DOI: 10.1111/j.1471-0528.2011.02994.

x
Systematic review
www.bjog.org

Acupuncture for premenstrual syndrome:

a systematic review and meta-analysis of
randomised controlled trials
S-Y Kim,a,b H-J Park,a,b H Lee,a,b H Leeb,*
a
Department of Oriental Medical Science, Graduate School, College of Korean Medicine, Kyung Hee University b Acupuncture and Meridian
Science Research Centre, College of Korean Medicine, Kyung Hee University, Seoul, Korea
*Correspondence: Dr H Lee, Acupuncture and Meridian Science Research Centre, College of Korean Medicine, Kyung Hee University,
1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-701, Korea. Email erc633@khu.ac.kr

Accepted 1 March 2011. Published Online 24 May 2011.

Background Although acupuncture is widely applied in obstetrics
and gynaecology, evidence for its efficacy in treating premenstrual
syndrome (PMS) is equivocal.
Objective To summarise and evaluate the current evidence for
acupuncture as a treatment for PMS.
Search strategy Ten databases were searched electronically, and
relevant reviews were searched by hand through June 2009.
Selection criteria Our review included randomised controlled
trials (RCTs) of women with PMS; these RCTs compared
acupuncture with sham acupuncture, medication, or no treatment.
Data collection and analysis Study outcomes were presented as
mean differences (for continuous data) or risk ratios (RRs) (for
dichotomous data) with a 95% confidence interval (95% CI). The
risk of bias was assessed using the assessment tool from the
Cochrane Handbook.
Main results Ten RCTs were included in our review. The
pooled results demonstrated that acupuncture is superior to all
controls (eight trials, pooled RR 1.55, 95% CI 1.33–1.80,
P < 0.00001). A meta-analysis comparing the effects of
acupuncture with different doses of progestin and/or anxiolytics
supported the use of acupuncture (four trials, RR 1.49, 95% CI
1.27–1.74, P < 0.00001). In addition, acupuncture significantly
improved symptoms when compared with sham acupuncture
(two trials, RR 5.99, 95% CI 2.84–12.66, P < 0.00001). No
evidence of harm resulting from acupuncture emerged. Most of
the included studies demonstrated a high risk of bias in terms
of random sequence generation, allocation concealment, and
blinding.
Author’s conclusions Although acupuncture seems promising for
symptom improvement in women with PMS, important
methodological flaws in the included studies weaken the evidence.
Considering the potential of acupuncture, further rigorous studies
are needed.
Keywords Acupuncture, premenstrual syndrome, systematic
review.

Please cite this paper as: Kim S-Y, Park H-J, Lee H, Lee H. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomised
controlled trials. BJOG 2011;118:899–915.

reproductive age exhibit PMS symptoms severe enough to

Introduction
Premenstrual syndrome (PMS) is a condition that presents
with distressing physical, behavioural, and psychological
symptoms, in the absence of organic or underlying psychi-
atric disease, which regularly recurs during the luteal phase
of each menstrual cycle, and which disappears or signifi-
cantly regresses by the end of menstruation.1 Although
mild symptoms occur in approximately 75% of women
of reproductive age,2 20–30% of women are reported to
suffer from clinically significant PMS.3 A recent evaluation
of published reports suggests that 13–18% of women of
warrant treatment.4 Women with PMS usually complain of
somatic symptoms, such as food cravings, mastalgia, bloat-
ing, headache, lack of energy, abdominal discomfort and
pain, and weight gain. Frequently reported affective
changes include depression, angry outbursts, crying spells,
anxiety, irritability, and feelings of being unable to cope.
When diagnosing and evaluating the effect of treatment for
PMS, the Daily Record of Severity of Problems (DRSP)
form is now accepted.1
The aetiology and pathogenesis of PMS have yet to be
established; therefore, a broad range of treatment options is

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 899
 Kim et al.
suggested.5 Before starting treatment, lifestyle changes, exer-
cise or cognitive behavioural therapy are encouraged as a
first-line option. For women who have moderate to severe
PMS, or for those in whom simple lifestyle adjustments
have failed, evidence-based pharmacological treatment
options include combined new contraceptive pills (cycli-
cally or continuously), continuous or luteal phase low-dose
selective serotonin reuptake inhibitors (SSRIs), and percu-
taneous estradiol with cyclical progestogen.1
As an integrated approach is beneficial, many women
with PMS seek complementary and alternative medicine
(CAM) treatments such as herbal preparations, manipula-
tive therapy, homoeopathy, and acupuncture.6,7 Although
acupuncture is widely applied in obstetrics and gynaecol-
ogy,8,9 evidence of its effectiveness for PMS is equivocal.
Moreover, acupuncture is not mentioned in the recent
Royal College of Obstetricians and Gynaecologists (RCOG)
guidelines for PMS management, whereas many other
CAM modalities with limited effectiveness have been listed.
In this context, we conducted a systematic review and a
meta-analysis to summarise and critically evaluate the cur-
rent evidence for, or against, the use of acupuncture for
PMS.
Methods
Data sources and searches
This systematic review was performed according to the
guidelines of the Preferred Reporting Items for Systematic
Reviews and Meta-analyses (PRISMA) statement.10 The fol-
lowing electronic databases were searched from their incep-
tion to June 2009, without language restrictions: PUBMED,
EMBASE, The Cochrane Library, AMED, SocINDEX,
CINAHL, Academic Search Premier, China National
Knowledge Infrastructure (CNKI), Korean Studies Informa-
tion Service System (KISS), and the National Digital
Science Library of Korea databases. The search terms used
were ‘acupuncture’ and ‘premenstrual’, ‘premenstrual syn-
drome’, or ‘PMS’. The references in all located studies and
reviews were manually searched for further relevant articles.
Publication types, e.g. conference proceedings, abstract
only, or theses, were not limited, as long as they met the
following inclusion criteria.
Study selection
Studies meeting the following criteria were included: (1)
the study was an RCT; (2) the study participants were
women who met the diagnostic criteria for PMS or pre-
menstrual tension syndrome; (3) the study compared nee-
dle acupuncture for one or more menstrual cycles with
sham acupuncture, usual care, waiting list or no treatment;
(4) if any concomitant treatment other than acupuncture
was given, this was given to both acupuncture and control
900 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
groups; and (5) the study reported changes or improve-
ments in PMS symptoms as outcome measures. Studies
looking only at specific symptoms of PMS (e.g. menstrual
migraine), comparing two different forms of acupuncture,
or comparing acupuncture with a herbal medicine, the effi-
cacy of which cannot be determined at present, were
excluded. Trials of acupuncture-related techniques (e.g.
auricular seed, laser, acupuncture point embedding or
injection, acupressure, magnetic devices, and moxibustion)
were excluded. No language restrictions were imposed.
Data extraction and risk of bias assessment
The study selection, data extraction and risk of bias assess-
ment were performed independently by two of the authors
(S-Y Kim and H Lee). Hard copies of all articles included
were obtained and read in full. Data from the articles were
validated and extracted using a predefined data extraction
form. We contacted study authors via e-mail or telephone
to collect further information when necessary. The details
of acupuncture and control interventions were tabulated
separately based on the recently revised Standards for
Reporting Interventions in Clinical Trials of Acupuncture
(STRICTA) recommendations.11
Quality assessment was also independently performed by
the two reviewers (S-Y Kim and H Lee) using the tool for
the assessment of risk of bias from the Cochrane Hand-
book for Systematic Reviews of Interventions.12 The follow-
ing items were assessed;
1 Was the allocation sequence adequately generated?
2 Was allocation adequately concealed?
3 Was knowledge of the allocated interventions adequately
prevented during the study?
4 Were incomplete outcome data adequately addressed?
5 Are reports of the study free of suggestion of selective
outcome reporting?
6 Was the study free of other problems that could put it at
a risk of bias? The answer ‘yes’ indicated a low risk of
bias (Y), ‘unclear’ indicated that the risk of bias was
uncertain (U), and ‘no’ indicated a high risk of bias (N).
The blinding to the allocated interventions was assessed
separately for participants and outcome assessors.
Disagreements were resolved by discussions between all
authors.
Data synthesis and analysis
All analyses were conducted using review manager
v5.0.21 for windows (The Nordic Cochrane Centre,
Copenhagen, Denmark). Studies were classified and com-
bined in the analysis according to the type of control used.
We used the mean difference (MD) with a 95% confi-
dence interval (95% CI) for continuous data. For dichoto-
mous data (e.g. the number of women reporting clinical
 Acupuncture for premenstrual syndrome

