Management of Usr-i-Tamth (Menstrual Pain) in Unani (Greco-Islamic) Medicine

Abstract

Usr-i-tamth in Unani (Greco-Arabic) medicine is pain associated with menstruation, and classical manuscripts are enriched with traditional knowledge for the management of usr-i-tamth (menstrual pain/dysmenorrhoea). Hence, a comprehensive search was undertaken to find classical manuscripts for the management of menstrual pain was. We searched the Cochrane database, PubMed/Google Scholar, and other websites for articles on complementary and alternative medicine treatment and management of menstrual pain. The principal management as per Unani manuscripts is to produce analgesia and to treat the cause of usr-i-tamth such as abnormal temperament, menstrual irregularities/uterine diseases, and psychological and environmental factors. Furthermore, Unani medicines with emmenagogue, antispasmodic, anti-inflammatory, and analgesic properties are beneficial for amelioration of usr-i-tamth. Herbs such as Apium graveolens, Cuminum cyminium, Foeniculum vulgare, Matricaria chamomilla and Nigella sativa possess the aforementioned properties and are proven scientifically for their efficacy in usr-i-tamth. Thus, validation and conservation of the traditional knowledge is essential for prospective research and valuable for use in the contemporary era.

Usr-i-tamth or auja al-rahim in Greco-Arabic (Unani) medicine is pain associated with menstruation ¹ or pain of uterine origin ² analogy of dysmenorrhoea/menstrual cramps or pelvic pain, respectively, associated with gynecological diseases. Dysmenorrhoea is a Greek word, ^3,4 Dys means “difficult,” “painful,” or “abnormal”; meno is “month”; and rrhea is “flow,” meaning difficult monthly flow. ³ Dysmenorrhoea is a common gynecological condition that can involve as much as 50% of women, and 10% of these women suffer severely enough to leave them incapacitated for 1 to 3 days each menstrual cycle. ^5,6 It has a major impact on health-related quality of life, health care utilization, and work productivity. ⁷ A clearly diagnosed case of primary dysmenorrhoea can be treated symptomatically and provided with proper follow-up, whereas when the diagnosis is unclear or whose vital signs or physical findings are abnormal a more thorough workup is warranted, including full laboratory studies, pelvic ultrasonography, and potentially an obstetrics/gynecology consultation. ⁸ There are 3 approaches for the management of primary dysmenorrhoea: nonpharmacological, pharmacological, and surgical. ⁹ Pharmacotherapy such as nonsteroidal anti-inflammatory drugs, opioid analgesics, and oral contraceptives are the most reliable and effective treatments for relieving dysmenorrhoea. In addition to pain relief, the basis of treatment includes reassurance and education. Treatment of secondary dysmenorrhoea involves correction of the underlying organic cause. ¹⁰ However, these drugs lead to various adverse effects and 20% failure rate to reduce dysmenorrhoea. ¹¹ Therefore, the general population is turning toward complementary and alternative medicine as the first line of defense to battle illnesses. A focus study showed 56% of gynecological patients have already turned toward alternative care. ¹² In traditional Unani medicine, herbs and other modalities of treatments are in use since antiquity for ameliorating menstrual pain. Therefore, it is need of the hour for the comprehensive exploration of long-established knowledge mentioned in classical Unani manuscripts for the management of auja al-rahim/usr-i-tamth and to implement the current researches conducted in integrative medicine/complementary and alternative medicine in the contemporary era.

Greco-Arabic, Arabic medicine, and Islamic medicine refer to medicine developed in the Islamic Golden Age, the period extending from the 6th century to the 13th century. Medicine was developed in all 4 periods of medieval Islamic culture, that is, Prophet period (570-633 AD), Caliph period (632-660AD), Umayyad period (660-750 AD), and Abbasid period (750-1258 AD). It was a fundamental part of medieval Islamic culture. It retains its traditional essence and is one of the ancient systems of medicine that exists till date. ¹³ Islamic physicians and scholars developed a large and multifaceted medical literature, searching, scrutinizing, and synthesizing the theory and practice of medicine. Some of the renowned physicians were Ali bin Rabban Tabri, Ali ibn al-’Abbas al-Majusi (Haly Abbas), Muhammad ibn Zakariyā Rāzī (Rhazes), Abu Sahl Masihi, Ibn Sīnā (Avicenna), Zayn al-Din Sayyed Isma’il ibn Husayn Gorgani (Ismail Gorgani), Ibn Rushd (Averroes), Ibn Zuhr (Avenzoar), Ibn al-Baitar, and so on. ¹⁴

