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Introduction

The climacteric, perimenopausal transition, is a multi-year phase that bridges the reproductive years and old age, encompassing the time leading up to the final menstrual period (menopause) and extending several years beyond. By the year 2026 estimated population of India will be 1.4 billion, people over the age of 60 will be 173 million and menopausal population is going to be 103 million which constitutes around 12% of the total population [1]. The current circumstances necessitate a concerted focus on this critical issue. Taking into account the life expectancy of women in developed countries, it has been shown that the post-menopausal period constitutes one third of a woman’s lifetime. The term climacteric is derived from a Greek word “klimacter” literally means critical point, climacteric is a critical transitional period in  a woman's life when she approaches menopause[2] Climacteric is a transitional phase encompassing pre and post which is marked by hypoestrogenic state leading to systemic osteoporosis, mood swings, decreased concentration, physical symptoms like weight gain, fatigue, central obesity, sleeplessness, decrease libido, and emotional shifts along with halting ovarian hormones and sexual activity which includes pre menopause, menopause and postmenopausal period. Menopause can significantly impact the well-being and family dynamics. Due to lack of awareness about menopause, cultural stigma surrounding menopause, limited access to healthcare services, busy schedules and prioritising family needs, fear of hormone replacement therapy (HRT), many women in midlife often suffer in silence compromising their physical and emotional health.

Stages Of Climacteric

Climacteric includes pre menopause, menopause and postmenopausal period.[3]

PRE-MENOPAUSE: Menopause is a natural process, in this phase ovulation may become erratic & then gradually stop. Menstrual cycles lengthen and flow may become irregular, profuse before the final period. This stage begins about 8 to 10 years before menopause. Once women enter in the pre menopause phase, oestrogen production starts to decline and it disturbs the balance with progesterone.

MENOPAUSE: Menopause is defined as amenorrhea for 12 conservative months. This marks the end of reproductive age. At this stage, the follicular pool decreases and nearly becomes null and there is decline in the oestrogen production. There is also disturbance in the hypothalamic-pituitary ovarian axis, this marks the end of the menstrual cycle.

POST MENOPAUSE: A Stage following menopause characterised by decrease in ovarian hormones which in-turn increase the risk of osteoporosis, Osteopenia, cardiovascular disease.

Factors affecting menopause

Stress factor: stress triggers cortisol release affecting hormonal imbalance, impacting neurotransmitter

Addiction: Addiction like smoking &Alcohol intakes affect menopause.Smoking accelerates ovarian ageing leading to early menopause,it constricts blood vessels worsening cramps.

Alcohol disrupts oestrogens and progesterones level leading to irregular cycles

Secondary diseases: Secondary diseases like Hypothyroidism, ovarian cyst, cushing's disease, endometriosis, PCOD, etc. cause early menopause.

Obstetric History has a possibility that nulliparous will have early menopause compared to multipara.

Lifestyle changes: lifestyle changes like Eating processed food, lack of work out, sleeping late, stressful life, improper diet.

Types of menopauses [4]

1. Natural menopause: Amenorrhea for 12 consecutive months due to natural decline of ovarian hormones oestrogen and progesterone. It starts after 40 yrs of age.
2. Induced menopause: Induced menopause caused due to any underlying cause or due to treatment for associated disease. like Amenorrhea,

Surgical removal of both ovaries, oophorectomy, iatrogenic ablation of ovarian functions i.e. chemotherapy.

1. Premature menopause: Premature menopause characterised by cessation of menstruation before the age of 40 years. Causes include - Hereditary, Surgical removal of ovaries, hysterectomy, Premature ovarian failure, Autoimmune disorders like Hashimoto's diseaseetc, Stress and lifestyle changes, Associated disorders like Epilepsy, hypothyroidism, cushion’s disorder etc.

