Uterine fibroids are the most common solid benign tumours in women of reproductive age. Uterine fibroid-related symptoms negatively impact physical and social activities, women's health-related quality of life, and work productivity. A 36year old female patient approached the outpatient department with complaints of menorrhagia and low back ache. Ultrasound scan revealed small intramural anterior wall fibroid measuring 13*15mm. She was suggested hysterectomy for the same; however, the patient was not willing to undergo surgery and was in quest of nonhormonal treatment. She was treated as per the Ayurvedic line of treatment of asrugdhara which is correlated to Menorrhagia (presenting complaint). She was administered Asokarishta, Chandraprabha vati and Pushyanuga churna tablets available in the Outpatient department. Treatment was continued for 6months with a follow up once in 15days and a repeat scan revealed shrinking size of the fibroid and relief in symptoms. Patient was willing to continue the medication for another 3months till all her symptoms subsided. A follow up scan also revealed that the fibroids had disappeared. During the treatment period patient has not reported any negative effects concerning the progression of disease nor regarding the medicines. An attempt has been made to present the successful management of fibroid with non-hormonal medicines in a patient of mid-thirties .This paper intends to instill confidence among Ayurvedic practitioners regarding the safe, noninvasive, non-hormonal cost-effective management of fibroids through Ayurvedic interventions.

Keywords: asrugdhara, fibroid, uterine fibroid, leiomyomas, fibromyoma, uterine fibroid

Fibroids occur in 20-40% of women during reproductive age and 11-19% in perimenopausal age.¹ They are clinically apparent in up to 25% of women and cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and, in rare cases, reproductive dysfunction.² Women experience distress and impaired work productivity due to fibroid. There are many women undiagnosed with significant symptoms emphasizing the need for improved awareness and management of fibroids.³

Uterine myomas have been classified according to their general uterine position: submucous, intramural, and subserosal. Intramural fibroids are located within the wall of the uterus and are the most common type; unless they may be asymptomatic. Though the exact cause of intramural fibroids is unknown, it is believed that fibroids develop from an abnormal muscle cell in the middle layer of the uterine wall. It rapidly multiplies and forms a tumor being influenced by estrogen.⁴ Traditionally, myomas have been the leading cause for hysterectomy, making this surgery the third most common surgical intervention worldwide. Removal of the uterus is inacceptable to women desirous of (further) child bearing though it offers a definitive solution to the problem. Newer procedures for fibroid removal may relieve symptoms, but duration of symptom relief and efficacy of the procedures in restoring fertility have not been evaluated. Such procedures include High-intensity focused sonography, Cryotherapy, Radiofrequency ablation, Magnetic resonance-guided focused ultrasound surgery; Anti-hormonal drugs like progestin or danazol block estrogen to treat fibroids. Uterine fibroid embolization (UFE) gonadotrophin-releasing hormone (GnRH) agonists and selective progesterone receptor modulators are some of the other treatment options for fibroid. While oral contraceptive pills have been used to treat fibroid related symptoms such as bleeding and dysmenorrhoea, their effect is usually based on their suppression/regulation of the menstrual cycle. The effect of ethinyl – estrogen/progesterone containing pills on myoma growth is less clear. Mirena, is one of the widely used levonorgestrel intrauterine devices, most commonly used in fibroid. Even though the bleeding and dysmenorrhoea-related symptoms are treated, the actual myoma size remains largely unchanged.⁵ 

The condition of uterine fibroid is similar to Garbhashayagatagranthi, mentioned in Ayurveda with vitiated vata affecting mamsa(muscle tissue), rakta (blood) and medas (fat) mixed with kapha producing rounded, protuberant, knotty and hard swelling. Fibroids can be related to the “Granthi” mentioned in Ayurvedic texts, and it can be managed according to the principle of Samprapti Vighatana (to break the pathogenesis).⁶

A 36year old female patient, a home maker, reported to the outpatient department of Regional Ayurveda Research Institute for Metabolic Disorders on 22^nd February 2016 with complaints of low back ache and painful heavy menstrual bleeding since 1year. She gave a history of irregular, heavy flow for 7 to 8days during each menstrual cycle. She was gravida 1, was nonvegetarian &had a less active lifestyle. She was diagnosed as having Fibroid from the prior reports and was advised hysterectomy. No other systemic complaints or family history related to this condition were significant. Past history seems to be insignificant. 

