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Menopause is a natural consequence of the aging process. It is a state of deficiency of female sex hormones, estrogen, and progesterone due to the reduced activities of ovaries. The permanent cessation of menstrual bleeding characterizes it. Some women do not experience any associated symptoms or very mild symptoms only. However, some women suffer from severe discomfort during menopause, which negatively impacts their quality of life. Management of menopausal syndrome is vital for the preservation of health and prevention of disorders in old age.
Menstruation is termed as ‘artava’ or ‘raja pravritti’ in Sanskrit. Its cessation (nivrutti) is known as menopause (rajonivrutti). The clinical features during menopause are collectively known as a menopausal syndrome. This article describes Ayurvedic perspective of pathophysiology and management of menopausal syndrome.
==Age of onset ==
The average age of onset of menopause is 50 years. [Su. Sa. Sutra Sthana 14/6]. This age may vary based on individual biological constitution, familial and geographical differences. [Arunadatta, A. Hr. Sharira Sthana 1/7].
==Physiology ==
Menopause is a normal physiological phenomenon in women’s life due to the aging process (jara). The decrease (kshaya) of menstruation (raja) is observed due to the natural process of biological decline due to ageing. [Su. Sa. Sharira Sthana 3/11]
Process of enstruation directly depends upon [[rasa dhatu ]], [[rakta dhatu]] and nutrient fluid (ahara rasa). The nutrient fluid (ahara rasa) is unable to nourish body tissues responsible for menstruation as a result of aging process in women of menopausal age. [Su. Sa. Sutra Sthana 14/19] This leads to a spontaneous decrease in the tissues elements and the metabolic process related to menstruation. Due to the wear and tear process of aging, it is reflected in reproductive physiology ([[shukra dhatau]]). This is observed in the form of deficiency of female hormones during the menopausal age. The [[pitta dosha]] is decreasing, and [[vata dosha]] is predominant at this age. Therefore a state of depleted [[kapha dosha]], moderate [[pitta dosha]], and aggravated [[vata dosha]] is observed during menopause.
==Classification==
Menopause is a natural condition (swabhavabala pravrutta vyadhi). In some cases, it can turn into an acquired pathological condition which is classified into two types based on age of onset.
a) Menopause at the appropriate age (kaalakrita): This occurs due to the natural aging process without any apparent clinical features.
b) Menopause before the appropriate age (akaalakrita): This can turn into a pathological condition due to improper diet and lifestyle, other comorbid medical and surgical conditions.
== Predisposing factors for early menopause (nidana) ==
a) Dietary factors:
The role of diet in menstruation (artava) is known. [A.Hr. Sharira Sthana 1/7]. The onset and cessation of menstruation depend upon dietary habits. [Ka. Sa. Sharira Sthana 5/4].
Excess and long-term consumption of the following food and dietary habits can lead to early onset of menopause. These factors are responsible for premature aging, too.
• Excessive use of sour, saline, pungent, alkaline substances
• Dried vegetables and meat
• Habitual use of food items prepared using sesame paste and rice flour
• Germinated or fresh leguminous cereals
• Incompatible, unsuitable, rough, alkaline substances
• Substances that are heavy to digest, cold potency and can cause obstruction in body channels
• Decomposed, heavy, putrefied, and stale food items
• Irregular dietary habits
• Food consumed in a state of indigestion [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
b) Lifestyle factors
• Excess daytime sleep
• Excessive indulgence in sexual activities
• Excessive alcohol consumption
• Irregular and excessive physical exercise causing agitation in the body. [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
c) Medical or surgical conditions
Any medical illness leading to a severe loss of tissue elements (dhatukshaya) can cause the early onset of menopause. Injury to the channels carrying menstrual blood (artavavaha srotas) or surgical removal of the reproductive organs leads to acquired menopause.
d) Psychological factors
Disturbed mental state due to fear, anger, grief, greed, confusion, and exhaustion can cause early menopause. [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
e) Time factor
Ageing is the fundamental factor for menopause. [Cha. Sa. [[Sharira Sthana]] 1/115]. It is responsible for gradual decrease of vital energy (ojas). The reproductive processes like menarche, lactation, and menopause occur at a particular age per the time factor (kala)[ Sha. Sa. Purva Khanda 4/96]
== Preclinical features (poorvarupa) ==
The preclinical features of old age (jara) are similar to that of menopause as below.
• Tiredness or loss of enthusiasm.
• Decline in memory.
• Wrinkles over skin.
• Greying of hair.
• Loose attachment of teeth to gums.
• Change in a behaviour and mood swings etc. [M. Ni. Jararoga nidana 2-3]
==Clinical features ==
The clinical features of aging (jara) and menopause are as below:
General features:
• The decreased capability of physical and mental activities.
• A decline in memory, intellect, and lustre.
