Green gram soup and barley porridge as dietary interventions for management of premenstrual syndrome in adolescent girl: A case report

Abstract

Women suffer from various conditions related to menstrual cycle due to changing lifestyle, bad food habits, physical and mental stress. Pre Menstrual Syndrome (PMS) is a combination of physical and emotional symptoms that many women get one or two weeks before the start of their menstrual period. In the present study, 14 years old female patient having symptoms-lower abdominal pain, backache, breast tenderness, constipation, pimples, tiredness and unexplained anger typically in luteal phase from last 4 months, was diagnosed with mild to moderate symptoms of PMS. After proper analysis, she was suggested to consume light to digest dietary articles advised in classical texts for minimizing specific symptoms during menstruation.Thus Green gram Soup and Barley porridge was prescribed to her as lunch and dinner respectively for first three days of menstruation cycle for continuous 6 cycles. It is observed that consumption of these dietary products during the menstruation time period assisted to minimize the symptoms of PMS. This illustrates that there is a wide scope to explore the ayurvedic dietary regimen recommended during menstruation which can be used more rationally to suit menstrual disorders.

1. Introduction

Pre Menstrual Syndrome [PMS] is a common health issue in teenagers and young women. According to American College of Obstetricians and Gynecologists (ACOG), PMS is a clinical condition portrayed by the cyclic presence of behavioral, affective and somatic groups of symptoms in luteal phase and relieved typically with the end of menstrual cycle [1]. Scientific evidence indicates that alterations in lifestyle choices and dietary patterns can influence the menstrual cycle, potentially leading to a spectrum of outcomes ranging from minor menstrual disturbances to substantial implications for fertility [2]. Improper dietary patterns are accountable for disturbing healthy menstruation cycle [3]. However, consumption of healthy diet is helpful to maintain physiological state of menstruation [4]. Ayurved science has emphasized certain code of conducts to be followed by menstruating women for first three days of every menstrual cycle [5]. Behavioral and dietary regimen is especially advised which might be useful for correction of associated symptoms of menstruation [6]. Amongst different dietary articles green gram soup and barley porridge (advised diet articles) assumed to be useful in management of mild to moderate symptoms of PMS [7,8]. Thus, in the present case report the effect of green gram soup and barley porridge was tested in 14 year old female suffering from PMS.

2. Patient information

The female patient aged 14 years was a student in ninth grade from Pune, India. She was of medium built, with a height of 155 cm, weighing 44 kg and BMI 18.3kg/m², Blood pressure 110/80 mmHg, Pulse 70/min, conscious and oriented.

2.1. Present medical history

The patient approached at Shree VishwAnagad Ayurved Clinic, Pune, India, on June 24, 2021 (fourth day of her menstrual cycle). She was reported mild lower abdominal pain localized to the hypogastric region, radiating to the lower back, mild bilateral breast tenderness and moderate constipation with lumpy, sausage formed stools. She was experiencing moderate - facial acne predominantly located on both cheeks, characterized by comedones and papules, constipation, fatigue, unexplained irritability. Symptoms like acne, constipation, fatigue and unexplained irritability initiated approximately 6–7 days preceding the onset of menstruation. She reported lower abdominal pain, lower backache, breast tenderness 2–3 days before menstruation. The symptoms worsened in severity on the day preceding and during menstruation. By the fourth day of menstruation, the patient reported relief from lower abdominal pain, lower backache, breast tenderness and unexplained irritability. However, fatigue, constipation and facial acne remained present until day 6–7 of the menstrual cycle. This cyclical symptom pattern has been consistent over the past four menstrual cycles. The patient was advised to undergo a comprehensive assessment including hematological analysis, glucose profiling, thyroid function testing and abdomino-pelvic ultrasonography. However, all resultant data obtained from these diagnostic modalities exhibited values within the established normal range.

Menstrual history: Her menarche age was 12 years and the menstrual cycle is at regular intervals. Cycle is of 28–30 days, with four days of bleeding pattern. Menstrual flow characteristics are color: red, smell: blood smell, not associated with blood clots. However, from the last four months she had been experiencing lower abdominal pain, backache, constipation preceding her menstruation. For the last three months, she was experiencing breast tenderness, unexplained anger and occurrence of pimples, leading to tiredness throughout her menstrual period.