Clinical findings

General examination (RogiPariksha)

 All vitals were stable on examination and it was assessed that the patient belonged to Pitta-vatajaprakruti. Per abdomen examination revealed that abdomen was soft, non-tender and no organomegaly was detected.

Investigation

Ultrasound scan of Abdomen & Pelvis revealed that uterus was anteverted and bulky in size measuring 89*53*39mm and showed a small intramural anterior wall fibroid measuring 13*15mm. Haemoglobin- 10.3gm%, ESR- 10mm/dl

Diagnosis

The clinical features along with the ultrasound scan report suggests that it is case of Intramural fibroid and was diagnosed as Garbhashyagata (intrauterine) Granthi (encapsulated growth). Based on the symptoms, it was treated on the lines of Pradara (Menorrhagia) and Granthi.

Based on Ayurvedic line of management of Asrigdhara (menorrhagia) & Rajodosha (menstrual disorders)and granthi (tumour) and the clinical experience, we formulated the line of treatment from medicines available at OPD. She was advised the following medicines initially for a period of 3months to observe changes in the menstrual cycle (Table 1).

The treatment was scheduled initially for 3months with a follow up once in 15days, however it was extended for next 6months with the supportive results and interest of the patient, till patient was completely relieved of symptoms. Patient was observed for a period of 6 months without any medications (Table 2).

Fibroids also known as Uterine leiomyomas (fibroids or myomas) are benign tumours of the human uterus, and the single most common indication for hysterectomy.² About 20% to 80% of women develop fibroids by the age of 50. In 2013, it was estimated that 171million women were affected worldwide. After menopause, they usually decrease in size. However, the management of fibroids is undergoing an important evolution, with the focus on patient’s quality of life. Spies et al.⁷ showed that symptomatic uterine fibroids can have a negative impact on health related quality of life (HRQL) through impairment of daily activities and anxiety, which may develop before and after diagnosis.⁷ Patients report psychological distress, helplessness in dealing with the diagnosis and treatment options, negative body image, effects on sexuality and a lack of support.⁸

Accordingly, surgical techniques and aggressive treatments are reserved for only those cases with heavy symptomatology, while the clinical diagnosis based on size and number of fibroids remains in a second plane in this situations.⁹ In this case the patient opted for Ayurvedic treatment instead of surgery as hysterectomy would have long term complications like osteoporosis.

According to Ayurveda, Uterine fibroid is considered as Garbhashyagata (intrauterine) Granthi (encapsulated growth). The symptoms are similar to the condition “pradara” which is menorrhagia. Treatment was aimed at reduction of symptoms of menorrhagia as well as treating the fibroid. It is based on the Ayurvedic principles of karyakaranabhava (Cause and effect theory). When the effect is treated, it should have an impact on its causative factors also. It has been observed that fibroids have reduced to half its size by the end of 6 months of treatment and fully disappeared later.