improvement), the results were presented as a risk ratio
(RR) with a 95% CI. As most Chinese trials report out-
comes based on a categorical assessment (e.g. ‘markedly
improved’, ‘improved’, ‘slightly better’ or ‘no effect’),13 we
performed a sensitivity analysis by re-analysing the dichoto-
mous outcomes. In other words, we compared the ‘all
improved versus no effect’ scenario (as reported) with the
‘improved or more versus slightly better or no effect’ sce-
nario to ascertain any discrepancies.
Although both fixed-effects and random-effects models
were computed, only random-effects results were presented
if there were no significant differences between the two
methods. Heterogeneity was examined with the I2 test,
where I2 values of 50% or more indicated a substantial
level of heterogeneity.14
Results
Study characteristics
Figure 1 summarises the results of the literature searches.
From a total of 306 titles, 199 records were screened, and
50 studies were deemed to be potentially relevant. These
50 full-text articles were read to confirm their eligibility.
Ten studies met our inclusion criteria (Table 1),15–24 after
the exclusion of two duplicates.25,26
Seven studies were conducted in China,15,16,18,20,22–24 two
were conducted in Korea,19,21 and one was conducted in
Croatia.17 Except for two articles in English17,21 and one in
Korean,19 the studies were all reported in Chi-
nese.15,16,18,20,22–24
Identification
Participants and settings
The trials were relatively small, with an average of 47
women per trial. Patients were diagnosed as having
PMS according to the International Statistical Classification
of Diseases and Related Health Problems, tenth revision
(ICD-10),19,21 the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition (DSM-IV),19,24 national
guidelines,15,20,22,23 textbooks,15,18,20,22,23 or other crite-
ria.16,17
Acupuncture interventions
A range of acupuncture techniques were adopted in the
studies included. Details of the reporting of interventions
are listed in Table 2, in accordance with the STRICTA
recommendations.11 Most (70%) of the studies tested tra-
ditional Chinese medicine (TCM)-style acupuncture, as
most studies originated from China. Two of the TCM
studies employed specific points on the back alone.22,23
The three non-TCM studies used scalp electroacupunc-
ture,18 traditional Korean acupuncture,19 and Korean
hand acupuncture.21 The acupuncture techniques varied
greatly in terms of acupuncture style, treatment variation
(i.e. fixed or individual), acupuncture point selection, and
manipulation method. The participants received 21.2 ses-
sions of acupuncture, on average (median 25.5 sessions;
SD 10.5 sessions) for between one and three menstrual
cycles (mean 2.4 cycles; SD 1.0 cycles; median 3.0 cycles).
The frequently used acupuncture points were as follows
(Table S1): LR3 (n = 6); SP6 (n = 5); PC6 (n = 4); GV20
(n = 4); CV4 (n = 5); CV6 (n = 4); CV17 (n = 3) except
acupuncture points at the back such as BL17 (n = 3);

BL18 and BL20 (n = 4, each); and BL23 (n = 6). Many of

295 of records identified 11 of additional records these points are commonly used in other obstetric and
through database identified through other
searching sources gynaecological conditions, and additional points were used
based on symptoms. Most studies employed forms of
149 of records excluded on the manual stimulation, such as twirling or lifting/thrusting
199 of records after
Screening

basis of title and abstract (or full the needle to elicit the de qi sensation (i.e. the patient’s
overlapping articles
text)
removed feeling of soreness, numbness, distension, heaviness, or a
No PMS study (n = 135)
No acupuncture study (n = 14) sensation like an electric shock around the point, together
with the practitioner’s feeling of tenseness around the
40 of full-text articles excluded,
needle).27 In only three studies were specific characteris-
50 of full-text articles
Eligibility

assessed for eligibility

with reasons tics or the educational background of the practitioner
Review (n = 7)
described: a Korean medicine doctor;19 an obstetrics/
Protocol (n = 1)
Physiological data only (n = 1)
gynaecology specialist;17 and a Korean hand acupuncture
Investigation of specific therapist.21
symptom of PMS or
10 of studies included in
Included

dysmenorrhea (n = 5)
qualitative synthesis
Inappropriate treatment and/or Types of control groups
control (n = 10) Four out of ten trials compared acupuncture with medica-
Controlled clinical trials (n = 4)
Case series (n = 9)
tion.16,18,22,23 There were three sham-controlled trials,
8 of studies included in Duplicates (n = 3) including two with superficial needling at non-acupuncture
quantitative synthesis points,17,24 and one with identical needling at real but irrel-
(meta-analysis)
evant acupuncture points.19 One Korean study compared
Figure 1. Flow chart of the studies included. Korean hand acupuncture with no treatment at all.21

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902
Table 1. Summary of the included RCTs (n = 10)

Author Design Diagnosis (mean Acupuncture Control (no Main outcome Main results* AE
Kim et al.

