Etiopathogenesis of Amenorrhea (Iḥtibās al-Ṭamth) in Unani medicine: A narrative review

INTRODUCTION

Amenorrhea is the absence of menstrual bleeding in women of reproductive age ^{[1, 2]} and is classified into two types: primary and secondary. Primary amenorrhea is defined as the absence of menarche by 14 years of age in the absence of secondary sexual characteristics, or the absence of menses by 16 years of age in the presence of normal growth and secondary sexual characteristics. ^{[3, 4]} Secondary amenorrhea is characterised by the cessation of previously regular menses for three months or previously irregular menses for six months. ^{[3, 5]} Amenorrhea is not considered a diagnosis in itself; rather, it represents a common clinical manifestation of underlying reproductive dysfunction ^[6]. According to WHO estimates, amenorrhea is the sixth-largest cause of female infertility, affecting 1.5-3% of all women of childbearing age. ^[7] The causes and pathophysiology of amenorrhea in modern medicine are primarily hormone-based. It is influenced by five key factors: a normal female chromosomal pattern, a well-coordinated hypothalamic-pituitary-ovarian (HPO) axis, an anatomically intact and functional outflow tract, a responsive endometrium, and adequate support from the thyroid and adrenal glands. The major causes of amenorrhea include: 1. Dysfunction of the Hypothalamic-Pituitary-Ovarian (HPO) Axis ^{[8, 9]}: (a) Hypogonadotropic hypogonadism (low gonadotropins leading to ovarian insufficiency); (b) Hypergonadotropic hypogonadism (high gonadotropins due to ovarian failure) 2. Thyroid and Adrenal Gland Disorders: Dysfunction of these endocrine glands can impact menstrual regulation 3. Metabolic Disorders: Conditions such as juvenile diabetes can contribute to amenorrhea. 4. Systemic Illnesses: Diseases like tuberculosis, anaemia, malnutrition, and significant weight loss can disrupt menstrual cycles. 5. Structural and Anatomical Abnormalities: Trauma or injury affecting the reproductive system, Uterine abnormalities such as Asherman’s syndrome, Tubercular endometritis, Polycystic ovary syndrome (PCOS), and Premature ovarian failure.^{[3-6,10,11-17]}

In the Unani system of medicine, diseases of the reproductive system are described in detail, though more emphasis is placed on symptom descriptions rather than a systematic approach. In classical Unani literature, Ihtibās al-Tamth is defined as the cessation of menstruation, which may range from a scanty flow to a complete cessation or occur at intervals of two months or more.^[18] According to Abbas Majoosi, menstrual flow and its cessation are governed by the body’s ṭabῑ‘at (innate natural power). Menstruation typically begins between the ages of 8 and 14 and continues until about the age of 60. In Khinsi women, who possess both male and female physical traits but predominantly female characteristics, menstruation does not occur. The duration of menstrual bleeding should not be shorter than 2 days or longer than 7 days; anything beyond this is considered abnormal. ^[18] As menstruation approaches, a woman may feel a heaviness in her body, and those with longer menstrual periods often experience more intense pain as the blood exits the body rapidly. 

Unani physicians have described the etiopathogenesis of Iḥtibās al-Tamth in detail. Understanding the maḥiyat (pathogenesis) from a Unani perspective is particularly important in the field of gynaecology, as most diseases in conventional medicine are hormone-based, leading to limited treatment options and potential side effects. This paper explores the asbāb (causes) and maḥiyat (pathogenesis) of Ihtibās al-Tamth in a more organised and systematic manner, and may help elucidate the disease’s course from a Unani point of view.

MATERIAL AND METHOD

A systematic review was conducted using both offline and online sources. Offline sources included Maulana Azad Library (MAL) and Ajmal Khan Tibbiya College Library (AKTC) at AMU, Aligarh, along with the Regional Research Institute of Unani Medicine (RRIUM) and various seminar libraries. Online sources comprised databases like Cochrane Library, PubMed, Scopus, AYUSH Portal, Internet Archive, Google Scholar, Research Gate, and Rekhta Books. Primary sources consisted of original works by renowned Unani scholars, such as Al-Qānūn fi’l Ṭibb, Kāmil al-Ṣanā‘a al-Ṭibbiyya, and Kitāb al-Kulliyyāt. Secondary sources included translated classical texts and books like Kulliyāti-Qānūn and Jame ul Hikmat. Tertiary sources involved journal articles, dissertations, and other relevant publications.

