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Management of Amenorrhoea (Ihtibas-al-Tamth) in Unani System of Medicine: A Review

Ayesha Raza ¹, Farheen Zehra ², Mohd Nayab ³*

¹ Head, Department of AmrazeNiswan, A&U Tibbia College and Hospital Karol Bagh, New Delhi, India

² PG Scholar, Dept of MahiyatulAmraz, NIUM, Bengaluru, India

³ Associate Professor, Dept. of Ilaj bit Tadbeer, NIUM, Bengaluru, India

Introduction

Menstruation is an important aspect of being female. It is also one of the biological differences between the sexes to which different cultures have given different meaning. Menstrual bleeding cessation is one of the most frequent gynecologic disorders among women in reproductive age¹. 

Historical Background

Menstruum was the earliest word used for menstruation derived from the latin word menstruus meaning month. The cyclic occurrence of menstruation was noted from earliest times and primitive people understood that it occurred at intervals which approximated the lunar months.The word menstruation was introduced by the ancient Greek, who assumed that menstruation was a cleaning process and the Bible refers to the woman as being unclean at that time. The menstrual cycle was studied by the ancient Greeks who aware of cycle length and the number of days of menstrual loss. Amenorrhoea is the absence of menses in women of reproductive age. Primary amenorrhea is defined either as absence of menarche by 14 years of age in the absence of secondary sexual characteristics or absence of menses by 16 years in the presence of normal growth and secondary sexual characteristics^2,3. 

Secondary amenorrhea is characterized as the cessation of previously regular menses for three months or previously irregular menses for six months^2,4,5.Amenorrhea is not a diagnosis but rather a most common clinical sign of reproductive dysfunction⁶.

According to WHO estimates, amenorrhea stands at sixth largest major cause of female infertility and affects 1.5-3% of all women in the childbearing age⁷. Whereas primary amenorrhea is quiet rare, secondary amenorrhea is not infrequent in women of reproductive age. The incidence is increasing because of increased reporting, better utilization of healthcare, declining trend in the child marriage and increased awareness due to social media⁸.

Nowadays there has been an increasing trend in usage of complementary and alternative medicine⁹.Unani System of Medicine (USM), as a holistic system of medicine and based on temperament, is one of the wealthiest branches of the CAM and was used thousands of years ago.Temperament is made of the action and reaction of four pivotal elements (fire, air, water, and soil) and creates different characteristics in living things¹⁰. In USM, temperament has been classified in different types: Hār (hot), Bārid (cold), Raṭab (wet), and Yābis (dry)¹¹. Any disturbances in normal temperament of organs can cause diseases. Treatment is based on modifying the temperament¹².

In classical Unani literature, Ihtibās al-Tamth is defined as cessation of menstruation, either it varies from scanty flow to complete cessation, or it occurs at interval of more than or equal to 2 months¹³.

According to Ali Ibne Abbas Majusi, Menstrual discharge and its cessation should occur by the innate power (tabiyat) of the body. Women start menstruating at the age of 8-14 years and cessation occurs upto60 years of age. The duration of the menstrual blood should not be less than 2 days and more than 7 days and if it extends more than this will be considered as abnormal. A woman’s body becomes heavy when the days are nearer to the menstruation and the woman in whom menstruation comes with longer period of time has experienced severe pain because the blood comes out of her body at once. The period of being free from the menstruation i.e zamanatahar and the minimum period of menstrual cycle is atleast 20 days and maximum is not more than 2 months and the menstruation that comes after 2 months is termed as amenorrhea¹³.

But the women who menstruate long before the age of 14 years are always thin and weak and their age is not so long because their temperament is very hot and due to hot abnormal temperament, the vessels of the menstruation get dilated that leads to early discharge of menstrual blood and the woman who starts menstruating much later than the age of 14 years is always dull and restless because her temperament is very cold and dry and the vessels are very narrow and thin and the blood of menstruation is thickened that cannot come out from those vessels that deviate from the menstrual flow and spread out in the body¹⁴.

