Obesity is a chronic metabolic disease resulting from multifactorial interactions, including genetic and environmental influences (1). From 1990 to 2022, the global prevalence of adult obesity increased across 188 countries (2–4). Obesity now represents a significant public health challenge, disproportionately burdening women. Excess adiposity activates inflammatory pathways, disrupts glucose and lipid metabolism, and elevates risks of endocrine disorders. Perimenopausal obesity, occurring in women aged ≥ 45 years, is characterized by significant physiological transitions during the reproductive cycle, such as declining ovarian function. These changes are frequently accompanied by psychological disturbances, including anxiety and depression (5, 6). Diminished ovarian function reduces endogenous estrogen levels while elevating follicle-stimulating hormone (FSH), impairing lipid metabolism regulation and altering the quantity, composition, and distribution of adipose tissue in perimenopausal women. Animal studies indicate that declining estrogen and rising FSH levels during reproductive aging may drive the distinct fat redistribution observed in menopausal obesity. Additionally, estrogen influences adipose tissue distribution, typically causing fat to accumulate centrally—shifting from subcutaneous to visceral layers, particularly in the hips, abdomen, and thighs (7). During perimenopause, reduced estrogen levels impair pancreatic β-cell responsiveness to glucose, compromising insulin-mediated glycemic control. This disrupts glucose oxidation and utilization, exacerbating hyperglycemia and metabolic dysregulation (8). Consequently, perimenopausal obesity-associated metabolic disturbances elevate risks of hyperlipidemia, type 2 diabetes mellitus, cardiovascular disease, breast cancer, and osteoporosis (9–12). Notably, obese menopausal or postmenopausal women face significantly higher overall mortality, with studies reporting a fourfold increase in cardiovascular-related deaths among those with a BMI > 29 kg/m² (13). Effective weight and body composition management during menopause is critical for preserving women’s health. Perimenopausal interventions offer a pivotal opportunity to mitigate disease risks and enhance quality of life.

Current mainstay treatments for perimenopausal obesity include lifestyle interventions, hormone replacement therapy (HRT), and bariatric surgery. However, adherence to lifestyle interventions is frequently suboptimal, while HRT carries significant risks, including breast cancer, cardiovascular diseases (e.g., coronary heart disease and stroke), cognitive decline, venous thromboembolism, and osteoporosis (14–16). Additionally, bariatric surgery entails substantial costs, creating considerable economic burdens for patients (17–19). Consequently, complementary approaches such as acupuncture are increasingly being explored (20). As a specialized acupuncture modality, acupoint catgut embedding has demonstrated favorable outcomes for reducing adiposity and alleviating perimenopausal symptoms compared to dietary interventions and traditional Chinese medicine in previous meta-analyses (21). Nevertheless, comparative evidence remains limited regarding the relative effectiveness of distinct acupuncture methods in perimenopausal obesity or their impacts on sex hormone and blood lipid levels. Therefore, the optimal selection of acupuncture techniques for managing perimenopausal obesity in clinical practice remains unclear.

This study employed a network meta-analysis (NMA) to synthesize direct and indirect evidence regarding the efficacy of different acupuncture methods in managing perimenopausal obesity. The results provide evidence-based guidance to assist clinicians in optimizing treatment strategies for this patient population.

