Uterus plays a vital role in the survival of all species in mammals.  It serves as the site for the implantation of zygote post-fertilization, and eventually for the developing fetus. In case of the failure of fertilization and subsequent absent implantation, human beings shed a significant amount of endometrium cyclically termed as “Menstruation”. [1] Menstruation is defined as the visible manifestation of cyclic physiological uterine bleeding due to shedding of the endometrium following invisible interplay of hormones mainly through Hypothalamo-pituitary-ovarian axis.[2] However, this crucial event may be associated with distressing symptoms such as “Oligo-hypomenorrhea,” where in menstrual bleeding occurs more than 35 days apart and is unduly scanty, lasts for less than 2 days, and remains constant at that frequency.[2]

Ayurveda, an ancient health science, is based on its sound knowledge of body physiology and pathology. Ayurveda offers a detailed description regarding menstruation under the term ‘Artava’ (menstrual blood). Almost all the Ayurveda literature threw light on Artava, the age of menarche, duration and amount of Artava, pure form of menstrual blood and its various pathologies.[3] Artavakshaya (Oligo-Hypomenorrhea) is one among the abnormalities of menstruation described in Ayurveda classics. As per one of the great triads of Ayurveda compositions, Sushrutasamhita, Artavakshaya refers to “absence of menstruation at its proper interval and/or menstruation scanty in amount and/or associated with pain in the genital tract wherein use of Shodhana (Purification) and Agneya dravya (hot potency drugs) is advocated.[4]

Yoga, an integral component of traditional Indian healthcare, has been increasingly recognized as a therapeutic modality influencing both physiological and psychological domains. The beneficial effects of yoga are primarily mediated through modulation of the autonomic nervous system and stress response pathways, thereby improving neuroendocrine regulation.[5] Dysregulation of the Hypothalamo–Pituitary–Ovarian Axis, often precipitated by stress and lifestyle disturbances, is a key factor in menstrual irregularities such as Artavakshaya. Yoga-based practices facilitate self-regulation of stress, improve hormonal balance, and enhance overall reproductive health.[6] Furthermore, yoga is a safe, cost-effective, and easily accessible intervention, with evidence suggesting comparable safety to routine care or physical exercise.[7]

In the present case, specific Yogasanas including Pavanamuktasana (Gas release posture), Paschimottanasana (Seated Forward Bend), and Hastapadasana (Standing Forward Bend) along with Suryanamaskara (Sun salutation) and Pranayama (Breathing techniques) were selected due to their targeted effects on the lower abdomen, pelvic circulation, and neuroendocrine balance. These postures involve controlled stretching and compression of abdominal and pelvic structures, potentially enhancing uterine perfusion and regulating menstrual function.

In this paper, we report the refractory case of Oligo-hypomenorrhea, treated successfully with an integrated approach of Ayurveda regimen including Nidanaparivarjana (Avoidance of etiological factors), Shamana Chikitsa (Palliative care) and Yoga. The present case provides supportive evidence of the promising results of integrated therapy combining yoga and Ayurveda in the management of refractory Artavakshaya related to Oligo-hypomenorrhea.

CASE REPORT

Patient information:

A 25-year-old patient (Height 5’4’’, weight 70kg, BMI- 26.0) visited Prasutitantra and Striroga OPD, with complaints of delayed menses for 2 months, scanty menstruation lasting for only 2 days of the cycle and severe pain in lower abdomen during menstruation since last 4 years. A detailed timeline of patient’s progress is mentioned in Table 1.

History of the present illness:

The patient was asymptomatic 3 years before visiting OPD for the first time on June 20, 2021. Later, she started developing symptoms of scanty menstruation with a duration of menstruation gradually decreasing from 5 days of the cycle and pain during menstruation increasing from mild pain to severe pain, making her unable to do her routine work. The patient has been visiting a private allopathic clinic for the same complaints and was being prescribed allopathic medication for 2 years (On and off). Ethinyl estradiol and Levonorgestrel combination pills, and Medroxy progesterone for withdrawal bleeding. However, no significant improvement was felt by the patient in the scanty as well as painful menstruation.

Complaints due to present illness:

The patient reported experiencing scanty menstruation lasting for 2 days of cycle, delayed menstruation with interval of 40-60 days and severe pain in lower abdomen during menstruation since last 4 years.

Associated complaints:

Patient also reported experiencing pain and swelling in bilateral knee joint stiffness all over body, body ache, and backache for last 3 years. She also complained of decreased appetite, disturbed sleep and constipation.

