Role of Piccha Basti in the Management of Abnormal UterineBleeding – A Case...

[Full title: Role of Piccha Basti in the Management of Abnormal UterineBleeding – A Case Report]

© 2024 Rajinder Kaur, et al . This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0). ( https://creativecommons.org/licenses/by/4.0/ ) CASE REPORT Role of Piccha Basti in the Management of Abnormal Uterine Bleeding – A Case Report Rajinder Kaur 1 * , Seema Shukla 2 , Charulata 3 1 PG Scholar, Department of PTSR, Rajiv Gandhi Government Post Graduate Ayurvedic College and Hospital, Paprola, Himachal Pradesh, India 2 HOD, Department of PTSR, Rajiv Gandhi Government Post Graduate Ayurvedic College and Hospital, Paprola, Himachal Pradesh, India 3 Lecturer, Department of PTSR, Rajiv Gandhi Government Post Graduate Ayurvedic College and Hospital, Paprola, Himachal Pradesh, India ABSTRACT The Ayurvedic classics mentioned various menstrual irregularities under the heading Artava vyapad . In this context, Asrigdara has been described by Acharyas as the excessive secretion of Rajas (menstrual blood) through vagina. Nowadays, a broader term abnormal uterine bleeding is used which describes irregularity in the menstrual cycle involving frequency, regularity, duration, and volume of blood flow. Acharyas described Asrigdar as Basti Sadhya entity and also advised to follow the treatment mentioned for Raktarsh, Raktatisar, and Raktapitta. Acharyas mentioned Piccha Basti as one of the treatment modality in these three diseases due to its Raktstambhan property Hence, due to the same property, Piccha Basti can be used in Asrigdar also . The aim of the study was to evaluate the efficacy of Piccha Basti in the management of excessive bleeding per vaginum. In the present case, a female patient aged 42 years consulted PTSR OPD of Rajiv Gandhi Ayurvedic College and Hospital Distt. Kangra (H.P.) with the complaints of heavy menstruation and generalized weakness since 5 years. She was advised routine investigations and an ultrasound scan of pelvic organ to rule out any pathology and was planned for Piccha Basti and Narayan Tail Anuvasna in Yogbasti Krama after clearance of menses for 3 months. Pictorial blood loss assessment chart was used to assess the blood loss before and after treatment. The treatment showed highly satisfactory results in controlling the excessive bleeding during menstruation which was evident through the PBAC score. Piccha Basti is an effective treatment for the management of Asrigdar. 1. INTRODUCTION Acharya Charak mentioned that the normal menstruation occurs at an interval of 1 month ( Masath ) and duration of 5 days ( Panchratranubandhi ) and not associated with any pain or burning sensation or any foul smell [1] The amount of menstrual blood is not very scanty nor excessive in amount [2] Moreover, the menstrual abnormalities have been mentioned as a separate entity under the heading Artava vyapad. Charak stated that Pradra means Pradirana (excessive secretion) of Raja (menstrual blood) [3] Commentator Chakrapani explained that due to the similar properties of Rakt and Raja , it is called Asrigdar [4] He also differentiated that due to pradiran (prolonged duration) of menstrual blood, it is called Pradar and due to the heavy flow of menstrual blood, it is called Asrigdar. [4] Acharyas Corresponding Author: Rajinder Kaur, PG Scholar, Department of PTSR, Rajiv Gandhi Government Post Graduate Ayurvedic College and Hospital, Himachal Pradesh, India Email: rajinderkaur 833@gmail.com mentioned to follow the treatment of Raktarsh, Raktatisar, and Raktapitta in Asrigdar. Raktatisar because all these entities involve bleeding from Adhogatamarg and follows Raktstambhan approach and