Conditions: Polycystic Ovarian Syndrome
Keywords: acupuncture LH/FSH total testosterone (TT) polycystic ovarian syndrome(PCOS)
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 60
Healthy volunteers: no

Brief summary:
This study evaluates the efficacy and safety in improving ovarian function of polycystic ovarian syndrome in adults. Half of patients will receive Tung's acupuncture therapy, while the other half will receive Diane-35(CPA/EE) as the control group.

Detailed description:
Both Tung's acupuncture therapy and Diane-35(CPA/EE) could improve the symptom of patients with polycystic ovarian syndrome, but until now there is no definite evidence to indicate acupuncture could play the same role in improving ovarian function. So we design this study to observe the change of follicular development, ovary size and sex hormone( testosterone, follitropin, luteinizing hormone) before and after the treatment, and evaluate the efficacy and safty of acupuncture.

Arms:
arm 1: The Tung's acupuncture group received acupuncture treatments twice per week for 12 weeks. The study took Tung's acupoints as main acupuncture points, which were Fuke, Huanchao, Tianhuang, Renhuang, as well as the traditional acupoints Guanyuan (CV4) and Zigong (EX-CA1). arm 2: Cyproterone acetate/ethinylestradiol (CPA/EE) was taken orally one tablet per day from the 8th day of menstrual cycle or any day for patients with amenorrhea. The pills were administered for 21 days consecutively. The patients then stopped taking the pills for seven days and, on the eighth day, continued to take the pills again for three menstrual cycles (28 day cycles).

Interventions: intervention 1: Tung's acupuncture intervention 2: Cyproterone acetate/ethinylestradiol (CPA/EE)
Intervention descriptions: intervention 1: The study took Tung's acupoints as main acupuncture points, which were Fuke, Huanchao, Tianhuang, Renhuang, as well as the traditional acupoints Guanyuan (CV4) and Zigong (EX-CA1). intervention 2: Cyproterone acetate/ethinylestradiol (CPA/EE) contains 2mg cyproterone acetate (an anti-androgenic progestin) and 0.035mg ethinylestradiol (CPA/EE). The pills were administered for 21 days consecutively. The patients then stopped taking the pills for seven days and, on the eighth day, continued to take the pills again for three menstrual cycles (28 day cycles).

Protocol document:
Prot_SAP_000.pdf: 
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The Efficacy of Tung's Acupuncture for Sex Hormones in 
Polycystic Ovary Syndrome: A Randomized Controlled Trial 
Study Protocol and Statistical Analysis Plan 
 
 
 
 
 
 
Trial registration number：NTC02729545 
Document Date:  28/3/2018  
 
 


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Study Protocol and Statistical Analysis Plan 
Study design 
The study was a randomized, drug-controlled, parallel group trial to determine the efficacy 
and safety of Tung’s acupuncture for sex hormones compared with the oral contraceptive 
(CPA/EE) in patients with PCOS. The trial was performed at the Acupuncture and Gynecology 
Department of Beijing Hospital of Integrated Traditional Chinese and Western Medicine. 
Participants were recruited through advertisements on local newspapers and posters and signed 
informed consent before study participation. The study lasted 28 weeks: a 1-4weeks baseline 
period, 12-week treatment period, and a 12-week follow-up period. 
 
Participants 
PCOS was diagnosed according to the Rotterdam criteria1: ultrasound-verified polycystic 
ovaries (≥12 follicles of 2–9 mm and/or ovarian volume ≥10 ml in one or both ovaries), 
oligo/amenorrhea, or clinical signs of hyperandrogenism (hirsutism or acne). Participants were 
considered eligible upon meeting the following conditions: 1) 18-45 years old; 2) met the 
diagnostic criteria for polycystic ovary syndrome, and no reproductive requirement in the six 
months; 3) volunteered to join this research and give informed consent prior to receiving 
treatment. 
The exclusion criteria included: 1) hypertensive patients with blood pressure exceed 160/100 
mmHg; 2) patients with a history of thrombosis, cerebrovascular disease, cancer, liver disease or liver 
dysfunction, hyperlipidemia, mental disorder and severe infection; 3) had taken any 
pharmacological treatments affecting reproductive endocrine system, or received acupuncture in 
the previous 3 months; 4) smoked more than 15 cigarettes a day; 5) patients with pacemakers, 
metal allergies or severe fear of acupuncture.  
 