(year) age)/menstrual (no of analysed/ of analysed/ measures

cycles randomised randomised
patients) patients)

Acupuncture vs Medication
Xu Parallel, Chinese standards for (A) Back shu point Medication (20/20) (1) Symptom score after (A) better than NR
(2006a)22 three arms diagnosis and treatment, acupuncture (20/20) three cycles control (P < 0.05)
Chinese guideline for (B) Standard acupuncture (B) vs control: NS
new Chinese medicine (20/20) (A) better than (B)
research for PMS, and (P < 0.05)
OB/GYN textbook (2) Clinical improvement (A) better than
(32.2 yrs)/3 rate after three cycles control (P < 0.05)
(B) vs control: NS
(A) better than (B)
(P < 0.05)
Xu Parallel, two Chinese guideline for new Point-through-point Medication (30/30) Clinical improvement rate Acupuncture better NR
(2006b)23 arms Chinese medicine research acupuncture at the after three cycles than control (P < 0.05)
for PMS and OB/GYN back (30/30)
textbook (31.1 yrs)/3
Guo Parallel, two Physical, psychological and Acupuncture (35/35) Medication (31/31) Clinical improvement rate Acupuncture better NR
(2004a)16 arms behavioral symptoms after three cycles than control (P < 0.05)
of PMS (30.9 yrs)/3
Hong Parallel, two OB/GYN textbook (NR, Scalp EA (35/35) Medication (31/31) Clinical improvement rate Acupuncture better NR
(2002)18 arms range 20-41 yrs)/3 after three cycles than control (P < 0.05)
Acupuncture vs sham acupuncture
Yu Parallel, two DSM-IV (31.6 yrs)/3 Acupuncture (30/33) Sham acupuncture (1) Changes in discomforts (1) Acupuncture better Two cases of
(2006)24 arms (30/32) after three cycles than control (P < 0.05) hypomenorrhea
(2) Changes in days with (2) Acupuncture better during 2nd cycle,
discomforts after three cycles than control (P < 0.05) recovered at 3rd cycle
(3) Clinical improvement rate (3) Acupuncture better in acupuncture group
after three cycles than control (P < 0.0001)
Kim Parallel, two ICD-10 criteria for PMS Acupuncture (10/10) Sham acupuncture MSSL score change between NS NR
(2005)19 arms and DSM-IV for PMDD (3/10) two cycles
(28.9 yrs)/1
Habek Parallel, two Symptoms of PMS, Acupuncture (18/18) Sham acupuncture Clinical improvement rate, Acupuncture better than One subcutaneous
(2002)17 arms diagnostic criteria (17/17) measurement time-point control (P = 0.008) abdominal haematoma
NR (30.2 yrs)/1 unclear in acupuncture group
Acupuncture vs no treatment
Shin Parallel, ICD-10 criteria (27 yrs)/1 Korean Hand acupuncture No treatment MSSL score at 4 weeks (A) better than control No serious AE
(2009)21 three arms (7/10) Korean Hand (7/10) (P < 0.001) (B) better observed
moxibustion (8/10) than control (P < 0.001)

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
 Acupuncture for premenstrual syndrome

In one Chinese trial, a herbal medicine widely used for

No serious AE

AE, adverse events; EA, electroacupuncture; ICD, International Classification of Diseases; MMSL, Menstrual Symptom Severity List; NR, not reported; NS, not significantly different between
PMS was given to both acupuncture and control groups.20

observed
Table 2 lists the details of control group interventions.

NR
AE

In several studies, acupuncture was compared with progestin

administered alone (medroxyprogesterone, 6 mg daily)22,23
or in combination with diazepam (medroxyprogesterone,

than control (P < 0.01)

than control (P < 0.05)

4 mg daily, and diazepam, 2.5 mg twice daily) starting on

than control (P < 0.05)

(1) Acupuncture better

(2) Acupuncture better

Main results*

the 14th or 16th day of the menstrual cycle, and continuing

Acupuncture better
for 10–14 days.15,16,18 Although most studies did not
describe the rationale for their selection of a control group,
two sham-controlled trials reported the use of pilot testing
or literature sources in their selection of a control
group.19,24
Clinical improvement rate after
(1) Symptom score after three

(2) Clinical improvement rate

Outcome measures
The Menstrual Symptom Severity List (MSSL) was used
Main outcome

to measure the treatment outcome in two studies.19,21

after three cycles
measures

Eight out of ten studies reported clinical improvement

based on a four-point Likert-type scale, with possible out-
three cycles

comes of ‘markedly improved’, ‘improved’, ‘slightly bet-

cycles

groups; OB/GYN, obstetrics and gynaecology; PMS, premenstrual syndrome; RCT, randomised controlled trial; yrs, years.

ter’, and ‘no effect’. The definitions of clinical

improvement or treatment effectiveness varied across tri-
als, and most studies compared all improvements to no
analysed/randomised

effect. In our statistical pooling of the numbers of women

Control (no of

with or without an improvement as a dichotomous out-

medicine (30/30)
patients)

Chinese herbal

come, two scenarios were analysed and compared: one

Medication

was an ‘as reported’ scenario comparing ‘all improve-

ments’ with ‘no effect’, and the other was a ‘re-calculated’
(22/22)

scenario comparing ‘improved or more’ with ‘slightly bet-

ter or no effect’.
analysed/randomised
Acupuncture (no of

Risk of bias assessment

medication (20/20)
Acupuncture plus

medicine (30/30)
patients)

*Data were re-analysed when statistics were missing or should be clarified.

