Efficacy and safety of acupuncture-related therapies in symptomatic endometriosis: a systematic review and network meta-analysis

The study provides summarized evidence on acupuncture-related therapies combined with pharmacotherapies for treating symptomatic endometriosis. The study also discovered that ear electro-acupuncture, when used as the sole or main intervention, has potential efficacy and safety for patients with symptomatic endometriosis.

A total of 8835 studies were retrieved from 8 databases and imported into NoteExpress (version 3.2.0) and Excel for literature management. After removing 302 duplicate studies, excluding 7830 non-compliant RCTs, and screening 680 titles and full texts deemed inappropriate, 23 studies involving 1776 patients met the inclusion criteria. The literature search process is illustrated in Fig. S3 . The details of the included studies are summarized in Table  2 . Control group interventions comprised the following: Shu-Mu acupuncture (one study) [ 22 ], acupuncture (two studies) [ 23 , 24 ], needle warming moxibustion (two studies) [ 25 , 26 ], needle warming moxibustion combined with Modified Neiyi Zhitong Formula (one study) [ 25 ], auricular needle-embedding (one study) [ 27 ], ear electroacupuncture (one study)[ 28 ], body electroacupuncture (two studies) [ 28 , 29 ], acupoint catgut embedding (three studies) [ 30 – 32 ], moxa stick moxibustion (two studies) [ 20 , 29 ], and laser moxibustion (one study) [ 19 ]. In the included studies, acupuncture refers to the insertion of filiform needles into the skin at specific acupuncture points on one side of the patient’s body. The procedure involved an even reinforcing-reducing technique based on the patient’s sensations, such as aching, distension, or numbness. Ten studies reported CER as an outcome indicator, nine studies reported VAS as an outcome indicator, and four studies provided data on adverse events. Table 2 Basic information about the included studies First author Year Total/experiment/control Age/experiment/control Intervention Prescription Outcome Dongfang [ 33 ] 2011 T: 30 C: 28 T: 34.6 ± 5.9 C: 34.6 ± 4.9 T: Abdominal acupuncture C: CT (Chinese proprietary medicine: Tianqi Tongjing Capsules ) Length of Intervention:3 menstrual cycles Freq: 3 times a week Duration: 20 min Zhongwan, Xiawan, Qihai, Guanyuan, Zhongji CER; McGill; Serum CA125 Sun [ 22 ] 2006 T: Shu-Mu acupuncture, acupuncture: respectively 30 C: 30 T: Shu-Mu acupuncture: 34.70 ± 8.71 Acupuncture: 35.68 ± 7.12 C: 36.24 ± 6.78 T: Shu-Mu acupuncture, acupuncture C: CT (Western medicine) Length of intervention: 3 circles, 1 circle by 20d, interval 10d each circle Freq: 7 times a week Duration: 30 min Shu-Mu: Ganshu, Pishu, Shenshu, Qimen, Zhangmen, Jingmen Acupuncture: Hegu, Zhongji, Guanyuan, Sanyinjiao CER; B-scan pelvic mass; Serum CA125; Adverse events Hu [ 34 ] 2020 T: 18 C: 18 T: – C: – T: Herbs-partition moxibustion C: Blank Length of intervention:3 months Freq: T: 1 time per week Duration: T: 1 h Hypogastrium: Shenshu, Guanyuan, Qugu Lumbosacral Region: Mingmen, Yaoshu CER; Serum CA 125; SF-36; Adverse events Rubi-Klein [ 23 ] 2010 T: 47 C: 54 T: – C: – T: Acupuncture C: CT (non-specific acupuncture) Length of intervention: 5 weeks Freq: 2 times a week Duration: – Acupuncture: Ciliao, Guilai, Zusanli, Zhongji, Sanyinjiao, Taichong, Ququan, Yinlingquan, Xuehai, Yingu CT: Jianzhen, Fengshi, Zhongfu, Touwei VAS; PDI Liang [ 24 ] 2018 T: 53 C: 53 T: – C: – T: Acupuncture C: CT (non-acupoint acupuncture) Length of intervention: 3 menstrual cycles Freq: 3 times a week Duration: 30 min Acupuncture: Sanyinjiao, Zhaohai, Taichong, Qichong, Guanyuan CT: less than 5 mm on each shoulder and upper arm surface VAS; EHP-30; MPI; BDI; POMS; Adverse events Xi [ 25 ] 2022 T: 80 C: 80 T: 31.78 ± 5.42 C: 32.36 ± 5.73 T: NWM + MNF C: NWM Length of intervention: 3 months Freq: 3 times a week Duration: 30 min NWM: Guanyuan, Zigong, Qihai, Sanyinjiao Neiyi Zhitong Formula: Danshen, Ezhu, Xiangfu, etc CER; Scores of TCM syndromes; VAS; Serum index Dongfang [ 27 ] 2001 T: 37 C: 30 Normal: 8 T: – C: – T: AN C: CT(traditional Chinese formula: Ezhu Danshen Decoction)/Blank Length of intervention: 3 menstrual cycles Freq: qod,4 times in total Duration: – AN: Tingzhong, Pizhixia, Neifenmi, Jiaogan, Neishengzhiqi TCM: Danshen, Chishao, etc CER; Scoring criteria for dysmenorrhea; Classification criteria of disease degree; Peripheral blood β-EP; Huifang [ 30 ] 2018 T: 36 C: 36 T: 33.94 ± 5.98 C: 31.31 ± 5.86 T: Acupoint catgut C: Acupuncture Length of intervention:12 weeks Freq: T:1 time 2 weeks C: 3 times a week Duration: T: – C:30 min Catgut: Sanyinjiao, Xuehai, Diji, Zigong, Guanyuan Acupuncture: Sanyinjiao, Xuehai, Diji, Zigong, Guanyuan VAS; Dysmenorrhea; symptom score; Serum prostaglandin level Tian [ 19 ] 2022 T: 38 C: 38 T: – C: – T: Laser moxibustion C: CT (Sham laser moxibustion) Length of intervention: 4 weeks Freq: 3 times a week Duration: 30 min Zigong GBS scores; VAS Jianfang [ 28 ] 2009 T: 42 C: 42 T: 34.93 ± 6.15 C: 33.83 ± 5.88 T: Ear electroacupuncture C: Body electroacupuncture Length of intervention: 3 treatments Freq: qod,10 times per treatment Duration: 30 min Ear-EA: Zigong, Pizhixia Neifenmi, Jiaogan Body-EA: Qihai, Guanyuan, Sanyinjiao, Diji, Tianshu, Zigong Degree of dysmenorrhea; Overall effectiveness; PGs Liu [ 35 ] 2015 T: 43 C: 43 T: 33.7 ± 4.4 C: 32.5 ± 4.6 T: A-M C: CT (gestrinone) Length of intervention: T: 3menstrual cycles C: 3 months Freq: T: for a week C: once a day Duration: T: 30 min C: – A-M: Guanyuan, Qihai, Taixi, Zigong, Dahe, Diji, Sanyinjiao + Guizhi Fuling Capsule gestrinone: 2.5 mg/day, 2 times a week CER Lu [ 29 ] 2014 T: 37 C: 32 T: – C: – T: M C: CT (traditional Chinese formula: Ezhu Danshen Decoction) Length of intervention: T: 3 weeks C: 1 month Freq: T: 3 times a week C: – Duration: T: 30 min C: – M: Zhongji, Guanyuan, Qihai CT: Ezhu, Danshen, Chishao, Xiangfu CER Jianfang [ 20 ] 2020 T: 35 C: 35 T: 32.29 ± 2.31 C: 31.82 ± 2.54 T: M C: CT (Dydrogesterone tablets) Length of intervention: 3 menstrual cycles Freq: T: 2 times per day C: 2–25d per menstrual cycle Duration: T: 20–30 min C: – M: Guanyuan, Tianshu, Zhongji, Shenque Dydrogesterone Tablets: once a tablet, 2 times per day VAS; CMSS; NMPP; DMPP; EHP-5 Qiuxia [ 36 ] 2018 T: 30 C: 30 T: 37.60 ± 4.64 C: 35.87 ± 4. 