Perimenopausal syndrome — the cluster of vasomotor, psychological, and somatic symptoms that accompany the hormonal transition before and after menopause — affects up to 80% of women to some degree. Hot flashes and night sweats are the most recognized symptoms, but the syndrome also includes insomnia, anxiety, depression, irritability, vaginal dryness, and reduced libido. Hormone therapy (HT) remains the most effective treatment for vasomotor symptoms, but its use is limited in women with contraindications (history of breast cancer, thromboembolism, established cardiovascular disease) or by personal preference. Acupuncture emerges as a non-hormonal alternative with a growing evidence base. A network meta-analysis (NMA) published in Frontiers in Neurology in January 2026, pooling 49 RCTs with 4,579 participants, is the most comprehensive study available on the topic — and provides clinically refined guidance on which acupuncture modality is most effective for each type of perimenopausal symptom.
The study was conducted by Xiaoyan Yang and team from Sichuan University of Medicine and Zhongshan Hospital, with searches in 8 databases (PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, CBM, and VIP) covering studies published through June 2025. The methodological strength of the NMA lies in the capacity to compare multiple interventions simultaneously — even when they have not been directly compared in the same RCT — using the chain of transitive comparisons. The study compared 6 main acupuncture modalities: acupuncture with moxibustion (AWM), acupuncture with Chinese medicine (ACM), electroacupuncture with moxibustion (EAWM), electroacupuncture (EA), auricular acupuncture combined with body acupuncture (AAA), and moxibustion alone (M).
RESULTS OF THE NMA OF ACUPUNCTURE FOR PERIMENOPAUSAL SYNDROME (FRONTIERS NEUROLOGY, JAN 2026)
The Network Approach: Why Each Modality Has Its Target
The main differential of this NMA is the granularity of the results: instead of simply concluding that "acupuncture works for menopause," the study identifies which of the 6 compared modalities is most effective for each symptomatic domain. This specificity has direct clinical importance — the medical acupuncturist can tailor the protocol to the patient's predominant profile. For the woman with intense hot flashes and moderate-intensity depression, EAWM (electroacupuncture with moxibustion) appears as the first-choice modality. For the patient whose central complaint is disruptive insomnia without frequent hot flashes, auricular acupuncture (AAA) leads. For the woman with predominantly anxious symptoms, electroacupuncture alone (EA) is superior.
Hormonal regulation — assessed by levels of FSH (follicle-stimulating hormone), LH (luteinizing hormone), and E2 (estradiol) — was best with AWM (acupuncture with moxibustion). This is clinically relevant because hot flashes are directly triggered by the oscillation of FSH/LH levels — and a modality that modulates the hypothalamic-pituitary-gonadal (HPG) axis through heat (moxibustion) and mechanical stimulus (needle) has a coherent pathophysiologic basis. ACM (acupuncture combined with herbal Chinese medicine) was superior for improvement of overall syndrome symptoms measured by TCM scales, suggesting synergy between herbal medicine and acupuncture in global hormonal modulation.
Implications for Treatment Individualization
Perimenopausal syndrome is eminently heterogeneous: one patient may present with predominant hot flashes; another may have insomnia as the principal complaint with mild hot flashes; a third may have frank depression as the central manifestation. This NMA validates what the clinical practice of medical acupuncture already operationalizes — the need to adapt the protocol to the patient's symptomatic pattern. The medical acupuncturist does not treat "menopause" as a generic condition, but assesses the specific set of symptoms, the intensity of each domain (vasomotor, psychological, somatic), and the phase of menopausal transition to construct an individualized protocol.
Another clinically relevant finding is that moxibustion appears consistently among the modalities of greatest efficacy. Moxibustion — a technique that warms acupoints with burning artemisia — has a deep heat effect on meridians associated with the reproductive axis (anatomic regions associated with autonomic innervation and pelvic vascularization). The combination of thermal stimulus with mechanical stimulus (needle) may have synergy in neuroendocrine modulation mechanisms.
Frequently Asked Questions
Yes, and this combination can be especially useful for patients on minimum-dose HT who still have residual symptoms. There is no contraindication to simultaneous use of acupuncture and HT. In practice, acupuncture may allow gradual reduction of the hormonal dose in some patients — a decision that should be made together with the responsible gynecologist. For patients who cannot use HT (history of thrombosis, hormone-dependent breast cancer), acupuncture emerges as the non-hormonal alternative with the largest evidence base for vasomotor and psychological symptoms.
The RCTs included in the NMA used protocols of 4–12 weeks, with most showing improvement in hot flashes from week 4. In clinical practice, response to treatment of perimenopausal syndrome is progressive — patients frequently report subjective improvement of overall well-being before objective reduction of hot flashes. Hot-flash frequency typically reduces visibly after 6–8 weeks of regular treatment. For patients with very frequent hot flashes (more than 7 per day), an intensive phase of 5 weekly sessions in the first 2–4 weeks may be considered.
This NMA focused on vasomotor symptoms (hot flashes), psychological symptoms (depression, anxiety), and sleep. Vaginal dryness — genitourinary syndrome of menopause (GSM) — has distinct pathophysiology (atrophy of the vaginal epithelium due to local estrogen deficiency) and is an outcome less frequently evaluated in acupuncture RCTs. There is preliminary evidence that acupoints associated with the reproductive axis (SP-6, CV-4, KI-7) may contribute to improved vaginal lubrication via neuroendocrine effect, but this indication requires confirmation in dedicated RCTs. For symptomatic GSM, topical vaginal estrogen continues to be the most effective standard treatment.
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).