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Menstrual disorders (view source)

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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.
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{{#seo:
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|title=Menstrual disorders
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|titlemode=append
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|keywords=Menstrual disorders,  artava (menstruation),  asrugdara (menorrhagia), dysmenorrhoea, amenorrhoea, Ayurveda, Indian system of medicine, charak samhita.
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|description=Sharira / Artava / Menstrual disorders
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|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg
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|image_alt=charak samhita
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|type=article}}
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<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.
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</p>
 
{{Infobox
 
{{Infobox
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|label2 = Authors
 
|label2 = Authors
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|data2 = Anagha S., Deole Y.S.
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|data2 = Anagha S.<sup>1</sup>, [[Yogesh Deole|Deole Y.S.]]<sup>1</sup>
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|label3 = Reviewers and Editor
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|data3 = [[Gopal Basisht|Basisht G.]]<sup>1</sup>, Tandon S.<sup>2</sup>
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 +
|label4 = Editor
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|data4 = [[Gopal Basisht|Basisht G.]]<sup>1</sup>
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|label3 = Reviewed by
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|label5 = Affiliations
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|data3 = Basisht G.
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|data5 = <sup>1</sup>[[Charak Samhita Research, Training and Development Centre]], I.P.G.T.& R.A., Jamnagar,
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<sup>2</sup> Obstetrician-Gynecologist, Orlando, USA
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|label4 = Affiliations
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|label6 = Correspondence email
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|data4 = [[Charak Samhita Research, Training and Development Centre]], I.P.G.T.& R.A., Jamnagar
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|data6 = carakasamhita@gmail.com
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|label5 = Correspondence email
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|label7 = Publisher
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|data5 = carakasamhita@gmail.com
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|data7 = [[Charak Samhita Research, Training and Development Centre]], I.T.R.A., Jamnagar, India
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|label6 = Date of first publication:
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|label8 = Date of first publication:
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|data6 =July 31, 2020
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|data8 = July 31, 2020
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|label9 = DOI
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|data9 = [https://doi.org/10.47468/CSNE.2020.e01.s09.025 10.47468/CSNE.2020.e01.s09.025]
 
}}
 
}}
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==Classification of menstrual disorders==
 
==Classification of menstrual disorders==
 +
 
===Types based on clinical presentation===
 
===Types based on clinical presentation===
 +
 
The menstrual disorders can be classified into three categories.
 
The menstrual disorders can be classified into three categories.
    
'''Table 1: Three categories of menstrual disorders'''  
 
'''Table 1: Three categories of menstrual disorders'''  
 +
 
{| class="wikitable"
 
{| class="wikitable"
 
|-
 
|-
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|}
 
|}
   −
==Age specific classification ==
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== Age specific classification ==
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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.  
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<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.  
    
'''1)Adolescent age:'''
 
'''1)Adolescent age:'''
   −
Menarche is the appearance of first menstrual bleeding in an adolescent girl. The age of menarche is mentioned as 12 years in the Ayurveda classics. [A.H. Sharira Sthana 1/7] However,clinical variations are observed due to two factors. [Ka. Sa. Sharira Sthana 5/4]
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Menarche is the appearance of first menstrual bleeding in an adolescent girl. The age of menarche is mentioned as 12 years in the Ayurveda classics. [A.Hr. Sharira Sthana 1/7] However,clinical variations are observed due to two factors. [Ka. Sa. Sharira Sthana 5/4]
    
'''a)Time factor(kala):''' Age of puberty, environmental conditions as per geographical area  
 
'''a)Time factor(kala):''' Age of puberty, environmental conditions as per geographical area  
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'''b)Activities of the girl child(karma):''' Diet, life style, exercise, exposure to light,psychological state etc.
 
'''b)Activities of the girl child(karma):''' Diet, life style, exercise, exposure to light,psychological state etc.
   −
Observational studies reveal the fact that menarcheal age is influenced by diverse variables such as genetics, geographic location, climate, psychological factors, socioeconomic status, body weight and height, nutrition, body fat and exercise, as well as the presence of chronic diseases.  
+
Observational studies reveal the fact that menarcheal age is influenced by diverse variables such as genetics, geographic location, climate, psychological factors, socioeconomic status, body weight and height, nutrition, body fat and exercise, as well as the presence of chronic diseases. <ref>Wang Z, Dang S, Xing Y, Li Q, Yan H. Correlation of body mass index levels with menarche in adolescent girls in Shaanxi, China: a cross sectional study. BMC Womens Health. 2016;16:61. Published 2016 Sep 6. doi:10.1186/s12905-016-0340-4</ref> <ref>Laitinen J, Power C, Järvelin MR. Family social class, maternal body mass index, childhood body mass index, and age at menarche as predictors of adult obesity. Am J Clin Nutr. 2001;74:287–294. [PubMed] [Google Scholar]</ref>
    
'''Disorders related to menarche are as below:'''
 
'''Disorders related to menarche are as below:'''
   −
*'''Primary amenorrhoea:''' The condition is characterized by absence of menarche even at the age of 16 years(i.e. after completion of childhood). It is mentioned as condition of“Shushka revati”[Ka. Sa. Kalpa Sthana 6/31]and “Shandhi yoni vyapad”.[Cha. Sa. Chikitsa Sthana 30/34-35]
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*'''Primary amenorrhoea:''' The condition is characterized by absence of menarche even at the age of 16 years(i.e. after completion of childhood). It is mentioned as condition of“Shushka revati”[Ka. Sa. Kalpa Sthana 6/31]and “Shandhi yoni vyapad”.[Cha. Sa.[[Chikitsa Sthana]] 30/34-35]
   −
In primary amenorrhea, a retrospective study concluded that Mullerian anomaly was the most prevalent etiological factor leading to amenorrhea followed by gonadal dysgenesis and racial, genetic and environmental factors could play role in the cause of primary amenorrhea.  
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In primary amenorrhea, a retrospective study concluded that Mullerian anomaly was the most prevalent etiological factor leading to amenorrhea followed by gonadal dysgenesis and racial, genetic and environmental factors could play role in the cause of primary amenorrhea.<ref>Kriplani A, Goyal M, Kachhawa G, Mahey R, Kulshrestha V. Etiology and management of primary amenorrhoea: A study of 102 cases at tertiary centre. Taiwan J Obstet Gynecol. 2017;56(6):761‐764. doi:10.1016/j.tjog.2017.10.010</ref>
    
*'''Secondary amenorrhoea :''' After the establishment of menarche, some girls may experience a secondary amenorrhea which may extend upto many months or even years.
 
*'''Secondary amenorrhoea :''' After the establishment of menarche, some girls may experience a secondary amenorrhea which may extend upto many months or even years.
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Both these conditions are due to the lack of coordination in the reproductive axis of vata-pitta-kapha.
 
Both these conditions are due to the lack of coordination in the reproductive axis of vata-pitta-kapha.
   −
*'''Primary dysmenorrhea:''' It is mentioned as “udavartini yoni vyapad”in Ayurveda[Cha. Sa. Chikitsa Sthana 30/25-26] which is a prevalent condition among the adolesent age group.
+
*'''Primary dysmenorrhea:''' It is mentioned as “udavartini yoni vyapad”in Ayurveda[Cha. Sa. [[Chikitsa Sthana]] 30/25-26] which is a prevalent condition among the adolesent age group.
    
'''2)Reproductive age:'''
 
'''2)Reproductive age:'''
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'''3)Climatric and perimenopause age:'''  
 
