DOI: 10.1111/tog.

12574 2019;21:209–14
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

A review of acupuncture in obstetrics and gynaecology

Faisal Karim MBBS BSc (Hons),a,* James Dilley MBChB MRCOG,b Elaine Cheung MBBS BSc (Hons) CoBC (Acupuncture) MRCOGc
a
ST1 in Obstetrics and Gynaecology, King’s College Hospital, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
b
Registrar in Obstetrics and Gynaecology, King’s College Hospital, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
c
Consultant Obstetrician and Gynaecologist, Royal Free London NHS Foundation Trust (Barnet site), London NW3 2QG, UK
*Correspondence: Faisal Karim. Email: faiskarim@outlook.com

Accepted on 10 December 2018. Published online 25 June 2019.

Key content Learning objectives

 Acupuncture is an ancient form of medicine involving sensory  To understand that there is a different but complementary option
stimulation via needle insertion. available when treatment success is not achieved with Western
 In the UK, Western medical acupuncture (WMA), an adaptation medicine and that women may opt for acupuncture over more
of traditional Chinese approach, is used in varying recognised treatment options.
circumstances, including in obstetrics and  To be aware that studies have shown that acupuncture can be a
gynaecology. beneficial treatment, but most studies are non-randomised.
 Outcome studies have demonstrated that acupuncture can be
Ethical issues
effective in pain management, fertility and obstetrics (during
 Women should be given information about all suitable treatments,
pregnancy, intrapartum and postpartum).
including acupuncture, to make an informed choice.
 Acupuncture is safe and has a very low risk of adverse
incidents if carried out by trained and accredited Keywords: acupuncture / alternative medicine / assisted
practitioners. conception / complementary medicine / dysmenorrhoea

Please cite this paper as: Karim F, Dilley J, Cheung E. A review of acupuncture in obstetrics and gynaecology. The Obstetrician & Gynaecologist 2019;21:209–14.
https://doi.org/10.1111/tog.12574

The primary therapeutic effects of needle insertion at the

Introduction
acupuncture points are achieved via stimulation of the
Acupuncture is an ancient form of medicine that is sensory nervous system. It can also have local effects, such as
approximately 3000 years old. A key part of traditional the release of neuropeptides and increase in local blood flow.6
Chinese medicine, it is also increasingly popular in the Clinical effects differ depending on tissue level (skin or
Western world, with an estimated 4 million sessions muscle) and the type and amount of stimulation provided by
provided annually.1 inserting the needle. The selection of specific points is also
The term ‘acupuncture’ is derived from the Latin acus (a based upon the nerve supply of the condition in question.5
needle) and puncture (a puncture).2 In traditional Chinese As acupuncture is regarded as a form of sensory
medicine, it is believed that stimulating specific points on the stimulation, it can be difficult to ascertain the appropriate
surface of the body affects the functioning of organs; a line, dose of stimulation for each condition. Since the dose
known as the meridian, links the points pertaining to each depends on each individual’s nervous system, it would be
organ. Energy, or Qi (the Chinese term for life energy), passes problematic to use a similar dose across different trials,
through the body via different meridians. Pain and/or disease although there is a lack of data on this means. Hence, trials
subsequently occurs when the flow of Qi is disrupted.4 may have been conducted in a suboptimal fashion.7
Acupuncture points, which map the whole body, lie along Another problem with acupuncture trials is that inserting a
these meridians. Normally 4–6 needles are inserted needle at a non-classical site will inevitably create some form
simultaneously, with the depth of insertion dependent on the of nervous stimulation. Often, placebo or sham acupuncture
body position. This is designed to redirect the flow of Qi to involves inserting a needle at classical sites but at a different
influence the body’s healing response and restore harmony.4 tissue level to the intervention needles, or at non-standard
Western medical acupuncture (WMA) is an adaptation of acupuncture points.5 Since both placebo and intervention
the traditional Chinese approach, involving evidence-based needles will cause sensory stimulation, it is difficult to
medicine and knowledge of anatomy and physiology. WMA accurately assess the effectiveness of the treatment
does not adhere to the traditional circulation of Qi and is the acupuncture. For this reason, sham or placebo acupuncture
main form of acupuncture practised in Western countries.5 cannot truly be defined as an inert placebo.

