“A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA  KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                ...
                      Dedicated To My Parents                      With Lots                 Of            Love & Respect....
ACKNOWLEDGEMENT        First and foremost I pray to the almighty God, who is omnipresent,omniscient and omnipotent. This u...
I sincerely express my deep sense of gratitude to Dr. Mamatha K.V. Professor Department ofPrasuti Tantra & Streeroga for s...
LIST OF ABBREVIATIONS –1. Ca.S-                CARAKA SAMHITHA2. Su.S       -         SUSHRUTA SAMHITHA3. A.S        -    ...
                                          ABSTRACTTitle -“A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA ANDLASUNADI...
CONTENTSCHAPTER NO.                              PAGE NO.  PART 1      INTRODUCTION                  1-2  PART 2      OBJE...
LIST OF TABLESTable No.                     List of Tables                Page No.                         CONCEPTUAL STUD...
26   Incidence according to Pain                          6427   Incidence according to Anubandha Vedana              6528...
R3   Amount of Blood loss54   Effect within the Group A & Group B             8455   Effect in between the Groups         ...
22   Incidence According to Varna of Artava             7123   Incidence According to Gandha of Artava            7224   I...
Sr.no      LIST OF FIGURES 1      Lasuna 2      Jeeraka 3      Hingu 4      Pipalli 5      Marica 6      Nagara 7      Sai...
Introduction                                     INTRODUCTION         Ayurveda, a medical system of world which is serving...
Introduction   menstrual disorder is rising in gynaecological practice which is precursor of infertilityand other problems...
Objective of study                               OBJECTIVE OF STUDY1. A conceptual study of Artava Kshaya.2. To evaluate t...
Historical review                                       Historical review        Kaumara bhrtya is one of the Astangas of ...
Historical reviewVagbhata I & II 6,7The clinical features of artava kshaya is explained. The Astanga Hrudaya the reference...
Previous work done                           PREVIOUS WORK DONE•   A comparative clinical study on Shatapushpadi vati and ...
Conceptual Study                                                 Artava    GiÉÉæ pÉuÉqÉÉiÉïuÉqÉç, x§ÉÏhÉÉÇ rÉSmÉirÉqÉÉaÉÉï...
Conceptual Study                                              Ahara                                                     En...
Conceptual Study       Pitta is the predominant dosha in rakta dhatu & responsible for the agneyatva ofit. Since the artav...
Conceptual StudyWûÏlÉrÉÉãlrÉÉxiÉÑ oÉÉsÉÉrÉÉ: MüÉrÉÇ aÉcNûÌiÉ vÉÉãÍhÉiÉqÉç |AjÉ mÉÔhÉïxuÉpÉÉuÉÉrÉÉ: MüÉrÉÇ rÉÉãÌlÉ cÉ aÉcNû...
Conceptual StudyParicharya 42,55,57,58        From the first day of menstruation the rajaswala stree must follow Brahmacha...
Conceptual StudyRutumati stree lakshana 54,55,56,61       When the purana raja is expelled out & collection of new raja ta...
Conceptual studyMenstruation 62,63,64,65       The menstruation is the cyclic physiological uterine bleeding out of sheddi...
Conceptual study        GnRH is released at the nerve endings near tuber cinereum. GnRH has a half lifeof 2-4 mins. It is ...
Conceptual study   •   Activates- after cessation of menstruation.   •   Peaks at 7th day of cycle.   •   Declines to disa...
Conceptual studyAction- Thorough binding to cytoplasmic receptor in the cells.Conjugates as- oestrogen, oestradiol & oestr...
Conceptual studyThyroid hormone-   •    Numerous acini & follicle are present in thyroid glands.   •    TSH released from ...
Conceptual studyOvarian cycleIt consist of          Development & maturation of follicles          Ovulation          Form...
Conceptual study        FSH surge            o 17 alpha hydroxy progesterone facilitates the +ve feedback action on       ...
Conceptual studyEndometrial cycle        Endometrium is the lining epithelium of uterine cavity above the level of interna...
Conceptual studyinvariable preceding feature which with withdrawal of hormone leads to degeneration &casting of endometriu...
Conceptual study        The degenerative process is rapid & involves the compounds of functionaldamaged layer. Breakdown o...
Disease Review                               Artava kshaya       Most of the menstrual disorders have been described under...
Disease Review   •     mÉÔuÉÉãï uÉ×kS: mÉUÇ MÑürÉÉïSè uÉ×kSÇ ¤ÉÏhÉ¶É iÉ̲kÉqÉç ||         A.WØû.xÉÔ11/34         Acharya V...
Disease Review        So for proper understanding this nidana84,85 is divided into   •    Aharaja   •    Viharaja   •    M...
Disease Review   Vataja vitiating hetu         Pittaja vitiating hetu         Kaphaja vitiating hetu         Atiprajagaran...
Disease ReviewAÉiÉïuɤÉrÉã rÉjÉÉãÍcÉ¨É MüÉsÉÉSvÉïlÉqÉç AsmÉiÉÉ uÉÉ rÉÉãÌlÉuÉãSlÉÉ ||xÉÑ.xÉÔ. 15/12The 3 cardinal features ...
Disease Review                                Samprapti SÉãwÉæUÉuÉ×iÉqÉÉaÉÉïiuÉÉSÉiÉïuÉÇ lÉvrÉÌiÉ Îx§ÉrÉÉ: || xÉÑ. vÉÉ. 2/...
Disease Review       Acharya Vagbhatta explains that the vata & kapha does the avarodha of rakta &causes nastartava33.   A...
Disease ReviewSamprapti GhatakaDosha-   o Vata – Apana vata, Samana vata   o Pitta –Pachaka pitta   o Kapha –Kledaka kapha...
Disease Review                                      ChikitsaxÉqmÉëÉÎmiÉ ÌuÉbÉOûlÉqÉãuÉ ÍcÉÌMüixÉÉ ||       The main object...
Disease Reviewdhatu, resulting into relative increase in agneya constituents of the body & finally causesincrease in artav...
Disease Review       So he has advised to treat vata dosha first which normalizes other all doshas90.As explained by Achar...
Disease ReviewLohitakshaya YonivyapaduÉÉiÉÌmɨÉÉprÉÉÇ ¤ÉÏrÉiÉã UeÉ: |xÉ SÉWû MüÉvrÉïuÉæuÉhrÉï rÉxrÉÉÇ xÉÉ sÉÉãÌWûiɤÉrÉÉ |...
Disease review Oligomenorrhoea 97,98,99        It can be defined arbitrarily as one in which the cycle lasts longer than 3...
Disease review     Surgical removal of endometrium i:e Ablation of endometrium by laser,    resectoscope.    Due to absenc...
Disease review     Hypothalamus causes    GnRH deficiency    Vigorous exercise    Pseudocyesis    Brain tumors    Psychoge...
Disease review        Nutritional factors       Extreme obesity       Excessive weight loss in the athletes & ballet dance...
Disease review        Due to intra uterine adhesions       Due to chronic endometritis       Hormonal causes       Disturb...
Disease review This includes      i.   Mode of onset of menses     ii.   Sudden change in environment, emotional stress, o...
Disease review     ix.   Special investigations             a. Urine Pregnancy Test- To exclude pregnancy in woman with ac...
Disease review        endogenous estrogens which has primed the endometrium & the diagnosis       is anovulation.       If...
Drug Review  Lasuna –Botanical name- Allium sativumFamily – LILIACEAETable no: 5                  Rasa            Guna    ...
Drug Review  JeerakaBotanical name- Cuminum cyminumFamily – UMBELLIFERAETable no: 6               Rasa         Guna       ...
Drug Review  HinguBotanical name-– Ferula northaxFamily – UMBELLIFERAETable no: 7                     Rasa         Guna   ...
Drug Review  PipalliBotanical name – Piper longumFamily – PIPERACEATable no: 8                Rasa         Guna        Vir...