'''3)Climatric and perimenopause age:'''  
   −
*Menopause is the permanent cessation of menstruation and declining ovarian function. It is a natural physiological process due to aging(jaravastha). The age of menopause is 50 years.[Su. Sa. Sharira Sthana 3/11] 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.
+
*Menopause is the permanent cessation of menstruation and declining ovarian function. It is a natural physiological process due to aging(jaravastha). The age of menopause is 50 years.[Su. Sa. Sharira Sthana 3/11]  
    +
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:'''
 +
 +
*Food and beverages that are excessively hot in potency cause disturbances in the physiology of menstruation especially in the growth and development of follicles/ovum. (andopachaya). [ Ka. Sa. Kalpa Sthana 7/32]
 +
 +
*Consumption of excessive salty, sour, heavy, pungent substances, those producing burning sensation(vidahi), excessive use of unctuous substances, meat of domestic, aquatic and fatty animals, mixture of cooked rice and pulses (krushara), curd, vinegar, curd-water(mastu) and wine leads to excessive menstrual bleeding. [Cha.Sa. [[Chikitsa Sthana]] 30/204]
 +
 +
'''2. Lifestyle factors:'''
 +
 +
*The daily activities in general and those during menstruation influence reproductive health. [Cha. Sa. [[Chikitsa Sthana]] 30/7-8], [Su.Sa. Sharira Sthana 2/24-25]
 +
 +
*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 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]
 +
 +
*Use of artificial objects for sexual pleasure are considered as risk factors for menstrual disorders. [Cha. Sa. [[Chikitsa Sthana]] 30/7-8] [A. Hr. Uttara Sthana 33/27-28]
 +
 +
'''3. Psychological factors:'''
 +
 +
*Mental stress, anxiety and excessive thinking causes vitiation of channels of transportation of [[rasa dhatu]] and lead to disturbances in the physiology of menstruation. [Cha. Sa. [[Vimana Sthana]] 5/13] Stress is a major cause for hormonal disturbance in HPO axis leading to menstrual abnormalities.
 +
 +
'''4. Improper use of therapeutic interventions:'''
 +
 +
*Administration of nasal medication (nasya) during menstrual phase, administration of strong medication for purification therapy (shodhana) in a woman who is sensitive to mild purgatives (mrudu koshtha) leads to disorders of menstruation. [Ka. Sa. Siddhi Sthana 4/6] [Ka. Sa Siddhi Sthana 3/20]
 +
 +
'''5. Congenital factors:'''
 +
 +
*The defects in gametes (beejadosha), especially in the ovum of mother can cause congenital anomalies related to female reproductive system. [Cha. Sa. [[Sharira Sthana]] 4/ 30].
   −
1. Dietary factors:
+
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]
−
• Food and beverages that are excessively hot in potency cause disturbances in the physiology of menstruation especially in the growth and development of follicles/ovum. (andopachaya). [ Ka. Sa. Kalpa Sthana 7/32]
+
</div>
−
• Consumption of excessive salty, sour, heavy, pungent substances, those producing burning sensation(vidahi), excessive use of unctuous substances, meat of domestic, aquatic and fatty animals, mixture of cooked rice and pulses (krushara), curd, vinegar, curd-water(mastu) and wine leads to excessive menstrual bleeding. [Cha.Sa. ChikitsaSthana 30/204]
  −
2. Lifestyle factors:
  −
• The daily activities in general and those during menstruation influence reproductive health. [Cha. Sa. Chikitsa Sthana 30/7-8], [Su.Sa. ShariraSthana 2/24-25]
  −
• 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. 
  −
• 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. Ni. 16/27]
  −
• Use of artificial objects for sexual pleasure are considered as risk factors for menstrual disorders. [Cha.Sa. Chikitsa Sthana 30/7-8] [A. Hr. Uttara Sthana 33/27-28]
  −
3. Psychological factors:
  −
• Mental stress, anxiety and excessive thinking causes vitiation of channels of transportation of [[rasa dhatu]] and lead to disturbances in the physiology of menstruation. [Cha. Sa. Vimana Sthana 5/13] Stress is a major cause for hormonal disturbance in HPO axis leading to menstrual abnormalities.
  −
4. Improper use of therapeutic interventions:
  −
• Administration of nasal medication (nasya) during menstrual phase, administration of strong medication for purification therapy (shodhana) in a woman who is sensitive to mild purgatives (mrudu koshtha) leads to disorders of menstruation. [Ka. Sa. Siddhi Sthana4/6] [Ka.Sa Siddhi Sthana 3/20]
  −
5. Congenital factors:
  −
• The defects in gametes (beejadosha), especially in the ovum of mother can cause congenital anomalies related to female reproductive system. [Cha. Sa. Sharira Sthana 4/ 30].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]
   
===Pathophysiology===
 
===Pathophysiology===
−
Functions of 5 types of vata  in reproductive physiology [A.S.Sutra Sthana 20/2]
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'''Functions of 5 types of vata  in reproductive physiology''' [A.S. Sutra Sthana 20/2]
−
Type of Vayu Related Functions Physiological functions
+
{| class="wikitable"
−
Prana vayu Maintanance and control of intellect(buddhi), sense organs (indriya),mind, vasomotor activities. Neural regulation at  hypothalamo-pitutary level
+
|-
−
Udana vayu Production of strength(bala), energy(urja), memory(smriti), nourishing channels of body tissues(srota preenana)
+
!Type of Vayu !!Related Functions !! Physiological functions
−
Samana vayu Helps in the function of digestive fire(agni), moves inside the channels of menstrual blood as well as ovum(artava vaha sroto vichari) • Any kind of transformation process related to reproductive physiology like Synthesis of all hormones,
+
|-
 +
|'''Prana vayu''' ||Maintenance and control of intellect(buddhi), sense organs (indriya),mind, vasomotor activities. || Neural regulation at  hypothalamo-pitutary level
 +
|-
 +
|'''Udana vayu''' ||Production of strength(bala), energy(urja), memory(smriti), nourishing channels of body tissues(srota preenana)||Neural regulation at  hypothalamo-pitutary level
 +
|-
 +
|'''Samana vayu'''|| Helps in the function of digestive fire(agni), moves inside the channels of menstrual blood as well as ovum(artava vaha sroto vichari) || Any kind of transformation process related to reproductive physiology like Synthesis of all hormones,
 
Eg:-Aromatization of testosterone into estrogen
 
Eg:-Aromatization of testosterone into estrogen
−
• Receptor mechanism in cells, functions of gap junctions
     −
Vyana vayu All kinds of movements,clearing/widening the channels of transportation(sroto vishodhana),Flow  of sweat and blood(sweda- asruk sravana), helps in ejaculation of semen and helps in fertilization, nourishment of all the tissues • Circulation of reproductive hormones  
+
Receptor mechanism in cells, functions of gap junctions
−
• Spasm followed by relaxation in spiral arteries- damage of arteriolar wall- escape of blood(mechanism of menstrual bleeding)
+
|-
−
Apana vayu Elimination of menstrual blood(artava nishkramana) Shedding of superficial functional layer of endometrium along with blood from the uterine cavity.
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|'''Vyana vayu'''|| All kinds of movements,clearing/widening the channels of transportation(sroto vishodhana),Flow  of sweat and blood(sweda- asruk sravana)|| Helps in ejaculation of semen and helps in fertilization, nourishment of all the tissues Circulation of reproductive hormones  
 +
Spasm followed by relaxation in spiral arteries- damage of arteriolar wall- escape of blood(mechanism of menstrual bleeding)
 +
|-
 +
|'''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:
 +
 
 +
1)Primary vitiation: Due to degeneration of body components(dhatukshaya)
   −
• The vitiation of vata occurs in two ways:
  −
1)Primary vitiation: Due to degenration of body components(dhatukshaya)
   
2)Secondary vitiation: Obtructive pathology (avarodha)
 
2)Secondary vitiation: Obtructive pathology (avarodha)
−
• If this indirect vitiation is by the influence of pitta, it leads to increase in menstrual bleeding. It is mainly because of the increase in fluidity(dravatva) and flowing nature(saratva) of [[pitta]].But if the properties like hotness(ushnatva) and sharpness(teekshnatva) are increased, then it leads to destruction of body tissues([[dhatu]] kshaya) and thus the quantity of menstrual discharge also gets decreased.[A.S.Uttara Sthana 38/47]
+
 
−
• The pathology of excessive menstrual bleeding (asrugdara) is explained as the occlusion of apana vayu with [[pitta]] (pittavruta apana).[Su. Sa. Nidana Sthana 1/37]
+
*If this indirect vitiation is by the influence of pitta, it leads to increase in menstrual bleeding. It is mainly because of the increase in fluidity(dravatva) and flowing nature(saratva) of [[pitta]].But if the properties like hotness(ushnatva) and sharpness(teekshnatva) are increased, then it leads to destruction of body tissues([[dhatu]] kshaya) and thus the quantity of menstrual discharge also gets decreased.[A.S.Uttara Sthana 38/47]
−
• Heavy menstrual bleeding is also included in the disorders of blood (raktapradoshaja vikara).[ Cha. Sa. Sutra Sthana 28/11]
+
 
−
• The obstructive pathology due to kapha usually leads to decrease in the fuction 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 pathology of excessive menstrual bleeding (asrugdara) is explained as the occlusion of apana vayu with [[pitta]] (pittavruta apana).[Su. Sa. Nidana Sthana 1/37]
 +
 
 +
*Heavy menstrual bleeding is also included in the disorders of blood (raktapradoshaja vikara).[ Cha. Sa.[[Sutra Sthana]] 28/11]
 +
 
