acupuncture for treating primary and secondary dysmenorrhea (period pain)

DR MIKE ARMOUR

Dysmenorrhea and pelvic pain

Post doctoral research fellow, NICM, Western Sydney University, Australia

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THE PROBLEM : PRIMARY DYSMENORRHEA

• Most common form of period pain (French 2008).

• Effects at least half of all women during their reproductive life (Latthe 2006, Zahradnik 2010).

• Reduces quality of life (Burnett et al. 2005; Campbell & McGrath 1997; Hillen et al. 1999).

• The most common reason for school absenteeism amongst adolescent girls (Davis & Westhoff 2001).

• Around 5-30% of women miss one or more days of work or school per month due to menstrual pain (Zahradnik 2010, Andersch & Milsom 1982).

• Affects school performance (Banikarim 2000, Hillen 1999).

• Despite these negative effects women under-report dysmenorrhea during medical consultations (Jamieson & Steege 1996; Sundell, Milsom, & Andersch 1990).

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• Most common symptom is suprapubic cramping and pain, occurring shortly (<8 hours) after the onset of menstrual bleeding and usually worse in the first 48 hours of menses when menstrual flow is heaviest (Proctor & Farquhar 2006).

• Other common symptoms are headache, nausea, vomiting, back or leg pain, fatigue, bloating and bowel changes (Hillen 1999).

THE SYMPTOMS

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THE CAUSE

• Multiple possible pathways but the primary contributor is an excess of prostaglandin (PGF2a) causing uterine ischemia (Harel 2008, Dawood 2006).

• Secondary symptoms are due to prostaglandins entering systemic circulation (Howard 2000).

• TCM perspective is that primary dysmenorrhea is often caused by dietary or lifestyle imbalance (Zhu 2009).

• A number of patterns underlie primary dysmenorrhea, dependent on the presenting signs and symptoms.

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Current best practice guidelines for biomedical treatments include:

• Non-steroidal anti-inflammatories (NSAIDS) such as ibuprofen, naproxen sodium and mefenamic acid. Reduces the amount of prostaglandins released (Marjoribanks 2010).

• Combined oral contraceptive pill (COC). Reduces pain via suppressing ovulation and reducing the thickness of the uterine lining causing less prostaglandin release (Wong 2009).

Three major areas:

• Approximately 25% of women do not get sufficient relief from NSAIDs or the COC (Dawood 1990; Howard et al. 2000).

• NSAIDs have significant adverse events including nausea, headache and dizziness (Griffin 1998; Marjoribanks et al. 2010).

• The COC is not suitable for women who do not desire contraception

CURRENT TREATMENTS

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Acupunctures effectiveness in treating period pain has been discussed in recent systematic reviews, however many of the trials included have had methodological issues (Cho 2010; Smith 2016).

There are a number of clinical issues with current acupuncture trials:• Most of the RCTs from China use daily or near daily treatment, that may

not be possible in Australia or New Zealand (NZ).• All of the RCTs either did not include or did not report on the use of

moxibustion and self-care advice, which are common, characteristic components of acupuncture treatment.

• Many trials from China used electro-acupuncture, which is not commonly used in clinical practice in Australia or NZ (Smith 2014).

ACUPUNCTURE FOR PRIMARY DYSMENORRHEA

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Manualisation is a suitable option for balancing a loosely and tightly defined intervention (Schnyer 2002).

• Manualisation allows the flexibility to choose points based on TCM diagnosis. Patients have their history taken, a TCM diagnosis given based on their signs and symptoms and the practitioner is able to choose from a range of points, as well as co-interventions, such as moxibustion.

• How do we decide what points are useful and effective in treating primary dysmenorrhea ?

• Focus groups and interviews with practitioners who have experience with treating women’s health conditions.

• Practitioners are asked to rate which points (taken from a number of textbooks) they think are compulsory or optional in the treatment of

primary dysmenorrhea. Practitioners can add their own point suggestions.

WHAT ARE WE DOING

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Commonly treated in clinic as part of other conditions (i.e. fertility).Qi and blood stagnation most common pattern seen, followed by cold stagnation. Damp-heat not commonly seen.Diet and lifestyle advice considered to be vital in both initial and long term success. This advice was tailored to the individual but often followed common themes.

Many practitioners found it was difficult for women to afford the time and money to have regular treatmentMost practitioners would like to treat weekly or twice weekly in an ideal world.Practitioners all felt that 3 menstrual cycles of treatment would produce significant improvement.Almost all practitioners did not use EA in their practice. This was mostly due to feeling that there was a lack of training in this area.

