Skip to content

Advertisement

BMC Complementary and Alternative Medicine

What do you think about BMC? Take part in

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Effects of acupoint-stimulation for the treatment of primary dysmenorrhoea compared with NSAIDs: a systematic review and meta-analysis of 19 RCTs

Contributed equally
BMC Complementary and Alternative MedicineBMC series – open, inclusive and trusted201717:436

https://doi.org/10.1186/s12906-017-1924-8

Received: 7 November 2016

Accepted: 11 August 2017

Published: 31 August 2017

Abstract

Background

Primary dysmenorrhoea (PD), defined as painful menses in women with normal pelvic anatomy, is one of the most common gynaecological syndromes. Acupoint-stimulation could potentially be an effective intervention for PD. Our aim was to determine the effectiveness of acupoint-stimulation compared with Non-Steroidal Anti-Inflammatory Drugs (NASIDs) in the treatment of PD.

Methods

Six databases were searched to December 2014. Sixteen studies involving 1679 PD patients were included. We included randomized controlled trials that compared acupoint-stimulation with NASIDs for the treatment of PD. The main outcomes assessed were clinical effectiveness rate, symptom score, visual analogue score, variation in peripheral blood prostaglandin F2α (PGF2α) and side effects. All analyses were performed using Comprehensive Meta-Analysis statistical software.

Results

(1) The total efficacy was better than control group: odds ratio = 5.57; 95% confidence interval (95% CI) = 3.96, 7.83; P < 0.00001; (2) The effect of intervention was positive in relieving the severity of PD symptoms: mean difference (MD) = 2.99; 95%CI = 2.49, 3.49; P < 0.00001; (3) No statistical difference existed between two groups in terms of a reduction in the VAS: MD = 1.24; 95%CI = −3.37, 5.85; P = 0.60; (4) The effect of intervention on the variation in peripheral blood PGF2α between two groups was positive: MD = 7.55; 95%CI = 4.29,10.82; P < 0.00001; (5) The side effects of control groups was more than the acupoint-stimulation group: OR = 0.03; 95%CI =0.00,0.22; P = 0.0005.

Conclusions

According to this article, acupoint-stimulation can relieve pain effectively in the treatment of PD and offers advantages in increasing the overall effectiveness.

Keywords

Acupoint-stimulationPrimary dysmenorrhoeaMeta-analysisSystematic reviewNon-steroidal anti-inflammatory drugs

Background

Dysmenorrhea is the most common gynecologic complaint among adolescent and young adult females. The prevalence of dysmenorrhoea appears to differ across the world, ranging from 80% in Western Australia [1], to 60% in Canada [2], 48.4% in Mexico [3], and 79.9% in Iran [4]. Over 50% of females of reproductive age have painful menstruation; among them, 10% have severe dysmenorrhoea, whereby their monthly lives’ quality is impaired from 1 to 3 days differently [5]. It starts some hours before menstruation and continues for up to 48–72 h, and takes the form of pains and cramps in the lower abdomen radiating towards the inner side of the thighs [6]. Half of such cases experience systemic symptoms, such as nausea, vomiting, diarrhoea, fatigue, irritability and dizziness [7, 8], which reduce the quality of life. The patients with mild-to-moderate pain can manage their pain without drugs or with a small amount of non-prescription drugs. However, approximately 15% of all women experience severe dysmenorrhoea to a level that affects work or study; such women need drugs to relieve their pain [9]. Dysmenorrhea in adolescents and young adults is usually primary, and is defined as painful menses in women with normal pelvic anatomy [10]. In ~ 10% of females with severe dysmenorrhea symptoms, pelvic abnormalities such as endometriosis or uterine anomalies may be found (secondary dysmenorrhea) [11]. This article mainly discusses primary dysmenorrhoea (PD).

In recent years, there are more and more researches about the pathogenesis of PD. In addition to factors relating to the body’s nerve, genetic and immune systems, and psychological/social factors, the pathogenesis is generally considered to be mainly related to two factors: (1) abnormal uterine contraction, and (2) endocrine and metabolic factors. The state of uterine ischemia and hypoxia causes the uterine muscle to contract, increasing intrauterine tension, and so leading to abdominal pain. Patients with abnormal uterine contractions and the subjective feeling of abdominal colic have been consistently reported over time. Many types of molecular endocrine factors play an important role in the pathogenesis of PD, such as prostaglandins (PGs), oxytocin (OT) and vasopressin (VP), β-EPs, nitric oxide (NO), noradrenaline (NE), endothelins, and magnesium and calcium ions. In particular, prostaglandin F2α (PGF2α), cyclooxygenase (COX) metabolite of arachidonic acid, causes potent vasoconstriction and myometrial contractions, leading to uterine ischemia and pain [12].

Treatment for PD includes a variety of pharmacological and non-pharmacological methods. Common pharmacological interventions include Non-Steroidal Anti-Inflammatory Drugs (NASIDs) and oral contraceptives. NSAIDs are widely used as the first-line therapy for females with dysmenorrhoea [13, 14]. However, there are often adverse events associated with the use of NSAIDs, including stomach ache, diarrhoea, nausea, and liver or kidney damage after discontinuing medication [13]. Therefore, many patients with PD are seeking complementary and alternative techniques such as acupoint-stimulation to treat the symptoms of PD [15], which emphasizes stimulating the acupoint(s) to strengthen the body’s endogenetic regulated function, so as to preventing and treating diseases by regulating the meridian system.

