E-ISSN:2456-3110

Review Article

Sexual Health

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 11 NOVEMBER
Publisherwww.maharshicharaka.in

Rejuvenating Sexual Health Holistically: An Approach in Ayurveda

Kulkarni SV1*, Patil SS2
DOI:10.21760/jaims.9.11.32

1* Shraddha V Kulkarni, Final Year Post Graduate Scholar, Department of Prasuti Tantra and Streeroga, Sri Sri College College of Ayurvedic Science and Research, Bengaluru Karnataka India, Bengaluru, Karnataka.

2 Shruti S Patil, Associate Professor, Department of Prasuti Tantra and Streeroga, Sri Sri College of Ayurvedic Science and Research, Bengaluru, Karnataka, India.

Sex is one of the three primary human instincts, with self-preservation and social instinct, and is thus well developed in the typical individual. Sexual Dysfunction is referred to as problems that a person or partner encounters during any phase of typical sexual activity - physical pleasure, desire, preference, arousal, or orgasm. A person’s inability to participate in a sexual relationship as they would wish is how the World Health Organization describes sexual dysfunction. It can affect both men and women and may be caused by physical, or psychological factors. Sexual dysfunction, if not addressed promptly, can significantly impacts fertility. Since sexual dysfunction usually coincides with anatomical as well as psychological factors, a comprehensive sexual history, evaluation of general health, and reproductive health, and identification of any additional sexual problems (if any) are critical while diagnosing sexual dysfunction. The concept of sexual dysfunction is not new to Ayurveda. Classics include various references to it in the context of Yoni Vyapads, Dosha Vriddhi, Kshaya, Ojus, Artava Vaha Sroto Viddha Lakshana, and Manovikaras, along with probable causative factors and solutions. Ayurveda addresses the anatomical, psychological, and endocrinological aspects of sexual dysfunctions. Following Dinacharya, Rajaswala Paricharya, Garbhini Paricharya, and Sutika Paricharya provide extensive treatment regimens by focusing on the overall health of an individual’s reproductive, psychological, and endocrinological well-being. Female sexual dysfunction is a multifactorial condition that requires a holistic approach. Modern medical treatments offer targeted solutions, while Ayurvedic therapies promote balance and long-term vitality.

Keywords: Female Sexual dysfunction, anatomical, psychological, Yoni Vyapads, Paricharya

Corresponding Author How to Cite this Article To Browse
Shraddha V Kulkarni, Final Year Post Graduate Scholar, Department of Prasuti Tantra and Streeroga, Sri Sri College College of Ayurvedic Science and Research, Bengaluru Karnataka India, Bengaluru, Karnataka.
Email: 		Kulkarni SV, Patil SS, Rejuvenating Sexual Health Holistically: An Approach in Ayurveda. J Ayu Int Med Sci. 2024;9(11):225-239.
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Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-10-12 2024-10-22 2024-11-02 2024-11-12 2024-11-26
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© 2024by Kulkarni SV, Patil SSand 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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Shraddha V et al. Rejuvenating Sexual Health Holistically

Introduction

Sex is one of the three primary human instincts, with self-preservation and social instinct, and is thus well developed in the typical individual. In humans, sex is an emotional and physical experience that is obvious to some extent. According to WHO, sexual dysfunction is defined as an individual’s incapacity to engage in desired sexual relationships. Some people see bonding as the foundation of marriage. The majority, regard marriage as primarily a sexual connection with the goal of reproduction and a stable family life.

In Ayurveda, Maithuna (sexual union) is considered an essential aspect of life and one of the four aims of human existence (Purusharthas), along with Dharma (duty or virtue), Artha (prosperity), and Moksha (liberation). Ayurveda recommends aligning sexual practices with the seasonal cycles (Ritucharya) to promote harmony. If indulged excessively, that is Pradnyaparadha.

Sexual fulfilment fosters a deep emotional connection, strengthening the bond between partners. Unfortunately, sexual disorders and maladjustments are frequent, and they are a major cause of relationship conflict and divorce. However, it must be acknowledged that these challenges are not always the reason for incompatibility.

Sexual Dysfunction is referred to as problems that a person or partner encounters during any phase of typical sexual activity – physical pleasure, desire, preference, arousal, or orgasm. Physical or psychological issues may be the cause, impacting both men and women.

Sexual dysfunction, if not addressed promptly, can significantly impacts fertility. Female sexual dysfunction (FSD) is a widespread issue that has a negative impact on a woman's quality of life. Sexual problems are prevalent among women, but they become a dysfunction when they cause discomfort, rather than a natural physiological response to stressful conditions.

Methodology

This study involves reviewing literature about female sexual dysfunction with its critical understanding and mode of management as per various references mentioned in Ayurveda classics.

Understanding of Female sexual dysfunction

It refers to the conditions causing distress or interpersonal difficulties.

Types of Female Sexual Dysfunction

Major types of female sexual dysfunction are

  • Desire disorders: Absence of interest in or desire for sex.
  • Arousal disorders: The inability to get enthusiastic/physically aroused during intercourse.
  • Disorders related to orgasm: Absence or delay of orgasm (climax).
  • Pain disorders: Experiencing pain during sexual activity makes one wish to avoid having sex.

Other terms related to female sexual disorders

1. Hypoactive Sexual Desire Disorder (HSDD) - It is characterized by a lack of sexual fantasies and thoughts, as well as a desire for or responsiveness to sexual engagement, which creates personal anguish or interpersonal issues.
2. Female Sexual Arousal Disorder (FSAD) - It is characterized by a lack of sexual arousal, which can cause anxiety. Symptoms may include a lack of genital lubrication or pleasure despite a willingness to engage in sexual activity.
3. Female Orgasmic Disorder - Difficulty or inability to achieve orgasm following sexual desire and stimulation, causing emotional misery. This can occur even if sexual desire and excitement are present.
4. Genito-Pelvic Pain/Penetration Disorder (GPPPD) - Pain associated with vaginal penetration, including difficulties with intercourse, fear of pain, or tensing of pelvic floor muscles, making intercourse uncomfortable or impossible.
5. Sexual Aversion Disorder (SAD) - An extreme aversion or avoidance of all genital sexual contact with a partner, often accompanied by fear, anxiety, or disgust.
6. Persistent Genital Arousal Disorder (PGAD) - Spontaneous, persistent, and unwanted genital arousal, unrelated to any feelings of sexual desire, and which does not subside with orgasm, often causing distress.
7. Dyspareunia - Pain during intercourse might be physical or psychological. It can involve the vulva, vagina, or deep pelvic structures.


