Decreasing bleeding due to uterine fibroid with electroacupuncture

CASE REPORT
Decreasing bleeding due to uterine fibroid with
electroacupuncture
Yusuf €Ozgur Çakmak, M.D., Ph.D., a Ihsan Nuri Akpınar, M.D., b Tevfik Yoldemir, M.D., c and Safiye Çavdar, Ph.D. d
a Acupuncture Program for Physicians and Department of Anatomy, School of Medicine, University of Yeditepe, Kayisdagi;
b Department of Radiology, and c Department of Obstetrics and Gynecology, School of Medicine, University of Marmara,
Pendik; and d Department of Anatomy, School of Medicine, University of Marmara, Haydarpasa, Istanbul, Turkey
Objective: To report the usefulness of electroacupuncture (EA) for the management of menorrhagia due to submucous
uterine fibroid.
Design: Case report.
Setting: University hospital.
Patient(s): A 48-year-old woman with a symptomatic submucous uterine fibroid, who presented with severe
menorrhagia.
Intervention(s): Electroacupuncture.
Main Outcome Measure(s): Doppler ultrasonographic assessment of uterine blood flow and number of pads used
during menorrhagia.
Result(s): Doppler ultrasound revealed decreased blood flow of the uterine artery with EA stimulation. With
repetitive sessions of EA fewer pads were used during menorrhagia.
Conclusion(s): We present the first human case in which decreasing uterine artery blood flow with EA improved
menorrhagia due to uterine fibroma. Electroacupuncture could be a useful, alternative, and relatively noninvasive
tool for the management of fibroids with menorrhagia as a severe complaint. (Fertil SterilÒ 2011;96:e13–5. Ó2011
by American Society for Reproductive Medicine.)
Key Words: Fibroid, menorrhagia, electroacupuncture, uterine, blood flow, myoma
Uterine fibromas mostly occur in reproductive-age women, with
a frequency ranging from 20% to 25% (1). Surgical removal is the
most common management for uterine fibroids. If the patient is
young and wants to bear children, myomectomy is the preferred option.
However, after myomectomy there is the risk of fibroid recurrence,
up to 50% in some series (2–4). Thus, one third of all patients
are known to undergo reoperation for the treatment of uterine
fibroids (5). Furthermore, myomectomy can lead to pelvic adhesions,
which may inhibit future chances of conception. Hysterectomy
is usually the last preference of those patients in cases of
recurrence of fibromas after myomectomy.
One of the most common symptoms of submucous fibromas is severe
bleeding (menorrhagia) during the menstrual cycle (6). For patients
with a symptomatic fibroid and surgical risk, such as a history
of thromboembolic episodes, severe obesity, uncontrolled diabetes,
and immunocompromised states, clinicians usually look for an alternative
method of treatment. Uterine artery embolization is one of the
various modalities available for the management of uterine fibroid as
an alternative to hysterectomy (7). Magnetic resonance imaging–
guided focused ultrasound surgery is a newer treatment option for
women with fibroids (8). Just like uterine artery embolization,
Received February 22, 2011; revised March 23, 2011; accepted March 25,
2011; published online May 11, 2011.
Y. € O.Ç. has nothing to disclose. I.N.A. has nothing to disclose. T.Y. has
nothing to disclose. S.Ç. has nothing to disclose.
Reprint requests: Yusuf € Ozg€ur Çakmak, M.D., Ph.D., Department of Anatomy,
School of Medicine, University of Yeditepe, Kayisdagi, Atasehir
34725, Istanbul, Turkey (E-mail: cozgur@yahoo.com).
focused ultrasound surgery also preserves the uterus. Percutaneous
nerve stimulation or electroacupuncture (EA) shows a very selective
action in increasing or decreasing blood flow of a target organ when
the appropriate nerve and stimulation frequency combinations are
used (9–11).
Considering the positive results of transient ligation of the uterine
artery, we theorized that decreasing the blood flow of the uterine artery
with EA may also have a positive effect for uterine fibroids, especially
those with menorrhagia. We present the first case study in
the literature reporting the reduction of uterine bleeding with EA,
in a woman with menorrhagia due to uterine fibroma.
CASE REPORT
A 48-year-old pale-looking woman presented to our center with a
6-month history of menorrhagia. Preoperative evaluation revealed
a submucous myoma with intramural component extending 1 cm
near to the serosa. The dimension of the myoma was 3 3 3.5
cm on vaginal ultrasonography. Several techniques have been proposed
for the treatment of such submucous fibroids, most of them
sharing the objective of producing an intracavitary protrusion of
the intramural component. The observation of rapid migration of
the residual intramural component of the fibroid toward the uterine
cavity (12), with a parallel increase of myometrial thickness during
hysteroscopic myomectomy (13), is the basis of excision of fibroid
by a two-step procedure.
