Acupuncture and Polycystic Ovarian Syndrome

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Objective

The objective of this paper will be to review clinical trials; randomized and non randomized and observational studies on polycystic ovarian syndrome.

Introduction

This review describes the etiology, pathogenesis, signs and symptoms and treatment options. It also explores the use of acupuncture as an intervention in the treatment of polycystic ovarian syndrome. The paper will also determine limitations and suggest further improvements that should be made on future studies. Polycystic Ovarian Syndrome is an endocrine system disorder where by the ovaries secrete very high levels of the male hormones resulting into a number of symptoms which include the following: Irregular or missed periods; high blood sugar or insulin resistance; multiple ovarian cysts; hirsutism (excessive facial hair); thinning or loss of scalp hair; and trouble loosing weight. The most common symptoms are missed periods and unwanted weight gain (Agbagbu, 2008). Medical professionals do have a problem diagnosing PCOS due to the fact that the symptoms do vary from woman to woman. The varying is so conspicuous such that some patients may have numerous ovarian cysts while others may have none. Many of the patients do have irregular menses. Taking medical history, blood tests to determine the levels of hormones and pelvic ultra-sonography to determine the presence of ovarian cysts is a surest way of making accurate diagnosis (Eisenberg et al, 2002). Treatment of PCOS majorly depends on the presenting symptoms. The high levels of the male hormones can be regulated by use of oral contraceptives, high blood sugars and abnormal weight gain can be controlled by use of drugs used in the management of diabetes. Excessive facial hair and loss of scalp hair can be managed by use of spironolactone and propecia respectively. One of the complications of PCOS that has even initiated a lot of research studies on use of alternative medicine in treatment of PCOS is infertility which is basically caused by the disturbance in the normal ovarian cycle (Eisenberg et al, 2002). Research studies have shown that maintaining of healthy weight is one of the best ways to manage PCOS as a loss of 10 percent body weight helps to lower blood sugar that further helps the patient in regulating menstrual cycle. Proper nutrition and body exercises are also surest ways of managing symptoms of PCOS (Barnes et al, 2002). Surgery can be used to remove the ovarian cysts to allow for ovulation but it comes with side effects such as scarring of ovarian tissues forming adhesion leading to infertility. The use of acupuncture has also been shown to treat and manage PCOS with high levels of success rates (Barnes et al, 2002). Acupuncture is one of the oldest healing practices that is aimed at restoring and maintain health through the stimulation of acupoints on the body. According to Kaptchuk, (2002), the acupuncture practice that has been scientifically studied basically involves “penetration of the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation”.

The current pharmacological treatment for PCOS are effective but have adverse effects therefore creating the need to explore other treatment method that will cause minimized or no adverse effects. This need led to carrying out of clinical studies on the use of acupuncture in the treatment of POCS. Most of current studies are majorly on treatment of the symptoms and complications of PCOS such as infertility and ovulatory dysfunction. According to NIH (1998), “acupuncture is the manipulation of thin metallic needles inserted into anatomically defined locations on the body to affect bodily functions.” The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body; which are essential for health. Disruption of this flow is believed to be responsible for disease. Acupuncture can correct imbalances of flow at identifiable points close to the skin.

Systemic Review of Literature

In the recent past years, many clinical studies on the role of acupuncture in the treatment and management of polycystic ovarian syndrome and its associated effects have been carried out. Most of these studies are those on evaluating the role of acupuncture in induction of ovulation in women experiencing anovulation/oligoovulation and the effects of acupuncture on body metabolism. Acupuncture has also been used successful to treat and or control the symptoms of PCOS such as abnormal weight gain and insulin resistance.