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A Comparative Clinical Study Of Krishna Tila Kashaya And Lasunadi Vati In Artava Kshaya, Kulkarni, Shilpa A, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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Artava kshaya psr

  1. 1. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” BY Dr. Shilpa A. Kulkarni. B.A.M.S. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka In partial fulfillment of the requirements for the degree of MASTER OF SURGERY (Ayu) In “PRASOOTI TANTRA AND STREE ROGA” UNDER THE GUIDANCE OF Dr. RAMADEVI G. M.D. (AYU) Asst. Professor P. G Studies Dept of Prasooti Tantra and Stree Roga . DEPARTMENT OF POST GRADUATE STUDIES IN PRASOOTI TANTR AND STREE ROGA S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574118 2009 -2010
  2. 2.          Dedicated To My Parents       With Lots Of Love & Respect.  
  3. 3. ACKNOWLEDGEMENT First and foremost I pray to the almighty God, who is omnipresent,omniscient and omnipotent. This unforgettable moment of contentment on the successfulcompletion of this dissertation work which is a milestone, I bow my head at the feet of the AlmightyLord Ganesha, Yallamma devi & Renukadevi. My deep sense of gratification is due to my parents Dr. Ashok Kulkarni &Dr.(Mrs).Jyoti Kulkarni who are the architects of my career. I am highly indebted to myparents who have played a valuable role in molding my thoughts towards higher studies with aconstant showering of affectionate blessings which are the driving forces behind my work. With lotsof love and regards the boundless encouragement of my brother Mr.Amit Kulkarni.Who has motivated me towards this course. I am grateful to my maternal aunt Mrs Neeta Tambolkar for her valuable support & alwaysencouraging me. It is indeed my fortune to have carried out this dissertation work at Sri DharmasthalaManjunatheshwara College of Ayurveda, Udupi. In this regard, I would like to express my heart feltgratitude to Honorable Dr. D. Veerendra Heggde Dharmadhikari Sri Kshetra Dharmasthala,President of Sri Dharmasthala Manjunatheshwara Educational Society (Regd) for his courtesy, graceand blessing to carry out this work . I feel myself very lucky to carry out this dissertation work under thevaluable guidance of Dr.G.Ramadevi, Asst. Professor who has helped me in each &every step in all respects. Her prompt suggestions, optimistic view & motherlyaffection showered on me during this whole period & inspired me to accomplishthis work in all respect. I am deeply thankful to Dr. Usha V.N.K. Prof. & HOD, Department of Prasuti Tantra andStreeroga, of SDM College of Ayurveda, for her concern and generosity towards the dissertation work.
  4. 4. I sincerely express my deep sense of gratitude to Dr. Mamatha K.V. Professor Department ofPrasuti Tantra & Streeroga for support towards my work, providing me valuable knowledge andgiving exposure to practical aspects of the subject. I extend my heartful thanks to Dr. Suchetha and Dr. Vidya Ballal Department of PrasutiTantra & Streeroga for the support & concerned towards my work. I express gratitude to Dr. Veena Mayya.and Dr. Krishna Bai. for their guidance towards thesubject. I am grateful to Dr. U. N. Prasad, Principal, S.D.M. College of Ayurveda, Udupi invaluablesupport & guidance for completion of my work. I sincerely thank Dr. Shrikanth U. Dean of PG Studies and Dr. U. Govind Raju Co-Dean ofPG Studies for the support throughout my work. My gratitude to Dr. Y. N. Shetty, Superintendent SDM Ayurveda Hospital, Udupi forsupport. I sincerely thank Dr. Jonah. Asst Professor Department of Kayachikitsa for valuable supportand guidance during my work. My thanks to Mr. Harish Bhat librarian, & other library staff for there generous help duringthe course of the study. I express my indebted gratitude towards my friends Dr. Vijayalakshmi, Dr. Sujata, Dr.Sukanya, Dr. Kavya, Dr. Shubha. for there timely valuable support & suggestions. I am thankful to my friends Dr. Keertan, Dr. Rathod, Dr. Vijayashankar for their support &timely help. I cannot move further before thanking my roommates Varsha, Deepti &Shruthi who not only helped me but stood by me during hours of stress anddejection. Last but not least I am grateful to all my classmates and friends who have directly orindirectly supported and helped me through out the work. I am thankful to all my patients for their cooperation through out the study, who arepillars of my research work. Dr. Shilpa.
  5. 5. LIST OF ABBREVIATIONS –1. Ca.S- CARAKA SAMHITHA2. Su.S - SUSHRUTA SAMHITHA3. A.S - ASTANGA SANGRAHA4. A.H - ASTANGA HRUDAYA5. Dh.N - DHANWANTARI NIGHANTU6. Bp.N - BHAVAPRAKASHA NIGHANTU7. Rj.Ni - RAJA NIGHANTU8. Ma.Ni - MADANAPALA NIGHANTU9. Sh.S.Ma. Kh - SHARANGADARA SAMHITA MADHYAMA KHANDA.10. Kai.N- KAIYADEVA NIGHANTU11. Y.R- YOGA RATNAKARA12. Sa.N- SALIGRAMA NIGHANTU13. BT- BEFORE TREATMENT14. AT- AFTER TREATMENT15. &- AND16. %- PERCENTAGE17. SD STANDARD DEVIATION18. SE STANDARD ERROR19. df DEGREE OF FREEDOM20. d DIFFERENCE
  6. 6.   ABSTRACTTitle -“A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA ANDLASUNADI VATI IN ARTAVA KSHAYA” Woman is symbol of beauty. ‘Beauty must not be skin deep’. It should be maintainedinternally also. There are many physiological changes takes place in women’s body which ismarkedly seen in the reproductive life. Menstrual cycle is such a unique phenomenon in the bodywhich includes dramatical monthly change in the hormones, which ends finally with the sheddingof endometrium. If there is any alter in this phenomenon leads to menstrual irregularities which holdsattention of all research institutes to address the problem with new formulation of drugs. Thus tomake awareness about this condition with its side effects is very important. Though, ‘Artavakshaya’ is described as a symptom in classics, but in present study itappears like a disease. The people have come to know the importance of the reproductive health.Thus the line of treatment selected for this study is shamana Chikitsa. The drugs selected are agneya dravyas i:e Krishna Tila Kashaya & Lasunadi vati possesspittavardhaka & vatakapha shamaka property.Objectives : A conceptual study of Artava Kshaya. To evaluate the efficacy of Krishna Tila Kashaya with Guda To evaluate the efficacy of Lasunadi vati. To compare the efficacy of Krishna Tila kashaya with Guda & Lasunadi vatiStudy design: This research work is a single blind comparative clinical study with pre test andpost test design. 30 women presenting with pratyma lakshanas of Artava kshaya were randomlyselected and categorized into 2 groups of 15 patients each. Group A were given Krishna TilaKashaya and Group B were given Lasunadi vati for a period of 3 menstrual cycle & follow up forfurther 3cyclesResult: These drugs showed good improvement in duration of flow, intermenstrual period,amount of flow, changes in the pain& weight.Key words- Reproductive life, Menstrual cycle, shedding of endometrium, Artava Kshaya,hormonal treatment, shamana Chikitsa, agneya dravyas, Krishna Tila Kashaya, Lasunadi vati. 
