Case series on the effect of ayurvedic medications in the management of symptoms of vulvovaginal atrophy in postmenopausal women

Abstract

This case series investigates the effectiveness of Ayurvedic treatments in managing genital symptoms of Vulvovaginal Atrophy (VVA) in postmenopausal women. VVA, characterized by genital, sexual, and urinary symptoms due to reduced estrogen levels, significantly impacts the quality of life in this demographic. The study focuses on three cases of postmenopausal women presenting with common VVA symptoms such as vaginal burning, itching, and discomfort during intercourse. Utilizing Ayurveda's holistic approach, which emphasizes restoring balance through diet, lifestyle adjustments, and herbal remedies, the treatment targeted the underlying Vata dosha predominance and dhatu kshaya (tissue depletion). Treatment included local therapies like Yoni pichu (medicated vaginal tampons) and internal medications aimed at rejuvenating and strengthening the body's tissues. The outcomes highlight the potential of Ayurvedic medicine as a complementary approach to alleviate VVA symptoms, improve sexual function, and enhance overall well-being in postmenopausal women, underscoring the need for further research in this promising area.

1. Introduction

Vaginal health serves as a pivotal marker for healthful aging in post-menopausal women. Insufficient estrogen production alters the anatomy and function of urogenital tissue, culminating in Vulvovaginal Atrophy (VVA). Although VVA possesses the potential to impact women at any stage within their life cycle, its prevalence is particularly noted in the post-menopausal period. The manifestation of VVA is characterized through a triad of symptom categories: genital (encompassing dryness, burning, itching, irritation, and bleeding), sexual (including dyspareunia and various other sexual dysfunctions), and urinary symptoms (such as dysuria, increased frequency and urgency, along with recurrent urinary tract infections) [1].

The prevalence rate of genital symptoms linked to menopause increases as women progress through different menopausal stages. These symptoms typically worsen over time. Many women often do not report these symptoms and consequently do not receive treatment. Severe symptoms of genitourinary syndrome of menopause (GSM), also known as vulvovaginal atrophy (VVA), are directly linked to a decreased quality of life in postmenopausal women. This significant impact on the quality of life of many women should be acknowledged as being on par with other well-known conditions and diseases in the community [2].Nonhormonal treatments are often the first option for symptomatic women. Vaginal lubricants can reduce pain during sexual activity, but they do not have a long-term therapeutic effect [3]. Certain studies indicate that taking oral hormone therapy (HT) may exacerbate symptoms of urinary incontinence [4].

Ayurveda considers Rajo Nivritti (cessation of menstruation) as a swabhavika vyadhi (Physiological condition) happening in the middle of Praudhavastha and Jaravastha that is between the ages of 45 and 50 years [5]. In this phase, Vata dosha [6] is predominant. Kapha kshaya and dhatu kshaya are associated with Menopause. The kshina dhatu fails to perform their routine functions and also causes certain signs and symptoms depending upon the dhatu involved [7]. Yoni dhumayana, yoni vedana and maidhuna asakthi are the lakshanas of Sukra dhatu kshaya [8].

However, physiologically, it is essential to restore the average health of women during this period. As it is the period of Vata vridhi and dhatu kshaya occurring at Jaravastha, the treatment selected should be vata-samana,balya, jeevaniya, rasayana and rasadi dhatu vardhaka [9]. Rasayana may prevent disease, and helps to attain dhatu samyatha; thus the ill effects of Jara can be minimised [10]. Along with this, sthanika chikitsa (Local treatment) like Yoni pichu (vaginal tampon with medicines) indicated in the management of Yoni Vyapad chikitsa (Diseases of female reproductive organs) can also be utilized for management of genital symptoms of vulvovaginal atrophy in the postmenopausal state [11]. With increased life expectancy of modern times, women spend one-third of their life in the postmenopausal stage. Currently, well-established effective complementary and alternative medicine treatments for VVA are lacking.

