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Chinese herbal medicine for endometriosis?

A brand new Cochrane review suggests that 'Chinese herbal medicine may be useful in relieving endometriosis-related pain with fewer side effects than experienced with conventional treatment'.

A brand new Cochrane review suggests that 'Chinese herbal medicine may be useful in relieving endometriosis-related pain with fewer side effects than experienced with conventional treatment'.

Great! Let's all use this approach or send our patients to one of the many Chinese herbal outlets in our high streets. After all, Cochrane reviews are trustworthy – in fact, they are the best, the undisputed 'Rolls Royce of evidence-based medicine'.

But perhaps this one (Flower A, Liu JP, Chen S, Lewith G, Little P. Chinese herbal medicine for endometriosis. Cochrane Database Syst Rev 2009;Issue 3. Art. No.: CD006568. DOI: 10.1002/14651858.CD006568.pub2) is an exception? If we read beyond the 'plain language summary' from which I took the above quote, we soon develop doubts. The review is based on only two very small trials published in Chinese.

I don't read Chinese, so I should not mutter about these articles, but some of the data extracted from these studies look very odd indeed: one of the trials apparently reported a symptomatic relief rate of 96% for patients treated with Chinese herbs, and in both studies the frequency of adverse effects was zero! Thus the Chinese herbal treatment was deemed to be better than the conventional therapy given to patients in the control group. There was no placebo-group in either of the studies.

Call me distrustful, but if that does not sound too good to be true, then what does? We should remember that several research groups have independently shown that China does not seem to ever generate a negative result when it comes to Traditional Chinese Medicine (TCM). So, perhaps scepticism would have been appropriate when evaluating these studies and drawing conclusions from them.

And this is where, I think, the more general problem lies: we currently see more and more Cochrane reviews of TCM. They tend to exclusively produce positive findings. To make matters worse, their reviewers tend to be somewhat uncritical supporters of TCM.

If we accept that virtually all Chinese TCM studies are positive, the results of such reviews must be clear, even before the protocol has been written. This means we might have more and more Cochrane reviews which are, albeit based on the existing data, misleading. In the end, this could turn out to be a serious threat to the reputation of the Cochrane Collaboration. Houston, we (and the Cochrane Collaboration) have a problem!

The solution might be rather obvious. A concentrated dose of critical evaluation is required. If I apply only a pinch of salt to the evidence summarized in the review in question, I would conclude as follows: 'The currently available data from clinical trials are insufficient. Therefore the value of Chinese herbal treatments for endometriosis is unknown.'

This is clear and to the point – but now read what the authors of the review came up with: 'Post-surgical administration of Chinese Herbal Medicine (CHM) may have comparable benefits to gestrinone but with fewer side effects. Oral CHM may have a better overall treatment effect than danazol; it may be more effective in relieving dysmenorrhea and shrinking adnexal masses when used in conjunction with a CHM enema. However, more rigorous research is required to accurately assess the potential role of CHM in treating endometriosis.'

Professor Edzard Ernst Professor Edzard Ernst

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