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Open Access Full Text Article   Case Report

Ayurveda Approaches for Management of Chronic Secondary Amenorrhoea Complexed with Hormonal Replacement Resistance, PCOD, and Thyroid Dysfunction: A Comprehensive Case Analysis 

Anjali Verma ¹*, Aayushi Agarwal ²

¹ Assistant Professor, Prasuti Tantra and Stree Roga, Rishikul Govt PG Ayurveda college and Hospital, Uttarakhand Ayurveda University, Haridwar, Uttarakhand, India

² PG scholar, Prasuti Tantra and Stree Roga, Rishikul Govt PG Ayurveda college and Hospital, Uttarakhand Ayurveda University, Haridwar, Uttarakhand, India

 

 

INTRODUCTION 

Absence of menstruation for duration of 6 months or more in whom normal menstruation has been established is termed as secondary amenorrhoea ¹. The prime cause being the disruption or incordination of the hypothalmo-pitutory-ovarian axis which is responsible for the coordination between hormones and reproductive organs².

In ayurveda the entire system involved in the process of stimulation, formation, maintenance and shedding of endometrial cells is referred as Aartavvaha Strotas with its root being Garbhashaya and Aartavvahi Dhamniya. ³

Menstruation is the visible manifestation of cyclic physiologic uterine bleeding due to shedding of endometrium following invisible interplay of hormones mainly through HPO axis ⁴. Ayurveda classics mentioned that sookshma kesha like sira are responsible to regenerate the endometrium by providing nourishment over whole month to uterus ⁵. 

This case study is about a 29 yrs old female with the primary complaint of secondary amenorrhoea along with history of withdrawal bleeding , Hypothyroidism and PCOD. The treatment primarily aimed at correction of vitiated Vata dosha, dhatu pooshan which ultimately leads to correction of HPO axis. As a result the patient gradually shifted from withdrawal bleeding to natural menstruation and further resulted in regulation of cyclic interval.

CASE DISCUSSION 

A 29 years old female visited OPD of PTSR Dept. Rishikul Campus, Haridwar with the chief complaint of Secondary Amenorrhoea since 8-10 yrs, She had a history of withdrawal bleeding since 2 yrs. She further had associated complaint of Hypothyroidism since last 11 yrs and PCOS since 2 yrs. The patient was underweight as well with no congenital anatomical abnormalities of the reproductive tract system. Also there was no such relevant family history from maternal side.

 

 

PERSONAL DETAILS AND GENERAL PHYSICAL EXAMINATION 

Chronology of Menstrual History 

S.NO.	ONSET OF MENSUS	NATURE OF BLEEDING	DURATION OF BLEEDING	AMOUNT OF BLEEDING	INTERVAL
1.	December 2022	Withdrawal	3 days	3 regular sized pad/ day ; partially soaked	40-45 days
2.	Janurary 2023	Withdrawal	3- 5 days	3 regular sized pad/ day; partially soaked	30-40 days

 

PERSONAL HISTORY  Appetite- Reduced  Bowel – constipated ; incomplete evacuation  Micturition – Normal ; 3-4 times/ day Sleep- Disturbed	VITALS Blood pressure- 120/78 mm Hg Pulse rate- 80 beats/ min  Height- 156 cm Weight-  45 kg  BMI- 18.5	GENERAL EXAMINATION Build- Normal Pallor – Absent  Icterus- Absent  Cynosis- Absent  Edema- Absent
HAEMATOLOGICAL– [05/10/2023] Haemoglobin- 10.4 gm/dL TLC- 3730/uL MCV- 72.9 fL MCHC- 29.8 g/dL Haematocrit – 34.8 % Platlet count – 1.17 lakh/cumm	THYROID PROFILE– [05/10/2023] Total T3- 107.00 nmol/L Total T4- 10.60 µg/dl TSH- 9.27 uIU/mL	ULTRASOUND LOWER ABDOMEN- [14/07/2022] Bilateral polycystic ovaries  Rt ovary- 32 × 33 × 18 mm ; vol- 10 cc Lt ovary- 34 × 34 × 16 mm ; vol- 10 cc Multiple peripherally placed antral follicles and increased stromal echogenicity.