Although previously publications have reported that acupuncture-related treatments are effective for primary dysmenorrhea, the evidence is low convincing due to insufficient methodological quality and small sample size. Given the safety of acupoint-stimulation [16], therefore, the purpose of this systematic review and meta-analysis study is to determine the effectiveness of acupoint-stimulation in treating PD.

Methods

Search strategy

We searched six electronic databases that included PubMed, the Cochrane Library, Embase, the Chinese Academic Journals Full-text Database, the Chinese Science and Technology Journal Full-text Database (CNKI), Wanfang Data, and the Chinese Biomedical Literature Database (VIP). The index terms were the following: dysmenorrhoea, menorrhagia, painful menstruation, menstrual, pain, painful menstruation, menstrual pain, menstrual pains, acupuncture, moxibustion, auricular point, ear acupoint (administering persistent/temporary pressure with Cowherb seed/finger force to stimulate pressure points), electroacupuncture, acusector, acupoint application, randomized controlled trials, controlled clinical trials, and random. The above terms in Chinese were adapted and searched in Chinese databases. The studies were published between the first year they were available and December 2014, which of the language is Chinese and English.

Selection criteria and exclusion criteria

Selection criteria

  • Research Type

  • Research Subjects

  • Interventions

  • Outcomes (Clinical effectiveness rate, Symptom score, Visual analogue score, Peripheral blood PGF2α, Side effects)

Research type

Randomized controlled trials (RCTs).

Research subjects

Patients with a definite PD diagnosis: PD is defined as painful menses in women with normal pelvic anatomy. An eligible patient is diagnosed based on the PD Clinical Guideline of the Society of Obstetricians and Gynaecologists of Canada.

Interventions

Intervention groups – acupoint-stimulation, including acupuncture, moxibustion, ear acupressure, electroacupuncture, acupoint application; Control groups – NSAIDs.

Outcomes

(1) Clinical effectiveness rate

It was a dichotomous outcome and the overall effectiveness of acupoint-stimulation therapy as a subjective assessment, which was defined as the proportion of participants who got relieved pain and was based on response evaluation criteria used in the treatment of insomnia with acupoint-stimulation. What’s more, it was reported by trial participants themselves. For example, clinical therapeutic effect criteria were categorized as cure, markedly effective, effective, or ineffective. According to the Guideline for Clinical Trials of New Patent Chinese medicines (GCTNPCM) [17] evaluation standards, which define: Cured: after treatment, the score of symptoms was;restored to 0, abdominal pain and other symptoms disappeared and the dysmenorrhea did not recurred 3 menstrual cycles after treatment; Markedly effective: after treatment, the score of symptoms was decreased to less than 1/2 of the score before treatment, abdominal pain obviously relieved and other symptoms improved and the patient without taking analgesics could insist in work; Effective: after treatment,the score of symptoms decreased to 1/2–3/4 of the score before treatment, abdominal pain relieved and other symptoms improved, and the patient could work after taking analgesics; Ineffective: abdominal pain and other symptoms did not change. The total number of “cure, markedly effective, effective” were used to calculate effective rate.

(2) Symptom score

In accordance with the GCTNPCM, the patients’ symptom scores were recorded before and after treatment [18].

(3) Visual analogue score (VAS)

In the paper, we draw a 10 cm above the horizontal line and horizontal line of the end of 0, indicating no pain; on the other side of 10, said the pain; middle part of said varying degrees of pain. Feel the patient according to uniform mark on the horizontal line, indicating the degree of pain [19].

(4) Peripheral blood PGF2α.

The blood was taken from cubital vein within 24 h in the last menstrual period before treatment and within 24 h in the next menstrual period after treatment for one course, and the plasma PGF2α levels in the two groups were determined with radioimmunoassay.

(5) Side effects

To observe the vital signs before and after treatment and whether there were fainting, stomach ache, diarrhoea, nausea, and liver or kidney damage during the treatment and other adverse events occurred, and recorded.

Exclusion criteria

  1. (1)

    Trials where it was unclear whether a randomized trial was being conducted;

     
  2. (2)

    Trials conducted using combinations of treatments and many medical interventions;

     
  3. (3)

    Trials in which the data were inadequate and difficult to extract.

     

Data extraction and quality assessment

Searches were conducted and the data extracted by two independent researchers. Each trial identified in the search was evaluated for design, eligibility criteria for participants, and outcome measures. Any disagreement between researchers with regard to the eligibility of a trial was resolved by consulting a third researcher. We created a form for data extraction which included: (1) basic information about each trial, including the topic, first author, dateline and journal; (2) basic information about the patients, including the number of cases in each group and the mean age; (3) the study design and intervention; and (4) the outcomes.

The quality of the trials included in this study was assessed by other two researchers according to the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.

Statistical analyses

All analyses were performed using Comprehensive Meta-Analysis statistical software, RevMan 5.1.0 (Cochrane Collaboration, Copenhagen, Denmark). Continuous outcome variables were analyzed using a standardized measure; dichotomous variables were compared and the results presented as odds ratios/risk ratios (OR/RR).