Menstruation begins after the age of 14 years because before this age the blood is not perfect and mature enough and spent in the growth and development of the body and no waste remains that can be eliminated as menstruation¹⁴.

Menstruation stops after the age of 40 years, because after this age the temperament of a woman changes to coldness and the liver produces less blood and that is produced also tends towards coldness¹⁴.

Types according to Unani System of Medicine:

 In Unani classical literature it can be divided into¹⁵

1. Primary Amenorrhea
2. Secondary/Pathological Amenorrhea
3. Physiological Amenorrhea

Primary Amenorrhea-

The first case is that the flow of blood towards the internal organs of a woman is not that much that the wastes/fuzlat tamthiya (menstrual waste) can be separated from the blood and eliminated in the menstruation. As in a woman whose uterus or ovaries or both the organs are much smaller than their normal size at birth as compared to the rest of the body because quwwate namiya could not increase these organs to their normal size. So that they could not achieve their physical perfection (tabayi kamal) even in youth, that we could termed it as primary amenorrhea¹⁵.

Sometimes those organs are completely absent since birth, such women never menstruate from the beginning to the end of her life and the body wastes of such woman that cannot be eliminated through menstruation are naturally discharged or dissolved in some other ways.

Pathological Amenorrhea

According to different causes it, could be of 7 types: it may occur due to deficiency of blood, exercise, or excessive elimination of blood through epistaxis or by venesection, concentrated blood(ghaliz) or dominancy of any humor like ghaliz sauda or ghaliz balgham or may occur due to any obstruction(sudda) to the vessels or due to simple or complex abnormal temperament that results in amenorrhea^15,16,17.

Physiological Amenorrhea

1. In old age, blood storage and its production in the body decreases, besides the reproductive organs also die/wither like the rest of the body and remain nominal, so there is not enough blood flow to these genital organs to remove menstrual waste from it that we could termed as menopause/ sin yās in conventional medicine¹⁵.
2. Cessation of menstruation in pregnancy is caused by the fact that the placenta is attached to the opening of the veins that open into the uterus and provides nutrition to the fetus hence menstruation stops¹⁸.
3. In women, the menstrual blood is divided into three parts; the first type is the original and the most subtle one which provides nutrition to the fetus. The second type goes to the pistaan (mammary glands) which is connected to the raham (uterus) through vessels and converted into milk, thus cessation of menstruation occurs, and the third leftover part of blood is the waste and sediment (tilchat) that remains stagnant and expels out during childbirth and helps the fetus slide out^19,20.

In Conventional Medicine the causes of Primary Amenorrhoea can be classified into the following groups^21-25.

1. Outflow tract abnormalities 
2. Ovarian causes 
3. Hypothalamic causes 
4. Pituitary causes 
5. Other causes

Outflow tract abnormality:

Outflow tract abnormalities include an imperforate hymen, a transverse vaginal septum and Mayer–Rokitansky–Kuu¨ster– Hauser (MRKH) syndrome. The commonest cause is an imperforate hymen. In these cases, there is periodic shedding of the endometrium; however, the menstrual blood fails to come out due to blockage in the outflow tract. This can cause haematocolpos and may present as cyclical pain with primary amenorrhoea. A bulge at the vaginal introitus (bluish membrane) is commonly seen²¹.

Ovarian causes (hyper-gonadotrophic hypogonadism)

Primary ovarian insufficiency (POI), previously known as premature menopause or premature ovarian failure is the cessation of ovarian function below 40 years of age. If it occurs before menarche, then it presents as primary amenorrhoea.

POI can occur due to chromosomal abnormalities such as Turner’s syndrome [45XO] or gonadal agenesis. It can also arise iatrogenically, as a consequence of chemotherapy and radiotherapy used for childhood malignancy^21,22.

Turner’s syndrome [45XO] is characterized by typical phenotypic features such as short stature, shield chest, wide nipples, and a low hair line. Primary amenorrhoea in these girls is due to underdeveloped (streak) ovaries resulting in an impairment of the H–P–O axis. In those with Turner’s syndrome with a mosaic karyotype, there is a higher likelihood of initiating puberty. However, most women fail to menstruate or have early secondary amenorrhoea^21,22.