CAUSES OF IḤTIBĀS AL-ṬAMTH

DISCUSSION

In Unani medicine, Iḥtibās al-Tamth has been elaborately described with reference to its types, causes, and pathogenesis, which are discussed in this section.  Iḥtibās al-Tamth (amenorrhea) refers to the cessation of menstruation,^[19,20] which can range from a scanty flow to complete absence, or it can occur with intervals of two months or more.^[18,21] This condition is marked by either primary amenorrhea (absence of menstruation from the beginning) or secondary amenorrhea (cessation of menstruation after it has begun)^[21]. Menstruation may completely stop, decrease in quantity, or extend beyond two months. According to Sahib-e-Kamil, normal menstruation typically begins between 10 and 14 years of age and ceases between 36 to 60 years. The usual menstrual cycle ranges from 20 to 60 days; if it exceeds this duration, it is considered abnormal and termed Ihtibās al-Ṭamth ^[21]. General Causes of Ihtibās al-Ṭamth are: Viscosity of humors ^{[22, 23],} Narrow uterine veins ^{[24, 25],} Weakness of the Quwwat mumaiyaza or Quwwat Dāfi‘a (excretory power) ^[26], and Strong Quwwat Hāḍima (digestive power) ^{[21, 27].} Asbāb that causes sudda: Due to excessive obesity, the menstrual passage becomes blocked or obstructed ^{[25, 26, 27]}. The cause of (obstruction) Sudda is due to a healed ulcer or thickening or hardening of tissues, such as a callus, hypertrophic flesh, or fatty tissue ^[28]. The cause of menstrual cessation is an obstruction in the uterine vessels where menstrual blood flows, and this obstruction occurs due to a cold temperament, which weakens uterine muscles and closes the mouth of these vessels ^{[26, 27]}. Lean and thin means that there is excessive weakness in the body ^{[21, 27, 28]}. Uterine and Ovarian diseases (e.g., inflammation of the uterus, Leucorrhea, inflammation of the ovary, bladder, or uterine ulcers, etc.)^{[18, 23, 24, 29]}. Other causes: Excessive use of cold substances ^{[28, 29]}. Excessive emotional stress ^[29]. Chronic malaria and tuberculosis ^[29]. Anaemia ^{[21, 24, 25, 29]}. Sometimes it may be due to Hunger or a deficiency of nutrition ^[26]. The blood in the body is not enough to keep the fuḍlā ḥayḍ in the body, or even forms that can be expelled through menstruation. It may occur due to Blood scarcity caused by a chronic disease that dries up the body’s fluids, leading to amenorrhea ^[28]. Sometimes it is caused by excessive evacuation, or it may occur under certain conditions. Excessive anal bleeding, severe nasal bleeding, or any form of haemorrhage from the body causes excessive loss of blood. As a result, ṭabῑ‘at is not able to perform its normal function; it gets diverted, and hence menstruation stops ^{[18, 21, 26, 28]}. Asbāb within Rahim; uterine injury ^{[18, 26, 28]}. The cause of amenorrhea is a wound or abortion ^[28]. Excessive heat in the uterus causes dryness ^[24]. If the uterus is displaced or tilted to one side, such that its mouth is directed away from the vaginal opening, then menstrual blood may not flow properly ^[23,24]. Other causes of amenorrhea are Nāṣūr (Non-healing Uterine ulcers) ^[25]. Menstrual bleeding stops due to interference with other organs, such as when the weak liver fails to produce sufficient menstrual blood, so blood cannot be expelled from the body, leading to amenorrhea ^{[21, 23, 26, 29]}. Weakness of the (stomach) Mi‘da affects digestion, and when digestion is impaired, blood production decreases, which leads to amenorrhea ^[28].