  7. 7. CONTENTSCHAPTER NO. PAGE NO. PART 1 INTRODUCTION 1-2 PART 2 OBJECTIVES OF THE STUDY 3 PART 3 CONCEPTUAL STUDY 3.1 Historical Review 4-5 3.2 Previous work done 6 3.3 Conceptual Study 3.3.1 Artava 7-12 3.3.2 Menstruation 13-22 3.3.3 Disease review Artava Kshaya Ayurvedic view 23-34 Modern view 35-42 3.4 Drug Review 43-50 PART 4 CLINICAL STUDY 4.1 Materials and Methods 51-53 4.2 Observations 54-79 4.3 Results 80-89 4.4 Discussion 90-105 PART 5 CONCLUSION 106-107 PART 6 SUMMARY 108-109 PART 7 ANNEXURE 7.1 Bibliography 110-125 7.2 Case proforma 126-130
  8. 8. LIST OF TABLESTable No. List of Tables Page No. CONCEPTUAL STUDY 1 Aharaja Hetu 25 2 Viharaja Hetu 26 3 Manasika Hetu 26 4 Anya hetu 26 DRUGS 5 Lasuna 43 6 Jeeraka 44 7 Hingu 45 8 Pipalli 46 9 Marica 47 10 Nagara 48 11 Saindhava 49 12 Jambira 49 13 Krishna Tila 50 14 Guda 50 OBSERVATION TABLES 15 Incidence According to Age 54 16 Incidence According to Marital Status 55 17 Incidence According to Habitat 55 18 Incidence According to Religion 56 19 Incidence According to Education 57 20 Distribution According to Occupation 58 21 Incidence According to Socio- Economic Status 59 22 Incidence According to Duration of Illness 60 23 Incidence According to Duration of Blood Loss 61 24 Incidence according to Intermenstrual Period 62 25 Incidence according to Amount of Blood Loss 63
  9. 9. 26 Incidence according to Pain 6427 Incidence according to Anubandha Vedana 6528 Incidence according to Diet 6629 Incidence according to Rasa Sambhandhi 6730 Incidence according to Diet Habit 6831 Incidence According to Mental Stress 6832 Incidence According to Mala 6933 Incidence According to Weight 6934 Incidence According to Habits 7035 Incidence According to Rajo Pravrutti 7136 Incidence According to Varna of Artava 7137 Incidence According to Gandha of Artava 7238 Incidence According to Akruti 7239 Incidence According to PallorSamhanana and Pramana 7340 Incidence According to Shabda, Sparsha, Druk 7341 Incidence According to Prakruti 7442 Incidence according to Vikruti 7443 Incidence according to Sara 7544 Incidence according to Satva 7645 Incidence according to Ahara Shaktikti 7746 Incidence according to Vyayama Shakti 7747 Incidence according to Srothas Affected 7848 Incidence according to Tenderness in Vagina 7949 Incidence according to Condition of Cervix 79 RESULTS TABLESR1 Duration of flow50 Effect within the Group A & Group B 8051 Effect in between the Groups 81R2 Interval between two menstrual cycle52 Effect within the Group A & Group B 8253 Effect in between the Groups 83
  10. 10. R3 Amount of Blood loss54 Effect within the Group A & Group B 8455 Effect in between the Groups 85R4 Change in Pain56 Effect within the Group A & Group B 8657 Effect in between the Groups 87R5 Change in Weight58 Effect within the Group A & Group B 8859 Effect in between the Groups 89 LIST OF GRAPHS OBSERVATION GRAPHS1 Incidence According to Age 542 Incidence According to Marital Status 553 Incidence According to Habitat 554 Incidence According to Religion 565 Incidence According to Education 576 Distribution According to Occupation 587 Incidence According to Socio- Economic Status 598 Incidence According to Duration of Illness 609 Incidence According to Duration of Blood Loss 6110 Incidence according to Intermenstrual Period 6211 Incidence according to Amount of Blood Los 6312 Incidence according to Pain 6413 Incidence according to Anubandha Vedana 6514 Incidence according to Diet 6615 Incidence according to Rasa Sambhandhi 6716 Incidence according to Diet Habit 6817 Incidence According to Mental Stress 6818 Incidence According to Mala 6919 Incidence According to Weight 6920 Incidence According to Habits 7021 Incidence According to Rajo Pravrutti 71
  11. 11. 22 Incidence According to Varna of Artava 7123 Incidence According to Gandha of Artava 7224 Incidence According to Akruti 7225 Incidence According to PallorSamhanana & Pramana 7326 Incidence According to Shabda, Sparsha, Druk 7327 Incidence According to Prakruti 7428 Incidence according to Vikruti 7429 Incidence according to Sara 7530 Incidence according to Satva 7631 Incidence according to Ahara Shaktikti 7732 Incidence according to Vyayama Shakti 7733 Incidence according to Srothas Affected 7834 Incidence according to Tenderness in Vagina 7935 Incidence according to Condition of Cervix 79 RESULTS GRAPHSR1 Duration of flow36 Effect within the Group A & Group B 8037 Effect in between the Groups 81R2 Interval between two menstrual cycle38 Effect within the Group A & Group B 8239 Effect in between the Groups 83R3 Amount of Blood loss40 Effect within the Group A & Group B 8441 Effect in between the Groups 85R4 Change in Pain42 Effect within the Group A & Group B 8643 Effect in between the Groups 87R5 Change in Weight44 Effect within the Group A & Group B 8845 Effect in between the Groups 89
  12. 12. Sr.no LIST OF FIGURES 1 Lasuna 2 Jeeraka 3 Hingu 4 Pipalli 5 Marica 6 Nagara 7 Saindhava 8 Gandhaka 9 Jambira 10 Lasunadi Vati 11 Krishna Tila 12 Guda 13 Krishna Tila Kashaya
  13. 13. Introduction    INTRODUCTION Ayurveda, a medical system of world which is serving the ailing humanity sincethe creation of life is not behind in recognizing the most pragmatic feature of a womanviz. women are the roots of progeny. Women are considered as one of the most essentialfactors of the continuity of human race. God has given this magnanimous gift only to thewomen. Mother is the most sacred and beautiful word in the world but the tragedy is thatall women are not Mother. But the root of the importance of women lies in their capacityof creation. This is the reason why the question of fertility is most important for women.All hazards that hamper the capacity of fertility attract unique attention for cure. For the same human being are trying to develop newer resources as well as tryingto improve the quality of life by acquiring sound health. This health can be achieved onlywhen all of the processes in the body are in equilibrium. The normalcy of the physical &emotional factors also counts. There are many normal physiological phenomenons taking place in the bodywhich is carried out in a cyclic manner. If there is any alteration in this will give rise tothe pathological conditions. Among all these physiological changes, menstrual cycle isone of them. Menstrual cycle is a beautiful hormonal change that takes place every monthin women life. There is a well coordination between the hormones & the shedding of theendometrium that takes place every month indicating the normal menstruation. Geographical conditions, racial factors, nutritional standards, environmentalinfluences and indulgence in strenuous physical activity can affect hormonal status andmenstrual cycles of woman. Even on completing her family, having irregular and scantymenstruation is continuous stress denoting hormonal aberrations. There is a sharpincrease in the incidence of same in modern age hence requires solution. A slightdeviation in the menstrual cycle which may be excessive or low is filled with fear ofsome serious pathology of internal genital organs. In the modern world, the Life style, food habit and just for unnecessary desireshave increased stress, strain and restlessness which have resultantly increased menstrualdisorders. Artava dusti is very important among gynaecological problems. Ratio of “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   2  
