Acupuncture for hot flushes | Cam-Cancer

Acupuncture for hot flushes

Abstract and key points

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.

A large number of systematic reviews have been published that address acupuncture and hot flushes.

  • Hot flush severity and frequency: A Cochrane review in 2013, which included trials in cancer patients, concluded there was no difference in hot flush frequency but there may be a small effect on hot flush severity. However, the results of trials were variable and the evidence judged very low quality. Systematic reviews published subsequently (n=11) have produced conflicting conclusions, mainly due to differences in interventions compared and because of the risk of bias.
  • Prostate cancer: evidence from one small RCT is insufficient to assess effects in men with prostate cancer

Adverse effects: Most systematic reviews state that no serious adverse events were reported. One systematic review highlighted two trials that reported slight bleeding or bruising at the needle site while 14 (15%) participants with fatigue, pruritus, and nausea were reported in one trial.

Mild adverse effects, e.g. pain or bleeding at the site of acupuncture can generally be expected in about 10% of all cases of treatment with acupuncture, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.

Citation

Karen Pilkington, Edzard Ernst, CAM Cancer Consortium. Acupuncture for hot flushes [online document]. June 10, 2021.

Document history

Last updated and revised in June 2021 by Karen Pilkington.
Updated in September 2018 by Karen Pilkington.
Fully revised and updated in July 2015 by Karen Pilkington.
Summary first published in April 2013, authored by Edzard Ernst.

What is it?

Description

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 acus, ‘needle’ (noun), and pungere, ‘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.

Ingredients/Components

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

Background and prevalence

The history of acupuncture can be traced to ancient China and its Taoist philosophy (White 1999). 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 ago (Birch 1999). 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 diagnosis (Birch 1999). Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.

Acupuncture became particularly popular outside Asia after the US president Richard Nixon visited China in 1971 (White 1999). 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.

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, for example, acupuncture was used by up to 17% of gynaecological cancer patients (Molassiotis 2006, Molassiotis 2005). Acupuncture was the therapy most frequently provided by integrative oncology centres across Europe, being provided by 55% of 47 centres (Rossi 2015).

Application and providers

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’) flows (BAcC 2019). 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’ (Filshie 1999, White 2009).

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 vomiting (White 2009,  Zhao 2008).

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 obtained (Ahn 2008). Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins (Zhao 2008).

Legal issues and cost

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. Information on the regulation of acupuncture in European countries can be found on websites such as that of the European Traditional Chinese Medicine Association (ETTMA)

In many European countries, the cost of acupuncture ranges between EUR 35 and 95 for the first session (60-90 mins) and EUR 35-75 for ordinary appointments of 30-60 mins. One series of treatments would normally comprise 5-20 sessions. See the ETCMA website (above) for coverage of cost by public health insurers across Europe.

Does it work?

A large number of systematic reviews have been published that address acupuncture and hot flushes. The systematic reviews discussed here and presented in Table 1 include a 2013 Cochrane review and 11 systematic reviews published subsequently.

  • Hot flush severity and frequency: A Cochrane review published in 2013 concluded there was no difference in hot flush frequency but there may be a small effect on hot flush severity. However, the results of trials were variable and the evidence judged very low quality. Systematic reviews published subsequently (10) have produced conflicting conclusions, mainly due to differences in interventions compared and because of the risk of bias.
  • Prostate cancer: evidence from one small RCT is insufficient to assess effects in men with prostate cancer

A 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 chemotherapy (Dodin 2013). 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.

At least 11 systematic reviews have been published since the Cochrane review (Frisk 2014; Garcia 2015; Chen 2016; Chiu 2016; Chien 2017; Pan 2018; Wang 2018; Qan'ir 2019; Chien 2020; Liu 2020; Yuanqing 2020). These have included a varied number of studies, ranging from 7 to 13 randomised controlled trials of acupuncture for hot flushes in cancer patients (see Table 1). 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 electroacupuncture 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. Several of the reviews included studies other than RCTs further complicating interpretation. While individual trials have reported beneficial effects on hot flushes, conclusions of systematic reviews and the results of meta-analyses have been conflicting.

Most trials are in breast cancer patients but two systematic reviews assessed the evidence on managing hot flushes in men with prostate cancer (Frisk 2016; Qan'ir 2019). Uncontrolled studies and quasi-experimental studies were included alongside RCTs respectively. Only one small trial (n=31) in men with prostate cancer was included in the first review and the evidence was reported as insufficient in the more recent review. 

No RCTs have been published since the most recent systematic review.

Overall, the evidence on acupuncture for hot flushes in cancer patients, while promising, is limited  due to the risk of bias in most trials and heterogeneity in the results.

Is it safe?

Adverse events

In about 8-10% of all patients, acupuncture causes mild, transient adverse effects such as pain, haematoma or bleeding at the site of needling (White 1997, Witt 2009). Most commonly reported problems are local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%) (Melchart 2004).   In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record (White 2004). 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 reports (Ernst 2010).

Safety incidents have been assessed that were linked to acupuncture treatments received in a healthcare setting (UK National Health Service) (Wheway 2012). The 325 incidents over a 3 year period included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorised as low or no harm.

A systematic review that specifically assessed adverse effects of non-hormonal pharmacological interventions in breast cancer survivors, suffering from hot flashes included two trials of non-hormonal medication versus acupuncture (Hervik 2016). In the comparison based on these two trials (108 participants), a significant difference was found between the groups in favour of acupuncture, with OR of 1.75, 95 % CI of 01.09–2.75 and I2 of 0 % (P = 0.02).

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy  ((BAcC (British Acupuncture Council) website 2021, BMAS (British Medical Acupuncture Society 2021), Hervic 2016). 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.

Interactions

None known, except for electro-acupuncture where the electrical current might interfere with pacemakers and is used with caution in epilepsy (Filshie 1999).

Warnings

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.

Recommendations from the US National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology in 2017 indicate that “oncology acupuncture” is a specialty area of practice (Zia 2017). Specific concerns include higher risks of infection and bleeding due to neutropenia and thrombocytopenia and possibility for hemodynamic instability due to dehydration and malnutrition. It was proposed that clinical practice guidelines are followed that take into account lab values such as absolute neutrophil and platelet counts.

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