To obtain a standard deviation of the change from baseline for the experimental intervention, use (R1 = 0.5) [20]:
$$ SD(C)=\sqrt{SD{(B)}^2+ SD{(F)}^2-\left(2\times {R}_1\times SD(B)\times SD\times (F)\right)} $$

SD(B) represents the standard deviation before intervention; SD(F) represents the standard deviation after intervention.

The research team evaluated homogeneity among the trials via I2. If I2 was ≥50%, the trials were considered to be heterogeneous, and a random-effect model based on a Mantel-Haenszel (MH) or inverse variance (IV) statistical approach was selected. If I2 was <50%, the studies were considered to be homogeneous, and a fixed-effects model based on an MH or IV statistical approach was used. Pooled summary statistics of the differences in the ratio or mean of the individual studies were developed. Pooled differences in ratios or means, and two-sided P-values were calculated and used as criteria for determining the level of statistical significance. P < 0.05 was considered to indicate statistical significance. Moreover, a sensitivity analysis was conducted based on the leave-one-out cross-validation procedure [21].

Results

Study selection

A flow chart of the included/excluded studies is shown in Fig. 1. Database searches yielded 70 studies from PubMed, 28 from the Cochrane Central Register of Clinical Trials, 215 from Embase, 552 from CNKI, 328 from Wanfang Data, 279 from VIP, and 479 from CBM. After removal of duplicate records, 849 records remained. Following the first review based on the title, 149 records were remained, and the abstracts were reviewed based on the pre-defined eligibility criteria. A total of 82 records were selected for full text review and data processing. During this phase, 63 papers were excluded, so 19 studies were included in the final meta-analysis, comprising 1679 participants.
Fig. 1

PRISMA 2009 Flow Diagram

Characteristics of the included studies

Table 1 shows the main characteristics of the 19 RCTs [18, 19, 2238].
Table 1

Characteristics of the 19 Trials Identified in the Literature Search

Studies

Randomization Method

Sample Size Intervention/Control

Age(I/C)

Intervention

Outcomes

Time of initiation of acupoint-stimulation and Course of Treatment

Follow-up Visit

Intervention group

Control group

Primary

Secondary

Zhang LM et al.

(2012) [22]

Random number table

45/45

13–27/11–25

Acupuncture at

SP 10 SP 6 CV 6

LI 4

Indometacin

Clinical efficacy

N/A

The treatment started 3 days before menstrual onset, once every day and was given for 3 days for 3 menstrual cycles

3 months

Lin Q et al.

(2012) [23]

Random number table

80/60

15–30/15–30

Eye acupuncture at the lower-jiao area; liver area; kidney area; the liver area; the heart area; the spleen area

Ibuprofen

Clinical efficacy

Uterine artery blood flow signals

The treatment started 5 days before menstrual onset, once every day and was given for 4–5 days for 3 menstrual cycles

3 months

Hu YL et al.

(2012) [18]

Random number table

60/50

15–30/15–29

Eye acupuncture at the lower-jiao area; liver area; kidney area; the liver area; the heart area; the spleen area

Ibuprofen

Clinical efficacy

PGF+

recurrence rate

The treatment started 2 days before menstrual onset, once every day and was given for 4–5 days for 3 menstrual cycles

6 months

Cao Y et al. (2011) [24]

Random number table

29/30

15–29/20–28

Acupuncture at EX-B8 SP 8 BL 32

Ibuprofen

Clinical efficacy

symptom score+

VAS + side effects

The treatment started during the menstrual period, once every day and was given for 3 menstrual cycles

3 months

Zhi LX et al. (2007) [25]

SPSS Random number

60/60

19.60 ± 3.20/18.93 ± 2.60

Superficial needling

at SP 6

Indometacin

Clinical efficacy

symptom score+

analgesic time

The treatment started 3 days before menstrual onset, once every day and was given for 5 days for 3 menstrual cycles

3 months

Bo LN et al. (2013) [26]

Random number table

69/64

13–35

Moxibustion at

CV 4 CV 8 SP 6

Fenbid

N/A

VAS + COX + PGF +

OT + side effects

The treatment started 7 days before menstrual onset, once every day and was given for 7 days for 3 menstrual cycles

3 months

Ren XL et al. (2013) [27]

Registration order

40/40

16–28/18–27

Moxibustion at

CV 4 SP 6

Ibuprofen

Clinical efficacy

PGF

The treatment started 3 days before menstrual onset, once every day and was given for 6 days for 3 menstrual cycles

3 months

Zhu Y et al. (2010) [28]

Random number table

51/51

18–26/19–25

Sandwiched moxibustion at CV 8

Indometacin

Clinical efficacy

symptom score

+side effects

The treatment started 3 days before menstrual onset, once every day and was given for 5 days for 3 menstrual cycles

3 months

Li JM et al. (2012) [29]

Random number table

30/30

19–30

Electroacupuncture

at BL 32

Fenbid

Clinical efficacy

symptom score

The treatment started during the menstrual period, once every day and was given for 3 menstrual cycles

3 months

Wang K et al. (2005) [30]

Random number table

30/28

16–28/15–24

Ear acupoint at TF 2 CO 18 CO 10 CO 12

Indometacin

Clinical efficacy

N/A

The treatment started 3 days before menstrual onset, once every day and was given for 6 days for 3 menstrual cycles

