- Acupuncture usually entails the needling of specific points on the body surface.
- The data from reliable clinical trials are scarce as most trials are methodologically weak while several sham-controlled studies reported no difference between acupuncture and sham; thus the evidence is insufficient to draw firm conclusions about the effectiveness of acupuncture as a treatment of hot flushes in women with cancer.
- Serious complications are probably very rare.
Acupuncture typically entails needling specific points of the body surface. According to Traditional Chinese Medicine (TCM) philosophy, illness is caused by imbalances of energies in the body and acupuncture is a treatment that re-balances energies. Therefore, it is claimed by TCM-practitioners to be helpful in most human condition. By contrast, most Western acupuncturists follow the principles of conventional medicine and would employ acupuncture only for specific conditions. Acupuncture might be advocated for a wide range of conditions and symptoms, including cancer-related hot flushes.
The evidence from clinical trials of acupuncture as a treatment for hot flushes in women with breast cancer is contradictory. Even though some encouraging studies exist, comparisons with sham acupuncture are less positive and any effects appear to be short-term. Most trials are burdened with a high risk of bias and the totality of the trial data is therefore unconvincing.Mild adverse effects, e.g. pain or bleeding at the site of acupuncture can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.
Last updated in October 2017 by Karen Pilkington.
Fully revised and updated in July 2015 by Karen Pilkington.
Summary first published in April 2013, authored by Edzard Ernst.
Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for hot flushes [online document]. October 21, 2017.
Acupuncture refers to the insertion of fine needles at specific points (acupuncture points or acupoints) on the body for the prevention or treatment of disease or the maintenance of health. The term ‘acupuncture’ is derived from Latin and means ‘piercing with a sharp instrument’. from Latinacus,‘needle’ (noun), andpungere,‘to prick or puncture’ (verb).
Acupuncture is usually performed with fine, solid needles but many variations exist. ‘Acupoints’ might, for instance, be stimulated by electrical currents with or without needles (electro-acupuncture), by pressure (acupressure involving use of ‘press’ needles, studs or manual pressure), by heat (moxibustion) or laser light (laser-acupuncture). Techniques that do not involve the insertion of needles are not always classed as acupuncture.
Acupuncture is often part of a complex intervention that includes use of herbal mixtures, moxibustion (burning of herbs), and dietary and lifestyle advice
Application and dosage
Acupuncture is applied to the body surface including the ears and scalp. The dosage (number of points stimulated, depth of needle insertion, duration of stimulation and frequency and duration of treatment sessions) depends on the condition treated. Sometimes only one acupoint is stimulated; more commonly several needles are applied. A specific area of the body (for example, ear-acupuncture) may be treated but, more commonly, several areas are needled. Needles are usually removed after a 30 minute treatment session but press needles and studs may be left for several days or, in some cases, weeks. Needles may be stimulated by manual manipulation or left unstimulated. Treatments may be repeated at regular intervals, for example once or twice weekly, or treatment can comprise of a single session.
The placement of needles is determined by the condition being treated and, to some extent, by the type of acupuncture being applied. In traditional Chinese or East Asian forms of acupuncture, acupoints are considered to be located along channels or ‘meridians’ through which a vital force or energy (‘Qi’) flows1. Diagnosis is carried out using a number of methods including peripheral pulses, the appearance of the tongue, speech, history and overall impressions of the patient. The ‘symptom pattern’ and underlying ‘imbalances’ guide selection of points. In ‘Western medical’ acupuncture, points are selected according to contemporary neurophysiology and are considered to be sites where external stimuli result in a greater sensory stimulus, so-called ‘trigger points’2,3.
The history of acupuncture can be traced to ancient China and its Taoist philosophy4. It has been practised in China for more than 2000 years and in other East Asian countries including Japan, Korea and Vietnam, for between 1000 to 2000 years arriving in Europe several hundred years ago5. In traditional Chinese medicine (TCM), the life energy ‘Qi’ flowing through the body in meridians and the balance of ‘yin’ and ‘yang’ are thought to determine human health. Illness is seen as an imbalance of these energies and acupuncture is perceived to be one method for re-balancing the imbalance. Traditionally, acupuncture was not used primarily for specific problems such as pain control but to treat a wide range of symptoms or problems based on the pattern of diagnosis5. Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.
Acupuncture became popular outside Asia after the US president Richard Nixon visited China in 19714. Acupuncture treatments were originally provided by traditional acupuncturists but as interest in the technique extended, health professionals adopted and adapted the techniques, using acupuncture alongside conventional treatment.