  14. 14. Introduction   menstrual disorder is rising in gynaecological practice which is precursor of infertilityand other problems, so it requires more attention. Menstrual disorder affect on mentalstate of women. Many Menstrual disorder i.e secondary amenorrhoea, oligomenorrhoea,require counselling with appropriate treatment. There is an altered physiology in theH-P-O-U axis. Hence this requires attention that can answer the rising question. In Modern medical science Hormonal Treatment which has a good therapeuticutility is used for menstrual disorders but this is not devoid of side effect. So, in contemporary era it is very important to provide a particular etiopathologyand treatment for “Artavakshaya”. There are many processes and Methods available inAyurvedic classics to alleviate Artavakshya. But it is yet, the on going research to findout a method of treatment, which is more near to procurance of permanent cure withoutside effects. It must be easier for administration and warmly acceptable by all class ofpatients. In the classics treatment is mentioned to keep the doshas in equilibrium. It can beachieved by• Samshodhana – Cleansing process which is in form of Panchakarma.• Samshamana – Palliative measures which is in form of Agneya dravyas. Hence for the present study shamana line of treatment is selected as the medicines are easily available, are palatable & cost effective. For the treatment of Artavakshaya many drugs are available. In such recipes, we haveselected “Krishna Tila Kashaya ” & “Lasunadi Vati” for oral administration.  “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   2  
  15. 15. Objective of study  OBJECTIVE OF STUDY1. A conceptual study of Artava Kshaya.2. To evaluate the efficacy of Krishna Tila Kashaya with Guda.3. To evaluate the efficacy of Lasunadi vati.4. To compare the efficacy of Krishna Tila kashaya with Guda & Lasunadi vati. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                        3
  16. 16. Historical review Historical review Kaumara bhrtya is one of the Astangas of Ayurveda, Prasooti tantra & Stree rogais included under it. But today Prasooti tantra & Stree roga is dealt as distinct specialty.Vedic SamhitaVedas the first written records of Indian literature contains innumerable references inrelation to stree roga.RigvedaScattered reference for the treatment of anartava is found.1YajurvedaThe reference for tila & Krishna Tila to be the uttama Tila is available.2Athrava vedaThe different drugs for the treatment of artava kshaya is available , Krishna Tila to be theuttama Tila. 1,2Manu smrutiThe reference for rutumati is available.3 further specifies the Tila & Lasuna are useful inproduction of beeja.4Samhita periodCaraka SamhitaThe reference for lasuna, jeeraka, hingu, trikatu & tila is available.Sushruta samhita 5About the artava kshaya its lakshana with chikitsa is available.Acharya Dalhana explains the use of Krishna tila in artava kshaya.The explainations for lasuna, jeeraka, trikatu & tila is found. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                            4 
  17. 17. Historical reviewVagbhata I & II 6,7The clinical features of artava kshaya is explained. The Astanga Hrudaya the referencefor nagara is found.Kashyapa samhita 8Use of lasuna is explained in Kalpastana for Pushpadusti.Yoga Ratanakara 9The use of Krishna tila kwath with Guda is found.Baishaya RatnavaliThe use of Krishna tila kwatha for artava kshaya is found.Vaidya Jeevan10The method of preparation of lasunadivati is found.NighantuBhavaprakasha Nighantu11A short description of Artava kshaya & use of Krishna tila along with guda is explained.Dhanvantari Nighantu, Shodala Nighantu, Kaiyadeva Nighantu, Raja Nighantu,Bhavaprakasha Nighantu explains about lasuna12 jeeraka13 trikatu15,16,17, hingu14, tila19.Reference for guda is available in Raja valbha, Raja Nighantu & Nighantu RatnakarReference for saindhava is available in Bhavapraksha Nighantu & nighantu RatnakarReference for Jambira18 is available in Dhanvantari Nighantu, Kaiyadeva Nighantu,Bhavaprakasha Nighantu.Modern20The reference for oligomenorrhoea & Hypomenorrhoea is available in almost all the text. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                            5 
  18. 18. Previous work done  PREVIOUS WORK DONE• A comparative clinical study on Shatapushpadi vati and Krishna Tila kwatha in artava kshaya by Dr. Der C in G.A.U. Jamnagar in 2002.• Management of artava kshaya with Shatapushpa curna by Dr. Archana Ghose in Gopabandhu Ayurvedic Mahavidyalaya, Puri, Utkal University Bhubaneshwar in 2004.• Role of Krishna Tila and Arkapushpa taila uttara basti in management of artava kshaya by Dr. Trivedi Rujuta in G.A.U. Jamnagar in 2005.• Effect of Satapushpa taila nasya in artava kshaya with reference to hypo and oligomenorrhoea, Dr Nikita Sirigere in S.D.M.College of Ayurveda,Udupi, RGUHS, Banglore in 2006. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”  6 
  19. 19. Conceptual Study Artava    GiÉÉæ pÉuÉqÉÉiÉïuÉqÉç, x§ÉÏhÉÉÇ rÉSmÉirÉqÉÉaÉÉïiÉç vÉÑkSqÉÏwÉiÉçM×üwhÉÇ ÌuÉaÉlkÉÇ uÉÉrÉÑmÉëãËUiÉÇ sÉÉãÌWûiÉÇ mÉëuÉiÉïiÉãiÉSÉiÉïuÉqÉÑcrÉiÉã || A. WØû.vÉÉ 1/1 AÂhÉ S¨É OûÏMüArtava which is to be considered as menstrual blood is clearly explained by commentaryArunadatta.21Synonyms of Artava 22 Shonita,23 Asruk ,24 Raja,25 Rakta,26 Lohita,27 Rudhira,28 Pushpa 29Artava nirmana   Artava is considered as upadhatu of rasa dhatu by all the acharyas,30,31,32,33 exceptAcharya Bhavaprakasha & Sharangadhara who consider artava as upadhatu of rakta, 34,35but no further description is available. So to consider the artava as upadhatu of rasa dhatuholds good. It is important to understand the utpatti of rasa dhatu according to “Dhatu PoshanaSiddhanata.” The ahara which enters into the amasaya, gets converted into ahara rasa by theaction of Pachaka pitta, Kledaka kapha & Jataragni from which rasa dhatu is formed. Bythe action of Rasa dhatvagni, Prasada bhaga & Kitta bhaga is formed. The Kitta bhagaforms the rasa mala i:e Kapha. The Prasada bhaga again divides into Stula bhaga whichremains as rasadhatu & Sushkma bhaga helps in the formation of Uttarottara dhatu &Upadhatu i:e artava & stanya. Astanga Samgraha states the opinion that the blood gets collected in thegarbhasaya as artava & is expelled out every month for 3days.36 Vishvamitra’s opinion coated by Dalhana in his commentary as there are somesmall capillaries present in the uterus which fill the uterus with rakta/artava for the wholemonth & is expelled out every month if the conception does not occur37. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       7     
  20. 20. Conceptual Study Ahara  Enters Amasaya Jataragni Pachaka pitta Kledaka kapha Ahara rasa Kitta Rasadhatu Mutra & Mala Rasadhatvagni Prasada bhaga Kitta bhaga (Kapha)Stula bhaga Sukshma bhaga Remains asRasa dhatu Upadhatu Uttarottra dhatu                                     (Artava, Stnaya) (Raktadi dhatus) Artava swarupa 38,39,40AÉiÉïuÉqÉÉalÉãrÉqÉç | xÉÑ.vÉÉ.3/3Colour & lakshana of rakta is similar to that of artava i:e Gunjaphala,41 Padmalakta,41Indragopha,41 Shashasruka, 42,44 Laksharasa, 42,43 etc. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       8     
  21. 21. Conceptual Study Pitta is the predominant dosha in rakta dhatu & responsible for the agneyatva ofit. Since the artava has similarities with rakta36,39 it also gains agneyatva. But as we knowthat artava is formed from the rasa dhatu which has soumya guna. So artava is soumya atthe time of formation. But at time of expulsion, it will gains agneya guna. To make iteasy to understand, Acharyas have given the simile of the Parthiva substance whichcombines with the Tejas & turns as dhuma. The Ikshu rasa which initially vitiates kaphabut when it turns as phanita it becomes Tridoshakari (Su.Su.14/7 Cakrapani Tika). In thesame way, the guna of Artava changes & it gets agneyatva at the time of expulsion.Artava pramana  The pramana of artava is 4anjali.45,46Suddha artava lakshana 41,42,43,44 o Colour of artava resembles gunjaphala, padmalakta, indragopha, shashasruka o Flow of artava is for 3- 5 days o Na atibahula naatyalpa o Character of artava – comes through the yoni every month, which is not picchila in nature, does not cause daha & vedana, does not stains the cloth.  Prathama atrava darshana & artava nivrutti  The age or prathama rajodarshana is mentioned as 12yrears,47,48,49 16years 50 & 47,48,49age of artava nivrutti is 50 years. The artava is present from garbhakala,112 but it is visible only after certain time.Jara avastha & pakwa shareera causes artava nivrutti. While explaining about the sameacharyas explain that like a bud, dry fruit & dry flower does not have fragrance in eitherof a young plant or old tree, in the same way the way the artava is present in the hiddenform before prathama rajodarshana & after the rajonivrutti respectively. The fire ispresent in the wood but it is generated only after certain time & efforts.50,44 The concept of Dhatuparipuranta51,52 is explained by the acharyas which willfurther clear the concept of prathama rajodarshana. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       9     