3 months

Yang M et al. (2009) [31]

Random number table

36/36

14–28/13–27

Acupoint application at CV 4

Indometacin

Clinical efficacy

N/A

The treatment started 2 days before menstrual onset, once every day and was given for 4 days for 6 menstrual cycles

6 months

Chen LW et al. (2006) [32]

Random number table

30/28

16–28/15–24

Acupoint application at CV 4 CV 3 CV 6

Indometacin

Clinical efficacy

N/A

The treatment started 7 days before menstrual onset, once every day and was given for 10 days for 3 menstrual cycles

N/A

Liu C et al. (2011) [33]

Random number table

40/40

21.22 ± 5.86/20.96 ± 6.12

Moxibustion at

CV 4 EX-B8

Fenbid

Clinical efficacy

symptom score

The treatment started 7 days before menstrual onset, once every day and was given for 10 days for 3 menstrual cycles

3 months

Zhu C et al. (2011) [34]

Random number table

20/20

17–28/18–27

Acupuncture at

CV 4 CV 3 SP 10

SP 8 LI 4 LI 11

Indometacin

Clinical efficacy

N/A

The treatment started 7 days before menstrual onset, once every day and was given for 7 days for 3 menstrual cycles

3 months

Li ZL et al. (2012) [35]

Random number table

100/100

13–30/14–35

Acupoint application

at CV 3 CV 8 BL 32 SP 6

Ibuprofen

Clinical efficacy

symptom score

The treatment started 7 days before menstrual onset, once every day and was given for 9 days for 6 menstrual cycles

6 months

Gurkan K et al. (2013) [19]

Registration order

11/24

13.1 ± 1.0/12.8 ± 0.9

Acupuncture at

HT 7 PC 6 LI 4

LI 10 SP 6 LR 3

ST 36 GB 26 SP 15

Naproxen sodium

N/A

VAS

The treatment was given three times on the 5th and 2nd days prior to the expected menstruation date and on the third day of menstruation for 1 month

N/A

Jiang LY

(2007) [36]

Registration order

34/34

19.35 ± 4.33/20.55 ± 4.51

Acupuncture at BL31 BL32 BL33 LI 3

SP 6 SP 8 CV 4 ST 36

Indometacin

Clinical efficacy

N/A

The treatment started 4 days before menstrual onset, once every day and was given for 7 days for 3 menstrual cycles

N/A

Xing QX

(2011) [37]

Registration order

60/54

15–27/16–32

Pricking bloodletting at the liver area;kidney area; the liver area;the uterus area; HT 7

Indometacin

Clinical efficacy

N/A

The treatment started during the menstrual period, once every day and was given for 3 menstrual cycles

3 months

Ji L et al.

(2012) [38]

Random number table

30/30

22 ± 3/22 ± 2

Sandwiched moxibustion at CV 8

Indometacin

Clinical efficacy

symptom score+

PGF + PGE2

The treatment started 3 days before menstrual onset, once every day and was given for 6 days for 3 menstrual cycles

3 months

The above literatures didn't mention intention-to-treat or per-protocol analysis

Clinical outcomes

Clinical effectiveness rate

Seventeen trials examined the effects of acupoint-stimulation and reported the clinical effectiveness rate of treatment for participants with PD who used those therapies versus the rate for a control group. Analysis of pooled data using a fixed-effect model showed that the effect of intervention on the clinical effectiveness rate was positive [OR = 5.57, 95%CI (3.96, 7.83), P < 0.00001] (Fig. 2). That is to say, the clinical effectiveness rate, the acupoint-stimulation group being superior to the NSAIDs.
Fig. 2

Meta-analysis of the Clinical Effective Rate

Symptom score

Six trials reported the symptom score. Analysis of pooled data using a fixed-effect model showed that the effect of intervention on the symptom score was positive [MD = 2.99, 95%CI (2.49, 3.49), P < 0.00001] (Fig. 3). The curative effect of acupoint-stimulation on PD is significant.
Fig. 3

Meta-analysis of the Symptom Score

visual analogue score

Three trials reported the VAS; analysis of pooled data using a random-effect model showed that I2 = 98%, indicating heterogeneity. So, the trial by Cao (2011) was excluded from analysis, then analysis of the pooled data using a random-effect model showed that there was no statistical difference in variation of VAS between the groups receiving acupoint-stimulation and the control groups [MD = 1.24, 95%CI (−3.37,5.85), P = 0.60] (Fig. 4).
Fig. 4

Meta-analysis of the VAS

Peripheral blood PGF2α

Four trials examined the effects of acupoint-stimulation and reported peripheral blood PGF2α of participants with PD who used those therapies versus the rate for a control group. Analysis of the pooled data using a fixed-effect model showed that the effect of intervention on the variation in peripheral blood PGF2α between the groups receiving acupoint-stimulation and the control groups was positive [MD = 7.55, 95%CI (4.29, 10.82), P < 0.00001] (Fig. 5). In the study, it is indicated that acupoint-stimulation can effectively decrease peripheral blood PGF2α level in the patient of PD, so as to inhibit PGF2α-induced spastic contraction of uterine muscle, improve the decrease of blood flow, and relieve the symptoms of the patient of dysmenorrhea.
Fig. 5

