Acupuncture and Moxibustion in the Treatment of Gynecological Perioperative Anxiety: A Systematic Review and Meta-Analysis

Introduction

Surgery is a commonly used approach to treat gynecological diseases and often acts as a significant source of stress in clinical settings, eliciting various levels of psychological and physiological stress responses in patients. Studies have shown that a high incidence of anxiety, ranging from 92% to 93%, is frequently observed among patients awaiting surgery, making it a prominent adverse experience related to surgical procedures.¹ Preoperative anxiety not only affects the patient’s nervous and endocrine systems, but also hinders the smooth progress of surgery and anesthesia. Furthermore, its persistence can impact postoperative recovery and subsequent quality of life.² Recent research^3,4 has revealed that in the context of elective surgery across different departments, a higher number of patients experiencing preoperative anxiety are from the gynecology and obstetrics departments. This association is closely related to the unique reproductive system and physiological functions in females. Therefore, it is especially important to implement effective interventions to alleviate perioperative anxiety in order to facilitate the swift recovery of postoperative patients.⁵

In recent years, the use of sedatives and anxiolytic drugs before surgery has become a common method to reduce anxiety in patients. Although effective, these medications can cause complications like postoperative nausea, vomiting, and pain. These problems not only affect patient satisfaction and comfort but also impact the recovery outcomes of patients.^6,7 Therefore, there is a pressing requirement for more effective and safer treatments. As a result, there is a growing focus on complementary and alternative interventions. For example, acupuncture and moxibustion therapy have become widely utilized approaches, providing patients with advantages and minimal side effects at relatively low expenses. Research has demonstrated notable benefits of acupuncture in the realm of neurological disorders.^8–10 For instance, a meta-analysis conducted by Xiong Jingwen confirmed that acupuncture can effectively alleviate myofascial pain,¹¹ likely through the inhibition of P2X7R to relieve neuropathic pain.¹² Furthermore, some experts contend that acupuncture can stimulate the central nervous system of the spinal cord and higher central nervous system to participate in pain processing.¹³ Acupuncture has also been suggested to regulate the functions of the heart and brain, particularly in clinical conditions associated with neuroendocrine imbalance, such as menopause, depression, and insomnia.¹⁴

Acupuncture and moxibustion therapy have been extensively studied for their potential to reduce preoperative anxiety in gynecology. For instance, Wunsch et al¹⁵ demonstrated the effectiveness of auricular acupuncture at specific acupoints in alleviating anxiety in patients undergoing outpatient gynecological surgery. Similarly, Abadi et al¹⁶ successfully improved preoperative anxiety and reduced State-Trait Anxiety Inventory (STAI) scores in patients scheduled for cesarean section by applying pressure at Yintang and Shenmen points. Furthermore, Yuan et al¹⁷ observed that acupuncture not only alleviates preoperative anxiety and pressure, but also diminishes the use of anesthetic drugs and stress responses, leading to stable breathing and homeostasis during the operation. It also imparts a protective effect on vital organs, promotes recovery, effectively reduces postoperative pain, and prevents discomfort such as nausea and vomiting during the recovery period. However, Oviedo et al¹⁸ reported that otopoint pressure and auricular acupuncture treatment did not result in lower anxiety and pain scores compared with a placebo in patients scheduled for induced abortion. Additionally, recent randomized controlled trials (RCTs) have investigated the efficacy of acupuncture and moxibustion in managing anxiety related to gynecological surgery. Notably, there is a lack of a comprehensive meta-analysis addressing the impact of acupuncture and moxibustion therapy on perioperative anxiety in patients with gynecologic diseases undergoing surgical treatment, as well as the effect of different intervention methods on perioperative anxiety for different types of gynecological surgeries. Therefore, a more extensive systematic review is needed.

The purpose of this research is to methodically examine current literature and perform a meta-analysis to evaluate the efficacy and safety of traditional acupuncture and moxibustion treatments in reducing perioperative anxiety and pain associated with gynecological surgery. The objective is to offer evidence-based perspectives for medical practice.

Materials and Methods

The study followed the reporting guidelines specified in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).¹⁹ The protocol for this meta-analysis can be accessed in the PROSPERO registry (CRD42023432717).

Literature Search

Search Strategy

The researchers conducted a comprehensive search of PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, VIP, and CBM to identify relevant studies published from the establishment of the databases to March 20, 2023. The search employed a combination of subject terms and free-text terms, integrating keywords such as acupuncture and moxibustion, auricular therapy, electroacupuncture, acupressure, gynecological surgery, laparotomy, laparoscopic surgery, cesarean section, induced abortion, anxiety, and depression. Additionally, they meticulously reviewed the references of relevant studies to ensure the inclusion of all pertinent articles. Subsequently, they performed supplementary searches to capture the latest literature and avoid any potential omissions. The detailed search strategy can be found in the Appendix 1 Using PubMed database search as an example, the search is as shown in Table 1.

