AYURVEDA IN FEMALE DISEASE

Introduction

The definition of sthree as given by Raja Nighantu is “Sthree cha artava bhavati sravati ithi stree.” That means, stree is one who discharges artava or menstrual blood. The importance of menstruation can be gauged from this statement. Artava is one of the causative factors for the maintenance of generations.
Woman’s life can be classified into three – pre-reproductive, reproductive and post-reproductive phases. Menstruation is the main phenomenon seen in reproductive phase. Onset and cessation of menstruation are the borders of reproductive phase. Cessation of menstruation is known as Rajo nivruthi or Menopause.
Menopause, a derivation of the ancient Greek words ‘menos’ (month) and ‘pausos’ (ending), means the end of the monthly or menstrual cycle, the central external marker of human female fertility. Menopause is simply one event in the whole range of anatomical, physiological and psychological events, which contribute to the perimenopause. Clinically perimenopausal time more important because during this time, periods are often erratic and infrequent, fertility is impaired. It is attended by a wide variety of symptoms, signs and metabolic adjustments – the ultimate cause of which is a major reduction in the level of circulating oestrogens.
When menopause begins to a woman is difficult to answer. But, a time will come to every woman if they live long enough, when they are no longer fertile. It is just that the path each woman takes to that point is unique. Her life will be influenced by many factors other than just hormonal ones. Her expectations of the menopause and related symptoms, her life experiences, her culture and circumstances will all influence her perception and experience of the perimenopausal time. Some may experience one or two classic symptoms like hot flushes or night sweats from time to time and their perimenopausal time may pass quite easily. Others find it much more difficult suffering many of the symptoms simultaneously and for a protracted time.
In Ayurvedic classics we can get only scattered references about Rajonivruthi. It describes the menarche (Rajodarsana) and menopause (Rajonivruthi), where in which age of menarche and menopause are grossly described. [(m]]is] m]]is] rj]: sˆ]IN]]\ rs]j]\ s]/rv]it] t]/r/y]h\ v]ts]r]d/v]]dx]] dUDv]*\ y]]it] p]Vc]]x]t]: X]y]m]/ ) A.H Sa 1/7])

The good quality of natural nourishment, the life which mingles with nature, the life style following Dinacharya and Ritucharya may be some of the reasons for minimal appearance of menopausal symptoms in the past age.
Nowadays, changing socio-economic status gives women a stressful life. This life and the depleting health status in that age prior to ageing may be the causes for appearance of more symptoms in perimenopausal period. In the present century, progressive increase in life span resulted in an increasing number of women living long after menopause and developing long term consequences of menopause such as osteoporosis. Women are largely seeking information on the subject and want to decide for themselves a particular treatment opinion. The media play an important role informing women about the various treatment options, particularly Hormone Replacement Therapy (HRT). But, HRT is not devoid of side effects and contra-indications.
Here comes the importance of Ayurvedic management. For the health consequences of a natural event like menopause if a natural and safe answer is obtained, it will be the best. The management should help her to look upon menopause as a life event, a stage in life to be recognized and coped within a positive way with minimum problems. Considering these factors, an attempt has been made to study scientifically and statistically a formulation which comprehensively give relief to the silent sufferers of perimenopausal symptoms. The formulation selected is Sathavari gopakanyadi kwatha, mentioned in Chikitsa manjari. The efficacy of this formulation is compared to the proven efficacy of Sathavari ksheerapaka in perimenopausal symptoms.
The total dissertation is divided into three parts
Part I Review of literature
- Vayaparinama and stree sareera
- Rajonivruthi lakshanas ( Perimenopausal symptoms)
- Management
Part II Drug Review
Part III Clinical Study
- Research methodology
- Observation and Results
- Discussion, Summary and Conclusion

Vayaparinama
There is only one thing without any change; that is the word ‘change’ (Karl Marx – Das capital). Everything living and non-living in the nature is liable to change. The changes are a part of ageing of everything.
The appearance of sexual characters is also affected by ageing. In females, the reproductive capacity is in full bloom in a particular period of her life span.
There is no description of life-span specific to females. Each individual has 3 distinct phases in their life span – the childhood (balyavastha), the adulthood (Madhyamavastha) and old age (vriddhavastha).

Balyavastha: - This age lasts upto 16 years. During this span the dhathus are immature, thus unable to withstand stress and strain.
Acharyas susrutha,vagbhata,Hareetha and Bhavamisra opines that balyavastha is upto sixteen years of age. Kasyapa has subdivided the period from foetal stages to sixteen years as stage of garbha,bala and kumara..Charaka extends the phase upto 30 years and divides into two Aparipakwa dhathuguna period (upto 16 years) and vardhamana dhathuguna period (upto 30 years)
Few Acharyas owing to female reproductive capacity have used some specific terms. Hareeta Samhitha classifies age upto 5 years as bala followed by mugdha from 6 to 11 years. (Ha.Pra.Kha.5/13). In Parasasasmruthi, upto 8 years a girl is called as gouri, upto 9 years as rohini, upto 10 as kanya and is followed by rajaswala.
The clearest sign of puberty in females is the initiation of menstrual cycle.The appearance of secondary sexual character and menarche are important features of the later part of balyavastha. Hormones from anterior pituitary and gonads control these processes. All these changes occur in the growing period, specifically in pubertal phase.

Madhyamavastha (Middle age)

Acharyas have difference in opinion about the age-limits of this span. .Charaka and Vagbhata state the limit as upto 60 years.According to Charaka, this is the spring season of life because during this period all the body elements are in their excellence, exhibiting their peak qualities and functions(Ch.S.Vi.8/122). .Vagbhata consider upto 30 years as youvana followed by sampurnanta(full maturity) upto 40 years. The period following upto 60 years is aparihani.(A.S.Sa.8/24)

Susrutha extends the middle age upto 70 years and subdivides upto four. (Su.S.Su.35/29)
I Vriddhi - Stage of development upto 20 years
II Youvana - Adult age upto 30 years
III Sampounata - Full maturity upto 40 years
IV Parihani - Slight decline of dhathus upto 70 years

For Kasyapa, youvana is from 16 to 34 years and for Hareetha, upto 25 years. The Madhyama stage that follows is upto 70 years for both.
Specifically, a woman is denoted as prouda upto 28 years and pragatbha upto 41 years. Hareetha says in between 24 to 37 years she is in her best age. (Ha.Pra.Kha.5/13)

Susrutha’s opinion about beginning of parihari and the age limit of pragatbha are note worthy. Because, beginning about age 40, fertility deceases dramatically in women, which is the first sign of impending ovarian failure.
This is referred to as a stage of pitta dominance.

