Acupuncture and moxibustion trial to test adjuncts for premature ovarian insufficiency

When a woman’s ovaries fall silent before her 40th birthday, the diagnosis is premature ovarian insufficiency, or POI, a condition that brings menstrual disruption, infertility, hot flashes, anxiety, and elevated long-term risks of osteoporosis and cardiovascular disease. Hormone replacement therapy remains the standard of care, relieving hypoestrogenic symptoms and protecting bones and blood vessels, yet it cannot replenish the depleted follicular pool or reliably restore fertility. Now a research team in Guizhou, China, has designed one of the most methodologically ambitious trials yet to ask whether two ancient therapies, acupuncture and moxibustion, can add measurable ovarian benefit when layered onto modern hormone treatment. The protocol, published in Frontiers in Endocrinology, describes a multicenter, assessor-blinded, 2 × 2 factorial randomized controlled trial that will recruit 144 women across three clinical centers.

The factorial architecture is the trial’s defining technical feature. Rather than comparing a single combined treatment against a control, the investigators treat acupuncture and moxibustion as two independent randomized factors, each present or absent. Every participant receives standard oral estradiol/dydrogesterone therapy, marketed as Femoston, following a sequential 28-day regimen: one milligram of estradiol daily for the first 14 days, then one milligram of estradiol plus 10 milligrams of dydrogesterone daily for the following 14 days, providing both hormone replacement and endometrial protection. On top of this common hormonal background, women are assigned in a 1:1:1:1 ratio to Femoston alone, acupuncture plus Femoston, moxibustion plus Femoston, or combined acupuncture and moxibustion plus Femoston, with 36 participants in each group.

This design allows statisticians to estimate the main effect of acupuncture by pooling the two groups that receive it, 72 participants, against the 72 who do not, and to do the same for moxibustion. The acupuncture × moxibustion interaction, whether the two modalities amplify or interfere with one another, will also be estimated but is explicitly exploratory, because the trial was not powered specifically for that question. The investigators argue that this structure resolves an ambiguity that plagues conventional three-arm comparisons: if a combined treatment outperforms a control, it is often unclear whether the benefit arises from one component, the other, or their synergy. The factorial design disentangles those possibilities within a single trial.

The primary outcome is the change from baseline to week 12 in antral follicle count, or AFC, the total number of 2 to 9 millimeter antral follicles visible in both ovaries on transvaginal ultrasound. AFC provides a direct ultrasound-based estimate of the recruitable follicle pool and is a clinically recognized marker of ovarian reserve. The 12-week window was chosen on empirical grounds: a prior randomized study in women with POI reported measurable increases in both AFC and anti-Müllerian hormone after a comparable three-month estradiol/dydrogesterone regimen with or without adjunct acupuncture, and a recent 12-week sham-controlled trial in women with diminished ovarian reserve found that acupuncture three times weekly produced significantly greater AFC improvement than sham, although the between-group AMH difference was not statistically significant. Importantly, the protocol cautions that a biomarker change at 12 weeks should not be interpreted as restoration of the primordial follicle pool or of fertility.

Secondary outcomes span the multidimensional clinical burden of POI. Serum anti-Müllerian hormone will be measured in a central laboratory using the Roche Elecsys AMH assay on a cobas e 602 electrochemiluminescence platform, with fasting blood samples processed within two hours, centrifuged, aliquoted, stored at minus 80 degrees Celsius, and transported on dry ice from the three recruitment centers to minimize inter-laboratory variability. Follicle-stimulating hormone, luteinizing hormone, and estradiol will be measured by chemiluminescent immunoassay. Transvaginal color Doppler ultrasound will capture ovarian hemodynamic parameters, including peak systolic velocity, resistance index, and pulsatility index. Patient-reported measures include the modified Kupperman Scale for hypoestrogenic symptoms, the Self-Rating Anxiety Scale for psychological distress, Traditional Chinese Medicine syndrome scores, and menstrual status, all assessed at baseline and week 12.

Clinical pregnancy, defined as an intrauterine gestational sac with fetal cardiac activity confirmed by ultrasound, will be analyzed as an exploratory reproductive outcome recorded during treatment and at follow-up visits at weeks 24 and 48. The trial was not powered for pregnancy endpoints, and the investigators emphasize that conception during follow-up may be strongly influenced by subsequent ovulation induction, in vitro fertilization and embryo transfer, or other assisted reproductive technology. Post-randomization summaries of spontaneous conceptions versus conceptions following ART will be regarded as exploratory rather than randomized causal comparisons. Participants who become pregnant will discontinue acupuncture and moxibustion immediately and transfer to pregnancy follow-up.

