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{{#seo:
{{#seo:
|title=Menstrual disorders
|title=Menstrual disorders
|keywords=Menstrual disorders, artava (menstruation), asrugdara (menorrhagia), dysmenorrhoea, amenorrhoea, Ayurveda, Indian system of medicine, charak samhita.
|keywords=Menstrual disorders, artava (menstruation), asrugdara (menorrhagia), dysmenorrhoea, amenorrhoea, Ayurveda, Indian system of medicine, charak samhita.
|description=Sharira / Artava / Menstrual disorders
|description=Sharira / Artava / Menstrual disorders
|image=http://www.carakasamhitaonline.com/mediawiki-1.32.1/resources/assets/ogimgs.jpg
|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg
|image_alt=charak samhita
|image_alt=charak samhita
|type=article
|type=article}}
}}
<p style="text-align:justify;">The physiology of menstruation can be understood by studying the concept of “artava” and its disorders. Fundamentally artava is originated from agni (fire) element. Therefore, menstrual blood is [[pitta]] [[dosha]] dominant. Menstruation and regulation of hypothalamo-pituitary-ovarian axis are important functions of [[vata]] [[dosha]]. Whereas the repair and restore functions in uterus after menstruation are carried out by [[kapha]] [[dosha]]. Hence all three [[dosha]] play role in physiology of menstruation. Therefore, the menstrual disorders need to be understood on the [[dosha]] axis and their abnormalities. The duration of normal menstrual flow is generally 5 days, and the normal menstrual cycle typically lasts between 21 and 35 days.
The physiology of menstruation can be understood by studying the concept of “artava” and its disorders. Fundamentally artava is originated from agni (fire) element. Therefore, menstrual blood is [[pitta]] [[dosha]] dominant. Menstruation and regulation of hypothalamo-pituitary-ovarian axis are important functions of [[vata]] [[dosha]]. Whereas the repair and restore functions in uterus after menstruation are carried out by [[kapha]] [[dosha]]. Hence all three [[dosha]] play role in physiology of menstruation. Therefore, the menstrual disorders need to be understood on the [[dosha]] axis and their abnormalities. The duration of normal menstrual flow is generally 5 days, and the normal menstrual cycle typically lasts between 21 and 35 days.
</p>
{{Infobox
{{Infobox
|label2 = Authors
|label2 = Authors
|data2 = Anagha S., Deole Y.S.
|data2 = Anagha S.<sup>1</sup>, [[Yogesh Deole|Deole Y.S.]]<sup>1</sup>
|label3 = Reviewers and Editor
|data3 = [[Gopal Basisht|Basisht G.]]<sup>1</sup>, Tandon S.<sup>2</sup>
|label4 = Editor
|data4 = [[Gopal Basisht|Basisht G.]]<sup>1</sup>
|label3 = Reviewer and Editor
|label5 = Affiliations
|data3 = Basisht G.
|data5 = <sup>1</sup>[[Charak Samhita Research, Training and Development Centre]], I.P.G.T.& R.A., Jamnagar,
<sup>2</sup> Obstetrician-Gynecologist, Orlando, USA
|label4 = Affiliations
|label6 = Correspondence email
|data4 = [[Charak Samhita Research, Training and Development Centre]], I.P.G.T.& R.A., Jamnagar
|data6 = carakasamhita@gmail.com
|label5 = Correspondence email
|label7 = Publisher
|data5 = carakasamhita@gmail.com
|data7 = [[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India
|label6 = Date of first publication:
|label8 = Date of first publication:
|data6 =July 31, 2020
|data8 = July 31, 2020
|label9 = DOI
|data9 = [https://doi.org/10.47468/CSNE.2020.e01.s09.025 10.47468/CSNE.2020.e01.s09.025]
}}
}}
== Age specific classification ==
== Age specific classification ==
<div style="text-align:justify;">
Chronological age is an important factor of examination[Cha.Sa. [[Vimana Sthana]] 8/122]. Therefore, it is also considered in the diagnosis of menstrual disorders.
Chronological age is an important factor of examination[Cha.Sa. [[Vimana Sthana]] 8/122]. Therefore, it is also considered in the diagnosis of menstrual disorders.