Through a thorough literature review, the general causes of Ihtibās al-Ṭamth were classified into Asbāb-i-Maraḍ, i.e., Asbāb Wāṣila, Asbāb Bādiya, and Asbāb Sū’-i-Mizāj, i.e., Asbāb Mubarrida, Asbāb Mujaffifa, Asbāb Musakhkhina, as shown in Table 1. The pathogenesis of Iḥtibās al-Ṭamth (Amenorrhea) in Unani medicine is associated with an imbalance in the Mizāj (temperament) and derangements in the Quwa of the uterine system. As illustrated in Figures 1 and 2. Classical Unani literature indicates that Sū’-i-Mizāj Ḥārr Yābis Māddī and Sū’-i-Mizāj Bārid Māddī of the uterus can cause Iḥtibās al-Ṭamth, which aligns with the findings of this study. In Sū’-i-Mizāj Bārid Māddī, Asbāb Bādiya, Asbāb Wāṣila, and Asbāb Mubarrida contribute to the development of Sū’-i-Mizāj Bārid Māddī of the uterus. Due to Asbāb Mubarrida and Asbāb Bādiya, constriction of vessels leads to obstruction and ultimately. Blockage of the menstrual flow, leading to retention of menstrual blood ^{[18, 22, 23, 25-27]}. This results in Iḥtibās al-Ṭamth. Additionally, Asbāb Mubarrida causes the humors to solidify ^{[21, 27, 28, 29]}, leading to the accumulation of humor, and fluid does not flow; it becomes stagnant. Moreover, Asbāb Mubarrida and Asbāb Wāṣila weaken Quwwat Dāfi‘a ^[26], leading to the retention of menstrual flow, and cause Iḥtibās al-Ṭamth ^{[22, 30]}.

In Sū’-i-Mizāj ḤārrYābis Māddī, Asbāb Wāṣila, Asbāb Bādiya, Asbāb Mujaffifa, and Asbāb Musakhkhina contribute to the development of Sū’-i-Mizāj ḤārrYābis Māddī of the uterus. Firstly, due to the predominance of heat in the body as well as in the uterus, fluids become dry ^{[23, 24, 25]}. Secondly, Excessive emotional stress causes the (spirit) Rūḥ to move outward and away from the body ^[29], and internally, it causes dryness within the body. Due to the dryness of the humor, menstrual blood is not eliminated, and a state of retention and stagnation occurs, resulting in Iḥtibās al-Ṭamth ^[30].

CONCLUSION

Iḥtibās al-Tamth is becoming more common today due to lifestyle changes, stress, and poor nutrition. It can lead to problems such as infertility, weak bones, delayed physical and emotional growth, and poor overall health. Understanding its causes and mechanisms through the Unani system helps in achieving better diagnosis and treatment.

Unani scholars have explained the causes of amenorrhea in great detail. They describe it as resulting from changes in temperament (Sū’-i-Mizāj), imbalance in body humors (Akhlāṭ), weakness in the uterine faculty (Quwa), or blockage in the uterine passages. By identifying the exact cause, treatment can be planned according to Unani principles, which focus on restoring balance in the body naturally.

In modern medicine, many gynaecological problems, such as PCOD, AUB, and premature ovarian failure, still lack clear causes and complete cures. Most treatments rely on hormones, which may have side effects. Unani medicine, with its holistic and temperament-based approach, offers a broader and more natural understanding of the disease process. Therefore, studying the Unani concept of etiopathogenesis can help improve the management of amenorrhea and related disorders even in the modern era.

ACKNOWLEDGEMENT: None stated.

FUNDING: No Funding.

COMPETING INTEREST: No competing interest.

