E-ISSN:2456-3110

Research Article

Dysmenorrhea

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 11 NOVEMBER
Publisherwww.maharshicharaka.in

Management of Kashtartava (Dysmenorrhea) with Vishwadi Kwatha: An Open Labelled Single -Arm Clinical Trial

Sivanandan A1*, Denish R M2
DOI:10.21760/jaims.9.11.2

1* Anagha Sivanandan, Assistant Professor, Department of Prasuti Tantra and Stree Roga, Murlidhar Ayurved College, Rajkot, Gujarat, India.

2 Metaliya Denish R, BAMS Student, Murlidhar Ayurved College, Rajkot, Gujarat, India.

Introduction: Kashtartava (Dysmenorrhea) is a commonly reported menstrual disorder which affects the working ability and quality of life of the woman. Due to in discreet diet and lifestyle, young women are more liable to get afflicted with this disorder in present era. This trial was planned to evaluate the effect of Vishwadi Kwatha which is an unexplored formulation in the management of dysmenorrhoea.

Materials and Methods: 18 patients fulfilling the inclusion criteria were selected from the OPD of Prasutitantra & Streeroga, of the institution (3 drop outs). Oral administration of Vishwadi Kwatha in a dose of 40ml, twice a day, before meals was given for 1 month. The effect of therapy was assessed by change in the scores of assessment criteria including Visual Analogue Scale. Follow up was done for 1 month.

Result: Statistically highly significant (p<0.001) results were obtained in both the duration (75.60 %) and severity (73.68% relief) of menstrual pain and also in associated symptoms like Aruchi(93.75% relief), and Bala-Bhramsha (91.17% relief).The mean VAS score of 7.467±1.407 before treatment was reduced to 2.333±0.9 after treatment.

Discussion: Vishwadi Kwatha was mentioned in Shoola Prakarana of Bhaishajyaratnavali as Sadya Shoolahara. The formulation is having Vatanulomana, Dipana-Pachana, Artavajanana, Kaphahara, and Shrotoshodhana properties which will help the easy expulsion of properly formed Artava through the unobstructed channels by correcting the Vimarga Gati of Vayu.

Conclusion: Oral administration of Vishwadi Kwatha was found to be effective in the management of Kashtartava and recommended for further research.

Keywords: Kashtartava, Dysmenorrhea, Vishwadi Kwatha, Menstrual cramps, Shoola

Corresponding Author How to Cite this Article To Browse
Anagha Sivanandan, Assistant Professor, Department of Prasuti Tantra and Stree Roga, Murlidhar Ayurved College, Rajkot, Gujarat, India.
Email: 		Sivanandan A, Denish R M, Management of Kashtartava (Dysmenorrhea) with Vishwadi Kwatha: An Open Labelled Single -Arm Clinical Trial. J Ayu Int Med Sci. 2024;9(11):8-14.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-10-16 2024-10-24 2024-11-04 2024-11-14 2024-11-24
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© 2024by Sivanandan A, Denish R Mand 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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Anagha S et al. Management of Kashtartava (Dysmenorrhea) with Vishwadi Kwatha

Introduction

Dysmenorrhea is a commonly reported menstrual disorder which due to its incapacitating nature affects the working ability and quality of life of the women. It has a detrimental effect on the individual as well as the communities in terms of school and work absenteeism, interference with daily living activities, limitation in socialization and cost of medication and hospitalization.[1]

The worldwide prevalence of dysmenorrhoea ranges from 45% to 95% among the females of reproductive age, with 2% to 29% experiencing severe pain.[2,3] A greater prevalence (70% to 90%) is generally reported among younger women (age <24 years).[4]

Painful menstruation with associated symptoms like bloating of abdomen, nausea, vomiting, diarrhoea, constipation, tiredness, nervousness etc. can be considered under the terminology Kashtartava which needs special medical attention as it degrades the quality of life of women. The main cause of Kashtartava is unhealthy and faulty dietary habits, sedentary lifestyle, suppression of natural urges, etc. which lead to obstructions in Srotas (bodily channels) and Vimarga Gamana (improper movement) of Apana Vayu leading to the manifestation of symptoms of Kashtartava. In conventional medical system, dysmenorrhea is treated by NSAIDs, antispasmodic, analgesics, OCP`s etc. which cannot provide a permanent relief and their long- term use can cause many side effects also. But immediate symptomatic relief is always demanded by the patients especially in case of pain predominant conditions like dysmenorrhoea. Even though Ayurveda aims at eliminating the root cause of the diseases through its holistic approach, immediate relief from symptoms is also a matter of concern.