As all the tissue components get depleted gradually during this age, menstruation also gets diminished naturally. But this transition stage of reproductive physiology may create many symptoms like excessive bleeding, irregularity in the cycle, psychological and vasomotor disturbances in the female.
As all the tissue components get depleted gradually during this age, menstruation also gets diminished naturally. But this transition stage of reproductive physiology may create many symptoms like excessive bleeding, irregularity in the cycle, psychological and vasomotor disturbances in the female.
</div>
==Causes of menstrual disorders==
==Causes of menstrual disorders==
<div style="text-align:justify;">
'''1. Dietary factors:'''
'''1. Dietary factors:'''
*Suppression of natural urges (vega dharana) of micturition, defecation etc. leading to aggravation of “apana vayu” cause menstrual disorders. [Cha. Sa. [[Chikitsa Sthana]] 30/25-26].
*Suppression of natural urges (vega dharana) of micturition, defecation etc. leading to aggravation of “apana vayu” cause menstrual disorders. [Cha. Sa. [[Chikitsa Sthana]] 30/25-26].
A case control study in 300 subjects has proven the association of suppression of urges of micturition and defaecation with primary dysmenorrhoea.<ref>Vrinda Roy(2011),A case-control study to evaluate the association between Mutra-purisha vegadharana and primary dysmenorrhoea,PG dissertation,department of Swasthavrutta, VPSV Ayurveda college, Kottakkal, Kerala.</ref>
A case control study in 300 subjects has proven the association of suppression of urges of micturition and defecation with primary dysmenorrhoea.<ref>Vrinda Roy(2011),A case-control study to evaluate the association between Mutra-purisha vegadharana and primary dysmenorrhoea,PG dissertation,department of Swasthavrutta, VPSV Ayurveda college, Kottakkal, Kerala.</ref>
*The specific activities like continuous travelling especially in jerky vehicles,continuos sitting or standing in one position , excessive walking and exersion cause vitiation of “apana vayu” and lead to menstrual disorders. [A. Hr. Nidana thana 16/27]
*The specific activities like continuous travelling especially in jerky vehicles,continuos sitting or standing in one position , excessive walking and exersion cause vitiation of “apana vayu” and lead to menstrual disorders. [A. Hr. Nidana thana 16/27]
It is responsible for altering the reproductive physiology and causing menstrual abnormalities. [Cha Sa [[Chikitsa Sthana]] 30/7-8], [Cha Sa [[Chikitsa Sthana]] 30/34-35]
It is responsible for altering the reproductive physiology and causing menstrual abnormalities. [Cha Sa [[Chikitsa Sthana]] 30/7-8], [Cha Sa [[Chikitsa Sthana]] 30/34-35]
</div>
===Pathophysiology===
===Pathophysiology===
'''Functions of 5 types of vata in reproductive physiology''' [A.S. Sutra Sthana 20/2]
'''Functions of 5 types of vata in reproductive physiology''' [A.S. Sutra Sthana 20/2]
|'''Apana vayu'''|| Elimination of menstrual blood(artava nishkramana) || Shedding of superficial functional layer of endometrium along with blood from the uterine cavity.
|'''Apana vayu'''|| Elimination of menstrual blood(artava nishkramana) || Shedding of superficial functional layer of endometrium along with blood from the uterine cavity.
|}
|}
<div style="text-align:justify;">
*The vitiation of vata occurs in two ways:
*The vitiation of vata occurs in two ways:
*The obstructive pathology due to [[kapha]] usually leads to decrease in the function due increase in the properties like coldness (sheeta), dullness/slowness (manda) and immobility (sthiratva). While explaining the pathology of secondary amenorrhoea(artava nasha), it is clarified that the [[dosha]] causing the occlusion of [[vata]] here is either [[kapha]] or another form of [[vata]] itself, but not [[pitta]].[Dalhana commentary on Su. Sa. Sharira Sthana 2/21]
*The obstructive pathology due to [[kapha]] usually leads to decrease in the function due increase in the properties like coldness (sheeta), dullness/slowness (manda) and immobility (sthiratva). While explaining the pathology of secondary amenorrhoea(artava nasha), it is clarified that the [[dosha]] causing the occlusion of [[vata]] here is either [[kapha]] or another form of [[vata]] itself, but not [[pitta]].[Dalhana commentary on Su. Sa. Sharira Sthana 2/21]
</div>
===General features===
===General features===
<div style="text-align:justify;">
The increase or decrease in quality and/or quantity of menstrual blood(artava)can lead to various abnormal conditions. The states can be assessed by following clinical features.