Ayurvedic view point inspection [9,10]: Her body constitution is Pitta-Kaphadosha dominant, having medium sattva (psychic state), agnimandya (low digestive power), nadi (pulse): pittapradhan kaphanubadhi, tongue: sama (coated), koshtha (nature of bowel): krura (hard), mala (feces): sama mala (foul smelling, sticky stools), mutra (urine): pale yellow, 6 to 7 times per day, no burning sensation, no nocturia.

2.2. History of past illness

No history of metabolic diseases like diabetic mellitus, thyroid disorder, PCOD, dysmenorrhea, anemia, affective disorders. No history for use of contraceptive pill.

2.3. Family history

Patient's father has a 15 year history of type 2 diabetes and is on prescribed allopathic medicines. Her mother has no history of menstrual problems. There is no significant medical history in other family members. The patient has a younger sister, aged 8, who has not yet reached menarche.

2.4. Patient's daily routine

We noted the patient's daily routine (the approximate timing has been mentioned in parentheses). The patient reported waking up (usually 6:30 a.m) followed by light exercise and shower. Breakfast commonly consisted of poha, upma, paratha or an egg omelet, along with a cup of warm cow milk (between 8:00 am to 8:30 am). Due to the online schooling, this routine was consistent Lunch typically included, vegetarian dishes such as chapati, vegetable curry and salads (between 12:30 p.m. and 1:30 p.m.). In the evenings, she ate light snacks before light outdoor activities and studying, followed by dinner (around 7:30 p.m.–8.00 p.m.) and a light walk and them went to bed (by 10:30 p.m.). Notably, her daily meals for lunch, evening snacks, and dinner typically comprised dry, spicy, and tangy food items like bhakri and dry chutneys, pickles, chickpea flour articles (farsan, bhel) almost 5–6 times per week.

2.5. Etiology and physiopathology of disease

The consumption of pungent, salty and sour foods may contribute to the development of disease conditions through disruptions in the functions of Vata and Pitta, as well as imbalances in the Rasa, Rakta and Raja tissues, leading to disturbances in the Rasavaha and Raktavaha srotas. Despite a regular menstrual cycle occurring every 28–30 days, with a four-day bleeding pattern characterized by normal flow without clots, the patient exhibited symptoms including lower abdominal pain, backache, constipation, breast tenderness, unexplained anger, pimples and fatigue throughout the menstrual period. These symptoms are contrary to the normal menstrual experience according to Ayurveda. According to Ayurvedic principles, this condition is diagnosed as Vatapittaj Rajodushti, indicating an imbalance primarily involving Vata and Pitta doshas during menstruation. As per ACOG. diagnosis criteria, present symptoms cover affective and somatic groups of symptoms. Symptoms erupt in the luteal phase and are relieved typically with the end of the menstrual cycle. History of complaints is for 4 consecutive cycles which confirmed the Premenstrual Syndrome [[1], [11]].

3. Treatment protocol

Patient was having mild to moderate symptoms of PMS and not meeting PMDD (Premenstrual Dysphoric Disorder) criteria, thus no pharmacological intervention was advised [12]. She was advised to follow her routine and asked to consume specific diet regimen viz Green gram soup and Barley porridge. This diet has been outlined as diet for menstruating women. having therapeutic potential of ingredients towards Rasa, Rakta, Shukravaha srotas (microchannels) (Table 1).

Table 1.

Diet articles consumption schedule for patient.

Sr No	Diet regimen	Dose	Duration	Administration time
1	Green Gram soup (MudgaYusha)	250 gm	First 3 days of menstruation cycle for continuous 6 cycles [total 6 months cycles]	Lunch
2	Barley porridge (YavaPayas)	150 gm		Dinner

Preparation of advised products takes longer time period of cooking, thus ready to use sachets of both products along with preparatory leaflet were given to her at every visit. She was put on diet regimen (details provided in the Box 1 below): 250 gm of Green gram soup for lunch and 150 gm of Barley porridge for dinner only for the first 3 days of menstruation cycle for continuous 6 cycles [total 6 months cycles]. She was not advised to change her routine and diet for rest of the days. If the patient desires a larger quantity of food, additional sachets of the prescribed diet were given to her. If she required to eat in between two meals, then she was permitted to have fresh seasonal fruits like mango, jackfruit, fresh coconut, pomegranate, ripened small banana, cow milk, ghee and rock salt processed ShaliLaja (puffed rice). She was asked to record diet during the study duration (six months).

