Supplements Mentioned - Turmeric, Hingvashtak, black cumin, Eranda, Anu Thailam, Ashok Powder, Lodhra powder, Kanchanar Guggulu, Shatavari Gritham, Sukumara Gritham.

Athreya family welcomes listeners to another case study podcast. Here at Athreya Herbs, we support Ayurvedic practitioners with these unique case studies which our community brings into discussions. We have with us the founder and director of Heal Ayurveda based in LA, Naomi Boas, a busy practitioner and a clinician at Southern California University of Health Sciences. She has been with us for quite some time and has very interesting cases. I am really proud of Naomi for the batch that she graduated from, where I teach as well. She is one of the successful practitioners out there in the Los Angeles area. Welcome, Naomi!

Naomi - Thank you so much and namaste Dr. Jay thank you for having me and I’m excited to be here.

Vaidya - We are excited to have you here now getting onto the case. I am really excited about this case as you have a very detailed intake which is essential for a case discussion. Shall we begin?

Naomi - Yes sure, so my client came to me in April 2020 and she had not had a menstrual cycle for the past three years which was her primary complaint. She is 27 years old, the Pitta-Vata constitution. She also has secondary complaints of  -Weight gain, irregular bowel movements, skin issues, and a few years ago she started feeling a little sluggish- Low energy.

Vaidya - For all our Ayurvedic practitioner families, in Ayurveda, missing periods in the active reproductive phase of life are called Anaartava, artava means the menstrual flow, and Anaartava means (lack of) non existing or missing menstrual flow. Three years is quite a period and you can definitely understand that this patient must’ve done everything in her capacity to address this.

Naomi - Yes she has and that is why she eventually came to Ayurveda as she was not getting any help elsewhere. She did get her labs done. She has low luteinizing hormone which also plays a role in it. It seems to have started when she was on her hormonal birth control pills for many years, she was not able to tell me exactly how many years but then she quit for three years and went back on copper IUD.

Vaidya - So she must’ve been on birth control right around her puberty or after the menstrual cycles become regular.

Then she went on from birth control pills to copper IUD.

Naomi - Yes, after that the periods went away completely And she hasn’t had a period in three years.

Vaidya - does she still have the copper IUD?

Naomi - No, she had that taken out.

Vaidya - So that is the primary complaint of this patient. It seems to be a case that needs the utmost attention. Can you give us a little more history of this patient, what all things she has done so that we can look into what has given her some relief or whether nothing has given any relief to her?

Naomi - the primary thing that she did it to that gave her some relief was acupuncture. She said when she was going to acupuncture consistently her periods returned for two months. And it was both the needling and herbs that she was taking. But after those two months, she has not had her period in 2 years. The second thing that she did was seed cycling to trigger her periods, She’s taking fish oil, turmeric, and B12. Her diet is mostly plant-based other than acupuncture and trying these supplements, and seed cycling, that's been fairly recent. I don’t know if she wasn’t doing it long enough to notice any change but at that time she came to see me. There was definitely no change.

Vaidya - The secondary complaint is also that she has been having weight issues along with these issues. I remember reading through the case history She also has some PMS symptoms.

Naomi - yes that is very interesting, so she does get PMS-like symptoms around certain times of the month however she was not able to pinpoint exactly when she should have been ovulating because obviously, she doesn’t have her periods so she doesn’t know about her cycles. She does become irritable, hungry, and moody around a certain time of the month. She says it's like she is getting the symptoms but nothing is coming out.

Vaidya - is there no white discharge or anything similar to that?

Naomi - No, she didn’t mention anything like that.

Vaidya - is she sexually active?

Naomi - No not right now, she isn’t sexually active and her libido was non-existent.

Vaidya - That makes sense because three years of no flow means that there is no nourishment going towards the reproductive tissues. Tell me a bit about her weight gain and what was the extra weight that she is referring to?

Naomi - she was around 135 to 145 lbs at some point although she said she has been changing her diet a little bit while doing various lifestyle changes like exercising a little more and she started to lose weight but as she says she is at a plateau of 121 lbs which isn’t too high but she feels like she can never get past this weight or go lower than that.

Vaidya - She has an image of her body which she wants to get to that shape but even with the diet and other protocols she is not able to get to that image of her body.

Naomi - exactly so she says she feels bigger and bloated around sometimes of the month and she said before the copper IUD she was able to lose weight really easily.

Vaidya - is there any gas or bloating because some people say that they want to lose weight but then there is bloating which they relate to this abdominal miss shape(disfigurement?) in the sense bloating makes their abdomen swell out a little bit where their body may change.