We preferred to remove the fibroid through a two-steps procedure,
by means of traditional resectoscopic surgery, as originally
0015-0282/$36.00 Fertility and Sterility â Vol. 96, No. 1, July 2011 e13
doi:10.1016/j.fertnstert.2011.03.110 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.

FIGURE 1
Pre- and post-Doppler ultrasound measurements for right and left uterine arteries.
Çakmak. Management of menorrhagia with electroacupuncture. Fertil Steril 2011.
hypothesized by Loffer (12). First, surgical excision of the intracavitary
portion of the fibroid by means of the usual progressive resectoscopic
excision was done. This action must stop at the level of the
plane of the endometrial surface, so that the identification of the passage
between the fibroid and the adjacent myometrial tissue is not
impaired (cleavage plane). Once the cleavage plane was identified
the usual cutting loop of the resectoscope was inserted into the plane
between the fibroid and myometrium, along the surface of the fibroid
(usually clearly recognizable by its smooth, white, compact
surface), thus bringing about its progressive dissection from the myometrial
wall. Between the strokes of the resectoscope, ‘‘hydromassage’’
was performed to squeeze out the intramural portion of the
submucous fibroid at its base (12). This was accomplished by rapid
changes of intrauterine pressure using an electronically controlled
irrigation and suction device (Endomat; Karl Storz) (14). Indeed,
by interrupting and restarting the supply of distension liquid several
times, the maximum possible migration of the intramural component
of the fibroid into the cavity was obtained. Some parts of the
intramural portion were left behind while avoiding perforation.
Because the patient had persistent menorrhagia, postoperative sonography
1 month later revealed the persistence of some parts of the
intramural component of the previous fibroid. Either repeat hysteroscopic
surgery or vaginal hysterectomy was suggested to the patient
after consideration of her age, but she refused it. She had been using
oral contraceptives for severe menorrhagia for 2 months after the operation
(September and October 2010), during which symptoms persisted.
The patient suffered from side effects of the oral
contraceptives and gave them up in October 2010. She reported using
45 pads in November and 48 pads in December 2010 during her
menorrhagic periods. Finally she decided to have a hysterectomy
1 month later, and she asked for an alternative method for the relief
of menorrhagia while she was waiting for her scheduled surgery.
We informed the patient about a possible noninvasive experimental
technique: decreasing uterine blood flow with EA. She gave written
consent before the EA session. Electroacupuncture was performed
with Cefar Acus 4 (CefarCompex Accessories). We used SP6 (tibial
nerve territory) and ST29 (T12–L1 dermatomes territory) (9) acupuncture
points for electrostimulation with 80-Hz frequency and 180-microseconds
wavelength (intensity of the stimulus started with 3 mA
and increased up to 4.5 mAwithout pain). Acupuncture was performed
by a licensed and experienced (7 years) acupuncturist. Acupoint locations
were confirmed by a Pointoselect digital acupuncture point detector
(Schwa-Medico), and single-use 0.20 13-mm sterile stainless
acupuncture needles (Suzhou Kangsheng Medical Devices) were inserted
relatively superficially (approximately 1 cm), sufficiently deep
to stimulate sensory elements of the skin while remaining minimally
invasive for patients. The blood flow to the uterine arteries was checked
with a Doppler ultrasound scanner before and during the 15th minute
of EA. Uterine blood flow parameters were measured by a color Doppler
ultrasound scanner (Acuson Antares Premium edition; Siemens)
with a 7-MHz transvaginal (endocavitary ) probe. The transvaginal
probe was gently placed, and the uterine artery was detected. Doppler
ultrasound measurements, before and 15 minutes after the EA, revealed
that blood flow decreased in the uterine artery within
e14 Çakmak et al. Management of menorrhagia with electroacupuncture Vol. 96, No. 1, July 2011

15minutes.Thepulsatilyindexincreasedfrom3.44to3.55intheleft
uterine artery and from 5.67 to 8.64 in the right uterine artery. Before
EA the volume flow was 0.094 L/min in the left uterine artery, and it
decreased to 0.080 L/min after EA. The baseline value of volume
flow in the right uterine artery was 0.084 L/min and decreased to
0.055 L/min after EA (Fig. 1).
For the following 6 days, EAwas used for 30 minutes daily. There
was a decrease in blood flow of the uterine arteries and in the amount
of menorrhagia. At the end of the menstrual period the patient
reported using 28 pads.
DISCUSSION
In the present case we demonstrate that menorrhagia of a submucous
fibroma could be decreased with EA. The Doppler ultrasound results
revealed that uterine artery blood flow was decreased at both sides,
and thereby total pad usage per menstrual bleeding decreased from
48 and 45 pads to 28.
