Evaluation of clinical efficacy and investigation of mechanism of action of acupuncture treatment in the management of polycystic ovarian syndrome

Polycystic Ovarian Syndrome (PCOS) has the clinical manifestations of irregular menstrual cycles, anovulatory infertility, amenorrhoea, insulin resistance, polycystic ovaries, androgen disturbance, hirsutism and/or acne. The condition affects an estimated 5 to 10% of women of reproductive age (Hull 1987; Polson 1988; Lo 2006), although this varies depending on the diagnostic criteria used (Michelmore 1999). Farquhar et al. (1994) suggested the prevalence of PCOS to be 21% in a New Zealand study. Due to the lack of uniformed definition of PCOS, the prevalence of PCOS can have a highly variable prevalence estimates, ranging from 2.2% to 26% . (Nidhi 2011) Through researches, evidence suggests the potential usefulness of acupuncture in the treatment of the PCOS disorder (Ku 2001; Petti 1998; Ulett 1998). It was postulated that beta-endorphin and various neuropeptides (like protein pro-opiomelanocortin) within the nervous system may be implicated in producing the effects of acupuncture. Aleem (1987) revealed the presence of beta-endorphin in the follicular fluid of both normal and polycystic ovaries. Stener-Victorin (2000) s study suggested that acupuncture may have a role in ovulation induction. Further details of current acupuncture studies in PCOS can be found in Chapter Four. Acupuncture is currently used in public hospitals in China for the treatment of PCOS. Clinical studies conducted in China have suggested that the effectiveness of using acupuncture may be significant. However, the methodological quality of those trials was poor with limited long-term follow-up. The present study aimed to evaluate the action of body acupuncture on menstrual pattern through a pilot study (Stage II) and a randomised controlled study (Stage V). However, in order to plan the RCT properly from Chinese medicine point of view, it was important to first standardise the Chinese medicine syndrome differentiation for PCOS or otherwise an inaccurate clinical response may be obtained. This was achieved by utilising a questionnaire (Stage III) as a tool development in this study. In addition to understanding the needs of Chinese women with PCOS, an epidemiological data was performed in Stage IV, so as to attempting to address their needs in the RCT stage. An effective CM treatment protocol would then be proposed to serve as a guide for the clinical acupuncture management of adult women with PCOS. The findings are promising and further studies are required. The design for this doctoral program study composed of the following 6 stages: 1. Stage I Comprehensive systematic literature review of current acupuncture treatment for PCOS patients in human studies in all available Chinese and English Literature. This stage has been published as Cochrane Systematic Review paper; 2. Stage II Pilot Clinical Study involving real body acupuncture group; 3. Stage III Development of Traditional Chinese Medicine (TCM) Syndrome Differentiation Diagnostic Questionnaire (Tool) for PCOS according to the results of comprehensive literature review in stage I and also the National Disease Criteria set by the State Administration of Traditional Chinese Medicine in the Peoples Republic of China; This is important as to standardise the CM diagnosis of PCOS in Stage V; 4. Stage IV Collection of Epidemiological data among Asian women of PCOS, to ascertain the psychological needs of Chinese women with PCOS; and to attempting to fulfil this in Stage V; 5. Stage V Randomised Single Blinded Acupuncture Clinical Trial involving a) real body acupuncture group; b) placebo (sham) body acupuncture group; For this study, there are two types of outcome measures that are under consideration. The primary outcome measure was the return of menstruation from amenorrhea while the secondary measures were the changes in LH, FSH concentration, LH: FSH Ratio, Progesterone, Oestrogen and Androgenic hormone concentration; 6. Stage VI Investigation of the Mechanism of Acupuncture Treatment on the Management of PCOS. Based on the findings from Stage One, various case studies suggested that there may be a