PRACTITIONERS EXPERIENCE

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4 group factorial RCT – designed to test the contribution of changing treatment timing or mode of needle stimulation. 12 treatments in total, delivered over three menstrual cycles. All treatment sessions 60 minutes long, needles retained 20-30 minutes at practitioner discretion.

• All groups received a treatment in the first 48 hours of menses. • All groups could use moxibustion.• All groups received diet and lifestyle (self-care) advice based on their

TCM diagnosis.

OUR TRIAL

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DEMOGRAPHICS

HF-MA (n=18) HF-EA (n=19) LF-MA (n=19) LF-EA (n=18) Total (N=74) p-value mean (SD) mean (SD) mean (SD) mean (SD) mean (SD) Demographic Age 29.9 (7.2) 31.2 (7.4) 31.1 (6.6) 29.3 (5.6) 30.4 (6.7) 0.80BMI (n %)*

Underweight 0 (0.0) 2 (10.5) 1 (5.2) 0 (0.0) 3 (4.0) Normal 9 (50.0) 8 (42.1) 13 (68.4) 11 (61.1) 41 (55.4) 0.50

Overweight 4 (22.2) 6 (31.5) 4 (21.0) 4 (22.2) 18 (24.3) Obese 5 (27.7) 3 (15.7) 1 (5.2) 3 (16.6) 12 (16.2)

Previously given birth No 14 (77.7) 16 (84.2) 13 (68.4) 15 (83.3) 58 (78.4) 0.62

Yes 4 (22.2) 3 (15.7) 6 (31.6) 3 (16.6) 16 (21.6) Menstrual characteristics Age of Menarche (years) 12.5 (1.7) 12.7 (1.4) 13.2 (1.6) 12.3 (0.9) 12.7 (1.5) 0.31Age of onset of dysmenorrhea (years) 15.8 (6.8) 13.7 (1.5) 15.9 (5.8) 13.3 (1.5) 14.7 (4.7) 0.19Length of menstrual cycle (days) 28.1 (1.8) 28.7 (2.1) 27.8 (2.0) 28.6 (2.1) 28.3 (2.0) 0.50Length of menses (days) 5.3 (1.9) 4.9 (0.8) 5.4 (1.2) 5.6 (1.7) 5.3 (1.2) 0.49Additional Menstrual Symptoms

No 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Yes 18 (100) 19 (100) 19 (100) 18 (100) 74 (100) 1.0

Pain relief with analgesia No - Pain still present 2 (11.1) 2 (10.5) 0 (0.0) 0 (0.0) 4 (5.4)

Yes - Partial Relief 13 (72.2) 16 (84.2) 15 (78.9) 17 (94.4) 61 (82.4) 0.37Yes - Complete relief 3 (16.6) 1 (5.2) 3 (15.7) 1 (5.6) 8 (10.8)

Currently drinking alcohol No 2 (11.1) 3(15.7) 9(47.3) 3(16.6) 17 (22.9) 0.03*

Yes 16 (88.9) 16(84.2) 10 (52.6) 15(83.3) 57 (77.0) Expectation of benefit from

acupuncture Unsure 9 (50.0) 4 (21.0) 10 (52.6) 7 (38.8) 30 (40.5)

Probably will help 4 (22.2) 14 (73.6) 8 (42.1) 8 (44.4) 34 (46.0) 0.040*Definitely will help 5 (27.8) 1 (5.2) 1 (5.2) 3 (16.6) 10 (13.5)

SF-36 HRQoL Physical function 55.8 (2.9) 55.0 (3.9) 52.8 (8.4) 53.7 (7.4) 54.3 (6.1) 0.46

Role physical 54.8 (5.0) 46.4 (9.7) 50.2 (7.8) 47.6 (8.0) 49.7 (8.4) 0.01 *Bodily pain 49.1 (7.4) 43.6 (5.3) 44.8 (9.3) 43.4 (7.4) 44.9 (7.7) 0.08

General health 51.3 (10.6) 50.4 (10.4) 52.8 (9.9) 51.6 (7.7) 51.5 (9.6) 0.90Vitality 48.1 (9.8) 45.4 (7.8) 48.2 (9.9) 48.9 (6.5) 47.7 (8.6) 0.61

