PCOD vs. PCOS: Understanding the Difference and How to Treat It Naturally in the Unani System of Medicine

Executive Summary

The contemporary landscape of women’s reproductive health is currently besieged by a rising tide of endocrine disorders, most notably Polycystic Ovarian Disease (PCOD) and Polycystic Ovary Syndrome (PCOS). Once considered rare, these conditions have escalated into a veritable epidemic, particularly within the South Asian demographic, driven by rapid urbanization, sedentary lifestyles, and dietary transitions. While modern allopathic medicine views these primarily through the lens of hyperandrogenism and insulin resistance, the Unani System of Medicine (Tibb-e-Unani) offers a profound, holistic etiopathological framework rooted in the Humoral Theory (Nazaria-e-Akhlat). This report provides an exhaustive, expert-level analysis of the PCOD/PCOS crisis, delineating the subtle yet critical clinical differences between the two conditions, and detailing the robust therapeutic protocols of Unani medicine. These protocols, encompassing Ilaj-bil-Ghiza (Dietotherapy), Ilaj-bil-Tadbeer (Regimental Therapy), and Ilaj-bil-Dawa (Pharmacotherapy), aim not merely to suppress symptoms but to restore the fundamental Mizaj (Temperament) and eliminate the morbid Balgham (Phlegm) responsible for the disease pathology.

1. The Global and Regional Epidemiology: An Emerging Crisis

1.1 The South Asian Phenomenon

The global burden of Polycystic Ovary Syndrome (PCOS) has seen a dramatic escalation over the last three decades, but nowhere is the trajectory more alarming than in India and the broader South Asian region. Epidemiological surveillance indicates that India had the highest prevalence of PCOS in 2021, recording a staggering rate of 269.8 per 100,000 women. Furthermore, the total percentage change in prevalence has surged by 86.9%, a figure that underscores the rapid acceleration of this condition alongside industrialization and lifestyle westernization.

While global estimates generally place PCOS prevalence between 6% and 7%, regional studies within India reveal a far more severe reality. Depending on the diagnostic criteria employed—ranging from the National Institutes of Health (NIH) consensus to the broader Rotterdam criteria—prevalence rates in Indian subpopulations of reproductive age have been documented between 3.7% and 22.5%. A 2024 study focused on the Delhi National Capital Region (NCR) reported a prevalence of 17.40% among college-going women aged 18–25 years, indicating that nearly one in five young women in urban centers is affected.

The etiology of this regional disparity is multifactorial. Genetic susceptibility in South Asian populations appears to be compounded by environmental stressors. In conflict-affected zones like Kashmir, prevalence rates have skyrocketed to between 29% and 35%, suggesting a potent correlation between chronic psychological stress, cortisol elevation, and neuro-endocrine disruption. This "epidemic" is characterized not just by reproductive dysfunction but by a high burden of Disability-Adjusted Life Years (DALYs), reflecting the long-term metabolic and psychological toll of the syndrome.

1.2 PCOD vs. PCOS: Delineating the Clinical Entities

A pervasive confusion exists in lay and even some semi-professional circles regarding the interchangeability of the terms PCOD and PCOS. It is clinically imperative to distinguish between them, as their prognosis, severity, and management strategies differ significantly.

Polycystic Ovarian Disease (PCOD) is fundamentally a structural abnormality of the ovaries caused by a combination of hormonal imbalance and genetic tendencies. It is often characterized by the ovaries releasing immature eggs which, unable to be discharged, calcify or remain as fluid-filled sacs. However, PCOD is often considered a transient or milder condition. Women with PCOD may still ovulate regularly or with minimal intervention, and the metabolic fallout is generally less severe.

Polycystic Ovary Syndrome (PCOS), conversely, is a complex, systemic metabolic and endocrine syndrome. It is defined by a triad of features: hyperandrogenism (clinical or biochemical), ovulatory dysfunction (oligo-anovulation), and polycystic ovarian morphology. PCOS is associated with severe systemic comorbidities, including profound insulin resistance, type 2 diabetes, cardiovascular disease, endometrial cancer, and non-alcoholic fatty liver disease (now termed Metabolic Dysfunction-Associated Steatotic Liver Disease or MASLD).

