Endometriosis is the most common problem encountered in Gynaecology. This is a hormone-dependent gynecologic disease, with clinical manifestations of adhesion and progressive growth of endometrial cells in organs other than the uterus. ¹ This disease affects a large portion of the population. Half of the patients with endometriosis display clinical symptoms of pelvic pain and infertility, thereby reducing the quality of life of women. ^{2, 3} Endometriosis is a relatively common and potentially debilitating condition affecting up to 10-15% of reproductive age group women. It is seen in 30-40% of women with infertility. Certain guidelines given in Samhitas are utilized for understanding such diseases.

According to Ayurveda classics, endometriosis cannot be codified under a single disease entity. Our Acharya’s have emphasized Lakshanas (symptoms) like Shula (pain) throughout the Striroga Prakarana (Gynaecology), among which Vatiki yoni vyapad, Udavartini yoni vyapad bear close resemblance to the clinical picture of endometriosis, which makes finding an effective, validated treatment protocol for the management of pain in endometriosis. ⁴

Acharya Charaka explains Vatiki - a woman of Vata prakriti, when consuming improper diet and indulges in other activities capable of aggravating Vata; thus, provoked Vata reaches the reproductive system and produces pricking and other pains, stiffness, sensation as if creeping of ants, roughness and numbness, local symptoms and fatigue or lethargy etc. Due to Vata Vaigunya menstruation appears with irregularity and is painful. Vata gets aggravated due to Vega dharana and moves in the reverse direction, then settles in yoni and produces the pain, initially pushes raja in an upward direction, then discharges it with difficulty. The woman feels relief immediately after the discharge of menstrual blood in Udavartini. ⁵

The Gynaecological reasons for chronic pelvic pain are diverse. This diversity ends in the clinical diagnosis of endometriosis in about one-third of the cases during their reproductive period. After a definitive diagnosis of endometriosis has been made out for those suffering from chronic pelvic pain, the patients are forced to travel through the traumatic paths of long-term medication leading to frustration and depression. This case study describes Sodhana chikitsa and its effectiveness in the management of endometriosis.

A 37-year-old female (Swedish national) visited the Outpatient Department (OPD) of Ayurveda Hospital in December 2020 for the management of 7 years of chronic pelvic pain with chief complaints of severe lower abdominal and pelvic pain and heavy bleeding during menstruation. The patient reported that the pelvic pain starts one day prior to menstruation and stops 1-2 days after the onset of bleeding. The pain is most severe on the first day of the menstrual cycle, associated with heavy bleeding with clots. History of painful periods since menarche.

She was advised to take Oral Contraceptive pills (OC pills) in the year 2000, which she continued for 8 years. On medication, she got temporary relief from the symptoms, which reappeared on the stoppage of OC pills. She denied taking OC pills and resorted to oestrogen pills for the management of pain from 2008 to 2012. Stopped oestrogen pills when side effects- abnormal facial hair growth noted. From 2013 again, the pain and bleeding became worse. The pain aggravated, and she was advised for a USG scan in April 2015, which showed endometriosis, cyst in the left ovary. After which, she was advised by the Gynaecologist to have OC pills again. But she resorted to herbal medicine. She was unmarried but a non-virgin without having any habits or addictions. Her family history- Nothing specific revealed. Her personal history revealed a constipated bowel habit, occasional acidity and disturbed sleep. She attained menarche at the age of 12 years, a menstrual period with a duration of 3-4 days and an interval of 24-26 days. Her Last Menstrual Period (LMP) was on 03/11/2020. The amount of bleeding was excessive on the second day, evident from the usage of four to five heavily soaked pads. No history of hypertension, diabetes, thyrotoxosis, no surgical history was obtained. No history of any drug Allergy.

Patient was found to be average built and weighing 60.7 kg. Her blood pressure was 120/80 mmHg, pulse rate was 70/minutes, and BMI was 24.7 kg/m². Ashta sthana pareeksha details are given in the diagnostic assessment. She is of Kapha-vata prakriti (~constitution based on bodily humour) with Madhyama satva (~mental constitution). Dasavidha rogi pareeksha details are mentioned in the diagnostic assessment. Examination of external genitalia didn’t reveal any abnormal findings. Per speculum examination showed a normal cervix without any significant abnormality. Bimanual examination revealed a bulky uterus; no tenderness was detected. Her bowel and bladder habits were normal.