The increase or decrease in quality and/or quantity of menstrual blood(artava)can lead to various abnormal conditions. The states can be assessed by following clinical features.
{| class="wikitable"
{| class="wikitable"
e)Other bleeding disorders(anyad raktalakshana)
e)Other bleeding disorders(anyad raktalakshana)
</div>
===Special features===
===Special features===
==== Types of vitiation of menstrual blood (artava) ====
==== Types of vitiation of menstrual blood (artava) ====
<div style="text-align:justify;">
There are eight types of deviated/abnormal states of menstrual blood (artavadushti) as mentioned in the table.
There are eight types of deviated/abnormal states of menstrual blood (artavadushti) as mentioned in the table.
{| class="wikitable"
{| class="wikitable"
Currently, apart from the three types of vitiation due to vata-pitta-kapha, clotted appearance(grandhibuta) as well as scanty menstruation(ksheena) are also treated with good efficacy by Ayurvedic treatment modalities. More research studies focusing on the diagnosis and treatment aspects of abnormal variations in the characteristic features of menstrual blood(artava dushti) are needed.
Currently, apart from the three types of vitiation due to vata-pitta-kapha, clotted appearance(grandhibuta) as well as scanty menstruation(ksheena) are also treated with good efficacy by Ayurvedic treatment modalities. More research studies focusing on the diagnosis and treatment aspects of abnormal variations in the characteristic features of menstrual blood(artava dushti) are needed.
</div>
== Examination of patients ==
== Examination of patients ==
=== Observation (darshana) ===
=== Observation (darshana) ===
<div style="text-align:justify;">
On examining the patient, the general health status should be the prime concern. In case of clinical conditions like scanty bleeding or amenorrhea, the patient may be emaciated(krusha) and there may be discoloration of skin (vaivarnya) or pallor which is mentioned as the clinical features of a disorder of reproductive tract namely “arajaska yoni vyapad” [Cha.Sa. [[Chikitsa Sthana]] 30/17]. The same presentation is found in heavy menstrual bleeding also.
On examining the patient, the general health status should be the prime concern. In case of clinical conditions like scanty bleeding or amenorrhea, the patient may be emaciated(krusha) and there may be discoloration of skin (vaivarnya) or pallor which is mentioned as the clinical features of a disorder of reproductive tract namely “arajaska yoni vyapad” [Cha.Sa. [[Chikitsa Sthana]] 30/17]. The same presentation is found in heavy menstrual bleeding also.
All these are supposed to be noted in direct observation in clinically practice even though it is not always feasible in regular set up. But, per speculum examination of vaginal tract reveals many hidden diagnoses.
All these are supposed to be noted in direct observation in clinically practice even though it is not always feasible in regular set up. But, per speculum examination of vaginal tract reveals many hidden diagnoses.
</div>
===Palpation(sparshana) ===
===Palpation(sparshana) ===
<div style="text-align:justify;">
Per abdominal examination by palpation as well as bi-manual examination of uterus and adnexa is important in the diagnosis of menstrual disorders.
Per abdominal examination by palpation as well as bi-manual examination of uterus and adnexa is important in the diagnosis of menstrual disorders.
In cases where direct observation of characters of menstrual blood is not feasible, it can be understood by proper interrogation. Detailed history regarding diet, life style and sexual activity is necessary for the successful treatment of menstrual disorders.
In cases where direct observation of characters of menstrual blood is not feasible, it can be understood by proper interrogation. Detailed history regarding diet, life style and sexual activity is necessary for the successful treatment of menstrual disorders.
</div>
==Laboratory investigations==
==Laboratory investigations==
'''Purification therapy(shodhana chikitsa):'''
'''Purification therapy(shodhana chikitsa):'''
<div style="text-align:justify;">
Purification therapy is the first line of treatment in quantitative or qualitative decrease of menstrual blood due to obstructive/occlusion pathology(avarodha). Here, therapeutic emesis([[Vamana]]) has major role as the condition is predominantly due to [[kapha]].
