CellMed 2023; 13(14): 4.1-4.23
Published online November 30, 2023
https://doi.org/10.5667/CellMed.2023.017
© Cellmed Orthocellular Medicine and Pharmaceutical Association
Correspondence to : *Arshiya Sultana
E-mail: drarshiya@yahoo.com
† These authors contributed equally to this manuscript
This is an open access article under the CC BY-NC license. (http://creativecommons.org/licenses/by-nc/3.0/)
Menopause is a physiological phase experienced by all women as part of normal aging known as menopause. Per se, menopause is not a disease, but hormonal imbalance may lead to menopausal symptoms in some women. The unani physician described that in Sinn-i-Inḥiṭāṭ/ Sinn al-Yās, Burūdat (coldness) increases lead to Ihtibās al-Tamth (amenorrhea) that can occur naturally. Besides, Khilt Dam (blood) production decreases from the liver, slight production occurs, tends towards Burūdat. Therefore, at this age, Ihtibās al-Tamth is associated with Alāmāt Sinn al-Yās (menopausal symptoms) including weight gain, loss of appetite, hirsutism, fatigue, headache, backache, arthralgia, neck pain, general myalgia, nervousness, anxiety, depression, and insomnia. The traditional Unani manuscripts are enriched with knowledge for the management of Alāmāt Sinn al-Yās. Consequently, an extensive exploration of classical texts concerning the management of Alāmāt Sinn al-Yās was undertaken. Moreover, PubMed, Scopus, Google Scholar, and other indexing databases were thoroughly explored for evidence-based approaches to managing menopausal symptoms. The principle management as per Unani texts is to treat the cause of Alāmāt Sinn al-Yās. Unani medicines with emmenagogue, anti-inflammatory, analgesic, cardioprotective, and neuroprotective properties are beneficial for the amelioration of Alāmāt Sinn al-Yās. Unani Herbs such as Asgandh, Aslusūs, Khārkhasak, Tagar, Shuneez, Ustukhuddus, Zafran, and M̒ a̒̒ jūn Najāh possess properties and are proven scientifically for their efficacy in Alāmāt Sinn al-Yās. Hence, the substantiation and preservation of traditional knowledge assume paramount importance in facilitating prospective research and proving invaluable in the modern era. Moreover, the conduct of randomized controlled trials, systematic reviews, and meta-analyses becomes imperative.
Keywords Alāmāt Sinn al-Yās; Anti-inflammatory; Anti-spasmodic; Menopausal symptoms; Mizaj; Ihtibās al-Tamth; Sinn-i-Inḥiṭāṭ
In recent years, menopause has turned out to be an important issue.1 Menopause is a natural physiological phase encountered by women universally, constituting an intrinsic component of the ageing process, commonly referred to as menopause. Women’s life expectancy has increased and they spend more than one-third of their life after menopause2 due to an improvement in nutrition and living conditions.1 Per se, menopause is not a disease but hormonal imbalance may lead to menopausal symptoms in some women.3,4 It is defined as the permanent cessation of menstruation for one or more than a year because of the loss of ovarian follicular activity. 4,5 The average age of menopause is between 42 and 55 years with an average age of onset of 51 years. 6,7 According to reports, nearly 80% of women in Western countries and over 60% of Chinese women are reported to experience menopausal issues. Consequently, increased focus and attention should be directed towards addressing peri- and post-menopausal symptoms, as they can significantly impact an individual’s well-being and performance both within their homes and in professional settings.2
Unani physicians mentioned the average for menopause is between 40 to 60 years.8
At the onset of menopause, women encounter a range of physical, emotional, and urogenital symptoms that exert a substantial influence on their daily routines, personal relationships, career pursuits, and social engagements.1 Clinical manifestations of the menopausal syndrome include uterine bleeding, somatic symptoms, vasomotor episodes, urogenital problems, sleep disturbance and mood disorders, skin formication, and sexual dysfunction.14,15 Many other symptoms and conditions including palpitations, forgetfulness, restless legs, muscle and joint pains, depressive mood, osteoporosis, and dyslipidemia are also associated with it.16 Menopausal women are also at relatively high risk for memory loss, hypertension and diabetes.17 Hence, the menopausal syndrome has an impact on women’s quality of life. 15, 18
The cause of menopausal symptoms is an oestrogen deficiency.2 The standard and effective treatment is long-term hormone replacement therapy (HRT).15,17 Nevertheless, it is associated with an increased risk of carcinoma breast, ovarian cancer, endometrial hyperplasia stroke,9,10 gall stones and venous thromboembolism.17 Heart and estrogen/progestin replacement study (HERS), also established an increased risk of cardiovascular disease (CVD) and breast malignancy amongst women randomized to hormone therapy.2 Additionally, significant proportions of menopausal women are unwilling to use hormone therapy or have contraindications. As a result, there is a growing interest among patients and physicians alike in exploring novel options for managing menopausal symptoms.2 This includes an inclination towards complementary therapies that incorporate the use of natural products, which offer favourable efficacy and minimal side effects.15