Vriddhavastha (Old age)
This stage begins after 60years according to Charaka and vagbhata I and after 70 years according to susrutha and Vagbhata II. In Bhavaprakasa, this period is beyond 50 years. He opines the woman is Taruni (Young) upto 32 years, adhirudha upto 50 years after which she is vridha. (Bha.Pra.Pu.Kha.5/281) Yogaratnakara also approves this view. (Y.R.Yathricharya 10)

There is diminution in the qualities of tissue elements in this stage ie, rasadi dhathus get depleted speedily with declinement of – veerya, dharanaskthi, smaranasakthi etc. Roughnesses of skin, graying of hair, baldness, flabby muscles, loose joints, decreased excellence of dhathus, less efficiency in all work etc, also appear to characterize ageing.
There are descriptions about the step-by-step depletion of dhathus and their loss of functions due to increasing age vagbhata I and sarngdhara have mentioned something is being lost at the end of each decade of life. (A.S.Sa.8/25, Sa.S.Pra.Kha.6/20)

Chart 2

This description gives the actual deterioration time for all these factors. Vagbhata opines 100 years as life span and sarngadhara, 120 years. So changes are to be made according to this era.
In woman’s life, the important reproductive era ceases before vriddhavastha,ie, during late middle age. But a complete loss of functional ability of a tissue will not become apparent in a day. It is a gradual change from normal to abnormal and then to loss. Thus a step-by-step depletion of dhathus noted above may start for each factor a few years earlier and progress to a critical stage by that age.
Bhavamisa says old age is beyond 50 years and this opinion coincides with the mean age of menopause (50.8years).
The particular stages of life in relation with a woman’s reproductive capacity can be shown as below.

Stree shareera
The knowledge of anatomy and physiology of female reproductive system is essential to study Rajolivruthi lakshamas. So a brief descriptions of female anatomy and physiology is necessary before going into the details
Female reproductive organs are divided into external and internal organs.

External genitalia
The female external genitalia, commonly referred to as vulva, includes mons veneris, labia majora, labia minora, clitoris and conventionally the perineum.
The word ‘Bhaga’ is used by Susrutha to mention external genitalia. Acharya says Bhaga is of twelve angulas. ( Su.S.Su 35/12)
Internal Genital Organs
The internal genital organs in female includes, vagina , uterus, Fallopian tubes and the ovaries

Vagina: - The vagina is a fibro muscular tube that extends upward and backward from the vulva to the uterus. Posteriorly its length is 9 cm, which is greater than its anterior length (around 7.5 cm). The diameters of the canal is about 2.5cm, being widest in the upper part and narrowest at its introitus.

Structures

(1) Mucous coat, which is lined by, stratified squamous epithelium without any secreting glands. It is firmly attached to the underlying muscle and rugae.
(2) Sub mucous layer of loose areolar vascular tissues.
(3) Muscular layer consisting of indistinct inner circular and outer longitudinal and
(4) Fibrous coat derived from the endopelvic fascia and is highly vascular.

Arterial supply: - 1) mainly supplied by vaginal branch of internal iliac artery (2) In addition upper part supplied by cervico vaginal branch of uterine artery and the lower part by the middle rectal and internal pudendal arteries

Venous drainage: - The rich vaginal venous plexus is drained into the internal iliac veins by the vaginal veins

Lymphatic drainage: - Lymphatics from the upper 1/3 of vagina drain into external iliac nodes, from the middle 1/3 into the internal iliac nodes and from the lower 1/3 into medial group of superficial inguinal nodes.

Nerve supply: - Lower 1/3 is pain sensitive and is supplied by pudendal nerve.Upper 2/3 is pain insensitive and is supplied by sympathetic (L1,L2 ) and parasympathetic (S2,S3) nerves derived as vaginal nerves.

Vaginal secretion: -

The vaginal pH, from puberty to menopause is acidic because of the presence of Doderlein’s bacilli, which produce lactic acid from the glycogen present in the exfoliated cells. The pH varies which the oestrogenic activity and ranges between 4 -5. This pH has a protective role in decreasing pyogenic infections.
The term ‘Yoni’ used Acharyas may be the external orifice of vagina. Susrutha says that Yoni is having three Avarthas. The first Avartha may be the vaginal canal and fornices [x]\K]n]]By]]k&it]y]o*in]: t]/r/y]]v]t]]* p]/rkIit]*t]] t]sy]]st]&&t]Iy]estv]]v]t]*e g]B]*x]yy]] p]/rit]iSQt]] (Su.S.Sa 5/55)]

The Uterus
The uterus is a hollow pear-shaped organ with thick muscular walls. In the young milliparous adult, it measures 8cm long, 5cm wide and 1.5 cm thick. It is situated in the pelvis between the bladder in front and the rectum behind. It is divided into body or corpus, isthmus and cervix.
The upper expanded part of the uterus is termed body or corpus. Fundus is the part, which lies above the openings of the uterine tubes. The body proper is triangular and lies between the opening of the tubes and the isthmus. The superolateral angles of the body of the uterus project outwards from the junction of the fundus and body, called the cornu of the uterus. The uterine tube, round ligament and ligament of ovary are attached to it.
The uterus tapers down to a small constricted area – isthmus
Cervix is cylindrical in shape and measures about 2.5cm. It is made up of involuntary muscles in the upper part whereas the lower part is mainly fibrous connective tissue.
Structures
There are three layers to the uterine wall, the outer being a peritoneal covering that is continuous with the peritoneum of the supporting broad ligaments. The middle layer or myometrium comprises bundles of smooth muscle fibres embedded in connective tissue and forming three ill defined layers – circular, longitudinal and interlacing layer in between them. The third layer of uterus – the lining or endometrium – is a very vascular mucous membrane.
Arterial supply
Uterus is supplied (1) chiefly by two uterine arteries (2) partly by ovarian arteries.
Venous drainage
Veins form a plexus along the lateral border of the uterus which drains through the uterine, ovarian and vaginal veins into internal iliac veins
Lymphatic drainage
Upper lymphatics from the fundus and upper part of the body pass mainly to the aortic nodes and superficial inguinal nodes. Lower lymphatics pass to external iliac, internal iliac and sacral nodes.
Nerve supply
Sympathetic (T12, L1) and parasympathetic (S 2,3,4) nerves
Function of Uterus
The main function of uterus is to retain the fertilized ovum and to give space and nourishment for its development.

.
The uterus remains small united puberty, when it enlarges greatly in response to the estrogens secreted by the ovaries. After menopause, the uterus atrophies and becomes smaller and less vascular. These changes occur because the ovaries no longer produce estrogens and progesterone.
During pregnancy, uterus becomes greatly enlarged as the result of the increasing production of estrogen and progesterone.
The second avartha of thryavartha yoni described by Susrutha may be the cervix and the third, uterus. Garbhasayya, which has the shape like a fish named Rohithaka lies in this third avartha. (Su.Sa.5/55) Here Garbhasayya can be considered as uterine cavity and its lining.

The Fallopian tubes
The uterine tubes are paired structures measuring about 10cm and are situated in the medial three-fourth of the upper free margin of the broad ligament. Each connects the peritoneal cavity in the region of ovary with the cavity of uterus. For purpose of description, it is divided into four parts – the infendibulum, the ampulla, the isthmus and intramural part.
Blood supply
Uterine artery supplies about medial 2/3rd and ovarian artery about lateral 1/3rd. veins drain into uterine veins.
Lymphatic drainage
Lymphatics drain into lateral aortic and pre aortic nodes.
Nerve supply
Supplied by sympathetic (T10-L2) and parasympathetic (derived from vagus and from pelvic splanchnic nerves).
Function of the uterus tubes

The uterine tube receives the ovum from the ovary and provides a site where fertilization of the ovum can take place. It provides nourishment for the fertilized ovum and transports it to the cavity of uterus.