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8. Vaginismus - An involuntary spasm of the muscles around the vaginal opening that makes penetration painful or impossible. It is typically associated with sexual anxiety.
9. Female Sexual Interest/Arousal Disorder (FSIAD) - Combines lack of sexual desire and arousal, impacting both mental and physical aspects of arousal (e.g., no lubrication, lack of genital tingling).
10. Sexual Dysfunction Due to a General Medical Condition - Sexual problems resulting from physical conditions such as hormonal imbalances, diabetes, cardiovascular issues, or medications affecting sexual function.

Normal Sexual Function

Sexual function and reactions include both the mind (thoughts and emotions) and the body (the neurological, circulatory, and hormonal systems). Sexual reaction involves

  • Desire, also called interest or libido
  • Arousal
  • Orgasm
  • Resolution

Desire (libido) - Desire refers to the desire to participate in or sustain sexual activity. Thoughts, words, images, fragrances, and touch may all arouse sexual interest or desire. Desire may be clear from the start or may develop as sexual action and stimulation begin. For women, sexual desire and arousal are frequently linked. Sexual stimulation can elicit feelings of excitement and pleasure, as well as physical reactions. The need for sexual fulfilment grows as sexual activity and closeness progress.

Arousal - Arousal is a subjective component of sexual excitement that is experienced and contemplated. It also has a physical component: an increase in blood flow to the vaginal region. Blood flow may rise without woman's awareness or arousal. In women, increasing blood flow causes clitoris and vaginal walls to enlarge (a process known as engorgement). Increased blood flow results in more vaginal secretions (which provide lubrication). This reflexive response produces engorgement and lubrication, which happens within seconds after receiving a sexual stimulation. This reaction is triggered by the brain perceiving something sexual, which may not be pleasurable or subjectively appealing.

In this reaction, younger women are likely to experience genital tingling and throbbing. Although lubrication in response to sexual stimuli may not diminish as women age, genital blood flow from sexual stimuli may.

Orgasm - The culmination or height of sexual ecstasy is known as an orgasm. Muscle tension in the entire body increases right before orgasm. The muscles around the vagina contract rhythmically when the orgasm commences. Women may experience many orgasms. Hormones released during orgasm may lead to emotions of well-being, relaxation, or tiredness (resolution).

Resolution - Resolution entails a feeling of well-being and extensive muscle relaxation. Resolution usually follows orgasm. However, resolution might be gradual following stimulating sexual activity that does not result in orgasm. Some women respond to extra stimulation practically immediately following resolution.

What Is Masturbation?

Masturbation is a form of autoeroticism in which a person sexually stimulates their genitals to attain sexual arousal or other sexual pleasure, usually leading to orgasm. Stimulation can be done using hands, common items, sex toys, or, in rare cases, the mouth. Masturbation may also be practiced with a sexual partner.

Causes of Female Sexual Dysfunction

Female sexual dysfunction (FSD) can have a variety of causes, often interrelated across physical, psychological, and interpersonal factors.

Numerous factors can affect sexual response. They include age; relationship duration and quality; and personal psychological factors stemming from relationships in childhood with parental figures; previous losses, traumas, and ways of coping with emotions generally; sickness; and the consumption of medicine, and alcohol.

1. Physical Causes - Hormonal changes from menopause, pregnancy, or menstrual cycles can affect desire. Medical conditions (like diabetes or heart disease), chronic pain, and pelvic disorders may impact sexual function, causing pain or discomfort. Certain medications, substance use, and lifestyle factors like alcohol or smoking can also reduce libido.


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Additionally, vaginal dryness and atrophy, common after childbirth or during menopause, may lead to discomfort during intercourse.

2. Psychological Causes - Anxiety, depression, and stress whether from work, family, or finances can reduce libido and interfere with sexual enjoyment.

Past trauma or abuse may lead to emotional barriers that make intimacy challenging. Additionally, issues with body image and self-esteem can decrease comfort and desire for intimacy, further impacting sexual function and satisfaction.

3. Interpersonal and Relationship Factors - Relationship issues like conflict, poor communication, and mismatched desire can reduce sexual satisfaction. Major life changes such as pregnancy, parenthood, and menopause also impact intimacy and desire.

4. Lifestyle Factors - Physical inactivity, sleep deprivation, and a poor diet can reduce energy, disrupt hormone levels, and lower libido.

5. Sociocultural Factors - Cultural or religious beliefs, along with societal expectations and gender roles, can lead to feelings of guilt, shame, or inhibition around sexuality, impacting a woman’s comfort and openness to sexual expression.

Diagnosis

Female sexual dysfunction can be defined as at least one of the following:

  • Pain during sexual activities
  • Loss of sexual desire
  • Impaired arousal
  • Inability to achieve orgasm

Hence diagnosis is done by the following methods -

  • Interview with the woman and, sometimes, her partner
  • Pelvic examination

Treatment

  • Treatment of causes of sexual pain
  • Medications, including hormone therapy
  • Pelvic physical therapy
  • Sometimes, personal or couple's psychotherapy or sex therapy

Sexual Dysfunction in Ayurveda

The concept of sexual dysfunction is not new to Ayurveda. The Vajikarana is one of the eight branches of Ayurveda that is solely focused on enhancing sexual ability. Also, it is mentioned in Chaturvidha Purushartha i.e., Dharma (Righteousness), Artha (wealth), Kama (Pleasure), and Moksha (Liberation).

Ayurveda classics include various references to it in the context of Yoni Vyapads, Dosha Vriddhi, Kshaya, Ojas, Artava Vaha Sroto Viddha Lakshana, and Manovikaras, along with probable causative factors and solutions.

Nidanas

Direct reference for sexual dysfunction in females is not mentioned but in different contexts like Yoni Vyapads, Dosha Dushti, Artavavaha Sroto Viddha Lakshanas, or Manovikaras. Hence the Nidanas of Yoni Vyapads and Sroto Dushti Karanas can be considered as Nidana for sexual dysfunction. Considering the same Nidana, Mithyachara includes Dosha Prakopaka Ahara and Vihara, Vega Dharana, Unhygienic practices, and Vata Kshaya, which can cause sexual dysfunction.

Lakshana

Lakshanas for sexual dysfunction in females are considered mentioned in various places.