Hypothalamic-pituitary causes (hypogonadotropic hypogonadism)

Suppression of the H–P–O axis can be triggered by energy depleting causes such as stress, anorexia, weight loss, excessive exercise, chronic illnesses or infections like tuberculosis. The levels of serum FSH, LH and estradiol levels are low in this group. 

Congenital Kallmann’s syndrome is a familial disorder that affects the hypothalamus. It is typified by a lack of GnRH production. This results in the absence of pubertal changes. It is also associated with anosmia or hyposmia^21,22.

Pituitary causes of hypogonadotropic hypogonadism include hypopituitarism, hyper-prolactinaemia (due to either pituitary adenomas or being drug-induced) and empty sella syndrome. Empty sella syndrome causes hyper-prolactinaemia. 

Constitutional delay of puberty is a diagnosis of exclusion. This occurs due to a temporary delay in the maturation of the H–P–O axis. There is usually a family history of late menarche. Bone age is delayed and eventually puberty is achieved spontaneously^21,22.

Causes of Secondary Amenorrhoea: Most of the causes of primary amenorrhoea attributable to hypo-gonadotrophic hypogonadism can also cause secondary amenorrhoea. Generally, they can be split into uterine, ovarian, drug-induced, or physiological^21,25-27.

With Signs of androgen excess

1. PCOS 
2. Late-onset of congenital adrenal hyperplasia                  
3. Androgen-secreting ovarian cancer                 
4. Cushing’s syndrome 

Without signs of androgen excess:

• Physiological causes:
• Pregnancy
• Menopause   
• Lactation

Pathological Causes:

• Premature ovarian insufficiency: Spontaneous (autoimmune) or following radiotherapy or chemotherapy.
• Uterine causes: Asherman’s syndrome  
• Hypothalamic causes: Stress, anorexia, excessive weight loss, chronic illnesses, renal disorders, cardiac disorders, infections  
• Pituitary causes: Pituitary tumours, head injury, cranial irradiation, hypopituitarism, Sheehan’s syndrome Contraception: Post pill amenorrhoea, depot injection, drugs (for example, selective serotonin reuptake inhibitors, olanzapine, phenothiazines, metoclopramide).

Uterine causes

Asherman’s syndrome can result as a consequence of intrauterine adhesions. These may occur as a sequela to uterine fibrosis after excessive postpartum curettage or postpartum endometritis. Adhesions can cause obliteration of the endometrial cavity, cervical OS or cervical canal leading to secondary amenorrhoea²³.

Hysterosalpingogarm and hysteroscopy are useful investigations to evaluate uterine synechiae.

Ovarian causes

PCOS is the most common cause of secondary amenorrhoea. As per the Rotterdam criteria, two out of three of the following features should be present to diagnose PCOS: 

1. Oligomenorrhoea or amenorrhoea
2. Clinical or biological evidence of hyperandrogenism 
3. Polycystic appearance of the ovaries on ultrasound.
4. Oligomenorrhoea or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later endometrial cancer^25-27.

Premature ovarian insufficiency (POI)

It is defined as experiencing menopause before the age of 40 years. Secondary amenorrhoea with features of hyperandrogenism can be caused by the late onset of congenital adrenal hyperplasia, androgen-secreting ovarian tumours and Cushing’s syndrome²⁴.

Drug-induced

Menstrual irregularities are common after the use of contraception techniques. The intrauterine system, progestogen-only injectable drugs and oral contraceptive pills can induce amenorrhoea. A spontaneous resumption of menstruation usually occurs after stopping contraception; however, it can take up to a year for fertility to return, especially in the case of progesterone injections. Medications such as selective serotonine reuptake inhibitors, olanzapine, phenothiazines and metoclopramide can cause hyper-prolactinaemia. This can lead to amenorrhoea^25-27.

Physiological

Pregnancy and lactation are the most common causes of secondary amenorrhoea. These two conditions result in a hyper-prolactinaemic state. Menopause is also a physiological cause of amenorrhea^26,27.