Ovaries
The ovaries are paired sex glands in female and are oval in shape. It measures about 3 cm in length, 2 cm in breadth and 1 cm in thickness. They lie against the lateral wall of the pelvis in a depression called the ovarian fossa.
Structure
A single layer of cubical cell known as germinal epithelium covers the ovary. The substance of the gland consists of outer cortex and inner medulla.
Arterial supply
Ovaries are supplied by (1) ovarian artery (2) Uterine artery
Venous drainage
Veins emerge at the hilus and form a pampiniform pluxes and condense into single ovarian vein which drains into inferior venacava.
Lymphatic drainage
Lymphatics from the ovary communicate with lymphatics from uterine tube and drains to lateral aortic and pre aortic nodes.
Nerve supply
Ovaries are supplied by ovarian plexus, which contains both the sympathetic (T10, 11) and parasympathetic (S 2,3,4) nerves.
Age related changes of Ovaries
Before puberty the ovary is smooth, but after puberty the ovary becomes progressively scarred as successive cosposa lutea degenerate. After the menopause, the ovary becomes shrunken and its surface is pitted with scars.

Functions

Mainly ovaries have two functions (1) The production of ova (2) The production of hormones.
There is no direct mentioning about ovaries in classical textbooks. Susrutha while describing ‘Pesis’ has mentioned about pesis covering the ‘antharphala’ similar to pesis of male testicle (Su.Sa.5/41). Susrutha also says ‘antharphala’ is a vital point. Since trauma to the ovaries will produce complications such as menstrual irregularity, infertility and even affect next generation, we can correlate ovaries to the antharphala mentioned by Susruthacharya.

Artava chakra (Menstrual cycle)

The reproductive life in female starts in the pubertal period. The cyclical discharge of blood from the uterus in response to the hormonal changes is known as menstruation and is the active signs of reproductive span in a woman’s life.

Menstruation is coined by the terms ‘artava’ in ayurveda.

The phenomenon, which happens with a regular internal is artavam [`t]O B]v]\ a]t]*v]\ ,`t]v]e wd\ a]t]*v]m]/ ].The word Artavam denotes the whole process regarding the cyclical reproductive function in female. There are many synonyms like rajas, shonitam, raktam, asruk, lohitam, pushpam, rudhiram etc. to denote artava
Acharya Charaka uses purana rajas for bahirpushpa (menstruation) and beeja navaraja or tarunaraja for antarpushpa (may be ovum). Chakrapani used utbhuta, prabhuta or upachita rajas for bahirpushpa and anubhutas, alpa or styanibhuta rajas for antarpushpa.

Artava darsana kala

Artava appears in females around 12 years onwards and disappears around 50 years (Su.Sa.3/9) according to modern medical service, in 50 percent of girls menarche occurs by the age of 13.
Duration and character of menstruations

In general, the duration of menstrual cycle is assumed as twenty eight days, which is liable to change, and ranges from 24 –35 days. Menstrual cycle begins with the onset of menstrual bleeding and ends just before the next menstruation.
Charaka describes the character of normal menstruation. ‘The menstruation that which has an inter menstrual period of one month, pain and burning sensation.. The expelled blood is not very unctuous, not very scanty, nor excessive in amount. (c.s.ca 30/122)

Process of formation of Rajas

Artava has been described as upadhathu of rasadhathu. There are many theories regarding the formation of Artava.
Charaka,Susrutha,Vagbhata II,Dalhana and chakrapani opine that rajas is formed from rasa (----------------) Sarngadhara and Bhavamisra opine the same
(Bha Pra Pu 3/212,Sha sa Pu 5/16)
Since raktha dhathu and rajas are derived from the same parent rasadhathu, we can consider both these views identical. Some Acharyas considered the earlier stage where raktha itself is formed from rasa and others took the later stage, where formed rakta gives a past of it to accumulate as rithukala rudhira to be expelled out.
Rasadhathu, the first tissue element in the body is having the role of nourishment of all the tissues, Balyavastha is the growing age, where there is a dominant functioning of sleshmadosha .Rare is the assayadhathu of sleshma dosha and salabhuta dominant, thus much similar to its assay: These two are having “ekavruddhikshaya karanatwa” (A.S.Su 19/47-56) thus in balyavastha, rasa gets its prime nourishment.
The sara of each dhathu is considered to be a tool to assess the status of that dhathu. Rasa is the first tissue element. Instead of ‘rasasara’,the first mentioned one among the diseruption of sarapurushas is twaksara.This may be because ,skin is like a mirror which reflects the status of rasa in our body. Twak sara is marked by unctous, smooth, soft and lustrous skin and the hair also posses a characteristic shining (C.S.vi 8/114).These properties are best seen in the childhood. Thus, we can infer the period of excellence of rasadhathu is in the balyavastha or, it attains maturity by the age of 12 years.Astava being the upadhathu of rasa begins to appear after the complete development of the dhathu.

Agneyatva of Astava

While describing the process of formation of dhathus and upadhathus,sarugadhara states that due to the action of pitta upon rasa dhathu and upadhathus are formed respectively.Here,the precursor of raktha and astavava,rase is slaishmika.The pitta which acts on rasa to produced becomes agneya.Chakrapani has clarified this :- astava is soumya due to influence of rasa which at time of excretion due to specific changes is assumes agneya charachers.(S.S .Su 14/7-chakrapany)

Astava utpatti Hetu

The factors responsible for the beginning of reproductive phase are mentioned in the classics. Vayas and keta are said to be two factors those have an effect on astava utpath [(a) Sa.Sa .Pu 5/16
(b) c.s.sa .4/30 chakrapani]
Dalhana opines dhathu paripurnatha due to vaya parinama is the factor which brings about astava .(s.s .su-14/18-Dalhana tika).The dhathu paripurnata is recognized as a factor for astava utpathi by Shala also.
Kasyapa gives specific importance to the maturity of sexual organs.Acharya says development of yoni (external and internal genital organs) and gradual accumulation of astava during yuvavastha (youth) causes menstruation (ka .sam.khilasthana 9/22)
Astava nishramana is one of the functions of apana vayu.
Swabhava(mature) is also a cause for asava utpath
Inmythology ,menstruation is said to have been influenced by planets like moon,sun etc. In Greek mythology,it was believed that the beginning of menstrual phenomenon is due to the bite of one mysterious poisonous snake.
The factors approved as the causes by the Acharyas,especially dhathuparipurnata is not worthy. Kisyapa’s observation of maturation of genital organs is the main event in puberty the onset and maintenance of menstrual cycle is controlled by some hormones.
Endocrinology of Puberty (Page 25 Endocrinology

Puberty consists of two distinct hormonal process: gonadal maturation (gonadarche) and adrenal androgen secretion (adrenarche)

Before puberty, the secretion of Follecle stimulating hormone (FSH) and Leutinising hormone(LH) is negligible.Prior to puberty, there is negligible secretion of ovarian hormones but a slight rise in secretion of estrogen as puberty approaches.The adrenal cortex begins to secrete increasing amounts of dihydro epiandrosterone(DHEA) and its sulphate(DHEAS) approximately two years before the onset of the pubertal changes.The stimulus that causes the onset is unknown but it is believed to be a function of the rate of maturation of hypothalamus. It is heralded by the decreased sensitivity to negative feed back and therefore an increased secretion of LH, FSH and ovarian steroids.

