Hetuvyadhikar Roga in Ayurveda: Menstruation Irregularity Associated with Type 2 DM – A Case Study

Introduction

Ayurveda, the ancient science of life, describes a variety of fundamental principles for diagnosing and treating diseases. One such principle is Nidanarthakara Roga, where Acharya Charaka states that one disease can lead to the development of another, where the primary disease (Swatantra Vyadhi) acts as the causative factor for the development of a secondary disease (Paratantra Vyadhi). Nidanarthakara Vyadhi is further divided into two types: Ekarthakara Vyadhi and Ubhayarthakari Vyadhi[1] . Ekarthakara Vyadhi occurs when the symptoms of the primary disease relapse, but only the symptoms of the associated condition are present. Ubhayarthakari Vyadhi, on the other hand, occurs when the primary disease persists along with the associated disease. Acharya Vagbhatta mentions in the same context that treating the primary disease often results in the resolution of the secondary condition[2]. Acharya Charaka provided several examples of Nidanarthakara Roga: Pratisyaya (coryza) can act as a causative factor for Kasa (cough), which may further lead to Kshaya (tuberculosis). Similarly, untreated Jvara (fever) can lead to Raktapitta (hemorrhagic disorder), and Plihavriddhi (splenomegaly) can lead to Udara Roga (ascites)[3].

In the present era, individuals frequently present with multiple coexisting lifestyle and metabolic disorders, making the identification of a definitive diagnostic condition increasingly challenging. Disorders such as obesity and diabetes often coexist, potentially predisposing individuals to or indicating more profound systemic derangements. Prior studies have related obesity as a Nidanarthakara factor for diabetes, HTN, PCOD, etc[4].

Acharya Bhavapraksha drew a connection between the etiopathogenesis of Prameha (diabetes) and Rajodosha (menstrual disorders). Bhavapraksha also mentioned that females with regular menstruation have fewer chances of developing Prameha[5]. A prospective cohort study of 75,546 women shows that women with menstrual irregularities are at a higher risk of developing diabetes. The risk increases with obesity, less physical activity, and a low-quality diet[6]. The frequency of oligomenorrhea before the diagnosis of diabetes was nearly two-fold higher in women with type 2 diabetes than in the control group[7].

In modern times, PCOD (Polycystic Ovarian Disease) has emerged as one of the major causes of menstrual irregularities. The incidence of PCOD is increasing among women of reproductive age. Moreover, women affected by PCOD are at a higher risk of developing diabetes mellitus, due to associated hormonal imbalances and insulin resistance[8].

In this study, we will explore how the principle of Nidanarthakara Roga was applied in the case of a patient with menstruation irregularities and diabetes, leading to favorable outcomes in both menstruation and blood sugar levels.

Patient Information

A 38-year-old married female presented to the Outpatient Department (OPD) of the National Institute of Ayurveda (NIA) on 25th March 2023 with complaints of prolonged menstrual cycles lasting 40-50 days, heavy bleeding with large clots, abdominal pain during the bleeding phase, and myalgia. The patient had been suffering from this condition for the past year. She got married at the age of 26, and her Gravida history was G2P2L2A0 with a 3-year interval between two deliveries.

History of Present Illness

The patient had been getting regular periods with a cycle of 28-30 days. Her past and present menstrual history is provided in Table 1.

The patient missed her periods in early June 2022 and, upon testing with an HCG detection card, the result was negative. She later got her period at the end of July 2022, with an interval of 48 days. Initially, the bleeding was normal for two days, but on day 3, heavy bleeding (8-10 fully soaked pads) and large clots began, which persisted for the next three days. After that, bleeding reduced (1 pad per day) but continued for the next five days.

She experienced lower abdominal pain during the first five days, which hampered her daily activities to the extent that she could not get out of bed. The patient also suffered from myalgia and fatigue throughout the entire bleeding phase.

Subsequent cycles became delayed and increasingly painful.