Table 1: Comparative Pathophysiology and Clinical Features of PCOD vs. PCOS

It is crucial to recognize that a patient may present with Polycystic Ovaries (PCO) on ultrasound without having the syndrome (PCOS). PCO is a morphological description, whereas PCOS is a functional diagnosis requiring the exclusion of other disorders like thyroid dysfunction or hyperprolactinemia.

2. Unani Etiopathogenesis: The Humoral Perspective

The Unani System of Medicine, tracing its roots to Hippocrates and Galen and refined by Arab scholars like Avicenna (Ibn Sina), does not view diseases as isolated organ dysfunctions but as systemic disturbances in the body's Humoral Balance (I'tidal-e-Akhlat).

2.1 The Concept of Marz Akyas Khusyutur Rehm

In classical Unani literature, the specific entity of PCOS is not described using modern terminology but is comprehensively covered under the heading of Marz Akyas Khusyutur Rehm (Cystic Ovarian Disease) or disorders involving Ihtibas-e-Tams (Amenorrhea), Uqr (Infertility), and Saman-e-Mufrit (Obesity).

The fundamental pathology is attributed to a deviation in the temperament (Mizaj) of the ovaries and the uterus. Specifically, PCOS is classified as a disease of Su’-e-Mizaj Barid Balghami (Cold and Phlegmatic Temperament).

2.2 The Role of Balgham (Phlegm) and Madda (Matter)

Unani physiology posits four humours: Blood (Dam), Phlegm (Balgham), Yellow Bile (Safra), and Black Bile (Sauda). Health requires their equilibrium. In PCOS, the pathology is driven by the dominance and corruption of Balgham.

• Viscosity and Obstruction (Sudda): Balgham is cold and moist (Barid Ratab). When it becomes abnormal (Akhlat-e-Ghaliz), it increases in viscosity and stickiness (Lazujat). This thickened, cold fluid accumulates in the ovarian tissue and uterine vessels.
• Cyst Formation: The ovarian follicles require heat (Hararat) to mature and rupture. The accumulation of cold, viscous phlegm dampens the metabolic heat of the ovary. Consequently, the follicles fail to mature or rupture, and the retained fluid solidifies into cysts (Akyas).
• Metabolic Stagnation: The cold temperament slows down the Quwwat-e-Ghariya (innate metabolic power). This directly correlates with the modern understanding of metabolic slowdown, obesity, and insulin resistance found in PCOS patients. The body accumulates fat (Farbahi) because it lacks the heat to metabolize nutrients effectively.

2.3 Ihtibas-e-Tams (Amenorrhea) and Uqr (Infertility)

Amenorrhea (Ihtibas-e-Tams) is a cardinal symptom of PCOS. In Unani theory, menstruation requires blood to be of appropriate fluidity and the expulsive faculty (Quwwat-e-Dafia) of the uterus to be functional.

• Mechanism of Amenorrhea: The dominance of Balgham makes the blood viscous and sluggish. The coldness constricts the uterine vessels and weakens the expulsive faculty, leading to the retention of menstrual blood. This retention is not benign; the trapped matter further corrupts the temperament of the uterus, leading to Uqr (infertility).
• Male Pattern Features: Ibn Sina noted that when amenorrhea persists, the retained matter and lack of female purgation (menstruation) can cause women to develop male characteristics, resembling the modern observation of virilization and hirsutism due to hyperandrogenism.

3. Diagnostic Framework in Unani Medicine

While modern medicine relies heavily on ultrasonography and hormonal assays, Unani diagnosis integrates these findings with a holistic assessment of the patient's temperament.

3.1 Assessing the Temperament (Mizaj)

The physician (Hakim) evaluates signs of Su’-e-Mizaj Barid (Cold Temperament):

• Physical Signs: Excessive whiteness or pallor of the skin, laxity of muscles, cold clammy skin, and obesity (Saman-e-Mufrit) are indicative of phlegmatic dominance.
• Pulse (Nabz): The pulse in phlegmatic disorders is typically slow (Bati), soft (Layyin), and broad (Areez), reflecting the lack of heat and excess moisture in the vessels.
• Menstrual History: A history of delayed cycles (Taakhir-e-Haiz), scanty flow (Qillat-e-Haiz), and pale or viscous menstrual blood confirms the diagnosis of Ihtibas-e-Tams due to phlegm.

