Featured Case

MODERN DIAGNOSIS: Chronic menorrhagia 

ABOUT THE DISEASE:

Menorrhagia can be defined as abnormally heavy or prolonged bleeding at menstruation.  Menorrhagia is one of the most common gynaecologic complaints.  The causes of menorrhagia can be Hormone imbalance, Dysfunction of the ovaries, Uterine fibroids, Polyps, Adenomyosis, Intrauterine device, Pregnancy complications, Cancer, Inherited bleeding disorders, Medications, Other medical conditions.  

In this case report, Dr Jyoti Joshi treats a 41-year-old woman who has been suffering from chronic menorrhagia for 5-6 years. Since her menarche at the age of 13, she has always had a very painful menstruation. Her presenting symptoms were heavy vaginal bleeding with severe abdominal and cervical pain. On taking conventional medicines, the menstrual bleeding was under control, but the severe abdominal and cervical pain persisted. An exploratory laparotomy done revealed adhesions of internal organs, making it impossible to treat the condition. And her CA125 was constantly increasing, making it a health concern. 

Diagnostic Criteria: The clinical evaluation is the basic diagnostic criteria but to understand the underlying cause, blood investigations and imaging will be suggested. In this patient, the diagnosis was confirmed with imaging.   

Diagnosis confirmation reports;  

Image 1. Documents confirming the diagnosis- Exploratory Laprotomy , Follow up conventional medicine, Pelvic Sonography and MRI Abdomen and Pelvis attached below

CA 125 Values before starting the ayurvedic treatments: 

Image 2. CA 125 Blood value attached below

Treatment: Normally, in this clinical condition the cause is addressed. In this patient, as she was not responding to the conventional medicines and even hormonal injections, hysterectomy was the final option. But she was not eligible for the procedure and was suggested to manage the symptoms until menopause by taking pain killers and hormonal injections.  

Prognosis: The prognosis varies depending upon the cause. A mere hormonal imbalance can be managed with medicines but underlying anatomical causes can be difficult to treat. As this patient had internal organ adhesions, hysterectomy could not be done. The disease could only be managed symptomatically.  

Image 1. Discharge Summary- Exploratory Laparotomy 2018. Follow up of conventional medicines

Image 2. CA 125 Blood value dated 22.11.2018

Pelvic Sonography dated 19.11.2019 and MRI Abdomen and Pelvis dated 30.12.2019

AYURVEDIC DIAGNOSIS: Asrgdara 

ABOUT THE DISEASE:

Any abnormality in the menstrual cycle that leads to excessive and prolonged uterine bleeding can be correlated as Asrgdara in Ayurveda. The word Asrgdara is made up of two words ie. asrg and dara. ‘Asrg’ means ‘rakta/raj’ and ‘dara’ means continuous/excessive flow. According to Caraka, the disease in which there is an excessive flow of raja is called ‘asrigdara’. Acarya Sushruta and Madhava have mentioned general bodyache, weakness, giddiness, mental confusion, feeling of darkness, dyspnoea, thirst, burning sensation, delirium, anaemia, drowsiness and convulsion, disorders of vata are symptoms associated with excessive per vaginal bleeding. The causative factors of asrgdara are psychological, improper food and activities. Caraka describes primarily food habits that cause emaciation or obesity and pelvic congestion as causative factors. Madhava, Bhavprakasha and Yogratnakar included psychological and viharajanya causes, which produce vasomotor disturbances, and chronic inflammation that can lead to abnormal uterine bleeding.   

In this case report, Dr Jyoti Joshi treats a 41-year-old woman who has been suffering from chronic menorrhagia for 5-6 years. Since her menarche at the age of 13, she has always had a very painful menstruation. Her presenting symptoms were heavy vaginal bleeding with severe abdominal and cervical pain. On taking conventional medicines, the menstrual bleeding was under control, but the severe abdominal and cervical pain persisted. An exploratory laparotomy done revealed adhesions of internal organs, making it impossible to treat the condition. And her CA125 was constantly increasing, making it a health concern. 

Diagnostic Criteria: Diagnosis is based on clinical evaluation by the physician and the previous reports pertaining to the clinical condition.   

Treatment: Asrgdara is one of the diseases affecting the garbhashaya. Normal menstrual flow can be attributed to the proper movement of apanavayu. Apanavayu in its normal form performs the function of excretion of body constituents like vit, mutra, shukra and artava in the downward direction. The vitiated apanavayu will also cause vitiation in the artava. There are lots of single drugs and formulations in Ayurveda that are very effective in normalising the apanavayu and controlling the menstrual bleeding. Vasti is an good choice of treatment, ie Uttara vasti as it pacifies vata and can thus gives relief from symptoms like cervical and abdominal pain.   

Treatment rationale and principle of the physician: Direct reference of kasisa in gulma is mentioned in Rasaratna samucchayam. The uterus was bulky like 8 weeks and palpable at baseline. Vayu apamarga was identified as the causative factor, so vasti was decided. Lodhra is basically stambhaka in nature. This combined along with sita jala is pittarakta pras?daka.  

Prognosis: Tridoshaja and presence of associated symptoms like Trushna, Daha, Jwara, Daurbalyata, Swasa and Vataja rogas are considered as asadhya. In this patient, the disease was chronic and severe, making it asadhya. But with appropriate treatments, the physician was able to manage the condition.   

OUTCOME MEASURES:

This 41-year-old female patient, had been suffering from chronic menorrhagia since her menarche, but is very severe for 5-6 years. In spite of trying conventional medicine for years, she did not get relief from her symptoms: irregular bleeding per vagina, severe cervical and abdominal pain, fatigue and being worried all the time. Hysterectomy was suggested but could not be done, due to internal organ adhesions. She was advised to continue the pain killers and hormonal injections to manage her symptoms until her menopause. So she stopped all the modern medicines and opted for Ayurveda.

The outcomes were measured by assessing the subjective and objective parameters. Subjective assessment: she got complete relief from severe cervical and abdominal pain. Even after stopping her pain killers and hormonal therapies, she has no abnormal menstrual bleeding. She is emotionally stable now and feels energetic and happy.  

Objective parameter: During treatment, the CA 125 value was monitored, and repeated scans were taken to assess the condition. High CA 125 values are associated with many pathological conditions, but since this patient has endometriosis, this is a concern and is at risk for cancer. At baseline, the value was high. The patient is continuing the medications.  

Image 1. CA 125 values - During and after Ayurvedic Treatment attached below

Image 2. Pelvic Sonography and MRI Abdomen and Pelvis during Ayurvedic Treatment attached below.

DISEASE MODIFYING EFFECT- In remission: The patient must continue the ayurvedic medicines because endometriosis could not be directly managed due to the internal organ adhesion. Diet and lifestyle restrictions are advised to be strictly followed.  

Image 1. CA 125 Values recorded during and after treatment

Image 2. Pelvic Sonography and MRI Abdomen and Pelvis during and after treatment