There was no family history of diabetes mellitus. The patient also had no previous history of diabetes. She was diagnosed with type 2 diabetes for the first time after her blood sugar tests were conducted at NIA.

Table 1 : Past and present menstrual history

Clinical Findings

• Per Abdomen:
• Inspection:
  Umbilicus: Centrally placed, inverted
• Palpation:
  Soft, no tenderness observed
  No organomegaly observed
• Percussion:
  Tympanic
• Auscultation:
  Normal bowel sounds heard
• Gynaecological Examination

Pelvic Examination:

• Examination of Vulva:
  • Pubic Hair: Normal
  • Clitoris: Normal
  • Labia: Normal
  • Discharge: Nil

Laboratory Findings

Laboratory tests revealed elevated fasting blood glucose (180 mg/dL), postprandial glucose (353 mg/dL), and HbA1c (7.8%), confirming diabetes mellitus. Thyroid function tests were unremarkable.

 Radiographical Findings

Abdominal ultrasonography showed a bulky uterus with a heterogeneous echotexture. The endometrium was normal in size, centrally placed, with a thickness of 9.4 mm. Both ovaries were slightly bulky and showed multiple follicles distributed peripherally with relatively echogenic stroma.

• Right ovary: 10–12 non-dominant follicles, 3–9 mm
• Left ovary: 9–11 dominant follicles, 3–7 mm

Presence of immature follicles indicates Polycystic Ovarian Disease (PCOD) morphology.

Ayurveda Perspective

In Ayurveda, abnormal menstrual bleeding can be correlated with Asrigdara. Asrigdara is a rakta pradoshaja vyadhi (blood-related disorder)[9,10]. There are four types of Asrigdara, and excessive bleeding with bright red blood is a feature of Pittaja Asrigdara[11]. Large clots, termed in Ayurveda as Granthibhuta Artava, suggest Kapha-Vata features[12]. Additionally, myalgia, fatigue, and vertigo are common symptoms of Asrigdara[13].

Based on the clinical and laboratory features, the patient was diagnosed with Pitta-Kapha dominant Asrigdara as the Pradhan Vyadhi (primary disorder) and Diabetes Mellitus as the Anubandha Vyadhi (secondary disorder). Diabetes was diagnosed for the first time, and the patient was unaware of her condition.

Therapeutic Interventions

The treatment protocol was selected based on Ayurvedic principles, incorporating Vyadhipratyanika and Dosha Pratyanika[14] actions of the drugs.

• Dosha Pratyanika (To break pathogenesis and neutralize Doshas)

Shodhana Karma:

• Vamana (therapeutic emesis) was administered to eliminate vitiated Pitta and Kapha.
  As Asrigdara is to be treated as Raktapitta[15], the treatment followed the Charaka Samhita’s recommendation for Vamana in cases of Adhogata Raktapitta (bleeding from the uterus or rectum)[16].

Shamana Aushadha:

1. Avipattikara Churna (5 g), BD before food:
   Avipattikara Churna is indicated in Pittaja disorders, all twenty types of Prameha (diabetes), as well as in conditions like Vibandha (constipation) and Agnimandya (digestive impairment)[17]. In this case, it was chosen to pacify aggravated Pitta and enhance the digestive fire (Agni), preventing the formation of Ama (toxic metabolic by-products). By promoting digestion and metabolism, it helps form Nirama Ahara Rasa, which nourishes the Dhatus (body tissues) in a balanced way.
2. Kutki Churna (1 g) after food with Munakka and Dhaga Mishri:
   Kutki has purgative actions and eliminates vitiated Pitta and Kapha from the body, purifies the blood, and improves overall health. Due to its properties, Kutki was chosen as a Dosha Pratyanika medicine[18].
3. Nagkesar Churna (1 g) + Kaharwa Pishti (500 mg) + Sphatika Bhasma (500 mg), BD after food:
   Nagkesar exhibits multiple therapeutic actions: Pachana (digestive), Raktastambhana (hemostatic), Swedaghna (reduces sweating), Kandughna (relieves itching), Dourgandhyanashana (removes foul odor), Jwaraghna (antipyretic), Trushnaghna (relieves thirst), and Kusthaghna (useful in skin disorders).
   Kaharwa Pishti (Amber Pishti) is widely used in Ayurvedic medicine for its cooling, hemostatic, and rejuvenating properties.
   Sphatika Bhasma, made from purified alum, is known for its hemostatic, antimicrobial, and astringent properties. It is commonly used in conditions like Asrigdara, Raktapitta, nasal bleeding, and Shweta pradara (leucorrhea).
   Hence, the combination is beneficial in treating Kapha-Pitta Asrigdara, especially in cases of irregular and excessive uterine bleeding.

