Rédacteurs : Johan Nguyen, Claude Pernice, Jean-Luc Gerlier
Sommaire
endometriosis
Endométriose : évaluation de l'acupuncture
1. Systematic Reviews and Meta-Analysis
1.1. Generic Acupuncture
1.1.1. Giese 2023
Giese N, Kwon KK, Armour M. Acupuncture for endometriosis: A systematic review and meta-analysis. Integr Med Res. 2023 Dec;12(4):101003. https://doi.org/10.1016/j.imr.2023.101003
| Background | Current endometriosis treatments do not always provide symptom relief, with many using complementary approaches. This study examined the effectiveness of acupuncture on pain and quality of life in people with endometriosis. |
|---|---|
| Methods | Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Allied and Complementary Medicine Database (AMED) and Embase (Ovid), Epistemonikos, and Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCOhost) on 20 March 2023. Trials were included if they used penetrating acupuncture. Risk of bias was assessed with Cochrane RoB2 and GRADE for overall evidence certainty. Random-effects meta-analyses were undertaken, using Hedges' g or mean difference (MD) both with 95 % confidence intervals (CI). |
| Results | Six studies involving a total of 331 participants were included. Evidence for benefit was found for acupuncture compared to non-specific acupuncture on overall pelvic pain (g = 1.54, 95 % CI 0.92 to 2.16, 3 RCTs, n = 231, low certainty evidence, p<0.001), menstrual pain (g = 1.67, 95 % CI 1.23 to 2.12, 1 RCT, n = 106, moderate certainty evidence, p<0.001), and non-specified pelvic pain (MD -2.77, 95 % CI 2.15 to 3.38, 2 RCTs, n = 125, low certainty evidence, p<0.001), and compared to usual care on menstrual pain (g = 0.9, 95 % CI 0.15 to 1.64, 1 RCT, n = 19, very low certainty evidence, p = 0.02). Most studies reported low rates of adverse events. |
| Conclusion | Acupuncture treatment for endometriosis demonstrated clinically relevant improvements in pelvic pain and should be considered as a potential treatment intervention. |
1.1.2. Wang 2023
Wang Y, Coyle ME, Hong M, He S, Zhang AL, Guo X, Lu C, Xue CCL, Liang X. Acupuncture and moxibustion for endometriosis: A systematic review and analysis. Complement Ther Med. 2023 Sep;76:102963. https://doi.org/10.1016/j.ctim.2023.102963
| Objectives | This study aimed to examine the effect of acupuncture on symptoms and health-related quality of life in patients with endometriosis. |
|---|---|
| Methods | Nine biomedical databases were searched to April 2022 to identify randomized controlled trials of acupuncture and/or moxibustion used alone or as adjunct to guideline-recommended pharmacotherapy for the treatment of endometriosis. One reviewer extracted data and another verified the data. A random effects model was used to calculate mean differences. |
| Results | Fifteen trials involving 1018 patients met the inclusion criteria, but diversity in comparisons and outcome measures prevented meta-analysis. Compared to sham acupuncture, manual acupuncture was more effective at reducing dysmenorrhea VAS pain score (mean difference [MD] - 2.40, 95 % CI [- 2.80, - 2.00]; moderate certainty evidence), pelvic pain VAS score (MD - 2.65, 95 % CI [- 3.40, - 1.90]; high certainty evidence) and dyspareunia VAS scores (MD - 2.88, [- 3.83, - 1.93]), lessened the size of ovarian cyst (MD - 3.88, 95 % CI [- 7.06, - 0.70]), and improved quality of life. Compared to conventional therapy, manual acupuncture plus conventional therapy and warm needle alone resulted in greater improvements in quality of life than conventional therapy. Among the six studies that reported safety, fewer adverse events were reported in participants who received acupuncture or moxibustion. |
| Conclusions | Low to moderate certainty evidence from single studies showed that manual acupuncture may improve pain-related symptoms and quality of life; however, there is insufficient evidence on the overall effectiveness of acupuncture and moxibustion for endometriosis |
1.1.3. Mira 2018 ☆
Mira TAA, Buen MM, Borges MG, Yela DA, Benetti-Pinto CL. Systematic review and meta-analysis of complementary treatments for women with symptomatic endometriosis. Int J Gynaecol Obstet. 2018;143(1):2-9. [181372].