According to a survey, it was found that 22% of women sought alternative therapies for addressing menopausal symptoms and stress management. These alternative approaches encompassed non-prescription remedies, chiropractic and naturopathic care, massage therapy, dietary soy, herbal remedies, and acupuncture.19 Certain naturally occurring plant-based compounds have shown to have some beneficial effects in relieving menopausal symptoms similar to HRT but without appreciable adverse effects.17 Studies have observed the potential benefits of flavonoids/isoflavones, structurally similar to oestrogen as they exert oestrogenic activity in human tissue. Flavonoids/Isoflavones are assumed to protect against chronic diseases such as breast cancer, osteoporosis, and cardiovascular disease.20
The principle management as per Unani texts is to treat the cause of
The scrupulous traditional Unani texts were explored to understand the concept of menopause and its management. The Unani texts referred were Ṭabarī, Abū al- Ḥasan Raban,
Perimenopause, menopausal transition, and menopause: The correct terminology for older terms perimenopause or climacteric is menopausal transition. WHO includes only the portion of perimenopause before the final menstrual period in the menopausal transition. The WHO urges that the term “climacteric” not be used to avoid confusion. Perimenopause means “‘
Historical background: Most of the early medical writings focused on the onset and mean age of menopause perhaps due to the related sexual and sub-fertile inconvenience. During the period of Ancient history spanning from 3600 BCE to 500 CE, the onset of menopause in women may have been perceived as the beginning of female aging within ancient Egyptian society. This perception was predominantly rooted in the societal belief that the primary role of women during that time was childbearing, along with engaging in various menial tasks. This understanding was further solidified during the Middle Ages. Notably, during the reign of Rameses II, it was widely recognized that postmenopausal women were no longer fertile. There is an indication in the medical papyrus called Ebers, which contains a passage referring to a woman who experienced amenorrhea for an extended period. Alongside the absence of menstruation, she also suffered from a burning sensation in her stomach, which could only be alleviated through vomiting. This particular case may have garnered medical attention initially due to the elderly woman being suspected of being pregnant and subsequently developing hyperemesis gravidarum. However, upon realizing the inexplicable absence of pregnancy, the diagnosis documented in the Ebers papyrus concluded that the woman had been bewitched. This account possibly represents one of the earliest literary references connecting witchcraft and menopause, a connection that was responded to in a rather unsympathetic manner, as evidenced by the remark that Hattusili III's sister, at the age of sixty, was considered beyond any hope.23
Menopause was well-known as early as the 4th century B.C. by the ancient Greeks. Aristotle (384–322 BC) specified that menopausés mean age was approximately 50 years. In his work, ‘
In Post classical era (500CE-1500CE), Pliny the Elder (23-79AD) of Rome and Soranus (1st/2nd century AD), the Greek gynaecologist from Ephesus confirms the age of menopause in women. The latter commented that “…
Ibn Sīnā (980-1030 AD) stated that menopause occurs sometimes early at the age of 35 and often between 40-50 years. He said that amenorrhea may lead to complications such as indigestion, fatigue, hysteria, loss of appetite, insomnia, frequency of micturition etc.8 Al-Jurjānī and Al-Baghdādī (1117-1213AD)mentioned permanent
In the 6th A.D., the Greek Byzantine Physician, Paulus Aegineta stated “
In the Contemporary period (1914-present), menopausal symptoms have also been known for a long time, but it was not until the 1930s that climacteric symptoms might be effectively treated with oestrogen isolated from the urine of pregnant women. However, treatment was not very widespread until after the publication of Robert A Wilson’s best-selling book ‘Feminine
The possible danger of hormone replacement therapy was highlighted by Smith et al. (1975) who reported an association between the use of cyclic estrogen therapy and endometrial cancer. 24
Age of
Ibn Sīnā states that menstruation cessation in women occurs at age
The first stage is
In the case of women, their
Aetiopathogenesis,
According to Baghdādī, there is the accumulation of
In conventional medicine, the symptoms of menopausal transition are changes in menstrual patterns, vasomotor symptoms (hot flushes and sweating), sleep disturbances, psychological and mental disturbances, depression, irritability, mood swings, loss of concentration, poor memory, headache, dizziness, palpitations, joint aches and back pain, urinary incontinence, dry, itchy skin, and weight gain.
