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discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/263741652

Effects of acupuncture on menopause-related

symptoms and quality of life in women in natural
menopause: A meta-analysis of randomized
controlled trials
Article in Menopause (New York, N.Y.) July 2014
DOI: 10.1097/GME.0000000000000260 Source: PubMed

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Menopause: The Journal of The North American Menopause Society

Vol. 22, No. 2, pp. 000/000
DOI: 10.1097/gme.0000000000000260
* 2014 by The North American Menopause Society

REVIEW ARTICLE
Effects of acupuncture on menopause-related symptoms and quality
of life in women on natural menopause: a meta-analysis of
randomized controlled trials
Hsiao-Yean Chiu, RN, PhD,1 Chieh-Hsin Pan, RN, MSN,1 Yuh-Kae Shyu, RN, PhD,2
Bor-Cheng Han, PhD,3 and Pei-Shan Tsai, RN, PhD1,4
Abstract
Objective: This meta-analysis aims to evaluate the effects of acupuncture on hot flash frequency and severity,
menopause-related symptoms, and quality of life in women in natural menopause.
Methods: We systematically searched PubMed/Medline, PsychINFO, Web of Science, Cochrane Central Register of Controlled Trials, and CINAHL using keywords such as acupuncture, hot flash, menopause-related symptoms, and quality of life. Heterogeneity, moderator analysis, publication bias, and risk of bias associated with the
included studies were examined.
Results: Of 104 relevant studies, 12 studies with 869 participants met the inclusion criteria and were included in
this study. We found that acupuncture significantly reduced the frequency (g = j0.35; 95% CI, j0.5 to j0.21) and
severity (g = j0.44; 95% CI, j0.65 to j0.23) of hot flashes. Acupuncture significantly decreased the psychological,
somatic, and urogenital subscale scores on the Menopause Rating Scale (g = j1.56, g = j1.39, and g = j0.82,
respectively; P G 0.05). Acupuncture improved the vasomotor subscale score on the Menopause-Specific Quality of
Life questionnaire (g= j0.46; 95% CI, j0.9 to j0.02). Long-term effects (up to 3 mo) on hot flash frequency and
severity (g = j0.53 and g = j0.55, respectively) were found.
Conclusions: This meta-analysis confirms that acupuncture improves hot flash frequency and severity, menopauserelated symptoms, and quality of life (in the vasomotor domain) in women experiencing natural menopause.
Key Words: Acupuncture Y Hot flashes Y Menopause-related symptoms Y Quality of life Y Meta-analysis.

enopause-related symptoms, such as hot flashes,

sleep difficulties, mood swings, and urogenital atrophy,
are the most common and most troubling complaints
reported by women during the menopausal transition, with a
prevalence of approximately 50%.1,2 These symptoms can reduce
womens productivity and quality of life (QoL).3,4

Received February 18, 2014; revised and accepted March 20, 2014.
From the 1Graduate Institute of Nursing, College of Nursing, Taipei
Medical University, Taipei, Taiwan; 2Department of Nursing, Fu Jen
Catholic University, New Taipei City, Taiwan; 3School of Public Health,
Taipei Medical University, Taipei, Taiwan; and 4Sleep Science Center,
Taipei Medical University Hospital, Taipei, Taiwan.
Funding/support: This meta-analysis was supported by a grant (grant
NSC 102-2628-B-038-004-MY3 to P.-S.T.) and by postdoctoral fellowship funding (grant NSC 102-2811-B-038-028 to H.-Y.C.) from the
Ministry of Science and Technology of Taiwan.
Financial disclosure/conflicts of interest: None reported.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal_s Web site (www.menopause.org).
Address correspondence to: Pei-Shan Tsai, RN, PhD, Graduate Institute of Nursing, College of Nursing, Taipei Medical University, 250
Wu-Hsing Street, Taipei 110, Taiwan. E-mail: ptsai@tmu.edu.tw

Menopausal hormone therapy (HT) is considered the most

effective treatment for relieving vasomotor symptoms; however,
long-term HT could increase the risk of chronic cardiovascular
diseases (eg, stroke and venous thromboembolic events)5 and
cancer (eg, ovarian cancer and breast cancer).6,7 Antidepressants,
including selective serotonin reuptake inhibitors, can also be
used for treating vasomotor symptoms.8 However, many periand postmenopausal women refuse or discontinue antidepressant use because of potential adverse effects such as nausea,
palpitations, and headaches. Hence, nonpharmacologic therapies targeting menopause-related symptoms with minimal or no
adverse effects are urgently required. A recent review indicated
that approximately half of women experiencing menopauseassociated symptoms use complementary and alternative medicine therapy, instead of pharmacologic therapies, for managing
their menopausal symptoms.9
Acupuncture, a complementary and alternative medicine
therapy, has been suggested as an effective approach to managing vasomotor symptoms. One systematic review10 including
six articles found that acupuncture exhibited no specific effects
on the frequency and severity of hot flashes in perimenopausal
or postmenopausal women. Nonetheless, since its publication,
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CHIU ET AL

many randomized controlled trials (RCTs) have been published.

