Keywords

Rajonivritti; Menopause

Introduction

Menopause is a natural event as a part of the normal process of ageing; it is turning into a major health problem in recent years, in developed as well as developing countries like India. Currently, the number of menopausal women is about 43 million and projected figures in 2026 have estimated to be 103 million. According to Indian Menopause Society (IMS) research, there are about 65 million Indian women over the age of 45 and this figure is expected to creep-up. Average age of Menopause in around 48 years but it strikes Indian women as young as 30-35 years [1]. So, the menopausal health demands even higher priority in Indian scenario. Menopause is thus a gradual and natural transitional phase of adjustment between the active and inactive ovarian function and occupies several years of a women's life. Menopausal transition is characterized by varying degree of somatic and psychological changes. The period may be uneventful or may manifest through various symptoms. The group of symptoms is known as "Menopausal Syndrome".

Literature Review

In Ayurveda, Menopause is dealt with the JaraPakwaAwastha of body: “Rasadevstriya raktaranjhapravertate. Twadsharadh dwadashawardha yatapichaha kshayam||” (su. Su. 14\4)

Jara and Rajonivritti are manifested due to progressive reduction in the functional ability of Srotas and Agni, which results into an inadequate tissue nutrition. The term 'Rajonivritti' is made up of two different words viz. "Rajah" and "Nivritti". According to Sanskrit language the root word for "Rajah" is given as ‘Rajascha’ which means to give colour to the substance. i.e. ‘Rajascharage cha’ The word Rajah is used synonymously for various substances like Artava or streepushpa (related with menstrual cycle), Raja Guna (A type of Manasdosha), Parag (Pollen grains of flower), Renu (minute dust particles), synonym of a plant named Parpataetc. Here, in the context of this subject, the meaning of Rajah is taken as Artava and Stripushpa [2] i.e. substances related with menstrual cycle.

Ni+vru+kin, Apravruttihi, uparam, vyaparati, uparatihi, itihemchand| the word Nivritti is derived from Sanskrit Varnas ‘ni’ and ‘vrutta’. AcharyaHemchandra has coated the synonyms of the word Nivritti like Apravritti, Uparama, Virati, Vyparati, Uparati etc. Meaning of these all words can be understand as Accomplishment, Fulfillment, Completion, End, Discontinuance of the influence of one rule over another, Resulting, Ceasing, desisting, abstaining form, Inactivity, Impropriety, Final beatitude.

Rajonivritti so can be meant as-

“Rajyatirajyatenena va tasya nivrutti|”

“Rajo stree pushpasya nivruttasya|”

As a consequence, the whole term Rajonivritti means "End of ArtavaPravritti" or "Cessation of menstruation".

Nidana of Rajonivritti

According to SwabhavaparamVada "No cause exists behind destruction of anything. Absence of factors responsible for production of it may be a cause for its destruction". (Theory of natural destruction)

“Pravruttiheturbhavana na nirodhestikaranam|

Kechittaatropimanyatehetunhehoravartanam||”

So, by understanding the "Rajah UtpattiHetus", we would explore the cause of Rajonivritti. These are–Kala, Swabhava, DhatuParipurnata, Karma, Vayu.

Kala

Ayurveda has always given much emphasis to this factor. Kala remains present everywhere and are considered as a major factor behind any process or activity. In Ayurvedic science, Kala is mentioned at various places as a causative factor like.

Cause of Kshaya and Vriddhi. (Cha. Su. 17/77)

Cause of Garbhavakranti (Cha. Sha. 2)

Cause of GarbhaVriddhi (Cha. Sha. 2)

Cause of oneset of Prasava (Su. Ni. 8/7-8)

Cause of Bala, Taruna and Vriddhaavastha (Cha. Vi. 8)

Cause of Mrityu (Cha. Sha. 1/115) etc.

In Ayurveda, the "Vaya" is described on the basis of Kala only. The characteristics of particular age or the changes taking place in different stages of age have to attributed to the Kala. AcharyaCharaka also beautifully explains that the same foetus after passing of sometime becomes child, young and old. Thus; it is clear that after a specific time, female body manifest "Rajonivritti" at the age of 50 years then process of aging starts [3].