role for acupuncture in regulating menstruation pattern in PCOS but there was nil randomised controlled trial identified to assess the efficacy of action of acupuncture in treatment of PCOS when this project was proposed. Furthermore, preliminary evidence from the literature review suggested that acupuncture may be useful in regulating menstrual pattern in women with PCOS. This confirms the importance of this research project as to fill in the gap of current medical understanding of using acupuncture in women with PCOS. From the descriptive analysis that was performed in Stage Three, it can be concluded that the syndrome diagnostic questionnaire that developed in this project could possibly be a useful tool in Chinese medicine syndrome differentiation for women with PCOS. It is warranted for further analysis and tested for internal validity. In Stage Four, a total of 57 patients agreed to participate were interviewed. All patients responded to all 4 questions (Cronback s alpha > 0.9) asked thus for this study it has a 100% response rate. Among all the factors of concern, most of interviewed subject expressed problems of having PCOS as : difficulty to control weight, frustration about difficulty to reduce weight, frustrated due to PCOS and its related medical problems, unable to conceive and menstrual irregularity, as well as pressure from workplace. Based on the results from pilot study in Stage Two (11 subject recruited) and the RCT in Stage Five (146 subjects recruited), acupuncture can be recommended as effective menstrual regulation intervention for PCOS. In Stage V, the inter-menstrual days in the control group is 302.45 day and 348.32 days pre and post treatment respectively (p=0.001). In the interventional group, the mean inter-menstrual days are 297.69 and 33.82 days pre and post treatment respectively (p=0.000). There is no menstrual pattern change in the control group pre and post treatment. Acupuncture demonstrated statistically significant difference toward hormonal profiles before and after the real body acupuncture intervention among women with PCOS. Within the interventional group, it can be seen that there are six treatment outcomes that were found to have a significant differences (p0.05) in prolactin, oestrogen (E2) and testosterone in both control and interventional groups. Stage V is aimed to elicit whether acupuncture can assist in return of menstruation for lady with PCOS and has complete amenorrhoea. As this is the initial aim of the study, ovulation was not chosen to be the outcome measure for this RCT. This also becomes one of the limitations for this study as we cannot definitely answer whether acupuncture can induce ovulation for lady with PCOS, although improvements were noted in the LH:FSH ratio and progesterone level. It is important to note that menstruation return may not necessary to protect the uterus from hyperplasia. Overall speaking, the results from the statistical analysis and the insights that were gathered from those results have proposed the following mechanisms in relation to Chinese and Western medicine perspective: 1. Acupuncture significantly increases β-endorphin levels for periods up to 24 hours and may have regulatory effect on FSH, LH and androgen. 2. Decrease hypothalamic-pituitary-adrenal (HPA) axis activity by inhibiting release of corticotrophin-releasing factor (CRF), causing decreased adrenocorticotrophic hormone (ACTH) release from the pituitary gland and decreased cortisol and/or dehydroepiandrostenedione (sulfate) release from the adrenal cortex. 3. β-endorphin increased levels secondary to acupuncture affects the hyperthalamic-pituitary-adrenal (HPA) axis through promoting the release of ACTH through stimulation of its precursor pro-opiomelanocortin synthesis. 4. Needle insertion into the skin and muscle may stimulate ergoreceptors and initiate afferent nerves activity. 5. If acupuncture needles were placed in the same somatic segment of the ovary, they may stimulate the oxytocin axis resulting in decreased release and secretion of ovarian androgens. In conclusion, the designed acupuncture protocol for PCOS proposes that the usage of acupuncture is effective to induce return of menstruation from oligomenorrhoea

