Acupuncture as an independent or adjuvant therapy to standard management for menopausal insomnia: A systematic review and meta-analysis

This systematic review and meta-analysis analyzed 28 randomized clinical trials involving 2,063 Chinese women aged 40-60 years with menopause-related insomnia, investigating whether acupuncture is effective as an independent or adjuvant treatment. Menopausal insomnia affects 38-50% of women during this transition, and is often more severe and prolonged than in premenopausal women, causing daytime dysfunction and being associated with higher prevalence of anxiety, depression, and cardiovascular disease. Although menopausal hormone therapy (MHT) and benzodiazepines are established treatments, they carry significant risks including breast cancer, cardiovascular events, dependence, and increased risk of falls. The methodology included searches of seven databases up to April 2024, assessing studies that compared traditional acupuncture (manual or electroacupuncture) with sham acupuncture, standard care, or inactive controls.

Methodological quality was assessed using Cochrane tools, and meta-analyses were conducted with RevMan software. The most robust results came from six trials controlled with sham acupuncture, demonstrating that acupuncture significantly reduced Pittsburgh Sleep Quality Index (PSQI) scores by 2.68 points, increased total sleep time by 57.17 minutes, improved sleep efficiency by 11%, and reduced wake-after-sleep-onset by 38.80 minutes. These benefits were maintained at 4-week follow-up, suggesting durable effects. Sixteen studies comparing acupuncture with standard medication showed significant reductions in PSQI scores, Kupperman Index, and Hamilton depression and anxiety scales.

Interestingly, subgroup analysis revealed that treatments longer than 8 weeks did not confer additional benefits, possibly due to 'fatigue' of acupuncture points with continuous stimulation. Five studies evaluated acupuncture as adjuvant therapy, demonstrating favorable reductions in PSQI scores compared with standard care alone. The most frequently used acupuncture points were GV-20, HT-7, SP-6, BL-23, KI-3, EX-HN22, LR-3, PC-6, CV-4, and GV-24, reflecting traditional Chinese medicine principles for treating kidney deficiency and heart-kidney disharmony. Treatment frequency ranged from 1-7 sessions per week, with 3 sessions weekly being most common.

Adverse events were significantly less frequent with acupuncture compared with Western medication, consisting mainly of mild pain and bleeding at the puncture site, which resolved rapidly. GRADE assessment rated the evidence as very low to moderate due to risk of methodological bias and substantial heterogeneity between studies. Important limitations include the limited number of articles, all conducted in China, potential cultural bias, blinding difficulties, heterogeneity in sham acupuncture methods, and lack of long-term follow-up studies. Treatment individualization according to traditional Chinese medicine principles contributed to variability in results.

The clinical implications suggest that women with menopausal insomnia who experience limited effects from Western medication may benefit from acupuncture alone or combined, potentially preventing medication dependence. A minimum treatment period of 4 weeks appears necessary for therapeutic effects, serving as a reference point for evaluating clinical efficacy.