Swabhava

Swabhava means a natural phenomenon or a specific feature, which is difficult to explain with Karya-Karana Vada. Ayurveda has considered "Swabhava" as a causative factor in a generalized way. (e.g. In regard to SristiUtpatti etc.)

It is a Swabhava of Tarunavastha or Dhatuparipurnaavastha of female to produce "Rajah".

It is a Swabhava of body to degrade every moment. Rajah is also a physiological entity, which is having Swabhava of degradation and ultimately manifests in Rajonivritti. Moreover, according to the Swabhavoparamvada, (Theory of natural destruction) a substance, which is produced and got an existence, will deteriorate and ultimately get vanished naturally. Nothing is eternal in this universe. So, Rajah too produced and manifested at a particular age and it will be vanished by nature termed as Rajonivritti [4].

Vayu

"Vayu" as an active substance in the body as well as in the universe, which is assumed to be a major factor behind every process. Initiation, Progress, Division and Destruction are of a prime importance for any activity, which is carried out by Vayu. In human body, out of five types of Vayu, "ApanaVaya" and "VyanVayu" are mainly responsible for the functions related to Artava. All the body functions are under the control of "VyanaVayu". So, normal functions of yoni and Garbhashaya are also carried out by VyanaVayu. As Artava is related to "Artavavahasrotas", it comes under the activity field of ApanaVayu. ApanaVayu helps in all excretory activities like Mala, Mutra, Shukra, Artava and GarbhaNiskramana, and also, helps to control these activities during the conditions of stress. So, it can be concluded that combined effect of these two Vayus are responsible for Rajah Utpatti as well as its cyclic expulsion at every month. Hence, it can be considered as a causative factor for Rajah Nivritti also, and any vitiation of these factors may alter this process. Vitiated stage Vayu in the body is very well understood in the case of Rajonivritti. Factors like Vriddhavastha, generalized Dhatukshaya, generalized Rukshata and Shosha will lead to Vatavriddhi. Hence, a vicious cycle will come into play and all the functions of Vata will be affected including Rajah Utpatti, which may be manifested as Rajaonivritti. In this way, Vayu is responsible for Rajonivritti.

Dhatukshaya

Dhatu nourishes the body and holds the body. Normality of this substance in the body will be manifested, as 'Swasthya" and any vitiation will hamper the normal activity of the body.

Dhatuparipurnata is considered as a responsible factor for "Rajah Utpatti". For human being, reproduction is ultimate goal, in Balyavastha, this cannot be achieved because the condition of Dhatus are not mature, and so that the Rajah and Shukra are also not manifested. But, in Taruna or Yuvaavastha, Dhatu attains the stage of Paripurnata or maturity and manifested as Rajodarshana, which marks the starting of reproductive life for a woman. The same thing is true for Rajonivritti also, with the advancement of age, the condition of Dhatus deteriorates day by day. (i.e. Dhatukshaya) As a result, UpadhatuArtava is not formed in a normal way and it gradually ceases, so quality of reproduction vanishes, which is termed as Rajonivritti. So, it can be concluded that, immature stage of Dhatu, which is characteristic of childhood and deteriorating stage (Kshaya) of Dhatu, which is characteristic of Artava. Acharya Kashyapa also supports the above statement by quoting.

“Heenyonyastubalayakayangachanti shoonitam|

Athapurnaswabhavayaha kayan yoni cha gachanati|”

Abhighata

Acharya Sushruta has mentioned that the Viddhata of the roots of Artavavaha Srotas i.e. Garbhashaya and Aartavavhi Dhamanis (uterus and uterine or ovarian arteries) will lead to Artavanasha. This Viddhata may take place due to any direct or indirect trauma (Abhighata) to the Artavavaha Srotas, and will directly lead to Artavanasha and manifests as Akalaja Rajanivritti [5].

Karma/activities

Ayurveda has considered Karma as a generalized factor for any activity. Karma is considered by two ways. First is Purvajanmakrita and other is, Aajanmakrita (Karma of this life). The prior is responsible for many things, because the science believes in the concept of Atma and Punarjanama. The later one has a direct relationship between Karana and Karya, which includes all the Pragyaparadhas for diseased condition and vice a versa.