• Wrinkling of skin and greying of hair.
• Various comorbid conditions due to decrease in strength and immunity [[(ojas)]]) ex. Dyspnoea (shwasa) [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
Psychological and behavioral changes:
• Excess fear, anger, grief, greed, confusion, and exhaustion.
• The woman is subdued with malaise, depression, sleepiness, drowsiness, lassitude, and lack of enthusiasm. [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
Changes in blood tissue:
• There is decrease in quality of blood tissue ([[rakta dhatu]]) in terms of its vitalizing action (jeevaniya). [Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
Changes in the musculoskeletal system:
• Laxity of muscles ([[mamsa dhatu]])
• Looseness of joints(sandhi)
• Decrease in bone marrow ([[majja]]) .[Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
Changes in adipose tissue:
• Fat (meda) becomes abundant and attains more liquidity.[Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
Changes in the reproductive system:
• There is decreased production and secretion of reproductive hormones (shukra dhatu) and decreased libido.[Cha. Sa. [[Chikitsa Sthana ]] 1/2/3]
==Diagnostic aspects==
===Dosha predominance in symptoms related to menopause==
Vata Pitta Kapha
Headache Hot flashes Weight gain
Palpitation Increased sweating Vaginal discharge with itching
Numbness of limbs Increased thirst Edema
Bloating of abdomen Burning micturition
Constipation Burning sensation in vagina
Sleeplessness Anger bursts
Giddiness Fainting
Inability to concentrate
Stress
Depression
Loss of memory
Loss of libido
Dyspareunia
Joint pain, back ache, body ache
Dryness and pain in vagina
Urge incontinence
Increased frequency to micturition
Wrinkles
===Symptoms related to decreasing tissue elements (dhatu kshaya) and vitiation of tissues (dhatupradoshaja vikara) seen in menopause (jara) ===
Dhatu Symptoms of decrease Symptoms of vitiation of transportation channel
[[Rasa dhatu]] Intolerance to sound (shabda asahishnuta), palpitation(hrudrava), pain(shula), tiredness(shrama), giddiness(bhrama), emaciation(shosha), dryness(raukshya) Heaviness in the body(gaurava), drowsiness(tandra), body ache(angamarda), blackouts(tama), anemia(pandutwa), obstruction of channels(srotorodha), tiredness (angavasada), diminished digestive power(agni), wrinkling of skin and greying of hair
[[Rakta dhatu]] Liking for cold(shishira preeti), collapse of veins(sira shaithilya), dryness(rukshata) Skin changes like appearance of blue mole (nilika), freckles/blemish (vyanga), portwine mark (piplu), black mole of the size of sesame seed (tilakalaka)
[[Mamsa dhatu]] Pricking pain(toda),debility of body(gatra sada),reduced muscle mass, joint pain(sandhi vedana) Granuloma(adhimamsa), enlargement of thyroid gland (galaganda)
[[Medo dhatu]] Numbness over back region(kati swapana), feeling of emptiness of joints(sandhi shoonyata), dryness(raukshya) Obesity, numbness and burning sensation in hands and feet, dryness in mouth, palate, and throat, excessive thirst and laziness, burning sensation and numbness in various organs of the body, continuous drowsiness
[[Asthi dhatu]] Pain in bones (asthi shoola), brittleness of teeth and nails (danta nakha bhanga) , hair fall (khalitya) Pain and brittleness of bones and teeth, discoloration of body, abnormal changes in hair, nails etc.
[[Majja dhatu]] Osteoporosis (asthi saushirya), pain in joints(parva bheda), constant cutting pain/dull pain in bones (asthi toda) Pain in the joints (parvvaruk), giddiness(bhrama), unconsciousness (moorcha), blackouts(tama)
[[Shukra dhatu]] Decreased sexual pleasure, decreased libido, dyspareunia, decreased secretions from reproductive glands. Inability to enjoy sexual life
[ Su. Sa. Sutra Sthana 15/9], [A.Hr. Sutra Sthana 11/17-20], [Cha. Sa. Sutra Sthana 28]
===Symptoms of vitiation of other channels (srotodushti lakshana) of body seen in menopause (jara)===
Srotas Symptoms of vitiation
Pranavaha srotas (respiratory system) Dyspnoea on exertion
Mutravaha srotas (urinary system) Urge incontinence, increased frequency, difficulty in micturition, burning micturition
Purishavaha srotas (large intestine and rectum) Constipation, irregular bowels, increased flatus, abdominal distension
Swedavaha srotas (sweat channels) Increased perspiration, excessive burning sensation, and horripilation
Artavavaha srotas (female reproductive system) Dyspareunia, infertility, cessation of menstruation
==Therapeutic aspects==
Menopause is a natural phenomenon. The pathological conditions associated with menopause can be prevented by proper care and health-promoting measures. Rejuvenation therapy (rasayana) is the preferred treatment. [Cha. Sa. Sharira Sthana 1/115, Chakrapani], [ Su. Sa. Sutra Sthana 2/7] The treatment protocol for prevention of menopausal syndrome and premature onset includes the following measures:
• Oleation(snehana) and sudation (swedana)
• Purification therapy with unctuous medication (shodhana- snigdha virechana)
• Therapeutic enema with strength promoting medicines (yapana basti) )[Su Sa.Sutra Sthana 2/7]
• Rejuvenation therapy(rasayana)
• Aphrodisiac medications (vrushya prayoga)
• Wholesome diet and lifestyle modification (hita ahara-vihara)[Su.Sa.Sutra Sthana 2/7]
• Those who consume milk and ghee daily can maintain normal reproductive health for a longer period. [A. S. Sharira Sthana 1/64]
==Contemporary approach==
Diagnosis of menopause:
A woman is noted to have attained menopause only retrospectively. It is diagnosed when there is cessation of menstruation for 12 consecutive months in a woman of the climacteric period.