• Vyadhi Pratyanika (To reduce symptoms)

1. Ashokarishta: 20 mL twice daily (BD) after food:
   Ashokarishta is indicated in conditions such as Asrigdara, Rakta Pitta (bleeding disorders), and Prameha (urinary disorders), as well as in managing pain during menstruation.[19]

Dietary and Lifestyle Modifications

A Pitta-pacifying diet was prescribed, excluding spicy, oily, and fermented foods while incorporating cooling, astringent items (e.g., pomegranate, coconut water, cumin water). Pranayama and yoga were recommended for stress management.

Follow-up and Outcome

The patient was followed up regularly every fifteen days. Significant improvement in menstrual health and blood sugar levels was observed. The situation gradually improved with each menstrual cycle. Pain and clotting reduced after the first menstrual cycle, and the menstrual cycle became regular after 6 months of continuous treatment. A reduction in heavy bleeding was recorded, with the number of sanitary pads used during the cycle shown in Table 4

Table 2.  Progressive reduction in menstrual bleeding and cycle duration with regularization of periods

 Table 3: Progressive Impact on DM: Blood sugar was measured at every 3 month.

Table 4: Time line of events of case

Discussion

The principle of Hetuvyadhikar Roga proved effective in this case. The imbalance of Pitta and Vata in hypermenorrhoea contributed to metabolic disturbances, which exacerbated Madhumeha (diabetes). By addressing hypermenorrhoea, the underlying metabolic imbalance was corrected, leading to significant improvements in blood sugar levels.

Ultrasonography (USG) revealed the presence of multiple immature follicles in both ovaries, suggesting Polycystic Ovarian Disease (PCOD) morphology. PCOD is associated with an increased risk of metabolic disorders, including a significantly higher likelihood of developing diabetes mellitus.

This observation aligns with the *Ayurvedic concept of Nidānarthakara Roga, wherein a primary disorder (in this case, PCOD) acts as a causative factor for the development of another disease, such as Prameha (diabetes). In Ayurveda, diagnosis is primarily based on clinical symptoms (lakshanas), reinforcing the idea that interconnected imbalances should be addressed together.

This case highlights Ayurveda’s holistic approach, which does not treat diseases in isolation but addresses interconnected imbalances. By treating the root cause of the disease (hypermenorrhoea), the associated condition (diabetes) showed significant improvement, thus validating the classical Ayurvedic principle that treating the primary disease often results in the spontaneous resolution of associated conditions.

Conclusion

This case study underscores the clinical relevance of the Hetuvyadhikar Roga principle in modern practice. By treating hypermenorrhoea as the primary disorder, significant improvements were observed in both menstrual health and diabetes management.

The patient exhibited classical signs and symptoms consistent with Asrigdara (abnormal uterine bleeding), as outlined in Ayurvedic texts. Based on these findings, the diagnosis of Asrigdara was confirmed, and treatment was tailored accordingly.

Further research and clinical studies are essential to validate these findings, as they will help integrate Ayurvedic principles into mainstream healthcare, bridging traditional wisdom with modern medical practice.