According to Unani scholars,
The other details of each symptom with its management are as follows.
For
Unani medicine believes in a holistic approach by following the principles which emphasize the elimination of cause through a nutritious diet, and drugs (internal & external), So the drugs with
Waja ‘al-Mafāṣil (Musculoskeletal discomfort, joint pain, etc): According to Ibn Sīnā, the causes of
Menopause as per requires no medical treatment. However, management mostly focus on reducing signs and symptoms and preventing or managing chronic disorders that may be seen with ageing. Treatments include lifestyle modification and dietary/ home remedies, conventional and alternative treatments. The lifestyle modification includes water-based vaginal lubricant or a silicone-based lubricant or moisturizer to decrease vaginal discomfort, adequate sleep, avoid caffeine/tea, avoid excessive alcohol and smoking, stress, hot weather, hot beverages, spicy foods, and even a warm room to avoid hot flashes. Massage, deep breathing, paced breathing, guided imagery, and progressive muscle relaxation may help women with menopausal symptoms. Diet includes fruits, whole grain, and vegetables, limit oils, saturated fats, and sugars. Calcium or vitamin D supplements are essential to meet daily requirements. Regular physical activity or exercise protects against osteoporosis, heart disease, diabetes, and other conditions related to ageing. 34
Recent verdicts showed that hormone therapy is linked to an increased risk of endometrial and breast cancers, have their side effects. So, both researchers and the public are frequently fascinated to herbal/plant based therapies as a safe alternative. 4, 35 Many methods have been endorsed as reliefs in managing the symptoms of menopause, but few of them have scientific evidence to back up the claims.
Some complementary and alternative treatments that have been or are being studied include acupuncture, exercises and yoga, hypnosis. 34
The plant-based therapies embrace the oral use of phytoestrogens (dietary soy isoflavones and soy extracts), herbal remedies (sage, red clover, lavender, winter cherry, valerian, etc.) Unani, Chinese and other medicinal herbs. 36,37 Oscar et al (2016) conducted a systematic review and meta-analysis of intervention studies on plant-based therapies with menopausal symptoms. 36
Certain foods and plant components contains phytoestrogens as a naturally occurring oestrogen, similar to oestrogen in function and structure. Phytoestrogens are classified into three types: isoflavones, lignans, and coumestan. Isoflavones have some estrogen-like properties. By attaching to oestrogen receptors, phytoestrogens influence biological responses in plants and mimic the effects of endogenous oestrogens.6, 34 They have oestrogenic as well as antiestrogenic characteristics. Phytoestrogens have steroid strengths ranging from 1/50 to 1/2000 of steroids, yet they have no endometrial-related side effects. Numerous studies have found that frequent consumption of phytoestrogens in Asian women's diets results in a reduction in menopausal symptoms, endometrial cancer, breast cancer, and an increase in bone mass when compared to other regions. By attaching to oestrogen receptors, phytoestrogens stimulate biological reactions in plants and imitate the effects of endogenous oestrogens.6 A meta-analysis of 174 RCTs involving 9626 people found that phytoestrogens had a low risk of negative effects. Long-term (>5 years) use of soy phytoestrogens was connected to an increased risk of endometrial hyperplasia. A new meta-analysis, however, found a slight inverse link between endometrial cancer risk and higher consumption of legumes and isoflavone-derived dietary soy products. 4
Botanical supplements can function through a variety of mechanisms, including oestrogenic, progestogenic, and/or serotonergic pathways. Botanicals with oestrogenic activity are thought to mimic the activities of oestrogens. Endogenic oestrogen (estradiol, E2) plays a dynamic role in uterine and mammary development, pregnancy maintenance, bone density maintenance, cardiovascular disease prevention, and menopausal symptom relief. Oestrogens primarily exert their biological effects by binding to oestrogen receptors (ERs) (ER and ER, followed by dimerization of ERs) and collaborating with oestrogen-responsive elements (EREs) at the promoters of oestrogen-responsive genes, thereby triggering transcription and generating oestrogenic responses, both of which are required for normal physiological functions. ERs can also attach to other transcription factors like as Fos and Jun, which are directly bound to DNA via responsive elements such as activator protein-1 (AP1) binding sites to regulate transcription of associated genes. Oestrogen stimulates rapid signalling pathways as well, such as mitogen-activated protein kinases (MAPK). 37
Clinical trials have proven that
A single-blind RCT in 37 hyperlipidemic postmenopausal women reported that the
In a triple-blind, RCT, the administration of valerian at a dose of 530 mg twice daily for 2 months resulted in a significant reduction in the severity and frequency of hot flashes in 60 postmenopausal Iranian women with no observed side effects, compared to placebo.50 Another study, a randomized double-blind placebo control trial in 68 menopausal women with the chief complaint of hot flashes, advised 255 mg valerian capsules three times a day for 8 weeks in the valerian group (n=35), while the placebo group (n=33) was advised to take a placebo. The severity of hot flashes showed a statistically significant difference between pre-and post-treatment in the valerian group (p<0.001), while this difference was not significant in the placebo group.46 Valerian is also recommended for menopausal symptoms, insomnia, and mental difficulties due to its phytoestrogen components, and the available evidence strongly supports its effects on hot flashes and other menopausal symptoms.
