Acupuncture and Related Therapies for Endometriosis: A Network Meta-Analysis of Randomized Controlled Trials

This network meta-analysis represents the most comprehensive study to date on acupuncture-related therapies for endometriosis, analyzing 42 randomized clinical trials with 3,656 participants. Endometriosis is a gynecologic condition that affects 6-10% of women of reproductive age, characterized by the growth of endometrial tissue outside the uterus, causing intense pain and significant impact on quality of life. Conventional treatment with hormonal medications often causes side effects that lead 10-43% of patients to discontinue treatment. The researchers conducted a systematic search of eight databases, including PubMed, EMBASE, and Cochrane Library, plus Chinese databases, covering publications from inception through April 2024.

The study included six main acupuncture interventions: manual acupuncture, electroacupuncture, moxibustion, auriculotherapy, catgut embedding (catgut suture implantation), and acupoint application, plus combined therapies. Primary outcomes were pain scores on the Visual Analog Scale (VAS), serum CA-125 levels (an endometriosis marker), and clinical response rates. The methodology used Bayesian analysis to compare different treatments directly and indirectly, allowing therapy ranking by efficacy. Quality assessment followed Cochrane guidelines, with most studies showing low risk of bias for random sequence generation and selective reporting.

The results demonstrated consistent superiority of acupuncture therapies over Western medicine. For pain reduction, catgut embedding obtained the best ranking (76.8% probability of being the most effective), followed by acupoint application (70.1%) and manual acupuncture (66.6%). Manual acupuncture showed significant pain reduction compared with Western medicine (MD: -2.33; 95% CI: -4.37, -0.29). For CA-125 levels, acupoint application was most effective (ranking 86.3%), demonstrating significant reduction compared with Western medicine (MD: -11.86; 95% CI: -18.81, -4.86).

Combined therapy also showed superiority over Chinese and Western medicine in multiple outcomes. As for response rates, auriculotherapy obtained the best performance (93.2% probability), with an odds ratio of 8.01 (95% CI: 2.08, 45.37) compared with Western medicine. Safety analysis revealed a lower incidence of adverse events with acupuncture therapies. Of the 42 studies, only 7 reported adverse events, with acupuncture therapies mainly causing mild subcutaneous bruising and occasional dizziness, while hormonal medications caused irregular vaginal bleeding, nausea, headache, and breast discomfort.

The clinical implications are substantial, suggesting that acupuncture therapies offer effective and safer alternatives to conventional treatment. Catgut embedding, which involves implanting biodegradable threads into acupoints for prolonged stimulation, emerged as particularly promising for pain management. Auriculotherapy, with its ease of application and excellent overall results, represents an accessible option for many patients. Limitations include heterogeneity in treatment protocols, variable study duration, and predominance of Chinese participants, limiting global generalization.

In addition, the impossibility of complete blinding in acupuncture studies may introduce performance bias. Many studies also did not specify the qualifications of the acupuncturists or standardized protocols. The 'combined therapy' classification grouped different combinations, preventing specific analysis of the best combined protocols. This study provides robust evidence for integrating acupuncture therapies into the management of endometriosis, especially for patients who do not tolerate or prefer to avoid hormonal treatments.

The results support the development of clinical guidelines that include these therapies as first-line or adjunctive options. Future research should focus on protocol standardization, international multicenter studies, and direct comparisons among different acupuncture techniques to establish the most effective combinations for different clinical presentations of endometriosis.