 +
*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.
−
Symptoms of decrease of menstrual blood(artavakshaya)* Symptoms of increase in menstrual blood (artavavriddhi)**
+
{| class="wikitable"
−
primary or secondary amenorrhea, oligomenorrhea (yathochita kala adarshanam ) body aches (angamarda)
+
|-
−
scanty menses/ hypomenorrhea (alpata) excessive menstrual bleeding (atipravrutti)
+
! Symptoms of decrease of menstrual blood(artavakshaya)* !! Symptoms of increase in menstrual blood (artavavriddhi)**
−
pain in genital tract, dysmenorrhoea (yoni vedana) bad smell (daurgandhya)
+
|-
−
*[Su. Sa. Sutra Sthana 15/12], **[Su. Sa. Sutra Sthana 15/16]
+
|primary or secondary amenorrhea, oligomenorrhea (yathochita kala adarshanam ) || body aches (angamarda)
−
A special condition characterized by excessive menstrual loss is explained in Ayurveda which is known as “Asrugdara”. It includes:
+
|-
−
a)Menorrhagia: excessive bleeding in terms of quantityand duration(atiprasangena pravruttam).  It is defined as menstrual blood loss greater than 80 ml.
+
|scanty menses/ hypomenorrhea (alpata) || excessive menstrual bleeding (atipravrutti)
−
b)Metrorrhagia: intermenstrual bleeding(anrutavapi pravruttam)
+
|-
−
c)Menometrorrhagia: combination of the above two conditions
+
|pain in genital tract, dysmenorrhoea (yoni vedana) ||bad smell (daurgandhya)
−
d)Polymenorrhea:decreased interval of cycles, bleeding occuring more ofen than every 21 days
+
|}
 +
 
 +
* *[Su. Sa. Sutra Sthana 15/12], **[Su. Sa. Sutra Sthana 15/16]
 +
 
 +
A special condition characterized by excessive menstrual loss is explained in Ayurveda which is known as “Asrugdara”.  
 +
 
 +
It includes:
 +
 
 +
a)'''Menorrhagia''': excessive bleeding in terms of quantity and duration(atiprasangena pravruttam).  It is defined as menstrual blood loss greater than 80 ml.
 +
 
 +
b)'''Metrorrhagia''': intermenstrual bleeding(anrutavapi pravruttam)
 +
 
 +
c)'''Menometrorrhagia''': combination of the above two conditions
 +
 
 +
d)'''Polymenorrhea''':decreased interval of cycles, bleeding occurring more often than every 21 days
 +
 
 
e)Other bleeding disorders(anyad raktalakshana)
 
e)Other bleeding disorders(anyad raktalakshana)
 +
</div>
 +
 
===Special features===
 
===Special features===
 +
 
====Excess menstrual bleeding (asrugdara)====
 
====Excess menstrual bleeding (asrugdara)====
 +
 
The specific features of different types of “asrugdara” are mentioned in the table.
 
The specific features of different types of “asrugdara” are mentioned in the table.
−
Sl no: Type Characteristic features Probable gynecological correlation  
+
{| class="wikitable"
−
1. Vata dominant • Menstrual blood is frothy, thin, rough, blackish or reddish, resembling washings of flower of Butea monosperma (palasha).*
+
|-
−
• With or without pain*
+
!Sl no: !! Type !! Characteristic features !! Probable gynecological correlation<ref>Prof.Premvati Tewari, Ayurveda Prasutitantra evam Striroga, Part 2, Chapter 2, Artavavyapad,Chaukhambha orientalia,Varanasi, vol. 2, 2012, Page No:187,190,192,194.</ref>
−
• Flows quickly, does not clot**
+
|-
−
• Smells like iron(lohagandhi), cold*** Severe pain and bleeding due to hyperemia of pelvic organs-pelvic congestion syndrome or pelvic sympathetic syndrome
+
|1. ||Vata dominant || •Menstrual blood is frothy, thin, rough, blackish or reddish, resembling washings of flower of Butea monosperma (palasha).*
−
2. Pitta dominant • Menstrual blood is blue, yellow or blackish in color, hot, comes in profuse amount repeatedly, and with pain*
+
•With or without pain*
−
• Associated with burning sensation, redness over body, thirst, mental confusion, fever and giddiness*
+
 
−
• Resembles the water mixed with smoke or extract of Indian berberis(rasanjana) or cow urine in color, having musty or fishy smell***
+
•Flows quickly, does not clot**
−
• Not attracted  by ants and flies, does not coagulate, hot*** Menometrorrhagia due to pelvic congestion caused by infection/inflammation
+
 
−
3. Kapha dominant • Menstrual blood is slimy, pale, heavy, unctuous, cold, mixed with mucous and thick, discharged with mild pain*
+
•Smells like iron(lohagandhi), cold***
−
• Associated symptoms like vomiting, anorexia, nausea, dyspnea and cough*
+
||Severe pain and bleeding due to hyperemia of pelvic organs-pelvic congestion syndrome or pelvic sympathetic syndrome
−
• Blood resembles the water mixed with red ochre, excreted very slowly, get clotted like a muscle**
+
|-
−
• Like flowers of Bauhinia variegata(kovidara), pale, gets clotted in the shape of fibers, smells like fat*** Menorrhagia due to early stage of tubercular endometritis or chronic endometritis due to other causes.
+
|2. ||Pitta dominant ||•Menstrual blood is blue, yellow or blackish in color, hot, comes in profuse amount repeatedly, and with pain*
−
4. Sannipataja • Foul smelling, slimy, yellowish, resembling ghee, marrow, muscle fat etc.*
+
 
−
• Continuously suffering from thirst, burning sensation, fever, anaemia, and weakness*
+
•Associated with burning sensation, redness over body, thirst, mental confusion, fever and giddiness*
−
• Resembles a sour liqid called “Kanji” prepared from rice and foul smelling.**
+
 
−
• Blue like bronze, dirty and foul smelling.*** Endometrial/cervical carcinoma  
+
•Resembles the water mixed with smoke or extract of Indian berberis(rasanjana) or cow urine in color, having musty or fishy smell***
 +
 
 +
•Not attracted  by ants and flies, does not coagulate, hot***
 +
|| Menometrorrhagia due to pelvic congestion caused by infection/inflammation
 +
|-
 +
| 3. || Kapha dominant || •Menstrual blood is slimy, pale, heavy, unctuous, cold, mixed with mucous and thick, discharged with mild pain*
 +
 
 +
•Associated symptoms like vomiting, anorexia, nausea, dyspnea and cough*
 +
 
 +
•Blood resembles the water mixed with red ochre, excreted very slowly, get clotted like a muscle**
 +
 
 +
•Like flowers of Bauhinia variegata(kovidara), pale, gets clotted in the shape of fibers, smells like fat***  
 +
|| Menorrhagia due to early stage of tubercular endometritis or chronic endometritis due to other causes.
 +
|-
 +
| 4. || Sannipataja || •Foul smelling, slimy, yellowish, resembling ghee, marrow, muscle fat etc.*
 +
 
 +
•Continuously suffering from thirst, burning sensation, fever, anaemia, and weakness*
 +
 
 +
•Resembles a sour liquid called “Kanji” prepared from rice and foul smelling.**
 +
 
 +
•Blue like bronze, dirty and foul smelling.***
 +
|| Endometrial/cervical carcinoma  
 
or  
 
or  
 
Senile pyometra
 
Senile pyometra
−
*[Cha. Sa. Chikitsa Sthana 30/211-224], **[ Su. Sa. Sutra Sthana 14/21]
+
|}
−
***[A. S. Sutra Sthana 36/16]
+
 
 +
* *[Cha. Sa. [[Chikitsa Sthana]] 30/211-224], **[ Su. Sa. Sutra Sthana 14/21], ***[A. S. Sutra Sthana 36/16]
 +
 
