Dry Cupping Therapy: A Way Forward in the Management of Primary Dysmenorrhoea

Dysmenorrhea is a common gynaecological problem in women of reproductive age; in general, it begins with the first ovulation cycle and occurs about two years after menarche and most of the severe episodes occurs before 25 years of age. Primary dysmenorrhoea (Usre Tams Tashannuji) is one of the most common gynaecologic disorders, refers to painful menstruation. In classical Unani texts dysmenorrhoea is defined under topics like Ehtebas-e-tams and Waja-u-zahar and aujae rehm. Hijama (dry cupping) over the umbilicus removes the blood and fluid from the site of inflammation to give relief from the menstrual pain. It also diminishes swellings.


INTRODUCTION
Dysmenorrhoea is a Greek word, [1,2] Dys means ''difficult,''''painful,'' or ''abnormal''; meno is ''month''; and rrheais''flow,'' meaning difficult monthly flow [3,4]. The term dysmenorrhea refers to severe painful cramping sensation in the lower abdomen often accompanied by sweating, tachycardia, headache, nausea, vomiting, diarrhoea, and tremulousness occurring just Review Article before or during the menses [5]. Primary dysmenorrhea is defined as painful menses in women with normal pelvic anatomy usually begins during adolescence [6] and it occur about 50% of menstruating females [7].It is unusual for symptoms to start within first six months after menarche. Affected women experience sharp, intermittent spasm of pain usually concentrated in the supra pubic area. Pain may radiate to the back of the legs or the lower back. Pain usually develops within hours of the start of the menstruation and peaks as the flow becomes heaviest during the first day or two of the cycle [8].

INCIDENCE
More than 50% of post pubescent menstruating women are affected by dysmenorrhoea, with 10-12% of them having severe dysmenorrhoea with incapacitation for 1-3 days each month [9] Dawood [10]. Dysmenorrhoea is most common in women between the ages of 20 and 24 years, with most of the severe episodes occurring before 25 years of age [11].

Etiopathogensis of Dymenorrhoea
One reason that has been suggested as an explanation for primary dysmenorrhea is an increased production of uterine prostaglandins derived from cyclooxygenase (COX)-2 activities [12,13]. Studies have shown that an inhibition of prostaglandin synthesis occurs through inhibition of COX-2 that could be exerted by nonspecific non-steroidal anti-inflammatory drugs (NSAIDs). These drugs have useful effects such as antiinflammatory, antipyretic and analgesic [14,15]. Moreover studies have indicated that the conventional treatment for primary dysmenorrhea has a failure rate of 20% to 25%. [16]. The risk factors for dysmenorrhea are; age<20 years, nulliparity, heavy menstrual flow,smoking, high/upper socioeconomic status; attempts to lose weight, physical activity, disruption of social networks, depression and anxiety [11]. The conventional medicines prescribed for treatment of dysmenorrhea are NSAID and OCPs (prostaglandin inhibitors) that have notable side effects like nausea, stomach irritation, gastrointestinal ulcers and renal blood flow etc [4].

Unani Concept of Dysmenorrhoea
In Unani system of medicine dysmenorrhea is described under the heading of Usre Tams According Hakim Ajmal Khan, stated that Patient may become unconscious or faint due to severity of pain, restlessness. Patient feels heaviness in the pelvic area & pain in thighs, hips and in back.Back ache, heaviness in lower abdomen, pain occur before menstruation, nausea, vomiting. [17]. According to Hippocrate, usre tams occurs due to stagnation of menstrual blood secondary to cervical obstruction and causes painful menstrual period. According to Shaikhur Rayees Abu Ali Husain bin Abdullaha bin Sina Usre Tams occurs due to obstruction in the menstrual blood flow. He also described that if the menstrual blood is balanced in quality and quantity, the cycle is regular [18].

