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INTRODUCTION
Asrigdara is defined as excessive and prolonged menstrual bleeding, or even scanty bleeding occurring between menstrual cycles. It is termed as Pradara due to the excessive discharge of Raja, and when there is an excessive excretion of Asrk (blood), it is specifically referred to as Asrigdara.[1] Acharya Charaka has described Asrigdara as a distinct disease entity along with its management in the Yoni Vyapada Chikitsa.[2, 3] He has also classified it under Raktaja Vikara and mentioned its pathogenesis as Pitta Avrita Apana Vayu.[3, 4] Acharya Sushruta has described Asrigdara as a separate disease in the Sharira Sthana, specifically in the Shukra Shonita Shuddhi Sharira Adhyaya.[1, 3]
In Samhitas, many causative factors like Atilavana, Amala, Katu rasa sevana, Viruddha Ahara and Vihara like Chinta, Bhaya, Krodha, etc., are explained as Nidana of Asrigdara. Vitiated Vatadi Doshas affect the Artava Vaha Strotasa and causes Asrigdara. If not properly managed, Asrigdara can lead to several complications (Upadrava) such as Bhrama, Moorcha, Daha, Angamarda, Pralapa, Pandutva, and Tandra, among others. Acharya Charaka describes four types of Asrigdara - Vataja, Pittaja, Kaphaja and Sannipataja. Madhava Nidana, Bhavaprakasha and Yogaratnakara also mention the same. Acharya Charaka, while describing treatment, mentions management of Pitta-Vataja Asrigdara, which implies acceptance of Dwidoshaja Asrigdara.[5]
Pubertal menorrhagia refers to excessive and/or prolonged uterine bleeding that occurs during adolescence, especially in the early post-menarche years, in the absence of any organic pelvic pathology. The most common cause is the physiological immaturity of the hypothalamic-pituitary-ovarian (HPO) axis, which results in anovulatory cycles due to lack of a luteal phase and progesterone deficiency.[6] This leads to unopposed estrogenic stimulation of the endometrium, causing endometrial proliferation without regular shedding, and eventually irregular, heavy or prolonged bleeding.[7] Pubertal menorrhagia is typically self-limiting as the HPO axis matures, but if unmanaged, it can result in iron deficiency anemia and negatively impact the adolescent’s quality of life.[8] Most cases occur within the first two years of menarche and constitute a significant portion of abnormal uterine bleeding in adolescents.[9] In such cases, reassurance, correction of anemia, and hormonal therapy, if needed, form the basis of treatment.[10]
Among the three Doshas, Vata plays a significant role in both the physiology and pathology of the reproductive system, and Basti is regarded as the most effective treatment for Vata-related disorders.[11, 12, 13] Along with Basti, Nasya Karma (transmucosal nasal administration) is also commonly recommended in the management of Vandhyatva (infertility) and various menstrual disorders.[13, 14] Acharya Kashyapa explains the use of Nasya in Atyartava and Artavakshaya in the chapter Shatapuspa Shatavari Kalpa Adhyaya, which is clinically found effective. According to Acharya Kashyapa, Nasya Karma administered just after menstruation can cause Soshana of Yoni (dryness due to reduced estrogen), suggesting that Nasya may potentially modulate estrogen levels-an essential therapeutic approach in the management of menorrhagia caused by hormonal imbalance.[15]
PATIENT INFORMATION and CLINICAL FINDINGS
All related information with Signs and Symptoms present at the time of enrolment in both the patients are given below (Tables 1).
