Management of Abnormal uterine bleeding in a perimenopausal woman through Ayurveda: An experience

INTRODUCTION Abnormal Uterine Bleeding (AUB) [ICD 11 code: GA20.5] is a common and frequent presenting complaint in the gynecology outpatient department among the reproductive age group. The International Federation of Gynaecology and Obstetrics in November 2010, accepted a new classification system for causes of AUB in the reproductive years, based on the acronym Polyps, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia-Coagulopathy, Ovulatory Disorders, Endometrial Causes, Iatrogenic, Not Classified (PALM-COEIN), which was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the problem of AUB.[1] AUB is defined as uterine bleeding in women of reproductive age, not related to pregnancy, and deviates from normal patterns in terms of regularity, frequency, volume, or duration.[2] As per the reports, the global prevalence is approximately 3%–30%, and is estimated to be responsible for 30% to 70% of gynecological complaints among peri- or postmenopausal women.[3] AUB is more common in the perimenopausal age group of 41–45 years, and in women who have given birth multiple times or had previous uterus or adnexa surgeries. Follicular development during perimenopause is very unpredictable, which leads to variable estrogen levels, resulting in anovulatory cycles and irregular AUB.[4] The physical and emotional health of women is significantly impacted by AUB, which may jeopardize their longevity and quality of life. Thus, it is essential to investigate the factors responsible for the cause to prevent it in the future. For perimenopausal women with AUB, routine or periodic examinations are essential for an early diagnosis and a successful course of treatment. Noninvasive imaging techniques, including sonography, computed tomography, and magnetic resonance imaging, as well as invasive techniques such as hysteroscopy and blind biopsy, are being used to diagnose endometrial pathology. Hormonal (combined oral tablets, progestins, Gonadotropin-releasing Hormone [GnRH]), nonhormonal (NSAIDs and tranexamic acid), and surgical (dilation and curettage, endometrial ablation, and hysterectomy) treatments are among the available options.[4] In Ayurveda, AUB can be studied under the context of Asrigdara or Raktapradara (~menorrhagia or metrorrhagia), which is characterized by excessive and/or prolonged blood loss during menstruation or even scanty blood loss during the intermenstrual period.[5] In Asrigdara, Vata dosha (~Dosha responsible for movement and cognition), mainly Apana vata (~one of the five subtypes of Vata situated in the pelvic region) is aggravated and vitiates the Rakta dhatu (~blood tissue). Rakta and Pitta (~Dosha responsible for regulating body temperature and metabolic activities) have quite similar properties, so the causes that vitiate Rakta would also aggravate Pitta, leading to Asrigdara.[6] The treatment suggested in classics focuses on balancing the aggravated Doshas, particularly Vata and Pitta, and providing nourishment to the reproductive tissues, and includes Shamana chikitsa (~palliative therapy), Panchakarma (~five major bio-cleansing therapy), Pathya ahara, and Vihara (~wholesome diet and lifestyle regimen). This case report highlights the efficacy of an individualized Ayurveda regimen tailored to manage AUB successfully without reliance on synthetic hormones or invasive procedures. PATIENT INFORMATION A 46-year-old, married, nonprofessional, urban resident, female presented at Prasuti Tantra evam Stri Roga outpatient department on May 22, 2024, complaining of irregular menstrual cycle with scanty to heavy menstrual bleeding associated with lethargy for three months. The cycle came at intervals of 23–25 days and lasted for almost 18–21 days. Her history revealed that she had a physiological menstrual cycle pattern three months back, and there was no chronic ailment such as thyroid disorder, hypertension, diabetes, bleeding disorder, chronic/acute liver disease, or systemic inflammatory or allergic manifestation. She had a reproductive obstetric history that included one full-term stillbirth, two live births via lower-segment cesarean section, and two spontaneous abortions. She underwent bilateral tubal ligation 20 years back and cholecystectomy three years back. Her routine vaccination was complete, although the status of cervical cancer vaccination was not known. There is no history of thrombolytic medication. CLINICAL FINDINGS The patient follows a vegetarian diet with a satisfactory appetite. She reports constipation but normal micturition, occurring 3–4 times daily. Sleep is satisfactory, and there are no known habits, addictions, or current medications. Family history is noncontributory. Menarche occurred at the age