Social function 50.7 (8.2) 43.9 (11.3) 44.9 (10.7) 47.6 (7.0) 46.7 (9.7) 0.15Role emotional 49.6 (6.6) 47.6 (8.9) 47.6 (8.9) 49.0 (8.0) 48.4 (8.1) 0.83Mental health 51.0 (6.3) 50.3 (5.8) 47.3 (8.1) 49.6 (7.2) 49.5 (6.9) 0.38

Overall mental component 48.1 (8.1) 44.8 (10.0) 46.1 (9.4) 47.9 (8.7) 46.7 (9.0) 0.68Overall physical component 54.1 (6.6) 49.4 (6.7) 51.4 (6.3) 49.3 (6.9) 51.0 (6.8) 0.13

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PAIN SCORE CHANGESGroup HF–MA

n=18HF–EAn=19

LF–MAn=19

LF–EAn=18

Unadjusted Mean [95% CI]

Adjusted Mean [95% CI]




Adjusted Mean [95% CI



Peak pain (Day 1-3 of menstrual period)

Baseline 4.5 [3.5 to 5.4]

4.4 [3.4 to 5.5]

5.1 [4.2 to 6.0]

5.7 [4.7 to 6.8]

5.3 [4.4 to 6.2] 5.5 [4.5 to 6.5]

4.7 [3.7 to 5.7] 5.0 [3.9 to 6.0]

Month 1 3.4 [2.5 to 4.4]

3.4 [2.4 to 4.4]

4.0 [3.1 to 5.0]

4.6 [3.6 to 5.7]

4.7 [3.8 to 5.7] 4.9 [4.0 to 5.9]

3.8 [2.8 to 4.8] 4.0 [3.0 to 5.0]

Month 2 3.7 [2.8 to 4.6]

3.7 [2.6 to 4.7]

4.0 [3.0 to 4.9]

4.6 [3.5 to 5.6]

4.1 [3.2 to 5.1] 4.3 [3.3 to 5.3]

3.9 [2.9 to 4.9] 4.1 [3.1 to 5.2]

Month 3 3.4 [2.5 to 4.4]

3.4 [2.3 to 4.5]

3.3 [2.3 to 4.2]

3.9 [ 3.0 [2.1 to 4.0] 3.2 [2.2 to 4.2]

3.8 [2.8 to 4.8] 4.1 [3.0 to 5.1]

1 month follow up 2.7 [1.8 to 3.6]

2.7 [1.6 to 3.8]

3.7 [2.8 to 4.7]

4.3 [3.2 to 5.4]

3.4 [2.5 to 4.4] 3.7 [2.7 to 4.6]

3.7 [2.8 to 4.8] 4.0 [2.9 to 5.0]


2.8 [1.8 to 3.9]

3.6 [2.6 to 4.5]

4.2 [3.1 to 5.2]

3.5 [2.5 to 4.5] 3.7 [2.7 to 4.7]

3.7 [2.8 to 4.7] 4.0 [ 2.9 to 5.0]


2.9 [1.8 to 4.0]

3.6 [2.6 to 4.5]

4.2 [3.1 to 5.2]

3.8 [2.8 to 4.7] 4.0 [3.0 to 4.9]

4.0 [3.0 to 4.9] 4.2 [3.2 to 5.3]

Average Pain Baseline 2.4 [1.7 to

3.1]2.6 [1.8 to

3.3]2.7 [2.1 to

3.4]3.3 [2.6 to

4.1]3.2 [2.5 to 3.9] 3.5 [2.8 to

4.2]2.6 [1.9 to 3.3] 2.9 [2.2 to 3.6]

Month 1 2.2 [1.5 to 2.9]

2.3 [1.6 to 3.1]

2.6 [1.9 to 3.3]

3.3 [2.5 to 4.0]

2.7 [2.1 to 3.4] 3.0 [2.4 to 3.7]

2.4 [1.7 to 3.1] 2.7 [2.0 to 3.4]

Month 2 2.5 [1.8 to 3.3]

2.7 [2.0 to 3.5]

2.4 [1.7 to 3.1]

3.0 [2.3 to 3.8]

2.5 [1.8 to 3.1] 2.8 [2.1 to 3.5]

2.2 [1.5 to 2.9] 2.5 [1.8 to 3.2]

Month 3 2.1 [1.4 to 2.8]

2.3 [1.5 to 3.0]

2.0 [1.4 to 2.8]

2.7 [1.9 to 3.4]

1.7 [1.0 to 2.4] 2.0 [1.7 to 3.1]