| PATIENT | 1 | 2 |
|---|---|---|
| Date of Visit | 05/09/24 | 09/01/25 |
| Age (Years) | 13 | 16 |
| Sex | Female | Female |
| BMI | 21.5 kg/m2 | 18.9 kg/m2 |
| Symptoms | Excessive menstrual bleeding PV with increased duration Severe pain in abdomen during menses | Prolonged and excess bleeding PV during menses with reduced intermenstrual period |
| Onset (years) | 2 years | 1 year |
| Menarche | Before 2 years (Age-11) | Before 3 years (Age-13) |
| Pelvic Pathology (ruled out by USG) | Absent | Absent |
| LMP at 1st visit in OPD | 24/08/24 | 04/01/25 |
| Thyroid Dysfunction | Absent | Absent |
| Other systemic illness | None | None |
| Past Tx | Hormone replacement by OC Pills, Bolabaddha Rasa | None |
| Past Tx Duration | OCPs for 2-3 months after 1 year of menarche, Bollabaddha Rasa for 2 months after about 4-6 months of previous treatment | - |
| Current Tx | Udumbara Phala Nasya | Udumbara Phala Nasya |
| Current Tx duration (follow up) | 7 days for 2 consecutive cycles 3 times (every month after cessation of menses) | 7 days for 2 consecutive cycles 3 times (every month after cessation of menses) |
| SIGNS AND SYMPOMS | ||
| LMP | 23/08/24 | 04/01/25 |
| PLMP | 31/07/24 | 16/12/24 |
| Menstrual Cycle Duration Interval Pain during menses Passage of clots Foul Smell Pads per cycle | 8-10 days 10-20 days +++ ++ + 30-35pads/cycle | 10-11 days 15-25 days ++ ++ - 35-40pads/cycle |
| Menorrhagia | ✓ | ✓ |
| Metrorrhagia | × | × |
| Polymenorrhoea | ✓ | ✓ |
| Dysmenorrhoea | ✓ | ✓ |
| Irregular Cycles | ✓ | ✓ |
| Gen. weakness and Lethargy | ✓ | ✓ |
| Dizziness | ✓ | × |
| Weight loss | Mild | Severe |
| PALM-COIEN criteria | × | × |
| Coagulopathy | × | × |
| Vitals | Stable | Stable |
DIAGNOSTIC ASSESMENT
Investigations done before enrolment of patients are described in (Table 2)
| PATIENT 1 | PATIENT 2 | |
|---|---|---|
| USG findings Uterus Rt ovary Lt ovary ET Other comments | N- 57×28×42 mm N - 24×16 mm N - 23×17 mm 10.3 mm Not any | N- 56×26×50 mm N - 22×12 mm N - 20×14 mm 6.3 mm Min to mild free fluid in cul-de-sac |
| CBC: Hb RBC WBC PC | 9.8 g% 4.64 mil/cmm 6900/cmm 347000/cmm | 10.6 gm% 4.31 mil/cmm 12600/cmm 288000/cmm |
| BT CT | 1:57 min 4:41 min | 2:13 min 5:33 min |
| RBS | 105 mg/dl | 119 mg/dl |
| TSH T3 T4 | 2.160 mcIU/mL 1.04 ng/dl 90 mcg/mL | 2.29 mcIU/mL 1.567 ng/dl 75 mcg/mL |
Based on history and clinical investigations patient 1 and patient 2 are diagnosed with Dysfunctional Uterine bleeding, which is abnormal uterine bleeding in absence of any pelvic pathology. This can also be titled as Pubertal Menorrhagia but as per Ayurveda we can correlate with Asrigdara based on her lakshanas (~symptoms) similarity with DUB i.e., Deergakala anubandhi (~prolonged menstrual bleeding), Atiartava pravritti (~excessive menstrual bleeding), anrutavamapi (~intermenstrual bleeding or reduced interval of cycle). Here Pubertal Menorrhagia can be titled under DUB.
CASE 1
Her USG was performed on September 05, 2024, and no significant abnormality were detected, the Endometrial thickness was 10.3 mm. This USG was performed on 13th day of her menstrual cycle which can be considered as a normal scan. She already had other blood investigations done priorly on August 16, 2024. Which showed normal Haematocrit levels, normal Thyroid function test, normal bleeding and clotting time. This can be concluded as the patient was having complaint of Menorrhagia in absence of any Pelvic pathology, Thyroid dysfunctions or any coagulopathies. However, her Haemoglobin level was very low i.e. 9.8 gm%. This might be because of excess blood loss through menses. Hormone assessment was done during late follicular phase (on16/08/25) showed high level of LH (Luteinizing Hormone) which was 20.26 with normal level of FSH (Follicle Stimulating Hormone) which was 5.71. Such high levels of LH and presence of complaints despite normalcy of other investigations suggests that ovulation was about to proceed soon after the LH surge but she got her menses in next 7 days (without medication) which clearly suggests Luteal Hase Defect occurring with reduced levels of Progesterone. This normally occurs in early menarche where there is absence of Progesterone with unopposed Estrogen.
