Abstract
Menorrhagia is a common problem. Medical management for menorrhagia includes hormonal and nonhormonal treatments. These treatments have different side effects, which reduce quality of life. Complementary and traditional medicines have been used to handle menorrhagia for centuries in many cultures. There is a lot of information and data in Iranian traditional documents or books about medicinal herbs that are used by Iranian traditional medicine scientists for the treatment of menorrhagia. The aim of this study was to review the approaches to menorrhagia in Iranian traditional medicine texts. In this study, some main Iranian traditional medicine manuscripts including Canon of Medicine and Al-Havi of Rhazes were studied to extract important information about menorrhagia management. Iranian traditional medicine physicians have relied on an organized system of etiological theories and treatments for menorrhagia. Their methods for menorrhagia management may be able to convince the desire of many women to preserve their uterus and avoid hormonal therapy.
Introduction
Menorrhagia is a common problem 1 that affects physical, emotional, and social activities and quality of life. 2 Menorrhagia may induce severe anemia 3 ; it is defined as a menstrual blood loss of 80 mL or more per menstrual cycle 4 or prolonged bleeding that continues for more than 7 days. 3 The prevalence of menorrhagia increases with growing age 5 and includes 18.5% of gynecologic visits in the United States of America. 2 Menorrhagia may be associated with pelvic pathology, systemic disorders, or may be iatrogenic. 6 Many women undergo hysterectomy because of menorrhagia. 5 Medical management for menorrhagia includes hormonal and nonhormonal treatments. Nonsteroidal anti-inflammatory drugs, antifibrinolytics, progestogens, combined oral contraceptive pills, gonadotropin-releasing hormone agonists (GnRH agonists), and so on are used. 7 These treatments have different side effects as well as gastrointestinal symptoms, liver disease, obesity, and thromboembolic diseases. Moreover, hypoestrogenic state as a side effect of these therapies can lead to rapid bone demineralization and menopausal symptoms such as vaginal dryness and hot flushes and so on, which reduce the quality of life. 7,8
Complementary and traditional medicines have been used to handle menorrhagia for centuries in many cultures. Iranian traditional medicine in the medieval period was one of the best developed systems of medicine. Indeed, many Iranian medical documents, like the Canon of Avicenna (Al-Qanun fit-teb or Canon of Medicine, 1025 AD), were standard textbooks in medical schools until the 16th century in Europe and have been used in the 19th century in the Middle East. 9 Makhzan-ol-Advieh is another Iranian traditional medicine book that is written about herbs, spices, and medical vocabulary. This book, which is written by Mohammad Hossein Aghili Alavi Khorasani in the 18th century, is the largest and one of the latest traditional Persian pharmacopeias. 10
Menorrhagia has been discussed extensively in Iranian traditional medicine under the subject of Efrat-e-tams. Efrat-e-tams covers a range of menstrual problems and menorrhagia is considered a subtype of it. There is a lot of information and data in Iranian traditional documents or books about medicinal herbs that are used by Iranian traditional medicine scientists for the treatment of Efrat-e-tams (menorrhagia). The purpose of this article is to review the management approaches in menorrhagia in the Iranian traditional medicine texts such as the Canon and Makhzan-ol-Adviyeh.
Materials and Methods
In this study, 7 main Iranian traditional medicine references and some others including Canon of Medicine, Al-Havi of Rhazes, Makhzan-al-Advieh and Moalejat (Medicine) of Aghili, Eksir-e-Azam of Azam Khan, Zakhireh Kharazmshahi of Seyyed Esmail Jorjani, and Sharh-ol-Asbab of Nafis-ibn-Evase Kermani were studied to collect important information about menorrhagia. We searched the term of Efrat-e-tams (menorrhagia) in uterine diseases chapters of these books. Then, we collected and classified issues about menorrhagia managements. Furthermore, a search in PubMed, Google Scholar, Scopus, and some other databases up to May 2014 was done to get related data about this field. The key terms of search were menorrhagia, treatment, and related terms.