 

 

INVESTIGATION

Management Protocol

The treatment involved several visits with the primary aim of correcting the vitiated Vata dosha and ensuring proper Dhatu poshana (nourishment of tissues) for the proper formation of Artava upadhatu (reproductive tissues) from Rasa Dhatu (nutritive fluid). This aimed to synchronize the Artavavaha srotas (channels related to menstruation), resulting in the proper stimulation, release, and action of female reproductive hormones. This in turn, affects the HPO (Hypothalamic-Pituitary-Ovarian) axis and improves overall wellbeing, addressing associated illnesses.

The treatment protocol included Shamana chikitsa (palliative therapy), which was revised during subsequent visits based on the patient's condition, and Shodhana chikitsa (purification therapy) at specific intervals. During the treatment period, a total of 6 Basti sessions and 3 Nasya sessions were performed, approximately one month apart, alternating between the two treatments. The brief summary of the management protocol is as follows;

 

 

 

 

 

 

 

TIME PERIOD	MANAGEMENT	OUTCOME
April- May 1ST visit	Deepana- Pachana    Shamana a Chikitsa - Vatanulomana   Shodhana Chikitsa - 1 sitting of Yog Basti including Anuwasana Basti with Dashmool Taila and Asthapan Basti with Shatpushpadi Kwath		Before	After
		Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present    - - - - - Reduced  Constipated Disturbed	Present   - - - - - Normal Irregular  Disturbed(on/off)
June- July	Deepana- Pachana    Shamana  Chikitsa- Vatanulomana Balya  Rasayana	Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present  6 months - - - - - Reduced since 7 days  Irregular  Disturbed (on/off)	Absent    5/07/2023 3 days 6 months Natural 3 pad/day  Normal Regular  Sound
August- September	Shamana  Chikitsa- Vatanulomana Balya Medohara    Shodhana Chikitsa-  1 sitting of Matra Basti with Bala Taila	Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present  2 months  5/07/2023 3 days 6 months Natural 3 pad/day  Normal Constipated  Sound	Absent    4/09/2023 3 days 2     months Natural 2     pad/day Normal Regular  Sound
October- November	Shamana  Chikitsa- Vatanulomana Balya Rechaka    Shodhana Chikitsa- 2 sittings of matra basti with Dashmool  Taila  Pratimarsha nasya of Mahanarayan taila	Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount    Appetite Bowel Sleep	Present  1.5 months  4/09/2023 3 days 2     months Natural 2     pad/day   Normal Regular  Sound	Absent    10/10/2023 4     days 36 days  Natural 2     pad/day   Normal Regular  Sound
December- January	Shamana  chikitsa- Vatanulomana Balya Rasayana    Shodhana Chikitsa- 1 sitting of Nasya with  Jyotishmati Taila for 7 days	Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present   30/11/2023 4     days 1 month 20  days Natural 2     pad/day Reduced Regular  Disturbed	Absent    25/01/2024 5     days 1 month 25 days Natural 2     pad/day Normal Regular  Sound
February- March	Deepana- Pachana  Shodhana Chikitsa-  1 sitting of Nasya with Mahanarayan taila for 7 days  1 sitting of Matra Basti with Dashmool  Taila    Shamana a chikitsa- Vatanulomana Balya Rasayana	Amenorrhoea  M/H- LMP Duration  Interval Nature  Amount    Appetite Bowel Sleep	Present 25/01/2024 5     days 1 month 25 days Natural 2     pad/day   Reduced Regular  Sound	Present - - - - -   Normal Regular  Sound
April- May	Shamana Chikitsa- Vatanulomana Balya Rasayana    Shodhana Chikitsa- 1 sitting of Nasya with Mahanarayan taila for 7 days	Amenorrhoea    M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present   01/04/2024 3  days 2 month 6 days Natural 2     pad/day Normal Regular  Sound	Absent    07/05/2024 3     days 1 month 6 days Natural 2     pad/day Normal Regular  Sound
June- July	Shamana a chikitsa- Vatanulomana Balya   Shodhana Chikitsa- 1 sitting of Matra Basti with Dashmool  Taila	Amenorrhoea  M/H- LMP Duration  Interval Nature  Amount  Appetite Bowel Sleep	Present 07/05/2024 3     days 1 month 6 days Natural 2     pad/day Normal Regular  Sound	Absent  11/06/2024 3     days 33 days Natural 2     pad/day Normal Regular  Sound