CASE 2
Her USG was performed on January 01, 2025, and no significant abnormality were detected, the Endometrial thickness was 6.8 mm. This USG was performed on 6th day of her menstrual cycle which can be considered as a normal, but the scan shows presence of free fluid in cul-de-sac which is normally seen at the time of Ovulation. Hence this case can be considered of having early ovulation that might causes early bleeding. After that other blood investigations were done priorly on same date. Which showed normal Haematocrit levels except for WBC which suggest presence of some other infections irrespective of menstrual irregularities, normal Thyroid function test, normal bleeding and clotting time. This can be concluded as the patient was having complaint of Menorrhagia in absence of any Pelvic pathology, Thyroid dysfunctions or any coagulopathies. However, her Haemoglobin level was very low i.e. 10.3 gm%. This might be because of excess blood loss through menses. Hormone assessment was done during mid follicular phase showed low level of LH (Luteinizing Hormone) which was 1.63 with normal level of FSH (Follicle Stimulating Hormone) which was 5.54. Here low levels of LH suggest ovulation had already occurred and as here cycle length is 20 days, it can be assumed as reduced follicular phase length with normal length of luteal phase.
Diagnostic Challenges
As few years after attaining menarche there are multiple changes in the female body both physiologically, psychologically and endocrinologically where hormonal imbalances can occur at different level in different adolescent girls. Hence same cause cannot be found in each and every girl. Therefore, same diagnosis in not possible in all adolescent girls with pubertal menorrhagia.
THERAPEUTIC INTERVENTIONS
Both the patients were treated through Nasya chikitsa as follows:
Medication Period
After cessation of menses from the very next day patient was advised to take Nasya (Nasal instillation of medicine) of Udumbara phala Extract (which was priorly prepared in GMP certified Parul Ayurved Pharmacy). Patients were advised to instil 4 drops in each nostril once daily (in morning after taking bath and before having breakfast) for 7 days continuously. After that stop the Nasya. Wait till commencement of menses in next cycle. Then again patients were called for follow up on the next day of cessation of menses of next cycle and again advised to do Nasya for one more cycle with same protocol and once again stop the instillation after 7 days and wait for commencement of next cycle. 2nd follow up after cessation of menses of 3rd cycle.
No medicine period
After 2nd follow up till commencement of next menses. Final (3rd) follow up after cessation of 4th cycle.
Hence total period of treatment given with medicine was for 2 consecutive cycles and one month without medicine.
OUTCOME
The outcome of this case series reveals that the patient feels relieved in signs and symptoms, and it will be described as follows:
Changes in signs and symptoms, before and after treatment are shown as follows (Table 3).
| Sign and symptoms | Patient 1 | Patient 2 | ||
|---|---|---|---|---|
| Before treatment | After treatment | Before treatment | After treatment | |
| Menstrual Cycle Duration Interval Pain during menses Passage of clots Foul Smell Pads per cycle | 8-10 days 10-20 days +++ ++ + 30-35pads/cycle | 5-6 days 25 days + - - 15-17 pads/day | 10-11 days 15-25 days ++ ++ - 35-40pads/cycle | 6 days 30 days + - - 18-20 pads/day |
| Menorrhagia | Present | Absent | Present | Absent |
| Metrorrhagia | Absent | Absent | Absent | Absent |
| Polymenorrhoea | Present | Reduced | Present | Absent |
| Dysmenorrhoea | Severe | Mild | Moderate | Mild |
| Nature of Cycles | Irregular | Regular | Irregular | Regular |
| Gen. weakness and Lethargy | Moderate | Absent | Severe | Mild |
| Dizziness | Moderate | Absent | Mild | Absent |
| Weight loss | Mild | Absent | Severe | Mild |
Differences of LH and FSH before and after treatment for both cases are shown in (Table 4).