The classical reference of the trial drug Vishwadi Kwatha[5] which is an unexplored formulation in the field of management of Kashtartava, emphasizes that it will provide immediate pain relief (Sadya Shoolahara). The ingredient drugs are easily available and cost effective and they are having the properties to correct the pathology of Kashtartava. Thus, a clinical trial was planned to evaluate the efficacy of Vishwadi Kwatha in the management of Kashtartava.

Materials and Methods

Selection of patients: Patients of age group 12-30 years presenting with signs and symptoms of Kashtartava i.e., painful menstruation with or without associated complaints like nausea, vomiting, constipation, breast tenderness, headache, light headedness, anorexia, nervousness etc. were screened and enrolled from the OPD of department of Prasuti Tantra and Stree Roga, Murlidhar Ayurved College Hospital, Rajkot.

Patients who are the pre-diagnosed cases of pelvic pathologies like uterine fibroid, adenomyosis, ovarian cyst etc, congenital/ acquired anomalies and malignancy of uterus or genital tract, those who are kknown cases of heavy menstrual bleeding, acid peptic disease, peptic ulcer, gastro-esophageal reflux disorder, or any other bleeding disorders were excluded from the study.

Preparation of Drug:

The raw drugs for the preparation of trial drug Vishwadi Kwatha were collected from the authentic sources. The pharmacognostical study and pharmaceutical analysis of the trial drug were carried out from the concerned laboratories of B.K.Mody Government Pharmacy college, Rajkot. The raw drugs were made into Yavakuta (coarse powder) from the pharmacy of Murlidhar Ayurved College, and subjected to air-tight packing in polythene bags. Shodhana (purification) of Hingu was done from the department of Rasashastra and Bhaishajya Kalpana as per the classical reference. The ingredients of Vishwadi Kwatha[5] were as per given in table 1.

Table 1: Ingredients of Vishwadi Kwatha

Name of the drugsLatin namePart usedTotal quantity
ErandaRicinus communisRoot1 part (≈6.67g)
ShunthiZingiber officinaleRhizome1 part (≈6.67g)
YavaHordeum vulgare L.Seed1 part (≈6.67g)
Hingu (fried in ghee)Ferula asafoetidaGum resin2 Rati (250 mg)
Sauvachala LavanaBlack salt--2 Rati (250 mg)

Method of preparation of Vishwadi Kwatha: Coarse powder (Yavakuta) of Erandamoola, Shunthi and Yava in equal quantity (total 20gm) boiled with 16 parts of potable water (320 ml) and reduced to 1/8th part (40ml).[6] It is added with 250 mg of Hingu (which is fried with ghee) and 250 mg of Sauvarchala Lavana as Prakshepa.


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Patients were advised to prepare the Kwatha (decoction) as per the above-mentioned method. Freshly prepared Kwatha was advised to be taken in a dose of 40ml twice a day, before food, for 1 month. Pathya Apathya (Do’s and Don’ts) chart was provided to the patients in local language.

Collection of data: The study was started after getting the approval from institutional ethics committee (IEC).