has Pitta Pradhan Dosha associated with Vata and Rakt as Predominant Dushya. Commentator Dalhan mentioned Adhograkpitta must be taken from Raktapitta. [5] It is mentioned that if the patient suffering from Raktapitta is emaciated then Sanshamni Kriya [6] must be followed instead of Sanshodhan. The Samshamni Kriya must include Stambhak (hemostatic) and Tarpan (Nourishing) Chikitsa . Moreover, Piccha Basti mentioned in Raktarsh [7] and Raktatisar [8] has Raktstambhak property and, hence, can be used in Asrigdar also. The term used heavy menstrual bleeding (HMB) is defined as excessive blood loss interfering with physical, social, emotional, and material quality of life. It is generally caused by condition affecting uterus or its vascularity, rather any disturbance of the function of HPO axis [9] The PALM COEIN classification system describes the cause of AUB in the reproductive years. PALM includes polyp, adenomyosis, leiomyoma, or hyperplasia and COEIN includes ARTICLE INFO Article history: Received on: 07-09-2024 Accepted on: 14-10-2024 Published on: 31-10-2024 Key words : Abnormal Uterine Bleeding, Artava vyapad , Asrigdar , Piccha Basti , Yogbasti International Research Journal of Ayurveda & Yoga Vol. 7(10), pp. 37-41, October, 2024 Available online at http://irjay.com ISSN: 2581-785 X DOI: 10.48165/IRJAY.2024.71007

Kaur, et al. : Ayurvedic approach for AUB management 2024; 7(10):37-41 38 coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and entities that are not yet classified. The hormonal imbalance leads to the endometrial hyperplasia that causes menorrhagia. Thus, irregularity in the menstrual cycle in its frequency, regularity, duration, and volume of blood flow is called as abnormal uterine bleeding (AUB) [10] It is more commonly experienced by extremes of reproductive age group. This article highlights the dynamic result obtained due to the hemostatic action of Piccha Basti in the management of Asrigdar. 2. PATIENT INFORMATION A female patient aged 42 years consulted PTSR OPD of Rajiv Gandhi Government Postgraduate Ayurvedic College Distt. Kangra (H.P.) with the complaints of heavy menstruation and generalized weakness since 5 years. On enquiry, she told that she had irregularity in menses with increased duration and decreased interval. She told that her duration of menses was 6–7 days along with the passage of clots. The bleeding was heavy on the first 3 days and was not associated with foul smell. She also complained of pain in lower abdomen which was bearable and non-radiating. Further, she told and she had generalized weakness since 5 years. The patient came for Ayurvedic treatment on April 03 2023 and the treatment was continued up to June 12 2023. The total duration of the treatment was of 3 months 2.1. Past History She gave a history of thyroid dysfunction. No history of DMII, HTN, and PTB 2.2. Surgical Intervention Diagnostic D and C was done in 2022 and in 2023 but she got no relief in heavy menstruation 2.3. Clinical Finding The patient was afebrile and her vitals were stable. The patient looked pallor and was moderately ill looked. She was of moderate body build and the systemic examination was normal 2.4. Ashta Vidha Pariksha Mentioned in Table 1 below 2.5. Dashvidha Pariksha Mentioned in Table 2 below. The mensutral history and investigation reports are mentioned in Tables 3 and 4 below 2.6. Diagnostic Assessment On the basis of the menstrual history of the patient, the PBAC score was calculated which comes out to be 364 which suggests heavy menstrual bleeding mentioned in Table 4 below. The hematological findings revealed moderate anemia. The patient was diagnosed with abnormal uterine bleeding 2.7. Therapeutic Intervention