Spasmodic or primary dysmenorrhoea
It is usually life-long. It can cause severe and frequent menstrual cramping from severe and abnormal uterine contractions. In Unani, it is called "Usre Tams Tashannuji". The cause of primary dysmenorrhea is not well established. However, the responsible cause has been identified on the hyper-production of uterine prostaglandins, particularly of PGF2a and PGF2 [19]. While exploring the Unani literature in depth it is observed that the condition of spasmodic dysmenorrhoea is very much mimicking to balghami khilt or saudavi khilt [20].

Congestive or secondary dysmenorrhoea
This type is due to some physical cause. It usually starts later in life. It may be caused by another medical condition, such as pelvic inflammatory disease or endometriosis. In Unani, This type of dysmenorrhoea is known by the name of "Usre Tams Iltehabi.

Management of Dysmenorrhoea
Treatments for primary dysmenorrhoea are predominantly based on the three main theories of aetiology.
 On account of the PG-based etiology of primary dysmenorrhea, the current most common pharmacological treatment for dysmenorrhea is non-steroidal antiinflammatory drugs (NSAIDs) [21,22]. However, long-term use of NSAIDs has been associated with side effects such as headache, dizziness, drowsiness, loss of appetite, nausea, vomiting, gastrointestinal bleeding, increased acute asthma, dysuria, and acne but still it is used most commonly [23,24].  Oral contraceptives often used as secondline therapy. The synthetic hormones in oral contraceptives suppress ovulation and reduce the thickness of the endometrial lining of the uterus, thereby reducing the volume of menstrual fluid, PG synthesis and dysmenorrheic pain [25][26][27]. However, a recent meta-analysis has confirmed the long-suspected association between oral contraceptive use and the risk of venous thromboembolism [28] and use in some women may therefore be contraindicated.  Other currently available therapeutic approaches for the management of dysmenorrheic pain include: transcutaneous electric nerve stimulation, which alters the body's ability to receive or perceive pain signals; transdermal nitroglycerin patches, which inhibit uterine contractions; acupuncture/acupressure; and surgical interventions such as laparoscopic uterosacral nerve ablation surgery [27] [29,30]. Such therapeutical approaches, however, are not considered to be effective enough to be widely used in clinical practice and RCTs showing efficacy of such approaches are limited [30]. Many women also resort to alternative nonpharmacologic therapies. Alternative approaches include heating pads for cramps, extra bed rest or sleep, physical exercise, meditation, aromatic oils, ginger root tea, salt water, increased calcium intake, increased vitamin D intake and various food sources such as beans, tofu and salmon [24] [31,32].
In dealing with dysmenorrhea, medications such as prostaglandin synthesis inhibitors, nonsteroidal anti-inflammatory drugs and contraception pills are used irregularly because of fear of their side effects. Therefore, there is an urge to develop new and simpler treatment for dysmenorrhea. For this purpose, dry cupping therapy can be used. As In classical Unani literature hijamat bila sharat (dry cupping) over the umbilicus has been used to relieve the colic pain of gaseous distension and the menstrual pain [33].

Cupping therapy
Cupping therapy is a complex therapy having multidimensional roles and benefits in various diseases including acne, herpes zoster, paralysis, and pain management.
Cupping therapy is popular as ʻAl-Hijamaʼ in Egypt and Arabic countries. It is an intervention of Asian medicinal systems such as Unani, Ayurveda, Chinese, Tibetan, and Oriental Medicine in Asia, the Middle East, and European countries. In Europe, cupping therapy was customarily used by monastery practitioners and folk healers up to the 19 th century. It also finds a mention in the famous Egyptian Papyrus Ebers (1550 BC) in the west and ancient Greek medicine. Hippocrates (Greece) preached the cupping based treatments related with musculoskeletal diseases of the back and extremities, gynecological complaints, pharyngitis, ear ailments, and lung diseases. There are different cupping methods viz. weak/light cupping, medium cupping, strong cupping, moving cupping, needle cupping, moxa/hot needle cupping, empty/flash cupping, full/bleeding cupping, herbal cupping, and water cupping. Dry and wet cupping are commonly practiced in the Far East, Middle East, and Eastern Europe as well. Thus, cupping therapy maintains a strong historical account that needs to be rejuvenated in modern times [34].