The following are some of the sexual dysfunction-related symptoms in Yoni Vyapad:

  • Acharya Sushruta explains Atyananda Yonivyapad as[1]

अत्यानन्दा न सन्तोषं ग्राम्यधर्मेण गच्छति || (Su. Utta. 38/15)

This condition is due to Dushti of Kapha Dosha. Women's dissatisfaction with coitus.

  • Paripluta Yonivyapad - Acharya Sushruta has mentioned in Vataja type of Yoni Vyapadas[2]

परिप्लुतायां भवति ग्राम्यधर्मे रुजा भृशम् ||१०|| (Su. Utta. 38/10)

Meaning pain during coitus which is dyspareunia.

  • Acharana Yoni Vyapad:[3]

मैथुनेऽचरणा पूर्वं पुरुषादतिरिच्यते || (Su. U. 38/16)

As explained by Acharya Sushruta, this is classified under the Kaphaja type of Yoni Vyapads. Which means the woman gets aroused before the man.


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It might be linked to a condition called premature orgasm, which is characterized by hyperexcitation before coitus or earlier than the partner. As per Charakacharya's explanation of Acharana Yoni Vyapad, it is mentioned[4]

योन्यामधावनात् कण्डूं जाताः कुर्वन्ति जन्तवः| सा स्यादचरणा कण्ड्वा तयाऽतिनरकाङ्क्षिणी||१८|| (Cha. Chi. 30/18)

The lady has excessive sexual desire as a result of itching which is due to unhygienic practices.

  • Also, for Vipluta Yonivyapad similar explanation is given by Acharya Vagbhata[5]

…विप्लुताख्या त्वधावनात्| सञ्जातजन्तुः कण्डूला कण्ड्वा चातिरतिप्रिया||५०|| (A.S. U.38/50)

Described symptoms such as "अतिरतिप्रिया॥" which refers to an excessive urge for sexual activity but it is caused due to unhygienic practices. Such kind of explanation is not seen in any of the sexual dysfunctions in females. Although some of the symptoms are not directly associated with sexual dysfunction, they can be explained by the many ways that symptoms of sexual dysfunction manifest.

They are as follows -

Ojas - Ojo Visramsa - Kriya Sannirodha (lack of normal functioning of the body)

Mano Vikara - Raja Tama Dushanjanya - Kama (lust), Harsha (Euphoria)

Looking into these symptoms it can be referred to symptoms related to female sexual dysfunction.

Sexual Dysfunction in Artavavaha Sroto Viddha Lakshana[6]

Maithuna Asahishnuta, which means intolerance for sexual acts is one of the symptoms of painful sex (dyspareunia).

The sexual dysfunction-related symptoms in Dosha Dushti are as follows[7],[8],[9]

VriddhiKshayaPrakopa
VataIndriyopaghata (decline in sensory perception), Alpa Balatwa (reduced strength)Apraharsha (Not getting desire / Aroused).Harshana (hyperexcitability), Tarshana (Satisfaction).
PittaOjovibhramsha - deprived OjasPrabha Hani (reduced luster)Visruti (excessive secretion)
KaphaAvasada (fatigue), Sroto Pidana (congestion in srotas)Daurbalya (weakness), Dhumayana (feel like smoke)Shopha (swelling)

Diagnosis and Evaluation of female sexual dysfunction

Acharyas has discussed the diagnosis of the disease. Darshsna (inspection), Sparshana (physical examination), and Prashna Pareeksha (obtaining a full history) have all been described. These methods allow for correct diagnosis.[10]

Prashna - Taking thorough history.

Enquiring about sexual problems enables clinicians to educate patients about risk of STDs, promote safer sex practices, assess need for contraception, refute sexual myths, and diagnose sexual dysfunction. Many sexual issues may be addressed by offering accurate information and reassurance. However, treating sexual dysfunction necessitates a thorough biopsychosocial examination and management. Even if a patient presently has no sexual difficulties, they will learn that future sexual concerns may be addressed in a competent, confidential, and non-judgmental environment.

History taking -

  • Carefully inquire into sexual functioning - Frequency, satisfaction, and emotional factors
  • Inquire about the patient's comfort levels during history taking as well as during sex
  • Medical and medication history
  • Severe psychological trauma due to childhood sexual abuse
  • Nature of the problem, and Degree of distress
  • Whether the condition is lifelong or acquired?
  • It is situational or generalized?
  • Frequency of masturbation, or coitus
  • How does she get orgasm?
  • Sexual history – 1st sexual experience, past relations
  • Relationship history

Darshana Pariksha - Female sexual dysfunction can be diagnosed using Darshana, which involves inspecting the external genitals.

Sparshana Pariksha - In dyspareunia, a “manual" examination is conducted with one or two fingers in the vagina (going from posterior to anterior) with the other hand held away from the abdomen to avoid confusion about the cause of discomfort. A bimanual examination is also performed.


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Physical examination

Routine pelvic examinations are an important part of general medical treatment; however, this is not the case for women seeking care for sexual issues. Given the prevalence of unpleasant prior sexual experiences, including abuse, a pelvic examination should only be conducted when there is a clear indication, and the technique should be well described to the patient.

Dyspareunia requires a thorough examination of the vulva, vagina, and pelvis. It should be highlighted that, while a physical examination can establish proper anatomy and the healthy nonaroused state of the genitalia, it does not guarantee healthy sexual function. However, such an evaluation may be both informative and healing.

The examination's purpose is to discover illness; however, it also serves as a chance to educate the patient about normal anatomy and sexual function, as well as to replicate and localize discomfort experienced during sexual engagement.

Investigation - Laboratory tests: For diabetes, thyroid problems, renal/liver/heart diseases, epilepsy, depression, etc., and Hormonal assessment to rule out the causes.

Treatment Approach

Goal of treatment in Ayurveda

The purpose of Ayurvedic treatment is to restore Dosha Samyata, restore Dhatu Dushti, which leads to increased libido and sexual dysfunction, preserve the ovulatory cycle, and maintain harmony of hormones.

Chikitsa

Treatment includes various aspects based on Physical and Psychological causes.

Treatment for Physical causes includes Ahara and Vihara - Vata Shamaka Ahara and Vihara (Dietary and behavioral changes), Rasayana and Vajikarana, Shodhana (detoxification) - includes Snehana, Swedana, Basti, Sthanika Chikitsa (local treatments) - includes Sneha Yoni Pichu, in Dhatu Kshaya - Santarpana and Brumhana Chikitsa, and Following Paricharyas - Dinacharya, Rajaswalacharya, Garbhini Paricharya, and Sutika Paricharya.