In Rajah, the importance of karma is described by Acharyas in variouscontexts, like “Yathachagnirdarushusarvagataha prayatnabhannopalbhyatetatha stripunsayoho shonit shatruke kalavekshaswakarmaveksha cha bhavata|” (including Aharaja and Viharaja) may affect the Rajoniuritti. Moreover, Acharya Charaka has described the factors, which are responsible for growth; these include Kalayoga (Opportunity), Swabhava Sansiddha (Favourable disposition of the nature), Ahara Saushthava (Excellence of properties of food) and Avighata (absence of inhibiting factors). people are naturally strong; birth at a time when people naturally gain strength; favourable disposition of time; excellence of the quality of the spermovum and uterus etc. are also considered as promotive of health. This environmental, Aharaja and Viharaja factors also influence on Rajoniuritti. In contrary, Acharya Charaka has also quoted that a person will lost his strength luster etc. unnaturally before the age due to MithyaAhara and Vihara, unable to enjoy a healthy and full span of life. These some Nidanas may become causes for Akalaja Rajoniuritti. From above description, it can be inferred that some of the favourable and unfavourable circumstances also play an important role for Rajoniuritti. It is little for imagination that a woman living under unfavourable conditions is likely to develop aging earlier and gets Rajonivritti also earlier. Modern science also believes that severe malnourished women or women living in high altitude get an earlier Menopause.

Types of Rajonivritti

Ayurvedic science has divided all diseases into 4 major types i.e. Agantuj, Sharira, Manasa and Swabhavika. Techurvidhaha Agantavaha shariraha manasaha swabhavikasheti|” (Su. Su. 1/24). Concentrating on 'Swabhavika' type, it is described that this type includes all those conditions, which are naturally occurring. Acharya Sushruta has mentioned a group of naturally occurring diseases under the heading of Swabhavabala Pravritta includes Kshudha (Hunger); Pipasa (Thirst), Nidra (Sleep), Jara (Aging) and Mrityu (Death). Further Acharya Dalhana has commented over it as-

“Prakrutigrhunat prakrutibhavarogagruhantantae cha chadachita swabhavikaha kadachita doshajaha|” (Dalhana on Su.Su. 1/33)

Although these diseases are naturally occurring diseases, sometimes they are being acquired, which is described as "Doshaja". Hence, they are further divided into two type's viz. Kalakrita and Akalakrita.

In the same manner, Rajonivritti is a naturally occurring condition in every woman as that of Jaravastha etc. Swabhavika Vyadhies. Hence, Rajonivritti also can be divided into two types. Kalaja Rajonivritti and Akalaja Rajonivritti.

Kalaja Rajonivritti

If Rojonivritti occurs at its probable age (i.e. around 50 years of age), it is called as Kalaja Ronivriti. According to Acharya Sushruta, the timely Rajonivritti (i.e. natural diseases like aging) occurs only when the protective measurements of healthcare are being practiced. This condition is Yapya by Rasayana etc.

Akalaja Rajoniuritti

If Rajoniuritti occurs before or after its probable age (i.e. around 50 years), it is termed as Akalaja Rajoniuritti. Akalaja Rajoniuritti takes place due to absence of the protective measurements of health care. In this type of Rajoniuritti, symptoms are very acute and special medical attention should be given to avoid its hazardous effects. According to Acharya Dalhana, it should be treated on the basis of nature of illness (Roga) and Dosha involved in it. This Akalaja Rajoniuritti is more likely treatable than Kalaja Rajoniuritti. This magnitude of Kalaja and Akalaja Rajoniuritti is bound to vary from person to person on the basis of Prakritti as noted by Acharya Charaka himself in Vimana Sthana. Therefore, ultimately the responsibility of deciding Kalaja or Akalaja Rajoniuritti is shouldered upon physician's experience. Probable Samprapti (Pathogenesis) of Rajoniuritti.

Rajonivritti janya lakshana

As the pathogenesis of Rajonivritti is not elaborately described in Ayurvedic text, few points should be taken into consideration (including Nidanas, which are already described previously) in this regard. First of all, classics have quoted the age around 50 years as the probable age for Rajnivritti.