REFERENCES

1. Munro MG, Balen AH, Cho S, Critchley HOD, Díaz I, Ferriani R, Henry L, Mocanu E, van der Spuy ZM. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. The FIGO ovulatory disorders classification system. Int J Gynaecol Obstet. 2022 Oct; 159(1):1-20. [PMC free article] [PubMed]
2. Munro MG, Balen AH, Cho S, Critchley HOD, Díaz I, Ferriani R, Henry L, Mocanu E, van der Spuy ZM. FIGO Committee on Menstrual Disorders and Related Health Impacts, and FIGO Committee on Reproductive Medicine, Endocrinology, and Infertility. The FIGO Ovulatory Disorders Classification System†. Hum Reprod. 2022 Sep 30; 37(10):2446-2464. [PubMed]
3. Kumar P, Malhotra N. Jeffcoate’s Principles of Gynaecology, 7th ed.New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2008.
4. McIver B, Romanski SA, Nippoldt TB. Evaluation and management of amenorrhea. Mayo Clin Proc. 1997 Dec; 72(12):1161–8. https://doi.org/10.4065/72.12.1161. PMid:9413300
5. Biernbaum SL. Primary Care Medicine. 6th ed. Lippincott Williams & Wilkins; 2009:836–43.
6. Gynaecology Gynaecology Gindoff PR, Jewelewicz R. Gynaecology and Obstetrics. Lippincott Williams &               Wilkins; 2004.
7.  Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Williams Gynaecology. New York: McGraw-Hill; 2008.
8.  Klein DA, Paradise SL, Reeder RM. Amenorrhea: A systematic approach to diagnosis and management. Am Fam Physician. 2019 Jul 1; 100(1):39–48. [PubMed]
9.  Gibson SM, Fleming N, Zuijdwijk C, Dumont T. Where have the periods gone? The evaluation and management of functional hypothalamic amenorrhea. J Clin Res Pediatr Endocrinol. 2020 Feb 6; 12(Suppl 1):18–27. [PMC free article] [PubMed]
10.  Dutta UR, Ponnala R, Pidugu VK, Dalal AB. Chromosomal abnormalities in amenorrhea: a retrospective study and review of 637 patients in South India. Arch Iran Med. 2013; 16(11):632–8.
11.  Berek JS, Novak E. Berek & Novak’s Gynaecology. 15th ed. Philadelphia: Lippincott Williams & Wilkins; 2012.
12.  Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams Gynaecology. New York: McGraw-Hill Education; 2016.
13.  Catherine HJ, Adam BH. Primary amenorrhea: investigation and treatment. Obstet Gynecol Reprod Med. 2007; 17(8):247–52.
14.  Quilligan EJ, Zuspan FP. Current Therapy in Obstetrics and Gynaecology. 5th ed. Philadelphia: WB Saunders; 2000.
15.  Obeagu EI, Obeagu GU. Gut mucosal immunity in HIV-exposed infants: a review. Asian J Dent Health Sci. 2024; 4(2):50–5. https://doi.org/10.22270/ajdhs.v4i2.82
16. Mortimer CH, Yeo T. Gonadotropin-releasing hormone. J Clin Pathol. 1977; 30(7):46–54. https://doi.org/10.1136/jcp.s1-7.1.46. PMid:801478 PMCid:PMC1436119
17. Ransom SB. Practical Strategies in Obstetrics and Gynaecology. 1st ed. London: WB Saunders; 2000. https://doi.org/10.1016/S0015-0282(00)00648-8
18. Majoosi AIA. Kamil us Sana. Vol. 1. New Delhi: CCRUM; 2010.
19. ‌Qarshi HNH. Jame-ul-Hikmat. New Delhi: Idara Kitab-ul-Shifa; 2011.
20. Arzani A. Mufarreh ul Quloob. New Delhi: Idara Kitab- ul- Shifa; 2002.
21. Khan MA. Akseer-e-Azam (Urdu translation by Kabiruddin HM). New Delhi: Idara-e-Kitab-ul-Shifa; 2011.
22. . Sina I. AAHIA. Kulliyat-e-Qanoon (Urdu Translation by Kabiruddin HM) New Delhi: Aijaz Publication House; 2015.
23. Razi AMBZ. Kitabul Hawi. (Urdu Translation by CCRUM) Vol. 9. New Delhi: CCRUM Ministry of H&FW; 2010
24. Arzani A. Tibbe Akbar. New Delhi: Idara Kitab-ul-Shifa, 2008.
25. Raban Tabri A. Firdaus-ul-Hikmat. New Delhi: CCRUM; 2010. Ibn Sina. Al Qanoon Fil Tib (Urdu translation by Kantoori GH). New Delhi: Idara Kitab-us-Shifa; 2007.
26. Jurjani. Zakheera Khawarzam Shahi (Urdu translation by Khan AH). New Delhi: Idara Kitab-us-Shifa; 2010.
27. Baghdadi IH. Kitabul Mukhtarat-fil-tib (Urdu translation by CCRUM). Vol 4. New Delhi: CCRUM; 2007.
28. Jilani G. Makhzinul Hikmat. Deoband: Faisal Publication; 2009
29. Nafis IB. Kulliyat-e-Nafisi (Urdu Translation by Kabiruddin HM) New Delhi: Idara Kitab-us-Shifa; 1954.
30. Qarshi HNH. Jame-ul-Hikmat. New Delhi: Idara Kitab-us-Shifa; 2011.
31. Razi AB. Kitab-ul-Mansuri. New Delhi: CCRUM; 1991.
32. Qamri AMH. Ghina Mana (Urdu translation). New Delhi: CCRUM; 2008.
33. Khan HA. Haziq. New Delhi: CCRUM; 2002.
34.  Rushd I. Kitab-ul-Kulliyat. New Delhi: CCRUM; 1987.
35. Chandpuri K. Mujazil Qanoon. 3rd ed. New Delhi: Qaumi Council Barae Farogh Urdu Zaban; 1998.
36. Samarqandi NU. Moalejate Shareh Asbab translated by Kabeer Uddin. 3rd ed. New Delhi: Idara Kitab ul Shifa, 2014.