Front. Med. Frontiers in Medicine Front. Med. 2296-858X Frontiers Media S.A. 10.3389/fmed.2025.1731543 Systematic Review The efficacy of acupuncture and related treatments on chronic pelvic inflammatory disease: a network meta-analysis Zheng Yitong 1 Conceptualization Formal analysis Investigation Methodology Writing – original draft Writing – review & editing He Jintao 1 Methodology Writing – original draft Zheng Yijun 2 Formal analysis Investigation Writing – review & editing Ni Dongyi 3 Formal analysis Investigation Writing – review & editing Wang Yong 1 * Funding acquisition Resources Supervision Writing – review & editing The Affiliated TCM Hospital of Guangzhou Medical University, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China Medical College of Acupuncture Moxibustion and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China Correspondence: Yong Wang, touger20@163.com 12 01 2026 22 01 2026 2025 12 1731543 24 10 2025 25 11 2025 01 12 2025 Copyright © 2026 Zheng, He, Zheng, Ni and Wang. 2026 Zheng, He, Zheng, Ni and Wang https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Objective

To compare the efficacy of different acupuncture and related therapies for chronic pelvic inflammatory disease (CPID) and their effects on inflammatory factors via Network Meta-Analysis.

 Methods

Eight databases were systematically searched (up to April 20, 2025) for randomized controlled trials (RCTs) of acupuncture-related therapies for CPID. Eighty-four RCTs involving 8,147 patients were included. Study quality was assessed using the Cochrane risk-of-bias tool, and data were analyzed with R software.

 Results

AI interventions showed higher total effectiveness than conventional treatment. SUCRA rankings for total effectiveness: moxibustion combined with warm needle (89.1%), acupoint application therapy combined with ultrasound drug penetration (88.0%), and acupuncture combined with cupping (86.8%) ranked highest, while conventional treatment was the lowest (0.2%). For inflammatory factors: acupuncture showed the best improvement in IL-2 (61.6%); acupoint injection was optimal for TNF-α regulation (95.8%); moxibustion combined with acupuncture best modulated IL-6 (92.6%); and acupoint injection was best for CRP regulation (99.4%).

 Conclusion

Acupuncture and related therapies are effective for CPID, with differences in regulating specific inflammatory factors, providing an evidence-based foundation. However, limitations like publication bias exist, warranting validation by high-quality studies.

 Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD420250655000.

 acupuncture non-acupuncture physical therapy chronic pelvic inflammatory disease network meta-analysis treatment The author(s) declared that financial support was not received for this work and/or its publication. section-at-acceptance Obstetrics and Gynecology Introduction

Chronic Pelvic Inflammatory Disease (CPID) is a persistent inflammatory condition primarily affecting women of reproductive age, often resulting from inadequately treated acute episodes. It significantly impairs patients’ quality of life and is a major cause of infertility (1) and chronic pelvic pain (2), imposing a substantial burden on global healthcare systems due to its high prevalence and associated long-term complications. Antibiotic therapy remains the first-line clinical regimen (3); however, approximately 40% of patients experience poor outcomes due to antimicrobial resistance (4), hypersensitivity reactions (5), or treatment intolerance, leading to frequent recurrence and disease chronicity. This situation underscores the urgent need for effective complementary and alternative medicine (CAM) options to address these therapeutic challenges.

Acupuncture and related therapies within Traditional Chinese Medicine (TCM), such as moxibustion, acupoint injection, and warm acupuncture, have garnered increasing attention due to their multi-targeted anti-inflammatory mechanisms. Preclinical and clinical studies suggest potential pathways of action: electroacupuncture may reduce pro-inflammatory cytokine levels (e.g., TNF-α, IL-6) by modulating the NF-κ B signaling pathway (6); moxibustion at the Shen que acupoint has been shown to significantly improve reproductive outcomes (7); and acupoint injection therapy might alleviate autoimmune disease progression and modulate inflammatory cytokines (e.g., IL-10, IFN-γ) (8).

Despite these encouraging findings, significant limitations persist in the current evidence base. The relative efficacy ranking among nine commonly used acupuncture and related interventions remains unclear, and high-quality randomized controlled trials (RCTs) for direct comparisons are lacking (9). Furthermore, methods for assessing and reporting key inflammatory biomarkers (e.g., IL-2, TNF-α, IL-6, CRP) vary considerably across studies, hindering effective data integration and interpretation. Conventional pairwise meta-analysis methods are inadequate for fully utilizing the available indirect comparative evidence, preventing the construction of a comprehensive efficacy network encompassing all nine interventions.

To address these limitations, this study employs, for the first time, a Bayesian framework Network Meta-Analysis (NMA). We comprehensively compare these nine interventions, systematically and quantitatively assessing their efficacy in improving clinical symptoms (e.g., total effective rate) in CPID patients. Additionally, we analyze their modulatory effects on four key inflammatory biomarkers (IL-2, TNF-α, IL-6, CRP) to elucidate potential mechanistic differences. The findings of this study aim to provide high-level evidence to support individualized therapeutic decision-making for CPID and inform the optimal integration of acupuncture and related therapies within contemporary medical practice.

 Data and methods

This study strictly adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines (10) to ensure transparency and reproducibility. The protocol was prospectively registered on the PROSPERO platform (11) (Registration number: CRD42025065500).

Literature search strategy

We systematically searched eight electronic databases for randomized controlled trials (RCTs) investigating various acupuncture modalities for chronic pelvic inflammatory disease (CPID): Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Wan fang Data, and VIP Database (Database for Chinese Technical Periodicals), China biomedical literature service system (CBM). The search period spanned from database inception to April 20, 2025. To maximize comprehensiveness, we supplemented the electronic search by manually reviewing the reference lists of included studies. The search strategy employed a combination of subject headings (e.g., Me SH terms) and free-text keywords. Key English search terms included: “Pelvic Inflammatory Disease,” “Chronic Pelvic Inflammatory Disease,” “Acupuncture,” “Acupuncture Therapy,” “Electroacupuncture,” “Moxibustion,” “Acupoint Injection,” “Warm Needling,” “fire acupuncture,” “auricular acupuncture,” “electroacupuncture,” “Cuppin”,” “Randomized Controlled Trial,” and their relevant synonyms and variations (see Supplementary Table 1).

 Inclusion criteria

Studies were included if they met the following criteria:

Study type: RCT.

(2) Participants: Female patients diagnosed with CPID (12), no age restriction.

(3) Interventions: Control group received conventional therapy, including drug treatment, routine care, etc. The treatment group received different acupuncture-related therapies, e.g., moxibustion, acupuncture, acupoint patch, floating needles, warm acupuncture, acupoint injection, cupping, either alone or combined with the control group.

 Exclusion criteria

Studies were excluded based on the following:

  Duplicate publications or literature with potentially overlapping data (i.e., same authors, data source, interventions, overlapping timelines).

  Literature where only the abstract was available and full text was inaccessible.

  Studies only comparing treatment duration without relevant outcomes.

 Literature screening and data extraction

Two reviewers (Yijun Zheng and Jintao He) independently performed the literature screening and data extraction, respectively, according to the pre-defined criteria. Literature screening: Yijun Zheng screened the titles, abstracts, and subsequently the full texts of retrieved records to identify studies eligible for inclusion. Data extraction: Jintao He performed data extraction from the included studies using a standardized form. Extracted information included: (1) Basic information (first author, publication year); (2) Control and treatment interventions; (3) Specific intervention operation time and acupoints used; (4) Data on observed outcome indicators; (5) Basic participant information. Any discrepancies during screening or extraction were resolved through discussion or consultation with a third reviewer.

 Risk of bias assessment

The methodological quality of the included RCTs was assessed independently by two reviewers using the Cochrane Risk of Bias tool (13). The assessment evaluated seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. Each domain was judged as “low risk,” “high risk,” or “some concerns” (referred to as “unclear” in some contexts). Risk of bias summary and graph were generated using Rev Man 5.3 software.

 Statistical analysis

A multi-software analytical workflow was implemented in accordance with established standards for high-quality network meta-analyses (14). Risk of bias was assessed using Review Manager 5.4.1, and Bayesian network meta-analysis was conducted using Stata MP-64 16.0. Publication bias evaluation and result visualization were performed using the metafor and ggplot2 packages in R 4.4.3. For dichotomous outcomes such as efficacy rates, odds ratios (OR) and their natural logarithms (lnOR) were used as effect measures. For continuous outcomes, including inflammatory markers, either standardized mean differences (SMD) or mean differences (MD) were applied based on data standardization. Evidence networks were constructed and closed loops identified using network graphs. Heterogeneity was assessed with the I2 statistic, with a fixed-effects model applied when I2 ≤ 50% and a random-effects model otherwise. Inconsistency within closed loops was evaluated using node-splitting methods, and consistency or inconsistency models were selected based on P-values and 95% confidence intervals (CI). Model convergence was confirmed by iterative calculation of the potential scale reduction factor (PSRF), with values between 1.00 and 1.05 indicating satisfactory convergence. The surface under the cumulative ranking curve (SUCRA) was generated to rank interventions using the netrank command. Publication bias was assessed using adjusted funnel plots and Egger’s test. Finally, multiple outcome measures were integrated via network meta-analyses to establish a two-dimensional evaluation system incorporating both clinical relevance and statistical significance.

 Results Literature search results

Initial screening identified 1,676 records. After removing duplicates and clearly irrelevant records, further screening based on study type, participants, interventions, and outcomes resulted in the inclusion of 84 articles (15–98). The screening process is detailed in Figure 1.

Flowchart for literature search and screening.

Flowchart of study identification and screening process. It starts with records identified through databases, showing specific numbers for PubMed, Embase, Cochrane, and others. Duplicate records removed totaled one thousand eight hundred seventy-six, leaving one thousand four hundred fifty-seven for screening. Three hundred sixteen were excluded after the title and abstract review. Full-text articles assessed for eligibility were one hundred twelve, resulting in eighty-nine reports. Records excluded for eligibility reasons totaled six. Finally, eighty-four studies were included in the quantitative synthesis. Basic characteristics of included literature after screening

A total of 84 RCTs involving 8,147 participants were included. Nine intervention types were involved: moxibustion (MOX), acupuncture (AC), traditional Chinese medicine (TCM), acupoint application therapy (AAT), ultrasonic drug penetration (UDD), floating needle (FN), warm needle moxibustion (WN), acupoint injection (AI), and cupping (CUP). Basic characteristics are summarized in Table 1.

Basic characteristics of included RCTs.