| LH | FSH | |||
|---|---|---|---|---|
| B/T | A/T | B/T | A/T | |
| Case 1 | 20.26 | 7.89 | 5.71 | 6.21 |
| Case 2 | 1.63 | 8.56 | 5.54 | 6.35 |
DISCUSSION
The presented case series involved two adolescent females with features of Pubertal Menorrhagia, correlating with the Ayurvedic diagnosis of Asrigdara, which is characterized by excessive or prolonged discharge of Asrk (blood) from the vaginal canal. This disorder is listed under Yonivyapad and specifically addressed by Acharya Charaka and Acharya Sushruta as a distinct pathological entity.[1, 17] According to Ayurveda, Asrigdara is primarily caused by Pitta vitiation, obstructing Apana Vayu, thereby disturbing the Artava Vaha Srotasa (channels carrying menstrual blood).[4] In modern gynecology, Pubertal Menorrhagia is defined as abnormal uterine bleeding (AUB) in adolescents, occurring within the first 2-3 years after menarche, commonly due to anovulatory cycles resulting from the immaturity of the hypothalamic-pituitary-ovarian (HPO) axis.[6] In both patients presented, no organic pathology, endocrine disorders, or coagulation defects were found, supporting a diagnosis of DUB.[9, 10]
Case 1 demonstrated high LH (20.26 mIU/mL) in the late follicular phase with normal FSH, which suggests an upcoming LH surge but there is inadequate luteal support. This is reflective of a luteal phase defect, a common manifestation in early adolescence due to incomplete maturation of the HPO axis. This aligns with the modern understanding that unopposed estrogen leads to excessive endometrial proliferation and erratic shedding due to absence of progesterone, resulting in menorrhagia.[7, 8] Case 2, in contrast, showed low LH (1.63 mIU/mL) with evidence of presence of free fluid in POD assuming occurrence of ovulation, causing shortened follicular phase. It is a rare condition in adolescent girls. The clear cause behind the presenting symptoms can’t be ruled out but post medication results were promising. Despite differing hormonal patterns, both patients presented clinically with prolonged cycles, reduced interval between cycles (polymenorrhea), dysmenorrhea, and general fatigue-hallmark features of both Pubertal Menorrhagia and Pitta-Vataja Asrigdara.
The Ayurvedic diagnosis of Pitta-Vataja Asrigdara is supported by the clinical features: excessive bleeding (Pitta), painful menses and irregularity (Vata), presence of clots, and systemic fatigue. Acharya Charaka clearly states that when Pitta is predominant and blocks the course of Apana Vayu, it leads to Raktapravritti beyond physiological limits.[17] He classifies four types of Asrigdara-Vataja, Pittaja, Kaphaja, and Sannipataja, but emphasizes dual Dosha involvement, particularly Pitta and Vata, in prolonged and irregular menstruation.[5] The choice of Udumbara Phala (Ficus racemosa) is justified by its Kashaya rasa, Sheeta veerya, and Raktastambhaka and Pittahara properties, which suit the management of Pitta-Rakta dushti in Asrigdara.[18] Ayurvedic text named Sahastrayogam clearly states direct use of Udumbara (Ficus Racemosa) apakwa phala (Unripe fruit) in management of Asrigdra.[19] In various Ayurvedic texts use of Udumbara apakwa phala, pakwa phala, patra, twaka and kshira in various formulations has been described in different Stri Roga Vikaras.[20] Moreover, Ficus Racemosa fruits contain Tannins and Flavonoids which helps in increasing the concentration of PGE2 and supressing endothelial prostaglandins.[21, 22] Nasya Karma, a Shirovirechana procedure, is indicated in various gynecological disorders involving hormonal imbalances. Acharya Kashyapa has advocated Nasya Karma in both Artavakshaya and Atyartava, indicating its dual action on insufficient and excessive bleeding, likely due to its systemic effect on neuroendocrine pathways.[13] The nasal mucosa’s proximity to the brain’s limbic and hypothalamic systems makes it a possible route for systemic effect through transmucosal absorption. This can have a direct impact on Hypothalamus and Anterior Pituitary gland which releases hormones like GnRH, LH and FSH, and thus regulating their normal levels. The timing of Nasya-immediately post-menstruation-was based on Kashyapa’s recommendation, which aims to influence post-menstrual hormonal reset.
