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376 Maryam Nikoosokhan
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12 Use of Certain Herbal Drugs to Cure
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Various Gynecological Disorders
Seyyed Ahmad Askari1, Shakila Hajizadeh2, Mojgan Tansaz3, Bahia Namavar
1
Jahromi
Traditional Medicine and Materia Medica Research Center, Shahid Beheshti
4,5
, and Sayyedeh Fatemeh Askari
6,7
*
University of Medical Sciences, Tehran, Iran; 2Department of Traditional
Pharmacy, School of Traditional Medicine, Shahid Beheshti University of Medical
Sciences, Tehran, Iran; 3Department of Traditional Medicine, School of Traditional
Medicine, Shahid Beheshti University of Medical Science,Tehran, Iran; 4Infertility
Research Center, Shiraz University of Medical Sciences, Shiraz, Iran;
5
Department of Obstetrics & Gynecology, School of Medicine, Shiraz University
of Medical Sciences, Shiraz, Iran; 6Cardiovascular Diseases Research Center,
Birjand University of Medical Sciences, Birjand, Iran; 7Department of
Pharmacognosy and Traditional Pharmacy, School of Pharmacy, Birjand
University of Medical Sciences, Birjand, Iran
Abstract
In his book Canon of Medicine, Avicenna refers in Chapter 21 (Volume 3) to various types of gynecologic disorders such as abortion, pelvic pain, amenorrhea, cervical stenosis, uterine displacement,
dysmenorrhea, false pregnancy, hysteria, libido disorders, vaginal dryness, infertility, obstetric dys
tocia, oligomenorrhea, polymenorrhea, postpartum hemorrhage, uterine rupture, uterine abscess,
uterine dysperiment, uterine pain, uterine prolapse, and vaginitis. He also discusses methods of
contraception and diagnoses of pregnancy. In addition, Avicenna lists specic vaginal prescriptions
and forms of administration for each ailment, such as forzajah and hamoul (cotton ball), fetilah (wick),
shiāf (pessary), ābzan and jalous (sitz bath), hoqnah (enema), and bakhour (fumigation). e ingredients
of the formulations come either from animal sources (mare’s milk, duck fat, chicken skin, bone marrow), plants (cinnamon, saron, camomile, olive oil), or minerals such as sulfur, petroleum, and kohl
(“kohl” is a black powder, usually antimony trisulde or lead sulde, that was used as eye makeup,
especially in Eastern countries). is chapter deals specically with the pathology of vaginitis and its
treatment in the light of Avicenna’s Canon of Medicine.
-
*Email: sfaskari98@gmail.com
© CAB International 2023. Medicinal Plants Used in Traditional Persian Medicine
. H. Schulz, Seyed Ahmad Emami and Farsad Nadjafi)