Study Year Intervention Sample size Mean age Course Acupoint Outcomes
M Liu (15) 2018 MOX_MTUT 30 30 32 31 once/15 min/d, once/15 min/d − F1, F2, F3
B Wang (16) 2024 MOX_ACUT 38 38 −− once/30 min/donce/30 min/d CV4, CV3, GV20 F1, F13
YH Kang (17) 2024 MOXUT 81 81 3130 once/30 min/d1 moxa cone 10 min, 2 once/d CV6, ST29, ST36, SP6, BL F1
YY He (18) 2024 MOX_ACAC 42 43 34 35 once/d, 30 min/once, once/d, 30 min/once EX-CA1, CV4, ST29, CV3, BL32, SP6, ST36 F1
LH Wang (19) 2024 MOX_AATUT 35 35 36 36 once/d, 30 min/once, once/d, 6 h/once CV8, CV4, CV6, ST36, SP6 EX-CA1, EX-CA1, CV6, CV3 GV4, BL23, BL28 F1, F3, F12, F13
YM Li (20) 2020 MOXUT 60 60 46 46 once/d, 20–30 min/once, once/d, 20–30 min/once CV4, CV6, SP6, ST36, CV8 F2, F3
YP Wang (21) 2015 MOXUT 32 32 33 34 once/d, 30 min/once, once/d, 30 min/once CV8, CV4, SP6, ST36 F1
XG Nong (22) 2017 MOXUT 42 42 34 34 once/d, 5–10 min/once, once/d, 5–10 min/once CV4, CV6, SP6, ST36, CV8 F1, F3, F12, F13
MF Xu (23) 2015 MOXUT 46 46 – once/d, 30 min/once, once/d, 30 min/once CV8, CV6, CV4, CV3, EX-CA1 F1, F3, F13
XQ Yang (24) 2021 MOXUT 45 45 31 30 3 moxa cone/once, once/d3 moxa cone/once, once/d CV4 F1, F12, F13
FH Cheng (25) 2023 AAT_UDDAAT 3434 58 58 once/d, 30 min/once, once/d, 30 min/once EX-CA1, CV3, CV6, BL23, GV4, BL28, AP F1, F3, F12, F13
HJ Wei (26) 2021 ACUT 53 53 37 36 once/d, 50 min/once, once/d, 50 min/once – F1, F2, F3, F13, F12
QY Pan (27) 2023 MOXUT 52 52 31 31 once/15 min/d, once/15 min/d Fuke, HP F1, F2, F3
DD Liu (28) 2023 FNUT 30 30 37 38 2 d/once, 2 min/once 2 d/once, 2 min/once −CPSTABLEENTER− F1, F13
GB Qi (29) 2018 AAT UT 9090 42 41 2 d/once 2 d/once EX-CA1, CV6, ST25 F1, F13
SF Tian (30) 2022 AC UT 35 35 90 90 once/d, 20–30 min/once once/d, 20–30 min/once BL F1, F12
B Jiang (31) 2020 MOX_AC UT 30 30 38 39 once/d, 20∼30 min/once once/d, 20∼30 min/once CV4, CV12 F1
Y Wu (32) 2021 FN UT 40 40 37 36 2 d/once, 2 min/once 2 d/once, 2 min/once – – F1, F13
L Luo (33) 2020 WN UT 50 50 34 33 once/d once/d CV4, ST29, CV6, SP6 F1
XP Shi (34) 2017 AI UT 40 40 32 32 d/once d/once CV4, EX-CA1 F3, F12, F13
Q Cheng (35) 2009 AI UT 107 107 20 46 20 46 −CPSTABLEENTER− CV3, CV4, EX-CA1 F2, F3
Y Chen (36) 2017 MOX UT 125 125 42 42 d/once, 6–7 min/once d/once, 6–7 min/once SP6, ST36, BL, ST39, EX-CA1, CV4 CV12 F2, F3
Y Li (37) 2016 MOX_ WN UT 132 130 - - d/once, 30 min/once d/once, 30 min/once −CPSTABLEENTER− F1
C Zhang (38) 2022 AC UT 40 40 33 33 d/once, 30 min/once d/once, 30 min/once CV6, CV4, CV3, SP6, ST36, EX-CA1 F1, F13
YC Huang (39) 2011 TCM_WN WN 55 50 31 2 d/once d/once CV6, CV4, SP6, ST36 EX-CA1, BL23 F1
NN Kong (40) 2022 AAT UT 45 49 39 39 −CPSTABLEENTER− CV6, EX-CA1, ST25 F1, F3, F13
HL Sang (41) 2017 AAT UT 90 90 31 32 8 h/once 8 h/once CV8 F1, F3
L Shi (42) 2021 AC_WN WN 46 46 30 30 d/once, 30 min/once d/once, 30 min/once BL23, CV4, GV4, SP6, BL32, SP10, BL18 F1, F3, F12
S Tao (43) 2016 MOX UT 30 30 36 38 d/once, 15–30 min/once d/once, 15–30 min/once SP6, BL23, BL32 F1
J Liu (44) 2022 WN UT 30 30 36 36 2 d/once 2 d/once ST25, CV6, CV4 EX-CA1, ST36, SP6 F1, F3, F12
X Jin (45) 2019 WN UT 40 40 32 32 d/once d/once CV4, CV6, ST28, ST29, ST30, SP6 F1, F3, F12
L Wang (46) 2020 WN UT 60 60 31 32 d/once, 30 min/once d/once, 30 min/once CV4, CV3, SP6 F1, F12
HX Xiao (47) 2024 AAT_WN UT 46 46 46 45 d/once, 30 min/once d/once, 30 min/once CV4, ST36, CV6, EX-CA1, SP10, ST29 F1
XJ Xia (48) 2020 WN UT 45 45 35 34 d/once, 30 min/once d/once, 30 min/once BL18, BL23, BL20, CV4, CV6, ST28, ST29 F1, F2, F3
L Shi a (49) 2021 WN UT 50 50 37 36 d/once, 30 min/once d/once, 30 min/once BL18, BL23, BL20, CV4, CV6, SP6, ST36 F1, F12, F13
WX Tang (50) 2021 WN UT 55 55 34 35 d/once, 30 min/once d/once, 30 min/once SP10 CV4 CV3 ST36 SP6 EX-CA1 ST29 F1, F2, F3
JR Zhou (51) 2015 WN_TCM WN 30 30 38 38 d/once d/once CV4, CV6, EX-CA1, SP10, SP6, KI3, LR3, SP9, BL23, BL32, BL52 F1, F13
HL Zheng (52) 2008 WN UT 45 40 33 34 d/once, 40 min/once d/once, 40 min/once CV4, CV6, ST36, BL23 F1, F13
J Wang (53) 2023 WN UT 43 43 36 36 once/2 d, 30 min/once once/2 d, 30 min/once BL23, BL20, BL18, ST36, SP6, CV4, CV6 F1, F12
LJ Chen (54) 2019 AAT UT 40 40 37 35 once/2 d, 30 min/once once/2 d, 30 min/once CV3, CV4, CV6, CV8, EX-CA1, BL32 F1
YM Yu (55) 2023 AAT UT 70 70 36 36 once/d, 2–4 h/once once/d, 2–4 h/once CV4, CV6, EX-CA1, CV3 F1, F3, F13
XJ Song (56) 2022 AAT UT 50 50 36 57 2 d/once, 4 h/once 2 d/once, 4 h/once CV4, CV6, EX-CA1, CV3 F1, F3, F13
SY Huang (57) 2018 AI UT 50 50 32 32 once/d once/d CV4, CV3, EX-CA1, EX-LE3 F12
W Hu (58) 2023 MOX_AC UT 40 40 44 43 d/once, 30 min/once d/once, 30 min/once CV12, CV10, CV6, CV4 F1, F3, F12, F13
GR Shi (59) 2021 AC UT 45 45 32 33 d/once, 30 min/once d/once, 30 min/once CV3, BL31-34, CV6, CV4, ST25, CV12, CV17, GV20 F1, F3, F13
Y Yuan (60) 2024 WN UT 34 34 45 45 −CPSTABLEENTER− ST36, CV4, CV3, EX-CA1, BL23, GV4, EX-BL7, SP6 F1, F2, F3, F13
LH Qiu (61) 2019 AC_MOX_CUP UT 55 52 42 41 d/once, 30 min/once d/once, 30 min/once ST36, BL23, BL54, ST29, CV3, EX-CA1, SP6, CV4, BL32 F1
QC Yi (62) 2018 MOX_AC AC 45 45 29 29 d/once d/once CV4, AX-CA1, BL25, BL32, SP6 F1, F13
P Zhou (63) 2014 AC_TCM UT 80 40 29 29 d/once, 30 min/once d/once, 30 min/once SP6, CV6, CV4, ST29, SP10, LR2, SP9 F1
Y Tian (64) 2022 AAT UT 35 35 38 38 2 d/once 2 d/once EX-CA1, ST25, CV6 F13
MX Liao (65) 2014 AC UT 30 30 34 34 once/d, 30 min/once once/d, 30 min/once ST25, CV4, CV3, EX-CA1, SP10, SP6, ST28, SP9, LI4, LR3, SP8, CV6, ST36 F1, F12
MX Liao a (66) 2014 AC UT 35 35 33 34 once/d, 30 min/once once/d, 30 min/once CV3, EX - CA1, SP10, SP6, ST25, CV4 F1, F13
BK Li (67) 2016 AC UT 30 30 33 33 once/d, 30 min/once once/d, 30 min/once SP6, ST25, SP10, LI4, ST28, SP8, ST36, SP9 F1, F12
XQ Huang (68) 2023 AC UT 61 61 41 42 once/d, 20 min/once once/d, 20 min/once CV4, CV6, CV8, SP6 F1, F3, F12, F13
ZX Cheng (69) 2020 AC UT 30 30 41 35 once/d, 40 min/once once/d, 40 min/once DU20, CV4, CV6, ST36, SP6, ST29, EX - CA1, CV3, LR3 F1
J Li (70) 2021 MOX UT 45 45 36 34 once/d, 30 min/once once/d, 30 min/once CV3, CV6, ST36, GB34, SP6, SP10 F1
T Nie (71) 2023 AC UT 41 41 34 35 once/d, 40 min/once once/d, 40 min/once CV3, CV4, CV6, ST25, SP6, ST36 F1, F13
GL Shi (72) 2017 AC UT 43 43 38 38 once/d, 30 min/once once/d, 30 min/once CV3, EX - CA1, SP10, SP6, ST25, CV4 F1, F13
LY Liu (73) 2010 AC UT 59 59 35 34 once/d, 30 min/once once/d, 30 min/once CV6, CV3, SP10, ST36, SP9, SP6 F1
HX Tao (74) 2009 AC UT 30 30 35 34 once/d, 30 min/once once/d, 30 min/once CV6, CV3, SP10, ST36, SP9, SP6 F1
J Lu (75) 2013 AC UT 52 51 – – once/d, 30 min/once once/d, 30 min/once ST25, CV4, EX - CA, SP6 F1
L Tian (76) 2020 AC UT 72 72 36 36 once/d, 30 min/once once/d, 30 min/once CV4, ST28, ST29, BL23, BL32 F1, F2, F3, F13
F Liao (77) 2019 AC_CUP UT 60 60 45 46 once/d, 30 min/once once/d, 30 min/once CV4, CV3, EX - CA1, ST29, SP6, ST36, BL23 F1, F3, F12, F13
XL Huang (78) 2018 AC_AI UT 40 40 32 32 once/d, 30 min/once once/d, 30 min/once CV6, CV3, SP6, SP9, ST36 F1, F2, F3
LH Li (79) 2021 AC UT 80 80 38 39 once/d, 30 min/once once/d, 30 min/once BL32, CV4, SP6, CV6, BL31, BL26 F1, F13
CX Yang (80) 2024 AC UT 43 43 31 32 once/d, 30 min/once once/d, 30 min/once CV4, BL23, BL32, ST28, ST29, CV6, SP6, SP10, EX - CA1 F1
RR Cheng (81) 2023 AC UT 30 30 34 34 once/d, 30 min/once once/d, 30 min/once ST36, SP6, EX - CA1, CV6, CV3 F1, F3, F12
JJ Cheng (82) 2017 AC UT 60 60 36 34 once/d, 30 min/once once/d, 30 min/once CV4, CV3, SP10, ST36, SP6, SP9, ST29, EX - CA1 F1, F3, F12
J Mo (83) 2019 AC UT 40 40 36 36 once/d, 30 min/once once/d, 30 min/once EX - CA1, ST29, SP10, CV4, CV3, SP6, GB34, ST36 F1
X Tian (84) 2018 AC UT:AC_CUP 30 30 34 34 once/d, 30 min/once once/d, 30 min/once SP6, CV4, ST29, CV3, EX - CA1, BL32, ST36, BL23, BL54 F1
X Liu (85) 2020 AC UT 50 50 36 34 once/d, 30 min/once once/d, 30 min/once CV4, ST29, BL32, CV3, EX - CA1, ST36, SP6, BL23, BL54 F1
H Yan (86) 2008 AC UT 30 30 45 45 once/d, 30 min/once once/d, 30 min/once BL23, BL32, BL37, SP6 F1
R Shi (87) 2021 AC UT 35 35 37 37 once/d, 30 min/once once/d, 30 min/once ST36, GV4, EX - BL7, CV4, BL23, EX - CA1 F1, F3, F12, F13
LZ Chen (88) 2014 AC UT 38 38 33 33 once/d, 30 min/once once/d, 30 min/once CV6, CV3, CV4, EX - CA1, SP6, ST36, BL20, BL30, BL32, BL23, BL25 F1
C Zhang (89) 2024 AC UT 30 30 32 32 once/d, 30 min/once once/d, 30 min/once CV6, CV3, CV4, EX - CA1, ST36, SP6 F1, F3, F12, F13
WC Li (90) 2014 AC UT 50 50 35 34 once/d, 30 min/once once/d, 30 min/once ST36, CV3, PC6, BL25, SP6, CV4, ST29, GB34, SP9 F1, F2, F3
XL Luo (91) 2022 AC UT 51 51 32 32 once/d, 30 min/once once/d, 30 min/once CV8, CV4, BL23, BL20 F1
XQ Liu (92) 2023 AC UT 30 30 38 37 once/d, 30 min/once once/d, 30 min/once GV3, SP6 F2, F3, F13
MP Dai (93) 2015 MOX UT 84 81 31 32 once/d, 30 min/once once/d, 30 min/once CV3, EX-CA1, ST36, SP6 F1
DB Wu (94) 2015 AAT UT 50 50 32 34 Once/4–6 h, 24 h/once once/4–6 h, 24 h/once GB26, CV6, SP6, CV3, SP8, BL32 F1, F2, F13
YE Wu (95) 2023 AAT UT 43 43 42 42 once/d, 6 h/once once/d, 6 h/once SP6, GB26, CV3 F3, F12, F13
ZY Ye (96) 2023 AC UT 43 43 41 41 once/d, 30 min/once once/d, 30 min/once GB26, EX-CA1, SP10, SP6, CV3, SP9, CV4, ST36, BL23 F1
YX Miao (97) 2015 MOX_AC UT:AC 50 50 28 28 once/d, 30 min/once once/d, 30 min/once SP6, ST29, SP10, CV6, LR2, CV4 F1
HL Zhen (98) 2008 WN TCM 45 40 33 34 once/d 40 min/once once/d 40 min/once CV4, CV6, ST36, BL23 F1, F13

