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available at www.sciencedirect.com
a
Hospital of Korean Medicine, Kyung Hee University Medical Center, Kyung Hee University, #1 Hoegi-Dong, Dongdaemun-Gu,
Seoul 130-701, Republic of Korea
b
Stress Clinic, Kyung Hee University East-West Neo Medical Center, Kyung Hee University, Seoul, Republic of Korea
Available online 17 March 2010
KEYWORDS Summary
Background: The effectiveness of acupuncture in the case of premenstrual syndrome (PMS) is
Acupuncture;
not fully understood.
Premenstrual
Objectives: To assess the effectiveness and adverse effects of acupuncture for the symptomatic
syndrome;
treatment of PMS from randomised controlled trials (RCTs).
Systematic review;
Search strategy: Electronic databases, including English, Korean, Japanese and Chinese, were
Randomised
systematically searched up to January 2009 with no language restrictions.
controlled trials
Selection criteria: RCTs comparing acupuncture with control investigating acupuncture for PMS
were considered.
Data collection and analysis: Study collection and quality assessment were performed by two
reviewers using the criteria described in the Cochrane Handbook.
Main results: Nine studies were systematically reviewed. Only two of the nine trials reported
details regarding sequence generation and allocation concealment. Four studies reported a
signicant difference in reduction of PMS symptoms for acupuncture treatment compared
with pharmacological treatment. Two studies reported the improvements in primary symptoms
within the acupuncture and herbal medications groups compared with baseline. Only two RCTs
reported information regarding acupuncture-related adverse events, which included one case
of a small subcutaneous haematoma.
Conclusions: Although the included trials showed that acupuncture may be benecial to patients
with PMS, there is insufcient evidence to support this conclusion due to methodological aws
in the studies, including unknowns in sequence generation, concealment of allocation, blinding
and outcome measures.
2009 Elsevier Ltd. All rights reserved.
Abbreviations: PMS, premenstrual syndrome; RCT, randomised controlled trial; PMDD, premenstrual dysphoric disorder; SMD, stan-
dard mean differences; OR, odds ratios; CI, 95% condence intervals; AT, acupuncture; AA, auricular acupuncture; ACE, acupoint catgut
embedding; AI, acupoint injection.
Corresponding author. Tel.: +82 2 958 9498; fax: +82 2 958 9187.
0965-2299/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2009.12.001
Acupuncture for PMS 105
Contents
Century Journal Project, China Doctor/Master Dissertation assess the effects of acupuncture alone on PMS symptoms.
Full Text DB and China Proceedings Conference Full Text DB). Trials that compared different forms of acupuncture to
We also searched the databases of clinical trials such as Cur- each other were also excluded. Trials that compared dif-
rent Controlled Trials (http://www.controlled-trials.com), ferent acupoints to each other were excluded. Types of
the National Centre for Complementary and Alternative control interventions considered in this review included
Medicine (NCCAM) at the National Institutes of Health no acupuncture treatment (wait-listed or treatment as
(NIH) (http://nccam.nih.gov/) and the Complementary and usual), placebo-controlled (sham acupuncture, minimal
Alternative Medicine Specialist Library at the NHS National acupuncture or non-invasively controlled), pharmacologic
Library for Health (http://www.library.nhs.uk/cam/). The treatment (such as progesterone, antidepressants or pyri-
reference lists of articles were checked for further relevant doxine) or non-conventional interventions (such as herbal
publications and experts in complementary medicine. Man- medication).
ufacturers of acupuncture equipment were asked for any
additional trials. We conducted an additional manual search
Types of outcome measures
of relevant journals, symposia, conference proceedings
The primary outcomes for this review were any scales for
and retrieved relevant trials; all identied publications
overall symptoms or particular symptoms of PMS, and the
were cross-referenced. If necessary, personal contact was
improvement of overall symptoms (as a dichotomous mea-
made with the authors of the published studies to request
sure). Secondary outcomes included adverse events.
additional data.
Keywords used to search for RCTs included (acupunc-
ture OR electroacupuncture OR scalp acupuncture OR Data collection and quality assessment
catgut embedding OR auricular acupuncture OR merid-
ian OR acupoint) AND (premenstrual syndrome OR Each study identied by the search strategy was assessed
premenstrual tensions OR PMS OR premenstrual dys- against the inclusion criteria by one of the reviewers.
phoric disorder OR PMDD OR premenstrual). As all Where there was uncertainty regarding eligibility, a second
of the various databases used in this study possessed reviewer also assessed the study and a decision was reached
their own subject headings, each database was searched through discussion. Both reviewers independently assessed
independently. whether the studies met the inclusion criteria and disagree-
ments were resolved by discussion. Further information was
Study selection sought from the authors where articles contained insuf-
cient information to make a decision regarding eligibility.
Types of studies Study collection and quality assessment were performed
This review was restricted to RCTs that compared acupunc- by two reviewers who followed the detailed descriptions
ture with a control group, which included no treatment, of these tasks provided in the Cochrane Handbook for
placebo treatment, pharmacologic treatment or non- Systematic Reviews of Interventions.11 The following char-
pharmacologic treatments for the alleviation of PMS acteristics were assessed: (a) Was the allocation sequence
symptoms. No restriction was imposed on studies with adequately generated? (b) Was allocation adequately con-
respect to language, publication type, blinding or the type cealed? (c) Was knowledge of the allocated interventions
of design such as parallel or cross-over designs. This review adequately prevented during the study? (d) Were incom-
excluded quasi-randomised trials. plete outcome data adequately addressed? (e) Were reports
of the study free of any suggestion of selective outcome
reporting? (f) Was the study apparently free of other prob-
Types of participants
lems that could put it at a risk of bias? The judgements
This study included women of any age who met the medi-
made by the review authors involved answering these spe-
cally dened diagnostic criteria for PMS or PMDD. This study
cic questions. The answer Yes indicated a low risk of
excluded women with cyclical mastalgia alone, as opposed
bias (Y), the answer Unclear indicated an uncertain risk
to part of PMS. Trials on menstrual disorders distinct from
of bias (U) and the answer No indicated a high risk of
PMS (e.g., dysmenorrhoea) or on only one symptom of PMS
bias (N).