Table 1 Example of PubMed Search

Inclusion and Exclusion Criteria

To establish the inclusion criteria, we followed the Participants, Intervention, Comparison, Outcomes, and Study (PICOS) framework. The criteria were as follows: (1) Participants: The study included adult inpatients or outpatients undergoing elective gynecological surgery with preoperative data, without ethnic restrictions, and experiencing perioperative anxiety. (2) Intervention: The treatment group received otopoint pressure, auricular acupuncture, electroacupuncture, acupuncture, acupressure, or moxibustion. The control group received sham acupuncture, sham acupoints, conventional treatment, or drug treatment. (3) Primary outcome measures involve anxiety assessments, including State-Trait Anxiety Inventory (STAI-S),²⁰ Visual Analogue Scale - Anxiety (VAS-anxiety),²¹ and Self-Rating Anxiety Scale (SAS).²² Additional measures assessed as secondary outcomes encompass pain, depression, and sedation through VAS-anxiety, Hamilton Depression Rating Scale (HAMD), Burns Depression Checklist (BDC), Self-Rating Depression Scale (SDS), Bispectral Index (BIS), and Ramsay Sedation Scale (Ramesay) scores. Moreover, we incorporated the initial postoperative exhaust time, the initial postoperative defecation time, and recovery time for postoperative bowel sounds. (4) Study design: Randomized controlled trials conducted in either Chinese or English.

The exclusion criteria are as follows: (1) Articles that are not related to gynecological surgery or do not include acupuncture and moxibustion intervention in the treatment group. (2) Articles categorized as meta-analyses, reviews, animal experiments, case reports, conference abstracts, guidelines, letters, or graduation theses. (3) Articles lacking outcome measures of interest or extractable data, or containing incorrect data. (4) Articles that used other treatment combination methods. (5) In cases where literature exists in both Chinese and English versions, the English version will be retained.

Study Selection and Data Extraction

The obtained results were imported into the EndNote X9 software, and two authors (Xiu Wang and Qianqian Yu) independently performed literature screening according to the predefined inclusion and exclusion criteria. After removing duplicate studies, the titles and abstracts of the literature underwent primary screening. Subsequently, studies that did not satisfy the inclusion criteria were excluded, and the complete texts of the remaining literature were carefully examined to identify eligible studies. In the event of any disagreements, a third investigator (Xia Xu) was consulted for discussion and decision-making.

Two investigators (Junlan Liu and Xuyuan Gao) independently conducted data extraction using a pre-defined spreadsheet. The extracted and recorded data information included: author, year, country, sample size, age, surgery type, intervention measure, specific intervention process, and outcome measure. Any discrepancies were resolved through discussion between the two investigators, and if needed, a third investigator (Jun Zhu) was consulted.

Risk-of-Bias Assessment

The risk of bias for each study was evaluated by two independent reviewers (Xiudie Wang and Lanlan Wang) using Version 2 of the Cochrane Risk-of-Bias Tool for randomized trials (RoB 2.0).²³ Each study was placed into categories of “low risk of bias”, “some concerns”, or “high risk of bias” according to the following domains: bias arising from the randomization process, bias due to deviations from the intended intervention, bias from missing outcome data, bias in the measurement of outcomes, and bias in the selection of the reported results, including deviations from the registered protocol. Trials were considered to have an overall high risk of bias if one or more domains were rated as “high risk of bias”, and were deemed to have an overall low risk of bias if all domains were rated as “low risk of bias”.

Statistical Analysis

Data analysis was conducted using Stata 15.1. Heterogeneity was quantified through Cochran’s Q test and Higgins I². Significant heterogeneity among the studies was indicated by a significance level of P < 0.10 or I² > 50%, leading to the adoption of a random-effects model for analysis. Conversely, a fixed-effects model would be selected if heterogeneity was not significant. In cases of excessive heterogeneity, sensitivity analysis and subgroup analysis were performed to explore the sources of heterogeneity. Funnel plots were used to visually represent potential publication bias, and statistical assessment of publication bias was carried out using Begg and Egger tests. If publication bias was identified, the trim-and-fill method was applied to analyze its impact on the results of the meta-analysis. A significance level of P < 0.05 indicated the statistical significance of the combined statistics of the included studies.