Another systematic review11 and a recent meta-analysis12 concluded that acupuncture reduced hot flash frequency and severity more than no intervention, but the observed effect was
not greater than the effect of sham acupuncture. Postmenopausal women with or without breast cancer were included in
that meta-analysis.12 the effects of acupuncture on menopauserelated symptoms should be examined separately in these two
populations. In addition, because both reviews focused on the

effects of acupuncture on the reduction of hot flash frequency

and severity and on overall QoL, other menopause-related
symptoms and subdomains of QoL in women experiencing
natural menopause were not assessed. Therefore, conducting
a meta-analysis of acupuncture for managing menopauserelated symptoms and QoL in women experiencing natural
menopause is relevant.
We estimated the overall effect of acupuncture on hot flash
frequency and severity, menopause-related symptoms, and

TABLE 1. Characteristics of included randomized controlled trials in women in natural menopause

Authors (year of
publication)

Exp/Con

Menopause
status

Sample size
(Exp/Con)

Age (y)

Duration
(wk)

Dose of
treatment (min)

19/18

51.7

Twice 30 min weekly

480

134/133

53.8

10 sessions

12

Unknown

Frequency

Avis et al (2008)

TCMA/SA

Perimenopausal and
postmenopausal

Borud et al (2009)

TCMA/usual care

Postmenopausal

Kim et al (2011)

AG/SA

Perimenopausal and
postmenopausal

25/26

51.5

Twice 20 min/wk in the first

4 wk and once 20 min/wk
in the remaining 3 wk

220

Kim et al (2010)

AG/usual care

Perimenopausal and
postmenopausal

116/59

51.3

Three 20-min sessions per week

240

Nedeljkovic et al (2013) AG/SA

Postmenopausal

10/10

53.0

30 min per session

12

Unknown

Nir et al (2007)

AG/SA

Postmenopausal

12/17

55.3

Twice 20 min/wk in the first

2 wk and once a week in
the remaining 5 wk

180

Painovich et al (2012)

AG/SA

Perimenopausal and
postmenopausal

12/12

56.3

Three 30-min sessions per week

12

1,080

Park et al (2009)

Maxibustion/
wait list

Perimenopausal and
postmenopausal

21/10

51.7

Four sessions in the first 2 wk

and three sessions in the
remaining 2 wk

Unknown

Sunay et al (2011)

TCMA/SA

Postmenopausal

27/26

49.4

Twice 20-min sessions per week

200

Venzke et al (2010)

TCMA/SA

Postmenopausal

27/24

53.4

Twice weekly\ 25 min in the first

4 wk and once a week in the
remaining 8 wk

12

400

Vincent et al (2007)

AG/SA

Perimenopausal and
postmenopausal

51/52

52.0

Biweekly 30-min sessions

300

Wyon et al (2004)

EA/SA

Postmenopausal

15/13

53.9

Twice weekly 30 min in the

12
420
first 2 wk and once a week
in the remaining 10 wk
Follow-up refers to the duration of follow-up after completion of therapy. Exp/Con, experimental/control; AR, attrition rate; ITT, intention-to-treat; TCMA,
traditional Chinese medicine acupuncture; SA, sham acupuncture; NR, not reported; QoL, quality of life; MSQoL, Menopause-Specific Quality of Life; AG,
acupuncture group; MRS, Menopause Rating Scale; EA, electroacupuncture.

Menopause, Vol. 22, No. 2, 2015

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ACUPUNCTURE AND NATURAL MENOPAUSE

QoL in postmenopausal women to provide evidence for best

practices and to provide suggestions for future research.

views and meta-analyses.17 The types of studies, participants,

interventions, comparisons, and outcomes used in this investigation are described.

METHODS
Identification of studies
This meta-analysis was conducted according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) statement, which provides detailed guidelines on
the reporting items that should be included in systematic re-

Studies
We included prospective RCTs that examined the effects
of acupuncture on menopausal symptoms and QoL, included
10 or more (n Q 10) study participants, and were published
or accepted for publication in peer-reviewed journals. No
language restrictions were included.

TABLE 1. Continued
Exp/Con
AR (%)

Use of ITT
analysis

Adverse
effect

Follow-up
(mo)

CV4, KI3, SP6,

BL23, HT6, KI7

0/5.5

Yes

NR

Daily diary

No standard point

2.2/11

No

NR

6 and 12

Hot flash frequency

and severity
Menopause symptoms

Daily diary
MRS

ST36, SP6, LI4, PC6,

HT7, HT8, CV4

7.4/11.5

Yes

None

Hot flash frequency

and severity

Daily diary

6.8/18.6

Yes

Common cold, 4.3%;

muscle pain, 1.7%;
joint pain, 1.7%;
headache, 0.8%; nausea,
0.8% (unrelated?)

0.5 and 1

None

Outcomes

Instruments

Hot flash frequency

and severity
QoL

Daily diary
MSQoL

Hot flash frequency

and severity

Menopause symptoms
Hot flash frequency
and severity

Acupuncture
points

ST36, SP6, LI4, PC6,

HT7, HT8, CV4

MRS
Daily diary
MRS-II

CV4, GV20, GB20, PC6,

ST36, SP6, LI4, KI3

0/0

No

Hot flash frequency

and severity
QoL

Daily diary
MSQoL

Basic: KD3, SP6, REN4,

and UB23; add another
one to two points for
additional symptoms

0/23.5

Yes

Number of vasomotor
symptom
QoL

Daily diary
MSQoL

40/80

No

NR

No

Hot flash frequency

and severity
QoL
Menopause symptoms

Daily diary
MSQoL
MRS

9.5/0

Yes

Discomfort (fatigue,
stomach upsets,
flare-ups, and headache),
19%; burn, 23.8%

No

Menopause symptoms

MRS

3.6/3.7

No

None

No

12.9/14.3

No

None

1 and 3

Yes

None

1 and 7 wk

Yes

NR

3 and 6

Menopause symptoms

Hot flush frequency

Flash score (log)

