BY SAUNDERS, N. Lic.Ac. BA(Hons) Traditional Acupuncture & BERRY, K. BHSc TCM Acupuncture, MSc Research
Menopause is a natural phenomenon and is defined as 12 consecutive months without a period. The average age of menopause in developed countries is 51 years.1
Although it is a natural process, the years preceding and succeeding the menopause can be associated with various symptoms, ranging in severity from mild to debilitating. The average duration of symptoms is seven years.2
Numerous factors influence the overall impact of menopause, including the age at which it occurs, ethnicity, culture, socio-economic background, general health and wellbeing. Whether menopause is surgically-induced or occurs naturally also plays a vital role. Furthermore, there are differences between women who have given birth to children versus those who have not, with the question of whether this was due to choice or circumstance further complicating the issue. For example, women who have been pregnant but never had children report having a more negative attitude toward menopause. However, women who have never had children are also less likely to report certain symptoms, such as hot flashes and vaginal dryness.3 4
Since the menopausal transition is such an individual and elongated process, tailored treatments such as those used in acupuncture may provide significant benefits.
Various studies have shown that acupuncture may offer relief from some of the most common menopausal symptoms. However, it is currently under-utilized in clinical practice.
Vasomotor symptoms (VMS), including hot flashes and night sweats, are among the most common issues menopausal women experience. They affect approximately 70% of women in Western cultures. VMS are also one of the best-studied areas with regard to acupuncture and menopause.
A 2009 review by Alfhaily and Ewies5 concluded that the majority of studies on acupuncture for VMS reported 50% reductions in hot flashes that lasted for up to six months. A 2015 meta-analysis by Chiu et al.6 supports these results. It reviewed 12 studies with a total 869 participants, finding that acupuncture significantly reduced hot flash frequency and severity. It also found that acupuncture improved menopause-related psychological, somatic, and urogenital symptoms, as well as overall quality of life.
The results of these reviews suggest that acupuncture has significant benefits for women suffering from menopausal VMS.
DEPRESSION AND ANXIETY
Many menopausal women also suffer from mood disorders such as depression and anxiety. This is another area where acupuncture may help.
A 2013 review by Sniezek and Siddiqui7 included six trials with a total of 605 female subjects aged 18–71. Of these studies, four were on depression (with three focusing on major depressive disorder), one was on anxiety, and one was on both conditions. One of the studies involved menopausal women with depression and VMS.
The authors of the study concluded that although the quality of the evidence was mixed, acupuncture was “promising” as a therapy for menopausal women with depression. They went on to say: “At this time, it is reasonable to use acupuncture as an adjunctive therapy for treating depression in postmenopausal women who have vasomotor symptoms.”
An earlier 2007 review by Pilkington et al.8 focused on acupuncture for anxiety. It included 12 controlled trials, 10 if which were RCTs. All of the trials reported positive outcomes.
SLEEP DISTURBANCE AND INSOMNIA
A 2015 review by Berezza et al.9 included 12 studies on acupuncture for sleep disorders in post- menopausal women. The studies involved a wide range of treatment protocols, interventions, and durations. Overall, 75% reported improvements in sleep complaints following acupuncture treatment.
Osteoporosis is a common issue in post-menopausal women. Several large-scale reviews indicate that acupuncture could help.
A 2018 systematic review and meta-analysis by Pan et al.10 included 35 studies and a total of 3014 participants. It found that, compared with pharmaceutical treatment alone, warm acupuncture increased bone mineral density (BMD) of the femur and lumbar spine. It also increased serum calcium and estradiol levels, reduced serum alkaline phosphatase, and relieved pain. Electroacupuncture also had positive effects on serum calcium, serum alkaline phosphatase, and pain.
A 2020 review by Xu et al.11 supported these results. It included 13 systematic reviews and meta-analyses published between 2013 and 2018. They found high quality evidence that acupuncture and moxibustion can improve BMD in primary osteoporosis. They also found that these therapies could benefit visual analog scale (VAS) pain scores, although the quality of the evidence was lower.