67 T: Body electroacupuncture C: Body electroacupuncture + sham acupoint Length of intervention: 3 menstrual cycles Freq: 1 time a day per menstrual cycle Duration: 20 min Body-EA: Ciliao, Zhongji, Zusanli, Sanyinjiao, Diji Sham acupoint: sham VAS; CER; SF-36 scores; EHP-5 scores; Safeties (routine blood test, urinalysis, hepatorenal function) Lili [ 31 ] 2022 T: 38 C: 37 T: 35.85 ± 4.68 C: 35.26 ± 4.56 T: Acupoint catgut C: CT (GnRH-α) Length of intervention: 3 months Freq: T: - C: 4 pills, 3 times per day Duration: – Catgut: Guanyuan, Tianshu, Zhongji, Zigong, Qihai, Sanyinjiao, Xuehai, Taichong, Zusanli GnRH-α: 150 μg, 1 time per day CER; FSH; E2; LH; Hemorheology Qiang [ 26 ] 2021 T: 36 C: 36 T: 37.23 ± 4.83 C: 36.89 ± 5.27 T: NWM C: CT (Chinese proprietary medicine: Guixiang Wenjing Zhitong Capsules) Length of intervention: 3 menstrual cycles Freq: T: once a week Duration: T: 20 min Guiyang WenjingZhitong Capsules: 4 ~ 6 pills, 3 times per day NWM: Shangliao, Ciliao, Zhongliao, Xialiao VAS; PGE2; TCM Symptom score; CER Dongdong [ 37 ] 2020 T: 43 C: 43 T: 39.79 ± 4.55 C: 40.98 ± 5.00 T: Gestrinone + acupoint catgut C: CT(Gestrinone) Length of intervention: 3 months Freq: T: 1 time per month C: 2 times a week Duration: – Catgut: Guanyuan, Tianshu, Zhongji, Zigong, Diji, Qihai, Ciliao, Taichong, Xuehai, Zusanli, Sanyinjiao CER; VAS; Serum IL-1β; TNF -α Meirong [ 38 ] 2021 T: 30 C: 30 T: 32.36 ± 4.65 C: 32.83 ± 5.03 T: Eelectroacupuncture + Tong Bining Granules C: CT (Sham acupuncture + Tong Bining Granules) Length of intervention: 3 months Freq: 3 times a week Duration: 20 min EA: Qihai, Guanyuan, Taixi, Dahe, Zigong, Diji Sham acupuncture: 1cun lateral CER; Dysmenorrhea symptom score; TCM symptom score; Peripheral blood CA125; IL-6; TNF-α; Adverse events Qiaozhang [ 39 ] 2012 T: 32 C: 30 T: - C: - T: Abdominal acupuncture + infrared C: Abdominal length of Intervention: 3 months Freq: 3 times or more per menstrual cycle Duration: 25 min Abdominal acupuncture: Zhongwan, Xiawan, Qihai, Guanyuan, Zhongji Infrared: abdomen CER; Dysmenorrhea symptom score; Serum CA125 Peng [ 40 ] 2017 T: 45 C: 45 T: 35.8 ± 7.8 C: 33.5 ± 6.8 T: Herbs-partition moxibustion C: CT (mifepristone tablets) Length of intervention: 3 months Freq: T: qod; C: once a day Duration: – Herbs-partition moxibustion: Dazhui, Mingmen mifepristone tablets: 12.5 mg, once per day, for 3 months CER; serum CA125; Blood-serum IL-8; Pelvic mass size Guangxian [ 32 ] 2014 T: 28 C: 29 T: - C: - T: Acupoint catgut C: NWM Length of intervention: 3 months Freq: 3 times or more per menstrual cycle Duration: 25 min Acupoint catgut: Sanyinjiao, Shenshu, Ciliao, Xuehai, Zigong, Guanyuan NWM: Same Dysmenorrhea Observation Scale; Serum CA125; SF-36 Qiaoyi [ 21 ] 2019 T: 35 C: 35 T: 35.13 ± 7.12 C: 34.28 ± 6.81 T: NWM C: CT (contraceptive pills) Length of intervention: T: 3 menstrual cycles C: 3 months Freq: T: 3 times per menstrual cycle C: 1 time per day Duration: T: 30 min C: – NWM: Zusanli, Sanyinjiao, Tianshu, Qihai, Zhognwan, Siman, Shuidao Drospirenone:1 time a day, for 28 days VAS; SF-36 Ning [ 41 ] 2022 T: 30 C: 31 T: 34.23 ± 5.95 C: 33.87 ± 6.75 T: A + Shaofu Zhuyu decoction C: Shaofu Zhuyu decoction Length of intervention: 3 menstrual cycles Freq: once per day Duration: 30 min A: Shangliao, Ciliao, Zhongliao, Xialiao CER; Serum CA125; VAS T experimental group, C control group, CT conventional treatment (mainly pharmacotherapy and non-pharmacotherapy) included placebo (sham laser acupuncture, sham acupuncture, etc.), Chinese proprietary medicine (Gui Xiang Wenjing Zhitong capsules, Tong bining, etc.), and western medicine (dydrogesterone tablets, GnRH-α, gestrinone, mifepristone tablets, contraceptive pills, etc.), VAS Visual Analog Scale, CER clinical efficacy rate, A acupuncture, AN auricular needle-embedding, A-M acupuncture, and medicine, NWM needle warming moxibustion Basic information about the included studies T: 30 C: 28 T: 34.6 ± 5.9 C: 34.6 ± 4.9 T: Abdominal acupuncture C: CT (Chinese proprietary medicine: Tianqi Tongjing Capsules ) Length of Intervention:3 menstrual cycles Freq: 3 times a week Duration: 20 min CER; McGill; Serum CA125 T: Shu-Mu acupuncture, acupuncture: respectively 30 C: 30 T: Shu-Mu acupuncture: 34.70 ± 8.71 Acupuncture: 35.68 ± 7.12 C: 36.24 ± 6.78 T: Shu-Mu acupuncture, acupuncture C: CT (Western medicine) Length of intervention: 3 circles, 1 circle by 20d, interval 10d each circle Freq: 7 times a week Duration: 30 min Shu-Mu: Ganshu, Pishu, Shenshu, Qimen, Zhangmen, Jingmen Acupuncture: Hegu, Zhongji, Guanyuan, Sanyinjiao CER; B-scan pelvic mass; Serum CA125; Adverse events T: 18 C: 18 T: – C: – T: Herbs-partition moxibustion C: Blank Length of intervention:3 months Freq: T: 1 time per week Duration: T: 1 h Hypogastrium: Shenshu, Guanyuan, Qugu Lumbosacral Region: Mingmen, Yaoshu CER; Serum CA 125; SF-36; Adverse events T: 47 C: 54 T: – C: – T: Acupuncture C: CT (non-specific acupuncture) Length of intervention: 5 weeks Freq: 2 times a week Duration: – Acupuncture: Ciliao, Guilai, Zusanli, Zhongji, Sanyinjiao, Taichong, Ququan, Yinlingquan, Xuehai, Yingu CT: Jianzhen, Fengshi, Zhongfu, Touwei VAS; PDI T: 53 C: 53 T: – C: – T: Acupuncture C: CT (non-acupoint acupuncture) Length of intervention: 3 menstrual cycles Freq: 3 times a week Duration: 30 min Acupuncture: Sanyinjiao, Zhaohai, Taichong, Qichong, Guanyuan CT: less than 5 mm on each shoulder and upper arm surface VAS; EHP-30; MPI; BDI; POMS; Adverse events T: 80 C: 80 T: 31.78 ± 5.42 C: 32.36 ± 5.73 T: NWM + MNF C: NWM Length of intervention: 3 months Freq: 3 times a week Duration: 30 min NWM: Guanyuan, Zigong, Qihai, Sanyinjiao Neiyi Zhitong Formula: Danshen, Ezhu, Xiangfu, etc CER; Scores of TCM syndromes; VAS; Serum index T: 37 C: 30 Normal: 8 T: – C: – T: AN C: CT(traditional Chinese formula: Ezhu Danshen Decoction)/Blank Length of intervention: 