Box 1. Preparatory guidelines.

• 1.Method of preparation of Green Gram Soup: Ready to cook Sachet A (Green gram powder-30 gm) should be taken out in a stainless steel vessel. Add 300 ml of potable water in it and cook on low flame without keeping a lid on the vessel till the mixture achieves semisolid consistency. Lastly add Sachet B (powder of Prakshep Dravyas-Dried pomegranate arils 4 gm, Rock salt 3 gm, Dry ginger powder 0.5 gm, Coriander seeds powder 1 gm, Long pepper powder 0.5 gm, Cumin seeds powder 1 gm - Total: 10 gm) to the boiling soup with homogeneous mixing. Have this whole warm mixture for lunch.
• 2.Method of preparation of Barley porridge: Ready to cook Sachet C (Barley powder 20 gm and candy sugar- 10 gm) should be taken out in a stainless steel vessel.Add 125 ml of Cow Milk to the above mixture. Boil the mixture on low flame without keeping a lid on the vessel until Barley is cooked completely and semisolid consistency is attained.Have this warm Barley porridge for dinner.

Alt-text: Box 1

Follow up & Outcomes:

It was conductedevery month on the fourth day of menstruation for 6 consecutive cycles. Symptom severity and number of episodes in luteal phase to first four days of menstruation recorded by her were observed. Also regular consumption of advised dietary regimen was observed.It is observed that patient has consumed dietary regimen advised to her. Also no additional dietary sachets were required during the course of treatment. The patient recorded her symptoms along with their severity grades on a daily basis. These symptoms were predominantly observed starting one week before menstruation and continuing until the fourth day of menstruation. The occurrences of these episodes were calculated and are presented in a table. From Table 2, it can be said that substantial relief for lower abdominal pain, backache, breast tenderness, constipation, tiredness was perceived in patient, whereas complete relief for occurrence of pimples was not achieved. To minimize unexplained anger and to maintain the diet continuity, counseling during each visit worked well (Table 2).

Table 2.

Patients symptoms episodes before-after treatment record.

Symptom	Number of Episodes (from 1 week before menses to 4th day of menses)
	Before treatment	1st Follow-up	2nd Follow-up	3rd Follow-up	4th Follow-up	5th Follow-up	6th Follow-up
	20/06/21	19/07/21	17/08/21	16/09/21	16/10/21	15/11/21	13/12/21
Unexplained Anger	8	7	7	4	2	1	1
Tiredness	10	7	9	7	4	3	1
Breast tenderness	5	2	7	2	1	0	0
Back pain	9	5	6	4	3	1	2
Abdominal pain	7	4	5	2	2	1	2
Constipation	10	11	11	10	6	5	6
Pimples	9	10	11	11	9	7	6

4. Discussion

PMS is the commonest health issue in young women. It's is a cyclic phenomenon of somatic and affective symptoms appearing in the luteal phase and interfering with one's work or lifestyle followed by a symptom-free interval right from the fourth day of menstrual cycle to next luteal phase (day 13) [13]. According to ayurved, this phase is called as Rutuvyatit kala which is governed by Pitta dosha. Patients' symptoms persist for four days during the menstrual cycle (rajastravkala), which is regulated by the vata dosha [14]. The patient's symptoms, including lower abdominal pain, backache, breast tenderness, constipation, pimples, tiredness and unexplained anger, primarily indicate an imbalance in vata and pitta doshas. During PMS, unexplained anger may be mediated by complex interactions involving hormonal fluctuations impacting neurotransmitter activity, along with psychological stressors and the mind-body connection. Despite the patient's menstrual cycle maintaining regularity with a duration of 28–30 days, characterized by a four-day bleeding pattern and normal flow without clotting, she consistently experienced the mentioned symptoms during specific intervals of her cycle.From an Ayurvedic viewpoint, the symptoms stem from the interplay of vata dosha, the mind and rasadhatu. Many of these symptoms arise due to obstruction in the apana vata, resulting in constipation and menstrual irregularities. The patient's diagnosis of Vatapittaj Rajodushti signifies an imbalance in vata and pitta during menstruation. Additionally, the presence of Mandagani, indicating low digestive power, exacerbates this imbalance, further disrupting rasa and raktadhatu, impacting menstrual microchannels and contributing to premenstrual syndrome. Consequently, this disturbance extends to Aartavavaha (menstrual microchannels) and Manovaha Srotodusti (mind), ultimately contributing to premenstrual syndrome. Despite the patient generally adhering to a healthy lifestyle, the primary etiological factors in her case were traced back to improper dietary habits. She exhibited a strong preference for dry, spicy, and tangy tastes, consistently consuming meals with similar flavor profiles. This dietary pattern likely contributed to the vitiation of Vata and Pitta doshas, ultimately leading to the manifestation of vatapittaj rajodushti (PMS). Since all of her symptoms were of mild to moderate severity and did not meet the criteria for Premenstrual Dysphonic Disorder (PMDD), no pharmacological intervention was recommended. However, dietary guidelines specific to menstruation were advised to be followed during her monthly cycle. Suggested dietary regimen containing green gram and barley as main source drugs along with herbal additives, processed with heating, converted into food articles such as green gram soup and barley porridge proved to be minimizing PMS symptoms seen in the patient. Green gram soup is recommended for maintaining sharirbala (strength) and normalizing agni (digestive fire). Its properties of being laghu (easy to digest), deepan (appetizer) and vatashamak (pacifying vata) may contribute to alleviating associated menstrual symptoms. Similarly, the properties of Barley porridge, such as koshtha shodhana (promoting bowel evacuation) and karshana (toning), are emphasized. Together, these dietary components synergistically improve Agni, pacify apana vata, and nourish Rasadhatu (plasma tissue) and other bodily entities. Over a six-month period, the combined effect of consuming both dietary products helped this patient, who maintained a healthy lifestyle, to find relief from PMS symptoms.