The Arabic and Persian manuscripts, for example, Ibn Sina’s al Qānūn fī al-Ṭibb (Canon of Medicine), Al Razi’s kitab al Hawi fi al-Tibb (Continens Liber) and al Mansuri (Liber al mansoris), Al-Jurjani’s Zakhirah-i Khvarazm’Shahi, Rabban Tabri’s Firdous al-Hikmat (Paradise of Wisdom), Al-Majusi’s Kitāb Kāmil aṣ-Ṣinā ʿa aṭ-Ṭibbiyya (Liber Regius/Complete Book of the Medical Art), Ibn Rushd’s Kitab al-Kulliyat, and Ibn Zohr’s Kitab al-Taysir were referred for causes and management of uterine pain/menstrual pain. In addition, Tibb-i-Akbar, Kitab al-Mukhtarat Fi’l Tibb, Rumuze-i-Az’am, Jamia al-Hikmat Iksir-i-Az’am, and others were also referred. Furthermore, the English-language literature on various scientific websites such as Google Scholar, PubMed, Medline, Cochrane Database, Science Direct, and Ovid search engines were browsed for contemporary approaches to manage menstrual pain in complementary and alternative medicine. Terms such as dysmenorrhoea, pelvic pain, menstrual cramps, menstrual pain, herbs, complementary and alternative treatment for menstrual cramps, acupuncture and dysmenorrhoea, anti-inflammatory herbs for dysmenorrhoea, and antispasmodic herbs were searched. The inclusion criteria were the aforementioned terms and full-length freely accessible articles and abstracts were excluded.

Results and Discussion

Other terms for dysmenorrhoea/pelvic pain are dard-i-rahim, waja’al-rahim, or auja al-rahim (uterine pain). ^2,15 Al-Majusi, Al-Jurjani, and Az’am Khan discuss usr-i-tamth (dysmenorrhoea) with menstrual disorders ¹⁶ or ihtibas al-tamth (amenorrhea), ^1,17,18 and Ibn Sina’s in al Canon summarized this disease under the heading of auja al-rahim. ²

In ancient civilizations, physicians were familiar with various gynecological disorders, including dysmenorrhoea, amenorrhea, prolapse of uterus, cancer, and leucorrhoea. ¹⁹ Buqrat (Hippocrates) proposed that delaying motherhood could cause disorders of the uterus, with painful menstruation. ²⁰ The causes of auja al-rahim/usr-i-tamth are summarized in Table 1.

Table 1.

Causes of Usr-i-Tamth/Auja al-Rahim.

Manuscript Name	Causes
Kitab al Hawi fi al-Tibb in ninth volume	Al-Razi (868-925 AD) states that rataq (atresia both congenital and acquired), insidad fam al-rahim (cervical obstruction), saratan al-rahim (uterine cancer), inqilab al-rahim (inversion of uterus), waram al-rahim (inflammation of uterus), riyah-i-ghaleez, sil (tuberculosis), ihtibas al-tamth (amenorrhoea), qillat-i-tamth (oligomenorrhoea), nazf al-dam (menorrhagia), sailan al-mani (ovulatory discharge), masae (polyp), inzilaq al-rahim (uterine inversion), buthur al-rahim (cervical erosion), and quruh al-rahim (uterine ulcer) are causes for dard-i-rahim
Kitāb Kāmil aṣ-Ṣinā ʿa aṭ-Ṭibbiyya	Al-Majusi (930-994 AD) surmised that ulcerated saratan al-rahim (cancer) leads to severe pain in suprapubic area radiating to groin and back
al Qānūn fī al-Ṭibb	Ibn Sina (980-1037 AD) discusses that su’mizaj-i-mukhtalif (different distemperament), amraze al-rahim sabqa (previous uterine diseases), rataq (atresia), saratan al-rahim (uterine cancer), waram al-rahim (inflammation of uterus), rutubat al-ghaleeza (tenuous morbid matter), isterkha-i-ribatat rahim (laxity of ligaments), quruh al-rahim (uterine ulcer), riyah-i-ghaleez (morbid gases), and sudda al-rahim (uterine obstruction) leads to auja al-rahim
Kitab al-kulliyat and Kitab us-Taiseer	Ibn Rushd (1126-1198 AD) and Ibn Zohr in (page 178) describe that usually all types of su’ mizaj al-rahim (distemperament of uterus) can occur in uterus, which leads to different types of diseases
Iksir-i-A’zam	A’zam Khan 32 mentions the causes of dard-i-rahim are su’mizaj, riyah-i-ghaleez, rutubat al-ghaleeza (tenuous morbid matter), quruh al-rahim, buthur al-rahim, saratan al-rahim, physiometra, inqilab al-rahim, shuqaq al-rahim (uterine rupture), mailan al-rahim (displacement of uterus), excessive intercourse, and postpartum period uterine pain or pain occurring during menstruation
Makhazanul Hikmat	Gulam Jilani classified usr-i-tamth into 5 categories: baize, tashannuji, warami, suddi, and gishai