COGNITIVE DECLINE AND ALZHEIMER’S DISEASE
The risk of cognitive decline, including Alzheimer’s disease (AD), also increases significantly following menopause. A 2019 systematic review and meta-analysis by Huang et al.12 found that acupuncture provided some benefits. It included 13 studies comparing acupuncture with medication alone. The results showed that acupuncture had positive effects on Mini Mental State Examination scores, Ability of Daily Living Scale scores, AD Assessment Scale-Cognition scores, and a high clinical efficacy rate.
Acupuncture works via numerous physiological mechanisms, accounting for its diverse effects on the human body. One of the most critical of these is purinergic signaling, a system which utilizes adenosine triphosphate (ATP) as a signaling molecule in the regulation of a range of physiological functions. In the short-term, it plays a role in neurotransmission, neuromodulation, and secretion. In the longer-term, it influences proliferation, differentiation, migration, and death, thus directing the activity and fate of cells.13
Purinergic receptors have been investigated as potential therapeutic targets in a broad range of disorders, including many which affect peri and post-menopausal women. They include depression and anxiety, sleep disturbances, osteoporosis, endocrine disorders, cardiovascular, and neurodegenerative disease. In terms of VMS, studies have suggested that acupuncture influences the release of beta-endorphins.7 These neurochemicals are thought to be involved in the pathophysiology of VMS, although this is still not clearly understood.
Acupuncture also appears to influence cortisol, cortisol metabolites, and DHEA levels.10 Cortisol levels tend to increase following menopause, contributing to changes in mood, metabolism, bone density, and cognitive decline. It is, therefore, possible that the same underlying mechanisms play a role in the treatment of VMS, depression, anxiety, sleep disorders, abdominal obesity, osteoporosis, and dementia.
Further suggested mechanisms for acupuncture’s effects on obesity include anti-inflammatory and antioxidant effects, regulating the endocrine system, promoting digestion, and influencing lipid metabolism.14
Meanwhile, animal studies have shown that acupuncture may offer some protection against osteoporosis by regulating the OPG/RANK/RANKL signaling pathways. All of these are involved in the protection of bone tissue.15
Finally, MRI studies on patients with AD or mild cognitive impairment have shown that acupuncture activates and deactivates several regions of the brain. They include the basal ganglia, cerebellum, cognitive, visual, and sensorimotor-related areas.16
Menopause is fast becoming a specialty area. In the past 40 years, our understanding of female endocrinology has improved greatly, expedited by the rapid growth of assisted reproductive therapy.
This growth, coupled with women becoming more vocal about their experiences and seeking solutions, has brought menopause to the forefront of both medicine and the media.
The primary mainstream approach to treating menopausal symptoms is hormone replacement therapy (HRT), comprising either estrogen or progesterone monotherapy, or a combination of the two.
HRT has been controversial since the publication of the Women’s Health Initiative17, which suggested that its use increased the risk of breast cancer, stroke, and pulmonary embolism. However, industry-funded guidelines developed in partnership with clinical specialty groups have pointed to flaws in this study.
Current prescribing guidelines suggest that the benefits of HRT generally outweigh the risks for most women aged 60 or under, or within 10 years of menopause.1 However, there is also evidence that these hormones can increase the risk of breast cancer and ovarian cancer. With so much conflicting information in circulation, the decision regarding whether or not to take HRT is a difficult one. Acupuncture, on the other hand, has a demonstrated track-record of safety and when performed by appropriately trained clinicians, has been found one of the safest treatments in modern medicine.18
Therefore, many women are now choosing other modalities, such as acupuncture, as a first-line treatment. Acupuncturists can also play a crucial therapeutic role by helping to inform and support women in adopting beneficial lifestyle changes.