Results

Literature Search and Study Selection

After conducting database searches and manual retrieval, a total of 856 articles were obtained. Following the screening of titles and abstracts, 248 duplicate articles and 547 irrelevant articles were excluded. Subsequently, attempts were made to download the full texts of the remaining 61 articles, but the full texts of 8 articles were unavailable. Finally, 20 studies^18,24–42 were included, after excluding 5 studies without data, 2 studies lacking exact treatment time, 3 studies without specific surgery type, 1 study lacking a control group, 6 studies where the Chinese version was excluded and the English version retained, and 16 studies involving other combined treatment methods. The literature screening process is outlined in Figure 1.

Figure 1 Studies selection flowchart.

Characteristics of Included Studies

Twenty studies^18,24–42 were eligible and included, involving a total of 3254 patients, with 1578 patients in the treatment group and 1676 in the control group. These studies were conducted in four countries. The surgeries under consideration included cesarean section,^{24,29,31,33,35,42} induced abortion,^18,27,34 laparoscopic surgery,^{26,28,30,32,36–41} and laparotomy.^25,28 The various interventions employed in these studies are detailed below. For the treatment group, otopoint pressure was used in ten studies,^{18,25,26,28,30,33,35,38–40} auricular acupuncture in four studies,^18,34,37,42 acupressure in three studies,^24,27,32 acupuncture in one study,³² electroacupuncture in one study,⁴¹ moxibustion in one study,²⁹ and acupoint application in two other studies.^31,36 In the control group, one study⁴¹ utilized Midazolam Injection, eight studies^{18,25,26,28,30,34,37,42} employed sham acupuncture, and fifteen studies^{24,25,27,29,31–36,38–42} described conventional treatment. Intervention times varied, including pre-operation,^18,42 the night before the operation, or 12–24 hours before the operation,^{24–26,30,32,39–41} the day after enrollment,³⁷ after baseline measurement,²⁸ 1 hour before the operation,^33,35 3–5 minutes before the operation,³⁴ and post-operation or 6 hours after the operation.^{27,29,31,36,38} Furthermore, the treatment durations also varied. For example, otopoint pressure often continued until 72–96 hours after the operation. Auricular acupuncture had different durations, such as preoperatively lasting 3–5 minutes, throughout the entire cesarean section, each time lasting 30 minutes, extending to 72–96 hours after the operation, and lasting for a course of treatment, typically 11 days. Acupressure preoperatively lasted 3–5 minutes, 2–4 hours at one night before the operation, or after the operation, and 8–10 hours after, with a 5-minute intervention each time. Electroacupuncture was administered 24 hours and 2 hours before anesthesia induction. In terms of postoperative intervention, there were seven sessions of acupressure, acupoint application replaced every 4 hours until anal exhaust, as well as moxibustion and otopoint pressure with no specific time description. The specific acupoints and procedures involved in the intervention are detailed in Table S1.

Primary outcomes, including STAI-S, VAS-anxiety, and SAS, were derived from the results of three anxiety scales. Additionally, VAS-anxiety scores for pain were reported in six studies,^{18,24,32–35} while BIS and Ramsay scores were reported in four studies.^25,28,32,41 Furthermore, depression scores, including BDC, SDS, and HAMD, were reported in four studies.^27,29,36,38 The first postoperative exhaust time was noted in five studies,^{25,26,29,31,38} and the first postoperative defecation time was mentioned in two studies^26,31 reported the first postoperative defecation time, and three studies^29,31,38 The characteristics of the included literature are detailed in Table 2.

Table 2 Characteristics of Included Literature

Risk of Bias Assessment

Figure 2 presents the summary of the risk-of-bias assessment based on Cochrane criteria. Two studies^6,43 exhibited a high risk of bias in one domain. Due to inadequate information, ten studies^{1,4,6,7,18,19,25,27,28} were assessed with some concerns in at least one domain. One study⁶ demonstrated bias in randomization, while five studies^1,4,19,25,43 described inadequate randomization. Additionally, five studies^4,6,19,27,43 were assessed with some concerns for deviations from established interventions. All the studies were evaluated as having a low risk of bias for missing outcome data. Furthermore, one study⁴³ was judged to have a high risk of bias in the outcome measurements. For the selection of reported results, ten studies^{1,4,6,7,18,19,25,27,28,43} were assessed with some concerns, while the remaining studies were considered to have a low risk of bias. Overall, two studies^6,43 were evaluated as having a high risk of bias, ten studies^{2,3,5,15–17,24,26,29,30} were assessed with a low risk of bias, and eight studies^{1,4,7,18,19,25,27,28} were assessed with some concerns. The risk-of-bias summary is depicted in Figure 2.

Figure 2 Risk of bias domain and summary for each included study.