Inguinal Endometriosis: An Uncommon Differential Diagnosis as an Inguinal Tumour

Inguinal endometriosis can present as a rare tumor when it occurs outside the abdomen and pelvis. We present a patient with a painful tumor in the right inguinal region, where its diagnosis was made before the operation. This enabled a conservative excisional surgery to be performed. The literature is reviewed and the diagnosis as well as management are discussed

Chinese Herbal Medicines for the Treatment of Type A H1N1 Influenza: A Systematic Review of Randomized Controlled Trials

Chinese herbs are thought to be effective for type A H1N1 influenza. Series of Chinese herbs have been authorized recommended by the Chinese government, and until now a number of clinical trials of Chinese herbs for H1N1 influenza have been conducted. However, there is no critically appraised evidence such as systematic reviews or metaanalyses on potential benefits and harms of medicinal herbs for H1N1 influenza to justify their clinical use and their recommendation. CENTRAL, MEDLINE, EMBASE, CBM, CNKI, VIP, China Important Conference Papers Database, China Dissertation Database, and online clinical trial registry websites were searched for published and unpublished randomized controlled trials (RCTs) of Chinese herbs for H1N1 influenza till 31 August, 2011. A total of 26 RCTs were identified and reviewed. Most of the RCTs were of high risk of bias with flawed study design and poor methodological quality. The combination of several Chinese herbal medicines with or without oseltamivir demonstrated positive effect on fever resolution, relief of symptoms, and global effectiveness rate compared to oseltamivir alone. However, only one herbal medicine showed positive effect on viral shedding. Most of the trials did not report adverse events, and the safety of herbal medicines is still uncertain. Some Chinese herbal medicines demonstrated potential positive effect for 2009 type A H1N1 influenza; however, due to the lack of placebo controlled trial and lack of repeated test of the intervention, we could not draw confirmative conclusions on the beneficial effect of Chinese herbs for H1N1 influenza. More rigorous trials are warranted to support their clinical use

The efficacy of using acupuncture in managing polycystic ovarian syndrome

Purpose of review Polycystic ovarian syndrome (PCOS) is a common reproductive disorder, which significantly impairs the fertility of 3-10% of women at reproductive age. It is getting very popular for women with PCOS to seek alternative therapies to treat PCOS, for example, acupuncture. This review examines the currently available evidence from the randomized controlled trial to guide future recommendation on using acupuncture to assist the treatment of PCOS. Recent findings PCOS is manifested by oligo-amenorrhoea, infertility, and hirsutism. The standard treatment of PCOS includes oral pharmacological agents, lifestyle changes, and surgical modalities. Pharmacologically based therapies are only effective in 60% of the patients, which are also associated with different side-effects. As such, acupuncture offered an alternative option. Acupuncture can affect β-endorphin production, which may, in turn, affect gonadotropin-releasing hormone secretion and affecting ovulation and menstrual cycle. Therefore, it is postulated that acupuncture may induce ovulation and restore menstrual cycle via increasing β-endorphin production. Summary Although modern medical science has discovered the action mechanisms underlying how acupuncture may manage the symptoms of PCOS, majority of the trials are small in sample size and lack of consistency in the choice of acupoints. Larger scale trials are needed to provide standardized protocols

Evaluation of a culturally tailored education to promote breast and cervical cancer screening among Chinese-Australian women

This paper aims to evaluate the impact of the culturally sensitive and linguistically appropriate education program on the following: (i) awareness of screening practices (breast awareness, mammogram, and Pap smear test); (ii) screening intention within the next six months; and (iii) knowledge about breast and cervical cancer among Chinese-Australian women. Titled “Happy and Healthy Life in Sydney,” this was a quasi-experimental study with both pre- and post-test design. A convenience sample of 288 Chinese women was recruited through Chinese organizations such as churches and community centers. Participants completed the questionnaires before and after the educational program. The results show that the program was effective in promoting awareness of breast and cervical cancer screening and resulted in increased participative intentions in both mammogram and Pap smear testing within the next 6 months. Results also indicate that knowledge and belief scores were significantly increased. Conclusion: Our study supports that educational programs which use culturally sensitive and linguistically appropriate strategies are effective in improving both knowledge of breast and cervical cancer and awareness of their early detection practices among Chinese-Australian women

Factors influencing the choice of hysterectomy approach for the management of fibroid uterus

