E-ISSN:2456-3110

Case Report

Postpartum Hypothyroidism

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 1 January
Publisherwww.maharshicharaka.in

Importance of Virechana in Postpartum Hypothyroidism - A Case Report

Dakshini S.1*, Bhavana K.2
DOI:

1* Sai Dakshini, Consulting Physician, Satkriti Ayurveda, Chennai, Tamil Nadu, India.

2 K.M. Bhavana, Assistant Professor, Akkamahadevi Ayurveda Medical College, Bidar, Karnataka, India.

Background: Postpartum Hypothyroidism is generally a temporary condition that affects about 5% of women, usually self-resolving in nature. In rare cases, it continues to become subclinical Hypothyroidism. It occurs as a state of Hyperthyroidism followed by Hypothyroidism. Materials and Methods: A 39-year-old female presented with weight gain and hair fall after the birth of her second child due to postpartum hypothyroidism that wasn’t controlled with medical intervention. The treatment protocol that was chosen was classical Virechana followed by 15 days of internal medication. Observations and Results: After 4 weeks of Ayurvedic treatment the TSH level from 19.03 uIU/ml came down to 1.44 uIU/ml. Apart from this changes in the symptoms were assessed with the Zulewski et al. scale, the score reduced from 8 to 2 suggesting an euthyroid state. Conclusion: Overall it was concluded that one round of classical Virechana had significant changes on the laboratory parameters and the symptoms, ultimately being an effective way to control hypothyroidism.

Keywords: Hypothyroidism, Postpartum Hypothyroidism, Galaganda, Panchakarma, Virechana, Ayurveda

Corresponding Author How to Cite this Article To Browse
Sai Dakshini, Consulting Physician, , Satkriti Ayurveda, Chennai, Tamil Nadu, India.
Email: 		Sai Dakshini, K.M. Bhavana, Importance of Virechana in Postpartum Hypothyroidism - A Case Report. J Ayu Int Med Sci. 2023;8(1):213-218.
Available From
https://jaims.in/jaims/article/view/2197

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-11-28 2022-11-30 2022-12-07 2022-12-14 2022-12-21
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 17%

© 2023by Sai Dakshini, K.M. Bhavanaand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Ayurveda is a science that encompasses both preventive and curative forms of medicine. Its vast knowledge cannot be looked upon as just a means of curing disease, rather a way of living.

In recent times, a difference can be drawn in the ways of Living, thus giving rise to an increasing number of Lifestyle disorders. But these disorders have long before been told in the texts, along with specific reasoning as to why they occur, explaining about the lifestyle changes.

One such Lifestyle disorder that’s seen a steep increase is Hypothyroidism. A hypo-metabolic clinical state of the thyroid gland results in something known as Hypothyroidism. It is seen more often in Whites and Asians. Six times more prevalent in women, Hypothyroidism can be primary and secondary owing to whether the fault lies in the hypothalamic-pituitary axis or the thyroid gland as such.[1]

Primary hypothyroidism is diagnosed when the levels of TSH are increased along with increased levels of free T4 or it can be subclinical when the levels of TSH are increased but Free T4 is in its normal range. Postpartum Hypothyroidism occurs after the birth of a child, a period of acute Hyper-thyroidism which ultimately moves into a Prolonged Hypothyroidic state.

In Ayurveda the features of hypothyroidism can be be understood as a vitiation in the Doshas and the Dhatus, particularly the Pitta and Kapha Dosha vitiation that ultimately affects the Rasa dhatu all the way to the Shukra dhatu. Symptoms such as diffuse neck swelling, weight gain and fatigue all have separate references such as Acharya Charaka’s Galaganda in the 11th chapter of Chikitsa Sthana or Sroto Dusti Lakshanas, even Kaphaja Nanatmaja Vikaras according to Charaka Samhita Sutrasthana 20th chapter but don’t fall into the same Roga as such but can be easily treated if the Samprapti is understood.

Aim and Objectives

To evaluate the efficacy of Virechana as a Panchakarma measure in Postpartum hypothyroidism.