Hot flash frequency

and severity

Daily diary

Hot flash frequency

Daily diary

DU20, LI4, LI11, PC6, HT7,

DU14, UB15, UB18, UB20,
UB23, REN6, REN17, SP6,
KID3, GB34, ST36, LIV3
CV12, CV4, ST36, SP6

ST36, LI4, KI3, LR3,

EX-NH3, CV3
Select 6-12 points from UB23,
UB20, UB15, UB17, DU9,
DU4, SP9, SP6, LU7, KI6,
KI3, KI7, H6, H7, LIV3,
DU24, GB20
SP4, SP6, HE7, LL11, LIV2,
KI6, LU7, PC6, GB34, LIV3,
REN4, GB20
BL15, BL23, BL32, HT7,
SP6, SP9, LR3, PC6, GV20

Bleeding, 66.7%;
discomfort, 58.3%

9.8/13.5
0/15.4

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CHIU ET AL

Participants
Women experiencing natural menopause and aged between
40 and 60 years were included.
Interventions
Studies that used various forms of acupuncture (ie, traditional Chinese medicine acupuncture [TCMA], acupressure,
electroacupuncture, laser acupuncture, ear acupuncture, and
moxibustion) as interventions were included.
Comparisons
Studies with a control group, either inactive (ie, sham acupuncture or usual care) or active (ie, HT), were included.
Outcome measures
Studies that reported parameters related to the frequency or
severity of hot flashes, to menopause-related symptoms assessed
using the Menopause Rating Scale (MRS), or to QoL assessed
using the Menopause-Specific Quality of Life (MSQoL) questionnaire were included. The MRS describes 11 menopauserelated symptoms (evaluated on a five-point Likert scale) under
three dimensions: psychological, somatic, and urogenital. The
total MRS score ranges from 0 (asymptomatic) to 44 (highest
degree of complaints). The scale exhibits good reliability and
validity.18,19 The MSQoL questionnaire consists of 29 items
evaluated on a seven-point Likert scale. Each item is used to
assess the impact of one of four types of menopausal symptoms
experienced in the last month. The four types of symptoms are
measured in the psychosocial, physical, sexual, and vasomotor
subscales. Higher scores indicate more menopausal symptoms.
Previous studies have demonstrated that the instrument is reliable
and valid.20,21
Data source and searches
We systematically searched electronic databases, including
PubMed/Medline, PsychINFO, Web of Science, Cochrane Central
Register of Controlled Trials, and CINAHL, until December
15, 2013. The search terms were presence of menopause,
menopause-related symptoms, and QoL. These criteria were
combined with Bacupuncture[ OR Bacupuncture points[ OR
Bacupressure[ and Brandomized controlled trials.[
Study selection
Two authors (H.-Y.C. and Y.-K.S.) independently screened
the titles and abstracts of potentially eligible articles by using
the described search strategy. Duplicate studies were removed
from the number of potentially eligible articles. The full texts
of the remaining studies were retrieved and reviewed. Studies
that met the inclusion criteria were selected for meta-analytic
evaluation.
Data extraction and collection
Two reviewers (H.-Y.C. and C.-H.P.) extracted various
data from each publication, including the following: (1) study
characteristics (eg, authors names and year of publication);
(2) participant population characteristics (eg, age, menopause

Menopause, Vol. 22, No. 2, 2015

status, and number of participants in each group); (3) intervention characteristics (eg, type, frequency, duration, and number
of acupuncture points); and (4) outcome measures and instruments (Table 1). Disagreements among researchers were
resolved by discussion until a consensus was reached.

Study quality assessment

Two authors (H.-Y.C. and C.-H.P.) assessed the quality
of each study by using the criteria recommended in the
Cochrane Handbook for Systematic Reviews of Interventions
5.1.0.22 Six domains related to the risk of bias were assessed:
(1) random sequence generation, (2) allocation concealment,
(3) blinding of participants and personnel, (4) blinding of
outcomes assessment, (5) addressing incomplete outcomes
data, and (6) selective reporting. The corresponding author
(P.-S.T.) rechecked discrepancies, and a consensus was reached
by discussion.