Other Existing Illness:

The patient was found to have following illness co-existing with the present one. She was a known case of erythema nodosum in the last 4 years and had been on allopathy medication (Prednisolone 10 mg, Etoricoxib 90mg). She had hypocalcemia for the past 3 years and was being treated for the same with allopathy medication.  However, despite of regular consumption of prescribed medication for above pathologies, patient reported to have pain and swelling in bilateral knee joint. There was no any significant surgical history.

Family and Social History:

The patient had a family history of Type II Diabetes mellitus from mother, grandmother and Hypertension from father. There was no family history of Tuberculosis. The patient had no addiction history. The patient belonged to an upper-middle-class socio-economic background. She was educated till 8^th grade and has been working as a housewife. She got married 9 years back with an active married life of 9 years.

Menstrual History:

At the time of the first OPD visit, the patient’s last menstrual period (LMP) was on 20/04/2021. She reported oligomenorrhea with a menstrual cycle interval ranging from 40–60 days and a duration of bleeding of 2 days. The menstrual flow was scanty and associated with passage of clots. The patient also complained of severe dysmenorrhea, significantly affecting her daily activities.

Obstetric History:

The obstetric history was G2P2L2A0. The first pregnancy (G1) resulted in a full-term normal delivery (FTND) of a female child 8 years ago at home. The second pregnancy (G2) resulted in a full-term normal delivery of a female child 6 years ago at Fullara Hospital.

Data from Diagnostic Tests:

Ultrasonography:

Ultrasonography dated 20/04/2021 revealed no detectable pathology, with normal uterine size and endometrial thickness measuring 6 mm.

Hematological Investigations:

Laboratory investigations dated 23/02/2018 showed: Serum calcium – 7.4 mg/dL (low), erythrocyte sedimentation rate (ESR) – 30 mm/hr (elevated), rheumatoid factor – negative, and C-reactive protein (CRP) – negative.

Biochemistry report:

Biochemical analysis dated 22/02/2018 revealed mildly elevated liver enzymes: serum glutamic-pyruvic transaminase (SGPT) – 49 IU/L and serum glutamic-oxaloacetic transaminase (SGOT) – 66 IU/L.

Table No. 01:  Timeline of patient’s progress and modification of treatment plan.

CLINICAL DIAGNOSIS

Based on detailed analysis of history as well as subjective and objective parameters of the patient, the case was diagnosed as Oligo-hypomenorrhea from modern perspective and ‘Artavakshaya’ from Ayurveda point of view.

Etiopathology:

A detailed assessment of etiological factors revealed the involvement of multiple nidana (causative factors) contributing to the pathogenesis of the condition.

• Aharaja nidana (dietary factors): Regular intake of one glass of milk daily at night and consumption of two eggs at night thrice weekly indicate Guru bhojana (heavy diet) and Ati madhura rasa sevana (excessive intake of sweet taste).
• Viharaja nidana (lifestyle factors): The patient reported Atichankramana (excessive walking), Vega avarodha (suppression of natural urges), Diwaswapna (day sleeping), and Prajagarana (night awakening).
• Manasika nidana (psychological factors): Presence of Shoka (stress/grief).

According to Acharya Sushruta, Rasakshaya (depletion of Rasa dhatu) is an important causative factor for Dhatukshaya (depletion of Dhatu). Acharya Vagbhata has described that depletion of Dhatu (body tissues) subsequently leads to depletion of its corresponding Upadhatu (secondary tissues).[8] In this context, Acharya Charaka has enumerated several factors responsible for depletion of Dosha, Dhatu, and Upadhatu, which can be considered as nidana for Artavakshaya. Among these, the patient exhibited Asatmya ahara sevana (intake of incompatible food), Atichintana (excessive thinking), Atapsevana (excessive exposure to sunlight), Prajagarana (night awakening), and Vega vidharana (suppression of natural urges), which serve as samanya nidana (general etiological factors) in this case.

These factors collectively lead to Rasakshaya, which subsequently affects its Upadhatu Artava, ultimately resulting in Artavakshaya.

Pathophysiology

As per Ayurveda principles, since Artava alpata (scanty menses), Yathochita kala Adarshanam(delayed menses) and painful menses are the main features of this disease, the roga marga (disease pathway) can be considered to be Abhyantara (internal origin). Because the major symptoms are concerned with menstruation, the srotasa dushti (impaired channel) involved is rasavaha srotasa and artavavaha srotasa.  And the primary seat of this disease is Tryavarta Yoni (reproductive tract). Based on the origin of the disease, the disease can be categorized as Nija roga (internal) since dosha vitiation has caused the disease. Since all three dosha are involved in the disease manifestation, it could be termed as “Sannipataja roga”.