Materials and Methods

A 39-year-old female came into the OPD in Chennai, Tamil Nadu on 18/11/2022 with primary complaints of hair fall, and weight gain over the past six years. Although she noticed the symptoms starting 6 years back after the birth of her second child, she noticed a progression over the past year with a weight gain of 9 kilos in 1 year, and patchy baldness setting to appear. She was diagnosed of having Primary Hypothyroidism, developing after the caesarean delivery of her second child (Postpartum Hypothyroidism). She was put on Thyronorm 50mcg along with 12 mcg once daily on an empty stomach in the morning, but the symptoms persisted along with elevated TSH levels. Over the past year she also started experiencing irregular menstrual cycles, with 50 to 55 day intervals. The patient wasn’t seeing any change with allopathic medication; hence she was interested in starting Ayurvedic treatment. The patient had no significant medical history, and family history.

Table 1: Dasha Vidha Pariksha assessment of the patient (at the time of first consult)

Prakruthi Pitta Pradhana Kaphanubandhi
Vikruthi Kapha Pitta
Saara Madhyama
Saatmya Pravara
Samhanana Pravara
Pramana Pravara
Satva Pravara
Ahara Shakthi Madhyama
Vyayamashakthi Heena
Vaya Madhyama

When it came to planning the treatment protocol, assessing the Dosha status was first. Astavidha Pariksha was also assessed. The Mala was Vikrutha with regular episodes of constipation and Mutra was in the Prakrutha Awastha, Shabda - Snigdha, Akruthi - Sthula, Sparsha - Ushnam, Druk - Prakrutha.

Upon examination of the neck, a diffuse swelling was palpated with no nodal formations. The patient weighed 99 kilos and was 152 cm in height with a BMI of 42.8 while starting the treatment.

Intervention: Prior to starting with Ayurvedic medications, one round of Classical Virechana Karma was conducted for relieving the Pitta Vikruthi and acquiring Sroto Shodhana.


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Table 2: Panchakarma treatment plan that was followed, with specifications of the medicine used and dosage.

Deepana Pachana Avipattikar Churna ½ tsp-0-1/2 tsp before food for 3 days
Snehapana Guggulutiktaka Ghritham Was given in accordance to Agni (3 days)
Sarvanga Abhyanga followed by Bhaspa Sweda Dhanwantaram Tailam 3 days
Virechana Trivruth Lehya 70mg for 1 day.

Post Virechana

Samsarjana Krama was advised, for 5 days. As the patient was Non vegetarian proper Pathyam was advised including non-vegetarian options.

Patient was told to follow a largely – Pitta balancing diet, along with additions of Kaphahara Ahara and Vihara. She was advised to exercise daily, and stop consumption of heavy meats, and start intake of meat soups, and lean meats into her diet.

Post Virechana the following medications were given (first for 15 days)

1. Sowbhagya Shunti 1 tsp-0-0 empty stomach with warm water

2. Kanchanara Guggulu 1-0-1 after food

3. Avipattikar Churna 0-0-1/2 tsp with water at bedtime

4. Shatbindu Taila - Nasya 2 drops each nostril, daily.

5. Guduchi tab 1-0-1 after food

Assessment Criteria

Subjective Criteria

The Zulewski et al. scale was used. This scale includes the most common symptoms of Hypothyroidism, a score of 1 is given if the symptom persists, otherwise zero.

A total score of more than and equal to 5 equates to hypothyroidism, a score of less than, equal to 3 equates a euthyroid state, and between 3-5 shows an intermediate state.[2]

Objective Criteria

Levels of TSH and T4 and T3 were checked before and after a round of classical Virechana.


Observations

Upon first consultation, it was observed that the TSH levels weren’t even responding to the Allopathic medication indicating the level of Sroto-Avarohana in the body.

The patient was asked to stop her allopathic thyroid medication during the course of treatment to estimate the true efficacy of Virechana.

The patient complied and the medicine was stopped from the first consult itself, 5 days ahead of Deepana Pachana.

Virechana was planned, and the patient was advised to take Avipattikar Churna as Deepana Pachana medication

Guggulutiktaka Ghritham was chosen as the Snehapana Oushadhi and dosage was planned according to her Agni Pariksha.