Results

Primary Outcome Measures

STAI-S Score for Anxiety

Four research studies (involving a total of 505 participants and 6 groups of data)^24,32,40,41 w reported preoperative STAI-S scores. Before the surgery, the post-treatment STAI-S scores were compared with the baseline data to evaluate the impact of acupuncture and moxibustion on preoperative anxiety. A pooled analysis identified significant heterogeneity (I² = 97.8%), leading to the utilization of a random-effects model for analysis. The pooled results (Figure 3A) indicated that acupuncture and moxibustion appeared to have a tendency to improve preoperative anxiety (MD = −3.38, 95% CI [−9.58 to 2.82]) compared with the control group, but the difference was not statistically significant (P = 0.286).

Figure 3 STAI-S score for anxiety. (A) Pre-operation; (B) Post-operation; (C) Post-treatment to completion of operation. (D) Pre-operation; (E) Post-operation; (F) Post-treatment to completion of operation.

The impact of acupuncture and moxibustion on postoperative anxiety was assessed by comparing postoperative STAI-S scores with baseline data in three studies involving 4 groups of data^24,40,41 comprising 434 participants. Significant heterogeneity (I² = 94.4%) was revealed in the pooled analysis, leading to the use of a random-effects model for the analysis. The pooled results (Figure 3B) indicated a statistically significant beneficial effect of acupuncture and moxibustion on postoperative anxiety (MD = −3.50, 95% CI [−6.93 to −0.07]) compared with the control group (P = 0.046).

Four studies, involving 5 sets of data,^24,26,40,41 were conducted with a total of 508 participants to report the STAI-S scores during surgery. The STAI-S scores at the completion of the surgery were compared with post-treatment data to evaluate the impact of acupuncture and moxibustion on intraoperative anxiety. The pooled analysis indicated significant heterogeneity (I² = 98.0%), leading to the implementation of a random-effects model for the analysis. The overall findings (Figure 3C) demonstrated that acupuncture and moxibustion appeared to have a tendency to alleviate anxiety during surgery (MD = −1.09, 95% CI [−7.32 to 5.13]) when compared with the control group, although the difference was not found to be statistically significant (P = 0.730).

VAS-Anxiety and SAS Scores

The review included six studies with a total of 1902 participants among 8 groups of data^{24,30,33,35,41,42} reporting preoperative VAS-anxiety and SAS scores. Before the surgery, the post-acupuncture scores were compared with the baseline data to evaluate the effect of acupuncture and moxibustion on preoperative anxiety. The analysis of the pooled data showed significant heterogeneity (I² = 97.5%), thus a random-effects model was used for the analysis. The pooled results (Figure 3D) illustrated that acupuncture and moxibustion can effectively alleviate preoperative anxiety (SMD = −1.04, 95% CI [−1.73 to −0.35]) compared with the control group, and this difference was statistically significant (P = 0.003).

Six research studies (involving 9 sets of data)^{18,24,34,37,39,41} with a total of 837 participants, reported postoperative VAS-anxiety and SAS scores. Following surgery, postoperative scores were compared to baseline data to evaluate the impact of acupuncture and moxibustion on postoperative anxiety. The pooled analysis revealed significant heterogeneity (I² = 90.8%), necessitating the use of a random-effects model for analysis. The combined results (Figure 3E) indicated that acupuncture and moxibustion had a positive impact on postoperative anxiety (SMD = −0.78, 95% CI [−1.21 to −0.35]) compared to the control group, and this difference was statistically significant (P < 0.001).

Three separate research studies, each involving data from 5 groups,^24,25,41 totaling 466 participants in all, presented results on VAS-anxiety and SAS scores during surgery. The scores recorded at the end of surgery were compared with post-treatment data to evaluate the impact of acupuncture and moxibustion on anxiety levels during the operation. Analysis of the combined data revealed a marked heterogeneity (I² = 97.2%), prompting the adoption of a random-effects model for analysis. The overall findings (Figure 3F) indicated a trend towards the reduction of intraoperative anxiety with acupuncture and moxibustion intervention (SMD = −0.44, 95% CI [−1.51 to 0.64]) compared to the control group, although this difference did not achieve statistical significance (P = 0.427).

Secondary Outcome Measures

Pain Score

After surgery, the postoperative VAS-pain scores from three studies, which involved a total of 427 participants and 5 groups of data,^18,24,34 were compared with baseline to evaluate the impact of acupuncture and moxibustion on postoperative pain. The analysis used a random-effects model due to significant heterogeneity (I² = 86.1%25) identified through pooled analysis. The results from the pooled analysis (Figure S1A) indicated that acupuncture and moxibustion exhibited a preventive effect on postoperative pain (MD = −0.67, 95%25 CI [−2.23 to 0.90]) compared to the control group, although the difference was not statistically significant (P = 0.403).