Meta-analysis of the Peripheral Blood PGF2α

Side effects

Three trials reported the side effects between acupoint-stimulation and control group. Analysis of pooled data using a random-effect model showed that I2 = 83%, indicating heterogeneity. So the trial by Bo (2013) was excluded from analysis, then analysis of the pooled data using a fixed-effect model showed that the side effects of control groups were more than the acupoint-stimulation group. [OR = 0.03, 95%CI (0.00, 0.22), P = 0.0005] (Fig. 6).
Fig. 6

Meta-analysis of the Side Effects

Quality assessment

The risks of seven biases among the 19 trials were evaluated, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases according to the criteria in the Cochrane Handbook for Systematic Reviews. Fifteen of the studies described correct randomization methods. There was only one trial with allocation concealment and blinding of participants and personnel and blinding of outcome assessment, and nearly all of the trials failed to mention allocation concealment, the blinding of the participants and personnel, and the blinding of outcome assessments. The methodological qualities of the included trials are summarized in Figs. 7 and 8.
Fig. 7

Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies

Fig. 8

Risk of bias summary: review authors’ judgements about each risk of bias item for each included study

Funnel plot of publication bias

The research team performed an analysis of all the included studies, using a funnel plot to determine publication bias in all of the literature. The outcome from the funnel plot analysis is summarized in Fig. 9. The outcome suggests that there was little publication bias.
Fig. 9

Total Effects of Intervention Groups

Discussion

Meta-analysis of clinical effect

In the 19 RCTs included, 17 reported a clinical effectiveness rate and 6 reported symptom scores and 4 reported variation in the level of PGF2α in the peripheral blood of women with PD. The meta-analysis revealed that acupoint-stimulation is superior to NSAIDs in the treatment of PD in terms of clinical effectiveness rate and symptom improvement and reducing the concentration of PGF2α in peripheral blood.

Only one RCT reported uterine artery blood flow signals. The results showed that the uterine arterial pulsation index (PI) and uterine arterial resistance index (RI) of the dysmenorrheal patients were significantly increased in the eye acupuncture group before treatment. Moreover, most studies used a subjective, self-reported index of treatment effects as the outcome measure. Because participants self-reported without additional objective outcomes, their pain status could not be assessed accurately [39]. Furthermore, the included studies used different treatments for the intervention group, such as acupuncture, moxibustion, ear acupressure, electroacupuncture and acupoint application, which of the purpose is to highlight the specificity of acupoints.

The reason for NSAIDs being a drug of positive control

NSAIDs act by inhibiting the enzyme that catalyzes the conversion of arachidonic acid to cyclic endoperoxides, namely COX, which in turn inhibits the production of PGs [40, 41]. The resulting lower levels of PGs lead to less vigorous contractions of the uterus, and therefore to less discomfort. Thus, NSAIDs alleviate primary dysmenorrheic pain predominantly through the suppression of endometrial PGs synthesis [42]. Although NSAIDs is the first-line treatment for PD, it also has shortcomings, which can inhibit the synthesis of COX-1, as well as COX-2, finally it is easy to cause adverse reactions of gastrointestinal and central nervous system. Vane [43] indicated in 1994 that the effective treatment effect of NSAIDs was due to inhibition of COX-2, however, the adverse reactions imputed the suppression of COX-1. Therefore, we consider that NSAIDs may be used as a drug of positive control.

Although the results are encouraging, the conclusions from the current study should be carefully considered before being applied to clinical practice specific patients especially individuals with NSADIs contraindication. This study aims to collect all RCTs relating to acupoint-stimulation treatment of PD and use systematic review to gauge the effectiveness of acupoint-stimulation in the treatment of PD in order to use this treatment more widely in clinical practice.

Different conclusions of the published literature

Some evidence indicates that acupoint-stimulation is effective in treating primary dysmenorrhea [4449], but that evidence was largely based on one small, randomized, controlled trial. However, two more recent sham acupuncture randomized controlled trials failed to show evidence of pain reduction [50, 51]. One of the major challenges may be the subjective nature of the symptoms’ presentations and acupoints utilized. Although a few reviews [15, 21, 52, 53] of acupuncture for the treatment of PD are currently available, none of those reviews analyze the potential mechanism of acupuncture for the treatment of PD, which is the key research content in future. Therefore, a systematic review with a meta-analysis is necessary so that quality evidence can be put forward for the use (or not) of acupoint-stimulation for the treatment in individuals with PD.

Limitations and strengths

The limitations of this evaluation system are as follows: (1) most of the researches did not mention how the sample size was estimated, and most sample sizes were small, leading to a low inspection efficiency; (2) in some of the studies there was inadequate reporting of allocation concealment; implementing or not fully implementing allocation concealment will lead to an exaggerated curative effect; (3) the results were heterogeneous on account of their use of subjective indicators to evaluate the curative effect (symptom scores, VAS), so that implementation of the blinding method is important, but the included studies did not describe the implementation of the blinding method; (4) the study was limited to Chinese and English research, leading to the possibility of selection bias, and the terminology or the guidelines used in clinical managements might not be in the same language.