3.2 Correlating Modern Diagnostics

Unani practitioners today utilize modern tools to confirm the extent of the pathology:

• Ultrasonography: To visualize the "poly-cystic" morphology, confirmed as Akyas in the ovaries.
• Hormonal Assays: Elevated LH, Testosterone, and Insulin are interpreted as biochemical evidence of the metabolic derangement caused by the humoral imbalance.

4. Therapeutic Pillar I: Ilaj-bil-Ghiza (Dietotherapy)

Dietotherapy is the foundation of Unani treatment. Since PCOS is a disease of Cold and Moist (Barid Ratab) temperament, the treatment principle is Ilaj-bil-Didd (Treatment by contraries). The patient must adopt a Hot and Dry (Garm-o-Khushk) diet to counteract the coldness, dry the excess moisture, and dissolve the phlegmatic cysts.

4.1 Principles of the Anti-PCOS Unani Diet

The objective is to reduce phlegm production (Taleel-e-Balgham) and generate metabolic heat (Tawleed-e-Hararat).

Table 2: Unani Dietary Classification for PCOS Management

4.2 Comprehensive 7-Day Unani Diet Plan for PCOS

This plan integrates the Mizaj theory with modern low-glycemic index (GI) requirements to manage insulin resistance.

• Early Morning (Empty Stomach):
• Soaked Almonds (4) + Walnuts (2).
• Or: Warm water with 1 tsp Honey and lemon (cuts phlegm).
• Breakfast:
• Daliya (Broken wheat porridge) cooked with milk and cinnamon.
• Or: Vegetable Oats with carrots and beans (no potatoes).
• Or: 1-2 Boiled Eggs (protein generates heat).
• Mid-Morning Snack:
• Roasted Chana (Chickpeas): Excellent for absorbing gastric moisture and reducing phlegm.
• Or: 1 Apple or Papaya bowl.
• Lunch:
• 2 Multigrain Rotis (Barley/Wheat mix) + 1 cup Dal (Lentils) + 1 cup Dry Vegetable Curry (e.g., Methi/Fenugreek or Bitter Gourd).
• Salad: Radish, Carrot, Onion (avoid Cucumber).
• Evening Tea:
• Herbal Tea: Ginger + Cinnamon + Clove.
• Snack: Pumpkin seeds or Sunflower seeds.
• Dinner:
• Lightest meal of the day.
• Grilled Chicken or Fish + Sautéed Vegetables.
• Or: Moong Dal Khichdi (light and digestible).
• Bedtime:
• 1 cup Warm Milk with a pinch of Turmeric (Haldi) - Anti-inflammatory and antiseptic.

Crucial Note: Dinner should be consumed at least 2-3 hours before sleep to prevent the formation of nocturnal phlegm.

5. Therapeutic Pillar II: Ilaj-bil-Tadbeer (Regimental Therapy)

Regimental therapy employs physical methods to detoxify the body and restore balance. For PCOS, the primary goals are Istifragh (Evacuation of morbid matter) and Imala (Diversion of blood flow) to the uterus to stimulate menstruation.

5.1 Hijama (Cupping Therapy): The Gold Standard

Hijama is extensively used in Unani medicine for PCOS to remove subcutaneous toxins, resolve stagnation, and improve ovarian blood flow.

5.1.1 Mechanism of Action

• Detoxification: Wet cupping (Hijama-bil-Shart) extracts the stagnated blood and inflammatory mediators from the interstitial spaces, reducing systemic inflammation.
• Hormonal Modulation: Research indicates that wet cupping can significantly decrease LH and testosterone levels while increasing FSH and progesterone, thereby restoring the ovulatory feedback loop.
• Ovarian Stimulation: Local suction increases microcirculation to the ovaries, helping to dissolve the cyst wall and promote follicle rupture.

5.1.2 Anatomical Points for Hijama in PCOS

The efficacy of Hijama depends on the precise location of application. A combination of Sunnah points and specific organ-reflex points is used.

Table 3: Hijama Points Protocol for PCOS & Infertility

Protocol Note: Wet cupping is typically performed on the back points (1, 55, 11-13). Dry cupping or "Moving Cupping" (massage with suction) is often preferred for the anterior ovarian points (125, 126) to stimulate blood flow without incision, although some practitioners use wet cupping here for severe stagnation.