Purification therapy is the first line of treatment in quantitative or qualitative decrease of menstrual blood due to obstructive/occlusion pathology(avarodha). Here, therapeutic emesis([[Vamana]]) has major role as the condition is predominantly due to [[kapha]].
Substances promoting the properties of pitta (agneya dravya) like sesame oil (tila tail), black gram(masha)are advised to be taken regularly by the women. But in case of extreme decrease of endometrial thickness, ghee(ghrita) is having greater role than oil(taila)for promoting the endometrial proliferation and maintenance of preferred level of growth.[A.S. Sharira Sthana 1/64]
Substances promoting the properties of pitta (agneya dravya) like sesame oil (tila tail), black gram(masha)are advised to be taken regularly by the women. But in case of extreme decrease of endometrial thickness, ghee(ghrita) is having greater role than oil(taila)for promoting the endometrial proliferation and maintenance of preferred level of growth.[A.S. Sharira Sthana 1/64]
</div>
===Treatment for increased state of menstrual blood ===
===Treatment for increased state of menstrual blood ===
<div style="text-align:justify;">
'''Purification therapy:'''
'''Purification therapy:'''
*By considering the association of [[doshas]] diagnosed on the basis of color and smell of blood,haemostatic drugs should be given to arrest the bleeding.[Cha. Sa [[Chikitsa Sthana]] 30/86]
*By considering the association of [[doshas]] diagnosed on the basis of color and smell of blood,haemostatic drugs should be given to arrest the bleeding.[Cha. Sa [[Chikitsa Sthana]] 30/86]
</div>
===Treatment for abnormal state of menstrual blood: ===
===Treatment for abnormal state of menstrual blood: ===
<div style="text-align:justify;">
'''Purification therapy :'''
'''Purification therapy :'''
In abnormalities of menstrual blood (artava dushti), oleation(snehana),sudation(swedana), purification therapies(vamana, virechana, basti) as well as local therapies including intra uterine drug administration(uttarabasti) is advised.[Su. Sa. Sharira Sthana 2/12]
In abnormalities of menstrual blood (artava dushti), oleation (snehana),sudation(swedana), purification therapies(vamana, virechana, basti) as well as local therapies including intra uterine drug administration(uttarabasti) is advised.[Su. Sa. Sharira Sthana 2/12]
In the management of dysmenorrhoea (udavartini) also, oleation(snehana), sudation (swedana), enema therapy (both unctuous as well as decoction like dashamoola and milk) especially unctuous enema(anuvasanabasti) and intra uterine oil administration(uttara basti) are recommended.[Ch. Sa. [[Chikitsa Sthana]] 30/228]
In the management of dysmenorrhoea (udavartini) also, oleation(snehana), sudation (swedana), enema therapy (both unctuous as well as decoction like dashamoola and milk) especially unctuous enema(anuvasana basti) and intra uterine oil administration(uttara basti) are recommended.[Ch. Sa. [[Chikitsa Sthana]] 30/228]
'''Pacification therapy:'''
'''Pacification therapy:'''
|}
|}
*[A.Hr. Sharira Sthana 1], **[A.S. Sharira Sthana 1]
*[A.Hr. Sharira Sthana 1], **[A.S. Sharira Sthana 1]
</div>
===Diet and lifestyle modification for prevention of menstrual disorders ===
===Diet and lifestyle modification for prevention of menstrual disorders ===
<div style="text-align:justify;">
In general, cereals like rice(shali), barley(yava), alcoholic preparations (madya),meat preparations capable of increasing [[pitta]] are beneficial for promoting the female reproductive health.[Su.Sa. Sharira Sthana 2/16]
In general, cereals like rice(shali), barley(yava), alcoholic preparations (madya),meat preparations capable of increasing [[pitta]] are beneficial for promoting the female reproductive health.[Su.Sa. Sharira Sthana 2/16]
All these activities are likely to cause physical strain for the woman and their adverse effects are reflected even in her future progeny.[Su. Sa. Sharira Sthana 2/24-25]