The strengths of this evaluation system are as follows: this is the first report that comparing the effect of acupoint-stimulation and NSADIs in the treatment of PD, and it provides new evidence and open new horizons that acupoint-stimulation can relieve pain effectively in the treatment of PD and offers advantages in increasing the overall effectiveness.

Perspectives

In our future research, we will conduct some trials relating to acupoint-stimulation for the treatment of PD, which will focus on the following aspects to prevent bias: (1) an estimation of sample size, (2) a fully random design incorporating allocation concealment, and (3) a blind design for the proposer, performer and measurer.

Conclusion

The current evidence reveals that acupoint-stimulation in the treatment of PD has some obvious advantages compared with treatment by NSADIs. The advantages are that acupoint-stimulation can alleviate the symptoms of dysmenorrhoea, reduce the level of peripheral blood PGF2α and has fewer side effect, so it can be used to treat PD patients, especially individuals with NSADIs contraindication.

Abbreviations

CI: 

Confidence interval

CNKI: 

Chinese Science and Technology Journal Full-text Database

COX: 

Cyclooxygenase

COX-2: 

Cyclooxygenase 2

GCTNPCM: 

The Guideline for Clinical Trials of New Patent Chinese Medicines

IV: 

Inverse variance

MD: 

Mean difference

MH: 

Mantel-Haenszel

NE: 

Noradrenaline

NSAIDs: 

Non-Steroidal Anti-Inflammatory Drugs

OR: 

Odds ratios

OT: 

Oxytocin

PD: 

Primary dysmenorrhoea

PGF2α: 

Prostaglandin F2α

PGs: 

Prostaglandins

PI: 

Pulsation index

PRC: 

People’s Republic of China

RCTs: 

Randomized controlled trials

RI: 

Resistance index

RR: 

Risk ratios

TCM: 

Traditional Chinese Medicine

VAS: 

Visual analogue score

VIP: 

Chinese Biomedical Literature Database

VP: 

Vasopressin

Declarations

Acknowledgments

Medical writing services were provided by YiHeAn Biotechnology Co. Ltd.. Authors retained full control of manuscript content.

Funding

This project was supported by the Science Foundation on Traditional Chinese Medicine/Integrative Medicine of the Tianjin Health and Family Planning Commission (2015036).

Availability of data and materials

Data are all contained within the paper.

Authors’ contributions

W.L.Z., Y.Z. And S.L.S conceived and designed the review; Y.X. And W.L.Z analyzed the data; H.E.B. Contributed reagents/materials/analysis tools; Z.M.Z., W.L.Z. And T.L. wrote the paper. All authors read and approved the final manuscript.

Authors’ information

All authors contributed to the design and concept, performed the searches required for their assigned sections, wrote a section, read, revised and critiqued the successive versions, and approved the final manuscript. YZ coordinated the effort and integrated the sections and comments.

Ethics approval and consent to participate

N/A.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Graduate School, Tianjin University of Traditional Chinese Medicine
(2)
Department of Gynecology and Obstetrics, Nankai Hospital, Tianjin Academy of Integrative Medicine
(3)
Department of Neurology, Nankai Hospital, Tianjin Academy of Integrative Medicine
(4)
Department of Chinese Medicine, Tianjin Hearing Impairment Specialist Hospital
(5)
Department of Public Health, School of Chinese Medicine, Tianjin University of Traditional Chinese Medicine
(6)
Department of Gynecology and Obstetrics of Chinese Medicine, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine
(7)
Department of Chemical Engineering, University of Florida
(8)
Institute for Cell & Tissue Science and Engineering, University of Florida
(9)
Laboratory of Anatomy, School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine

References

  1. Hillen TIJ, Grbavac SL, Johnston PJ, Straton JAY, Keogh JMF. Primary dysmenorrhea in young western Australian women: prevalence, impact, and knowledge of treatment. J Adolesc Health. 1999;25(1):40–5.View ArticlePubMedGoogle Scholar
  2. Burnett MA, Antao V, Black A, Feldman K, Grenville A, Lea R, Lefebvre G, Pinsonneault O, Robert M. Prevalence of primary dysmenorrhea in Canada. J Obstet Gynaecol Can. 2005;27(8):765–70.View ArticlePubMedGoogle Scholar
  3. Ortiz MI, Rangel-Flores E, Carrillo-Alarcón LC, Veras-Godoy HA. Prevalence and impact of primary dysmenorrhea among Mexican high school students. Int J Gynecol Obstet. 2009;107(3):240–3.View ArticleGoogle Scholar
  4. Jalili Z, Safizadeh H, Shamsipoor N. Prevalence of primary dysmenorrhea in college students in Sirjan. Kerman Payesh. 2005;4(1):61–7.Google Scholar
  5. Dawood MY. Dysmenorrhea. Clin Obstet Gynecol. 1983;26(3):719–27.View ArticlePubMedGoogle Scholar
  6. Jun EM, Chang S, Kang DH, Kim S. Effects of acupressure on dysmenorrhea and skin temperature changes in college students: a non-randomized controlled trial. Int J Nurs Stud. 2007;44(6):973–81.View ArticlePubMedGoogle Scholar
  7. Speroff L, Fritz MA. Clinical Gynecologic Endocrinology and Infertility (7th edition). Philadelphia: Lippincott Williams and Wilkins, 2005, Menstrual disorders; pp. 401–464.Google Scholar
  8. Balbi C, Musone R, Menditto A, Prisco LD, Cassese E, D’Ajello M, et al. Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol. 2000;91(2):143–8.View ArticlePubMedGoogle Scholar
  9. Ylikorkala O, Dawood MY. New concepts in dysmenorrhea. Am J Obstet Gynecol. 1978;130(7):833–47.View ArticlePubMedGoogle Scholar
  10. Pu BC, Fang L, Gao LN, Liu R, Li AZ. Animal study on primary dysmenorrhoea treatment at different administration times. Evid Based Complement Alternat Med. 2015;2015:367379.View ArticlePubMedPubMed CentralGoogle Scholar
  11. Harel Z. Dysmenorrhea in adolescents and young adults: from pathophysiology to pharmacological treatments and management strategies. Expert Opin Pharmacother. 2008;9(15):2661–72.View ArticlePubMedGoogle Scholar
  12. Alvin PE, Litt IF. Current status of etiology and management of dysmenorrhea in adolescents. Pediatrics. 1982;70(4):516–25.PubMedGoogle Scholar
  13. Dawood MY. Nonsteroidal anti-inflammatory drugs and changing attitudes toward dysmenorrhea. Am J Med. 1988;84(5):23–9.View ArticlePubMedGoogle Scholar
  14. Kaplan Ö, Nazıroğlu M, Güney M, Aykur M. Non-steroidal anti-inflammatory drug modulates oxidative stress and calcium ion levels in the neutrophils of patients with primary dysmenorrhea. J Reprod Immunol. 2013;100(2):87–92.View ArticlePubMedGoogle Scholar
  15. Yang H, Liu CZ, Chen X, Ma LX, Xie JP, Guo NN, Ma ZB, Zheng YY, Zhu J, Liu JP. Systematic review of clinical trials of acupuncture-related therapies for primary dysmenorrhea. Acta Obstet Gynecol Scand. 2008;87(11):1114–22.View ArticlePubMedGoogle Scholar
  16. Lin JG, Chen YH, Gao XY, Lao L, Lee H, Litscher G. Clinical efficacy, mechanisms, and safety of acupuncture and moxibustion. Evid Based Complement Alternat Med. 2014;2014:356258.PubMedPubMed CentralGoogle Scholar
  17. Zheng X-Y. Guideline for clinical trials of new patent Chinese medicines. 1st ed. Beijing: Ministry of Health of the People’s Republic of China; 1993. p. 263–5.Google Scholar
  18. Hu YL, Lin Q, Li Y, Zheng XM. Effect of eye acupuncture on plasma PGF 2α in patients of primary dysmenorrhea. World J Acupuncture-Moxibustion. 2012;22(1):17–22.View ArticleGoogle Scholar
  19. Kiran G, Gumusalan Y, Ekerbicer HC, Kiran H, Coskun A, Arikan DC. A randomized pilot study of acupuncture treatment for primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol. 2013;169(2):292–5.View ArticlePubMedGoogle Scholar
  20. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). The Cochrane Collaboration, 2011, Available from: http://www.cochrane.org/handbook. Accessed 17 July 2015.
  21. Xu T, Hui L, Juan YL, Min SG, Hua WT. Effects of moxibustion or acupoint therapy for the treatment of primary dysmenorrhea: a meta-analysis. Altern Ther Health Med. 2014;20(4):33–42.PubMedGoogle Scholar
  22. Zhang LM, Yang HY. The 45 cases on single acupuncture treatment for primary dysmenorrhea. Fujian J TCM. 2012;43(2):25–6.Google Scholar
  23. Lin Q, Chen WZ, Li Y, Hu YL. Effect of eye acupuncture on uterine artery blood flow in patients with primary dysmenorrhea. Shanghai J Acupunct Moxibustion. 2012;31(12):885–7.Google Scholar
  24. Cao Y. Acupuncture clinical analysis of primary dysmenorrhea. Master Thesis Heilongjiang Chin Med College 2011: 26-29.Google Scholar
  25. Zhi LX. Randomized controlled study on superficial needling for treatment of primary dysmenorrhea. Zhongguo Zhen Jiu. 2007;27(1):18–21.PubMedGoogle Scholar
  26. Bo LN. A literature mining and randomized controlled trial of moxibustion in treating primary dysmenorrhea. Doctor Thesis Chengdu Chin Med College 2013: 43-60, 67-70.Google Scholar
