Acupuncture for polycystic ovary syndrome – A cross-sectional survey of clinical practice amongst acupuncturists trained in reproductive medicine

Abstract

Introduction

Polycystic ovary syndrome (PCOS) is a complex lifelong disorder. While previous research reported on the effectiveness of acupuncture for PCOS symptoms, robust information on how PCOS is treated in community clinical practice remains sparse. This study explores how practitioners with training and certification in biomedicine and acupuncture for menstrual and reproductive health, American Board of Oriental Reproductive Medicine (ABORM) Fellows, approach the treatment of people with PCOS within the acupuncture clinic setting.

Methods

Between February and March 2020, ABORM Fellows (n = 346) received a link to an online survey collecting characteristics of point selection, rationale, treatment frequency, and outcome measures used. Quantitative data was analysed using descriptive statistics. Qualitative data was coded, checked for interrater reliability, and analysed using a qualitative descriptive approach.

Results

One hundred and twenty-seven ABORM Fellows responded (36.7%). Practitioners reported a pragmatic approach to the treatment of PCOS in their acupuncture clinics, consistent with practising using a partnership model, especially with respect to treatment timings and frequency, often dictated by their patients’ practical and financial considerations. Acupuncture points SP6 (Sanyinjiao), SP9 (Yinlingquan), LR3 (Taichong), EX-CA-1 (Zigong), and CV4 (Guanyuan) were commonly used, following a combination of rationales provided including Drain Damp, Tonify the Spleen, and both Qi and blood movement. Local anatomy, timing of ovulation, and knowledge from research literature on acupuncture for PCOS also influenced point selection rationale.

Conclusions

When treating PCOS in clinical practice, ABORM Fellows rely on both traditional and modern aspects of acupuncture and biomedicine to inform diagnosis, treatment, and outcome measures.

Introduction

Polycystic ovary syndrome (PCOS) is a complex disorder with lifelong endocrine, metabolic, and psychological co-morbidities, that occur throughout the reproductive lifespan [1], [2], [3], when its characteristic menstrual cycle disturbances account for 70–80% of anovulatory infertility [4,5]. People with PCOS can also experience hirsutism, acne, and male pattern alopecia [1,6], along with metabolic complications and hyperinsulinemia from insulin resistance, resulting in decreased health-related quality of life and increasing the prevalence of anxiety and depression [7,8]. PCOS is diagnosed on the basis of clinical signs of oligo- or amenorrhea, the presence of multi-follicular or polycystic ovary or ovaries, and clinical or biochemical signs of hyperandrogenism [6,9,10]. Depending on the population studied and the diagnostic criteria used, prevalence is believed to be between 5% and 20% [3,6,11], with an estimated hospitalization rate twice as high for people with PCOS in comparison to the general population [3,12]. The economic burden of PCOS has been estimated at USD$8 billion per year in the USA [11], while in the U.K. [13] and in Australia [1,14] it has been conservatively calculated at USD$312 million and USD$285 million per year, respectively.

Hormonal contraceptives, clomiphene, and metformin had been classified as first-line treatment options [15] until the publication of the 2018 International Evidence-Based Guideline for the Assessment and Management of PCOS [6]. The 2018 guideline recommends lifestyle interventions as first-line treatment, advising healthcare practitioners to look at patients holistically in order to address lifestyle and emotional well-being, rather than simply addressing PCOS symptoms [6,16].

People with PCOS have expressed a preference for the use of traditional, complementary, integrative medicine (TCIM) approaches for the management of symptoms [17]. They report a belief in acupuncture's potential benefits and are open to its use alongside lifestyle interventions for weight management [18]. The overall effects of acupuncture and other modalities of traditional Chinese medicine (TCM) for the management of clinical symptoms of PCOS (used either alone or in combination with lifestyle advice or medication) have been reported in research [19], [20], [21], [22], [23], [24], [25]. Acupuncture has been shown to restore regular menstrual cycles [22,[24], [25], [26]] and ovulation rate [24]. Electroacupuncture (EA) studies revealed how it can normalise gene expression in skeletal muscle in a similar way to exercise [27] and how it can improve glucose metabolism [27,28]. Improvements in health-related quality of life [19,22,26] and body mass index [19,28] have also been reported in trials of acupuncture and TCM modalities. Although promising, data from large-scale, well-designed RCTs is still insufficient to draw robust conclusions and the quality of evidence ranges from moderate to very low [25].

Our team has previously reported that PCOS ranks amongst the most commonly seen conditions within the variety of menstrual health issues that acupuncturists in Australia and New Zealand see in their clinics [29,30], but robust information on how PCOS is treated in acupuncture clinical practice is still sparse. Despite patient demand and positive attitudes from healthcare practitioners towards integrating acupuncture into conventional care, implementation challenges in most Western countries remain due to paradigm differences between the predominant biomedical system, and acupuncture's “culturally foreign” practice framework [31,32].

Surveys of real-world practice are one of the recommendations included in the strategy to address discernible discrepancies between basic research and clinical practice of acupuncture [33]. Previous research has demonstrated that acupuncture practice varies considerably by geographic location, which may be due to factors including differences in practitioner training and their role within the healthcare system, with most practitioners outside of China working in private practice rather than the hospital or mainstream medical system [34,35]. One key difference in acupuncture practice is how frequently treatment is delivered, with much higher treatment frequencies and better treatment outcomes reported in China compared to other countries [36], where delivering frequent treatments is often a barrier [37]. Therefore, acupuncture practice characteristics are often linked to the predominant healthcare model.

A survey of acupuncturists in the U.K. identified the need for specialist up-to-date knowledge of TCM, biomedicine, and research in the field of reproductive health, highlighting the example provided by the American Board of Oriental and Reproductive Medicine (ABORM) in the USA [38]. Following expansion throughout North America, the ABORM has since become an international organisation, allowing practitioners worldwide to complete post-graduate continuing professional development requirements and examination [39] to obtain board-certification and become ABORM Fellows. Some ABORM Fellows are prolific contributors to acupuncture research literature and dissemination [40], [41], [42], [43], [44], which may result in a more in-depth understanding of current best evidence for treatment of PCOS.

This study describes aspects of the clinical approach by ABORM Fellows when treating people with PCOS, including acupuncture point selection, rationale, treatment frequency, and outcome measures.