Does anyone care about sex?

Clinical guidelines recommend pharmacological treatments (combined oral contraceptives and progestogens) or surgery to reduce pain symptoms and improve sexual function [4, 7]. However, satisfaction rates with hormonal treatment are low due to significant side effects [8, 9]. Laparoscopic excision has also shown benefits in improving sexual function and reducing discomfort during sexual intercourse after 4–12 months, as well as after 5 years; however, over one third of women will require repeated surgery [4].

Given the significant burden caused by endometriosis, effective and acceptable treatment options that are in line with patients’ needs are urgently required. The number one priority for people with endometriosis is an effective treatment [10], and accordingly, they seek help beyond the recommendations of clinical guidelines. A cross-sectional survey (n = 1575) found 82.8% of people with endometriosis and their family members wanted more research into treatment options; over half of these people (43.6%) noted an interest in complementary and alternative medicine (CAM) treatments [11]. The World Health Organization (WHO) reported that acupuncture is the most widely used traditional and complementary medicine worldwide [12]. A retrospective evaluation, undertaken by Schwartz et al. in Switzerland using medical charts and a questionnaire (n = 574), found that 62.5% of women with endometriosis sought CAM support, with one quarter choosing acupuncture/traditional Chinese medicine (TCM; [13]).

Acupuncture has shown promising results in relieving the pain symptoms of endometriosis and has been suggested for people with endometriosis who do not experience relief with usual care [14]. However, data on acupuncture for dyspareunia are limited.

A Brazilian randomized controlled trial (RCT) reported a 65% decrease in sexual pain using a 0–10-point visual analogue scale after five acupuncture treatments compared to a 13% reduction after five sessions of simulated acupuncture (n = 42, mean difference [MD] −2.88, [−3.83, −1.93], p < 0.00001), which was also found at the 2‑month follow-up (n = 42, MD −3.86, [−4.77, −2.95], p < 0.00001; [15]). This study was included in a systematic review and meta-analysis that also reported on a Chinese RCT that found a positive effect of acupuncture compared to danazol; however, the difference was not statistically significant (n = 26, risk ratio 1.07, [0.57, 2.00], p = 0.84).

An Italian pilot study without a control group reported that 19 of 34 women with deep infiltrating endometriosis experienced dyspareunia. Sexual pain scores were reported to decrease from a mean intensity of 5.74 before treatment to 3.89 on a 0–10 numerical rating scale after 15 acupuncture treatments (p < 0.0001; [16]).

A Chinese RCT reported no change in dyspareunia after acupuncture compared to superficial needling, but the baseline pain scores were 0, which does not allow for improvement.

Findings suggest that acupuncture can improve pain during sexual intercourse in people with endometriosis. Even a small number of five treatments may be enough to cause significant changes. The main treatment strategy was to invigorate Qi and Blood especially in the lower abdomen in order to alleviate pain (LIV‑3, SP‑6, SP-10, Ren‑3, BL-17, GB-29, L.I.-4, SP‑8, Ren‑6, ST-29, BL-32, Zigong, LIV‑8, KID-10). Additional strategies were to tonify Spleen and Stomach (SP‑6, ST-36, Ren-6), resolve dampness (SP‑6, Ren‑3, SP‑9, KID-10), and calm the Shen (P‑6; [17]).

However, the total number of studies investigating the effect of acupuncture on dyspareunia was small with limited sample sizes. Additionally, the persistence of an effect has only been evaluated in one study after 2 months, and therefore prolonged effect sizes remain unclear. Furthermore, these acupuncture treatment details may not reflect the ideal treatment for dyspareunia, since the acupuncture protocols were not specifically designed to treat dyspareunia in endometriosis, but to treat the breadth of pain symptoms in endometriosis.

The main treatment strategy to move Qi and Blood aligns with major textbook recommendations for endometriosis-related pain [18, 19]. However, strategies to treat the base root as well, such as strengthening the Kidneys and addressing either heat or cold, which is suggested to be vital by expert consensus if present [20], are omitted in both protocols. Furthermore, standardized acupuncture protocols were used, which have been criticized for lacking ecological validity [21], and treatment effects may be underestimated [22].

Both addressing the root cause and individualizing the treatment are especially important in this context, since the impact of endometriosis on sexual function is not limited to pain but includes a range of further physiological functions (desire/arousal, orgasm, satisfaction) and psychological components (anxiety, fear of pain, feelings of guilt toward the partner). Given that acupuncture is claimed to be a holistic modality providing both physical and psychological treatment aspects [23], it is likely that acupuncture has the potential to treat the complexity of sexual dysfunction rather than pain alone.

Interestingly, a cross-sectional survey in Australia and New Zealand including 111 TCM practitioners showed that dyspareunia was an uncommon presenting symptom (n = 15, 13.5%), despite affecting almost three quarters of women with chronic pelvic pain [24]. The authors discussed whether this may reflect the normalization of pelvic pain associated with the menstrual cycle and/or TCM practitioners overlooking signs and symptoms. The neglect of dyspareunia and sexual function in people with endometriosis in research is even more pronounced in textbooks on endometriosis, where dyspareunia is rarely mentioned, with only one case of a woman with dyspareunia being reported. Her TCM diagnosis was Qi stagnation and blood stasis, and the therapeutic strategy accordingly was to regulate Qi to invigorate blood circulation and to resolve stasis to stop pain. However, no acupuncture details were given for this case.

Based on the current literature, it remains unclear why the treatment of dyspareunia is omitted in almost all textbooks and most clinical research on acupuncture for endometriosis. While there are many possible explanations at different levels, we must critically ask ourselves whether we—TCM practitioners, authors, and researchers—consider sexual well-being in people with endometriosis to be a negligible luxury.

A range of acupuncture details for dyspareunia have been presented. However, studies including dyspareunia are very limited and have not specifically focused on the treatment of dyspareunia or sexual function but on pelvic pain symptoms in general.