Acupuncture combined with Chinese herbal medicine in the treatment of perimenopausal insomnia: A systematic review and meta-analysis
Li et al. · Medicine · 2023
Evidence Level
MODERATEOBJECTIVE
Evaluate the efficacy of acupuncture combined with traditional Chinese medicine versus Western medicine in the treatment of perimenopausal insomnia
WHO
1,188 perimenopausal women with insomnia, distributed across 15 randomized controlled trials
DURATION
Treatment periods ranging from 3 to 16 weeks across the included studies
POINTS
Various points including EX-HN1, ST-36, SP-6, HT-7, GV-20, among others, according to syndrome differentiation pattern
🔬 Study Design
Acupuncture + Chinese Herbal Medicine
n=666
Acupuncture (manual, electroacupuncture, auricular) combined with Chinese herbal formulas
Western Medicine
n=582
Medications such as diazepam, eszopiclone, estazolam, and others
📊 Results in numbers
Overall efficacy rate
Pittsburgh Sleep Quality Index (PSQI)
FSH (follicle-stimulating hormone)
Hamilton Anxiety Rating Scale
Percentage highlights
📊 Outcome Comparison
Treatment efficacy rate
This study showed that combining acupuncture with Chinese herbal medicine may be more effective than conventional medications for treating insomnia during perimenopause. Women who received the integrated treatment had better sleep quality and less anxiety, with a lower incidence of side effects.
Article summary
Plain-language narrative summary
Perimenopausal insomnia (PMI) is a common problem that significantly affects the quality of life of women in the menopausal transition age range. This systematic review and meta-analysis, published in 2023, represents the most comprehensive analysis to date on the efficacy of acupuncture combined with traditional Chinese medicine in treating this condition. The researchers conducted a rigorous search across eight databases — including PubMed, Cochrane Library, and specialized Chinese databases — identifying 15 randomized clinical trials involving 1,188 women with perimenopausal insomnia.
The methodology followed PRISMA protocols, ensuring transparency and reproducibility of the results. Inclusion criteria were rigorously defined: randomized controlled trials comparing acupuncture combined with Chinese herbal medicine versus conventional Western medicine. The experimental group received various types of acupuncture (manual, electroacupuncture, auricular) combined with traditional herbal formulas, while the control group received medications such as diazepam, eszopiclone, estazolam, and others.
Primary results demonstrated significant superiority of the integrated approach. The overall efficacy rate was 18% higher in the group that received acupuncture combined with herbal medicine (RR: 1.18; 95% CI: 1.08-1.29; P = 0.001). The Pittsburgh Sleep Quality Index (PSQI), the gold-standard instrument for assessing sleep quality, showed a mean improvement of 2.77 points in the integrated treatment group compared with conventional medications (WMD: -2.77; 95% CI: -4.15 to -1.39; P < 0.0001).
Analyses of hormonal biomarkers revealed important findings for understanding the mechanisms of action. Follicle-stimulating hormone (FSH), elevated during perimenopause, showed a significant reduction of 31.45 mIU/mL in the combined acupuncture group (WMD: -31.45; 95% CI: -42.7 to -20.2; P < 0.001), suggesting regulation of the hypothalamic-pituitary-ovarian axis. The Hamilton Anxiety Rating Scale (HAMA) also showed an improvement of 2.62 points (WMD: -2.62; 95% CI: -3.93 to -1.32; P < 0.0001), indicating benefits in controlling perimenopause-associated anxiety.
Interestingly, levels of estradiol (E2) and luteinizing hormone (LH) showed no significant differences between groups, suggesting that the therapeutic benefits may occur through mechanisms that are not exclusively hormonal. Safety analysis revealed a superior profile of the integrated approach: only 1.49% of patients treated with acupuncture and herbal medicine experienced adverse events, compared with 9.66% in the conventional medicine group.
The clinical implications are substantial. The combination of acupuncture with Chinese herbal medicine offers an effective and safe therapeutic alternative for women who cannot or do not wish to use conventional hormone therapy. The traditional Chinese medicine approach, based on pattern differentiation (kidney deficiency, liver qi stagnation, heart-kidney disharmony), allows treatment to be tailored to each patient's individual characteristics.
Strengths
- 1First comprehensive meta-analysis on acupuncture combined with Chinese herbal medicine for perimenopausal insomnia
- 2Robust sample of 1,188 participants across 15 randomized controlled trials
- 3Rigorous methodology following PRISMA protocols
- 4Assessment of multiple outcomes including sleep quality, hormones, and anxiety
- 5Safety analysis demonstrating a lower incidence of adverse events
Limitations
- 1All included studies were conducted in China, limiting global generalizability
- 2High heterogeneity between studies due to variability in herbal formulations and acupuncture protocols
- 3Lack of adequate blinding in most of the included studies
- 4Lack of detail on allocation concealment and random sequence generation
- 5Need for studies of higher methodological quality to confirm the findings
Expert Commentary
Prof. Dr. Hong Jin Pai
PhD in Sciences, University of São Paulo
▸ Clinical Relevance
Perimenopausal insomnia is one of the most frequent reasons for referral to our service, especially in women who refuse or have contraindications to hormone therapy and who tolerate conventional hypnotics — diazepam, eszopiclone, estazolam — poorly because of residual daytime effects and the potential for dependence. This meta-analysis, bringing together 1,188 participants across 15 randomized trials, reinforces that acupuncture combined with Chinese herbal medicine produces a 2.77-point improvement on the PSQI and a 2.62-point reduction on the Hamilton Anxiety Rating Scale in direct comparison with these drugs, with an adverse-event rate of only 1.49% versus 9.66% in the medication group. For the clinician treating women between 45 and 55 with mixed complaints of insomnia, hot flashes, and anxiety, this evidence consolidates the indication of an integrative approach as a primary therapeutic line, not as a second-choice resort.
▸ Notable Findings
The most striking result is not the sleep score itself but the 31.45 mIU/mL reduction in FSH in the integrated treatment group. Elevated FSH is a marker of follicular depletion and correlates directly with the intensity of vasomotor symptoms and fragmented sleep; its modulation suggests action on the hypothalamic-pituitary-ovarian axis. Paradoxically, estradiol and LH did not differ between groups, which indicates that the mechanism of action does not rely solely on estrogenic restoration — it likely involves modulation of neurotransmitters such as serotonin, beta-endorphin, and GABA, pathways extensively documented in the acupuncture literature. This dissociation between FSH and E2 is clinically useful: it explains why women with contraindications to estrogen can still benefit fully from the integrative approach.
▸ From My Experience
In my practice at the HC-FMUSP Pain Center, I usually see the first subjective responses — fewer nighttime awakenings, reduced sleep latency — around the third or fourth session when we combine acupuncture with herbal medicine. In women with a kidney-deficiency-with-rising-fire pattern, which corresponds to most perimenopausal patients we see, I prefer to combine points such as Shenmen (HT-7), Sanyinjiao (SP-6), and Taixi (KI-3) with auricular therapy on the ear. On average, I run ten to twelve weekly sessions until stabilization, then move to biweekly maintenance for two to three months. I do not recommend this approach in isolation when there is untreated underlying major depression — in those cases the psychiatrist needs to be on the team first. The finding regarding FSH is consistent with what I observe clinically: simultaneous improvement in hot flashes and sleep, without our needing to alter hormone replacement.
Full original article
Read the full scientific study
Medicine · 2023
DOI: 10.1097/MD.0000000000035942
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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