Treatment for Psychological causes includes - Following Sadvritta and doing Dharana of Dharaneeya Vegas and also following Paricharyas.

Discussion

Sexual Dysfunction in Ayurveda

Female sexual dysfunction symptoms have been listed in Ayurveda in various places and not all under one title. The reasons are likewise distinct, and the references are dispersed.

For proper sexual function, Ojas and Veerya are two important factors.

Role of Ojas in sexual function[11]

Ojas is a vital energy or essence that is essential for general health, immunity, and vigor. It is often described as the ultimate product of digestion and the essence that sustains physical and mental health. Ojas plays a significant role in sexual function and reproductive health, serving as a source of strength and stability.

Ojas influences sexual function:

1. Vitality and Libido: Ojas is associated with vigor and vitality, which directly influences libido or sexual desire. Higher levels of Ojas are thought to enhance sexual drive, stamina, and pleasure.
2. Reproductive Health: Ojas support reproductive fluids and the energy for procreation. It is believed to nurture both sperm and ovum, supporting fertility and the capacity to conceive healthy offspring.
3. Emotional Stability: Balanced Ojas promote emotional well-being, which is essential for healthy sexual relationships. Emotional stability reduces stress, anxiety, and emotional exhaustion, enhancing one's ability to connect and experience intimacy.
4. Immunity and Strength: Since Ojas is the essence of all bodily tissues (Dhatus), it strengthens the immune system, keeping infections and diseases at bay. A healthy immune system encourages resilience, physical endurance, and mental clarity, all of which benefit a healthy sexual life.
5. Energetic Presence and Attraction: Individuals with high Ojas often exude a unique, attractive glow and a strong, positive aura.


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This magnetism enhances confidence and appeal, which can positively affect sexual relationships.

Role of Veerya in Sexual Function

Veerya (or Virya) is a concept that represents strength, potency, and the vital energy linked to vitality and reproductive power. While Veerya is often associated with male potency, also considered essential for female sexual and reproductive health. In women, Veerya is thought to support not only reproductive capacity but also overall sexual vitality, desire, and emotional well-being.

Veerya is associated with female sexual function:

1. Reproductive Strength and Fertility: Veerya plays a role in nourishing the Shukra Dhatu (reproductive tissue), which is vital for female fertility as well. Healthy Shukra Dhatu, supported by Veerya, is considered important for the creation and maintenance of reproductive cells, as well as for conceiving and carrying a pregnancy.
2. Libido and Sexual Vitality: Veerya is thought to boost sexual energy, which in turn fuels libido or sexual desire in women. It provides the energetic foundation for sexual satisfaction, ensuring that sexual encounters are fulfilling both physically and emotionally.
3. Emotional Health and Stress Resilience: Veerya is considered a supportive factor in maintaining mental and emotional health. It enhances stress resilience and reduces feelings of fatigue or low energy, which can have a direct impact on sexual desire and emotional connection with a partner.
4. Physical Vitality and Endurance: In women, Veerya supports overall physical strength and stamina, which enhances sexual endurance and comfort. This allows for a greater capacity to enjoy sexual activity without feeling drained or fatigued, thereby improving sexual satisfaction.

Nidanas of Female Sexual Dysfunction as per Ayurveda

Ahara Nidanas

1. Ati Bhojana (Overeating): Overeating strains the digestive system, leading to Kapha and Pitta imbalances that can reduce energy levels and cause a sluggish, heavy feeling. This imbalance can reduce libido and impair circulation in reproductive tissues, leading to reduced sexual sensitivity and pleasure.

2. Abhojana (Skipping Meals): Inadequate nutrition weakens Rasa Dhatu (plasma tissue), which is vital for building Shukra Dhatu (reproductive tissue). This can cause decreased sexual energy and lead to a lack of interest or desire for sexual activity due to physical and mental exhaustion.
3. Viruddha Bhojana (Incompatible Food): Incompatible food combinations disturb Agni (digestive fire), leading to Aama (toxins) buildup and Tridosha Such imbalances can result in hormonal disruption, reduced libido, and low sexual vitality, especially affecting mood and mental clarity.
4. Akala Bhojana (Untimely Eating): Eating late or at irregular hours disrupts the natural digestive and sleep cycles, leading to Pitta and Vata This can cause poor circulation and reduce the natural energy associated with arousal, making it harder to experience sexual satisfaction.
5. Ashuchi Bhojana (Unhygienic Food): Consuming unhygienic or contaminated foods can lead to infections and chronic health issues, which affect reproductive organs directly, impacting sexual health and potentially leading to discomfort or pain during intercourse.
6. Eka Rasa Prayogam (Consumption of the Same Foods): Relying heavily on the same type of food may create nutrient imbalances or deficiencies. For example, a diet low in healthy fats can reduce lubrication and elasticity of reproductive tissues, leading to dryness and discomfort during intercourse.

Vihara Nidanas (Lifestyle-Related Causes) and Sexual Dysfunction

1. Vega Dharana (Suppression of Natural Urges): Suppressing urges to urinate, defecate, or pass gas disrupts Apana Vayu (downward energy flow) essential for reproductive health. This blockage can result in discomfort or pain during sexual activity, lowering interest and satisfaction.
2. Ratri Jagarana (Staying Awake at Night): Poor sleep quality and staying up late disturb the natural Vata and Pitta cycles, leading to fatigue, and irritability. It affects overall energy levels and increases stress, which suppresses libido, reduces sexual responsiveness, and leads to fatigue that affects physical and emotional readiness for intimacy.


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3. Diva Swapna (Sleeping During the Day): Daytime sleep increases Kapha and affects the digestive and reproductive systems, leading to lethargy and weight gain, which can impact body image and sexual self-confidence.
4. Vyayama (Exercise): Avyayama (Lack of Physical Activity): Insufficient exercise leads to Kapha buildup, causing lethargy and reducing sexual vitality.
5. Ativyayama (Excessive Physical Activity): Overexertion increases Vata, causing dryness and depletion in Rasa Dhatu, leading to fatigue and reduced desire for sexual activity.
6. Stress from Work or Lifestyle: Excessive workload, emotional stress, and lack of relaxation practices disrupt hormonal balance and affect sexual health, reducing overall interest and satisfaction in sexual activity.