RESULT

PARAMETER	BEFORE TREATMENT	AFTER TREATMENT
AMENORRHOEA	PRESENT	ABSENT
M/H –  INTERVAL DURATION NATURE AMOUNT	1 YEAR 3-5 DAYS  WITHDRAWAL  3 PAD/ DAY	35- 40 DAYS 3-5 DAYS NATURAL  3-4 PAD/DAY
USG FINDINGS	PCOD PRESENT  Rt ovary- 32 × 33 × 18 mm ; vol- 10 cc Lt ovary- 34 × 34 × 16 mm ; vol- 10 cc Multiple peripherally placed antral follicles	PCOD ABSENT   Rt ovary- 20 × 36 mm  Lt ovary- 26 × 42 mm
THYROID PROFILE	HYPOTHYROIDISM Total T3- 107.00 nmol/L Total T4- 10.60 µg/dl TSH- 9.27 uIU/mL Thyroxine – 75 mcg	HYPOTHYROIDISM Total T3- 130 nmol/L Total T4- 9.81 µg/dl TSH- 5.049 uIU/mL
APPETITE	REDUCED	NORMAL
BOWEL	CONSTIPATED; INCOMPLETE EVACUATION	REGULAR
SLEEP	DISTURBED	SOUND
WEIGHT	45 KGS	47 KG

 

 

The patient came up with the chief complaint of amenorrhoea and withdrawal bleeding but now after the treatment initially menstruation occurred without withdrawal and later on the interval of cycle was regularised. Also the associated complaints of reduced appetite, incomplete evacuation of bowel and disturbed sleep were completely resolved. Changes were observed in the size of ovaries with resolution of cyst and dose alteration for hypothyroidism was done. Thus patient showed significant results after the Ayurvedic management protocol.

DISCUSSION

The present case of 29 years old unmarried female is unique due to its complexity and rare combination. Secondary Amenorrhoea coupled with history of withdrawal bleeding suggests hormonal imbalance affecting her menstrual cycle. Further Hypothyroidism is a condition where thyroid gland does not produces enough hormone which in turn disrupt menstrual regularity, and exacerbate PCOS symptom presenting as irregular menses. Further the unique interplay of these conditions in as unmarried woman add layer of diagnostic and therapeutic challenge. It requires a comprehensive approach targeting the entire Artavvaha Strotas i.e. endocrine and functional reproductive tract.

UTILITY OF DEEPANA- PACHANA

Deepana-Pachana dravyas improve the metabolism and purify the Aama (toxins) by Aama Pachana resulting in optimal functioning of the Dhatuagni, Jataragni, Bhootagni and hence optimal formation of dhatu.

UTILITY OF DHATU POSHANA

Menstrual cycle consists of 2 cycles namely endometrial cycle and the ovarian cycle. Endometrial cycle deals with regeneration, proliferation, secretion and shedding of endometrium which is related with the Artava/ Raja that is shedded every month. The ovarian cycle involves development and maturation of follicle, ovulation and formation of corpus leutum. It can be referred as Beeja in Ayuveda which is the saptam dhatu Shukra responsible for ‘Garbha’ i.e. conception⁶. Thus for a healthy menstrual cycle both the cycles – the endometrial and the ovarian cycle must be coordinated which involves the nourishment of Artava as well as the Sukra dhatu. The concept of nutrition in Ayurveda is explained as Khale- Kapota Nyaya⁷, Kedari Kulya Nyaya⁸ where each dhatu provide nutrition to its next dhatu. Thus Rasayana, Vajikarana, Balaya dravyas enhances and supports the formation of Rasa and Shukra dhatu.

