In a world where menstruating women still face taboos, Dr Syeda Ayeman Mazhar explores concepts and recommendations in Unani medicine known for millennia and the role of alternative approaches in painful conditions.

Due to this, she becomes psychologically disturbed and sometimes she even starts hating the monthly cycle which leads to the beginning of psychological trouble and cessation of menses. Sometimes, the girl due to her lack of knowledge and poor maintenance of personal and menstrual hygiene, may give rise to many critical health conditions.

The Unani system of medicine came into existence as a blend of the Greek and Arab systems. UNANI originated from the word IONIAN which designates its foundation to Greece. TIBB denotes medicine. (Park K. 1999) Unani physicians were the earliest to categorize the disease based on diverse anatomical and physiological indications of the body. Hippocrates elucidated that the disease was a typical process and its signs were the response of the body against the disease condition. (Khan AM 2009) Arab physicians familiarized the Unani system in India and took firm roots in the territory soon. The Unani System had its existence in India throughout the 13th and 17th centuries. Soon it spread all over the realm and persisted widespread amongst the masses.

An exceptional physician and scholar of Unani Medicine, Hakim Ajmal Khan (1868-1927) from the Sharifi family was the one, who kept the spirit high. (Hamdani 1998) Throughout history, menstruation has been viewed as an inescapable burden that women must endure. In Ancient cultures, taboos of menstruation were prevailing, owing to the man’s fear of the ‘mysterious flow’. A menstruating woman was kept isolated and confined, that too in cruel ways so that her ‘deadly contagion’ would not poison the earth, herself, and mankind. (Sue Reddish 2006). It is surprising to explore concepts and recommendations known for millennia and the role of alternative approaches in painful conditions.

Concept of tams/haiz (menstruation) in the Unani System of Medicine:

According to eminent Unani Physicians, haiz or menses is a bloody fluid matter that is released from the uterus of every fit and healthy woman and continues from the uterus of the woman for some days. Its release starts from puberty till menopause every month at a regular interval of time, but its release is always stopped during pregnancy and lactation. (Jurjani 1878) (Jeelani ) (Qarshi (Fazlurrehman) (Ferozuddin) (Shareef)

ISTILAHI TAREEF (Terminological definition): Optimum menses is that which is appropriate in its quality and quantity, nor less neither more, releases at the time in accordance to a woman’s tabi’at and her nature and routine, and at a regular interval of its cycle. That type of menses enhances a woman’s health and well-being and additionally, it evacuates every morid matter from her body. (Anjum R 2001)

The Modern Concept of Menstruation:s
Modern physicians define this as follows: Menses is that natural bloody discharge which is released from the uterus under the influence of different hormones after getting stimulus from the hypothalamus-pituitary ovarian axis at regular intervals of time. Its release continues from the attainment of puberty till the attainment of menopause at a regular interval of time but its discharge is stopped during pregnancy and sometimes during lactation. (Dutta DC)(Dawn C S) (Pitchard) (Tindal VR)

Menstruation is the natural part of the reproductive cycle in which blood from the uterus exits through the vagina. (Wateraid.org. 2012) It is a natural process that first occurs in girls usually between the ages of 11 and 14 years and is one of the indicators of the onset of puberty among them. (Stefanie Kaiser 2008) The normal range for ovulatory cycles is between 21 and 35 days. While most periods last from 3 to 5 days, duration of menstrual flow normally ranges from 2 to 7 days. For the first few years after menarche, irregular and longer cycles are common. (Diaz A et.al. 2006)

Normal Menstruation

When the hormone levels decrease, the endometrium layer, as it has been changed throughout the menstrual cycle, is not able to be maintained. This is called menses, considered day 0 to day 5 of the next menstrual cycle. The duration of menses is variable. Menstrual blood is chiefly arterial, with only 25% of the blood being venous blood. It contains prostaglandins, tissue debris, and relatively large amounts of fibrinolysis from endometrial tissue. The fibrinolysis lyses clot so that menstrual blood does not contain clots typically unless the flow is heavy.