of 13 years. Her past menstrual cycles were regular with a duration of 4–5 days every 26–28 days and medium flow. Presently, her menstrual cycles occur every 18–21 to 23–25 days, with flow varying from scanty to heavy. Obstetrical history includes a first full-term intrauterine fetal demise delivered vaginally, followed by two full-term caesarean deliveries with healthy, living children. She has experienced two spontaneous miscarriages. Her last delivery was 20 years ago, and she underwent tubal ligation at that time. On general examination, her height is 158 cm and her weight is 54 kg. She has a temperature of 98.6°F, blood pressure of 110/60 mmHg, and respiratory rate of 16 breaths per minute. Mild pallor is present. There is no evidence of thyroid enlargement or significant lymphadenopathy. No pedal edema is noted. On systemic examination, no abnormalities were detected in the cardiovascular and respiratory systems. On gynecological examination, abdominal findings revealed a scar in the subcostal region of the right upper abdomen attributed to cholecystectomy and another vertical scar between the umbilicus and pubic symphysis attributed to caesarean section and tubal ligation. There was no tenderness, guarding, or palpable mass. Due to ongoing vaginal bleeding, vaginal examination was not performed on the first visit; however, it was conducted on May 29, 2024. On vaginal examination, the cervix was found to be firm, mobile, and nontender on palpation; the uterus was anteverted, firm to feel, mobile, and nontender; fornices revealed no adnexal masses or tenderness. Speculum examination showed a healthy cervix with mild mucoid discharge. The Pictorial Blood Loss Assessment Chart (PBAC)[7] score was recorded as 382 on May 22, 2024. Dashavidha pariskha (~ten-fold examination of the patient) The patient has Vata-Pitta prakriti (~physical constitution) with Madhyama (~moderate) Samhanana (~compactness of tissues or organs), Sara (~excellence of tissue elements), Satmya (~homologation), Satva (~psychic condition), Vyayamashakti (~power of performing exercises), and Aharashakti (~power of intake and digestion of food). However, she had Krura koshtha (~irregular bowel habits). TIMELINE The detailed timeline of the case is mentioned in Figure 1. DIAGNOSTIC ASSESSMENT The diagnosis was based on the clinical history, clinical examination, PBAC score, and investigations such as hemoglobin, Fasting Blood Sugar (FBS), blood group and Rh type, Liver Function Test (LFT), Kidney Function Test (KFT), thyroid profile, Bleeding Time (BT), Clotting Time (CT), Ultrasonography (USG)-lower abdomen, urine routine examination, histopathological examination of endometrial tissue. The PBAC score and investigations were done on the first visit and following subsequent visits. Her FBS, thyroid profile, BT, CT, KFT, LFT, and urine routine and microscopy reports were within normal limits. However, her USG findings (dated May 24, 2024) revealed a thickened endometrium (12 mm). Hence, an endometrial biopsy was planned, and the tissue was collected and sent for histopathological examination. The report was suggestive of cystic glandular hyperplasia without atypia. THERAPEUTIC INTERVENTION The patient was provided with Ayurveda therapeutic intervention for 95 days, including Shodhana and Shamana chikitsa, along with dietary advice and lifestyle modification [Table 1]. She was advised Eladi kashaya, which was prepared by putting 12 g of coarse powder in a wide-mouthed open steel pan, and 200 mL of water was added to it, then the pan was kept on a medium flame. When 1/4th (50 mL) of water remained after boiling, the pan was removed from the stove and filtered with a sieve. The filtered portion or decoction was instructed to be consumed freshly prepared every time. FOLLOW-UP AND OUTCOME The patient was assessed through clinical examinations which included general physical examination, abdominal examination, vaginal and speculum examination. At the end of the treatment of 95 days, marked improvement was observed, with menstrual bleeding reducing from heavy to scanty and irregular to regular menstrual cycle, featuring normal flow sustained for four days. There was a notable reduction in endometrial thickness from 12 mm to 6 mm, along with a decrease in both bleeding time and clotting time, and an increase in hemoglobin levels. Clinical markers PBAC and MBQoL were markedly improved,[8] from 382 to 83, and 52–12, respectively. Her menstrual cycle became regular with a duration of 3–4 days and an interval of 28–29 days. The patient had improvement in bowel movements. Subsequent investigation on follow-up showed gradual improvement in biochemical and radiological findings. Her endometrial thickness was reduced from 12 to 6 mm, and her hemoglobin level rose from 9.8 to 11.4 g/dl.