Acupuncture +
Chinese herbal

Adequate sequence generation

One study used a computer-generated random number
sequence to allocate patients to the treatment and control
groups (Table 3).24 Nine studies did not clearly report how
Acupuncture plus herbal medicine vs herbal medicine

their random numbers were generated.15–23

Chinese medicine research
Chinese guideline for new
diagnosis and treatment,
Diagnosis (mean

Chinese standards for

age)/menstrual

for PMS and OB/GYN

textbook (31.1 yrs)/3
& OB/GYN textbook

Allocation concealment
Acupuncture plus medication vs medication
cycles

Only one study adequately concealed group assignments by

adopting central randomisation.24 It was not clear whether
(30.9 yrs)/3

group allocation was adequately concealed in the remaining

nine trials.

Blinding
Parallel, two

Parallel, two
Design

Blinding was evaluated separately for patients and outcome

Table 1. (Continued)

assessors. We could not judge whether the patients were

arms

arms

blinded for the three sham-controlled trials because of

insufficient information.17,19,24 For outcome assessor blind-
(2004b)15

(2009)20

ing, all studies received ratings of ‘unclear’ or ‘no’ because

Author
(year)

Peng
Guo

of poor reporting or the self-reporting nature of the out-

come measures used.

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904
Table 2. Acupuncture interventions in the included studies based on the STRICTA recommendations (n = 10)

First Acupuncture rationale Details of needling Treatment regimen Other components Practitioner Control intervention
Kim et al.

author of treatment background

(year)
Style of Treatment Acupuncture Number of needles per Number of Other Setting Rationale Description of
acupuncture rationale treatment session Acupuncture sessions/frequency interventions and for the the control
variation points used (uni/ and duration given to the context of control
bilateral/NR) Insertion of sessions acupuncture treatment
depth Response sought group
Stimulation method
Retention time
Needle type

Acupuncture vs medication
Xu (A) Back Historical Fixed NR 30 sessions NR Hospital NR NR Medroxyprogesterone,
(2006a)22 shu point context and BL15, 17, 18, 20, 21, 23 Once daily 14 days 6 mg daily, from
acupunc- literature (NR) before menstruation 16th day of
ture sources 1 cun for three cycles, rest menstrual cycle for
De-qi response Manual, during period 10 days
manipulation at every
5 min
30 min
0.25 · 40 mm
(B) Standard NR Fixed NR 30 sessions
acupunc- GV20, CV4, 6, Ex-CA1 Once daily 14 days
ture (Zigong), SP6, ST36 (NR) before menstruation
NR for three cycles,
De-qi response Manual, rest during period
manipulation at every
5 min
30 min
0.25 · 40 mm
Xu Point-through- Historical Fixed NR 30 sessions NR Hospital NR NR Medroxyprogesterone,
(2006b)23 point context and From GV8 to 7, 6 to 5, Once daily 14 days 6 mg daily, from
acupuncture literature 4 to 3/BL18 to 19, 20 before menstruation 16th day of
at the back sources to 21, 22 to 23/BL47 to for three cycles, rest menstrual cycle for
48, 49 to 50, 51 to 52 during period 10 days
NR
De-qi response Manual,
point-through-point
acupuncture method
30 min 0.38 · 40 mm

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 Table 2. (Continued)

First Acupuncture rationale Details of needling Treatment regimen Other components Practitioner Control intervention
author of treatment background
(year)
Style of Treatment Acupuncture Number of needles per Number of Other Setting Rationale Description of
acupuncture rationale treatment session Acupuncture sessions/frequency interventions and for the the control
variation points used (uni/ and duration given to the context of control
bilateral/NR) Insertion of sessions acupuncture treatment
depth Response sought group
Stimulation method
Retention time
Needle type

Guo TCM Historical Fixed NR 30 sessions NR Hospital NR NR Medroxyprogesterone,

(2004a)16 acupuncture context and BL17, 18, 20, 23 Once daily from 4 mg daily and diaze
literature followed by GV20, 14 days before pam 2.5 mg twice
sources CV17, CV4, SP6, PC6, menstruation for daily
LR3 three cycles,
0.5–1 cun rest during period
De-qi response Manual,
manipulation at every
5 min
0–30 min
0.35 · 40 mm

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Hong Scalp EA Historical Semi- NR Approximately 30 NR NR NR NR Medroxyprogesterone
(2002)18 context and standardised Basic points: MS1, 5; sessions (4 mg daily and
literature additional points based Three times/week diazepam 2.5 mg
sources on symptoms: MS2/ for three cycles, rest twice daily, starting
MS3/MS4 for 5 days during from 14 days before
Beneath the epicranial period menstruation,
aponeurosis stopping at the end
Electrical intensity was of menstruation
adjusted for patients to
feel comfortable
Electrical, 1.3–1.7 Hz
60 min
0.65 · 25 mm
Acupuncture for premenstrual syndrome

905
906
Table 2. (Continued)

First Acupuncture rationale Details of needling Treatment regimen Other components Practitioner Control intervention
Kim et al.

author of treatment background

(year)
Style of Treatment Acupuncture Number of needles per Number of Other Setting Rationale Description of
acupuncture rationale treatment session Acupuncture sessions/frequency interventions and for the the control
variation points used (uni/ and duration given to the context of control
bilateral/NR) Insertion of sessions acupuncture treatment
depth Response sought group
Stimulation method
Retention time
Needle type

Acupuncture vs sham acupuncture

Yu TCM Historical Semi- NR Nine sessions NR Hospital NR Pilot test for Superficial
(2006)24 acupuncture context and standardised Basic points: GV20, Ex-HN3, Three sessions, sham acupuncture at
literature 5, SP6, 10; additional from 7 days before acupuncture non-acupuncture
sources points based on menstruation, for control on points 1 cm away
symptoms: LR3, CV17, three cycles 12 healthy from basic
LR14/Ex-CA1 (Zigong), volunteers acupuncture points
CV4, SP9/ST36, CV6/PC6, at 0.2–0.3 cun
HT7/BL23, GV4, KI3 depth, induction of
bilaterally de-qi response
Different depths for unclear
different acupuncture
points
De-qi response Manual,
manipulation at every
10 min
30 min
0.30 · 25 mm,
0.30 · 40 mm
Kim TCM Historical Semi- -NR 18–20 sessions, from NR Hospital Korean Historical Acupuncture at SI5
(2005)19 acupuncture context and standardised Basic points: SP6, CV6; 14 days before medicine context and and ST40 considered
literature additional points based on menstruation doctors literature ineffective to PMS,
sources symptoms: LR2, 3, SP10, twice weekly, for sources de-qi elicited
LI4/ST36 (NR) 8 weeks
NR
De-qi response Manual
NR
0.30 · 30 mm (DongBang,
Korea)

