https://ijpccr.com/articles/intracranial-epidermoid-cyst-a-rare-case-series-of-3-patients

Endometriosis is one of the most common benign gynaecological diseases characterized by the implantation and growth of viable endometrial tissue outside the uterine cavity. The symptoms of endometriosis can be correlated to many of the Yoni vyapads described in our classics. In the present case, a 37-year-old female (Swedish national) reported chief complaints of severe lower abdominal and pelvic pain and heavy bleeding during menstruation from the past 7 years, especially one day prior to menstruation and stops 1- 2 days after the onset of bleeding. She was advised for a USG scan which showed endometriosis, cyst in the left ovary. Sodhana chikitsa was followed, and the whole treatment period spanned for a total of 42 days. The patient was advised to follow up after 6 months. After the treatment, there was a significant improvement in the patient’s conditions, and in turn, the patient also expressed greater satisfaction with the result.

Endometriosis; Yoni vyapad; Vatiki; Sodhana chikitsa

Endometriosis is the most common prob- lem encountered in Gynaecology. This is a hormone-dependent gynecologic dis- ease, with clinical manifestations of adhe- sion and progressive growth of endome- trial cells in organs other than the uterus. (1) This disease affects a large portion of the population. Half of the patients with endometriosis display clin- ical symptoms of pelvic pain and infertil- ity, thereby reducing the quality of life of women. (2,3) Endometriosis is a relatively common and potentially debilitating con- dition affecting up to 10-15% of repro- ductive age group women. It is seen in 30-40% of women with infertility. Certain guidelines given in Samhitas are utilized for understanding such diseases. According to Ayurveda classics, endometriosis cannot be codified under a single disease entity. Our Acharya’ s have emphasized Lakshanas (symptoms) like Shula (pain) throughout the Striroga Prakarana (Gynaecology), among which Vatiki yoni vyapad, Udavartini yoni vya- pad bear close resemblance to the clinical picture of endometriosis, https://ijpccr.com/ 103 Achuthan & Nellikode / International Journal of Preclinical & Clinical Research 2021;2(4):103–107 which makes finding an effective, validated treatment proto- col for the management of pain in endometriosis. (4) Acharya Charaka explains Vatiki - a woman of Vata prakriti, when consuming improper diet and indulges in other activities capable of aggravating Vata; thus, provoked Vata reaches the reproductive system and produces pricking and other pains, stiffness, sensation as if creeping of ants, roughness and numbness, local symptoms and fatigue or lethargy etc. Due toVata Vaigunyamenstruation appears with irregularity and is painful. Vata gets aggravated due to Vega dharana and moves in the reverse direction, then settles in yoni and produces the pain, initially pushesraja in an upward direction, then discharges it with difficulty. The woman feels relief immediately after the discharge of menstrual blood in Udavartini. (5) The Gynaecological reasons for chronic pelvic pain are diverse. This diversity ends in the clinical diagnosis of endometriosis in about one-third of the cases during their reproductive period. After a definitive diagnosis of endometriosis has been made out for those suffering from chronic pelvic pain, the patients are forced to travel through the traumatic paths of long-term medication leading to frustration and depression. This case study describes Sod- hana chikitsa and its effectiveness in the management of endometriosis. Patient Information A 37-year-old female (Swedish national) visited the Outpa- tient Department (OPD) of Ayurveda Hospital in December 2020 for the management of 7 years of chronic pelvic pain with chief complaints of severe lower abdominal and pelvic pain and heavy bleeding during menstruation. The patient reported that the pelvic pain starts one day prior to menstru- ation and stops 1-2 days after the onset of bleeding. The pain is most severe on the first day of the menstrual cycle, associ- ated with heavy bleeding with clots. History of painful periods since menarche. She was advised to take Oral Contraceptive pills (OC pills) in the year 2000, which she continued for 8 years. On medication, she got temporary relief from the symptoms, which reappeared on the stoppage of OC pills. She denied taking OC pills and resorted to oestrogen pills for the management of pain from 2008 to 2012. Stopped oestrogen pills when side effects- abnormal facial hair growth noted. From 2013 again, the pain and bleeding became worse. The pain aggravated, and she was advised for a USG scan in April 2015, which showed endometriosis, cyst in the left ovary. After which, she was advised by the Gynaecologist to have OC pills again. But she resorted to herbal medicine. She was unmarried but a non-virgin without having any habits or addictions. Her family history- Nothing specific revealed. Her personal history revealed a constipated bowel habit, occasional acidity and disturbed sleep. She attained menarche at the age of 12 years, a menstrual period with a duration of 3-4 days and an interval of 24-26 days. Her Last Menstrual Period (LMP) was on 03/11/2020. The