Nonsurgical management of Adenomyosis through Ayurveda: A single-case observation

INTRODUCTION Adenomyosis (ICD-11 Code: GA11) is a gynecological condition characterized by the presence of functional endometrial tissue within the uterine myometrium or muscular wall of the uterus.[1] This often leads to symptoms such as Heavy Menstrual Bleeding (HMB), severe menstrual cramps, and chronic pelvic pain. While the exact cause of adenomyosis remains unclear, it is most commonly diagnosed in women between the ages of 35 and 50 years, often coinciding with significant phases of their reproductive years. For a long time, adenomyosis was primarily identified through histopathological examination following a hysterectomy in perimenopausal women experiencing HMB or pelvic pain.[2] The prevalence of focal and diffuse Adenomyosis was found to be 17% globally, with 1% prevalence among the general population.[3] Adenomyosis significantly affects the quality of life in a large number of cases due to Abnormal Uterine Bleeding (AUB) and pain, necessitating long-term management through either medical or surgical treatment. The treatment approach is determined by the factors such as the woman’s age, reproductive status and clinical symptoms.[4] Currently, there is no definitive medical management for Adenomyosis and available pharmacological treatments often present limited efficacy and potential side effects such as incomplete disease control, recurrence of symptoms after discontinuation, weight gain, mood changes, irregular bleeding, and decreased bone density depending on the therapy used. As a result, many patients ultimately undergo hysterectomy as a definitive solution, particularly in cases unresponsive to conservative therapy. In Ayurveda, Adenomyosis can be correlated with Vatika yoni vyapada (~gynecological disorder caused by vitiated Vata dosha) and Udavartini yoni vyapada (~dysmenorrhea with frothy discharge). The pathophysiology involves the vitiation of Apana vata (~one of the five subtypes of Vata, situated in the pelvic region), which, when obstructed, disrupts its Anulomagati (~normal movement of Vata), leading to stagnation and localized pathology in the uterus. In addition, the involvement of Vyana vata (~a subtype of Vata, that is seated in Hridaya) contributes to the spread into myometrium. The association of Pitta (~Dosha responsible for regulating body temperature and metabolic activities) and Kapha (~Dosha responsible for regulating body fluids and keeping the body constituents cohesive) leads to inflammation, congestion, and tissue overgrowth. Clinically, this manifests as pelvic pain, numbness, frothy menstruation, vaginal dryness, and black-colored menstrual blood, indicating vitiation of blood (~Rakta dushti) and impaired uterine function. Thus, in the present case report, an effort has been made to explore the effectiveness of Ayurveda interventions in managing Adenomyosis, highlighting the importance of a tailored, integrative approach in improving the patient's quality of life without surgical intervention. PATIENT INFORMATION A 42-year-old married, working woman came to Streeroga Outpatient Department (OPD) of Ayurveda hospital on November 1, 2023, with complaints of severe pain in lower abdomen before the onset of menstruation and associated with HMB with clots during menstruation, dyspareunia, and dysuria for the last four years. The intensity of pain is usually severe affecting her daily chores, further enforcing her to take leave from office work during her menstrual periods. Earlier, under the consultation of a gynecologist in the nearby hospital, Ultrasonography (USG)-Pelvis was done on October 30, 2023, which was suggestive of adenomyotic changes in the myometrium. The patient was taking Oral contraceptive pills along with analgesics during menstruation. Since, there was no significant relief through the medications, thus, was advised for hysterectomy. As the patient was not willing for hysterectomy, she visited the OPD for the Ayurveda management. The patient had a regular menstrual cycle and an obstetric history of P3L3A1 (Parity 3, Live 3, Abortion 1), with all three live births delivered through normal vaginal delivery. CLINICAL FINDINGS The patient was overweight with body mass index of 27.4. On physical examination, all vitals were stable and menstrual cycles were regular, with intensity and duration of 4–5 pads/day for