Manasika Nidanas

Anxiety and Stress: Prolonged stress, grief, or anxiety can elevate Vata Dosha and affect hormonal levels, impacting libido and enjoyment. Emotional distress can disrupt the flow of energy (Prana) and create psychological barriers to sexual intimacy. Anxiety and stress lead to mental and emotional factors like self-consciousness, fear, and distraction, it also increases muscle tension, making sexual experience physically uncomfortable or painful, which further discourages sexual activity. When a female experiences stress, HPA axis, which is central stress response system, becomes activated. This triggers release of cortisol, body's primary stress hormone, as well as adrenaline.

Impact on hormones

Lowered Estrogen Levels: Chronic stress and high cortisol levels lower estrogen production, which is crucial for vaginal lubrication, libido, and overall reproductive health. Low estrogen can lead to vaginal dryness and discomfort, affecting sexual satisfaction and arousal.

Low Progesterone level: High cortisol levels also reduce progesterone levels, which can lead to menstrual irregularities and mood swings, both of which can impact sexual desire and comfort.

Yoni Vyapad

Yoni Vyapad describes a group of conditions affecting the female genital tract, which can manifest as physical, or functional issues.

Female sexual dysfunction (FSD) can be one of the outcomes of these disorders because the physical, emotional, and functional disruptions associated with Yoni Vyapad can directly impact sexual well-being. Like Vata imbalance in Yoni causes a lack of lubrication and painful intercourse (dyspareunia), while Pitta leads to inflammatory conditions, and Kapha Dushti leads to abnormal discharge, infections, or a general feeling of heaviness.

Anya Vyadhis

Conditions like Amavata (rheumatoid arthritis-like disease), Prameha (diabetes and urinary disorders), Sthoulya (obesity), and Rajayakshma (Ayurvedic equivalent of tuberculosis) affect physical health. Like rheumatoid arthritis, Amavata is an inflammatory and autoimmune disease. This results in joint discomfort, stiffness, edema, exhaustion, and limited movement. Since Kapha and Pitta imbalances cause symptoms including excessive urination, increased thirst, exhaustion, weight changes, and, in chronic situations, nerve damage and poor circulation, Prameha can be equated with diabetes mellitus in contemporary medicine. and Similar to TB, Rajayakshma, commonly referred to as "the king of diseases," is characterized as a wasting illness. A persistent cough, weight loss, exhaustion, fever, appetite loss, and general weakness are the symptoms of significant tissue depletion and imbalances in all three Doshas. The disturbance of sexual function caused by these symptoms might be any kind of sexual dysfunction condition.

Other

Depletion of Ojas: Sexual energy and desire are linked to Shukra Dhatu, the reproductive tissue, which culminates in the production of Ojas, the essence of vitality and immunity. Excessive stress, poor diet, overexertion, and lack of rest can deplete Shukra Dhatu, resulting in low libido, fatigue, and decreased interest in sexual activity.

Ayurveda Perspective on Masturbation[12]

कालार्थकर्मणां योगो हीनमिथ्यातिमात्रकः|

सम्यग्योगश्च विज्ञेयो रोगारोग्यैककारणम्||१९|| (A.H.Su. 1/19)

Proper balance in the alignment of time, purpose, and actions in sensory organs (Jnanendriyas) and organs of action (Karmendriya) is the cause of health, while imbalance leads to disease.


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Hence proper and balanced used (Samyaka Yoga) of Indriya (here it is considered as genitals) and Indriyartha (sensation) will give health and other benefits.

Misuse or overuse of Karmendriyas, such as excessive physical exertion or manipulation, can disrupt balance, leading to exhaustion or strain in the body. This imbalance can contribute to disease. Hence, it is not advisable.

Understanding of Lakshanas related to female sexual dysfunction

Acharyas' explanation of the Lakshanas can be used to comprehend these symptoms. The vitiation of Doshas in the Sthana (reproductive organs) is the cause of the symptoms described in Yoni Vyapads, and it manifests itself in many ways.

Here is the understanding

Atyananda Yoni Vyapad - This is classified under Kapha Dosha Pradhan Yoni Vyapad. Here woman is not satisfied even after having intercourse.

This can be interpreted as either nymphomania or frigidity, which is the incapacity of women to experience an orgasm during sexual activity.

Hypersexuality is a medical condition that causes unwanted or excessive sexual arousal causing people to engage in or think about Sexual activity to the point of distress or impairment.

Compulsive sexual behavior is characterized by excessive sexual fantasies, urges, and behaviors, as well as the impulse to act on them with consenting individuals.[13]

Persistent Genital Arousal Disorder (PGAD): Spontaneous, persistent, and unwanted genital arousal, unrelated to any feelings of sexual desire, and which does not subside with orgasm, often causing distress.

Paripluta Yoni Vyapad - this is classified under Vataja Variety by Acharya Sushruta. This is having symptoms as pain during coitus which is dyspareunia

Dyspareunia is classified into three forms of pain: superficial, vaginal, and deep. Superficial dyspareunia results from attempted penetration, which is frequently caused by anatomical or irritative problems, or vaginismus.

Vaginal dyspareunia is the discomfort caused by friction (i.e., lubrication issues), which includes arousal disorders. Deep dyspareunia is discomfort from thrusting that is frequently accompanied by pelvic illness or relaxation.

Genito-Pelvic Pain/Penetration Disorder (GPPPD): Pain associated with vaginal penetration, including difficulties with intercourse, fear of pain, or tensing of pelvic floor muscles, making intercourse uncomfortable or impossible.

Causes of Genito-Pelvic Pain/Penetration Disorder

  • Inflammation or infection of the urinary tract
  • Increased sensitivity of the genital area to pain
  • Injuries in the genital area
  • A history of sexual trauma
  • Inflammation or infection of the urinary tract
  • Inadequate lubrication from insufficient foreplay

Acharana and Vipluta Yoni Vyapad - Persistent sexual desire is evident here, but it is brought on by unsanitary conditions such as failing to wash the genitalia. This exacerbates vaginal infections (Krimis), which causes severe itching and increases the local blood supply, ultimately leading to increased sex desire.

There is no diagnosis of sexual dysfunction when excessive sexual desire is seen as a result of unsanitary behavior.