| Background | Despite advances in treatments for endometriosis, some symptoms persist owing to the chronic inflammation observed in this disease. | |
|---|---|---|
| Objective | To identify resources, methods, and/or complementary treatments to alleviate the pain symptoms of endometriosis, and to identify adverse effects of treatments. | |
| Methods | SEARCH STRATEGY: Lilacs, Scielo, PEDro, Scopus, Pubmed, CENTRAL Cochrane, Science Direct, and Google Scholar were searched for studies published in Portuguese, English, and Spanish to July 31, 2017, using the terms “physical therapy” OR “complementary treatment” AND “endometriosis”. SELECTION CRITERIA: Randomized controlled trials relating to complementary pelvic pain treatment and adverse effects. DATA COLLECTION AND ANALYSIS: Eight studies were identified; two studies were included in the meta-analysis. | |
| Main Results | The complementary interventions studied were acupuncture, exercise, electrotherapy, and yoga. All were inconclusive in affirming benefit but demonstrated a positive trend in the treatment of symptoms of endometriosis. Meta-analysis of acupuncture showed a significant benefit in pain reduction as compared with placebo (P=0.007). | |
| Conclusions | Numerous complementary treatments have been used to alleviate the symptoms of endometriosis, but only acupuncture has demonstrated a significant improvement in outcomes. Nevertheless, other approaches demonstrated positive trends toward improving symptoms; this should encourage investigators to design controlled studies to support their applicability. | |
1.1.4. Xu 2017 ☆
Xu Y, Zhao W, Li T, Zhao Y, Bu H, Song S. Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis. PLoS One. 2017;12(10):. [176386].
| Background | Endometriosis is a multifactorial, oestrogen-dependent, inflammatory, gynaecological condition that can result in long-lasting visceral pelvic pain and infertility. Acupuncture could be an effective treatment for endometriosis and may relieve pain. Our aim in the present study was to determine the effectiveness of acupuncture as a treatment for endometriosis-related pain. |
|---|---|
| Methods | In December 2016, six databases were searched for randomised controlled trials that determined the effectiveness of acupuncture in the treatment of endometriosis-related pain. Ultimately, 10 studies involving 589 patients were included. The main outcomes assessed were variation in pain level, variation in peripheral blood CA-125 level, and clinical effective rate. All analyses were performed using comprehensive meta-analysis statistical software. |
| Results | Of the 10 studies included, only one pilot study used a placebo control and assessed blinding; the rest used various controls (medications and herbs), which were impossible to blind. The sample sizes were small in all studies, ranging from 8 to 36 patients per arm. The mean difference (MD) in pain reduction (pre- minus post-interventional pain level-measured on a 0-10-point scale) between the acupuncture and control groups was 1.36 (95% confidence intervals [CI] = 1.01-1.72, P<0.0001). Acupuncture had a positive effect on peripheral blood CA-125 levels, as compared with the control groups (MD = 5.9, 95% CI = 1.56-10.25, P = 0.008). Similarly, the effect of acupuncture on clinical effective rate was positive, as compared with the control groups (odds ratio = 2.07; 95% CI = 1.24-3.44, P = 0.005). |
| Conclusions | Few randomised, blinded clinical trials have addressed the efficacy of acupuncture in treating endometriosis-related pain. Nonetheless, the current literature suggests that acupuncture reduces pain and serum CA-125 levels, regardless of the control intervention used. To confirm these findings, additional, blinded studies with proper controls and adequate sample sizes are needed. |
1.1.5. Lund 2016 ☆
Lund I, Lundeberg T. Is acupuncture effective in the treatment of pain in endometriosis? J Pain Res 2016 Mar 24;9:157-65.[186541].