Causes of Amenorrhea in Unani

Cessation of menstrual blood occurs either due to weakness of power of transformation (Quat-i-mumayyaza) or the cause lies in the raham itself or present in the whole body or may occur due to the following reasons¹⁹.

1. It may occur due to lack of nutrition in the body or may occur due to different routes of evacuation, for example epistaxis, piles, rupture of any vein may cause haemorrhage that leads to lack of blood in the body^13,14,16,19.
2. Sometimes lack of blood may occur due to any chronic illness that dries up the body’s content/matter or the whole blood is so absorbed in the other substances of the body that no waste remains as it is found in such fatty and healthy women whose temperament is resembling to those of men¹⁹.
3. Sometimes the viscosity of blood changes as it becomes so thin that it continues to dissolve, and no waste remains or sometimes due to coldness or due to dryness it becomes thick¹⁶.
4. Sometimes the strength (Quwwat) becomes weak due to abnormal temperament and other causes (asbab-i-muzaefa)^16,19.
5. Sometimes the cause is present in the organ itself because generally the causes of amenorrhea are present in the vessels in the form of obstruction (sudda). The cause of obstruction is either due to unhealed ulcers or sometimes a membranous or muscular flesh or fat is attached to the uterus^13,14,16,19.
6. Sometimes it is due to exhaustion, or sometimes it is caused by injury to the uterus or sometimes it happens due to any ulcer or due to any abortion.
7. If the causelies in the whole body, then it could be chronic fever or due to any disease of cold temperament like ascites^13,14,16,19.
8. Sometimes amenorrhea occurs due to the involvement of other organs like when the liver is weak it will not produce blood in enough amount or it is unable to differentiate the menstrual blood, or sometimes obstruction occurs in the liver itself^13,14,16,19.
9. If the organ involved is stomach, then it will cause abnormal temperament of digestion so that it will disturb the formation of kailoos that leads to amenorrhea^13,14,16,19.

Etiopathogenesis of Amenorrhea in Unani

Ihtibās al-Tamth usually occurs due to zoaf (weakness)in quwwat dafya (elimination pawer) of raham due to su’-i-mizaj barid-yabis sada/maddi. As a result, quwwat masika overpowers the quwwat dafiyah²⁸. Ibn Rushd described sudda (which is formed by ghilzat and lazujat of balgham) as one of the causes of zoafquwwatdafiah²⁰.

1. Su’-i-mizāj umūmi: Majūsi mentioned that if temperament of woman becomes bārid as in farbahi, it causes zoaf-i-jigar as a result liver is unable to convert chyme into blood; in its place it converts it into tenacious balgham¹³. All those organs which receive this balghami khūn; become cold and moist in mizāj like that of balgham. Even the mizāj of uterus changes to cold and moist which is not suitable for its normal functions¹³.
2. Defect in madda khūn haiz: It may be qualitative, quantitative or both; qualitative disturbance leads to ghilzat-i-khūn as a result blood is unable to diffuse into the minute capillaries. It has been mentioned that intake of ghaliz aghziya leads to a greater quantity of balgham and sauda, which increases viscosity of blood which does not pass out easily from minute blood vessels. Quantitative disturbance is either due to Qillatdam because of Qillat-i-ghiza, haemorrhage, chronic debilitating diseases strengthening of QuwwatHazima¹⁹. In all these conditions no fuzla left behind to be excreted in the form of menstruation²⁸.
3. Defect in Ala-i-mukhrijahaiḍ: It is mainly due to formation of sudda which is caused by:
4. Harārat Mujaffifa (extreme heat), Barudat Mujaffifa (due to excessive intake of cold water) or Yubūsat produce kasāfat and inqibaḍ in the sphincters of the uterine capillaries and cause obstruction in the flow of KhunHaiḍ^13,16,28,29.
5. Accumulation of Madda Saudāwi or Balgham lazīj in the body due to consumption of Ghalīz Aghziya. These Saudāwi mādda or Balgham lazīj flow with circulation and blocks the vessels which carry the menstrual blood¹³.
6. Obstruction caused by Ratqi.e Zaida ghosht (cryptomenorrhea) covers the uterine OS or vaginal opening, which does not allow the blood to expel out resulting in Ihtibās al Tams^14,28.
7. Warm Raham blocks the uterine vessels²⁸.
8. Mailan al Rahim (dislocation of uterus)²⁸.
9. Farbahi (obesity): Due to obesity narrowing of the lumen of blood vessels develops and reduces blood circulation which results in Ihtibas Tams^13,16.
10. Laghri ba Ifrat due to Su’-i-mizaj (Barid or Barid Yabis, Har or Har Yabis) causes Ihtibās al-Tamth¹⁹.