AbstractAimThe aim of this study was to identify factors influencing the choice between different approaches in hysterectomy for uterine fibroids.MethodsA cross-sectional study was conducted involving 285 women who had undergone hysterectomy for uterine fibroids at the Liverpool Hospital, New South Wales, Australia.ResultsThis study shows that several factors influenced the choice of hysterectomy approach. First, concomitant adnexal surgery increased the likelihood of undergoing an abdominal hysterectomy rather than either a vaginal or a laparoscopic hysterectomy by 10- and fivefold (both p < 0.01), respectively. Second, women with a larger uterus (>280 g) had a 20 (p < 0.05) and 10 (p < 0.01) times greater chance of undergoing an abdominal hysterectomy than either a vaginal or a laparoscopic hysterectomy, respectively. Third, gynecologic endoscopists were more likely to perform laparoscopic hysterectomy than gynecologic generalists (p < 0.001).ConclusionCertain clinical parameters determine the choice of hysterectomy approach. Surgeons' expertise also has significant influence over the choice between laparoscopic and traditional approaches for hysterectomy

Hormonal treatment for endometriosis associated pelvic pain

AbstractBackground: Endometriosis is a common gynecological problem associated with chronic pelvic pain. Objective: To evaluate the effectiveness of current hormonal treatments of endometriosis associated pain.Materials and Methods: Randomized Controlled studies identified from databases of Medline and Cochrane Systemic Review groups were pooled. 7 RCTs were recruited for evaluation in this review. Data from these studies were pooled and meta-analysis was performed in three comparison groups: 1) Progestogen versus GnRHa; 2) Implanon versus Progestogen (injection); 3) Combined oral contraceptive pills versus placebo and progestogen. Response to treatment was measured as a reduction in pain score. Pain improvement was defined as improvement ≥1 at the end of treatment. Results: There was no significant difference between treatment groups of progestogen and GnRHa (RR: 0.036; CI:-0.030-0.102) for relieving endometriosis associated pelvic pain. Long acting progestogen (Implanon) and Mirena are not inferior to GnRHa and depot medroxy progesterone acetate (DMPA) (RR: 0.006; CI:-0.142-0.162). Combined oral contraceptive pills demonstrated effective treatment of relieving endometriosis associated pelvic pain when compared with placebo groups (RR:0.321CI-0.066-0.707). Progestogen was more effective than combined oral contraceptive pills in controlling dysmenorrhea (RR:-0.160; CI:-0.386-0.066), however, progestogen is associated with more side effects like spotting and bloating than the combined contraceptive pills. Conclusion: Combined oral contraceptive pills (COCP), GnRHa and progestogens are equally effective in relieving endometriosis associated pelvic pain. COCP and progestogens are relatively cheap and more suitable for long-term use as compared to GnRHa. Long-term RCT of medicated contraceptive devices like Mirena and Implanon are required to evaluate their long-term effects on relieving the endometriosis associated pelvic pai

Acupuncture for female subfertility

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the clinical effectiveness and safety of acupuncture for female subfertility

Light in the Darkness: Accessibility to Palliative Care for Cancer Patients of Chinese Background and Their Families

Background: Palliative care (PC) improves the Quality of Life (QoL) of patients and their families facing life-threatening illness, through the provision of physical, psychosocial and spiritual support. Cancer is the most frequently recorded principal diagnosis for PC-related services. However, studies have found that people from culturally and linguistically diverse communities face unique challenges when trying to access PC. Chinese Australians, a large non-English speaking ethnic minority in Australia, remain under-represented in PC service delivery. Aim and Objectives: This project aims to address the barriers that prevent Chinese Australians from receiving and benefiting from PC, through the perspective of cultural and linguistic issues. Methodology: The project comprises a general survey of Chinese Australian cancer patients and their caregivers, as well as in-depth one-to-one interviews. Information sessions on PC were conducted in four Sydney suburbs. The questionnaires were distributed and collected before the sessions. The Survey sought to assess participants’ knowledge and level of understanding about PC, and the difficulties they face when trying to access the services available to them