Does Acupuncture Work For Menstrual Pain?

How is your relationship with your monthly cycles?  Do you dread the onslaught of painful cramps?  Many women face this difficulty, you are not alone, and no – it does not have to be your “normal.”  Menstrual pain is a significant personal and public health problem – according to a recent epidemiological survey, about 45–90% of women in the world suffer from this condition during their menstrual period, among which 10–25% have severe pain that renders them incapacitated for 1-3 days each month, significantly disrupting work hours and quality of life^[i].

Menstrual pain is medically referred to “dysmenorrhea,” a Greek word that means “difficult monthly flow.”  This is an appropriate term, because the cramping pain is often accompanied by other “difficulties” such as swelling, low back and leg pain, diarrhea, mood swings, headache, fatigue, loss of appetite, nausea and vomiting, and more.  No fun.

Dysmenorrhea is classified as primary or secondary: in primary dysmenorrhea, menstrual cramps occur that have nothing to do with any physical abnormalities or identifiable pelvic disease.  Secondary dysmenorrhea is less common and occurs due to some specific pelvic or systemic condition such as endometriosis, adenomyosis, pelvic inflammatory disease, adhesions, ovarian cysts, celiac disease, thyroid conditions, congenital malformations, polyps, uterine fibroids, etc.  Depending on the underlying cause for your menstrual pain, there is a good chance that Acupuncture and Traditional Chinese Medicine can offer relief and help shift your relationship with your monthly cycles into something much more positive.  Can you imagine the possibility of enjoying the ebb and flow of your cycles?

“Feminine wisdom is the intelligence at the heart of creation.”    Deepak Chopra, M.D.

Our female bodies and menstrual cycles have long been associated with the macrocosmic cycles of nature, such as the waxing and waning of the moon and tides and the changing of the seasons.  The monthly ripening of the egg and subsequent pregnancy or release of menstrual blood mirrors these natural processes, and imbues life with creation.

So what happens to cause so many women to suffer during their cycles?  We will focus on primary dysmenorrhea here, as that accounts for the vast majority of cases.  There are multiple factors that may contribute.  From a biomedical perspective, menstruation is an inflammatory process: if pregnancy does not occur, the uterus must shed the endometrial lining to begin anew.  Progesterone declines in the absence of an embryo, and this signals the release of multiple inflammatory pathways to begin reducing blood supply to the uterine lining to allow for tissue breakdown and shedding.  In primary dysmenorrhea, there is often a much higher production of these pro-inflammatory prostaglandins, cytokines, chemokines and matrix metalloproteinases (MMP).  These restrict blood flow, and therefore oxygen, to the uterus (ischemia), which in turn leads to excess cramping and pain.  There is also evidence that prostaglandins can increase the sensitivity of nerve endings to pain and lower the pain perception threshold^[ii].  Risk factors include early age onset of menses, smoking, alcohol abuse, being overweight or underweight, genetics, and exercise (too little or too much).  Western medicine offers treatment in the form of oral contraceptives and prostaglandin synthetase inhibitors, also known as non-steroidal anti-inflammatory drugs (NSAIDS). Although prescription medications can sometimes bring immediate relief, many women do not get significant pain relief from these methods, and they can lead to unwanted side effects.  Luckily, there are other approaches that can help!

In 1997, the National Institute of Health (NIH) issued a consensus report that suggested acupuncture is an effective approach in the treatment of menstrual cramps^[iii].  Numerous studies demonstrate how helpful it can be:

• A 2018 systematic review and meta-analysis evaluated the current evidence across 60 randomized controlled trials regarding the efficacy and safety of acupuncture on primary dysmenorrhea.  The results showed that acupuncture “reduced menstrual pain and associated symptoms more effectively compared to no treatment or NSAIDs, and the efficacy could be maintained during a short-term follow-up period.”  The review showed a “significant reduction in all the variables such as the visual analog scale score for pain, menstrual cramps, headache, dizziness, diarrhea, faint, mood changes, tiredness, nausea, and vomiting in the study group compared with those in the control group.”^[iv]
• A 2019 review published in the Obstetrical & Gynecological Survey examined the evidence regarding the use of acupuncture in obstetrics and gynecology, and found the data demonstrated “acupuncture is beneficial in the treatment of labor pain, back pain in pregnancy, and dysmenorrhea.”^[v]
• A review article was published in 2021 investigating the mechanism of acupuncture in primary dysmenorrhea.  They found evidence from clinical and animal studies on the anti-inflammatory characteristics of acupuncture for inflammation-induced visceral pain.^[vi]   

