Imagine knowing that for around two weeks of a month, you will lose yourself both mentally and physically. To know that you can probably pinpoint, to the day, when your life spirals out of control and can lead to relationship dysfunction, not being able to work or suicidal thoughts or even actions.
Imagine knowing that there is not currently an understanding of why this condition occurs.
Imagine being misdiagnosed with bipolar, or other mental health disorders or even dismissed as only having premenstrual tension, so you are not given the right support or education.
Imagine knowing that there is no cure for the hell that arrives every month except an elevation of trying medication from oral contraceptives to anti-depressants, to HRT and or finally the hysterectomy.
This is the life for people with PMDD. It is why I wrote my dissertation on it. It is why I want more people to know about this condition. It is why I am working, for free, for three months with three PMDD superheroes. Because I want to help and provide a voice for people living with this condition.
In May 2021 I had the absolute pleasure to present to the Luna Hub, on how acupuncture would view and treat premenstrual dysphoric disorder (PMDD).
It is a space close to my heart as I was finally diagnosed in 2018, with PMDD, after many years of doctors appointments and the dread of two weeks of hell before my period started.
The Luna Hub offers amazing support and reliable information for people living with this condition.
Education on PMDD is still relatively limited and for people living with it, it can be two weeks of mentally and physically debilitating symptoms including:
lethargy
marked depression
decreased interest in life
mood swings
overwhelm
anxiety
change in appetite
difficulty in concentration
marked anger
insomnia or hypersomnia
Today's blog is going to examine the following:
My dissertation called "Treating the mental-emotional symptoms of Premenstrual Syndrome and Premenstrual Dysphoric Disorder: a review of the relationship between acupuncture ‘dose’ and moderation of emotional symptoms"
I hope you find it useful. As always please message me with any questions.
Love from Andrea
Healing with acupuncture, nutrition, and exercise
Acupuncture
I liken the Liver, which is responsible for many of the signs and symptoms of PMDD, to Jeff Bezos or Amazon. The Liver (in Chinese medicine) is responsible for ensuring everything (Qi) gets to where it should, efficiently and smoothly.
But when things start to go wrong then stuff starts to not run smoothly. Parcels get stuck. Go to the wrong places and don't get delivered.
This can look like:
impatience and irritability
headache
head distension
dizziness
chest oppression
depression
In acupuncture, there is no distinct difference in the pathogenesis of PMS or PMDD and so for this purposes I have included both. I know though that for people that suffer each month, there is a world away of difference.
Does acupuncture work for PMS/PMDD?
Performing the simple acupressure protocol at LIV3 and LI4 is an effective method to decrease the severity of PMS symptoms, anxiety and depression, and to improve the QOL. Pressure at LIV3 and LI4 appears to be equally effective.
The results suggest that acupuncture could be another treatment option for PMDD patients.
Kim, 2005
MSSL-D score change between two cycles from (16.78+4.30 to 7.56+2.36). In the acupuncture group, psychological symptoms of PMS significantly decreased in the second menstrual cycle p<0.05 compared to the first menstrual cycl
Zhang, 2017
DRSP for mood mean difference -9.03, 95% confidence interval -10.71 to -7.35. WHOQOL-BREF mean difference 2.85, 95%, CI 1.47 to 4.23. Acupuncture may provide a greater reduction in mood-related symptoms than sham acupuncture. Quality of life may be improved with acupuncture vs sham acupuncture
What can you do?
Below I have added two acupressure points that you might want to use during your signs and symptoms of PMDD.
The idea is to find these points with a tip of a finger and press down on them, whilst moving your finger ever so slightly. I would hold the point for about 5 minutes.
Liver 3
Spleen 6
*Do not use this point if pregnant or think you may be pregnant*
With the flat of your hand use the edge of your little finger on the tip of your inside ankle. Spleen 6 is found on a line directly above the tip of your ankle and on the point where your index finger rests on your leg.
In trials using Spleen 6, electro-acupuncture was found to be useful.
If you do go and see your acupuncturist, then they will discuss treatment frequency and duration.
From September 2021 I am working, for free, with three PMDD superheroes to examine treatment frequency, but I would definitely expect it to be for a minimum of three months.
What causes Liver Qi stagnation?
In acupuncture, cause is an important part of diagnosis. It is why we ask about your history. What happened around the time the symptoms appeared.
We would be looking at:
Emotions: this is stress, represed feelings, PTSD, neglect or abuse. Gabor Mate has an amazing book called "The Body Says No" which looks at the role of stress and illness.
Lack of movement: our Qi or vital energy starts to slow down and stagnate when the body doesn't move. Do you live a sedentary life? Do you find exercise helps your signs and symptoms?
Nutrition
As part of your acupuncture treatment you will be given Chinese medicine nutrition advice, specific to what you need.
I recently wrote a blog post about this here.
Below is a general guide for suggestions to make to your own food intake, if you have PMDD.
Fermened foods can be beneficial for a person's mental health. Examples of this could be cheese, yoghurt, kimchi, kefir
Don't overeat
Avoid sugar and stimulants
Chew food properly
Include pungent foods
Limit meat intake
Beneficial foods include carrot, fennel, garlic, grapefruit, peach, plum, radish, butternut squash, turmeric, basil, cardmom, coriander, clove, watercress, turnip
Movement
As I mentioned above, a lack of movemember can cause Liver Qi stagnation. With this in mind, I urge your to find an exercise that works for you.