In 1990, a study on relationship between blood radioimmunoreactive beta-endorphin and hand skin temperature during the electro-acupuncture induction of ovulation by Chen et al (1990, p. 1) in which 13 cycles of anovulation menstruation in 11 cases were treated with electro-acupuncture (EA) ovulation induction. The study showed that six of 13 menstruation cycles treated with EA showed ovulation, while the other 7 cycles failed to do so (n=13). No EA effects were found in normal control subjects. In 6 cycles, there was increased hand skin temperature (HST) with 5 cycles showing ovulation after EA treatment. Decreased HST was manifested in 7 cycles with only one of them producing ovulation. All the normal subjects showed no regular change in HST. The study concluded that in anovulatory women, the hyperactive sympathetic system can be depressed by EA and that the central sympathetic system can be used to regulate the function of the hypothalamus-ovarian axis by use of EA to induce ovulation. One of the earlier studies carried by Takeshi Asho et al, (1976, p. 391) titled “influence of acupuncture stimulation on plasma levels of LH, FSH, progesterone and estradiol in normally ovulating women” showed that there was a great variation in plasma levels of these four hormones in the pre-ovulatory case under stimulation. It was revealed that 15 minutes after stimulation the plasma levels of LH, FSH and Estradiol dropped while the progesterone level rose. After a period of 30 minutes, the progesterone level begun to drop while the LH and FSH levels returned to normal levels. Progesterone levels rose again and LH and FSH levels dropped after 60 minutes after the start of stimulation. Estradiol levels also decreased. The study found out that acupuncture stimulation could control the mechanism of ovulation and /or luteal function and that properly performed acupuncture together with other measures might provide a new means of fertility regulation. In another study on effects of electroacupuncture and Gonadotrophin releasing hormone treatments on hormonal changes in anoestrous sows by Lin et al (1987), found out that electro-acupuncture induced ovulation but with varied figures during the study. This is well demonstrated in the paragraph on results and discussion where they state that

“However, we also found an unexplainable phenomenon in which all responding sows showed oestrus several days later than the expected time….. This discrepancy remains to be explained.” (p.125).

This statement shows that more studies needs to be carried to validate how electro-acupuncture induces ovulation. They concluded that therapeutic effects of electroacupuncture may involve a synergism of somatic-ovarian and uterine reflex, and activation of the hypothalamo-pituitary-ovarian axis. The use of acupuncture in treatment of female infertility has also been explored by Gerhard and Postneek (1992, p. 171) in a study entitled “auricular acupuncture in the treatment of female infertility” where 45 infertile women suffering from oligomenorrhea (n=27) or luteal insufficiency (n=18) were treated with auricular acupuncture. The results of this study were compared to those of 45 women who received hormone treatment. The results were as follows; “women treatment with acupuncture had 22 pregnancies, 11 after acupuncture, four spontaneous and seven after appropriate medications. The study showed that women treated with hormones had 20 pregnancies, five spontaneously and fifteen in response to therapy. Four women of each group had abortions. Side effects were observed only during hormone treatment with various disorders of the autonomic nervous system normalized during acupuncture. It was observed that acupuncture was able to induce more physiologic menstrual cycles than those by hormone therapy which may also explain the lower abortion rate in acupuncture patients. Further results showed that acupuncture and electroacupuncture has little or no adverse effects with success rates as high as 90%. The use of acupuncture has also been shown to have long lasting therapeutic effects as the study showed that 80-90% of the patients did not show any of the signs and symptoms of PCOS which they experienced earlier. In a study to explain the role of electro-acupuncture in the release of GnRH from the medio-basal hypothalamus in conscious female rabbits by Yang et al (1994) demonstrated that EA was effective in the treatment of chronic anovulatory diseases such as pubertal dysfunctional uterine bleeding, and hypothalamic amenorrhea. The study showed that there is an acceleration of the slow and low pulsating secretion of LH and FSH (Yu, Zheng & Yu, 1989). In this study, points used for EA in the female rabbit model were correspondent to that used in human beings. Stener-Victorin et al (2000) carried out a non-randomized, longitudinal study with a sample size of 24 between the age of 24 and 40 to evaluate how electro-acupuncture could affect oligoovulation and/or anovulation and other related endocrine features in PCOS. There was a period of three months before and after the first and last electro-acupuncture respectively totaling an average of nine months of study. Vaginal bleeding and basal body temperature (BBT) were used to monitor menstrual and ovulation cycle. The results showed that treatment with repeated electro-acupuncture induce regular ovulations in more than 1/3 of the women with PCOS (n=24). This study proves the fact that acupuncture can be used to stimulate regular ovulation but only with repeated sessions of acupuncture. It was also reported that the women did not experience any adverse effects such as nausea and voting which are very common with pharmacologic induction of ovulation. In 2007, Stener-Victorin, Jedel and Mannerås carried out a review on studies on acupuncture in polycystic ovary syndrome: current experimental and clinical evidence with the objective of evaluating the effects of acupuncture on metabolic pattern. PCOS has effects on the metabolic system where it causes insulin resistance and unwanted weight gain. The review showed that regular frequent muscle contractions as a result of low frequency EA have the potential to activate physiologic responses just as in physical exercise. When this is performed on a daily basis, weight loss and insulin sensitivity is induced hence decreasing blood glucose and lipid levels (Lee, et al 2006). This shows that acupuncture can be used in treatment of effects of PCOS.