As biological stimulation of Kala, Vayu, Swabhava, Karma, Kshayaavastha and Abhighata etc. leads to Akriya-Sheelata of Srotas (vital channels) of the body. Hampering the Rasa Vahana Karma. This nourishing Rasa Dhatu decreases both qualitatively and quantitatively and ultimately resulting in starvation of all the Dhatu (Rasa-Raktadi) of the body. No further Dhatu production and along with destruction of existing Dhatus and Updhatus leading to permanent Amenorrhoea i.e. Rajonirvritti. And because of generalize This age limit is dominated by "Vata Dosha" with imbalanced Pitta and Kapha deprived state.

“Vardhakye vardhamanenavayunarasashoshanat | Na yatha dhatuvruddhi shyat tatastraniljayate|”

This dominant Vata Dosha will have effect all over the female body including all anatomical as well as physiological factors by virtue of its characters i.e. "Laghuta" and "Rukshara". At the age about 50 years, the decline process starts in female body due to Jaravastha as a natural process. So, considering all these points, the probable Samprapti. Dhatukshayka leads to Vatavriddhi (increased Laghu, Ruksha, Khara Guna) which can displace the imbalanced pittc and along with Kaphakshaya (decreased Gura, Snigdha, Drava Guna) produces Rajonirvritti Janya Lakshana [6]. In the presence of Vata Prakopaka Nidanas these Lakshan become vigorous and can bring early menopause i.e. Akalaja Rajonirvritti.

Lakshanas of Rajonivritti (Menopausal Symptoms)

As there is no direct reference available regarding Lakshanas of Rajonivritti in the Ayurvedic classics, the clinical symptoms manifested by the patients of Rajonivritti are the manifestations of Dhatukshayaja Lakshanas along with vitiated Doshas.

On the basis of available symptoms, differentiation can be done by applying Doshic theory to facilitate management of menopausal syndrome as Vataja Lakshanas, Pittaja Lakshanas and Kaphaia Lakshanas. As this condition is characterized by generalized Vatavriddhi, the Vataja Lakshanas are more dominantly observed that pittaja and Kaphaja Lakshanas.

Vataja akshana

Shirahshoola (Headache), HridSpandana (Palpitation), HastaPadaSuti (Numbness), ShabdaAsahishnuts (Noise- Intolerance), Bala-Kshaya (Weakness), Adhmana (Distension of abdomen), Vibandha (Constipation), Anidra/Alpanidra (Sleepnessness), Bhrama (Vertigo), AnavasthitaChitatvam (Mood swing), Vaichitya (Loss of concentration), Vishaada (Depression), Chinta (Anxiety), Smritimandhya (Decreased memory), KrichchhraVyavayata (Loss of libido), Maithunaasahishnuta (Dyspareunia), Vak sang (Change in voice), Vali (Wrinkling of skin), Asthivedana (Pain in bones), Katishool (Low backache), SandhiVedana (Joint pain), Vamanatvam (Loss of ht.), Angamarda (Body ache), Yoni vedana (Pain in vagina), Yoni shushakta (Vaginal dryness), prabhutamutrata (Frequency), Urge incontinence, Mutrakrichhrata (Pain in micturition).

Pittaj lakshana

Osha (Hot flushes), Atisveda (Sweating), Amarsha (Irritability), Yoni daha (Burning sensation), Yoni daurgandhya (Foul smelling), Mutradaha (Burning sensation in Urine).

Kaphaja lakshana

Atisthaulaya (Weight gain), Yoni kandu (Itching), Yoni srava (Vaginal discharge).

The factors present in the female body at the time of Rajonivritti, should be considered as the base for the whole etiopathogenesis. Here because of SwabhavikaVatavriddhi due to Jaraavastha, leads to Akriyasheelta of Srotas leads to Rasa vahanaHanni produces Shirahshoola, HridSpandana, HastapadaSupti, Bala- Kshaya and Angamarda ultimately it leads to Ras-RaktadiDhatuKshya which is responsible for ShabdaAsahishnuta, Bhrama, smritimandhya, Maithunasahishnuta, vali, Vamanatvam, Yoni vedana and Urge incontinence and if there is presence of other VataPrakopakaNidana which further vitiates Vata, leads to VataPrakopa, which leads to production of Adhmana, VibandhaAnidra/Alpanidra, Vak sang, Asthivedana, Katishool, SandhiVedana, Yoni shushkta, Prabhutamutrata and Mutrakrichata.