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 Acupuncture in obstetrics and gynaecology

Acupuncture in obstetrics and gynaecology inactivated laser. There is, therefore, some evidence to
indicate that moxibustion and acupuncture can correct
Acupuncture is increasingly offered as an adjunct therapy to breech presentation at term, but further evidence is
conventional treatment. In obstetrics, no adverse fetal effects required to confirm this.
have been noted when using acupuncture, although data are
limited thus far. When used for relief of gynaecological During labour
conditions, no long-term side effects have been noted beyond Pain during labour has been described as the most severe
the initial pain of needle insertion. Acupuncture is not pain that one can experience. It is caused by uterine
known to have any teratogenic side effects and avoids the contractions, cervical dilatation and stretching of the
ingestion of medication. This may be why some women vaginal and pelvic floor.16 In China, acupuncture has been
prefer this option during and outside of pregnancy.4,5 used as analgesia during labour for centuries.17
In a 2011 Cochrane review, Smith et al.18 concluded that
Breech acupuncture is beneficial for reducing pain in labour,
Breech presentation occurs in 3–4% of term pregnancies.8 In increases maternal satisfaction and reduces the requirement
Western countries, it has become more common to deliver for pharmacological analgesia. More data and further trials
breech babies by caesarean section because this carries a are required to be able to make a clinical recommendation.
lower infant morbidity and mortality risk than planned A 2010 review by Cho et al.19 revealed that although
vaginal breech delivery.9 External cephalic version (ECV), acupuncture does seem to reduce the requirement for other
where the fetus is manually rotated from a breech to a forms of analgesia compared with conventional analgesia, the
cephalic presentation through the mother’s abdominal wall, evidence is weak. Compared with placebo acupuncture or
is a safe and effective way to reduce the requirement for a conventional analgesia, acupuncture does not seem to
caesarean section when attempted after 36 weeks of provide more effective pain relief.17–19
gestation.10,11 There is, however, a risk of fetal distress, None of the studies discussed so far have noted any adverse
abdominal pain and bruising, and failure of the procedure, side effects or harmful outcomes. The use of acupuncture in
which is why women may seek an alternative to ECV. labour shows a trend for a reduced requirement for analgesia
Moxibustion, which involves burning the herb mugwort, (including use of epidural) and can also increase maternal
can be used to attempt to adjust breech to cephalic satisfaction with the analgesia provided during labour.
presentations. It is applied to the acupuncture point Further studies are needed, but this evidence suggests that
Bladder 67 (BL67, Zhiyin), located at the tip of the fifth acupuncture is a valid choice that may help women to
toe, at between 28 and 37 weeks of gestation.12,13 Treatment manage their pain in labour. Guidelines published in 2014 by
lasts for 15–20 minutes and is repeated up to 10 times per the National Institute for Health and Care Excellence
day, for up to 10 days. Currently, there is no consensus on (NICE)20 indicate that acupuncture will not be offered, but
the best treatment pattern.13 It has been suggested that the if the woman requests it, it can be used during labour.
longwave infrared radiation produced by burning the moxa
sticks induces maternal hormone production, resulting in Induction of labour
fetal activity and uterine contraction.14 Side effects including Induction of labour may be required if warranted by
blisters, burns and burning sensations have been noted in concerns for the safety of the mother, her baby, or both.
8.5% of women who used this,15 and the unpleasant burning Traditionally, it involves mechanical (e.g. membrane
odour has also been noted.11 Moxibustion trials have sweeping, artificial rupture of membranes, balloon insertion
reported no harm to the fetus. into the uterus) or pharmacological (synthetic oxytocin or
In a 2012 Cochrane review, Coyle et al.11 found that, prostaglandin) methods.21
compared with the use of acupuncture, moxibustion reduced A 2017 Cochrane review by Smith et al.21 concluded that
the number of non-cephalic presentations at birth. They also there was no evidence to suggest that using acupuncture (or
found that, compared with no treatment, moxibustion acupressure, which involves applying physical pressure to
combined with acupuncture reduced the number of acupuncture points) reduced the caesarean section rate.
non-cephalic presentations at birth and the caesarean However, where acupuncture was used, there was a greater
section rate. The quality of evidence was deemed moderate, change in the Bishop’s score22 and cervical dilatation23
with clinical heterogeneity and differing levels of compared with usual (mechanical or pharmacological)
statistical heterogeneity. methods. No difference was noted between acupuncture
Subsequently, a 2014 randomised controlled trial (RCT) by and placebo/sham acupuncture.24 Furthermore, electro-
Coulon et al.15 showed no benefit of moxibustion and acupuncture (acupuncture involving passing a small electric
acupuncture in correcting breech presentation at term current between sited needles) reduced the caesarean section
compared with a placebo treatment, which was an rate compared with usual care, but there was no difference