Clinically, both cases showed substantial improvement. Menstrual bleeding duration and quantity reduced, pain subsided, and cycle regularity improved. Notably, the hormonal assessment showed significant modulation. In Case 1, LH reduced from 20.26 mIU/mL to 7.89 mIU/mL post-treatment, and in Case 2, LH increased from 1.63 to 8.56 mIU/mL, suggesting movement toward physiological balance based on individual baseline deviations. FSH levels showed mild upward correction in both, aligning with hormonal axis maturation. These changes indicate that Nasya might be influencing central hormonal feedback mechanisms, potentially stabilizing the HPO axis. Moreover, here Nasya is given by the aqueous extract of Ficus Racemosa fruit. This means no Taila (oil) or Ghrita (ghee) has been processed with it hence it contains pure form of phytoconstituents that works on controlling bleeding. Plus, the colourless, odourless and tasteless effect of extract ensures easy and convenient administration of a Panchakarma procedure like Nasya in adolescent girls. Importantly, the therapy was administered without any oral medication, ensuring that the observed effects could be attributed primarily to the Udumbara Phala Extract Nasya. No adverse effects were noted, reinforcing the safety and tolerability of this method in adolescents.
These results suggest that Nasya Karma may exert a regulating effect on HPO axis function, leading to normalization of ovulatory cycles. It appears neither suppressive (like OCPs) nor merely symptomatic, but rather homeostatic in action. This is consistent with Ayurveda’s aim of restoring equilibrium rather than substituting physiological functions.[13, 14]
The heterogeneity of hormonal patterns in adolescent menorrhagia-as seen in our two cases-indicates that uniform treatment approaches may be insufficient. Ayurvedic categorization based on Dosha dominance and symptom expression provides a useful framework for individualized therapy. Further, the intervention was well tolerated, had no side effects, and required no systemic hormone use-making it suitable for adolescent management. This also raises the possibility that Ayurveda’s Shamana therapies (like Nasya) may offer a more natural path to HPO axis maturation in early adolescence, especially in conditions that are self-limiting but symptomatic, such as pubertal Menorrhagia. While modern medicine acknowledges the transient nature of such dysfunctions, it lacks a clear non-hormonal management protocol, particularly for girls reluctant to use hormonal medications.
Strength and Limitations
This study was done on only 2 adolescent girls if this could be done with larger sample size it might show exact effect on all pubertal menorrhagia cases. While it had shown promising effects in many cases of DUB in patients aged from 18 to 50 years.
CONCLUSION
Udumbara Phala (Ficus racemosa) Nasya demonstrates therapeutic efficacy in the management of pubertal Menorrhagia, clinically correlating with Pitta-Vataja Asrigdara. Its pharmacodynamic properties-specifically astringent tannins, flavonoids, and anti-inflammatory constituents-support hemostasis by promoting vasoconstriction, reducing capillary permeability, and modulating prostaglandin synthesis (notably inhibiting excess PGI₂ while enhancing PGE₂). The transmucosal nasal administration facilitates rapid systemic absorption and may act via the olfactory-limbic-hypothalamic axis, thereby influencing gonadotropin-releasing hormone (GnRH) pulsatility and subsequent pituitary secretion of LH and FSH. This aligns with Ayurvedic principles where Nasya Karma is said to influence Shirastha marma and regulate Apana Vayu function. Unlike exogenous hormonal therapies, Udumbara Phala Nasya appears to promote endogenous neuroendocrine equilibrium without disrupting hypothalamic-pituitary-ovarian (HPO) axis maturation, offering a non-hormonal, bio-regulatory approach for adolescent menstrual dysfunctions.