References:1. Jane FM, Davis SR. A Practitioner’s Toolkit for Managing the Menopause. Climacteric. 2014; 17(5): p.564-579.2.Hillard T, Abernathy K, Hamoda H, et al. British Menopause Society Management of the Menopause Sixth Edition 2017.3. Thurston RC, Joffe H. Vasomotor Symptoms and Menopause: Findings from the Study of Women’s Health across the Nation. Obstetrics and Gynecology Clinics of North America. 2011; 38(3): p. 489-501.4. Hess R, Olshansky E, Ness R, et al. Pregnancy and Birth History Influence Women’s Experience of Menopause. Menopause. 2008;15(3): p. 435-441.6.5. Alfhaily F, Ewies AAA. Acupuncture in managing menopausal symptoms: hope or mirage?. Climacteric. 2007; 10(5): p. 371-380.6. Chiu HY, Pan CH, Shyu YK, Han BC, Tsai PS. Effects of acupuncture on menopause-related symptoms and quality of life in women in natural menopause: a meta-analysis of randomized controlled trials. Menopause. 2015 Feb; 22(2): p. 234-244.7. Sniezek DP, Siddiqui IJ. Acupuncture for Treating Anxiety and Depression in Women: A Clinical Systematic Review. Medical Acupuncture. 2013; 25(3): p.164-172.8. Pilkington K, Kirkwood G, Rampes H, Cummings M, Richardson J. Acupuncture for anxiety and anxiety disorders – a systematic literature review. Acupuncture in Medicine. 2007; 25(1-2): p.1-10.9. Bezerra AG, Pires GN, Andersen ML, Tufik S, Hachul H. Acupuncture to Treat Sleep Disorders in Postmenopausal Women: A Systematic Review. Evidence-Based Complementary and Alternative Medicine. 2015; 2015:563236.10. Pan H, Jin R, Li M, Liu Z, Xie Q, Wang P. The Effectiveness of Acupuncture for Osteoporosis: A Systematic Review and Meta-Analysis. The American Journal of Chinese Medicine. 2018; 46(3): p.489-513.11. Xu G, Xiao Q, Zhou J, et al. Acupuncture and moxibustion for primary osteoporosis: An overview of systematic review. Medicine (Baltimore). 2020; 99(9): e19334.12. Huang, Q., Luo, D., Chen, L. et al. Effectiveness of Acupuncture for Alzheimer’s Disease: An Updated Systematic Review and Meta-analysis. Current Medical Science. 2019; 39: p.500–511.13. Burnstock G. Purinergic Signalling: Therapeutic Developments. Frontiers in Pharmacology. 2017;8:661. Published 2017 Sep 25. doi:10.3389/fphar.2017.0066114. Wang LH, Huang W, Wei D, et al. Mechanisms of Acupuncture Therapy for Simple Obesity: An Evidence-Based Review of Clinical and Animal Studies on Simple Obesity. Evidence-Based Complementary and Alternative Medicine. 2019; 2019:5796381.15. Huang F, Zhao S, Qiu M, et al. Acupuncture for primary osteoporosis: A network meta-analysis of randomized controlled trials protocol. [published correction appears in Medicine (Baltimore). 2019 May;98(21): e15898]. Medicine (Baltimore). 2019;98(15):e15108.16. Shan Y, Wang JJ, Wang ZQ, et al. Neuronal Specificity of Acupuncture in Alzheimer’s Disease and Mild Cognitive Impairment Patients: A Functional MRI Study. Evidence-Based Complementary and Alternative Medicine. 2018; 2018: 761919717. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013; 310(13): p.1353-1368.18. Linde, K., Streng, A., Hoppe, A., Jürgens, S., Weidenhammer, W., & Melchart, D. (2006). The programme for the evaluation of patient care with acupuncture (PEP-Ac) – a project sponsored by ten German social health insurance funds. Acupuncture in Medicine, 24(Suppl), 25–32. https://doi.org/10.113610.1136/aim.24.Suppl.25