the three days. Her last menstrual period was on November 1, 2023. Per vaginal examination revealed anteverted uterus, bulky in size, tender fornices with no palpable adnexal mass, mobile cervix, and absent Cervical motion tenderness. Per speculum examination showed hypertrophied cervix, mild milky white discharge, and Nabothian cyst present at 5 o’ clock position. The USG dated October 30, 2023 showed bulky uterus of size 9.3 cm × 4.8 cm × 4.2 cm, with endometrial thickness of 6 mm, patchy area of altered echotexture in myometrium, suggestive of early adenomyosis. The patient was known case of hypothyroidism for 15 years and was taking 25 mcg of thyronorm. Ashtavidha pariksha (~eight-fold examination of the patient) Nadi (~pulse) was Vata-Pittapradhana, Mala (~excreta) was Prakrita (~normal), and Mutra was Samyak (~regular). The Jihwa (~tongue) appeared Sama (~coated with Ama), Shabda (~voice) was Spashta (~clear). Sparsha (~tactile examination) was Anushnasheeta (~neither too hot nor cold), Drik (~eye and eyesight) was Prakrita, and Akriti (~body stature) was Sthula (~obese). TIMELINE Detailed timeline of the case is provided in Figure 1. DIAGNOSTIC ASSESSMENT The detailed evaluation of subjective and objective parameters was done through clinical history, physical examination, and investigations. Subjective parameters such as HMB, dysmenorrhoea, dyspareunia, dysuria, and objective parameter including USG-Pelvis were assessed. Based on the investigations, the case was diagnosed as adenomyosis associated with hypothyroidism. According to the Ayurveda principles, the case was diagnosed with Vatika yonivyapada with Pittanubandha, based on clinical presentation of the patient and pathophysiological analysis. On evaluating the Samprapti (~etiopathogenesis) involved in the case, predominant involvement of Vata and Pitta dosha with vitiation of Rasa (~primary product of digested food), Rakta (~blood tissue), and Maṃsa (~muscle tissue) as the primary Dushyas (~which get vitiated) were observed. The Srotas (~structural or functional channels) implicated were Rasavaha (~channels carrying nutrient fluids), Raktavaha (~channels carrying blood tissue), and Artavavaha (~fallopian or uterine tubes), which play an important role in nutrient transport, blood circulation, and menstrual regulation. The Srotodushti (~deformity in the body channels) involved Vimarga gamana (~diversion of the flow of the contents to improper channels) and Granthi (~formation of nodular growths). The Adhishthana (~place of manifestation of disease) was identified as the Garbhashaya (~uterus). Furthermore, the Agni (~digestive and metabolic fire) of the patient was Manda (~diminished), necessitating its correction as the primary therapeutic objective to restore systemic balance and initiate further management. THERAPEUTIC INTERVENTIONS Internal medicines were started from the day one of the consultation and continued up to the next menstrual cycle along with Thyronorm (25 mcg), as advised by the allopathic physician, on empty stomach. Internal medicines were stopped during the menstrual period for four days and again started after menstruation. Yoga basti and Matra basti were advised later with medications, as mentioned in Table 1. FOLLOW UP AND OUTCOME The subjective parameters such as HMB were assessed through Pictorial Blood Loss Assessment Chart (PBAC) scoring to quantify menstrual blood loss, with scores >100 indicating menorrhagia.[5] Dysmenorrhea was assessed with Working ability, Location, Intensity, Days of pain, and Dysmenorrhea (WaLIDD) score to comprehensively assesses dysmenorrhea severity, especially in conditions such as adenomyosis.[6] Further, dyspareunia and dysuria were assessed with Visual Analog Scale (VAS) to measure pain intensity. All these parameters aid in subjective evaluation and treatment monitoring. Further, the objective parameter (USG findings) was assessed before and after treatment. The details of the changes observed in assessment parameters are indicated in Table 2. After undergoing Yoga basti and Matra basti procedures, her menstrual pain significantly reduced, and a USG performed five months after the treatment showed a normal study. The patient exhibited significant improvement in menstrual bleeding, achieving normal flow without dysmenorrhea, and associated symptoms including dyspareunia and dysuria, which completely resolved after treatment.