(e.g., mastalgia) were excluded.
Figure 1 Flow diagram showing the number of studies included and excluded from the systematic review. RCT, randomized
controlled trial.
108
Table 1 Characteristics of RCTs of acupuncture for premenstrual syndrome.
Study Subjects (mean age) Intervention type, Type of control group Main Outcomes/Result Quality
treatment frequency assessment*
(treatment period);
treated acupoints
Fang et al., 200822 90 women with physical, AT, daily 14 d before Herbal medication Improved primary symptoms within all Y-Y-N-Y-N-N
psychological and behavior menstruation (3 menstrual (Xiaoyao Pills) 8pills 3 groups from baseline (95.5%, 88.1%,
symptoms of PMS (24.8 y) cycles); GV24, LI4, LR3, times daily 14 d before p < 0.05); between-group differences not
SP6 menstruation reported
Habek et al., 200230 35 women with PMS in the AT plus AA, 7 sessions. Sham AT (at thighs and Reduced PMS symptoms with AT vs sham U-U-Y-Y-N-Y
Department of Gynecology (third luteal phase); arms described (p < 0.001 vs p > 0.05), success rate of
and Obstetrics (30.6 y) GV20,LI4, LR3, CV3,4,6, non-meridians) treatment AT vs sham (77.8% vs 5.6%)
PC6, GB34, BL23, and
Shenmen
Kim et al., 200528 20 women with PMS or AT, twice per week (2 Sham AT (at SI5, ST40) Reduced Menstrual Symptom Severity U-U-Y-N-Y-N
PMDD DSM-IV criteria menstrual cycles); SP6, List scores from baseline within AT group
(28.9 y) CV9, and adjunctive points (49.8%, p < 0.05)
Liu and Han, 200623 88 women with PMS or ACE, once on 15 d before Fluoxetine 20 mg per d Signicant difference in responder rates Y-U-N-Y-N-Y
PMDD DSM-IV criteria (28 y) menstruation, (3 menstrual with reduced premenstrual dysphoric
cycles); PC6, SP6, CV4,17, disorder symptom scores in ACE vs
LR3, and adjunctive points control (93.2% vs 72.7%, p<0.005)
Shin et al., 30 women with PMS Hand AT, 10 sessions. (a) Wait-list control Reduced Menstrual Symptom U-U-N-Y-Y-Y
200829 ICD-10 criteria (27 y) (4 wks); A5,6,8,12,16,18, (b) Hand moxibustion; A5, Severity scores in Hand AT vs control
N18, F6 6,8,12,16, 18, N18, F6 (p < 0.001)
Wang and Wu, 200724 60 women with physical, AT, daily 14 d before Herbal medication Improved primary symptoms within all Y-Y-N-Y-N-N
psychological and behavior menstruation (3 menstrual (Xiaoyao Pills) 8 pills 3 groups from baseline (96.8% 64.3%,
symptoms of PMS (26 y) cycles); GV24, LI4, LR3, times daily 14 d before p < 0.05); between-group differences not
SP6 menstruation reported
Xu, 200527 102 women with physical, AT plus AI, once every Diazepam 5 mg once per d, Signicant difference in responder rates Y-U-N-Y-N-N
psychological and behavior three d from 10 d before oryzanol 10 mg three times of reduced Menstrual Symptom scores
symptoms of PMS (28.4 y) menstruation (3 menstrual per d with AT plus AI vs control (92.6% vs
cycles); LI4, LR3, CV4,6, 75.0%, p < 0.05)
GB20, EX-HN5, ST36, SP6
Xu, 200625 60 women with (a) AT, daily 14 d before Medroxyprogesterone Reduced PMS symptom scores with U-U-N-Y-Y-N
physical, menstruation (3 menstrual 6 mg daily from 16th AT(a) vs control (12.3 vs 7.2
psychological and cycles); d to 25th d of points, p < .005); no between-group
behavior symptoms BL15,17,18,20,21,23 menstrual cycle differences in AT(b) vs control
of PMS (32.4 y) (b) classical AT; GV20, (p > 0.005)
CV4,6,19, SP6, ST36
Xu and Sun, 200626 60 women with physical, AT, daily 14 d before Medroxyprogesterone 6 mg Signicant difference in responder rates U-U-N-Y-N-N
psychological and behavior menstruation (3 menstrual daily from 16th d to 25th d with reduced PMS symptom scores in AT
symptoms of PMS (31 y) cycles); GV3,4,5,6,7,8, of menstrual cycle vs control (90.0% vs 60.0%, p < 0.005)
study? (d) Were incomplete outcome data adequately addressed? (e) Were the results of the study free of suggestion of selective outcome reporting? (f) Was the study apparently free of
other problems that could put it at a risk of bias?
Key: (Y) Yes; (U) Unclear; (N) No.
Acupuncture for PMS 109
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