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Benefits of Acupuncture in PCOS with Dr Carolyn Ee

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Benefits of Acupuncture in PCOS with Dr Carolyn Ee

Are you referring your patients with polycystic ovary syndrome to an Acupuncturist?

Being pigeonholed typically as an intervention we think of for chronic pain, acupuncture can often be overlooked as a therapeutic option in complex metabolic disease.

Today we are joined by Dr Carolyn Ee, a GP with dual qualifications in Chinese medicine and a passion for research. Ahead of her forthcoming speaking engagement at the ATMS PCOS Symposium in Sydney, September 2018, Dr Ee joins us to help us understand the mechanisms by which acupuncture plays a role in PCOS and other metabolic diseases.

This is a taste of Dr Ee's research and expertise on this topic and we are sure after listening you'll be referring your patients with metabolic conditions to your local acupuncturist for co-management.  

Covered in this episode

[00:33] Introducing Dr Carolyn Ee
[01:25] PCOS terminology changes?
[02:08] From a GP to Chinese medicine
[05:38] The fascinating history of acupuncture
[08:56] Medical acupuncture in Australia
[10:55] Balancing the sympathetic and parasympathetic nervous systems
[15:03] Designing acupuncture research
[25:37] Centre of Research Excellence: Guidelines for PCOS
[27:56] What role can acupuncture play?
[32:28] Future areas of research for acupuncture?
[34:24] The regulation of acupuncture and Chinese medicine in Australia
[40:19] Catch Dr Carolyn Ee at the ATMS PCOS Symposium

Special Thanks to:

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Doctor Carolyn Ee. Who's a GP and research fellow at the National Institute of Complementary Medicine, that's NICM, in Western Sydney University and was one of the first practicing medical doctors in Australia to gain dual qualifications in Chinese medicine. 

Doctor Ee specialises in clinical trials on acupuncture in women's health and is the current chair of the Royal Australian College of General Practitioners, that's the RACGP, Integrative Medicine Specific Interest Group. She also leads the Jacka Foundation Integrative Medicine Program at NICM which focuses on clinical service delivery, education and translational research in integrative medicine. 

Welcome warmly to FX Medicine, Carolyn Ee. How are you? 
Carolyn: Hi. Very good. Thanks. 
Andrew: Now, Carolyn, we're going to be talking today about the relevance of acupuncture for polycystic ovarian syndrome. So there's all these acronyms flying around the place, PCOS. Can I just ask first off, PCOS, PCOD, is there one that's more appropriate now? 
Carolyn: That's actually really good question. It's PCOS at the moment, which is polycystic ovary syndrome. But I know that there's been some discussions around changing the terminology. But for the moment it is a syndrome and it refers to, I guess...a syndrome is a, you know, collection of signs and symptoms that's not seen as a, I guess, a disorder so much. 
Andrew: And of course, we have to go back to your beginnings because you are dually qualified. What made you undertake medicine in the first place and then drew you to Chinese medicine and acupuncture? 
Carolyn: Yeah, look, I wanted to be a doctor from the time I was quite little. I wanted to help people basically. And I really enjoy the...I guess the clinical interaction with patients. But I think...you know, when I was a junior doctor, it was quite an eye-opener, you know, all my time was spent in hospitals with really sick people and often they didn't seem to be getting better. And a lot of people came in because of iatrogenic side effects, so, side effects from taking pharmaceuticals. And I was just...I just wondered if there was, you know, other ways to help my patients get better, if there was a way to help them achieve better health and wellbeing. And I was really interested in the philosophy of Chinese medicine and it's fascinating because it's tied into, you know, the religions, Buddhism and Taoism. It's tied into martial arts, so there's a sort of this under-pinning philosophy that I found really interesting and that was, you know, diametrically opposite to, I guess, biomedicine. 
And so I decided as a very young junior doctor after doing three years in a hospital system that I needed to really pursue that and go into it on a very deeper level. I didn't want to just do a couple of weekend courses. That wasn't going to satisfy me at that point. 