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 Table 2. (Continued)

First Acupuncture rationale Details of needling Treatment regimen Other components Practitioner Control intervention
author of treatment background
(year)
Style of Treatment Acupuncture Number of needles per Number of Other Setting Rationale Description of
acupuncture rationale treatment session Acupuncture sessions/frequency interventions and for the the control
variation points used (uni/ and duration given to the context of control
bilateral/NR) Insertion of sessions acupuncture treatment
depth Response sought group
Stimulation method
Retention time
Needle type

Habek TCM acupunc- Historical Fixed NR Mean 2.6 sessions Progestin Health Physician NR Superficial
(2002)17 ture + ear context and Standard acupuncture (range 2–4) (n = 3), and centre (OB/GYN) acupuncture at
acupuncture literature point: GV20, CV3, 4, 6, Once every other fluoxetine non-acupuncture
sources LI4, LR3, PC6, GB34, BL23 day for 7 days, (n = 1) points without de-qi
(bilateral)/Ear acupuncture: during the 3rd
Shenmen luteal phase of
NR the cycle
De-qi response 30 min/session
Manual
NR
NR
Acupuncture vs no treatment
Shin (A) Korean Textbooks Fixed NR Ten sessions NR Laboratory Korean hand NR No treatment

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(2009)21 Hand A5, 6, 8, 12, 16, 18, N18, Once per 3 days within a acupuncture
acupunc- F6 (bilateral) for 4 weeks hospital therapist
ture <1 mm
NR
Manual
NR
NR
(B) Korean Textbooks Fixed NA
Hand A5, 6, 8, 12, 16, 18, N18,
moxibus- F6 (bilateral)
tion NA
NA
Moxibustion, three times
per sessions 30 min NA
Acupuncture for premenstrual syndrome

907
908
Kim et al.

Table 2. (Continued)

First Acupuncture rationale Details of needling Treatment regimen Other components Practitioner Control intervention
author of treatment background
(year)
Style of Treatment Acupuncture Number of needles per Number of Other Setting Rationale Description of
acupuncture rationale treatment session Acupuncture sessions/frequency interventions and for the the control
variation points used (uni/ and duration given to the context of control
bilateral/NR) Insertion of sessions acupuncture treatment
depth Response sought group
Stimulation method
Retention time
Needle type

Acupuncture plus medication vs medication

Guo TCM Historical Fixed NR 30 sessions Identical Hospital NR NR Medroxyprogesterone,
(2004b)15 acupuncture context and BL17, 18, 20, 23 followed Once daily from medication 6 mg daily, for
literature by GV20, CV17, CV4, 14 days before as in the 10 days, from
sources SP6, PC6, LR3 menstruation for control group 16 days before
0.5–1 cun three cycles, rest menstruation
De-qi response during period
Manual, manipulation at
every 5 min
0–30 min
0.25 · 40 mm
Acupuncture plus herbal medicine vs herbal medicine
Peng TCM acupunc- Historical Fixed NR Approximately Jiaweixiaoyao Hospital NR NR Jiaweixiaoyao
(2009)20 ture + Chinese context and LR3, CV4, 6, SP6, GV24 21 sessions powder, powder, once daily,
herbal medi- literature (NR) Once every other day once daily, from 14 days before
cine sources NR for 7 days from from 14 days menstruation, for 14
De-qi response 14 days before before days
Manual, manipulation at menstruation, rest menstruation,
every 5 min during period, for for 14 days
30 min three cycles
0.30–35 · 25–40 mm

De-qi means acupuncture-evoked specific sensations, such as soreness, numbness, heaviness, and distention at the site of needle placement, and these sensations may spread to other parts
of the body; acupuncture point ST36 refers to the 36th point of the stomach meridian. Some extra points have Chinese names.
EA, electroacupuncture; min, minutes; NA, not applicable; NR, not reported; STRICTA, standards for reporting interventions in controlled trials of acupuncture; TCM, traditional Chinese medi-
cine; TKM, traditional Korean medicine.

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
 Acupuncture for premenstrual syndrome

Table 3. Risk of bias assessment in the included studies (n = 10)

First author (year), Risk of bias assessment

location
(1) (2) (3) (4) (5) (6)
Adequate Allocation Blinding? Incomplete Free of Free of
sequence concealment? outcome data selective other bias?
generation? Participant Outcome adequately outcome
assessor addressed? reporting?

Xu (2006a), China22 U U N U Y Y Y
Xu (2006b), China23 U U N U Y Y Y
Guo (2004a), China16 U U N U Y Y N
Hong (2002), China18 N U N U Y Y Y
Yu (2006), China24 Y Y U U Y Y Y
Kim (2005), Korea9 U U U U N Y N
Habek (2002), Croatia17 U U U U Y N N
Shin (2009), Korea21 U U N N U Y N
Guo (2004b), China15 U U N U Y Y Y
Peng (2009), China20 U U N U Y Y Y

(1) Was the allocation sequence adequately generated? (2) Was the allocation adequately concealed? (3) Was knowledge of the allocated inter-
ventions adequately prevented during the study? (4) Were incomplete outcome data adequately addressed? (5) Are reports of the study free of
suggestion of selective outcome reporting? (6) Was the study apparently free of other problems that could put it at a risk of bias?
N, no (high risk of bias)12 ; U, unclear; Y, yes (low risk of bias).