Ayurvedic Review

The term rajonivrutti (menopause) can be coined for menopause. Rajonivrutti (menopause) is the part of jaraavstha (old age). In which the human body is in constant deterioration where the dhatus keep on receding. Rajonivrutti (menopause) is a swabhavikavastha.  The artava (oven) which is seen every month begins at the age of 12 and ceases at the age of 50 due to jaraavastha (old age) in which streesharira (female body) gets jeerna and body is fully in grip of senility [5]. Chakrapanitika also shares the same viewpoint [6]. It is a common observation that the physiological state of the body does not remain one and the same throughout the lifespan. These physiological changes of women’s life are divided into 3 different stages that are Balyaavstha (childhood), praudhaavstha (young age), jaraavastha (oldage). Considering the total lifespan of an individual according to Charak and Sushrut is 100 years and jaraavastha (oldage) beyond 60 and 70 years respectively. Parashar says the period ofBalaupto 8 years is considered as Gauri, Rohiniupto 9 years, Kanyaupto 10 years and above that age is Rajaswala (menstruating women) [7] According to Yogratnaka, Madhyamavastha[8] is further classified into Taruni and Adhirudha in which there is vrudhi of pitta dosha (increase in pitta dosha). Hence, the RajoNivrutti (menopause) phase is dominated by vatadosha, pitta is in madhyamavastha and kapha is in hinaavastha. Though the word rajonivrutti (menopause) has not been mentioned in ayurveda, rajonivrutti kala (menopausal phase) has been explained by almost all acharyas. Arundatta opines as the age is not fixed [9] for rajonivrutti (menopause)because it depends on ahar(diet) and vihar (lifestyle). A female having vatapradhanprakruti (vata dominant body constitution) indulging in ruksha (dry), shita (cold), laghu (light) or vatakaraaharvihar (vata dominant diet and lifestyle) will show vatajalakshanb(symptoms of vatadosha) more prominently than others, further resulting in an early menopause, Similarly kaphaprakriti(kapha body constitution)women will not suffer from same symptoms. Hence to conclude age is definitely not the only criteria to decide the preponderance of menopause. The factors responsible for Rajopravruttin(menarche) should also be considered a cause of rajonivrutti (menopause) including prakruti (body constitution) or svabhav, Kala (time), Dosha, Abhighat(accident ),Karma other factors like sarvasharirvruddhikar bhava explained by acharyaCharakkalyog, svabhavsansiddhi, aaharsaushtavam, abhighat[10]. Acharya Dalhana considered atisanshodhan, atisamshaman, vegadharan, asatmyaanna, manasantap, ativyayam, anashan, atimaithun leading to vataprakopa (increase in vata) can lead to akalajarajonivrutti that is premature menopause. [¹¹]

Samprapti of RajoNivrutti[12]

VataPrakopa is dhatukshayajanya

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rasa raktadhatuaadiposhana reducing

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raja Being upadhatu also show's depletion

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Artavavahasrotas also obtains rukshatashosha causes

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RAJONIVRUTTI

Management Protocol:Since this phase can't be avoided, acceptance is the key. Support care and love from family plays a major role in this phase. Consuming healthy food, exercising regularly, meditation, yoga, engaging in hobbies and regular health checkups are needed for smooth transition through this phase. Treatment protocols include Rasayanchikitsa, panchakarma, balya and jeevaniyaaushadhi, yoga and meditation, diet and lifestyle, counselling.

Panchkarma: Snehan with Bala, ksheerabala, mahanarayanTaila can be administered, Svedan like mruduswedan.  Basti- various basti such asYapanabasti, panchatiktaksheerabasti, bruhanbasti, Shirodhara, Nasya.

Rasayan Chikitsa: Rasayanchikitsa offers complete physiological and metabolic rejuvenation for ageing [13]. Drugs from different gana (groups) can be used according to different conditions like Jeevaniyagana, Brihaniyagana, Balyagana, Vayasthapanagana[14].

Basti Chikitsa: During rajonivrutti kala (menopausal period) there is dominance of vatadosha. In such conditions basti will play an important role as it is termed as Ardhachikitsa in vatavyadhi, AacharyaSushrut mentioned Basti as vayasthapayati[15].

Yapan Basti: The word Yapan means to maintain. Basti which can be given in sarvakala and helps in improving bala, shukra, mamsa[16]. In Chakrapanitika he says that yapanbasti does yapan of aayush and increases longevity of life [17]. Eg. of yapanbastiis Mustadiyapanbasti can be given in rajonivrutti kala (menopausal period) which has sadyobalajananeffect and acts as rasayan too.