Su’-i-Mizaj Barid Sada increases the viscosity of blood whereas Har Sada dries up the Rutubat of blood and makes it Kasif. Due to increased viscosity or Kasafat blood fails to diffuse into minute capillaries of uterus^13,14,16.

Ibn Sina and Ibn Hubl Baghdadi mentioned Qillat Haiz (oligomenorrhea) under the title of Ihtibās al-Tamth as the causes and the pathophysiology of both are same^16,19.

SYMPTOMS:

According to Ismail Jurjani:¹⁵

1. If the cause is waram, cryptomenorrhea, trauma, lack of appetite, obesity, or weakness (laghiri), its symptoms will appear in their respective places^13,14.

2. And if the cause is weakness of liver, then there will be signs of liver diseases^13,14,16,19.

1. It could be due to viscous substances like thick phlegm or black bile^13,14,16,28.
2. Amenorrhea causes various problems such as discoloration of the face and diseases of the head like headaches, grabbing language and tongue can reach to such an extent that the woman cannot speak with her mouth due to the weakness of the muscles of the tongue¹⁴.
3. Cessation of menstruation leads to paralysis, and some suffer from gastrointestinal diseases and the digestive power becomes weak and the appetite decreases, desire to eat bad things increases, feels like nausea and stomach burning and feels thirstier^13,14.
4. Some women experience cough and shortness of breath, some have difficulty in urination and some women experience weakness in the muscles, pain in the back and neck^13,14.
5. Some women get muharrika fever and chills and some develop liver diseases that ends up with ascites but in some women, ascites is caused by dripping of yellowish fluid that separates from the blood and accumulates in the abdomen and sometimes it spreads with the blood to all the organs resulting in warm all over the body^13,14,18,19.

According to temperament:¹⁶

1. Amenorrhea that occurs due to simple cold abnormal temperament, it includes, sleep is deeper, and flatulence is more in the dream state and the body colour becomes white, the pulse becomes irregular(mitfawit) and the sweat is cold, urine is profuse and mucus predominates in faeces^13,14,16,19.
2. Amenorrhea that occurs due to simple hot abnormal temperament, it will be indicated by inflammation and the uterus will remain dry and the other symptoms will be those only that indicate abnormal hot temperament^13,14,16,19.
3. Amenorrhea that occurs due to simple abnormal dry temperament that includes (laghiri) and emptying of veins¹⁶.

Management

In conventional medicine, only treatment of secondary amenorrhea is through hormone supplements based on estrogen and progesterone compounds is the mainstay of the treatment for these conditions which though effective have got their own consequences like weight gain, migraine, mood swings, abdominal distention etc^30,31,32. Moreover, they are contraindicated in patients with thromboembolism, stroke, hypertension, myocardial infarction and liver disease³³.Hence, there is a need for alternate therapy which is safe, effective, easily available and has long-lasting effects.

The treatment methodology of the Unani system of medicine is called Ilaj bil Zid. It means, the medicine which has the opposite Mizaj (Temperament) of the affected Akhlat is chosen. In secondary amenorrhea the patient is treated with lifestyle modifications through tadbir (regimental therapy), ghiza (diet), dawa (medicines), use of strong emmenogogue drugs to induce menstruation, use of Munzij (coctive) wa mushil-i-balgham advia (purgative) drugs for tanqia-i-badan (detoxification of the body¹⁸.

