Artava Kshaya with Hypothyroidism: A case study

Artava Kshaya is the condition inwhich themenstruation does not occur in its appropriate time, which can be correlated with oligomenorrhoea with Scanty Menstrual low. Hypothyroidism is one of the causative factors of oligomenorrhoea, i.e. Artava Kshaya. The prevalence of hypothyroidism in the reproductive age group ranges from 2% to 4%. It affects female fertility in the form of menstrual irregularities, infertility and spontaneous irst trimester miscarriages. In modern science, thyroxine is used for the management of hypothyroidism which is useful but with speci ic side effects. A 27 years old married female with the complaints of delayed and scantymenstrual low for four years with an obstetric history of G1P1L1 & on 12.5 thyroxine tablet, visited the OPD. A urine pregnancy test was negative. Thyroid pro ile showed high TSH level, i.e. 9.23 uIU/ml and USG report showed small-sized Uterus with thin endometrium and very small-sized both ovaries without detectable follicles. Based on the symptoms and investigations, the patient was diagnosed as a case of Artava Kshaya with hypothyroidism. The principle of treatment was focused on Agnideepana, Strotoshodhana, Artava Pravartana and Vata Kapha Shamana. A treatment scenario was selected for the management, and follow up was done after every month.

Thyroid hormone levels within normal limits are responsible for proper metabolism of the body and menstrual function and for its maintenance the hypothalamic-pituitary-thyroid axis plays a key role. Among the thyroid hormones, slight increase in TSH (thyroid-stimulating hormone) levels with standard T3 (triiodothyronine) and T4 (thyroxine) indicates subclinical hypothyroidism. In contrast, high TSH levels accompanied by low T3 and T4 levels indicate clinical hypothyroidism.
Women are more likely to develop hypothyroidism than men. In population-based studies, women were seven times more likely to have TSH levels above 10 uIU/ml (Garber et al., 2012) than men. The prevalence of hypothyroidism in the reproductive    TSH -a thyroid-stimulating hormone, T3-triiodothyronine, T4 -thyroxine, WNL -within the standard limit  (Lincoln et al., 1999). Anovulation is the primary manifestation seen in hypothyroidism and associated with changes in cycle length, i.e. oligomenorrhoea and amount of bleeding.
As per Ayurveda, hypothyroidism occurs due to Jatharagni (digestive ire) and Dhatvagni (tissue ire ) Mandya (low) with Prakopa (vitiation) of Vata and Kapha Dosha and Strotodushti of Rasavaha, Raktavaha, Medovaha strotas. Thus, in case of Artava Kshaya due to hypothyroidism, principles of treatment should be Agnideepana (stimulation of digestive ire) at Jatharagni and Dhatvagni level, Strotoshodhana (cleansing of microchannel), Vatakapha Shamana and maintaining the regularity of cycle.

MATERIALS AND METHODS
The present case study was carried out by following Good Clinical Practice guidelines, Studies on Hormonal Imbalance and Ayurved Textual references. Written informed consent was taken from the patient before starting the treatment. A urine pregnancy test was negative. On taking a detailed history, she said that menstruation appears after taking medication only. Last Menstrual Period was 11/5/18. Menstrual cycle was irregular with an interval of 60 -150 days and painless scanty bleeding (1 pad/day) for 3-4 days without foul smell and clots. Her married life was nine years and had obstetric history G 1 P 1 L 1 (gravida, parity, live birth) with secondary infertility with no history of using contraception. The patient had a history of taking medicine for hypothyroidism for the last one and half years.

Case Report
Patient belongs to lower-middle socio-economic class with vegetarian dietary habit. Her appetite was good with good digestion; bowel and bladder habit was regular. On examination, no thyroid enlargement was noted. No abnormality detected on per speculum and vaginal examination.

Investigations
All haematological and biochemical parameters were within normal limits. The patient had the latest thyroid pro ile, which showed normal T3, T4 lev-els with free T4-1.29 ng/dL and high TSH level, i.e. 20.0 uIU/mL. Ultrasonography report showed Small-sized Uterus with thin endometrium, very small-sized ovaries without detectable follicles on 12/10/2018.
Based on the symptoms and investigations, she was diagnosed as a case of Artava Kshaya with hypothyroidism and treatment was started as shown in the Table 1.

Treatment
On irst follow up: after eight days, she feels relieved from the heaviness of the body, mild headache, body ache. Menstruation not initiated.
Then continue with the following treatment, as shown in Table 2.
On second and third follow up: on 20/12/2018 and 22/01/2019, she feels completely relieved from all other complaints. In 3 rd follow up, her TSH level was 9.23 uIU/mL. Both the times following treatment shown in Table 3 was added for eight days only.
After ive months of the above-said treatment, the patient showed marked improvement with the initiation of the menstrual cycle without hormonal medications with the good and painless low for 4-5 days. Thyroid pro ile comes to normal limits (TSH -1.80 uIU/mL) as shown in Table 4, and it is marked and noticeable improvement in USG, as shown in Table 5.

Discussion
In the Samprapti ( Kumari Asava, which is indicated in Strotodushti, Daurabalya (Acharaya and Samhita, 2013) (debility), also acts on ovaries to correct the function and induce ovulation (Hebbar, 2011). It may also in luence female hormones and helps to the treatment of disturb menstrual cycle (Singh, 2016). It contents Kumari, Haritaki, Jatamansi as main ingredients with many other herbal drugs which exhibit hepatoprotective activity, helps in proper metabolism of hormones in the liver, Improves digestion etc. Acts as Vata Kapha Shamak and Pitta vardhak (Acharaya and Samhita, 2013). Cap. U-gyneatone Forte is a phytoherbal formulation which consists of Haridra, Shatavari, Shata-pushpa and some active herbs which act as menstruation regulator and as a health tonic for females of fertile age group (PRNewswire, 2014; of Capsule Ugyanetone, 2020).

CONCLUSIONS
Thus, we can conclude from this study that Artava Kshaya with hypothyroidism well treated with this Ayurveda regimen. Navak guggula prove to be effective in Medoroga chikitsa. Raja Pravartini Vati gives good result in initiation and regulation of the menstrual cycle. Kumariasava and Dashmula are best effective in strotodushti and vataj doshdushti, respectively. Shadbindu tail plays a primary role in hormonal balance, and so establishes normal menstruation. Cap. U-gyneatone Forte is an excellent uterine and health tonic for females.