So I decided to do another undergraduate degree at RMIT and I think it was the best decision I ever made. That was the bachelor of applied science in Chinese medicine and did that in three years. So I got exemptions for some of the other subjects. Went to China for seven months, did all that, learned about Chinese herbs and graduated. And then started to go about thinking about how I'm going to combine the two medical degrees. 
Andrew: I could imagine that you would've copped some flak from your peers, from your cohort in medicine going, "Oh, she's one of those." Sort of thing. 
Carolyn: Yeah. Look, it was interesting. I think early on people were a lot more open to things. I think there’s a lot more skepticism now, to be honest. 

But, you know, people were, you know, fairly welcoming of that. They were, you know...they saw that I was pursuing something I was passionate in. Interestingly, one colleague of mine who is from China, a doctor colleague told me that I was making a terrible decision! He was probably the only one who said that. 
Andrew: Yeah. 
Carolyn: But I didn’t get it at all. It's really changed my outlook on health and how we view health. And of course, I've, you know, come back to biomedicine. I'm a practicing GP now. I consider myself a doctor first and foremost. And these are all the additional tools in my toolbox. 
Andrew: Yeah. I think it's funny when people sort of pooh-pooh something without knowing about it. As you mentioned, you know, you take it back to martial arts and Tai Chi and things like that. Well, anybody open to mindfulness or... 
Carolyn: Yeah, yeah. That experiential stuff, you know, can really change the way that a doctor or any health professional who looks at the human body and how it works I think. 
Andrew: What about the history of acupuncture itself? When you were taught acupuncture, surely you had to delve back into the history but what...how did it make its way into modern medicine particularly in Australia I guess? 
Carolyn: Yes, yeah. Look, I think I would say that one thing that got me into research was that we were taught a lot about the history of Chinese medicine and the history of acupuncture and heard from so on. 

But no one really told me how it all worked and I was...as you say, I was searching for, you know, how does it work? And what’s the mechanism? And when I was just told well, there’s 2,000 years of history and that's enough, you know. All that, you know, 2,000 years' worth of anecdotes.  
So I thought, "Well, I really want to know and use my scientific mind to find out." But if we go back to the history of acupuncture and it’s use. I think originally, people think that it might've originated from thousands of years ago, that if someone was injured like, you know, with sort of lacerating injury, that they had some kind of painkilling effect. And if, you know, if soldiers were at battle and they were pierced by something, they seemed to have these contradictory analgesic effects.  
And so found I think, acupuncture needles that were made of bone, that were obviously quite big and probably quite invasive thousands of years ago. And then over time they evolved into...I think they've used various types of metal and of course, now we've got thereally modern acupunture needles that are all very thin and produced, you know, according to those strict manufacturing conditions. You know all sterile and one use only and so on. And they even have the guide tube so it's all...you know, so it protects the shaft of the needle from, you know, handling, with hands. 
Andrew: Oh, of course, for CCSD. 

Carolyn: Yeah, exactly. And then in the west, it became very popular probably after the '70s where there was a lot of interest after Nixon went to China on a tour and one of his staff I think reportedly had appendicitis and had the appendix removed under the anesthesia that was augmented with acupuncture. And that was a really...you know, that was obviously that sort of life-changing, "Wow. I've experienced it," event. 

And it became much more popular in the west after that after some seminal research by J. S. Han where he did...I think it was on a rabbit. And he gave acupuncture to one group of rabbits and then he took out the cerebrospinal fluid. So the fluid that sort of bathes the spinal cord. And then he injected that into the cerebrospinal fluid of other rabbits. And then found that it had this analgesic effect so he deduced that it was something in the CFS. And we found it was endorphins but what was responsible was the pain killing effects. 