All these activities are likely to cause physical strain for the woman and their adverse effects are reflected even in her future progeny.[Su. Sa. Sharira Sthana 2/24-25]
</div>
==Menstrual Hygiene ==
==Menstrual Hygiene ==
==Current Researches==
==Current Researches==
<div style="text-align:justify;">
*PCOS is diagnosed as per the standard Rotterdam criteria<ref>Rui Wang, Ben Willem J. Mol, The Rotterdam criteria for polycystic ovary syndrome: evidence-based criteria?, Human Reproduction, Volume 32, Issue 2, 1 February 2017, Pages 261–264, https://doi.org/10.1093/humrep/dew287</ref>. Recent studies suggest the incorporation of raised level of Anti mullerian Hormone (AMH) along with the sonography findings to define polycystic ovarian morphology (PCOM).<ref>Fraissinet A, Robin G, Pigny P, Lefebvre T, Catteau-Jonard S, Dewailly D. Use of the serum anti-Müllerian hormone assay as a surrogate for polycystic ovarian morphology: impact on diagnosis and phenotypic classification of polycystic ovary syndrome. Hum Reprod. 2017;32(8):1716-1722. doi:10.1093/humrep/dex239</ref>
*PCOS is diagnosed as per the standard Rotterdam criteria<ref>Rui Wang, Ben Willem J. Mol, The Rotterdam criteria for polycystic ovary syndrome: evidence-based criteria?, Human Reproduction, Volume 32, Issue 2, 1 February 2017, Pages 261–264, https://doi.org/10.1093/humrep/dew287</ref>. Recent studies suggest the incorporation of raised level of Anti mullerian Hormone (AMH) along with the sonography findings to define polycystic ovarian morphology (PCOM).<ref>Fraissinet A, Robin G, Pigny P, Lefebvre T, Catteau-Jonard S, Dewailly D. Use of the serum anti-Müllerian hormone assay as a surrogate for polycystic ovarian morphology: impact on diagnosis and phenotypic classification of polycystic ovary syndrome. Hum Reprod. 2017;32(8):1716-1722. doi:10.1093/humrep/dex239</ref>
*Menstrual blood-derived stem cells (MenSCs) are a novel source of mesenchymal stem cells (MSCs). They are found to be having therapeutic effects in various diseases, including liver disease, diabetes, stroke, Duchenne muscular dystrophy, ovarian-related disease, myocardial infarction, Asherman syndrome, Alzheimer's disease, acute lung injury, cutaneous wound, endometriosis, and neurodegenerative diseases.<ref>Chen L, Qu J, Xiang C. The multi-functional roles of menstrual blood-derived stem cells in regenerative medicine. Stem Cell Res Ther. 2019;10(1):1. Published 2019 Jan 3. doi:10.1186/s13287-018-1105-9</ref>
*Menstrual blood-derived stem cells (MenSCs) are a novel source of mesenchymal stem cells (MSCs). They are found to be having therapeutic effects in various diseases, including liver disease, diabetes, stroke, Duchenne muscular dystrophy, ovarian-related disease, myocardial infarction, Asherman syndrome, Alzheimer's disease, acute lung injury, cutaneous wound, endometriosis, and neurodegenerative diseases.<ref>Chen L, Qu J, Xiang C. The multi-functional roles of menstrual blood-derived stem cells in regenerative medicine. Stem Cell Res Ther. 2019;10(1):1. Published 2019 Jan 3. doi:10.1186/s13287-018-1105-9</ref>
</div>
===List of Thesis works===
===List of Thesis works===
The list of thesis works done on various menstrual disorders can be seen [[Media:Thesis_list-Menstrual_disorders.pdf |here.]]
The list of thesis works done on various menstrual disorders can be seen [[Media:Thesis_list-Menstrual_disorders.pdf |here.]]
===Abbreviations ===
===Abbreviations ===
<div style="text-align:justify;">
Sa. = Samhita, Cha. = Charak, Su. = Sushruta, Ka. = Kashyapa, Sha. =Sharangadhara, A. = Ashtanga, Hr. = Hridaya, S. = Sangraha,
Sa. = Samhita, Cha. = Charak, Su. = Sushruta, Ka. = Kashyapa, Sha. =Sharangadhara, A. = Ashtanga, Hr. = Hridaya, S. = Sangraha,
Ha. = Harita
Ha. = Harita
</div>
=== Reference list of Menstrual disorders ===
=== Reference list of Menstrual disorders ===
<div style="text-align:justify;">
The list of references for menstrual disorders in classical texts of Ayurveda can be seen [[Media:References_table-_menstrual_disorders.pdf |here.]]
</div>
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