Panchatiktaksheera Basti: Asthikshayalakshan are predominantly seen in (old age) and there is predominance of vatadoshas in which there is vayu and aakashmahabhutapradhana to pacify the asthikshayalakshanthis basti is useful, ksheer is madhur and pruthvi + jalamahabhutapradhanghrta is snigdhaagni, balavardhak and vatashamakTikta rasa has aakash + vayumahabhutasanghatan. It has the property of deep penetration and tends to go towards asthidhatuand even majjadhatu[18]. Since adhisthan of basti is pakvashay which is purishdhara kala though asthidhara kala has not been mentioned by acharyasushrut, but dalhan explains purishdhara kala itself is asthidhara kala [19]. Hence panchatiktaksheerabasti is very useful in nourishing asthi as well as majjadhatu.

Probable mode of action of shirodhara: Shira is the seat of pranavayu, tarpakakapha, pittadharakala closely resemble majjadharakala that in turn nurtures the nerves in the brain [20]. The scalp also serves as a site of bhrajakapitta which has an inseparable relationship with the hair follicles. Most of the absorption of the drug occurs through bhrajakapitta, through the dhatwaagni that helps do the pachana of the poured drugs over the scalp. As the scalp has various sebaceous glands, it causes dilation due to increased vascularity and helps to permit transfer of molecules. The scalp skin is the best route of administration of drugs due to comparatively thinner Epidermal layer richer blood supply Presence of Emissary which are valves and help in faster absorption [21]. But it is advisable to use drugs having properties of ushnatiknasukhmavyavahi and snigdha qualities. The benefits of shirodhara include producing hypnotic and a tranquilising effect. Regulates the neuro- endocrine system controls over the cortisol hormones thereby reducing stress, hot flashes and insomnia. The levels of serotonin decrease tasks relieving anxiety and mood swings. The effect depends upon the nature of the drug that is in use.

Discussion

Probable Mode of Action of Nasya: Oil that is poured through the nose through the shringatakamarma nourishes the mind due to nourishment of the tarpakakapha [22]. Removes the DosaSanghat and gives poshan to the brain.[23] All the action depends upon the type of drug used for nasya. Medicated oil shows its impact on the neuro endocrine system, it stimulates the olfactory nerves.  Which in turn stimulates the hypothalamic pituitary ovarian axis to release neurochemicals that work on ACTH hormone that regulates the secretion of cortisol. The benefits include Improving the thermo regulatory function That reduces hot flashes and excessive sweating. The hypothalamo pituitary ovarian axis Is also stimulated that decreases palpitation, irritability and mood swings.

Diet: Foods such as different Dhanya, dugdhaVargaphalavarga have to be consumed. Fruits have to be consumed as a whole fruit and not in the form of juices or shakes. Food that are to be avoided are cold dry fermented food articles, refined sugars, caffeine

Phytoestrogens: Phytoestrogens are also called dietary oestrogen. Since oestrogen is in decline in climacteric phase it has to be administered through some other form. Phytoestrogens are a diverse group of non-steroidal plant derived “POLYPHENOLIC COMPOUNDS” which exhibit structural similarity and mimic the effect of naturally occurring oestrogen compounds in the body. The effect of the following drugs containing phytoestrogens has been proved clinically, they are Ashoka, Shatavari, Vidari, Jatamansi, Punarnava, Aamlaki, Guduchi.

Yoga: Yogasana such as padmasana, trikonasana, bhadrasana, bhujangasana, shitali pranayama, tadasana, naukasana.Theseasanas increase blood circulation, concentration, stability, calms and soothes mind, stimulates different organs, decreases stress and anxiety, stimulates digestion.

Routine follows ups: Blood investigations like BSL, calcium, lipid profile. Periodic gyno check-ups like PAP, Vaginal, cervical smears, mammography to rule out any pathologies.

Conclusion

This conceptual study concludes as Menopause is a natural process and it is more than just an oestrogen deficiency. It's a complex life stage characterised by a multitude of symptoms that disrupt daily life. From an Ayurvedic perspective, menopause marks the Vata-dominant phase, leading to various symptoms.Additionally, Pitta and Vatadosha imbalances may also manifest during this phase. Ayurveda offers a comprehensive approach to manage menopausal symptoms through: Shamanchikitsa (mind-body balance), Tailored diet, Yoga, Meditation, Panchakarma procedures (detoxification and rejuvenation).

This conceptual study concluded as based on ayurvedic understanding of climacteric futuristic research may be planned. These therapies have proven exceptionally effective in improving psychological and cognitive well-being, making them an essential line of treatment for menopause management.