Randomization and blinding  
Eligible participants were randomly allocated into either acupuncture group or CPA/EE group 
in a ratio of 1:1 by a computer-generated, randomly location sequence (random list generated with 
SPSS 13.0). The random number and group assigned were sealed in the envelope. Randomization 
was performed by an independent administrator who had no other role in this study. All other 
individuals involved in the study including patients, practitioners, and outcome assessors were 
blinded to the randomization procedure. In this study, physicians could not be blinded due to the 
nature of the intervention. The acupuncturists had to know the group assignment because of 
manipulation. Data collection was performed by 2 blinded evaluators. Data entry and analysis was 
undertaken blind to the study group. Apart from the differences in treatment methods between the 
two groups, all subjects were treated as equally as possible. 
 
Treatment protocol 
Acupuncture group: the acupuncture group received acupuncture treatments twice per week 
for 12 weeks with a total of 24 times. Huatuo brand needles (size 0.20mm×25mm , 
0.20mm×40mm,manufactured by Suzhou Medical Appliance, Suzhou, Jiangsu Province, China) 
together with SDZ-V Electro-Acu Stimulators (Suzhou Medical Appliance, Suzhou, Jiangsu 


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Province, China) were used. The study took Tung's acupoints as main acupuncture points, which 
were Fuke, Huanchao, Tianhuang, Renhuang, as well as the traditional acupoints Guanyuan (CV4) 
and Zigong (EX-CA1). The location of these acupuncture points referred to Tung's Acupuncture12. 
Fuke point (Fig 1) is on the ulnar side of the proximal joint of thumb. There are two points up and 
down, 1/3 of the distance away from the interphalangeal joint. Huanchao point is on the middle of 
the central joint, on the ulnar side of ring finger. Tianhuang point is at the same location of Yin 
Lingquan (SP9), on the medial side of the shank, on the lower border of the medial condyle of the 
tibia. Renhuang point is at the same location of San Yinjiao (SP6), on the medial side of the shank, 
3 cun directly above the tip of the medial malleolous, on the posterior border of the medial aspect 
of the tibia. The specific manipulation was as follows: Fuke were inserted vertically closed to the 
bone (depth,7.5mm) with 0.20 mm×25mm  needles, Huanchao was inserted vertically closed to the 
bone (depth,5-7.5mm) with 0.20 mm×25mm  needle, the bilateral two points alternately used (left 
Fuke with right Huanchao, right Fuke with left Huanchao). Bilateral Tianhuangs, Renhuangs were 
inserted vertically with a depth of 20-30mm, and stimulated manually by rotating the needle to 
evoke de qi (deﬁned as numbness, heaviness, pressure, soreness, or tingling). The insertion of 
CV4 and EX-CA1 was straight to the abdominal muscle until the needle sensation was achieved. 
Bilateral EX-CA1s were connected to an electrical stimulator with a continuous wave of 20Hz, 
and slowly increased the current intensity to a slight tremor in the abdomen. At the same time a 
moxa box was administered via smokeless moxa stick on the lower abdomen for 30minutes. 
CPA/EE group: CPA/EE (Diane-35, Bayer Healthcare Co. Ltd) was taken orally from the 8th 
day of menstrual cycle or any day for patients with amenorrhea, one tablet per day, and the pill was 
administered for 21 days consecutively. The patients then stopped taking the pill for seven days 
and on the eighth day, the patients began the pill again for three menstrual cycles (28 day cycles). 
Patients were asked to visit the doctor every menstrual cycle, in order to receive the medicine of 
next cycle and communicate with the doctor about their physical condition, or the patients were 
required to visit the doctors if they feel any discomfort. 
 