Three research studies, including 4 sets of data,^32,33,35 were conducted to evaluate the impact of acupuncture and moxibustion on pain levels 6 hours after an operation. A total of 1233 participants were involved in these studies, which compared the VAS-pain scores at 6 hours post-operation with those at the time of completion. The pooled analysis unveiled substantial heterogeneity (I² = 83.8%), leading to the application of a random-effects model. The combined results (Figure S1B) demonstrated that acupuncture and moxibustion effectively alleviated pain among patients at the 6-hour mark post-operation (MD = −1.35, 95% CI [−2.08 to −0.63]) when compared to the control group, and this difference was deemed statistically significant (P < 0.001).

Sedation score

Two studies, which involved 3 groups of data,^28,41 were conducted with a total of 313 participants to report preoperative BIS. Prior to surgery, the preoperative BIS scores were compared with baseline data in order to evaluate the impact of acupuncture and moxibustion on preoperative sedation. A pooled analysis revealed a significant level of heterogeneity (I² = 97.3%), leading to the use of a random-effects model. The pooled results (Figure S2A) demonstrated that acupuncture and moxibustion are capable of improving preoperative sedation (MD = −5.46, 95% CI [−10.31 to −0.60]) when compared with the control group, and this difference was found to be statistically significant (P = 0.028).

Three research trials (involving 6 sets of data)^25,32,41 with a total of 433 participants documented BIS and Ramsay indicators. Following surgery, the postoperative scores were compared to the baseline data in order to evaluate the effects of acupuncture and moxibustion on postoperative sedation. A combined analysis indicated substantial heterogeneity (I² = 70.0%), leading to the utilization of a random-effects model. The collective findings (Figure S2B) demonstrated that acupuncture and moxibustion were able to enhance postoperative sedation (SMD = −0.38, 95% CI [−0.70 to −0.05]) in comparison to the control group, with a statistically significant difference (P = 0.023).

Depression Score

Four studies, encompassing 4 sets of data,^27,29,36,38 were conducted involving a total of 449 participants. These studies reported measures of BDC, SDS, and HAMD. The evaluation following the operation aimed to assess the impact of acupuncture and moxibustion on postoperative depression by comparing post-treatment and pre-treatment data. The analysis of combined results revealed substantial heterogeneity (I² = 87.7%), leading to the adoption of a random-effects model for the analysis. It was indicated by the pooled results (Figure S3) that acupuncture and moxibustion exhibited a positive impact on postoperative depression (SMD = −1.20, 95% CI [−1.84 to −0.56]) in comparison with the control group, with this difference proving to be statistically significant (P < 0.001).

The First Postoperative Exhaust Time

The first exhaust time post-operation was reported in a total of 406 participants across five studies, involving 6 groups of data.^{25,26,29,31,38} Significantly high heterogeneity (I² = 83.8%) was observed in the pooled analysis, leading to the utilization of a random-effects model. The combined results (Figure S4) illustrated that acupuncture and moxibustion could effectively enhance the first postoperative exhaust time (MD = −8.08, 95% CI [−10.94 to −5.21]) in comparison to the control group, with a statistically significant difference (P < 0.001).

The First Postoperative Defecation Time

In two studies involving 2 groups of data,^26,31 a total of 174 participants reported the first postoperative defecation time. A pooled analysis revealed that the heterogeneity was not significant (I² = 0.0%), leading to the usage of a fixed-effects model for analysis. The pooled results (Figure S5) indicated that acupuncture and moxibustion had a beneficial effect on the first postoperative defecation time (MD = −11.80, 95% CI [−13.00 to −10.59]) compared with the control group, and the difference was statistically significant (P < 0.001).

Postoperative Bowel Sound Recovery Time

Three studies (involving 3 groups of data)^29,31,38 involving 240 participants, showcased the postoperative recovery time for bowel sounds. A combined analysis found considerable heterogeneity (I² = 95.0%), leading to the utilization of a random-effects model for the assessment. The consolidated findings (Figure S6) indicated that acupuncture and moxibustion resulted in a reduction of the postoperative recovery time for bowel sounds (MD = −6.13, 95% CI [−9.86 to −2.40]) compared to the control group, with a statistically significant difference (P = 0.001).