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 Karim et al.

between placebo and electro-acupuncture.21 Although the dysmenorrhoea, with women who were followed up for up to
2008 NICE guidelines25 state that there is insufficient 1 year. There is, however, evidence to indicate that
evidence to warrant the use of acupuncture for induction acupuncture is more effective than non-steroidal anti-
of labour, the woman may use it if she wishes. inflammatory drugs (NSAIDs) at reducing menstrual pain
Available data suggest that acupuncture does not reduce and improving quality of life and is less likely to cause adverse
the caesarean section rate, but may improve the readiness of events. Therefore, for women who are offered the use of
the cervix for labour. No known adverse effects were reported NSAIDS, or for whom NSAIDs are effective but cause adverse
in the use of acupuncture. Further research is required, effects, acupuncture may be suggested as a complementary
especially to assess how acupuncture affects cervical therapy as it may have a similar, if not better, outcome.
readiness. To make an informed decision regarding their Differences in the styles of acupuncture used, reported
care, women should be informed that acupuncture may have outcomes and follow-up outcomes, and the risk of bias and
a similar effect to conventional treatment methods. statistical heterogeneity mean that further trials are required to
assess the value of acupuncture in treating primary
Hyperemesis gravidarum dysmenorrhoea and provide a more conclusive outcome.32
Nausea and vomiting occur in 50–80% of pregnancies. Secondary dysmenorrhoea is generally caused by problems
Hyperemesis gravidarum is a severe form of pregnancy- with the reproductive system. It tends to start later in life
related sickness that affects 0.3–1.0% of pregnancies.26 The than primary dysmenorrhoea and worsens over time.
definition of hyperemesis gravidarum varies, but generally Conditions such as endometriosis and fibroids can cause
includes severe, protracted nausea, weight loss of >5% of secondary dysmenorrhoea.33
pre-pregnancy weight, electrolyte imbalances, starvation Endometriosis occurs when tissue from the lining of the
(ketonuria) and exclusion of other diagnoses.27 In 90% of uterus is found abnormally outside of the uterus – most
affected pregnancies, hyperemesis gravidarum usually commonly in the pelvic or abdominal cavity. The most
commences between the fourth and seventh weeks of common symptom is dysmenorrhoea, although other
gestation, peaks around the ninth week and resolves by the symptoms can include dyschezia, dyspareunia and
20th week.26,28 subfertility. Normal fluctuations in hormones cause the
In a 2016 Cochrane review by Beolig et al.,28 it was shown that endometrial lining of the uterus to break down at the end of
fewer women who undergo acupuncture require additional each menstrual cycle. However, in endometriosis, the
antiemetic medication compared with those receiving a placebo. abnormally ectopic endometrial lining also breaks down,
However, comparing acupuncture with metoclopramide, there resulting in bleeding. The reasons why this should cause pain
was no difference in the rate of reduction of nausea and vomiting are unclear, but it is potentially caused by the fact that the
experienced. Acupuncture had no effect on preterm birth, ectopic bleeding tissue cannot be removed as menstrual
stillbirth, miscarriage or neonatal death. outflow, subsequently causing inflammation of the sites.33–35
Although they used small sample populations, other studies Endometriosis is the third leading reason for gynaecological
have shown that acupuncture can reduce hyperemesis hospitalisation and hysterectomy in the USA and affects
gravidarum, in addition to intravenous rehydration.29 women’s quality of life. Medical pain management is
Therefore, it appears reasonable to offer acupuncture as a frequently inadequate, and although surgical intervention
complementary treatment to resolve hyperemesis gravidarum may be curative, its associated risks mean that it may not be a
or/and reduce medication usage, but further studies are viable option.34,35 A 2011 review by Zhu et al. demonstrated
required to improve the quality of the evidence available. that there is insufficient evidence to support the effectiveness of
acupuncture in relieving the pain of endometriosis.35 One
Dysmenorrhoea study of auricular acupuncture36 demonstrated a reduction in
Dysmenorrhoea, or period pain, describes painful cramps of pain compared with those receiving Chinese herbal medicine.
uterine origin. Primary dysmenorrhoea describes pain that Nevertheless, the small sample size, lack of randomisation and
starts within the first 3 years of menarche, in women difficulty in determining the ways in which outcomes were
<26 years of age, with no known organic cause. Primary assessed means that further research is required to fully explore
dysmenorrhoea is typically characterised by cramp-like and the effect of acupuncture in endometriosis.
colic-like spasms in the suprapubic region, peaking within
the first few days of menstruation. It is also associated with Assisted conception
diarrhoea, vomiting, back pain and headaches.30 It is the Approximately one in seven couples in industrialised
most common cause of pain in young women, with countries experience subfertility and seek help to
estimated prevalence rates ranging from 16.1–81%.31 conceive.37 Medical help includes assisted reproductive
There is limited evidence to suggest that acupuncture is technologies, such as controlled ovarian stimulation with or
more effective than placebo acupuncture for the treatment of without intrauterine insemination and in vitro fertilisation.38