Role of Ayurveda line of treatment in Female Sexual Dysfunction

The Ayurveda approach to management focuses on general health improvement, bringing Doshas into balance, and ultimately maintaining the body's health.

1. Ahara

Diet plays an important role in getting healthy. Following proper meal time, eating freshly prepared food, Samyak Ushna Ahara, and eating with proper pase (neither too fast nor too slow) helps in the proper digestion of the food and maintains the digestive system in harmony.

Vata Prakopaka Ahara is the causative factor for the Yoni Vyapads, or it is said that no diseases can occur without the involvement of Vata Dosha.


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Hence, the diet should be Vata Shamaka, Snigdha, and Ushna. For example -

  • Barley (Yava): Ruksha (dry), Guru (heavy to digest), Madhura (sweet), Sara (laxative), Vatanulomana (remove intestinal gas), Vrishya (aphrodisiac), Sthairyakara (increases stability).
  • Godhuma (Wheat): Madhura (sweet), Snigdha (unctuous), Guru (heavy), Shita (cold potency). Important sources of nutrients include dietary fiber, resistant starch, trace minerals, certain vitamins, phytoestrogens, and antioxidants.
  • Shashtika Shali: Shashtika Shali is known as rice that is harvested in 60 days. It is Snigdha (unctuous), Guru (heavy to digest), Madhura (sweet), and Vrishya (aphrodisiac) properties
  • Masha: Masha has properties like Madhura (sweet taste), Snigdha (unctuous), Balakara (increases strength), Sleshma-Mala-Pittakara (increases Kapha and Pitta Dosha, excretory materials). It is Guru (heavy), Ushna (hot in potency), pacifies Vata Dosha. Advised to consume with Sharkara (sugar), Kshoudra (honey), and Ghrita (ghee) it will act as an excellent aphrodisiac.
  • Garlic (Allium sativum): Tikshna (penetrating), Ushna (hot potency), Katu Vipaka (post-digestive effect), Hrudya (good for heart), Keshya (good for hair), Guru (heavy to digest), Vrishya (aphrodisiac), Snigdha (unctuous), Rochana (imparts taste), Dipana (increases digestive power).
  • Shatavari (Asparagus racemosus): Madhura-Tikta Rasa (sweet and bitter taste), Sheeta Virya (cold potency), Madhura Vipaka (anabolic post-digestive effect), Vata and Pitta Hara, Kapha Vardhaka. Used as a reproductive tonic, it helps regulate the female reproductive system, ovulation, and fertility.
  • Ksheera: Ksheera contains properties such as Rasayana, Balya, Medhya, Madhur, Sheeta, Snigdha, Guru, Jeevaniya, Ajanma Satmya, Sara, Mrudu and Pichchila. It has similar properties to Ojas. Milk contains water, proteins, lipids, fatty acids, minerals, enzymes, vitamins, phospholipids, and pigments in trace amounts. According to modern science, milk has nutritive, antioxidant, and immunomodulatory properties.

These food items are rich in nutrients like vitamins A, C, D, E, B complex, and minerals like Mg, Se, Zn, Fe, Ca, and Mn are essential for maintaining healthy sexual function in females.

2. Vihara

Vihara is behavioral changes. This includes Nidra (sleep), Vyavaya (Sexual activity), Vyayama (physical activity), etc. These factors also have a relation with sexual function.

Sleep - Sukha (happiness), Dukha (unhappiness), Pushti (good physique), Karshya (emaciation), Vrushata (sexual power), Klibata (impotence), Gyan (knowledge), and Agyan (illiteracy), Jivita (long life), Ajivita (death) all these factors depend on Nidra. Sleep plays a vital role in good health and well-being throughout life. Getting enough quality sleep at the right times can help protect mental health, physical health, quality of life, and safety.

Maithuna (Intercourse) - Sex is one of the instincts, during the night time is good and wholesome for health. Bhavapraksha has explained the time of intercourse as - at night during the cold season, at day time during the summer season, at day and night in the spring season which should be avoided during the evening, full moon days, midnight, and mid-day.

Vyayama (exercise) - Exercise should be healthy and in harmony with one’s body constitution. While performing exercise avoid overexertion, lifting heavy weight (beyond the capacity.

3. Rasayana

Rasayana is the method used to create Prashasta Rasadi Dhatus.

Rasayana helps to improve Arogya, Poshana of Dhatus, Vayasthapana (Youthfulness), gives complexion, and Jarasthapana.[14]

Rasayana essentially means nutrition at all levels from macro to micro. It replenishes the vital fluids of the body, and boosts the Ojas and the immune system, thus providing a protection sheet against disease by enhancing the immunity i.e., Vyadhi Kshamatwa.

Rasayana therapy is a comprehensive and specialized regimen capable of maintaining health, longevity, and improved mental faculty by acting at the level of Rasa (nutrition),


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Agni (digestion and metabolism), and Srotas (microcirculation), thus enabling the organism to procure the best qualities of different Dhatus and thereby enhances the immunity.

Examples of Rasayanas - Shatavari, Shatapushpa, Lashuna, Amla.

Achara Rasayana[15]

It is a mode of living behavior and conduct.

Achara Rasayana is a code to lead a stress-free life that fetches longevity. As major sexual disorders are stress-related hence Achara Rasayana is being taken as a main tool to postpone the onset of Jara and its related psychological disorders. Also do the Dharana of Dharaneeya Vegas like Krodha, Bhaya, Shokadi.

Vajikarana

Vajikarana, also known as Vrishya Chikitsa, is one of Ashtanga Ayurveda's eight primary specialties. This subject is concerned with aphrodisiacs, virility, and improving the health of progeny and also helps to increase sexual capacity and treatment of sexual disorders.

The term Vajikarana means strengthening, stimulating, or producing virility.

Vajikarana especially focuses on aphrodisiac therapy and sexual and reproductive health. It Vajikarana Chikitsa causes Tushti (satisfaction), and Pushti (Dhatu Poshana), helps in Sadhya Sampraharsha, and Gives Oorja, and Apatyaprada.[16]

As per Charak Samhita, by proper use of these formulations, one becomes endowed with a good physique, potency, strength, and complexion and sexually exhilarated and sexually potent.

The difference between Rasayana and Vajikarana is that the Rasayana promotes all the Dhatus while Vajikarana specifically increases Shukra Dhatu and sexual potency.