  22. 22. Conceptual StudyWûÏlÉrÉÉãlrÉÉxiÉÑ oÉÉsÉÉrÉÉ: MüÉrÉÇ aÉcNûÌiÉ vÉÉãÍhÉiÉqÉç |AjÉ mÉÔhÉïxuÉpÉÉuÉÉrÉÉ: MüÉrÉÇ rÉÉãÌlÉ cÉ aÉcNûÌiÉ || MüÉ. xÉÇ. ÎZÉ. 9/19 As per above reference by Kashyapa,51 as the Shukra is present from thechildhood similarly the Artava (Shonita) is also present, which is not visible due to veryminute quantity. It is be visible in Yoni after the maturation of all organs. Here the word ‘hina yoni’ may point towards the developing female genital organand ‘purnaswabhavaya’ means attainment of maturity, feminine figure with formation ofmenstrual blood & ovum Acharya Bhela also believes that Dhatuparipurnata is one causative factor ofArtavapravritti.52Artava chakra The artava chakra is for one masa –i:e one lunar month (Chandra masa)-28days. Theentire masa is divided into 3phases. • Rajasrava kala- 3-5days • Rutukala- 12-16days • Rutuvyatitakala- 9-13daysRajasrava kala There are different opinion regarding the time duration of rajasrava, 3days,33,485days,53 7days.52 Acharya Bhavamishra has added scanty flow for 16days. In this phasethere is predominance of vayu. The vayu is required for expulsion of artava fromgarbhasaya54,55,56. As garbhasaya is a pelvic organ apana vata is considered to play amajor role in this regard. The artava is carried by the dhamanis to garbhasaya for thewhole month. This collected artava is carried by vayu to yoni mukha & is excreted out asrajasrava.52,54,56 There is presence of rajovaha siras which carries the raja & expels it out everymonth51.  “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       10     
  23. 23. Conceptual StudyParicharya 42,55,57,58 From the first day of menstruation the rajaswala stree must follow Brahmacharya. She should use bed made of darbha spread over the ground. She should eat in palm leaf or unbroken utensils made up of clay. She should eat little quantity of food to maintain the agni. She must always use havisya 42 & yavaka.55,57 She must avoid diwaswapana, anjana, asrupata, snana, abhyanga, lepa, nakhachedana, excessive laughing, talking, work or exercise, use of ornaments, excess consumption of teekshana, katu, lavana ahara. The use of nasya, vamana, swedana is contraindicated in this period. On 4th day, she must bath over head, dress herself in new cloths or white coloured dress wearing ornaments & garlands, indulge herself in pious hymns. She must 1st see her husband’s face.Rutukala It is for the period of 12days54,59, 16 days56or it is considered for the whole monthif yoni garbhasaya is shuddha56 . Acharya Kashayapa60 explains the kala for Brahmana’s as 12days, Ksatriya’s as10days, Vaisaya’s 10days, Sudra’s 9days. The different opinion of rutukala from12-16days is clarified by Acharya Dalhana by saying that the first 3 days & last one daythere is yoni sankocha, So this kala is not favorable for conception. Hence rutukala canbe considered for 12days.54Paricharya  As explained earlier, on 4th day the woman must take bath & dress herselfbeautifully & approach her husband happily & joyfully. The sexual contact must be oneven or odd days for male & female child respectively. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       11     
  24. 24. Conceptual StudyRutumati stree lakshana 54,55,56,61 When the purana raja is expelled out & collection of new raja takes place whichindicates new rutuchakra. After taking bath on 4th day woman is considered shuddha. Theyoni, garbhasaya & shonita is considered as shuddha i:e free from disease this lady istermed as rutumati. The woman’s face looks prasanna, kledata is seen on mukha, danta, who isinterested in reading priya katha & anxious to have sexual relation. Shithilata overkukshi, eyes & hairs is seen. She has twitching over arms, breast, pelvis, umbilicus, thighs & hips, who ishappy & excited is termed as rutumati.Predominance of dosha  This can be interpreted with changes in proliferative phase in which endometriumincreases in thickness. The regeneration of endometrium can be considered due to prithivi& jalamahabhuta, which are the bhoutika component of kapha. Acharya vagbhatta says that the use of ghrita & ksheera56 or use of taila &masha60 which are brumhana in nature, nourishes the endometrium & further helps tomaintain the pregnancy.Rutuvyatitakala  After sunset as the lotus closes, similarly the constriction of yoni is seen afterrutukala, so the yoni does not accept shukra for conception.54,55,56 This stage can becompared to secretary phase of menstruatal cycle, where there is increase in productionof progesterone which has thermogenic effect, makes cervical mucus hostile & hampersthe sperm motility. In this phase the basal body temperature is increases by 0.80F.  Sincethe temperature & progesterone levels are increased, we can say that, this phase isdominated by pitta.   “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”                                       12     
  25. 25. Conceptual studyMenstruation 62,63,64,65 The menstruation is the cyclic physiological uterine bleeding out of shedding ofthe endometrium due to invisible interplay of the hormones mainly throughHypothalamus – Pituitary –Ovarian- Uterine axis. For this phenomenon to occur innormalcy, the axis must be actively coordinated, positive response of the endometriumtowards the ovarian hormones i:e estrogen and progesterone with patent outflow tract. • In a normal healthy woman menarche occurs at the age of 10-16yrs, 12.5yrs being the mean. • Cyclic menstruation persists throughout the reproductive era of life with an average rhythm of 28±7 days, bleeding for 4-6 days. • Normal blood loss 20-80ml, average being 35ml. • Menstrual blood contains- endometrial debris, dark altered blood, mucus, vaginal epithelial cells, PG enzymes and bacteria.Physiology- 66,67,68,69 With vast hormonal interaction Neuro endocrinology is responsible for menstrualcycle & reproductive functions in a woman. The well established knowledge of normal menstruation, clearly states theimportance of cyclic ovarian steroid secretions which inturn is controlled byHypothalamus-Pituitary-Ovarian-Uterine axis in treating various gynecological disorders.Hypothalamus- Hypothalamus with its several nuclei & extrinsic normal connections is theregulating factor in the chain of Hypothalamus-Pituitary-Ovarian-Uterine axis. Schally &Guillemin in 1971 discovered a decapeptide called gonadotropin releasing factor(GnRH).GnRH factor is secreted by median eminence & the arcuate nucleus which mediate theneural control of gonadotropin secretion of pituitary. GnRH is released into thehypophysial portal vessels & thus reaches pituitary. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 13