3 menstrual cycles Freq: qod,4 times in total Duration: – AN: Tingzhong, Pizhixia, Neifenmi, Jiaogan, Neishengzhiqi TCM: Danshen, Chishao, etc CER; Scoring criteria for dysmenorrhea; Classification criteria of disease degree; Peripheral blood β-EP; T: 36 C: 36 T: 33.94 ± 5.98 C: 31.31 ± 5.86 T: Acupoint catgut C: Acupuncture Length of intervention:12 weeks Freq: T:1 time 2 weeks C: 3 times a week Duration: T: – C:30 min Catgut: Sanyinjiao, Xuehai, Diji, Zigong, Guanyuan Acupuncture: Sanyinjiao, Xuehai, Diji, Zigong, Guanyuan VAS; Dysmenorrhea; symptom score; Serum prostaglandin level T: 38 C: 38 T: – C: – T: Laser moxibustion C: CT (Sham laser moxibustion) Length of intervention: 4 weeks Freq: 3 times a week Duration: 30 min GBS scores; VAS T: 42 C: 42 T: 34.93 ± 6.15 C: 33.83 ± 5.88 T: Ear electroacupuncture C: Body electroacupuncture Length of intervention: 3 treatments Freq: qod,10 times per treatment Duration: 30 min Ear-EA: Zigong, Pizhixia Neifenmi, Jiaogan Body-EA: Qihai, Guanyuan, Sanyinjiao, Diji, Tianshu, Zigong Degree of dysmenorrhea; Overall effectiveness; PGs T: 43 C: 43 T: 33.7 ± 4.4 C: 32.5 ± 4.6 T: A-M C: CT (gestrinone) Length of intervention: T: 3menstrual cycles C: 3 months Freq: T: for a week C: once a day Duration: T: 30 min C: – A-M: Guanyuan, Qihai, Taixi, Zigong, Dahe, Diji, Sanyinjiao + Guizhi Fuling Capsule gestrinone: 2.5 mg/day, 2 times a week T: 37 C: 32 T: – C: – T: M C: CT (traditional Chinese formula: Ezhu Danshen Decoction) Length of intervention: T: 3 weeks C: 1 month Freq: T: 3 times a week C: – Duration: T: 30 min C: – M: Zhongji, Guanyuan, Qihai CT: Ezhu, Danshen, Chishao, Xiangfu T: 35 C: 35 T: 32.29 ± 2.31 C: 31.82 ± 2.54 T: M C: CT (Dydrogesterone tablets) Length of intervention: 3 menstrual cycles Freq: T: 2 times per day C: 2–25d per menstrual cycle Duration: T: 20–30 min C: – M: Guanyuan, Tianshu, Zhongji, Shenque Dydrogesterone Tablets: once a tablet, 2 times per day VAS; CMSS; NMPP; DMPP; EHP-5 T: 30 C: 30 T: 37.60 ± 4.64 C: 35.87 ± 4. 67 T: Body electroacupuncture C: Body electroacupuncture + sham acupoint Length of intervention: 3 menstrual cycles Freq: 1 time a day per menstrual cycle Duration: 20 min Body-EA: Ciliao, Zhongji, Zusanli, Sanyinjiao, Diji Sham acupoint: sham VAS; CER; SF-36 scores; EHP-5 scores; Safeties (routine blood test, urinalysis, hepatorenal function) T: 38 C: 37 T: 35.85 ± 4.68 C: 35.26 ± 4.56 T: Acupoint catgut C: CT (GnRH-α) Length of intervention: 3 months Freq: T: - C: 4 pills, 3 times per day Duration: – Catgut: Guanyuan, Tianshu, Zhongji, Zigong, Qihai, Sanyinjiao, Xuehai, Taichong, Zusanli GnRH-α: 150 μg, 1 time per day CER; FSH; E2; LH; Hemorheology T: 36 C: 36 T: 37.23 ± 4.83 C: 36.89 ± 5.27 T: NWM C: CT (Chinese proprietary medicine: Guixiang Wenjing Zhitong Capsules) Length of intervention: 3 menstrual cycles Freq: T: once a week Duration: T: 20 min Guiyang WenjingZhitong Capsules: 4 ~ 6 pills, 3 times per day NWM: Shangliao, Ciliao, Zhongliao, Xialiao VAS; PGE2; TCM Symptom score; CER T: 43 C: 43 T: 39.79 ± 4.55 C: 40.98 ± 5.00 T: Gestrinone + acupoint catgut C: CT(Gestrinone) Length of intervention: 3 months Freq: T: 1 time per month C: 2 times a week Duration: – CER; VAS; Serum IL-1β; TNF -α T: 30 C: 30 T: 32.36 ± 4.65 C: 32.83 ± 5.03 T: Eelectroacupuncture + Tong Bining Granules C: CT (Sham acupuncture + Tong Bining Granules) Length of intervention: 3 months Freq: 3 times a week Duration: 20 min EA: Qihai, Guanyuan, Taixi, Dahe, Zigong, Diji Sham acupuncture: 1cun lateral CER; Dysmenorrhea symptom score; TCM symptom score; Peripheral blood CA125; IL-6; TNF-α; Adverse events T: 32 C: 30 T: - C: - T: Abdominal acupuncture + infrared C: Abdominal length of Intervention: 3 months Freq: 3 times or more per menstrual cycle Duration: 25 min Abdominal acupuncture: Zhongwan, Xiawan, Qihai, Guanyuan, Zhongji Infrared: abdomen CER; Dysmenorrhea symptom score; Serum CA125 T: 45 C: 45 T: 35.8 ± 7.8 C: 33.5 ± 6.8 T: Herbs-partition moxibustion C: CT (mifepristone tablets) Length of intervention: 3 months Freq: T: qod; C: once a day Duration: – Herbs-partition moxibustion: Dazhui, Mingmen mifepristone tablets: 12.5 mg, once per day, for 3 months CER; serum CA125; Blood-serum IL-8; Pelvic mass size T: 28 C: 29 T: - C: - T: Acupoint catgut C: NWM Length of intervention: 3 months Freq: 3 times or more per menstrual cycle Duration: 25 min Acupoint catgut: Sanyinjiao, Shenshu, Ciliao, Xuehai, Zigong, Guanyuan NWM: Same Dysmenorrhea Observation Scale; Serum CA125; SF-36 T: 35 C: 35 T: 35.13 ± 7.12 C: 34.28 ± 6.81 T: NWM C: CT (contraceptive pills) Length of intervention: T: 3 menstrual cycles C: 3 months Freq: T: 3 times per menstrual cycle C: 1 time per day Duration: T: 30 min C: – NWM: Zusanli, Sanyinjiao, Tianshu, Qihai, Zhognwan, Siman, Shuidao Drospirenone:1 time a day, for 28 days VAS; SF-36 T: 30 C: 31 T: 34.23 ± 5.95 C: 33.87 ± 6.75 T: A + Shaofu Zhuyu decoction C: Shaofu Zhuyu decoction Length of intervention: 3 menstrual cycles Freq: once per day Duration: 30 min CER; Serum CA125; VAS T experimental group, C control group, CT conventional treatment (mainly pharmacotherapy and non-pharmacotherapy) included placebo (sham laser acupuncture, sham acupuncture, etc.), Chinese proprietary medicine (Gui Xiang Wenjing Zhitong capsules, Tong bining, etc.), and western medicine (dydrogesterone tablets, GnRH-α, gestrinone, mifepristone tablets, contraceptive pills, etc.), VAS Visual Analog Scale, CER clinical efficacy rate, A acupuncture, AN auricular needle-embedding, A-M acupuncture, and medicine, NWM needle warming moxibustion Thirteen [ 19 – 21 , 23 , 25 , 28 , 30 , 31 , 33 – 37 ] employed randomization methods such as random number tables, computer-generated stochastic methods, or random number cards, which were classified as low risk for selective bias. The remaining studies mentioned randomization but lacked specific details, leading to an uncertain risk classification. The blinding method in four studies [ 19 , 28 , 38 , 39 ] was deemed low risk, with two employing double blinding and the other two using single blinding. Three studies [ 23 , 39 , 