2. Patient information

2.1. Case 1

A 49-year-old woman visited the outpatient department (OPD) with complaints of burning sensation in the vagina and painful intercourse for the last 3 months. She also experienced mood swings and excessive sweating, especially at night, which resulted in sleep disturbance. She reached menopause at the age of 47 and has no known comorbidities. Her blood glucose levels (Fasting Blood Sugar - 98 mg/dl; Post Prandial Blood sugar - 126 mg/dl; HbA1C - 5.4) and blood pressure (130/80 mm Hg) were within normal limits. No pus cells or epithelial cells were seen in the urine routine examination. Pap smear examination and per speculum examination showed no signs of cervical pathologies. Vaginal pH was 6.4. Cytologic examination of vaginal smear showed decrease in superficial cells and increase in parabasal epithelial cells. Trans vaginal Sonogram showed thin endometrium with 3.2 mm thickness.

2.2. Case 2

A 55-year-old female visited the outpatient department with complaints of itching in the vulval region and occasional thin discharge from the vagina. She experienced menopause at 51 years of age and had no known co-morbidities. Her blood sugar values were within normal limits. She had a history of similar complaints one year ago for which she received treatment from a gynecologist, including the local application of estrogen creams for a period of one month. After 8 months, the complaints recurred but she didn't seek proper attention until the symptoms worsened, leading her to visit the outpatient department.

Per speculum examination revealed a pale, dry vagina with absent mucosal rugae and mild inflammation of the cervix. Vulval inspection showed signs of itching. Ultrasound examination of the pelvis showed atrophic changes in the uterus and ovaries with a thin endometrium (3.8 mm). Vaginal pH was measured at 6.8. Microscopic examination of a vaginal smear showed an increase in parabasal cells and a decrease in superficial cells. There was no evidence of Trichomonas infection, candidiasis, or bacterial vaginosis.

2.3. Case 3

A 49-year-old woman presented at the outpatient department with persistent vaginal irritation for the last 8 months. She underwent a hysterectomy with bilateral salpingo-oophorectomy at the age of 45 in March 2019, due to uterine fibroids and had no history of prior hormone therapy.

Upon local examination, sparse pubic hair, dryness of labia, diminished elasticity and turgor of labial skin, and a narrower introitus were noted. The patient experienced pain upon speculum insertion, so per speculum examination was not performed. Vaginal pH was measured at 6.1. The vaginal smear revealed an increase in parabasal cells (25.5 %) and a decrease in superficial vaginal epithelial cells (2.8 %). The demographic details of the patients are presented in Table 1.

Table:1.

Demographic characteristics of patients.

Characteristics	Patient 1	Patient 2	Patient 3
Age (years)	49	55	49
BMI(kg/m2)	24.2	21.6	24.4
Occupation	House wife	House wife	House wife
Nature of physical activity	Moderate	Moderate	Moderate

3. Diagnostic assessment

The current paper discusses the therapeutic outcomes of Ayurvedic treatments on three post-menopausal women presented with at least one significant symptom indicative of atrophic vaginitis. The treatment regimen, encompassing both oral and local vaginal applications of Ayurvedic formulations, was administered at the Regional Ayurveda Research Institute - Thiruvananthapuram (RARI-TVM) during the period 2022–23.

The absence of cervical abnormalities was critical to selecting these subjects, a prerequisite confirmed through meticulous speculum examinations and Papanicolaou (Pap) smear tests. Furthermore, these women had not engaged in any oestrogen therapy treatments in the eight weeks preceding this treatment, nor did they have a history of liver disease, breast cancer, or other significant medical conditions. Additionally, other conditions causing chronic vulvar and vaginal itching, discharge, and pain were excluded relying on comprehensive medical histories, pelvic examinations, and Pap smear/microscopic analyses.

This exploratory inquiry into Ayurvedic interventions for atrophic vaginitis in post-menopausal women contributes to a broader understanding of alternative therapeutic options beyond conventional hormone therapy.

