Introductory

False notions due to ignorance and superstition regarding menstruation continue to have such a powerful hold on the imagination of most women that irregularities in the menstrual cycle are looked upon with great fear, suspicion and grave concern.

They talk of the accumulation of ‘poisons’ in the system, think of premature onset of menopause, become scared at the prospect of an unwanted pregnancy or shudder at the misfortune of a sterile life and some even get haunted by the nightmare of ‘cancerous disease’.

This anxiety aspect of irregular and scanty menstruation assumes practical importance in the clinical management of the condition in general practice, apart from its other physiological, pathological and psychological aspects.

Classification

It is indeed difficult to classify menstrual disorders as we have to deal with varying symptoms and not with clear cut disease entities. The text-book picture of anyone single disorder is not generally found in clinical practice but more than one of these coexist in one or other of the cycles.

The term irregular and scanty menstruation comprises:

(1) Oligomenorrhea in which the cycles are lengthened. It is closely related to amenorrhoea, but a precise clear-cut differentiation between the two is often difficult.

(2) Polymenorrhoea where menstruation occurs at shorter intervals than the normal average cycle.

(3) Hypomenorrhoea where the menstrual discharge is scanty in quantity. It is often found along with oligomenorrhea.

Management

A complete history-taking and physical examination are always necessary in these cases in order to eliminate any systemic disease, endocrine dysfunctions, local pelvic disorders.

Malnutrition, psychic disturbances, and unfavourable living conditions or occupational environments have also to be considered though it is difficult to change the last one for most of the patients.

General measures like diet, and where possible adjustments or changes in living or occupational environments, exercise, and reduction of obesity should be adopted besides the selected line of treatment.

Psychotherapy

Anxiety being the main feature of these disorders, simple psychotherapy may prove helpful if the busy physician can spare the time for it.

Patiently listening to the patient’s complaints produces confidence and reassurance to the patient and her tension may be relieved.

A clear and sympathetic explanation of the basic mechanism of the menstrual cycle in simple language gives confidence and results in success of the treatment.

There are instances where women menstruate at their very first visit to a physician or when a specimen of blood is taken for tests and investigation.

Serious and chronic mental symptoms should however, be referred to a psychiatrist.

Sex-hormones

Steroids and gonadotropins have proved somewhat disappointing in inducing ovulation or restoring or regularizing menstruation.

This is perhaps due to the fact that they act as a substitute therapy while the real cause of the disorder remains untreated.

And hence their indiscriminate use is to be avoided.

Selection of drug

Many patients do not however, benefit to any appreciable degree even after one or more of the above measures have been adopted.

It was considered, therefore, desirable to investigate the usefulness of aloes, which was used with myrrh and iron for menstrual disorders before the introduction of hormones.

In the present study, a compound of aloes (Alarsin) with known pharmacology was selected, as its ingredients appeared to me to be suited to deal with the causes of these disorders to a certain extent.

Pharmacology and chemistry

1. Aloes indica

(Samsk: Ghrita Kumari. Eng.: Indian aloes. Guz.: Kunvar. Mahr.: Korphad. Tel.: Kalba India. Tamil: Katthalai, Kumari. Can.: Kathaligida. Mal.: Kattavala. Bengali: Ghrit Kumari).

Its active principles are glycosides, aloin, traces of an essential oil resin gum with small quantities of anthraquinone derivatives.

It is an appetizer with a bitter taste; it is digestive, laxative, antiseptic and indirectly emmenagogue.

By stimulation of the pelvic circulation, it causes congestion of the uterus and is used in menstrual irregularities.

2. Balsamodendron myrrh

(Samsk.: Vola, Rasagandha. Eng.: Myrrh. Hind.: Bol. Beng.: Gandbarash. Can.: Bola. Mahr.: Hirabol. Bom.: Bhensa Bol. Td: Balintrapolum. Tam.: Vellaippap-Olam).

It contains essential oil, is bitter to taste and contains resin-myrrh.

It is haematinic, appetizer and emmenagogue.

When orally administered, it is excreted by the mucous membrane of the genito-urinary tract which it stimulates, disinfects and regulates.

It is used in amenorrhoea caused by anaemia along with iron and also in painful and scanty menstruation.

3. Iron (iron in bhasma form)

It is a reputed preparation for anemia and debility.

It is considered to be free from the side-effects of iron therapy, like constipation or blackening of teeth.