Ashokarishta, is a popularpoly herbal Ayurvedic medicine mentioned in the classical text BhaishajyaRatnavali in the context of Streeroga (Gynecology).¹⁰ It is extensively used in the conditionPradara/Raktapradara/ Asrukdhara (as mentioned in Ayurveda) which is characterized by qualitative and quantitative increase in flow of menstrual bleeding. It mainly contains medicinal plants like Ashoka (Saraca indica Linn), Amalaki (Emblica officinalis Gaerth), Bibhitaki (Terminalia bellerica), Jeeraka (Cumimum cyminum Linn), Haritaki (Terminaliachebula Retz.), Shunti (Zingiber officinalis Rosc), Amra (Mangifera indica Linn), Vasa (Adhatoda vasica), Chandana (Santalum album), Daruharidra (Berberisaristata DC), Dhataki (Woodfordia fruiticosa  (L.) KURZ), Musta (Cyprus rotundus Linn), Kamala (Nymphaea nouchali BURM. F.), and Guda (Jaggery). It contains 5–10 % of self-generated alcohol, which acts as a medium for herbal active principles. Ashoka contains mainly tannins, saponins, β-sitosteroland exhibits anti-oxidant, anti-inflammatory activities, hence indicated in Uterine bleeding.¹¹ It has both antioxidant and Hematoprotective potentials which is essentially needed for management of menorrhagia.¹² Ashoka bark contains phenol glycoside which has direct effect on uterine musculature. It stimulates both endometrium and ovarian tissue. It decreases blood flow and tones up the endometrial vascularity and thus, checks excessive bleeding.¹³ 

Pushyanuga churna is mentioned in classical Ayurvedic text Charaka Samhita in the context of gynecological disorders.¹⁴ It contains medicinal plants like like Pata (Cissampelos pareira L.), Jambu (Syzygiumcumini (L.) SKEELS), Amra (Mangifera indica L.), Pashana bheda (Aerva lanata (L.) JUSS. EX SCHULT, Daruharidra (Berberis aristata DC), Shalmali (Bombax ceiba L.), Kamala (Nymphaea nouchali BURM. F.), Kumkuma (Crocus sativus L.), Ativisha (Aconitum heterophyllum WALL. EX ROYLE), Musta (Cyperus rotundus Linn), Bilva (Aegle marmelos (L.)CORREAEX.SCHULTZ), Lodhra (Symplocos racemosa), Rakta chandana (Pterocarpus santalinus L.F.), Kutaja(Holarrhena pubescens (BUCH.-HAM.) WALLICH EX DO), Dhataki (Woodfordia fruticosa (L.) KURZ), Yastimadhu (Glycyrrhiza glabra L.), Arjuna (Terminalia arjuna (ROXB.)WIGHT &ARN) and other drugs. It is also indicated in Asrigdhara (Menorrhagia, Metrorrhagia and other gynecological disorders.¹⁵ Pushyanugachurna acts as uterine tonic, menstrual regulator and astringent i. e. vasoconstrictive in action.¹⁶

Chandraprabhavati is a herbomineral Ayurvedic formulation indicated in Striroga (Gynaecological disorders), ArtavaRuja (Dysmenorrhoea) and other genitourinary disorders. It mainly contains Shilajathu (Bitumen) and Guggulu (Commiphora mukul) which exert scraping action,thereby help in reduction of fibroid. Lohabhasma (Ferrous compound) and Makshika (Copper pyrite) helps in balancing hematopoetic component.¹⁷

Poly herbal syrup also contains drugs Ashoka, Lodhra etc , the action of which are explained earlier. Most fibroids do not require treatment unless they are causing symptoms to the patient. After menopause, fibroids shrink, and it is unusual for them to cause problems. Symptomatic Management is mostly indicated except in extreme cases where invasive procedures or surgery is opted. In the present case, whether intramural fibroids are to be treated or not, was a major question. As per the study by Mayra J Thompson et.al 2016, it is reported in the literature the need to manage intramural myomas and to treat them appropriately.¹⁸ As the size of the fibroid was 13*15mm, it could have been self-limiting, but for the bothering symptoms of menorrhagia. Hence, it was decided to administer the Ayurvedic medicines available in the Outpatient department such as Ashokarista, Pushyanuga churna & Chandraprabhavati.

Surgical intervention need not be the only management for uterine fibroids. This case illustrates a situation where methodical Ayurvedic intervention can not only help in relieving symptoms but also restores fertility of the women and avoid further complications and successful management.

Authors are grateful to Director General, Central Council of Research in Ayurvedic Sciences for his constant support and encouragement.

Author declares that there are no conflicts of interest towards the article.

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