In the present study, Adenomyosis associated with hypothyroidism was diagnosed based on the medical history and available clinical investigations. According to the patient’s dietary and lifestyle history, the patient was habituated to regularly consume Vata-vardhaka ahara (~Vata aggravating diet) such as refrigerated foods, cold drinks, and fermented items such as pickles. Furthermore, the patient was involved in irregular eating habits such as improper meal timings, frequent skipping of meals, and daily intake of Dahi (~curd) at night, along with the excessive consumption of Vata-aggravating pulses such as Masoor dal (red lentil), Chana dal (Bengal gram), Rajma (kidney beans), and Chole (chickpeas). In addition, there was the habit of withholding the urge to urinate during working hours and was under work-related stress constantly. These factors collectively contributed to Vata aggravation (~Vatakopa) along with Pitta, which, in accordance with the Ayurveda principle of Sthanasamshraya (~stage of localization), localized in the Sroni (~pelvis) and Garbhashaya, ultimately leading to the manifestation of Adenomyosis. The treatment strategy was designed to address these imbalances through Amapachana (~digestion of toxic byproduct generated due to improper or incomplete digestion) to eliminate toxins, Vatanulomana to restore normal pelvic function and alleviate the pain, Lekhana (~therapeutic scraping) to reduce abnormal tissue proliferation, and Raktashodhana (~blood purification) for controlling HMB. Rakta-shodhana pacifies vitiated Pitta and purifies the Rakta dhatu. Due to Apana vata vaigunya, Artava rakta leads to stagnation and impaired flow in Artava-vaha srotas. Rakta-shodhana therapies enhance circulation, reduce congestion, and improve tissue oxygenation, which helps relieve pelvic pain and heaviness. In Adenomyosis, endometrial tissue penetrates myometrium, creating granular, congested, and tender tissues. Rakta-shodhana reduces stagnant, vitiated blood, and supports healthier tissue turnover, preventing further pathogenesis. Conventional treatments for Adenomyosis, include hormonal therapy and hysterectomy, which may provide symptom relief but often involve significant risks such as hormonal side effects and surgical complications. The results of the assessment indicate a clear and consistent improvement in both subjective and objective findings over a five-month treatment period. The PBAC score decreased from 179 before treatment to 80 after five months. A PBAC score above 100 typically indicates AUB; hence, the reduction by 99 points (over 55%) is both clinically and statistically significant, indicating the normalization of menstrual flow. Dysmenorrhea, assessed using the WaLIDD score, reduced from 12 to 0, showing a complete resolution of menstrual pain. A reduction of even 3–4 points on this scale is considered meaningful, so a 12-point decrease is highly significant. Similarly, Dyspareunia and Dysuria, evaluated using the VAS, showed complete relief from 7 to 0 and 6 to 0, respectively, far exceeding the commonly accepted two-point change that denotes statistical and clinical relevance. Ajamodadi churna is Deepana, Pachana, Shoolanashana (~analgesic), Shothahara (~reducing inflammation and swelling), and Vatanulomana.[7,8] Owing to the Ushna guna (~hot attributes) and Srotavrodhanashaka (~clearing the obstructive pathology in body channels) properties of the drugs, Pachana of Ama on the affected site takes place, which also removes the obstruction to the movement of Vata. Dashamoola has been indicated for the treatment of Udavarta, thus, is particularly effective in managing congestive dysmenorrhea and has anti-inflammatory, analgesic actions.[9] The Dashamoola formulation is categorized under the Shvayathuhara mahakashaya (~group of ten anti-inflammatory Dravya) and is valued for its notable anti-inflammatory, antioxidant, and moderate analgesic properties.[10]Dashamoola kashaya is characterized by Katu rasa (~pungent taste), Katu vipaka (~pungent bio-transformed Rasa), Laghu, and Ruksha guna (~light and dry attributes), along with Ushna virya (~hot potency), which aid in Aampachana, clearing Kapha dosha avarana (~occlusion due to vitiated Kapha), and pacifying Vata dosha. Since Udavartini is a Vata-dominant Tridoshaja vyadhi, Dashamoola known for its potent Vatahara action, helps in restoring balance by disrupting the pathological process (~Samprapti vighatana). Its Deepana and Amapachana properties alleviate constipation, while its Vedanasthapana (~analgesic) and Shothahara effects help in reducing menstrual discomfort.[11] Furthermore, Dashamoola plays a crucial role in modulating inflammatory responses by inhibiting the activation of pro-inflammatory cytokines such as nuclear factor-κB, tumor necrosis factor-α, Interleukin-1 beta (IL-1β), and interferon.