Valerian is a herb that contains volatile oils, including monoterpenes, sesquiterpenes, and valepotriates. It is classified as a phytoestrogenic herb, meaning it contains compounds that have estrogenic and antiestrogenic properties similar to natural estrogens found in the body. One of the mechanisms through which valerian exerts its effects is by increasing the levels of gamma-aminobutyric acid (GABA) in the synaptic cleft, which can lead to improved sleeping patterns. The calming effects of valerian are likely attributed to its ability to increase GABA levels, which suppress reuptake, enhance neurotransmitter release, and influence glutamine levels in the plant extract. 51
A single-blind, RCT was conducted involving 60 perimenopausal women, with 30 participants assigned to each group. The intervention group received 3 grams of Tribulus powder, while the placebo group received a placebo, both administered twice daily for 8 weeks. Notably, a significant decrease in MRS (Menopause Rating Scale) total and composite subscale scores (P < 0.001) was observed, indicating a reduction in menopausal transition symptoms. Importantly, no significant side effects were reported during the study.The data analysis revealed that Tribulus was more effective than the placebo in alleviating menopausal symptoms, as evidenced by a higher mean reduction in MRS scores in the Tribulus group compared to the placebo group (19.80 vs. 11.97). Specifically, the Tribulus group showed a greater reduction in somatic symptoms (8.23 vs. 4.72), psychological symptoms (6.63 vs. 4.47), and urogenital symptoms (4.93 vs. 2.73) after the intervention. Based on these findings, it can be concluded that Tribulus may offer a safe alternative to hormone replacement therapy for managing menopausal symptoms .54
A study observed oestrogenic activity for some fractions of an ethyl acetate extract of
A double-blind placebo RCT was conducted involving two groups: the experimental group receiving 3 capsules daily containing 330 mg of liquorice extract, and the placebo group receiving 3 capsules daily containing 330 mg of starch. The trial spanned 8 weeks of intervention followed by a 4-week follow-up period. A total of ninety menopausal women experiencing hot flashes were selected and randomly assigned, with 45 patients in each group. The results showed a significant decrease in hot flashes in the experimental group compared to the placebo group. This reduction in hot flashes persisted for 2 weeks following the administration of the capsules.57
A four-arm RCT was conducted involving 120 menopausal women, with 30 participants in each group. Group 1 received 380 mg
A randomized clinical trial established that chaste berry was effective in the treatment of hot flashes. The mechanism of action was it stimulates the expression of genes related to progesterone receptors. 71 Die et al also reported the chaste berry effect in menopause. 70 Apigenin could also induce progestogenic activity. In summary, Vitex species have oestrogenic properties and apigenin and penduletin compounds are their ERβ- selective compounds, whereas rotundifuran and agnuside have been reported to activate ERα- dependent responses. 37
Menopause is a natural phase that all women experience as part of the normal ageing process. Traditional knowledge found in classical manuscripts provides valuable insights into the management of
We are thankful to the authors cited in the texts.
Nil
Nil
CellMed 2023; 13(14): 4.1-4.23
Published online November 30, 2023 https://doi.org/10.5667/CellMed.2023.017
Copyright © Cellmed Orthocellular Medicine and Pharmaceutical Association.