MOX, moxibustion; AC, acupuncture; TCM, traditional Chinese medicine; AAT, Acupoint application therapy; UDD, ultrasonic drug penetration FN, floating needle; WN, warm needle moxibustion; AI, acupoint injection; CUP, cupping; UT, conventional treatment. F1, curative effect; F2, IL-2; F3, TNF-a; F12, IL-6; F13, CRP. “–” Means: not report.

 Inclusion of study risk of bias assessment

The methodological quality of the 84 included studies was evaluated using the Cochrane Risk of Bias tool, assessing seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. The assessment results for each domain are detailed below:

Random Sequence Generation: Low Risk: 49 studies (59.8%) employed standardized methods (e.g., random number tables, computer randomization). Unclear Risk: 19 studies (23.2%) provided insufficient detail regarding the randomization procedure. High Risk: 9 studies (11.0%) utilized potentially biased sequence generation methods, introducing risk of selection bias.

Allocation Concealment: Low Risk: 27 studies (32.9%) implemented adequate concealment methods (e.g., sealed envelopes, central randomization). Unclear Risk: 25 studies (30.5%) did not report sufficient information to judge concealment. High Risk: 32 studies (39.0%) failed to conceal allocation adequately, allowing researcher access to group assignments prior to participant enrollment and substantially elevating selection bias risk.

Blinding of Participants and Personnel: Low Risk: 30 studies (36.6%) employed strategies to blind participants and/or personnel (e.g., placebo, sham procedures, blinding training), minimizing performance bias. Unclear Risk: 8 studies (9.8%) provided inadequate information regarding blinding implementation. High Risk: 39 studies (47.6%) explicitly did not blind participants and personnel due to the nature of the intervention, potentially influencing the measurement of intervention effects.

Blinding of Outcome Assessment: Low Risk: 28 studies (34.1%) implemented methods to blind outcome assessors (e.g., independent assessment, blinded adjudication), reducing detection bias risk. Unclear Risk: 6 studies (7.3%) lacked clear reporting on outcome assessor blinding. High Risk:43 studies (52.4%) did not blind outcome assessors, introducing potential detection bias if assessors were aware of group assignments.

Incomplete Outcome Data: Low Risk:65 studies (79.3%) appropriately handled missing outcome data (e.g., intention-to-treat analysis). Unclear Risk:10 studies (12.2%) failed to report attrition/exclusion rates or reasons. High Risk: 2 studies (2.4%) exhibited high risk due to substantial missing data or inappropriate handling (e.g., high loss-to-follow-up rates, per-protocol analysis with significant exclusions).

Selective Reporting: Low Risk: 72 studies (87.8%) reported outcomes consistent with pre-specified protocols or trial registries. Unclear Risk: 6 studies (7.3%) lacked accessible protocols or registrations, precluding definitive assessment. High Risk: No studies (0%) were judged as high risk for selective outcome reporting. Overall reporting completeness was good.

Other Potential Sources of Bias: Low Risk: 14 studies (17.1%) addressed potential confounding biases (e.g., disclosed funding sources, reported balanced baseline characteristics). Unclear Risk:64 studies (78.0%) did not report sufficient information on potential biases such as funding conflicts, baseline imbalances, or other study-specific limitations. High Risk: No studies (0%) were definitively judged as high risk based on reported information. The potential impact of unreported biases requires consideration, potentially through subgroup analyses.

Among the assessed domains, selective reporting exhibited the lowest overall risk of bias. However, significant methodological concerns were identified: Allocation concealment posed a high risk in a substantial proportion of studies (39.0%, n = 32). Deficiencies in random sequence generation introduced high risk in 11.0% (n = 9) of studies. Inadequate blinding of participants/personnel (high risk: 47.6%, n = 39) and blinding of outcome assessment (high risk: 52.4%, n = 43), along with unclear reporting on blinding strategies, were prevalent issues. Specific high-risk judgments for blinding implementation occurred in 8 studies for participants/personnel and 6 were unclear for outcome assessment. These limitations, particularly in selection bias (randomization, concealment) and performance/detection bias (blinding), may compromise the stability and validity of pooled effect estimates. Subsequent sensitivity analyses are warranted to explore the potential influence of these biases. These methodological limitations must be thoroughly considered when interpreting the overall findings of this systematic review. Graphical representations of the risk of bias assessments across all included studies and domains are provided in Figures 2, 3.

Bias risk ratio chart.

Grid displaying a comparison of different models or studies across multiple criteria. Rows are labeled with names like Jang2020 and BVLC2016, while columns represent criteria such as P(AUDC), Subjective Speed, and more. Cells contain color-coded symbols: green check marks, yellow circles, and red crosses indicating performance levels.

Bias risk summary chart.

Bar graph showing risk of bias in several categories. Categories include random sequence generation, allocation concealment, blinding of participants, blinding of outcome assessment, incomplete outcome data, selective reporting, and other bias. Bars indicate low (green), unclear (yellow), and high (red) risk. Allocation concealment and blinding of participants show higher red sections. A key indicates color meanings. Direct comparison results

Prior to the network meta-analysis, a direct comparison meta-analysis was performed on the 84 included RCTs to evaluate pairwise intervention effects. Results are summarized in Table 2. Heterogeneity was assessed using the I2 statistic: a fixed-effect model was applied when I2 ≤ 50%, and a random-effects model when I2 > 50%. For dichotomous outcomes (e.g., overall effectiveness), odds ratios (OR) with 95% confidence intervals (CI) were used; for continuous outcomes (e.g., inflammatory factors), mean differences (MD) with 95% CI were used.

Direct comparison heterogeneity test results table.

Outcomes Pairwise meta-analysis No of study Heterogeneity (%) OR 95%CrI
F1 (Effectiveness) AAT_UDD VS. AAT 1 NA 16.25 (1.88, 999.38)
UT vs. AAT 7 0 0.21 (0.12, 0.37)
AC_CUP vs. AC 1 NA 9.88 (0.81, 173.81)
MOX_AC vs. AC 5 0 6.04 (2.51, 16.10)
UT vs. AC 28 0 0.20 (0.05, 0.81)
UT vs. AC_AI 2 0 0.17 (0.02, 0.88)
UT vs. MOX 9 60.60 0.32 (0.10, 0.96)
WN vs. UT 8 0 14.28 (0.98, 5.96)
WN vs. TCM_WN 2 0 0.27 (0.10, 0.73)
Outcomes Pairwise meta-analysis No of study Heterogeneity (%) MD 95%CrI
F2(IL-2) UT vs. AAT 1 NA −1.89 (−11.94, 8.20)
UT vs. AC 5 98.80 −0.24 (−5.28, 4.78)
UT vs. AC_AI 1 NA −0.60 (−1.09, 9.47)
UT vs. Al 2 99.60 −8.86 (−17.56, −1.73)
UT vs. MOX 4 99.30 −0.48 (−5.48, 4.53)
WN vs. UT 3 99.70 0.75 (−5.26, 6.74)
Outcomes Pairwise meta-analysis No of study Heterogeneity (%) MD 95%CrI
F3(TNF-α) AAT_UDD vs. AAT 1 NA −12.39 (−37.99, 12.90)
UT vs. AAT 6 99.40 10.30 (−1.00, 21.65)
UT vs. AC 10 100 5.06 (−2.92, 13.00)
UT vs. AC_AI 1 NA 0.57 (−24.78, 25.84)
UT vs. AC_CUP 1 NA 0.45 (−24.77, 25.68)
WN vs. AC_WN 1 NA 0.77 (−24.47, 25.80)
UT vs. Al 2 100 32.30 (6.43, 50.24)
UT vs. MOX 5 100 6.55 (−4.66, 17.87)
UT vs. MOX_AAT 1 NA 0.50 (−24.60, 25.81)
UT vs. MOX_AC 1 NA 0.81 (−24.32, 26.26)
WN vs. UT 5 100 5.55 (-16.83, 5.83)
Outcomes Pairwise meta-analysis No of study Heterogeneity (%) MD 95%CrI
F12(IL-6) AAT_UDD vs. AAT 1 NA −1.76 (−152.57, 149.07)
UT vs. AAT 1 NA 4.08 (−145.99, 154.14)
UT vs. AC 10 100 20.73 (−29.62, 70.84)
UT vs. AC_CUP 1 NA 51.95 (−99.65, 201.95)
WN vs. AC_WN 1 NA 11.05 (−138.43, 161.64)
UT vs. Al 2 99.90 −72.06 (−184.05, 34.86)
UT vs. MOX 2 99.80 103.44 (−5.47, 214.22)
UT vs. MOX_AAT 1 NA 0.34 (−150.24, 151.38)
UT vs. MOX_AC 1 NA 179.58 (20.34, 338.96)
WN vs. UT 5 100 −190.73 (-205.47, −175.99)
Outcomes Pairwise meta-analysis No of study Heterogeneity (%) MD 95%CrI
F13 AAT_UDD vs. AAT 1 NA −1.76 (−152.57, 149.07)
UT vs. AAT 1 NA 4.08 (−145.99, 154.14)
UT vs. AC 10 100 20.73 (−29.62, 70.84)
Outcomes Pairwise meta-analysis No of study Heterogeneity (%) MD 95%CrI
F1 (Effectiveness) AAT_UDD VS. AAT 1 NA 16.25 (1.88, 999.38)
UT vs. AC_CUP 1 NA 51.95 (−99.65, 201.95)
WN vs. AC_WN 1 NA 11.05 (−138.43, 161.64)
UT vs. Al 2 99.9 −72.66 (−184.05, 34.88)
UT vs. MOX 2 99.8 103.44 (−5.47, 214.22)
UT vs. MOX_AAT 1 NA 0.34 (−150.24, 151.38)
UT vs. MOX_AC 1 NA 179.58 (20.34, 338.96)
WN vs. UT 5 100 −190.73 (−205.47, -175.99)
F1 (effectiveness)

Nine direct comparisons were analyzed. AAT_UDD showed superior effectiveness over AAT (OR = 16.25, 95% CI: 1.88–999.38). Both AC_CUP (OR = 9.88, 95% CI: 0.81–173.81) and MOX_AC (OR = 6.04, 95% CI: 2.51–16.10) were more effective than AC alone. Multiple therapies—including WN, AAT, AC, AC_AI, and MOX—demonstrated higher effectiveness than UT (all OR < 0.37, I2 = 0–60.6%). TCM_WN also outperformed WN alone (OR = 0.27, 95% CI: 0.10–0.73).