| Background | Endometriosis is a multifactorial, estrogen-dependent, inflammatory gynecological condition - often with long-lasting visceral pelvic pain of different origin, and infertility among women. Current management options for patients' are often inadequate, with side effects for many for whom acupuncture techniques could be an alternative. Earlier studies have discussed the efficacy of acupuncture, but not its methodological aspects. |
|---|---|
| Objectives | To summarize the documented clinical effects of acupuncture on rated visceral pelvic endometriosis-related pain, and associated variables among individuals, within and between studied groups, and to discuss the methodological treatment aspects. |
| Methods | Published full text clinical studies, case reports, and observational studies with abstracts written in English were searched by using the keywords “Acupuncture and Endometriosis” in databases such as PubMed, Web of Science, and CINAHL. The reporting guidelines, Standards for Reporting Interventions in Clinical Trials of Acupuncture was used for the methodological report. |
| Main results | Three studies were found including 99 women, 13-40 years old, with diagnosed endometriosis. The studies were different in research design, needle stimulation techniques, and evaluation instruments. Methodological similarities were seven to12 needle insertions per subject/session, and 15-25 minutes of needle retention time. The needles were placed in lower back/pelvic-abdominal area, in the shank, feet, and hands. Treatment numbers varied from nine to 16 and patients received one to two treatments per week. Similarity in reported treatment effects in the quoted studies, irrespective of research design or treatment technique, was reported decrease of rated pain intensity. |
| Discussion | Meta-analysis is the standard procedure for the evaluation of evidence of treatment effects, ie, on a group level, usually without analysis of the individual responses even with obvious spread in the results leading to lack of guidance for treatment of the individual patient. By conceptualizing pain as subjective, the individual aspect should serve as the basis for the analysis to allow clinical recommendations. From a physiological and a western medical perspective, acupuncture can be regarded as a type of sensory stimulation that induces changes in the function of the central nervous system that partly can explain the decrease of perceived pain in response to acupuncture treatment irrespective of the technique. |
| Authors' conclusions | Endometriosis is often painful, although with various origin, where standard treatments may be insufficient or involve side effects. Based on the reported studies, acupuncture could be tried as a complement as it is an overall safe treatment. In the future, studies designed for evaluating effectiveness between treatment strategies rather than efficacy design would be preferred as the analyses of treatment effects in the individual patients. |
1.1.6. Rocha 2012 ☆
Rocha ALL, Reis FM, Petraglia F. New trends for the medical treatment of endometriosis. Expert Opin Investig Drugs 2012;21(7):905-919. [157188].
INTRODUCTION: Endometriosis is a benign sex hormone-dependent gynecological disease, characterized by the presence and growth of endometrial tissue outside the uterus; it affects 10% of women of reproductive age and is associated with infertility and pain. Treatment of endometriosis involves conservative or radical surgery, or medical therapies. The goals for endometriosis treatment may be the relief of pain and/or a successful pregnancy achievement in infertile patients. Treatment must be individualized with a multidisciplinary approach. The classical treatments carry adverse side effects and in some cases a negative impact on quality of life. New agents promise a distinct perspective in endometriosis treatment. AREAS COVERED: The aim of this paper is to systematically review the literature evidence of new medical treatments for endometriosis, defined as pharmacological treatments not yet commonly available and currently under investigation. EXPERT OPINION: These new medical therapies would be used associated with surgical treatment and, in the future, will render possible the association of hormone therapy with non-hormonal treatment for endometriosis. [Several studies have demonstrated the positive effect of acupuncture in the relief of pelvic pain and treatment of infertility. Limited evidence from RCTs suggests that acupuncture is effective in treating dysmenorrhea].
1.1.7. Zhu 2011 ☆
Zhu X, Hamilton KD, Mcnicol ED. Acupuncture for pain in endometriosis. Cochrane Database Syst Rev 2011. CD007864. [160372].
