OBJECTIVE: To compare the effectiveness and safety of different acupuncture-related therapies combined with pharmacotherapies for treating symptomatic endometriosis. METHODS: A pre-defined search strategy was conducted across eight databases (Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal Database, PubMed, Embase, Cochrane Library, and Web of Science) from inception to May 1, 2023. The included studies were evaluated for methodological quality using the Cochrane risk of bias assessment tool. The surface under the cumulative ranking (SUCRA) was applied to rank the acupuncture-related therapies for each outcome. RESULTS: Twenty-three randomized controlled trials (RCTs) involving one thousand five hundred forty-five patients were included in the network meta-analysis. Ear electroacupuncture (SUCRA = 83.0%), needle warming moxibustion with Modified Neiyi Zhitong Formula (SUCRA = 80.6%), and auricular needle-embedding (SUCRA = 79.6%) demonstrated a statistically significant reduction in comprehensive symptoms compared to the control group. Studies have shown that body electroacupuncture (OR = 4.33, 95% CI 1.20-15.61), acupoint catgut (OR = 4.32, 95% CI 1.08-17.25), and auricular needle-embedding (OR = 7.56, 95% CI 1.89-30.28) are statistically significantly more effective than conventional treatment. CONCLUSION: The results of this analysis suggest that acupuncture-related therapies are effective in managing symptomatic endometriosis. Further high-quality randomized controlled trials are warranted to explore their efficacy and safety in greater depth. TRIAL REGISTRATION: Our study protocol was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY)
registration number: INPLASY202380077.