Endometriosis: Reviewing the evidence behind guidelines, research on acupuncture, and the Accredited Register of Acupuncturists in the healthcare sector
By RCCM Trustee Lianne Aquilina
Lianne reviews the evidence behind current clinical guidelines for endometriosis and finds that some key limitations appear to have been missed. She then summarises the current evidence for acupuncture for endometriosis, which suggests some benefits.
What is Endometriosis?
Endometriosis is a chronic inflammatory condition defined by the occurrence of endometrial-like tissue outside the uterus. This endometrial type of tissue grows in different parts of the body. During the menstrual cycle, these cells mimic the endometrial cells of the womb lining by building up and breaking down.
This results in bleeding outside the womb in parts of the body and places where no bleeding should occur. Unfortunately, this results in pain, inflammation, and scar tissue.
Endometriosis is classified as hormone-related. The exact cause of endometriosis remains unknown.
Endometriosis can cause severe pelvic pain, period pain, heavy bleeding, and pain during and after sexual intercourse. Pain can occur during a bowel movement and urination. There may be rectal bleeding or blood in the urine. Women can experience abdominal bloating and fatigue. Endometriosis can also lead to fertility problems. Other symptoms suggestive of endometriosis include cyclical cough, chest pain, shoulder tip pain, and catamenial pneumothorax.
It is important to note that this chronic condition can seriously affect a woman’s quality of life, including their physical, psychological, emotional health and wellbeing.
Although there is currently no cure for endometriosis, treatments are offered to ease the debilitating symptoms. The European Society of Reproductive Medicine (ESHRE) highlights that treatments can offer partial or temporary pain relief and that symptoms often reoccur after discontinuation of treatment.
Treatment Options
The treatment management of endometriosis outlined by the National Health Service includes over-the-counter painkillers, the prescribing of medication, hormone therapy, and surgery.2
The ESHRE update for treatment management of endometriosis states that there are limitation reasons for caution around the evidence base for this condition and that therefore, no firm recommendations could be made on the most appropriate treatment.3
Pain Management
It should be noted that there are weak or strong healthcare recommendations for the management of endometriosis-associated pain based on the limited evidence base. For example, a weak recommendation for the use of analgesics (paracetamol and non-steroidal anti-inflammatories) based on “very low-quality” evidence, or a strong recommendation for surgery to reduce endometriosis-associated pain based on limited evidence.
Some medications have shown promise but have not been proven, and can have severe, dose-limiting side effects.
Recently, a systematic review and metanalysis published on acupuncture for endometriosis found that acupuncture was beneficial for pelvic pain and menstrual pain. The quality of the evidence is considered low. However, in the grand scheme of the available quality of evidence based on which treatment options and recommendations are made, acupuncture in a research output is more than a promising intervention.4 Acupuncture treatment for endometriosis demonstrated clinically relevant improvements in pelvic pain. More about this later…
Acupuncture
Traditional Acupuncture
An acupuncturist’s perspective of endometriosis includes complexity, albeit manageable. Diagnosis and treatment strategy are based on the collection and differentiation of an individual’s presenting symptoms, including psychological and emotional context.
Patterns of disease can generally be subclassified as endometriosis due to Blood Stasis and Qi Stagnation, endometriosis due to Cold Stasis, endometriosis due to Blood Stasis and Heat, damp heat, and/or Kidney Deficiency. These pathophysiological mechanisms are associated with the quality, consistency, and flow of “blood.”
Acupuncture and Moxibustion for Endometriosis: A Systematic Review
A systematic review of acupuncture found insufficient evidence on the overall effectiveness of acupuncture and moxibustion for endometriosis. The researchers found that studies were of low to moderate certainty. The studies showed acupuncture may improve endometriosis pain-related symptoms and improve quality of life, with few adverse events presenting. Acupuncture plus conventional therapy indicated greater improvements for patients. However, more research is most certainly required to explore this finding.14
Acupuncture for Endometriosis: Systematic Review and Meta-analysis
In 2023, a review found low-quality evidence for a positive impact of acupuncture on endometriosis. Low-quality evidence means that you cannot be certain of the positive effects that were found. The researchers concluded that acupuncture was beneficial for endometriosis-associated pelvic pain (low certainty) and menstrual pain (moderate certainty) and that acupuncture should be considered as a potential treatment intervention.15 The authors conclude that acupuncture may cause a large reduction in pelvic pain compared to non-specific acupuncture at the end of treatment. It is reported as uncertain whether this reduction in pain continues after cessation of treatment, as studies did not report this. Most studies recounted low rates of adverse events.
Acupuncture and Endometriosis
When it comes to best practice and the care of women with endometriosis for the partial or temporary relief of painful symptoms, I recommend trying acupuncture. Treatment options are commonly tested for efficacy in the clinical setting, and when ineffective, they require trying a range of alternative approaches to ascertain what works and does not work for an individual. Acupuncture is no different.
You may not be aware that acupuncture is a treatment option, mainly as it is not included in guidelines, and sources wrongly state there is no evidence supporting acupuncture as a treatment. It will become evident whether an acupuncturist is helping to manage endometriosis-associated pain and improves a person’s quality of life. Feedback, visual analogue pain scales, and other validated tools can be incorporated to monitor pain reduction within teams.
A primary or secondary healthcare provider can refer directly to an acupuncturist on an accredited health and social care register. Patients can also self-refer to the British Acupuncture Council: “Find Us.”
Lianne Aquilina RDN, BSc Hons, MBAcC, MSc
Lianne is an individual expert for draft healthcare guidelines, consults on evidence base policy development for registered health professions. She is a peer reviewer of research before publication. Lianne’s current research project is exploring the clinical practice of Chinese herbal medicine for threatened miscarriage in inpatient and outpatient hospital settings in China. Lianne is a member of the British Acupuncture Council.
The Professional Standards Authority protects the public by overseeing the regulation and registration of healthcare professionals. The PSA oversees registrant members of the British Acupuncture Council.
Resources:
Endometriosis UK Pain and Symptom Diary