References:

1. Carakasamhita, Nidana Sthana, Apasmara Nidanam 5/104. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 3 jan 2025).
2. Ashtanga Hridaya, Sutrasthana, Doshabhediya Adhyayam 12/62. Available from: http://niimh.nic.in/ebooks/ehrudayam(Accessed on 3 jan 2025).
3. Carakasamhita, Nidana Sthana, Apasmara Nidanam 8/16-19. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 12 jan 2025).
4. Shivaranjani J Kantharia, SN Gupta, M. V. Patel, Kalapi B. Patel Understand the Concept of Nidanarthakara Roga w.s.r. to Obesity International Journal of Ayurveda and Pharma Research. 2023;11(4):31-34. https://doi.org/10.47070/ijapr.v11i4.2762
5. Bhavpraksha of Bhavamishra with vidhyotini Hindi commentary by Pandit shri Brahmshankhar Mishra, 2022 madhyama khanda o8/23, Page no 400
6. Wang, Y. X., Shan, Z., Arvizu, M., Pan, A., Manson, J. E., Missmer, S. A., Sun, Q., & Chavarro, J. E. (2020). Associations of Menstrual Cycle Characteristics Across the Reproductive Life Span and Lifestyle Factors With Risk of Type 2 Diabetes. JAMA network open, 3(12), e2027928. https://doi.org/10.1001/jamanetworkopen.2020.27928
7. Shim U, Oh JY, Lee HJ, Hong YS, Sung YA. Long Menstrual Cycle Is Associated with Type 2 Diabetes Mellitus in Korean Women. Diabetes Metab J. 2011;35(4):384-389.
8. Agrawal, A., 4th, Dave, A., & Jaiswal, A. (2023). Type 2 Diabetes Mellitus in Patients With Polycystic Ovary Syndrome. Cureus, 15(10), e46859. https://doi.org/10.7759/cureus.46859
9. Sushruta Samhita, Sutra Sthanam, Vyadhisamuddeshiya Adhyaya 24/9. Available from: http://niimh.nic.in/ebooks/esushruta(Accessed on 3 jan 2025).
10. Carakasamhita, Sutra Sthana, Vividhaashitpitiya adhyaya 28/11. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 3 jan 2025).
11. Sushruta Samhita, Sharira Sthanam, Shukra-Shonita Shuddhi Shariram 2/19. Available from: http://niimh.nic.in/ebooks/esushruta(Accessed on 3 jan 2025).
12. Sushruta Samhita, Sharira Sthanam, Shukra-Shonita Shuddhi Shariram 2/14. Available from: http://niimh.nic.in/ebooks/esushruta(Accessed on 3 jan 2025).
13. Sushruta Samhita, Sharira Sthanam, Shukra-Shonita Shuddhi Shariram 2/19. Available from: http://niimh.nic.in/ebooks/esushruta(Accessed on 3 jan 2025).
14. Carakasamhita, Vimana Sthana, Rogabhishakajitiya adhyaya 8/13. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 3 jan 2025).
15. Carakasamhita, chikitsa Sthana, Yonivyapadachikitsa adhyaya 30/228. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 3 jan 2025).
16. Carakasamhita, Nidana Sthana, Raktapitta nidanam 2/16. Available from: http://niimh.nic.in/ebooks/ecaraka(Accessed on 3 jan 2025).
17. Bheshajya Ratnavali of Kairaj Govind das sen edited with Siddhiprada Hindi Commentry by Prof. Siddhi Nandan Mishra Publsihed vy Chaukhambha Surbharti Prakashan, 53/24-28 Page No. 903
18. Bhavprakash nighantu of Bhavmishra commentary by Padmshru prof. K.C. Chunekar, Edited by Late Dr. G.S. Pandey, Published by Chaukhambha Bharati Academy, Haritkyadi Varga 1/151-152 Page no. 37.
19. Bheshajya Ratnavali of Kairaj Govind das sen edited with Siddhiprada Hindi Commentry by Prof. Siddhi Nandan Mishra Publsihed vy Chaukhambha Surbharti Prakashan, 66/111-114 Page No. 1038