Incomplete outcome data reporting
Two studies had a high attrition rate.19,21 The numbers of
dropouts in these two studies were highly imbalanced
between the treatment and control groups: this probably
affected the outcomes.19 Statistical analysis was performed
only on the patients who completed the protocol,19,21
introducing a substantial bias into these studies. The other
eight studies were rated as having a low risk of bias.
Selective outcome reporting
Although most of the studies were evaluated as having a
low risk of bias, the risk of bias was deemed high in one
study where the outcome measurement was not clearly pre-
specified or reported.17
Other sources of bias
Four out of ten studies were rated as having a high risk of
bias for reasons not listed above: two trials did not report
definitive diagnostic criteria,16,17 and two other studies
involved either vulnerable subjects, i.e. nurses working in
the study hospital,19,21 or patients with an extreme baseline
imbalance.19
Main outcomes
PMS (Figure 2A; n = 429, pooled RR 1.55, 95% CI 1.33–
1.80, P < 0.00001, I2 = 28%).15–18,20,22–24 Our re-analysis of
these data using the ‘improved or more’ versus the ‘slightly
better or no effect’ criterion confirmed a significant
improvement in symptoms achieved by acupuncture (pooled
RR 2.35, 95% CI 1.73–3.19, P < 0.00001, I2 = 29%).
Excluding one outlier did not significantly change the overall
benefit of acupuncture over controls (seven trials, n = 394,
pooled RR 1.52, 95% CI 1.34–1.72, P < 0.00001, I2 = 0%).17
Acupuncture versus medication (four trials,
232 women analysed)
Four studies compared approximately 30 sessions of acu-
puncture over three menstrual cycles with different doses
of progestin (4–6 mg daily), with or without anxiolyt-
ics.16,18,22,23 Overall, women receiving acupuncture were
approximately 1.5 times more likely to experience symptom
improvement than those on hormonal preparations with or
without anxiolytics (Figure 2B; four trials, n = 232, pooled
RR 1.49, 95% CI 1.27–1.74, P < 0.00001, I2 = 0%). The
result remained significant when the ‘all improvements’
versus ‘no effect’ data were re-analysed as ‘improved or
more’ versus ‘slightly better or no effect’ (pooled RR 2.19,
95% CI 1.57–3.05, P < 0.00001, I2 = 0%).

Acupuncture versus all controls (eight trials, 429 women Acupuncture versus sham acupuncture (three trials,
analysed) 108 women analysed)
When pooled, the results from eight RCTs showed a signifi- Three studies compared acupuncture with sham acupunc-
cant benefit of acupuncture on improving the symptoms of ture: for sham control, one study adopted identical

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 909
 Kim et al.

A AT Control Risk ratio Risk ratio

Study (year) Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Guo 2004A 32 35 20 31 17.7% 1.42 [1.07, 1.88]
Guo 2004B 18 20 13 22 11.8% 1.52 [1.04, 2.22]
Habek 2002 14 18 1 17 0.6% 13.22 [1.94, 89.96]
Hong 2002 32 35 20 31 17.7% 1.42 [1.07, 1.88]
Peng 2009 26 30 19 30 15.8% 1.37 [1.01, 1.86]
Xu 2006A 19 20 10 20 8.9% 1.90 [1.21, 2.98]
Xu 2006B 27 30 18 30 15.2% 1.50 [1.09, 2.06]
Yu 2006 29 30 15 30 12.4% 1.93 [1.34, 2.78]

Total (95% CI) 197 218 116 211 100.0% 1.55 [1.33, 1.80]
Total events
Heterogeneity: c² = 9.69, df = 7 (P = 0.21); I² = 28%
0.05 0.2 1 5 20
Test for overall effect: Z = 5.74 (P < 0.00001)
Favors control Favors AT

B AT Medication Risk ratio Risk ratio

Study (year) Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Guo 2004A 32 35 20 31 31.5% 1.42 [1.07, 1.88]
Hong 2002 32 35 20 31 31.5% 1.42 [1.07, 1.88]
Xu 2006A 19 20 10 20 12.2% 1.90 [1.21, 2.98]
Xu 2006B 27 30 18 30 24.8% 1.50 [1.09, 2.06]

Total (95% CI) 110 120 68 112 100.0% 1.49 [1.27, 1.74]
Total events
Heterogeneity: c² = 1.39, df = 3 (P = 0.71); I² = 0%
0.2 0.5 1 2 5
Test for overall effect: Z = 4.97 (P < 0.00001)
Favors medication Favors AT

C AT Sham AT Risk ratio Risk ratio

Study (year) Events Total Events Total Weight M-H, random, 95% CI M-H, random, 95% CI
Habek 2002 14 18 1 17 15.2% 13.22 [1.94, 89.96]
Yu 2006 26 30 5 30 84.8% 5.20 [2.31, 11.72]

Total (95% CI) 40 48 6 47 100.0% 5.99 [2.84, 12.66]

Heterogeneity: c² = 0.83, df = 1 (P = 0.36); I² = 0%

0.01 0.1 1 10 100
Test for overall effect: Z = 4.69 (P < 0.00001)
Favors sham AT Favors AT

Figure 2. Forest plots of acupuncture for premenstrual syndrome (PMS). The vertical line shows the ‘no effect’ point. An event indicates a patient
with clinical improvement in the symptoms of PMS: A, acupuncture versus all controls; B, acupuncture versus medication; C, acupuncture versus
sham acupuncture. Sham acupuncture indicates superficial needling on non-acupuncture points. AT, acupuncture therapy; CI, confidence interval.

needling on real acupuncture points that are considered
ineffective in PMS,19 and the other two studies used
superficial needling at non-acupuncture points.17,24 The
pooled results from the two trials reporting clinical
improvement rates demonstrated a non-significant impact
of acupuncture on symptom improvement, with significant
heterogeneity (two trials, n = 95, pooled RR 4.31, 95% CI
0.44–42.29, P = 0.21, I2 = 82%).17,24 The result was chan-
ged, however, when the ‘all improvements’ versus ‘no
effect’ data were re-analysed as ‘improved or more’ versus
‘slightly better or no effect’ (Figure 2C; pooled RR 5.99,
95% CI 2.84–12.66, P < 0.00001, I2 = 0%). The other
sham-controlled trial produced non-significant MSSL score
changes from data collected over the course of two
menstrual cycles (one trial, n = 13, MD 3.43, 95% CI
0.04–6.82, P = 0.05).19
Acupuncture versus no treatment (one trial,
14 women analysed)
Compared with no treatment, the MSSL score significantly
improved after ten sessions of Korean hand acupuncture
(one trial, n = 14, MD )13.60, 95% CI )15.70 to )11.50,
P < 0.00001).
Acupuncture and medication versus medication alone
(one trial, 42 women analysed)
Guo investigated whether acupuncture treatment coupled
with progestin (6 mg daily) alleviated the symptoms of PMS
more than progestin alone.15 Acupuncture was significantly
associated with improved symptoms (RR 1.52, 95% CI
1.04–2.22, P = 0.03), and this statistical difference was
maintained in a ‘improved or more’ versus ‘slightly better or
no effect’ analysis (RR 1.93, 95% CI 1.03–3.59, P = 0.04).

