|Year : 2022 | Volume
| Issue : 1 | Page : 11-16
Management of secondary amenorrhea and PCOS by Vamana and Virechana - a case report
T Prarthana1, Veena G Rao2
1 Department of Panchakarma, Sri Sri College of Ayurvedic Sciences, Bangalore, India
2 Department of Panchakarma, JSS Ayurveda Medical College, Mysore, India
|Date of Submission||29-Jul-2021|
|Date of Acceptance||23-Mar-2022|
|Date of Web Publication||04-Aug-2022|
Dr. T Prarthana
Department of Panchakarma, Sri Sri College of Ayurvedic Science & Research Hospital, 21st Km, Kanakapura Main Road, Udayapura Post, Bangalore 560082, Karnataka
Source of Support: None, Conflict of Interest: None
A 34-year-old female patient presented with a prolonged history of absence of menstruation and dyspareunia was clinically diagnosed as Artava Kshaya (amenorrhea). She was treated with Vamana Purva Snehapana (oral ingestion of fats) with Guggulutikta Ghrita and Aragvadha Mahatikta Ghrita followed by Vamana (emesis therapy) and Mahakalyanaka Ghrita Snehapana followed by Virechana (purgation therapy). On the 15th day after Shodhana and Samsarjana Karma (dietetic regimen after therapeutic purgation), the menstrual cycle appeared after ten years. The patient weight was reduced by 5 kg after the completion of therapeutic emesis and purgation. Symptomatic improvement was observed in concurrent symptoms such as dyspareunia and puffiness of the face. The patient was observed for the next two years without any therapeutic intervention, and she had regular menstrual cycles with moderate flow during that period. This case demonstrates the role of Vamana and Virechana in the management of Artava Kshaya.
Keywords: Aragvadha Mahatikta Ghrita, Artava Kshaya, Guggulutikta Ghrita, Polycystic ovarian syndrome
|How to cite this article:|
Prarthana T, Rao VG. Management of secondary amenorrhea and PCOS by Vamana and Virechana - a case report. J Res Ayurvedic Sci 2022;6:11-6
|How to cite this URL:|
Prarthana T, Rao VG. Management of secondary amenorrhea and PCOS by Vamana and Virechana - a case report. J Res Ayurvedic Sci [serial online] 2022 [cited 2022 Nov 26];6:11-6. Available from: http://www.jrasccras.com/text.asp?2022/6/1/11/353410
| Introduction|| |
Artava Kshaya (amenorrhea) can be a symptom of many gynecological diseases such as Yoni Vyapada (vaginal diseases), Vandhyatva (infertility), polycystic ovary syndrome (PCOS), etc. It can be correlated to a certain extent with oligomenorrhea, hypomenorrhea, and secondary amenorrhea based on signs and symptoms. Hormonal imbalance is a common cause of menstrual irregularities. The common treatment for such menstrual disorders is hormonal therapy/hormonal pills in contemporary medicine. Long-term usage of hormonal therapy leads to various side effects such as cyst formation, weight gain, and chances of carcinoma. Among treatment modalities advised by various Acharya, Dalhana has advised detoxification involving emesis therapy with drugs of hot potency for the management of Artava Kshaya. Commentator Chakrapani has advised both emesis and purgation therapy in its management and this principle was incorporated in devising the therapeutic plan for the patient whose case study is being reported here.,
| Patient Information|| |
A 34-year-old female patient weighing 70 kg with body mass index (BMI) of 27.3 kg/m2 came to Vedam Ayurveda Hospital, Bangalore, India, with complaints of cessation of menstruation for the last ten years associated with dyspareunia and no other co-morbidity. The last menstrual period was on 20.6.2008. The patient had attained her menarche at 13 years of age and is married for 16 years with obstetric history (Gravida) G2 (Parity) P2 (Live birth) L2. The patient had received depo medroxyprogesterone acetate (DMPA) for two years post her second delivery in 2008 and noticed irregular menstrual cycles initially, and gradual cessation of menstruation occurred after a year of using DMPA. The patient noticed a gradual increase in weight by 10 kgs, and hence discontinued DMPA after her 8th dose in 2008. Secondary amenorrhea was observed even after discontinuation of DMPA. The patient experienced a continuous increase in weight by 6 kg over the last few years, associated with puffiness of the face and hair loss. The abdomen and pelvis ultrasound examination was suggestive of polycystic ovaries (PCOs). She was diagnosed with PCOS and advised to start hormonal therapy by her gynecologist. The patient had taken herbal life formula to reduce her weight but was unsuccessful and was given a water-based lubricant for dyspareunia. She was advised oral contraceptive pills, but she declined to take them due to fear of weight gain. Her dietary habits included chicken/fish twice weekly, regular use of sweet, spicy, deep-fried and junk food. The patient had no history of undergoing sterilization. There was no previous relevant medical or family history of gynecological illness such as PCOS.