The patients were diagnosed with VVA based on their clinical signs and symptoms. Common clinical manifestations of VVA include vaginal dryness, itching, burning, and dyspareunia. To support the final diagnosis, vaginal pH and microscopic examination of vaginal smear were conducted. Vaginal pH was measured by placing a pH strip on the lateral vaginal wall until it was moistened. A vaginal pH > 4.5 indicates atrophic vaginitis. Microscopy was used to assess the relative proportions of parabasal and superficial vaginal epithelial cells. In postmenopausal women, a diagnosis of VVA is made if less than 5 % of superficial cells are present. Additionally, pelvic ultrasound shows the postmenopausal status of the uterus and ovaries.

4. Therapeutic intervention

The patients in all three cases received internal and external Ayurvedic medications considering the imbalance of doshas and the dhatukshaya (depletion of bodily tissues) due to Jara Avastha(ageing). (Table 2).

Table:2.

Details of treatment for VVA patients.

	Internal medications
Case 1	Internal medication
	Drakshadi Kashaya [11] (Chikitsasthana; Jwarachikitsa :Chapter 1,Verse 55-58.) 48 ml twice daily before food for 14 days
	Local treatment
	Yoni pichu (tampon soaked with medicine) with sukumara ghritha [11] (Chikitsasthana;Vidradi Vridhi chikitsa:Chapter 13,Verse 41-47) (Medicated ghee preparation) - done consecutively for a period of seven days per month, for three months on OPD basis
Case 2	Internal medication
	Aragwadhadi Kashaya [11][ (Sootrasthana; Sodhanadi gana Samgrahaniya: Chapter 15,Verse 17-18) 48 ml twice daily before food for 14 days
	External medication
	Yoni kshalana (vaginal douche) with Aragwadhadi Kashaya for seven days
	Local treatment
	Yoni pichu (tampon soaked with medicine) with sukumara ghritha (medicated ghee preparation) - done consecutively for a period of seven days per month, for 3 months on OPD basis
Case 3	Internal medication
	Satavari ksheera kashaya 60 ml twice daily before food for 14 days
	Local treatment
	Yoni pichu (tampon soaked with medicine) with sukumara ghritha (medicated ghee preparation) - done consecutively for a period of seven days per month, for three months on OPD basis

Patients were instructed to keep a thin pad soaked with sukumara ghritha at the external meatus once daily for a duration of 30 minutes daily over the course of the remaining three months to be self-administered at home.

For all three cases, yoni pichu with Sukumara ghrita was administered to address the local symptoms of vaginal atrophy [12]. Yoni pichu involves the use of a vaginal tampon made of cotton and gauze soaked in medicated oil/ghee/Kashaya. Before being soaked in ghee, the tampon was sterilised. Patients were instructed to empty their bladder before the administration of yoni pichu. The tampon was kept in the vagina for 1 h or until the urge to urinate. The tampon was designed with threads at the vaginal opening for easy removal by the patient.

5. Follow up and outcome

The assessment of symptom severity, vaginal pH levels, and the percentage composition of superficial and parabasal cells within the vaginal epithelium was conducted at baseline and subsequently after a three-month treatment period. Symptomatic evaluations were systematically undertaken bi-weekly during the course of treatment.

The outcomes of the treatment were significant, offering substantial symptomatic relief (Table 3)to all participants. Furthermore, measurements of vaginal pH and the distribution of epithelial cell types at the conclusion of the treatment period exhibited noteworthy alterations, as depicted in Table 4. Throughout this period, no adverse drug reactions (ADR) or adverse events (AE) were reported, indicating a favorable safety profile. Moreover, adherence to the prescribed treatment protocols among the study's participants was notably high.

Table:3.

Symptom severity assessment table.