If you do not enjoy high-intensity exercise, I really recommend Qi Gong with Iga who runs classes in Royston.
Cycle Tracking
I suspect if you believe you have PMDD or already have a diagnosis you have been cycle tracking. If you haven't you can download and print my own period tracker here.
During the menstrual cycle, Chinese medicine treats each phase independently. This includes the foods you should be eating to support yourself but also how you expend your energy.
Cycle tracking and ensuring I don't plan 'big' during the luteal phase has helped me on my occasions now.
Winter: Day 1 of your full flow is where your hormones are at their lowest levels. For people with PMDD this is often a time when signs and symptoms start to abate.
Spring: Follicular phase or Yin & Blood which is approximately days 4 to 14.
This where oestrogen is rising and your are feeling positive, you have more energy and you are able to focus.
It is during this time that you can use this energy to make plans, enjoy nights out, do the big presentation at work.
Ovulation and summer: around day 14 then we have ovulation and the corpus lutem is formed
Autumn: Luteal phase and Yang & Qi
From around days 15 to 28 this is the time when progesterone starts to decline (along with the already declining oestrogen). This is when PMDD sufferers really start to find things falling apart.
During this phase, cycle tracking has really saved me. This is not the time to be doing those things in the first half of your cycle.
If you would like to see the full presentation, you can click below for the PDF version.
Treating the mental-emotional symptoms of Premenstrual Syndrome and Premenstrual Dysphoric Disorder: a review of the relationship between acupuncture ‘dose’ and moderation of emotional symptoms
Abstract
Premenstrual syndromes (PMS) and premenstrual dysphoric disorder (PMDD) are conditions with a broad range of physical and psychological symptoms that occur in the luteal phase of the menstrual cycle and end shortly after menses commences. These symptoms contribute to a reduction in quality of life during the reproductive years and PMDD has been shown to have an adverse effect on people’s lives with disability-adjusted life years lost (DALY) of almost four years and a significantly higher frequency of suicide attempts versus controls.
Currently, acupuncture is not recommended by the Royal College of Obstetricians and Gynaecologists (RCOG) as a complementary therapy in the treatment of PMS or PMDD as previous evidence has had a high risk of bias and therefore further data would be required before recommendation.
Research aim
This systematic literature review (SLR) aims to understand if the ‘treatment dosage’ of acupuncture for sufferers of PMS and PMDD will alter the efficacy of treatment for women’s mental-emotional symptoms. Dosage will incorporate frequency of treatment, treatment length and acupuncture points and needles in the treatment.
Methods
The Cochrane, PubMed and Google Scholar databases were used to initiate a systematic literature search for Randomised Controlled Trials (RCT).
Results
The four randomised controlled trials (RCTs) reported effectiveness in treating the mental-emotional symptoms of PMS or PMDD using acupuncture, however, it cannot be concluded that treatment dosage contributed, positively or negatively, to that outcome.
Conclusion
The global lack of awareness around PMS and PMDD means they are still an underrated entity that affects the well-being of people with reproductive cycles leaving them with no consistent treatment options. Whilst treatment dosage did not conclusively contribute positively or negatively to the effectiveness of treatment, there is low-quality evidence that acupuncture may provide relief for mental-emotional symptoms of PMS and PMDD. Further studies should incorporate Chinese medicine clinical knowledge around the menstrual cycle to construct larger, higher-quality studies to assess the effectiveness of acupuncture. They should focus on using one outcome measure, The Daily Record of Severity of Problems (DRSP), and do a direct comparison between acupuncture and selective serotonin reuptake inhibitors (SSRIs).
Keywords
Acupuncture, acupressure, premenstrual syndrome, premenstrual dysphoric disorder, mental-emotional
Introduction
1.1 Biomedical perspective on premenstrual syndrome and premenstrual dysphoric disorder
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are conditions that conservatively impact 3,779,000 of the United States of America population alone (Halbreich et al., 2003, p. 13) often with life-altering effects and impairment of quality of life. Halbreich et al., (2003, p. 13) calculate that the burden of PMS/PMDD and severity, during the late luteal phase is 0.50 according to the Global Burden of Disease (GBD). This ranks alongside mild intellectual disability, Down's Syndrome and unipolar major depression. Women with undiagnosed PMDD are expected to experience a disability-adjusted life years (DALY) loss of an estimated 3.8 years (Freeman, 2005, p. 436).
Despite this burden and the large population of sufferers the mechanism which triggers PMS and PMDD remains uncertain. Presently the Royal College of Obstetricians and Gynaecology (RCOG) propose two theories. The first is that certain people are sensitive to progesterone and progestogens. The second theory is that neurotransmitters serotonin and y-aminobutyric (GABA) could be responsible (‘Management of Premenstrual Syndrome’, 2017, p. 10). Studies have explored the role of stress (del Mar Fernández et al., 2019, p. 11), childhood neglect (Wakatsuki et al., 2020, p. 1) and post-traumatic stress (PTSD) (Pilver et al., 2011, p. 9) and have found that there are predispositions between people who have suffered from these in the past, or presently, and who go on to experience PMS and PMDD.