Data analysis
Quantitative data were entered into Comprehensive Meta
Analysis software, version 2.0 (Biostat, Englewood, NJ), and
two-sided P values were used. Effect sizes (g) were calculated using the means and SDs of pre-post differences and the
differences between experimental and control group sample
sizes (presented with CIs). An inverse variance random-effects
model was used to analyze data because it is more conservative
than a fixed-effects model.23 In this meta-analysis, the effects of
acupuncture on hot flashes, menopause-related symptoms, and
QoL were examined using the mean difference between baseline and completion of therapy, and the mean difference between completion of therapy and 3 months after completion of
therapy (long-term effects).
To establish whether the results of the studies were consistent, we investigated between-study heterogeneity by evaluating Cochran Q and I2 statistics,24 which indicate the evidence
and proportion of variability across studies that are not explained
by chance alone. Roughly, Q statistics less than 0.05 and I2
values of 50% or more represent substantial heterogeneity,
whereas Q statistics of 0.05 or more and I2 values less than
50% reflect homogeneity across studies. Visual examination
of a forest plot was performed to confirm heterogeneity. To
explore which treatment components affected the effects of
acupuncture on the frequency and severity of hot flashes, we
performed moderator analyses and meta-regression. Specifically, differential effects of different types of acupuncture and
different control groups, as well as interaction effects between
treatment doses and acupuncture, were investigated. In this
study, moderator analyses were limited to instances in which
groups were represented by at least two studies to ensure that
sufficient data could be obtained for analyses. For categorical
moderators, a mixed-effects model was used to compare differences in effect sizes at each comparison.25 Meta-regression
was used to analyze continuous moderators.25 Potential publication bias was examined using a funnel plot. Beggs rank
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ACUPUNCTURE AND NATURAL MENOPAUSE

FIG. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.

correlation test26 and Eggers intercept test27 were used to

examine publication bias, with the significant level set at 0.05.
RESULTS
Search results
Figure 1 shows the flow of information. The literature search
initially identified 106 articles. Of these, 50 duplicates were
excluded using Endnote software. After the initial review,
39 studies were excluded for the following reasons: a randomized controlled design was not used or the participants and
interventions were unrelated to the topic of this study. Seventeen studies were marked for further screening. Five studies
were excluded: two had used the same sample, one was a
quasiexperimental study, one did not provide sufficient data for
analysis, and one included participants with ovary resections.
Twelve studies28<39 were included in the meta-analysis.
Study characteristics
Table 1 shows the study characteristics. The sizes of the
study samples ranged from 20 to 267 participants, yielding a
total of 869 participants. The mean age of the participants was
52.87 years. Of the 12 studies, 6 studies focused on postmenopausal women and 9 studies used a sham acupuncture control
group. The mean intervention duration was 8.5 weeks (range,
4-12 wk), and the mean acupuncture dose was 391.1 minutes

(range, 180-1,080 min). The mean attrition rate for the treatment and control groups were 7.7% and 16.8%. Seven studies
(58%) used intention-to-treat (ITT) analysis. Five (41.6%)
of the included studies reported no adverse effect, and four
studies did not report adverse effects. Only one study examined changes in urine calcitonin geneYrelated peptide (CGRP)
after acupuncture.
Overall effects of acupuncture on hot flash
frequency and severity
As shown in Figure 2, 10 studies28<34,37<39 investigated the
effects of acupuncture on the frequency of hot flashes in women
experiencing natural menopause. A summary effect size of
j0.35 was found (95% CI, j0.5 to j0.21; P G 0.0001). The
Cochran Q and I2 statistics reflected homogeneity (Q = 7.21,
df = 10, P = 0.62, I2 = 0). Eight studies28<34,38 explored the
effects of acupuncture on hot flash severity. Pooling resulted
in a summary effect size of j0.44 (95% CI, j0.65 to j0.23;
P G 0.0001). The Cochran Q and I2 statistics reflected homogeneity (Q = 10.64, df = 7, P = 0.16, I2 = 34.22).
Differential effects of acupuncture type on
hot flash frequency and severity
For hot flash frequency, moderator analyses showed that
TCMA interventions28,29,37 yielded an effect size comparable
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CHIU ET AL

FIG. 2. Forest plots of mean effect sizes for studies measuring hot flash frequency (A) and hot flash severity (B).

with that of non-TCMA acupuncture interventions30<34,38

(g= j0.42 and g = j0.31; P = 0.45). Similarly, moderator
analyses showed that TCMA interventions28,29 yielded an
effect size for hot flash severity comparable with that of nonTCMA acupuncture interventions28,29,32<34,38 (g = j0.48 and
g = j0.42; P = 0.80).
Sham versus usual care controls
For hot flash frequency, the pooled effect size for studies in
which sham acupuncture controls have been used28,30,32<34,37<39
(g = j0.20; 95% CI, j0.41 to 0.01) was significantly smaller
(P = 0.04) than that for studies in which usual care controls
have been used29,31 (g = j0.49; 95% CI, j0.68 to j0.30). For
hot flash severity, the pooled effect sizes for studies in which
sham acupuncture controls have been used29,31 (g = j0.39;
95% CI, j0.68 to j0.09) and for studies in which usual care
controls have been used28,30,32<34,38 (g = j0.50; 95% CI,
j0.83 to j0.18) were not significantly different (P = 0.61).
Interaction effects between treatment
doses and acupuncture
The effect size of acupuncture on hot flash frequency was
not significantly associated with the number of treatment
doses, the number of sessions, and the duration of treatment
in weeks (B = 0.0003, B = 0.01, B = j0.01 and P = 0.57,
P = 0.45, P = 0.50, respectively). For hot flash severity, the