Results
Etiologies and Types of Menorrhagia in Iranian Traditional Medicine
According to Iranian traditional medicine literature, menorrhagia is one of the gynecological disorders named Efrat-e-tams. Based on Avicenna’s opinion, Efrat-e-tams has at least one of the fallowing symptoms: (a) heavy menstrual blood loss during a menstrual cycle, (b) prolonged bleeding that continues for more than 7 days, and (c) noncyclic bleeding such as intermenstrual bleeding, uterine bleeding in pregnancy, and postpartum bleeding. 11 Therefore, Efrat-e-tams may be equal to menorrhagia, metrorrhagia, menometrorrhagia, hypermenorrhea, and intermenstrual bleeding. Avicenna divided menorrhagia into 2 main categories: pathological and nonpathological. Based on the mechanism of bleeding, the pathological type is also divided into 2 subtypes: uterus disorders and bloody disorders, with several subtypes in each. 12
Treatment Approaches
According to Iranian traditional medicine manuscripts, the nonpathologic type does not require treatment because it is a kind of congestion or hyperemia and is a way to dispel unnecessary substances, meaning that some blood losses have some advantages for them. In this group, treatment is necessary only when it causes weakness of the body. 12 The management of the pathologic category includes 2 main approaches: the first is nonmedical treatment such as improving the lifestyle, special foods consumption, and the cupping; and the second approach is medical. The medical approach is also divided into 2 types: administration of herbal medicines and other natural remedies is the first step and treatment with pharmaceutical formulation of 2 or more bioactive substances if the first approach is not effective. 13,14
No Medical Treatment
The main step in this part is dietary modification. The patient’s diet should contain plenty of easily digestible foods like yolk of soft-boiled egg. Other recommendations are meat juice (ma-ol-lahm) containing Sumac, kebab, and roasted meat with aromatic spices. Vinegar and citron pickle are suitable astringent and styptic agents in this situation. 12 The other nonmedical treatment that is effective and is used in severe types of menorrhagia is a method in which hands from shoulder to wrist and legs from inguinal region to ankle are fastened. This process causes the blood to remain in the limb and decrease blood entrance to uterine vessels. This method results in blood deprivation, which is an important treatment technique in Iranian traditional medicine approaches. 15 After that, a warm cupping (vacuum is prepared using fire) without bloodletting (Hejamate belasharat) of the breast is performed on the area between chest and mammary glands. 11,16 Also, phlebotomy (Fasd) is applied for special vessels as an appropriate plan in some cases. 15,17,18
Medical Treatment
Simple medicines
Simple medicines are single botanical, mineral, or animal agents and are usually preferred to multicomponent medicines in Iranian traditional medicine because they usually cause fewer side effects, which lead to improved patient compliance. 19
Simple medicines are administrated in 2 ways: oral and topical. Topical preparations include suppository, sitz bath, lotion, balm, and cleansing. 12,14 Ferzajeh and Homoul are 2 kinds of vaginal suppositories that are made of components that are kneaded and get dried in shade. Abzan is a traditional remedial sitz bath that is effective to treat menorrhagia. In this procedure, the patient should sit in a tub filled with water in which a special plant is boiled before. Tela is a kind of lotion that is used topically. It is used on lower abdominal surface on uterine, pubic, external genitalia, and lumbosacral regions. The other form of drug application is balm, which is used topically and named Zemad in Iranian traditional medicine, containing some components and suitable fluid, which makes it pasty. This form needs to be dressed with a soft cloth. Cleansing with watery topical preparations is named Estenja. 20
Plantain is one of the best medicinal plants for menorrhagia treatment that is used by some of Iranian traditional medicine practitioners. This plant is used either orally or vaginally. The other plant that is still used frequently by Iranian traditional medicine practitioners is Persian Gulnar, which grows wild in Iran, and it can be used either orally or topically. Other simple medicinal plants and their roots of administration are listed in Table 1.
Suggested Simple Medicines for Menorrhagia Treatment.