Day 1 - 30 ml

Day 2 - 60ml

Day 3 - 90 ml

During Snehapana the patient followed strict protocol and Samyak Snigdha Lakshanas were seen after the 3rd day.[3]

Kanji was advised and taken after Udgaara Shuddhi and Ksuth Pravruthi.

Mala was passed easily, with slight Snigdhatha every day.

After finishing Snehapana the patient underwent Abhyanga and Baspa Sweda for three days, with Dhanwantaram Tailam.

During this period, the patient felt very light and found relief from her muscle stiffness and fatigue.

Upon assessing whether the hair loss had decreased, she observed that it did when she combed her hair.

On the third day of Abhyanga the patient was told to take Trivrith Lehyam 70ml at 8:30 in the morning.

After taking the Lehyam, the Vegas began after nearly 1 and a half hours. The patient was comfortable and was passing loose stools at first.



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Table 3: Record of stools passed, with timings.

Number of Vegas Time Observation
1 10:30 Light yellow stools, loose
2 10:45 Light yellow stools, loose
3 10:53 Loose stools
4 11:09 Semi solid stools
5 11:20 Loose, light yellow stools
6 11:32 Darker stools, loose
7 11:45 Loose dark stools
8 11:56 Loose dark stools
9 12:15 Watery stools
10 12:44 Watery stools
11 1:06 Watery stools
12 1:40 Watery stools

Table 4: Assessment of Shuddhi after completion of Virechana

Vegika Shuddhi Anthika Shuddhi Maniki Shuddhi Lingaka Shuddhi
12 Kaphantha Madhyama Indriyashudhi Ksuthpippasa Pravruthi Laghutha

During the Virechana she experienced slight abdominal pain at first which gradually subsided. She was advised to keep sipping on warm water regularly and place a hot water bag if she felt too much discomfort.

At 3:30pm, she began to feel hungry and was advised to take Kanji.

After finishing Virechana the patient felt a great difference in her body, felt light and was able to properly pass motion over the next few days. She was given the Samsarjana Krama and was able to follow it properly.

Symptomatically

  • Patient found a slight difference in hair-fall.
  • Sense of fatigue was absent
  • Patient found relief from the body ache.

Table 5: Weight loss before and after Virechana

Before Virechana After Snehapana After Virechana
99 98.3 kilos 95.5 kilos

Table 6: Difference found in the levels of TSH within a week of Virechana

Before Ayurvedic Treatment (27/1/2021) Pre -Virechana (08/11/2022) Post -Virechana (30/11/2022)
15.62 uIU/ml 19.03 uIU/ml 1.44 uIU/ml

Zulewski et al. scale before treatment and after treatment

Table 7: Before treatment - 8 (more than 5 indicating Hypothyroidism)

Signs and symptoms Score
Slowness of movement 1
Ankle reflex 0
Coarse skin 1
Periorbital puffiness 1
Cold skin 1
Diminished sweating 1
Hoarseness of voice 0
Paraesthesia 0
Dry skin 1
Weight increase 1
Hearing impairment 0
Constipation 1

Table 8: After treatment - 2 (assessed after the Samsarjana Krama was completed)

Signs and symptoms Score
Slowness of movement 1
Ankle reflex 0
Coarse skin 0
Periorbital puffiness 1
Cold skin 0
Diminished sweating 0
Hoarseness of voice 0
Paraesthesia 0
Dry skin 0
Weight increase 0
Hearing impairment 0
Constipation 0

Discussion

The above patient is a clear example of how with just one round of classical Virechana, the TSH levels can be reduced even without levothyroxine. Understanding the symptoms and Dosha predominance and plainly adopting a Hetu Vyaadhi Viparitha Chikitsa is beneficial than just giving symptomatic medication.

Virechana was chosen as the season was not compatible for Vamana.

Avipattikar Churna was chosen as Deepana Pachana medication since she was suffering from Apanavayu Vikruthi and was having Vibandha. As Avipattikar Churna was both a Pitta Rechaka and a Deepana Dravya and was easily available it was selected.


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Guggulutiktaka Ghritham was chosen as the Snehapana Oushadhi as it is both Pitta and Kaphahara in nature. In the Phalasruthi it has been clearly mentioned that it can be used for Gandamala and Jatrurdhwagada both of which were seen in this case.