Rutu Chakra

Eventhough there is no detailed description about separate phases of Artava chakra or Rutu chakra in our classics, they have mentioned about both Anthara Rutu and Bahya Rutu ie, ovulation and menstruation
The normal artava chakra is given as one chandramasa (28 days) by our Cahryas,This period of rutuchakra has been divided into 3 different phases according to the readiness of reproduction organs for conception. These 3 phases are (1) Rutukala (11) Rutavateela kala and (III) Rajah kala.

Rutu kala
About the duration of rutukala,these are 4 opinions
(1) It is of 12 days after menstruation
(2) It is of 16 days after menstruation
(3) It is for the whole month
(4) It is present even in the absence of menstruation (A.S.Sa 1/47,Su.Su 3/6, B.P 10/2)
The controversy in number of days may be because, those who says Ruthukala as 12 days are counting days after the cessation of menstrual flow and it becomes 16 days if counted including 4 days of menstruation.
This Rutukala is charecteristised by the formation of ‘naveena rajah’. Puranarajah is that which formed in the previous Ruthukala and it is expelled in the form of artavarakta during rajasravakala (Cha. Sa.4.7)
After the discharge of rakta, the whole reproductive organs are preparing for conception. This phase can be taken for the Proliferative phase of endometrium. It can be considered as the Follicular phase of ovarian cycle because in this stage, shonitam (ovum) is being ready for fertilization.
Events in the ovaries – Under the influence of FSH, the group of about 20 secondary follicles grow and begins to secrete oestrogen and nhibition. By about 6th day, the oestrogens and inhibin secreted by dominatnt follicle decrease the secretion of FSH which causes the less developed follicles to stop growing . The mature (Graafian) follicle continues to enlarge until it is more than 20mm in diameter and ready for ovulation
Events in uterus – Oestrogen secreted by the follicles stimulate the repair of endometrium; cells of stratum basalis undergo mitosis and produce a new stratum functionalis. The short,straight endometrial glands develop and the arterioles coil and lengthen as they penetrate stratum functionalis

Ovulation is the process of release of ovum from the ovaries which occur on the 14th day of the 28 days menstrual cycle. In Ayurveda, the process of ovulation can be inferred by the lakshanas of Ruthumati. The woman will appear somewhat exhausted is in a happy mood. These will be “sphurana’ over the region of pelvis and breast. Eyes appear to be sleepy and flanks empty. These will increase libido. [A H Sa 1/20]
Acharyas says vata is responsible for all movements including the nishkramana of shonita. Kapha and Vata lakshanas are seen in Rutumati eventhough rutukala is dominated by kapha

(II) Rutavateeta kala
The Rutavateela kala is present for 14 days between the end of Rutukala and the beginning of rajahkala .In this phase, it is told that “Yoni sankocha” is taking place ie,yoni does not allow the entry of sukra . (Su. Sa. 3/9)

The endometrium will not be fit for nidation and the increased consistancy of cervical mucus obstructs the path of sperm. So, the changes occurring in the uterus after ovulation which are described as secretory phase of endometrium and changes occurring in the ovary in the luteal phase can be included in Rutavateeta kala.
Events in the ovary – after ovulation, LH stimulates the development of corpus luteum which secretes progesterone and some oestrogens. If oocyte is not fertilized,corpus luteum has a life span of only 2 weeks and degenerates to a corpus albicans. If oocyte is fertilized, corpus luteum is “rescued” from degeneration by hCG, a hormone produced by the embryo as early as 8-12 days after fertilization.
Events in uterus – The preparatory changes in endometrium peak about1 week after ovulation. If fertilization does not occurs, the level of progesterone decreases and menstruation ensues.
In the Proliferative phase, the slimy nature of cervical mucous may due to kapha and the thick,white consistency of mucous in the secretory phase may be due to the agneyatwa of pitha along with vatha. As ushna is the property of pitha, pitha is the dominant dosha in Rutavateeta kala.
(III) Rajah kala
The accumulated rajas in the garbhasaya and is expelled out of the body in this period (Su.Sa 3/20, A.H.Sa 1/7)
This phase is present for 3-7 days about 5 days in average.
This phase is influenced mainly by vata. ‘Chalana,presana’ (movement , motivation to move) are the properties of Artava nishkramana is attributed to apana vatha
This changes occurring in the Menstual phase can be included in rajahkala.
Events in ovaries – 20 0r 50 small secondary follicles begin to enlarge follicular fluids secreted by the granulose cells and oozing from blood capillaries accumulates in the enlarging antrum.
Events in the uterus – Menstrual flow occurs because the declining level of ovarian hormnones stimulate the release of prostaglandin that cause the uterine spiral arterioles to constricts and the cells they supply become oxygen deprived and start to die. Then the entire stratum functionalis sloughs off.

Hormonal influences in Normal Menstrual cycle

Initiation of menstruation is the clearest sign of puberty.During menstruation low levels of estrogen and progestrogen are released into the blood stream. Hypothalamus controls the secretions of these hormones through the release of LHRH by which pituitary is stimulated to produce FSH .FSH stimulates the ovaries to produce estrodiol,which causes endometrium to proliferate.As circulating oestradiol increases, FSH and LH levels fall until around day 14 of the cycle.LH then peaks and ovulation generally occurs.If fertilization doesnot take place,estrogen and progestogen levels fall and endometrium is shed – menstruation takes place. The falling levels of estrogen and progestrogen are detected by the hypothalamus and the cycle starts again.

Hormones
Even though the detailed description of Artava, Raja,Sukhru, their functions etc coincide with the nature and functions of sex hormones, the overt description of hormones is not available in our Ayurvedic classics.
In the development of female body and other female specific characteristics, sex hormones, especially oestrogen and progesterone play an important role.
Hypothalamus produces a series of specific releasing and inhibiting hormones out of that Gonadotrophic releasing hormone which is concerned with the release, synthesis and storage of both gonadotrophins (FSH and LH) from anterior pituitary.

The principal hormones secreted from the ovaries are (1) Oestrogens (II)Progesterone (III) Androgen (IV)testosterone and adrenal corticosteroids are other steroidal hormones

Oestrogen:

The oestrogen is predominantly oestradiol (E2) and to a lesser extent oestrone.The sites of production in the ovary are

Predominant sites are granulose cells of the follicles and from the same cells after luteinisation to form corpus luteum
Small quantity is also produced from the these cells and ovarian stroma
The important biological activities of estrogen are (1) Estrogen promote the development and maintenance of female reproductive structures, secondary sex characteristics including distribution as adipose tissues in the abdomen, mons pubis and hips; voice pitch, a broad pelvis and pattern of hair growth on the head and body
(2) Estrogens increase protein anabolism; in this regard, oestrogen are synergistic with human growth hormone (hGH)
(3) Estrogen lower blood cholesterol level
(4) Moderate levels of estrogen in the blood inhibit both the release of GnRH by the hypothalamus and the secretion of LH and FSH by the anterior pituitary gland.
(5) oestrogens contribute to the maintenance of sexual libido and various aspects of behaviour in women.