910 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG

Acupuncture and herbal medicine versus herbal medicine
alone (one trial, 60 women analysed).
Peng compared acupuncture combined with herbal medi-
cine against herbal medicine alone.20 The result as origi-
nally reported (‘all improvements’ versus ‘no effect’
analysis) indicated that acupuncture was better than the
control (RR 1.37, 95% CI 1.01–1.86, P = 0.04); however,
when the data were analysed as ‘improved or more’ versus
‘slightly better or no effect’, we found no significant differ-
ence between acupuncture and the control (RR 1.56,
95% CI 0.80–3.03, P = 0.19).
Safety
Adverse events were reported in four studies.17,20,21,24 No
serious adverse events were reported during treatment.20,21
Minor adverse events, which were resolved by the end of
treatment, included a small subcutaneous haematoma fol-
lowing acupuncture,17 hypomenorrhoea, and a shortened
menstrual cycle.24
Discussion and conclusion
Summary of main findings
Our systematic review and meta-analysis have found a
favourable effect of acupuncture over various controls
(n = 429, pooled RR 1.55, 95% CI 1.33–1.80, P < 0.00001).
We analysed four trials that compared acupuncture for
3 months against progestin treatment with or without anx-
iolytics. The pooled results showed acupuncture to be
superior to the control treatments in reducing the symp-
toms of PMS (n = 232, pooled RR 1.49, 95% CI 1.27–1.74,
P < 0.00001). When compared with sham acupuncture,
acupuncture significantly impacted symptom improvement
(n = 95, RR 5.99, 95% CI 2.84–12.66, P < 0.00001). No
evidence emerged for any significant harm caused by acu-
puncture. These results appear promising, but it should be
stressed at the same time that they are based on a small
number of small trials with a high risk of bias. Therefore,
before rushing into a positive conclusion, a careful inter-
pretation is necessary to provide doctors and patients with
unbiased evidence.
Applicability of evidence
The trials we reviewed differed in the types of acupuncture
interventions used, control procedures, and outcome mea-
sures. Such differences are common in studies of both acu-
puncture and PMS.28,29
It is not easy to evaluate whether the tested acupuncture
treatment was appropriate or optimal for the relief of
PMS symptoms. Because the active components of acu-
puncture treatment have not been identified, various fac-
tors could have an impact on outcomes, including pattern
diagnosis, acupuncture points selected, intensity, duration,
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Acupuncture for premenstrual syndrome
frequency of stimulation, total number of sessions, and
treatment period. Although acupuncture interventions vary
greatly, it is notable that most of the studies included
involved more than 20 sessions of acupuncture treatment
over three menstrual cycles. The acupuncture points
applied in each study were also the commonly used ones
in general acupuncture practice for obstetrics/gynaecology
conditions.
The pooling of eight RCTs produced positive outcomes
for acupuncture. However, as the definitions and categori-
cal classifications of symptom improvement are heteroge-
neous, the pooled results should be interpreted with
caution. Given that the empirical evidence indicates that
some countries produce only positive results in acupunc-
ture studies,30 our review may not be free from publication
bias.
There was poor reporting of adverse events in the studies
included, which makes a benefit/harm analysis difficult.
Although acupuncture has been reported to be relatively
safe,31,32 the thorough reporting of adverse events in groups
receiving acupuncture is nevertheless necessary to analyse
its benefit/harm profile.
Risk of bias in the studies included
In our ‘risk of bias’ assessment, we tried to fully report
how each trial was rated for six critical domains.
All of the included studies were found to have a high
risk of bias: RCTs without adequate allocation conceal-
ment, for instance, tend to overestimate the benefit of
interventions. Therefore, meta-analyses of such trials also
favour interventions.33 Most of the trials in our review
lacked adequate reporting of their randomisation and allo-
cation concealment methods. Only one trial adequately
generated random numbers and concealed group assign-
ments.24 Therefore, the positive outcomes in these studies
might be too optimistic. As clinical studies of PMS have
shown that there is a substantial placebo effect,34 and
because outcome measures of PMS rely heavily on self-
reporting, blinding is crucial for a rigorous study design.
Nevertheless, none of the eligible studies were rated as hav-
ing a low risk of bias for patient and assessor blinding;
thus, their positive outcomes are likely to be overestimated.
Previous acupuncture studies have usually concluded that
acupuncture is better than no treatment, but is not supe-
rior to sham acupuncture; this indicates that acupuncture
is merely a placebo.35 In this context, it is noteworthy that
in our analysis, sham-controlled trials demonstrated greater
benefits than did the acupuncture versus medication stud-
ies. This encouraging result appears to derive from the low
responder rate (12.8%) in the sham group compared with
the responder rate (83.3%) in the treatment group (Fig-
ure 2C). It is not clear whether acupuncture definitely out-
performs sham acupuncture or produces effects similar to
911
 Kim et al.
those produced by medication, as the studies included were
confounded by methodological flaws.
Other problems that could threaten the validity of the
trials should be noted. Although the menstrual cycle is an
important factor in PMS research, the small sample sizes
and short study durations of the trials included can be
problematic. Regarding the control issue, a lack of a true
placebo control for acupuncture has been an inevitable
obstacle, and the specific effects of acupuncture for PMS
have not been illuminated. Used as a control in some of
the studies included, medroxyprogesterone can be contro-
versial, as it has been reported as ineffective or may even
produce PMS symptoms.1
Limitations and strengths of this review
Although our literature searches included English, Chinese,
and Korean databases, and included searching by hand for
relevant articles, we cannot be absolutely certain that all
relevant RCTs were found.
Bias can be introduced in many ways in the process of
locating and selecting studies for inclusion in a meta-analy-
sis;36 our systematic review may not be an exception. As
90% of the eligible studies support acupuncture for PMS, a
possible publication bias should have been explored. How-
ever, the number of studies included in our meta-analysis
(eight) may be too small to test for funnel plot asymmetry
in order to distinguish chance from real asymmetry.37
Because of poor reporting in the studies, this review cannot
determine whether the positive outcomes exclusively reflect
the effect of acupuncture in women with PMS. Only three
included trials reported on the intensity and improvement
of different symptoms, thus we don’t have a clear picture
of which aspects of the symptoms were helped by acupunc-
ture.
A recently published review examines the same topic as
the present article.38 It included two trials comparing acu-
puncture with herbal medicines of unproven efficacy,39,40
and another two trials testing the embedding of catgut in
acupuncture points,41 or acupuncture combined with injec-
tions of herbal medicines,42 which were all excluded in our
review. The interpretation of the data from such trials can
be less generalisable, and thus less clinically applicable.
Exclusion of such trials serves the aim of our review well:
i.e. restricts our evaluation to just the evidence on acu-
puncture for PMS. In addition, without any convincing
reason, Cho et al. failed to locate several important studies
that were included and analysed in our review.15,16,24 Dif-
ferent inclusion criteria could only partly explain this dis-
crepancy. Compared with the previous systematic review,
we believe that the more comprehensive search and more
rigorous inclusion/exclusion criteria of our review
strengthen the validity and generalisability of the current
evidence from our review.
912 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Implications for practice and research
Although acupuncture appears to relieve symptoms associ-
ated with PMS, and no serious harm resulting from acu-
puncture was reported, we rightly acknowledge at the same
time that our review is based on a small number of studies
of low methodological quality. Therefore, the choice of acu-
puncture for women with PMS who do not respond to
other therapeutic interventions cannot be offered at pres-
ent. Considering the potential of acupuncture demonstrated
in the trials included, however, additional, large clinical
studies of high methodological quality will be necessary to
firmly determine the value of acupuncture in the manage-
ment of PMS. These studies should implement adequate
diagnostic criteria, optimal interventions, validated out-
come measures, and a detailed reporting of how diagnoses
(both in western and in traditional Chinese medicine) were
made. Acupuncture researchers should follow the STRICTA
recommendations and adopt the CONSORT statement to
improve the quality of their reporting.11,43 As it is unclear
whether acupuncture alleviates the somatic symptoms of
PMS, the emotional symptoms, or both, outcomes should
be carefully collected. Given that PMS is closely related to
quality of life (QoL), the assessment of which depends on
self-reported symptoms,44 the measurement of QoL should
also be an interesting addition to future studies. In addi-
tion, women’s experience of the impact of PMS on their
lives may vary across cultures or countries,45–47 and famil-
iarity with or expectations of acupuncture treatment may
also be different.48 As these are likely to result in different
outcomes, future studies should take account of which
aspects of PMS acupuncture may help with, what character-
istics responders to acupuncture may have, and to which
direction different cultures under different healthcare set-
tings may affect the outcome. Although there has been no
economic evaluation of the use of acupuncture for PMS, it
is interesting that some recent European studies reported
that in the treatment of other conditions acupuncture is
more cost-effective for women than for men.49,50 Future
economic analyses will help determine the true potential of
acupuncture for women with PMS.
In conclusion, although acupuncture seems promising for
symptom improvement in women with PMS, important
methodological limitations in the studies included under-
mine the evidence. Considering the potential of acupuncture
in the trials included, further rigorous studies are needed.
Disclosure of interests
None.
Contribution to authorship
S-YK and H-JP formulated the idea for conducting a sys-
tematic review; S-YK and HL performed literature searches,
study selection, data extraction, risk of bias assessment,