Naomi - Yes, She’s definitely has had to bloat and she was able to pinpoint certain foods like raw cabbage, protein at night eggs at dinner time or protein at dinner time seemed to be a thing and then the smoothie that she makes which is pretty heavy, she said that she feels like it just sits in her stomach.

Vaidya - so she is trying everything but isn’t mindful of what works and what doesn’t work. Is there anything other than that in terms of what kind of work she does?

Naomi - she is a chef at an Ashram but a fairly new job.

Vaidya -  Is the job stressful or not?

Naomi - It was not but she like many of us has been commuting and everything before so when I did have the Constitution we were already in quarantine so she actually said that she was feeling a lot less stressed because she wasn’t having to commute and be out and about.

Vaidya - I understand. Is she a vegetarian?

Naomi - Yes mostly she is plant-based so mostly vegan. She said that she isn’t as strict anymore because obviously, she’s trying to get her periods back so she is willing to do whatever within a certain capacity she can do.

Vaidya - are there any Mutravaha Srotas( please check this- Mutravaha Srotas (urinary system) and Srotogata Vikaras (urinary disorders) symptoms like urinating frequently or difficulty in urination?

Naomi - No she says nothing.

Vaidya - Can you give us some information about her bowel movements and digestion in general.

Naomi - very inconsistent for about three years and some days she doesn’t go at all So it’s very complicated and when it does come out it’s hard and it’s difficult to come out whereas the other days it’s runny and massive in the quantity that’s what she said. She said it’s gotten a little better, that she is focusing on consistent eating times also, adding probiotics did not help her fluctuating bowel movements.

Vaidya - Alright that’s a good piece of information right there. Apart from gas and bloating does she have constipation or runny or loose stool with a large amount of expulsion that happens once or twice a week?

Naomi - Yes correct.

Vaidya - has she gone through any miscarriages or abortions or pregnancies?

Naomi - She’s never had them. That’s about it, skin wise she does get breaks out in the Chin area and she feels like her pores are really large and clogged on her nose and her forehead. Also in the past three years again she hasn’t had a lot of energy.

Vaidya - There seems to be that three years ago there was something that triggered it maybe the IUD insertion or it something that was going on in her life that triggered this so everything traces back to the issue three years ago. How about exercises or any other physical activity?

Naomi - Yes she exercises regularly precisely one time a day. She tries to do yoga, so she tries to get some movement in at least once a day.

Vaidya - Is she doing anything for her low energy like an energy drink or a protein shake? Some people do have some kind of protein or energy stimulant.

Naomi - yes she has been drinking coffee at the time she came to see me she had just quit a few weeks ago and she Felt better that she had quit. I think in her smoothie she does Hemp protein.

Vaidya - Does she have any siblings? I am asking these questions because if anybody in her family has these issues her mom or siblings.

Naomi - she does have a younger brother she said is healthy, that's her only sibling but her mother has semi-irregular periods. But she never lost her period completely.

Vaidya - in the morning she has a smoothie, at lunchtime she has whatever she cooks in the kitchen or does she have a specific eating routine.

Naomi - She does have a routine. Her eating seemed pretty good. She had specific times a day, in the morning breakfast at 9, lunch between 12 and 1 dinner around 5 or before the quarantine, it was earlier than 6 or 7. At the time she came to see me she was experimenting with intermittent fasting also where she was skipping dinner as she was fasting. She is mostly plant-based but she will have an egg or a small piece of salmon depending on how she feels. So she is not a strict vegan.

Vaidya - So she is a Pescatarian. Did you notice her tongue?

Naomi - Yes I did, on video. Her tongue was pink with teeth marks and swollen. And also did have a slight coating.

Vaidya - So was it a thick tongue or just a regular tongue that is swollen with teeth marks on it. Was it a normal pink color with slight or very minimal Ama coating?

Naomi - It looked swollen and minimal ama coating.

Vaidya - How about pulse? 

Naomi - I didn’t get to because the consultation was online.

Vaidya - Does she have a regular sleep cycle.

Naomi - she sleeps between 10 and 11 wake up at 5:30. It is easy to fall asleep but sometimes she wakes up in the middle of the night but then she will go back to sleep.

Vaidya - So about 6 1/2 to 7 1/2 hours of sleep. How is her Agni in general?

Naomi - So she has a super strong desire to eat that is she has a super strong appetite and then she has those bowel movements which are super irregular. So she fluctuates between super constipated and massive and loose stool.

Vaidya - did you somewhat guess her Prakriti at this point.

Naomi - Yes, she had completed the form so I had that information.