Menopause, Vol. 22, No. 2, 2015

effect size was not significantly associated with the number

of treatment doses, the number of sessions, and the duration
of treatment in weeks (B = 0.0006, B = 0.02, B = j0.03 and
P = 0.23, P = 0.30, P = 0.13, respectively).
Effects of acupuncture on menopause-related symptoms
As shown in Figure 3, four studies30<32,36 used the MRS to
investigate the effects of acupuncture on menopause-related
symptoms. For the psychiatric subscale (eg, sleep problems,
depressed mood, and anxiety), a mean effect size of j1.56
was obtained (95% CI, j2.21 to j0.92; P G 0.0001). The
Cochran Q and I2 statistics reflected heterogeneity (Q = 16.05,
df = 3, P = 0.001, I2 = 81.31). A mean effect size of j1.39 was
obtained (95% CI, j2.04 to j0.75; P G 0.0001) for the somatic subscale (eg, hot flashes, and heart, joint, and muscular discomfort). The Cochran Q and I2 statistics reflected
heterogeneity among studies (Q = 18.02, df = 3, P G 0.0001,
I2 = 83.36). A mean effect size of j0.82 was obtained
(95% CI, j1.46 to j0.19; P = 0.011) for the urogenital
subscale (eg, sexual problems, vaginal dryness, and bladder
problems). The Cochran Q and I2 statistics reflected heterogeneity among studies (Q = 11.45, df = 3, P = 0.01, I2 = 73.79).
Effects of acupuncture on QoL
As shown in Figure 4, three studies32,34,35 used the three
MSQoL subscales to investigate the effects of acupuncture
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ACUPUNCTURE AND NATURAL MENOPAUSE

FIG. 3. Forest plots of mean effect sizes for studies measuring the psychiatric, somatic, and urogenital aspects of the Menopause Rating Scale.

on QoL. A mean effect size of j0.27 was obtained

(95% CI, j0.69 to 0.16; P = 0.23) for the physical subscale.
The Cochran Q and I2 statistics reflected homogeneity
(Q = 0.264, df = 2, P = 0.876, I2 = 0). A mean effect size of
j0.38 was obtained (95% CI, j0.81 to 0.05; P = 0.08) for the
psychiatric subscale. The Cochran Q and I2 statistics reflected homogeneity (Q = 0.215, df = 2, P = 0.898, I2 = 0). For
the sexual subscale, a mean effect size of j0.2 was obtained (95% CI, j0.63 to 0.23; P = 0.36). The Cochran
Q and I2 statistics reflected homogeneity among the studies
(Q = 0.397, df = 2, P = 0.820, I2 = 0). A mean effect size of
j0.46 was obtained (95% CI, j0.9 to j0.02; P = 0.04) for
the vasomotor subscale. However, the Cochran Q and I2 statistics reflected heterogeneity among the studies (Q = 5.942,
df = 2, P = 0.051, I2 = 66.34).
Long-term effects of acupuncture on the frequency and
severity of hot flashes and on menopause-related symptoms
As shown in Figure 5, the long-term effects of acupuncture on
hot flash frequency and severity were investigated in five30<33,39
and four30<33 studies, respectively. Mean effect sizes of j0.53
and j0.55 were obtained for hot flash frequency (95% CI,

j0.76 to j0.3; P G 0.001) and hot flash severity (95% CI,

j0.79 to j0.3; P G 0.0001). The Cochran Q and I2 statistics
reflected homogeneity for both outcomes (Q = 6.05, df = 4,
P = 0.20, I2 = 33.93; Q = 1.93, df = 3, P = 0.59, I2 = 0).
As shown in Figure 5, three studies30<32 used the psychiatric,
somatic, and urogenital subscales of the MRS to investigate the
long-term effects (up to 3 mo after completion of therapy) of
acupuncture on menopause-related symptoms. No significant
long-term effects were found for the psychiatric, somatic, and
urogenital subscales (P 9 0.05).
Publication bias
The funnel plots for all models were inspected and found to
be approximately symmetrical (see Supplementary Figures 1-3,
Supplemental Digital Content 1, http://links.lww.com/MENO/A100).
Regression analyses of Beggs rank correlation test and Eggers
intercept test were not statistically significant for any model,
suggesting the absence of publication bias.
Study quality assessment
Table 2 presents study quality assessment. Most of the
studies achieved high quality scores for random sequence

FIG. 4. Forest plots of mean effect sizes for studies measuring menopause-related quality of life in the psychiatric, physical, sexual, and vasomotor
domains.
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CHIU ET AL

FIG. 5. Forest plots of long-term effect sizes for studies measuring hot flash frequency (A), hot flash severity (B), and menopause-related symptoms (C).

generation (10 low risk), blinding of participants and personnel

(11 low risk), incomplete reporting of outcomes data (9 low
risk), and selective reporting (8 low risk). Seven studies blinded
assessors, and six studies concealed group allocation.

DISCUSSION
This meta-analysis entailed investigating the effects of
acupuncture on menopause-related symptoms and QoL in
women experiencing natural menopause. We found small to
large effect sizes of acupuncture on hot flash frequency and
severity, menopause-related symptoms, and QoL in the vasomotor domain among women experiencing natural menopause. The effects of acupuncture on the frequency and
severity of hot flashes persisted up to 3 months. Because this
meta-analysis included high-quality RCTs with large samples,
our findings should be considered valid.
Although the mechanisms of hot flashes are not well understood, a reduction in the concentration of A-endorphin in the