Not only are aetiological factors elusive, but PMS and PMDD symptoms can also vary widely including depression, lethargy, breast tenderness, irritability, mood swings and bloating. Diagnosis is made when these symptoms are tracked for two cycles and only occur during the luteal phase of the menstrual cycle and disappear not long after the start of menses. The Daily Record of Severity of Problems (DRSP) is considered the easiest to use and also consistently provides reliable records of symptoms (‘Management of Premenstrual Syndrome’, 2017, p. 11).
PMDD has strict criteria from The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) which requires that five out of eleven stipulated syndromes are met, during the luteal phase and severe enough to disrupt daily life, for diagnosis to be made. The criteria are in table 1 below (Epperson et al., 2012).
Table 1: Diagnostic and Statistical Manual of Mental Disorders criteria for premenstrual dysphoric disorder
Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
Decreased interest in usual activities
Marked irritability or anger or increased interpersonal conflicts
Subjective difficulty in concentration
Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
Lethargy, easy fatigability, or marked lack of energy
Marked anxiety, tension, and/or feelings of being keyed up or on edge
Marked change in appetite; overeating or specific food cravings
Hypersomnia or insomnia
A sense of being overwhelmed or out of control
Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of “bloating” or weight gain
Because of the broad variety of symptoms and under-education of primary healthcare practitioners, women can go many years being undiagnosed, misdiagnosed and untreated before they are finally given a diagnosis (Osborn et al., 2020, p. 2).
When a diagnosis is achieved Selective Serotonin Reuptake Inhibitors (SSRIs) are considered the first-line option for treatment of severe PMS and PMDD (‘Management of Premenstrual Syndrome’, 2017, p. 20). People with PMS have been shown to have low concentrations of serotonin and whilst the action of SSRIs on PMS is unknown clinical trials have repeatedly shown their effectiveness compared to placebo (‘Management of Premenstrual Syndrome’, 2017, p. 20) with symptoms starting to alleviate within 48 hours of starting the treatment (Steinberg et al., 2012, p. 5). However, SSRIs own side effects can lead to abandonment (Marjoribanks et al., 2013, p. 5), leaving people with biomedical alternative treatments such as ovulation suppression, hysterectomy or bilateral oophorectomy (Osborn et al., 2020, p. 2).
Presently, the RCOG does not advocate for acupuncture as a complementary therapy in the treatment of PMS or PMDD. Despite there being evidence of benefit there is a high risk of bias in studies and therefore further data would be required before recommendation. (‘Management of Premenstrual Syndrome’, 2017, p. 14)
1.2 Chinese medicine perspective on premenstrual syndrome and premenstrual dysphoric disorder
PMS symptoms have been recorded by Chinese medicine since the Ming dynasty, and in Ye Tianshi’s Gynaecological Records (1644-1911) twenty-two perimenstrual symptoms were recorded, including emotional changes (Chou & Morse, 2005, p. 356). An epidemiological study conducted by Qiao et al. (2017, p. 8), observed 675 patients and they concluded that the mechanism of PMDD has two primary subtypes: liver invasion, causing impatience and irritability or liver qi depression leading to emotional depression and low spirits.
Whilst conventional medicine defines PMS and PMDD as a sum of cyclical emotional and physical symptoms, the principle of Chinese Medicine is to diagnose individual symptoms and “to treat a disease, find the Root” (Maciocia, 2015, p. 1175). The root of the emotions of anger, rage, depression, impatience and irritability are all considered to commence with a liver pathology (Maciocia, 2009, Chapter 16) and the liver is also considered to be the root cause of PMS. When the liver is stagnant this will cause any number of premenstrual signs and symptoms (Chou & Morse, 2005, p. 357).
Conversely, problems in the emotional life are the most important, if not the only, cause of liver qi stagnation Maciocia (2015, p. 532). When the liver is functioning well and qi is coursing smoothly then the person’s mental-emotional health will be happy. If liver qi stagnates then the stagnation will affect the emotional state, causing anger and frustration. Worry and sadness can also impede liver qi.
Despite the root of PMS and PMDD belonging to the liver, it is essential in treatment that diagnosis also reflects the phase of the menstrual cycle (Flaws, 2010, p. 25). In Chinese Medicine, the menstrual cycle follows the cycle of yin and yang flowing through four stages. From Blood, on the first day of menses, to Yin from days seven to fourteen, to Yang with ovulation on day fourteen to day twenty-one and finally to Qi from day twenty-one to day twenty-eight (Flaws, 2010, p. 24). Thus the treatment principle should also necessitate treating according to where the person is in their menstrual cycle, alongside their Chinese medicine pattern (Flaws, 2010, p. 59).
Currently, studies on acupuncture for treating gynaecological conditions have mainly focussed on dysmenorrhea and menopause however the treatment of other menstrual-related conditions, including PMS and PMDD have been understudied (Smith & Carmady, 2010, p. 56).
1.3. Research aim and objective
1.3.1. Research aim
To investigate the relationship between acupuncture ‘treatment dosage’ and if it alters the efficacy of treatment for the mental-emotional symptoms of PMS or PMDD.