2.2 [1.5 to 3.0] 2.5 [1.8 to 3.2]


1.8 [1.0 to 2.6]

2.3 [1.6 to 3.0]

2.9 [2.2 to 3.7]

2.0 [1.4 to 2.8] 2.4 [1.7 to 3.1]

2.2 [1.5 to 3.0] 2.6 [1.8 to 3.3]


1.7 [1.0 to 2.5]

2.3 [1.6 to 3.0]

2.9 [2.1 to 3.6]

2.0 [1.4 to 2.8] 2.3 [1.6 to 3.0]

2.2 [1.5 to 3.0] 2.5 [1.8 to 3.2]


2.0 [1.2 to 2.7]

2.3 [1.6 to 3.0]

2.9 [2.1 to 3.6]

2.3 [1.6 to 3.0] 2.6 [1.9 to 3.3]

2.4 [1.6 to 3.0] 2.7 [1.9 to 3.4]

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OTHER PAIN OUTCOMES

HF–MAn=18

HF–EAn=19

LF–MAn=19

LF–EAn=18





Unadjusted Mean [95% CI] Adjusted Mean [95% CI

Unadjusted Mean [95% CI] Adjusted Mean [95% CI]

Duration of pain (hours per day)

Baseline 4.0 [1.9 to 6.2] 3.0 [0.9 to 5.2] 6.6 [4.5 to 8.8] 7.4 [5.3 to 9.6] 7.0 [4.8 to 9.1] 7.0 [5.0 to 9.0] 6.5 [4.3 to 8.7] 6.5 [4.4 to 8.6]

Month 1 4.0 [1.7 to 6.1] 2.9 [0.8 to 5.1] 6.4 [4.3 to 8.6] 7.2 [5.1 to 9.4] 7.3 [5.2 to 9.5] 7.4 [5.4 to 9.4] 6.5 [4.4 to 8.8] 6.6 [4.5 to 8.8]



1 month follow up 3.1 [0.9 to 5.3] 2.1 [0.0 to 4.3] 5.2 [3.1 to 7.4] 6.0 [3.9 to 8.2] 5.2 [3.0 to 7.3] 5.2 [3.2 to 7.2] 4.0 [1.8 to 6.2] 4.1 2.0 to 6.2]

6 month follow up 3.0 [0.8 to 5.2] 2.0 [0.0 to 4.1] 5.1 [3.0 to 7.2] 6.0 [3.8 to 8.1] 5.3 [3.1 to 7.4] 5.3 [3.3 to 7.3] 4.0 [1.8 to 6.2] 4.0 [2.0 to 6.1]

12 month follow up 3.3 [1.1 to 5.5] 2.3 [0.1 to 4.5] 4.9 [2.8 to 7.1] 5.8 [3.6 to 8.0] 5.5 [3.4 to 7.7] 5.6 [3.6 to 7.6] 4.3 [2.1 to 6.5] 4.3 [2.2 to 6.5]

Analgesic medication (doses per day)

Baseline 0.52 [0.32 to 0.74] 0.34 [0.16 to 0.52]

0.7 [0.49 to 0.9] 0.55 [0.37 to 0.72]

0.47 [0.26 to 0.67] 0.38 [0.21 to 0.56]

0.51 [0.30 to 0.72] 0.43 [0.25 to 0.61]

Month 1 0.25 [0.05 to 0.47] 0.25 [0.07 to 0.43]

0.62 [0.41 to 0.82] 0.60 [0.43 to 0.78]

0.33 [0.13 to 0.54] 0.30 [0.12 to 0.48]

0.43 [0.21 to 0.64] 0.42 [0.24 to 0.60]

Month 2 0.36 [0.15 to 0.56] 0.37 [0.19 to 0.54]

0.51 [0.30 to 0.71] 0.43 [0.25 to 0.61]

0.29 [0.09 to 0.49] 0.29 [0.11 to 0.47]

0.43 [0.21 to 0.64] 0.42 [0.24 to 0.60]

Month 3 0.34 [0.13 to 0.55] 0.28 [0.10 to 0.46]

0.46 [0.26 to 0.67] 0.40 [0.23 to 0.58]

0.25 [0.05 to 0.46] 0.21 [0.04 to 0.39]

0.38 [0.17 to 0.60] 0.39 [0.20 to 0.57]

1 month follow up 0.28 [0.07 to 0.48] 0.22 [0.05 to 0.40]

0.58 [0.37 to 0.78] 0.51 [0.33 to 0.70]