Menopause, Vol. 22, No. 2, 2015

hypothalamus resulting from low concentrations of estrogen

might be a possible cause. Reduced concentrations of endorphin lead to a drop in the set point of the thermoregulation
center in the hypothalamus40,41 and regulate the release of
CGRP,42 a vasodilator that may mediate the abovementioned
vasomotor symptoms.43 One possible mechanism for the effects of acupuncture on vasomotor symptoms might involve the
excretion of CGRP via modulation of A-endorphin. Although
a previous study44 suggested a significant reduction in urine
CGRP after acupuncture, one study included in this review29
failed to prove the hypothesis. Therefore, the exact mechanism
underlying the effects of acupuncture on vasomotor symptoms
remains unclear.
Arguably, our findings showed that sham acupuncture could
induce a treatment effect comparable with that of true acupuncture for the reduction of hot flash frequency. This result is
in line with previous reviews.11,12 A compelling finding from a
previous systematic review concluded that approximately 60%
of RCTs revealed that sham acupuncture was as efficacious
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Copyright 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

ACUPUNCTURE AND NATURAL MENOPAUSE

TABLE 2. Risk of methodological bias score
Authors (year of
publication)

Random sequence
generation

Avis et al (2008)
+
Borud et al (2009)
+
Kim et al (2011)
+
Kim et al (2010)
+
Nedeljkovic et al (2013)
+
Nir et al (2007)
+
Painovich et al (2012)
+
Park et al (2009)
+
Sunay et al (2011)
j
Venzke et al (2010)
+
Vincent et al (2007)
+
Wyon et al (2004)
?
(+) Low risk; (j) high risk; (?) unclear risk.

Allocation
concealment

Blinding of participants
and personnel

Blinding of outcomes
assessment

Addressing incomplete
outcomes data

Selective
reporting

?
+
+
j
+
j
j
+
j
+
j
+

+
j
+
+
+
+
+
+
+
+
+
+

+
+
+
+
+
j
j
+
j
j
+
j

+
+
+
+
+
+
j
+
+
?
+
?

j
+
+
+
+
+
+
j
+
j
j
+

as true acupuncture, especially when superficial needling was

applied to nonpoints.45 A possible reason for the treatment
effect of sham acupuncture on hot flashes is that sham acupuncture (light touch of the skin) might induce a limbic touch
response, resulting in emotional and hormonal reactions46
such as release of A-endorphin.47,48 Because A-endorphin is
involved in the mechanism of vasomotor symptom reduction
after acupuncture, this contention might explain why sham
acupuncture yields an effect on hot flash frequency similar to
that produced by true acupuncture.
Studies have provided inconsistent findings on the effects
of acupuncture on sleep problems,28,49,50 mood disturbances,28,51
and sexual problems.52 The results from this meta-analysis demonstrated that acupuncture yielded large effect sizes on the severity
of menopause-related symptoms. Previous studies demonstrated that acupuncture could significantly reduce serum folliclestimulating hormone and luteinizing hormone levels and increase
serum estradiol levels. This might be a potential explanation for
the beneficial effects of acupuncture on menopause-related
urogenital symptoms. In addition, the abovementioned mechanism might relieve somatic symptoms and thus improve
psychological symptoms. However, because only four studies
were included to examine the effects of acupuncture on
menopause-related symptoms, more studies are required to
further investigate the effects of acupuncture, as well as its
underlying mechanisms, on the reduction of menopause-related
symptoms. Furthermore, because heterogeneity was found
across the studies, our findings must be interpreted with caution.
Although the beneficial effects of acupuncture on QoL in
postmenopausal women have been explored in a previous
meta-analysis,12 our study differed from the previous one in
that we separately analyzed the effects of acupuncture on
menopause-specific QoL in three domains. Our findings revealed that acupuncture significantly improved QoL in the
vasomotor domain, but not in the psychiatric, physical, and
sexual domains, whereas the previous meta-analysis12 demonstrated no significant improvement in overall QoL in postmenopausal women after acupuncture. Because acupuncture
directly reduces the frequency and severity of hot flashes, it is
therefore reasonable to speculate that QoL in the vasomotor

domain could be improved. Heterogeneity was observed

across studies that were included in the analysis of QoL in
the vasomotor domain. It could partially be explained by the
small number of studies included in the meta-analysis. More
RCTs are required to explore the effects of acupuncture on
menopause-specific QoL.
Compellingly, we found that the effects of acupuncture on
hot flash frequency and severityVbut not on menopauserelated symptoms and QoLVcan be maintained up to 3 months
only. Of the studies included, most located the acupuncture
points based on previous experiences or published evidence
for treating hot flashes. Hence, it is reasonable to infer that the
long-term effects of acupuncture could only be observed in hot
flashes. Nonetheless, because the effects of acupuncture on
menopause-related symptoms and QoL in women on natural
menopause were only investigated in a few studies, more RCTs
are needed to explore the long-term effects of acupuncture.
Among the studies included in this meta-analysis, several
studies that had high attrition rates did not use ITT analysis.34,37
ITT analysis is known to provide the most conservative estimates of treatment effects53 and protects against attrition bias
caused by nonrandom loss to follow-up.54 Thus, it is possible
that the current findings may overestimate the beneficial effects
of acupuncture on menopause-related symptoms and QoL.
The current meta-analysis has several limitations. First, a
relatively small number of RCTs were included, and only one
study compared acupuncture with HT. Second, some included
studies did not report sufficient information on the outcomes
of interest, which may limit the value of the current metaanalysis.
CONCLUSIONS
The current meta-analysis supports that acupuncture may
improve hot flashes, menopause-related symptoms, and QoL
in the vasomotor domain among women in natural menopause.
Effects on hot flashes are maintained up to 1 to 3 months. The
effects of true acupuncture on the reduction of hot flash frequency do not significantly differ from those of sham acupuncture, but are greater than the effects of no intervention.
Moderating effects of treatment doses, sessions, and duration
Menopause, Vol. 22, No. 2, 2015

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CHIU ET AL

have not been found. More rigorous study designs with allocation concealment and assessor blinding and using objective
measurements of menopause-related symptoms (eg, hormone
levels) are needed to evaluate the effects of acupuncture on
menopause-related symptoms in women in natural menopause. In clinical settings, acupuncture should be considered
as an adjunct treatment for reducing menopause-related
symptoms, particularly hot flashes, in addition to HT and
other pharmacologic therapies.