  26. 26. Conceptual study GnRH is released at the nerve endings near tuber cinereum. GnRH has a half lifeof 2-4 mins. It is released in pulsatile manner into portal vessels & reaches the anteriorpituitary gland. The pulsatility & amplitude of its release varies with the various phasesof menstrual cycle. In preovulatory phase, it pulses once in every 60 mins but slows down to one in3hrs in luteal phase with increased amplitude of each pulse. Higher center like temporal lobe influences the hypothalamus. Emotional upsetare known to stimulate or depress the H-P-O axis & causes menstrual irregularities. The factors that stimulate GnRH are epinephrine estrogen & endogenous opiods& that which inhibits are dopamine & serotonin.Pituitary glands- Ant.pituitary glands is located at the base of brain in a bony cavity called sella turcicaconsist of 3 cells- • Chromophobe or parent cell. • Chromophil cells as esonophil or alpha cells. • Basophil or beta cells. The β cells secrete gonadotropins that control the ovarian function & menstrual cycle.Gonadotrophins are FSH & LH.Gonadotrophins- These are water soluble glycoprotein of higher molecular wt. β cells secrete FSH& LH in pulsatile manner in responsible to pulsatile GnRH. It has 2 subunit α & β. Inwhich α subunit is concerned with FSH, LH & hCG.Functions of FSH­ • Controls the ripening of the primordial follicle in conjunction with the LH. • Activates the secretion of estrogen. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 14
  27. 27. Conceptual study • Activates- after cessation of menstruation. • Peaks at 7th day of cycle. • Declines to disappear at 18th day. • Half life of FSH is 4 hrs. • Estrogen suppresses FSH secretion through negative feed back mechanism.Functions of LH- • It activates the secretion of estrogen. • Helps in ovulation. • Following ovulation helps in secretion of progesterone with the help of granulose & theca cells. • LH surge- 24-36 hrs prior to ovulation at 75ng/ml.Prolactin- • Prolactin is alcoholic soluble protein (polypeptide). • Half life is 30 mins. • Secreted by α cells. • Main action is lactation. • Suppressive action on pituitary ovarian axis, hence hyper prolactinaemia causes amenorrhoea or oligomenorhoea. • Normal prolactin level is 25ng/ml.Ovarian steroids- The ovarian steroid hormones are derived from cholesterol, which includeestrogen, progesterone, testosterone & androstenedione.Oestrogen- C18 steroid are natural estrogen, granulose cells of graafian follicles & theca cellsbeing the main source & adrenal cortex the secondary source of supply. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 15
  28. 28. Conceptual studyAction- Thorough binding to cytoplasmic receptor in the cells.Conjugates as- oestrogen, oestradiol & oestriol.Rise in level- 6-7days prior to ovulation oestradiol level rises & peaks 2 days beforeovulation.Normal value- 50ug.Peak level-300ug.Progesterone- • Source- Corpus luteum & some small amount from adrenal glands. • Peak level in mid luteal phase about 15ng/ml with degeneration of corpus luteum its level falls inducing menstruation. • In anovulatory cycles progesterone is absent or is in less amount which is from extra ovarian source. • Excreted through- urine as sodium pregnandiol, 3-glucuronide. • Daily production from Corpus luteum- 20-30mg. • Excreted through urine 3-6mg/daily. • Mid luteal phase level less than 15ng/ml suggests luteal phase defect & ovulatory dysfunction.Inhibin- • It is non steroidal water soluble protein (peptide). • Secreted by graafian follicle which suppresses pituitary FSH. • Inhibin consist of 2 peptides A(α) & B(β). • In graafian follicle, estrogen is responsible for secretion of inhibin which suppresses FSH & stimulates LH secretion.Sex hormone binding proteins (SHBP)-Estrogen & androgen are bound to SHBP secreted by the liver & remain inactive. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 16
  29. 29. Conceptual studyThyroid hormone- • Numerous acini & follicle are present in thyroid glands. • TSH released from anterior pituitary stimulates the follicles to synthesis iodine containing Thyroxine (T4) & Tri-iodothyronine (T3) these hormones are related to body growth & metabolic needs. • Thyroid activity has a good influence on ovarian function which alters with thyroid dysfunction leading to menstrual disorders.Prostaglandins Prostaglandins are unsaturated fatty acids which are a cyclopentane ring with 20carbon atoms.TypesThe active forms of prostaglandins are PGD2, PGE2, PGF2 .Functions • Elevates intracellular concentration of Ca. ions in uterine muscles. • Prostaglandins play an important role in regulating the reproductive cycle. These hormones also cause degeneration of carpus luteum (luteolysis). Prostaglandins increase the receptive capacity of cervical mucosa for sperms and cause reverse peristaltic movements of uterus and fallopian tube during coitus. This increases the velocity of sperm transport in female genital tract.Physiology of menstruation 66,68,70,71It can be made easy to understand by dividing it into • Ovarian cycle • Endometrial cycle “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 17
  30. 30. Conceptual studyOvarian cycleIt consist of Development & maturation of follicles Ovulation Formation & degeneration of corpus luteum I. Development of follicle –Preantral phase The cohort of growing follicle undergoes a process of development & differentiation which takes place in 85days & lasts for the ovarian cycle. Initial recruitment & growth of primordial follicles are not under the control of any hormones. The action of FSH over the primordial follicle starts at the follicular size of 2.5mm otherwise there is atresia. The granulose cells require FSH receptor & grow faster than the theca cells. Dominant follicle is formed by day 5-7, which contains maximum FSH receptors & high antral concentration. FSH induces LH receptors on granulosa cell of dominant cell follicle which is necessary for LH surge to induce ovulation, lutenisation of granulose cells to form corpus luteum & secretion of progesterone. II. Ovulation It is possible in following factors Endocrine LH surge- o Peak level of estrogen 24-48hrs in late follicular phase results in LH surge giving +ve feedback mechanism to anterior pituitary. LH surge persist for 24hrs. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 18
  31. 31. Conceptual study FSH surge o 17 alpha hydroxy progesterone facilitates the +ve feedback action on estrogen to induce FSH surge giving rise to plasminogen activator producing plaminogen then plasmin which helps in lysis of the wall of the follicles. o Thus the combined effect of LH/FSH is required for maturation, rupture of follicle & expulsion of oocyte. Stretching factor- Passive stretching cause’s necrobiosis of the overlying tissue. Contraction of the micro muscles due to increased local prostaglandin secretion. III. Formation & degeneration of corpus luteum It is divided into 4 stages. a. Stage of proliferation b. Stage of vascularisation c. Stage of maturation d. Stage of regressionAfter ovulation the ruptured graffian follicle develops into corpus luteumHormonal changes i. LH receptor in granulosa cells in dominant follicle is induced by FSH in presence of high levels of estrogens which leads to mid cycle LH surge to cause luteinisation of granulosa cells & secretion of progesterone. ii. In preovulatory phase, with increased secretion of oestradiol & 17α hydroxy progesterone is a prerequisite for adequate corpus luteum formation. iii. Low level of prolactin. iv. Life span of corpus luteum is 12-14days v. The progesterone along with estrogen secrets relaxin & inhibin. vi. Progesterone along with estrogen from corpus luteum, maintains the growth of fertilized ovum. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 19