 F2 (IL-2)

Among six comparisons, only AI significantly reduced IL-2 levels compared to UT (MD = –8.86, 95% CI: −17.56 to −1.73), despite high heterogeneity (I2 = 99.6%). All other comparisons showed no significant differences with wide confidence intervals.

 F3 (TNF-α)

AI was superior to UT in reducing TNF-α (MD = 32.30, 95% CI: 6.43–50.24), though heterogeneity was high (I2 = 100%). None of the other ten comparisons showed statistically significant differences.

 F12 (IL-6)

MOX_AC significantly lowered IL-6 compared to UT (MD = 179.58, 95% CI: 20.34–338.96). No other comparisons among the ten analyzed reached statistical significance, with several showing high heterogeneity (I2 up to 100%).

 F13 (CRP)

None of the ten direct comparisons for CRP showed statistically significant differences. High heterogeneity was observed in key comparisons such as UT vs. AI (I2 = 99.9%) and UT vs. MOX (I2 = 99.8%).

 Evidence map of reticulation

F1 (Effectiveness): 73 papers covered 15 interventions. Frequent comparisons existed between AAT_UDD, MOX_WN, and AC_MOX_CUP. Three closed loops were present: Loop 1: AAT_UDD—MOX_WN—AC_MOX_CUP; Loop 2: MOX_WN—TCM_WN—WN; Loop 3: AC_MOX_CUP—WN—MOX_WN (see Figure 4A).

Network plot of meta-analysis. (A) Efficacy. (B) IL-2. (C) TNF-α. (D) IL-6. (E) CRP.

Five network diagrams labeled A to E, each showing nodes connected by lines of varying thickness. Nodes are labeled with abbreviations like UT, AC, MOX, and AAT. Line thickness indicates different strengths of connections between nodes. Each diagram varies in node arrangement and connection styles.

F2 (IL-2): 15 papers covered 7 interventions. Frequent comparisons between AC and AI. One closed loop: AC—AI—MOX—AC (see Figure 4B).

F3 (TNF-α): 33 papers covered 12 interventions. Frequent comparisons between AC and AI. One closed loop: AC—AI—MOX—AC (see Figure 4C).

F12 (IL-6): 24 papers covered 11 interventions. Frequent comparisons between MOX_AAT and AAT_UDD (see Figure 4D).

F13 (CRP): 29 papers covered 12 interventions. Frequent comparisons between MOX_AAT and AI. One closed loop: AI—MOX_AAT—AC_CUP—AI (see Figure 4E).

 Results of reticulated meta-analysis under the consistency model and cumulative probability ranking

Under the consistency model, all PSRF values equaled 1.00, indicating good model stability. Results comparing different interventions against acupuncture (AC) and conventional treatment (CT, UT) are presented below (Tables 3, 4 and Supplementary Tables 2–5 summarize pairwise comparisons).

Results of network meta-analysis of efficacy.

OR95%Cri
AAT
0.07 (0, 0.5)* AAT_UDD
0.91 (0.51, 1.67) 13.08 (1.65, 383.89)* AC
0.82 (0.1, 4.25) 11.97 (0.64, 465.13) 0.91 (0.11, 4.36) AC_AI
0.08 (0, 0.6)* 1.13 (0.02, 52.4) 0.09 (0, 0.61)* 0.1 (0, 1.67) AC_CUP
1.12 (0.26, 4.07) 16.32 (1.35, 546.93)* 1.23 (0.3, 4.07) 1.37 (0.17, 14.3) 14.37 (1.26, 517.84)* AC_MOX_ CUP
0.23 (0.04, 1.03) 3.44 (0.24, 126.88) 0.26 (0.05, 1.06) 0.29 (0.03, 3.45) 3.02 (0.22, 114.68) 0.21 (0.03, 1.45) AC_WN
0.49 (0.07, 2.26) 7.07 (0.43, 268.88) 0.54 (0.08, 2.28) 0.59 (0.05, 7.53) 6.31 (0.38, 251.44) 0.44 (0.05, 3.14) 2.09 (0.19, 18.64) FN
1.51 (0.79, 2.96) 21.82 (2.69, 644.24)* 1.67 (1.02, 2.69)* 1.83 (0.37, 15.63) 19.22 (2.59, 595.72)* 1.36 (0.39, 5.62) 6.45 (1.53, 35.49)* 3.07 (0.71, 22.19) MOX
0.8 (0.09, 4.21) 11.64 (0.62, 467.49) 0.88 (0.11, 4.32) 0.97 (0.07, 13.18) 10.31 (0.57, 411.35) 0.71 (0.07, 5.79) 3.4 (0.29, 33.6) 1.63 (0.13, 18.94) 0.53 (0.06, 2.66) MOX_AAT
0.23 (0.09, 0.57)* 3.37 (0.37, 102.84) 0.26 (0.12, 0.51)* 0.28 (0.05, 2.62) 2.98 (0.35, 94.45) 0.21 (0.05, 0.97)* 0.99 (0.2, 6.07) 0.47 (0.09, 3.66) 0.15 (0.06, 0.35) 0.29 (0.05, 2.6) MOX_AC
0.07 (0, 0.49)* 0.94 (0.02, 44.32) 0.07 (0, 0.51)* 0.08 (0, 1.43) 0.83 (0.02, 41.64) 0.06 (0, 0.63)** 0.28 (0.01, 3.41) 0.13 (0, 2.08) 0.04 (0, 0.31) 0.08 (0, 1.39) 0.29 (0.01, 2.28) MOX_WN
0.28 (0.08, 0.88)* 4.1 (0.39, 133.39) 0.31 (0.1, 0.87)* 0.34 (0.05, 3.45) 3.64 (0.36, 121.35) 0.25 (0.05, 1.37) 1.2 (0.23, 7.58) 0.58 (0.09, 4.95) 0.19 (0.06, 0.55)* 0.35 (0.05, 3.46) 1.21 (0.32, 4.3) 4.26 (0.5, 141.73) TCM_WN
4.53 (2.74, 7.82)* 65.38 (8.43, 1895.5)* 5 (3.81, 6.61)* 5.49 (1.18, 45.4)* 57.48 (8.11, 1764.02)* 4.07 (1.27, 15.98)* 19.34 (4.84, 102.68)* 9.19 (2.25, 63.93)* 3 (2.03, 4.51)* 5.68 (1.19, 45.33)* 19.47 (9.53, 43.04)* 68.03 (10.08, 2156)* 16.15 (5.95, 48.54)* UT
1.02 (0.52, 2.03) 14.8 (1.81, 439.77)* 1.13 (0.67, 1.87) 1.24 (0.25, 10.58) 13.03 (1.72, 407.2)* 0.92 (0.26, 3.82) 4.34 (1.17, 21.94)* 2.08 (0.47, 15.1) 0.68 (0.37, 1.21) 1.28 (0.25, 10.63) 4.4 (1.89, 10.81)* 15.18 (2.4, 472.14)* 3.63 (1.47, 9.99)* 0.23 (0.14, 0.34)* WN

*(P < 0.05) valid.

Results of network meta-analysis of IL-2.

MD95% Cri
AAT
1.67 (−9.59, 12.96) AC
1.31 (−12.88, 15.57) −0.34 (−11.55, 10.94) AC_AI
−6.92 (−20.75, 4.96) −8.6 (−18.96, −0.06) −8.23 (−22.03, 3.74) AI
1.43 (−9.82, 12.65) −0.24 (−7.3, 6.86) 0.11 (−11.12, 11.4) 8.38 (−0.18, 18.75) MOX
1.9 (−8.18, 11.98) 0.24 (−4.77, 5.24) 0.61 (−9.45, 10.65) 8.86 (1.68, 17.67)* 0.48 (−4.55, 5.49) UT
1.13 (−10.57, 12.9) −0.53 (−8.34, 7.35) −0.16 (−11.89, 11.52) 8.08 (−1.06, 18.96) −0.3 (−8.09, 7.5) −0.77 (−6.8, 5.26) WN

*(P < 0.05) valid.

 F1 (effectiveness)

Compared to CT (UT), patients with CPID showed significantly increased effectiveness after treatment with: Acupoint application therapy (AAT vs. UT: OR = 4.53, 95%CrI = 2.74–7.82); Acupoint application therapy + ultrasonic drug penetration (AAT_UDD vs. UT: OR = 65.38, 95%CrI = 8.43–1895.5); Acupuncture + acupoint injection (AC_AI vs. UT: OR = 65.38, 95%CrI = 5.49–45.4);Acupuncture + cupping (AC_CUP vs. UT: OR = 57.48, 95%CrI = 8.11–1764.02); Acupuncture + moxibustion + cupping (AC_MOX_CUP vs. UT: OR = 4.07, 95%CrI = 1.27–15.98); Acupuncture + warm needle moxibustion (AC_WN vs. UT: OR = 19.34, 95%CrI = 4.84–102.68); Floating needle (FN vs. UT: OR = 9.19, 95%CrI = 2.25–63.93); Moxibustion (MOX vs. UT: OR = 3.00, 95%CrI = 2.03–4.51); Moxibustion + acupoint application therapy (MOX_AAT vs. UT: OR = 5.68, 95%CrI = 1.19–45.33); Moxibustion + acupuncture (MOX_AC vs. UT: OR = 19.47, 95%CrI = 9.53–43.04); Moxibustion + warm needle moxibustion (MOX_WN vs. UT: OR = 68.03, 95%CrI = 10.08–2156.00); Traditional Chinese medicine + warm needle moxibustion (TCM_WN vs. UT: OR = 16.15, 95%CrI = 5.95–48.54);Acupuncture (AC vs. UT: OR = 5.00, 95%CrI = 3.81–6.61); Warm needle moxibustion (WN vs. UT: OR = 0.23, 95%CrI = 0.14–0.34)

Compared to Moxibustion + warm needle moxibustion (MOX_WN), the following interventions showed significantly lower effectiveness: Acupoint application therapy (AAT vs. MOX_WN: OR = 0.07, 95%CrI = 0–0.49);Acupuncture (AC vs. MOX_WN: OR = 0.07, 95%CrI = 0–0.51);Acupuncture + moxibustion + cupping (AC_MOX_CUP vs. MOX_WN: OR = 0.06, 95%CrI = 0–0.63); Warm needle moxibustion and moxibustion (WN vs. MOX_WN: OR = 15.18, 95%CrI = 2.4–472.14) (see Table 3 for details).

 F2 (IL-2)

Compared to CT (UT), acupoint injection (AI) significantly increased IL-2 levels (AI vs. UT: MD = −8.6, 95%CrI = −18.96 to –0.06).

Compared to acupuncture (AC), acupoint injection (AI) also significantly increased IL-2 (AI vs. AC: MD = −8.6, 95%CrI = −18.96 to −0.06) (see Table 4).