Investigations
• Vaginal cytology: showing maturation index of at least 10/85/5 (features of low estrogen)
• Serum estradiol: <20 pg/ml
• Serum Follicle Stimulating Hormone (FSH) and Luteinizing hormone (LH) :>40mIU/ml (three values at weeks interval required)
Management
Hormone Therapy (HT)
It is indicated to overcome the short-term and long-term consequences of estrogen deficiency.
It is administered in different forms like:
• Oral estrogen regime- for those who underwent hysterectomy
• Estrogen and cyclic progestin – for those with intact uterus
• Continuous estrogen and progestin therapy-prevents endometrial hyperplasia
• Transdermal administration
• Subdermal implants
• Percutaneous estrogen gel
• Transdermal patch
• Vaginal cream
• Progestins- in patients with a history of breast carcinoma or endometrial carcinoma
• Levonorgestrel intrauterine system(LNG-IUS)
• Tibolone, Testosterone, parathyroid hormone are also used.
Hormone therapy has many risks like endometrial cancer, breast cancer, venous thromboembolic disease, coronary heart disease, alteration in lipid metabolism etc. So, it is to be used with lowest effective dose and for a short period of time.
Non-hormonal Treatment
It includes a nutritious diet, exercise, lifestyle modification, supplementation of calcium, vitamin D, vitamin E etc.
Abnormal Menopause:
• Premature menopause: Occurrs before the age of 40 years.
• Delayed menopause: Fails to occur even beyond 55 years.
• Artificial menopause: Permanent cessation of ovarian functions done by artificial means.
a) Surgical menopause-
• Menstruating women with bilateral oophorectomy experience the symptoms of menopause
• Post-hysterectomy cases
b) Radiation menopause-
• Ovarian functions may get suppressed by external gamma radiation.
• Intra cavity introduction of radium can destroy the endometrium and depress ovarian functions.
==Current Research==
• The modified Kupperman index, Menopause Rating Scale(MRS), MENQOL Questionnaire, etc. are the most widely used and internationally accepted scales used for research related to menopause and associated conditions.
• The role of complementary and alternative therapies is well known in managing menopausal symptoms. A systematic review and meta-analysis of randomized controlled clinical trials (RCTs) showed yoga therapy is effective and safe for reducing menopausal symptoms.
• A clinical trial was conducted to evaluate the efficacy of Shirodhara and Saraswatarishta compared to hormone replacement therapy (HRT) in the management of the menopausal syndrome. The study showed promising results, especially in managing the psychological symptoms related to menopause.
• Various research studies have shown the efficacy of rejuvenation therapy(rasayana) using the oral administration of different herbal drugs. [Ref?? ]Some studies are being conducted on a combination of procedures like therapeutic enema (basti), nasal administration (nasya) etc.
==List of thesis works done==
1. Deena Raval (1974): Rajonivrutti Ek Adhyayana , Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
2. Kritidevi Gohil(1995): A Clinical Study on Rajonivrutti with special reference to Menopausal syndrome, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
3. Kritidevi Gohil (1998): A Clinical Study on the management of climacteric stage in women with special reference to Menopausal syndrome by using certain Ayurvedic formulations; Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
4. Shipra Dhar (1999.): Effect of Vacha, Ashwagandha, Ulatakambala and Jatamansi on Menopausal Syndrome , Department of Prasuti tantra and stree roga,IMS,BHU,Varanasi
5. Ajay Sood (2000) : Comparative study between Rasayanakalpavati and Shankhapushpavati in clinical Study on Rajonivrutti, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
6. Ami Modi (2000) : A comparative pharmaco-clinical study of Rasayanakalpavati and Mamsyadivati on Rajonivrutti Avasthajanyalakshana, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
7. Sunitha (2001) : Study on Ayurvedic concept of pathogenesis of Perimenopausal Syndrome & Evaluation of efficacy of a Rasayana Compound in its Management , Department of Prasuti tantra and stree roga ,NIA, Jaipur.