Outcome measurements 
The change in LH/FSH ratio from baseline at end of treatment was considered as the primary 
outcome in this study, and secondary outcomes include the changes in BMI, FSH, LH, TT, 
ovarian volume, polycystic ovary number and menstrual frequency at week 12 and 24 from 
baseline. The blood samples were measured at the 2-3rd Day of menstrual cycle during the 
baseline period, after the last treatment and 12-week follow-up period. If no ovulation or bleeding 
had occurred during the period, the measurements were taken one week after the end of treatment 
and 12-week follow-up period. The sex hormones were analyzed by chemiluminescent 
microparticle immunoassay at the medical laboratory of Beijing Hospital of Integrated Traditional 
Chinese and Western Medicine.  
The polycystic ovary number and volume were measured by ultrasound, which were together 
with BMI and menstrual frequency taken 3-7th days after menstruation during the baseline period, 
after the last treatment and 12-week follow-up period. The polycystic ovary number was defined 
as the number of ovaries with cysts/follicles (>12 cysts), the ovarian volume was measured in 
three dimensions by an experienced sonographer who was blinded to the group.  
Safety evaluation included acupuncture related adversary events such as hematoma, fainting, 
severe pain, post-treatment soreness and local infection during and after acupuncture, as well as 


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CPA/EE related adversary events like vomiting, nausea, headache and skin reactions during taking 
pills. 
 
Sample size 
This trial was a difference test design, the primary outcome measure was the change of the 
ratio of LH/FSH from baseline at the end of treatment. Based on the results of our pilot study2 and 
previous studies3,4, we anticipated a mean difference in the ratio of LH/FSH was 1.2 (SD, 0.8) in 
CPA/EE group, and 1.68 (SD, 0.2) in Tung’s acupuncture group. Sample size was determined 
with a 0.05-probability of a type I error and 80% power，2 sided test with a 20% attrition rate. 30 
patients will be needed for each group, which implied a total sample size of 60 participants for the 
entire trial.  
 
Statistical analysis 
Statistical analysis performed using SPSS 13.0 statistics software (SPSS Inc, Chicago, IL, 
USA) and the statistician was blinded from group allocation. The Kolmogorov-Smirnov test was 
used to test the normal distribution of continuous variables. Continuous variables were presented 
by mean (standard deviation) if they were normally distributed or by median with interquartile 
range if they are not normally distributed. The modified intention-to-treat (ITT) approach was 
used to analyze the study group, all subjects with at least having one treatment data in randomized 
groups were included. A paired samples t test or Wilcoxon Matched-Pairs SignedRanks test was 
examined to compare the differences between the quantitative indices before and after treatment in 
one group, while an independent sample t test or Mann-Whiney U test was used for comparison 
between groups. The entire statistical test used bilateral examination and estimation of the median 
with 95% CI was calculated.  
 
 
References 
 
1. Rotterdam T, group EAs Pcw. Revised 2003 consensus on diagnostic criteria and long-term health risks related 
to polycystic ovary syndrome (PCOS). Hum Reprod. 2004; 19: 41–47. 
2. Cao Y, ZhangL, ZhaoD, Liu Z. DONG's extraordinary acupoints for the ovarian function of polycystic ovary 
syndrome: a randomized controlled pilot trial. Zhongguo Zhen Jiu. 2017; 7: 710-714. 
3. Yan-Hua Zheng, MM, Xin-Hua Wang. Effectiveness of Abdominal Acupuncture for Patients with Obesity-Type 
Polycystic Ovary Syndrome: A Randomized Controlled Trial. J Alternative Compl Med. 2013; 9: 740–745. 
4. Wu Hongqin, Ruan Xiangyan,et al. Efficacy of Diane 35 vs Diane 35 plus metformin on polycystic ovarian 
syndrome women under comprehensive management. Journal of Capital Medical University. 2014; 4:401-413.