40 ] reported patient dropouts, which were classified as high risk for withdrawal bias. The remaining studies either did not report any dropouts or lacked sufficient information, resulting in a low or unclear risk classification. None of the studies published research protocols, leading to an unclear classification for reporting bias. Specific details are provided in Fig.  3 . Fig. 3 Risk bias assessment table of the included studies. A Risk of bias assessment by individual trials; B overall risk of bias assessment using the Cochrane tool Risk bias assessment table of the included studies. A Risk of bias assessment by individual trials; B overall risk of bias assessment using the Cochrane tool Clinical efficacy evidence map: Ten studies reported on clinical efficacy rates, encompassing a total of eleven acupuncture types. The evidence network diagram is presented in Fig. S4 . In the diagram, each of the 11 intervention nodes forms a closed loop. The size of the dots represents the sample size, while the thickness of the lines corresponds to the number of randomized controlled trials. The CER for acupuncture treatments of EMs was higher compared to conventional treatments, and the difference was statistically significant (OR = 2.87, 95% CI (1.90, 4.82), P  < 0.0001) (Fig.  4 ). Fig. 4 Probability diagram of CER. A  Acupuncture, B body electroacupuncture, C ear electroacupuncture, D needle warming moxibustion, E needle warming moxibustion and Modified Neiyi Zhitong Formula, F Shu-Mu acupuncture, G acupoint catgut, H acupuncture and medicine, I auricular needle-embedding, J control group (conventional treatment), K moxa stick moxibustion Probability diagram of CER. A  Acupuncture, B body electroacupuncture, C ear electroacupuncture, D needle warming moxibustion, E needle warming moxibustion and Modified Neiyi Zhitong Formula, F Shu-Mu acupuncture, G acupoint catgut, H acupuncture and medicine, I auricular needle-embedding, J control group (conventional treatment), K moxa stick moxibustion This forest plot shows the results of subgroup analysis for Chinese Patent Medicine and Traditional Chinese Medicine in the treatment of a particular condition. In general, neither the Chinese Patent Medicine nor the Traditional Chinese Medicine subgroup demonstrated significant treatment effects. The risk ratio for the Chinese Patent Medicine group was 1.06 (95% CI 0.93–1.21), while the risk ratio for the Traditional Chinese Medicine group was 1.07 (95% CI 0.86–1.33). Both groups showed risk ratios close to 1, and their 95% confidence intervals included 1, suggesting no statistically significant difference in treatment effects. In addition, heterogeneity within the Chinese Patent Medicine group and the Traditional Chinese Medicine group was I 2  = 0.0% ( P  = 0.959) and I 2  = 0.0% ( P  = 0.894), respectively, indicating consistency across studies. The overall heterogeneity between the groups was P  = 0.931, suggesting no significant differences between the groups (Fig. S5 ). We constructed separate funnel plots for the outcome indicator CER to examine possible publication bias. Visual examination of the funnel plot did not reveal any significant publication bias. The details are shown in Fig. S6 . The results from the network meta-analysis demonstrated that, compared to the control group (conventional treatment), ear electroacupuncture [MD = 9.43, 95% CI (1.35, 65.89)], needle warming moxibustion combined with Modified Neiyi Zhitong Formula [MD = 8.00, 95% CI (1.49, 42.76)], auricular needle-embedding [MD = 7.56, 95% CI = (1.89, 30.28)], body electroacupuncture [MD = 4.33, 95% CI (1.20, 15.60)], acupuncture and medicine [MD = 3.53, 95% CI (0.88, 14.09)], acupoint catgut [MD = 3.37, 95% CI (1.25, 9.10)], needle warming moxibustion [MD = 2.38, 95% CI (0.72, 7.86)], Shu-Mu acupuncture [MD = 1.38, 95% CI (0.28, 6.80)], and moxa stick moxibustion [MD = 1.00, 95% CI (0.23, 4.43)] all showed superior effectiveness in improving CER. The probability ranking of the various acupuncture and moxibustion interventions in terms of CER improvement was led by ear electroacupuncture, with a SUCRA of 83.0%, as shown in Fig.  5 . A comparison of the different interventions is presented in Tables 3 and 4 . Fig. 5 SUCRA plot for CER Table 3 League table on CER Table 4 League table on VAS Ear-EA ear electroacupuncture, NWM  +  MNF needle warming moxibustion + Modified Neiyi Zhitong Formula, Body-EA body electroacupuncture, A-M acupuncture and medicine, Catgut acupoint catgut embedding, NWM needle warming moxibustion, Shu-Mu A Shu-Mu acupuncture, Moxa moxa stick moxibustion, AC acupuncture, CT conventional treatment SUCRA plot for CER League table on CER League table on VAS Ear-EA ear electroacupuncture, NWM  +  MNF needle warming moxibustion + Modified Neiyi Zhitong Formula, Body-EA body electroacupuncture, A-M acupuncture and medicine, Catgut acupoint catgut embedding, NWM needle warming moxibustion, Shu-Mu A Shu-Mu acupuncture, Moxa moxa stick moxibustion, AC acupuncture, CT conventional treatment According to the SUCRA values (Fig.  5 ), C (ear electroacupuncture) (SUCRA = 83.0%) was the preferred option for improving CER, followed by E (needle warming moxibustion combined with Modified Neiyi Zhitong Formula) (SUCRA = 80.6%), I (auricular needle-embedding) (SUCRA = 79.6%), B (body electroacupuncture) (SUCRA = 63.4%), H (acupuncture and medicine) (SUCRA = 56.9%), G (acupoint catgut embedding) (SUCRA = 56.2%), D (needle warming moxibustion) (SUCRA = 43.3%), F (Shu-Mu acupuncture) (SUCRA = 28.4%), K (moxa stick moxibustion) (SUCRA = 25.2%), A (acupuncture) (SUCRA = 18.8%), and J (conventional treatment) (SUCRA = 14.6%). A total of nine studies reported the VAS, involving nine acupuncture and moxibustion methods, and the evidence network diagram is shown in Fig. S7 . The figure includes nine intervention nodes, which do not form any closed loop. The VAS for acupuncture and moxibustion in the treatment of EMs was lower than that for conventional treatment, with a statistically significant difference (MD = −0.73, 95% CI (−0.93, −0.54), P  < 0.0001) (Fig. S2 ). We