1.3.2. Research objectives
Data will be extracted from Cochrane, PubMed and Google Scholar on studies for PMS, PMDD using acupuncture.
The data will be synthesised to establish if there is a correlation between acupuncture treatment dosage and treatment efficacy of mental-emotional symptoms of PMS or PMDD.
Methodology
This SLR will be conducted to identify all relevant literature that fits the inclusion criteria to answer the research question. By using precise and systematic methods, bias can be minimised, thus providing authentic findings from which conclusions can be drawn and decisions made (‘Literature Review as a Research Methodology’, 2019).
2.1 Search strategy
Database
Cochrane provides high-quality evidence crucial for evidence-based medicine (Metzendorf et al., 2014, p. 367)
PubMed gives access to 23 million abstracts (Metzendorf et al., 2014, p. 366)
Google Scholar is a simple search tool that includes academic and grey literature (Haddaway et al., 2015, p. 1)
2.2 Key search terms
The main search terms used were “acupuncture”, “acupressure”, “auricular acupuncture”, “premenstrual dysphoric disorder”, “premenstrual tension” with abbreviations as necessary.
2.3 Inclusion and exclusion criteria
A rationale of the inclusion and exclusion criteria is summarised in table 2 below.
Table 2: inclusion and exclusion criteria
2.4 Outcome measures
2.4.1 Primary outcomes
Specific mental-emotional symptoms using a validated prospective screening tool including Premenstrual Symptom Screening Tool (PSST), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D), Menstrual Symptoms Severity List (MSSL) or Daily Record of Severity of Problems (DRSP).
Quality of life, measured by Short Form (SF) SF-36 or SR-12 or WHO Quality of Life -BREF Scale (WHOQOL-BREF)
2.4.2 Secondary outcomes
Adverse events or abandonment
2.5 Ethics
SLR’s are research papers that collate, synthesise and analyse primary research. Since this review is based entirely on published studies it does not require ethical approval.
Findings
This SLR was conducted based on the principles of Preferred Reporting Items for Systematic Reviews (PRISMA) which allows transparent and complete reviews that are considered trustworthy and applicable (Page et al., 2021, p. 1).
3.1. Literature search using Preferred Reporting Items for Systematic Review
3.2. Overview of findings
Please refer to Appendix One for full details of the studies used in this SLR.
3.2.1. Acupuncture study populations
A total of 241 women were evaluated over the four studies. Zhang (2017) had the biggest participant population with 105 women.
Only Carvalho et al. (2013) provided an extensive dissection of the population they were studying breaking down the acupuncture and sham acupuncture by age, pregnancies, menstruation days, menstrual cycle, marital status, ethnic group, physical activity and propensity to binge eating. Bazarganipour (2017) gave a division based on BMI, age and education. Kim et al. (2005) and Zhang (2017) did not provide any background information on their participants.
3.2.2. Efficacy of acupuncture treatments
All four of the studies reported a reduction in PMS or PMDD mental-emotional symptoms, compared to sham, however, none of the studies used an identical outcome measure.
Carvalho et al. (2013) reported on HAM-D and HAM-A which saw a reduction in depression and anxiety of 52% and 59% respectively when using acupuncture versus control. Bazarganipour (2017) used the Hospital Anxiety and Depression Scale (HADS) which saw a significant decrease in depression score pre and post-treatment of LIV-3 (11.50+2.16 vs 10.17+0.46) and LI-4 (11.60+2 vs 10.36_2.23) compared with placebo (9.22+2.02 vs 8.72+2.90). Kim et al. (2005) measured the psychological symptoms of PMS using MSSL-D which showed a significant decrease (p<0.05) between the two menstrual cycles. Zhang (2017) measured mood outcomes using DRSP and WHOQOL-BREF which showed that acupuncture may provide a greater reduction in mood-related symptoms than sham acupuncture and that quality of life could be improved as well.
3.2.3. Acupuncture treatment dosage: frequency, acupuncture points, needle retention
There was no indication or rationale in any of the studies as to why the frequency of treatments, acupuncture points or length of treatments were chosen.
3.2.3.1. Frequency of acupuncture treatments
The number of treatments ranged from thirteen (Kim et al., 2005) to twenty-eight treatments (Bazarganipour, 2017). Three studies (Carvalho et al., 2013, Kim et al., 2005, Zhang, 2017) gave treatments every week of the month; however, Carvalho et al. (2013) and Kim et al. (2005) treated twice a week for two menstrual cycles, whereas Zhang (2017) treated three times a week for one menstrual cycle. Bazarganipour (2017) treated every day during the fourteen days before menstruation for two menstrual cycles.
3.2.3.2 Acupuncture points
The number of acupuncture points used began at two (Bazarganipour, 2017) with the maximum being twelve (Zhang, 2017). Carvalho et al. (2013) used six acupuncture points and Kim et al. (2005) used seven.
Liver 3 and Large Intestine 4 were the two acupuncture points used in all four studies. Spleen 6 was the second most commonly used point, appearing in three of the studies (Carvalho et al., 2013, Kim et al., 2005, Zhang, 2017).
3.2.3.3. Acupuncture needle retention
Treatment timing was included in three of the studies (Bazarganipour, Carvalho et al., 2013, Zhang) which ran from 20 minutes, 45 minutes and 30 minutes respectively.