Progestogens
The most potent naturally occurring progestogen in women is progesterone. It is a 21- carbon steroid which is not only important for its own endocrine effects but also because it is a precursor molecule in the synthesis of steroids in all tissues which produce them. Progesterone is secreted primarily by the corpus luteum during luteal phase of menstrual cycle and by the feto-placental unit during pregnancy. It is produced in small quantities by the adrenal cortices in both sexes.

The biological actions of progesterone includes
(1) Antagonism of the growth promoting effects of oestrogen on the endometrium and conversion of this rapidly proliferating organ into a secretory structure capable of maintaining an implanted blastocyst.
(2) Progesterone inhibits ovulation in women probably by inhibiting the release of LH releasing factor from the hypothalamus.
(3) Conversion of cervical mucus from a very viscous to a non-viscous fluid and makes it less easily penetrable by spermatozoa
(4) Stimulation of mammary gland growth and development
(5) Associated with the rise in basal body temperature that occurs immediately after ovulation and which persists during most of the luteal phase
(6) Inhibition of uterine motility.

Rajonivruthi Menopause means permanent cessation of menstruation at the end of reproductive life and as such cannot be diagnosed until after the event.
The phase of time on either side of this last bleed is described as perimenopause and it is during this time that many women will experience physical and psychological symptoms along with the emotional changes, which some women will attribute to the menopause.
There is no identical term in the Ayurvedic classics to denote the last menstrual bleed. Kasyapa, while describing the properties and actions of Satahwa and Shathavari says that, they are useful for a wide variety of menstrual problems including ‘Artava atikrakrantatha and akarmanyatha.’
Acharyas have considered rajonivruthi as a sign of ageing or jara. J ara is a swabhavabala pravrutha vyadhi like kshudha (hunger), pipara (thirst),nidra (sleep) and mrityu(death)[sv]B]v]b]l]p]/rv]&tt]]: X]ut]/ip]p]]s]] j]r]m]&ty]uin]¨] p]/rB]&t]y]: Su.Su.24/8]
Rajonivruthi is a conjunction of two words – rajas and nivruthi. Rajas is used to represent menstruation here. The word ‘nivruthi’ has the following meanings
(1) Cessation (2) Disappearance (3) Inactivity (4) Suspension.
To denote the final stoppage of menstruation we may take the meaning of nivruthi as cessation. Thus,Rajonivruthi is used here as an identical terminology for menopause.
Definitions given by WHO for different terms related to menopause.
1) Natural Menopause - a permanent cessation of menstruation resulting from the loss of ovarian follicular activity.
2) Perimenopause (climacteric) - The term perimenopause should include the period immediately prior to the menopause ( when the endocrinological, biological and clinical features of approaching menopause commence) and at least the first year after menopause.
3) Menopausal transition - The term menopausal transition should be reserved for that period of time before Final Menstrual Period (FMP) when variability in the menstrual cycle is usually increased.
4) Pre menopause - This term is used to refer to one or two years immediately before the menopause or to refer to the whole of the reproduction period prior to menopause. [ The group recommended that the term should be used consistently in the latter sense to encompass the entire reproduction period upto FMP]
5) Post menopause - The era following the date of last menstrual bleed which cannot be determined until 12 months of sponataneous amenorrhoea has been observed.
Age of menopause
The age of menopause ranges between 45 – 55 years average being 50 years in western countries. In India, the average age is considered as 47-49 years.
Little is known about the factors which determine the age of menopause.It does not appear to be related to age of menarche, socio-economic factors, race,parity ,weight or height.The age tends to be lower in women who smoke and in those who have had no children.
Regarding the age of first and last menstruation, all Acharyas are having the same opinion and it is said to be 12 and 50 years respectively. (A.S.Sa.1/7).while mentioning the reason behind rajapravruthi and Rajonivruthi,acharyas says that; as in young or aged plants,flowers and fruits do not come up, as in bud and decaying flower there is no fragrance, in males shukra before 16 and after 70 years of age and in females raja and sthanya before 12 and after 50 years are not visible.(A.S.Sa.1/21)

Causes of Rajanivruthi
Since Acharyas consider Rajonivruthi as a sign of Jara (ageing), causes of jara are responsible for rajonivruthi.
1 Swabhava - Menopause is said to be a swabhavika vyadhi. charaka specifies the cessation of existence is always in the course of nature while quoting the theory of natural destruction(Cha.Sa.16/28).In females, as menstruation is a natural process which is needed for the reproduction of generations it also ceases naturally.
2 Kala - Kala is the cause for all changes in the world and none can block the flow of time. It is an important factor in ageing. (Cha.Sa.3/8)Kala is responsible for vardhakya and jara (Cha.Soo. 17/78)
Favourable and unvaourable life also plays important role in ageing process. Kalayoga (proper time),aharasoushthava (balance diet) and avighatha (lack of growth supporting factors) are the growth promoting factors according to charaka.So, if women are living under unfavourable condition they are likely to attain rajonivruthi earlier.

Endocrinology

The endocrine changes during the perimenopausal period are considered under those that occur before, at and after menopause.

Endocrine changes before menopause

From the age of 35-45 years onwards, the primordial follocles in the ovary are relatively resistant to stimulation by gonadotrophins. In the last 5 – 15 years of reproduction life, the cycles tend to be anovulatory and irregular. The failure to ovulate or deficiency in the corpus luteum formation causes an absence or decrease in progesterone secretion. Anovulatory cycles become more frequent with increasing periods of unopposed oestrogen secretion immediately preceding the menopause.
Throughout reproductive life,until the menopause the main circulating oestrogen is oestradiol (E2). Oestrone (E1) is produced in small amounts by the ovary and by peripheral conversion of andostenedione derived from ovary and from the adrenal cortex.
The reduction in the plasma E2 levels in woman aged 46-56 years with regular menstrual cycles stimulates the regular hypothalamic – pituitary feed back mechanism causing a rise in FSH secretion which may be the first indication of approaching menopause. The rise in luteinizing hormone (LH) levels tends to occur late.
The main endocrine changes before menopause are increased hypothalamic pituitary activity which is often comined with periods of decreased or absent progesterone secretion and unopposed oestrogen secretion

Endocrine changes at the menopause

Menstruation ceases when insuffient follicular develop and insuffient oestrogen is secreted to produce adequate endometrial proliferation.The menopause may occur abruptly with a sudden exhaustion of the oocytes and a sudden fall in oestrogen secretion. But, commonly it is progressive with decreasing oestrogen secretion and decreasing loss at each menstrual cycle over several months and years. The cycles which are anovulatory with deficient or absent progesterone secretion may be associated with excessive dysfunctional uterine bleeding.
Endocrine changes after menopause