 F3 (TNF-α)

Compared with acupoint injection (AI), patients with chronic pelvic inflammatory disease were more likely to receive cupping after acupuncture [AC vs. AI: MD = 27.31, 95%CrI = 7.85, 46.82)], Acupoint application therapy[AAT vs. AI: MD = 22.05, 95%CrI = 1.01, 43.11)], acupuncture + acupoint injection [AC_AI vs. AI: MD = 31.74, and 95%CrI = 0.95, 62.57)], acupuncture + cupping [AC_CUP vs. AI: MD = 32.05, 95%CrI = 1.29, 63.07)], moxibustion [MOX vs. AI: MD = −25.86, 95%CrI = −46.86, −4.8)], and moxibustion + acupoint application therapy [MOX_AAT vs. AI: MD = −31.98, 95%CrI = −62.82, −1.2)], moxibustion + acupuncture [MOX_AC vs. AI: MD = −31.56, 95%CrI = −62.41, −0.6)], and warm needle moxibustion [WN vs. AI: MD = −26.86, 95%CrI = −47.89, −5.8)] treatment resulted in a significant increase in TNF-α.

IL-2 decreased significantly in patients with chronic pelvic inflammatory disease after treatment with acupoint injections [AI vs. UT: MD = −32.4, 95%CrI = −50.13, −14.59)] compared to conventional treatment (UT) (see Supplementary Table 2).

 F12 (IL-6)

Compared to Moxibustion + Acupuncture (MOX_AC), acupoint injection (AI) significantly increased IL−6 (AI vs. MOX_AC: MD = 253.59, 95%CrI = 61.51–448.84).

Compared to CT (UT), Moxibustion + Acupuncture (MOX_AC) significantly decreased IL-6 (MOX_AC vs. UT: MD = −180.7, 95%CrI = −340.82 to −21.17) (see Supplementary Table 3).

 F13 (CRP)

Compared to Acupoint Injection (AI), the following interventions significantly decreased CRP: Acupoint application therapy (AAT vs. AI: MD = −17.22, 95%CrI = −25.41 to −9.01); Acupoint application therapy + ultrasonic drug penetration (AAT_UDD vs. AI: MD = 16.34, 95%CrI = 5.18–27.54);Acupuncture (AC vs. AI: MD = 16.98, 95%CrI = 8.85–25.13);Acupuncture + cupping (AC_CUP vs. AI: MD = 17.37, 95%CrI = 6.61–28.15);Floating needle (FN vs. AI: MD = −19.78, 95%CrI = −29.09 to −10.46);Moxibustion + acupoint application therapy (MOX_AAT vs. AI: MD = −18.93, 95%CrI = −29.69 to −8.12); Moxibustion + needling (MOX_AC vs. AI: MD = −18.48, 95%CrI = −27.81– −9.16); Warm needle moxibustion (WN vs. AI: MD = −18.38, 95%CrI = −26.90 to −9.88); Warm needle moxibustion + traditional Chinese medicine (WN_TCM vs. AI: MD = −15.00, 95%CrI = −26.90 to −9.88)

Compared to CT (UT), the following significantly decreased CRP: Acupoint application therapy (AAT vs. UT: MD = −3.39, 95%CrI = −6.47 to −0.27); Acupoint injection (AI vs. UT: MD = −20.60, 95%CrI = −28.22 to –12.96); Moxibustion (MOX vs. UT: MD = −13.44, 95%CrI = −17.90 to −8.99) (see Supplementary Table 4).

 Cumulative ranking probability results

The interventions were ranked based on the SUCRA results (see Supplementary Table 5).

F1 (Overall Response Rate): MOX_WN (89.1%) > AAT_UDD (88.0%) > AC_CUP (86.8%) > MOX_AC (72.2%) > AC_WN (71.0%) > FN (53.3%) > MOX (15.0%) > AC (36.3%) > WN (30.4%) > UT (0.2%).

F2 (IL-2): UT (66.2%) > AC (61.6%) > MOX (58.6%) > WN (55.4%) > AC_AI (57.1%) > AAT (46.4%) > AC_CUP (4.7%).

F3 (TNF-α): AI (95.8%) > AAT_UDD (82.0%) > MOX (51.6%) > AC_CUP (34.0%) > AC (46.7%) > MOX_AC (35.4%) > WN (47.95%) > UT (27.4%).

F12 (IL-6): MOX_AC (92.6%) > MOX (79.0%) > AAT_UDD (41.0%) > AC_WN (57.3%) > AC_CUP (58.5%) > AC (46.3%) > WN (56.1%) > UT (32.0%)

F13 (CRP): AI (99.4%) > MOX (90.5%) > AAT_UDD (53.0%) > MOX_AC (36.9%) > WN_TCM (61.5%) > AC (52.5%) > FN (25.6%) > WN (37.3%) > UT (13.5%).

In the cumulative probability line chart, the higher the SUCRA value for a particular therapy, the higher its efficacy ranking. The SUCRA rankings for the efficacy of different acupuncture therapies in improving various outcome measures for chronic pelvic inflammation are as follows (see Figure 5):

Cumulative probability line graph. (A) Efficacy. (B) IL-2. (C) TNF-α. (D) IL-6. (E) CRP.

Five cumulative probability plots labeled A to E display treatment rankings. Each plot features curves representing different treatments, denoted by distinct colors and labels. The x-axis shows rank, while the y-axis indicates cumulative probability. Legends below each plot define treatment identifiers, with variations across the plots.

F1 ranking: TCM_WN (0.75) > AC_WN (0.70) > MOX_AAT (0.65) > AC_AI (0.60) > AAT (0.55) > MOX_AC (0.50) > UT (0.45) > AC_CUP (0.40) > AAT_UDD (0.35) > FN (0.30) > G (0.25) > AC_MOX_CUP (0.20) > MOX (0.18) > WN (0.15) > MOX_WN (0.12) > AC (0.10).

F2 ranking: MOX (0.75) > AAT (0.65) > AC_AI (0.58) > WN (0.50) > AI (0.35) > AC (0.25) > UT (0.10).

F3 ranking: AC_AI (0.82) > AAT (0.75) > AI (0.68) > MOX_AC (0.55) > AAT_UDD (0.48) > AC_CUP (0.42) > MOX (0.35) > UT (0.28) > G (0.22) > AC_WN (0.18) > MOX_AAT (0.15) > WN (0.12) > AC (0.10).

F12 sorted as: AC_CUP (0.78) > AAT (0.70) > MOX (0.65) > UT (0.58) > WN (0.50) > G (0.42) > AAT_UDD (0.35) > AC_WN (0.28) > MOX_AAT (0.22) > MOX_AC (0.18) > AC (0.15) > AI (0.10).

F13 ranking: AC_CUP (0.85) > UT (0.78) > MOX (0.72) > AAT (0.65) > AI (0.58) > AAT_UDD (0.50) > G (0.42) > MOX_AAT (0.35) > WN (0.28) > WN_TCM (0.22) > MOX_AC (0.18) > FN (0.15) > AC (0.10).

 Publication bias analysis

F1 (Effectiveness): Points are scattered without obvious asymmetry, suggesting low publication bias risk.

F2 (IL-2): Fewer points on the right side (positive effect size area) may indicate missing negative results (potential publication bias).

F3 (TNF-α): Symmetrical point distribution, suggesting low bias risk.

F12 (IL-6): Dense clustering on the left side (negative effect size area) may suggest concentration of negative results in small sample studies.

F13 (CRP): Points are generally symmetrical at the top, with few outliers at the bottom, suggesting low overall bias risk. See Supplementary Figure 1 for funnel plots.

 Discussion

By integrating data from 84 randomized controlled trials (RCTs) involving 8147 patients with chronic pelvic inflammatory disease (CPID), this network meta-analysis systematically compared the efficacy of nine interventions, including moxibustion (MOX), acupuncture (AC), traditional Chinese medicine (TCM), acupoint application therapy (AAT), ultrasonic drug penetration (UDD), floating needle (FN), warm needle moxibustion (WN), acupoint injection (AI), and cupping (CUP).(The aforementioned interventions are combined in pairs or multiples to form composite treatment protocols based on clinical needs). Key findings revealed that: AI demonstrated optimal efficacy for modulating TNF-α (SUCRA = 95.8%) and CRP (SUCRA = 99.4%). MOX + AC showed superior improvement in IL-6 (SUCRA = 92.6%). AC achieved the most significant reduction in IL-2 (SUCRA = 61.6%). Moxibustion combined with warm needle moxibustion (MOX + WN) and AAT + UDD ranked highest for overall clinical effectiveness (SUCRA = 89.1 and 88.0%, respectively).

As the first study to establish a multi-dimensional efficacy evaluation system using Bayesian modeling, we quantified the specific advantages of interventions across clinical and inflammatory endpoints—overcoming the single-endpoint limitations of traditional meta-analyses. This approach integrated direct and indirect evidence to establish an “intervention–inflammatory target” precision-matching model, providing an evidence-based foundation for individualized CPID therapy.

Efficacy and mechanism from a traditional Chinese medicine perspective

According to Traditional Chinese Medicine (TCM), chronic pelvic inflammatory disease (CPID) is fundamentally characterized by the accumulation of damp-heat and blood stasis in the lower jiao, which disrupts the normal circulation of qi and blood. This pathological pattern aligns with the classical TCM principle that “obstruction leads to pain,” and helps explain the persistent lower abdominal discomfort, distending pain, and lumbosacral soreness commonly observed in CPID patients.

Among the interventions examined in this study, moxibustion combined with warm needle therapy demonstrated particularly strong therapeutic effects—a finding consistent with the TCM treatment strategy of “warming the meridians to unblock obstruction and promoting blood flow to relieve pain.” Moxibustion acts to warm and strengthen the lower jiao, effectively dispelling cold-dampness, while warm needle therapy directs thermal stimulation deeply into affected tissues. Together, these methods enhance qi and blood circulation, directly addressing the stasis and cold-dampness that underlie CPID pathology.

In terms of acupoint selection, the treatment protocols commonly adopted in the included studies emphasized the use of core points such as Guanyuan (CV4), Qihai (CV6), and Sanyinjiao (SP6). Guanyuan and Qihai, located on the Conception Vessel (Ren Mai), function to warm and tonify the lower jiao. Sanyinjiao, a key point of the Spleen Meridian, helps regulate the functions of the Liver, Spleen, and Kidney. When combined with local points such as Zhongji (CV3) and the extra point Uterus (CA-CV), this combination reflects a treatment strategy that integrates systemic regulation with targeted local intervention.

It is also noteworthy that the analgesic effect of acupuncture is not limited to CPID. Systematic reviews have confirmed its efficacy in managing various chronic pain conditions (99), supporting the broader relevance of our findings. This suggests that acupuncture’s ability to regulate qi and blood circulation represents a shared mechanism that contributes to its therapeutic effects in CPID and other chronic inflammatory disorders.

This study not only confirms the clinical value of specific acupuncture and moxibustion therapies for CPID but also interprets their mechanisms of action through the lens of TCM theory. By integrating classical TCM knowledge with modern clinical evidence, this work helps to establish a more coherent and evidence-informed understanding of how acupuncture treats CPID.

 Interpretation of results Clinical efficacy

MOX + WN (SUCRA = 89.1%) and AAT + UDD (SUCRA = 88.0%) significantly outperformed monotherapies (e.g., AC alone: SUCRA = 36.3%). This synergy arises from: Moxibustion attenuating inflammation via the NLRP3/Caspase-1/GSDMD pathway (100). Warm needle therapy enhancing microcirculation and inflammatory mediator clearance through PI3K/AKT/mTOR signaling (101). Ultrasound drug delivery improving immune function via localized blood flow and anti-inflammatory absorption (102). Acupoint application induces the regulation of IL-6 and IL-10 by ovalbumin (OVA) to alleviate inflammation and achieve local anti-inflammatory effects (103).