3.2.4. Intervention and control type
Acupuncture was used in three of the studies (Carvalho et al., 2013, Kim, Zhang) and Bazarganipour used acupressure. All the studies used sham acupuncture as control.
3.2.5. Adverse events in acupuncture treatments
Only one study (Zhang, 2017) reported a haematoma, pain at the needle site and itching at the needle site
Discussion
This SLR aimed to understand if the ‘treatment dosage’ of acupuncture will alter the efficacy of treatment for the mental-emotional symptoms of PMS and PMDD that people experience. Treatment dosage, for this SLR, reflects the frequency of treatments, treatment length and acupuncture or acupressure points used.
There is currently no study that examines the relationship between dosage and clinical outcomes in PMS and PMDD.
4.1 Acupuncture treatment dosage
The heterogeneous nature of the four trials means that it was not possible to conclude if one or any of them had a more powerful effect on the treatment of the mental-emotional symptoms of PMS and PMDD. Indeed since all showed effectiveness in treatment, this may lead to an assumptive conclusion that treatment dosage played no part in the outcome.
This possible conclusion was corroborated by Armour & Smith (2016, p. 420) who discovered that treating dysmenorrhea with a higher treatment frequency of acupuncture did not provide greater relief from pain. They did see a greater benefit when treatments occurred in the week before menses than treatments occurring during menses.
Flaws (2010, p.440) emphasises that to treat premenstrual complaints it is better to treat throughout the phase of the menstrual cycle every day, or every other day, from the onset of symptoms until the time of symptoms ending. However, in a systematic review, Zhang et al. (2019, p.6) evaluated intervention timing, acupuncture and premenstrual syndrome and concluded that there was no compelling evidence to suggest that intervention timing affected the reduction of PMS.
4.1.1 Acupuncture points
There was no uniformity of acupuncture points or number of points selected across the four trials. Liver 3 and Large Intestine 4, known as the ‘Four Gates’ or ‘Siguan’ were used in all four studies. Spleen 6 was the second most commonly used point and featured in three of the studies.
‘Four Gates’ the combination of points of Liver 3 and Large Intestine 4 is considered a well known traditional point prescription for nervous tension (Ross, 1996, p. 55). As Source points, on their respective channels, they are considered tonifying, in Yin channels, balancing and useful for emotional imbalance (Ross, 1996, p. 62). Whilst Bazarganipour et al. only used these points in their study they did not use them together with Group 1 only using Liver 3 and Group 2 using Large Intestine 4. There was no rationale as to why these points were chosen or why they were not used together.
In a study conducted by Shan et al. (2014, p. 5), they discovered that using ‘Siguan’ showed extensive bilateral cortical and subcortical activation during testing in comparison to sham acupuncture. These points have also been used on primary dysmenorrhea with successful outcomes (Li et al., 2008).
Spleen 6 was the second most commonly used acupuncture point, being used in three out of the four studies. A study conducted by Pang et al. (2021) which whilst outside the scope of this SLR as it was not an RCT or SR showed that electroacupuncture at Spleen-6 for six minutes was found to increase functional connectivity (FC) between the left amygdala, brainstem and right hippocampus. It also decreased FC between the left amygdala and left thalamus, bilateral supplementary motor area. The importance of this being that the aberrant amygdala resting-state functional networks were involved in PMS (Pang et al., 2018).
In Armour’s systematic review they noted the need for reporting the rationale for point selection (2018, p. 18) to determine if studies are using treatments that reflect clinical practice.
4.1.2 Needle retention
Each of the studies indicated different needle retention times but no rationale as to the length. The classics assert that needles should be retained depending on the nature of the disease and the time of year. For light diseases, the qi should complete one circulation of the body, which is considered to be 30 minutes. (Unschuld & Tessenow, 2011, p. 260). For other diseases, it is simply enough to insert the needle and immediately remove it. Currently, acupuncture needle retention duration has not received great attention in clinical practice (Oh et al., 2018, p. 459) and not regarding PMS and PMDD. A retrospective study conducted by Oh et al. (2018) on needle retention and acupuncture in oncology tentatively found that there was no significant difference in the outcome, regardless of needle retention time however they called for more robust RCTs to confirm their findings.
4.2 Outcome measure
The diverse outcome measures used in each of the studies means that a more thorough comparison of treatment results could not be undertaken.
Although all reported a reduction in mental-emotional scores, against intervention, each study used a different outcome measuring tool. Zhang (2017) was the only RCT that used DRSP which is considered the easiest to use and also consistently provides reliable records of symptoms (‘Management of Premenstrual Syndrome’, 2017, p. 11)
By using one specific outcome measure it would enable a standardised approach to allow researchers to evaluate clearly and accurately to understand which treatment approaches are the most effective (Comet Initiative | Home, n.d.).
4.3 Limitations of studies: Sample size, number of trials and risk of bias
Armour (2018, p.19) in their systematic review found that acupuncture studies for PMS have not been undertaken to a high methodological standard with risk of bias so recommend there is a need for further studies which use blinding, three-armed trials, blinded clinician-rated scales and subjective patient-outcomes.