Along with myrrh it has been used in irregular menstruation due to anemia.

4. Rubia cordifolia

(Samsk.: Manjista. Eng.: Indian madder. Bom.: Itari. Tel.: Tamravalli. Tamil.: Manjitti. Mal.: Point).

It contains a glycoside man Justin.

It is sedative and anti-inflammatory, tonic and astringent.

It acts on the uterine muscles through the nervous system.

Used in scanty menstruation, amenorrhoea, after delivery and in endometritis.

5. Peganum harmala

(Samsk. and Hindi: Hurmal. Eng.: Syrian rue. Bengal: Isbaod. Guz.: Hurmuro. Mahr.: Harmala. Telugu: Shimaloranti. Tamil: Shimaiazhavanavirai.)

Its seeds contain three alkaloids harmine, harmaline and harmalol.

It is anti-spasmodic, sedative, abortifacient and emmenagogue.

Used in amenorrhoea, dysmenorrhoea. Harmal is described in Indian Medicine as alterative, aphrodisiac and lactagogue.

Selection of patients

Patients were selected at random from the outpatient department of the Hospital.

They complained of persistent irregular menstrual periods with prolonged inter-menstrual periods of scanty flow.

They had been previously treated elsewhere along usual lines. But as their complaints persisted they evinced a great desire of their own accord to have this treatment.

Their willing co-operation enabled me to collect useful observations.

They received the Aloes compound only.

About 50 patients were thus treated. The detailed reports on nine typical cases out of these fifty are given below.

Case Notes

CASE No. 1 - M.R., aged 35

With complaints of pre-sterility, scanty menses following operation on 3-12-1951; frequent attacks of cold off and on.

(1) Investigations: Chest screening and skiagram revealed nothing abnormal; R.T. tubes blocked; and Eosinophilia: T 10,672, E. 35%.

(2) Obstetric and gynaecological examination: A well-built and well-nourished woman with no other disease was operated for Tubo-ovarian masses on both sides on 3-12-1951.

Bil. Tubo-ovarian masses of tubercular nature. Tubo-ovarian masses on the right side removed - salpingostomy on left side done - D and C was done later on 29-6-1959.

Very scanty endometrial tissue obtained which was not sufficient for histopathology: pre-sterility - married since 15 years - was treated for a long time for hypomenorrhoea with drugs including hormone preparations.

Menstrual history: 1-2-3/1½-2-2½ months; pre-menstrual tension syndrome +. Past menstrual history before 10 years 3-4/4-5.

Pelvic examination: D and F shifted to left - P.S. NAD - AV Mass Rt. Fx. tender.

Last M.P.: Before 10 years.

Treatment with Aloes compound: Started on 23-1-1961 - 2 tablets t.d.s.

Observations: L.M.P. 15-1-1961: flow for 3 days scanty. L.M.P. 11-2-1961: flow better 3 days. L.M.P. 12-3-1961: flow better than before treatment but less than 11-2-1961. L.M.P. 8-4-1961: flow better.

Remarks: Satisfactory.

CASE No. 2 - R.I., aged 22

With complaints of irregular menses, married three years but no issue.

(1) Investigations: Ova of hookworm +; R.T. done tubes patent 25-1-1961. Husband’s semen NAD. Urine nil abnormal. Hb.: 85%; R.B.C.: 4.01 mill/cmm.

(2) General examination: RS/CVS-NAD; Str. Liv. Scanty; Sec, sex well-developed; well built; slight anemia; B.P. 110/70.

(3) Obstetric and gynaecological examination: Pre-sterility.

(4) M. History: 5-6/2-4 months flow scanty - no dysmenorrhoea - 3 years since Menarche since 4 years.

(5) Pelvic examination: CX D and B conical - Ut.: A.V. smaller in size Fx. Rt. Palpable - Lt. Clear.

(6) Last M.P.: 20-9-1960 to 27-12-1960.

(7) Treatment with Aloes Compound: Started on 27-12-1960.

(8) Observations: L.M.P. 19-1-1961: flow 5-6 better. L.M.P. 1-3-1961: flow 5 days better. L.M.P. 14-4-1961: flow 4-5 days better.

(9) Remarks: D and C done on 1-5-61. Endometric showed normal secretory phase. Had her period again on 20-5-1961, but very much less probably due to D and C.

