Polycystic ovary syndrome (PCOS) and premature ovarian insufficiency (POI) represent two opposite poles of female ovarian dysfunction: PCOS presents with hyperandrogenism, anovulatory cycles, and insulin resistance — affecting 8–13% of women of reproductive age — while POI is characterized by early depletion of the follicular reserve with hypergonadotropism before age 40. Both cause subfertility and have limited therapeutic options. An umbrella review of meta-analyses published in Frontiers in Medicine in November 2024 comprehensively synthesized all the evidence accumulated in 38 meta-analyses on the use of acupuncture in these two conditions, gathering data from 27,106 patients with PCOS and 19,098 with POI — totaling 46,204 participants.
The study was conducted by Tianyu Bai, Xinyun Deng, Jieyu Bi, Linlin Ni, Zhaohui Li, and Xiumei Zhuo. The umbrella review of meta-analyses is the highest level of the evidence hierarchy in medicine: a systematic review of systematic reviews, which synthesizes the findings of multiple meta-analyses to offer the most comprehensive view possible on a clinical question. For PCOS, 20 meta-analyses covering reproductive, endocrine, and metabolic outcomes were included. For POI, 18 meta-analyses evaluated parameters of ovarian reserve, hormonal levels, and symptoms. The methodological quality of the included meta-analyses was assessed using the AMSTAR-2 tool.
UMBRELLA OF META-ANALYSES — 38 REVIEWS, 46,204 PATIENTS
PCOS: reproductive and metabolic benefits
For PCOS, the umbrella revealed consistent benefits of acupuncture in multiple domains. In reproductiveoutcomes, the included meta-analyses demonstrated significantly higher pregnancy and ovulation rates in acupuncture groups compared with controls — a relevant finding given that chronic anovulation is the principal cause of subfertility in PCOS. In endocrine outcomes, acupuncture significantly reduced serum levels of LH (luteinizing hormone) and testosterone — the principal markers of hyperandrogenism and hypothalamic-pituitary axis dysfunction in PCOS. The reduction of LH results in less stimulation of the ovarian theca cells producing androgens, while normalization of testosterone contributes to the resumption of ovulatory cycles. In metabolic outcomes, acupuncture improved insulin resistance (assessed by HOMA-IR) and the lipid profile in several of the reviewed meta-analyses.
Acupuncture as adjuvant to ovulation induction in PCOS
One of the most clinically relevant findings of this umbrella is the benefit of acupuncture as an adjuvant to ovulation induction protocols in PCOS. Several of the included meta-analyses demonstrated that the combination of acupuncture with clomiphene citrate (or letrozole) produces ovulation and pregnancy rates superior to those of pharmacotherapy alone. The proposed mechanism involves modulation of hypothalamic β-endorphins: in experimental studies, acupuncture has been associated with an increase in β-endorphins that may inhibit the pulsatile secretion of GnRH and contribute to normalizing the LH pulse frequency — which is abnormally elevated in PCOS. This neuroendocrine "reset" effect contributes to the restoration of ordered folliculogenesis and adequate follicular development for ovulation. In parallel, the reduction of hyperinsulinemia by acupuncture removes a permissive cofactor for ovarian hyperandrogenism.
Frequently Asked Questions
Yes — the benefits of acupuncture in PCOS go beyond fertility. Regulation of the menstrual cycle (reduction of very long cycles or amenorrhea), control of hyperandrogenism (reduction of acne and hirsutism), improvement of insulin resistance (relevant for prevention of type 2 diabetes), and impact on anxiety and depression — frequently associated with PCOS — are all benefits independent of reproductive intent. The protocol can be adapted according to the predominant symptoms of each patient.
Yes — acupuncture can be used as an adjuvant to HRT (hormone replacement therapy), which is the standard treatment for POI. While HRT relieves climacteric symptoms and protects bones and the cardiovascular system, acupuncture may contribute to preserving residual ovarian function and amplifying overall well-being. There is no contraindication to the combination. For women with POI who desire pregnancy and are in assisted reproduction protocols with egg donation, acupuncture may improve uterine receptivity — a field with growing evidence but not yet systematically reviewed.
The meta-analyses of this umbrella were based on studies of 1 to 6 months in duration. Improvement in hormonal parameters (LH, testosterone) generally begins to be observed after 4–8 weeks of regular treatment (2–3 sessions/week), but menstrual regularization and improvement of ovulation frequently require 3 months of continued treatment. In studies with the best response, ovulatory cycles returned in 50–70% of patients after 3 months of acupuncture — a datum that should be interpreted with caution given that part of PCOS tends to improve with weight loss itself and concomitant lifestyle changes.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).