Effect of vamana in artavakshaya (oligomenorrhoea): A case story

Menstruation is the age-old sign of womanhood and fertility. Even a slight disturbance invariably leads to anxious uncertainty in the woman ,which, in most cases is willfully ignored and later panicked. Artavakshaya (decreased menstruation) is one such distressing condition drawing a large number of females to the gynecological OPD. Majority of them resort to Ayurvedic treatment only after a series of failed hormonal experiments. This further disturbs body metabolism making it tougher to accept superficial treatment.

Before proceeding into the case, understanding the following terms are important :

·         

ARTAVA

It represents the essence of female fertility. It is the upadhatu (by product) of rasa dhatu (the original dhatu). It is carried to the garbhashaya(uterus) and expelled by vata ( dosha ) . Shonita, asrk, raja, rakta, lohita, rudhira, pushpa, bija are synonyms used. It may be used to denote menstrual fluid, ovarian hormones or ovum. 

ARTAVA VYAPAD

It is a compilation of all  pathologies associated with artava .

ARTAVAKSHAYA

It is defined as a condition characterized with delayed menstruation (uchita kala adarshanam), decreased quantity (alpata), vaginal pain (yoni vedana) and a desire to have katu, amla, lavana , vidahi ahara(sour and pungent foods)

ANARTAVA

 It is the non- appearance of artava (artavam nashyati striyaaha). Kshaya(decrease) occurs and it is obstructed at the level of  srotas(channels)by vata and kapha . Artavakshaya existing over a period of time may lead to anartava (absence of menstruation).

The symptoms of artavakshaya can be explained as

ü  Oligomenorrhea- infrequent or very light menstruation.  Menstrual periods occurs at intervals of greater than 35 days, with only 4-9 periods in a year with previous regular menstrual history.

ü  Hypomenorrhea- release of small quantity of blood at menstruation and duration of bleeding being less than normal. Most authors use the term hypomenorrhoea both to describe a menstrual loss less than normal, and also a cycle less frequent than normal. Hence the term scanty menstruation is also given to the same.

ü  Dysmenorrhea- Painful menstruation

ü  Secondary amenorrhea- Absence of menstruation for more than 3 cycles or 6 months in women who previously had menstruation.

CASE SUMMARY

A 20 year old unmarried female with history of regular menstruation since menarche gradually developed irregular menstruation along with dysmenorrhea. She visited the OPD with complaints of amenorrhea since 5 months. Associated complaints included white discharge per vaginum and constipation since 4 months. She had history of hormonal treatment and also progesterone challenge test with disturbing side effects like weight gain and lethargy. Detailed history taking and examination was done. Secondary sexual characters +. 
Initially, Artavajanaka oushadhi (drugs that induce menstruation) was given. As the establishment of the cause was essential, further investigations were carried out. USG showed multiple ovarian follicles with central thickened ovarian stroma (PCOS) and ruled out tumours; Hb- 10.4gm%; RBS-100mg/dl, TSH- WNL. Prolactin levels were normal.

The first follow up showed no improvement. The treatment was improvised and the patient was advised to undergo Panchakarma. Based on the condition of the patient i.e. roga(disease) and rogi(diseased) bala (strength), vamana (emesis) was scheduled.

Day 1 & 2: Deepana pachana(carminatives & digestives) with chitrakadi vati 2 tid;

     panchakola phanta 30 ml tid

Day 3: snehapana (ghee intake) with mahakalyanaka ghrta 30 ml

Day 4: snehapana 60 ml

Day 5: snehapana 90ml

Day 6: snehapana 140ml

   Samyak snigdha lakshana (signs of adequate oleation)

Day 7: Visrama kala (rest) with kapha utkleshaka ahara (foods that provoke kapha)

Day 8: Vamana was carried out successfully.

           

           Vega: 6/ pittantam/no complications

Madhyama samsarjana karma (moderate diet) was advised to be followed.

Medicines advised: Kumaryasava & shatavari guda

The patient was asked to come for review after a month or with the onset of periods.