The inclusion and exclusion criteria for this SLR uncovered only four studies focusing on acupuncture and treatment of mental health symptoms, specifically for PMS and PMDD. Further studies are needed which include larger sample sizes to allow for meaningful meta-analysis. Since there is no trial that investigates a comparison of acupuncture and SSRIs this would be imperative for future study, since SSRIs are currently the first line of treatment for these conditions (Armour, 2018, p. 18).
4.4 Side effects
In a study conducted in 2013 by Majoribanks et al. (2013), they found that women with PMS were more likely to discontinue SSRI treatment due to adverse effects when compared with placebo (OR 2.55, 95% CI 1.843.53). The most common symptoms were nausea, asthenia, somnolence, fatigue, decreased libido and sweating (Marjoribanks et al., 2013, p. 5).
Side effects were reported in one of the studies with acupuncture, which included a haematoma, itching at the needle site and pain at the needle site (Zhang, 1017). Ernst et al., (2003) found that like all therapies acupuncture can have adverse effects, however, when used correctly and safely with a qualified practitioner it is a safe treatment method.
4.5 Diagnosis
Flaws maintain that three things are essential for the treatment of gynaecological pathologies. Firstly, it is necessary to diagnose correctly, secondly create the best treatment principle and thirdly and fundamentally for this SLR, to treat at the appropriate frequency (2010, p.440).
No discernible evidence was provided in any of the RCTs that suggested a Chinese medicine diagnosis was made to diagnose any of the participants beyond their biomedical diagnosis of PMS or PMDD. Qiao et al. (2017, p. 8), concluded that the mechanism of PMDD has two primary subtypes: liver invasion, causing impatience and irritability or liver qi depression leading to emotional depression and low spirits.
For the correct treatment principle, Qiao et al., (2017, p. 8) recommend that suppressing a hyperactive liver to address descending rebellious qi and coursing the liver to relieve depression will provide improved clinical results. Again, no reference could be found in any of the studies that a treatment principle was applied for participants.
4.6 For future acupuncture studies
Whilst the four studies reported effectiveness in treating PMS or PMDD, with reductions in mental-emotional symptoms, compared to sham, it cannot be concluded that ‘treatment dosage’ altered the effectiveness of acupuncture. The lack of uniformity in treatment dosage, no cohesive use of outcome measures, lack of trials, small sample sizes and no comparison to currently accepted pharmaceutical intervention means that any evidence of acupuncture as a viable treatment option for the mental-emotional symptoms of PMS or PMDD is regarded sceptically (Armour, 2018).
For future studies it would be important to not only address each of these problems but also include rationales for Chinese medicine diagnosis, treatment principle and point prescription so that it is clear what the treatment for populations is.
Conclusion
The importance of further research into PMS and PMDD cannot be underestimated. PMS and PMDD are serious conditions that affect the quality of life of a person’s reproductive years every month. Whilst this SLR was not able to positively conclude that acupuncture ‘treatment dosage’ had an impact on mental-emotional symptoms of PMS or PMDD there is low-quality evidence that acupuncture may help with the mental-emotional signs and symptoms. Higher quality and bigger studies must be undertaken that could provide tangible evidence that acupuncture may or may not have a positive benefit for sufferers of PMS and PMDD. These studies should also focus on using one outcome measure to enable a broader analysis of results and a direct comparison of acupuncture versus SSRIs.
At the moment biomedical medication continues to show superior efficacy in the treatment of symptoms, however the adverse events which occur alongside lead to the abandonment of treatments. Whilst acupuncture is not risk-free it has been shown that when administered by a qualified practitioner it has very minimal side effects and acupuncture may provide benefits and an improvement of quality of life to millions of people.
References
6.1 References for this systematic literature review
Armour, M., & Smith, C. A. (2016). Treating primary dysmenorrhoea with acupuncture: A narrative review of the relationship between acupuncture ‘dose’ and menstrual pain outcomes. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society, 34(6), 416–424. https://doi.org/10.1136/acupmed-2016-011110
Armour, M., Ee, C. C., Hao, J., Wilson, T. M., Yao, S. S., & Smith, C. A. (2018). Acupuncture and acupressure for premenstrual syndrome. Cochrane Database of Systematic Reviews, 8. https://doi.org/10.1002/14651858.CD005290.pub2
Carvalho, F., Weires, K., Ebling, M., de Souza Rabbo Padilha, M., Ferrão, Y. A., & Vercelino, R. (2013). Effects of acupuncture on the symptoms of anxiety and depression caused by premenstrual dysphoric disorder. Acupuncture in Medicine, 31(4), 358–363. https://doi.org/10.1136/acupmed-2013-010394
Chou, P. B. Y., & Morse, C. A. (2005). Understanding premenstrual syndrome from a Chinese medicine perspective. Journal of Alternative and Complementary Medicine (New York, N.Y.), 11(2), 355–361. https://doi.org/10.1089/acm.2005.11.355
Comet initiative | home. (n.d.). Retrieved 26 April 2021, from https://www.comet-initiative.org/
del Mar Fernández, M., Regueira-Méndez, C., & Takkouche, B. (2019). Psychological factors and premenstrual syndrome: A Spanish case-control study. PLoS ONE, 14(3). https://doi.org/10.1371/journal.pone.0212557
Epperson, C. N., Steiner, M., Hartlage, S. A., Eriksson, E., Schmidt, P. J., Jones, I., & Yonkers, K. A. (2012). Premenstrual dysphoric disorder: Evidence for a new category for DSM-5. The American Journal of Psychiatry, 169(5), 465–475.
