&

art & science complementary therapy

Dysmenorrhoea and acupuncture:
a review of the literature
Cunningham S, Tan D (2011) Dysmenorrhoea and acupuncture: a review of the literature.
Nursing Standard. 24, 44, 39-47. Date of acceptance: June 6 2011.

Summary frequent gynaecological complaints, affecting
between 25% and 50% of women, and up to
This article provides an overview of dysmenorrhoea – pain during 90% of adolescents (Dawood 2006, Iorno et al
menstruation – and the use of acupuncture to manage this common 2008, Ozgoli et al 2009).
gynaecological problem. Severe dysmenorrhoea can be distressing, Dysmenorrhoea is classified as primary
adversely affecting social and occupational activities. Treatments or secondary. Primary dysmenorrhoea is
vary from over-the-counter remedies to hormonal control. However, distinguishable from secondary dysmenorrhoea
for some women satisfactory pain relief is difficult to achieve and by the absence of any identifiable pathological
alternative options are increasingly being sought. Complementary changes. Secondary dysmenorrhoea is associated
therapies such as acupuncture are gaining popularity and the with an identifiable pathological condition
evidence base for their use is growing. This article discusses the such as endometriosis, fibroids (myomas),
current evidence for the use of acupuncture to treat dysmenorrhoea adenomyosis, endometrial polyps and pelvic
and seeks to inform nurses, especially those working in primary inflammatory disease (Proctor and Farquhar
care, so that they are able to advise women on the range of 2007a). Primary dysmenorrhoea is recognised
available treatment options. as a chronic, cyclical, pelvic and spasmodic type
Authors of pain associated with menstruation (also known
as menses), and is typically known as ‘period
Sheila Cunningham, principal lecturer, and Dan Tan, senior lecturer, pain’ or ‘menstrual cramping’ (Smith et al 2010).
School of Health and Social Sciences, Middlesex University, London. Other features may include nausea, vomiting,
Email: s.cunningham@mdx.ac.uk headache, nervousness, fatigue, diarrhoea,
Keywords bloating, breast tenderness, mood changes,
backache and dizziness. These symptoms often
Acupuncture, complementary and alternative therapies, appear one or two days before or at the onset
dysmenorrhoea, primary care, women’s health of menstruation and reach a peak within the first
These keywords are based on subject headings from the British 48 hours (Hwang et al 2009).
Nursing Index. All articles are subject to external double-blind peer
review and checked for plagiarism using automated software. For Quality of life
author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles There is limited research on how the symptoms
visit our online archive and search using the keywords. of primary dysmenorrhoea affect women’s daily
activities. In one study, 51% of women surveyed
reported that their activities had been limited,
while 17% reported missing school or work
MENSTRUAL DISORDERS AND associated (Burnett et al 2005). In another study, 13-51%
adverse symptoms are a significant health issue of young women interviewed reported being
for many women of child-bearing age. Nurses absent from school or work at least once,
may be required to discuss and advise patients with 14% stating that absence was the result of
on treatment options to enable them to make severe symptoms (Proctor and Farquhar 2006).
informed decisions. Therefore knowledge of the An American study estimated that severe
benefits and limitations of treatments is important. dysmenorrhoea resulted in the loss of 600 million
Menstrual disorders are increasingly working hours in 2006 (Helms et al 2006). The
recognised as having a significant effect on effect of lost working hours as a result of primary
women’s personal, social and occupational lives. dysmenorrhoea in the UK is unknown as this is not
For younger females this may also affect school recorded specifically, but is monitored collectively
attendance and concentration (Smith 2008, as ‘genitourinary’ problems in self-reported illness
Ortiz 2010). Dysmenorrhoea is one of the most (Health and Safety Executive (HSE) 2005).