In a study titled “influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy, fertility and sterility” by Paulus et al (2002) found out that only 26% of women undergoing in-vitro fertilization (IVF) became pregnant compared to 43% who received acupuncture before and after IVF. This shows a 50% success rate when acupuncture is combined with IVF. In this study, all the women had similar characteristics. IVF is generally expensive and cannot be afforded by most women therefore leaving acupuncture as the better option in terms of money and psychosocial distress associated with IVF. A Swedish/Italian controlled study from the Biology of reproductive journal, (no date and authors); carried out by a group of doctors involved inducing development of polycystic ovaries with injection of estradiol valerate with the control group receiving no therapy hence maintained features of PCOS. The group treated with acupuncture showed reduction in or decrease in polycystic ovaries. The doctors then carried out a similar study on women with PCOS. The study concluded that repeated regular electroacupuncture sessions can reverse anovulation resulting into regular ovulations. It further found out that acupuncture reduces neuroendocrine and endocrine factors indicative of PCOS. This study therefore has shown evidence that PCOS has hormonal origin and can be induced artificially. On 10^th April, 2009, research results from a clinical trial study in Australia carried out by Chinese medicine clinical research center reported that 70% of women aged between 18 and 35 years had their menstrual cycle restored for three consecutive months and several became pregnant. The study included 108 women who experienced anovulation/oligoovulation (they from Sydney and Guangzhou, china) and were given regular treatments of acupuncture. These study findings were presented at the annual scientific meeting of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Auckland (Danford, 2009).

Traditional Chinese medicine (TCM) has also been used to induce ovulation in PCOS. In a study carried out in 1982 by Ge, Zhang and Shen (1982) titled “induction of ovulation with traditional Chinese medicine” had tremendous results revealing that TCM can be successfully used in treatment of PCOS. 95 patients were used with 36 of them suffering from PCOS. The following parameters were taken from each and every patient; routine history, basal body temperature, general and pelvic examinations and records for each patient was made. In some cases, traditional Chinese medicine was used in combination with western medicine. The results showed that the success of induction largely depends on reproductive endocrine status of a particular patient. In patients with PCOS and luteal insufficiency, induction of ovulation was successful. This study therefore confirms that complimentary and alternative medicine is still the better option for treating PCOS and its associated effects. There were no side effects reported with the results showing high success rate.

In another study done by Wang et al (1988), to evaluate the treatment of polycystic ovary syndrome with Chinese drug Longdan Xiegan Tang. The study had a sample size of 28 patients of which 27 cases were amenorrhea with one being ovulatory uterine bleeding. All the 28 patients were treated with Longdan Xiegan Tang (LDXGT) once daily. The results for the study were classified under the following therapeutic effects; class 1: menstruation recommenced in amenorrheal patients; cessation of anovulatory uterine bleeding with more than 50% of the menstrual cycles showing biphasic BBT. Class 2: menstruation recommenced in amenorrheal patients; anovulatory uterine bleeding cessation and less than 50% of the menstrual cycles showing biphasic BBT. Class 3: after a course of treatment of at least 3 months, there was still no menstruation or else uterine bleeding persisted. According to the results, the treatment totaled 13 months for all 28 patients during which time there occurred 93 menstruations (67.9%). Of the 27 cases of amenorrhea, menstruation returned in 26 cases. In the one case of uterine bleeding, the bleeding stopped on the 10^th day after treatment. This study too shows that TCM are very effective in the treatment of PCOS. The success rates are very promising and therefore more studies needs to be carried out to authenticate and evaluate the reliability and effectiveness of Traditional Chinese Medicine (Complimentary and Alternative Medicine) in treatment and management of PCOS and the associated effects.