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 Acupuncture in obstetrics and gynaecology

The high failure rate of assisted conception methods means reduced effectiveness of smooth muscle relaxation. Mixed
that other therapies, including acupuncture, are being urinary incontinence is a combination of SUI and urgency
considered. urinary incontinence.41
In women who had acupuncture on or around the day of The results of several trials have suggested that acupuncture
embryo transfer, there was an increase in the live-birth rate is beneficial to those experiencing urinary incontinence
compared with control individuals who received usual care. because it reduces the number of incontinence episodes.
No benefit of acupuncture was seen when compared with Acupuncture may also have a similar effect to anticholinergic
placebo/sham acupuncture. This might be associated with the therapy and improves quality of life by reducing symptoms.42
study quality38 or the fact that placebo acupuncture is not an For SUI specifically, when compared with pharmaceutical
inert control. treatment (midrodine), acupuncture appeared to improve
Taking all the evidence together, acupuncture does not symptoms, but there was no statistical difference in the cure
seem to improve the clinical pregnancy rate or live-birth rate, rate.43 Nonetheless, there is insufficient data to make a firm
whether performed at the time of transvaginal oocyte conclusion. As such, in both instances, further high quality
retrieval or around the time of embryo transfer during RCTs are required to assess how acupuncture affects
in vitro fertilisation, but there was also no evidence that urinary incontinence.
acupuncture increases the rate of miscarriage.38,39 However,
there is a lack of standardisation of the acupuncture points Polycystic ovary syndrome
utilised between studies, and controls often included placebo/ Polycystic ovary syndrome (PCOS) is characterised by
sham acupuncture, which might elicit an effect. oligomenorrhoea, infertility (often caused by failure to
ovulate) and hirsutism (secondary to excessive androgen
Urinary incontinence production). It is also associated with metabolic disorders
Urinary incontinence can be classified as stress urinary such as diabetes mellitus,44 and is potentially associated with
incontinence (SUI), urgency urinary incontinence or mixed an alteration in the autonomic nervous system – specifically
urinary incontinence.40 SUI is the unintentional loss of urine increased sympathetic nervous activity.45 Based on the 2003
on physical exertion, coughing or sneezing. This is caused by Rotterdam criteria,46 PCOS is diagnosed when two of
increased intra-abdominal pressure resulting in the bladder the three following criteria are met: polycystic ovaries,
pressure being greater than urethral resistance.40 Urgency oligoovulation or anovulation, and hyperandrogenaemia
urinary incontinence is secondary to alterations in the (and excluding other causes of hyperandrogenaemia).46 The
nervous system, resulting in muscle hypersensitivity and prevalence rate of PCOS varies between studies, potentially