  27. Ren XL. Clinical study on the treatment of primary Dysmenorrhea with moxibustion. Global Traditional Chin Med. 2013;6(6):431–2.Google Scholar
  28. Zhu Y, Chen RL, Le JI, Miao FR. Efficacy observation of primary dysmenorrhea treated with isolated-herbal moxibustion on Shenque (CV8). Zhongguo Zhen Jiu. 2010;30(6):453–5.PubMedGoogle Scholar
  29. Li JM. Clinical study of electro—acupuncture treatment of primary dysmenorrhea Ci Liao acupoints. Master Thesis. Guangzhou Chin Med College. 2012: 15-17.Google Scholar
  30. Wang K, Pan WY, Duan YH. Clinical study on the treatment of primary dysmenorrhea with auricu1ar acupuncture. Guangdong Med J. 2005;26(12):1728–30.Google Scholar
  31. Yang M. The clinical observation of 36 cases on dysmenorrhea moxibustion treatment of primary dysmenorrhea. Hainan Med J. 2009;20(7):226–7.Google Scholar
  32. Chen LW. The clinical observation of primary dysmenorrhea treated with the Chinese native medicine sticks on the acupuncture point. Master Thesis Guangzhou Chin Med College 2006: 20-22.Google Scholar
  33. Liu C, Zhang HY. Therapeutic effect of moxibustion on primary dysmenorrhea due to damp-cold retention. World J Acupuncture-Moxibustion. 2011;21(3):1–4.Google Scholar
  34. Zhu C. Clinical study on the treatment of haemorrheological nature blood stasis type of primary dysmenorrhea with moxibustion. Hubei J TCM. 2011;33(1):65–6.Google Scholar
  35. Li ZL, Li YQ, Pan FQ, Bian WH, Chu JZ, Zhu PQ. Clinical observation on Chinese herbs acupoint of Yugui wenjing decoction stick to treat haemorrheological nature blood stasis type of primary dysmenorrhea. Modern J Integrated Traditional Chinese Western Med. 2012;21(5):483–4.Google Scholar
  36. Jiang LY. Clinical experience of acupuncture for treatment of 34 cases in primary dysmenorrhea. J Emerg Tradit Chin Med. 2007;16:620–1.Google Scholar
  37. Xing QX. Observation on the therapeutic effect of pricking bloodletting at ear points on primary dysmenorrhea. Shanghai Zhenjiu Zazhi. 2011;30:235–6.Google Scholar
  38. Ji L, Chen RL, Deng PY, Zhou LJ, Do SC, Zhu Y. Treatment effect of herb-partitioned moxibustion for dysmenorrhea of cold stagnation type and its effect on PGF2ɑ and PGE2. Shanghai J Acupunct Moxibustion. 2012;31:882–4.Google Scholar
  39. Sale H, Hedman L, Isberg A. Accuracy of patients’ recall of temporomandibular joint pain and dysfunction after experiencing whiplash: a prospective study. J Am Dent Assoc. 2010;141(7):879–86.View ArticlePubMedGoogle Scholar
  40. Warner TD, Giuliano F, Vojnovic I, Bukasa A, Mitchell JA, Vane JR. Nonsteroid drug selectivities for cyclo-oxygenase-1 rather than cyclo-oxygenase-2 are associated with human gastrointestinal toxicity: a full in vitro analysis. Proc Natl Acad Sci U S A. 1999;96(13):7563–8.View ArticlePubMedPubMed CentralGoogle Scholar
  41. Ruoff G, Lema M. Strategies in pain management: new and potential indications for COX-2 specific inhibitors. J Pain Symptom Manag. 2003;25(2):S21–31.View ArticleGoogle Scholar
  42. Dawood MY. Dysmenorrhea. J Reprod Med. 1990;33(1):168–78.Google Scholar
  43. Vane JR. Towards a better aspirin. Nature. 1994;36(2):215–6.View ArticleGoogle Scholar
  44. Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006;108(2):428–41.View ArticlePubMedGoogle Scholar
  45. Doty E, Attaran M. Managing primary dysmenorrhea. J Pediatr Adolesc Gynecol. 2006;19(5):341–4.View ArticlePubMedGoogle Scholar
  46. Proctor M, Farquhar C. Diagnosis and management of dysmenorrhea. BMJ. 2006;332(7550):1134–8.View ArticlePubMedPubMed CentralGoogle Scholar
  47. Sanfilippo J, Erb T. Evaluation and management of dysmenorrhea in adolescents. Clin Obstet Gynecol. 2008;51(2):257–67.View ArticlePubMedGoogle Scholar
  48. French L. Dysmenorrhea. Am Fam Physician. 2005;71(2):285–91.PubMedGoogle Scholar
  49. Durain D. Primary dysmenorrhea: assessment and management update. J Midwifery Women’s Health. 2004;49(6):520–8.View ArticleGoogle Scholar
  50. Smith CA, Crowther CA, Petrucco O, Beilby J, Dent H. Acupuncture to treat primary dysmenorrhea in women: a randomized controlled trial. Evid Based Complement Alternat Med. 2011;2011:612464.PubMedPubMed CentralGoogle Scholar
  51. Kempf D, Berger D, Ausfeld-Hafter B. Laser needle acupuncture in women with dysmenorrhoea: a randomised controlled double blind pilot trial. Forsch Komplementmed. 2009;16(1):6–12.View ArticlePubMedGoogle Scholar
  52. Chung YC, Chen HH, Yeh ML. Acupoint stimulation intervention for people with primary dysmenorrhea: systematic review and meta-analysis of randomized trials. Complement Ther Med. 2012;20(5):353–63.View ArticlePubMedGoogle Scholar
  53. Abaraogu UO, Tabansi-Ochuogu CS. As acupressure decreases pain, acupuncture may improve some aspects of quality of life for women with primary Dysmenorrhea: a systematic review with meta-analysis. J Acupunct Meridian Stud. 2015;8(5):220–8.View ArticlePubMedGoogle Scholar

Copyright

© The Author(s). 2017

Advertisement