Result- The patient reported after 6 days elated with the onset of periods. She was advised to continue the above medicines along with tila kashaya and proper pathya (panned diet).

DISCUSSION

Artavakshaya- Anartava diagnosis was done by analysing presenting complaints and  chikitsa sutra (line of treatment) was implemented . The approach includes shodhana(detoxification), artavajanaka dravya prayoga(drugs that induce ovulation & menstruation) , anuvasana basti (enema therapy with oil).

As dosha avarana (block) included kapha & vata , vamana was adopted initially with consequent Basti  to regulate disturbed Vata. 
Vamana is a panchakarma procedure which is Kapha hara, thereby removing the obstruction and metabolic imbalance at the gross and root levels. It is agneya dhatu vardhana (increasing the hot elements) thereby stimulating the regulation of the the artava which is agneya (fiery) is nature.  

It also possibly helps to

     

• ·         Correct  hampered metabolism
• ·         Increase blood supply to brain by stimulating it
• ·         Tonic release of gonadotropins
• ·         Promote follicle growth
• ·         Proper enzymatic activity and conversion
• ·         Decrease fat cells, Decrease weight
• ·         Decrease peripheral aromatization
• ·         Regulate blood sugar and insulin levels
• ·         Decrease excess male hormones and hormonal activity, increase SHBG
• ·         Improve progesterone production
• ·         Ensure regular ovulation and menstruation 

CONCLUSION:

Menstruation is a complicated ritual, There are a lot of factors influencing its physiology. Geographical conditions, nutritional standards, environmental influences and indulgence in strenuous physical activity can affect pituitary functions, hormonal status and thereby menstrual cycles . The disturbance produced on the doshas is made visible by the varying hormonal levels. Shodhana (purification) along with Nidana parivarjana( following the regimen during menstruation) is necessary to restore optimum health without any undue complications. Vamana being the recommended procedure here, was helpful in clearing channels and setting the system back to normalcy. 

 In whole, Ayurveda focuses on prevention and maintenance of health. The purity of shukra (sperm)and artava (ovum) are treated with high priority so that the future progeny is not compromised.  Thus a holistic approach to the well being of the patient is required, rather than a mere reversal of symptoms. Correcting the basic underlying pathology is the aim of Ayurveda. 

The mode of treatment though time-tested and eternal, needs further clinical evaluation and validation to be established further.  

GARBHINI PARICHARYA- Beyond just prenatal care

“Woman is considered superior to man

 Because

 She is the one who possesses the route to bear a child” - Charaka.

    

            Ayurveda has stressed on this aspect of womanhood wherever possible- Her ability to procreate. She is the one who contributes the other half of the seed and also acts as a substratum for the fetus to grow and flourish. Therefore she forms the bija(seed) and kshetra(base), thus calling for more attention, health wise. Thus it’s not just antenatal care that Ayurveda is focusing on, but a comprehensive prenatal care or perhaps beyond. “A productive tree is that which grows in a well watered fertile soil, bearing a healthy seed”. Therefore garbhini paricharya mentioned by acharyas can be executed faithfully if the woman is in good health while entering into conception and is considered complete when she is able to get back to her own self post delivery. Thus all the below mentioned regimens should be taken into consideration while planning for conception.

1.       Rajaswalacharya ( regimen during menstruation)

2.       Rtukalacharya ( regimen during fertile period)

3.       Garbhadhana (Conception)

4.       Garbhini paricharya( regimen during pregnancy)

5.       Sukha prasava (regimen during labour)

6.       Sutikaparicharya (regimen for post-partum care)

Fulfilment of pre-requisites makes things easier for both the patient and the physician. Considering the fact that the fetus is the product of planned conception, the aforesaid garbhini paricharya (care of pregnant woman) has been explained. Like said earlier, this is just a part of the big picture. 