Clinical Features

Unani scholars hypothesized that in waram al-rahim, site of pain in pelvis varies according to the presence of waram (inflammation) in different parts of the uterus. ^2,16,21 During menstruation a patient experiences spasmodic pain. ^2,15 Lower abdominal pain during menstruation or pelvic pain is also associated with other systemic symptoms such as fatigue, headache, fever, anxiety, abdominal pain, and syncope. ¹

Management

Usoole ilaj (Principle of Treatment)

In traditional Greco-Arabic medicine, 3 modalities of treatment are Ilaj bi’l-tadbir (regimental therapy), ilaj bi’l-dawa (treatment by medication), and ilaj bi’l-yad (surgical treatment). To reduce uterine pain/menstrual cramps, analgesics and antispasmodics ² are useful and treat the cause of pain. ¹⁵ Ibn Sina mentioned that to relieve sudda drugs with quwat-i-qabiza and quwat-i-mulattifa properties are beneficial as quwate qabiza neutralizes the harmful effect produced by quwate talteef and tahleel. ² Ibn Zohr in his compilation Kitab al-Taysir writes that ta’dil-i-mizaj is needed with oral diet and drugs in su’ mizaj har and externally motadil roghaniyat are useful. He said that in su’mizaj barid musakhin roghaniyat, huqna, mashrubat, and diet are useful for ta’dil-i-mizaj and locally external application of roghaniyat such as roghan sosan, roghan sowa, and roghan habus zaru are useful. ²²

Ilaj bi’l-tadbir and Ilaj bi’l-dawa

Greco-Arabic scholars advocate to avoid psychological stress, anxiety, ²¹ strenuous exercise such as running, jumping, and quickly moving down stairs and work, excessive coitus, and to take complete bed rest. ¹

Historically, pessaries have been used to treat menstrual irregularities, dysmenorrhoea, infertility, incompetent cervix, malposition of a uterus, and uterovaginal prolapse. ²³ Ancient Greeks were aware of dysmenorrhoea. ²⁴ Hippocrates and Aristotle advocated breathing exercise to relieve pain. ²⁵ Pedanius Dioscorides (AD 40-AD 90) writes that “fennel cures painful urination; expels menstrual flow; stops bowel discharge; brings out breast milk; breaks kidney and urinary stones.” ²⁶ He also recommended baboona (chamomile) for menstrual pain. ²⁷ Soranus (AD 98-AD 138) the Greek gynecologist from Ephesus advised “local application of a bladder filled with hot oil and held over the aching lower abdomen. ²⁵ Ghidh wa parhez (diet therapy), hijamah bila shart, ^2,15 nutool or takmeed (fomentation), ¹⁵ abzan (sitz bath), ^15,28 dalk, ¹⁵ tila, ²⁹ hamul (pessary), ^15,29,30 zamad, ¹⁵ huqna (suppository), ^15,30 and firzaja (pessary) ^30,31 are useful in dysmenorrhoea.

Ta’dil-o-tabdil-i-mizaj and tanqiya is recommended for normalization, restoration, and potentiating of normal physiological function after purging out the khilte raddiya from the affected organ. Infrequently, if the khilt is not evacuated then muhallil (resolvent/anti-inflammatory), antispasmodics, analgesics, and mulattif advia are used. ¹⁷

The management with single and compound Unani medicine is summarized in Table 2. Scholars mentioned that Jundbedaster or roghan bazrul banj or zafran or hab qar is the best medicine for dard-i-rahim. They said that roghan mastagi or roghan badam talkh is useful for all types of uterine pain and joshanda nasreen is useful in dard salabat rahim. ¹⁵ Rewand khatayi powder (5 g) and sugar starting 2 days before menses and continued for 3 days during menses is effective in dard- i-rahim. ^18,29,32,33 Majun of murr and honey is also useful in usr-i-tamth. ^15,33

Table 2.

Management of Usr-i-Tamth/Auja al-Rahim Suggested in Greco-Arabic Medicine.