1 Oestrogens:
Post menopausally, the predominanat circulating oestrogen changes from E2 produced by the ovary to E1 produced from extra ovarian sources.The efficiency of conversion of androstenedione to E1 increases with increasing age. The conversion rate also increases in proposition to the amount of body fat and the plasma levels of E1 in post menopausal woman correlate closely with body weight,Obese woman have high levels of both plasma E1 and E2 than thin women.
2 Androgens:
After menopause, the ovarian stroma and adrenals continue to secrete androsteine dione, dihydroepiandrosteone (DHEA), DHEA sulphate (DHEAS) and testosterone. In post menopausal women with intact ovaries the plasma levels of androstenedione and testosterone are moderately increased compared with younger reproductive women in the follicular phase of menstrual cycle. The hirsuitism and defeminization which occurs in some post menopausal women may be due to the increased secretion of androgens by the ovary
3 Progesterone
The perimenopause and menopause are as much a progesterone deficiency as an oestrogen defiency syndrome. The plasma progesterone and 17-hydroxy progesterone levels are considerably reduced in post menopausal as compared with premenopausal women.
4 Gonadotrophins
Immediately after the menopause, plasma FSH and LH levels rise rapidly, reaching or maximum 2-3 years post menopausally when the levels of FSH and LH are respectively 13 fold and 3 fold greater than the average levels in the early Proliferative phase of pre-menopausal women. 5-10 years after the menopause the FSH and LH levels begins to fall. The rise in plasma FSH and LH are due to increased production by the pituitary.
5 Prolactin
Plasma prolactin levels fall after the menopause probably due to the decrease in plasma oestrogen. Prolactin stimulates the adrenal cortex and increases the ratio of oestrogens to corticoids secreted by the adrenals. Post menopausal women with osteoporosis have a decreased plasma androstenedione/cortisone ratio compard to postmenopausal women without osteoporosis and this decrease may be due to the decreased prolactin secretion which may be a contributing factor in osteoporosis.
The endocrine changes at the perimenopausal period are summerised below (Dewhurts 614 table 41.3)

Samprapthi
Status of doshas:
Menopausal period is the sandhikala (twilight period) of middle and old age where vatadosha gradually takes its dominance. There is increase of vatha gunas with decrease in the soumya gunas of kapha. Vatha increases degenerative process which causes the depletion of dhathus. Dhathukshaya is one of the causes of vatakopa. As dhathukshaya progresses, vata gets more and more vitiated leading to many minor ailments and serious diseases.
Among the features of ageing the reduction in prabha,aguimandya etc. denotes decrease of pitta while palitha, vali denotes excessive activity of pitha during old age. While mentioning the dominance of doshas in various ages, Acharyas say middle age is the period of dominance of pitha.
So, the doshic status at the perimenopausal age is dominated vatha associated with an increased pitha and a decreased kapha.

Status of dhathus

The gradual depletion of dhathus is a part of old age (jara) and starts from rasa to end with sukra.Vagbhata I and Sarngadhara have mentioned that twak is depleted in 5th decade, Twak and rasadhathu are interrelated since the ‘Twaksara purusha is mentioned instead of rasasara by Acharya. From this, we can assess that rasadhathu is depleted qualitatively and quantitatively in 5th decade (the age with is correlated with age of menopause). When rasadhathukshaya occurs, its upadhathu raja becomes irregular and then ceases completely. With respect to rasa dhathukshaya, the other dhathus also begin to degrade. The ksheena dhathus fail to perform their routine functions, which adds more miseries to years following menopause.

Status of Srothas
The depletion of dhathus vitiates vata which in turn leads to artava kshaya through agnivaishamya and rasakshaya. So, rasavaha and artavahasrothas are more involved including the successive involvement of all srothases with the prolongation of age
Samprapti ghatakas

Saririka Manasiaka

Doshas Vata ↑↑↑ Rajas ↑↑
Pitha ↑↑ Thamuas ↑↑ Kapha ↓↓↓ Satwa ↓↓

Dhathus Rasa involved more followed by gradual decrease of others.

Upadhathu Arthava

Srothas Mainly artava vaha and rasavaha

Perimenopausal symptoms

Perimenopausal symptoms are the physical and psychological symptoms commonly experienced in the climacteric period due to oestrogen defiency. Since they are a group of symptoms, the term ‘Menopausal Syndrome’ is also used.These symptoms often pre-date menopause.
According to time of onset, they are grouped into two – short and intermediate term symptoms and long term consequences. Short term symptoms include vasomotor symptoms like hot flushes and night sweats, skin symptoms, bladder symptoms, psychological symptoms etc. Long term consequences include osteoporosis, cardiovascular disease, Alzheimer’s diseases etc. Major perimenopausal symptoms are Hot flushes, night sweating, sleep disturbances, urinary complaints, pigmentations, joint pain, head-ache, palpitation, vaginal dryness, loss of libido, bloating, pricking sensation of soles and palms, Loss of memory, irritability, anxiety, depression.
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The Pathophysiology of main perimenopausal symptoms

Hot flushes and night sweats - Hot flush is an intense and often intolerable sensation of heat, usually starting in the trunk and spreading upwards to neck, face and forehead and frequently involving the whole body. Sweating may be particularly marked at night, when patients complain of night sweats.
A fall in oestrogen concentration in the mid brain increases the pulsatile activity in the neurons leading to the GnRH centre and these increased pulses, appear to spill over into the preoptic nuclei, causing a periodic sudden downward resetting of the thermoregulatory centre.
The skin and body temperature changes may be explained by this sudden downward resetting of the thermoregulatory centre in the mid brain, which results in a compensatory peripheral vasodilation, a rise in skin temperature with sweating and loss of body heat. The acute sensation of intense heat of the flash thus arises in the thermoregulatory centre and is perceived centrally.
Hot flushes and night sweats (Daha and Athisweda) are the results of vitiated pitha
.
Sleep disturbances
Sleep disturbances during the perimenopausal time are commonly characterized by early morning wakening associated with hot flushes and the inability to get back to sleep. They are the results of the sudden adrenergic activation in the central nervous system.
Mood and psychological changes
The psychological complaints may be due to a combination of factors including (1) Oestrogen defiency (2) inherent personality (3) adverse social circumstances,life events and cultural background. The psychological symptoms include: - (1) Depression, fluctuation of mood and crying for no reason.(2) irritability,short temper and aggressiveness (3) anxiety,nervousness and tension (4) inability to concentrate,forgetfulness and poor memory (5) loss of confidence and the ability to make decisions (6) loss of energy and libido, and tiredness.
Charaka gives the qualities of excellent health of Sathwa which includes a good smruthi,mahotsaha, vishadarahithya,gambheera budhi etc (Ch.S.Vi .8/121). From the psychological symptoms of menopausal women, it is evident that these are not in equilibrium in them, Rajasa bhavas (irritability , attacks of fear, excitability etc) and thamasa bhavas (lassitude, sadness ,loss of memory etc)dominate as results of disturbed equilibrium (A.H.Sa 3/7)
Urinary symptoms
Perimenopausal women may complain of the following urinary symptoms
1) Incontinence, which may be genuine, due to a urethral abnormality; reflex, due to detrusor instability; or over flow incontinence.
2) Frequency,urgency and pain on micturation, which may be associated with bladder infection or dysfunction and
3) Difficulty in voiding, which be due to detrusor underactivity, urethral overactivity or mechanical obstruction.
The normal functioning of the urinary system and reproductive system are closely related to apanavatha which does the vatha vinmoothra nishkramandi kriya (AH --_) Vatha vaigunya in old age causes the urinary symptoms.