 Inflammatory response

In this study, IL-2, TNF-α, IL-6, and CRP were selected as key inflammatory markers because they are closely related to the pathological mechanisms of chronic pelvic inflammatory disease (CPID): the core of CPID is persistent inflammatory response, and these four markers can comprehensively assess the inflammatory status by reflecting the degree of disease activity from the dimensions of immune regulation, pro-inflammatory response, and acute inflammation, respectively. They have been widely demonstrated to correlate with disease severity, treatment efficacy and prognosis in pelvic inflammatory diseases, and are commonly used in international and national studies to evaluate inflammation, facilitating cross-sectional comparison and interpretation of results.

IL-2 is mainly secreted by T cells, which can promote the proliferation of immune cells and enhance the immune response, and changes in its level can reflect the dynamic changes of the body’s immune regulation function in inflammation. TNF-α is an important pro-inflammatory cytokine, which can initiate the inflammatory cascade reaction and induce the release of other inflammatory factors, and plays a key role in the development of pelvic inflammatory injuries. IL-6 is a combination of proinflammatory and anti-inflammatory effects, and persists in chronic inflammation, and has been shown to play a role in both inflammation and anti-inflammatory diseases. IL-6 has both pro-inflammatory and anti-inflammatory effects, and is continuously elevated in chronic inflammation, correlating with tissue damage, pain and inflammation prolongation, and is a sensitive indicator of the degree of active inflammation. CRP is an acute phase protein synthesized by the liver, and is rapidly elevated in response to inflammatory stimuli, which can reflect the intensity of the body’s acute inflammatory response, and is often used to assess the effect of inflammation control after treatment. Therefore, changes in IL-2, IL-6, TNF-α and CRP levels were evaluated as indicators of inflammation improvement.

IL-2 Reduction: AC (SUCRA = 61.6%) outperformed conventional therapy (UT; SUCRA = 66.2%), likely due to UT’s insufficient suppression of baseline inflammation. AC’s immunomodulatory role involves inhibiting TLR4/NF-κB signaling (104–106). TNF-α/CRP Suppression: AI ranked first for both (SUCRA > 95%), attributable to localized drug effects at acupoints (107, 108). IL-6 Modulation: MOX + AC (SUCRA = 92.6%; MD = 253.59, 95% CI: 61.51–448.84) leverages synergistic warming (via PI3K/AKT/mTOR) and needling effects (109–111). Electroacupuncture further suppresses inflammation through neural pathways (112, 113).

 Comparison with prior reviews

Unlike previous reviews focused solely on antibiotics, this study integrated nine acupuncture therapies and four inflammatory biomarkers into a coherent evidence network, establishing a “therapy–target” association framework. Using Bayesian network meta-analysis with SUCRA ranking, we clarified the efficacy hierarchy of acupuncture therapies in inflammation control, overcoming the limitations of qualitative comparisons. Furthermore, we identified the “MOX + AC → IL-6 → PI3K/AKT/mTOR” pathway, extending evidence on acupuncture’s anti-inflammatory mechanisms. The model showed excellent convergence (PSRF = 1.00), consistent with the approach of Fan Y, Zhu C, etc.(114), confirming methodological robustness.

 Clinical implications

Unlike previous reviews that primarily focused on antibiotic treatments, the present study integrated nine acupuncture-related therapies and four inflammatory biomarkers into a comprehensive evidence network, thereby establishing a more holistic evidence base for “therapy–target” associations. By adopting a Bayesian framework for network meta-analysis, this study provided quantitative rankings of interventions based on the surface under the cumulative ranking curve (SUCRA), overcoming the qualitative limitations of conventional pairwise meta-analyses and clarifying the efficacy hierarchy of different acupuncture modalities in modulating inflammatory responses. Furthermore, the identification of the “moxibustion plus acupuncture → IL-6 → PI3K/AKT/mTOR signaling pathway” axis adds a new dimension to the mechanistic understanding of acupuncture’s anti-inflammatory effects. The model demonstrated excellent convergence (PSRF = 1.00), which aligns with the analytical approach employed by Fan et al. (2) in a study on acute gouty arthritis, underscoring the methodological robustness and reliability of our findings.

 Limitations

Despite a robust evidence network and model convergence (PSRF = 1.00), limitations include: methodological Constraints: blinding challenges in acupuncture trials and inadequate reporting of allocation concealment may introduce bias. Evidence Gaps: limited RCTs for interventions like floating needles or cupping weaken network confidence. Statistical Inconsistency: direct/indirect comparison discrepancies for IL-6 and CRP require head-to-head RCT validation. Heterogeneity: variability in acupuncture duration/point selection (e.g., IL-2, TNF-α) warrants subgroup exploration. Generalizability: short intervention periods (2–4 weeks) and non-standardized techniques limit extrapolation.

 Conclusion

This Bayesian network meta-analysis establishes optimal CPID therapies: overall Efficacy: MOX + WN or AAT + UDD (SUCRA > 88%). Targeted Modulation: TNF-α/CRP → AI (SUCRA > 95%). IL-6 → MOX + AC (SUCRA = 92.6%). IL-2 → AC (SUCRA = 61.6%). Clinical decisions should align inflammatory profiles with “therapy–target”*matching (e.g., AI for antibiotic resistance). Future multicenter RCTs should validate combination therapies and molecular targets to standardize acupuncture in chronic inflammatory disease management.

 Data availability statement

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

 Author contributions

YitZ: Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. JH: Methodology, Writing – original draft. YijZ: Formal analysis, Investigation, Writing – review & editing. DN: Formal analysis, Investigation, Writing – review & editing. YW: Funding acquisition, Resources, Supervision, Writing – review & editing.

 Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

 Correction note

This article has been corrected with minor changes. These changes do not impact the scientific content of the article.

 Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmed.2025.1731543/full#supplementary-material