Vaidya - So what type of bioenergy does she have?

Naomi - She’s a Pitta and Vata type.

Vaidya - I think we have enough information about this case to critically think and discuss what happened and where. As you mentioned she showed you some blood tests that had a low LH luteinizing hormone.

Naomi - yes and her doctor basically told her she doesn’t have any hormones she is not ovulating but he doesn’t know why and wanted her to go on birth control again. Of course, she doesn’t want to.

Vaidya - This is my observation sometimes what happens in some people when they get on birth control pills in the early part of their menstrual life their body will get a signal that the hormones are being supplemented from the outside and the natural secretion or production of these hormones sometimes comes down. That Could be the first piece of this patient’s puzzle why the periods were well regulated when she was on birth control for 6 to 8 years and then after she stopped they stopped as well. So birth control in some way is regulating externally the Prana and Apana flow. When we look at the hormonal regulation of the cycle we look at the Prana, Samana, and Apana flow. The birth control pills were regulating the hormones and once they were stopped, the Prana to Apana flow was without any external support. As I explained the body will stop making its own hormones when it is supplemented from outside. Right at the moment she stopped the birth control she went into the copper IUD and the IUD would have even worsened the Apana-Vata State. Apana and Vata would have gotten really aggravated, first of all, it’s not being regulated and pushed down in the Anuloma Gati (downward movement) of Vata which we know because Vata has to move downwards from Prana to Samana to Apana. This Anuloma movement or downward movement of Vata( Adhogati) Is disrupted or blocked by the IUD. There was a very feeble flow of Prana towards Apana then she introduced the IUD, this made the Apana get really aggravated. So what happens in these cases is that what is reflected in her bowel movement. The Apana gets aggravated and accumulates so on those days that it is accumulating she has those hard and difficult to pass bowels. When the Apana reaches its right amount or quantity that is needed for its movement and pushes out all the bowel- loose and also in large amounts so it is all related to the Apana not being properly moving. It is almost like a reservoir or a dam has been constructed because of IUD and now the dam has to fill up to the brim and then it overflows. So that is the mechanical detail behind the process that is taking place. The second is also the Aama aspect of it because the Mala(bodily waste?) is not moving properly, the Artava (female reproductive tissue or Menstruation) is not moving out of the body so whatever that constitutes the Artava is now reestablished into the body. This is a common thing among people who don't have a regular period they start gaining some weight because whatever waste that was supposed to go out when the Artava does not support the conception, the Artava present there would be reestablished into the body. An unhealthy Artava or Malaroopi that is the waste quality of the Artava is being reabsorbed. When it’s reabsorbed into the body what happens is that the blood gets more agitated because Artava and blood have a very close relationship because Rasa converts into Rakta in the liver, Rasa converts to Rakta in the uterus if it is conceived it supports the pregnancy otherwise is released out as menstrual cycle by the body. Right now what is happening to all that menstrual blood which is forming internally all the symptoms are present. She is irritable, she is moody which means internally the cycle is taking place. All the stagnant Artava is getting back into her blood which is making her break out in terms of skin issues and also she is having these energy issues because once the Rakta gets polluted by Artava then the Prana doesn’t circulate very well as Prana is the one circulated by Rakta. Rakta is somewhat deficient and abnormal it involves the skin and that is why the skin starts to break out. She may feel a little extra hot at night times. Usually, that is what happens in these people because when all the menstrual blood is being taken into the blood that is when she may feel a little extra hot or warm or extra sweaty and sometimes these people may also feel a bit moody or agitated or ravenous appetite, they may also have itching skin. Maybe in this particular case, it might not be present but I am just trying to inform the audience about what to look out for as Artava, Ama, Mala are trying to come through the skin.

Naomi - That is so interesting, she mentioned because of her body temperature that she always had cold hands and feet but when it’s hot outside she feels like she is dying because it is so hot.