Weight gain
Increase in body weight is a recognized feature during the 5th decade in many women and central fat deposition becomes more pronounced after the menopause. The post menopausal deposition of abdominal fat may be due to the relative hyperandrogenic state resulting from continued stromal production of androgen together with oestrogen deficiency – the hall mark of menopause.

Bone and skeletal symptoms

Osteoporosis is common in perimenopausal females which causes fractures from an excess of bone resorption over bone formation associated with loss of ostrogen. The three commenest sites of fractures in post menopausal women are spine,hip and radius though fractures of the pelvis and proximal humerus are also associated with osteoporosis.
Many of the women in the climacteric age complain of generalized aches and pains. It is not possible to say whether they are human related or not.
All the types of pains are due to vathakopa (----) the asthi and vatha are having Asrayasrayi bandha. Parva or asthisanti is the seat of sleshaka kapha. In old age,decrese in kapha causes soonyasthana in the sandhis and that space is occupied by aggrevated vatha and produces pain.

Cardiovascualr diseases

Cardiovascular disease is commoner in postmenopausal than premenopausal women of the same age.Following menopause, LDL cholesterol concentration in women rise. Oestrogen has a protective effect through its effect on HDL: LDL ratio, and also stimulate vasodilation increased blood flow. So, postmenopausal women are having more chances of attack of cardiovascular disease.
The depletion of raktha and mamsa leads to structural changes in vessels – sirasaithilya and dhamani saithilya which causes loss of elasticity ( A.S.Su.19/36,37). These are powerful pathogenic features of cardiovascular complications.

Sexuality

The effect of perimenopause on sexuality depends upon cultural, psychological and social factors as well as on hormonal and physical changes associated with the menopause and ageing. Organic changes in the pelvic musculature, vaginal epithelium and secretion obviously contribute to decreased activity and decreased libido

Chart 2

Menstrual pattern in post menopausal period

Menstrual irregularities often occurs with the periods becoming chaotic and heaving just before the menopause. Thi is because of unopposed oestrogen stimulation from the failure to ovulate. It results in a thickened and hypertrophied endometrium which is shed erratically. Any irregular bleeding in perimenopausal years should raise the possibility of genital tract cancer.

Tissue and organ changes during perimenopausal period

Theses changes are of atrophic type and affect the external genitalia as well as the internal organs. They take time to occur – over a number of years.

Vulva - The labia majora is flattened, making the minor labia more evident.The sexual hair becomes grey, sparse. The clitoris shrinks.

Vagina - Vaginal epithelial maturation decreases, the glycogen containing.superficial cells disappear and vaginal pH increases to between 6.0 and 8.0 making it more prone to the attack of pyogenic organisms which results in atrophic vaginitis and dyspareunia. The fibrous and elastic tissue surrounding vagina and ligamental supports of uterus becomes thinner and weaker so that vaginal and uterine prolapse becomes common.

Uterus -The uterus becomes small with a relatively large cervix – a return to infantile proportion. The myometrium and endometrial stroma become replaced by fibrous tissue and the endometrium is usually thin and atrophic.Fibromyomas usually shrinks following menopause.

Tubes and Ovaries - The tubes show great shrinkage becoming thin. Ovary shrinks after menopause and appears white and wrinkled. The tunica albuginea thickens and the cortex thin. The medulla increases in size relative to the cortex and appear active with abundance of stromal cells containing lipids droplets and mitochondria. The stromal cells are the probable sites of androgen synthesis.

Lower Urinary Tract - Since lower urinary tract and genital tract have a common embryological origin they may undergo simlar atrophic changes at the menopause. The epithelium of the urethra and trigone, which is squamous and non-keratinized, may become thinner and regress and be replaced by transitional epithelium from the bladder.The connective and elastic tissue of the urethra and bladder become thinner and the muscles lose their tone.
Breast - Breast tissue is hormone dependent and full mammary development requires oestrogen, progesterone,prolactin and growth hormones. Oestrogen cause duct development and progesterone, alveolar and lobular development. glandular tissue of the breast tends to decrease and fat and connective tissue to increase with the decrease in ovarian function at perimenopausal time.
Skin - Skin contain both androgen and oestrogen receptors and E2 is concentrated in the basal layers of epidermis. Perimenopausally, the skin thickens and collagen decreases and is bout 30 % is lost in the first 5 years after menopause.
Bone and Skeleton - In old women the bones become thin in their shell and spongy in their texture. Bone loss starts in the 4th and 5th decades but in women there is a sudden acceleration immediately after the menopause. Following the menopause there is increased osteoclastic activity, leading to greater resorption of bone, which causes osteoporosis.

Akalaja Rajonivruthi (Abnormal Menopause)
It is most common for the menopause to occur naturally (kalaja rajonivruthi) during the late forties or early fifties.If menopause occurs before the age of 40 years and after the age of 55 years, it can be termed as akalaja rajonivruthi or abnormal menopause.
Premature menopause.
When menopause occurs earlier than 40 years, it is described as premature.The definition of premature. The definition of premature menopause as given by WHO: - “ Ideally, premature menopause should be defined as menopause that occurs at an age less than two standard deviations below the mean estimated for the reference population.”
In practice, in the absence of reliable estimated of the distribution on age at natural menopause in population in developing countries, the age of 40 years is frequently used as an arbitrary cut-off point, below which menopause is said to be premature.The diagnosis of premature menopause should never be made until all other causes of amenorrhoea have been excluded, when menopause occurs early, there is often a history of similar occurrence amongst the other members of the family.
Induced menopause
It is the cessation of menstruation which follows either surgical removal of both ovaries (with or without hysterectomy) or iatrogenic ablation of ovarian function (example: - by chemotherapy or radiation).
Late (Delayed) Menopause
Regular menstruation upto the age of 53 years is not uncommon and is of little significance. Beyond that age, it should be regarded as unusual and if continuous beyond 55 years, there is clear indication for further investigations
Causes of delayed menopause are (a) Constitutional ( a familial or racial tendency ) (b) Uterine fibroids (c) Diabetes mellitus (d) Oestrogen tumours of ovary.