Informed written consent was taken from each patient before enrolling to the clinical trial. A specially prepared proforma was used to record the data of patients before and after treatment. Effect of therapy was assessed based on the scores of visual analogue scale (VAS)[7] for severity of pain before and after treatment as well as the grading of other subjective parameters as per the assessment criteria[8] given in table no. 2


Table 2: Assessment Criteria for Symptoms of Kashtartava

CriteriaGrading
0123
Duration of painNo painUp to 24 hoursUp to 48 hoursUp to 72 hours
Severity of PainMenstruation is not painful and daily activity remains unaffectedMenstruation is painful daily activity is not affected no analgesic required.Menstruation is painful and daily activity affected. Oral analgesics required.Menstruation is painful and daily activity affected, need to take off from work or school. Oral analgesics not effective need to go to hospital or take injectable
Aruchi (Anorexia)AbsentLoss of appetite without alteration in eating habits.Oral intake decreased without significant weight loss, dehydration or malnutritionInadequate oral caloric or fluid intake, tube feeding, TPN or hospitalization indicated
Chardi (Vomiting)Absent1 episode/24 hours, Intervention not indicated2-5 episodes/24-hour, Outpatient IV hydration, medical intervention needed>5 episodes/24 hr. Tube feeding, TPN or hospitalization indicated.
Vibandha (Constipation)No constipation, occasional or intermittent symptoms.Frequency once in a day with passage of very hard stoolBowel evacuation on 2 -3 days, regular laxative or enema not usefulObstipation with manual evacuation indicated.
Bala-Bhramsha (Fatigue)No fatigueRelieved by RestFatigue not relieved by rest, limiting instrumental activities of daily livingFatigue not relieved by rest, limiting self- care and activities of daily living
Shira Shula (Head ache)No headacheMild pain persists for less than 6 hours.Moderate pain limiting instrumental ADL*Severe pain, limiting selfcare ADL.
Bhrama (Dizziness)No dizzinessMild unsteadiness or sensation of movement, 1-2 times during menstrual periodModerate unsteadiness or sensation of movement, limiting instrumental ADL.Severe unsteadiness or sensation of movement, limiting instrumental ADL
Pindikodveshtana (Calf muscle cramps)No crampsMild pain persists for less than 6 hours.Moderate pain limiting instrumental ADLSevere pain, limiting selfcare ADL

*ADL- Activities of Daily Life.

The data of total 15 patients who had completed the treatment protocol along with follow up were considered for analysis of effect of therapy.

Results

Effect of therapy on pain as per VAS (Visual Analogue Scale) Scores: The mean VAS score was 7.467±1.407 before treatment and it was reduced to 2.333±0.9 after treatment. The distribution of VAS Score among 15 patients, before and after treatment is shown in the graph no:1

jaims_3788_00.JPG
Graph 1: VAS Score (before and after treatment)


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Highly significant difference(p<0.001) was observed in VAS Score of severity of pain before and after treatment as shown in table no:3.

Table 3: Effect of therapy on VAS Scores

Mean ± SDMean DifferencetPSignificance
BTAT
7.467± 1.4072.333±0.9005.133±1.06018.754<0.001HS

*HS: Highly Significant
The percentage of relief in different symptoms of Kashtartava is given in table no. 4.

Table 4: Effect of therapy on chief complaints and associated complaints (n=15)

N*Assessment CriteriaMean ScoreMean DifferencePercentage of Relief
BTAT
15Duration of pain2.730.672.0675.60 %
15Severity of pain2.530.671.8673.68%
11Aruchi1.060.06193.75 %
6Chardi0.7330.20.5372.72%
9Vibandha0.660.130.5380%
14Bala-bhramsh2.260.22.0691.17%
8Shirashoola10.130.8686.67%
4Bhrama0.400.4100%
8Pindikodweshtana1.0670.20.8681.25%

*N= Number of patients presenting with the symptom
Wilcoxon Signed Rank test was applied to find out the significance of difference between the scores given to the symptoms before treatment (BT) and after treatment (AT) as per the assessment criteria. Statistically highly significant (p<0.001) differences between the scores were obtained in duration of pain, severity of pain, Aruchi, and Bala-Bhramsha. Significant (p<0.05) results were obtained in Chardi, Shirashoola and Pindikodweshtana. The difference was insignificant in the scores of Vibandha and Bhrama.

Discussion

Ayurvedic approach towards dysmenorrhea differs from the conventional medical approach which target only pain by controlling prostaglandin synthesis through nonsteroidal anti-inflammatory drugs or by suppression of ovarian function through oral contraceptives. Ayurveda addresses the subtle and holistic mechanisms of digestion, metabolism, formation of the menstrual blood and the process of its expulsion which all are inter-connected.

