Changes

==Laboratory investigations==

==Laboratory investigations==

===In decreased state of menstrual blood (artavakshaya)===

===In decreased state of menstrual blood (artavakshaya)===

Common clinical conditions and laboratory investigations:

 

Investigation Value/Result Possible diagnosis

'''Common clinical conditions and laboratory investigations:'''

Urine Pregnancy Test Positive Pregnancy

S. FSH LH level increased or LH:FSH ratio>2:1 PCOS

!Investigation!! Value/Result !! Possible diagnosis

S.Total Testosterone increased

S. estradiol increased

|Urine Pregnancy Test || Positive || Pregnancy

S. SHBG reduced

S. Prolactin increased Hyperprolactinaemia

|S. FSH, S. LH || LH level increased or LH:FSH ratio>2:1 ||PCOS

S. TSH Increased Hypothyroidism

(common)

|S.Total Testosterone|| increased

decreased Hyperthyroidism

S.AMH AMH-lower level

|S. estradiol ||increased

FSH-High,Estradiol-low Premature ovarian failure

|S. SHBG || reduced

|S. Prolactin || increased || Hyperprolactinaemia

|S. TSH || Increased || Hypothyroidism(common)

|S. TSH ||decreased ||Hyperthyroidism

|S.AMH || AMH-lower level,FSH-High,Estradiol-low ||Premature ovarian failure

 

S- serum, FSH- Follicle Stimulating Hormone, LH- Luteinizing Hormone, SHBG-Sex Hormone Binding Globulin, TSH-Thyroid Stimulating Hormone, AMH-Anti Mullerian Hormone

S- serum, FSH- Follicle Stimulating Hormone, LH- Luteinizing Hormone, SHBG-Sex Hormone Binding Globulin, TSH-Thyroid Stimulating Hormone, AMH-Anti Mullerian Hormone

===In increased state of menstrual blood (artavavrudhi/asrugdara)===

===In increased state of menstrual blood (artavavrudhi/asrugdara)===

• Haemoglobin estimation is done in every case.

*Haemoglobin estimation is done in every case.

 

In cases not responding to usual therapy,  

In cases not responding to usual therapy,  

• platelet count

 

• prothrombin time

*platelet count

• bleeding time and clotting time

 

• partial thromboplastin time

*prothrombin time

 

*bleeding time and clotting time

 

*partial thromboplastin time

 

In suspected cases of thyroid dysfunction, S.TSH, T3, T4 estimations are recommended.

In suspected cases of thyroid dysfunction, S.TSH, T3, T4 estimations are recommended.

== Imaging techniques==

== Imaging techniques==

=== In decreased state of menstrual blood (artavakshaya)===

=== In decreased state of menstrual blood (artavakshaya)===

• In primary amenorrhea, trans-abdominal sonography (TAS) is recommended to confirm the presence of uterus and adnexae.

 

• In secondary amenorrhea, oligomenorrhea, hypomenorrhea etc. trans-vaginal or trans-abdominal sonography may reveal the presence of poly cystic ovary.

*In primary amenorrhea, trans-abdominal sonography (TAS) is recommended to confirm the presence of uterus and adnexae.

 

*In secondary amenorrhea, oligomenorrhea, hypomenorrhea etc. trans-vaginal or trans-abdominal sonography may reveal the presence of poly cystic ovary.

 

Ultra Sonological findings in PCOD:  

Ultra Sonological findings in PCOD:  

• Ovaries are enlarged(ovarian volume ≥ 10 cm3 )

 

• Stroma is increased, Capsule is thickened and pearly white in color.

*Ovaries are enlarged(ovarian volume ≥ 10 cm3 )

• Presence of multiple (≥12) follicular cysts measuring about 2-9mm in diameter, crowded around the cortex(periphery)- “string of pearls sign”

 

*Stroma is increased, Capsule is thickened and pearly white in color.

 

*Presence of multiple (≥12) follicular cysts measuring about 2-9mm in diameter, crowded around the cortex(periphery)- “string of pearls sign”

 

=== In increased state of menstrual blood (artavavrudhi/ asrugdara) ===

=== In increased state of menstrual blood (artavavrudhi/ asrugdara) ===

Transvaginal Sonography (TVS ) and Color Doppler:

 

'''Transvaginal Sonography (TVS ) and Color Doppler''':

 

Findings of Endometrial Hyperplasia

Findings of Endometrial Hyperplasia

• Endometrial thickness >12 mm

 

• Hyper echoic and regular outline

*Endometrial thickness >12 mm

• Angiogenesis and neovascular signal study

 

*Hyper echoic and regular outline

 

*Angiogenesis and neovascular signal study

 

TVS is very sensitive to detect any anatomical abnormality like fibroids, adenomyosis etc. or other abnormalities of uterus, endometrium and adenexae.