As part of initial assessment Ashta sthana pareeksha & Dasavidha Pareeksha was done. Nadi (Pulse) was regular with 72 beats per minute, Mutram (Urine) was clear and flow and quantity was normal (Frequency of urination: 3-4 times during morning and 1-2 times at night), Malam (Stool) was formed with nomal toilet once daily early morning, No coating was noted on Jihva (Tongue) and the shape of tongue was normal, Sabda (Sound) was normal, Sparsa (Skin) was normal to touch, Drik (Vision) was normal. She was of young vaya: (age) and of moderate built and height Akruthi (General appearance and built). Her (Basic constitution) Prakruthi was assessed as Kapha- Vata. Vikruthi (Imbalances): Vata, Kapha and Pitta was assessed to be vitiated on tridosha level, and Dhushya (vitiation of tissues): Dhatus (Tissue level) Rasa, Rakta and Mamsa was found to be vitiated. (Quality and quantity of tissues) Sara, Samhanana (Compactness), Satva (Mental strength and tolerance) were found to be normal, with moderate Vyayama sakthi (Exercise tolerance) and (Compatabilities) Satmya.

CBC-WNL, Urine –WNL Laboratory tests were unremarkable. Previous specialized evaluations included Radiological ultrasound revealed (abdominal ultrasonography), bulky uterus with adenomyosis. The left endometriotic cyst 5 X 2.3 cm was seen adherent to the uterus. A probable diagnosis, Vatiki yonivyapat (~gynaecological conditions in Ayurveda which includes painful menstruation), was drawn out from the presenting complaints and the previous medical reports produced by the patient during the OPD visit on 11^th December 2020. She was advised for admission the same day.

The treatment given was Amapachana (~digestion of undigested food), Agnideepana (~increase digestive fire), Srotosodhaka (~clear channel) and Vata anulomana (~downward movement of Vata), and finally Pitta pacifying. The therapeutic plan was to perform Shodhana Karma (~cleansing therapies) after correcting her Agni (~digestive fire) by Purvakarma (~preparatory therapies). Initially, Hinguvachadi churna (6 g) was given for improving the digestive fire prior to cleansing therapy for three days. The sequence of treatment was as follows:

Endometriosis is one of the challenging clinical entities for the practitioners of Ayurveda. The complicated clinical scenario demands accurate diagnosis and management to prevent surgical intervention. This present case report emphasized the importance of an Ayurvedic treatment protocol for the management of pelvic pain connected with endometriosis. The patient was treated on the line of management of Vatiki yonivyapad. Treatment focused on Agni deepana, Aama pachana with Shodhana in order to remove the Aama and get the Doshas back into normal. The treatment protocol aims for the pacification of Vata dosha and correction of digestive fire, thereby abolishing the chronic pelvic pain associated with endometriosis. Due to the unavoidable role of Vata dosha in the present disease entity, cleansing therapies like purgation and enema procedures hold prime importance for the pacification of Vata dosha.

A course of medicated enema with intrauterine instillation of medicated formulation has been selected after purgation, giving due importance to the analgesic properties of the drugs. Same time Pitta pacifying medicines were given at the time of discharge. Follow up USG was advised, which was politely refused by the patient. However, she was constantly in touch with proper follow up of oral medicines. For the last two years, no follow up possibly due to a reduction of symptoms.

Previous studies have proved the efficacy of Sodhana and Samana therapy in the management of chronic pelvic pain in endometriosis ⁶ and infertility as a consequence of endometriosis. 7 This study results were also in agreement with the previously reported studies. When the treatment principles are individualized and applied clinically, it yields excellent results to patient satisfaction. Ayurveda blesses the feminine world with numerous drugs, which helps to maintain their health in a natural way. Hence Ayurveda plays a major role in treating endometriosis and thereby prevent complications.

This case study showed that if the plan of treatment is selected according to principles of Ayurveda along with proper drug, dose, duration, Anupana, Pathya and Apathya there is an assertion of progress in treatment. The Ayurvedic management protocol - Sodhana chikitsa is highly effective and recommended in managing the chronic pelvic pain associated with endometriosis.