| Clinical Findings|| |
The clinical findings of general examination and examination in perspectives of Ayurveda are depicted in [Table 1] and [Table 2].
|Table 2: Pathological factors and patient examination in perspectives of Ayurveda|
Click here to view
Before 2008, the patient had irregular cycle duration and delayed for 45- 55 days. The menses were painful with reduced menstrual flow during cycles. The patient had taken eight doses of DMPA injection and stopped DMPA in 2008. After approx four months, the menstrual cycle ceased completely. The timeline of the clinical events in the case is described in [Table 3].
| Diagnostic Assessment|| |
Laboratory tests on December 3, 2018 showed red blood cells of 4.0 million cells/mcL, white blood cells of 4300 cells/mcL, platelets 250,000/mcL, and Hb 12.2 g/dL. USG of abdomen and pelvis revealed polycystic ovarian changes. Right ovary: 12 cc volume, bulky right ovary reveals small peripherally arranged follicle. Left ovary: 10 cc.
Amenorrhea, acanthosis nigricans, male pattern baldness, and USG suggestive of PCOs were observed in the patient. The patient was clinically diagnosed with Artava Kshaya based on the signs and symptoms and was treated along the same line.
| Intervention|| |
Detailed therapeutic strategy was selected and adopted as listed in [Table 4] and [Table 5]. Medicines were procured locally from AyurCentral Pharmacy, and Madanaphala Pippali (powdered seeds of Randia dumetorum) and Piper nigrum was obtained from Shimoga district in the month of April 2018.
| Follow-up and Outcome|| |
After purgation therapy on the 15th day, the patient resumed her menstruation since its absence for 10 years. No discomfort was experienced, and mild clots were observed during the initial two menstrual cycles. The patient reported that there was complete reduction in symptoms of dyspareunia. After completing treatment, total weight was reduced from 70 to 65 kg. BMI had reduced from 27.3 to 24.21 kg/m2. USG of abdomen and pelvis was done on the 3rd day of the cycle and reports revealed normal study of ovaries. On further follow-up, it was reported that the patient had regular menstrual cycle of 4–5 days/28–32 days with moderate flow since the last two years till date without any intervention of medicines.
| Discussion|| |
PCOS is one of the most common endocrine disorders affecting women in their reproductive years and the most common cause of anovulatory infertility. It is characterized by varied combinations of clinical (oligomenorrhea/amenorrhea, hirsutism, acanthosis nigricans, obesity, acne, male pattern balding), biochemical (increased serum levels of luteinizing hormone [LH] and androgens), and sonography findings (enlarged PCOs), according to the 2003 ESHRE ASRL (Rotterdam) criteria.
Amenorrhea is an expected result of using DMPA because ovulation is stopped. Approximately 50% of women will have amenorrhea after 1 year of use and over 70% will report amenorrhea with longer duration of use. The amenorrhea experienced with it only occurs while using DMPA. When a patient discontinues using DMPA, normal menstruation will return. Similar to the delay in fertility after discontinuation of DMPA, other adverse effects, such as weight gain, depression, and menstrual irregularities, may continue for as long as one year after the last injection.