 
==== 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.
−
Sl. No Type Characteristic features Vitiating factor Clinical gynecological disorders  
+
{| class="wikitable"
−
1. Vataja Red, black or dark violet in color, thin, dry, frothy and scattered (very small clots mixed with liquid substance), excreted slowly with perforating or piercing type of pain* Vata* Oligomenorrhea with dysmenorrhea caused by nutritional deficiency
+
|-
−
2. Pittaja Yellowish or bluish in color, free from unctuousness, excreted blood is hot and associated with burning sensation*
+
!Sl. No !!Type !!Characteristic features !! Vitiating factor !! Clinical gynecological disorders<ref>Prof.Premvati Tewari, Ayurveda Prasutitantra evam Striroga, Part 2, Chapter 2, Artavavyapad,Chaukhambha orientalia,Varanasi, vol. 2, 2012, Page No:150-151.</ref>
−
The color of blood resembles that of hibiscus (japa),or saffron, associated with dysuria ** Pitta* Inflammatory condition of reproductive organs due to infection especially chronic pelvic cellulitis associated with oligomenorrhoea.
+
|-
−
3. Kaphaja Whitish or slightly yellowish in color, appears as if mixed with bone marrow, too thick and slippery, unctuous and settles down if put in the water*
+
|1. ||'''Vataja''' || Red, black or dark violet in color, thin, dry, frothy and scattered (very small clots mixed with liquid substance), excreted slowly with perforating or piercing type of pain*   || Vata* || Oligomenorrhea with dysmenorrhea caused by nutritional deficiency
−
Retention of urine, body stiffness or idleness, lethargy, drowsiness, sleepiness**  
+
|-
−
Kapha* Chronic endometritis, endocervicitis or cervicitis associated with oligomenorrhoea.
+
|2. ||'''Pittaja''' || Yellowish or bluish in color, free from unctuousness, excreted blood is hot and associated with burning sensation*
 +
The color of blood resembles that of hibiscus (japa),or saffron, associated with dysuria **  
 +
||Pitta* || Inflammatory condition of reproductive organs due to infection especially chronic pelvic cellulitis associated with oligomenorrhoea.
 +
|-
 +
|3. || '''Kaphaja''' || Whitish or slightly yellowish in color, appears as if mixed with bone marrow, too thick and slippery, unctuous and settles down if put in the water*  
 +
Retention of urine, body stiffness or idleness, lethargy, drowsiness, sleepiness**
 +
|| Kapha* || Chronic endometritis, endocervicitis or cervicitis associated with oligomenorrhoea.
 +
|-
 +
|4. || '''Kunapagandhi''' || Smell of dead tissue, excessive blood discharge, associated with features of pitta like burning sensation* || Rakta* || Early stage of endometrial carcinoma.
 +
|-
 +
|5. || '''Granthibhuta''' || Clotted appearance, features of both kapha and vata.* ||  Kapha-vata* ||Malignant disorders of reproductive system specially cervical carcinoma
 +
|-
 +
|6. || '''Puti-puya''' || Putrid and purulent discharge.* associated with other features of pitta and kapha. || Pitta-kapha*/
 +
Rakta- Pitta#
 +
|| Acute infection of reproductive system especially acute endometritis leading to pyometra.
 +
|-
 +
|7. || '''Ksheena''' || Delayed, scanty and associated with pain.* || Vata-pitta* || Hypoestrogenic oligomenorrhoea caused by nutritional deficiency.
 +
|-
 +
|8. || '''Mutra-purishagandhi''' || Smell of urine and feces. || Sannipata* ||Cervical carcinoma specially 3rd or 4th stage.
 +
|}
 +
 
 +
* *[Su. Sa. Sharira Sthana 2/4], [A.S. Sharira Sthana 1/24], **[Ha.Sa. Trutiya Sthana 48/19,22, 23], #[A. Hr. Sharira Sthana 1/11]
 +
 
   −
4. Kunapagandhi Smell of dead tissue, excessive blood discharge, associated with features of pitta like burning sensation* Rakta* Early stage of endometrial carcinoma.
+
'''Prognosis of abnormal menstrual blood(artavadushti):'''
−
5. Granthibhuta Clotted appearance, features of both kapha and vata.* Kapha-vata* Malignant disorders of reproductive system specially cervical carcinoma
+
{| class="wikitable"
−
6. Puti-puya Putrid and purulent discharge.* associated with other features of pitta and kapha. Pitta-kapha*/
+
|-
−
Rakta- Pitta#
+
!Curable !!Incurable  
−
Acute infection of reproductive system especially acute endometritis leading to pyometra.
+
|-
−
7. Ksheena Delayed, scanty and associated with pain.* Vata-pitta* Hypoestrogenic oligomenorrhoea caused by nutritional deficiency.
+
|Vata dominant, pitta dominant, Kapha dominant || Kunapagandhi, granthibhuta,putipuya,ksheena, mutra-purishagandhi
−
8. Mutra-purishagandhi Smell of urine and feces. Sannipata* Cervical carcinoma specially 3rd or 4th stage.
+
|}
−
*[Su. Sa. Sharira Sthana 2/4], [A.S. Sharira Sthana 1/24]
  −
**[Ha.Sa. Trutiya Sthana 48/19,22, 23]
  −
#[A. Hr. ShariraSthana 1/11]
  −
Prognosis of abnormal menstrual blood(artavadushti):
  −
Curable Incurable  
  −
Vata dominant, pitta dominant, Kapha dominant Kunapagandhi, granthibhuta,putipuya,ksheena, mutra-purishagandhi
      
In the opinion of Vagbhata, the condition of mutra-purishagandhi in incurable and all other disorders are difficult to cure.[Su.Sa.Sharira Sthana 2/5] [A.Hr. Sharira Sthana 1/ 12]
 
In the opinion of Vagbhata, the condition of mutra-purishagandhi in incurable and all other disorders are difficult to cure.[Su.Sa.Sharira Sthana 2/5] [A.Hr. Sharira Sthana 1/ 12]
−
Currently, apart from the three types of vitiations 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 focussing on the diagnosis and treatment aspects of abnormal variations in the characterestic 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) ===
−
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.
+
<div style="text-align:justify;">
−
In case of primary amenorrhoea, development of secondary sexual characters should be noted. For example, the breast development is absent or less in conditions called “ shushka revati”[Ka. Sa. Kalpa Sthana 6/31] and “shandhi yoni vyapad”. [Cha.Sa. ChikitsaSthana 30/35]
+
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.
 +
 
 +
In case of primary amenorrhoea, development of secondary sexual characters should be noted. For example, the breast development is absent or less in conditions called “ shushka revati”[Ka. Sa. Kalpa Sthana 6/31] and “shandhi yoni vyapad”. [Cha.Sa.[[Chikitsa Sthana]] 30/35]
 +
 
 
The features like obesity, enlargement of thyroid gland, excessive androgenic hair growth, etc. which give a clue regarding the metabolic and endocrinal disorders like poly cystic ovary syndrome(PCOS), thyroid dysfunction, hyperprolactinemia etc. leading to menstrual irregularities also should be observed.  
 
The features like obesity, enlargement of thyroid gland, excessive androgenic hair growth, etc. which give a clue regarding the metabolic and endocrinal disorders like poly cystic ovary syndrome(PCOS), thyroid dysfunction, hyperprolactinemia etc. leading to menstrual irregularities also should be observed.  
 +
 
The similar descriptions of diagnostic features due to hyperandrogenism and insulin resistance found in case of PCOS are mentioned in the disorder called “pushpaghni jataharini”. [Ka. Sa. Kalpa Sthana 6/33]
 
The similar descriptions of diagnostic features due to hyperandrogenism and insulin resistance found in case of PCOS are mentioned in the disorder called “pushpaghni jataharini”. [Ka. Sa. Kalpa Sthana 6/33]
 +
 
The color index for normal menstrual blood (artava) is available in the text books of Ayurveda.  It is mentioned as different shades of red having resemblance with the followings.
 
The color index for normal menstrual blood (artava) is available in the text books of Ayurveda.  It is mentioned as different shades of red having resemblance with the followings.
−
• the color of fruit of Abrusprecatorius(gunja)[Cha. Sa. Chikitsa Sthana 30/226]
+
 
−
• the color of red lotus flower[Cha. Sa. ChikitsaSthana 30/ 226]
+
*the color of fruit of Abrusprecatorius(gunja)[Cha. Sa. [[Chikitsa Sthana]] 30/226]
−
• the color of an insect called red velvet mite(indragopa)[Cha. Sa. ChikitsaSthana 30/226]
+
 
−
• the color of blood of rabbit[Su. Sa. ShariraSthana 2/ 17 ]
+
*the color of red lotus flower[Cha. Sa. [[Chikitsa Sthana]] 30/ 226]
−
• the color of solution Lacciferlacca(laksha rasa)[Su. Sa. Sharira Sthana 2/17 ]
+
 
−
• blackish red[Su. Sa. Sharira Sthana 3/ 10]
+
*the color of an insect called red velvet mite(indragopa)[Cha. Sa. [[Chikitsa Sthana]] 30/226]
 +
 
 +
*the color of blood of rabbit[Su. Sa. Sharira Sthana 2/ 17 ]
 +
 
 +
*the color of solution Laccifer lacca(laksha rasa)[Su. Sa. Sharira Sthana 2/17]
 +
 
 +
*blackish red[Su. Sa. Sharira Sthana 3/ 10]
 +
 
 
The abnormal range of color shades are mentioned as the clinical features of different types of abnormal states of menstrual blood(artavadushti) as well the features of different types of excessive bleeding(asrugdara).
 