Vaidya - Yes because cold hands and feet are because of General Vata aggravation that’s going up. The heat is all centrally built which means Koshta(gut) and then the organs are all warm or hot. These people will specifically at night time feel extremely hot like they would complain-I woke up and noticed the back of my head was sweaty. That is because when they lie down the Ama and Artava mixed blood will pool in the back of the body as it gravitates there. Otherwise, if it is because of the gut then whatever she is doing like the probiotics would make a little difference. It’s not coming from the Pitta origin, it’s all coming from Vata, Ama, and Kapha. That also explains why she has no libido because there is no Vata to instigate the interest in sex so Vata is responsible for that and she doesn’t have that.Ultimately the first approach to this case will be to push the Vata downwards helping Vata’s normal gati or movement that’s Adhogati. The action we will be looking at will be like Anulomana action and the possibility that this patient may have issues with conception because her mother also has been having these issues and she has herself been having these issues for the last 8 to 10 years. Once she gets the period back she should start with nourishing treatments right away because the Garbhashaya or the uterus would be depleted so soon after the periods are back she should go back to Artava nourishing herbs followed up by tissue nourishment because Vata has been chronically aggravated. Tissue damage is very common in Vata chronic conditions. Let us see what we can do in this case the first thing is that since she is having constipation and somewhat loose and large bowel movements, doing a Virechana will not be indicative because she may have a delicate digestive system being Pitta-Vata constitution, Virechana, for a Vata-Pradana-Anartava condition. Anaartava that lacks menstruation may not be a real suitable treatment, rather you start with something as simple as starting with Hingvashtak. Hing by itself has great action on the menstrual flow. In the past discussions I told you about this case where the patient came to me and asked how she can improve her menstrual cycle, she had two or three weeks of delay, and just taking one capsule of Hing made her cycle to come back in one or two days. Hing has the ability to push Vata down and specifically, Artava based Vata that needs to be mobilized. Hingvashtak three times a day about half a teaspoon is recommended to be taken with warm water before meals. Ideally, the classic way of administering the first morsel of the food with a little bit of ghee but that kind of a concept does not exist in our culture. Back in India, people do eat like that and I find that it is easier for people to just put it in a quarter cup of warm water, mix it, and drink right before eating which is also beneficial. So the patient can use it three times a day. Through this, you can also think of improving her gas and bloating. If you are doing this at the beginning of the meal then at the end of the meal you wanna do Garbhashaya Shudhikaran, There are specific herb in Ayurveda, Garbhashaya Shudhi cleanses the uterus and channels of Rasa towards the uterus. We have herbs like black cumin - Bhavaprakasha says Krishna Jeerakam( black cumin) Garbhashaya Shudikaram Param. Black cumin is one of the best uterine cleansers, it is very bitter and warming. It digests the Ama and moves the Vata down so half a teaspoon of black cumin and half a teaspoon of castor root powder or Eranda Moola Churna(Powder) (Eranda is the root of castor) mixed in hot water after meals. Eranda moola is very good for removing Vata from the colon and spine. Vata is mobilized in two ways- musculoskeletal mobilization and organ mobilization. This will take care of channeling the Rasa without Vata into the uterus. That is what we are trying to achieve with this. When I initially started I said that the Prana, Samana, and Apana flow is interrupted, so something has to be done for Prana. I would highly recommend that this patient does a course of seven days of Nasya. It will not only help her to clean the head and neck region but also so much of her life is surrounded or occupied by thinking of irregular periods, so it somewhat cleanses the thought process as well. We put up to 5 drops in each nostril before a shower because we are doing it as pratimarsha Nasya, not cleansing, we are doing it as a regularising type of Nasya. While the patient is lying down or has their head tilted up we put 4 to 5 drops in each nostril and lie down for another 2 to 3 minutes then gargle with hot water, spit it out and later in the shower whatever is coming out sniff it in and spit it out. That would make the luteinizing hormone secreted by the pituitary to be activated because if you don’t do the Shiras (the head action) then whatever one is doing Vata, Anulomana can bring what happened to the acupuncture and Chinese medicine, it’ll start but it won’t continue because we didn’t do the Prana aspect of it. If we do just the Apana or Samana aspect it would come back but it won’t be regulated. We do Nasya Kriya for 7 days whether it’s every alternate day or every third day or consecutively for the seven days in a month, every month is fine. In my practice, I have found that if you give them a little gap for example you do it one day with 1 to 2 days of the gap and then repeat again. That is because it is a bit sensitive and in people doing it after some time there is a bit of irritation, sniffing, they are constantly blowing their nose. Doing this every day can be a little taxing and especially in the summer season so it is better to do it once in 2 or 3 days that would help her in her case.

Naomi - Is Anu Thailam great for that?