| Background | Endometriosis is a prevalent gynaecological condition, significantly affecting women's lives. Clinical presentations may vary from absence of symptoms to complaints of chronic pelvic pain, most notably dysmenorrhoea. The management of pain in endometriosis is currently inadequate. Acupuncture has been studied in gynaecological disorders but its effectiveness for pain in endometriosis is uncertain. |
|---|---|
| Objectives | To determine the effectiveness and safety of acupuncture for pain in endometriosis. |
| Methods | Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group (MSDG) Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, CNKI and TCMDS (from inception to 2010) and reference lists of retrieved articles. Selection criteria: Randomised single or double-blind controlled trials enrolling women of reproductive age with a laparoscopically confirmed diagnosis of endometriosis and comparing acupuncture (body, scalp or auricular) to either placebo or sham, no treatment, conventional therapies or Chinese herbal medicine. Data collection and analysis: Three authors independently assessed risk of bias and extracted data; we contacted study authors for additional information. Meta-analyses were not performed as only one study was included. The primary outcome measure was decrease in pain from endometriosis. Secondary outcome measures included improvement in quality of life scores, pregnancy rate, adverse effects and rate of endometriosis recurrence. |
| Main results | Twenty-four studies were identified that involved acupuncture for endometriosis; however only one trial, enrolling 67 participants, met all the inclusion criteria. The single included trial defined pain scores and cure rates according to the Guideline for Clinical Research on New Chinese Medicine. Dysmenorrhoea scores were lower in the acupuncture group (mean difference -4.81 points, 95% confidence interval -6.25 to -3.37, P < 0.00001) using the 15-point Guideline for Clinical Research on New Chinese Medicine for Treatment of Pelvic Endometriosis scale. The total effective rate ('cured', 'significantly effective' or 'effective') for auricular acupuncture and Chinese herbal medicine was 91.9% and 60%, respectively (risk ratio 3.04, 95% confidence interval 1.65 to 5.62, P = 0.0004). The improvement rate did not differ significantly between auricular acupuncture and Chinese herbal medicine for cases of mild to moderate dysmenorrhoea, whereas auricular acupuncture did significantly reduce pain in cases of severe dysmenorrhoea. Data were not available for secondary outcomes measures. |
| Authors' conclusions | The evidence to support the effectiveness of acupuncture for pain in endometriosis is limited, based on the results of only a single study that was included in this review. This review highlights the necessity for developing future studies that are well-designed, double-blinded, randomised controlled trials that assess various types of acupuncture in comparison to conventional therapies. |
2. Clinical Practice Guidelines
| ⊕ positive recommendation (regardless of the level of evidence reported) Ø negative recommendation (or lack of evidence) |
2.1. European Society of Human Reproduction and Embryology (ESHRE) 2022 Ø
Endometriosis. Guideline of European Society of Human Reproduction and Embryology. 2022. [219845]. URL
| Treatment of endometriosis-associated pain. Non-medical management strategies. The GDG recommends that clinicians discuss non-medical strategies to address quality of life and psychological well-being in women managing symptoms of endometriosis. However, no recommendations can be made for any specific non-medical intervention (Chinese medicine, nutrition, electrotherapy, acupuncture, physiotherapy, exercise, and psychological interventions) to reduce pain or improve quality of life measures in women with endometriosis, as the potential benefits and harms are unclear. Non-medical management strategies for infertility. Regarding non-medical strategies on infertility, there is no clear evidence that any non-medical interventions for women with endometriosis will be of benefit to increase the chance of pregnancy. No recommendation can be made to support any non-medical interventions (nutrition, Chinese medicine, electrotherapy, acupuncture, physiotherapy, exercise, and psychological interventions) to increase fertility in women with endometriosis. The potential benefits and harms are unclear. |
2.2. Japan Society of Obstetrics and Gynecology (JSOG, Japan) 2022∼
Harada T, Taniguchi F, Kitajima M, Kitawaki J, Koga K, Momoeda M, Mori T, Murakami T, Narahara H, Osuga Y, Yamaguchi K. Clinical practice guidelines for endometriosis in Japan (The 3rd edition). J Obstet Gynaecol Res. 2022 Sep 26. https://doi.org/10.1111/jog.15416
| There are no relevant studies with a high level of evidence, and there are no reliably effective complementary or alternative therapies (Evidence level II, Strength of recommendation ) The above results demonstrate that acupuncture, acupressure, and electroacupuncture may be as effective as or more effective than analgesics. |
2.3. American College of Obstetricians and Gynecologists 2018 ⊕
Dysmenorrhea and endometriosis in the adolescent. ACOG Committee Opinion No. 760. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;132:e249-58. [197580].
| Adolescents with endometriosis often benefit from ongoing education and support and integration of other multidisciplinary services such as biofeedback, pain management teams, acupuncture, and herbal therapy. |
2.4. Collège National des Gynécologues et Obstétriciens Français / Haute Autorité de Santé (CNGOF / HAS, France) 2017 ⊕
- HAS et CNGOF. Prise en charge de l'endométriose. Haute Autorité de Santé. 2017. Recommandations. 39P. [99725]. Argumentaire. 399P. [99726].