Limitations and the Future of Acupuncture in Treatment of POCS

The use of acupuncture is limited in that its use in treatment and management of different types of diseases is still under studies/clinical trials. It can therefore only be used in situations where by research studies have shown that advantages over ways disadvantages or rather the adverse effects are greatly reduced as compared to those of pharmacological interventions. One the factor that is greatly limiting the use of acupuncture especially in the management and treatment of PCOS is lack of awareness and knowledge on PCOS. This can only be reversed through awareness campaigns and seminars to educate people on the use and importance of acupuncture as a therapeutic measure in treatment and management of different diseases and disorders. The approving and integration of acupuncture in national health care system will be the first major step of making it accessible and acceptable. Just like the physician practitioner and licensure boards that approves and licenses physicians, a body should be formed to regulate the training, credentialing, and certifying of acupuncturist. More research and clinical studies needs to be done so that the use of acupuncture in the treatment and management of PCOS can be taken to advanced levels with scientific backing and evidence. There is also need to develop a wide body of literature on the use of acupuncture in the treatment and management of PCOS and its associated effects. More studies are also needed to evaluate the effect of acupuncture in women with PCOS.

Conclusion

Many people across the world are turning to complementary alternative medicine to treat the many types of diseases most of which have adverse effects if pharmacological measures are used. Acupuncture being one of CAM, is becoming more popular with majority of patients with more professionals being trained as acupuncturist. The current available data on use of acupuncture in the treatment of PCOS shows that acupuncture can be an alternative or compliment to pharmacological interventions due to the fact that it has no adverse effects. From the above studies, we can therefore conclude that acupuncture is the safest way to treat and manage PCOS as the adverse effects associated with pharmacologic interventions are not experienced by women with PCOS. The studies have therefore clearly determined the therapeutic effects of acupuncture on the treatment and management of PCOS and the associated signs and symptoms. These can be summarized as follows: Increasing of blood flow to the ovaries as ovaries of PCOS are normally deprived of nutrients, regulation of hypothalamus pituitary ovarian axis-HPOA (menstrual cycle), reducing of ovarian volume and the number of ovarian cysts, controlling of hyperglycemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reduction of cortisol levels and assisting in weight loss and anorexia.

Table 1: Summary of Studies Reviewed

References

1. Agbagbu, M. N., (2008). Polycystic ovarian syndrome: Treatment and management. Lagos, Nigeria: Adenijo Book Publishers.
2. Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin R. L., (2002). Complementary and alternative medicine use among adults. United States: CDC Advance Data Report #343. 2004.
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12. Stener-Victorin, E., Waldenstrom, U., Tagnfors, U., Lundeberg, T., Lundstedt, G., Janson, P. O., (2000). Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand, 79:180–8.
13. Stener-Victorin, E. Jedel, E., & Mannerås, L., (2007). Acupuncture in polycystic ovary syndrome: Current experimental and clinical evidence. Journal of Neuroendocrinology 20(3), 290 – 298.
14. Takeshi, A., (1976). The influence of acupuncture stimulation on plasma levels of LH, FSH, progesterone and oestradiol in normally ovulating women. Am Journal of Chin Med, 4(4):391-401
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16. Yang, S. P., Yu, J., He, L., (1994). Release of gonadotropin-releasing hormone (GnRH) from the medio-basal hypothalamus induced by electroacupuncture in conscious female rabbits. Acupunct Electrother Res 19:19–27.
17. Yu, J., Zheng, H. M., & Ping, S. M., (1989). Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation [Chinese]. Chung Hsi I Chieh Ho Tsa Chih 9:199–202.

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