NURSING
DownloadedSTANDARD julyNo
from RCNi.com by ${individualUser.displayName} on Aug 26, 2017. For personal use only. 6 ::other
vol 25
usesno 44 :: permission.
without 2011 39
Copyright © 2017 RCN Publishing Company Ltd
&
art & science complementary therapy synthesis of hormones and prostaglandins),
the environment (cold climates may affect
vasoconstriction of uterine arteries) and exposure
to tobacco smoke, may also influence the severity
There also appears to be variation in the of primary dysmenorrhoea ( Spears 2005, Proctor
prevalence of primary dysmenorrhoea among and Farquhar 2007a). Smoking is believed to cause
ethnic groups. Polat et al (2009) reported that vasoconstriction of the uterine arteries. This is
45.3% of Turkish female students surveyed likely considering the link between placental blood
experienced severe pain. This figure is higher than flow and low birth weight infants in women who
previously reported in the literature for Western smoke during pregnancy (Wang et al 2004).
women. Ortiz (2010) found that 64% of Mexican Primary dysmenorrhoea has also been associated
female university students experienced primary with an early menarche and a longer duration of
dysmenorrhoea, while Chiou and Wang (2008) menstruation (Proctor and Farquhar 2007b).
reported a prevalence of 73% in students in south
Taiwan. Primary dysmenorrhoea is therefore
Hormonal effects
a worldwide problem for women. Interestingly,
the condition was found to be more common Spears (2005) proposed that hormones also
among students studying health care than in those play a role in primary dysmenorrhoea. It has
studying other subjects, and particularly in been reported that females who experience
nursing students, who reported a higher intensity dysmenorrhoea have higher levels of
of pain (Chiou and Wang 2008). prostaglandins, leukotrienes, vasopressin
Bettendorf et al (2008) recognised that for some hormones and platelet activating factor in
women pain may be sufficient to affect social and menstrual fluid (Dawood 2006). Collectively,
occupational roles adversely. Smith (2008) found these chemicals induce pelvic pain associated with
that the effect of the condition on work is more arterial vasoconstriction blood clot formation
acute in predominantly female professions, such as and uterine contractility. A decline in
nursing, and suggested that interventions aimed at progesterone during the secretory phase
reducing absenteeism in these professions should of the menstrual cycle leads to spasmodic pain.
be considered. One small study suggested that pain Pain occurs as a result of deterioration of the
may be more severe at night as a result of changes uterine spiral arteries of the endometrium and
in uterine blood flow, which may also affect disintegration of endometrial cells, which
women who work shifts (Celik et al 2009). stimulate the nerve endings and produce pain.
Uterine hypercontractility, reduced uterine
blood flow and increased peripheral nerve
Causes
hypersensitivity caused by leukotriene release,
Until recently, medical and gynaecological induce the sensation of pain. One prostaglandin
literature attributed dysmenorrhoea to emotional (PGF2 alpha) also increases platelet aggregations,
or psychological problems (Proctor and Farquhar which increases clotting of menstrual blood
2007a). However, Durain (2004) emphasised accompanying dysmenorrhoea (Spears 2005,
that social and emotional problems can both Dawood 2006). Furthermore, it has been reported
contribute to and be a consequence of primary that levels of some hormones may also have an
dysmenorrhoea. Nurses need to be aware of this influence in the pain mechanism; these include
when assessing individuals’ health beliefs to oxytocin, follicle stimulating hormone and
achieve pain relief and improve quality of life. oestradiol, which were found to be higher in
The aetiology of primary dysmenorrhoea is women with dysmenorrhoea (Liedman et al 2008).
complex and not yet fully understood (Proctor and High levels of some types of prostaglandin also
Farquhar 2007a). However, certain observations correlate with the menorrhagia (excessive bleeding
emerge in the literature. For example, nulliparous during menses) that some women experience
women who smoke, and those not taking oral during the first three days of menses (Milling-Smith
contraceptives are more likely to report disabling et al 2007). Leukotrienes also promote
symptoms (Burnett et al 2005). However, inflammation in the endometrial tissue.
socio-economic status and age at menarche
are not specifically associated with primary
Pharmacological pain relief
dysmenorrhoea (Weissman et al 2004). The
condition has been reported as being less common Pain associated with dysmenorrhoea is often
in the first two years after menarche (the period reported as occurring over a broad area, extending
of anovulatory cycles), and increases in incidence to the lumbar region and along the inner thighs.
with the ovulatory menstrual cycle (Harel 2006). This may be because of the innervations of the
It has been suggested that various factors, such lower abdominal and back muscles along with
as genetics (variants on chromosome 22 and the the uterus, which share sensory and motor nerve

40 july 6 :: vol 25
Downloaded noRCNi.com
from 44 :: 2011 NURSING
by ${individualUser.displayName} on Aug 26, 2017. For personal use only. No other uses STANDARD
without permission.
Copyright © 2017 RCN Publishing Company Ltd
pathways. This can be described as referred pain (Connelly 1994). The corollary is an imbalance
(Spears 2005, Mannix 2008). and lack of flow or ill-health. Pain results when
Many women self-medicate and only seek qi does not flow freely (Maciocia 1994). Qi also
further advice if the pain is severe or disabling. incorporates Yin and Yang (two aspects of energy
Harel (2006) found that women often flow) and a framework that connects to daily life.
underestimate the amount of analgesia required, Practitioners may take a lifetime to perfect the art
which may explain poor pain control. Many of diagnosis and treatment, using a holistic TCM
women achieve pain relief by taking medications approach. There is a belief that health, including
which inhibit prostaglandins, for example women’s reproductive health, should be treated
non-steroidal anti-inflammatory drugs using an integrated ‘whole person’ approach rather
(NSAIDs) such as ibuprofen, which target the than a reductionist ‘organ’ approach (Cassidy
inflammatory response. In women resistant to 2002). There is no equivalent term in western
NSAIDs, leukotriene suppression medication physiology for the complex foundation of qi, and
(montelukast) has been used to achieve pain even though the Chinese concept of blood (xue)
relief. However, this is not a standard approach has some connection with western physiological
and has had variable success (Clinical Knowledge understanding, this is also rather different.
Summaries 2010). In TCM, blood is considered a nutrient
Evidence-based data support the efficacy of substance that flows through all vessels
cyclo-oxygenase inhibitors, such as ibuprofen, nourishing various organs. Organs too have
naproxen sodium and ketoprofen, and connections; for example, the liver and spleen are
combined oral contraceptives. Cyclo-oxygenase important in maintaining reproductive health
inhibitors reduce the amount of menstrual (Cassidy 2002). Dysmenorrhoea is thought to
prostanoids released, with a reduction in uterine result from interruption of the flow of blood and
hypercontractility, while oral contraceptive qi. This intangible ‘vital energy’ (qi) flows around
pills inhibit endometrial development. the body in a network of channels or meridians.
Further approaches to dysmenorrhoea and There are 12 main meridians, six of which are
recommended treatments are indicated in Box 1 Yin and six are Yang, and numerous minor ones,
(Clinical Knowledge Summaries 2010). forming a network of energy channels throughout
the body. In acupuncture, each meridian is related
to and named after an organ or function, for
Traditional Chinese medicine
example, the lung, kidney, gallbladder, stomach,
According to traditional Chinese medicine spleen and heart (Helms 1987).
(TCM) philosophy, there is a life force called qi The lack of free blood flow may be the result of
(pronounced chee) that flows within the body an excess of qi and blood, leading to an obstruction
in a harmonious and balanced way in health or blockage, or a deficiency resulting in slower than
normal flow or lack of nourishment or warmth
in the uterus. Therefore, if any factor affects
BOX 1 a woman’s qi or blood circulation, blockage and
Approaches to dysmenorrhoea lack of nourishment may occur, possibly leading
and treatments to dysmenorrhoea (known as Tong Jing in TCM).
The clinician should consider the following: Hwang et al (2009) indicated that during
a woman’s menstrual cycle, qi pairs with blood,
4Explain what dysmenorrhoea is and its benign nature.
acting synergistically to move it smoothly through
4Enquire into associated aggravating factors such as the body during preparation of the uterus, and for
smoking, being overweight, alcohol consumption ovum release and eventually menstrual flow.
and stress. However, if there is an obstruction then qi or blood
4Outline treatment options, including: cannot flow and clotting will occur. If the flow of
– Non-drug treatments (dietary supplements, qi is interrupted, weakened or erratic, this affects
vitamins, local heat pads and transcutaneous the flow of blood resulting in stagnation. The pain
electrical nerve stimulation) or relaxation experienced before menses and blood clots indicate
techniques that may be of benefit. an obstruction or a deficiency; however, pain
– Analgesia (over-the-counter medications such as
during or after menstruation is attributable to a
paracetamol or non-steroidal anti-inflammatory
deficiency of both qi and blood.
drugs, or codeine if pain is severe) to
alleviate symptoms. Mild analgesics with A complex process of consultation and
adjuvants, for example paracetamol and caffeine, diagnosis involves physical examination
may be considered. (for example measuring hand temperature or
– Combined oral contraceptives are effective conducting tongue diagnosis) and questioning
and may be useful if contraception is also required. the woman about her menstrual timing and
(Clinical Knowledge Summaries 2010)
blood flow to ascertain the cause of primary
dysmenorrhoea and therefore plan appropriate