CASE No. 3 - M.J., aged 37

With complaints of scanty irregular menses for 1 year and giddiness, attributed to scanty menses.

Investigations: Urine: normal; Hb 10.9 gms.; R.B.C. 3.9 mill/cmm.

General examination: Obese; anaemia; no vitamin deficiency signs; RS-CVS: NAD; B.P. 130/80 mm.

Obstetric and gynaecological examination: No dysmenorrhoea; 5 F.T.N.D. 13, 11, 9, 8, 7 years ago - 2 alive; L.D. 7 years 6 ago - breast feeds given for 1½ years.

M. History: 1-2, 24-26 days scanty since 1 year. 2-3/26-28 days before.

Pelvic examination: Cx: D and F.; Ut.: R.V. mobile falls back; Fx.: clear.

Last M.P.: 5-3-1961 scanty for day only.

Treatment with A.C.: Started on 11-3-1961 - 2 t.d.s.

Remarks: Patient benefited by treatment.

CASE No. 4 - H.S., aged 38

With complaints of irregular scanty menses for 2 years and pain in lower abdomen off and on.

(1) General examination: Well built, obese +, no anaemia; no sign of deficiency; B.P. 110/70; RS/CVS/CNS: NAD; other treatment received: nil.

(2) Obstetric and gynaecological examination: H/past illness: nil; 4 F.T.N.D. L.D.: 3 years ago; only one child alive. Not nursing.

(3) M. History: 1-2 ys/2-3 months, irregular scanty. No dysmenorrhoea - no other complaint.

(4) Pelvic examination: P.V. CX D and F; A.V.N. size, Fx: clear; P.S.N.D.

(5) Last M.P.: 7-3-1961.

Treatment with A.C.: Started on 13-3-1961, 2 tablets t.d.s.

Observations: L.M.P. 7-3-1961: flow scanty - for only a day. L.M.P. 15-4-1961: flow scanty - for 2 days. L.M.P. 19-5-1961: flow better ++ for two days only.

Remarks: Quantity of flow was more and patient was satisfied with flow. She discontinued treatment as she left Bombay; was re-examined after 4 months. Pelvic findings same. Periods were not as regular as before. L.M.P. 27-8-1961 and 3-10-1961: flow better 1-2 days.

CASE No. 5 - K.R., aged 35

With complaints of no issue though married 15 years; pre-sterility and irregular scanty menses for last 5 years.

Investigations: Urine: trace of sugar; otherwise normal referred for fasting blood-sugar. 12.7-’61 124 mg./100 cc. fasting urine: clear; R.T.: tubes blocked.

General examination: C. good; Obesity: ++ no anaemia; STI: stomatitis; RS/CVS: NAD; B.P. 148/80 mm. Hg.

Obstetric and gynaecological examination: Slight incapacitation caused; dysmenorrhoea a day previous to period and on 1st day; pre-sterility.

M. History: Menarche: does not remember the age. Present M.P. 1-2 days / 1-2-3 months irregular scanty since 5 years. Slight dysmenorrhoea. Past M.H. 3-4/26/28 flow ++ 5 years ago.

Pelvic examination: CS: D and B; Ut: R.V.N. Size; Fx.: clear; Fungus infection of the vulva.

Treatment with A.C.: Started on 1-7-1961: 2 t.d.s.

Observations

Remarks: Throughout her treatment her periods were more or less regular - bleeding increased to some extent. She was relieved of the discomfort she used to feel at the time of her periods.

CASE No. 6 - H.Y., aged 27

With complaints of secondary sterility and irregular scanty menses.

Investigations: Endometrial biopsy on 20 days of cycle showed secretory pattern.

General examination: Well built; slightly emaciated; RS/CVS: NAD; conjunctiva: no anaemia; B.P. 110/70; a bald tongue stomatitis. Bowels and micturition normal.

Obstetric and gynaecological history: Pain, bodyache at the time of menses. Married 8 years ago; 1 F.T.N.D. 5 yrs. ago male child. No other complaint.

M. History: Pre-menses history day / 1-1½ months. Flow scanty since 3 yrs. Past M.H. 2-3/4-5 weeks; flow normal. Menarche: at the age 14 yrs. L.M.P. 2-7-1961 after amenorrhoea of two months.

Pelvic examination: CX: D. and F - Ex appeared normal on P.S. Ut: R.V. mobile, N. size brought F. Fx. clear.