Compound medicines
The second line of medical treatment in Iranian traditional medicine for menorrhagia is administration of multicomponent medicines containing 2 or more bioactive pharmaceutical substances. 19 Many such multicomponent preparations were prescribed by Iranian physicians when the menorrhagia was severe and intractable to other forms of treatment. Management classification in this part is similar to simple medical therapy. Examples are described in Table 2.
Suggested Compound Medicines for Menorrhagia Treatment.
Discussion
Menorrhagia is currently a major gynecological complaint in women. Present therapies have many adverse effects and are sometimes not efficient and therefore leads to hysterectomy and its complications. 6,8,21 Iranian traditional medicine physicians knew the multiple forms of menorrhagia and relied on a structured system of etiology and treatment. They described functional and anatomical etiologies. Some forms of menorrhagia, such as bleeding due to trauma, 22 drug, polyp, and fibroma 23 (bavasir), are still the main menorrhagia etiologies. Other etiologies such as dis-temperaments that are functional causes may not be related to current categories.
Menorrhagia (Efrat-e-tams) has 2 major treatment approaches in Iranian traditional medicine: nonmedical and medical. Iranian traditional medicine scholars used even diet recommendations for menorrhagia treatment, and they were not content with drug only.
In the medical approach, Iranian traditional medicine physicians apply multiple drug dosage forms such as oral, vaginal suppository (Ferzajeh/Homoul), sitz bath (Abzan), lotion (Tela), cleansing (Estenja), and balm (Marham). These varieties of drug forms increase physician options to management of menorrhagia and improve the compliance of patients.
In current herbal medicine, tannin-containing herbs are known to be effective for hemorrhage. 24 Tannins have an astringent function and can contract capillary endothelium, and it results in decreased exudation and menstrual blood loss. 8 It should be noted that many medicinal herbs mentioned for menorrhagia management in Iranian traditional medicine are rich in tannins, for example, carob, 25 –28 quince, 29 Amaranth wide, 30 water lily flower, 31 coral, 32 jasmine, 33 acacia, 34 dracaena, 35 coriander, 36 tamarix, 37 cypress, 38 millet, 39 sheng, 40 sandal wood, 41 rose, 42 lentil, 43 knotweed, 44,45 cedar, 45,46 Spanish chestnut, 45 myrtle, 47 sumac, 48 and oak apple. 49 Therefore, antihemorrhage effects of these herbs are to be anticipated. Nowadays, plantain shows not only hemostatic activity but also possesses hematopoietic property. 50 However, clinical studies need to be done on these (Iranian traditional medicine) recommended menorrhagia treatments to prove their efficiency and safety.
Conclusion
Menorrhagia’s current medical treatment shows many side effects, and hence traditional remedies have found empiric support over the past centuries. Some of these approaches may still be helpful to conventional medicine. These remedies may be able to convince many women to preserve their uterus and avoid hormonal therapy.
This study may provide clues to new researches for the control of menorrhagia with natural remedies.
Footnotes
Authors’ Note
This article is drawn from Hajar Memarzadehzavareh’s PhD degree thesis from the School of Traditional Medicine, Shahid Beheshti University of Medical Sciences.
Acknowledgments
The authors gratefully acknowledge the help of the following individuals: Dr Rasoul Chopani, Dr Mohammad Babaian, Dr Sohrab Dehghan, and Dr Shirin Fahimi.
Author Contributions
Study concept and design: Hajar Memarzadeh Zavareh, Marzieh Qaraaty, Mojgan Tansaz. Acquisition of data: Hajar Memarzadeh Zavareh, Marzieh Qaraaty, Maliheh Tabarrai. Analysis and interpretation of data: Hajar Memarzadeh Zavareh, Marzieh Qaraaty, Maliheh Tabarrai. Drafting of the manuscript: Hajar Memarzadeh Zavareh, Marzieh Qaraaty, Maliheh Tabarrai. Critical revision of the manuscript for important intellectual content: Mohammad Kamalinejad, Tahereh Eftekhar, Mojgan Tansaz. Study supervision: Mojgan Tansaz.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval
This study did not warrant institutional review board review as no human subjects were involved.