4.1. Limitation of case report

While this outcome was observed in a single patient, further research on a larger sample size would be necessary to establish evidence for the significant effectiveness of such dietary products in relieving symptoms of premenstrual syndrome (PMS).

4.2. Strengths

The case report allowed for the assessment of the prescribed dietary regimen's effects when administered for three days during menstruation for continuous six cycles. There were no dietary alterations for the remaining month. The patient experienced relief from PMS symptoms, excluding pimples. This relief was achieved through the dietary changes implemented during the initial three days of her menstrual cycle. Consistent counseling and support from family members played a pivotal role. They maintained the patient's adherence to the treatment and encouraged the adoption of a healthier lifestyle.

5. Conclusion

Diet including green gram soup and barley porridge for the first three days of menstruation over six continuous cycles alleviated mild to moderate symptoms of premenstrual syndrome in an adolescent girl following a healthy lifestyle.

Patients perspective

"I experienced lower abdominal pain, backache, breast tenderness, constipation, pimples, tiredness and unexplained anger since some months. All these symptoms starts before a week of onset of my menstrual cycle and improve with the cycle ends up i.e. on the 4th day of menstruation, which has been occurring since last 4 months. My mother decided to take advice from my family physician and thus visited Shree VishwangadAyurved Clinic, Pune on June 24, 2021. I have listed all my complaints to the doctor. She took my whole history for half an hour, diagnosed & explained to me about the PMS. She also explained me about my age and need of modification of my diet and basically rather than taking any medications. This was biggest relief as I was very nervous to start any medicines. So they put me on the specific diet i.e. Green gram soup and Barley Porridge for first 3 days of menstruation for continuous 6 cycles. Firstly it was difficult for me to keep on only this diet but later on day by day I was feeling very good and my all the symptoms except pimples [not that much changes] were significantly reduced. Doctor keeps boosting me throughout my journey. At last I am feeling healthier even I think twice before having junk food now; my cravings for spicy and tangy food reduced. My eating habits are improved a lot & I see new me. I thank a lot to doctor for advising me the best dietary regimen."

Informed consent

Written informed consent for publication of patient's clinical details was obtained from her before initiation of treatment.

Source of funding

This paper did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Ankita Shirkande: Conceptualization, Methodology, Software, validation, formal analysis, investigation, resources, data curation, Writing – original draft, Writing – review and editing, Visualization, Supervision, Project administration, Funding acquisition Madhuri Pawar: formal analysis, Visualization, Supervision Abhijeet Shirkande: Conceptualization, Methodology, Software, validation, formal analysis, resources, data curation, Writing – original draft, Writing – review and editing, Visualization, Supervision, Project administration, Funding acquisition Gunvant Yeola: Visualization, Supervision.

Declaration of generative AI in scientific writing

None.

Conflict of interest

None.