So I think establishing that the physiological mechanism of acupuncture has really led to, I guess, its popularity in the west. So I'm a medical acupuncturist as well so I...after training in Chinese medicine, I did the Grad cert in the medical acupuncture in Monash. So I can give acupuncture to my patients and they get Medicare rebates for it. So that's...I guess that's a... the embracing of this modality amongst medical doctors and there’s, you know, medical acupuncture journals and you know, societies and so on. 
Andrew: So is the medical use of acupuncture, is that restricted to the useful pain? 
Carolyn: It certainly is now in the guidelines for...as a baseline treatment for low back pain. So for example, I think it was quite recently, a year or two ago, it was the American College of Physcians releasing their guidelines on management of acute and chronic low back pain. And acupuncture's in there as, you know, one of the baseline treatments. So obviously try that before you ever go to, you know, more dangerous things like...or dangerous things like opioids I should say so... 
Andrew: Yeah. 
Carolyn: So, you know, the fact that it's made its way into the guidelines, yes, it clearly indicates that there is a recognition that it's effective for pain. But what I'm really interested in which brings it to the polycystic ovary syndrome that I'm researching at the moment. Is its effect on the sympathetic nervous system. So the fight or flight response. And it's really interesting data coming out, that's very early, but I think, you know, potentially really powerful at these…. You know, not just on the opioids which is reasonably well-established. But on things like your adrenaline levels and the balance between the sympathetic and parasympathetic. 
Andrew: So we're talking about Vagus nerve stimulation here? 
Carolyn: Yes, we are. Yep. Absolutely. And we’re also talking about reduction of the other side, so the sympathetic nervous system. 
Andrew: The sympathetic. 
Carolyn: And that seems to...yeah. So increasing the parasympathetic and decreasing the sympathetic. 

And that brings it...that's got an impact on things like insulin resistance. And so that's got a lot of different ramifications for our link up with chronic disease. 
Andrew: Now this is really interesting because I was speaking...I've spoken a couple of times to Emrys Goldsworthy about this. He uses various ways of innervating the Vagus nerve by, you know, gargling, singing, and I think there's an inner part of the oracle of the ear. 
Carolyn: There’s a few things, yeah. 
Andrew: Yes. But is that where you administer the acupuncture or do you administer the acupuncture to other sites where you're accessing the Vagus nerve? 
Carolyn: So the Vagus nerve can be accessed through the ear. So we are using ear acupuncture in one of our trials. And we're actually trialing a new device that's FDA cleared but is not currently available in Australia. That will provide what we call protracted acupuncture to the ear. So it's actually pitched as sort of newer modulation and it's really taking on, you know, the roots of acupuncture and applying a very modern take to it. 

And what I'm really excited about is that...are these...there were a couple of trials published in the Australian Family Physcian actually, many years ago. But they...this study looked at the effect of ear acupuncture on appetite and recorded that needling the ear and stimulating the points in the ear seemed to reduce appetite. And so what we're trying to see is, is this one of the potential mechanisms as well as the effect on the sympathetic nervous system that can help women with PCOS manage their weight. 

Because if they manage their weight which is quite difficult for them to get on top of, then it can really significantly change all of the other aspects of their condition. So it can improve their fertility, it reduces risk of diabetes and so on. And it changes from the physical signs as well, so they have less acne and less excessive facial hair. 
Andrew: This is quite stunning if this is going to have a clinical effect. Because you're accessing a vagus nerve and you're dampening a multitude of biochemical processes or aberrant biochemistry by accessing one pathway. This is huge. 
Carolyn: Yeah. I think so. And we...I was a bit skeptical about the effects of acupuncture on metabolic disorders and overweight obesity. I thought, "Well, how can you lose weight if you lie down on the couch for half an hour, you know, once a week and have some needles put in?" Then I thought, "No, that's rubbish. You have, you know, eat well and exercise more and it's quite simple." 

And then I started looking at the evidence on this and I just found it really surprising that it's quite, it's often quite hard to show a difference between acupuncture and sham acupuncture. And the reason is that there’s no placebo for acupuncture. You know, anything that you use as a sham is going to have an effect. Because the patient's got to believe that, you know, the needle's been inserted. So in that way, the difference between the two types of demotion is really quite small. 

But what I found in some systematic reviews that I...that came up in my literature search was that there was a distinct difference and quite a clinically significant difference as well. Between acupuncture and sham acupuncture for managing obesity and overweight. 

Andrew: Wow.