 References Ravel J Moreno I Simón C. Bacterial vaginosis and its association with infertility, endometritis, and pelvic inflammatory disease. Am J Obstet Gynecol. (2021) 224:251–7. 10.1016/j.ajog.2020.10.019 33091407 Hillier S Bernstein K Aral S. A review of the challenges and complexities in the diagnosis, etiology, epidemiology, and pathogenesis of pelvic inflammatory disease. J Infect Dis. (2021) 224:S23–8. 10.1093/infdis/jiab116 34396398 Savaris R Fuhrich D Maissiat J Duarte R Ross J. Antibiotic therapy for pelvic inflammatory disease. Cochrane Database Syst Rev. (2020) 8:Cd010285. 10.1002/14651858.CD010285.pub3 32820536 Huemer M Mairpady Shambat S Brugger S Zinkernagel A. Antibiotic resistance and persistence-Implications for human health and treatment perspectives. EMBO Rep. (2020) 21:e51034. 10.15252/embr.202051034 33400359 Dilley M Geng B. Immediate and delayed hypersensitivity reactions to antibiotics: aminoglycosides, clindamycin, linezolid, and metronidazole. Clin Rev Allergy Immunol. (2022) 62:463–75. 10.1007/s12016-021-08878-x 34910281 Jiang L Li P Wang Y Jiang M Han X Bao Y Anti-inflammatory effects of acupuncture in the treatment of chronic obstructive pulmonary disease. J Integr Med. (2023) 21:518–27. 10.1016/j.joim.2023.11.005 37989696 Song J Sun Z Ma Y. Efficacy and safety of Shen Que (RN8) moxibustion on reproductive outcomes in unexpected poor ovarian responders: a randomized controlled trial. J Ovarian Res. (2024) 17:177. 10.1186/s13048-024-01493-2 39210342 Yan S Chen Y Huang Z Zhong W Wang X Tang Y Acupoint autohemotherapy attenuates dncb-induced atopic dermatitis and activates regulatory T cells in BALB/c mice. J Inflamm Res. (2024) 17:2839–50. 10.2147/JIR.S454325 38751687 Kidwell K Almirall D. Sequential, multiple assignment, randomized trial designs. Jama. (2023) 329:336–7. 10.1001/jama.2022.24324 36692577 Page M McKenzie J Bossuyt P Boutron I Hoffmann T Mulrow C The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj. (2021) 372:n71. 10.1136/bmj.n71 33782057 Ruano J Gay-Mimbrera J Aguilar-Luque M Gómez-García F Parra-Peralbo E Isla-Tejera B. Evolution of appraisal tool usage preferences in PROSPERO records: a study of non-Cochrane systematic reviews. BMC Med Res Methodol. (2023) 23:294. 10.1186/s12874-023-02114-0 38097923 Curry A Williams T Penny M. Pelvic inflammatory disease: diagnosis, management, and prevention. Am Fam Physician. (2019) 100:357–64. Crocker T Lam N Jordão M Brundle C Prescott M Forster A Risk-of-bias assessment using Cochrane’s revised tool for randomized trials (RoB 2) was useful but challenging and resource-intensive: observations from a systematic review. J Clin Epidemiol. (2023) 161:39–45. 10.1016/j.jclinepi.2023.06.015 37364620 Liu W Fan Y Wu Y Hou X Xue B Li P Efficacy of acupuncture-related therapy in the treatment of knee osteoarthritis: a network meta-analysis of randomized controlled trials. J Pain Res. (2021) 14:2209–28. 10.2147/JPR.S315956 34321920 Liu M Yang CM Wang Y. Efficacy of moxibustion on Dong’s extraordinary points combined with microwave therapy on chronic pelvic inflammatory disease and its effect on serum IL-2 and TNF-α. Shanghai J Acupunct Moxibustion. (2018) 37:1156–9. 10.13460/j.issn.1005-0957.2018.10.1156 Wang B Fang YM. Effect of moxibustion combined with acupuncture on female chronic pelvic inflammatory disease and its influence on clinical symptoms and quality of life. Chinese Foreign Women’s Health Res. (2024) 12:50–2. Kang Y Lai HQ Yang YC. Clinical observation on moxibustion combined with Huoxue Bushen Formula for chronic pelvic inflammatory disease. Guangming J Chinese Med. (2024) 39:1999–2002. 10.3969/j.issn.1003-8914.2024.10.029 Wang Y He YY. Clinical effect of moxibustion combined with microwave physiotherapy and antibiotics on chronic pelvic inflammatory disease. Chinese Foreign Med Res. (2024) 22:155–8. 10.14033/j.cnki.cfmr.2024.36.040 Wang L Lai YT. Clinical observation on moxibustion combined with acupoint application as adjuvant treatment for chronic pelvic inflammatory disease of qi stagnation and blood stasis type. J Pract Traditional Chinese Med. (2024) 40:2200–2. Li Y Zhu WH Yin D Zhang XS Ou JX. Observation on the curative effect of moxibustion combined with Chinese medicine enema on chronic pelvic inflammatory disease. Inner Mongolia J Traditional Chinese Med. (2020) 39:111–2. Wang Y Zhang GZ Li YH Wang YJ Li N Wei YH. Clinical observation on moxibustion therapy combined with scraping for chronic pelvic inflammatory disease of cold-dampness stagnation type. Modern J Integr Traditional Chinese Western Med. (2015) 24:2197–9. 10.3969/j.issn.1008-8849.2015.20.010 Nong X Cheng WP. Efficacy of moxibustion combined with ligustrazine on chronic pelvic inflammatory disease of cold-dampness stagnation type and its effects on CRP, IL-6 and TNF-α. Chinese J Basic Med Traditional Chinese Med. (2017) 23:387–9. Xu M Qu Z. Curative effect observation of moxibustion box combined with traditional Chinese medicine directional drug penetration therapy apparatus on chronic pelvic inflammatory disease. J Clin Rational Drug Use. (2015) 4:91–2. 10.15887/j.cnki.13-1389/r.2015.04.052 Yang X Wang SM. Effect of salt-separated moxibustion with moxa cones combined with Chinese medicine enema on chronic pelvic inflammatory disease and its influence on inflammatory factors. Guangming J Chinese Med. (2021) 36:423–5. 10.3969/j.issn.1003-8914.2021.03.037 Chen F. Study on the effect of ultrasonic drug penetration combined with acupuncture point application in chronic pelvic inflammatory disease with damp-heat and stagnation evidence. World J Complex Med. (2023) 9:130–3. 10.11966/j.issn.2095-994X.2023.09.04.35 Wei H Yan SY Yin YR Li JX Wang YL Duan ZF. Effects of electroacupuncture combined with Chinese medicine enema on pelvic floor electromyography, inflammatory mediators, and immune function in patients with chronic pelvic inflammatory disease. Shanghai J Acupunct Moxibustion. (2021) 40:585–9. 10.13460/j.issn.1005-0957.2021.05.0585 Pan Q Xu LP Mo Z. Clinical observation on Erdan Hongteng Baijiang decoction combined with moxibustion for chronic pelvic inflammatory disease. J Sichuan Traditional Chinese Med. (2023) 41:173–6. Liu D. Observation on the curative effect of Fu’s acupuncture combined with enema on abdominal pain caused by pelvic inflammatory disease. Chinese Health Care. (2023) 41:29–32. Qi G. Therapeutic effect of Fuke Qianjin tablets combined with acupoint application assisted by antibacterial drugs on chronic pelvic inflammatory disease of dampness-heat accumulation type. Lab Med Clinic. (2018) 15:1204–7. Li L Tian SF. Effect of compound tengjiang decoction retention enema combined with acupuncture at Baliao points on the expression of IL-1β and IL-6 in pelvic inflammatory disease. Chinese Sci Technol J Database. (2022) 9. Jiang B Zhang SQ. Combined treatment of chronic pelvic inflammatory disease with abdominal acupuncture, moxibustion, and Chinese medicine enema. China Pract Med. (2020) 15:133–5. 10.14163/j.cnki.ll-5547/r.2020.04.062 Wang J Wu Y Hu HX. Clinical study on hongteng decoction combined with Fu’s acupuncture therapy for abdominal pain in pelvic inflammatory disease. Acta Chinese Med Pharmacol. (2021) 49:86–9. 10.19664/ccudi.1002-2362.210103 Luo L Dou YX. Clinical effect of Huangqi Guizhi Wuwu decoction combined with warm needle moxibustion on chronic pelvic inflammatory disease. Clin Res Pract. (2020) 5:141–3. Shi X. Effect of acupoint injection with Astragalus Injection on systemic inflammatory response and sexual life quality in patients with chronic pelvic inflammatory disease. Western J Traditional Chinese Med. (2017) 30:102–4. Cheng Qing Z Zhang Y. Effects of astragalus injection at acupoints on IL-2 and TNF-α levels in patients with chronic pelvic inflammatory disease. China Med Guide. (2009) 6:62–3. Chen Y. Study on the effect of ultrasonic drug penetration combined with acupuncture point application in chronic pelvic inflammatory disease with damp-heat and stagnation evidence. Med Forum. (2017) 21:1388–9. 10.19435/j.1672-1721.2017.11.066 Li Y. Clinical observation on thunder-fire moxibustion warm needle combined with Chinese medicine enema for chronic pelvic inflammatory disease. Clin J Chinese Med. (2016) 8:33–5. 10.3969/j.issn.1674-7860.2016.11.015 Zhang C. Clinical study on manpen formula I combined with acupuncture for chronic pelvic inflammatory disease of dampness-heat stasis type. Guangming J Chinese Med. (2022) 37:806–8. 10.3969/j.issn.1003-8914.2022.05.026 Huang Y Zheng M Li YM. Clinical observation on 55 cases of chronic pelvic inflammatory disease treated with oral Chinese medicine combined with warm needle moxibustion. China Inf Traditional Chinese Med. (2011) 3:154. Kong N. Clinical study on pelvic inflammation decoction combined with acupoint application for chronic pelvic inflammatory disease. Pract Clin J Integr Traditional Chinese Western Med. (2022) 22:36–9. 10.13638/j.issn.1671-4040.2022.14.010 Sang H Jia SH Li YP Cui W. Shaofu Mixture combined with acupoint application for chronic pelvic inflammatory disease of dampness-heat stasis syndrome. Chinese J Basic Med Traditional Chinese Med. (2017) 23:1436–8. Shi L Liu LWJ. Efficacy of Tongyuan acupuncture method combined with warm needle moxibustion on chronic pelvic inflammatory disease of qi stagnation and blood stasis type and its effect on serum TNF-α, IL-6, IL-1β levels. J Sichuan Traditional Chinese Med. (2021) 39:202–4. Tao S Song CH Wang JK Mu X Guo R Wu XK. Observation on nursing effect of mild moxibustion combined with microwave physiotherapy on chronic pelvic inflammatory disease of qi stagnation and blood stasis type. J Nurs Sci. (2016) 31:47–9. 10.8870/j.issn.1001-4152.2016.12.047 40489808 Liu J. Study on the effectiveness of warm needle moxibustion combined with Chinese medicine retention enema in the treatment of chronic pelvic inflammatory disease. Chinese Sci Technol J Database Med Healt. (2022) 14:2221–4. Jin X Wang Q. Therapeutic effect of warm acupuncture and moxibustion combined with Huangqi Guizhi Wuwu decoction on chronic pelvic inflammation and its effect on uterine hemodynamics and serum inflammatory factors. Asia-Pacific Traditional Med. (2019) 15:130–2. 10.11954/ytctyy.201907043 Wang L Ying HZ Huang F. Clinical study on warm needle moxibustion combined with Qingre Huoxue decoction for chronic pelvic inflammatory disease with pattern of internal binding of stasis and toxin. J New Chinese Med. (2020) 52:102–4. 10.13457/j.cnki.jncm.2020.23.029 Xiao H Wu AL Liu AH. Application effect of warm needle moxibustion combined with acupoint application in patients with chronic pelvic inflammatory disease. Qingdao Med J. (2024) 56:238–40. 10.3969/j.issn.1006-5571.2024.03.020 Xia X Ding N Wang X. Warm needle moxibustion combined with Chinese medicine retention nema for chronic pelvic inflammatory disease of qi stagnation and blood stasis type and its effect on serum inflammatory factors. J Liaoning Univer Traditional Chinese Med. (2020) 22:163–6. 10.13194/j.issn.1673-842X.2020.01.044 Shi L Sun ZX. Effects of warm needle moxibustion combined with massage on hemorheology and inflammatory factors in patients with chronic pelvic inflammatory disease. Hainan Med J. (2021) 32:1430–3. Tang W. Effect of warm needle moxibustion combined with Chinese medicine retention enema on efficacy and inflammatory factor levels in chronic pelvic inflammatory disease of qi stagnation and blood stasis type. Chinese Sci Technol J Database Med Health. (2021) 13:404–6. Zhou J. Observation on the effect of warm needle moxibustion combined with traditional Chinese medicine on 30 cases of chronic pelvic inflammatory disease. Clin J Chinese Med. (2015) 18-9:21. 10.3969/j.issn.1674-7860.2015.05.008 Zhen H Wang Y Liu XJ. Efficacy observation on warm needle moxibustion for chronic pelvic inflammatory disease of cold-dampness stagnation type. Chinese Acupunct Moxibustion. (2008) 28:736–8. Wang J. Analysis of the effect of warm needle moxibustion on chronic pelvic inflammatory disease. Electronic J Pract Gynecol Endocrinol. (2023) 10:4–6. 10.3969/j.issn.2095-8803.2023.12.002 Chen L Tang C. Clinical effect of acupoint application combined with Yinjia Pills and oral antibiotics on chronic pelvic inflammatory disease of dampness-heat stasis type. China Modern Med. (2019) 26:164–7. Yu Y. Observation on the effect of acupoint application combined with Chinese medicine retention enema on chronic pelvic inflammatory disease. Reflexol Rehabil Med. (2023) 4:11–3. Song X Xie Y Liu M. Acupoint application combined with Chinese medicine retention enema for chronic pelvic inflammatory disease. Changchun Univer Traditional Chinese Med J. (2022) 38:779–82. 