Postmenopausal osteoporosis is morbidity found in peri and post-menopausal women. The term Menopause is made up of two words “Meno” and “Pause”. Meno refers to Menstruation (month) and Pause denotes, to stop, cessation. Therefore, menopause refers to “permanent cessation of menstruation”. This results from loss of ovarian follicular activity. Natural Menopause is recognized to have occurred after 12 consecutive months of amenorrhoea, for which there is no other obvious pathological or physiological cause. An adequate biological marker for the event does not exist.
The term Peri-Menopause is the period surrounding Menopause – before, during and after. The length of this period varies, but it is usually considered to last approximately 7 Yrs., beginning with the decline in ovarian function in a woman’s 40s and continuing until she has not had a menstrual period for 1 year.
Age at Menopause:
In India age varies between 45-50 yrs. average being 47yrs. It is generally not common for a woman to menstruate after 50 yrs. Delayed Menopause may be related to good nutrition and sound health. 1% of women have Menopause before 40 Yrs.
Following Menopause, due to deficiency of estrogen, there is loss of bone mass by 3-5% per year. As a result, arthritic changes often develop in the joints and in some women well-marked osteoporosis may be seen, particularly in the spine and pelvic girdle, which renders these bones liable to fracture.
By definition, osteoporosis is the reduction in the quantity of bone. According to W.H.O. osteoporosis is defined based on the following bone density levels:
- BMD is compared to two norms – healthy young adults (T-score) and age-matched (Z-Z score). A T-score within 1 SD (+1 or -1) of the young adult mean indicates normal bone density.
- A T-score of 1 to 2.5 SD below the young adult mean (-1 to -2.5) indicates low bone mass.
- A T-score of 2.5 SD or more below the young adult mean (> -2.5 SD) indicates the presence of osteoporosis.
Estrogen deficiency is a dominant pathogenic factor in bone loss. This can be noted for the first time during perimenopause. From 1.5 years before menopause to 1.5 years after menopause, spine bone mineral density (BMD) decreases by 2.5% per year, compared with a premenopausal loss rate of 0.13% per year.
In Ayurveda, Rajonivritti as a diseased condition is not described separately, though Rajonivritti Kala is mentioned by almost all Acharyas without any controversy. Here the word Rajonivritti means the end of Artava pravritti or cessation of menstruation. Rajonivritti is mainly a stage of Jaravastha. Acharya Sushruta and the other Acharyas mentioned 50 years as the age of rajonivritti, when the body is fully in grip of senility but Acharya Arundatta opines that the age mentioned above is a probable age and not a fixed one. Hence considering the variations, factors influencing it can be logically quoted as either environmental or the individuality of a woman including their Ahara- Vihara. During aging gradually Kshaya of all dhatus occurs due to dominant Vata Dosha. Acharya Charaka admitted the occurrence of Jaravastha (aging) from the age of sixty while susruta considered it at the age of forty. This event can be considered under Kala and Svabhaava. But when its onset occurs unduly it concludes as a disease. Vata vriddhi in this phase results in a much decrease of Asthi Dhatu. The possible etiopathogenesis of Rajonivritti- janya Asthi- Kshaya can be discussed as under:
Reasons of Asthi- Kshaya:-
- Sahaja Nidana: Abnormal or weak Beeja, Beejabhaga, Beejabhagavayava related to the formation of Asthi Dhatu if passed on to the Garbha at the time of conception may lead to weak and disease- prone Asthi Dhatu in the progeny. During the development of the fetus among the six Bhava, Pitrija Bhava is responsible for the formation of Asthi Dhatu. Therefore, Pitrija Bhava Dushti can be a cause of improper Asthi Dhatu Nirmana. Vata Dosha causes Asthi- Kshaya, women with Vata dominant Prakriti are prone to develop the disease. Ahara which aggravates Vata, lack of food intake or production of Ama in the body due to unwholesome or irregular dietary habits can be responsible for Asthi-Kshaya. Similarly, Vihara like Ati-karshana (Excessive dieting) of the body due to various reasons, Avyavama (without exercise), Divasvapna, wrong postures, Chinta, Shoka etc. aggravate Vata which leads to the imbalance of Asthi Dhatu proportion in the body.
- Svabhavaja Nidana: Postmenopausal osteoporosis is peculiar in women. This is due to women having genetically lower bone mass than men. In Ayurvedic texts, these are considered under Streekara Bhava.