Vaidya - Yes, it would be great. So we have the Apana and Ama aspect being taken care of, the Prana aspect being addressed by the Nasya Karma. Going towards the function of the uterus, the flow of Rasa towards the uterus, for that we can do a classical Arishtam - Ashokarishtam, Ashoka can be made into an alcoholic preparation if not then a combination of powder of Ashoka, powder of Lodhra, or capsule containing Ashoka and Lodhra which can be prepared. There are two types of treatments- Dosha Pratyanika Chikitsa, Vyadhi Pratyanika Chikitsa. In the treatment, we need to do something specific to the Dosha aggravation and something very specific to the disease itself or the disease pathway, what the disease has developed. The Ashoka and Lodhra are like tonics for the uterus, in the case you mentioned the patient’s uterus does not look abnormal but the flow is not happening. The flow can be improved by the astringent quality of Ashoka and Lodra. Both of them are Ruksha( drying in quality). So whatever stagnant plug-in has happened, like her skin pores that were clogged the same is happening to the uterus, and others are all clogged in. The Ashoka and Lodhra powders can be given. So, usually what I do is ask them to take Lodra and Ashoka Powder on an empty stomach in the morning and empty stomach at night. The quantity required is also very less. You can use a quarter teaspoon of each one of them, mix it with honey, and give it to the patient that is early in the morning and at night. By now you are thinking – the patient is taking Nasya, Hingvashtak, black cumin & Eranda at breakfast, lunch, and dinner, and now the third one. All our listening practitioners should always keep in mind patient’s will take something that is easy the compliance increases when you do something easy, if you gave them a long protocol being overambitious they will not be able to do it and come back saying that they were not able to do it or it was nasty or this was disgusting. We have to encourage the patients as much as possible, we already have three things going in that sense, maybe 1 or 2 pills will be the maximum you want to add. In terms of pills what can be suggested is that you wanna do something that reduces a bit of the body weight and help with Ama in Rasavaha Srotas, Mamsavaha Srotas, Medovaha Srotas. Kanchanar Guggulu- 2 in the morning, 2 in the night will be helpful for this patient. She is about 120 lbs so maybe two pills three times a day can be done. This would be the treatment in the initial month and then when she comes back we will think about something to improve or reinforce the flow of Artava, which would be something like Shatavari, Vidari Kanda. Do you remember about the tonic herbs that we want to do on the second follow-up, that is what you need to do for this patient. Don’t recommend Shatavari and Ashwagandha in the first visit because there is Ama that is clogging and Vata is not able to move them through so you want to do a little bit of Ama Pachana that is done by the black cumin as Vata Anulomana that is done by the Hingvashtak, these things can be the first steps of the treatment and then continue with the nutritional or types of herb. I welcome you to share with us what was going on in your mind when you were dealing with this case.

Naomi - I honestly did not go that in-depth with the details as you explained but I did of course trace it back to the birth control and the IUD just affected her hormones and created an imbalance. The thing I really understood from your case analysis is because I was thinking since she is not getting a period she probably is dry and needs nourishing herbs. I was also thinking Ghee or Shatavari Ghee and the female herbs like Ashoka came to my mind but I feel like I was skipping the first steps in a way and going straight to nourishing her. This was really informative.

Vaidya - If The same patient was about 95 lbs and immediately I would’ve switched to thinking she is a Krusha, it means having a lean body so we would’ve definitely gone towards Shatavari Gritham, or Sukumara Gritham or Phalasarpis Gritham all of these can be beneficial. Naomi you got to the right area, remember she will have fertility issues when she gets her periods back. You want to recommend this ghee for an extended amount of time like 1 teaspoon every day for 6 months as it will make her fertility and libido come back.

I think this was a great case and we went into the clear Vata protocols and how we got to the core and of its manifestation. I think it will take about 3 to 4 months for this patient to respond to the treatment or start having somewhat regular periods. So you can Inform her that you can help but you have to tell her that she would need to invest in about six months.

Naomi - yes and she is one of those types that will follow up. She followed up to give me her lab results and is constantly present in asking if I have any other suggestions. So I think she will definitely be compliant and stick with it.

Vaidya - Coming to the last part any nourishment should be from the diet point of view and not an herbal point of view initially. You can keep her on stews, soups at night. Now it might be okay to even do some kind of raw food at the lunchtime but with sufficient amounts of Sandigdha Dravyas like maybe olive oil with the salad or sesame seeds roasted or hemp seeds, something which will be bitter in terms of the salad ingredients and a little bit of the oiliness will help her to digest the Amma and regulate or balance out the Vata, so diet can be nourishing in this case.

I really enjoyed discussing this case, I would look forward to getting your feedback about how the patient responded to the kind of protocol that we were doing. When you are back on the podcast we will briefly touch base with this case. Thank you Naomi for taking this time and sharing your experience and patience with us. It is a great Dharma for the Ayurvedic profession as such to bring these cases to discuss and help other Ayurvedic practitioners here through Athreya Herbs.

Naomi - thank you so much, Dr. Jay. I learned so much and my client will be really happy as well. I very much appreciate it.