NURSING
DownloadedSTANDARD julyNo
from RCNi.com by ${individualUser.displayName} on Aug 26, 2017. For personal use only. 6 ::other
vol uses
25 no 44 :: permission.
without 2011 41
Copyright © 2017 RCN Publishing Company Ltd
&
art & science complementary therapy symptoms rather than as a holistic (mind, body,
spirit) model. Unlike the use of pharmaceutical
drugs, acupuncture (if administered by a qualified
practitioner) is almost entirely free from side
treatment. Tongue diagnosis is central to effects and is safe for long-term use (Flaws 2005).
TCM since it is believed that the tongue has Acupuncture is defined as the practice of
a relationship with and is connected to the inserting needles into the body to reduce pain or
meridians and body organs; observing the induce anaesthesia (Connelly 1994). This involves
tongue can therefore reveal harmony or stimulating anatomical or acupuncture points
disharmony (Cassidy 2002). by penetrating the skin with thin, solid, sterile
From a TCM perspective, the goal of treatment metallic needles, which are manipulated
is to restore the energetic balance in the body, manually or by electrical stimulation. In a large
while considering social, lifestyle, emotional and survey of patients of members of the British
causative environmental factors (Cassidy 2002). Acupuncture Council, MacPherson et al (2006)
Common causative factors associated with found that an increasing number of people
dysmenorrhoea may be emotional stress, were seeking acupuncture treatment for a wide
excessive exposure to cold or dampness, variety of conditions. They found that 71% of
over-exertion, chronic illness and excessive sexual patients were female, of which 8% were seeking
activity (Maciocia 1994). Disharmonies may treatment for gynaecological problems.
be caused by internal factors such as the seven
emotions of anger, joy, sadness, grief, pensiveness,
Efficacy of acupuncture: a review of
fear and fright, or external factors such as wind,
the literature
cold, damp, fire and heat (Mantle 2008). Anger,
frustration, resentment and hatred may all lead The results of small-scale studies with lack of
to qi stagnation (in this instance, affecting the control groups should be viewed with caution.
meridian linked to the liver and more accurately In many instances, studies suggesting the
known as liver qi stagnation). It is suggested that effectiveness of acupuncture were case studies
in women qi stagnation in the liver causes blood and not randomised controlled trials. However,
to stagnate in the uterus, which may manifest the appearance of systematic reviews means that
as painful periods (Flaws 2005). the efficacy of acupuncture is gaining a critical
Cold environments are believed to cause the scientific audience and it is recognised that critical
uterus to contract, which may lead to stasis of the review of the quality of studies is paramount.
blood in the uterus and painful menses (Mantle Although the mechanisms of acupuncture are
2008). Excessive exposure to cold or dampness not yet fully understood there is evidence to
from an external or internal source (intake of cold support the fact that acupuncture affects the
and raw foods and drinks) are contributing factors. nervous, humoral, vascular and immune systems
Women are viewed as being particularly prone to (Cassidy 2002). The National Institute for Health
‘invasion of cold’ in the uterus immediately after and Clinical Excellence (NICE) (2009) has issued
menstruation and childbirth as the uterus and guidelines on the use of acupuncture for back
blood are in relatively weakened states at these pain. Proposed physiological explanations of
times (Flaws 2005). Also, according to TCM how acupuncture works in dysmenorrhoea
theory, beginning sexual activity at too young an include pain modulation (release of serotonin
age and having multiple births at close intervals as an analgesic mediator), an increase in
may also deplete qi and blood, causing lack of endorphin levels (endogenous morphine) and
nourishment in the uterus and resulting in painful an increase in anti-inflammatory mediators
periods (Maciocia 1994). (Cassidy 2002).
Stux et al (2003) outlined a Western
physiological explanation of the effects of
Acupuncture
acupuncture, which may explain its effect on
Chinese and other Asian cultures have been using women with dysmenorrhoea. This explanation
acupuncture to restore, promote and maintain relates to pain nerve fibres and pathways (known
good health for many thousands of years. sensory pain fibres ascending to the brain from the
Traditional Chinese acupuncture has been in periphery carrying pain messages and using nerve
existence for more than 5,000 years (Connelly chemicals such as Substance P and serotonin to do
1994, Maciocia 1994). It is a complex system of this), and is supported by the work of Goldstein
examination, diagnosis and treatment. At its et al (1979) who demonstrated that naloxone
inception it was considered preventive could block the analgesic effect of endorphins
(Connelly 1994). In the West, acupuncture, released during acupuncture. Mo et al (1993)
including the practice of traditional Chinese indicated that acupuncture may alter reproductive
acupuncture, has been viewed as a way to manage hormone levels, and Stener-Victorin et al (1999)