REFERENCES
1. Moilanen J, Aalto AM, Hemminki E, Aro AR, Raitanen J, Luoto R.
Prevalence of menopause symptoms and their association with lifestyle
among Finnish middle-aged women. Maturitas 2010;67:368-374.
2. Gjelsvik B, Rosvold EO, Straand J, Dalen I, Hunskaar S. Symptom
prevalence during menopause and factors associated with symptoms and
menopausal age. Results from the Norwegian Hordaland Womens Cohort Study. Maturitas 2011;70:383-390.
3. Hess R, Thurston RC, Hays RD, et al. The impact of menopause on
health-related quality of life: results from the STRIDE longitudinal study.
Qual Life Res 2012;21:535-544.
4. Dibonaventura MD, Wagner JS, Alvir J, Whiteley J. Depression, quality
of life, work productivity, resource use, and costs among women
experiencing menopause and hot flashes: a cross-sectional study. Prim
Care Companion CNS Disord 2012;14:PCC.12m01410.
5. Main C, Knight B, Moxham T, et al. Hormone therapy for preventing
cardiovascular disease in post-menopausal women. Cochrane Database
Syst Rev 2013;4:CD002229.
6. Greiser CM, Greiser EM, Doren M. Menopausal hormone therapy and
risk of ovarian cancer: systematic review and meta-analysis. Hum Reprod
Update 2007;13:453-463.
7. Bakken K, Fournier A, Lund E, et al. Menopausal hormone therapy and
breast cancer risk: impact of different treatments. The European Prospective
Investigation Into Cancer and Nutrition. Int J Cancer 2011;128:144-156.
8. Shams T, Firwana B, Habib F, et al. SSRIs for hot flashes: a systematic
review and meta-analysis of randomized trials. J Gen Intern Med
2014;29:204-213.
9. Posadzki P, Lee MS, Moon TW, Choi TY, Park TY, Ernst E. Prevalence
of complementary and alternative medicine (CAM) use by menopausal
women: a systematic review of surveys. Maturitas 2013;75:34-43.
10. Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot
flushes: a systematic review. Climacteric 2009;12:16-25.
11. Cho SH, Whang WW. Acupuncture for vasomotor menopausal symptoms: a systematic review. Menopause 2009;16:1065-1073.
12. Dodin S, Blanchet C, Marc I, et al. Acupuncture for menopausal hot
flushes. Cochrane Database Syst Rev 2013;7:CD007410.
13. Gallicchio L, Whiteman MK, Tomic D, Miller KP, Langenberg P, Flaws
JA. Type of menopause, patterns of hormone therapy use, and hot flashes.
Fertil Steril 2006;85:1432-1440.
14. Bhattacharya SM, Jha A. A comparison of health-related quality of life
(HRQOL) after natural and surgical menopause. Maturitas 2010;66:431-434.
15. Topatan S, Yildiz H. Symptoms experienced by women who enter into
natural and surgical menopause and their relation to sexual functions.
Health Care Women Int 2012;33:525-539.
16. Ozdemir S, Celik C, Gorkemli H, Kiyici A, Kaya B. Compared effects of
surgical and natural menopause on climacteric symptoms, osteoporosis,
and metabolic syndrome. Int J Gynaecol Obstet 2009;106:57-61.
17. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items
for Systematic Reviews and Meta-Analyses: the PRISMA statement.
Open Med 2009;3:e123-e130.
18. Heinemann K, Ruebig A, Potthoff P, et al. The Menopause Rating Scale
(MRS) scale: a methodological review. Health Qual Life Outcomes
2004;2:45.
19. Schneider HP, Heinemann LA, Rosemeier HP, Potthoff P, Behre HM.
The Menopause Rating Scale (MRS): reliability of scores of menopausal
complaints. Climacteric 2000;3:59-64.