The alteration in any phase of these can create an inflammatory environment in which pain can be manifested as a main symptom leading to Kashtartava. Thus, the first focus of Ayurvedic management of Kashtartava is to correct Agni (digestive fire) and prevent the formation of Ama. This can lead to formation of “Shuddha Artava” which is easy to be expelled. Samprapti(etiopathogenesis) of Kashtartava mainly depends on the vitiation of Vata Dosha with or without the involvement of vitiated Kapha Dosha. The line of treatment should be Dipana-Pachana (digestive), Artavajanana (promoting the production of Artava), Kaphahara (alleviating Kapha), Shrotoshodhana (clearing the channels) and Vatanulomana (correction of the direction/function of Vata) which will help the easy expulsion of properly formed Artava through the unobstructed channels by the coordinated activity of Vayu. The main causative factors for vitiation of Vata are directly involved in the pathogenesis of Kashtartava. In this study, excessive use of Katu and Madhura Rasa, faulty dietary habits like Samashana (mixing the wholesome and unwholesome foods), improper sleep, lack of Vyayama (exercise) and Vata- Pitta Prakruti (physical constitution) were identified as the main risk factors for development of Kashtartava. Excessive use of Katu Rasa may be leading to Vata- Pitta Prakopa and excessive use of Madhura Rasa may be leading to Kapha Prakopa leading to the Avarana Samprapti of Kashtartava. A previous research on Kashtartava also reported the lack of Vyayama (physical exercise) in majority (74.19 %) of patients.[9] Another research study[10] on Kashtartava had reported that majority (66.6%)of the patients were having Vata -Pitta Prakriti which is similar to the findings of the present study. The commonest associated complaint was found to be Bala-Bhramsha (unusual tiredness) which was reported by 94.44% of the patients. 77.77% of patients reported Aruchi (anorexia) as an associated complaint.61.11% were having Pindikodweshtana (calf muscle cramps), 50% were having Vibandha (constipated bowel) during menstrual period. 44.44% of patients reported Shirashoola (head ache) and Chardi (vomiting) as associated complaints. 22.22% of patients were complaining of Bhrama (giddiness) during menstrual period. In one of the previous studies, the commonest associated complaint was found to be nausea (58.3%) and also 35% patients reported Aruchi (anorexia)[10]


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Another study also reported nausea (33.1%,) as the commonest associated complaint followed by vomiting (21.2%).[11] These indicate the prominent role of Kapha Dosha in the Samprapti of Kashtartava along with the Vata Dosha.

Probable mode of action of Vishwadi Kwatha in Kashtartava

Majority of the ingredient drugs of Vishwadi Kwatha are having Ushna Veerya (hot potency) and predominant Rasa (lingual tastes) are Katu (pungent), Kashaya (astringent) and Madhura (sweet). Eranda and Shunthi are having Madhura Vipaka and the rest of the drugs including Prakshepa Dravya are having Katu Vipaka. Eranda, Hingu and Sauvarchala Lavana are having Snigdha Guna while Shunthi and Yava are Rooksha. Thus, the ingredients of Vishwadi Kwatha as well as, the formulation are mainly having Vata-Kapha Pradhana Tridoshahara action in the body. Shunthi is having the properties like Deepana, Rochana, Vrushya, Vibandhanut, Shophahara etc. which are helpful in breaking the Samprapti of Kashtartava. It has been widely used in gynaecological disorders. Various components of ginger like Gingerol, Shogaol, Paradol, Zingerones, and Gingerdione have anti-inflammatory pharmacological actions and act as a potent inhibitor of cyclooxygenase (COX-2), resulting in the inhibition of prostaglandins and leukotriene biosynthesis.[12] A systematic review published in 2022, on effectiveness of ginger compared with non-steroidal anti-inflammatory drugs (NSAIDs), suggested that the usage of ginger up to two grams per day in divided doses of powder or dietary form for three days from the first day of the menstrual cycle is safe and effective for primary dysmenorrhoea.[13] Ginger has been shown to share pharmacological properties with NSAIDs and recommended as it suppresses PG synthesis through the inhibition of cycloxygenase-1 and Cox 2 and has fewer side effects than NSAIDs.[14] Ginger is also found to be as effective as mefenamic acid on pain relief in primary dysmenorrhea and recommended as an alternative treatment for primary dysmenorrhea.[15] Eranda Moola is considered as the best drug for pacifying Vata and having a targeted action at the site of Apana Vayu i.e., Pakwashaya, Kati, Shroni, Vasti, Garbhashaya etc. It is especially indicated in diseases like Udavarata, Gulma, Anaha, Vasti-Shoola, Kati Shoola etc.