The intervention protocol is standardized in unusual technical detail. The acupuncture prescription comprises two alternating treatment sets: set A, performed in the supine position, includes abdominal points CV12, CV6, CV4, bilateral ST25, ST29, EX-CA1, and leg points ST36, SP6, and LR3; set B, performed prone, includes bilateral BL23, BL32, and KI3. Needles of 0.25 by 40 millimeters and 0.30 by 75 millimeters are inserted to prespecified depths, with BL32 advanced obliquely toward the second posterior sacral foramen to 60 to 75 millimeters. Gentle lifting, thrusting, and twirling elicit Deqi, the characteristic sensation of soreness, numbness, distension, or heaviness, and needles are retained for 30 minutes. The moxibustion arm applies self-adhesive moxa column patches, each burning roughly 10 minutes, to the identical acupoints without needle insertion, three columns per session for approximately 30 minutes. In the combined group, moxibustion is applied during needle retention after Deqi is achieved. Both external therapies are delivered three times weekly for 12 weeks, totaling 36 sessions.

Because acupuncture and moxibustion are physical interventions, participants and practitioners cannot be blinded, so the trial adopts an assessor-blinded design. Recruitment and screening personnel are separated from treatment practitioners, who play no role in outcome assessment. Outcome assessors, ultrasound physicians, laboratory technicians, data-entry staff, and statisticians remain blinded to allocation throughout. To minimize measurement variability, all baseline and week-12 AFC examinations, regardless of recruitment center, will be performed centrally in the ultrasound department of the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine using a GE HealthCare LOGIQ Fortis system with an RIC5-9-D transvaginal volume probe, and the same blinded physician will examine the same participant whenever feasible. Adverse events, including vasovagal reactions, hematomas, burns, and hormone-related symptoms such as breast tenderness and abnormal bleeding, will be recorded with a four-level severity grading scheme, and serious events reported to the ethics committee within 24 hours.

The sample size was planned from prior literature in which post-treatment AFC was 3.97 plus or minus 1.15 in the Femoston-only group and 5.14 plus or minus 1.33 in the acupuncture plus Femoston group, a between-group difference of 1.17 corresponding to Cohen’s d of approximately 0.94. G*Power calculations with 90 percent power and a two-sided alpha of 0.05 indicated 26 participants per group, increased to 36 per group to allow for roughly 20 percent dropout, for a total of 144. Within the factorial framework, each factor level includes up to 72 participants, yielding greater than 99 percent power to detect a main effect of that magnitude, with a minimum detectable standardized effect of approximately 0.54 at 90 percent power. The investigators stress that the planning benchmark derived from an acupuncture comparison does not imply the true moxibustion effect equals d of 0.94.

The trial’s eligibility criteria deliberately define a selected subgroup: women aged 22 to 40 with reproductive needs, basal FSH between 25 and 40 U/L confirmed on two occasions at least four weeks apart, and recruitment during the pretreatment phase before assisted reproduction. The investigators acknowledge that these criteria limit generalizability to adolescents, women with more advanced ovarian failure, those without fertility intentions, or patients with substantial comorbidity. The absence of sham controls means subjective outcomes such as anxiety and TCM syndrome scores may reflect treatment expectations and practitioner attention as well as specific physiological effects, although more objective biomarkers like AFC and AMH are less directly susceptible to such contextual influences. Registered with the International Traditional Medicine Clinical Trial Registry under identifier ITMCTR2025002408 and approved by the ethics committee of the First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, the trial may clarify whether either modality is associated with changes in ovarian reserve markers when added to standard hormone therapy, and may generate preliminary evidence on their potential interaction, providing a methodological basis for future larger trials designed around definitive reproductive outcomes such as live birth.

Subject of Research: Adjunctive effects of acupuncture and moxibustion in women with premature ovarian insufficiency receiving hormone replacement therapy: protocol for a multicenter, assessor-blinded, 2 × 2 factorial randomized controlled trial

Article Title: Adjunctive effects of acupuncture and moxibustion in women with premature ovarian insufficiency receiving hormone replacement therapy: protocol for a multicenter, assessor-blinded, 2 × 2 factorial randomized controlled trial

Article References: Lu, C., Ye, T., Cui, J., & Chen, B. (2026). Adjunctive effects of acupuncture and moxibustion in women with premature ovarian insufficiency receiving hormone replacement therapy: protocol for a multicenter, assessor-blinded, 2 × 2 factorial randomized controlled trial. Frontiers in Endocrinology, 17, Article 1952726. https://doi.org/10.3389/fendo.2026.1952726

Image Credits: AI Generated

DOI: 10.3389/fendo.2026.1952726

Keywords: acupuncture, moxibustion, premature ovarian insufficiency, hormone replacement therapy, factorial randomized controlled trial, reproductive medicine, Adjunctive, effects, women, premature, ovarian, insufficiency