Subgroup Analysis

Due to substantial heterogeneity, we performed a subgroup analysis for each outcome. The outcomes are presented in Table 3, and the forest plot is displayed in Figure S7. Subgroup analyses for preoperative, postoperative, and intraoperative anxiety (STAI-S) were conducted based on the type of acupuncture and moxibustion, the type of surgery, and the control interventions. The analysis revealed that electroacupuncture, the conventional treatment used in the control group intervention, and laparoscopic surgery could potentially contribute to the heterogeneity. For preoperative, postoperative, and intraoperative anxiety (VAS-anxiety and SAS), subgroup analyses were conducted based on the type of acupuncture, the type of surgery, and the control interventions. The findings suggested that otopoint pressure, electroacupuncture, and auricular acupuncture, the conventional treatment and sham used in the control group, cesarean section, laparoscopic surgery, and induced abortion could be potential sources of heterogeneity.

Table 3 Subgroup Analysis

Preoperatively, auricular acupuncture, otopoint pressure, and cesarean section exhibited significant effects on VAS-anxiety and SAS (P < 0.05). Postoperatively, auricular acupuncture, induced abortion, and laparoscopic surgery showed significant impact on VAS-anxiety and SAS (P < 0.05). Additionally, during the intraoperative period, otopoint pressure and laparotomy demonstrated significant effects on VAS-anxiety and SAS (P < 0.05).

Sensitivity Analysis

The study conducted sensitivity analyses for STAI-S (pre-operation, post-operation, and during the operation), VAS-anxiety, and SAS (pre-operation, post-operation, and during the operation), as well as VAS-pain (post-operation, completion of surgery to 6 hours after the operation), sedation (post-operation), depression, and the first postoperative exhaust time. The findings demonstrated the robustness of the meta-analysis results (Figure S8).

Publication Bias

Funnel plots were utilized to visually identify publication bias for STAI-S (pre-operation, post-operation, and during the operation), VAS-anxiety and SAS (pre-operation, post-operation, and during the operation), pain (post-operation), sedation (post-operation), and the first postoperative exhaust time (Figure S9). Quantitative analysis was performed using Begg and Egger tests. The findings revealed no publication bias, except for postoperative VAS-anxiety and SAS (Table S2). Consequently, the trim and fill method was implemented to address the bias in VAS-anxiety and SAS. Two additional articles were incorporated, and the results indicated (SMD = −1.004, 95% CI [−1.480 to −0.529]), suggesting the potential presence of publication bias but with minimal impact.

Discussion

This study conducted a meta-analysis of 20 articles to examine the efficacy of acupuncture and moxibustion techniques in alleviating anxiety, pain, sedation, depression, and associated clinical symptoms in the perioperative period of gynecological surgeries. The findings demonstrated significant improvements in postoperative STAI-S anxiety, preoperative and postoperative VAS-anxiety and SAS, VAS-pain (from completion of surgery to 6 hours after the operation), preoperative and postoperative BIS and Ramesay sedation, as well as BDC, SDS, and HAMD for depression due to acupuncture and moxibustion interventions. Moreover, there was a notable impact on enhancing the time to first postoperative exhaustion, first postoperative defecation, and the recovery time of postoperative bowel sounds. While there was a tendency towards improvement in outcome measures such as postoperative and intraoperative STAI-S anxiety, intraoperative VAS-anxiety, SAS, and postoperative VAS-pain, the differences were not statistically significant.

A previous meta-analysis has suggested that acupuncture and moxibustion treatments can effectively reduce preoperative anxiety in patients undergoing various surgeries, as indicated by reductions in STAI-S and VAS-anxiety scores.⁴⁴ However, the analysis covered a broad spectrum of surgeries, including neurosurgery, lithotripsy, gynecology, coronary angiography, orthopedics, breast cancer, laparoscopy, and cesarean section. The interventions were consistently administered prior to surgery. In contrast, our meta-analysis focuses specifically on patients undergoing gynecological surgery. Within the selected studies, participants underwent laparoscopic surgery in 10 studies (including one study involving both laparotomy and laparoscopic surgery), cesarean section in 6 studies, abortion in 3 studies, and laparotomy in 2 studies (including one study involving both laparotomy and laparoscopic surgery). Notably, among the studies demonstrating the most pronounced positive effects of acupuncture and moxibustion on perioperative anxiety, patients undergoing laparoscopic surgery and cesarean section were most representative. For example, Shu-Yu Kuo et al⁴⁵ revealed that, compared to conventional nursing care, applying pressure to the Shenmen auricular point could reduce cortisol levels, heart rate, anxiety, and fatigue in the early postpartum period following cesarean section. Similarly, Gul et al⁴⁶ conducted a double-blind RCT and found that applying finger pressure to the Shenmen point for 10 minutes could alleviate preoperative acute anxiety in pregnant women undergoing cesarean section with spinal anesthesia. However, further investigation is necessary to confirm whether patients undergoing cesarean section or laparoscopic surgery derive more significant benefits from acupuncture and moxibustion treatment. Additionally, significant heterogeneity was observed in all outcome indicators, except for the first postoperative defecation time.