Aragvadha Mahatikta Ghrita and Guggulutikta Ghrita (GTG) were chosen as Snehana Dravya before emesis therapy [Table 6]. Panchatikta are major ingredients and common in both the preparations which possess anti-inflammatory, antioxidant, and antihyperlipidemic activity.,,, Based on study findings, Commiphora wightii resin, a primary ingredient in GTG, has a potential role in reducing DHEA-induced PCOS by reducing the morphological abnormalities of the ovarian follicles and normal hormone levels in adult rats. Ginger can stimulate blood circulation for the treatment of inflammation and menstrual irregularities, and can also enhance antral follicle count and ovarian reserve function and has immunomodulatory, anti-inflammatory, anti-apoptotic, antihyperglycemic, antilipidemic actions.Tinospora cordifolia is a powerful anti-inflammatory herb. It helps in revitalizing all the body tissues and boosts metabolism naturally. It may have regularized the menstrual flow.
Aragvadha Mahatikta Ghrita is a variant of Mahatikta Ghrita, with Aragvadha in an increased proportion sharing the same benefits, and is capable of curing diseases which are difficult to treat. Aqueous and methanolic extracts of the Cassia fistula Linn possess anti-inflammatory and antioxidant activities. The alcoholic extract of Glycyrrhiza glabra has anti-androgenic effects probably by increasing the testosterone metabolism, down‐regulating androgen receptors, or activating estrogenic receptors.Gentiana kurroa possesses anti-inflammatory activity and is a good choice for treatment of amenorrhea, dysmenorrhea, etc.Asparagus racemosus helps in promoting normal development of ovarian follicles, regulates menstrual cycle, and revitalizes the female reproductive system. It also helps in combating hyperinsulinemia (high levels of insulin), mainly due to its phytoestrogen.
Mahakalyanaka Ghrita Snehapana was chosen for Purvakarma before purgation therapy [Table 4]. It is indicated in Artava Kshaya. Studies have shown that the extract of Triphala is found to possess the ability to scavenge free radicals such as diphenyl picrylhydrazyl and superoxide. The phenolic compounds present in these extracts are mostly responsible for their radical scavenging activity and may be helpful in controlling various hormonal influences which are causing menstrual irregularities. Curcumin showed beneficial effects in letrozole-induced PCOS in female Wistar rats.Goghrita (cow ghee), which is used as base in the preparation, is known to be directly absorbed in the cervical epithelium and acts locally on tissues. The lipid base helps in better absorption and delivery of active constituents. By virtue of these properties, it acts directly on the target tissue and helped in reinitiating signals on regularization of the menstrual cycle. Trivrita, the main constituent of Trivrita Lehya used for purgation therapy, is known to have anti-inflammatory, antioxidant, and immunomodulatory activities and helps in the elimination of toxins from the body.
PCOS is known to be a metabolic disorder. Emesis therapy improves metabolism of the body and reduces weight which may be due to the action on liver metabolism. Emesis therapy is indicated in disorders of Kapha and Medas. Obstruction of Apana Vayu by Kapha and Pitta can result in amenorrhea. Emesis therapy may be beneficial in removing the obstruction which may be due to gonadotropin-releasing hormone.
Purgation therapy is beneficial in the predominance of Vata and Pitta Dosha vitiation and Artava Kshaya and helps remove morbid matters in channels of circulation. As per the classical Ayurveda texts, purgation therapy is also indicated in diseases of the female reproductive system. Dalhana further adds that internal detoxification should be done with drugs of hot potency. After Virechana, the changes in the USG showed reduction in the ovarian volume and decrease in the number of non-dominant follicles which are positive changes. Apana Vayu plays a significant role in normalizing the function of menstrual blood and purgative therapy aids in the downward movement of Vata leading to Adhogamana of Raja (normal flow of menstrual blood).