TVS is very sensitive to detect any anatomical abnormality like fibroids, adenomyosis etc. or other abnormalities of uterus, endometrium and adenexae.

Saline Infusion Sonography (SIS):

 

'''Saline Infusion Sonography (SIS):'''

 

It is superior to diagnose endometrial polyps, submucous fibroids and intrauterine abnormalities like septate/subseptate uterus etc.

It is superior to diagnose endometrial polyps, submucous fibroids and intrauterine abnormalities like septate/subseptate uterus etc.

Endometrial Biopsy:

'''Endometrial Biopsy:'''

 

In office endometrial smpling to rule out hyperplasia or carcinoma.

In office endometrial smpling to rule out hyperplasia or carcinoma.

Hysteroscopy:

'''Hysteroscopy:'''

 

It is done for better evaluation of endometrial lesion and to take biopsy under direct vision.

It is done for better evaluation of endometrial lesion and to take biopsy under direct vision.

==Management==

==Management==

The management of menstrual disorders is broadly divided into two.

The management of menstrual disorders is broadly divided into two.

1. Purification therapy(shodhana/ panchakarma)

1. Purification therapy(shodhana/ panchakarma)

2. Pacification therapy(shamana)

2. Pacification therapy(shamana)

===Treatment for decreased state of menstrual blood ===

===Treatment for decreased state of menstrual blood ===

Purification therapy(shodhana chikitsa):

 

'''Purification therapy(shodhana chikitsa):'''

 

Purification therapy is the first line of treatment in quantitative or qualitative decrease of menstrual blood due to obstructive/occlusion pathology(avarodha). Here, therapeutic emesis([[Vamana]]) has major role as the condition is predominantly due to [[kapha]].Some scholars opine that therapeutic purgation (virechana) is contraindicated as it may lead to further decrease of [[pitta]].[Dalhana commentry, Su.Sa.Sutra Sthana 15/12] However, in chronic pathology both therapeutic emesis (vamana) and purgation (virechana) are recommended and  practically both the procedures are found to be effective.   

Purification therapy is the first line of treatment in quantitative or qualitative decrease of menstrual blood due to obstructive/occlusion pathology(avarodha). Here, therapeutic emesis([[Vamana]]) has major role as the condition is predominantly due to [[kapha]].Some scholars opine that therapeutic purgation (virechana) is contraindicated as it may lead to further decrease of [[pitta]].[Dalhana commentry, Su.Sa.Sutra Sthana 15/12] However, in chronic pathology both therapeutic emesis (vamana) and purgation (virechana) are recommended and  practically both the procedures are found to be effective.   

Pacification therapy(shamana chikitsa):

 

It is indicated in case of decrease of menstrual blooddue to the nutritional factors or diminished state of all body components(dhatu kshaya). Nourishing therapy is indicated if the digestive power is good. In other cases, the stimulation and enhancement of digestive fire(agnideepana) is indicated initially, followed by nourishment therapy. Judicious administrationof substances having the similar properties of blood are advised. [Su. Sa. Sutra Sthana 15/12].

'''Pacification therapy(shamana chikitsa):'''

 

It is indicated in case of decrease of menstrual blooddue to the nutritional factors or diminished state of all body components(dhatu kshaya). Nourishing therapy is indicated if the digestive power is good. In other cases, the stimulation and enhancement of digestive fire(agnideepana) is indicated initially, followed by nourishment therapy. Judicious administration of substances having the similar properties of blood are advised. [Su. Sa. Sutra Sthana 15/12].

 

Fish(matsya), horse gram (kulattha), sour substances(amla), sesame (tila), black gram(masha), beer(sura), cow’s urine(gomutra), diluted butter milk(udaschit), curd(dadhi),vinegar(shukta) are beneficial as food and drinks during decrease of menstrual blood.[Su. Sa. ShariraSthana 2/21-23]

Fish(matsya), horse gram (kulattha), sour substances(amla), sesame (tila), black gram(masha), beer(sura), cow’s urine(gomutra), diluted butter milk(udaschit), curd(dadhi),vinegar(shukta) are beneficial as food and drinks during decrease of menstrual blood.[Su. Sa. ShariraSthana 2/21-23]

Substances promoting the properties of pitta (agneya dravya) like sesame oil (tila tail), black gram(masha)are advised to be taken regularly by the women. But in case of extreme decrease of endometrial thickness, ghee(ghrita) is having greater role than oil(taila)for promoting the endometrial proliferation and maintenance of preferred level of growth.[A.S. Sharira Sthana 1/64]