Ghidh wa parhez (dietotherapy) Advocate light and nutritious diet 1 and avoid constipation. Diet such as cabbage, beet root 15 and meat soup 18 are beneficial. To relieve sudda or obstruction musk melon, fenugreek, barley water, vinegar with kibr and aabe nukhood are useful. Fresh garlic, onion, and radish convert ghaleez khilt into lateef. 21 Razi advised karnab and beet root for relief of uterine pain. 15 Hijamah bila shart Nutool or takmeed (fomentation) with Fasd Pain with nafkhe rahim, fasd (venesection) is advised followed by nutool of roghan sudab at the time of pain or nutool of joshandae birjansif is also useful for uterine pain 15 Abzan (sitz bath): Any one of them Abzan with warm water Joshanda (decoction) baranjasif, 15,28 or irsa, or soya or ghaar (leaves) Abzan of methi and khubazi or Joshanda waj or daroonj Waram sulb: Joshandae qust or joshandae sowa or tukhme katan, marsanjosh, pudina, baboona, naqoona, biranjasif or Joshanda sambalu is useful 15 Dalk (massage) Massage with oils of hina, gul or sosan or nargis, or seer or zabq 15 Tila (lotion) Lotion of fine powder of ushq, muqil, bahroza, miya 29 Hamul (pessary) Waram al-rahimi: Afiun khalis hamul for severe pain Burodat al-rahim: Muskhin drugs such as qutran and pudina nari Waram salbat al-rahim: Hamul of tukme katan, baboona, kali tulsi, naqoona, karnab peel single or combined is useful or marham dakhiluyun with roghan sosan is also useful 15 Hamul of mother milk or powdered salt or mazu or usra kurfa 15,29 Hamul of powder ushq, muqil, and baroza (equal quantity) 30 Zamad Zamad of fresh bottle gourd 15 Huqna (suppository) Huqna of milk and usra bartang or fresh butter 15 Joshanda khubazi or turbud also relieves uterine pain 30 Firzaja (pessary) Firzaja of ushq, muqil, bahroza, mayia sayila in equal quantities 30 Firzaja of shahade musaffa one part and breast milk 2 parts is recommended for dard-i-rahim that starts prior to menses and after intercourse 31 Oral Barid dard-i-rahim (cold uterine pain): Joshanda qust and joshanda sad or jowsheer, jundabaster each 1g with matbukh rihani is useful Joshanda methi or ushna or babuna Joshanda of ajwaeen, tukhme shibbat (2 misqal) mixed with qande safed (6 misqal) for 7 days relieve dard-i-rahim and waja’al-zuhr that occur before menses 15,18,32 Joshanda of poste phalli amaltas (21 g), jawatri (3 g), and qande siyah (25 g) for 3 days priors to menses 15,18,32 Rewand khatayi powder (5 g) and sugar starting 2 days before menses and continued for 3 days during menses 18,29,32,33 Hilteet 500 mg and qand siyah 68 g at morning 5 to 7 days during menstruation is useful to relieve dysmenorrhoea 28 Habbe muddir, 1 tablet 2 times a day 29 Jawarishe qurtum, 7 g at bed time 29 Barsha’sha 3 g at the time of uterine pain is also useful 29

Recent researches have proven complementary and alternative treatment such as aroma massage, ^3,34 heat patch, ³⁵ acupuncture, ^9,36 self-care acupressure, ³⁷ exercise, ³⁸ physical activity, ³⁹ far-infrared, ¹¹ dry cupping, ⁴⁰ and herbs are useful in dysmenorrhoea.

Current Studies

Diet

A good diet reduces the chances of constipation. A constipated bowel increases the symptoms of dysmenorrhoea by pressing against the uterus when it swells before menstruation. The standard dietary advice applies: increase the proportion of whole meal foods, vegetables, salads, fruit, and water; and reduce refined carbohydrates, which have a constipating effect. A similar diet therapy has been advocated in Unani medicine. ^1,15,18,21

Atallahi et al reported that wheat germ extract was effective for treating dysmenorrhoea and its systemic symptoms, probably because of its anti-inflammatory effects. ⁴¹ Furthermore, they proposed that wheat germ activates neuropeptides, cytokines, and macrophages due to its anti-inflammatory properties and, hence, can decrease inflammation within 2 weeks. Anti-inflammatory properties of wheat can enhance blood circulation, remove blood stasis, and reduce pain. In addition, the positive effects of some components of wheat germ such as vitamin B₁₂, thiamine, pyridoxine, magnesium, and vitamin E on the intensity of dysmenorrhoea have been previously highlighted. Vitamin B₁₂ and vitamin E act as antioxidants and lower the levels of prostaglandins and leukotrienes; thus, they can relieve pain. The benefits of omega-3 plus vitamin B₁₂ in easing menstrual pains have been thoroughly described. Twice-daily supplementation with 200 units of vitamin E has been reported to reduce the duration and severity of primary dysmenorrhoea. ⁹

Physical Activity

Regular physical activity is another positive way of dysmenorrhoea treatment by which it may diminish the symptoms of dysmenorrhoea in exercising young girls and women. Mahvash et al studied the effect of 8 weeks of isometric exercise on primary dysmenorrhoea and reported that intensity and duration of pain induced by primary dysmenorrhoea are reduced and less medicine was taken. ³⁹ Similarly, Unani scholars advised avoiding strenuous exercises; however, regular physical activity is useful for the amelioration of pain. ^1,21

