pcos scientific view
‘What is the evidence for the effectiveness of acupuncture in the treatment of Polycystic Ovary Syndrome (PCOS) in women of reproductive age?’
PCOS und Akupunktur
Evidence based acupuncture in the treatment of PCOS
Anmerkung: Diese Arbeit wurde im Rahmen des MSc Studiums am NCA erstellt. Auf Grund der Methodik fehlen die in der Praxis angewandten individuellen Behandlungen sowie ergänzende Techniken der TCM. Desweiteren erhebt diese Arbeit keinen Anspruch auf Vollständigkeit und stellt kein Heilungsversprechen dar.
1. Introduction
Polycystic ovarian syndrome (PCOS) is a common endocrine disorder, related to irregular menstruation and increased androgenic hormones (El Hayek et al., 2016). According to the ‘International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018’ (Misso et al., 2018) its incidence is in 8-13% of women in reproductive age. Furthermore, this guideline describes psychological, reproductive and metabolic features for PCOS.
1.1 Diagnostic criteria
One common problem in the research of PCOS is the use of different definitions, due to a variety of phenotypes (Balen and Michelmore, 2002). The lack of a uniform definition is also from clinical significance. Depending on the speciality of the doctor, the diagnosis will be made. For instance, a gynaecologist might be more interested in the reproductive aspects of PCOS, while an endocrinologist concentrates on impaired glucose tolerance (IGT). Hence, discrepancy in definition may lead to different treatments (Cussons et al., 2005).
Initially described as ‘amenorrhea associated with bilateral polycystic ovaries’ by Stein and Leventhal in 1935, the diagnostic criteria (DC) were changed and updated various times. Hyperandrogenism and chronic anovulation were included among the DC since the first conference of PCOS supported by the ‘National Institute of Health’ (NIH) in April 1990 (Azziz, 2006).
Because of the variety of symptoms, in 2003 the ‘Rotterdam Consensus Workshop’ (ROT) revised these criteria (Rotterdam, 2004). The scientists decided to broaden the criteria and included polycystic ovaries, diagnosed via ultrasound. Following the ROT, two out of three symptoms should appear. Hence, hyperandrogenism is not a deciding factor anymore.
Azziz (2006) questioned these criteria because it did not correspond with his observations.
In 2009 Azziz et al. drafted guidelines with the ‘Androgen Excess-PCOS-Society’ (AE-PCOS). The society pointed out the difficulty of providing a definition for a syndrome with different phenotypes and no uniform aetiology. As opposed to ROT, the AE-PCOS considers hyperandrogenism as diagnostic factor.
Table 1: DC (Azziz, 2006, Azziz et al., 2009; Rotterdam, 2004)
NIH 1990 | ROT 2003 | AE-PCOS 2009 |
Hyperandrogenism | Hyperandrogenism | Hyperandrogenism |
Chronic anovulation | polycystic ovaries | Ovarian Dysfunction |
An- or Oligo-Ovulation |
1.2 Treatment recommendations
Recommendations for the treatment of PCOS depend on the presenting features of the disease as well as the desired result (pregnancy, balanced androgens, etc.). E.g., people with obesity and IGT should modify their lifestyle first and then metformin can be recommended. Fertility issues should be treated primarily with clomiphene citrate (CC), while hyperandrogenism can be improved with oral contraceptives (Leon and Mayrin, 2018).
1.3 Intervention: Acupuncture
The use of complementary and alternative medicine (CAM) in the British population is significant: a survey from Thomas and Coleman (2004) evaluated a 10 per cent use of CAM from British adults.
Traditional Chinese Medicine (TCM) as a medical system based on 2500 years of experience (Noll, 2010). Originally, acupuncture belonged to the field of TCM (Kaptchuk, 2002) and involves the insertion of a needle into the skin. Integration of acupuncture as a relatively safe treatment in conventional care is increasing (Witt et al., 2009), especially in gynaecology (Kang et al., 2011). Furthermore, a review by Franconi et al. (2011) provides evidence of the usefulness of acupuncture to treat infertility due to PCOS.
Stimulation of the needle can be done manually or electrically with electro-acupuncture (EA). Johansson and Stener-Victorin (2013) have reported that an effect of acupuncture in PCOS is feasible because nervous pathways are activated.
1.4 Relevance for medicine
It is important to research PCOS, because the overhead costs for PCOS are tremendous and the quality of life of patients with PCOS is reduced (El Hayek, 2016). The associated morbidities, e.g. infertility, complications in pregnancy, IGT, cardiovascular disease, are huge in number and long-term (Fauser et al., 2012). With up to 70% undiagnosed women (Misso et al., 2018) and continuous amended guidelines, more information about PCOS is needed. Furthermore, only 2 systematic reviews (SRs) about acupuncture for PCOS are available via the COCHRANE Library. Both show limited evidence for the effectiveness of acupuncture in reproductive outcome (Jo et al., 2017) and ovulatory disorders (Lim et al., 2016).
Available SRs are commonly based on just one or two DCs (Jo, Lee and Lee, 2017; Luo et al., 2018). Recently, an SR was published by Jo, Lee and Lee (2017), only including Rotterdam criteria. Also, this SR evaluated research only until 2016. Due to the increasing importance of PCOS, a more up to date review would be appropriate. A broad search for the Medical Subheading (MeSh)-Term ‘ovarian syndrome, polycystic’ in PubMed, limited to 2017/01/01 – 2018/12/31 resulted in more than 1000 published papers (appendix 1).
1.5 Aims and objectives
In the context of the heterogeneity of the DC and the importance for actual research, this scoping review (ScR) aims to provide a broader and actual approach to evaluate the effectiveness of acupuncture for women suffering from PCOS. First, the quality of methodology will be assessed, second, the results will be presented in a narrative synthesis, and finally, a discussion about the findings and a conclusion with recommendations for further research will complete this review.
2. Methods
2.1 Search strategy
2.2 Study selection
2.2.1 Population of interest
2.2.2 Intervention
2.2.3 Comparison
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