Limitation of the study
The patient had lost previous reports of hormonal analysis. The diagnosis and treatment prescribed in the present case were based on Ayurveda approaches. Therefore, hormonal analysis was not done. There may be correlation between changes in hormonal levels such as follicle stimulating hormone, LH, prolactin, and thyroid stimulating hormone with etiopathology as well as the effect of Ayurveda interventions. However, such details are not explored in the present study. Studies such as evaluation of the effect of Ayurveda interventions in treating PCOS with special reference to hormonal analysis can be done to validate results observed in the present case.
| Conclusion|| |
The combination of therapeutic emesis and purgation therapy can help in the treatment of PCOS along with reduction in weight and dyspareunia. The effect observed in the present case study represents that the treatment narrated in Ayurveda for Artava Kshaya can be utilized for the management of PCOS. However, clinical study of large sample size is required to validate the findings of this case study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bourne and Hawkins. Shaw’s Textbook of Gynecology. Delhi: B.I. Churchill Livingstone Pvt. Ltd.; 1989. p. 336.
Sushruta . Sushruta Samhita. In: Acharya YT, Narayan Ram Acharya Kavyatirtha, editors. NibandaSangraha Commentary by Dalhana, Sutra Sthana, 15/12. Varanasi: Chaukambha Publications; 2010. p.70.
Sushruta . Sushruta Samhita, In: Yadavji Trikamji and Nanda Kishore Sharma Bhishagacharya, editors. Bhanumati Commentary of Chakrapani Dutta, Sutra Sthana. 1st ed. Chapter 15, Verse 12. Bombay: Pt. Shyamsundar Sharma, M.A. Registrar Agra University and Sec, Swami Lakshmi Ram Trust, Nirnaya Sagar Press; 1939. p. 115.
Agnivesha . Charaka Samhita. In: Acharya YT, editor. Chikitsa Sthana, 15/96–97. 2nd ed. Varanasi: Chaukamba Surabharati Prakashan; 2008. p. 520.
Bhavmishra . Bhavprakaash Samhita. In: Bramhashankar Misra, editor. Pratham Khanda, Haritakyadi Varga, 1/73. 11th ed. Varanasi: Chaukhambha Sanskrit Bhawan; 2007. p. 24.
Vagbhatta . Ashtanga Hrudaya. In: Vaidya Haridas Shiva Shastri, editor. Chikitsa Sthana, 21/57–60. Varanasi: Chaukambha Surabharati Prakashan; 2007. p. 345.
Agnivesha . Charaka Samhita. In: Acharya YT, editor. Chikitsa Sthana, 7/144–150. 2nd ed. Varanasi: Chaukamba Surabharati Prakashan; 2008. p. 457.
Vaidyanath R, Nishteshwar K, Sahasrayogam . Ghruta Kalpana. 2nd ed. Varanasi: Chaukambha Sanskrit Series Office; 2008. p. 82.
Agnivesha . Charaka Samhita. In: Acharya YT, editor. 2nd ed. Kalpa Sthana,7/23, Varanasi: Chaukamba Surabharati Prakashan; 2008. p. 663.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 Consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19-25.
Medroxy Progesterone Acetate-Subcutaneous Injectable Contraceptive (MPA-SC). Available from: http://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Subcutaneous_Injectable_Contraceptive.pdf
, last accessed on December 17, 2021.
What are the disadvantages of injectable DMPA for contraception? Available from: https://www.medscape.com/answers/258507-109040/what-are-disadvantages-of-injectable-dmpa-for-contraception
, last accessed on December 17, 2021.
Patel SV, Maru H, Chavda VK, Shah JN, Patel SS Ethanolic extract of Azadirachta indica
ameliorates ovarian defects through phosphoinositide-3 kinase inhibition in a rat model of polycystic ovary syndrome. Asian Pac J Reprod 2021;10:21-8.
Shah BN, Seth AK Pharmacological potential of Trichosanthes dioica—
An edible plant. IJCCR 2010;2:7.