After clearance of menses, Yogbasti (a course of eight therapeutic enemas) was administered for 8 days with the combination of Sneha Basti (oil enema) and Kashaya Basti (enema with medicated decoction) for 3 months. In this case, Piccha Basti and Narayan Tail Anuvasna Basti were given the details are mentioned in Table 5 below 2.8. The Yogbasti was given in the Following Manner in Each cycle 2.8.1. Piccha Basti • Poorva Karma: Local Snehan and Svedan of the lower abdomen and back were done • Pardhan Karma: The patient was asked to empty the bladder and was asked to lie in the left lateral position. The enema pot containing picha basti was held at 5 ft height was fitted with rubber catheter no. 5. The rubber catheter lubricated with oil was inserted in the anus and 300 mL of basti was given • Paschat Karma: The patient was to lie down and retain Basti as long as 48 min or till urge to defecate 2.8.2. Anuvasana Basti • Poorva Karma: Local Snehan and Svedan of the lower abdomen and back were done • Pardhan Karma: The patient was asked to empty the bladder and was asked to lie in left lateral position. The syringe containing Narayan Tail was fitted with rubber catheter no. 5. The rubber catheter lubricated with oil was inserted in the anus and 60 mL of basti was given • Paschat Karma: The patient was to lie down and retain Basti as long as 3 h 2.9. Follow-up and Outcome The patient followed up for the next cycle of Piccha Basti every month after the clearance of menses for 3 months starting from April and revealed marked reduction in blood loss in each cycle. PBAC score which was earlier 364 is now reduced to 101 after three cycles of treatment and marked improvement in the general health of the patient is also noted. No adverse events were observed during the intervention period mentioned in Table 6 below 3. DISCUSSION The contents of Piccha basti [12] contain Shalami pushpa, [13] ( Salmalia malbarica Schott & Endl.) Lodhra, [14] ( Symplocos racemosa Roxb.) Nagkesara, [15] ( Messua ferrae Linn.) Manjishta, [16] ( Rubia cordifolia Linn.) Mochrasa, [17] ( Salmalia malbarica ) , and Aja dughdha [18] (goat milk). The Piccha Basti contents are Kashaya Tikt Rasa Pradhan, Laghu Ruksha Guna, Madhur Vipaka, and Sheeth Virya . Due to the Ksahaya and Tikt Pradhan Rasa, they act as Kaph Pitta Shamak and their astringent action helps in checking the excessive bleeding. Laghu Ruksha guna helps in Shoshan of Kapha and Madhur Vipaka helps in curbing the vitiated Vata dosha. The additional properties of drugs like Dahshamak effects of Shalmali and Manjistha also aid in pacifying the vitiated Pitta Dosha . The Sankochak [15] properties of Lodhra help in constricting the blood vessels and thus reducing the bleeding. The Vrana Ropan properties of Mochras help in healing of the damaged lining of vessels . Ajadugdh is also described as Raktapitta Shamak and its Sheeth Virya also acts as Pitta Shamak. All these drugs having Madhur Vipaka act as Balya and hence overcome the generalized weakness. Furthermore, Narayan tail contains Vatashamak drugs which help in the Shaman of Vata. 3.1. Importance of Piccha Basti In abnormal uterine bleeding, there is irregular bleeding per vaginum in terms of frequency, duration and blood volume. Ovulatory dysfunction is one of the reasons behind the excessive and prolonged bleeding in this case. By equating these symptoms