Six to nine hours of bilateral uterine artery occlusion results in
a 24% volume reduction of dominant fibroid and up to 42% reduction
of menorrhagia symptoms up to 6 months after uterine artery occlusion
(15). Likewise, Istre et al. (16) also reported a case of dominant
myoma volume reduction 3 months after the occlusion of uterine arteries
for 6 hours. They reported 77.2% shrinkage in myoma volume,
in addition to diminished menorrhagia symptoms. Vilos et al. (15) reported
42% relief of menorrhagia symptoms, similar to our finding.
Uterine artery embolization is another modality available for the
management of uterine fibroid (7). However,amenorrhea(17) and
loss of ovarian reserve (18) have been reported due to the full blockage
of the blood supply to the ovaries during uterine artery embolization.
Just like uterine artery embolization, MRI-guided focused ultrasound
surgery also preserves the uterus (8). This procedure is performed
while the patient is inside a specially crafted MRI scanner that allows
doctors to visualize, locate, and ablate uterine fibroids. Initial results
with this technology are promising, but its long-term effectiveness is
not yet known. This new technique needs experienced clinicians and
ultrasound devices that can produce focused high-frequency, highenergy
sound waves to target and destroy the fibroids. Moreover, the
technique may not be considered for claustrophobic patients.
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When appropriate nerve and stimulation frequency combinations
are used (9–11), percutaneous nerve stimulation or EA shows a very
selective action in increasing or decreasing blood flow of a target
organ. We have previously demonstrated (9) that blood flow can
be increased in the testicular artery of humans with EA by using
a specific combination of stimulation frequency and a dermatome,
using the effective frequencies that have been proven to increase
blood flow in rats. Blood flow–decreasing parameters of electrostimulation
have also been described in rats (11). It has been demonstrated
that only high-frequency EA can decrease ovarian blood
flow in rats; on the other hand, the neuroanatomical pathways that
aid such a function consider central effects in addition to segmental
innervation because the ovarian blood flow responses to highfrequency
EA stimulation were also investigated after severance
of the ovarian sympathetic nerves (11).
Our case study has some limitations. First, the parameters for decreasing
blood flow by EA have not yet been defined and optimized.
Hence, the exact timing and spacing of treatment needs to be validated
with further studies. Next, whether long-term intermittent EA would
decrease uterine arterial blood flow parameters and cause long-term
fibroma shrinkage for a longer duration has to be answered. Third,
whether electrostimulation from the foot only (from the SP6 point)
rather than the SP6 and abdominal points ST29 together is enough
to decrease uterine blood flow has to be investigated, for possible further
usage for bleeding during surgery. Last but not least, we performed
EA for 6 days during the menstrual bleeding period.
However, the frequency of the EA could be increased to twice daily
or could be prolonged to days before the start of menstrual bleeding.
It has been demonstrated that functional plasticity occurs for uterine
blood flow after repetitive EA, and blood flow can still be influenced
after termination of repetitive EA sessions (19).
In conclusion, we present for the first time in the literature a case
study of management of menorrhagia due to fibroma with EA. This
report is the first trial of EA for decreasing uterine artery blood flow
in humans. We believe that the case presented here will be a step forward
for new treatment options with the aid of EA-assisted blood
flow reduction. Future randomized studies in large groups are necessary
to confirm our finding and to optimize the parameters of the
stimulation technique.
15. Vilos GA, Vilos EC, Abu-Rafea B, Hollett-Caines J,
Romano W. Transvaginal Doppler-guided uterine artery
occlusion for the treatment of symptomatic fibroids:
summary results from two pilot studies.
J Obstet Gynaecol Can 2010;32:149–54.
16. Istre O, Hald K, Qvigstad E. Multiple myomas treated
with a temporary, noninvasive, Doppler-directed,
transvaginal uterine artery clamp. J Am Assoc Gynecol
Laparosc 2004;11:273–6.
17. Guo WB, Yang JY, Chen W, Zhuang WQ. Amenorrhea
after uterine fibroid embolization: a report of
six cases. Ai Zheng 2008;27:1094–9.
18. Hehenkamp WJ, Volkers NA, Broekmans FJ, de
Jong FH, Themmen AP, Birnie E, et al. Loss of ovarian
reserve after uterine artery embolization: a randomized
comparison with hysterectomy. Hum
Reprod 2007;22:1996–2005.
19. Stener-Victorin E, Waldenstr€om U, Andersson SA,
Wikland M. Reduction of blood flow impedance in
the uterine arteries of infertile women with electroacupuncture.
Hum Reprod 1996;11:1314–7.
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