This study focuses on several critical health parameters in perimenopausal women, including BMI, body weight, waist circumference, body fat percentage, perimenopausal symptoms, estrogen-related indicators, and blood lipid levels. Fluctuations in these parameters significantly impact women’s health during the menopausal transition. Previous research (46) has demonstrated that even a modest weight gain of 2.5–5 kg in middle-aged women correlates with significantly elevated risks of chronic diseases and premature mortality, including diabetes, cardiovascular diseases, obesity-related cancers, and all-cause mortality. Clinical evidence (12) indicates that perimenopausal obese women achieving a body fat reduction exceeding 25% demonstrate healthier adipose distribution patterns and reduced risk of type 2 diabetes. The association between weight gain and adverse cardiac structural and functional changes is particularly notable, with the degree of BMI elevation and duration of exposure contributing to progressive cardiac dysfunction (46, 47). Notably, epidemiological studies (48) report that middle-aged women experiencing annual weight gain exceeding 0.75 kg have a 35% increased breast cancer risk, with abdominal obesity exhibiting a stronger association with breast cancer risk than overall obesity. Park et al. (49) quantified this relationship, demonstrating that each 10 cm increase in waist circumference corresponded to a 1.13-fold increase in postmenopausal breast cancer risk, suggesting waist circumference may better reflect visceral fat’s carcinogenic potential than BMI. These findings highlight the perimenopausal period as a critical window for weight management and visceral fat reduction to mitigate the risks of various diseases. The perimenopausal period is characterized by marked estrogen decline, accelerating bone loss and increasing the risk of postmenopausal osteoporosis. Research suggests maintaining BMI within 22–25 kg/m² mitigates the rate of bone density reduction (50). Additionally, moderate weight loss in perimenopausal obese women alleviates joint load, thereby potentially reducing exercise-related injury risks (51).

Acupuncture is a globally recognized therapeutic intervention demonstrating clinical efficacy in improving perimenopausal obesity. Research indicates that acupuncture may modulate hypothalamic activity, establishing a neuroregulatory circuit for appetite control that could improve perimenopausal obesity (52). Evidence further suggests that acupuncture regulates fatty acid metabolism while elevating serum levels of high-density lipoprotein and carnitine (53). Mechanistically, research hypothesize that acupuncture may act through AMPK-mediated signaling pathways, though this remains speculative and requires direct validation in future studies (54). Additionally, acupuncture has been shown to alleviates perimenopausal psychological symptoms including anxiety, panic, and insomnia (55, 56), while potentially reducing risks of chronic metabolic comorbidities, including hyperlipidemia and type 2 diabetes, in this population (57, 58).

ACE involves implanting absorbable surgical sutures at acupoints to provide more sustained stimulation compared to conventional acupuncture. Its prolonged therapeutic effect may be attributed to proteolytic enzyme activity and macrophage-mediated responses to the absorbable material, which collectively enhance and extend acupoint stimulation (59). ACE has shown potential in managing perimenopausal obesity through a proposed mechanism involving enhanced adipose tissue energy metabolism. This may be mediated through increased cyclic adenosine monophosphate levels and upregulation of uncoupling protein 1 expression in brown adipose tissue (60). Furthermore, ACE appears to modulate the hypothalamic-pituitary-gonadal axis, elevate serum estradiol and progesterone levels, and consequently attenuate obesity progression (41). Experimental evidence from ovariectomized rat models indicates ACE’s superior effect to estrogen therapy in improving lipid metabolism disorders induced by estrogen deficiency (61). Our findings (Tables 1, 2, 5, 6) suggest ACE significantly improves BMI, body weight, perimenopausal symptoms, and estradiol levels, potentially establishing it as a promising therapeutic strategy for perimenopausal obesity based on current evidence.

EA constitutes an enhanced form of traditional acupuncture that employs low-frequency pulsed currents at acupoints, synergistically integrating mechanical and electrical stimulation to enhance treatment outcomes. Regarding waist circumference (WC) reduction, EA demonstrated superior efficacy (Table 3). However, its lack of significant effect on BMI suggests its particular suitability for managing abdominal obesity in perimenopausal women with normal body mass index. Moxibustion represents a clinically relevant intervention for perimenopausal obesity, encompassing Traditional Chinese Medicine (TCM) modalities, including direct moxibustion, ginger-separated moxibustion, garlic-separated moxibustion, and warm needle acupuncture (62). Moxibustion may contribute to weight reduction in obese perimenopausal women by promoting localized hemodynamics and enhancing energy metabolism (63). This effect could be mediated through the browning of white adipose tissue (64). Additionally, moxibustion appears to support ovarian function by inhibiting apoptosis in aging ovarian tissue and strengthening antioxidant capacity, leading to normalized hormone secretion (65). WNA integrates moxibustion and acupuncture techniques by combining mechanical, thermal, and acupoint stimulation. This modality is widely adopted in Asian clinical practice (66). Our analysis identified WNA as particularly effective for body fat percentage reduction (Table 4).