Asrigdara is Pitta and Rakta dushti with Apana vayu vikriti. The function of Agni (~digestive/metabolic factors) is also impaired, so Rasa dhatu (~primary product of digested food) is not formed properly, and therefore, the formation of Artava (~ menstrual blood) is also impaired. Considering the pathogenesis involved in the disease, the first aim of treatment is to regulate the bleeding per vaginum. Eladi kashaya, Lodhrasava, and Avipattikara churna were initially used to stop bleeding and relieve constipation. Eladi kashaya (decoction of Ela [Elettaria cardamomum (L.) Maton], Lajjalu [Mimosa pudica L.], Mocharasa [Bombax ceiba L.], Haritaki [Terminalia chebula Retz.] and Pippali [Piper longum L.]) have been indicated to check Yoni pravaha (~uterine/vaginal flow) owing to the Deepana, Pachana, Srotoshodhana (~pacification of morbid Dosha in structural or functional channels), Vatanulomana, and Rakta stambhana (~hemostasis) properties of its ingredients.[9]Lodhrasava had Lodhra (Symplocos racemosa Roxb.) has the quality to improve the strength of uterine muscles, possesses anti-inflammatory, antioxidant, antiandrogenic, and wound healing properties.[10]Lodhra also possesses Kapha pitta shamaka and Rakta stambhaka properties due to its Kashaya rasa (~ astringent taste) and Sheeta virya (~cold potency).[11]Avipattikara churna has Pittashamaka and Vatanulomana properties, which helped to pacify the symptoms.[12]Punarnava mandoora is a herbo-mineral formulation indicated in Pandu (~anaemia) owing to its Raktavardhaka (~hematinic) property.[13] Basti (~medicated enema) is considered prime among all the therapeutic measures, especially for the management of Vata-vyadhi. Yapana basti performs both Shodhana (~purification) and Shamana (~pacifying effect), which is done by Niruha and Sneha basti, respectively. It can be administered irrespective of the season and age.[14] Considering the Doshika involvement in Asrigdara (Apana vayu vikriti), Yapana basti was planned as it is advocated in all types of Avrita vata, especially Pittavrita apana vata, and indicated in Rajovyadhi (diseases of menstruation). Hence, Mustadi yapana basti was administered.[14] A combination of 50 ml of Goghrita (cow ghee), 20 g of Kalka (~ medicated paste) of Madhuyashti (Glycyrrhiza glabra L.) and Shatapushpa (Foeniculum vulgare Mill.), 300 ml of Mustadi ksheera kashaya, 50 ml of honey, 12 g of Saindhava (Rock salt), and 50 ml of Mamsa rasa (~soup prepared with meat) was taken, and a total of 450 ml Yapana Basti was administered. Licochalcones B and D, along with isoflavones like glabridin of Glycyrrhiza glabra, exhibit potent antioxidant activity, effectively protecting red blood cells from oxidative hemolysis. Recent identification of dehydro-stilbene derivatives further supports the free radical scavenging potential of its phytoconstituents.[15]Shatapushpa exhibited anti-oxidant and free scavenging activity along with an increase in the number of red blood cells and white blood cells.[16] Antihemolytic effect of C. rotundus has been reported by a previous study.[17]Nasya (~medication through the nose) helps to regulate the menstrual cycle by improving the functioning of the central nervous system and endocrine glands. It stimulates olfactory nerves and the limbic system, which in turn stimulates the hypothalamus and leads to stimulation of GnRH neurons, regularizing GnRH pulsatile secretion, leading to ovulation.[18] This multimodal regimen, rooted in classical Ayurvedic principles, effectively restored the physiological rhythm of menstruation, enhanced uterine health, and improved the patient’s overall quality of life. While conventional treatments for perimenopausal bleeding are well established, this case contributes valuable clinical insight into the successful application of Ayurvedic therapeutics for Asrigdara, offering a promising, holistic alternative.

Asrigdara occurring in the perimenopausal phase represents a significant clinical concern in the domain of women’s health. The foundation of its effective management lies in precise Dosha-Dushya parikalpana and Samprapti vighatana (~breaking of pathogenesis). The present study elucidates the substantial therapeutic efficacy of Basti and Nasya karma, when administered adjunctively with Shamana chikitsa, in mitigating the clinical manifestations of Asrigdara. These interventions demonstrate a promising, integrative alternative to conventional hormonal or invasive surgical modalities. However, to establish robust clinical generalizability and mechanistic clarity, further methodologically rigorous investigations involving expanded sample sizes and standardized intervention protocols are imperative. Declaration of patient consent Authors certify that they have obtained a 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. Conflict of interest There are no conflicts of interest.

Asrigdara; Endometrial hyperplasia; Nasya; Yapana basti