Follow up period	Patient 1				Patient 2		Patient 3
	Burning Sensation Severity (0–10)	Dyspareunia Severity (0–10)	Mood Swings Severity (0–10)	Sleep Disturbance Severity	Vulval itching	Discharge per vagina	Vaginal irritation
Week 1	7	6	5	5	7	3	7
Week 4	3	4	3	3	3	0	5
Week 8	1	3	3	2	0	0	2
Week 12	0	2	2	1	0	0	0

Severity Scale: 0 = No symptoms, 10 = Severe symptoms.

Table:4.

Effect of ayurvedic treatment on main objective parameters.

	Vaginal pH		Cytologic examination of vaginal smear
	Before treatment	After treatment	Before treatment		After treatment
			Superficial cells	Parabasal cells	Superficial cells	Parabasal cells
CASE 1	6.4	5.2	4.2	35.2	6.8	23.7
CASE 2	6.8	5.7	3.1	27	5.5	19
CASE 3	5.9	4.3	2.8	47.5	6.2	42.3

6. Discussion

Approximately 50–60 % of women in the post-menopausal stage are affected by Vulvovaginal Atrophy (VVA), a condition that substantially impairs both the quality of life and sexual health of these women [13]. A significant challenge in the management and treatment of VVA is the pervasive lack of awareness among the affected population regarding the connection between their symptoms and menopause. Further compounding this issue is the general reluctance of these individuals to engage in discussions and seek medical advice for their condition, often due to feelings of embarrassment. This reticence hinders early detection and, consequently, the timely intervention of VVA, necessitating strategies to overcome these barriers to improve women's health outcomes in this demographic.

In Ayurveda, menopause, known as Rajo Nivrutti, is considered to be a natural occurrence and is described under Swabhava bala pravritta. Ayurveda considers Swabhava (by nature) and Jaravastha (Age) as causes for Rajonivritti. The symptoms of vulvovaginal atrophy (VVA) are similar to those described for vataja yonivyapath in Ayurveda, such as roughness, dryness, numbness in the vagina, tingling sensation, and pain. Rajonivritti is characterized by an aggravation of vata, alteration of pitha and kapha leading to their depletion, and subsequent depletion of dhatus resulting in decreased menstrual blood and ultimately diminished vitality. Management of discomfort related to Rajonivritti involves using rejuvenating (Jeevaneeya), vata-alleviating (Vatahara), and strengthening (Balya) medications. Rasayana drugs can be used to prevent further degenerative changes. Ayurvedic treatments for Yonirogas include internal and external oleation (Snehana), various forms of sudation (sweda), and localized treatments such as parisheka, kalka dharana, and pichu dharana using medicines that pacify vata.

Drakshadi Kashaya is recognized for its balancing effects on both vata and pitha doshas. Its efficacy is particularly noted in the management of symptoms associated with menopause, such as hot flashes, sleep disturbances, and mood swings. Consequently, it was administered orally in the first case presented. On the other hand, Aragwadhadi Kashaya, which harmonizes kapha and pitha doshas while also serving as an anti-pruritic (kandu nasaka), was utilized in the second case through yoni kshalana (vaginal douche) for a duration of seven days, addressing the specific condition presented. Shatavari possesses Balya (nutritive), Rasayana (rejuvenative) properties, along with qualities that balance Vata and Pitta doshas [14]. Ksheera, or milk, also has properties that pacify Vata and Pitha. It is Madhura rasa (sweet in taste) and Vipaka (digestive effect), Vrishya (supports vitality), Jeevaneeya (life-enhancing effects), and Dhatuvardhaka (promotes tissue growth) [11] (Sootrasthana; Dravadravya vijnaniya: Chapter 5, Verse 21-22.) Therefore, the administration of Shatavari ksheera kasaya (a medicinal preparation with milk) is both palatable, cost-effective, and beneficial for alleviating perimenopausal symptoms.