amount of bleeding was excessive on the second day, evident from the usage of four to five heavily soaked pads. No history of hypertension, diabetes, thyrotoxosis, no surgical history was obtained. No history of any drug Allergy. Clinical Findings Patient was found to be average built and weighing 60.7 kg. Her blood pressure was 120/80 mmHg, pulse rate was 70/minutes, and BMI was 24.7 kg/m2. Ashta sthana pareeksha details are given in the diagnostic assessment. She is of Kapha-vata prakriti (~constitution based on bodily humour) with Madhyama satva(~mental constitution).Dasavidha rogi pareeksha details are mentioned in the diagnostic assessment. Examination of external genitalia didn’t reveal any abnormal findings. Per speculum examination showed a normal cervix without any significant abnormality. Bimanual examination revealed a bulky uterus; no tenderness was detected. Her bowel and bladder habits were normal. Diagnostic Assessments As part of initial assessment Ashta sthana pareeksha & Dasavidha Pareeksha was done. Nadi (Pulse) was regular with 72 beats per minute, Mutram (Urine) was clear and flow and quantity was normal (Frequency of urination: 3-4 times during morning and 1-2 times at night), Malam (Stool) was formed with nomal toilet once daily early morning, No coating was noted on Jihva (T ongue) and the shape of tongue was normal, Sabda (Sound) was normal, Sparsa (Skin) was normal to touch, Drik (Vision) was normal. She was of young vaya: (age) and of moderate built and heightAkruthi (General appearance and built). Her (Basic constitution) Prakruthi was assessed as Kapha- Vata. Vikruthi (Imbalances): Vata, Kapha and Pitta was assessed to be vitiated on tridosha level, and Dhushya (vitiation of tissues): Dhatus (Tissue level) Rasa, Rakta and Mamsa was found to be vitiated. (Quality and quantity of tissues) Sara, Samhanana (Compactness), Satva (Mental strength and tolerance) were found to be normal, with moderate Vyayama sakthi (Exercise tolerance) and (Compatabilities) Satmya. CBC-WNL, Urine –WNL Laboratory tests were unre- markable. Previous specialized evaluations included Radi- ological ultrasound revealed (abdominal ultrasonography), bulky uterus with adenomyosis. The left endometriotic cyst 5 X 2.3 cm was seen adherent to the uterus. A probable diagnosis, Vatiki yonivyapat (~gynaecological conditions in Ayurveda which includes painful menstruation), was drawn out from the presenting complaints and the previous medical reports produced by the patient during the OPD visit on 11th December 2020. She was advised for admission the same day. https://ijpccr.com/ 104 Achuthan & Nellikode / International Journal of Preclinical & Clinical Research 2021;2(4):103–107 Therapeutic Interventions The treatment given was Amapachana (~digestion of undi- gested food), Agnideepana (~increase digestive fire), Sroto- sodhaka (~clear channel) and Vata anulomana (~downward movement of Vata), and finally Pitta pacifying. The therapeu- tic plan was to perform Shodhana Karma (~cleansing thera- pies) after correcting herAgni (~digestive fire) byPurvakarma (~preparatory therapies). Initially,Hinguvachadi churna(6 g) was given for improving the digestive fire prior to cleansing therapy for three days. The sequence of treatment was as fol- lows: Preparatory therapy The initial treatment was with Agni vishamya (Aama) which is the main root cause of all diseases. Hence the medication given focused on Agni deepana, Aama pachana, Vata anulo- mana. After that 15ml of Sapthasaram kwatha (Ref: Sahas- rayogam) two times a day, followed by 6g of Hinguvachadi churna (Ref: Sahasrayogam) with warm water. Along with the above-mentioned treatment, 15 ml ofSuku- maram kashayam (Ref: Ashtangahrudayam) two times a day, 15 ml of Thrayanthyadi kashayam(Ref: Ashtangahrudayam) two times a day, followed by 2 tablets of Krimighna vati (Ref: Charakasamhita) daily, 30 ml of Asokarishtam (Ref: Sahas- rayogam) after lunch and 10g of Manibadra gula (Ref: Sahas- rayogam) at bedtime was given. The detailed schedule of treat- ment is tabulated in Table 1. Asanas, Pranayama Ushtrasana, Bhadrasana, Gomukhasana, and Vajrasanawere advised. Ustrasana also known as Camel Pose is a deep back- ward bending pose. Bhadrasna or the Gracious Pose is good for activating the Mooladhara chakra. In Sanskrit ‘Bhadra’ means ‘auspicious’ and ‘asana’ means ‘pose’ .Gomukhasana A Sanskrit word, Gomukhasana literally translates into a cow face posture (go – cow, mukha – face, asana – pose). A seated yoga posture, Gomukhasana can be performed along with a set of different seated Asanas. It helps stretch the arms, triceps, shoulders, and chest. Vajrasana-vajra’ means diamond-shaped or thunderbolt; ‘ Asana’ means posture or pose. Vajrasana has been named after the shape it takes – a diamond or thunderbolt. Treatment was given for a duration of 42 days. Diet & Behavioural changes advised. Follow-up and outcome The patient recovered significantly from pain lower abdomen; bleeding was normal. The menstrual cycle was regular and at normal intervals without any complications. After six months of follow-up, there have been no further episodes of pelvic pain and the assessment was repeated at six menstrual cycles (at 4 th, 5 th, 6 th,7th, 8 th, and 9 th menstrual cycles without medicines).