created separate funnel plots for the outcome indicator CER to explore potential publication bias. The results indicated that the funnel plot was not perfectly symmetrical, suggesting possible publication bias or a small sample effect within the research network. The details are shown in Fig. S8 . According to the SUCRA values (Fig.  6 ), G (conventional treatment) (SUCRA = 99.4%) was the preferred option for statistically significant improvement in VAS, followed by D (needle warming moxibustion combined with Modified Neiyi Zhitong Formula) (SUCRA = 85.1%), C (needle warming moxibustion) (SUCRA = 66.3%), H (laser moxibustion) (SUCRA = 40%), E (acupoint catgut embedding) (SUCRA = 38.5%), B (body electroacupuncture) (SUCRA = 33%), A (acupuncture) (SUCRA = 32.9%), and F (auricular needle-embedding) (SUCRA = 4.9%). Fig. 6 SUCRA plot for VAS SUCRA plot for VAS Among the 23 studies included, 4 mentioned adverse reactions [ 22 , 23 , 32 , 36 ]. Four studies reported “no adverse reactions” [ 32 , 39 – 41 ], and 4 studies documented the symptoms and instances of adverse reactions in both the experimental and control groups [ 22 , 23 , 32 , 36 ]. The most frequently mentioned issue was “dizziness,” which was typically addressed with symptomatic treatments. No specific treatment measures were provided. Details are shown in Table  5 . Table 5 Adverse reactions or adverse events after different acupuncture and moxibustion methods First author/year Intervention Control (cases) Experiment Treatment Yuanzheng Sun [ 22 ], 2006 Acupuncture vs. Western medicine Weight gain (14), acne (11), breast distending pain (5), nausea and vomiting (7), hot flush (10), vaginal bleeding (8), liver dysfunction (8) Weight gain (3), acne (3), breast distending pain (1) Unclear Katharina Rubi-Klein [ 23 ], 2010 Acupuncture vs. non-specific acupuncture Unmentioned Dizzy (2) Unclear Dongdong Zuo [ 36 ], 2020 Acupoint catgut vs.. Western medicine Dizzy (2), feeble (2), stomach upset (3), leg swelling (1) Dizzy (1), stomach upset (1) Unclear Guangxian Chen [ 32 ], 2014 Acupoint catgut vs. needle warming moxibustion Skin burn (3) Unmentioned Immediately local ice-packing and inunction of flower oils for trauma, then gauze covering, keep the wound clean Adverse reactions or adverse events after different acupuncture and moxibustion methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Table S1 ) [ 8 ]. The study has been registered with INPLASY under the registration number INPLASY202380077. A comprehensive search was performed across eight electronic databases: Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal Database, PubMed, Embase, Cochrane Library, and Web of Science. The search covered the period from the inception of each database to May 1, 2023. Clinical randomized controlled trials comparing various acupuncture and moxibustion techniques for symptomatic endometriosis were included. The detailed search strategy is presented in Table  1 , with PubMed used as an example; the specific search terms and approach are provided in S1 Appendix. Table 1 Search strategy on PubMed #1 ((((endometriosis[MeSH Terms])) OR (endometrioses[Title/Abstract])) OR (endometrioma[Title/Abstract])) OR (endometriomas[Title/Abstract]) #2 (((((Needles[MeSH Terms]) OR (Acupuncture[MeSH Terms])) OR (Acupuncture Therapy[MeSH Terms])) OR (Moxibustion[MeSH Terms])) OR (Electroacupuncture[MeSH Terms])) OR (Acupuncture Points[MeSH Terms]) #3 (((((((((((Pharmacopuncture[Title/Abstract]) OR (needle[Title/Abstract])) OR (Acupuncture Treatment[Title/Abstract])) OR (Acupuncture Treatments[Title/Abstract])) OR (Treatment, Acupuncture[Title/Abstract])) OR (Therapy, Acupuncture[Title/Abstract])) OR (Moxabustion[Title/Abstract])) OR (moxibustion therapy[Title/Abstract])) OR (abdominal acupuncture[Title/Abstract])) OR (fire needle[Title/Abstract])) OR (warming needle moxibustion[Title/Abstract])) OR (herb-partition moxibustion[Title/Abstract]) #4 (((((((Acupuncture Point[Title/Abstract]) OR (Point, Acupuncture[Title/Abstract])) OR (Points, Acupuncture[Title/Abstract])) OR (Acupoints[Title/Abstract])) OR (Acupoint[Title/Abstract])) OR (Shiatsu[Title/Abstract])) OR (Zhi Ya[Title/Abstract])) OR (Chih Ya[Title/Abstract]) #5 ((acup*?point*[Title/Abstract]) OR (acup*[Title/Abstract])) #6 #2 OR #3 OR #4 OR #5 #7 ((((Random Allocation[MeSH Terms]) OR (Randomized Controlled Trial[MeSH Terms])) OR (Allocation, Random[MeSH Terms])) OR (Randomization[MeSH Terms])) OR (RCT) #8 #1 AND #6 AND #7 Search strategy on PubMed Participants: included patients met the diagnostic criteria for endometriosis [ 9 , 10 ]. (2) Interventions: the treatment group underwent various acupuncture or moxibustion therapies. (3) Control interventions: the control groups received placebo, sham acupuncture, conventional treatment, traditional medicine, or no treatment. (4) Outcomes: the outcomes included CER, VAS scores, and adverse events. The studies focus on pain evaluation in EMs as the primary endpoint. Adverse events were defined as side effects unrelated to the intended purpose of acupuncture treatments. CER was assessed following the “Guiding Principle for Clinical Study of New Chinese Drugs” [ 11 ], categorized into four grades: recovery, evident, effective, and effectless. Recovery: abdominal pain, dysmenorrhea, abnormal menstruation, dyspareunia, pelvic masses, and related symptoms completely resolved (VAS score drops to 0, with no recurrence after ceasing treatment for one menstrual cycle). Evident: symptoms were significantly alleviated (VAS score reduced by more than 1/2), allowing patients to function without pain medication. Effective: symptoms showed improvement (VAS score reduced by 1/4 to 1/2), with no worsening within three months post-treatment. Effectless: symptoms did not substantially change or worsened (VAS score reduced by less than 1/4). Study types: only clinical randomized trials were included. (1) Studies categorized as reviews, case reports, systematic reviews, experience summaries, animal studies, or case observations. (2) Duplicate publications, repeated citations, or papers using similar