- Jara: During Jaravastha, aggravation of Vata and Dhatu Kshaya are natural events so the degeneration in bones also occurs.
Lakshana of Asthi- Kshaya –
Falling of hair, nails and teeth, fatigue and looseness of joints are the signs and symptoms found in Asthi- Kshaya.
Pathogenesis of Postmenopausal Osteoporosis: –
- Rajonivritti-Janya Asthi- Kshaya is a disease concerned to Jaravastha and Asthi Dhatu hence Vata Dosha is a primary cause for its occurrence. Simultaneously Kshaya of Kapha occurs along with it. So, the symptoms related to Vata Prakopa and Kapha Kshaya bring out like Pain, dryness, weakness etc.
- This disease is related to Asthi and its Mala – Nakha and Kesha. Among them, Asthi is the main place affected by it.
- In Jaravastha, due to vitiation of Jatharagni formation of Dhatu does not occur because Jatharagni affects both Dhatvagni and Bhutagni.
- Initially, the disease involves Bahya Roga Marga but later on, due to the severity of it, Madhyama Roga Marga like Asthi Sandhi also become involved.
Prognosis
As the disease is affecting majorly in asthi (bone) and due to aging, the disease is considered as yapya (difficult to cure). So preventive management is better for it.
Management:
The treatment of Asthikshaya includes Nidana Parivarjana (Avoidance of etiological factors), Shodhana (Bio purification), Shamana (Palliative treatment), Rasayana (Rejuvenation) and Pathyapathya (Proper diet).
- Nidana Parivarjana (Avoidance of etiological factors): The individual suffering from Asthi Kshaya must avoid excessive indulgence in etiological factors responsible for vitiation of Vata, a decrease of Kapha like excessive exercises, unwholesome diets including dry, spicy food intake
- Shodhana Chikitsa (Biopurification): It is indicated in Bahudoshaavastha. Vaghbhatta had mentioned this in Asthikshayachikitsa. Acharya Charak has given a similar line of treatment for Asthi Pradoshaja Vikara which includes Panchakarma, especially Basti which contains Kshira, Ghrita and Tikta Dravya.
- Shamana Chikitsa (Palliative Treatment): The main aim of Ayurvedic therapy in Asthigatvata includes Vatashamak, Tarpak (nourishing) and Brimhan treatment. The Dravya which are of Swayoni i.e., similar to the respective dhatu is to be used for the treatment of the respective dhatu Kshaya. Here, in Asthi Kshaya, Dravya similar to Asthi dhatu should be used. The use of Taruna Asthi (mild bones of fish) increases the Asthi dhatu. The use of Asthi in its transformations i.e. Bhasma (ash) will also increase Asthi dhatu. Keeping this principle in mind many preparations are used in Ayurveda. Preparations like Ajasthi Bhasma, Kurma Prishthasthi Bhasma, Kaparda Bhasma, Praval Bhasma, Mrigashringa Asthi Bhasma, Asthi Bhasma of other animals etc.
- Rasayana: Rasayana is a boon for menopausal women and proves very good effects on females in the menopausal period. Rasayan drugs like Shatavari, Vidari, and Kumari reduce fatigue and vaginal dryness. For psychological symptoms, like irritability, anxiety, or depression, there are very effective drugs like Brahmi, Jyotishmati, Shankhapushpi can be given. Osteoporosis is the disease of Jaravastha. Jara is classified under Svabhavaja Vyadhi which becomes Yapya by Rasayana treatment. Some commonly used Rasayan drugs are Dwitiya Brahma Rasayana, Tritiya Triphala Rasayana, Chathurtha Triphala Rasayana, Chyavanaprasha Rasayana, Shatavari Rasayana, Shilajatu Rasayana etc.
Role of Basti- in Ayurveda Basti treatment is considered as a prime treatment modality. Lipid soluble drugs are absorbed by passive diffusion and some of the active ingredients are absorbed through active transport. The bioavailability of the drugs is higher when given as Basti. Modern medical science also suggests some of the nutrient enemas meant for the nutrition of the body, where absorption of carbohydrate, fat and protein is mentioned. Some popular oil preparations can be effective which are Kshirabala Taila, Chandanabala Lakshadi Taila, Dhanvantara Taila, Balaguduchyadi Taila, Balashwagandhadi Taila, Lakshadi Taila, Mahalakshadi Taila etc.