  32. 32. Conceptual studyEndometrial cycle Endometrium is the lining epithelium of uterine cavity above the level of internalos. It consist of surface epithelium, glands, stroma & blood vessels.2 distinct division are established 1. Basal zone- stratum basalis 2. Superficial function zoneThis cycle includes i. Regeneration ii. Proliferation iii. Secretary iv. MenstruationStage of Regeneration Starts before menstruation & completes 2-3days after menstruation.Stage of Proliferation From 5-6th day of cycle upto ovulation (14th day) & is dominated by ovarianestrogen.Stage of Secretory Corpus luteum liberates the combined effect of estrogen & progesterone.Progesterone receptors are now present in endometrium which is introduced by estrogen.This phase begin from day 15th of the cycle & ceases 5-6days prior to menstruation. Theaction of the progesterone is mainly on estrogen primed endometrium.Stage of Menstruation The retrogressive changes in the endometrium are due to withdrawal of support ofovarian hormone estrogen & progesterone. The regression of corpus luteum is an “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 20
  33. 33. Conceptual studyinvariable preceding feature which with withdrawal of hormone leads to degeneration &casting of endometrium causing bleeding.Menstruation The uterus is under the influence of estrogen in the initial stage and later undercombined action of estrogen & progesterone of ovarian cycle. Menstruation occurs with the withdrawal of both estrogen & progesterone alongwith the degeneration of corpus luteum. Level of the hormones fall to & below thebleeding threshold which initiates the menstruation. The degeneration of corpus luteum occur when the ovum is not fertilized which isthe fundamental of menstruation. Menstruation represents breaking down & casting off of an endometrium preparedfor a pregnancy which does not materialize & so is sometimes called as ‘weeping ofdisappointed uterus’. Endometrial ischemia is due to spiral artery vascular spasm which is the effect ofwithdrawal of the steroid hormones (estrogen & progesterone). Simultaneously there is a breakdown of lysosomes & a release of proteolyticenzymes which further promotes local tissue destruction. This layer of endometrium isthan shed leaving the deciduas basalis as the source of subsequent endometrial growth. Prostaglandin F2α is a potent vasoconstrictor causing vasospasm & endometrialischemia & it produces myometrial contraction that decreases the local uterine wall bloodflow & may serve to physically expel sloughing endometrial tissue from the uterus.Mechanism of bleeding from endometrium66,68,70,71 The degenerative changes are predominantly of vascular origin. Damage to thearteriolar wall is due to stasis of the blood & spasm of arterioles. Phase of relaxationleads to escape of blood out of the vessels through the damaged walls. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 21
  34. 34. Conceptual study The degenerative process is rapid & involves the compounds of functionaldamaged layer. Breakdown of lysosomes causes release of proteolytic enzymes whichleads into local tissue distruction. The bleeding occurs from broken arteries, veins & capillaries & also from thestromal hematoma. The blood along with superficial functional layer is shed into theuterine cavity. The blood coagulates in uterine cavity but is soon liquefied bythrombolysins released from endometrium. Proactivators of plasminogen is present in theendometrial tissue all the time & at the time of menstruation it is converted into activator,probably as a result of anoxia or breakdown of tissue. As a result of fibrinolysis theeffluent from the uterus consist of altered blood, rich of calcium but deficient inprothrombin & fibrinogen. The expulsion of this together with fragments of endometrium is brought about byuterine contraction. The spasm of straight stems of endometrial arterioles is very important which maybe due to action of PGF2α released from degenerating endometrium. The current concept of spasm, is to limit the amount of bleeding from arteriolethan the ischemic necrosis. The amount of the loss may be controlled by muscularcompression of larger arteries as they pass through the myometrium. Endothelium & Platelet Activating Factor (PAF) are the potent vasoconstrictor.When the endometrium breaks down, the basal layers are not involved because they aresupplied by blood vessels which come off the main arterioles proximal to the partaffected by the coiling & spasm. Post menstrually, new arterioles grow from the old stumps just as theendometrium grows from its basal layer. This is result of estrogen stimulus from nextripening graafian follicle. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA” 22
  35. 35. Disease Review Artava kshaya Most of the menstrual disorders have been described under the heading of astaartava dusti, asrgdhara, artava kshaya in our classics.The word kshaya is derived from ‘¤ÉÏ’ dhatu which means ‘to get reduced’ or ‘to cease’.As per Acharya Caraka ‘kshaya’ means ‘hrasa’ or ‘nyunata’.72¤ÉÏhÉÉ eÉWûÌiÉ ÍsÉXaÉÇ xuÉÇ | cÉ.xÉÔ17/62¤ÉÏhÉÉiÉïuÉlÉÉqÉ AÉiÉïuÉxrÉ xuÉmÉëqÉÉhÉ WûÉÌlÉ | vÉoS MüÉãwÉ When artava is reduced in quantity from its normal flow it is called askshinartava. Shabad kalpadruma the meaning of ‘Alpa’ has been written as ‘kshrudrapramana’ which is suggestive of lesser in quantity. Artava kshaya is not explained as a disease moreover it is a symptom in somediseases. Acharya Sushruta explains artava kshaya lakshanas under dosa dhatu malakshaya vriddhi vignanam in sutrastana. He explains same lakshanas under nastartava74 insharirastana, & anaratava49 explained according to Vagbhatta. Acharya Caraka has not mentioned artava kshaya separately but has mentioned assymptom of many disease. Nidana panchaka are required for formation of vyadhi. In artava kshaya, nidanasevana, khavaigunya, srotorodha, dosha dushya dusti & sammurchana all are seen. All these play key role in vyadhi utpatti. Thus artava kshaya can be considered asa disease.Nidana  Every action in this universe is not without any cause. For production of diseasesthe nidanas play a very important role.Nidana can be divided into samanya & vishesha nidana.Samanya nidana  • Nidana of vinshanti yonivyapad can also be considered as nidana of artava dusti75,75.77. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   23 
  36. 36. Disease Review • mÉÔuÉÉãï uÉ×kS: mÉUÇ MÑürÉÉïSè uÉ×kSÇ ¤ÉÏhÉ¶É iÉ̲kÉqÉç || A.WØû.xÉÔ11/34 Acharya Vagbhata mentions that the vruddhi & kshaya of uttaradhatu depends upon vruddhi & kshaya of purvadhatu78. • mÉÔuÉï: mÉÔuÉÉãïÅÌiÉuÉ×kSiuÉɲkÉïrÉãÎkS mÉUÇ mÉUqÉç | iÉxqÉÉSÌiÉmÉëuÉ×kSÉlÉÉÇ kÉÉiÉÔlÉÉÇ ¾ûÉxÉlÉÇ ÌWûiÉqÉç || xÉÑ.xÉÔ.15/18 Acharya Sushruta in sutrastana mentioned that the rasa dhatu kshaya is one of the causative factor for dhatu kshaya79. • Artava is upadhatu of rasa dhatu • urÉÉrÉÉqÉÉãÅlÉvÉlÉÇ ÍcÉliÉÉ Â¤ÉÉsmÉmÉÍqÉiÉÉvÉlÉqÉç | uÉÉiÉÉiÉmÉÉæ pÉrÉÇ vÉÉãMüÉã ¤ÉmÉÉlÉÇ mÉëeÉÉaÉU:|| MüTüvÉÉãÍhÉiÉ vÉÑ¢üÉhÉÉÇ qÉsÉÉlÉÉÇ cÉÉÌiÉuÉiÉïlÉqÉç | MüÉsÉÉã pÉÔiÉÉãmÉbÉÉiÉ¶É ¥ÉÉiÉurÉÉ: ¤ÉrÉ WãûiÉuÉ: || cÉ.xÉÔ.17/76,77 Acharya Caraka explained the samanya nidana of kshaya, the same nidanas play avery good role in artava kshaya80.Vishesha nidana  Acharya Kashyapa while explaining about beejopaghata & pushpopaghata saysthat, use of nasya during menstruation, consumption of teekshna dravya for panchakarmaprocedure & use of ushna annapana by a woman with mrudukosta having receivedsnehana & swedana causes pushpopaghata81. ¤ÉÏhÉÇ uÉÉiÉÌmɨÉÉprÉÉqÉç | A.xÉÇ. vÉÉ.1/24 Vitiation of vata & pitta dosha causes kshina Artava82. SÉæwÉæUÉuÉרÉqÉÉaÉïiuÉSÉiÉïuÉÇ lÉvrÉÌiÉ Îx§ÉrÉÉ: || xÉÑ.vÉÉ. 2/22 The margavarana is done by vata & kapha, thus hampering the physiologicalproduction of artava leading to artava kshaya83. As we know that artava is agneya in nature i:e pitta dosha pradhana. Hence thevishesha nidana for artava kshaya can be considered as vata kapha prakopaka nidana &pitta kshaya nidana. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   24 