methodologies and results recently published by the same author, with only the most authoritative selected. (3) Studies failing to evaluate the effects of acupuncture and moxibustion interventions on endometriosis. (4) Studies with incomplete or invalid data. (5) Studies with clear methodological errors, such as statistical flaws or improper randomization. Initial screening and exclusion of the literature were performed using NoteExpress software. Relevant data were recorded and summarized in Excel tables for further analysis. A third researcher was involved to resolve any discrepancies in the data. The remaining studies were reviewed independently by two researchers following the planned process. The inclusion results were cross-checked, and disagreements were resolved through discussion or, when necessary, a final decision by a third researcher. The extracted data included the following information—(1) study details: title, author, publication year, methodology, study type, and sample size. (2) Participant characteristics: baseline data such as age, gender, disease duration, and follow-up period. (3) Interventions and indicators: specific interventions, randomization methods, diagnostic criteria, disease progression, treatment duration, follow-up time, and adverse reactions. This also included clinical outcome indicators and factors influencing the risk of bias. Two investigators (YS and HZ) independently screened each article, with both blinded to each other’s findings. Based on the pre-defined inclusion criteria, the reviewers rigorously screened and selected eligible articles. Data extraction from these studies was conducted using a standardized data collection form. Disagreements between reviewers were resolved through discussion until a consensus was reached. If unresolved, the third review author (XYZ) was consulted. The risk of bias was independently assessed by two researchers using the Cochrane Collaboration’s criteria for evaluating trial quality [ 12 ]. The following seven items were considered: (1) random sequence generation, (2) allocation concealment, (3) double-blinding of participants and personnel, (4) blinding in outcome assessment, (5) withdrawals and loss to follow-up, (6) selective reporting, (7) other sources of bias. Each item was classified as having a low, uncertain, or high risk of bias [ 13 ]. Odds ratios were used to represent categorical data and bicategorical variable outcomes, while mean differences were applied for continuous variables. Both effect sizes and their 95% confidence intervals were used to report odds ratios and mean differences [ 14 ]. Heterogeneity tests, network meta-evidence maps, and contribution maps were generated using Stata software (version 15.1), JAGS (version 4.3.0), and RStudio (version 4.3.1) for data analysis. Network meta-analysis (NMA) was conducted using Stata software (version 15.1) with polymerization and analysis performed through Markov chain Monte Carlo simulation chains in a Bayesian framework, following the PRISMA NMA guidelines. According to the Stata software instructions, a P value greater than 0.05 indicates the consistency test is passed [ 14 – 16 ]. The validity and convergence of the model were assessed through convergence diagnostics. The fixed-effect consistency model was selected for correlation testing. The model achieved convergence prior to 50,000 iterations, demonstrating stability and eliminating the need for additional iterations or calculations. Convergence diagnostics are presented in Figs. 1 and 2 . Fig. 1 Convergence diagnostics of CER Fig. 2 Convergence diagnostics of VAS Convergence diagnostics of CER Convergence diagnostics of VAS The intervention hierarchy was summarized and reported using a P score [ 17 ]. The P score ranges from 0 to 1, where a value of 1 represents the best treatment without uncertainty, while 0 represents the worst treatment without uncertainty. The P score or surface under the cumulative ranking curve (SUCRA) can also be interpreted as the percentage effectiveness or acceptability of an acupuncture intervention. However, such scores should be interpreted cautiously unless clinically significant differences between interventions are evident. To assess potential bias in smaller studies, network meta-analysis (NMA) funnel plots were generated to examine publication bias. These plots were visually evaluated using symmetry criteria [ 18 ]. Consistency and inconsistency tests were performed on P values of all direct and indirect comparisons between all studies, and most P values were greater than 0.05, indicating that the effect of consistency between included studies was acceptable. Details will be marked in S2 and S3 Tables. The heterogeneity test revealed an I 2 value of 34% ( 0.1) in the Q test, indicating no significant heterogeneity among the included studies. This justified the use of a fixed-effects model for meta-analysis. To ensure the study’s accuracy and stability, a sensitivity analysis was conducted. Among the nine studies involving VAS data, Tian L (2022) [ 19 ], Jianfang N (2020) [ 20 ], and Qiaoyi P (2019) [ 21 ] were found to significantly influence heterogeneity. After excluding these studies, the heterogeneity test of the remaining six articles again showed no heterogeneity (I 2  = 37%  0.1). A fixed-effects meta-analysis was subsequently performed only after these exclusions. The detailed results are presented in Figs. S1 and S2 .

For patients with endometriosis, acupuncture, ear electroacupuncture, body electroacupuncture, needle warming moxibustion, needle warming moxibustion combined with Neiyi Zhitong Formula, Shu-Mu acupuncture, acupoint catgut, acupuncture and medicine, auricular needle-embedding, conventional treatment, moxa stick moxibustion, and laser moxibustion can achieve significant therapeutic effects. The clinical effective rate and Visual Analog Scale (VAS) were ranked with a certain degree of probability. Addressing pain associated with endometriosis is of paramount importance for both clinical practice and future research. However, the reliability of these outcomes must be confirmed through multi-center, high-quality, large-sample randomized controlled trials that directly compare various Western medicines with proprietary Chinese medicines to improve the quality of evidence.