meta-analysis, and wrote the initial draft; all of the authors
dissolved disagreements regarding study selection and risk
of bias assessment, and critically revised the article.
Details of ethics approval
Ethics approval was not required for this research.
Funding
This research was supported by the Basic Science Research
Programme through the National Research Foundation
(NRF) funded by the Korean Ministry of Education, Sci-
ence and Technology (R11-2005-014).
Acknowledgements
We appreciate Dr Younbyoung Chae for helping with the
data extraction of Chinese articles and Mr Daehoon Lee for
assisting with the literature search.
Supporting information
The following supplementary materials are available for this
article:
Data S1. Powerpoint slides summarising the study.
Table S1. Locations of frequently used acupuncture
points in the included studies.
Additional Supporting Information may be found in the
online version of this article.
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting information
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author.
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Journal club

Discussion points
1. Background: List and evaluate the available medical, surgical, complementary, and alternative medicine options for
the treatment of premenstrual syndrome,1 in addition to acupuncture.
Are you aware of any further management options?
2. Methods: Compare this paper with a previous systematic review on the topic.2 Pay particular attention to the
inclusion and exclusion criteria, the intervention(s) being compared, and the outcome measures used.
Describe the Cochrane Collaboration’s tool for assessment of bias in studies included.3
Using examples from this paper, describe the type(s) of bias addressed by each item in the tool.
Comment on the quality of the studies included, with reference to the tool.
Discuss the options for meta-analysing studies when they are very heterogeneous, statistically and/or clinically.
3. Results and implications: The Cochrane Handbook states: ‘Studies with limited follow-up or infrequent monitoring
may not reliably detect adverse effects; the absence of information must not be interpreted as indicating the
intervention is safe’.3 Discuss with reference to this paper.
Discuss the availability and cost of complementary and alternative medicine (CAM) therapies in your area, and
your legal and moral responsibilities when referring patients with PMS to services that offer CAM therapies. Are these
responsibilities clearly defined by law or national guidance? (Data S1) j
D Siassakos
University of Bristol & Southmead Hospital, Bristol, UK
Email jsiasakos@gmail.com

914 ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
 Acupuncture for premenstrual syndrome

References
1 RCOG. Management of Premenstrual Syndrome. Green-top Guideline No. 48. London: RCOG Press, 2007.
2 Cho SH, Kim J. Efficacy of acupuncture in management of premenstrual syndrome: a systematic review. Complement Ther Med
2010;18:104–11.
3 Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 [updated September 2009].
The Cochrane Collaboration, 2008 [www.cochrane-handbook.org].

ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG 915