A bird’s eye view:

FIRST TRIMESTER

      First trimester is that phase when lots of division and differentiation occurs. The woman is suddenly exposed to a new set of hormones confusing her system in and out. She has a higher BMR as opposed to the commencement of nausea. So it becomes essential to supply her with food that simple to digest (laghu) but high in calories, that makes for quick absorption before the system throws up. At the same time, there is a mention about not taking any “avoidable” drugs during the period of organogenesis (kashyapa) for fear of undue interference in the development process. Therefore maximum nourishment with minimum external intervention is the aim. The best food matching the above said requirement would be MILK*. The regimen includes

·         Food that is  sweet predominant, liquid based and cold in potency

·         The woman should not go around experimenting and should stick to food that has been good to her all these years

·         Milk in quantity that can be digested by the individual. It’s purely subjective. Milk is best taken without any additives; if necessary she can sweeten it with honey and ghrta or add madhura/ jeevaniya gana drugs

·         Red rice (old) cooked with milk

1.      मधुर शीत द्रव प्राय आहार

2.      प्रकृति सात्म्य भोजनं (सायं प्रातश्च)

3.      क्षीर in अल्प मात्रा

4.      असंस्कृत

5.      मधुर औषधि सिद्ध

6.      मधु एवं घॄत सिद्ध

7.      शष्टिक शालि  cooked with milk

SECOND TRIMESTER

      Second trimester is when you actually start feeling pregnant. The nausea wears off. You begin to feel cheerful and yay there is the long awaited bump. People start noticing, acknowledging smiles everywhere and again you feel all yourself. This is the only one trimester that you, if truth be told, get to enjoy. That’s probably why acharyas have instructed to take food that pleases the preggo’s heart. Thoughtful. Very thoughtful indeed.:).  Reminder: that doesn’t permit deviation from the norm as the fetus is slowly and steadily growing, imbibing a lot more than you imagine and learning things from the mother, including choice of taste. The aim is to have your choice of food, in good quantity, bearing in mind the health quotient. Butter gives maximum energy and curd helps digest the food due to its potency. Drugs that are mild diuretics help to maintain the water metabolism. The regimen includes

·         Food that’s pleasing to the mind

·         Milk, butter, curd, ghee

·         Milk with butter

·         Shasti rice(old red rice) with curd, meat of wild animals (strength giving)

·         Yavagu and payasa (sweet dish)

·         Gokshura (Tribulus terrestris) with milk or rice gruel

1.      हृध्यं च अन्नं

2.      दधि

3.      क्षीर

4.      सर्पि

5.      शष्टिक शालि ओदन + दधि + क्षीर

6.      क्षीर नवनीत संस्कृत आहार

7.      क्षीर सर्पि संस्कृत आहार

8.      मधुर औषधि सिद्ध सर्पि

9.      गोक्षुर सिद्ध सर्पि

THIRD  TRIMESTER

The third trimester is the most special of all. It can be termed the “genuine” waiting period. You become heavier, movements become sluggish; you feel dependent and miserable and to top it all, insomnia! All these coupled with the fervent excitement to see the little bundle of joy leads to anxiousness and apparent stress. The main aim here is to control vata while you are going berserk from within. This is achieved through the use of vatahara ,snigdha (oleating) therapy and basti (enema). Through this regimen, it’s possible to prime the body appropriately for upcoming labour and post delivery stress. This includes

·         Enabling proper movement of vata through ahara &aushadhi

·         Ghee with madhura gana/ prithakparnyadi gana (Uraria picta)

·         Yavagu with milk and ghrta

·         Basti

·         Treating kikkisa (itching) that later leads to striae

1.      वात अनुलोमन

2.      स्निग्ध यवगु (क्षीर) , जांगल रस

3.      आस्थापन बस्ति

4.      अनु्वासन बस्ति

5.      पृतक्पर्ण्यादि घृत

6.      किक्किस चिकित्सा

RELEVANCE IN MODERN ERA

·         Concept of pre-natal care needs to be re evaluated.

·         Increase awareness among masses

·         Need for research to set standards and make things easier to apply

·         Depleting resources is a cause for concern while treating using natural elements

·         Recognition by Govt. of India will only pave way for expanding the platform for all the above said.

* pure cow milk