42 july 6 :: vol 25
Downloaded noRCNi.com
from 44 :: 2011 NURSING
by ${individualUser.displayName} on Aug 26, 2017. For personal use only. No other uses STANDARD
without permission.
Copyright © 2017 RCN Publishing Company Ltd
TABLE 1
Description of studies investigating the effectiveness of acupuncture
Study Design Intervention Number Result
Helms (1987) Randomised controlled Acupuncture, 48 patients 90% of the acupuncture
trial (RCT). acupuncture placebo, group reported decreased
control. need for analgesia.
Mo et al (1993) Non-randomised trial Acupuncture treatment 34 patients Increase in progesterone
including anovulatory (30) to Ren and Chong and thus ovulation.
females. channels.
Stener-Victorin Prospective randomised Electro-acupuncture to 10 patients Decrease of uterine
et al (1999) trial including infertile bladder and spleen artery blood flow.
females. channel (controlled
GnRH – gonadotropin the
hormone for ovulation –
and hormones).
Habek et al (2003) Clinical prospective Manual acupuncture points: 57 patients (30 manual Statistically significant
placebo controlled trial. Du 20, Li 4, Ren 3, Ren 4, acupuncture and reduction in pain and use
Ren 6, Gb 34, Ub 23, Lp 6 27 placebo) of analgesia for the
and auriculoacupuncture acupuncture group. For
points. Placebo 93% of patients effects
acupuncture. lasted up to one year
following therapy.
Jun et al (2007) Non-RCT. Acupressure Sp 6, 58 patients Skin temperature change
CV 6, CV 12, meridien thus implying uterine blood
acupoints by nurses. flow and hence pain
Control (placebo). (although not directly
measured).
Iorno et al (2008) Non-randomised trial Eight weekly acupuncture 15 patients Pain score reduced
including non-steroidal sessions for two months significantly in 87% of
anti-inflammatory drug to Ki 3, Lv3, Sp 4, St 36, patients, using a visual
resistant nulliparous St 25, St-29, St30, analogue scale (VAS).
females. Ren 4, Ren 6, BL-62, Seven patients were pain
Ht 7, Li-4, Pc-6 and free six months after
Zi Gong. treatment.
Witt et al (2008) RCT, no details of needle Fifteen sessions of 649 patients Inconsistent data on needle
numbers or points. acupuncture over points or numbers. Pain
three months or control significantly reduced using
(no intervention). VAS and increased quality
of life in acupuncture patients
compared with control.
Yang et al (2008) Systematic review. Acupuncture. 30 RCTs and Distinct methodological
2 controlled clinical limitations and difficulty
trials in comparing across
studies. Some conflicting
results.
Cho and Hwang (2010) Systematic review of Acupuncture – varied use 27 RCTs Three studies indicated
27 RCTs. of controls and sham significant pain reduction
acupuncture. and two indicated no
difference in pain. Distinct
methodological limitations
and difficulty in comparing
across studies.
Lin et al (2010) Case study. Collateral meridian 1 patient Relief of pain after four
acupressure. treatments.
Wong et al (2010) RCT. Acupressure Sp 6 40 patients Statistically significant
two treatments, twice decrease in pain reported
a day for first three days using VAS, McGill pain
of the menstrual cycle. questionnaire and
Menstrual Distress
Questionnaire.