10

Menopause, Vol. 22, No. 2, 2015

20. Kulasingam S, Moineddin R, Lewis JE, Tierney MC. The validity of the
Menopause Specific Quality of Life Questionnaire in older women.
Maturitas 2008;60:239-243.
21. Hilditch JR, Lewis J, Peter A, et al. A menopause-specific quality of life
questionnaire: development and psychometric properties. Maturitas
1996;24:161-175.
22. Higgins J, Green S, eds. Cochrane Handbook for Systematic Review of
Intervention 5.1.0 (updated March 2011). The Cochrane Collaboration.
2011. Available at: http://www.cochrane-handbook.org.
23. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin
Trials 1986;7:177-188.
24. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-560.
25. Lipsey M, Wilson D, eds. Practical Meta Analysis. Thousand Oaks, CA:
Sage; 2001.
26. Begg CB, Mazumdar M. Operating characteristics of a rank correlation
test for publication bias. Biometrics 1994;50:1088-1101.
27. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis
detected by a simple, graphical test. BMJ 1997;315:629-634.
28. Avis NE, Legault C, Coeytaux RR, et al. A randomized, controlled pilot
study of acupuncture treatment for menopausal hot flashes. Menopause
2008;15:1070-1078.
29. Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flushes
Among Menopausal Women (ACUFLASH) study, a randomized controlled trial. Menopause 2009;16:484-493.
30. Kim DI, Jeong JC, Kim KH, et al. Acupuncture for hot flushes in perimenopausal and postmenopausal women: a randomised, sham-controlled
trial. Acupunct Med 2011;29:249-256.
31. Kim KH, Kang KW, Kim DI, et al. Effects of acupuncture on hot flashes
in perimenopausal and postmenopausal womenVa multicenter randomized clinical trial. Menopause 2010;17:269-280.
32. Nedeljkovic M, Tian L, Ji P, et al. Effects of acupuncture and Chinese
herbal medicine (Zhi Mu 14) on hot flushes and quality of life in postmenopausal women: results of a four-arm randomized controlled pilot
trial. Menopause 2014;21:15-24.
33. Nir Y, Huang MI, Schnyer R, Chen B, Manber R. Acupuncture for
postmenopausal hot flashes. Maturitas 2007;56:383-395.
34. Painovich JM, Shufelt CL, Azziz R, et al. A pilot randomized, singleblind, placebo-controlled trial of traditional acupuncture for vasomotor
symptoms and mechanistic pathways of menopause. Menopause 2012;
19:54-61.
35. Park JE, Lee MS, Jung S, et al. Moxibustion for treating menopausal hot
flashes: a randomized clinical trial. Menopause 2009;16:660-665.
36. Sunay D, Ozdiken M, Arslan H, Seven A, Aral Y. The effect of acupuncture on postmenopausal symptoms and reproductive hormones: a
sham controlled clinical trial. Acupunct Med 2011;29:27-31.
37. Venzke L, Calvert JF Jr, Gilbertson B. A randomized trial of acupuncture
for vasomotor symptoms in post-menopausal women. Complement Ther
Med 2010;18:59-66.
38. Vincent A, Barton DL, Mandrekar JN, et al. Acupuncture for hot flashes: a
randomized, sham-controlled clinical study. Menopause 2007;14:45-52.
39. Wyon Y, Wijma K, Nedstrand E, Hammar M. A comparison of acupuncture and oral estradiol treatment of vasomotor symptoms in postmenopausal women. Climacteric 2004;7:153-164.
40. Borud E, Grimsgaard S, White A. Menopausal problems and acupuncture. Auton Neurosci 2010;157:57-62.
41. Sturdee DW. The menopausal hot flushVanything new? Maturitas
2008;60:42-49.
42. Collin E, Frechilla D, Pohl M, et al. Opioid control of the release of
calcitonin geneYrelated peptide-like material from the rat spinal cord in
vivo. Brain Res 1993;609:211-222.
43. Wyon Y, Frisk J, Lundeberg T, Theodorsson E, Hammar M. Postmenopausal women with vasomotor symptoms have increased urinary excretion of calcitonin geneYrelated peptide. Maturitas 1998;30:289-294.
44. Wyon Y, Lindgren R, Lundeberg T, Hammar M. Effects of acupuncture on
climacteric vasomotor symptoms, quality-of-life, and urinary-excretion of
neuropeptides among postmenopausal women. Menopause 1995;2:3-12.
45. Moffet HH. Sham acupuncture may be as efficacious as true acupuncture:
a systematic review of clinical trials. J Altern Complement Med 2009;
15:213-216.
46. Lund I, Lundeberg T. Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls? Acupunct Med 2006;24:13-15.
* 2014 The North American Menopause Society

Copyright 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

ACUPUNCTURE AND NATURAL MENOPAUSE

47. Benedetti F, Arduino C, Amanzio M. Somatotopic activation of opioid
systems by target-directed expectations of analgesia. J Neurosci 1999;
19:3639-3648.
48. Amanzio M, Benedetti F. Neuropharmacological dissection of placeboanalgesia: expectation-activated opioid systems versus conditioningactivatedspecific subsystems. J Neurosci 1999;19:484-494.
49. Hachul H, Garcia TK, Maciel AL, Yagihara F, Tufik S, Bittencourt L.
Acupuncture improves sleep in postmenopause in a randomized,
double-blind,placebo-controlled study. Climacteric 2013;16:36-40.
50. Huang MI, Nir Y, Chen B, Schnyer R, Manber R. A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect
on nocturnal hot flashes and sleep quality. Fertil Steril 2006;86:700-710.

51. Dormaenen A, Heimdal MR, Wang CE, Grimsgaard AS. Depression in

postmenopause: a study on a subsample of the Acupuncture on Hot
Flushes Among Menopausal Women (ACUFLASH) study. Menopause
2011;18:525-530.
52. Dong H, Ludicke F, Comte I, Campana A, Graff P, Bischof P. An exploratory pilot study of acupuncture on the quality of life and reproductive hormone secretion in menopausal women. J Altern Complement Med
2001;7:651-658.
53. Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999;319:670-674.
54. Lachin JM. Statistical considerations in the intent-to-treat principle.
Control Clin Trials 2000;21:167-189.

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