0.27 [0.07 to 0.47] 0.26 [0.09 to 0.44]

0.44 [0.23 to 0.65] 0.43 [0.25 to 0.61]


0.55 [0.34 to 0.75] 0.50 [0.32 to 0.67]

0.27 [0.07 to 0.47] 0.26 [0.09 to 0.44]

0.47 [0.26 to 0.68] 0.45 [0.26 to 0.63]


0.54 0[.33 to 0.75] 0.49 [0.31 to 0.67]

0.31 [0.10 to 0.51] 0.29 [0.1 to 0.47]

0.58 [0.37 to 0.80] 0.52 [0.34 to 0.71]

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A short, three-month course of acupuncture reduces menstrual pain both in severity and duration, as well as reducing other bothersome menstrual symptoms and improving overall health and wellbeing. The effect of differential diagnosis based on TCM pattern was also examined and found that differential diagnosis did not have any effect on the outcomes measured.Acupuncture improved HRQoL, suggesting women had less problems with work or daily activities as a result of their physical health, less pain and subsequent limitations due to pain, more energy, and less interference from physical and emotional problems in social activities.Manual acupuncture was superior to electro-acupuncture in reducing analgesic usage and additional menstrual symptoms.

SUMMARY

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Acupuncture, on a weekly or ‘clustered’ treatment improves all measures of primary dysmenorrhea except absenteeism. Results were seen within 3 menstrual cycles, with most women experiencing relief in the second month.Treatment used common points and often moxibustion. The relationship with women was a very important therapeutic component. Diet and lifestyle advice was valued by women but its contribution to the outcome is uncertain.Education of women very important – most did not realize that period pain was not normal.Cost. Most women felt they could not spend the money on themselves. Practitioners need to think about strategies to reach these women.

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PREVALENCE>> Between 5-25% of women

worldwide have chronic pelvic pain

>> Endometriosis is the most common cause of pelvic pain with 30-50% of women with pelvic pain having a positive diagnosis.

>> Approximately 1 in 10 Australian women have endometriosis, however evidence is conflicting.

SYMPTOMS>> Non-cyclical pelvic pain>> Dysmenorrhea (period pain)>> Dyspareunia (pain on sexual

intercourse)>> Pain on urination>> Pain on bowel motions>> Fatigue – often chronic

THE PROBLEM : CHRONIC PELVIC PAIN

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Chronic pelvic pain impacts women’s health and wellbeing, including • social activities • mental and emotional health • work and finances • sexual relationships

Women with CPP also have:

• Increased rates of depression and anxiety

• Increased risk of other chronic pain conditions such as migraines

• Increased change of chronic fatigue syndrome, multiple sclerosis and lupus.

• Possibly due to genetic factors or HPA axis dysfunction

THE IMPACT

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PHARMACEUTICAL>> Analgesic medication.>> Hormonal therapy.

SURGICAL>> Generally effective>> Significant reoccurrence rate @

5 years>> Expensive>> Removal of tissue does not

always relieve symptoms>> Not relevant for those without a structural basis for CPP

CURRENT TREATMENTS

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PREVIOUS STUDIES>> 2 trials published in English.>> One using traditional Chinese

medicine, the other Japanese style

>> Both positive results for pain but inconclusive for mechanisms

POSSIBLE MECHANISMS>> Reduction of inflammation>> Changes in central pain

processing>> Reduction of NGF>> Increased endogenous opioids

ACUPUNCTURE: A POSSIBLE THERAPY ?

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DESIGN>> Recruitment via social media.>> Acupuncture + usual care vs

usual care alone>> 30 women aged 18-45 with a

confirmed diagnosis of endometriosis

>> Acupuncture twice per week for 8 weeks.

OUTCOMES>> Feasibility outcomes>> Changes in self-rated pain

scores>> Changes in severity of

secondary symptoms>> Changes in neural connectivity >> Changes in conditioned pain

modulation

OUR TRIAL: A FEASIBILITY STUDY

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CALL FOR PRACTITIONERS

We are looking to open two more study sites:1 in Sutherland Shire and 1 in or near Dee why. If you are interested in helping us, please come and speak to me after the seminar.

STAY IN TOUCH

You can follow us on twitter:

@Carolin05931746 – Prof Caroline Smith@drmikenz – Dr Mike Armour@drcarolynee - Dr Carolyn Ee

acupuncture for treating primary and secondary dysmenorrhea (period pain)

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