Table 1. Recommendations for the use of acupuncture in obstetrics and gynaecology

Condition Acupuncture successful? Recommendation

Correcting breech Moxibustion with acupuncture more successful when compared with no Further research required
presentation treatment

Pain in labour Can be beneficial in reducing pain in labour Further research required, NICE
guidelines state it can be used

Induction of labour Improves cervical readiness for labour but does not reduce caesarean section rate Further research required, NICE
guidelines state it can be used but
insufficient evidence available

Hyperemesis gravidarum Complementary treatment reduces medication usage Further research required

Primary dysmenorrhoea More effective than non-steroidal anti-inflammatory drugs Further research required

Secondary dysmenorrhoea Auricular acupuncture may be effective Further research required

Assisted conception Lack of evidence to suggest it improves the pregnancy rate or live birth rate Further research required

Urinary incontinence May reduce number of incontinence episodes and improve symptoms in stress Further research required
urinary incontinence

Polycystic ovarian syndrome May increase level of ovulation Further research required

Premenstrual syndrome Acupuncture and acupressure may reduce symptoms Further research required

NICE = National Institute for Health and Care Excellence.

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 Karim et al.

because different definitions are used for diagnosis, but it is for labour, reducing pain in labour and reducing medication
usually estimated as affecting 4–12% in women in their usage in hyperemesis gravidarum. It may also be used for
reproductive years.47 symptom relief in primary dysmenorrhoea, urinary
A 2016 Cochrane study44 highlighted that none of the incontinence and PMS, while increasing ovulation in PCOS
studies reviewed assessed whether acupuncture in PCOS (summarised in Table 1).
affected the live birth rate. Not all studies evaluated whether Further research is required in all areas to assess the
acupuncture altered the levels of ovulation although, in some effectiveness of acupuncture. When reviewing the evidence, it
instances, ovulation levels increased with acupuncture. There is important to be aware that sham or placebo acupuncture
was also insufficient data on adverse events. cannot be considered an inert placebo. Consequently, it is
In a 2009 study by Manneras et al.,45 which used rats associated with considerable effects, especially when compared
induced with PCOS, electro-acupuncture increased ovulation with no treatment control groups.51 In view of this, using sham
and, they concluded, may help to control the action of the acupuncture as the control group makes it difficult to assess the
sympathetic nervous system. Exercise had a similar effect, but true effectiveness of the acupuncture intervention.
to a lesser degree. This could help explain why acupuncture
has a positive effect in patients suffering from PCOS who Disclosure of interests
wish to conceive. There are no conflicts of interest.
There is evidence that acupuncture is effective in PCOS, in
particular for increasing ovulation levels, but further RCTs Contribution to authorship
with standardised recruiting criteria and outcomes are JD instigated and edited the article. FK researched and wrote
required. the article. EC edited the article. All authors read and
approved the final version of the manuscript.
Premenstrual syndrome
Premenstrual syndrome (PMS) is a clinical syndrome Acknowledgements
encompassing many different symptoms that interfere with With thanks to Nick Dalton-Brewer of King’s Fertility for his
women’s lives. It generally starts 5–11 days prior to insight into acupuncture used on a daily basis.
menstruation and stops at the start of menstruation or
shortly after menstruation has begun. Symptoms may be
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