The usual duration of the menstrual flow is 3-5 days but flows as short as 1 day and as long as 8 days can occur in a normal female. The amount of blood loss can range from slight spotting to 80 mL and the average being 30 mL. Loss of more than 80 mL of blood is considered abnormal. Various factors can affect the amount of blood flow, including medications, the thickness of the endometrium, blood disorders, and disorders of blood clotting, etc. (Herbison AE 2020) There are various types of menstrual disorders, including dysmenorrhea, premenstrual symptoms, menorrhagia, polymenorrhea, abnormal vaginal bleeding, amenorrhea, oligomenorrhea, and irregular menstruation. Menstrual patterns can be affected by several factors, including age, ethnicity, family history, smoking, physical activity, and dietary habits. (Liu Y et.al. 2004)

Unani Elucidation of the Menstruation cycle: Menstrual blood is excreta the retention of which in the body, likewise withholding of other excreta (for example urine & stool) causes severe diseases or complications. In hale and hearty females, blood loss occurs at the age of puberty from 12-16 years. This takes place in some women at the gap of 22 days & usually occurs for 3, 4, 5 or 7 days. After 7 days, it stops on its own. The state ceases on its own when the women attain the age of 44-55 years. Throughout pregnancy & following delivery, this blood is utilized in the growth & development of the fetus. Menstruation terminates after pregnancy & it provides nourishment to the fetus in the uterus for nine months till its growth & development are accomplished. The waste materials from the fetal food are evacuated during puerperium. This blood converts into milk in the maternal breast throughout lactation from which the newborn acquires its nourishment. Other than these periods retention of this blood in the body, or irregular menses are considered diseases & if not treated well may complicate into severe diseases, for example, ascites, headache, melancholia, epilepsy, unconsciousness, indigestion, and anorexia. etc. (Khan Ajmal 1983) As per some Unani scholars, menses commences between the ages of 10-14 years & ceases at 36-60 years. The minimum duration of the menstrual cycle is two days & maximum is 7 days & if it exceeds this, there is a possibility of it being unnatural. The women whose intervals between the two cycles are prolonged then they sense extra pain. (Akbar Arzani)

Ibne Hubl Baghdadi stated that menses typically start at the age of 10-14 years. In cold geographical areas, the onset is late and in hot climates, there is an early commencement. Termination of menses normally occurs from 36-60 years of age. There is complete absence of this physiological process in hermaphrodites. The average duration of menstrual flow varies from 2-7 days, prolonged duration is a distressing sign of some underlying pathological condition. The time interval concerning two cycles is 23 days. Though cases have been recorded with extended duration of nearly 2 months in the absence of any illnesses. If the duration between the two cycles crosses the physiological range, it may cause amenorrhea. (Ibne Sina 2007)

Concept of Menstrual disorders in ancient Greek Medicine
Common menstrual disorders are Usr-e-tams wa Ehtabas-e-tams (Dysmenorrhoea and Amenorrhea) and Kasrat-e-Haiz (Menorrhagia) which females generally complain of. Dysmenorrhea means painful menstruation to enough extent that it debilitates day-to-day accomplishments. (Dutta DC 2004) Amenorrhea exactly means the absence of menstruation. (Dawn CS 1990) As per Unani’s perception, the volume of blood in usr-e-tams is less, consistency is thick with painful and problematic bleeding. Ehtabas-e-tams denotes the absence of menstruation may be with or without pain. (Qarshi MH 2011) Both conditions are symptoms and are not considered as the disease. Generslly, normal menstruation commences between 10-14 years of age and ceases between 36- 60 years. The minimum duration of normal menstruation is 2 days and the maximum is 7 days, if it deviates more than that then it is abnormal.

Menorrhagia is defined as cyclic bleeding at normal intervals, the bleeding is either excessive in amount (>80ml) or duration> 7 days) or both. (Dutta DC 2004)

Unani definition Kasrat e tams – excessive bleeding (>than normal) with or without pain due to superfluous blood or anomaly in the uterus. Too much cyclic bleeding is termed as kasrat-e-haiz and if bleeding happens beside menstrual days (acyclic/abnormal uterine bleeding) it is called as Istehaza. Treatment for both is the same. (Qarshi MH 2011)

TADABEER-E-HAIZA (Care of the Menstruating Woman):

Most often, the girl due to lack of awareness thinks of the changes during puberty and menstruation as a disease.