Role of Rasayana and Vajikarana in sexual function

Rasayana rejuvenates reproductive tissues, enhances sexual vitality (Ojus), and regulates the cycles thus Improving fertility. Vajikarana Increases libido, improves reproductive health, enhances orgasmic ability, and improves sexual satisfaction.

It has antioxidant activity which protects reproductive tissues from oxidative stress, enhances neurotransmitter function improving libido.

4. Shodhana and Shamana

As mostly the cause of sexual dysfunction is due to psychological, local pathology or systemic involvement hence Shodhana and Shamana is important while treating female sexual dysfunction.

Yoni Vyapads mainly involves Vata Dosha. Chikitsa explained for Yoni Vyapads is Shodhana, Sthanika Chikitsa which helps in the eradication of disease. Snehana, Swedana followed by Basti corrects the Dosha Dushti and eliminates them. Detoxification followed by Internal medication helps to improve sexual health.

5. Sthanika Chikitsa

Gynecological diseases are caused by disturbances in the functioning genital tract. Sthanika Chikitsa means specific treatment given locally. This is beneficial when Stahnika Dosha Dushti is more as it gives strength to the specific Sthana.

Since most of the gynecological conditions are manifested due to Vata Dushti, local Treatments like Sneha Yoni Pichu done using the Taila or Ghrita Yukta tampons help in treating dryness of the vagina or local causes.

Local treatments work by enhancing circulation, reducing discomfort, and restoring tissue health and elasticity, all of which contribute to an improved sexual experience. These therapies not only address physical aspects but also help alleviate stress and tension, creating a supportive environment for sexual function and pleasure. By promoting overall vaginal health, balancing Doshas, and enhancing emotional well-being, these treatments are integral to holistic sexual wellness for women.

6. Importance of Paricharyas in Sexual Function

Role of Paricharyas in sexual function

Paricharyas emphasizes a balanced diet, mental state, and physical care.

The diet followed during this time helps to fulfil the requirements of the body while having mental support or an affectionate nature of a partner helps in building a bond between the couple.


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1. Rajaswala Paricharya[17]

Rajaswala Charya offers a supportive regimen that promotes menstrual health, emotional balance, and physical rejuvenation. This regimen not only keeps Doshas balanced and supports hormonal health but also fosters a positive and restful connection with the body. Through nurturing the reproductive tissues, supporting Ojas, and promoting emotional and physical comfort, Rajaswala Charya indirectly enhances a woman’s sexual function and libido, creating a foundation for balanced, fulfilling intimacy.

Sharirika

Ahara - Women should remain celibate for the first three days of menstruation and consume Havisha (a meal prepared with ghee, Shali rice, and milk) or Yawaka (a meal composed of barley and milk). She should not cover herself with ornaments.

Vihara - On the fourth day, the female should take a bath, wash her hair, dress in white, and wear a garland of flowers and ornaments. She should first meet her husband.

Manasika - Should focus on positive, desirable thoughts.

Reducing Physical Discomfort and Fatigue

Menstrual discomforts like cramps, bloating, and fatigue can lower sexual interest and comfort. Rajaswala Charya minimizes these symptoms by promoting relaxation and ease through warm baths and a light, digestible diet. Reducing menstrual discomfort enhances overall physical comfort, supporting a healthier sexual response and greater readiness for intimacy after menstruation.

2. Garbhini Paricharya[18]

Garbhini Paricharya refers to the regimen and care provided to a woman throughout pregnancy, aiming to support her health and that of the growing fetus. The practices and dietary recommendations in Garbhini Paricharya are focused on nourishing the body, balancing hormones, supporting a stable mind, and preparing the body for childbirth and recovery. While primarily aimed at a healthy pregnancy, Garbhini Paricharya indirectly supports sexual function by promoting overall reproductive health, emotional well-being, and the strength of the reproductive tissues.

Paricharyas followed -

Sharirika - Anuvasana Basti in the eighth month is recommended to assist women gain unctuousness and strength, as well as Vatanulomana and Sukhaprasava. It aids the natural birth (Nirupadrava), which can be referred to as delivery without an episiotomy or the use of an instrument, and prevents problems such as vaginal or cervical damage, which might worsen problems with sex. In the ninth month, Yoni Pichu with Taila is recommended, which aids Garbha Marga Snehanartha and lubricates the path.

Kukshi, Kati, Prushtha, and Parshwa become Mrudu and restores Vatanulomana thereby restoring Apana Vata Karma.

Manasika - उपचार: प्रियहितैर्भत्रा भृत्यैश्च गर्भधृक् ॥ (अ.हृ.शा.१।४२)

The spouse and servant's warm and pleasant behaviour aids in the maintenance of the pregnancy.

सन्तर्पणं प्रियाश्लेषोविहाराश्च मनोरमा । प्रियकरं चान्नपानं गर्भिणीनां हितं सदा ॥ (भै.र​.६८।१०४)

Manasika Karanas describes her pleasant way of living.

Impact of Garbhini Paricharya on Sexual Function[18]

…..अनुलोमे हि वायौ सुखं प्रसूयते निरुपद्रवा च भवति, ….. एवमुपक्रान्ता स्निग्धा बलवती सुखमनुपद्रवा प्रसूयते ||४|| (Su.Sha.10/4)

Strengthening Reproductive Tissues

Garbhini Paricharya emphasizes strengthening and nourishing the reproductive tissues (Shukra Dhatu) to support a healthy pregnancy, prevent complications, and promote long-term reproductive health. It uses foods and herbs rich in Shatavari, Bala, and Ashwagandha to enhance the elasticity and resilience of the uterine and vaginal walls. This nourishment supports postpartum recovery, helping the tissues regain comfort and sensitivity, which benefits sexual function.

Supporting Vaginal Health and Lubrication

The hormonal changes in pregnancy can impact vaginal moisture by promoting practices to maintain hydration and lubrication. It includes dietary recommendations such as ghee, milk,


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and nourishing fats to enhance tissue moisture, alongside oils for external massage around the abdomen and pelvic area to improve tissue hydration and elasticity. This focus on hydration reduces postpartum dryness and discomfort, supporting more comfortable and enjoyable sexual experiences.

Supporting Emotional and Mental Well-being

Garbhini Paricharya emphasizes emotional well-being as essential for a healthy libido and mental readiness for intimacy, recognizing that stress during pregnancy can impact postpartum sexual health. It encourages mindfulness practices, meditation, and simple, consistent routines to reduce stress and create a sense of stability and calm. This focus on emotional balance helps foster a positive outlook on intimacy, reducing anxiety and supporting a more fulfilling sexual connection after childbirth.