NURSING
DownloadedSTANDARD julyNo
from RCNi.com by ${individualUser.displayName} on Aug 26, 2017. For personal use only. 6 ::other
vol 25
usesno 44 :: permission.
without 2011 43
Copyright © 2017 RCN Publishing Company Ltd
&
art & science complementary therapy comparison with age and symptoms difficult.
The key outcome was not clinical efficacy in terms
of reduced pain and improved quality of life,
but rather the costs incurred.
suggested that a change in uterine blood flow In a systematic review of 30 randomised
in infertile women as a result of acupuncture controlled trials and two controlled clinical trials,
may help to explain the effectiveness of Yang et al (2008) concluded that most of the
acupuncture in gynaecological complaints trials were of poor methodological quality and
such as primary dysmenorrhoea. therefore the results should be treated with
The studies summarised in Table 1 are mainly caution. Secondary data analysis indicated that
small and this raises questions about the evidence there were conflicting results in trials regarding
and research base relating to the effectiveness of whether acupuncture-related therapies were
acupuncture. The effectiveness of acupuncture is more effective than control treatments. There was
not directly researched in many studies, however some evidence that treatment with acupuncture
comparison with more established treatments was superior to the control (no acupuncture).
is evident. Research reports and case studies However, Yang et al (2008) emphasised the need
are now emerging that analyse and promote for randomised, blinded, placebo-controlled
the use of specific techniques and needle-point trials to assess the effects of acupuncture.
combinations, which implies a more Iorno et al (2008) also reported that
evidence-based approach to practice. acupuncture was more effective than NSAIDs
In western Europe, the evidence base for the for pain relief in women with primary
use of acupuncture to treat dysmenorrhoea dysmenorrhoea, with relief lasting up to
has evolved over the past 20 years, but research six months. This small study concluded that
remains limited. Helms reported in 1987 acupuncture was a valuable resource and
that 90% (n=43) of women with primary supports the growing evidence base advocating
dysmenorrhoea showed improvement following its use. Acupuncture was of further clinical
acupuncture, with a significant reduction in benefit to women for whom NSAIDs were
analgesic requirements. This was significant in contraindicated or for whom hormonal control
comparison to the control group, an acupuncture of menstrual cycles was not possible.
placebo group and a non-intervention group Habek et al (2003) undertook a study to
of women. While this was a small group, the evaluate the effect of acupuncture in the treatment
effects were statistically significant. of women with primary dysmenorrhoea. They
Thomas et al (1995) compared different forms found that the occurrence of the condition in
of acupuncture and transcutaneous electrical nulliparous women was statistically relevant and
nerve stimulation (TENS) interventions, using there was a significant decrease in medication
sham (placebo) acupuncture and placebo TENS consumption following treatment with
as the controls. Although acupuncture was not acupuncture in comparison to the placebo
found to be statistically significant in terms of group. In this study, 93% of women undergoing
pain reduction when compared with sham a course of acupuncture obtained relief from
acupuncture or TENS, there were some primary dysmenorrhoea compared with
improvements for women in terms of reduced 3% in the control group. Pain relief lasted for
symptoms, for example vomiting, and work several months and in some cases up to a year
hours lost. However, this was a small study (Habek et al 2003).
sample with only 17 participants and TENS is Cho and Hwang (2010) carried out a
reputed to have similar actions to acupuncture systematic review on the efficacy of acupuncture
(Acupuncture Research Resource Centre 1999). and analysed 27 randomised controlled trials on a
Witt et al (2008) reported a statistically total of 19 databases from England, China, Korea
significant reduction in pain and improvement and Japan. Nine of the 27 trials described their
in quality of life associated with the use of methods of randomisation clearly. Cho and
acupuncture. This study of 649 women carried Hwang (2010) found that compared with
out in Germany measured pain relief using a pharmacological treatment or herbal medicine,
self-report questionnaire and a visual analogue acupuncture was associated with a significant
scale, and a self-report quality of life tool – the reduction in primary dysmenorrhoea. In their
validated Short Form (SF)-36 questionnaire. review, three studies reported reduced pain from
However, the researchers reported that baseline; however, two randomised controlled
acupuncture was not as cost effective as NSAIDs. trials did not find a significant difference between
Using acupuncture was resource intensive as acupuncture and sham acupuncture (a control
it was performed by physicians rather than mechanism not intended to stimulate acupoints).
other trained practitioners. This study used It should be noted that critics of sham
broad inclusion criteria, which makes acupuncture question the validity of this

44 july 6 :: vol 25
Downloaded noRCNi.com
from 44 :: 2011 NURSING
by ${individualUser.displayName} on Aug 26, 2017. For personal use only. No other uses STANDARD
without permission.
Copyright © 2017 RCN Publishing Company Ltd
method as a means of control. Despite some of the these therapies (Table 2) and the intended use and
methodological limitations of research conducted outcomes of each. Research into various therapies
on acupuncture, it appears there is evidence to is growing, but so is the need to understand the
support its effect on reducing pain; however, the nature of the evidence and review it critically.
authors emphasise the need for more research There are many similarities in Eastern and
to confirm this (Cho and Hwang 2010). Western medicine, however the originating
philosophies are quite different. Health beliefs are
important and patients may choose an alternative
Acupressure
approach to suit their personal beliefs, therefore
Acupressure involves the stimulation of nurses must be cautious of making assumptions.
meridians without the use of needles. This may Nurses need to have a critical understanding of the
be useful for those with a fear of needles. Jun treatment choices available so that they are able
et al (2007) used a non-randomised controlled to support patients to make informed decisions.
trial to measure the effect of acupressure, as a MacPherson et al (2006) carried out a survey
non-invasive intervention carried out by trained of 9,408 people and found that 95% of
nurses, on primary dysmenorrhoea. The individuals seeking acupuncture paid for it
intervention group received acupressure within privately; however, they did not indicate if
the first eight hours of menstruation whereas the acupuncture was obtained from practitioners
control group only received light touch. There who were also healthcare professionals. The
was a reported improvement in primary most common routes to an acupuncturist were
dysmenorrhoea in the experimental group, with self-referral (39%) or recommendation from
a corresponding increase in body temperature up a family member, a friend or a colleague (34%).
to two hours following treatment. The authors A relatively small number (10%) of people had
concluded that elevated body temperature was been recommended to consult an acupuncturist
the likely mechanism of pain relief, since this by a healthcare professional (GP, physiotherapist
was not evident in the control group.
Wong et al (2010) also found that women
obtained immediate relief of pain associated TABLE 2
with primary dysmenorrhoea with acupressure Types of complementary and alternative therapies
applied on days one to three of their menstrual
Group 1 Professionally organised 4Acupuncture.
period. In this case, pain relief was measured
alternative therapies 4Chiropractic.
using verbal pain scores and not body 4Herbal medicine.
temperature. In a case study using acupressure 4Homeopathy.
for the relief of menstrual pain, Lin et al (2010) 4Osteopathy.
found that it took four treatments for pain
Group 2 Complementary therapies 4Alexander technique.
relief to be obtained and relief only lasted
4Aromatherapy.
up to two months. 4Bach and other flower remedies.
4Body work therapies, including
Implications for nursing practice massage.
4Counselling stress therapy.
An increasing number of acupuncture 4Hypnotherapy.
practitioners are also nurses. From a nursing 4Meditation.
perspective it is appealing to think of the person 4Reflexology.
as a ‘whole’ and consider the mind, body and 4Shiatsu.
spiritual dimensions of the individual. Although 4Healing.
4Maharishi ayurvedic medicine.
acupuncture is a tried and tested system of
4Nutritional medicine.
complementary medicine (British Acupuncture 4Yoga.
Council 2009), the regulation of acupuncture
practitioners has been the subject of a Group 3 Alternative disciplines: 4Anthroposophical medicine.
consultation by the Department of Health (DH) 3a: Long-established and 4Ayurvedic medicine.
traditional systems of 4Chinese herbal medicine.
(2009), which concluded that it is a complex area.
health care 4Eastern medicine (Tibb).
As yet there are no recommendations on the 4Naturopathy.
regulation of such practitioners (DH 2011). 4Traditional Chinese medicine.
Complementary and alternative approaches 4Crystal therapy.
to therapy are gaining popularity. There is
3b: Other alternative 4Dowsing.
evidence that acupuncture can be effective for
disciplines 4Iridology.
some women with primary dysmenorrhoea, but 4Kinesiology.
whether this is comparable with conventional 4Radionics.
treatments remains unclear. Such increased
House of Lords Select Committee on Science and Technology (2000)
interest makes it essential that nurses are aware of