Claims of efficacy/alleged indications
According to TCM concepts, acupuncture is a therapy for most symptoms and diseases. Modern Western concepts are centred around conditions likely to be influenced through effects on neurotransmitters, such as musculoskeletal pain and nausea and vomiting3,7.
Mechanisms of action
Considerable research effort has been focused on finding physiological or histological evidence of the existence of concepts postulated within TCM acupuncture such as Qi, meridians and specific acupuncture points but conclusive proof has not been obtained6. Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins7.
Prevalence of use
In many countries, acupuncture is now one of the most popular forms of CAM. Most modern pain clinics and many oncology centres across the world routinely offer acupuncture as one of several therapeutic options. Exact prevalence figures vary from country to country and from setting to setting. A survey of cancer patients in Europe reported use of acupuncture by between 2 to 4% of patients before and after diagnosis but use varied by cancer type and acupuncture was used by up to 17% of gynaecological cancer patients8,9.
In most countries, acupuncture can be administered by both medically-trained and statutorily regulated health professionals (e.g. doctors, physiotherapists, nurses, midwives) and by non-medically-trained acupuncturists. The regulation of acupuncture varies from one country to another. In the UK, there is voluntary rather than statutory regulation and local authorities can regulate hygiene of acupuncture practice1.
Cost and expenditures
In the UK, average costs are £40-£70 for the first session, with ordinary appointments of between 30-60 minutes between £25-£501. One series of treatments would normally comprise 5-20 sessions. In Germany, costs of acupuncture for some conditions are covered by public health insurers.
A large number of systematic reviews have been published that address acupuncture and hot flushes. Several focus on a range of treatments for hot flushes in cancer patients e.g.11,25,26 while others cover a range of symptoms e.g.27,28. The systematic reviews discussed here and presented in Table1 are those that focus solely on acupuncture for hot flushes.
Two systematic reviews were published in 200910,29. The first focused on acupuncture for hot flushes in breast cancer patients and a special effort was made to include the Asian literature10. The second addressed hot flushes in prostate cancer patients29. Neither reviews found convincing evidence of beneficial effects of acupuncture on frequency or severity of hot flushes. This was due to the poor quality of the existing studies in the first review and lack of studies in the second review.
A subsequent Cochrane review included trials published up to 2013 of acupuncture in women with hot flushes related to the natural menopause or menopause due to surgical removal of ovaries, radiation, or chemotherapy12. Sixteen trials were included of which 5 were in women with a history of cancer. Overall, there was no significant difference between the acupuncture and sham acupuncture for hot flush frequency (MD -1.13 flushes per day, 95% CI -2.55 to 0.29, 8 RCTs, low-quality evidence) but flushes were significantly less severe in the acupuncture group. However, the effect was small, the results of individual trials were extremely variable and the evidence was judged to be of very low quality (SMD -0.45, 95% CI -0.84 to -0.05, 6 RCTs). When compared to no treatment, acupuncture appeared to be more beneficial but it was less effective than hormone therapy and the evidence was low or very low quality.
Five systematic reviews have been published since the Cochrane review. These have included a varied number of studies, ranging from 6 to 1213,30-33. The variation in number of studies is due to the different databases searched and to the definition of acupuncture used. In some cases, only acupuncture treatments that involve needling are included while, in others, related therapies such as acupressure and moxibustion are also assessed. Similarly, the control interventions may be limited to sham versions of acupuncture or encompass a wide range of active and inactive treatments. While individual trials have reported beneficial effects on hot flushes, conclusions of systematic reviews and the results of meta-analyses indicate that the evidence for these effects is not convincing. This is due to the risk of bias in most trials and lack of statistically significant between group differences.
One study published since the Cochrane review also tested acupuncture against a similar sham procedure16. A range of patient reported outcomes including hot flushes were measured at 4, 8 and 12 weeks after randomisation to the two groups. About three-quarters of the 47 women included had suffered hot flushes at baseline. No significant difference was detected between groups after treatment. Some apparent differences in the responses of different ethnic groups were highlighted as worth further investigation.
Long-term follow-up of one of the RCTs included in the Cochrane review has also been reported in several publications17,34,35. Eighty patients had 2 years previously been randomized to a course of acupuncture or sham acupuncture for hot flushes. Sixty-one women completed and returned questionnaires which assessed health related quality of life. Scores at the end of treatment and after 3 months showed a statistically significant difference between the groups but this difference became non-significant based on scores after 2 years.