10.13463/j.cnki.cczyy.2022.07.017 Huang S Liu J Ouyang XJ Wang CL Yuan WT Zhang Y Effect of acupoint injection on hemorheology and interleukin-2 and interleukin-6 in patients with chronic pelvic inflammatory disease. Med Equipment. (2018) 31:108–9. Hu W Zhao LN Wang HY Liu C Zhao N. Effect of abdominal acupuncture therapy combined with Moxibustion at Shenque on inflammatory factors and clinical symptoms in patients with chronic pelvic inflammatory disease. Chinese J Fam Plann Gynecotokol. (2023) 15:60–4. Shi G Fan ZL Liu M. Study on the clinical effect of Tongtiao Sanjiao acupuncture method on chronic pelvic inflammatory disease of qi stagnation and blood stasis type and its influence on vascular endothelial function and inflammatory response. Healthiness. (2021) 22:207–8. Yuan Y Zhang WT. Clinical value of Ganjiang Lingzhu decoction combined with warm needle moxibustion in treating chronic pelvic inflammatory disease of cold-dampness stagnation type. Today Health. (2024):94–6. Qiu LH. E-cupping therapy combined with acupuncture on treatment efficacy and quality of life in patients with chronic pelvic inflammatory disease. Chronic Pathematol J. (2019) 20:1017–9. Zhou P Zeng ZH Xiang YH. Clinical study on Qingre Lishi Huayu decoction combined with acupuncture and moxibustion for chronic pelvic inflammatory disease with dampness-heat stasis syndrome. World Sci Technol Modernization Traditional Chinese Med. (2014) 12:2630–5. Du X Tian Y Dang B. Study on Yinqiao Hongjiang decoction combined with acupoint application in the treatment of chronic pelvic inflammation of dampness heat stasis type. Sichuan J Anat. (2022) 30:2630–4. 10.11842/wst.2014.12.019 Liao M Shi Y Meng ZZ. Observation on the clinical efficacy of acupuncture on female chronic pelvic inflammatory disease with low-grade inflammation. J Clin Acupunct Moxibustion. (2014) 11:19–21. 10.3969/j.issn.1005-1457.2022.04.026 Liao M Shi Y Meng ZZ. Study on the effects of acupuncture on micro-inflammatory state-related inflammatory factors and clinical efficacy in chronic pelvic inflammatory disease. Chinese Community Doctors. (2014) 24:99–100. 10.3969/j.issn.1007-614X.2014.24.60 Li B. Effect of acupuncture on the clinical symptom and inflammatory factor of low-grade chronic pelvic inflammatory disease in female. China Foreign Med Treatment. (2016) 35:165–6. Huang X Yue Y He FF Wu ZP Li LY Yao Q. Clinical study on acupuncture combined with Xuefu Zhuyu decoction for chronic pelvic inflammatory disease with stasis-toxin internal accumulation syndrome. J New Chinese Med. (2023) 55:185–9. 10.166620/j.cnki.1674-0742.2016.11.165 Cheng Z Nie T Cheng XM. Effects of acupuncture combined with moxibustion on inflammation index and syndrome scores of traditional chinese medicine in patients with chronic pelvic inflammation. World Chinese Med. (2020) 15:1351–4. 10.13457/j.cnki.jncm.2023.03.041 Li J Wang YX. Clinical observation on acupuncture combined with Chinese medicine retention enema for chronic pelvic inflammatory disease. Chinese Med Modern Distance Educ China. (2021) 19:114–5. 10.3969/j.issn.1673-7202.2020.09.025 Nie T Tian LY Wang F Cheng ZX Cheng XM. Effects of acupuncture combined with self-formulated Penyan Formula on TCM syndrome scores and serum inflammatory factor levels in patients with chronic pelvic inflammatory disease. Jilin J Chinese Med. (2023) 43:724–7. 10.3969/j.issn.1672-2779.2021.20.044 Shi G. Observation on the clinical efficacy of acupuncture combined with self-formulated anti-inflammatory formula for female chronic pelvic inflammatory disease with low-grade inflammation. Asia-Pacific Traditional Med. (2017) 13:115–6. 10.13463/j.cnki.jlzyy.2023.06.024 Liu L Yang WF Gao M. Efficacy of acupuncture combined with Penyan Pills for chronic pelvic inflammatory disease. Pract Prevent Med. (2010) 17:717–8. 10.11954/ytctyy.201713055 Tao H Gu F. Efficacy observation on acupuncture combined with traditional Chinese medicine for chronic pelvic inflammatory disease. Shanghai J Acupunct Moxibustion. (2009) 28:375–6. Lu J Shen Q. Clinical observation on treating chronic pelvic inflammatory disease mainly with acupuncture. Shanghai J Acupunct Moxibustion. (2013) 32:644–5. Tian L Wang Y. Clinical efficacy of acupuncture on pelvic pain caused by chronic pelvic inflammatory disease and its effects on immune cells and serum inflammatory factors. World J Integr Traditional Western Med. (2020) 15:644–5. Liao F. The effect of acupuncture combined with cupping motion on hemorheology and inflammatory factors in chronic pelvic inflammatory disease. Guangming J Chinese Med. (2019) 34:174–6. 10.13935/j.cnki.sjzx.200501 Huang X. Practice research of acupuncture combined with acupoint injection in the treatment of patients with chronic pelvic inflammatory disease. Chinese J Modern Drug Appl. (2018) 12:197–9. 10.3969/j.issn.1003-8914.2019.02.002 Li L. Analysis of the curative effect of acupuncture combined with Fuke Qianjin Tablets on chronic pelvic inflammatory disease. Wo He Bao Bei. (2021) 31:197–9. 10.14164/j.cnki.cn11-5581/r.2018.17.118 Yang C Di ZF Liu X Xiao YD. Effects of acupuncture combined with internal nourishing exercise on pelvic mass diameter and uterine artery hemodynamic parameters in patients with chronic pelvic inflammatory disease. Liaoning J Traditional Chinese Med. (2024) 51:183–7. Chen R. Clinical observation on acupuncture and moxibustion combined with neuromuscular stimulation and hongteng decoction enema in the treatment of chronic pelvic inflammation. Chinese Med Modern Distance Educ China. (2023) 21:109–11. 10.13192/j.issn.1000-1719.2024.01.04 Cheng J Niu JF. Observation on the clinical efficacy of acupuncture combined with traditional Chinese medicine in patients with chronic pelvic inflammatory disease. Asia-Pacific Traditional Med (2017) 13:101–3. 10.3969/j.issn.1672-2779.2023.09.039 Mo J Liang QX Zhang L. Evaluation of the effect of acupuncture combined with physiotherapy and Chinese medicine retention enema on chronic pelvic inflammatory disease. World Latest Med Inf. (2019) 19:172. 10.11954/ytctyy.201721043 Liu X. Observations on the efficacy and prognosis of acupuncture combined with E-cupping exercise for chronic pelvic inflammatory disease. Chinese Health Care. (2020) 38:17–9. 10.19613/j.cnki.1671-3141.2019.49.113 Yan H Huang XH. 30 cases of chronic pelvic inflammatory disease treated with acupuncture and moxibustion: efficacy observation. J New Chinese Med. (2008) 40:69–70. 10.14033/j.cnki.cfmr.2018.30.062 Shi R. Study on the effect of acupuncture on chronic pelvic inflammatory disease and its influence on symptom improvement. China Modern Drug Appl. (2021) 15:229–31. Cheng L. Clinical observation on 38 cases of chronic pelvic inflammatory disease with qi stagnation and blood stasis type treated by combined use of acupuncture and medicine. Guiding J Traditional Chinese Med Pharm. (2014) 20:99–101. Zhang C. Clinical observation on combined acupuncture and medicine for chronic pelvic inflammatory disease of dampness-heat stasis type. J Pract Traditional Chinese Med. (2024) 40:47–9. 10.14164/j.cnki.cn11-5581/r.2021.03.101 Li W Deng ZJ Yang YQ. Analysis of clinical effect of integrated traditional Chinese and Western medicine on chronic pelvic inflammatory disease. Asia-Pacific Traditional Med. (2014) 10:63–5. Luo X. Effect of Chinese medicine retention enema combined with acupoint moxibustion nursing on clinical symptoms of patients with chronic pelvic inflammatory disease of qi stagnation and blood stasis type. Chinese Sci Technol J Database Med Health. (2022) 11:47–9. Liu X. Clinical observation on traditional Chinese medicine combined with acupuncture for chronic pelvic inflammatory disease. Electronic J Pract Gynecol Endocrinol. (2023) 10:10–2. Dai M. Clinical research on chronic pelvic inflammation treated with oral administration of chinese medicine combined with moxibustion. Henan Traditional Chinese Med. (2015) 35:2821–3. Wu D Huang YJ Liang SL Qiu MX Liang ST Shi GY Efficacy analysis of internal and external application of traditional Chinese medicine for chronic pelvic inflammatory disease. J Pract Traditional Chinese Med. (2015) 31:10–2. 10.3969/j.issn.2095-8803.2023.20.004 Wu Y Ma XL. Application of traditional Chinese medicine acupoint application combined with Hongteng decoction enema in the nursing of patients with chronic pelvic inflammatory disease. J Women Children’s Health. (2023) 2:145–7. 10.16367/j.issn.1003-5028.2015.11.1209 Ye Z Li Q Feng YH Zhang Q. Efficacy of self-formulated Hongteng Decoction combined with acupuncture on chronic pelvic inflammatory disease and its effects on serum IL-4 and TGF-β1 levels. J Sichuan Traditional Chinese Med. (2023) 41:171–5. Miao Y Xue LF. Observation on the clinical efficacy of self-formulated anti-inflammatory prescription assisted by acupuncture and moxibustion therapy on chronic pelvic inflammatory disease of dampness-heat and blood stasis type. J Clin Acupunct Moxibustion. (2015) 31:28–30. Zhen H Liu X. Observation on the efficacy of warm acupuncture in treating chronic pelvic inflammatory disease with cold-dampness stagnation pattern. Chinese J Acupunct Moxibustion. (2008) 28:736–8. Qingzhu Y. Randomized parallel controlled study of acupuncture combined with thermosensitive moxibustion for chronic pelvic inflammatory disease (Leukorrhea/Dysmenorrhea). J Pract Internal Med Traditional Chinese Med. (2018) 32:62–5. Xin T Liu DJ Wu JS Zheng LR. Analysis of the efficacy of acupuncture combined with Yi-Guan exercise for patients with chronic pelvic inflammatory disease. Med Res China Abroad. (2018) 16:132–3. Pan M Lan Y Wang Z. Wrist-ankle acupuncture has a positive effect on chronic pain: a systematic review and meta-analysis. Acupunct Herbal Med. (2023) 3:7–19. 10.1097/hm9.0000000000000059 Wang J Du K Liu C Chen X Ban W Zhu G Exploring the effects of moxibustion on cognitive function in rats with multiple cerebral infarctions from the perspective of glial vascular unit repairing. Front Pharmacol. (2024) 15:1428907. 10.3389/fphar.2024.1428907 39508044 Wang G Pan FW Song YD Xie YC. Mechanism study of warm needle moxibustion improving symptoms and joint pathological injury in rats with knee osteoarthritis. Hainan Med J. (2025) 36:1673–8. 10.3969/j.issn.1003-6350.2025.12.00 Zuo X Song GL Gong FL. Analysis of the impact of multifunctional pelvic therapy device combined with ultrasonic drug penetration on clinical symptoms and local microcirculation status in patients with pelvic inflammatory disease. China Med Device Inf. (2024) 30:79–82. 10.15971/j.cnki.cmdi.2024.14.058 Di JB Minfeng Y Lihong C. The effect of applying phlegm inducing formula to Yongquan acupoint on serum inflammatory factors induced by ovalbumin in asthmatic mice. Chin J Pediatr. (2023) 19. 10.16840/j.issn.1673-4297.2023.04.01 Wang L Yang J Lin L Huang J Wang X Su X Acupuncture attenuates inflammation in microglia of vascular dementia rats by inhibiting miR-93-mediated TLR4/MyD88/NF-κB signaling pathway. Oxid Med Cell Longev. (2020) 2020:8253904. 10.1155/2020/8253904 32850002 Li N Guo Y Gong Y Zhang Y Fan W Yao K The anti-inflammatory actions and mechanisms of acupuncture from acupoint to target organs via neuro-immune regulation. J Inflamm Res. (2021) 14:7191–224. 10.2147/JIR.S341581 34992414 Yang N Yang J Ye Y Huang J Wang L Wang Y Electroacupuncture ameliorates intestinal inflammation by activating α7nAChR-mediated JAK2/STAT3 signaling pathway in postoperative ileus. Theranostics. (2021) 11:4078–89. 10.7150/thno.52574 33754049 Zhong F Lin TY Ding WW Li G Zhao Y Bai CC. Clinical observation of Shipi Xiaoshui Powder No. 2 combined with moxibustion and acupoint injection intervening in upper limb lymphedema after breast cancer surgery. J Liaoning Univer Traditional Chinese Med. (2025) 27:143–7. 10.13194/j.issn.1673-842X.2025.01.026 Du X Zhou JH Chu XF Huang XQ Liu Y. Clinical observation on Yiqi Yangyin Jiangtang Formula combined with acupoint injection for initial type 2 diabetes mellitus. J Guangzhou Univer Traditional Chinese Med. (2024) 41:847–55. 10.13359/j.cnki.gzxbtcm.2024.04.006 Zhang X Lei Y Zhou F. Effects of moxibustion combined with supine gymnastics exercise on fatigue and inflammatory status in patients with diabetic nephropathy after hemodialysis. Chinese General Pract Nurs. (2025) 23:1876–9. 10.12104/j.issn.1674-4748.2025.10.021 Chen J Zhou YL Wang DY Zhang Q Liu H. Study on Chen’s neck three points acupuncture combined with cervical massage chiropractic and moxibustion for cervical spondylotic radiculopathy. Traditional Chinese Medicinal Res. (2025) 38:44–7. 10.3969/j.issn.1001-6910.2025.06.11 Pan H Xi YB Ding J Yin Q Xue HQ Yue HY. Exploring the effects of moxibustion at different temperatures on wound healing and cell apoptosis in pressure ulcer rats based on PI3K/AKT/mTOR signaling pathway. World J Acupunct Moxibustion. (2025) 35:125–34. 10.1016/j.wjam.2025.02.003 Ma H Liu X Cai H Yan Y Li W Zhao J. Electroacupuncture reduced airway inflammation by activating somatosensory-sympathetic pathways in allergic asthmatic rats. Chin Med J. (2025) 138:702–12. 10.1097/CM9.0000000000003074 38602180 Tan Z Dong F Wu L Xu G Zhang F. Transcutaneous electrical acupoint stimulation attenuated neuroinflammation and oxidative stress by activating SIRT1-induced signaling pathway in MCAO/R rat models. Exp Neurol. (2024) 373:114658. 10.1016/j.expneurol.2023.114658 38141805 Fan Y Zhu C Ji Y Peng J Wang G Wan R Comparison of efficacy of acupuncture-related therapies in treating acute gouty arthritis: a network meta-analysis of randomized controlled trials. Heliyon. (2024) 10:e28122. 10.1016/j.heliyon.2024.e28122 38576580

Edited by: Jieying Zhang, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, China

Reviewed by: Yihua Fan, Hospital of Chengdu University of Traditional Chinese Medicine, China

Tong Wu, China Academy of Chinese Medical Sciences, China