- Wattier JM. Antalgiques et alternatives thérapeutiques non médicamenteuses pluridisciplinaires, RPC Endométriose CNGOF-HAS. Gynécologie Obstétrique Fertilité & Sénologie. 2018;46(3):248-55. [192164]. |doi|
| Pour l’évaluation des traitements physiques, l’aveugle est difficile à obtenir. La notion de placebo, quand il est possible, est également complexe et sa validité limitée. L’acupuncture, l’ostéopathie et le yoga ont montré une amélioration de la qualité de vie chez des patientes ayant des douleurs liées à l’endométriose (NP4). Les prises en charge non médicamenteuses qui ont montré une amélioration de la qualité de vie peuvent être proposées en complément de la prise en charge médicale de l’endométriose (Accord d’experts). |
2.5. German and Austrian Societies for Obstetrics and Gynecology (Germany, Austria) 2014 ⊕
Ulrich U, Buchweitz O, Greb R, Keckstein J, von Leffern I, Oppelt P, Renne SP, Sillem M, Stummvoll W, De Wilde, Schweppe KW, and for the German and Austrian Societies for Obstetrics and Gynecology. National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis. Geburtshilfe Frauenheilkd. 2014;74(12):1104-1118. [192685].
| Owing to the lack of controlled, randomized studies to date on complementary and integrative approaches to the treatment of endometriosis, no recommendations can be made. Women with chronic recurrent endometriosis and corresponding symptoms may obtain relief of symptoms and an improvement in quality of life from the use of complementary therapies . In particular, these include the methods of acupuncture and Chinese medicine, classical homeopathy, herbal medicine, physiotherapy, etc. This should always be preceded by appropriate clinical screening for potential organ changes (endometriomas, hydronephrosis). Although results from larger scale, randomized and controlled studies are not yet available, initial investigations clearly point to acupuncture and Chinese herbal medicine having an effect on endometriosis-induced pain. |
2.6. American Society for Reproductive Medicine (ASRM, USA) 2014 ⊕
Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril. 2014;101(4):927-35. [197666].
| Acupuncture can also be considered an adjunctive therapy for pelvic pain associated whith endometriosis. |
2.7. European Society of Human Reproduction and Embryology (ESHRE) 2013 Ø
Guideline on the management of women with endometriosis. European Society of Human Reproduction and Embryology. 2013:97P. [196756].
| From the limited included evidence, we conclude that the effectiveness of high-frequency TENS, dietary supplements, acupuncture and traditional Chinese medicine are not well established for pain management in women with endometriosis. Recommendation The GDG does not recommend the use of nutritional supplements, complementary or alternative medicine in the treatment of endometriosis-associated pain, because the potential benefits and/or harms are unclear. However, the GDG acknowledges that some women who seek complementary and alternative medicine may feel benefit from this. |
2.8. World Endometriosis Society (WES) 2013 ⊕
Johnson NP, Hummelshoj L, World Endometriosis Society Montpellier Consortium. Consensus on current management of endometriosis. Human Reproduction. 2013;28(6):1552-68. [210797]. doi
| (38) There is some evidence of effectiveness of acupuncture, but it requires repeated treatments and effects are unlikely to be long lasting (weak). Consensus grading (γ). |
2.9. Royal College of Obstetricians and Gynaecologists 2012 Ø
Acupuncture and Chinese Herbal Medicine for Women with Chronic Pelvic Pain Scientific Impact Paper No. 30. Royal College of Obstetricians and Gynaecologists. 2012. [197593].
| Acupuncture and CHM may have roles to play in the treatment of CPP associated with dysmenorrhoea, endometriosis, IBS and PID, either as an adjunct or as an alternative to conventional treatments. Unfortunately the current evidence lacks rigour and the available trials are frequently small, poorly designed, and inadequately reported. As a consequence we can only consider this preliminary evidence. This area clearly requires further more rigorous investigation |