Due to the clinical heterogeneity, we proceeded with additional subgroup analyses focusing on acupuncture methods, types of surgery, and other relevant factors. The assessment of anxiety outcomes primarily included otopoint pressure, auricular acupuncture, acupuncture, electroacupuncture, and acupressure. While the statistical analysis revealed no significant impact of acupuncture and electroacupuncture on alleviating perioperative anxiety in patients, it was noted that patients receiving acupuncture or acupressure demonstrated a less pronounced increase in anxiety from admission to anesthesia induction compared to the control group.³² As the surgery date approaches, patients typically experience heightened anxiety, indicating a potential correlation with the timing of measurements. In contrast to the standard treatment group, patients undergoing laparoscopic surgery in the electroacupuncture and drug groups exhibited a noteworthy decrease in preoperative and postoperative anxiety levels. In our investigation, the control group comprised the drug group and conventional treatment. Electroacupuncture showed similar effectiveness to drugs, particularly Midazolam, a traditional anti-anxiety medication, without a statistically significant variance. Nonetheless, a statistical disparity was observed between electroacupuncture and conventional treatment.⁴¹

Although anxiety may not have been the primary focus in some of the studies included, particularly those examining postoperative functional recovery and pain, it’s important to recognize that all measures, including pain, sedation, and functional recovery, could impact patients’ emotional well-being. As a result, we investigated pain, sedation, and other relevant measures. Pain was predominantly addressed in a randomized, double-blind, three-arm trial, which illustrated that auricular acupuncture intervention did not reduce the pain score in females undergoing vacuum aspiration compared to the placebo group.¹⁸ Similarly, electroacupuncture did not exhibit a statistically significant effect on sedation. Additionally, electroacupuncture demonstrated efficacy on par with Midazolam in alleviating anxiety, consistent with previous findings.⁴¹ In terms of depression measures, while acupressure did not display statistical significance, it was observed that applying finger pressure at acupoints could alleviate postoperative depressive symptoms in patients undergoing induced abortion.²⁷ This effect may be attributed to the data collected before the operation and 7 days after the operation in our analysis. Furthermore, our analysis uncovered that acupuncture and moxibustion treatments, including otopoint pressure, acupoint application, and moxibustion, markedly improved the first postoperative exhaust time, first postoperative defecation time, and postoperative bowel sound recovery time, thus facilitating overall body function recovery.

Furthermore, this research has identified a range of acupoints involved in auricular acupressure, notably including Shenmen, subcortex, sympathia, endocrine, brain points, internal genitals, pelvis, uterus, ovary, heart, lung, spleen, liver, kidney, stomach, intestine, San Jiao (commonly known as “Triple Burner”), nerve fading point, and the “relaxation point” (located on the upper side wall of the triangular fossa). Essential points for auricular acupuncture encompass Cingulate gyrus, Thalamus, Point Zero, Shenmen, Cervix (left ear), Uterus (right ear), MA-TF-1 (apex of the triangular fossa), MALO1 (central side of the ear lobe), MA-TG2-TG4 (along the entire length of the vertically ascending tragus) (right ear), Heart, Kidney, Sympathetic, and Subcortex. Acupressure mainly entails Neiguan, Shenmen, Yintang, Taiyang, Sanyinjiao, Xingjian, and Taichong points. Acupuncture centers on CV17 (on the middle body line), bilateral LI4, HT7, LR3, ST36, PC6, and GV26. Electroacupuncture focuses on Baihui and Sishencong points. Moxibustion targets Shenque, Zusanli, and Neiguan. Applications of acupoints include Tian Shu, Zusanli, and Sanyinjiao. It is important to note that the selection of acupoints varies and cannot be entirely standardized, which may contribute to potential heterogeneity in the outcomes.