Carolyn: Now, the studies tend to be a bit small and the quality is not great. But the evidence is very compelling I think. 
Andrew: Can I just point out to our listeners though, Doctor Ee, that you are indeed expert in sifting out the issues of sham acupuncture? Correct? 
Carolyn: Yes, that's correct. And...so for my PhD which I submitted in 2016, I ran a randomised sham-controlled trial on acupuncture for menopausal hot flushes. So I used a, what's called a noninvasive sham needle. So it's a blunt needle. It doesn't go through the skin, but it still does provide quite a bit of sensation. Because it's...you know, that's quite in the same...it's about the same width as an acupuncture needle and if you can imagine sort of, you know, the pressure on a narrow point, is quite noticeable. 
Andrew: Yeah. 
Carolyn: And of course, it has to be noticeable because the women need to believe that the needle's gone through the skin. 

So we didn't tell them that it was noninvasive. We said it was a different type of needling. And we...it's...we eventually included quite a number of women who had had acupuncture before, who I think, so the cut off was sort of a month... And they nearly couldn't tell the difference even though they had had real needles before. They couldn't tell the difference between sham and real acupuncture. So most women thought they were getting the real thing. 
Andrew: Yeah. 
Carolyn: And it didn't matter if they had had acupuncture before or not. 
Andrew: With regards to acupressure... 
Carolyn: Yeah. 
Andrew: So, you know, could it be that you're getting a positive, not a placebo? Can you take me through... 
Carolyn: Yeah. 
Andrew: Is it an accepted sham? 
Carolyn: It is an accepted sham from a scientific point of view. So I think it's also accepted that it's not a perfect solution and there are many problems with it. 

So one, you know, obviously one argument is that the pressure and the sensation on skin and even surrounding muscle, you know, is enough to produce an effect. And also even though we tried it on non-acupuncture points, it didn't seem to make any difference. So both, you know, both groups had the same effect really. 

And it's a real wicked problem because if you think about it, you've got to have the patient or the participant rather believing that a needle's gone through the skin. How do you simulate that without that sensation? And people have tried different things. They've tried...they even tried sort of lying the patient down and showing them this mock video of pretending to needle them that it's not actually their hand and... 
Andrew: That's like a phantom limb type thing, is it? 
Carolyn: Yes, that's a phantom limb type thing. 
Andrew: Yeah. 
Carolyn: But obviously that's, you know, that's not really translatable to a large clinical trial. But, yeah, I don't know the answer to it, to be honest, but I think this theory that we went with when we chose sham was that a lot of the teaching in acupuncture says, you know, it's not going to work unless you have the needle sensation that's called...and my accent's terrible. So I believe it's called “deqi,” which means “the chi has arrived.” 
Andrew: Yeah. 
Carolyn: And from a physiological point of view, we believe that happens when we put the needle in, you twirl it and then the little muscle fibres all wrap around the needle and you get that sudden sort of...

Andrew: Rush…

Carolyn: It's quite marked, and some patients, they say, "Oh, yeah, that's it." Or, "I can feel..." You know, it's numb or it feels like there's some pressure or it's warm. 
Andrew: Yeah. 
Carolyn: And we are taught traditionally, that you need that sensation in order for it to work. And, you know, physiologically it makes sense because that's the sensation that could stimulate the small zone in the nerve fibres that carry pain and temperature and so on and that sort of activates that pain matrix. 

But having said that, there's a branch of, you know, there's branches of acupuncture that...for example, Japanese acupuncture, that don't require that needle sensation and that still seems to have a clinical effect. So there's arguments against that as well. 
Andrew: We've answered part of it, as usual, but not the full... 
Carolyn: But I think the thing is that with hot flushes, it was a subjective measure. So women had to count the hot flushes and so on. I think it probably doesn't matter as much with an objective measure like weight or insulin resistance. Because there's not the effect of expectancy or placebo with that. 

But having said that I think it, as I said, you know, I think it's really compelling that there were systematic reviews that showed a difference in weight between real acupuncture and sham acupuncture. 
Andrew: Just hooking onto a point you made about hot flushes in your previous research there, like, I do concede that there are marked differences shown when women have a positive outlook of their menopausal transition as opposed to a negative outlook. And so…

Carolyn: Absolutely. 