Arshiya Sultana1*†, Fahmida Kousar2 †, Shahzadi Sultana 3, Taseen Banu4†, Arfa Begum5
1Associate Professor, Department of Ilmul Qabalat wa Amraze Niswan (Gynaecology and Obstetrics), National Institute of Unani Medicine, Ministry of AYUSH, GOI, Bengaluru 560091, Karnataka, India 2 HoD &Associate Professor, A and U Tibbia College & Hospital, Karol Bagh, New Delhi. 3 India In-Charge Principal & HoD, Department of Ilmul Qabalat wa Amraze Niswan (Gynaecology and Obstetrics), Govt. Nizamia Tibbi College, Hyderabad, Telangana. 4 Assistant Medical Officer (Unani), GPHC, Minjur, Tiruvallur District, Tamil Nadu 5 PG Scholar, Department of Ilmul Qabalat wa Amraze Niswan (Gynaecology and Obstetrics), National Institute of Unani Medicine, Ministry of AYUSH, GOI, Bengaluru 560091, Karnataka, India
Correspondence to:*Arshiya Sultana
E-mail: drarshiya@yahoo.com
† These authors contributed equally to this manuscript
This is an open access article under the CC BY-NC license. (http://creativecommons.org/licenses/by-nc/3.0/)
Menopause is a physiological phase experienced by all women as part of normal aging known as menopause. Per se, menopause is not a disease, but hormonal imbalance may lead to menopausal symptoms in some women. The unani physician described that in Sinn-i-Inḥiṭāṭ/ Sinn al-Yās, Burūdat (coldness) increases lead to Ihtibās al-Tamth (amenorrhea) that can occur naturally. Besides, Khilt Dam (blood) production decreases from the liver, slight production occurs, tends towards Burūdat. Therefore, at this age, Ihtibās al-Tamth is associated with Alāmāt Sinn al-Yās (menopausal symptoms) including weight gain, loss of appetite, hirsutism, fatigue, headache, backache, arthralgia, neck pain, general myalgia, nervousness, anxiety, depression, and insomnia. The traditional Unani manuscripts are enriched with knowledge for the management of Alāmāt Sinn al-Yās. Consequently, an extensive exploration of classical texts concerning the management of Alāmāt Sinn al-Yās was undertaken. Moreover, PubMed, Scopus, Google Scholar, and other indexing databases were thoroughly explored for evidence-based approaches to managing menopausal symptoms. The principle management as per Unani texts is to treat the cause of Alāmāt Sinn al-Yās. Unani medicines with emmenagogue, anti-inflammatory, analgesic, cardioprotective, and neuroprotective properties are beneficial for the amelioration of Alāmāt Sinn al-Yās. Unani Herbs such as Asgandh, Aslusūs, Khārkhasak, Tagar, Shuneez, Ustukhuddus, Zafran, and M̒ a̒̒ jūn Najāh possess properties and are proven scientifically for their efficacy in Alāmāt Sinn al-Yās. Hence, the substantiation and preservation of traditional knowledge assume paramount importance in facilitating prospective research and proving invaluable in the modern era. Moreover, the conduct of randomized controlled trials, systematic reviews, and meta-analyses becomes imperative.
Keywords: Alāmāt Sinn al-Yās, Anti-inflammatory, Anti-spasmodic, Menopausal symptoms, Mizaj, Ihtibās al-Tamth, Sinn-i-Inḥiṭāṭ
In recent years, menopause has turned out to be an important issue.1 Menopause is a natural physiological phase encountered by women universally, constituting an intrinsic component of the ageing process, commonly referred to as menopause. Women’s life expectancy has increased and they spend more than one-third of their life after menopause2 due to an improvement in nutrition and living conditions.1 Per se, menopause is not a disease but hormonal imbalance may lead to menopausal symptoms in some women.3,4 It is defined as the permanent cessation of menstruation for one or more than a year because of the loss of ovarian follicular activity. 4,5 The average age of menopause is between 42 and 55 years with an average age of onset of 51 years. 6,7 According to reports, nearly 80% of women in Western countries and over 60% of Chinese women are reported to experience menopausal issues. Consequently, increased focus and attention should be directed towards addressing peri- and post-menopausal symptoms, as they can significantly impact an individual’s well-being and performance both within their homes and in professional settings.2
Unani physicians mentioned the average for menopause is between 40 to 60 years.8
At the onset of menopause, women encounter a range of physical, emotional, and urogenital symptoms that exert a substantial influence on their daily routines, personal relationships, career pursuits, and social engagements.1 Clinical manifestations of the menopausal syndrome include uterine bleeding, somatic symptoms, vasomotor episodes, urogenital problems, sleep disturbance and mood disorders, skin formication, and sexual dysfunction.14,15 Many other symptoms and conditions including palpitations, forgetfulness, restless legs, muscle and joint pains, depressive mood, osteoporosis, and dyslipidemia are also associated with it.16 Menopausal women are also at relatively high risk for memory loss, hypertension and diabetes.17 Hence, the menopausal syndrome has an impact on women’s quality of life. 15, 18