This deprived state of body vigoursly affects the ManovahaSrotas of females which are naturally considered as supple beings. This favours production of various Mansika diseases like Anavasthitachitatvam, Vaichitya, Vishaada, Chinta and KrichchhaVyavayata etc.

Again, the same etiological factors will lead to generalized Vatavriddhi, which will interfere the process of DhatuUtpatti and affect the metabolism of Dhatus. This event again aggravates the VataDosha and this Vicious cycle goes on.

Sadhyasadhyata (Prognosis)

Sadhyasadhyata of Rajonivritti is not mentioned separately in classics, but as mentioned earlier, Rajonivritti is Swabhavika, Vyadhi as Jara and Mrityu. Acharya Charaka considered them as, i.e. by nature they are incurable or having no treatment. Acharya Chakrapani while commenting on this verse mentioned that the word "Nish Pratikriya" means ordinary treatment and measures have no effect on aging (Rajonivritti) but it is "Yapya" by Rasayana treatment. Acharya Dlhana also commented that there does not exist any treatment to kalakrita. They may be made "yapya" by Rasayana, dietetics etc. Rajonivritti is also a naturally occurring condition and having good number of similarity with the process of aging, it should be considered as "Yapya" condition. 'Yapya' is partial amenability of disease to treatments. Rather a person lives with the disorder without cure but without disturbed by the disease. Because it is said that in "Yapya" stage, the disease recurs immediately after the treatment is withdrawn.

Chikitsa (Treatment) of Rajonirvritti Janya Lakshana

As such no treatment of Rajonirvritti has been given anywhere in Ayurvedic classics, being a Swabhavaj state of life. But on the basis of atiopathology and clinical picture treatment of Dhatukshaya can be given as per the fundamental of Ayurveda as time to time Samashodhana and Rasayana, therapy.

Discussion

According to Sushruta and various other references too; 50 years is mentioned as the age of Rajonivritti, when the body is moving towards the grip of senility. AcharyaArundatta opines that the age mentioned above is a probable age and not a fixed one. There may be some variations in this regard.

Considering the variations and factors influencing it, can be logically quoted as either environmental or the individuality of a woman. As Ayurveda has given more importance to Ahara and Vihara in the maintenance of heath, these factors too, should be considered for this fluctuation.

Conclusion

Menopause is not only the cessation of monthly menstrual cycle but it is a transition phase of life and body in which hormones becomes imbalanced which further aggravated by misconduct of changing life style and reflects as menopausal symptoms which collectively called as menopausal syndrome. Although it is not mentioned in Ayurvedic classics but Acharya Charaka established the fact that diseases are innumerable Ayurvedic diagnostic approach mainly depends on symptomatology based on the involvement Dosha so; Menopausal syndrome can be well understood on the basis of Dosha.

References

1. Padubidri VG (2010) Howkinsand Bourne, Shaw's a Textbook of Gynaecology. Menopause, Published by ELSEVIER, Amsterdam. p. 556.
2. Sushruta S, Sootrasthana (1970) Sharirasthana of Agnivesh. Acharya JT (ed) Chaukhamba Orenatila Varanasi, India.
3. Ashtanga S, Sharira Sthana (2005) Commentary by KavirajaAtrideva Gupta, ChaukhambaKrishnadasAcedemy, Varanasi, India.
4. Sushruta S, Nidana S, Ambika D (1981) 'Ayurveda-Tattav-Samdipika'Vyakhya, ChaukhambaSamsdritSamsthan, Varanasi, India.
5. Charaka S, ChikitsaSthana Translation by ShastriGirijashankarMayashankar, SastuSahityaVrdhakaKaryalaya – Ahmedabad, India.
6. Charaka S, Sootrasthana (1981) Translation by SastuSahityaVardhakaKaryalaya – Ahmedabad, India.