5.2 Fasd (Venesection)

In cases of severe amenorrhea (Ihtibas-e-Tams) where the blood is extremely viscous and the patient is plethoric, Fasd of the Saphenous Vein (Rage Safin) is indicated. This vessel, located at the ankle, is traditionally associated with the uterus. Bleeding from this vein causes Imala (Diversion), drawing blood downwards and stimulating menstrual flow.

5.3 Hammam (Turkish Bath) and Riyazat (Exercise)

• Hammam: Steam baths induce Tareeq (Sweating), which helps in the dissolution of visceral fat and the elimination of phlegmatic waste through the pores.
• Riyazat: Since Phlegm is cold, heat is its antidote. Moderate to vigorous exercise is mandatory. It increases the Hararat-e-Ghariziya (innate heat), burns the excess humours, and reduces insulin resistance.

6. Therapeutic Pillar III: Ilaj-bil-Dawa (Pharmacotherapy)

Unani pharmacotherapy utilizes drugs that act as Munzij (Concoctive - to mature the phlegm), Mushil (Purgative - to expel it), and Mudirr-e-Haiz (Emmenagogue - to induce periods).

6.1 Mufrad Advia (Single Drugs)

6.1.1 Asgandh (Withania somnifera / Ashwagandha)

• Pharmacology: Asgandh is an adaptogen that lowers cortisol. Elevated cortisol in PCOS drives insulin resistance and androgen production.
• Unani Action: It possesses Mohallil (resolvent) and Muqawwi (tonic) properties. By reducing stress (Gham/Fikr), it balances the neuro-endocrine axis and improves reproductive health.

6.1.2 Methi (Trigonella foenum-graecum / Fenugreek)

• Pharmacology: Potent insulin sensitizer. Studies show Fenugreek seeds can reduce ovarian cyst volume and regulate cycles comparable to Metformin.
• Unani Action: Hot and Dry temperament. It is Mufattih-e-Sudad (Deobstruent) – it opens the blockages in the ovarian vessels.

6.1.3 Kalonji (Nigella sativa / Black Seed)

• Pharmacology: Contains Thymoquinone. It lowers LH and Testosterone, decreases insulin resistance, and reverses follicular atresia.
• Unani Action: Mudirr-e-Haiz (Emmenagogue). It acts as a powerful Jali (Detergent), clearing obstructions in the uterus.

6.1.4 Sibr (Aloe barbadensis / Aloe Vera)

• Pharmacology: The dried juice (Elwa) is a strong stimulating laxative and uterine stimulant.
• Unani Action: Mizaj is Hot (2nd degree) and Dry (3rd degree). It acts as a Mus-hil (Purgative) for phlegm and a potent Mudirr-e-Haiz (Emmenagogue) to force the expulsion of retained menstrual blood.

6.2 Murakkab Advia (Compound Formulations)

6.2.1 Habb-e-Mudir

• Indication: Specifically for Ihtibas-e-Tams (Amenorrhea).
• Key Ingredients: Saffron (Crocus sativus), Aloe Vera (Sibr), and Ferrous Sulphate (Kushta Khabsul Hadeed).
• Dosage: 1-2 tablets, 2-3 times daily.
• Protocol: Treatment should commence 3-4 days before the expected date of menstruation and continue until the flow begins. It provides tonicity to the uterus while stimulating evacuation.

6.2.2 Dawa-ul-Luk (NOT Dawa-e-Luknat)

• Critical Distinction: There is often confusion between Dawa-e-Luknat and Dawa-ul-Luk.
• Dawa-e-Luknat is a paste used for speech impediments and lisping. It has NO role in PCOS.
• Dawa-ul-Luk is the correct formulation for PCOS. It contains Luk (Lac/Laccifer lacca), which is a potent Muhazzil (emaciating/slimming) agent.
• Indication: Obesity (Saman-e-Mufrit), hepatomegaly, and phlegmatic accumulations in the ovaries.
• Action: It dissolves the viscous fat and phlegm in the liver and ovaries, improving metabolism.