8. ManjuPateria (2002) : A clinical study on Manasa Bhavas in Menopausal syndrome and its management by Medhyarasayanavati and Shirodhara, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
9. Kaushal kamini (2002); Pharmacological of Varadadi Yoga w.s.r to Post Menopausal Syndrome; Department of Prasuti tantra and stree roga ,NIA, Jaipur.
10. Shaini M Bhaskar (2002): Study on the efficacy of Satavari Gopakanyadi Kwatha in Rajonivruttijanya Lakshana; Department of Prasuti tantra and stree roga, Govt. Ayurveda College, Thiruvananthapuram.
11. Umesh K Agarwal (2003): .Study on the effect of Satavari in Rajonivrutti Lakshanas, Department of Prasuti tantra and stree roga, Govt. Ayurveda College, Thiruvananthapuram.
12.Devangi Patel (2004) :The role of Nasya (with Medhya drug) in the Rajonivruttijanyalakshana w.s.r to Menopausal syndrome, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
13. Tellus Kurian (2004.): Clinical trial to evaluate the efficacy of Balasatavari Kwatham and Bala Tailam ointment in vaginal symptoms in women who attained menopause; Department of Prasuti tantra and stree roga, Govt. Ayurveda College, Thiruvananthapuram.
14. Usha Koli (2005): Pharmacognostic and Pharmacological Evaluation of Gauryadi Yoga w.s.r. to Post Menopausal Syndrome, Department of Prasuti tantra and stree roga ,NIA, Jaipur.
15.Jasmine Japee(2006):A clinical study on the role of Satavari in minimizing the risk of post-menopausal osteoporosis; Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
16. Kavita MB (2006) : Effect of Pranayama on Arthavanivritti W.S.R. to Climatric features; ; Department of Prasuti tantra and stree roga,SDMCA,Hassan , Karnataka.
17.Khyati Santavani (2009) :An assessment of Manasikabhavas in Menopausal syndrome and its management, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
18. Rituja Trivedi (2009): A clinical–Experimental study of Shatavaryadi Vati on Menopausal Syndrome (Rajonivruttijanyalakshana), I.P.G.T & R.A G.A.U Jamnagar.
19. Bharathi (2009): Evaluation of “AVA” Formula in the Management of Rajonivrutti Lakshana (Post-Menopausal Syndrome), Department of Prasuti tantra and stree roga ,NIA, Jaipur.
20. Meera Ravindran (2009): A clinical trial to assess the combined effect of Sukumara Kashayam and Shasthika Taila in Menopausal Vaginal symptoms, Department of Prasuti tantra and stree roga, Govt. Ayurveda College, Thiruvananthapuram.
21. Mamatha Rani (2011): Clinical Study on the Role of Menosol Compound in the Management of Menopausal Syndrome, Department of Prasuti tantra and stree roga ,NIA, Jaipur.
22.Mansi Modi (2012): Clinical evaluation of Ashokarishta, Ashwagandhachurna and Pravalpishti in the management of Menopausal syndrome, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
23. Neeta Kumari(2012) :Clinical evaluation of Ashokarishta, Ashwagandha Churna and Praval pishti in the management of Menopausal Syndrome, Department of Prasuti tantra and stree roga ,NIA, Jaipur.
24. Charulata (2012) : Clinical evaluation of Ashokarishta, Ashwagandha Churna and Praval Pishti in the management of Menopausal Syndrome; RGGPGAYC, Paprola.
25.Dipika Gupta (2013) : Role of Ashwagandha Arjuna Ksheerapaka and Soya Seeds in the management of Vata predominant features of Menopausal Syndrome; Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
26. Shrawan N Kamble (2014) : Study on Pitta predominant Menopausal syndrome and its management with Sodhana and Shamana therapy, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
27. Krithika Chaudhary (2015.): “A clinical study on Menopausal syndrome and its management by Vayasthapanagana Ghana Vati and Rasayanakalpa Vati’, Department of Prasuti tantra and stree roga, IPGT &RA, Jamnagar.
28. T. R. Thanga selva kumara (2016): Comparative clinical study between Lashuna and Shatavari in minimizing the risk of postmenopausal osteoporosis, Department of Prasuti tantra and stree roga, Parul institute of Ayurveda, Gujarat.
29. Anusree K M (2017): Effect of Yashtimadhu Churna with Ksheera in Perimenopausal Symptoms, Department of Prasuti tantra and stree roga, Govt. Ayurveda College, Thiruvananthapuram.
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