Andrew: And so, just from changing their mind that they actually gain benefit. So there is always the issue of the placebo response when whenever you're giving a hands-on therapy to a patient indeed... 
Carolyn: Absolutely. 
Andrew: You know, Professor Frank Rosenfeldt looked at cardiac research with this at Melbourne, at Alfred Hospital in Melbourne. And just by doing a foot massage they decreased...nocciseptic stimuli. They decreased pain medication requirements so... 
Carolyn: Yes. 
Andrew: ...Notwithstanding that that sort of aspect can be quite powerful, do you see biochemical changes, measurable changes, that you can go, "There is really something happening here"? 
Carolyn: Are you talking about hot flushes or….?
Andrew: Hot flushes. Like, I mean, the measurement of hot flushes is controversial, you know. What are you looking at? Adrenaline? It's not there so... 
Carolyn: Yeah. No. Yeah, there's no biomarker for hot flushes. 
Andrew: Yeah. 
Carolyn: I think that was the problem. Yeah, there's no biomarker. You could use a thermal skin conductor to measure, you know, how sweaty women are. So how many hot flushes they have. 

Andrew: Machine?

Carolyn: Yeah, yeah. But that's quite expensive and it doesn't actually correlate to how many hot flushes they think they're having. And that's the real thing. It's...what's important to the women, is how many hot flashes they think they're having. 
Andrew: So a subjective measure in this case really is the best that we've got? 
Carolyn: Yeah, yeah, exactly. So it's completely patient-reported outcome. You can’t do oestrogen levels, it means nothing. And so that was really the best that we had. 

Which is why I'm really interested in PCOS and metabolic conditions. Because they are biomarkers that we can measure. So for example, in the trial that we're running, we’re hoping to get some funding to measure how glucose and insulin changes after giving women a specific dose of glucose. So that’s the two hour oral glucose tolerance test. 
Andrew: Yeah. 
Carolyn: And that's the gold standard marker insulin resistance. 
Andrew: Yeah. 
Carolyn: And also looking at things like testosterone levels and obviously weight, and we’re looking at heart rate variability and to see if that improves. Because that's a surrogate marker of sympathetic tone. 
Andrew: Gotcha. Okay. So a number of things here. So you've got gross measurement, things like weight. You've got biochemical measurement, testosterone, other hormones. You can calculate the HOMA-IR from your results from the glucose tolerance test. So you've got a battery of tests that you can measure. Okay, so I've got to ask what's your experience? We haven't got the research made yet and I don't want to give too much away I guess, because you will be speaking at the ATMS Symposium in September about this but, you know, what are you feeling so far and what's the practice? 
Carolyn: Well, we're only just starting with this. So we're starting...we'll be opening up to recruitment very soon. And we probably won't have any preliminary data even in September yet. 

But what we do have is some qualitative data from focus groups that we ran last year in women with PCOS and really asking them, "Look. What do you think? Do you...would you try acupuncture? You know, what's been your experience with PCOS? You know, what have you tried? What works and what doesn't?" 

And it was really interesting because women talk to us about their weight loss journeys and their weight loss struggles and how they literally, "I've tried everything known to man. I know how to lose weight but then the weight just stacks back on, you know. I've been doing this for 30 years and I'm sick of it. Now I'm really worried about getting diabetes. I'm really worried about, you know, the future for my daughters. That's why I want to participate in this sort of research." 
So I think there's a real need to find solutions for these women. They are concerned about long-term consequences. So there's reports of increased risk of diabetes. So possibly four or five-fold and possibly of increased rate from heart disease as well. 

But, you know, a number of them are struggling with their fertility issues. There is...anxiety and depression is more common in women with PCOS as well. And then there's the weight. And there's the physical signs of the excess facial hair, which is very...you know, a lot of them struggle with. And the acne. And so they talk about this...what they call this...it's the whole package deal. It's like if you really cheated, sort of handed this package deal of infertility and weight struggles and growing a beard and they said, "It's so unfair. I think I'm...it's like I'm turning into a man. And I really want to find a solution for this." And I would...and they all said, you know, "Look, I'd be happy to participate in the sham control trial. It's no problem because, you know, I understand the scientific need for it." 
Andrew: I also think it's important to measure...to mention appropriate management because you're dealing with, sometimes, not just controversial, but really dangerous things here. Anxiety and depression. You know, you really need to think about appropriate management. So how do you wend your way there being dually qualified in medicine and also TCM? 
Carolyn: Yes. Look, I am a GP first, and I practice in quite a conventional clinic. So I would do everything that a regular GP would do. 