Hot Fomentation

The researchers assumed that abnormal and strong uterine contractions in women with dysmenorrhoea can decrease uterine blood flow and lead to ischemia that results in pain in the uterus. ¹¹ Another study recently observed that dysregulation of endometrial blood flow occurs in menstrual disorders. Unani scholars have advised that hot fomentation with warm water ¹⁵ or with decoction of various herbs such as baranjasif (Artemesia vulgaris), ^15,28 irsa (Iris ensata), or soya (Anethum sowa) or habbe al-ghaar (Prunus leaves) relieves uterine pain. Currently, these herbs are proven for their anti-inflammatory, antispasmodic, and analgesic effects. Additionally, heat causes an increase in blood flow to an area, improves tissue oxygenation, and dilution of intravascular bradykinin, prostaglandins, and histamine. Melzack’s gate-control theory can also explain the analgesia effect of local heat, massage, pressure, cold, and electrical stimulation for pain control via the nervous pathway. ³⁵

Navvabi Rigi et al in their randomized controlled trial compared the analgesic effect of iron chip containing heat wrap with ibuprofen for the treatment of primary dysmenorrhoea in 147 students (18-30 years old). They concluded that heat patch containing iron chip has comparable analgesic effects to ibuprofen and can possibly be used for primary dysmenorrhoea. ³⁵ Furthermore, the authors discussed that the physiological effects of thermal therapy act through vascular, nervous, and biophysical pathways. They also indicated that “local heat applied to the upper abdomen increases gastrointestinal motility and relaxes uterine musculature.”

Ke et al determined the efficacy of somatothermal far-infrared (FIR) belt using a parallel-arm randomized sham-controlled and double-blinded design on the management of patients with primary dysmenorrhoea. The authors demonstrated that the use of a belt made of far-infrared ceramic materials can reduce primary dysmenorrhoea. They summarized that

for women with dysmenorrhoea, the application of local heat can reduce muscle tension and relax abdominal muscles to reduce pain caused by muscle spasms. Heat can increase pelvic blood circulation to eliminate local blood and body fluid retention and diminish congestion and swelling, thereby enabling a reduction in pain caused by nerve compression. ¹¹

Previous studies also reported that the main cause of primary dysmenorrhoea is an abnormal increase in uterine prostaglandin level, leading to pain caused by uterine smooth muscle contraction. ⁴² Furthermore, Ke et al indicated that

FIR induced anti-inflammatory effects by inhibiting prostaglandin E2 (PGE2), and COX-2 elevation during inflammation. Therefore, reducing PGE2 by applying FIR may diminish uneasiness caused by dysmenorrhoea. ¹¹

Another study by Akin et al reported that a heating patch on the abdomen can be as effective as ibuprofen to treat dysmenorrhoea. They reported that local heat inhibits pain signals and increases proprioception. ^43,44

Hijamah bila Shart (Dry Cupping)

Sultana et al ⁴⁰ reported that hijamah bila shart was effective in ameliorating intensity of pain in dysmenorrhoea. Unani scholars surmised that application of the cups below the umbilicus leads to imalae mawad (shunting of morbid humors/blood) from the uterus toward the skin and decreases congestion, thereby suppressing the prostaglandin and release of β-endorphins that provide endogenous analgesia. Other concept for relieving of pain through dry cupping results from local lateral inhibition of Aβ sensory fibers in the spinal cord. The mechanism of psychogenic excitation of the central analgesia system is probably also the basis of pain relief by acupuncture ⁴⁰ and TENS. ¹⁰

Acupuncture

Smith et al proposed that acupuncture stimulation activated A-δ and C afferent fibers in a muscle. According to Smith et al,

During needle stimulation of acupuncture points such as SP6, SP8, and Ren 4 signals are transmitted to the spinal cord, and via afferent pathways to the midbrain. The perception of pain emerges from the resulting flow and integration of this information among specific brain areas and leads to a change in the perception of pain. The descending pain modulatory system is a key anatomical network that underlies the ability to change pain intensity. The associated improvement in dysmenorrhoea-related symptoms we propose are influenced by a subsequent mechanism arising from a release of neurotransmitters in relation to the integration of information from the neural pathways in response to needle stimulation. When these signals reach the hypothalamus and pituitary they trigger a neuroendocrine response. ^9,36

Auricular Acupressure

Acupressure involves the stimulation of acupuncture points and meridians without the use of needles. “Stimulating acupoint with pressure triggers the production of a morphine-like natural painkiller in the body called endorphins. Such acupressure promotes the secretion of neurotransmitters that lead to pain relief.” ⁴⁵ A systematic review of acupressure for primary dysmenorrhoea suggested that acupressure might be successful in the treatment of menstrual pain. ³⁷

Transcutaneous Electrical Nerve Stimulation (TENS)

It works by stimulating large diameter, cuntaneous, proprioceptic Aβ nerve fibers without activating the thinner Aδ and C pain fibers. In addition, TENS can stimulate the release of β-endorphins, which also help relieve pain. ¹⁰