So, it is having the prime role in Anulomana of Apana Vayu which helps in easy expulsion of menstrual blood in case of Kashtartava. Different clinical studies using Erandamoola Kwatha (decoction), Erandamoola Arka (distilled formulation) etc. have proven its efficacy in the management of primary dysmenorrhoea. [16,17] Yava is especially recommended in the diet as part of Rajaswala Paricharya for improving menstrual health and prevention of menstrual disorders. It is considered as Pathya (wholesome diet) for all kinds of Yoni Vyapad (gynaecological disorders). Laghu-Ruksha and Lekhana properties are helpful in removing excessive Kleda (accumulation of liquid waste) from the body which facilitate the process of expulsion of menstrual fluid and its Madhura rasa and Sheeta Veerya can contribute in increasing Dhatubala (strength of structural component of the body).[18] Hingu is having the properties like Deepana, Rochana, Chedana, and Anulomana. It is especially indicated in diseases like Shoola, Adhmana, Gulma etc. which are related to the features of Kashtartava. Recent research studies indicate the effectiveness of Shodhita Hindu in the management of primary dysmenorrhoea.[19] The chemical compounds like Azulene, ferulic acid, luteolin and umbelliferones present in Hingu were found to be responsible for its anti-spasmodic and anti-prostaglandin activity.[20]

The anti-inflammatory, analgesic and antispasmodic effects in asafoetida suggests a NSAID-like mechanism and a randomized comparative trial showed significant pain reduction on day one compared with mefenamic acid and suggested as an alternative for it in cases of primary dysmenorrhea.[21] Sauvarchala Lavana is especially Deepana-Pachana, Rochana and Vatanulomana in nature. Thus, the prominent Katu Rasa of the formulation may act on the Jatharagni level as Deepana-Pachana and prevent the formation of Ama which leads to the proper formation of Artava. Teekshna Guna of Eranda, Shunthi and Hingu may help to penetrate the Srotas and Lekhana property of Yava remove the Sanga (obstructions) in Srotas which facilitates the expulsion of Artava (menstrual blood). The Vatanulomana property of the drugs leads to the correction of Vimarga Gati of Vayu. All these ultimately results in relieving the symptoms of Kashtartava by promoting easy expulsion of menstrual blood.


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Conclusion

Kashtartava can be considered as a symptom-complex with the pathological origin of Agnidushti and formation of Ama leading to Sanga in Srotas resulting in impaired function (Vimarga Gamana) of Vata. The line of treatment for Kashtartava should be Dipana-Pachana, Artavajanana, Kaphahara, Shrotoshodhana and Vatanulomana along with Nidanaparivarjana. Drugs having the properties like Shoolaprashamana and Vedanasthapana are useful in the management of Kashtartava. The protocol of oral administration of Vishwadi Kwatha in a dose of 40ml twice a day, before food, for a duration of 1 month was found to be safe and effective in the management of Kashtartava and it is recommended for further multi-center trials with large sample size.

Acknowledgement

We would like to extend our sincere gratitude to Shree Yadunandan Education Trust, Murlidhar Ayurved College, Rajkot and Central Council for Research in Ayurvedic Sciences (CCRAS), New Delhi, that have provided financial support for this research. We are deeply grateful to our mentor, Prof. (Dr.) Prajakta Tomar (Ex.Principal, Murlidhar Ayurved College, Rajkot.) for her exceptional guidance and unwavering support throughout this research endeavor.

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