It seems that diseases of female reproductive system are one of the greatest challenges for modern medicine. Menstrual irregularities as one of the most frequent gynecologic complaints can affect the several aspects of women’s health including their physical, mental, and social health^34,35. Amenorrhea and its different etiologies can lead to various complications such as infertility, pregnancy complications, cardiovascular disease, metabolic diseases like diabetes, hypertension, and fatty liver, and psychological disorders such as anxiety and depression and reduce quality of life in women³⁶. Nowadays, due to some complications of hormonal therapy, many women have considered using alternative and complementary medicine³⁷.USM is known as one of the main branches of alternative and complementary medicine, which tries to treat illnesses with change in lifestyle and using medicinal plants.

Ilaj-bil-Dawa

Emmenagogue drugs used to treat amenorrhea and oligomenorrhea were systemically searched^38,39.

Some mufrad drugs like badiyan is a Carminative, Concoctive of phlegm and black bile, Analgesic, Emmenogogue, Anti flatus, Spermatogenic, Galactopoietics etc. It is used in the treatment of Amenorrhoea, galactopoietics, Halitosis, Cataract, Diuretic, Flatus colic, Stomatitis and Jaundice diseases⁴⁰.

The effect of Majoon Dabidul ward may be attributed to its anti- inflammatory, emmenagogue, antispasmodic, astringent, antiseptic, anti-microbial as well as anti-oxidants properties of all ingredients which are well documented in pharmacological and Classical Unani literature⁴¹.

Borax can use internally and externally in different doses according to diseases. Internally in doses varies from 10-30 grains, in acidity, amenorrhea, dysmenorrhea, menorrhagia, puerperal convulsions (PIH) and increase uterine contraction during labour pains⁴².

Famous Murrakkab:

1. Habb-e-Tinkar
2. Habb-e-Kabid Naushadri
3. Sufoof-e-Chutki
4. Habb-e-Tihal⁴³

Ilaj-bil-ghiza

Jalinoos also recommended four important facts about diet: 

1. Time of the food 
2. Type of the food 
3. Quantity of the food d) mizaj of the food.

Diet is one of the six essential factors which can modify the mizaj of an individual, e.g in PCOS patients it is deviated from balanced state to cold and moist state, high fat mass indicates the cold temperament as in case of PCOS patient ⁴⁴.

The reproductive features of PCOS were noted by Buqrat in the 5th century B.C (Hanson, 1975) has been associated with Sue Mizaj Barid Ratab (Excess of coldness and moisture) which is caused by qualitative and quantitative disturbances in the equilibrium of akhlat causing excessive production of Balgham (phlegm) resulting in chronic anovulation⁴⁴.

According to Unani physician Razi, mizaj of the obese person becomes Barid (cold) and in such condition, the Haar-Yabis (hot and dry) diet, drug and exercise are most suitable to reverse the conditions, however, cold and moist diet should be avoided¹⁸.

Ilaj-bil-Tadbeer

Jurjani and Ibn Sina, mentioned that application of wet cupping over the calf muscles induces the menstruation in amenorrhea as it diverts the flow of blood towards the uterus and facilitates Tanqia badan by eliminating the toxic substances in the form of menstruation. Unani concepts in the management of amenorrhea are proved scientifically in various studies^14,16.

For congestive pelvic conditions like PCOD, infertility, uterine fibroids etc. salt sitz baths and sulphur sitz baths are recommended^13,14,29.

Phlebotomy (Faşd) and     wet cupping (Hijama bish Shart) are    two     important      non-pharmacological      curativewaysthat are recommendedin amenorrhea⁴⁵. 

Phlebotomy is an important treatment    that    restores equilibrium through     bleeding    from    veins.     In    this    technique    Mawad-e-Fasida is excreted    by breaching in the blood vessels⁴⁶.Faşd of the saphenous vein is effective in restoring menstruation⁴⁷.

Wet cupping is the process of using a vacuum on surface of the body, along with the use of incisions, to remove capillary blood⁴⁸. Dry cupping is a process to divert the morbid material from one part to another by the use of vacuum inside the cup ⁴⁹.

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