Endometriosis affects approximately 10% of women of reproductive age worldwide — an estimate representing about 190 million people. It is a chronic inflammatory disease characterized by the presence of endometrium-like tissue outside the uterus, most frequently on the peritoneum, ovaries, and fallopian tubes, causing severe dysmenorrhea, chronic pelvic pain, dyspareunia, and, in many cases, infertility. Despite the enormous impact on quality of life, diagnosis is frequently delayed by more than 7 years after symptom onset. Conventional treatment — hormonal contraceptives, progestins, GnRH analogues, laparoscopic surgery — is effective but frequently insufficient for complete pain control, with frequent relapses and side effects that limit long-term adherence. A meta-analysis published in Archives of Gynecology and Obstetrics in October 2024 consolidates, for the first time in a comprehensive way, the evidence on the use of acupuncture for endometriosis-associated pain: 14 randomized clinical trials and 793 patients, with clinically significant results for pain, response rate, and inflammatory biomarker.
The study was conducted by researchers Cong Chen, Xuhao Li, Shiyou Lu, Jiguo Yang, and Yuanxiang Liu, with a systematic search of eight databases — PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, CBM, WanFang, and Weipu — covering publications from the inception of each database through December 2022. Two independent reviewers performed screening, data extraction, and methodologic quality assessment using the Cochrane risk-of-bias tool. Statistical analysis used Stata software. The 14 included trials compared different forms of acupuncture (conventional, electroacupuncture, auricular, warm needling, and fire acupuncture) against placebo, traditional Chinese medicine, and conventional Western treatments.
ACUPUNCTURE META-ANALYSIS FOR ENDOMETRIOSIS (ARCHIVES OF GYNECOLOGY AND OBSTETRICS, OCTOBER 2024)
Mechanisms: How Acupuncture Acts in Endometriosis
The pathophysiology of endometriosis pain is multifactorial: chronic peritoneal inflammation with release of prostaglandins, interleukins, and TNF-α; central sensitization of pelvic nociceptive pathways; growth of sympathetic and sensory nerve fibers into ectopic lesions; and dysregulation of the hypothalamic-pituitary-adrenal axis that perpetuates inflammation. Acupuncture acts on multiple of these mechanisms simultaneously, which may explain the magnitude of the effect observed in the meta-analysis (SMD −1.10 — classified as a large-magnitude effect by Cohen’s criteria).
Results: Pain, Clinical Response, CA-125, and Subgroups
The primary outcome — pain reduction (dysmenorrhea and chronic pelvic pain) — showed standardized mean difference (SMD) of −1.10 (95% CI −1.45 to −0.75; P<0.001). For context: SMD less than −0.5 is considered a moderate effect, and less than −0.8, a large effect — −1.10 falls in the very-large-effect range, clinically meaningful. The overall clinical response rate (global symptomatic improvement assessed by the criteria of individual trials) was significantly higher in the acupuncture group: RR 1.25 (95% CI 1.09–1.44; P=0.02) — that is, a quarter more patients responded adequately to treatment compared with controls.
The serum CA-125 marker — although not specific for endometriosis, it is widely used in monitoring disease activity — also reduced significantly in the acupuncture group (SMD −0.62; 95% CI −1.15 to −0.08; P=0.024). This finding is relevant because it suggests that acupuncture not only reduces pain perception, but acts on the inflammatory component underlying the disease. In subgroup analysis by modality: electroacupuncture and auricular acupuncture showed pain reductions superior to other modalities, while warm needling and auricular acupuncture led overall clinical efficacy. Curiously, fire acupuncture and electroacupuncture did not show significant difference for pain compared with control in the isolated subgroup — a result that should be interpreted cautiously given the small number of studies in those specific categories.
Frequently Asked Questions
No. Laparoscopic surgery is the treatment of choice for moderate-to-severe endometriosis (stages III–IV per the ASRM), especially when there are ovarian endometriomas, extensive adhesions, or disease-related infertility. Acupuncture is positioned as an adjunct in the control of pain and inflammation — it may reduce the need for analgesics and the intensity of symptoms before and after surgery. In mild endometriosis (stages I–II) with pain as the main complaint and without immediate fertility compromise, acupuncture may be considered part of integrated conservative management with hormone treatment. The therapeutic decision should be shared with the responsible gynecologist.
The trials in this meta-analysis used varied protocols — generally between 8 and 24 sessions over 1 to 3 months. In studies included in the meta-analysis, chronic pelvic pain typically responded in 4 to 6 weeks (2–3 sessions per week); dysmenorrhea, in 2 to 3 menstrual cycles. Frequency and duration should be individualized by the medical acupuncturist. Maintenance sessions (1×/week or 1×/month) are common after the intensive phase to preserve benefits.
There is no evidence of pharmacologic interaction between acupuncture and conventional hormonal treatments for endometriosis. Acupuncture may be performed concomitantly with oral contraceptives, progestins, hormonal IUDs, or GnRH analogues. The mechanisms are complementary, not competitive: hormonal treatment acts by suppressing estrogen stimulation of the lesions, while acupuncture modulates inflammatory and nociceptive responses. In patients with significant pain improvement on acupuncture, the gynecologist may consider reducing the dose of hormonal treatment — a clinical decision that should be made with appropriate medical follow-up.
Fonte Original
Archives of Gynecology and Obstetrics(em inglês)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).