Endometriosis is one of the challenging clinical entities for the practitioners of Ayurveda. The complicated clinical scenario demands accurate diagnosis and management to prevent surgical intervention. This present case report emphasized the importance of an Ayurvedic treatment protocol for the management of pelvic pain connected with endometriosis. The patient was treated on the line of management of Vatiki yonivyapad. Treatment focused onAgni deepana, Aama pachana with Shodhana in order to remove the Aama and get the Doshas back into normal. The treatment protocol aims for the pacification of Vata dosha and correction of digestive fire, thereby abolishing the chronic pelvic pain associated with endometriosis. Due to the unavoidable role of Vata dosha in the present disease entity, cleansing therapies like purgation and enema procedures hold prime importance for the pacification of Vata dosha. A course of medicated enema with intrauterine instillation of medicated formulation has been selected after purgation, giving due importance to the analgesic properties of the drugs. Same time Pitta pacifying medicines were given at the time of discharge. Follow up USG was advised, which was politely refused by the patient. However, she was constantly in touch with proper follow up of oral medicines. For the last two years, no follow up possibly due to a reduction of symptoms. Previous studies have proved the efficacy of Sodhana and Samana therapy in the management of chronic pelvic pain in endometriosis (6) and infertility as a consequence of endometriosis. (7) This study results were also in agreement with the previously reported studies. When the treatment principles are individualized and applied clinically, it yields excellent results to patient satisfaction. Ayurveda blesses the feminine world with numerous drugs, which helps to maintain their health in a natural way. Hence Ayurveda plays a major role in treating endometriosis and thereby prevent complications.