It is important to note that the timing of acupuncture and moxibustion interventions varied, with initiation ranging from 1 day before the operation, the night before the operation, 1 hour before the operation, to 3–5 minutes before the operation. Similarly, the varied durations of acupuncture and moxibustion interventions were primarily due to the different types of gynecological diseases or intervention methods employed. Our findings emphasized that when comparing post-treatment data before the operation with baseline data, key outcome measures included anxiety indicators such as STAI-S, VAS-anxiety, and SAS. Among patients receiving acupressure, acupuncture, electroacupuncture, or otopoint pressure from the night before the operation to 12–24 hours before the operation, especially those undergoing laparoscopic surgery and cesarean section, while there was no statistically significant difference in the STAI-S scores compared with the control group, the results indicated a significant effect of auricular point therapy combined with the “He” character on perioperative stress response in patients undergoing hysterectomy. Research has focused more on the impact of auricular point therapy combined with the “He” character on perioperative anxiety in gynecological surgery.⁴⁰ In addition, the study observed that VAS-anxiety and SAS scores predominantly originated from patients undergoing cesarean section and laparoscopic surgery. These patients received at least one of the following treatments: acupressure, otopoint pressure, or electroacupuncture, either from the night before or 24 hours prior to the operation, or otopoint pressure starting 1 hour before the operation in the case of cesarean section. These findings highlighted the variability in the initiation time of acupuncture and moxibustion interventions with respect to different types of gynecological diseases. Specifically, for cesarean section, a distinct gynecological surgery type, the initiation time for acupuncture and moxibustion intervention can be reduced to 3–5 minutes before the operation, which also alleviates anxiety. Our findings revealed that acupressure in cesarean section, otopoint pressure, and auricular acupuncture in induced abortion, along with electropuncture, auricular acupuncture, and otopoint pressure in laparoscopic surgery, improved postoperative STAI-S, VAS-anxiety, and SAS scores for anxiety compared to the baseline data, in the context of sufficiently early initiation time of interventions, long enough intervention durations, and adequate treatment durations. This suggests an effective impact of acupuncture and moxibustion on improving perioperative anxiety in gynecological surgery compared with the control group. Furthermore, acupuncture and moxibustion treatment methods tended to improve intraoperative STAI-S, VAS-anxiety, and SAS compared with the control group. However, the differences were not statistically significant, which also reflected the effectiveness of acupuncture and moxibustion treatment. Nevertheless, extensive in-depth research is required to explore the preferred start time, the optimal frequency, the effective dose, and the effective combination of acupuncture techniques with the types of gynecological surgeries, due to the limitations of this study.

To the best of our understanding, there is currently no comprehensive review or meta-analysis of randomized controlled trials examining the effectiveness of acupuncture and moxibustion in reducing perioperative anxiety in gynecological surgery. This study marks the initial effort to synthesize relevant literature and perform a meta-analysis to assess the potential therapeutic advantages of acupuncture and moxibustion for perioperative anxiety in gynecological surgery. We employed well-established assessment tools, specifically STAI-S and VAS-anxiety, to evaluate anxiety and enhance the dependability of our findings. Nevertheless, it is important to acknowledge several limitations. Firstly, there was evident clinical heterogeneity, potentially resulting from diverse intervention methods and types of surgeries. Due to limited original data, the heterogeneity stemming from clinical discrepancies was not comprehensively analyzed. Secondly, the inherent limitation of acupuncture and moxibustion therapy, which makes complete blinding unfeasible, may introduce bias into the research quality. While our assessment and analysis may have been biased, it is important to consider the potential for publication bias. Selecting studies published only in Chinese and English could introduce a degree of selection bias. We look forward to future research that can facilitate a more comprehensive discussion and analysis. Significant variations in treatment methods and selected acupuncture points exist across the studies included. Currently, there is no consensus on the superior acupuncture technique or point. Future research necessitates larger sample sizes and strict designs to substantiate the effectiveness and safety of acupuncture and moxibustion during the perioperative period of gynecological surgery. Furthermore, there is a need for additional research on acupuncture points and methods. The long-term efficacy and safety of acupuncture were not further analyzed in our current study due to the limited number of literature and lack of relevant reports. This emphasizes the necessity for future research to focus on these aspects, with the hope that more studies will explore long-term efficacy and safety, enhancing our understanding of acupuncture during the perioperative period in gynecological surgeries.

Conclusion

This meta-analysis included 20 studies for the first time to evaluate perioperative anxiety and pain in gynecological surgery. Acupuncture and moxibustion were found to reduce postoperative STAI-S, preoperative and postoperative VAS-anxiety and SAS, postoperative VAS-pain at 6 hours after operation, preoperative and postoperative BIS and Ramesay sedation, and BDC, SDS, and HAMD for depression, compared with conventional or sham treatment. Additionally, they significantly improved the first postoperative exhaust time, the first postoperative defecation time, and postoperative bowel sound recovery time. However, although there was a trend of improvement in preoperative and intraoperative STAI-S, intraoperative VAS-anxiety, SAS, and postoperative VAS-pain, the differences were not statistically significant. Due to significant heterogeneity in the included studies, further multicenter, large-sample, high-quality RCTs are required to consolidate the safety and efficacy of acupuncture and moxibustion therapy.