[12] Kanchanara guggulu functions as Vata-Kaphahara and has Lekhana property,[13] aiding in the reduction of Granthi (~nodular growth). The ingredients in the formulation help restore Dosha balance, correct Vatavaigunya (~impairment of Vata), reduce Ama accumulation, reduces excess Meda, and eliminate Srotorodha or Sanga, thereby promoting normal Dosha function and alleviating associated symptoms. Since both Vata and Kapha are involved in this condition, Kanchanara guggulu helps regulate their functions. When Vata, particularly Apana vayu, is in its normal state, it performs its physiological functions properly, preventing Vata prakopa and thereby relieving Udarashoola (~abdominal pain and dysmenorrhea). Adenomyosis, characterized by localized nodular clusters of smooth muscle, resembles a Granthi. Kanchanara guggulu, with its Ushna virya and Granthihara properties, aids in reducing its size effectively.[14] Chandraprabha vati, is anti-inflammatory and Vedanahara in nature and is primarily composed of Guggulu [Commiphora wightii (Arn.) Bhandari]and Shilajatu (Asphaltum punjabianum), exhibits Pachana, Lekhana, Chedana (~therapeutic excision), and Kledashoshana (~dryness of excessive moistness) properties.[15] In addition, it is specifically indicated for the management of Artavaruja (~menstrual pain).[16]Maharasnadi kwatha is a potent Ayurvedic formulation has Vata-Kapha shamana, Shothahara, and Vedanasthapana properties and has been indicated in Yoniroga, thus making it beneficial for conditions such as Adenomyosis.[17] Its Shothahara and Kapha-Vatahara actions help in reducing excessive secretions, alleviating inflammatory conditions and is further, documented for its reduction of pain, inflammation, and antipyretic activities.[18] Manjishthadi kashaya is mentioned in Vatarakta (~gout) and possesses Kaphapittashamana, Rakta prasadana (~enhancement of blood tissue), Pachana, Deepana, Lekhana properties, and has established ant-oxidant properties.[19,20]Abhayarishta was included in the treatment as the condition was primarily Vata-dominant. It helps in inducing Vatanulomana and maintaining Agni due to its Laghu (~light), Ruksha, and Sukshma (~minuteness) qualities.[21]Yoga basti has both local and systemic effects. Pain, inflammation, and pelvic disorders often attributed to aggravated Vata in Ayurvedic pathology, are effectively managed through Basti therapy, which serves as a targeted intervention to pacify Vata and restore reproductive system balance.[22] In addition, the Taila (~oil) used in the therapy penetrates the Srotas and alleviates Sankocha (~contractions) due to its Sukshma, Vyavayi (~substances with quick spread even without digestion), Vikasi (~quick spread and action) qualities, and further, Basti through rectal route helps normalizing the Apana vata, and physiological functioning of Vata dosha.[23,24]Yoga practices including Asanas (~postures) and Pranayama (~breathing exercises) reduce the intensity and duration of pain, improve pelvic blood circulation, and enhance parasympathetic nervous system activity. This results in reduced prostaglandin production, lower myometrial contractions, and alleviated tissue ischemia, which are the primary causes of menstrual cramps.[25] Although the present case demonstrates positive clinical and radiological outcomes following Ayurvedic intervention for Adenomyosis, certain limitations must be acknowledged. As a single-case report, the findings lack generalizability and cannot be extrapolated to a wider population. The objective assessment tools such as hormonal assays, inflammatory markers, and quality-of-life scales were not employed, which could have strengthened the clinical evidence. Further controlled clinical trials with standardized protocols are essential to validate these outcomes.

This case report highlights the effectiveness of Ayurveda in managing Adenomyosis through a holistic, nonsurgical approach. By restoring Dosha balance and addressing the root cause, Ayurveda therapies, including Yoga basti, Matra basti, and internal medications, led to significant symptom relief and uterine normalization. Unlike conventional treatments that often rely on hormonal therapy or hysterectomy, Ayurveda offers a natural, sustainable alternative. The positive outcomes observed in this case emphasize the need for further research to establish the standardized protocols, making Ayurveda a promising option for women seeking effective and holistic management of Adenomyosis. Patient perspective For years, I struggled with severe period pain, heavy bleeding with clots, and discomfort during intercourse, making daily life difficult. Despite taking hormonal pills and painkillers, I found no real relief. When my doctor suggested Hysterectomy, I was worried and wanted to explore other options. Turning to Ayurveda was the best decision-I followed the treatment, including internal medicines, therapies, diet changes, and Yoga. Within a few months, my pain reduced, bleeding became manageable, and my energy levels improved. I no longer needed painkillers, and my latest scan showed a normal uterus. Ayurveda helped me regain my health without surgery, and I feel truly grateful. Declaration of patient consent Authors certify that they have obtained patient consent form, where the patient has given her consent for reporting the case along with the images and other clinical information in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Adenomyosis; Dashamoola ksheerapaka; Dysmenorrhea; Matra basti; Yoga basti