Menstrual disorders

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.

Contributors

Section/Chapter/topic	Sharira / Artava / Menstrual disorders
Authors	Anagha S., Deole Y.S.
Reviewed by	Basisht G.
Affiliations	Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar
Correspondence email	carakasamhita@gmail.com
Date of first publication:	July 31, 2020

Classification of menstrual disorders

Types based on clinical presentation

The menstrual disorders can be classified into three categories.

Table 1: Three categories of menstrual disorders

Sr. No.	State of menstruation	Clinical conditions
1.	Decreased state (artava kshaya)	Amenorrhoea, oligomenorrhoea, and hypomenorrhoea
2.	Increased state (artava vrudhi/asrugdara)	Menorrhagia, metrorrhagia, polymenorrhea
3.	Vitiated state(artava dushti)	Painful menstruation ,burning sensation, abnormalities(vikruti) in menstrual discharge

Age specific classification

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:

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]

a)Time factor(kala): Age of puberty, environmental conditions as per geographical area

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. ,

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]

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.

• Secondary amenorrhoea : After the establishment of menarche, some girls may experience a secondary amenorrhea which may extend upto many months or even years.

• Dysfunctional uterine bleeding: Irregular or Excessive menstrual bleeding mainly due to anovulatory cycles and/or hormonal dis-balance.

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.

2)Reproductive age:

• It extends from the menarche to menopause during which all kinds of menstrual disorders are likely to be manifested if the female does not follow proper diet,regimens, hygeine and code of conduct advised during different phases of menstrual cycle.

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.

Causes of menstrual disorders

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. 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

Functions of 5 types of vata in reproductive physiology [A.S.Sutra Sthana 20/2]

Type of Vayu	Related Functions	Physiological functions
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)	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 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 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.

• The vitiation of vata occurs in two ways:

1)Primary vitiation: Due to degenration of body components(dhatukshaya)

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]

• 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 coldnesssheeta, dullness/slownessmanda and immobilitysthiratva. 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]

General 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)**
primary or secondary amenorrhea, oligomenorrhea (yathochita kala adarshanam )	body aches (angamarda)
scanty menses/ hypomenorrhea (alpata)	excessive menstrual bleeding (atipravrutti)
pain in genital tract, dysmenorrhoea (yoni vedana)	bad smell (daurgandhya)

• *[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 quantityand 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)

Special features

Excess menstrual bleeding (asrugdara)

The specific features of different types of “asrugdara” are mentioned in the table.

Sl no:	Type	Characteristic features	Probable gynecological correlation
1.	Vata dominant	•Menstrual blood is frothy, thin, rough, blackish or reddish, resembling washings of flower of Butea monosperma (palasha).* •With or without pain* •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
2.	Pitta dominant	•Menstrual blood is blue, yellow or blackish in color, hot, comes in profuse amount repeatedly, and with 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*** •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 liqid called “Kanji” prepared from rice and foul smelling.** •Blue like bronze, dirty and foul smelling.***	Endometrial/cervical carcinoma or Senile pyometra

• *[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)

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
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* 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. 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]

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.

Examination of patients

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.

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]

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 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. 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 solution Lacciferlacca(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).

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.

Palpation(sparshana)

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.

Interrogation (prashna)

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.

Laboratory investigations

In decreased state of menstrual blood (artavakshaya)

Common clinical conditions and laboratory investigations:

Investigation	Value/Result	Possible diagnosis
Urine Pregnancy Test	Positive	Pregnancy
S. FSH, S. LH	LH level increased or LH:FSH ratio>2:1	PCOS
S.Total Testosterone	increased	PCOS
S. estradiol	increased	PCOS
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)

• Haemoglobin estimation is done in every case.

In cases not responding to usual therapy,

• platelet count

• prothrombin time

• bleeding time and clotting time

• partial thromboplastin time

In suspected cases of thyroid dysfunction, S.TSH, T3, T4 estimations are recommended.

Imaging techniques

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.

Ultra Sonological findings in PCOD:

• Ovaries are enlarged(ovarian volume ≥ 10 cm3 )

• 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)

Transvaginal Sonography (TVS ) and Color Doppler:

Findings of Endometrial Hyperplasia

• Endometrial thickness >12 mm

• 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.

Saline Infusion Sonography (SIS):

It is superior to diagnose endometrial polyps, submucous fibroids and intrauterine abnormalities like septate/subseptate uterus etc.

Endometrial Biopsy:

In office endometrial smpling to rule out hyperplasia or carcinoma.

Hysteroscopy:

It is done for better evaluation of endometrial lesion and to take biopsy under direct vision.

Management

The management of menstrual disorders is broadly divided into two.

1. Purification therapy(shodhana/ panchakarma)

2. Pacification therapy(shamana)

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.

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]

Treatment for increased state of menstrual blood

Purification therapy:

In case of excessive menstrual bleeding, therapeutic purgation(virechana) is the treatment of choice.[Ka.Sa .SidhiSthana 2/13]

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.[Ch. Sa Chikitsa Sthana 30/86]

Treatment for abnormal state of menstrual blood:

Purification therapy :

In abnormalities of menstrual blood (artava dushti), oleation(snehana),sudation(swedana), purification therapies(vamana, virechana, basti) as well as local therapies including intra uterine drug administration(uttarabasti) is advised.[Su. Sa. Sharira Sthana 2/12]

In 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:

Specific combination of drugs is mentioned for different kinds of abnormal menstrual blood.

Type of abnormality	Drugs
Vataja	•Unctuous,hot,sour and salty substances* Internal: •Ghee processed with Clerodendrum serratum (bharangi) ,Madhuca longifolia(madhuka), Cedrus deodara ( bhadradaru)** •Milk processed with Gmelina arborea(kashmari), Phaseolus trilobus(kshudrasaha)** External: •Paste of Callicarpa macrophylla(priyangu) and sesame oil-applied in vagina**
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)* •Decoction of Cissampelospareira (patha),Tribulus terrestris(trikandaka), Holarrhenaantidysenterica(vrukshaka)**
Kunapagandhi(foul smelling) , Puti-puya(pus like appearance)	For removing bad smell- •Oral intake of decoction of Santalum album(chandana)* •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]

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. Sharira Sthana 2/16]

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]

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. Sharira Sthana 2/24, Ghanekar Teeka]

Contra indicated activities during bleeding phase of menstrual cycle [Su. Sa. Sharira Sthana 2/24-25]

• Sleeping during day time (divaswapna)

• Use of collyrium (anjana)

• 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]

Menstrual Hygiene

Menstrual hygiene management (MHM) refers to management of hygiene associated with the menstrual process.

It includes,

• using a clean menstrual management material to absorb or collect menstrual blood

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

• understanding the basic facts linked to the menstrual cycle and how to manage it with dignity and without discomfort or fear.

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).

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.

• 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.

• 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.

• 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:

• Sa. = Samhita

• Cha. = Charak

• Su. = Sushruta

• Ka. = Kashyapa

• Sha. =Sharangadhara

• A. = Ashtanga

• Hr. = Hridaya

• S. = Sangraha

• Ha. = Harita