(eds
DOI: 10.1079/9781800621671.0012
379
380 Seyyed Ahmad Askari etal.
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Introduction
Vaginal complaints are one of the most common reasons forcing women to go to healthcare providers (Mills, 2017). Surveys have
counted that more than 70% of females have
had a vaginal problem and have used topical
products to treat infections (Palmeira-deOliveira et al., 2015). Also, vaginitis has been
connected with other complications of the
female reproductive organs, like increased
susceptibility to and transmission of the
human immunodeficiency virus (HIV) infection (Cu-Uvin et al., 2002), infertility, and
poor pregnancy yields (Powell and Nyirjesy,
2014). Vaginitis is described as a condition
with symptoms of abnormal vaginal discharge, odor, itching, irritation, and burning
(Paladine and Desai, 2018). Uncomplicated
infections such as candidiasis, bacterial
vaginosis (BV), or trichomoniasis are easy to
diagnose and treat. However, about 8% of
infected females have a more complicated
condition because of failure to respond to
medicines or rapid recurrence of manifestations (Mills, 2017). Different types of
vaginitis are categorized based on the type
of microbial agent. BV occurs when Lactoba-
cillus spp., the main species in vaginal flora,
are replaced by anaerobic bacteria, such as
Gardnerella, Mobiluncus, Atopobium, Prevotella, Bifidobacterium, Sneathia, Mycoplasma,
Leptotrichia, and some novel bacteria from
the order Clostridiales referred to as BVassociated bacteria (BVAB) 1–3. Lactobacilli
are supposed to supply defense against infection by preserving an acidic pH in the vagina and providing hydrogen peroxide (H
Globally, it is estimated that 20–30% of
reproductive-age women attending sexually
transmitted infection clinics suffer from BV
(van Schalkwyk et al., 2015; Bautista et al.,
2016; Chen et al., 2021). Multiple sexual partners, tobacco use, herpes simplex virus or
HIV infection, douching, high-fat diets, age
15–44 years, alcohol intake, and stress are
factors that increase the risk of BV. In contrast, hormonal contraceptive use, estrogen
replacement therapy, and condom use are
risk-decreasing factors (Bagnall and Rizzolo,
2017). The gold standard of BV diagnosis is
the Nugent score to assess a Gram-stained
2O2
).
vaginal discharge smear (Tam etal., 1998).
Another diagnostic method is Amsel, including four criteria: grayish-white vaginal discharge, pH > 4.5, clue cells on saline wet
mount, and positive whiff-amine test (Amsel et al., 1983). Recommended treatment
for symptomatic women (even pregnant)
diagnosed with BV is:
• oral metronidazole 500 mg twice daily
for 7 days; or
• 0.75% w/w metronidazole gel, one ap-
plicator intravaginally every night for
5 nights; or
• 2% w/w clindamycin vaginal cream, one
applicator intravaginally every night for
7 nights (Workowski etal., 2015).
Trichomonas vaginalis as a causative agent of
trichomoniasis infected 10–25% of pregnant women or those attending clinics (Ifeanyi et al., 2018). Risk-increasing factors
are a history of delinquency, approved marijuana use, multiple sexual partners, increased age, lower education, poverty, and
douching (Sutton etal., 2007). Symptomatic
women suffer from diffuse yellow-green vaginal discharge, stinky odor, pruritus, irritation, edema, erythema, and dyspareunia.
The strawberry cervix is a characteristic clinical sign detected by colposcopy and infrequently during a typical examination
(Wølner-Hanssen etal., 1989). Trichomoniasis is linked with ailments such as cervicitis, urethritis, pelvic inflammatory disease,
ectopic pregnancy, infertility, pelvic pain,
neonatal death, premature delivery, and
severe disability in infants (Lossick, 1990;
Ifeanyi etal., 2018). The most typical test is
the visualization of the motile protozoans in
a saline preparation of the vaginal discharge,
but the gold standard is culture (Krieger
etal., 1988; Hobbs and Seña, 2013). Drugs
of choice for this infection are a 2-g dose of
either oral tinidazole or metronidazole
(Muzny and Schwebke, 2013; Workowski
etal., 2015). The chief complaint of BV patients is recurrence (Homayouni et al.,
2014). A 67% recurrence rate occurs within
the first month, 76% within 6 months, and
69% during 12 months of treatment (Hay,
2009) because of antibiotic resistance or
negative impacts of antibiotics on healthy
Gynecological Disorders 381
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vaginal microflora (Reiter and Kellogg
Spadt, 2019). Therefore, attention is directed to other therapies like treating sexual
partners, probiotic therapy, thermoplastic
polyurethane intravaginal rings, activated
charcoal, and herbal medicine (Javed et al.,
2019). Moreover, application of the recommended medicines is associated with adverse
effects such as dryness, irritation, candidiasis, gastrointestinal disorders, nausea, and
unpleasant metallic taste that leads to
poor acceptance by patients (Mahboubi,
2018). Women also suffer from many other
vaginal complaints like candidiasis, viral
vaginitis (herpes), and chlamydia or gonorrhea. They have no definite treatments,
and therefore finding new approaches and
medications to treat or manage them is
crucial. Traditional and complementary
methods are the sources to find new treatments. With a deep historical background
from the ancient era, Traditional Persian
Medicine (TPM) is one of the leading traditional medical systems.