Aartava can be considered as Dhatu when it governs both the functions of Dharana and Poshana as evident during pregnancy. In this stage the endometrium gets converted into decidua which participate in the formation of placenta which provide nutritional support to the growing foetus while in absence of fertilisation the secretory changes of endometrium cannot be continued resulting in shedding of endometrium referred as Bhaya Artava.  In this stage it performs the function of support hence considered as Updhatu. Thus the Rasyana Dravyas aims at correction of the depleting Ras Dhatu and Artava Updhatu. 

UTILITY OF SHAMANA CHIKITSA

Ayurveda focuses on relieving symptoms and restoring balance in the body. Shamana chikitsa is tailored to individual needs, considering their specific dosha imbalances and overall health status. It is revised after a time period according to symptoms.

 

UTILITY OF SHODHANA CHIKITSA

Nasya Karma 

Another important factor governing the menstrual cycle is channelized HPO axis any disruption at any level causes physiological disturbance of the cycle thus treatment motility aimed at correction of coordination is required which is achieved by Nasya Karma and coordination of Vata Dosha. As evident from classics “Nasa Hi Shirso Dwarama ’’⁹ thus for a medicine to act on the nervous system the shortest and the most preferred route is via nose. The nasal mucosa is rich in nerve endings and blood supply thus medicine stimulates these nerve endings and triggers sensory signals to brain resulting in activation of specific centre in brain namely hypothalamus and pitutory gland. 

Basti Karma 

Since the physiological mechanism of circulation of the reproductive hormones is carried out by Vata Dosha. The various subtute namely Prana Vata governs the movements of the upper body, Samana Vata stimulates jatharagni and hence formation of dhatu and updhatu. Apana vata controls all the secretory activities of the lower body. Any disruption in the circulating Vata Dosha leads to physiological incoordination leading to amenorrhoea. Thus correction of Vata Dosha involves Vatanulomana which is achieved via Shamana and Shodhana Chikitsa namely Basti Karma. 

Basti is referred as ‘Ardha Chikitsa’ in classics¹⁰. Pakwashya being the prime site of Vata Dosha is hence the most preferred route for Vatanulomana thus Basti becomes the treatment of choice as it involves administration of medicated oils or herbal decoction via anal route into the intestine. Also intestine lies in close proximity to the pelvic organ thus possess local therapeutic effects.   

In the present case, the treatment necessitates the careful channelization of the Artavavaha Strotas, which is intrinsically linked to the entire systemic network of the body. Given the complexity of these interconnected systems, a comprehensive and holistic approach is essential. This approach involves addressing all relevant systemic connections to ensure the effectiveness of the treatment. While this may extend the duration of the treatment process, it is expected to yield promising and sustainable results, ultimately contributing to the overall well-being of the patient.

 

 

CONCLUSION

By the present single case study we can evaluate that administration of Shamana Chikitsa along with local therapies helped in Amapachana, Agni Deepana, Dhatu Poshana And Vatanulomana resulting in regularization of menstrual cycle and improved overall well-being of the patient. Further clinical studies are needed to validate these findings and refine treatment protocols.

Acknowledgment and funding sources: There is no acknowledgment or funding resources

Conflict of Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Authors Contributions: All the authors have contributed equally.

Source of Support: Nil

Informed Consent Statement: Informed consent was obtained from the subject involved in the study

Data Availability Statement: The data presented in this study are available on request from the corresponding author. 

Ethics approval: N/A

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