Although menopausal hormone therapy (MHT) and behavioral interventions can improve BMI and perimenopausal symptoms, lifestyle modifications cannot achieve adequate weight control in all patients. Moreover, MHT is associated with elevated risks of breast cancer, coronary heart disease, stroke, cognitive impairment, venous thromboembolism, and osteoporosis (67). Consequently, complementary treatments are being increasingly investigated, among which acupuncture has emerged as one of the most rapidly growing modalities. The pathogenesis of perimenopausal obesity involves complex mechanisms. Currently, it is known that acupuncture ameliorates obesity and perimenopausal symptoms through multi-level, multi-system, and multi-target synergistic mechanisms; however, the precise pathways remain incompletely elucidated. Furthermore, therapeutic efficacy may vary depending on acupoint selection, combination strategies, and stimulation parameters, aspects whose underlying mechanisms require further characterization.

This review critically evaluates key advancements in acupuncture-based interventions for perimenopausal obesity, which have informed current clinical approaches. The analysis encompassed electroacupuncture, acupoint catgut embedding, warm needle acupuncture, and moxibustion, with comparisons drawn against other acupuncture treatments, drug therapy, sham acupoint, or blank controls. The findings demonstrate that acupoint catgut embedding was particularly effective in improving BMI, body weight, estradiol levels, and perimenopausal symptoms compared with control groups. Warm needle acupuncture showed advantages in reducing body fat percentage. Electroacupuncture reduced WC but did not significantly improve BMI. Acupoint catgut embedding and warm needle acupuncture were shown to regulated serum sex hormones and blood lipid levels. The evidence indicates distinct therapeutic advantages among different acupuncture methods for managing perimenopausal obesity. To our knowledge, this study represents the first comprehensive network meta-analysis comparing the effects of various acupuncture methods for this condition, providing valuable evidence to support clinical decision-making in acupuncture protocol selection.

This review has several limitations: (1) Only one study used blinding, and most omitted details on randomization and allocation concealment, increasing bias risk. (2) The substantial heterogeneity among perimenopausal women, characterized by variations in obesity severity, physiological status, and hormonal fluctuations, may introduce potential performance bias in the implementation of interventions. The limited sample size of eligible studies precluded comprehensive subgroup analyses to evaluate how these factors affect treatment efficacy. (3) The current evidence for acupuncture in managing perimenopausal obesity remains relatively scarce, particularly regarding long-term therapeutic outcomes. The present findings are limited to short-term evidence, whereas the long-term sustainability and safety of acupuncture for this specific condition have yet to be established. (4) All included studies were single-center investigations, which limits the methodological robustness and generalizability of the findings due to the lack of multicenter validation. Future research should prioritize rigorously designed, large-scale randomized controlled trials to validate these preliminary observations.

In conclusion, our study demonstrated the efficacy of acupuncture-related interventions in improving multiple outcomes in perimenopausal women, including obesity indicators, perimenopausal symptoms, serum sex hormone levels, and lipid levels. Several acupuncture-related therapies may demonstrate superior efficacy compared to WM or herbal medicine HM in managing perimenopausal obesity. Furthermore, ACE emerged as the most effective intervention for reducing BMI and body weight and for improving the Kupperman Index. EA was most effective in reducing waist circumference, while WNA was ranked highest for reducing body fat percentage. These approaches could be considered as alternative or adjunctive treatment options in clinical practice. The selection of specific acupuncture methods should be individualized according to patients’ clinical requirements and actual conditions. However, these preliminary findings require verification through more multicenter, large-sample, randomized controlled clinical trialsin the future to establish more definitive evidence.