Definition of cupping therapy
Cupping therapy is a therapy of alternative traditional medicine. Due to utilization of cups, it is called as cupping therapy. 'Hijama' is alternative name of cupping therapy. It is Arabic word, which means 'to suck' [35].
Cupping (Hijamat) therapy is very well documented as a result of several thousand years of clinical experiences in Unani medicine. In this procedure, suction is created by various means either with or without bloodletting [36]. Cupping or Hijamat is a method used for local evacuation or diversion of morbid humors in which a horn (singhi) is attached to the surface of the skin of the diseased part through negative pressure created by vacuum [37].

Common types of cupping therapy
Two types of cupping therapy are commonly in use these are: cupping with bloodletting (Hijamat bil shurt) and cupping without bloodletting (Hijamat bila shurt) describe as follows:  Dry cupping (Hijamat bila shurt) -This is the process of using a vacuum on different areas of the body in order to gather the blood in that area without incisions (small, light scratches using a razor).  Wet cupping (Hijamat bila shurt)-This is the process of using a vacuum at different points on the body but with incisions in order to remove 'harmful' blood which lies just beneath the surface of the skin. (It is recommended that wet cupping (hijamat) is only administered by a cupping therapist) [36] [37].

Indication and diseases that respond to cupping
Cupping has been used for a number of ailments. Different type of cupping is indicated in different diseases. Hijamat bil shurt is used in various diseases like heaviness of head, asthma, dyspnoea, migraine, quinsy, palpitation, headache, haemorrhoids, amenorrhea, renal and ureteric colic, plethora, pustules and boils, sciatica, gout, pain of the knee, diseases of the liver, spleen and psoriasis, etc. Hijamat bila shurt is used in various diseases like excessive menstrual bleeding, removal of deep swelling, scrotal hernia, sciatica, piles, hydrocele, gout, renal calculi and epistaxis, etc [37].
In the East Chinese have been practicing the art of cupping for at least three thousand years. In the West cupping therapy has its birth in Egypt. The Ebers Papyrus written around 1550 BC states that bleeding by wet cupping removed foreign matter from the body [38]. Egyptian and Greeks have been practicing the art of cupping since ancient times. Both Hippocrates and Galen were staunch advocates and user of this therapy [38]. Prophet Mohammad (PBUH) sanctioned the use of cupping [20].Cupping without bloodlettingworks on the principle of Imala-emavad,i.e. diversion of morbid humorsfrom one site to the other [36]. In Unani medicine to relieve usre tams hijamatbilashurt is applied below the umbilicus as it works on the principle of imala mavad diversion of morbid materials [3].

Mechanisms of action involved in cupping therapy for reducing pain
Although the exact mode of action of cupping to reduce pain is not well understood, three main possible hypotheses and theories might explain mechanisms of pain reduction. These include: 1. "Pain-Gate Theory" (PGT): this theory comprehensively explains how the pain is transmitted from the point of its inception to the brain, and how it is processed in the brain which sends back the efferent, protective signal to the stimulated or injured area.

CONCLUSION
Cupping therapy is one of the ancient medicine practice. There is growing evidence of its potential benefits in the treatment of some diseases, especially pain-related conditions. In gynaecological disorders it is very effective in Usre Tams Tashannuji by different mechanism of actions. No single theory could explain its full spectrum of effects. The beneficial effects of cupping therapy need to be substantiated by large randomized clinical trials, systematic reviews and meta-analyses in future. Basic scientific innovative research is also needed to verify the discussed theories about cupping along with inventing new theories.

CONSENT
It's not applicable.

ETHICAL APPROVAL
It's not applicable.