NURSING
DownloadedSTANDARD julyNo
from RCNi.com by ${individualUser.displayName} on Aug 26, 2017. For personal use only. 6 ::other
vol 25
usesno 44 :: 2011
without 45
permission.
Copyright © 2017 RCN Publishing Company Ltd
&
art & science complementary therapy courses, but perhaps they may be in future bearing
in mind that NICE (2009) recommends
acupuncture for the relief of back pain.
The House of Lords Select Committee on
or nurse) (MacPherson et al 2006). Owen et al Science and Technology (2000) responded to
(2001) suggested that doctors should have a role concerns of increasing use of complementary and
as ‘gatekeepers’, advising patients about alternative therapies and attempted to categorise
complementary or alternative approaches. them (Table 2). Concerns were expressed on a
They argued that if doctors are not appropriately number of issues, including safety and regulation
educated in these approaches there is the risk of practitioners; practices undertaken; whether
that patient care will not be consistent. an evidence base has been accumulated; whether
Smith (2009) suggested that knowledge and there are adequate information sources on the
awareness of complementary therapies such as subject; whether the practitioner’s training is
TCM and acupuncture may be of benefit to the adequate; and finally the potential prospects for
wider healthcare team, for example in the NHS provision of treatments. While concerns were
provision of pain relief in a palliative care setting. identified about valid evidence as measured by
A nurse who is also a practitioner or acupuncturist Western techniques, particularly the gold standard
will be in a better position to advise and support randomised controlled trial, it was acknowledged
patients seeking pain relief options. TCM and that there is a growing body of qualitative
acupuncture are not routinely taught on nursing information and potential value in these therapies.