Medicinal Herbs

Mudirr-i-hayd (emmenagogue) drugs are also useful for usr-i-tamth. Unani scholars surmised that usr-i-tamth is usually related to the viscous scanty menstrual flow. ^1,32 Furthermore, they opined that sudda (obstruction) in uterine blood vessels causes a decrease in blood flow to the uterus and leads to usr-i-tamth and qillat-i-tamth. Hence, Unani herbs with musakkin (analgesic), dafi’-i-tashannuj (antispasmodic), mudirr-i-hayd wa mudirr-i-bawl (emmenagogue and diuretic) properties are useful for pain relief and to increase the menstrual flow. Mudirr-i-hayd drugs have harr, mulattif, and mufatteh properties, ² and fluidizes blood to induce smooth blood flow, ³² dilates the uterine blood vessel, and increases blood circulation in uterine vessels, rectifies the functional defect of the uterus, ²² and consequently makes the blood flow easily through vessels and induces increased menstrual flow and relieves the pain.

Some herbs such as zanjabeel (Zingiber officinale Roscoe), ^46,47 saunf (Foeniculum vulgare Mill), ^48,49 gul surkh (Rosa damascena Herrm), ⁵⁰ zeera safaid (Cuminum cyminum Linn), baboona (Matricaria chamomilla L), ⁵¹ satar farsi (Thymus vulgaris L), ⁵² Noni (Morinda citrifolia L), ⁵³ sowa (Anethum graveolens L), ⁵⁴ hulba (Trigonella foenum-graecum L), ⁵⁵ combination of anisoon or saunf, zafran, ⁵⁶ chaturbeeja (Trigonella Foenum-graceum L, Lepidium sativum, Nigella sativa L, Trachyspermum ammi), ⁵⁷ hilteet (Ferula assafoetida L), and animal source such as fish oil ⁵⁸ are proven for their efficacy in dysmenorrhoea.

Studies have revealed that an inhibition of prostaglandin synthesis occurs during inhibition of COX-2 that could be exerted by nonspecific nonsteroidal anti-inflammatory drugs. These aforementioned herbs have useful effects such as anti-inflammatory, antipyretic, and analgesic. ⁴⁶ Therefore, nonsteroidal anti-inflammatory drugs are considered to be effective in the treatment of primary and secondary dysmenorrhoea as they can inhibit COX-2 and therefore prostaglandin synthesis and relieve pain. ⁵⁴

Ferula assafoetida (Hilteet) is currently scientifically and pharmacologically proven for its analgesic, antinociceptive, anti-inflammatory, and antispasmodic activity in animal models and are therefore helpful in reduction of menstrual pain. ⁵⁹

Anethum graveolens (Sowa)

Heidarifar et al ⁵⁴ in their randomized double-blind study found that Dill (Anethum graveolens) was as effective as a mefenamic acid in reducing the pain severity in primary dysmenorrhoea. They indicated that “dill seeds have tannin and anethol that have sedative effects though it increases the uterus contractions during and after child-bearing. Anethol cures anxiety, gastrointestinal comforts, and different pains.” Gharib Naseri et al believe that “the relaxant effect of Dill on the uterus contractions is due to close voltage-dependent calcium channels and also, indirectly, due to calcium-releasing disorders from the intracellular pool.” ⁶⁰ It is suggested that “opioid receptors, and α- and β-adrenoceptors are not involved in this inhibitory effect of Dill fruit hydroalcoholic extract on contraction.” ⁵⁴

Rosa damascena (Gul Surkh)

Bani et al investigated the effect of Rosa damascena extract on primary dysmenorrhoea in a double-blind crossover clinical trial and found that R damascena and mefenamic acid had similar effects on pain intensity. ⁵⁰ Hypnotic and analgesic effects of ethanolic extract of R damascena were shown in animals in studies performed by Rakhshandah et al, ⁶¹ who showed the analgesic and anti-inflammatory effects of hydroalcoholic extract of R damascena in mice. Boskabady et al investigated the relaxation effects of R damascena on pig tracheal and concluded that “ethanolic extract of R damascena has the effect of relaxation on the smooth muscle of trachea of an animal that is comparable to the effect of Theophylline.” ⁶² Mostafa-Gharabaghi et al in 2013 showed that the prescription of ethanolic extract of the fruit of Rosa damascena before cesarean section reduces the pain intensity of surgery and the need for analgesic drugs. ⁶³

Echinophora platyloba

Analgesic effect on dysmenorrhoea in Echinophora platyloba has been shown by Masoumeh et al. ⁶⁴

Matricaria chamomilla (Baboona)