Preparing the Body for Smooth Childbirth and Recovery

Garbhini Paricharya focuses on preparing the body for a smoother, less taxing delivery, which minimizes strain on pelvic and vaginal tissues, aiding quicker recovery and a faster return to normal sexual function. It incorporates gentle prenatal yoga and Abhyanga (oil massages) to strengthen muscles and reduce strain. This preparation supports a smoother birth experience, allowing for faster healing and a more comfortable return to intimate experiences postpartum.

3. Sutika Paricharya[19]

It refers to the specific regimen and care given to women after childbirth, during the postpartum period. This traditional care is designed to support physical and emotional recovery, restore reproductive health, balance the body, and ultimately help the woman regain normal sexual function over time. Sutika Paricharya is deeply restorative and works by nourishing the reproductive tissues, rebalancing hormones, alleviating stress, and building Ojas (vital energy).

Sharirika - Abhyanga with Bala Taila provides Bala, Vatahara, and Sutwak. Yoni Parisheka with Ushna Jala or Vatahara Kashaya - to reduce Vata and increase vigor. Udara Veshtana - Vata does not vitiate; reduces abdominal size.

Acharaya Bhavamishra has emphasized the need to achieve a prepregnant anatomical condition, which is required for optimal sexual performance. Yoni Gadhikarana and Kuskshi Hrasa have discussed how to reach the prepregnant condition.

Manasika - प्रजातमात्रामाश्वास्य सृतां शक्ला विजाविका | (Ka.Khi.11/18)

A joyful and delightful speech should be given to her immediately after delivery to encourage and reassure her. This helps in bonding and connecting with the partner which is again essential.

Sutika Paricharya aids in restoring normal sexual function after childbirth:

Rejuvenation of Reproductive Tissues

Sutika Paricharya offers a nourishing regimen to repair and rejuvenate weakened reproductive tissues post-childbirth. The dietary guidelines focus on healthy fats, proteins, and essential nutrients to strengthen these tissues and support uterine health, ultimately enhancing comfort and function during sexual activity.

Promoting Vaginal Health and Lubrication

Post-childbirth, women may experience dryness and discomfort, making sexual activity painful. Sutika Paricharya addresses this through internal nourishment and external therapies, such as Abhyanga (oil massages) with oils like Bala Taila, applied to the lower abdomen and reproductive area to restore lubrication and nourish vaginal tissues. This approach enhances lubrication and tissue health, making intimacy more comfortable and enjoyable.

Reducing Stress and Supporting Emotional Well-being

The postpartum period can bring mood swings, anxiety, and even postpartum depression, impacting sexual desire and readiness for intimacy. Sutika Paricharya includes stress-relieving practices to support emotional health, such as daily massage to calm the mind and soothe the nervous system. These relaxation techniques reduce stress, improve emotional well-being, and foster a more positive outlook on intimacy, helping restore natural libido.

Encouraging Physical Strength and Recovery

Physical weakness and fatigue after childbirth can lower energy levels and interest in sexual activity.


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Sutika Paricharya supports the gradual recovery of physical strength through gentle postnatal exercises, nutritious foods, and herbal tonics to restore muscle tone and resilience. As strength and stamina improve, so does the energy needed for intimacy, enhancing the overall quality of intimate relationships.

4. Dinacharya

Swastha is the one who has balanced Doshas, Agni, properly formed Dhatus, proper elimination of Malas, mind body soul are full of bliss. Following Dinacharya contributes to the balance of the Doshas and, as a result, the body's overall wellness.

Sharirika

Pratah Utthana keeps energy levels high as oxygen levels are high in the atmosphere and readily mix with hemoglobin. It also brings peace to the mind and freshness.

Shoucha, Danta Dhawana, Jihva Nirlekhana, Sneha Gandusha Dharana - it is for maintaining oral health, removes ama, reduces microbes’ and aids digestion as well as overall health.

Vyayama, Chankramana - increases the body strength, clears Srotas, and increases the perception power of organs, reduces stress, fat, fatigue, and lethargy.

Abhyang, Snana, Nasya - It removes sweat, improves blood circulation, and strength, reduces lethargy, and induces sound sleep. Sharpens the senses.

Conclusion

Female sexual dysfunction is a complex issue that benefits from a comprehensive treatment approach. While modern medical treatments offer targeted solutions, Ayurvedic remedies emphasize holistic, long-term wellness by encouraging balance and vitality. Integrating these two approaches can be advantageous for personalized therapy. Ayurveda, in particular, focuses on enhancing physical and mental and emotional well-being, which are essential for sexual wellness. It views sexual health as a reflection of overall vitality, which depends on balanced Doshas, reproductive wellness, emotional harmony, and strong Ojas (vital energy).

References

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2. Thakaral K K, editor. Sushruta Samhita of Sushruta, Uttaratantra; Yonivyapad pratishedhadhyaya: Chapter 38, Verse 10. Varanasi: Chaukambha Orientalia; 2019; 203.

3. Thakaral K K, editor. Sushruta Samhita of Sushruta, Uttaratantra; Yonivyapad pratishedhadhyaya: Chapter 38, Verse 16. Varanasi: Chaukambha Orientalia; 2019; 206.

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9. Astanga Hridaya with commentaries Sarvangasundara of Arundatta and Ayurvvedarasayana of Hemadri. Varanasi: Chaukhamba Sanskrit Series Office. p.183-85.

10. Kushwaha H S, editor. Ashtanga Hridaya of Vagbhata, Sutra Sthana; Ch.1, Ver.22. Varanasi: Chaukambha Orientalia; 2018. p. 14.

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12. Kushwaha H S, editor. Ashtanga Hridaya of Vagbhata, Sutra Sthana; Ch.1, Ver.19. Varanasi: Chaukambha Orientalia; 2018. p. 13.

13. https://www.verywellhealth.com/nymphomania-5209598


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14. Singh H C K. Charaka Samhita of Agnivesha, Chikitsa Sthana. 1, Ver.7-8. Varanasi: Chaukambha Orientalia; 2016. p. 2.

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19. Tewari P.V. Kashyapa Samhita of Vriddha Jivaka, Khilasthana. Sutikopakramaniyadhyay, Verse.18. Varanasi: Chaukambha Visvabharati; 2018. p. 578.

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