Due to this, she becomes psychologically disturbed and sometimes she even starts hating the monthly cycle which leads to the beginning of psychological trouble and cessation of menses. Sometimes, the girl due to her lack of knowledge and poor maintenance of personal and menstrual hygiene, may give rise to many critical health conditions.

Due to this reason, it is of utmost importance to make young girls aware of the menstrual cycle, that it is a normal physiological phenomenon, that it does not occur due to any abnormality or disease, but it’s a sign of good health.

Precautionary and Preventive measures during menses:
The following regimes should be kept in mind to avoid any disease or infirmity due to negligence and carelessness.
During menses, excessive and rapid movements along with mental exertion can be avoided. But light exercises can be performed e.g. playing tennis. Light exercises should be also beneficial in case of scanty menses. (Khursheed Azmi HKA) (Jeelani)
During menses, emotional disturbance such as anxiety, anger, depression, excessive joy, etc and other emotions that influence the temperament (mizaj) should be avoided and only daily mild to moderate activities are allowed. (Risala Tabeeb)
During menses, heavy and concentrated diets should be avoided. The diet should include proteins, fats, vitamins and iron and also contain fresh, green, leafy vegetables, and fresh fruits. Although the menstrual blood is considered toxic, its discharge causes significant loss of 1 mg of iron daily from the body. Thus, a balanced diet should be prescribed during the menstrual period.
In the winter season, intake of ginger, sesame seeds, etc. may be beneficial. (Khursheed Azmi HAS ) (Anonymous Risala Tabibunnisa)
Constipation during menses should be avoided. If the complaint of constipation arises, the leafy vegetables and papaya etc. should be taken and drinking plenty of water is advised. If this condition persists, then light Mulayyenaat (laxatives) should be taken. (Jeelani ) (Ferozuddin HM)
Penetrative sexual contact should be avoided during the menses (Surah Al-Baqarah: 222) During menstruation, personal and menstrual hygiene should be given utmost importance. The menstruating woman should keep herself, her surroundings, her clothes, her room and beddings clean. (Abdul Hameed HH) (Khursheed Azmi HAS) (Anonymous Risala Tabibunnisa) (Dutta DC)
Menstrual hygiene measures:
During the menstrual cycle, the principles of personal and menstrual hygiene should be maintained.

When the menstrual flow starts, the menstruating women must be counselled to use pads made of soft, neat and clean cloth locally.

These pads are commonly known as haiz ke jazib (absorbent of menses). (Khursheed Azmi HAS)

In the Indian scenario, most women use torn, old, and rough cloth as absorbent menses. It is very harmful. But some women are aware of hygiene and practising it, they use neat and clean cloth as absorbent menses. It is replaced when it is filled with blood.
But the most suitable practice is to use sanitary pads. These sanitary pads are easily available at medical stores and their use is favourable as they have the quality to absorb all the discharge efficiently and are beneficial for health.

However, some women develop sensitivity in the skin due to the use of sanitary pads on the vulval skin. To prevent this condition, intravaginal cups/tampons are used. They are more advantageous and easy to use. They are contraindicated in conditions like cervicitis, uterine canal stenosis, etc. The most common and dangerous side-effect of tampons is toxic shock syndrome. It was first reported in 1978 in the USA. Tampons cannot be used with the insertion of intrauterine contraceptive devices. (Khursheed Azmi HAS) (Dutta DC) (Tindal VR 5th Ed.)

Menstruating women should also be advised to take precautions that any chemicals may not enter the vulva and vagina such as powder, deodorant, and sprays which can cause extreme sensitivity. (Tindal VR 5th Ed.)

Along with the regimes mentioned above the general health of the menstruating women should be taken care of. Fresh, open air, sunlight, light exercises, sleeping early at night and waking up early in the morning, avoiding mental and physical exertions are a must to adopt.