Acupuncture and Menopause

Translation- Evidence Based Acupuncture Evidence Summary – Menopausal Symptoms

The menopause is a natural phenomenon and is defined as such when there have been twelve consecutive months without menstruation. In the West, the average age at which women reach menopause is 51 years [1]. Although it is a natural process, the years before and after menopause can be accompanied by various symptoms, ranging in severity from mild to debilitating. The average duration of these symptoms is seven years [2].

Various factors determine the overall impact that menopause can have, such as the age at which menopause occurs, ethnicity, culture, socioeconomic background, general health, and well-being. The question of whether menopause is caused by surgery or occurs naturally also plays a significant role. Additionally, there are differences between women who have given birth and those who have not, where the question of whether this was a conscious choice or a result of circumstances complicates matters further. For example, women who have been pregnant but have never had children report having a more negative attitude towards menopause. However, women who have never had children also less frequently report certain symptoms, such as hot flashes and vaginal dryness [3,4].

Because the transition to menopause and the period thereafter is such an individual and prolonged process, tailored treatments like those used in acupuncture can offer significant benefits. Various studies have shown that acupuncture can provide relief for some of the most common menopausal symptoms. However, it is still underutilized in clinical practice.

Vasomotor Symptoms
Vasomotor symptoms (VMS), including hot flashes and night sweats, are among the most common problems that women experience during menopause. Approximately 70% of women in Western culture suffer from them. VMS are also one of the most well-studied topics related to acupuncture and menopause.

A review from 2009 by Alfhaily and Ewies [5] showed that the majority of studies on acupuncture for VMS reported 50% reductions in hot flashes lasting up to six months. A meta-analysis from 2015 by Chiu et al.[6] supports these findings. In this analysis, 12 studies were evaluated, involving a total of 869 participants. The conclusion was that acupuncture significantly reduced both the frequency and severity of hot flashes. They also found that acupuncture brought improvement in menopause-related psychological, somatic, and urogenital symptoms, and furthermore enhanced overall quality of life.

The results of these studies suggest that acupuncture offers significant benefits for women suffering from VMS during menopause.

Depression and Anxiety
Many women in menopause also suffer from mood disorders, such as depression and anxiety. This is another area where acupuncture can help.

A review by Sniezek and Siddiqui [7] from 2013 included six studies with a total of 605 female participants aged 18-71 years. Four of these studies focused on depression (three on depressive disorder), one on anxiety, and one on both conditions. One of the studies involved women in menopause with depression and VMS.

The authors of the study concluded that, although the (methodological) quality of the evidence was variable, acupuncture was "promising" as a therapy for women in menopause with depression. They stated the following: "At this moment, it is reasonable to use acupuncture as an adjunct therapy for the treatment of depression in postmenopausal women experiencing vasomotor symptoms."

An earlier review from 2007 by Pilkington et al. [8] focused on acupuncture for anxiety. It included 12 controlled studies, of which 10 were RCTs. All studies reported positive results.

Sleep Disorders and Insomnia
A 2015 review by Berezza et al. [9] included 12 studies on acupuncture for sleep disorders in postmenopausal women. The studies encompassed a wide range of treatment protocols and interventions and varied in terms of study duration. Overall, 75% reported improvements in sleep complaints after acupuncture treatment.

Osteoporosis
Osteoporosis is a common issue among postmenopausal women. Various large-scale reviews indicate that acupuncture can be beneficial.

A systematic review and meta-analysis from 2018 by Pan et al. [10] included 35 studies with a total of 3014 participants. They found that, compared to pharmaceutical treatment alone, acupuncture with heated needles increased the bone mineral density (BMD) of the femur and lumbar spine, as well as the levels of calcium and estradiol. It reduced alkaline phosphatase and alleviated pain. Electroacupuncture also had positive effects on calcium, alkaline phosphatase, and pain.

A review from 2020 by Xu et al. [11] supported these findings. It included 13 systematic reviews and meta-analyses, published between 2013 and 2018. They found qualitatively strong evidence that acupuncture and moxibustion can improve BMD in primary osteoporosis. They also noted that these therapies can improve visual analog scale (VAS) pain scores, although the quality of the evidence was lower.