Kaur, et al. : Ayurvedic approach for AUB management 2024; 7(10):37-41 39 to Asrigdar, Piccha Basti can be well applicable in the treatment of AUB Due to excessive bleeding per vaginum along with generalized weakness, the Sanshamni treatment protocol was adopted in this case as mentioned in Raktapitta and Piccha Basti mentioned in Raktarsh and Raktatisar was chosen as the hemostatic modality 4. CONCLUSION The aim of the treatment was to control the excessive bleeding during menses and improving the general health of the patient through an Ayurvedic approach. In this case, management of abnormal uterine bleeding with Piccha Basti provides dynamic results in checking of excessive bleeding due to its hemostatic property 5. DECLARATION OF THE PATIENT CONSENT The authors certify that patient consent has been taken to report the case and understand that his name and initials will not be published 6. ACKNOWLEDGMENT Nil 7. AUTHORS’ CONTRIBUTIONS All the authors contributed equally to the design and execution of the article 8. FUNDING Nil 9. ETHICAL APPROVALS This manuscript does not required ethical approval as it is a case study 10. CONFLICTS OF INTEREST Nil 11. DATA AVAILABILITY This is an original manuscript and all data are available for only review purposes from principal investigators 12. PUBLISHERS NOTE This journal remains neutral with regard to jurisdictional claims in published institutional affiliation REFERENCES 1. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch. 30/227-228. Varanasi: Chaukhamba Bharati Academy; 2016 2. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch. 30/225. Varanasi: Chaukhamba Bharati Academy; 2016 3. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch.30/209. Varanasi: Chaukhamba Bharati Academy; 2016 4. Dutt C. The Charak Samhita of Agnivesha with the Ayurvedadipika Commentary. Chikitsasthan 30/204-224. Varanasi: Chaukhamba Orientalia; 2004 5. Shastri KA. Susruta Samhita of Susruta with the Nibandhasangraha Commentry of Sri Dalhanacharya. Utratantra 45/44. Varanasi: Chaukhamba Orientalia; Reprint 2020 6. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch 4/64. Varanasi: Chaukhamba Bharati Academy; 2016 7. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch 14/228. Varanasi: Chaukhamba Bharati Academy; 2016 8. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch 19/68. Varanasi: Chaukhamba Bharati Academy; 2016 9. Kumar S, Padubidri VG, Daftary SN. Shaws Textbook of Gynaecology. 18 th ed., Ch. 10. Netherlands: Elsevier; 2004. p. 119 10. Konar H. DC Dutta Textbook of Gynaecology. 7 th ed., Ch. 15. New Delhi: Jaypee Brothers Medical Publishers; 2016. p. 152 11. Higham JM, O`Brien PM, Shaw RW. Pictorial Blood Loss Assessment Chart. Available from: https://elearning.wfh.org [Last accessed on 2024 Aug 12] 12. Shastry KN, Chaturvedi GN. Vidyotini Vyakhya, Charaka Samhita. Ch. S. Ch. 14/225-228. Varanasi: Chaukhamba Bharati Academy; 2016 13. Sharma PV. Dravyaguna Vijana. Vol. 2. (Vegetable drugs). Varanasi: Chaukhambha Bharati Academy; 2013. p. 491 14. Sharma PV. Dravyaguna Vijana. Vol. 2. (Vegetable drugs). Varanasi: Chaukhambha Bharati Academy; 2013. p. 616 15. Sharma PV. Dravyaguna Vijana. Vol. 2. (Vegetable drugs). Varanasi: Chaukhambha Bharati Academy; 2013. p. 783 16. Sharma PV. Dravyaguna Vijana. Vol. 2. (Vegetable drugs). Varanasi: Chaukhambha Bharati Academy; 2013. p. 800 17. Sharma PV. Dravyaguna Vijana. Vol. 2. (Vegetable drugs). Varanasi: Chaukhambha Bharati Academy; 2013. p. 492 18. Shastri KA. Susruta Samhita Ayurveda Tattva Sandipika. Su. S. Su. 45/68. Varanasi: Chaukhamba Sanskrit Sansthan; 2017 How to cite this article: Kaur R, Shukla S, Charulata. Role of Piccha Basti in the Management of Abnormal Uterine Bleeding – A Case Report. IRJAY. [online] 2023;7(10);37-41 Available from : https://irjay.com DOI link- https://doi.org/10.48165/IRJAY.2024.71007