This network meta-analysis examined the effects of acupuncture-related therapies on the management of EMs across 23 studies involving 1776 participants. All included studies reported randomization, but nine studies [ 22 , 23 , 27 – 29 , 34 , 38 , 39 , 41 ] did not specify the method of random sequence generation. Regarding allocation concealment, six studies [ 19 , 21 , 22 , 24 , 32 , 33 ] provided details of the allocation concealment procedure. In terms of blinding, five studies [ 19 , 24 , 34 , 38 , 39 ] were deemed to have a low risk of bias. The acupuncture-related interventions assessed in the studies included acupuncture, ear electroacupuncture, auricular needle-embedding, body electroacupuncture, needle warming moxibustion, acupoint catgut embedding, Shu-Mu acupuncture, moxa stick moxibustion, and laser moxibustion. The clinical effective rate is the proportion of patients who show improvement, excluding those for whom the treatment was ineffective. Ear electroacupuncture ranked first in terms of clinical efficacy rate. The etiology of EMs is multifaceted. According to TCM, endometriosis is primarily caused by blood stasis in the uterus, with stagnation impacting the meridians and viscera. This condition is linked to psychological factors, cold coagulation with qi stagnation, and physical deficiency. Blood stasis leads to pain due to obstruction and eventually forms nodules and masses, making blood stasis a key pathological factor. Modern medicine, while recognizing the complexity of endometriosis, acknowledges that its exact etiology remains unclear. It is thought to involve multiple factors, including retrograde menstruation, coelomic metaplasia, genetic predisposition, immune dysfunction, inflammation, psychological factors, endocrine influences, and environmental exposures [ 42 ]. Acupuncture, a hallmark TCM therapy, is used to treat endometriosis through various techniques, including conventional acupuncture, specialized acupoint combinations, thunder-fire moxibustion, warm needle acupuncture, indirect moxibustion, abdominal acupuncture, auricular acupoint embedding, acupoint thread embedding, acupoint application, combined acupuncture–medication therapy, combined moxibustion–medication therapy, thread embedding with herbal medicine, heat-sensitive moxibustion, laser moxibustion, and acupoint application with moxibustion. Extensive prior research has explored the therapeutic mechanisms of acupuncture from both TCM and Western medical viewpoints [ 43 ]. From the TCM perspective, the core therapeutic principles involve regulating qi and blood circulation, promoting blood stasis removal, reducing inflammation, and alleviating pain through the stimulation of specific acupoints. This helps achieve meridian dredging, qi-blood harmonization, yin-yang balance, and the elimination of pathogenic factors. From the Western medical perspective, acupuncture is thought to reduce angiogenesis, modulate immune factors, regulate inflammatory mediators, lower estrogen levels, improve ovarian function, regulate hemorheology and hypercoagulable states, and influence the expression of apoptosis-related factors, ultimately improving the local microenvironment and inhibiting lesion progression [ 44 ]. In evaluating the efficacy and safety of acupuncture for EMs, variations in research findings and methodologies should be carefully considered. These differences may stem from patient population heterogeneity (age, disease duration, symptom severity), treatment protocol selection (acupoint choice, moxibustion type, treatment duration), and study design variations (sample size, randomization, blinding methodology). Thus, it is essential to take these factors into account when interpreting the effects of acupuncture interventions for EMs. Regarding efficacy, thunder-fire moxibustion and warm needle acupuncture may offer superior pain relief due to their enhanced thermal effects. Specialized acupoint combinations may provide more tailored treatment options for specific symptoms. Acupoint thread embedding and combined thread-herbal approaches could deliver more sustained therapeutic effects through prolonged acupoint stimulation and pharmacological action. In terms of safety, traditional interventions such as acupuncture and moxibustion are generally regarded as safe. Modern techniques, like laser moxibustion, may offer improved safety profiles by avoiding the thermal injury risks typically associated with traditional moxibustion. However, acupuncture point embedding may pose minor, reversible risks of foreign body reactions [ 45 , 46 ]. This review also includes clinical studies of Chinese patent medicines and herbal formulations, such as the Modified Neiyi Zhitong Formula, Ezhu Danshen Decoction, Guixiang Wenjing Zhitong Capsules, Tong Bining Granule, and Shaofu Zhuyu Decoction. These formulations primarily feature herbs known for their blood-activating and stasis-removing properties, such as E Zhu, Dan Shen, Xiang Fu, Chi Shao, Dang Gui, and Yan Hu Suo. From a pharmacological perspective, Chinese herbal medicine demonstrates a multi-target, multi-pathway mode of action. Previous studies indicate that Chinese herbs may function through several mechanisms, including inhibiting inflammatory factors, enhancing phagocytosis, modulating cellular immunity, regulating metabolic homeostasis, modulating oxidative responses, exhibiting anti-tumor effects, and regulating signaling pathways. Therefore, oral Chinese herbal medicine may be considered for endometriosis patients who experience pain and menstrual irregularities [ 47 – 49 ]. The optimal treatment approach should consider multiple factors, including patient age, preferences, reproductive plans, pain intensity, and disease severity. This suggests that multi-pathway pharmaceutical interventions could have substantial implications for the development of precision medicine in managing