References
Acupuncture Research Resource Cho SH, Hwang EW (2010) Flaws B (2005) A Compendium of House of Lords Select Committee
Centre (1999) Gynaecology and Acupuncture for primary Chinese Medical Menstrual Diseases. on Science and Technology (2000)
Acupuncture: The Evidence for dysmenorrhoea: a systematic Blue Poppy Press, Boulder CO. Complementary and Alternative
Effectiveness. Briefing Paper No. 4. review. British Journal of Obstetrics Medicine. http://tiny.cc/compalt
Goldstein A, Tachibana S,
http://tiny.cc/BP4gy (Last accessed: and Gynaecology. 117, 5, 509-521. (Last accessed: June 15 2011.)
Lowney L, Hunkapiller M, Hood L
June 15 2011.) Clinical Knowledge Summaries (1979) Dynorphin (1-13), an Hwang D-S, Sanghoon L,
Bettendorf B, Shay S, Tu F (2010) Dysmenorrhoea: extraordinarily potent opioid peptide. Yong-Suk K, Kyung-Suk L (2009)
(2008) Dysmenorrhoea: Management. www.cks.nhs.uk/ Proceedings of the National The Practical Application of Sa-Am
contemporary perspectives. dysmenorrhoea# (Last accessed: Academy of Sciences of the Acupuncture for Dysmenorrhea.
June 15 2011.) United States of America.
Obstetrical and Gynaecological www.aaaomonline.info/ameracu/
Survey. 63, 9, 597-603. Connelly DM (1994) Traditional 76, 12, 6666-6670. V48P24-Sa-Am.pdf (Last accessed:
Acupuncture: The Law of the Five Habek D, Cerkez Habek J, June 15 2011.)
British Acupuncture Council
Elements. Traditional Acupuncture Bobić-Vuković M, Vujić B
(2009) BAC Responds to NICE Iorno V, Burani R, Bianchini B,
Institute, Columbia. (2003) Efficacy of acupuncture
Guidelines Re Acupuncture for Minelli E, Martinelli F, Cotto S
Back Pain on the NHS. Dawood MY (2006) Primary for the treatment of primary
(2008) Acupuncture treatment
www.acupuncture.org.uk/the-news/ dysmenorrhea: advances in dysmenorrhoea. Gynakol
of dysmenorrhoea resistant to
press-statements/312.html pathogenesis and management. Geburtshilfliche Rundsch.
conventional medical treatment.
(Last accessed: June 15 2011.) Obstetrics and Gynecology. 43, 4, 250-253.
Evidence-based Complementary and
108, 2, 428-441
Harel Z (2006) Dysmenorrhoea Alternative Medicine. 5, 2, 227-230.
Burnett MA, Antao V, Black A
Department of Health (2009) in adolescents and young adults:
et al (2005) Prevalence of primary Jun EM, Chang S, Kang DH, Kim S
A Joint Consultation on the Report etiology and management. Journal
dysmenorrhoea in Canada. Journal (2007) Effects of acupressure on
to Ministers from the DH Steering of Paediatric and Adolescent
of Obstetrics and Gynaecology dysmenorrhea and skin temperature
Group on the Statutory Regulation Gynaecology. 19, 6, 363-371.
Canada. 27, 8, 765-770. changes in college students: a
of Practitioners of Acupuncture,
Health and Safety Executive
Cassidy C (2002) Contemporary Herbal Medicine, Traditional Chinese non-randomized controlled trial.
(2005) Managing Health at Work:
Chinese Medicine and Acupuncture. Medicine and Other Traditional International Journal of Nursing
Recording and Monitoring
Churchill Livingstone, Edinburgh. Medicine Systems Practised in the Studies. 44, 6, 973-981.
Information on Sickness Absence
UK. The Stationery Office, London.
Celik H, Gurates B, Parmaksiz C Including Work Relatedness. Liedman R, Hansson SR, Howe D
et al (2009) Severity of pain Department of Health (2011) www.hse.gov.uk/research/rrpdf/ et al (2008) Reproductive
and circadian changes in uterine Statutory Regulation of Practitioners rr310.pdf (Last accessed: hormones in plasma over the
of Acupuncture, Herbal Medicine, June 15 2011.) menstrual cycle in primary
artery blood flow in primary
Traditional Chinese Medicine and
dysmenorrhoea. Archives of Helms JM (1987) Acupuncture dysmenorrhea compared with
Other Traditional Medicine Systems
Gynaecology and Obstetrics. for the management of primary healthy subjects. Gynaecological
Practised in the UK. An Analysis
280, 4, 589-592. dysmenorrhea. Obstetrics and Endocrinology. 24, 9, 508-513.
Report on the Consultation.
Chiou MH, Wang HH (2008) http://tiny.cc/124338pdf (Last Gynaecology. 69, 1, 51-56. Lin JA, Wong CS, Lee MS et al
Predictors of dysmenorrhoea accessed: June 15 2011.) Helms RA, Quan D, Herfindal E, (2010) Successful treatment
and self-care behaviour Durain D (2004) Primary Gourley D (2006) Textbook of of primary dysmenorrhea by
among vocational nursing dysmenorrhoea: assessment and Therapeutics: Drugs and Disease collateral meridian acupressure
school female students. management update. Journal of Management. Eighth edition. therapy. Journal of Manipulative
Journal of Nursing Research. Midwifery and Women’s Health. Lippincott, Williams and Wilkins. and Physiological Therapeutics.
16, 1, 17-25. 49, 6, 520-528. Philadelphia PA. 33, 1, 70-75.

46 july 6 :: vol 25
Downloaded noRCNi.com
from 44 :: 2011 NURSING
by ${individualUser.displayName} on Aug 26, 2017. For personal use only. No other uses STANDARD
without permission.
Copyright © 2017 RCN Publishing Company Ltd
The Nursing and Midwifery Council (2008) Conventional methods such as oral analgesia
and the Royal College of Nursing (RCN) (2003) and hormonal control are effective for
have produced guidance and advice for nurses many women, however these are not always
and midwives on the standards of professional appropriate. In these cases, complementary
conduct expected when caring for patients approaches such as acupuncture may help
receiving complementary and alternative women to achieve pain relief.
therapies. The guidance identifies that some nurse Traditional Chinese acupuncture is based
practitioners engage in complementary therapies on a holistic view of the body and harmony
and the professional expectation is that they are between the vital life force (qi) and blood
competently trained. Overall, it is recommended flow. Stimulation of acupuncture points or
that nurses acknowledge and respect patient meridians with fine needles appears to offer
choice and support individuals in making relief from primary dysmenorrhoea. Although
informed decisions. the evidence base for acupuncture is increasing,
the research base remains limited. Professional
nursing bodies such as the RCN recognise
Conclusion
that complementary interventions are a
Primary dysmenorrhoea is a major issue for growing area of treatment and as such
many women. Although difficult to quantify, nurses need to be aware of such practices
pain and other distressing symptoms can and the relevant research to support and offer
interfere with daily activities and quality of life. best advice to patients NS