This case study showed that if the plan of treatment is selected according to principles of Ayurveda along with proper drug, dose, duration, Anupana, Pathya and Apathya there is an assertion of progress in treatment. The Ayurvedic management protocol - Sodhana chikitsa is highly effective and recommended in managing the chronic pelvic pain associated with endometriosis. https://ijpccr.com/ 105 Achuthan & Nellikode / International Journal of Preclinical & Clinical Research 2021;2(4):103–107 Table 1. The treatment schedule given to the patient Treatment procedure Method of administration Remarks Dipana, Pachana with H inguvachadi churna 3 days 5g daily before food with warm water Appetite-Good Bowel-Cleared once Micturition-Normal Sleep-Sound Snehapana with D adimadi ghritham 7 days Arohana krama after assessing Agni and K oshtha, maximum dose was 150 mL Days 1 2 3 4 5 6 7 Ghritha 30 60 75 80 90 110 150 ml ml ml ml ml ml ml Appetite- Good Bowel- Cleared once Micturition- Normal Sleep- Sound Bahya nehana with S wedana 3 days Sarvanga abhyanga with Dhanvanthara taila for 45 minutes followed by N adi veda swedana with Dasamula kwatha for 15 min. Appetite-Good Bowel-Cleared once Micturition-Normal Sleep-Sound V irechana Pradana karma -Virechana Virechana dravya Thrivrt churna -5 g + A vipathi choorna- 15 g mixed with luke warm water given at 7 am 14 Vegas Sansarjana karma 3 days M anda eya vilepi Advised rest Sn ehana 7 days Sarvanga abayanga– Dhannwantharam taila45 minutes for 7 days followed by N adi veda swedana with Dasamula kwatha for 15 min. Oral medication continued Appetite-Good Bowel-Cleared once Micturition-Normal Sleep-Sound Y oga vasti 8 days Y oga vasti 1st Day- Matra vasti After taking lunch Poorva karma – Abhyanga with Sarsapa taila in the lower abdomen and lower back followed by Swedana karma Pradana karma – Matra vasti dhanwantharam Mezhupakam thailam-90ml Paschat karma –Lying supine position 2nd day, 4th day, 6th Day- Kashayavasti was given 7 am Before food Poorva karma – Abayanga with Dhanwantharam taila in the lower abdomen and lower back followed by Swedana karma Pradana karma – Kashaya vasti (Niruha vasti). Paschat karma –Lying supine position iruha vasti with: Madanaphala, Musthadi, Laghupanchamula kwatha-320 ml aindhava lavana-15 g, Madhu (~Honey)-120 ml ahacharadi thailam7 Avarthi 120 ml Kalka- 30 g (Madhuka, Sathahwa, Pippali, Rasanjana, Thrivrut ) Anuvasana vasti with 90 ml D hanvantara taila Mezhukupakam Advised rest Sansarjana karma 3 days M anda eya vilepi Advised rest 7 days T hakradhara Oral medication continued Appetite-Good Bowel-Cleared once Micturition-Normal Sleep-Sound Patient was discharged Oral Medicines on discharge for 3 months Pradaroushadhi - 15 ml twice a day Sukumaram kashayam- 15 ml twice a day Bala thailam - 10 drops early morning with warm water https://ijpccr.com/ 106 Achuthan & Nellikode / International Journal of Preclinical & Clinical Research 2021;2(4):103–107 Declaration of patient consent Authors certify that they have obtained patient consent form, where the patient/caregiver has given his/her consent for reporting the case along with the images and other clinical information in the journal. The patient/ caregiver understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed. Table 2. Scheduled Diet Plan 6:30 am Herbal tea/ Barley water 8:00 am Broken wheat porridge/ Poha upma/ Idli with veg 11:00 am T ender coconut water/Herbal tea/ green tea 1:00 pm Kicchadi /steamed veg 4:00 pm Herbal tea 7:00 pm Mixed veg Soup, Chappathi, Mint chutney Table 3. Results after the treatment Symptoms Before Treatment After Treatment

Pelvic, low abdominal pain Pelvic low abdominal pain Reduced Up to 90 % Dysmenorrhoea Dysmenorrhoea Relieved Up to 90 % Heavy bleeding Heavy bleeding Reduced Up to 80 %

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