Development of Provisional Acupuncture Guidelines for Pelvic Pain in Endometriosis Using an e-Delphi Consensus Process

Endometriosis is a condition that affects approximately 10% of women in Western countries, characterized by the presence of endometrial tissue outside the uterus. Pelvic pain is the most frequently reported symptom, causing significant annual costs and substantial impact on patients' quality of life and mental health. Although conventional treatments such as hormonal therapies, analgesics, and surgery are available, their limitations include significant side effects and symptom recurrence, suggesting the need for additional therapeutic options.

Growing evidence supports the use of acupuncture as an effective intervention to reduce pain in women with endometriosis. However, the treatments used in research vary considerably, and it remains unclear which specific protocol could be recommended for clinical practice. This research project aimed to clarify how acupuncture could be used in the treatment of this condition.

The study comprised two main phases: a systematized literature review to extract details of acupuncture treatments from published research, and an e-Delphi study to obtain knowledge about details used by expert acupuncturists. The literature review examined 29 unique studies and found a wide range of treatment details with little agreement between studies. Many studies did not provide sufficient information about important treatment aspects, such as the style of acupuncture used, number of needle insertions, or whether needles were inserted unilaterally or bilaterally.

The e-Delphi study involved 20 international acupuncturists with a minimum of 5 years of experience treating endometriosis-related pelvic pain. The process was conducted over three rounds, with the first round collecting qualitative data and subsequent rounds building group consensus. Consensus was defined as a rating of at least 5 on a 7-point Likert scale by at least 70% of experts.

Results showed that experts reached consensus on 94 statements for recommended use, disagreed on 29 statements, and could not reach consensus on 55 statements. The provisional guidelines developed include recommendations to use TCM (Traditional Chinese Medicine) style acupuncture, Master Tung style, and electroacupuncture, applied in at least a partially individualized manner. Thirty-one acupuncture points are provisionally recommended, including CV-3, CV-4, CV-6, ST-25, ST-28, ST-29, ST-30, SP-4, SP-6, SP-8, SP-10, KI-3, LR-3, ST-36, among others.

The recommended protocol includes a needle retention time of approximately 30 minutes using disposable medical-grade stainless steel needles, with diameter and length depending on the patient's body and anatomy. The recommended treatment frequency is one to two times per week for a minimum of 2-3 months, continuing until pain relief. Important additional components include the use of Chinese herbal medicine, moxibustion, and dietary guidance, which were identified as critical factors for effectiveness.

The study highlighted the importance of treatment individualization and the application of a whole-systems approach. Experts agreed that blood stasis is always a branch of the condition, and practitioners need to also treat the underlying root, following the TCM root-and-branch theory. In addition, it is recommended to combine local and distal points, provide treatment throughout the menstrual cycle, evolve it appropriately, and adapt it to comorbidities such as infertility.

The main limitations of the study include its reliance on expert opinion, which is at the bottom of the evidence hierarchy, and the inherent variability that may arise from differences in participants' backgrounds. However, these limitations were mitigated by the international diversity of participants and their high level of expertise, with full retention of participants throughout the three rounds.

This work represents a significant initial attempt to fill the gap in guidance for clinicians in this area. The provisional guidelines offered provide a structured framework for treating endometriosis-related pelvic pain using acupuncture, based on the consensus of experienced international experts. The authors emphasize that these are provisional guidelines that await validation through future studies on the effectiveness of these specific protocols.