HTML Full Text

Introduction

Menopausal osteoporosis is emerging as one of the major communal health problems. Menopause known as Rajonivrutti; is related to ageing process in Ayurveda1 Dhatukshaya occurs because of ageing. Artav which is upadhatu of Rasa dhatu starts declining in consequence to the decline of Rasa dhatu .The function of reproductive organs and secondary sex charachters also tapers down.50 years is mentioned as Rajonivrutti Kala is mentioned  by  almost  all  Acharyas.2

Natural menopause has been defined by World Health Organization (WHO) as at least 12 consecutive months of amenorrhea not due to surgery or any other cause.3 The mean age at natural menopause (ANM) is 51 years in industrialized nations, while it is 48 years in poor and non-industrialized nations. Reduced production of estradiol, the most active form of estrogen as well as increased levels of follicle-stimulating hormone (FSH) and decreased levels of inhibin are observed in menopause.4 Most women experience near complete loss of production of estrogen by their mid?fifties. This results into hot flushes, Heart Discomfort, Sleep Problems, Depressive mood, Irritability, Anxiety, Physical & Mental Exhaustion, Sexual problems, and Dryness of Vagina while joint and muscular discomfort.5

Menopause and Osteoporosis : Pathophysiology

Bone metabolism occurs throughout life. There are three phases in bone metabolism. In the resorption phase, osteoclasts generate an acidic microenvironment between the cell and the surface of the bone, dissolving or resorbing the mineral content of the bone.  In the reversal phase osteoclasts undergo apoptosis and osteoblasts are recruited to the bone surface. In the formation phase, osteoblasts then deposit collagen; this is mineralized to form new bone. Bone metabolism involves repetitive turnover cycles for formation of bone osteoclasts and osteoblast. Osteoclast, breaking down the bone structure, referred as bone resorption and bone osteoblast building up the bone structure, known as bone remodeling. In women estrogen is needed to keep a healthy balance between bone resorption and bone remodeling. During menopausal stage; estrogen deficiency leads to increase in osteoclastic resorption whereas osteoblastic activity ; i.e bone deposition is reduced. There is increase in cytokines and IL-1, IL-6, and TNF.6

Rajonivruttijanya Asthikshaya :

In Ayurveda, menopause is depicted as Jarapakwaavastha manifesting into rajonivrutti. Ageing is associated with anuloma dhatu kshaya( degenerative changes) in the body. In Jaravastha (Ageing); Vatadosha is dominant .7 Predominance of vata manifests into symptoms like nidranash (insomnia), Chinta (anxiety), urinary symptoms, rukshata (dryness of vagina) and asthikshaya(osteoporotic changes) .Symptoms like hot flushes (sarvangdaha and swedadhikya), krodha(anger) and irritability are due to Pitta predominance. As said earlier;Vata is a predominant dosha in ageing process. Asthi is adhishthan of Vata.8 When Vata increases, there is kshaya of asthi. As ageing process, gradually muscles become flaccid, joints lose their hold, ,bones are devoid of reticular tissue, reproductive tissue declines and ojas starts depleting.9 Vatavruddhi leads to Asthikshaya and Asthisaushirya. Asthikshaya is “decrease in the bone tissue” and Asthisaushirya means “porous bones”. Acharya Hemadri explains “Saushirya” as “Sarandhratvam” which means “with pores”.10 Osteoporosis means the decline in the bone tissue. Osteopeniamis a pre-stage (prodromal symptom) of osteoporosis. Osteopenia presents with decrease in the bone mineral density and asthivedana (pain in bones). In rajonivrutti ,Majjakshayais followed by asthikshaya after fundamental of anulomkshaya.

According to Sushrutacharya; asthi remains in its own state even after death for a long time.11Kshayais ‘Kshiyateanenaiti Kshaya’; ‘Kriya kshayakaratwattu Kshayaityucyatebudhaihi’; ‘Kshayavyadhi visheshaha’12 . Decreases in quality and /or quantity is kshaya. Asthikshaya is decrease in bone tissue. Asthikshayadis plays as asthibheda, (asthishula (pain in bones), keshalomanakha, smashru, dantavikara and paata (disorders of hair, nails, teeth), sandhi shaithily (flaccidness of joints), rukshta (dryness). Asthidhatwagnimandya leads to the abnormality in the transformation of poshakadhatu (Dhatu specific nutrients) into poshya/sthayiasthidhatu, resulting in Asthidhatuvikriti. Generalized osteoporosis may be primary or secondary. Primary Osteoporosis is often due to aging and natural menopause in women. Osteoporosis caused or worsened by other disorders or medication exposures is referred as ‘Secondary Osteoporosis’. Bone mineral density (BMD) is the most important tool for the diagnosis of osteoporosis. The gold standard for measuring BMD is the dual-energy X-ray absorptiometry (DEXA) densitometer, a specialized X-ray device that precisely quantifies BMD at the spine, femur, and other skeletal site. Therefore screening of women post age of forty must be encouraged.