And we're very lucky in Australia to have this...to have had the first guidelines produced a few years ago by the Center for Research Excellence (CRE) in PCOS that I received funding from. And prominent speakers from.. at ATMS are also part of that, of that CRE. 

And those guidelines very clearly set out the, you know, the importance of screening for anxiety and depression and appropriate management. Then multidisciplinary management of PCOS, as well as the evidence for different treatments for fertility, for lifestyle and managing weight and so on. And there will be a new set of international guidelines released soon as well as I believe an app for women to manage their PCOS. 

So we're really lucky in Australia to have world leaders in PCOS management, working on a translation of these guidelines to practitioners. And so I'd really urge all the practitioners to come along and listen to Rob Norman and Nigel Stepto and other people, because they're really well ahead in their field. 
Andrew: Oh, well ahead. 
Carolyn: In PCOS. 
Andrew: Yeah, I'm a little bit scared of interviewing Nigel Stepto because his knowledge of physiology… Oh, my God, it outpaces mine like nothing else. But I think practitioners are going to learn a hell of a lot. That's in September 2018 for listeners. So you go onto the atms.com.au website, go to ‘events’ and look under there for registration to that event
When you're looking at appropriate management, safety...so I mentioned that thing about adjunct therapy. Where do you feel the place of integrative medicine is or integrative medicine approaches are, with regards to polycystic ovarian syndrome? 
Carolyn: Oh, that's a really good question. I always think of complementary therapies and acupuncture as an adjunct. So for example, in the study that we're about to open for recruitment, it is acupuncture as an adjunct to interventions for managing weight and PCOS. And that's the way I think about it as a general rule in clinical practice as well as research. And I think it's a really important angle to go for that I am not comfortable with ‘alternative medicine’ which is the rejection of biomedicine. I think we have so much to gain from utilising, you know, the advances that are being made and are being made all the time in biomedicine. 

I understand that the troubles that some patients have had with their experiences with...in conventional biomedicine. But I always encourage all my patients to use just the best of both worlds and that was the reason that I, you know, I've done this...you know, I’ve studied the two professions and tried to bring them together. Particularly in the research field is that, you know, I think they both complement each other beautifully. 

I think there are a lot of advantages to modalities like acupuncture, Tai Chi, yoga, mindfulness. They're non-pharmaceutical so you're not bringing into the mix, you know, the issues of, “Well, what are the pharmacokinetics of this? You know, how is it going to interact with other medications that are more...you know, what are the adverse effects of taking an ingestible?” 

So I like the fact that there's a lot of safety data on acupuncture. So there have been four very large studies looking at safety and we know that overall it’s a very safe procedure. And so I think, yeah, the adjunctive approach, absolutely, is the approach that I take. 
Andrew: Of course, there is the obvious one and that is the get a 100% compliance. 
Carolyn: Hopefully. 
Andrew: Well, unless you're chasing them around the room with a needle. 
Carolyn: Yeah, it's...I think with...you know, particularly with acupuncture for metabolic disorders, I think one of the really interesting things is not just the adjunctive approach but it's that...okay. Is it synergistic? 

So if we think about telling women to, you know, reduce calories. And so I'm really interested in whether the acupuncture's going to help them with that because of the possible effect on appetite suppression. 
Andrew: And will you be measuring, you know, things like cholecystokinin or ghrelin or alpha-melanocyte stimulating hormone or any of these sort of biochemical surrogates? 
Carolyn: Yeah. We thought about that. We thought about leptin and ghrelin…
Andrew: Leptin. 
Carolyn: The advice from Lisa Moran, who's a co-investigator and part of the CRE is that, you know, it's not the best biomarker for what we're looking at. 