Cognitive Decline and Alzheimer's Disease
The risk of cognitive decline, including Alzheimer's disease (AD), also significantly increases after menopause. A 2019 systematic review and meta-analysis by Huang et al. [12] concluded that acupuncture offered some benefits. It included 13 studies comparing acupuncture with medication alone. The results showed that acupuncture had positive effects on Mini Mental State Examination scores, Ability of Daily Living Scale scores, AD Assessment Scale-Cognition scores, and a high clinical efficacy rate.

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Mechanisms of Acupuncture
Acupuncture operates through numerous physiological mechanisms that explain its diverse effects on the human body. One of the most crucial of these is purinergic signaling, a system that utilizes adenosine triphosphate (ATP) as a signaling molecule in regulating a variety of physiological functions. In the short term, it plays a role in neurotransmission, neuromodulation, and secretion. In the long term, it influences proliferation, differentiation, migration, and cell death, thereby directing the activity and fate of cells [13].

Purinergic receptors have been investigated as potential therapeutic targets for a wide range of conditions, including many that affect peri- and postmenopausal women. These include depression and anxiety, sleep disorders, osteoporosis, endocrine disorders, cardiovascular, and neurodegenerative diseases. Regarding the Knowledge Centre, studies have indicated that acupuncture affects the release of beta-endorphins [7]. Slogan: Acupuncture – Effective on Many Points. It is believed that these neurochemical substances are involved in the pathophysiology of VMS, although the mechanism behind this is not yet clearly understood.

Acupuncture also seems to influence cortisol, cortisol metabolites, and DHEA levels [10]. Cortisol levels tend to rise after menopause, contributing to changes in mood, metabolism, bone density, and cognitive decline. It is therefore possible that the same underlying mechanisms play a role in the treatment of VMS, depression, anxiety, sleep disorders, abdominal obesity, osteoporosis, and dementia.

Other mechanisms suggested for the effects of acupuncture on obesity include anti-inflammatory and antioxidant effects, regulating the endocrine system, promoting digestion, and influencing fat metabolism [14].

Meanwhile, animal studies have shown that acupuncture can provide some protection against osteoporosis by regulating the OPG/RANK/RANKL signaling pathways. These are all involved in the protection of bone tissue [15].

Finally, MRI studies in patients with Alzheimer's disease or mild cognitive impairment have shown that acupuncture activates and deactivates different areas of the brain. These include the basal ganglia, the cerebellum, cognitive/visual, and sensorimotor-related areas [16].

Conventional Approach
The transition is rapidly becoming a specialty. Over the past forty years, our understanding of female endocrinology has greatly improved, accelerated by the growth of assisted reproductive therapies. This growth, coupled with the fact that women are becoming increasingly vocal about their experiences and in seeking solutions, has brought menopause to the forefront in both medicine and the media.

The main common treatment for menopausal symptoms is hormone replacement therapy (HRT), consisting of monotherapy of estrogen or progesterone, or a combination of both.

HRT has been controversial since the publication of the Women's Health Initiative [17], which suggested that its use increases the risk of breast cancer, strokes, and pulmonary embolism. Industry-funded guidelines developed in collaboration with clinical specialty groups, however, have pointed out shortcomings in this study. Current guidelines for prescribing hormones suggest that the benefits of HRT generally outweigh the risks for most women aged 60 or younger, or within ten years of menopause [1]. However, there is also evidence that these hormones may increase the risk of breast and ovarian cancer.

With so much conflicting information circulating, the decision on whether or not to take HRT is a difficult one. Acupuncture, on the other hand, has a demonstrably good reputation for safety and when performed by well-trained clinicians, it is considered one of the safest treatments in modern medicine [18].

Therefore, many women are now choosing modalities such as acupuncture as a first-line treatment. Acupuncturists can also play an important therapeutic role by informing and supporting women in making beneficial changes to their lifestyle.

