The clinical value of acupuncture for women with premature ovarian insufficiency: a systematic review and meta-analysis of randomized controlled trials

Premature ovarian insufficiency represents a significant medical condition that affects approximately 1% of women before 40 years of age, characterized by early decline in ovarian function. This syndrome can be caused by genetic, immune, viral, iatrogenic, and environmental factors, although in more than 50% of cases the cause remains unknown. Patients face symptoms such as menstrual irregularities, hot flashes, sweats, decreased libido, bone loss, and metabolic disturbances, impacting not only fertility but also quality of life and mental health. Conventional treatment is mainly based on hormone replacement therapy, which, although effective in relieving estrogen-deficiency symptoms, has specific limitations and contraindications.

In this context, acupuncture emerges as a promising therapeutic alternative, offering high safety and minimal side effects, with growing scientific interest in its application for reproductive and endocrine disorders.

This study aimed to assess the clinical efficacy of acupuncture in the treatment of women with premature ovarian insufficiency through a systematic review and meta-analysis of randomized clinical trials. The researchers conducted a comprehensive search of eight scientific databases through October 2023, including both English- and Chinese-language databases. Inclusion criteria rigorously followed the 2016 diagnostic guidelines from the European Society of Human Reproduction and Embryology, considering women under 40 years of age with persistent amenorrhea or oligomenorrhea for at least four months and follicle-stimulating hormone levels above 25 IU/L on two separate occasions. The methodology included analysis of various parameters such as hormone levels, antral follicle count, Kupperman scale, and overall efficacy rate.

To ensure robustness of results, subgroup and sensitivity analyses were performed, investigating potential sources of heterogeneity among studies.

The meta-analysis included 13 randomized controlled clinical trials involving 775 patients, divided into 388 in the acupuncture group and 387 in the control group, all studies conducted in China between 2019 and 2023. Results showed that acupuncture was significantly effective in reducing follicle-stimulating hormone levels, with statistically significant improvement compared with control groups. A significant increase was also observed in estradiol levels, an essential hormone for cardiovascular, neurologic, and bone protection, in addition to improvement of symptoms related to estrogen deficiency. Levels of anti-Müllerian hormone, an important marker of ovarian reserve, showed significant elevation after acupuncture treatment, suggesting improvement in follicular function.

The overall efficacy rate was 22% higher in the acupuncture group, with low heterogeneity among studies. Subgroup analyses revealed that the combination of acupuncture with Chinese herbal medicine and hormone replacement therapy demonstrated superior results in reducing follicle-stimulating hormone levels compared with non-acupuncture therapies.

Clinically, these results suggest that acupuncture may represent a valuable therapeutic option for women with premature ovarian insufficiency, especially considering the limitations of conventional hormone replacement therapy. For patients, acupuncture offers a non-pharmacologic approach with a favorable safety profile, demonstrating the ability to improve fundamental hormonal parameters and relieve symptoms associated with the condition. The reduction of follicle-stimulating hormone levels and the increase in estradiol may contribute to improved quality of life and reduced risk of long-term complications such as cardiovascular disease and osteoporosis. For health professionals, these findings indicate that acupuncture can be considered as adjunctive or alternative therapy, particularly in patients with contraindications to hormone therapy or those seeking complementary approaches.

The demonstrated safety, with only minor adverse events such as occasional subcutaneous bruising, makes acupuncture an attractive option in clinical practice. The results also suggest potential benefits of integrating acupuncture and Chinese herbal medicine, indicating possible therapeutic synergy.

The study has some important limitations that must be considered when interpreting the results. The significant heterogeneity observed in some parameters may be related to variations in acupuncture techniques, point selection, stimulation intensity, and acupuncturists' experience, all factors that influence clinical outcomes. All included studies were conducted in China, limiting the generalization of results to other populations and cultural contexts. The absence of adequate blinding, although understandable due to the nature of acupuncture intervention, may introduce bias into results.

Important outcomes such as pregnancy rate, impact on psychological health, and quality of life were not assessed in most studies, representing significant gaps for a complete clinical efficacy assessment. The relatively short follow-up period, mainly three months, may be insufficient to assess long-term effects, especially considering that complete follicular development requires approximately 85 days. Despite these limitations, this study represents the first meta-analysis to rigorously follow the updated 2016 diagnostic criteria, providing important evidence on the therapeutic potential of acupuncture in premature ovarian insufficiency and establishing a foundation for future larger-scale multicenter studies with superior methodologic quality.