An 4-arm RCT compared gabapentin, electroacupuncture, sham acupuncture and placebo tablets36,37. The mean reduction in a hot flush score was greatest with electroacupuncture at 8 and 24 weeks but it is not clear whether this was significantly different from the effect of sham acupuncture.
Acupuncture was used in combination with enhanced self-care and compared against self-care alone38. The trial was rigorously conducted but, while the combined treatment was reported to be more effective, blinding was not possible which is relevant when the outcome is self-assessed. As patients’ expectations are known to strongly influence the effect on hot flushes18,19, caution seems indicated when interpreting results, particularly in those studies in which there is no control or no blinding.
In about 8-10% of all patients, acupuncture causes mild, transient adverse effects such as pain, haematoma or bleeding at the site of needling20,21. In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record.22 Risk of cross-infection of blood borne disease, particularly hepatitis B, is minimised by the use of sterile disposable needles, and immunisation of acupuncturists. Rare cases of fatalities after acupuncture treatment have been reported although causality was not confirmed in many of these reports23.
Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy24,25. Bleeding abnormalities and anticoagulant treatment, oedema, epilepsy, pregnancy and needle phobia are among those conditions that have been suggested as relative, or in some cases absolute, contra-indications. Some points are considered ‘forbidden’ or not to be used for acupuncture needling.
None known, except for electro-acupuncture where the electrical current might interfere with pacemakers and is used with caution in epilepsy25.
Strict asepsis and use of sterile disposable needles are mandatory to avoid infections. Some patients faint during acupuncture and should thus be treated lying down.
- BAcC (British Acupuncture Council) website. Ten Top Things to Know. Accessed 17th April 2015.
- Filshie, J., Cummings, M. Western medical acupuncture. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 31-59.
- White A; Editorial Board of Acupuncture in Medicine. Western medical acupuncture: a definition. Acupunct Med. 2009 27(1):33-5.
- White A, Ernst E. Introduction. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp1-10.
- Birch S, Kaptchuk T. History, nature and current practice of acupuncture: an East Asian perspective. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 11-30.
- Ahn AC, Colbert AP, Anderson BJ, Martinsen OG, Hammerschlag R, Cina S, Wayne PM, Langevin HM. Electrical properties of acupuncture points and meridians: a systematic review. Bioelectromagnetics. 2008 29(4):245-56.
- Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 84(4):355-375.
- Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P. Complementary and alternative medicine use in patients with gynecological cancers in Europe. Int J Gynecol Cancer. 2006 16 Suppl 1:219-24.
- Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AM, Platin N, Kearney N, Patiraki E. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005 16(4):655-63.
- Lee MS, Kim KH, Choi SM, Ernst E. Acupuncture for treating hot flashes in breast cancer patients: a systematic review. Breast Cancer Res Treat. 2009 Jun;115(3):497-503.
- Rada G, Capurro D, Pantoja T, Corbalán J, Moreno G, Letelier LM, Vera C. Non-hormonal interventions for hot flushes in women with a history of breast cancer. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004923.
- Dodin, S., C. Blanchet, I. Marc, E. Ernst, T. Wu, C. Vaillancourt, J. Paquette and E. Maunsell. Acupuncture for menopausal hot flushes. Cochrane Database Syst Rev 2013 7: CD007410.
- Frisk, J. W., M. L. Hammar, M. Ingvar and A. C. Spetz Holm. How long do the effects of acupuncture on hot flashes persist in cancer patients? Support Care Cancer 2014 22(5): 1409-1415.
- Liljegren, A., P. Gunnarsson, B. M. Landgren, N. Robeus, H. Johansson and S. Rotstein. Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Res Treat 2012 135(3): 791-798.
- Walker EM, Rodriguez AI, Kohn B, Ball RM, Pegg J, Pocock JR, Nunez R, Peterson E, Jakary S, Levine RA. Acupuncture versus venlafaxine for the management of vasomotor symptoms in patients with hormone receptor-positive breast cancer: a randomized controlled trial. J Clin Oncol. 2010 Feb 1;28(4):634-40.
- Bao, T., L. Cai, C. Snyder, K. Betts, K. Tarpinian, J. Gould, S. Jeter, M. Medeiros, S. Chumsri, A. Bardia, M. Tan, H. Singh, K. H. Tkaczuk and V. Stearns. Patient-reported outcomes in women with breast cancer enrolled in a dual-center, double-blind, randomized controlled trial assessing the effect of acupuncture in reducing aromatase inhibitor-induced musculoskeletal symptoms. Cancer 2014 120(3): 381-389.