Symptoms :

Menopausal women usually show following symptoms :

1. Ushnaanubhuti Daha (Hot flushes)
2. Mutradaha(burning micturition),
3. Yonidaha,
4. Santapa
5. Krodha (anger),
6. Trushnakshudhadikyata (excessive thirst and hunger)
7. Svedaadikyata (Excessive sweating),
8. Glani (drowsiness),
9. Shirashoola (Headache),
10. Balakshaya (Weakness),
11. Vibandha (Constipation),
12. Anidra/Alpanidra (Sleeplessness),
13. Anavasthitachitatvam(Mood swing),
14. Chinta (Anxiety),
15. Krichchhra Vyavayata(Loss of libido),
16. Maithuna asahishnuta (Dyspareunia),
17. Sandhivedana (Joint pain),
18. Yoni Shushkata (Vaginal dryness).

Management :

Ahara (Nutrition) : Diet having low calcium, magnesium and vitamin-D; smoking or tobacco in any form, lack of exercise (sedentary life style), alcoholism, advanced age, history of fracture as an adult are etiological factors in postmenopausal osteoporosis. The nutrients of most standing to bone health are calcium and phosphorus, since they compose 80-90 percent of the mineral content of bone. Adequate calcium intake is important, with the current NOF guidelines recommending 1200 mg daily for women. Absorption of calcium citrate may be as much as 24% more than with calcium carbonate. In postmenopausal women, the intake of vitamin D should be in addition to sunlight exposure. 180-350 ug /day Vitamin K may be needed. Dried plum in its whole form has been observed to prevent bone loss in postmenopausal women, with long-lasting bone-protective effects.12 Postmenopausal women who previously consumed 100 g dried plum per day during one-year clinical trial retained bone mineral density to a greater extent than those receiving a comparative control.13

A dietary pattern study encouraged the intake of fruit, vegetables, whole grains, poultry and fish, nuts and legumes, and low-fat dairy products and discouraged the intake of soft drinks, fried foods, meat and processed products, sweets and desserts, and refined grains showed a beneficial impact on bone health. Overall, devotion to a healthy dietary pattern can improve bone mineral status and reduce the risk of osteoporosis.14

Vihara :Lifestyle modification; Aadequate physical activity is needed for maintaining bone health. Randomized clinical trials show that exercise training can prevent /minimize/reverse almost 1 % bone loss per year in both pre and postmenopausal women.15

Yoga and pranayama: Structured yoga- asanas, Pranayama, and Suryanamaskar induce improvement in BMD in postmenopausal osteoporotic female. Motorwala  et al have reported Improvement in T-score of DEXA scan.16

Walking as a singular exercise therapy for 6 months has shown significant effects on BMD at the femoral neck.17

Discussion

Menopause is inevitable. Ayurveda describes menopause as Rajonivrutti and it is a part of ageing process (jaravastha).There is anuloma kshaya in jaravastha where Rasa, rakta, Mamsa ,meda asthi, majja and shukra dhatu start depleting. Asthikshaya in menopausal women is of concern as this may lead to fractures. Ayurvedic management of menopausal asthikshaya is based on bringing homeostasis of vata, pitta and kahpa dosha . Ayurveda takes integrated approach in prevention and treatment of a disease. Rajonivrutti kala affects body and mind both. Therefore though the manifestation is asthidhatu kshaya ; there is indeed an involvement of manas doshas. Ayurveda takes care of body ,mind and soul while treating the patient. As the predominance of Vata is seen menopause the vatashamak dravyas along with Basti is highly recommended. There ia also an association of Pitta dosha ; which is manifested through hot flushes. In these cases; different types of ghruta fortified with pittashamak herbs are beneficial.

Conclusion

Menopause has been considered as a part of Jaravastha (Ageing process). Due to ageing; the risk of low bone mass and osteoporosis (Asthikshaya) is also increasing. The diet, lifestyle , medicines and Panchkarma can help in the maintenance of bone health. These modalities reduce osteoporosis , enhance bone remodeling. Herbs that are rich in phytoestrogens ,exercise, calcium and vitamin D supplementation can slow down the process of Asthikshaya. There is a scope of more clinical work to be done in this direction.