The cause of menopausal symptoms is an oestrogen deficiency.2 The standard and effective treatment is long-term hormone replacement therapy (HRT).15,17 Nevertheless, it is associated with an increased risk of carcinoma breast, ovarian cancer, endometrial hyperplasia stroke,9,10 gall stones and venous thromboembolism.17 Heart and estrogen/progestin replacement study (HERS), also established an increased risk of cardiovascular disease (CVD) and breast malignancy amongst women randomized to hormone therapy.2 Additionally, significant proportions of menopausal women are unwilling to use hormone therapy or have contraindications. As a result, there is a growing interest among patients and physicians alike in exploring novel options for managing menopausal symptoms.2 This includes an inclination towards complementary therapies that incorporate the use of natural products, which offer favourable efficacy and minimal side effects.15
According to a survey, it was found that 22% of women sought alternative therapies for addressing menopausal symptoms and stress management. These alternative approaches encompassed non-prescription remedies, chiropractic and naturopathic care, massage therapy, dietary soy, herbal remedies, and acupuncture.19 Certain naturally occurring plant-based compounds have shown to have some beneficial effects in relieving menopausal symptoms similar to HRT but without appreciable adverse effects.17 Studies have observed the potential benefits of flavonoids/isoflavones, structurally similar to oestrogen as they exert oestrogenic activity in human tissue. Flavonoids/Isoflavones are assumed to protect against chronic diseases such as breast cancer, osteoporosis, and cardiovascular disease.20
The principle management as per Unani texts is to treat the cause of
The scrupulous traditional Unani texts were explored to understand the concept of menopause and its management. The Unani texts referred were Ṭabarī, Abū al- Ḥasan Raban,
Perimenopause, menopausal transition, and menopause: The correct terminology for older terms perimenopause or climacteric is menopausal transition. WHO includes only the portion of perimenopause before the final menstrual period in the menopausal transition. The WHO urges that the term “climacteric” not be used to avoid confusion. Perimenopause means “‘
Historical background: Most of the early medical writings focused on the onset and mean age of menopause perhaps due to the related sexual and sub-fertile inconvenience. During the period of Ancient history spanning from 3600 BCE to 500 CE, the onset of menopause in women may have been perceived as the beginning of female aging within ancient Egyptian society. This perception was predominantly rooted in the societal belief that the primary role of women during that time was childbearing, along with engaging in various menial tasks. This understanding was further solidified during the Middle Ages. Notably, during the reign of Rameses II, it was widely recognized that postmenopausal women were no longer fertile. There is an indication in the medical papyrus called Ebers, which contains a passage referring to a woman who experienced amenorrhea for an extended period. Alongside the absence of menstruation, she also suffered from a burning sensation in her stomach, which could only be alleviated through vomiting. This particular case may have garnered medical attention initially due to the elderly woman being suspected of being pregnant and subsequently developing hyperemesis gravidarum. However, upon realizing the inexplicable absence of pregnancy, the diagnosis documented in the Ebers papyrus concluded that the woman had been bewitched. This account possibly represents one of the earliest literary references connecting witchcraft and menopause, a connection that was responded to in a rather unsympathetic manner, as evidenced by the remark that Hattusili III's sister, at the age of sixty, was considered beyond any hope.23
Menopause was well-known as early as the 4th century B.C. by the ancient Greeks. Aristotle (384–322 BC) specified that menopausés mean age was approximately 50 years. In his work, ‘
In Post classical era (500CE-1500CE), Pliny the Elder (23-79AD) of Rome and Soranus (1st/2nd century AD), the Greek gynaecologist from Ephesus confirms the age of menopause in women. The latter commented that “…
Ibn Sīnā (980-1030 AD) stated that menopause occurs sometimes early at the age of 35 and often between 40-50 years. He said that amenorrhea may lead to complications such as indigestion, fatigue, hysteria, loss of appetite, insomnia, frequency of micturition etc.8 Al-Jurjānī and Al-Baghdādī (1117-1213AD)mentioned permanent
In the 6th A.D., the Greek Byzantine Physician, Paulus Aegineta stated “
In the Contemporary period (1914-present), menopausal symptoms have also been known for a long time, but it was not until the 1930s that climacteric symptoms might be effectively treated with oestrogen isolated from the urine of pregnant women. However, treatment was not very widespread until after the publication of Robert A Wilson’s best-selling book ‘Feminine
The possible danger of hormone replacement therapy was highlighted by Smith et al. (1975) who reported an association between the use of cyclic estrogen therapy and endometrial cancer. 24
Age of
Ibn Sīnā states that menstruation cessation in women occurs at age
The first stage is
In the case of women, their
Aetiopathogenesis,
According to Baghdādī, there is the accumulation of
In conventional medicine, the symptoms of menopausal transition are changes in menstrual patterns, vasomotor symptoms (hot flushes and sweating), sleep disturbances, psychological and mental disturbances, depression, irritability, mood swings, loss of concentration, poor memory, headache, dizziness, palpitations, joint aches and back pain, urinary incontinence, dry, itchy skin, and weight gain.