Ernst, G., Strzyz, H., & Hagmeister, H. (2003). Incidence of adverse effects during acupuncture therapy-a multicentre survey. Complementary Therapies in Medicine, 11(2), 93–97. https://doi.org/10.1016/s0965-2299(03)00004-9
Flaws, B. (2010). A compendium of Chinese medical menstrual diseases (Third Edition). Blue Poppy Press. (Original work published 2005)
Freeman, E. W. (2005). Effects of antidepressants on quality of life in women with premenstrual dysphoric disorder: PharmacoEconomics, 23(5), 433–444. https://doi.org/10.2165/00019053-200523050-00003
Haddaway, N. R., Collins, A. M., Coughlin, D., & Kirk, S. (2015). The role of google scholar in evidence reviews and its applicability to grey literature searching. PLoS ONE, 10(9). https://doi.org/10.1371/journal.pone.0138237
Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28 Suppl 3, 1–23. https://doi.org/10.1016/s0306-4530(03)00098-2
Hardy, C., & Hunter, M. S. (2021). Premenstrual symptoms and work: Exploring female staff experiences and recommendations for workplaces. International Journal of Environmental Research and Public Health, 18(7). https://doi.org/10.3390/ijerph18073647
Jang, S. H., Kim, D. I., & Choi, M.-S. (2014a). Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: Systematic review. BMC Complementary and Alternative Medicine, 14(1), 11. https://doi.org/10.1186/1472-6882-14-11
Kim, S., Kim, S., Lim, J., Choi, C.-M., Sim, E., Koo, S., Lim, J., Ha, J., Shin, K., & Sohn, I. (2005). Effects of acupuncture treatment on the premenstrual syndrome: Controlled clinical trial. Journal of Acupuncture Research, 22(1), 41–60.
Li, C., Wang, Y., & Guo, X. (2008). [Acupuncture at Siguan points for treatment of primary dysmenorrhea]. Zhongguo Zhen Jiu = Chinese Acupuncture & Moxibustion, 28(3), 187–190.
Literature review as a research methodology: An overview and guidelines. (2019). Journal of Business Research, 104, 333–339. https://doi.org/10.1016/j.jbusres.2019.07.039
Maciocia, G. (2015). The Foundations of Chinese Medicine (3rd edition). Elsevier.
Maciocia, G. (2009). The Psyche in Chinese Medicine. Elsevier.
Management of premenstrual syndrome. (2017). BJOG: An International Journal of Obstetrics & Gynaecology, 124(3), e73–e105. https://doi.org/https://doi.org/10.1111/1471-0528.14260
Marjoribanks, J., Brown, J., O’Brien, P. M. S., & Wyatt, K. (2013). Selective serotonin reuptake inhibitors for premenstrual syndrome. The Cochrane Database of Systematic Reviews, 6, CD001396. https://doi.org/10.1002/14651858.CD001396.pub3
Metzendorf, M.-I., Schulz, M., & Braun, V. (2014). All information is not equal: Using the literature databases PubMed and the Cochrane library for identifying the evidence on granulocyte transfusion therapy. Transfusion Medicine and Hemotherapy, 41(5), 364–374. https://doi.org/10.1159/000366179
Oh, B., Eade, T., Kneebone, A., Hruby, G., Lamoury, G., Pavlakis, N., Clarke, S., Zaslawski, C., Marr, I., Costa, D., & Back, M. (2018). Acupuncture in Oncology: The effectiveness of acupuncture may not depend on needle retention duration. Integrative Cancer Therapies, 17(2), 458–466. https://doi.org/10.1177/1534735417734912
Osborn, E., Wittkowski, A., Brooks, J., Briggs, P. E., & O’Brien, P. M. S. (2020). Women’s experiences of receiving a diagnosis of premenstrual dysphoric disorder: A qualitative investigation. BMC Women’s Health, 20(1), 242. https://doi.org/10.1186/s12905-020-01100-8
Page, M. J., Moher, D., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … McKenzie, J. E. (2021). PRISMA 2020 explanation and elaboration: Updated guidance and exemplars for reporting systematic reviews. BMJ, 372, n160. https://doi.org/10.1136/bmj.n160
Pang, Y., Liao, H., Duan, G., Feng, Z., Liu, H., Zou, Z., Tao, J., Li, J., He, H., Gao, C., Liu, P., & Deng, D. (2021). Regulated aberrant amygdala functional connectivity in premenstrual syndrome via electro-acupuncture stimulation at sanyinjiao acupoint（SP6）. Gynaecological Endocrinology, 37(4), 315–319. https://doi.org/10.1080/09513590.2020.1855633
Pang, Y., Liu, H., Duan, G., Liao, H., Liu, Y., Feng, Z., Tao, J., Zou, Z., Du, G., Wan, R., Liu, P., & Deng, D. (2018). Altered brain regional homogeneity following electro-acupuncture stimulation at sanyinjiao (Sp6) in women with premenstrual syndrome. Frontiers in Human Neuroscience, 12, 104. https://doi.org/10.3389/fnhum.2018.00104
Pilver, C. E., Levy, B. R., Libby, D. J., & Desai, R. A. (2011). Posttraumatic stress disorder and trauma characteristics are correlates of premenstrual dysphoric disorder. Archives of Women’s Mental Health, 14(5), 383–393. https://doi.org/10.1007/s00737-011-0232-4
Premenstrual dysphoric disorder and suicide attempts as a correlation among women in reproductive age. (2018). Asian Journal of Psychiatry, 31, 63–66. https://doi.org/10.1016/j.ajp.2018.01.003
Qiao, M., Sun, P., Wang, H., Wang, Y., Zhan, X., Liu, H., Wang, X., Li, X., Wang, X., Wu, J., & Wang, F. (2017). Epidemiological distribution and subtype analysis of premenstrual dysphoric disorder syndromes and symptoms based on tcm theories. BioMed Research International, 2017, 1–9. https://doi.org/10.1155/2017/4595016
Ross, J. (1996). Acupuncture Point Combinations: The Key to Clinical Success. Churchill Livingstone.