EMs. The CER offers several advantages: (1) symptom relief can alleviate the pain and discomfort experienced by patients with endometriosis. (2) Symptom relief is also crucial for managing and controlling the disease. By addressing symptoms, the progression of the condition can be halted, thus reducing the risk of complications. (3) Symptom relief can improve patients’ overall life satisfaction and positively impact their mental and emotional well-being. However, due to the inherent variability in clinical practice, various factors must be considered, which presents challenges to the scientific rigor and reliability of research findings. The VAS also has several benefits: (1) it is simple to apply, and patients can quickly understand and complete the scale. (2) The continuous nature of the scale allows for a more precise and sensitive measure of pain, making it suitable for patients of varying ages and cognitive abilities. However, aside from pain relief (VAS), other menstrual symptoms, such as pelvic girdle (PG) pain and serum CA125, have not been assessed in the 14 studies reviewed regarding the effects of acupuncture and moxibustion on women with endometriosis. Therefore, future RCTs should incorporate objective and quantitative assessments of other aspects of endometriosis to address the limitations of prior research. The details are shown in Figs. 4 and 7 . Fig. 7 Probability diagram of VAS. A  Acupuncture, B body electroacupuncture, C needle warming moxibustion, D needle warming moxibustion and Modified Neiyi Zhitong Formula, E acupoint catgut, F auricular needle-embedding, G control group (conventional treatment), H laser moxibustion, I moxa stick moxibustion Probability diagram of VAS. A  Acupuncture, B body electroacupuncture, C needle warming moxibustion, D needle warming moxibustion and Modified Neiyi Zhitong Formula, E acupoint catgut, F auricular needle-embedding, G control group (conventional treatment), H laser moxibustion, I moxa stick moxibustion Several limitations should be noted: (1) the overall quality of the research included in the literature is relatively low, with considerable risk of bias; (2) only 23 studies were included, and just 9 studies mentioned the observation indicator—VAS. Therefore, the validity of the results remains uncertain; (3) although a network meta-analysis was conducted, a significant proportion of the studies had small sample sizes, which may reduce the statistical power of the findings; (4) discrepancies were observed in the rankings of the observation indicators. In addition, many studies did not report adverse events, limiting the ability to assess the safety of different acupuncture and moxibustion methods; (5) not all of the included studies provided details on syndrome differentiation and treatment. Moreover, there was variation in the selection of acupuncture points and treatment duration, which may have impacted the results. Consequently, the conclusions of this study should be interpreted with caution and considered carefully; (6) the lack of certain acupuncture and moxibustion therapies, due to the limited number of original studies, prevented a comprehensive comparison of the efficacy and safety of all available methods; (7) our search strategy only included studies published in Chinese and English, potentially introducing sampling bias. In addition, no multi-center studies involving women of different racial backgrounds were included, meaning the applicability of these therapies to non-Chinese populations remains uncertain.

Endometriosis (EMs) is a significant public health issue, affecting approximately 10% to 15% of women of childbearing age [ 1 ]. This condition is a chronic inflammatory disorder characterized by the presence of endometrial tissue outside the uterus, manifesting in symptoms such as pelvic abdominal pain, dysmenorrhea, infertility, dyspareunia, pelvic nodules, and endometriomas. Among these, pain is the primary clinical indicator of infertility and disease severity in EMs. As a systemic disease marked by widespread inflammation and an unclear etiology, it is challenging to eliminate, prone to recurrence, and carries a potential risk of malignant transformation [ 2 ]. The pain associated with EMs severely impacts patients’ quality of life. Western medical approaches to EMs include medication, surgical intervention, and expectant management; however, these therapies often result in adverse effects such as menstrual irregularities, gastrointestinal discomfort, or allergic reactions [ 3 , 4 ]. Recently, a combination of pharmacological and non-pharmacological treatments has been recommended, including acupuncture techniques (auricular, electroacupuncture, body acupuncture, and needle warming moxibustion), moxibustion, Neiyi Zhitong Formula, Guixiang Wenjing Zhitong capsules, and Tong Bining for managing endometriosis-related pain [ 5 , 6 ]. Research indicates that acupuncture and moxibustion can promote pelvic circulation, alleviate uterine smooth muscle spasms, regulate hormones, and relieve symptoms related to pelvic inflammatory disease and menopausal syndrome [ 7 ]. Despite these advancements, direct comparisons of the efficacy and safety of various acupuncture and moxibustion methods remain limited, making it difficult to comprehensively evaluate their clinical benefits. The clinical efficacy rate (CER) for endometriosis assesses the extent of symptom relief, including improvements in abdominal pain, dysmenorrhea, abnormal menstruation, dyspareunia, and endometriomas. Furthermore, the Visual Analog Scale (VAS) scores derived from existing literature have been systematically ranked to offer evidence-based recommendations for both patients and clinicians.

Below is the link to the electronic supplementary material. Supplementary file1 (DOCX 22 KB) Supplementary file2 (DOCX 13632 KB) Supplementary file3 (DOCX 27 KB) Supplementary file4 (DOCX 27 KB) Supplementary file5 (DOCX 13 KB) Supplementary file1 (DOCX 22 KB) Supplementary file2 (DOCX 13632 KB) Supplementary file3 (DOCX 27 KB) Supplementary file4 (DOCX 27 KB) Supplementary file5 (DOCX 13 KB)