Last M.P.: 2-7-’61.

Treatment with A.C.: Started on 6-7-‘61 - 2 t.d.s.

Remarks: This patient showed no improvement in the amount of flow; although the periods were more or less regular throughout the treatment.

CASE No. 7 - L.J., aged 24

With complaints of pain in the lower abdomen; scanty irregular periods for 2½ years; pre-sterility; married since childhood.

(1) Investigations: R.T. done on 8-8-’61. Tubes patent. Husband’s semen was normal.

(2) General examination: Well built, no deficiency symptoms; no anaemia. Secondary sex characters well developed; R.S./C.V.S.: NAD; B.P. 125/80 mm. Hg.

(3) Obstetric and gynaecological examinations: Married since childhood; pre-sterility.

(4) M. history: Menarche at the age of 14 (roughly about 10 years ago). P.M.H. 4-5/28-30 for 1 year before 2½ years. Present M.H. 4-5/11-11-21 since last 2½ years flow scanty. L.M.P. 28-8-Sl; no dysmenorrhoea, pain few days before menses, in the abdomen.

(5) Pelvic examination: P.V. Ex.: D and F; Ut.: R.V. mobile, normal size; Fx.: Rt. ovary palpable; Lt. N.A.D.

(6) Last M.P.: 28-6-1961.

(7) Treatment with A.C.: Started on 11-7-’61 2 t.d.s. for 3 months.

Observations

Remarks: Patient showed good response during the above treatment and the drug was well tolerated.

CASE No. 8 - J.K., aged 26

With complaints of pain in the abdomen for 2 years; scanty menses; pre-sterility - married 6 years.

(1) Investigations: Urine: N.A.D.; Endo biopsy on 5-3-’61 - proliferative phase; R.T. done on 25-7-61 tubes patent.

General Examination: Well built; no obvious signs of vitamin deficiency; not anaemic; no history of any illness; secondary sex characters well-developed; R.S./C.V.S.: N.A.D.

Obstetric and gynaecological examination: No dysmenorrhoea; lower abdominal discomfort slight at the time of menses - married 6 years; no issue.

M. History: Present M.H. spotting only 2-3 months since 2 years; P.M.H. 2-4/26-30 days flow N. before 2 years; Menarche at the age of 14; L.M.P. 11-7-’61.

Pelvic examination: P.V.: 15-7-1961 D and B; Ex.; A.V.N. size, a palpable cystic ovary; Right Fx. and left Fx.: N.A.D.; R.S.: N.A.D.

Last M.P.: 11-7-1961.

Treatment with A.C.: Started from 15-7-’61. 2 t.d.s.

Observations

Remarks: First period after amenorrhoea of 2 months; second period after about 41 days; next period after 35 days.

CASE No. 9 - B.M., aged 21

With complaints of irregular scanty menses: Married since 6 years but pre-sterility.

(1) General Examination: Well built; slight anaemia. No deficiency symptoms; R.S./C.V.S./C.N.S.: NAD., BP. 125/80 mm. Hg.

(2) Obstetric and gynaecological examination: Pre-sterility: Married since 6 years.

(3) M. History: P.M.H. 2-3 days/2-3 months since last 3 years.

(4) Pelvic examination: CX: D and B; Ut.: AV. smaller in size; Fx.: clear; P.S. Endo-cervicitis.

Last M.P.: 1-11-1960.

(6) Treatment with A.C.: Started on 21-1-1961; 2 t.d.s.

(7) Observations: L.M.P. 16-2-1961; flow 4 days improved. L.M.P. 14-3-61; flow 3 days less than before but still better. 20-4-61: flow for 3 days - better; patient was satisfied. 22-5-61: flow for 3 days scanty but better than before.

(8) Remarks: This patient was seen again after about 6 months without treatment. There was again a tendency to irregular menses after 5 to 6 weeks but the flow was better.

Observation

There was definite improvement as regards the regularity of menstrual cycles in most cases. In some of the cases there was even an increase in the quantity of the menstrual flow.

Summary

(1) The practical importance of management of irregular and scanty menstruation in general practice is stressed;

(2) The present day management and the usefulness of Aloes compound are mentioned.

Acknowledgement

My grateful thanks are due to Messrs. Alarsin Pharmaceuticals, Bombay 1, for their assistance in this clinical trial.