Substances promoting the properties of pitta (agneya dravya) like sesame oil (tila tail), black gram(masha)are advised to be taken regularly by the women. But in case of extreme decrease of endometrial thickness, ghee(ghrita) is having greater role than oil(taila)for promoting the endometrial proliferation and maintenance of preferred level of growth.[A.S. Sharira Sthana 1/64]

===Treatment for increased state of menstrual blood ===  

===Treatment for increased state of menstrual blood ===  

Purification therapy:

 

'''Purification therapy:'''

 

In case of excessive menstrual bleeding, therapeutic purgation(virechana) is the treatment of choice.[Ka.Sa .SidhiSthana  2/13]

In case of excessive menstrual bleeding, therapeutic purgation(virechana) is the treatment of choice.[Ka.Sa .SidhiSthana  2/13]

Pacification therapy:

 

• Hemostatic drugs (rakta stambhaka) are given only if the strength of patient is low and the vital parameters are disturbed. In this case, the medicines used for stopping blood as indicated in treatment of diarrhea with blood(raktatisara),bleeding disorders (raktapitta) and bleeding piles(raktarsha).[Ch.Sa.Chikitsa Sthana 30/228]

'''Pacification therapy:'''

• If the vital parameters are normal and strenght of patient is normal, then no medicine is advised to stop bleeding in the initial stage. Hemostasis treatment of vitiated blood leads to complications. [Ch.Sa.Chikitsa Sthana 30/228]

 

• By considering the association of [[doshas]] diagnosed on the basis of color and smell of blood,haemostatic drugs should be given to arrest the bleeding.[Ch. Sa Chikitsa Sthana 30/86]

*Hemostatic drugs (rakta stambhaka) are given only if the strength of patient is low and the vital parameters are disturbed. In this case, the medicines used for stopping blood as indicated in treatment of diarrhea with blood(raktatisara),bleeding disorders (raktapitta) and bleeding piles(raktarsha).[Ch.Sa.Chikitsa Sthana 30/228]

 

*If the vital parameters are normal and strenght of patient is normal, then no medicine is advised to stop bleeding in the initial stage. Hemostasis treatment of vitiated blood leads to complications. [Ch.Sa.Chikitsa Sthana 30/228]

 

*By considering the association of [[doshas]] diagnosed on the basis of color and smell of blood,haemostatic drugs should be given to arrest the bleeding.[Ch. Sa Chikitsa Sthana 30/86]

 

===Treatment for abnormal state of menstrual blood: ===  

===Treatment for abnormal state of menstrual blood: ===  

Purification therapy :

 

'''Purification therapy :'''

 

In abnormalities of menstrual blood (artava dushti), oleation(snehana),sudation(swedana), purification therapies(vamana, virechana, basti) as well as local therapies including intra uterine drug administration(uttarabasti) is advised.[Su. Sa. Sharira Sthana 2/12]

In abnormalities of menstrual blood (artava dushti), oleation(snehana),sudation(swedana), purification therapies(vamana, virechana, basti) as well as local therapies including intra uterine drug administration(uttarabasti) is advised.[Su. Sa. Sharira Sthana 2/12]

In the management of dysmenorrhoea (udavartini) also, oleation(snehana), sudation (swedana), enema therapy (both unctuous as well as decoction like dashamoola and milk) especially unctuous enema(anuvasanabasti) and intra uterine oil administration(uttara basti) are recommended.[Ch. Sa. ChikitsaSthana 30/228]

In the management of dysmenorrhoea (udavartini) also, oleation(snehana), sudation (swedana), enema therapy (both unctuous as well as decoction like dashamoola and milk) especially unctuous enema(anuvasanabasti) and intra uterine oil administration(uttara basti) are recommended.[Ch. Sa. ChikitsaSthana 30/228]

Pacification therapy:

 

Specific combinationof drugs is mentioned for different kinds of abnormal menstrual blood.

'''Pacification therapy:'''

Type of abnormality Drugs

 

Vataja • Unctuous,hot,sour and salty substances*

Specific combination of drugs is mentioned for different kinds of abnormal menstrual blood.