THERAPEUTIC INETRVENTION

This part comprises of detailed treatment protocol and guidelines which includes:

1. Ayurveda Shamana: The set of medicine prescribed for three-month course was as mentioned in Table 2. The treatment plan included I. Deepana- pachana (digestive power enhancement) with Ajamodadi churna for 7 days following which II. Ayurveda Shamana was initiated.
2. Yogasana: Including Suryanamaskara, Pavanamuktasana, Paschimottanasana, Hastapadasana, and Pranayama, performed as per standard guidelines under the supervision of a qualified yoga expert in the hospital, as detailed in Table 3 and Figure 1.
3. Exercises: Brisk walking and squatting daily for 15 minutes.
4. Lifestyle modification: comprising Meditation, stress management and enhancing spirituality. Avoidance of Divaswapna, and Ratrijagarana.
5. Dietary modification: Avoiding Adhyashana (overeating).

Table no. 2: Therapeutic Intervention

Table No. 03 Yoga Intervention Protocol:

RESULTS

Following treatment course, patient had her menstrual cycles regular a month apart and duration and amount of bleeding was improved from 2 days before treatment to 4-5 days following treatment. Intense pain during menstruation before was relieved completely. Patient got conceived in next cycle following complete treatment course. Patient lost 7 kg of weight and BMI was reduced from 26 to 23.4.

DISCUSSION

Considering the chief complaints of the patient that is delayed menses, scanty menses, and painful menses, a diagnosis of Artavakshaya was made based on the diagnostic features of Artavakshaya stated by Acharya Sushruta. From a contemporary perspective, the presentation fulfilled the diagnostic criteria of Oligo-hypomenorrhea, characterized by intermenstrual intervals exceeding 35 days and reduced duration of menstrual bleeding (<2 days).[9]

A detailed assessment of nidana revealed multiple contributory factors such as asatmya ahara sevana, atimadhura sevana, prajagarana, divaswapna, vegavidharana, and shoka. These factors are known to induce aamotpatti, leading to jatharagni mandya and impaired rasadhatu formation. Consequently, rasakshaya leads to artavakshaya due to upadhatu kshaya, while srotorodha at the level of rasavaha and artavavaha srotasa further impairs tissue nourishment and menstrual physiology. Based on this integrative pathophysiology, a multimodal therapeutic approach was adopted which is discussed in Table 4.

Additionally, the presence of bilateral knee joint pain and swelling, backache, and generalized body ache, along with agnimandya and jivha samata, indicates systemic involvement of aamotpatti with predominant vata–kapha dushti. The accumulation of ama leads to srotorodha and derangement of tissue metabolism, thereby contributing to both musculoskeletal manifestations and reproductive dysfunction.

In accordance with classical principles, correction of agni and elimination of aama constitute the initial therapeutic priority before instituting agneya dravya for artavakshaya. Hence, ama pachana was undertaken as a preparatory intervention. Ajamodadi churna, indicated in aamavata and kapha–vataja vyadhi, was administered for its deepana–pachana properties for a duration of 7 days. Restoration of agni was confirmed clinically, following which the planned therapeutic regimen was initiated. The administration of Ajamodadi churna facilitated agni deepana and ama pachana, thereby improving metabolic function and relieving systemic symptoms. Pharmacologically, its ingredients such as Trachyspermum ammi possess carminative, digestive, antioxidant, and anti-inflammatory properties, which contribute to enhanced gastrointestinal function and reduction of metabolic stress.

Simhanada Guggulu was prescribed for its aamapachana and anti-inflammatory actions. The presence of Commiphora mukul confers significant anti-inflammatory, anti-arthritic, hypolipidemic, and immunomodulatory effects through modulation of inflammatory mediators and signaling pathways. This explains the observed reduction in joint pain and swelling and improvement in systemic inflammatory status.

Since sex hormones undergo conjugation and metabolism in the liver[10], the presence of mildly deranged liver enzymes in this patient indicated impaired hepatic function, which could contribute to hormonal imbalance. Therefore, correction of hepatic metabolism was considered essential. Punarnavashtaka kwatha, indicated in yakrit vikara, was prescribed in view of its hepatoprotective, anti-inflammatory, and antioxidant properties.[11] The presence of Boerhavia diffusa in the formulation is known to enhance liver function and facilitate detoxification processes, thereby supporting endocrine homeostasis and menstrual regulation.

On evaluation of personal history, the patient was found to have significant psychological stress along with disturbed sleep patterns characterized by ratrijagarana and divaswapna. Such disturbances are known to disrupt circadian rhythm and alter nocturnal hormone secretion. Evidence suggests that sleep dysregulation adversely affects the hypothalamo–pituitary–ovarian axis, which plays a central role in the regulation of the menstrual cycle.