Karimian et al, in their triple-blind randomized clinical trial study compared the effect of mefenamic acid and Matricaria chamomilla on primary dysmenorrhoea in 90 female students. They found that Matricaria chamomilla was effective in decreasing the severity of primary dysmenorrhoea and reducing hemorrhage. ⁶⁵ Modares et al in their study found that Matricaria chamomilla tea was effective in reducing primary dysmenorrhoea. ⁶⁶

Thymus vulgaris (Satar Farsi)

Salmalian et al in triple-blind comparative study concluded that 25 drop of Thymus vulgaris essential oil as well as ibuprofen were effective in reducing the severity of pain and spasm in primary dysmenorrhoea. ⁵² Jaffary et al found that analgesic and antinociceptive effects of hydroalcoholic extract and essential oil of Thymus vulgaris. ⁶⁷ The active material of Thymus vulgaris oil is thymol and carvacrol. Thymus vulgaris has an antispasmodic and antimicrobial effect. Jaffary et al showed that all 3 treatments (placebo, Thymus vulgaris, 1% and 2%) reduced the severity of dysmenorrhoea but the most effective treatment was Thymus vulgaris 2%. Salmalian et al used Thymus vulgaris and mefenamic acid on primary dysmenorrhoea that showed the mean pain intensity before treatment was not significantly different between the groups. After medication, the mean pain intensity was reduced significantly in both groups; however, no significant difference was observed in reducing pain measure between the Thymus vulgaris and mefenamic acid groups. ⁵²

Fenugreek (Hulba)

Younesy et al, in their double-blind, randomized, placebo-controlled trial, evaluated the effects of fenugreek seeds on the severity of primary dysmenorrhoea among students. They suggested fenugreek seed powder during menstruation can reduce the severity of dysmenorrhoea. The authors discussed that the antispasmodic effect of fenugreek on the gastrointestinal system has been recognized and the diuretic property of the fenugreek decreases pelvic hyperemia. Anti-inflammatory, antipyretic, and anti-anxiety effects of leaf extracts of fenugreek were proved in animal models. Phytochemical studies have revealed that alkaloids, glycosides, and phenols are the major components in fenugreek extracts. ⁵⁵

Zingiber officinale (Zanjabeel)

Awed et al ⁴⁷ in their Quasi experimental research design evaluated the effect of ginger herbs on pain relief of primary dysmenorrhoea among females carried out at Shagra city it the Kingdom of Saudi Arabia. They found that fresh ginger 3 days before and in the first 2 days during the menstruation were effective and succeeded in relieving menstrual pain among the females with primary dysmenorrhoea. Ginger, the rhizome of Zingiber officinale, is a traditional medicine with anti-inflammatory and anticarcinogenic properties. ⁶⁸ It contains several constituents such as gingerol, gingerdiol, and gingerdione, beta-carotene, capsaicin, caffeic acid and curcumin. It has been shown that ginger acts as an inhibitor on cyclooxygenase and lipooxygenase, resulting in an inhibition of prostaglandin synthesis. ^69,70 Therefore, ginger has been used as an anti-inflammatory acting by inhibition of prostaglandin synthesis. Other studies showed that ginger is an effective and safe therapy for relieving pain in women with primary dysmenorrhoea if administered at the onset or during the 3 days prior to menstruation. ^46,47 It showed that ginger was as effective as mefenamic acid and ibuprofen in relieving pain in women with primary dysmenorrhoea. ⁵¹ The anti-inflammation action of ginger is through inhibition of prostaglandin biosynthesis and leukotrienes.

Fish Oil

The main mechanism of 1000 mg/day fish oil capsule is the suppression of prostaglandin synthesis. ⁵⁸ In a study performed by Zamani et al, fish oil is as effective in the treatment of primary dysmenorrhoea. This study compared the effect of using 4 g/day fish oil and it was compared with placebo. This study shows that fish oil is more effective than placebo on primary dysmenorrhoea. ⁷¹ Zafari et al found that the efficacy of fish oil was better than ibuprofen in the treatment of severe pain in primary dysmenorrhoea. ⁵⁸

Zafari et al also found that acupressure, fish oil capsules, and ibuprofen had similar effects in curing dysmenorrhoea. ⁷² According to studies conducted,

Consumption of fish oil causes the production of prostacyclin, which brings about a reduction in the contraction of myomeres and in the contraction of the vessels of the uterus, which, in turn, decreases ischemia, and reduces the intensity of dysmenorrhoea. Increasing the omega-3 fatty acids content of the diet brings about an increase in the inclusion of these fatty acids into the structure of cellular membranes. ⁷¹

In the study conducted by Deutch et al, ⁷³ the effectiveness of treatment with fish oil and seal oil was compared with that of a combination of fish oil and vitamin B₁₂, and it was found that the curative effect of fish oil and vitamin B₁₂ was more stable. ^73,74

Foeniculum vulgare (Badiyan)