6.2.3 Majun Dabeedul Ward

• Indication: Liver dysfunction and uterine inflammation.
• Action: Hepatoprotective. Since the liver metabolizes hormones, improving liver function is essential to clear excess estrogen and androgens.
• Dosage: 5-7 grams with Arq Mako or Arq Badiyan.

7. Lifestyle Management: Asbab-e-Sitta Zarooriya

Unani medicine asserts that health is maintained by the balance of six essential factors (Asbab-e-Sitta Zarooriya). An imbalance in these is the root cause of lifestyle diseases like PCOS.

1. Hawa-e-Muheet (Atmospheric Air): Living in damp, humid, or polluted environments aggravates the Phlegmatic temperament. Exposure to fresh, dry air is recommended.
2. Makool-o-Mashroob (Food and Drink): Adherence to the Hot/Dry diet (Section 4) is non-negotiable. Cold water must be avoided; warm water consumption is mandatory to dissolve phlegm.
3. Harkat-o-Sukun Badani (Physical Movement & Rest): A sedentary lifestyle is the primary enemy of the PCOS patient. Inactivity causes the "freezing" of humours. Regular, vigorous exercise is required to generate heat and improve insulin sensitivity.
4. Harkat-o-Sukun Nafsani (Mental Movement & Rest): Stress (Gham/Fikr) disrupts the brain-ovary axis. Psychological stress increases cortisol, which mimics the effects of coldness (constriction). Meditation and relaxation are prescribed.
5. Naum-o-Yaqzah (Sleep & Wakefulness):
• Phlegmatic Guideline: Patients with this temperament are prone to lethargy. They require 6-7 hours of sleep.
• Warning: Excessive sleep (>8 hours) or sleeping during the day (Qailoola) increases the production of Balgham and exacerbates obesity. Sleeping immediately after meals is strictly prohibited as it halts digestion.
6. Istifragh-o-Ihtibas (Evacuation & Retention): The body must efficiently eliminate wastes (sweat, urine, stool, menses). Constipation (Qabz) leads to the reabsorption of toxins (Fasad Madda). Usage of mild laxatives like Isabgol or Triphala may be required to ensure daily evacuation.

8. Safety Profile and Contraindications

While Unani treatments are natural, "natural" does not mean "harmless." The pharmacologically active ingredients, particularly emmenagogues, require careful management.

8.1 Pregnancy Contraindications

The most critical safety warning in PCOS management concerns pregnancy. Many drugs used to induce periods (Aloe Vera, Saffron, Habb-e-Mudir, Kalonji) are Emmenagogues (uterine stimulants).

• Abortifacient Risk: If a woman with PCOS conceives (which is the goal of treatment) but continues taking these herbs, there is a high risk of uterine contractions leading to miscarriage (Isqat-e-Haml).
• Protocol: All emmenagogue drugs must be stopped immediately if pregnancy is suspected or confirmed.

8.2 Long-term Usage Considerations

• Aloe Vera: Prolonged internal use of whole-leaf Aloe can act as a drustic purgative, leading to potassium depletion (hypokalemia) and electrolyte imbalance.
• Monitoring: Patients on complex formulations like Dawa-ul-Luk or Majun Dabeedul Ward for extended periods should undergo periodic liver function tests, although these drugs are generally hepatoprotective.

9. Conclusion

The "epidemic" of PCOD and PCOS in the modern world is a manifestation of a profound clash between human biology and a maladapted environment. In the Unani view, it is not merely a disorder of the ovaries but a systemic collapse of the Humoral Balance, specifically the dominance of the Cold and Phlegmatic (Barid Balghami) temperament.

Unani Medicine offers a comprehensive, time-tested solution that moves beyond symptom suppression. By accurately distinguishing between the structural PCOD and the systemic PCOS, practitioners can tailor treatments that address the root cause: the accumulation of viscous phlegm and the loss of metabolic heat.

Through the tripartite approach of Dietotherapy (adopting a Hot/Dry diet), Regimental Therapy (utilizing Hijama and Exercise to physically evacuate toxins), and Pharmacotherapy (using targeted herbs like Asgandh and formulations like Dawa-ul-Luk), Unani medicine provides a robust pathway to restoration. It empowers women to reclaim their reproductive health not by fighting their bodies, but by restoring the delicate equilibrium of Mizaj that defines true health.

10. Summary of Clinical Recommendations