Vaginitis in View of Avicenna
Leukorrhea is excessive vaginal discharge. It
is physiologic when related to different
phases of the menstrual cycle. Whenever it
turns into a pathologic condition, in TPM
the vaginitis caused is called sayalān-e rahem
and was used by Avicenna and some other
Persian traditional practitioners to describe
this condition. Traditional medicine scholars
believed that vaginitis causative factors are
uterine and extrauterine. Uterine factors are
related to the weakness of qowat-e-ghadiah,
which feeds the uterus (based on TPM, the
body performs its duties by some qowat or
powers). This qowat consists of four subsets
called qowat-e-jādebah (absorptive faculty),
qowat-e-māsekah (retentive faculty), qowate-hādemah (digestive faculty), and qowat-edāfe-ʿah (expulsive faculty). The “absorptive
faculty” absorbs the organ’s proper nutrition
from the blood. The “retentive faculty”
maintains the absorbed food for digestion.
The “digestive faculty” digests that food, and
the “expulsive faculty” disposes the waste
material from the organ. The debility of qo-
wat-e-ghadiah due to the following causes increases discharges and leads to sayalān-e
rahem. Debility of the “digestive faculty”
leads to poor digestion and increases waste.
Debility of the “retentive faculty” causes the
uterus to not hold in normal secretions;
thus, the level of vaginal discharge increases.
Debility of the “expulsive faculty” causes the
accumulation of waste material in the uterus
and expels it in the form of abnormal vaginal discharge (Shirooye etal., 2016; Adhami
etal., 2017).
Extrauterine factors are related to other
organs’ illness that affects the healthy
uterus. Production of discharge with an
extrauterine origin occurs because of the
body’s emtelā. Emtelā means the body is full
of waste materials. According to TPM, the
body’s health depends on the balance between the four khelt (humors), i.e., dam (sanguine), balgham (phlegm), safrā (yellow bile),
and sawdā (black bile). If any humor gets out
of quantitative or qualitative balance, it becomes abnormal, and the body seeks to
eliminate it. One of the disposal ways is to
put waste material into the uterus and repel
it through the discharge of the vagina.
Therefore, if the waste material cannot pass
through urine, stool, or sweat, vaginal discharge will increase and continue. Extrauterine origin of discharge can be from the
four humors. If “sanguine” overcomes,
thirst, blurred urine, and reddish vaginal
discharge manifest; if “phlegm” overcomes,
slight thirst, white urine, whitish discharge,
and obesity manifest; if “yellow bile” over
comes, excessive thirst, yellow urine, and
yellowish discharge manifest; and if “black
bile” overcomes, dry skin, blurred face color,
and dark vaginal discharge manifest (Dehdari and Hajimehdipoor, 2016; Sehar and
Ansari, 2016; Meyari etal., 2017).
Treatment of Vaginitis
in View of Avicenna
Avicenna mentioned specific vaginal formulations and dosage forms for each condition,
especially vaginitis (Askari etal., 2018). The
382 Seyyed Ahmad Askari etal.
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first step is purifying unbalanced humors
(mentioned in the previous section) from
the body by phlebotomy or purgative agents,
then purifying the uterus with special purgative and drier compounds like orris and
wild leek (Allium ampeloprasum) boiled for
eliminating the pathogens. The third step is
massaging the legs with emollient oils like
camel grass (Cymbopogon schoenanthus) oil
and hot herbal medicines with akarkara
(Anacyclus pyrethrum) and black pepper
(Piper nigrum). Then using, intravaginally,
uterus tonic and astrinent agents like boiled
aqueous extracts of pomegranate, akarkara,
myrtle, oak gall, and jolnār finally to prevent
a recurrence of vaginitis.