You'd really need to, for appetite, you'd really need to have a sort of all-day thing where, I think you sort of measure how much women are eating. And that's very long and drawn out and very expensive. 
Andrew: Yeah, it needs to be in a lab. 
Carolyn: We, unfortunately, yeah, we won't be doing that. 
Andrew: Got you. 
Carolyn: Yeah, but we are measuring some patient-reported outcomes. I think weight, self efficacy. So how confident women feel in controlling their eating in different situations like, well, watching TV or out in a social situation. 
Andrew: Got you. 
Carolyn: And that's a validated scale so... 
Andrew: Right. I think that's the issue though. As long as you're using a validated scale like... 
Carolyn: Absolutely. 
Andrew: Like, you know, you spoke about leptin. But if you've got leptin resistance, well, that's not going to help you, measuring leptin, because we know that obese people can have high amounts of leptin. So what's the point? 
Carolyn: That's right, yeah. So you need to be able to interpret it. It's got to be useful clinically. 
Andrew: Yeah. What about future research? What are the sort of, hot topics in acupuncture at the moment and, you know, what...where's our direction of inquiry heading? Certainly not just pain. 
Carolyn: Yeah, certainly not just pain. And my interest is in the role of acupuncture on dampening down that fight or flight response. And then the effects on weight and metabolic conditions. 

So and another sort of hot topic for me personally, is looking into the role of acupuncture for weight loss in breast cancer survivors. So we know that after a diagnosis of breast cancer, women do tend to gain weight and it's probably multifactorial. It probably is related to treatment factors. But we also know that this can increase the risk of tumor recurrence and I guess worsen prognosis overall. 
Andrew: Yeah. 
Carolyn: So the next step for this is to run a similar pilot study on women with early breast cancer, again, to see if there's an adjunctive effect of acupuncture on weight loss. 

So I'm in the process of just looking through results from a national survey that I've run through Breast Cancer Network Australia. Where we had over 300 women tell us about their...I guess what happened with their weight after breast cancer diagnosis, what they've tried and we're looking at whether or not we can predict those women who are at high risk of gaining more weight. And then target an intervention that can help them maintain a healthy weight and improve their long-term health outcomes. 
Andrew: Carolyn, can I ask you just to give us a little wrap-up, if you like, of some of the safety aspects and indeed registration aspects with regards to acupuncture in Australia? 

Because I hope I'm not overstepping the mark here, but are we getting to the over-medicalisation of acupuncture? Are we losing the rich history of traditional Chinese medicine by just doing this pain-related acupuncture? Obviously, you're not doing that, but I'm just wondering are we losing the rich history of acupuncture? 
Carolyn: That's an interesting question and I think the history will always be there. And, you know, we use the history all the time. For example, we use the diagnostic principles in coming to an acupuncture prescription. So I used that for the menopause study. We're using that in PCOS and we’ll use it in the breast cancer study as well. 

But if you look at what's happening in China where, you know, the use of acupuncture in Chinese herbal medicine is really quite mainstream. They are the experts in, I guess, bringing the two worlds together. So Western medicine and Eastern medicine. And so they will happily combine Western medical prescriptions with some acupuncture and some herbs and go and do your Tai Chi and go and have your Chinese massage as well. And the Chinese diet therapy. 

So it's all wrapped up into one and in fact, I know that the Chinese doctors in China are allowed to prescribe and they do practice Western medicine, in a way that they can't here. So I hear what you're saying in that, you know, are we losing that history. I think it's really fascinating really unpacking, you know, the mechanisms of acupuncture. And while I find the ferocity and the different diagnoses really interesting, I also think...well, you know, they were, I guess, formulated in a time where we didn't have the mechanisms that we do now to sort of look into the human body. So we can't, you know, they didn't have pathology, they didn't have radiology, they didn't have lots of different functional tests. They can't look at the microbiome and start looking at epigenetics. Now, that's another hot topic. 
Andrew: Yeah. That would be real interesting. Oh, my goodness. 
Carolyn: Yes. I know. So I think, you know, having the two come together is not losing anything, I think we're gaining a lot. And I think it would just increase the translatability of acupuncture. And that's, you know, that's the eventual goal, I think. That we can show, you know, what works, how it works, and ensure that it's provided safely and appropriately. 