Maciocia G (1994) The Practice Ortiz MI (2010) Primary Royal College of Nursing (2003) Acupuncture. Fifth edition. Springer,
of Chinese Medicine. Churchill dysmenorrhea among Mexican Complementary Therapies in Berlin. 240-251.
Livingstone, Edinburgh. university students: prevalence, Nursing, Midwifery and Health
Thomas M, Lunden T, Bjork J,
impact and treatment. European Visiting Practice. RCN, London.
MacPherson H, Sinclair-Lian N, Lundstrom-Lindsbedt V (1995)
Journal of Obstetrics, Gynaecology, Smith DR (2008) Menstrual Pain and discomfort in primary
Thomas K (2006) Patients
and Reproductive Biology. 152, 1, disorders and their adverse dysmenorrhoea is reduced by
seeking care from acupuncture
73-77. symptoms at work: an emerging pre-emptive acupuncture and low
practitioners in the UK: a national
survey. Complementary Therapies Owen DK, Lewith G, Stephens CR occupational health issue in the frequency TENS. European Journal of
in Medicine. 14, 1, 20-40. nursing profession. Nursing and Physical Medicine and Rehabilitation.
(2001) Can doctors respond to
Health Sciences. 10, 3, 222-228. 5, 3, 71-76.
patients’ increasing interest in
Mannix LK (2008)
complementary and alternative Smith GD (2009) The need for Wang L, Wang X, Wang W et al
Menstrual-related pain conditions:
medicine? British Medical Journal. complementary and alternative (2004) Stress and dysmenorrhoea:
dysmenorrhea and migraine. Journal
Doi: 10.1136/bmj.322.7279.154. medicine familiarisation in a population-based prospective
of Women’s Health. 17, 5, 879-891.
undergraduate nurse education.
Ozgoli G, Goli M, Moattar F study. Occupation and Environmental
Mantle F (2008) Acupuncture. Journal of Clinical Nursing. 18, 15,
(2009) Comparison of effects of Medicine. 61, 12, 1021-1026.
http://tiny.cc/nt_acupuncture 2113-2115.
(Last accessed: June 15 2011.) ginger, mefenamic acid, and Weissman AM, Hartz AJ,
Smith CA, Crowther CA,
ibuprofen on pain in women with Hansen MD, Johnson SR (2004)
Milling-Smith OP, Jabbour HN, Petrucco O, Beilby J, Dent H
primary dysmenorrhea. The Journal The natural history of primary
Critchley HOD (2007) (2010) Acupuncture to Treat
of Alternative and Complementary dysmenorrhoea: a longitudinal
Cyclooxygenase enzyme expression Primary Dysmenorrhea in Women:
Medicine. 15, 2, 129-132. study. British Journal of Obstetrics
and E series prostaglandin receptor A Randomized Controlled Trial.
and Gynecology. 111, 4, 345-352.
signalling are enhanced in heavy Polat A, Celik H, Gurates B et al downloads.hindawi.com/journals/
menstruation. Human Reproduction. (2009) Prevalence of primary ecam/2011/612464.pdf (Last Witt CM, Reinhold T, Brinkhaus B
dysmenorrhea in young adult female accessed: June 15 2011.) et al (2008) Acupuncture in patients
22, 5, 1450-1456.
university students. Archives of Spears LG (2005) A narrative with dysmenorrhea: a randomized
Mo X, Li D, Pu Y et al (1993) study on clinical effectiveness and
Gynaecology and Obstetrics. 279, 4, review of medical, chiropractic,
Clinical studies on the mechanism cost-effectiveness in usual care.
527-532. and alternative health practices
for acupuncture to stimulate American Journal of Obstetrics and
in the treatment of primary
ovulation. Journal of Traditional Proctor M, Farquhar C (2006) Gynecology. 198, 2, 166.e1-8.
dysmenorrhea. Journal of
Chinese Medicine. 13, 2, 115-119. Diagnosis and management of
Chiropractic Medicine. 4, 2, 76-88. Wong CL, Lai KY, Tse HM (2010)
dysmenorrhoea. British Medical
National Institute for Health and Stener-Victorin E, Waldenström U, Effects of SP6 acupressure on pain
Journal. 332, 7550, 1134-1138.
Clinical Excellence (2009) Low Nilsson L, Wikland M, Janson PO and menstrual distress in young
Back Pain: Early Management of Proctor ML, Farquhar CM (1999) A prospective randomised women with dysmenorrhea.
Persistent Non-Specific Low Back (2007a) Dysmenorrhoea. study of electro-acupuncture versus Complementary Therapies in Clinical
Pain. www.nice.org.uk/nicemedia/ http://tiny.cc/2007_0813 (Last alfentanil as anaesthesia during Practice. 16, 2, 64-69.
pdf/CG88NICEGuideline.pdf accessed: June 15 2011.) oocyte aspiration in in-vitro Yang H, Liu C Z, Chen X et al
(Last accessed: June 15 2011.) fertilization. Human Reproduction.
Proctor M, Farquhar C (2007b) (2008) Systematic review of clinical
Nursing and Midwifery Council Drugs for dysmenorrhoea. In Ledger 14, 10, 2480-2484. trials of acupuncture-related
(2008) Complementary Alternative WL, Ho PC (Eds) Gynaecological Stux G (2003) Technique of therapies for primary dysmenorrhea.
Therapies and Homeopathy. NMC, Drug Therapy. Informa Healthcare, acupuncture. In Stux G, Berman B, Acta Obstetricia et Gynecologica
London. New York NY. 21-32. Pomeranz B (Eds) Basics of Scandinavica. 87, 11, 1114-1122.

NURSING
DownloadedSTANDARD julyNo
from RCNi.com by ${individualUser.displayName} on Aug 26, 2017. For personal use only. 6 ::other
vol 25
usesno 44 :: permission.
without 2011 47
Copyright © 2017 RCN Publishing Company Ltd

Sign up to vote on this title
UsefulNot useful