Bokaie et al concluded that the efficacy of fennel drop 2% in pain relief in primary dysmenorrhoea is comparable to the efficacy of common nonsteroidal anti-inflammatory drugs such as mefenamic acid. ⁴⁸ F vulgare plant is an antispasmodic and can relieve menstruation pain. ⁷⁵ Another randomized, double-blind, placebo-controlled pilot trial also found that the magnitude of the reduction was significantly greater in the saffron, celery seed, and anise extracts group than in the mefenamic acid and placebo group. Both drugs effectively relieved menstrual pain as compared with the placebo. ⁵⁶ Moslemi et al also found that fennel was useful in dysmenorrhoea. ⁷⁶ F vulgare contains an antispasmodic and anethole agents. Fennel seeds were one of the acceptable herbal drugs of primary dysmenorrhoea in Iran. Fennel is an accepted herbal medication for treatment of dysmenorrhoea in Iranian culture. ⁴⁸ Omidvar et al studied the effect of fennel on pain intensity in dysmenorrhoea and found that 52% of patients in the study group (vs 8% placebo) considered the effect of treatment excellent. ⁷⁷

Chaturbeeja

In folk medicines, Chaturbeeja (combination of seeds of 4 plants, ie, Trigonella Foenum-graecum, Lepidium sativum, Nigella sativa, Trachyspermum ammi in equal quantity) has been traditionally used for a variety of applications including treatment of dysmenorrhoea, the most common gynecological symptom reported by women. A single-blind, prospective observational clinical study evaluated the efficacy of Chaturbeeja powder (3 g single dose with hot water) for 10 days (7 days prior to menstruation and 3 days during menstruation) in 25 patients of primary dysmenorrhoea (Kashtartava). It was observed that 12 patients had marked, 8 had moderate, and 5 had mild improvement. ⁵⁷

Morinda citrifolia (Noni)

Fletcher et al in their randomized double-blind placebo-controlled trial found that Morinda citrifolia (Noni) was effective in reducing pain during menstruation in primary dysmenorrhoea because of its anti-inflammatory property. ⁵³

Honey (Asl)

Honey has been used medicinally since ancient times. A single-blind crossover study was carried out on 60 female students with primary dysmenorrhoea. Pure honey consumption in women, who suffer from primary dysmenorrhoea, reduced significantly the severity of pain and amount of bleeding. It can be considered as an alternative treatment approach in affected women. ⁷⁸ Pure honey contains

a currently unidentified plant-derived compound with antimicrobial activity, and they have anti-inflammatory properties; and because of having enzymes, minerals, and prostaglandins, they are effective in alleviating pain (menstrual pain, backaches, headaches, etc). Moreover, pure honey opens body capillaries and vessels and controls menstrual bleeding. Pure honey decreases the concentration of the prostaglandins of the blood. Therefore, it seems that pure honey can be used as a remedy for menstrual pain. ⁷⁸

Effect of Medicinal Herbs on Primary Dysmenorrhoea: A Systematic Review

Mirabi et al, ⁷⁹ in their systemic review of 25 randomized controlled trials, found evidence regarding the use of herbal medicine for treating dysmenorrhoea in comparison with pharmacological treatment. The clinical trials were carried on Foeniculum vulgare (8 articles), Mentha piperita extract (1 article), Zataria multiflora (1 article), Valeriana officinalis (2 articles), Cinnamomum zeylanicum (1 article), Zingiber officinale (2 articles), Matricaria chamomilla (1 article), Stachys lavandulifolia (2 articles), Echinophora platyloba (1 article), Cuminum cyminum (1 article), Vitex agnus-castus (1 article), Menstrogol (2 articles), Menastil (1 article), and Achillea willhemsii (1 article) herbs. The review included 8 randomized double-blind clinical trials, 5 randomized single-blind clinical trials, 4 triple-blind studies, and 7 unblinded studies. They suggested F vulgare as a safe and efficacious plant. It seems that it can be used in the treatment of dysmenorrhoea. However, the results were limited by methodological flaws. Further rigorous placebo-controlled randomized controlled trials are recommended.

Conclusion

Unani manuscripts are very much enriched with information related to menstruation and pelvic pain/uterine pain/dysmenorrhoea and its management with diet therapy, hijamah bila shart (dry cupping), takmeed (hot fomentation), nutool therapy, and medicinal herbs with antispasmodic, analgesic properties such as ginger, rose, fenugreek, cumin, and so on. These herbs in recent times are pharmacologically proven for their anti-inflammatory, antispasmodic, and analgesic activities. Thus, traditional knowledge validation and protection is mandatory and prerequisite for prospective research and valuable for use in the modern-day era.

Authors’ Note

This article is drawn from Greco-Arabic classical manuscripts, journals, and dissertations (submitted to the Department of Amraze Niswan, Rajiv Gandhi University of Health Sciences) available in the National Institute of Unani Medicine library.