During the fertile years, the vaginal mucosa exhibits a thickened and rugated morphology, characterized by robust vascularization and lubrication for the majority of individuals. This physiological state facilitates sexual intercourse by reducing friction and potential injury. However, with the cessation of oestrogen production by the ovaries during menopause, significant morphological changes occur. The rugae, which are the folds that contribute to the elasticity of the vaginal wall, diminish, and the epithelial layer undergoes atrophy, leading to a reduction in vaginal elasticity. This condition can result in notable dyspareunia upon penetration. Concurrently, the activity of the sebaceous glands at the vulval area decreases, leading to a reduction in natural lubrication during arousal, further exacerbating discomfort during sexual activity. Additionally, the normal vaginal pH, which is maintained below 4.5 during the reproductive years as a protective mechanism against pathogens, rises to a value equal to or greater than 6 in the postmenopausal phase. This shift in pH further alters the vaginal microenvironment, potentially influencing the susceptibility to infections and the overall vaginal health.

The vulvovaginal symptoms observed during menopause may be attributed to Vata vriddhi (increase in Vata). The phenomenon of vaginal dryness can be categorized under terms such as raukṣyam (dryness) and paruṣyam (roughness), as delineated in the various manifestations of Vata imbalance, referred to as nata vikaras in Ayurvedic literature. Additionally, the condition of Yonisosham, marked by a notable absence of moisture within the vaginal region, is similarly recognized in classical Ayurvedic texts as a consequence of elevated Vata dosha.

Sukumara ghrita is described as rasayana in Ayurveda. It contains Punarnava (Boerhavia diffusa) as the main ingredient, specifically advocated for treating conditions within the vasti desa. Even though mentioned in the context of Vridhi chikitsa, its application extends significantly into the realm of both male and female reproductive dysfunction management. The methodology of administering medicinal substances through Yoni Pichu is noteworthy, as it facilitates the prolonged retention of therapeutic agents, thereby enhancing the absorption efficiency of ghee due to its lipid-soluble nature which seamlessly traverses the epithelial barriers. This practice not only serves to hydrate and soften a post-menopausal dry vagina but also aids in the restoration of vaginal pH balance. This, in turn, diminishes the susceptibility to vaginitis. In clinical observations, the application of Sukumara Ghrita via Yoni Pichu over a span of three months has evidently demonstrated therapeutic efficacy in all evaluated cases.

In the current study, notable improvements in symptoms, pH levels, and vaginal cytology were observed, with no adverse effects following a 12-week period of therapeutic intervention.

7. Patient Perspectives

Patient 1 (Recorded on 15th December 2022): "For months, I experienced burning in the vagina and pain during intercourse, which made me anxious and frustrated. After starting the Ayurvedic treatment, I gradually felt relief. By the end of three months, I could sleep better and felt more relief. The treatment was simple and did not cause any difficulties."

Patient 2 (Recorded on 28th March 2023): "Initially, I ignored the itching and discharge, thinking it was normal with age. But it kept coming back. I was hesitant to try hormone creams repetedly. The Ayurvedic treatment, especially the local applications, gave me lasting relief without any discomfort."

Patient 3 (Recorded on 10th April 2023): "After my surgery, I struggled with constant irritation and vaginal dryness. I was worried and didn’t know what to do. The Ayurvedic approach was very comforting. I noticed changes, and within weeks I felt much better. The treatment was easy to follow."

8. Informed consent

It was taken from each patient for publication of the study.

9. Conclusion

This report reveals the beneficial impact of Ayurvedic medications in managing the genital symptoms associated with vulvovaginal atrophy (VVA) in post-menopausal women.

Author contributions

ESS: planning and execution of treatment, follow up, documentation of case and drafting the article.

PB: treatment planning and reviewing.

LSR: Interpretation of data, Article drafting.

Declaration of generative AI in scientific writing

During the preparation of this article, the authors used Grammarly to check spelling and grammar. After this, the authors reviewed and edited the content as needed and taking full responsibility for the content of the publication. No generative AI tools were used to create content, generate ideas, or interpret results.

Funding sources

Source(s) of support in the form of grants, equipment, drugs, or all of these; NIL.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.