References:

1. Jane FM, Davis SR. A Practitioner’s Toolkit for Managing the Menopause. Climacteric. 2014; 17(5): p.564-579.
https://pubmed.ncbi.nlm.nih.gov/24998761/ [←]

2. Hillard T, Abernathy K, Hamoda H, et al. British Menopause Society Management of the Menopause Sixth Edition 2017.
[←]

3. Thurston RC, Joffe H. Vasomotor Symptoms and Menopause: Findings from the Study of Women’s Health across the Nation. Obstetrics and Gynecology Clinics of North America. 2011; 38(3): p. 489-501.[←]

4. Hess R, Olshansky E, Ness R, et al. Pregnancy and Birth History Influence Women’s Experience of Menopause. Menopause. 2008;15(3): p. 435-441.6.[←]

5. Alfhaily F, Ewies AAA. Acupuncture in managing menopausal symptoms: hope or mirage?. Climacteric. 2007; 10(5): p. 371-380.[←]

6. Chiu HY, Pan CH, Shyu YK, Han BC, Tsai PS. Effects of acupuncture on menopause-related symptoms and quality of life in women in natural menopause: a meta-analysis of randomized controlled trials. Menopause. 2015 Feb; 22(2): p. 234-244.[←]

7. Sniezek DP, Siddiqui IJ. Acupuncture for Treating Anxiety and Depression in Women: A Clinical Systematic Review. Medical Acupuncture. 2013; 25(3): p.164-172.[←]

8. Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders – a systematic literature review. Acupuncture in Medicine. 2007; 25(1-2): p.1-10.[←]

9. Bezerra AG, Pires GN, Andersen ML, Tufik S, Hachul H. Acupuncture to Treat Sleep Disorders in Postmenopausal Women: A Systematic Review. Evidence-Based Complementary and Alternative Medicine. 2015; 2015:563236.[←]

10. Pan H, Jin R, Li M, Liu Z, Xie Q, Wang P. The Effectiveness of Acupuncture for Osteoporosis: A Systematic Review and Meta-Analysis. The American Journal of Chinese Medicine. 2018; 46(3): p.489-513.[←]

11. Xu G, Xiao Q, Zhou J, et al. Acupuncture and moxibustion for primary osteoporosis: An overview of systematic review. Medicine (Baltimore). 2020; 99(9): e19334.[←]

12. Huang, Q., Luo, D., Chen, L. et al. Effectiveness of Acupuncture for Alzheimer’s Disease: An Updated Systematic Review and Meta-analysis. Current Medical Science. 2019; 39: p.500–511.[←]

13. Burnstock G. Purinergic Signalling: Therapeutic Developments. Frontiers in Pharmacology. 2017;8:661. Published 2017 Sep 25. doi:10.3389/fphar.2017.00661[←]

14. Wang LH, Huang W, Wei D, et al. Mechanisms of Acupuncture Therapy for Simple Obesity: An Evidence-Based Review of Clinical and Animal Studies on Simple Obesity. Evidence-Based Complementary and Alternative Medicine. 2019; 2019:5796381.[←]

15. Huang F, Zhao S, Qiu M, et al. Acupuncture for primary osteoporosis: A network meta-analysis of randomized controlled trials protocol. [published correction appears in Medicine (Baltimore). 2019 May;98(21): e15898]. Medicine (Baltimore). 2019;98(15):e15108.[←]

16. Shan Y, Wang JJ, Wang ZQ, et al. Neuronal Specificity of Acupuncture in Alzheimer’s Disease and Mild Cognitive Impairment Patients: A Functional MRI Study. Evidence-Based Complementary and Alternative Medicine. 2018; 2018: 7619197[←]

17. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013; 310(13): p.1353-1368.[←]

18. Linde, K., Streng, A., Hoppe, A., Jürgens, S., Weidenhammer, W., & Melchart, D. (2006). The programme for the evaluation of patient care with acupuncture (PEP-Ac) – a project sponsored by ten German social health insurance funds. Acupuncture in Medicine, 24(Suppl), 25–32. [←]