How does it work?  The mechanisms of acupuncture for dysmenorrhea are not yet fully understood, but evidence suggests it affects the endocrine, immune, and nervous systems, and may also act through electrical and mechanical signaling through the connective tissue and fascia.  According to a 2019 systematic review of the treatment of primary dysmenorrhea, acupuncture seems to alleviate pain by reducing the level of prostaglandins, mediating nitric oxide, increasing beta-endorphin levels, blocking the calcium channel, and enhancing circulatory flow through the uterus.^[vii]

The role of an acupuncturist is to investigate the underlying patterns of imbalance leading to the menstrual pain, then treat individually using safe, effective and natural therapeutic tools.  From a Traditional Chinese Medicine (TCM) perspective, in order for a normal period to occur, Blood must be abundant and move adequately.  Much like the biomedical understanding of dysmenorrhea, TCM views stagnation of blood as the primary pathological condition causing painful periods.  So what causes the stagnation?  This is where we must differentiate between various factors that can lead to stagnation, such as physical overwork, emotional strain, chronic illness, malnourishment, Blood deficiency, excess Heat, or exposure to Cold and Dampness.  Each of these patterns comes with unique signs and symptoms that can be addressed with various tools such as acupuncture, botanical medicine, nutrition, proper exercise, rest, and lifestyle guidance. Treatment often takes a minimum of 3 menstrual cycles to regulate and return the body to balance with less pain, but many women experience immediate relief upon beginning acupuncture.  

Here are some self-care and preventive measures that are commonly helpful, but of course best individualized by your practitioner for maximum benefit:

• Emphasize anti-inflammatory nutritional habits – eliminate foods that may contribute to an excess of the prostaglandins that contribute to uterine contractions such as dairy products, processed and junk foods, trans and hydrogenated fats, industrial seed oils, and food allergens; increase omega-3 oils from fish, hemp oil and flax oil; increase whole organic foods especially a diversity of plants.
• Stress reduction may help to relax the pelvic and low back muscles.
• Good posture and spinal alignment may improve blood flow and decrease cramps.
• Reduce tampon use – some women find that their menstrual cramping is worsened by tampon use and relieved when they switch to pads.
• Methods of contraception: a copper IUD may worsen spasmodic menstrual cramping.  A progestin-containing IUD and hormonal contraception can improve chronic dysmenorrhea.  Barrier methods have no bearing on dysmenorrhea.
• Maintain a healthy weight.
• Avoid smoking and excess alcohol.
• Food allergies may contribute to water retention, gas, and bloating, which may contribute to congestive menstrual pain.
• Maintain optimal digestive function.  Irregular bowel habits may be correlated to primary dysmenorrhea.
• Moderate exercise may improve blood flow and create an optimal pelvic musculature that will tend to reduce cramping pain.

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^[i] Rencz, F., Péntek, M., Stalmeier, P. F., Brodszky, V., Ruzsa, G., Gradvohl, E., Baji, P., & Gulácsi, L. (2017). Bleeding out the quality-adjusted life years: evaluating the burden of primary dysmenorrhea using time trade-off and willingness-to-pay methods. Pain, 158(11), 2259–2267. https://doi.org/10.1097/j.pain.0000000000001028

^[ii] Harel, Z. (2004). Cyclooxygenase-2 specific inhibitors in the treatment of dysmenorrhea. Journal of Pediatric and Adolescent Gynecology, 17(2), 75–79. https://doi.org/10.1016/j.jpag.2004.01.002

^[iii] Acupuncture. NIH Consensus Statement Online 1997 Nov 3-5; month, day]; 15(5):1-34.

^[iv] Woo, H. L., Ji, H. R., Pak, Y. K., Lee, H., Heo, S. J., Lee, J. M., & Park, K. S. (2018). The efficacy and safety of acupuncture in women with primary dysmenorrhea. Medicine, 97(23), e11007. https://doi.org/10.1097/md.0000000000011007

^[v] Bishop, K. C., Ford, A. C., Kuller, J. A., Dotters-Katz, S. (2019).  Acupuncture in Obstetrics and Gynecology.  Obstetrical & Gynecological Survey, 74(4):241-251.

^[vi] Yu, W. Y., Ma, L. X., Zhang, Z., Mu, J. D., Sun, T. Y., Tian, Y., Qian, X., & Zhang, Y. D. (2021). Acupuncture for Primary Dysmenorrhea: A Potential Mechanism from an Anti-Inflammatory Perspective. Evidence-Based Complementary and Alternative Medicine, 2021, 1–12. https://doi.org/10.1155/2021/1907009

^[vii] Sharghi, M., Mansurkhani, S. M., Ashtary-Larky, D., Kooti, W., Niksefat, M., Firoozbakht, M., Behzadifar, M., Azami, M., Servatyari, K., & Jouybari, L. (2019). An update and systematic review on the treatment of primary dysmenorrhea. JBRA Assisted Reproduction. https://doi.org/10.5935/1518-0557.20180083