According to Unani scholars,
The other details of each symptom with its management are as follows.
For
Unani medicine believes in a holistic approach by following the principles which emphasize the elimination of cause through a nutritious diet, and drugs (internal & external), So the drugs with
Waja ‘al-Mafāṣil (Musculoskeletal discomfort, joint pain, etc): According to Ibn Sīnā, the causes of
Menopause as per requires no medical treatment. However, management mostly focus on reducing signs and symptoms and preventing or managing chronic disorders that may be seen with ageing. Treatments include lifestyle modification and dietary/ home remedies, conventional and alternative treatments. The lifestyle modification includes water-based vaginal lubricant or a silicone-based lubricant or moisturizer to decrease vaginal discomfort, adequate sleep, avoid caffeine/tea, avoid excessive alcohol and smoking, stress, hot weather, hot beverages, spicy foods, and even a warm room to avoid hot flashes. Massage, deep breathing, paced breathing, guided imagery, and progressive muscle relaxation may help women with menopausal symptoms. Diet includes fruits, whole grain, and vegetables, limit oils, saturated fats, and sugars. Calcium or vitamin D supplements are essential to meet daily requirements. Regular physical activity or exercise protects against osteoporosis, heart disease, diabetes, and other conditions related to ageing. 34
Recent verdicts showed that hormone therapy is linked to an increased risk of endometrial and breast cancers, have their side effects. So, both researchers and the public are frequently fascinated to herbal/plant based therapies as a safe alternative. 4, 35 Many methods have been endorsed as reliefs in managing the symptoms of menopause, but few of them have scientific evidence to back up the claims.
Some complementary and alternative treatments that have been or are being studied include acupuncture, exercises and yoga, hypnosis. 34
The plant-based therapies embrace the oral use of phytoestrogens (dietary soy isoflavones and soy extracts), herbal remedies (sage, red clover, lavender, winter cherry, valerian, etc.) Unani, Chinese and other medicinal herbs. 36,37 Oscar et al (2016) conducted a systematic review and meta-analysis of intervention studies on plant-based therapies with menopausal symptoms. 36
Certain foods and plant components contains phytoestrogens as a naturally occurring oestrogen, similar to oestrogen in function and structure. Phytoestrogens are classified into three types: isoflavones, lignans, and coumestan. Isoflavones have some estrogen-like properties. By attaching to oestrogen receptors, phytoestrogens influence biological responses in plants and mimic the effects of endogenous oestrogens.6, 34 They have oestrogenic as well as antiestrogenic characteristics. Phytoestrogens have steroid strengths ranging from 1/50 to 1/2000 of steroids, yet they have no endometrial-related side effects. Numerous studies have found that frequent consumption of phytoestrogens in Asian women's diets results in a reduction in menopausal symptoms, endometrial cancer, breast cancer, and an increase in bone mass when compared to other regions. By attaching to oestrogen receptors, phytoestrogens stimulate biological reactions in plants and imitate the effects of endogenous oestrogens.6 A meta-analysis of 174 RCTs involving 9626 people found that phytoestrogens had a low risk of negative effects. Long-term (>5 years) use of soy phytoestrogens was connected to an increased risk of endometrial hyperplasia. A new meta-analysis, however, found a slight inverse link between endometrial cancer risk and higher consumption of legumes and isoflavone-derived dietary soy products. 4
Botanical supplements can function through a variety of mechanisms, including oestrogenic, progestogenic, and/or serotonergic pathways. Botanicals with oestrogenic activity are thought to mimic the activities of oestrogens. Endogenic oestrogen (estradiol, E2) plays a dynamic role in uterine and mammary development, pregnancy maintenance, bone density maintenance, cardiovascular disease prevention, and menopausal symptom relief. Oestrogens primarily exert their biological effects by binding to oestrogen receptors (ERs) (ER and ER, followed by dimerization of ERs) and collaborating with oestrogen-responsive elements (EREs) at the promoters of oestrogen-responsive genes, thereby triggering transcription and generating oestrogenic responses, both of which are required for normal physiological functions. ERs can also attach to other transcription factors like as Fos and Jun, which are directly bound to DNA via responsive elements such as activator protein-1 (AP1) binding sites to regulate transcription of associated genes. Oestrogen stimulates rapid signalling pathways as well, such as mitogen-activated protein kinases (MAPK). 37