The abnormal range of color shades are mentioned as the clinical features of different types of abnormal states of menstrual blood(artavadushti) as well the features of different types of excessive bleeding(asrugdara).
−
Apart from the color, the smell and consistency also should be noted. The peculiar nature of menstrual blood as it does not stain the cloth is particularly observed. [Su. Sa. ShariraSthana 2/ 17]
+
 
−
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.  
+
Apart from the color, the smell and consistency also should be noted. The peculiar nature of menstrual blood as it does not stain the cloth is particularly observed. [Su. Sa. Sharira Sthana 2/ 17]
 +
 
 +
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) ===
−
Per abdominal examination by palpation as well as bimanual examination of uterus and adnexa is important in the diagnosis of menstrual disorders.
+
<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.
 +
 
 
Tenderness (sparshasahatva) indicates the involvement of [[pitta]] along with [[vata]]. The secondary pelvic pathologies like uterine fibroid (garbhashaya arbuda), ovarian cyst(beejakoshagranthi), tubo-ovarian(TO) mass, adenomyosis,endometriosis, uterine polyps etc. which can cause menstrual abnormalities are kept in mind during palpation.
 
Tenderness (sparshasahatva) indicates the involvement of [[pitta]] along with [[vata]]. The secondary pelvic pathologies like uterine fibroid (garbhashaya arbuda), ovarian cyst(beejakoshagranthi), tubo-ovarian(TO) mass, adenomyosis,endometriosis, uterine polyps etc. which can cause menstrual abnormalities are kept in mind during palpation.
 +
 
===Interrogation (prashna) ===
 
===Interrogation (prashna) ===
 +
 
The associated symptoms with menstruation especially in case of dysmenorrhea, premenstrual syndrome, menopausal syndrome etc. are elicited through interrogation.  
 
The associated symptoms with menstruation especially in case of dysmenorrhea, premenstrual syndrome, menopausal syndrome etc. are elicited through interrogation.  
−
The typical feature suggestive of a particular pathology can be reveled through proper interrogation. Ex- immediate relief of pain after proper establishment of bleeding in primary/spasmodic dysmenorrhea (udavartini yoni vyapad).[ Cha. Sa. Chikitsa Sthana 30/25-26]
+
 
−
The etiological factors should be traced out through proper history taking which helps in both diagnosis as well as treatment. 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.
+
The typical feature suggestive of a particular pathology can be reveled through proper interrogation.  
 +
 
 +
Ex- immediate relief of pain after proper establishment of bleeding in primary/spasmodic dysmenorrhea (udavartini yoni vyapad).[ Cha. Sa.[[Chikitsa Sthana]] 30/25-26]
 +
 
 +
The etiological factors should be traced out through proper history taking which helps in both diagnosis as well as treatment.
 +
 
 +
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==
 
===In decreased state of menstrual blood (artavakshaya)===
 
===In decreased state of menstrual blood (artavakshaya)===
−
Common clinical conditions and laboratory investigations:
+
 
−
Investigation Value/Result Possible diagnosis
+
'''Common clinical conditions and laboratory investigations:'''
−
Urine Pregnancy Test Positive Pregnancy
+
{| class="wikitable"
−
S. FSH LH level increased or LH:FSH ratio>2:1 PCOS
+
|-
−
S. LH
+
!Investigation!! Value/Result !! Possible diagnosis
−
S.Total Testosterone increased
+
|-
−
S. estradiol increased
+
|Urine Pregnancy Test || Positive || Pregnancy
−
S. SHBG reduced
+
|-
−
S. Prolactin increased Hyperprolactinaemia
+
|S. FSH, S. LH || LH level increased or LH:FSH ratio>2:1 ||PCOS
−
S. TSH Increased Hypothyroidism
+
|-
−
(common)
+
|S.Total Testosterone|| increased || PCOS
−
decreased Hyperthyroidism
+
|-
−
S.AMH AMH-lower level
+
|S. estradiol ||increased || PCOS
−
FSH-High,Estradiol-low Premature ovarian failure
+
|-
−
S- serum, FSH- Follicle Stimulating Hormone, LH- Luteinizing Hormone, SHBG-Sex Hormone Binding Globulin, TSH-Thyroid Stimulating Hormone, AMH-Anti Mullerian Hormone
+
|S. SHBG || reduced || PCOS
 +
|-
 +
|S. Prolactin || increased || Hyperprolactinaemia
 +
|-
 +
|S. TSH || Increased || Hypothyroidism(common)
 +
|-
 +
|S. TSH ||decreased ||Hyperthyroidism
 +
|-
 +
|S.AMH || AMH-lower level,FSH-High,Estradiol-low ||Premature ovarian failure
 +
|}
 +
 
 +
'''S'''- serum, '''FSH'''- Follicle Stimulating Hormone, '''LH'''- Luteinizing Hormone, '''SHBG'''-Sex Hormone Binding Globulin, '''TSH'''-Thyroid Stimulating Hormone, '''AMH'''-Anti Mullerian Hormone
 +
 
 
===In increased state of menstrual blood (artavavrudhi/asrugdara)===
 
===In increased state of menstrual blood (artavavrudhi/asrugdara)===
−
• Haemoglobin estimation is done in every case.
+
*Haemoglobin estimation is done in every case.
 +
 
 
In cases not responding to usual therapy,  
 
In cases not responding to usual therapy,  
−
• platelet count
+
 
−
• prothrombin time
+
*platelet count
−
• bleeding time and clotting time
+
 
−
• partial thromboplastin time
+
*prothrombin time
 +
 
 +
*bleeding time and clotting time
 +
 
 +
*partial thromboplastin time
 +
 
 
In suspected cases of thyroid dysfunction, S.TSH, T3, T4 estimations are recommended.
 
In suspected cases of thyroid dysfunction, S.TSH, T3, T4 estimations are recommended.
 +
 
== Imaging techniques==
 
== Imaging techniques==
 +
 
=== In decreased state of menstrual blood (artavakshaya)===
 
=== In decreased state of menstrual blood (artavakshaya)===
−
• In primary amenorrhea, trans-abdominal sonography (TAS) is recommended to confirm the presence of uterus and adnexae.
+
 
−
• In secondary amenorrhea, oligomenorrhea, hypomenorrhea etc. trans-vaginal or trans-abdominal sonography may reveal the presence of poly cystic ovary.
+
*In primary amenorrhea, trans-abdominal sonography (TAS) is recommended to confirm the presence of uterus and adnexae.
 +
 
 +
*In secondary amenorrhea, oligomenorrhea, hypomenorrhea etc. trans-vaginal or trans-abdominal sonography may reveal the presence of poly cystic ovary.
 +
 
 
Ultra Sonological findings in PCOD:  
 
Ultra Sonological findings in PCOD:  
−
• Ovaries are enlarged(ovarian volume ≥ 10 cm3 )
+
 
−
• Stroma is increased, Capsule is thickened and pearly white in color.
+
*Ovaries are enlarged(ovarian volume ≥ 10 cm3 )
−
• Presence of multiple (≥12) follicular cysts measuring about 2-9mm in diameter, crowded around the cortex(periphery)- “string of pearls sign”
+
 
 +
*Stroma is increased, Capsule is thickened and pearly white in color.
 +
 
 +
*Presence of multiple (≥12) follicular cysts measuring about 2-9mm in diameter, crowded around the cortex(periphery)- “string of pearls sign”
 +
 
 
=== In increased state of menstrual blood (artavavrudhi/ asrugdara) ===
 
=== In increased state of menstrual blood (artavavrudhi/ asrugdara) ===
−
Transvaginal Sonography (TVS ) and Color Doppler:
+
 
 +
'''Transvaginal Sonography (TVS ) and Color Doppler''':
 +
 
 
Findings of Endometrial Hyperplasia
 
Findings of Endometrial Hyperplasia
−
• Endometrial thickness >12 mm
+
 
−
• Hyper echoic and regular outline
+
*Endometrial thickness >12 mm
−
• Angiogenesis and neovascular signal study
+
 
 +
*Hyper echoic and regular outline
 +
 
 +
*Angiogenesis and neovascular signal study
 +
 
 
TVS is very sensitive to detect any anatomical abnormality like fibroids, adenomyosis etc. or other abnormalities of uterus, endometrium and adenexae.
 
TVS is very sensitive to detect any anatomical abnormality like fibroids, adenomyosis etc. or other abnormalities of uterus, endometrium and adenexae.
−
Saline Infusion Sonography (SIS):
+
 
 +
'''Saline Infusion Sonography (SIS):'''
 +
 
 
It is superior to diagnose endometrial polyps, submucous fibroids and intrauterine abnormalities like septate/subseptate uterus etc.
 
It is superior to diagnose endometrial polyps, submucous fibroids and intrauterine abnormalities like septate/subseptate uterus etc.
   −
Endometrial Biopsy:
+
'''Endometrial Biopsy:'''
 +
 
 
In office endometrial smpling to rule out hyperplasia or carcinoma.
 
In office endometrial smpling to rule out hyperplasia or carcinoma.
   −
Hysteroscopy:
+
'''Hysteroscopy:'''
 +
 
 
It is done for better evaluation of endometrial lesion and to take biopsy under direct vision.
 