In Ayurveda, the features of Hypo-thyroidism can be understood as a vitiation in the Doshas and the Dhatus, particularly the Pitta and Kapha Dosha vitiation that ultimately affects the Rasa Dhatu all the way to the Shukra Dhatu [Symptoms such as diffuse neck swelling, weight gain and fatigue all have separate references such as Acharya Charaka’s Galaganda in the 11th chapter of Chikitsa Sthana or Sroto Dustila Kshanas even Kaphajananatmaja Vikaras according to Charaka Samhita Sutrasthana 20th chapter but don’t fall into the same Roga as such but can be easily treated if the Samprapti is understood.]

All Roga’s arise from a state of Agnimandya which is the same that can be said for Hypo-thyroidism. Due to excessive Kaphakara Ahara and Vihara a Dushti in the Agni can affect the Rasa Dhatu production and result in Uttara Uttara Dhathu Poshana ultimately resulting in features seen in Rasa Dhatu Pradoshaja Vikrara. Due to the chronicity even features of Shukra Pradoshaja Vikara’s can be seen in some cases.

Table 9: Clinical features and their Doshic breakdown[4]

Features Dosha Involved Predominant Dhatu involved
Neck swelling Kapha Rasa, Rakta, Mamsa and Meda
Weight gain Pitthaksaya and Kapha Vrudhhi Rasa and Medas
Puffiness of Face Kapha Vrudhi Rasa Dhatu
Hair fall Pitta and Kaphavriddhi Rasa, Raktadhaatu
Lethargy Pitta Ksaya and Kaphavriddhi Rasa Dhaatu
Altered texture of skin Pitta Ksaya Rasa, Rakthadhaatu
Constipation Vata Vriddhi Rasa Dhaatu

Conclusion

Hypothyroidism is one of the most prevalent Endocrine disorders seen in women. Over 5% of the population have diagnosed hypothyroidism where another 5% go undiagnosed. Levothyroxine is the main drug of choice in modern medicine, although it is told to be taken life-long with progressively increasing dosages.[5]

In this case, even after 6 years of childbirth and a progressively increased dose of levothyroxine the condition was uncontrolled. The patient had full faith in the treatment as she noticed visible changes at first, and adhered completely to the protocol without an issue. The internal medications were started after Samsarjana Krama and the patient was instructed to wean off the allopathic medication. Hypothyroidism can easily be managed by Ayurveda as this condition has been explained in our texts, in a scattered format. Most times, with timely Panchakarma and symptomatic medication the effects of hypothyroidism can regress. In such conditions of endocrine origin, Shodhana shows tremendous changes. With Shodhana being done regularly the patient is also known to respond better to any internal medications given. So, it should be considered as one of the first levels of treatment in cases like these.

Reference

1. Aswathy Prakash C, Byresh A. Understanding Hypothyroidism in Ayurveda. Department of PG studies in Kayachikitsa, Sri Kalabyraveshwara swamy Ayurvedic Medical College Hospital and Research Centre, Vijayanagar, Bangalore, Karnataka, Page No. 4/9.

2. Srivastava P, Khare J, Rai S, Ghanekar J. Zulewski's clinical score and its validation in hypothyroid patients: Experience in a tertiary care center in Western India. CHRISMED J Health Res 2020;7: Page No. 16-9

3. Chakrapani, Agnivesha: Charaka samhita, Varanasi, Chaukhambha Sanskrit sthana, 5th edition, 2001, sutrasthana, chapter 13, shloka 57, Page No. 258.

4. Aswathy Prakash C, Byresh A. Understanding Hypothyroidism in Ayurveda. Department of PG studies in Kayachikitsa, Sri Kalabyraveshwara swamy Ayurvedic Medical College Hospital and Research Centre, Vijayanagar, Bangalore, Karnataka, Page No. 4/9.

5. Chiovato L, Magri F, Carlé A. Hypothyroidism in Context: Where We've Been and Where We're Going. Adv Ther. 2019 Sep;36(Suppl 2):47-58. doi: 10.1007/s12325-019-01080-8. Epub 2019 Sep 4. PMID: 31485975; PMCID: PMC6822815.


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