!Type of abnormality !!Drugs

|Vataja ||| •Unctuous,hot,sour and salty substances*

 

Internal:

Internal:

• Ghee processed with Clerodendrum serratum (bharangi) ,Madhuca longifolia(madhuka), Cedrus deodara ( bhadradaru)**

 

• Milk processed with Gmelina arborea(kashmari), Phaseolus trilobus(kshudrasaha)**

•Ghee processed with Clerodendrum serratum (bharangi) ,Madhuca longifolia(madhuka), Cedrus deodara ( bhadradaru)**

 

•Milk processed with Gmelina arborea(kashmari), Phaseolus trilobus(kshudrasaha)**

 

External:

External:

• Paste of Callicarpa macrophylla(priyangu) and sesame oil-applied in vagina**

 

Pittaja • Sweet, cold and astringent substances*

•Paste of Callicarpa macrophylla(priyangu) and sesame oil-applied in vagina**

|Pittaja || •Sweet, cold and astringent substances*

 

Internal:

Internal:

• Decoction of Lilium polyphyllum (kakoli)/ root of Pueraria tuberose(vidarimula)/ Nymphaea alba(utpala)/ Madhucalongifolia (madhuka)/ Gmelina arborea (kashmari) mixed with sugar.**

 

• Paste of Anogeissuslatifolia (dhava) and Woodfordiafruticosa  (dhataki) flowers mixed with ghee**

•Decoction of Lilium polyphyllum (kakoli)/ root of Pueraria tuberose(vidarimula)/ Nymphaea alba(utpala)/ Madhucalongifolia (madhuka)/ Gmelina arborea (kashmari) mixed with sugar.**

 

•Paste of Anogeissuslatifolia (dhava) and Woodfordiafruticosa  (dhataki) flowers mixed with ghee**

 

External:

External:

• Vaginal application of paste of Santalum album (chandana)and Ipomoea digitata(payasya)**

 

• Vaginal douche with decoction of red ochre(gairika) and neem.**

•Vaginal application of paste of Santalum album (chandana)and Ipomoea digitata(payasya)**

Kaphaja • Hot,dry and astringent substances*

 

•Vaginal douche with decoction of red ochre(gairika) and neem.**

|Kaphaja || •Hot,dry and astringent substances*

 

Internal:

Internal:

• Decoction of Holarrhena antidysenterica (kutaja), Picrorhiza kurrooa (katuka)and Withania somnifera (ashwagandha)**

 

• Decoction of tender leaves of latex yielding trees mixed with honey**

•Decoction of Holarrhena antidysenterica (kutaja), Picrorhiza kurrooa (katuka)and Withania somnifera (ashwagandha)**

 

•Decoction of tender leaves of latex yielding trees mixed with honey**

 

External:

External:

• Vaginal application of paste of Randia dumetorum (madanaphala)**

 

• Irrigation of vagina with the decoction of Symplocos racemosa (rodhra) and Diospyros tomentosa (tinduka)**

•Vaginal application of paste of Randia dumetorum (madanaphala)**

 

•Irrigation of vagina with the decoction of Symplocos racemosa (rodhra) and Diospyros tomentosa (tinduka)**

Granthibhuta(clotted appearance) Decoction of Cissampelospareira (patha),  Piperlongum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhenaantidysenterica, (vrukshaka)*

Granthibhuta(clotted appearance) Decoction of Cissampelospareira (patha),  Piperlongum Linn, Zingiber officinale, Piper nigrum Linn (trikatu), Holarrhenaantidysenterica, (vrukshaka)*

• Decoction of Cissampelospareira (patha),Tribulus terrestris(trikandaka), Holarrhenaantidysenterica(vrukshaka)**

 

Kunapagandhi(foul smelling) For removing bad smell-

•Decoction of Cissampelospareira (patha),Tribulus terrestris(trikandaka), Holarrhenaantidysenterica(vrukshaka)**

• Oral intake of decoction of Santalum album(chandana)*

• Anoinment of paste of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula( triphala)in vaginal canal**

|Kunapagandhi(foul smelling) , Puti-puya(pus like appearance)|| For removing bad smell-

• Vaginal irrigation with decoction of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula (triphala)**

 

Puti-puya(pus like appearance)

•Oral intake of decoction of Santalum album(chandana)*

Ksheena(scanty) Same as artavakashaya**

 

*[A.Hr. Sharira Sthana 1]**[A.S. Sharira Sthana 1]

•Anoinment of paste of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula( triphala)in vaginal canal**

 

•Vaginal irrigation with decoction of Emblicaofficinalis ,Terminalia bellirica,Terminalia chebula (triphala)**

|-

|Ksheena(scanty) || Same as artavakashaya**

*[A.Hr. Sharira Sthana 1], **[A.S. Sharira Sthana 1]

===Diet and lifestyle modification for prevention of menstrual disorders ===

===Diet and lifestyle modification for prevention of menstrual disorders ===