Scientific Evaluation of Medicinal
Plants for Management of Vaginitis
Mentioned in Canon of Medicine
Most of the herbs mentioned by Avicenna in
the Canon were confirmed by in vitro studies as
excellent antimicrobial agents, i.e., antibacterial, antifungal, and antiprotozoal activity. This
section provides the latest scientific evidence
on medicinal plants mentioned in the Canon of
Medicine for vaginitis regarding their ability to
ameliorate gynecologic complications, emphasizing vaginitis. The common English name,
Arabic name, botanical family, scientific name,
and synonym of the plants are presented in
Table 12.1. Tables 12.2, 12.3, and 12.4 respect-
ively describe some in vitro, in vivo, and clinical
interventions of the individual plant species
against vaginitis.
Artemisia absinthium L.
There are many documented data approving the antimicrobial effects of Artemisia
absinthium. For example, davanone or silphiperfolane derivatives, components of
essential oils, were found to be active
against Candida by the paper disk diffusion
method (Obistioiu etal., 2014). Because of
the ethanol extract’s good antifungal and
antibacterial activity, this valuable herb
would be a candidate for gastrointestinal
ailments (Ivanov et al., 2021) and even
vaginitis. Moreover, different nanoparticles of A. absinthium were tested against
various microorganisms. Silver nanoparticles of A. absinthium showed good activity
against Pseudomonas aeruginosa, Escherichia
coli, Staphylococcus aureus, and C. albicans
via agar well diffusion assays (Aabed and
Mohammed, 2021). The copper nanoparticles of essential oil could inhibit the growth
of P. aeruginosa, Klebsiella pneumoniae, Pro-
teus mirabilis, Staphylococcus epidermidis,
Acinetobacter baumannii, S. aureus, Enterobacter aerogenes, C. albicans, and E. coli by
the disk diffusion method (Celebi et al.,
2021). The effect of a combination of Islamic traditional medicine drugs, including
A. absinthium and Quercus infectoria, on the
treatment of trichomonal vaginitis was investigated for 10 days and compared to
metronidazole. Results proved the traditional combination to be as effective as
metronidazole (Ahmad etal., 2011).
Ceratonia siliqua L.
Acacia nilotica (L.) Willd. ex Delile;
basionym: Mimosa nilotica L.
Recently, Ramalingam and Amaechi tested a
mixed herbal powder extract of Acacia arab-
ica (a synonym of Acacia nilotica) (barks) and
Terminalia chebula (fruits) against Streptococcus mutans, Lacticaseibacillus casei, Actino-
myces viscosus, and Candida albicans by the
agar diffusion method. The mixed extract
showed high antimicrobial activities (Ramalingam and Amaechi, 2020).
In an in vivo study, the effect of carob pods on
growth performance, antioxidant activities,
carcass and cecal characteristics, and equilibrium modification of the cecal microbiota
population was investigated. For this purpose, 80 weaned rabbits were allocated into
four dietary groups. It was found that carob
pods caused an increase in daily and final
body weights, glutathione peroxidase (GPx),
glutathione S-transferase (GST), catalase
(CAT), and superoxide dismutase (SOD) activities, as well as Lactobacillus and Bacillus
Gynecological Disorders 383
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Common English
Scientific name
Acacia nilotica (L.) Delile
Artemisia absinthium L. Wormwood Afsantin Asteraceae
Ceratonia siliqua L. Carob Kharnub Fabaceae
Cinnamomum verum
J. Presl
Citrullus colocynthis (L.)
Schrad.
