, Li Luo, Ling Zhang, Dan-Dan Qi, Song-Xi Shen, Shi-Peng Zhu, Ya-Fang Zhao, Xiao-Xuan Ren, Meng-Wei Guo, Xiao-Hong Li, Bo Ji, Lu-Fen Zhang, and Jiang Zhu. "Effects of Acupuncture Applied to Sanyinjiao with Different Stimuli on Uterine Contraction and Microcirculation in Rats with Dysmenorrhea of Cold Coagulation Syndrome." Evidence-Based Complementary and Alternative Medicine 2014 (2014): 6.
[44] [45] [46] [49] Armour, M., Dahlen, H. G., & Smith, C. A. (2016). More Than Needles: The Importance of Explanations and Self-Care Advice in Treating Primary Dysmenorrhea with Acupuncture. Evidence-Based Complementary and Alternative Medicine, 2016.
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