- Hervik, J. and O. Mjaland. Long term follow up of breast cancer patients treated with acupuncture for hot flashes. Springerplus 2014 3: 141.
- Otte JL, Carpenter JS, Zhong X, Johnstone PA. Feasibility study of acupuncture for reducing sleep disturbances and hot flashes in postmenopausal breast cancer survivors. Clin Nurse Spec. 2011 Sep-Oct;25(5):228-36.
- Mao JJ, Leed R, Bowman MA, Desai K, Bramble M, Armstrong K, Barg F. Acupuncture for hot flashes: decision making by breast cancer survivors. J Am Board Fam Med. 2012;25(3):323-32.
- White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
- Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009;16(2):91-7.
- White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
- Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
- BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Avialable online. Accessed 17th September 2018.
- Hervik JB, Stub T. Adverse effects of non-hormonal pharmacological interventions in breast cancer survivors, suffering from hot flashes: A systematic review and meta-analysis. Breast Cancer Res Treat. 2016;160(2):223-36.
- Johns C, Seav SM, Dominick SA, Gorman JR, Li H, Natarajan L, et al. Informing hot flash treatment decisions for breast cancer survivors: a systematic review of randomized trials comparing active interventions. Breast Cancer Res Treat. 2016;156(3):415-26.
- Wu X, Chung VC, Hui EP, Ziea ET, Ng BF, Ho RS, et al. Effectiveness of acupuncture and related therapies for palliative care of cancer: overview of systematic reviews. Sci Rep. 2015;5:16776.
- Tao WW, Jiang H, Tao XM, Jiang P, Sha LY, Sun XC. Effects of Acupuncture, Tuina, Tai Chi, Qigong, and Traditional Chinese Medicine Five-Element Music Therapy on Symptom Management and Quality of Life for Cancer Patients: A Meta-Analysis. J Pain Symptom Manage. 2016;51(4):728-47.
- Lee MS, Kim KH, Shin BC, Choi SM, Ernst E. Acupuncture for treating hot flushes in men with prostate cancer: a systematic review. Support Care Cancer. 2009 Jul;17(7):763-70.
- Garcia MK, Graham-Getty L, Haddad R, Li Y, McQuade J, Lee RT, et al. Systematic review of acupuncture to control hot flashes in cancer patients. Cancer. 2015;121(22):3948-58.
- Carlos LL-J, Cruz LA, Leopoldo VC, Campos FR, Almeida AM, Silveira RC. Effectiveness of Traditional Chinese Acupuncture versus Sham Acupuncture: a Systematic Review. Rev Lat Am Enfermagem. 2016;24:e2762.
- Chen YP, Liu T, Peng YY, Wang YP, Chen H, Fan YF, et al. Acupuncture for hot flashes in women with breast cancer: A systematic review. Journal Cancer Res Ther. 2016;12(2):535-42
- Chiu HY, Shyu YK, Chang PC, Tsai PS. Effects of Acupuncture on Menopause-Related Symptoms in Breast Cancer Survivors: A Meta-analysis of Randomized Controlled Trials. Cancer Nurs. 2016;39(3):228-37.
- Hervik J, Mjaland O. Acupuncture for the treatment of hot flashes in breast cancer patients, a randomized, controlled trial, with long-term quantitative and qualitative follow up. Maturitas. 2015; 81(1):143.
- Hervik J, Mjaland O. Long term follow up of breast cancer patients treated with acupuncture for hot flashes. Support Care Cancer. 2015; 23(1 suppl. 1):S370.
- Mao JJ, Bowman MA, Xie SX, Bruner D, DeMichele A, Farrar JT. Electroacupuncture Versus Gabapentin for Hot Flashes Among Breast Cancer Survivors: A Randomized Placebo-Controlled Trial. J Clin Oncol. 2015;33(31):3615-20.
- Mao J, Xie S, Bowman M, Bruner D, Li S, DeMichele A, et al. A randomized placebo-controlled trial of acupuncture and gabapentin for hot flashes among breast cancer survivors. Cancer research [Internet]. 2015; 75(9 suppl. 1).
- Lesi G, Razzini G, Musti MA, Stivanello E, Petrucci C, Benedetti B, et al. Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT). J Clin Oncol. 2016;34(15):1795-802.