Corylus avellana L. Hazel Jollawaz Betulaceae
Crocus sativus L. Saffron Zʿafaran
Iris spp. Iris Irsa
Juglans regia L. Walnut Jawz Juglandaceae
Lepidium sativum L. Cress H orf, habb-o-
Myristica fragrans Houtt. Nutmeg Jaw-e-zboa
Myrtus communis L. Myrtle As Myrtaceae
Ocimum basilicum L. Basil Ba
Olea europaea L. Olive Zaitun Oleaceae
Phoenix dactylifera L. Date palm Tamr Arecaceae
Pimpinella anisum L. Anise Anisun Apiaceae
Pistacia lentiscus L. Lentisk pistache,
Portulaca oleracea L. Purslane Baqlato-lhamqaʼ Portulacaceae
Punica granatum L. Pomegranate Jolnar Lythraceae
Quercus infectoria G. Olivier Oak gall, oak fruit
Rubus fruticosus L. Blackberry ʿOllaiq Rosaceae
Rumex spp. Dock Hommad
Tamarix spp. French tamarisk Tarfa
Thymbra capitata (L.) Cav. Thymus capitatus
Synonym
Acacia arabica
(Lam.) Willd.
Cinnamomum
zeylanicum
Blume
(L.) Hoffmanns.
& Link
name Arabic name
Gum arabic Aqaqia
Cinnamon Darsini
Bitter apple H anzal
mastic
Persian hyssop Hasha
rreshad
druj
Masta ka
Afes, balut Fagaceae
Botanical family
Fabaceae
Lauraceae
Cucurbitaceae
Iridaceae
Iridaceae
Brassicaceae
Myristicaceae
Lamiaceae
Anacardiaceae
Polygonaceae
Tamaricaceae
Lamiaceae
counts, and a decrease in total cholesterol
(TC), low-density lipoprotein cholesterol (LDL),
high-density lipoprotein cholesterol (HDL), and
triglyceride (TG) levels (Abu Hafsa etal., 2017).
As we know, the increment in Lactobacillus, normal microflora of the vagina, is a good point for
treatment of vaginitis.
Cinnamomum verum J. Presl; synonym:
Cinnamomum zeylanicum Blume
Miller et al. evaluated the antifungal and
antibacterial activity of essential oils isolated
from 59 plant species against Lactobacillus
acidophilus, S. aureus, C. albicans, S. mutans,
and E. coli. Plant samples were gathered,
frozen, and steam-distilled to obtain the individual essential oils. It was identified that
the essential oils from Citrus aurantifolia
(Christm.) Swingle (Rutaceae), Cinnamomum
zeylanicum (Lauraceae), Origanum vulgare
L.(Lamiaceae), and Lippia graveolens Kunth
(Verbenaceae) show significant or moderate
antimicrobial activity against all abovementioned microorganisms (Miller etal., 2015).
The impact of cinnamon leaf and bark
essential oils against C. albicans and Candida
auris was investigated in another study. The
antifungal activity of the essential oils
against selected fungi strains (C. albicans
ATCC 2091, C. albicans ATCC 10231, and
C.auris NCPF 8971) was determined using
the broth microdilution and disk diffusion
384 Seyyed Ahmad Askari etal.
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Table 12.2. Some in vitro studies on medicinal plants claimed to be effective in vaginitis in TPM.