Kaur, et al. : Ayurvedic approach for AUB management 2024; 7(10):37-41 40 Table 2: Dashvidha pariksha Prakriti Vatapitta Vikriti Lakshyanimitaj Sara Madhyam Samhanana Madhyam Pramana Madhyam Satmaya Sarva ras Satva Madhyam Vaya Madhyam Vyayamshakti Madhyam Aharshakti Abhyavaran shakti Jaranashakti Madhyam Madhyam Table 1: Ashta Vidha Pariksh Nadi 84/min Mala Once a day Mutra 3–4 times/day Jihwa Anavrutta Shabda Spashta Sparsha Anushan sheeth Drika Nirmal Aakriti Madhyam Table 4: Investigation Hb 9.0 g/dL BT 1 min 30 s Plt 1×10 3 /mm 3 CT 4 min 15 s ESR 24 mm/h Urine NAD RBS 112 mg/dL LFT TSB 0.4 mg/dL DSB 0.1 mg/dL SGOT 41 IU/mL SGPT 38 IU/mL RFT Blood urea 20 mg/dL HIV NR S. Creatinine 0.8 mg/dL VDRL NR TFT TSH 4.19 uIU/mL Hb: Hemoglobin, ESR: Erythrocyte sedimentation rate, Plt: Platelet, RBS: Random blood sugar, RFT: Renal function tests, TSH: Thyroid-stimulating hormone, TFT: Thyroid function test, BT: Bleeding time, CT: Clotting time, LFT: Liver function test, TSB: Total serum bilirubin, DSB: Doorstep banking, SGOT: Serum glutamic oxaloacetic transaminase, SGPT: Serum glutamate pyruvate transaminase, HIV: Human immunodeficiency virus, VDRL: Venereal disease research laboratory Table 6: Basti treatment protocol Days Cycle 1 Cycle 2 Cycle 3 Basti Dose D 1 April 05, 2023 May 08, 2023 June 05, 2023 Anuvasana 60 mL D 2 April 06, 2023 May 09, 2023 June 06, 2023 Piccha 300 mL D 3 April 07, 2023 May 10, 2023 June 07, 2023 Anuvasana 60 mL D 4 April 08, 2023 May 11, 2023 June 08, 2023 Piccha 300 mL D 5 April 09, 2023 May 12, 2023 June 09, 2023 Anuvasana 60 mL D 6 April 10, 2023 May 13, 2023 June 10, 2023 Piccha 300 mL D 7 April 11, 2023 May 14, 2023 June 11, 2023 Anuvasana 60 mL D 8 April 12, 2023 May 15, 2023 June 12, 2023 Anuvasana 60 mL Table 3: Menstrual history Parameters Past Present Duration of menses 5–6 days 6–7 days Interval between menses 28–30 days 15–20 days Pain during menses Absent Mild Amount of bleeding (No. of pads) 3–4 pads/day 5–7 pads/day Clots + +++ Foul smell Not present Not present Weakness Not present Present Flooding Present Not present Table 7: Treatment outcomes Parameters Before treatment After 3 months of treatment Duration of menses 6–7 days 4–5 days Interval between menses 15–20 days 26–28 days Pain during menses Mild mild Amount of bleeding (No. of pads) 5–7 pads/day 3–4 pads/day Clots +++ + Foul smell Not present Not present Weakness Present Not present Flooding 1 st and 2 nd day Not present PBAC score 364 101 PBAC: Pictorial blood loss assessment chart Table 5: PBAC scoring Pictorial blood loss assessment chart (PBAC) scoring [11] For each lightly stained pad and each small clot 1 point each For each moderately stained pad and for each large clot or each episode of flooding 5 point each For each completely saturated pad 20 point each Interpretation: A score of 100 or >100 indicates probable menorrhagia

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Asrigdara, Paschat-karma, Lodhra, Raktapitta, Raktatisara, Anuvasanabasti, Snehabasti, Tarpan, Stambhak, Manjishta, Surgical intervention, Effective treatment, Menstrual cycle, Excessive bleeding, Follow-up, Ultrasound scan, Menstrual abnormalities, Ayurvedic approach, Reproductive Age Group, Hormonal imbalance, Therapeutic intervention, Patient consent, Treatment outcome, Ovulatory dysfunction, Generalized weakness, Dashvidha Pariksha, Diagnostic assessment, Poorva Karma, Thyroid dysfunction, Raktarsh, Abnormal Uterine Bleeding, Madhur Vipaka, Normal Menstruation, Piccha basti, Routine investigation, Heavy Menstrual Bleeding, Patient Information, PALM-COEIN classification, Laghu-Ruksha-Guna, Clinical finding, Prolonged duration, Artava vyapad, Narayan Tail, Heavy menstruation, PBAC score, Ashta Vidha Pariksha, PTSR OPD, Hematological Finding, Authors' Contribution, Kashaya Basti, Rubia cordifolia Linn, Pradirana, Pardhan Karma, Pelvic organ.