Verma R, Tapwal A, Puri S Phytochemical profiling and GCMS study of Adhatoda vasica
Nees. An ethnomedicinal plant of North Western Himalaya. Biol Forum Int J 2016;8:268-73.
Singh OM, Singh TP Phytochemistry of Solanum xanthocarpum
: An amazing traditional healer. J Sci Indus Res 2010;69:732-40.
Kavitha A, Babu AN, Kumar MS, Kiran SV Evaluation of effect of Commiphora wightii
in dehydroepiandrosterone (DHEA) induced polycystic ovary syndrome (PCOS) in rats. Pharm Tutor 2016;4:47-55.
Ainehchi N, Khaki A, Farshbaf-Khalili A, Hammadeh M, Ouladsahebmadarek E The effectiveness of herbal mixture supplements with and without clomiphene citrate in comparison to clomiphene citrate on serum antioxidants and glycemic biomarkers in women with polycystic ovary syndrome willing to be pregnant: A randomized clinical trial. Biomolecules 2019;9:215.
Ali BH, Blunden G, Tanira MO, Nemmar A Some phytochemical, pharmacological and toxicological properties of ginger (Zingiber officinale
Roscoe): A review of recent research. Food Chem Toxicol 2008;46:409-20.
Khandelwal R, Dipti , Nathani S An ayurvedic approach to PCOS: A leading cause of female infertility. Int J Ayurveda Med Sci 2016;1:77-82.
Aggarwal BB, Prasad S, Reuter S, Kannappan R, Yadev VR, Park B, et al
. Identification of novel anti-inflammatory agents from ayurvedic medicine for prevention of chronic diseases: “Reverse pharmacology” and “bedside to bench” approach. Curr Drug Targets 2011;12:1595-653.
Pastorino G, Cornara L, Soares S, Rodrigues F, Oliveira MBPP Liquorice (Glycyrrhiza glabra
): A phytochemical and pharmacological review. Phytother Res 2018;32: 2323-39.
Skinder BM, Ganai BA, Wani AH Scientific study of Gentiana kurroo
Royle. Medicines (Basel) 2017;4:74.
Pachiappan S, Matheswaran S, Saravanan PP, Muthusamy G Medicinal plants for polycystic ovary syndrome: A review of phytomedicine research. Int J Herb Med 2017;5:78-80.
Khanage SG, Subash TY, Bhaiyyasaheb IR Herbal drugs for the treatment of polycystic ovarian syndrome (PCOS) and its complications. Pharmaceut Res 2019;2:5-13.
Sajeewane PS, Silva GDe, Nafeeza N Role of medicated ghrita and taila formulations in the management of Stree Vandhyatva (female subfertility). IJATM 2020;2:12-1.
Mohan MC, Abhimannue AP, Kumar BP Modulation of proinflammatory cytokines and enzymes by polyherbal formulation Guggulutiktaka ghritam. J Ayurveda Integr Med 2021;12:13-9.
Choudhary N, Prasad SB, Singh AS, Khatik GL, Prabhu KS, Mishra V, et al
. Phytochemistry and pharmacological potential of Operculina turpethum
. Plant Arch 2020;20:683-92.
Sushruta . Sushruta Samhita. In: Acharya YT, editor. ChikitsaSthana, 33/18. Varanasi: Chaukambha Surabharati Prakashan; 2014 Reprint, p. 517.
Sushruta . Sushruta Samhita. In: Acharya YT, editor. ShariraSthana, 2/4. Varanasi: Chaukambha Surabharati Prakashan; 2011 Reprint. p. 344.
Vagbhatta . Ashtanga Hrudaya. In: Vaidya Haridas Shiva Shastri, editor. ShariraSthana, 1/14. Varanasi: Chaukambha Surabharati Prakashan; 2007. p. 345.
Sushruta . Sushrutasamhita. In: Acharya YT, editor. ShariraSthana, 2/10. Varanasi: Chaukambha Surabharati Prakashan; 2010 Reprint. p. 345.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]