It is done for better evaluation of endometrial lesion and to take biopsy under direct vision.
 +
 
==Management==
 
==Management==
 +
 
The management of menstrual disorders is broadly divided into two.
 
The management of menstrual disorders is broadly divided into two.
−
1. Purification therapy(shodhana/ panchakarma)
+
 
−
2. Pacification therapy(shamana)
+
'''1. Purification therapy(shodhana/ panchakarma)
 +
'''
 +
 
 +
'''2. Pacification therapy(shamana)
 +
'''
 
===Treatment for decreased state of menstrual blood ===
 
===Treatment for decreased state of menstrual blood ===
−
Purification therapy(shodhana chikitsa):
+
 
−
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]].Some scholars opine that therapeutic purgation (virechana) is contraindicated as it may lead to further decrease of [[pitta]].[Dalhana commentry, Su.Sa.Sutra Sthana 15/12] However, in chronic pathology both therapeutic emesis (vamana) and purgation (virechana) are recommended and  practically both the procedures are found to be effective.   
+
'''Purification therapy(shodhana chikitsa):'''
−
Pacification therapy(shamana chikitsa):
+
<div style="text-align:justify;">
−
It is indicated in case of decrease of menstrual blooddue to the nutritional factors or diminished state of all body components(dhatu kshaya). Nourishing therapy is indicated if the digestive power is good. In other cases, the stimulation and enhancement of digestive fire(agnideepana) is indicated initially, followed by nourishment therapy. Judicious administrationof substances having the similar properties of blood are advised. [Su. Sa. Sutra Sthana 15/12].
+
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]].
−
Fish(matsya), horse gram (kulattha), sour substances(amla), sesame (tila), black gram(masha), beer(sura), cow’s urine(gomutra), diluted butter milk(udaschit), curd(dadhi),vinegar(shukta) are beneficial as food and drinks during decrease of menstrual blood.[Su. Sa. ShariraSthana 2/21-23]
+
 
 +
Some scholars opine that therapeutic purgation (virechana) is contraindicated as it may lead to further decrease of [[pitta]].[Dalhana commentry, Su.Sa.Sutra Sthana 15/12] However, in chronic pathology both therapeutic emesis (vamana) and purgation (virechana) are recommended and  practically both the procedures are found to be effective.<ref>Chauhan M; From the proceedings of Insight Ayurveda 2013, Coimbatore. 24th and 25th May 2013. OA03.05. A clinical study on the effect of vamana in anartava wsr to secondary amenorrhoea. Anc Sci Life. 2013;32(Suppl 2):S28. doi:10.4103/0257-7941.123842</ref> <ref>Bhingardive KB, Sarvade DD, Bhatted S. Clinical efficacy of Vamana Karma with Ikshwaaku Beeja Yoga followed by Shatapushpadi Ghanavati in the management of Artava Kshaya w. s. r to polycystic ovarian syndrome. Ayu. 2017;38(3-4):127-132. doi:10.4103/ayu.AYU_192_16</ref> <ref>Sreelakshmi Chaganti(2016), Evaluation of efficacy of virechana in polycystic ovarian syndrome,PG Dissertation, KLE Academy of higher education and research, Belgavi</ref>    
 +
 
 +
'''Pacification therapy(shamana chikitsa):'''
 +
 
 +
It is indicated in case of decrease of menstrual blooddue to the nutritional factors or diminished state of all body components(dhatu kshaya). Nourishing therapy is indicated if the digestive power is good. In other cases, the stimulation and enhancement of digestive fire(agnideepana) is indicated initially, followed by nourishment therapy. Judicious administration of substances having the similar properties of blood are advised. [Su. Sa. Sutra Sthana 15/12].
 +
 
 +
Fish(matsya), horse gram (kulattha), sour substances(amla), sesame (tila), black gram(masha), beer(sura), cow’s urine(gomutra), diluted butter milk(udaschit), curd(dadhi),vinegar(shukta) are beneficial as food and drinks during decrease of menstrual blood.[Su. Sa. Sharira Sthana 2/21-23]
 +
 
 
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 ===  
−
Purification therapy:
+
<div style="text-align:justify;">
−
In case of excessive menstrual bleeding, therapeutic purgation(virechana) is the treatment of choice.[Ka.Sa .SidhiSthana 2/13]
+
'''Purification therapy:'''
−
Pacification therapy:
+
 
−
• Hemostatic drugs (rakta stambhaka) are given only if the strength of patient is low and the vital parameters are disturbed. In this case, the medicines used for stopping blood as indicated in treatment of diarrhea with blood(raktatisara),bleeding disorders (raktapitta) and bleeding piles(raktarsha).[Ch.Sa.Chikitsa Sthana 30/228]
+
In case of excessive menstrual bleeding, therapeutic purgation(virechana) is the treatment of choice.[Ka.Sa .Sidhi Sthana 2/13]
−
• If the vital parameters are normal and strenght of patient is normal, then no medicine is advised to stop bleeding in the initial stage. Hemostasis treatment of vitiated blood leads to complications. [Ch.Sa.Chikitsa Sthana 30/228]
+
 
−
• 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.[Ch. Sa Chikitsa Sthana 30/86]
+
'''Pacification therapy:'''
 +
 
 +
*Hemostatic drugs (rakta stambhaka) are given only if the strength of patient is low and the vital parameters are disturbed. In this case, the medicines used for stopping blood as indicated in treatment of diarrhea with blood(raktatisara),bleeding disorders (raktapitta) and bleeding piles(raktarsha).[Ch.Sa.[[Chikitsa Sthana]] 30/228]
 +
 
 +
*If the vital parameters are normal and strenghth of patient is normal, then no medicine is advised to stop bleeding in the initial stage. Hemostasis treatment of vitiated blood leads to complications. [Ch.Sa. [[Chikitsa Sthana]] 30/228]
 +
 
 +
*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: ===  
−
Purification therapy :
+
<div style="text-align:justify;">
−
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]
+
'''Purification therapy :'''
−
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. ChikitsaSthana 30/228]
+
 
−
Pacification 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]
−
Specific combinationof drugs is mentioned for different kinds of abnormal menstrual blood.
+
 
−
Type of abnormality Drugs
+
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]
−
Vataja • Unctuous,hot,sour and salty substances*
+
 
−
Internal:
+
'''Pacification therapy:'''
−
• Ghee processed with Clerodendrum serratum (bharangi) ,Madhuca longifolia(madhuka), Cedrus deodara ( bhadradaru)**
+
 
−
• Milk processed with Gmelina arborea(kashmari), Phaseolus trilobus(kshudrasaha)**
+
Specific combination of drugs is mentioned for different kinds of abnormal menstrual blood.
−
External:
+
{| class="wikitable"
−
• Paste of Callicarpa macrophylla(priyangu) and sesame oil-applied in vagina**
+
|-
−
Pittaja • Sweet, cold and astringent substances*
+
!Type of abnormality !!Drugs
−
Internal:
+
|-
−
• Decoction of Lilium polyphyllum (kakoli)/ root of Pueraria tuberose(vidarimula)/ Nymphaea alba(utpala)/ Madhucalongifolia (madhuka)/ Gmelina arborea (kashmari) mixed with sugar.**
+
|'''Vataja''' ||| •Unctuous,hot,sour and salty substances*
−
• Paste of Anogeissuslatifolia (dhava) and Woodfordiafruticosa  (dhataki) flowers mixed with ghee**
+
 
−
External:
+
'''Internal:'''
−
• Vaginal application of paste of Santalum album (chandana)and Ipomoea digitata(payasya)**
+
 
−
• Vaginal douche with decoction of red ochre(gairika) and neem.**
+
•Ghee processed with Clerodendrum serratum (bharangi) ,Madhuca longifolia(madhuka), Cedrus deodara ( bhadradaru)**
−
Kaphaja • Hot,dry and astringent substances*
+
 
−
Internal:
+
•Milk processed with Gmelina arborea(kashmari), Phaseolus trilobus(kshudrasaha)**
−
• Decoction of Holarrhena antidysenterica (kutaja), Picrorhiza kurrooa (katuka)and Withania somnifera (ashwagandha)**
+
 
−
• Decoction of tender leaves of latex yielding trees mixed with honey**
+
'''External:'''
−
External:
+
 
−
• Vaginal application of paste of Randia dumetorum (madanaphala)**
+
•Paste of Callicarpa macrophylla(priyangu) and sesame oil-applied in vagina**
−
• Irrigation of vagina with the decoction of Symplocos racemosa (rodhra) and Diospyros tomentosa (tinduka)**
+
|-
 +
|'''Pittaja''' || •Sweet, cold and astringent substances*
 +
 