In this context, Ashwagandha ksheerapaka, containing Withania somnifera, was administered considering its adaptogenic and neuroendocrine-modulating properties. The presence of bioactive constituents such as somniferin contributes to anxiolytic and sleep-inducing effects, thereby reducing stress and restoring physiological sleep patterns. Additionally, its rasayana and brimhana (nourishing) properties promote tissue nourishment and support endometrial proliferation, which is essential in the management of artavakshaya.

Following correction of agni, metabolic status, hepatic function, and neuroendocrine balance, induction of menstruation using ushna dravya was undertaken. A combination of Ajamodadi churna and Tankana bhasma was prescribed for rajahpravartana.[12] Tankana bhasma, characterized by ushna virya and streepushpa janana properties, facilitates both ovulatory processes (antahpushpa) and menstrual flow (bahirpushpa).[13] Its addition to Ajamodadi churna potentiates uterine stimulation and improves pelvic circulation, thereby aiding in normalization of menstrual cyclicity and flow.

The integration of Yoga therapy provided an additional neurophysiological dimension to the treatment. Yoga has been shown to modulate autonomic balance, reduce sympathetic overactivity, and regulate the hypothalamic–pituitary–adrenal axis, thereby indirectly influencing the hypothalamo–pituitary–ovarian axis.[14,15] Reduction in cortisol levels and improvement in vagal tone contribute to normalization of hormonal rhythms and menstrual cyclicity.

The selected yogasanas exert specific physiological effects. Pavanamuktasana enhances abdominal and pelvic circulation through rhythmic compression, improving perfusion and metabolic activity of reproductive organs.[16] Paschimottanasana induces parasympathetic dominance and reduces stress, thereby improving neuroendocrine regulation. [17] Hastapadasana supports these effects by improving circulation and flexibility, contributing to overall pelvic health.

Lifestyle modifications and Pranayama further supported autonomic regulation and circadian rhythm alignment. Disturbed sleep patterns are known to alter GnRH pulsatility and downstream gonadotropin secretion; hence, correction of these factors is essential for restoring ovulatory cycles. Physical exercise, including brisk walking and squatting, contributed to weight reduction and improved insulin sensitivity. Adiposity and metabolic dysfunction are closely linked with menstrual irregularities; thus, reduction in BMI likely contributed to improved endocrine function and ovulation. Lifestyle modifications, including correction of sleep disturbances and incorporation of physical activity, further supported metabolic and hormonal balance. Improvement in body weight and BMI indicates enhanced insulin sensitivity and overall metabolic regulation, which are critical determinants of ovulatory function.

The overall clinical outcome, characterized by normalization of menstrual interval, duration, and flow, relief from dysmenorrhea, and subsequent conception, indicates effective restoration of artava dushti and reproductive physiology. The integrative approach demonstrates a synergistic effect, wherein Ayurvedic interventions corrected dosha–dhatu imbalance, improved hepatic and metabolic function, and restored agni, while Yoga contributed to neuroendocrine regulation and systemic homeostasis.

CONCLUSION:

This case report reflects an insight in the learning principles of Ayurveda and yoga therapy in management of a refractory Oligo-hypomenorrhea case. The success of the therapy is evident in that the patient not only got relief in all the symptoms but also got conceived after treatment. To improve the quality of evidence provided by this study, the same treatment protocol may be subjected to large size sample in the same issue.

Patient’s Perspective on Treatment

After a four months therapy, subjective feedback taken from the patient revealed that the patient was immensely satisfied with being relieved from all the symptoms. Apart from that, patient expressed that it was like a cherry on the cake being conceived immediately following the treatment plan. Additionally, her faith in Ayurveda and yoga was doubled than before.  

Declaration of Patient Consent

The authors confirm that they have acquired a patient consent form, in which the patient or caregiver has granted permission for the publication of the case, including accompanying images and other clinical details, in the journal. The patient or caregiver acknowledges that their name and initials will not be disclosed, and sincere attempts will be undertaken to safeguard their identity. However, complete anonymity cannot be assured.

Authors’ contribution

• Conceptualization and clinical management: AZ, DR
• Data collection and literature search: AZ, DR, SJ
• Writing – original draft: SJ, AM, PG, DS
• Reviewing & Editing: AZ, PG, DS, AM
• Approval of final manuscript: All authors

Conflicts of Interest

Authors declare that there are no conflicts of interest.

Source of Support

The authors declare no source of support

Table no 04. – Description and indications of medicines used.

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