Shan, Y., Wang, Z., Zhao, Z., Zhang, M., Hao, S., Xu, J., Shan, B., Lu, J., & Li, K. (2014, November 26). An fMRI study of neuronal specificity in acupuncture: The multi acupoint siguan and its sham point [Research Article]. Evidence-Based Complementary and Alternative Medicine. https://doi.org/https://doi.org/10.1155/2014/103491
Sibbald, B., & Roland, M. (1998). Understanding controlled trials: Why are randomised controlled trials important? BMJ, 316(7126), 201. https://doi.org/10.1136/bmj.316.7126.201
Smith, C. A., & Carmady, B. (2010). Acupuncture to treat common reproductive health complaints: An overview of the evidence. Autonomic Neuroscience: Basic & Clinical, 157(1–2), 52–56. https://doi.org/10.1016/j.autneu.2010.03.013
Steinberg, E. M., Cardoso, G. M. P., Martinez, P. E., Rubinow, D. R., & Schmidt, P. J. (2012). Rapid response to fluoxetine in women with premenstrual dysphoric disorder. Depression and Anxiety, 29(6), 531–540. https://doi.org/https://doi.org/10.1002/da.21959
Unschuld, P., & Tessenow, H. (2011). Huang Di Nei Jing Su Wen: An Annotated Translation of Huang Di’s Inner Classic – Basic Questions (Vol. 1). University of California Press.
Wakatsuki, Y., Inoue, T., Hashimoto, N., Fujimura, Y., Masuya, J., Ichiki, M., Tanabe, H., & Kusumi, I. (2020, January 6). Influence of childhood maltreatment, adulthood stressful life events, and affective temperaments on premenstrual mental symptoms of nonclinical adult volunteers. Neuropsychiatric Disease and Treatment. https://doi.org/10.2147/NDT.S232925
Zhang, G. C. (2017). Clinical study on the treatment of acupuncture for premenstrual syndrome. . Guang Zhou University of Chinese Medicine.
Zhang, J., Cao, L., Wang, Y., Jin, Y., Xiao, X., & Zhang, Q. (2019). Acupuncture for premenstrual syndrome at different intervention time: A systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2019, 1–9. https://doi.org/10.1155/2019/6246285
6.2 References for studies excluded in this systematic literature review
Hong, Y. (2002). Clinical therapeutic effect of scalp acupuncture on premenstrual tension syndrome. Chinese Acupuncture and Moxibustion, 22, 597–598. Retrieved 3 March 2021, from https://en.cnki.com.cn/Article_en/CJFDTotal-ZGZE200209010.htm
Guo, Z.-R., & Ma, L.-X. (2013). Acupuncture treatment for premenstrual syndrome. Medical Acupuncture, 25(3), 200–204. https://doi.org/10.1089/acu.2012.0913
Habek, D., Habek, J. Č., & Barbir, A. (2002a). Using acupuncture to treat premenstrual syndrome. Archives of Gynecology and Obstetrics, 267(1), 23–26. https://doi.org/10.1007/s00404-001-0270-7
Kim, S.-Y., Park, H.-J., Lee, H., & Lee, H. (2011). Acupuncture for premenstrual syndrome: A systematic review and meta-analysis of randomised controlled trials: Acupuncture for premenstrual syndrome. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 899–915. https://doi.org/10.1111/j.1471-0528.2011.02994.x
Shin, K. R., Ha, J. Y., Park, H. J., & Heitkemper, M. (2009). The effect of hand acupuncture therapy and hand moxibustion therapy on premenstrual syndrome among Korean women. Western Journal of Nursing Research, 31(2), 171–186. https://doi.org/10.1177/0193945908323650
Xu, Y. (2006). Clinical Study on the Treatment of Acupuncture of Back-Shu on Premenstrual Syndrome. Heilongjiang University of Chinese Medicine.
Xu, Y., & Sun, Y. (2006). Observation of therapeutic effect of point-through point acupuncture method in the back on premenstrual syndrome. Journal of Clinical Acupuncture and Moxibustion, 22, 37–38.
Comments