Clinical trials have proven that
A single-blind RCT in 37 hyperlipidemic postmenopausal women reported that the
In a triple-blind, RCT, the administration of valerian at a dose of 530 mg twice daily for 2 months resulted in a significant reduction in the severity and frequency of hot flashes in 60 postmenopausal Iranian women with no observed side effects, compared to placebo.50 Another study, a randomized double-blind placebo control trial in 68 menopausal women with the chief complaint of hot flashes, advised 255 mg valerian capsules three times a day for 8 weeks in the valerian group (n=35), while the placebo group (n=33) was advised to take a placebo. The severity of hot flashes showed a statistically significant difference between pre-and post-treatment in the valerian group (p<0.001), while this difference was not significant in the placebo group.46 Valerian is also recommended for menopausal symptoms, insomnia, and mental difficulties due to its phytoestrogen components, and the available evidence strongly supports its effects on hot flashes and other menopausal symptoms.
Valerian is a herb that contains volatile oils, including monoterpenes, sesquiterpenes, and valepotriates. It is classified as a phytoestrogenic herb, meaning it contains compounds that have estrogenic and antiestrogenic properties similar to natural estrogens found in the body. One of the mechanisms through which valerian exerts its effects is by increasing the levels of gamma-aminobutyric acid (GABA) in the synaptic cleft, which can lead to improved sleeping patterns. The calming effects of valerian are likely attributed to its ability to increase GABA levels, which suppress reuptake, enhance neurotransmitter release, and influence glutamine levels in the plant extract. 51
A single-blind, RCT was conducted involving 60 perimenopausal women, with 30 participants assigned to each group. The intervention group received 3 grams of Tribulus powder, while the placebo group received a placebo, both administered twice daily for 8 weeks. Notably, a significant decrease in MRS (Menopause Rating Scale) total and composite subscale scores (P < 0.001) was observed, indicating a reduction in menopausal transition symptoms. Importantly, no significant side effects were reported during the study.The data analysis revealed that Tribulus was more effective than the placebo in alleviating menopausal symptoms, as evidenced by a higher mean reduction in MRS scores in the Tribulus group compared to the placebo group (19.80 vs. 11.97). Specifically, the Tribulus group showed a greater reduction in somatic symptoms (8.23 vs. 4.72), psychological symptoms (6.63 vs. 4.47), and urogenital symptoms (4.93 vs. 2.73) after the intervention. Based on these findings, it can be concluded that Tribulus may offer a safe alternative to hormone replacement therapy for managing menopausal symptoms .54
A study observed oestrogenic activity for some fractions of an ethyl acetate extract of
A double-blind placebo RCT was conducted involving two groups: the experimental group receiving 3 capsules daily containing 330 mg of liquorice extract, and the placebo group receiving 3 capsules daily containing 330 mg of starch. The trial spanned 8 weeks of intervention followed by a 4-week follow-up period. A total of ninety menopausal women experiencing hot flashes were selected and randomly assigned, with 45 patients in each group. The results showed a significant decrease in hot flashes in the experimental group compared to the placebo group. This reduction in hot flashes persisted for 2 weeks following the administration of the capsules.57
A four-arm RCT was conducted involving 120 menopausal women, with 30 participants in each group. Group 1 received 380 mg
A randomized clinical trial established that chaste berry was effective in the treatment of hot flashes. The mechanism of action was it stimulates the expression of genes related to progesterone receptors. 71 Die et al also reported the chaste berry effect in menopause. 70 Apigenin could also induce progestogenic activity. In summary, Vitex species have oestrogenic properties and apigenin and penduletin compounds are their ERβ- selective compounds, whereas rotundifuran and agnuside have been reported to activate ERα- dependent responses. 37
Menopause is a natural phase that all women experience as part of the normal ageing process. Traditional knowledge found in classical manuscripts provides valuable insights into the management of
We are thankful to the authors cited in the texts.
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