Diagnosis of Perimenopausal symptoms
On perimenopausal women,the diagnosis of symptom is done prospectively by seeing the age and menstrual pattern ie, any of the following pattern of menstrual cessation are observed
(1) Sudden cessation (2) Gradual hypomenorrhoea progressive with each period till it ceases for a period of six month to 1 year. Diagnosis of menopause it self is done followingly :-
· Cessation of menstruation for consecutive 6 months to 12 months during perimenopausal age
· Serum oestradiol <20pg/ml
· Serum FSH and LH > 40 ml U/ml
Appearance of perimenopausal symptoms such as hot flushes and might sweating are used as evidence for making diagnosis. Assessment of serum oestrogen is poorly correlated with symptoms and vaginal cytological examination is unsatisfactory in that correlation between circulatory levels of oestrogen and the vaginal cytology is poor. Although a poorly prolificative vaginal smear is generally associated with low circulating levels of oestrogen, but converse cannot be assumed.

Differential diagnosis

Before coming to the diagnosis of perimenopausal symptoms, one should differentiate from other condition like pregnancy, polycytic ovarian disease etc.

Management of Rajo nivruthi lakshanas
Rajonivruthi is a sign of ageing or jara. It is a swabhavika vyadhi. Generally swabhavika vyadhis are incurable. Charaka says “Swabhavo nishprathikriya”----. But chakrapani says that the term nishprathikriya excludes Rasayana therapy. It is meant for delaying the process of ageing by preserving the excellence of tissue elements-not to stop or reverse the ageing process (Ch.S.Soo.7/49)
Or, we can consider Rajonivruthi lakshanas as yapya, which should be tried to manage with suitable medicines.
Dhathukshya, vishamagnitha and vathapitha predominance are the characteristics of perimenopausal period. So, the treatment adopted should be favourable to these factors.
Shamana chiktsa should be the main tool, because since perimenopausal women are approaching jara, the depleting dhathus cannot suffer the quick karshana effect of sodhana therapy.
Vitiation of vatha is the basic pathology of female disorders related to reproductive system (A.H.U.-). So, snehana - both bahya and abhyanthara in small doses have an important role in curative approach. Since agni is vishama,medicines should have the power to improve and maintain agni bala.

Role of Rasayanas

Rasayanas can block or reduce the fast progress of dhathukshaya. To be used as a preventive measure, rasayana therapy should be started in the earlier years. According to Susrutha and vagbhata I, vrudhi (growth) is ended up by the 2nd decade (----). After that, there is only restoration of dhathus by food and regimen. So, it will be ideal to give desirable dhathuposhaka dravyas where rasayanas are the drugs of choice. To reduce the severity of developed symptoms, rasayanas can be used in a curative aspect. Before rasayana therapy, doing a mild shodhana will increase the effectiveness of the therapy.

PreventiveAyurveda
Swasthavritha gives guidelines for leading a healthy life. The life style according to Dinacharya,rithucharya,rithukala charya etc. may be the cause for non-appearance or reduced appearance of menopausal symptoms in the past era.

A healthy Diet
A man can lead a disease free life with wholesome diet only food containing whole grains,fruits,vegetables and enough water should be taken.

Exercises
For many serious diseases, physical inactivity is a life style risk factors vyayama gives deha laghuthwa,karma samarthya Ghana gathratha (A.S ) through regular practice. Through the restoration of agni bala,deha laghava and uthsaha, proper exercise will reduce the consequences of menopause. Exercise increases bone, mass in perimenopausal woman if accompanied with balanced diet and adequate calcium intake.

Promotion and presentation of Sathwabala
A woman attaining the climacteric should be made aware that it is a physiological process. The promotion of satwaguna through measures like achara rasayana ,Sadvrutha etc. may be useful. Practicing yoga is a good tool to control and overcome stress and its related outcome.

Treatment options in modern Biomedicine

The treatment for menopause is of two types -
1) Hormonal 2) Non Hormonal
Hormonal Treatment
Menopausal period is said to be the oestrogen deprivation period and the perimenopausal symptoms are also directly related to the defiency of oestrogen.Therefore external supplementations as Hormone Replacement Therapy (HRT)
Routes of administration may be either oral or parentral.

Oral - Estradiol and estrone are fat soluble molecules and therefore not readily absorbed from the gut, unless the steroid ismicronised or if the oestrogens are esterified to carrier ester that makes them more water soluble. Oral administration is subjected to first pass effect of the liver with conversion of oestradiol to oestrone and conjugation to glucuronates and sulphates. Still, oral therapy usually succeeds in building up satisfactory serum oestradiol levels.

Parenteral - They can be trans – dermal patches percutaneous gels, subcutaneous implants or vaginal applications.
Trans dermal preparations offer a theoretically safe way to administer oestrogen, where the hepatic first pass effect in reduced, but have the limitations of skin absorption in at least 50% of instances and the potential for skin reactions to the adhesive material for the patch.
The application of oestradiol in gel formulation rubbed over the skin may reduce the problem of skin irritation but serum oestradiol levels may be lower than those available with oral therapy
The subcutaneous insertion of oestradiol pellets involves a surgical procedure and is associated with huge serum oestradiol levels as such it is responsible for tachyphylaxis in a significant number of women.
The vaginal rout is effective in delivering oestrogen when a restricted effect to the vagina is required but the request application of vaginal creams and pessaries may sometimes deliver more oestrogen to cause stimulation of uterus and vaginal bleeding.
Intranasal oestradiol spray,intrauterine and intra vaginal progestrogen implants are new methods of non - oral administration.

Benefits and Side-effects of HRT
Appropriate hormone treatment reduces Alzheimers disease, relieves vasomotor symptoms and psychological symptoms, protects and restores collagen,prevents and improves osteoporosis and reduces CVD and fatal colon carcinoa in eldery.
Fluid retention, breast tenderness, increased chance of breast cancer, nausea, headaches, leg cramp, dyspepsia, heaving with drawal bleeds, etc; are the side effects of HRT

Non-hormonal Treatments
Psychotropic drugs - Anti depressants or tranquiliser are used if women is having pre – existing psychiatric disorder or co-existing severe anxiety and depression

Vitamins and minerals
The vitamins like E, A, D3, B-complex etc. along with minerals like Boron,Magnesium, selenium Zinc etc. Are proved to be effective in relieving the menopausal symptom. Exerts ant – oxidant action – It is free from side – effects commonly associated with HRT.

Role of phyto oestrogen
Phytoestrogens are plant sources of oestrogen. They are non-steroidal oestrogens that occur natuarally in certain plant foods. They are similar to oestrogen produced in human body but are much weaker. However, they have oestrogen like effects only on some tissues and processes in the body and anti oestrogen on other tissues and body processes.
Phytooestrogens are characterized into four main groups
1) Isoflavones 2) Lignans 3) Coumestans 4) Resorcyclic acid lactones

They are mainly found in soybeans, chickpeas and other legumes. The highest concentration of phyto oestrogens are found in the whole food,lesser in processed foods.
Asian women, who typically consume a diet very high in food containing phyto oestrogen are observed to have an easier transition through peri-to post menopause, with fewer symptoms, a lower incidence of osteoporosis and a less risk of cardiovascular diseases and hormone dependent cancers

AYURVEDA IN FEMALE DISEASE

Tuesday, February 12, 2008

ayurveda in pregnancy

Saturday, February 2, 2008

FEMALE DISEASE AND AYURVEDA

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