53 Randomized Trials: Acupuncture Improves Insulin Resistance and Reproductive Parameters in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) affects approximately 6% to 20% of women of reproductive age, configuring the most prevalent endocrine disorder in this population. Beyond the reproductive manifestations — oligo/anovulation, hyperandrogenism, and polycystic ovarian morphology —, PCOS is strongly associated with metabolic disorders, with emphasis on insulin resistance, present in up to 70% of patients and considered the central pathophysiologic axis of the syndrome. When the physician evaluates a patient with PCOS, the clinical question is rarely limited to "does acupuncture work?" — but advances to "which type of acupuncture, for which outcome, with which protocol?"

A network meta-analysis published in Frontiers in Endocrinology in February 2026 answers this question with the largest dataset available to date: 53 RCTs, 4,406 participants, and 12 therapeutic modalities based on acupuncture compared simultaneously in a network — a statistical design that allows ranking the interventions even when they have not been directly compared in the same trials.

The 12 Compared Modalities

The differential of a network meta-analysis is the capacity to compare multiple interventions simultaneously, even when individual studies compared only two or three of them. The 53 RCTs evaluated the following acupuncture-based modalities (collectively termed acupuncture-related therapies, or ARTs): manual acupuncture (Acu), electroacupuncture (EA), moxibustion, acupuncture combined with moxibustion (Acu+Moxi), warm needle therapy (WNT), laser acupuncture (LA), acupoint injection therapy (AIT), catgut implantation at acupoints (CIAA), pharmacoacupuncture, auriculotherapy, and two additional combined protocols. All were compared with one another and with conventional treatment for PCOS.

Insulin Resistance: The Central Challenge of PCOS

Insulin resistance (IR) is recognized as the central pathophysiologic axis of PCOS, connecting the metabolic manifestations (visceral obesity, dyslipidemia, cardiovascular risk) to the reproductive ones (hyperandrogenism, anovulation). The HOMA-IR index is the most used marker to quantify IR in clinical practice and research. In this network meta-analysis, the modalities that produced the largest reductions in HOMA-IR were acupoint injection (MD = 2.20; 95% CI: 0.44–3.96) and the combination of acupuncture with moxibustion (MD = 1.06; 95% CI: 0.28–1.84).

Electroacupuncture also demonstrated benefits on metabolic markers, consistent with previous studies that document its effect on insulin sensitivity by modulation of autonomic and muscular pathways. Standard manual acupuncture presented more modest results specifically for the metabolic outcome, although it demonstrated efficacy in reproductive parameters such as ovarian volume and antral follicle count.

Reproductive and Hormonal Parameters

Beyond metabolic outcomes, the network meta-analysis evaluated reproductive and hormonal parameters critical for patients with PCOS. Laser acupuncture emerged as the most effective modality for reducing testosterone levels (MD = 0.59; 95% CI: 0.33–0.85) and luteinizing hormone (LH) (MD = 3.00; 95% CI: 0.47–5.53) — both central markers of hyperandrogenism and gonadotrophic axis dysregulation in PCOS.

For ovarian morphology, warm needle therapy (WNT) and manual acupuncture produced the largest reductions in antral follicle count — MD = 4.08 (95% CI: 0.63–7.53) and MD = 3.06 (95% CI: 1.07–5.05), respectively —, while manual acupuncture led in the reduction of ovarian volume (MD = 2.38; 95% CI: 0.67–4.08). Improvement in the LH/FSH ratio, relevant for menstrual regularity and ovulation, was observed with multiple modalities.

Body Composition: BMI and Waist–Hip Ratio

Obesity, especially of central (visceral) distribution, amplifies insulin resistance and worsens hyperandrogenism in PCOS. The network meta-analysis evaluated the impact of the different modalities on BMI and waist–hip ratio. The combination of acupuncture with moxibustion demonstrated the greatest effect on BMI (MD = 5.80; 95% CI: 3.38–8.22), while electroacupuncture was the most effective modality for reduction of waist–hip ratio (MD = 0.06; 95% CI: 0.02–0.09). The authors note that more prolonged treatments tended to produce greater benefits on body composition.

Safety Profile

All 12 evaluated modalities presented an acceptable safety profile: adverse events were non-serious and transient — bruises at the puncture site, slight pain sensation during the procedure, and rarely transient dizziness. No modality was associated with relevant complications. The authors highlight that the low frequency of serious events reported in more than 4,400 participants is favorable to the safety profile of acupuncture-based therapies as a therapeutic complement in PCOS, although they acknowledge that the documentation of adverse events was limited in part of the studies.

Limitations and Perspectives

Despite the large volume of data — 53 RCTs and 4,406 participants —, the authors acknowledge relevant limitations: the documentation of adverse events was limited in part of the studies; heterogeneity in PCOS diagnostic criteria (Rotterdam, Chinese guidelines, others) may have introduced variability in the studied populations; and treatment durations and acupoint protocols varied significantly across trials. Large-scale multicenter trials with standardized protocols are recommended to consolidate the findings and define optimized protocols for each PCOS patient profile.