 +
'''Internal:'''
 +
 
 +
•Decoction of Lilium polyphyllum (kakoli)/ root of Pueraria tuberose(vidarimula)/ Nymphaea alba(utpala)/ Madhucalongifolia (madhuka)/ Gmelina arborea (kashmari) mixed with sugar.**
 +
 
 +
•Paste of Anogeissuslatifolia (dhava) and Woodfordiafruticosa  (dhataki) flowers mixed with ghee**
 +
 
 +
'''External:'''
 +
 
 +
•Vaginal application of paste of Santalum album (chandana)and Ipomoea digitata(payasya)**
 +
 
 +
•Vaginal douche with decoction of red ochre(gairika) and neem.**
 +
|-
 +
|'''Kaphaja''' || •Hot,dry and astringent substances*
 +
 
 +
'''Internal:'''
 +
 
 +
•Decoction of Holarrhena antidysenterica (kutaja), Picrorhiza kurrooa (katuka)and Withania somnifera (ashwagandha)**
 +
 
 +
•Decoction of tender leaves of latex yielding trees mixed with honey**
 +
 
 +
'''External:'''
 +
 
 +
•Vaginal application of paste of Randia dumetorum (madanaphala)**
 +
 
 +
•Irrigation of vagina with the decoction of Symplocos racemosa (rodhra) and Diospyros tomentosa (tinduka)**
 
Granthibhuta(clotted appearance) Decoction of Cissampelospareira (patha),  Piperlongum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhenaantidysenterica, (vrukshaka)*
 
Granthibhuta(clotted appearance) Decoction of Cissampelospareira (patha),  Piperlongum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhenaantidysenterica, (vrukshaka)*
−
• Decoction of Cissampelospareira (patha),Tribulus terrestris(trikandaka), Holarrhenaantidysenterica(vrukshaka)**
+
 
−
Kunapagandhi(foul smelling) For removing bad smell-
+
•Decoction of Cissampelospareira (patha),Tribulus terrestris(trikandaka), Holarrhenaantidysenterica(vrukshaka)**
−
• Oral intake of decoction of Santalum album(chandana)*
+
|-
−
• Anoinment of paste of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula( triphala)in vaginal canal**
+
|'''Kunapagandhi(foul smelling) , Puti-puya(pus like appearance)'''|| For removing bad smell-
−
• Vaginal irrigation with decoction of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula (triphala)**
+
 
−
Puti-puya(pus like appearance)
+
•Oral intake of decoction of Santalum album(chandana)*
−
Ksheena(scanty) Same as artavakashaya**
+
 
−
*[A.Hr. Sharira Sthana 1]**[A.S. Sharira Sthana 1]
+
•Anoinment of paste of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula( triphala)in vaginal canal**
 +
 
 +
•Vaginal irrigation with decoction of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula (triphala)**
 +
|-
 +
|'''Ksheena(scanty)''' || Same as artavakashaya**
 +
|}
 +
*[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 ===
−
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. ShariraSthana 2/16]
+
<div style="text-align:justify;">
−
But, those who are having a physical constitution of predominance of [[kapha]]and those who  practice daily use of ghee(grita), milk(ksheera) and maintain the pleasant state of mind are likely to maintain the optimum status of menstrual physiology for a longer period.[A.S. Sharira Sthana 1/64]
+
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]
−
A series of do’s and don’ts-called as ideal regimen during menstruation (‘’’Rajasvala Paricharya)is recommended to be followed by the menstruating women in order to maintain healthy reproductive status.
+
 
−
Among them, the wholesome diet recommended during the bleeding phase of menstruation are light, unctuous and less processed. It is known as “havishya anna” which is usually used for offering in the fire during rituals. It includes, different kinds of rice(vrihi and shali), barley(yava),wheat(godhuma), green gram(mudga),black gram(masha), leaves like curry leaf,cardamom(ela), ginger(shunthi), pepper(maricha),Ferula asafoetida  (hingu), jaggery(guda),sugar(sharkara),rock salt(saindhava), jack fruit(panasa),coconut(narikela), banana(kadali),Zizipus jujube (badara),honey(madhu),cow’s milk, curd, ghee. [Su. Sa. ShariraSthana 2/24,GhanekarTeeka]
+
But, those who are having a physical constitution of predominance of [[kapha]] and those who  practice daily use of ghee(grita), milk(ksheera) and maintain the pleasant state of mind are likely to maintain the optimum status of menstrual physiology for a longer period.[A.S. Sharira Sthana 1/64]
−
Contra indicated activities during bleeding phase of menstrual cycle [Su. Sa. ShariraSthana 2/24-25]
+
 
−
• Sleeping during day time (divaswapna)
+
A series of do’s and don’ts-called as ideal regimen during menstruation (Rajasvala Paricharya)is recommended to be followed by the menstruating women in order to maintain healthy reproductive status.
−
• Use of collyrium (anjana)
+
 
−
• Weeping / Crying (rodana)
+
Among them, the wholesome diet recommended during the bleeding phase of menstruation are light, unctuous and less processed. It is known as “havishya anna” which is usually used for offering in the fire during rituals. It includes, different kinds of rice(vrihi and shali), barley(yava),wheat(godhuma), green gram(mudga),black gram(masha), leaves like curry leaf,cardamom(ela), ginger(shunthi), pepper(maricha),Ferula asafoetida  (hingu), jaggery(guda),sugar(sharkara),rock salt(saindhava), jack fruit(panasa),coconut(narikela), banana(kadali),Zizipus jujube (badara),honey(madhu),cow’s milk, curd, ghee. [Su. Sa. Sharira Sthana 2/24, Ghanekar Teeka]
−
• Anointment (lepana)
+
 
−
• Massage (abhyanga)
+
Contra indicated activities during bleeding phase of menstrual cycle [Su. Sa. Sharira Sthana 2/24-25]
−
• Chasing / Running (dhavana)
+
 
−
• Excessive Laughing
+
*Sleeping during day time (divaswapna)
−
• Indulging in long conversations
+
 
−
• Nasal instillation of medicine (nasya)
+
*Use of collyrium (anjana)
−
• Exposure to wind
+
 
−
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]  
+
*Weeping / Crying (rodana)
 +
 
 +
*Anointment (lepana)
 +
 
 +
*Massage (abhyanga)
 +
 
 +
*Chasing / Running (dhavana)
 +
 
 +
*Excessive Laughing
 +
 
 +
*Indulging in long conversations
 +
 
 +
*Nasal instillation of medicine (nasya)
 +
 
 +
*Exposure to wind
 +
 
 +
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 ==
−
Menstrual hygiene management (MHM) refers to management of hygiene associated with the menstrual process.   
+
Menstrual hygiene management (MHM) refers to management of hygiene associated with the menstrual process.<ref>https://www.unicef.org/wash/files/UNICEF-Guide-menstrual-hygiene-materials-2019.pdf</ref>
 +
   
 
It includes,
 
It includes,
−
• using a clean menstrual management material to absorb or collect menstrual blood
+
 
 +
*using a clean menstrual management material to absorb or collect menstrual blood
 +
 
 
E.g. Menstrual cloth, Reusable / Disposable sanitary pads, tampons, menstrual cup etc.
 
E.g. Menstrual cloth, Reusable / Disposable sanitary pads, tampons, menstrual cup etc.
−
• using soap and water for washing the body as required
+
 
−
• safe and convenient facilities to dispose of used menstrual management materials  
+
*using soap and water for washing the body as required
−
• understanding the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.
+
 
 +
*safe and convenient facilities to dispose of used menstrual management materials
 +
 +
*understanding the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.
 +
 
 
==Current Researches==
 
==Current Researches==
−
• PCOS is diagnosed as per the standard Rotterdam criteria . Recent studies suggest the incorporation of raised level of Anti mullerian Hormone (AMH) along with the sonography findings to define polycystic ovarian morphology (PCOM).  
+
<div style="text-align:justify;">
−
PCOS is considered as Vata- kapha dominant vitiation (artava dushti) in Ayurveda and many clinical trials are being conducted on Ayurvedic management of PCOS. A series of clinical trials on effect of a classical formulation of Cissampelos pareira (patha),  Piper longum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhena antidysenterica, (vrukshaka) mentioned for clotted type presentation (vata-kapha predominant granthibhuta artava dushti) was carried out. Oral administration of the formulation, therapeutic purgation(virechana), medicated enema(basti) showed good results in 170 patients of PCOS. The efficacy in terms of symptomatic relief, correction of hormonal levels and improvement in the quality of life was observed.    
+
*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>
−
• Various methods have been developed to quantify the menstrual blood loss and validated for the purpose of research. Among them, alkaline hematin method is considered as the gold standard and is considered as the best when used in conjunction with a pictorial method like menstrual pictogram.  
+
 