And you asked about registration as well? 

Andrew: Yeah.

Carolyn: I don't know if this is a topic that's come up in another podcast or do you want me to go through that at all?
Andrew: Yeah, just a little bit. Because you're dual qualified. Whereas you get a lot of doctors who have done medical acupuncture which is called...forgive me if I get this wrong. Is it called dry needling now? 
Carolyn: Yeah, so dry needling is a different thing altogether. So dry needling doesn't use any acupuncture principles. It really is just using an acupuncture needle and putting it into a trigger point. 
Andrew: Got you. 
Carolyn: So it's often done by, you know, musculoskeletal doctors or by physiotherapists. 

So medical acupuncture is when, obviously, you're using some of the principles of Chinese medicine but you don't have to do those TCM diagnosis. So you don't have to look at the tongue and pulse. So it's really sort of using that physiological knowledge of how it works. 
And Chinese medicine is a regulated profession in Australia. So what that means is that all our Chinese medicine practitioners have to be registered with the Australian Health Practitioner Regulation Agency under the Chinese Medicine Board. And this is a, you know, this was a really important step forward, I think. And we’re still the only Western nation to nationally regulate our practitioners. So chiro’s and osteo’s are, again, under the same scheme. 

And it’s… I think it's important. Because, yeah, acupuncture is not without risk. It needs to be done under certain conditions to reduce the risk of infection, for example. And also there are some new guidelines that were released a couple of years ago by the Chinese Medicine Board about safe prescribing of Chinese herbs. And there's a separate registration for dispensing as well. 
Andrew: Okay. 
Carolyn: So taking into account the, I guess, potential safety concerns of herbal medicine, it is important that this profession is regulated. 

And it increases the, you know, the credibility of the profession as well to conventional health practitioners. So I think my boss, Alan Bensoussan, so the Director of NICM Health Research Institute, responded there. You know, they’re the founding people to put that, you know, that paper, that publication, together to drive the move towards regulation. And my mentor and PhD supervisor Charlie Xue, you know, set up the Victorian Board and now it's national. And I'm on the reference group for the board. 

Andrew: Ahh, brilliant work. 

Carolyn: So I fully support registration. I think it's a wonderful thing. The, you know, the job of the board is to protect the public and I think that can only be a good thing. 
Andrew: Yes. That's absolutely well said. And I’ve got to say hat's off and good on you, for your work thus far and your future work. You know, you've worked really diligently with registration, with your work with a lot of women's groups, with looking at, you know, hot flushes previously. Now you're going to be looking at polycystic ovarian syndrome. Can't wait to hear you speak at the 2018 ATMS Symposium in September. That'll be fantastic. 
So I just...thank you so much for taking us through the acupuncture aspects for polycystic ovarian syndrome today on FX Medicine. 
Carolyn: Thank you. Thanks so much for having me. 
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Dr Carolyn Ee
ATMS Event: PCOS Symposium
NICM: National Institute of Complementary Medicine
RACGP: Royal Australian College of General Practitioner's Speicifc Interest Groups
American College of Physcians
Alfred Hospital: Integrative Cardiac Wellness Group
Centre for Research Excellence (CRE) in PCOS
Professor Robert Norman
Professor Nigel Stepto
Assoc Prof Lisa Moran
Breast Cancer Network of Australia
Australian Health Practitioner Regulation Agency (AHPRA)
Chinese Medicine Board of Australia
Prof Alan Bensoussan
Prof Charlie Xue

Research explored in this podcast

Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci. 2003 Jan;26(1):17-22

Han JS. Acupuncture and endorphins. Neurosci Lett. 2004 May 6;361(1-3):258-61. 

Richards D, Marley J. Stimulation of auricular acupuncture points in weight loss. Aust Fam Physician. 1998 Jul;27 Suppl 2:S73-7.​

Ee C, Xue C, Chondros P, et al. Acupuncture for Menopausal Hot Flashes: A Randomized Trial. Ann Intern Med. 2016;164:146–154. 


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