Plant
Acacia arabica
Cinnamomum
zeylanicum
Olea europaea Leaves/methanol
Phoenix dactylifera Fruit/aqueous
Rumex
hymenosepalus
Rumex nervosus Aerial parts/
Tamarix africana Leaves and stems/
Tamarix aphylla Aerial parts/aqueous
Part/extract Result
Chewing sticks/
aqueous extract
Essential oil Antibacterial (against Gram-positive
Bark oil Antifungal activity against Candida
extract
Leaves/acetone
extract
Leaves/aqueous
extract
Leaves/aqueous
extract
extract
Bunches/ethanol
extract, butanol
fraction
Root Growth inhibition against E. coli
Root Gram-positive bacteria, Gram-negative
aqueous extract
hydroalcoholic
extract
ethanol extract
Antimicrobial effect on S. fecalis,
by ditch plate method
and -negative bacterial strains),
antifungal (against Candida strains),
and antiviral (against H1N1 and
HSV-1) activity, by broth
microdilution method
albicans, by MIC test
High strength for controlling
bacterial biofilms in food and
related products and anti-Candida
strains, by a broth microdilution
method
Antimicrobial activity against oral
pathogens especially C. albicans, by
agar disk diffusion
Potential antimicrobial activity against
C. albicans and Escherichia coli, by
agar disk diffusion
Antimicrobial effect against Bacillus
cereus and C. albicans, by macro
broth dilution
Antimicrobial activity against
Staphylococcus aureus, E. coli,
and C. albicans, by zone inhibition
assay
High activity against C. albicans
and moderate activity against
Bacillus subtilis, by zone inhibition
assay
and C. albicans, dose-dependently
bacteria, and yeast (C. albicans)
growth inhibition by synthesized
silver nanoparticles, by well diffusion
method
Antimicrobial activity against
Gram-positive bacteria
Antifungal effect against C. albicans,
by agar disk diffusion
Growth inhibition of C. albicans, E. coli,
Enterococcus faecalis, Klebsiella
pneumoniae, Pseudomonas
aeruginosa, and MRSA, by agar disk
diffusion
Reference
Almas (2001)
Brochot etal. (2017)
Shahina etal. (2018)
Edziri etal. (2019)
Karygianni etal.
(2014)
Markin etal. (2003)
Pereira etal.
(2007a)
Zaheer (2018)
Fathy etal. (2021)
Villalobos-Noriega
etal. (2021)
Rodríguez-León
etal. (2018)
Al-Asmari etal.
(2015)
Chekroun-
Bechlaghem etal.
(2019)
Al-Omar etal.
(2020)
H1N1, a subtype of influenza A virus; HSV-1, herpes simplex virus serotype 1.
Model
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Post-weaning Piglet Camellia sinensis
Weaned rabbits Rabbit Ceratonia siliqua Pods ↑ Daily and final body w eights; ↓ TC, LDL,
Species Plant Part Results
Punica granatum
Leaves
Fruit
↑ Average daily g ain; ↑ gut health and
micr obial ecology; ↓ severity of an
Escherichia coli challenge
HDL, and TG lev els; ↑ GPx, GST, CAT,
Reference
Bontempo etal. (2014)
Abu Hafsa etal. (2017)
DHEA-induced PCOS Mice Cinnamomum
Doxorubicin-induced
cardiotoxicity and
nephrotoxicity
Cyclophosphamide-induced
immunosuppressed and
then infected
Cyclosporine and
hydrocortisone
acetate-induced
immunosuppressed
Citrobacter
rodentium-infected
Fat-containing diet Broilers Punica granatum Seed ↑ Fat-cont aining diets digestion; ↑ crude fat
Bacillus counts
Bark ↓ Insulin, IGF-1, and LH; improving cyclicity
zeylanicum
Rat Phoenix dactylifera Chitosan
nanoparticles
of extract
Mice Punica granatum Peel ↓ Mortality of Candida albicans, moderate-
Rat Punica granatum Peel ↓ Growth of C. albicans; 100% cure in all
Mice Punica granatum Peel ↓ Pathogenicity of C. rodentium inf ection; ↑
and ovary mor phology; ↑ serum FSH
level
↓ Heart and kidney apopt osis; ↑ PD-1
activity molds
doses after 15 days of treatment
abundance of proteobacteria and
verrucomicr obia; ↓ actinobacteria
digestibility and cecum Lactobacillus
count
Dou etal. (2018)
Sahyon and Al-Harbi
(2020)
Akroum (2017)
Bassiri-Jahromi etal.
(2018)
George etal. (2019)
Rezvani etal. (2018)
Gynecological Disorders 385
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