−
• Medical therapies for heavy menstrual bleeding include hormonal treatments; levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives are most commonly used. Endometrial ablation is a minor surgical procedure that is associated with low operative morbidity and can be performed as an outpatient. Hysterectomy remains the definitive treatment of choice when medical therapies have failed and endometrial ablation is not suitable. Clinical trials using certain Ayurveda formulations and therapeutic purgation (virechana) have shown appreciable results in the management of excessive menstrual bleeding, especially in case of dysfunctional uterine bleeding. , ,  
+
PCOS is considered as [[Vata]]- [[kapha]] dominant vitiation (artava dushti) in Ayurveda and many clinical trials are being conducted on Ayurvedic management of PCOS.  
−
• Conventional management options for dysmenorrhea include non-steroidal anti-inflammatory drugs and hormonal contraceptives. In Ayurveda, the drugs or procedures which pacify [[vata]] are advised for the treatment of dysmenorrhea . Clinical trials have shown that enema with medicated oil (matra basti) is an effective protocol for the management of dysmenorrhea. , , Various Ayurvedic formulations having carminative, analgesic and anti-inflammatory properties are also proven their efficacy in the management of dysmenorrhea. ,
+
 
−
• Topical heat, exercise, and nutritional supplementation are also beneficial and practice of Yoga has greater impact in patients of dysmenorrhea.  
+
A series of clinical trials on effect of a classical formulation of Cissampelos pareira (patha),  Piper longum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhena antidysenterica, (vrukshaka) mentioned for clotted type presentation (vata-kapha predominant granthibhuta artava dushti) was carried out. Oral administration of the formulation, therapeutic purgation(virechana), medicated enema(basti) showed good results in 170 patients of PCOS. The efficacy in terms of symptomatic relief, correction of hormonal levels and improvement in the quality of life was observed.<ref>Dr. krupa D. Patel (2011) A clinical study on Polycystic Ovarian Disease (PCOD) & it’s management by Shatpushpa tail matra basti & Pathadi Kwatha ,PG dissertation ,Dept of Prasutitantra and Stree Roga, IPGT&RA, Jamnagar.</ref> <ref>Dr. Ashokan (2014) ,Clinical study on Ayurvedic treatment modalities in the management  Vata – Kaphaja Artavadushti (w.s.r.to PCOS), PhD thesis ,Dept of Prasutitantra and Stree Roga, IPGT&RA, Jamnagar.</ref> <ref>Dr. Pravin Dhote (2015),Clinical study on Vata Kaphaja Artavdushti (w.s.r. to PCOS) and it’s management by Ayurvedic treatment Modalities” , PG dissertation ,Dept of Prasutitantra and Stree Roga, IPGT&RA, Jamnagar.</ref> <ref>Dr. Ashiya (2018), Managementof Artava Dushti w.s.r to Polycystic Ovarian Syndrome with Virechana and Pathadi kwatha – a randomized controlled clinical trial, PG dissertation ,Dept of Prasutitantra and Stree Roga, IPGT&RA, Jamnagar.</ref> <ref>Archana S. (2019),Management of ArtavaDushti w.s.r to polycystic ovarian syndrome by PalashadiBasti and PathadiChoorna : A randomized controlled clinical trial , PhD thesis ,Dept of Prasutitantra and Stree Roga, IPGT&RA, Jamnagar.</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.  
+
   
−
List of abbreviations of classical Ayurveda texts:  
+
*Various methods have been developed to quantify the menstrual blood loss and validated for the purpose of research. Among them, alkaline hematin method is considered as the gold standard and is considered as the best when used in conjunction with a pictorial method like menstrual pictogram.<ref>Magnay JL, O'Brien S, Gerlinger C, Seitz C. A systematic review of methods to measure menstrual blood loss. BMC Womens Health. 2018;18(1):142. Published 2018 Aug 22. doi:10.1186/s12905-018-0627-8</ref>
−
• Sa. = Samhita
+
 
−
• Cha. = Charak
+
*Medical therapies for heavy menstrual bleeding include hormonal treatments; levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives are most commonly used. Endometrial ablation is a minor surgical procedure that is associated with low operative morbidity and can be performed as an outpatient. Hysterectomy remains the definitive treatment of choice when medical therapies have failed and endometrial ablation is not suitable.<ref>Davies J, Kadir RA. Heavy menstrual bleeding: An update on management. Thromb Res. 2017;151 Suppl 1:S70‐S77. doi:10.1016/S0049-3848(17)30072-5</ref>
−
• Su. = Sushruta
+
 
−
• Ka. = Kashyapa
+
Clinical trials using certain Ayurveda formulations and therapeutic purgation (virechana) have shown appreciable results in the management of excessive menstrual bleeding, especially in case of dysfunctional uterine bleeding.<ref>Pooja Chauhan(2019)Management of Asrigdara with Virechana and Vasadi Ghanavati : An open labeled Randomized comparative clinical trial, PG dissertation,Department Stree Roga and of Prasuti Tantra, IPGT&RA, Jamnagar, Gujarat.</ref> <ref>Roopa K.V(2011),A critical study on the role of virechana in the samprapti vighatana of asrigdara w.s.r to DUB, PG Dissertation,Department of Prasuti tantra and stree roga, RGUHS,Bangalore.</ref> <ref>Jamuna Devi R(2004), Management of asrigdara with special reference to dysfunctional uterine bleeding with “ashoka yoga, PG Dissertation, Department of Prasuti tantra and stree roga,GAM,Puri,Orissa</ref>
−
• Sha. =Sharangadhara
+
−
• A. = Ashtanga
+
*Conventional management options for dysmenorrhea include non-steroidal anti-inflammatory drugs and hormonal contraceptives. In Ayurveda, the drugs or procedures which pacify [[vata]] are advised for the treatment of dysmenorrhea .
−
• Hr. = Hridaya
+
 
−
• S. = Sangraha
+
Clinical trials have shown that enema with medicated oil (matra basti) is an effective protocol for the management of dysmenorrhea.<ref>Dr. Kaumudi Karunagoda (2010)A comparative clinical study of Dashmoola Taila Matra Basti and Tila Taila Matra Basti in the management of Kashtartava, PG dissertation, Department Stree Roga and of Prasuti Tantra, IPGT&RA, Jamnagar, Gujarat</ref> <ref>Dr.Amit Tanna (2011),A further study of Kashtartava (Dysmenorrhea) and its management by Dashmula Taila Matra Basti and Tila Taila Matra Basti, PG dissertation, Department of Stree Roga and Prasuti Tantra IPGT&RA, Jamnagar, Gujarat.</ref> <ref>Dr. HLMG Sajeewani (2012),Further Clinical Study on Kashtartava with special reference to Primary Dysmenorrhea and its management by Matra Basti, PG Dissertation, Department of Stree Roga and Prasuti Tantra IPGT&RA, Jamnagar, Gujarat</ref>
−
• Ha. = Harita  
+
 
−
References:
+
Various Ayurvedic formulations having carminative, analgesic and anti-inflammatory properties are also proven their efficacy in the management of dysmenorrhea.<ref>Arun gupta(2020),Management of Udavartini Yoni Vyapad(Dysmenorrhoea), with Shoola Prashamana Dashemani and Eranda Brusht Haritaki Shunthi Churna-a comparative clinical study, PG Dissertation, Department of Stree Roga and Prasuti Tantra IPGT&RA, Jamnagar, Gujarat</ref> <ref>Chayaa Der (2002),A comparative clinical study of Satapushpa Vati and Krishna Tila Kwatha on Artava Kshaya , PG Dissertation, Department of Stree Roga and Prasuti Tantra IPGT&RA, Jamnagar, Gujarat</ref>
 +
 
 +
*Topical heat, exercise, and nutritional supplementation are also beneficial and practice of Yoga has greater impact in patients of dysmenorrhea.<ref>Habeeb Mini (2003),A study on the effect of selected Yoga and Nature cure techniques in Udavarta Yoni Vyapada, Deptt. Of Swasthavrutta by Govt.Ayurvedic College Thiruvananthapuram, Kerala.</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>
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===List of Thesis works===
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The list of thesis works  done on various menstrual disorders can be seen [[Media:Thesis_list-Menstrual_disorders.pdf |here.]]
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===Abbreviations ===
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Sa. = Samhita, Cha. = Charak, Su. = Sushruta, Ka. = Kashyapa, Sha. =Sharangadhara, A. = Ashtanga, Hr. = Hridaya, S. = Sangraha,
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Ha. = Harita
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=== Reference list  of Menstrual disorders ===
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<div style="text-align:justify;">
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The list of references for menstrual disorders  in classical texts of Ayurveda can be seen [[Media:References_table-_menstrual_disorders.pdf |here.]]
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==References==
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