  37. 37. Disease Review So for proper understanding this nidana84,85 is divided into • Aharaja • Viharaja • Manasika • Abhighataja • AnyaAharaja hetu 84,85Table no: 1 Vataja vitiating Pittaja vitiating Kaphaja vitiating hetu hetu hetu According to Atikatu, Tikta, Atikatu, Amla, Atimadhura, Lavana, rasa Kashaya Lavana, Amla predominant According to Excessive Excessive Excessive guna consumption of consumption of consumption of Sheeta, Laghu, Ushna & Vidahi Abhishandi, Guru, Ruksha ahara ahara Picchila ahara According to Abhojana, ------------------- Atibhojana, pramana of laghubhojana Adhyasana, Ajirna ahara. According to Excessive intake of Excessive intake of Excessive intake of dravya Koddalaka, Mudga, Kshara, Dadhi, Pisti, Ishu, Masha, Shyamaka, Takra, Kanji Anupa mamsa Atishushka shakaViharaja hetu 84,85Table no: 2 “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   25 
  38. 38. Disease Review Vataja vitiating hetu Pittaja vitiating hetu Kaphaja vitiating hetu Atiprajagarana Atapasevana Diwaswapana Vegadharana Agni-Dhuma sevana Ativyavaya AtivyayamaManasika hetu 84,85Table no: 3 Vataja vitiating hetu Pittaja vitiating hetu Kaphaja vitiating hetu Shoka, Chinta, Bhaya Irsha, Krodha HarshaAnya hetu 84,85Table no: 4 Vataja vitiating hetu Pittaja vitiating hetu Kaphaja vitiating hetu Dhatukshaya, Atiraktastrava Atisantarpana,Virechana Rogatikarshana ayogaAbhighataja hetu 86AÉiÉïuÉWãû ²ã iÉrÉÉãqÉÔïsÉÇ aÉpÉÉïvÉrÉ AÉiÉïuÉuÉÉÌWûlrÉ¶É kÉqÉlrÉ: |iÉ§É ÌuÉkSÉrÉÉ uÉlkrÉÉiuÉÇ qÉæjÉÑlÉÉxÉÌWûwhÉÑiuÉqÉÉiÉïuÉlÉÉvÉ¶É ||xÉÑ.vÉÉ. 9/12 The mula of artavavaha srothas being garbhasaya & artavavahi dhamani whereinjury causes infertility, dyspareunia & amenorrhoea.PoorvaroopaSpecific reference for the poorvaroopa is not present in the classicsRoopa73 “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   26 
  39. 39. Disease ReviewAÉiÉïuɤÉrÉã rÉjÉÉãÍcÉ¨É MüÉsÉÉSvÉïlÉqÉç AsmÉiÉÉ uÉÉ rÉÉãÌlÉuÉãSlÉÉ ||xÉÑ.xÉÔ. 15/12The 3 cardinal features mentioned by acharya Sushruta • Yathochittakala adarshana- Delayed menstruation • Alpata – scanty menstrual flow • Yoni vedana- pain in vaginal region.Yathochittakala adarshana73-Normal interval between 2 menstrual cycles is one month.As explained in the classicsqÉÉÍxÉ qÉÉÍxÉ UeÉ: x§ÉÏhÉÉÇ | A.WØû.vÉÉ. 1/7If menstrustion fails to occur by one month showing irregularity in the cycle & increasedintermenstrual period can be termed as Yathochittakala adarshana.Alapata73The meaning of alpa is kshudra pramana. This may be considered as reduced inmenstrual flow.In artava kshaya both pramana & avadhi are altered from the normal i:e. 3-5days with 4anjali pramana (35ml according to modern).Yoni vedana73Vitiation of vata causes yoni vedana. The vata mainly affected is apana vata. As there ispartial filling of the garbhasaya for the whole month by the sukshma keshikas due tosrothorodha. This little quantity of artava is excreted out with great difficulty causingyoni vedana. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   27 
  40. 40. Disease Review Samprapti SÉãwÉæUÉuÉ×iÉqÉÉaÉÉïiuÉÉSÉiÉïuÉÇ lÉvrÉÌiÉ Îx§ÉrÉÉ: || xÉÑ. vÉÉ. 2/21 SÉãwÉæËUirÉÉÌS- | A§É SÉãwÉÉ: MüTüÉã uÉÉrÉÑuÉÉïiÉMüTüÉæ cÉ; lÉ iÉÑÌmɨÉÇ, ÌmɨÉuÉ×®Éæ iÉxrÉÉÌiÉmÉëuÉ×ͨÉuÉ×k±Éã£üiuÉÉiÉç , MÑüsÉijÉÉÌSuÉÉiÉMüTüWûUSìurÉÉuÉcÉUhÉÉgcÉ | lÉvrÉiÉÏÌiÉ mÉëuÉiÉïqÉÉlÉÇ lÉ SØvrÉiÉã, lÉ iÉÑ xÉuÉïjÉÉ ¤ÉrÉÇ rÉÉÌiÉ || xÉÑ.vÉÉ. 2/21 QûsWû. OûÏMüÉ Acharya Sushruta while explaining about nastaratava says that, the vitiation of vata &kapha does avarana to the marga of artava leading to srothorodha of artavavaha srothas 74causing artava kshaya. Hence the above samprapti can be understood in the followingway. • The nidanas mentioned in artava kshaya vitiates the vata mainly apana vata & the kapha. The kapha does the avarana of apana vata & this kaphavritta apana vata does margavarodha in artavavaha srothas resulting in reduction in flow of artava leading to artava kshaya74. • Vitiated apana vata causes khavaigunya in artavavaha siras that fills the uterus for the whole month. This leads to partial filling of menstrual blood in the uterus causing reduced flow resulting in artava kshaya.73 • The nidanas of vata & kapha prakopaka ahara vihara leads to jataragni mandya not only produces ama but also vitiates samana vata, pachaka pitta, kledaka kapha, which have good role in digestion. Thus the production of ahara rasa is hampered which ultimately affects the formation of rasa dhatu by causing dhatavagni mandya. Artava being the upadhatu of rasa dhatu its utpatti is also affected. Finally leading to artava kshaya. Acharya Kashyapa while explaining the causes for beejopaghata &pushpopaghata explains that in the mrudu kosta woman after proper snehana & swedana,intake of excessive & teekshana dravyas, ushna annapana, there is jeevarakta skalanacausing puspopaghata finally causes artava dusti.81 “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   28 
  41. 41. Disease Review Acharya Vagbhatta explains that the vata & kapha does the avarodha of rakta &causes nastartava33. As explained acharya Sushruta iÉrÉÉãqÉÑïsÉÇ aÉpÉÉïvÉrÉ AÉiÉïuÉuÉÉÌWûlrÉ¶É kÉqÉlrÉ; iÉ§É ÌuÉ®ÉrÉÉuÉlkrÉÉiuÉÇ qÉæjÉÑlÉÉxÉÌWûwhÉÑiuÉqÉÉiÉïuÉlÉÉvÉ¶É || xÉÑ. vÉÉ. 9/12 The mula of artavavaha srothas is garbhasaya & artava vahini dhamani. If anytrauma to this may lead to artava nasha86. While describing about nastaartava, Acharya Dalhana explains that the kapha &vata obstructs the artava vaha srothas resulting into nastartava. Here the meaning ofnastartava does not mean that the artava is destroyed completely, but there is suppressionof artava which causes irregularity in menstruation74. Nidana sevana Intake of teekshana oushadha Abhighata Vata kapha prakopa byVata dusti-apana vata Mrudu kosta woman artvavaha Kaphadusti srothasIncrease in sthanika kledata After proper ArtavanashaProduces avarana to apana vata Snehana & Swedana Kaphavrita apana vata Causes jeeva rakta skalana Artava vaha srothas Pushpopaghata ARTAVA KSHAYA “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   29 
  42. 42. Disease ReviewSamprapti GhatakaDosha- o Vata – Apana vata, Samana vata o Pitta –Pachaka pitta o Kapha –Kledaka kaphaDushya- Rasa, RaktaUpadhatu- ArtavaAgni –Jataragni, DhatavagniSrotas-Rasavaha, RaktavahaSrotodusti- SangaUdbhvastana -AmasayaAdhisthana- GarbhsayaSancharasthana- SarvashareeraVyakta sthana – Yoni, Garbhasaya. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   30 
  43. 43. Disease Review ChikitsaxÉqmÉëÉÎmiÉ ÌuÉbÉOûlÉqÉãuÉ ÍcÉÌMüixÉÉ || The main objective of chikitsa is samprapti vighatana. This mainly can beachieved in 2ways Samshodhana Samshamana o Samshodhana includes Panchakarma which can be defined as therapeutic measures applicable to cleanse excessively accumulated dosha from the body. This is for bahu dosha avastha. o Samshamana includes oral medication which pacifies the disease. This is advised for madhyam dosha avastha. o In alpa dosha avastha, langhana chikitsa can be done86. Hence different mode of chikitsa works on vitiated dosha & dhatu at differentavastha. Acharya Sushruta while explaining about the chikitsa of artava kshaya says that,the chikitsa can be adopted according to vitiation of the dosha.iÉ§É xÉÇvÉÉãkÉlÉqÉÉalÉãrÉÉlÉÉÇ cÉ SìurÉÉhÉÉÇ ÌuÉÍkÉuÉSÒmÉrÉÉãaÉ: ||xÉÑ.xÉÔ.15/12 Here both shodhana & shamana chikitsa which is in form of agneya dravyas canbe given. But the selection of the chikitsa should be done wisely73. Acharya Dalhana commenting on the same says only vamana karma must be donenot the virechana. Due to virechana the pitta dosha is reduced which in turn decreasesartava, as we know that AÉiÉïuÉqÉÉalÉãrÉqÉç | while vamana removes the soumya “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   31 
  44. 44. Disease Reviewdhatu, resulting into relative increase in agneya constituents of the body & finally causesincrease in artava. So he advised vamana73. Charakapani explains that both vamana & virechana are used to clear urdhva &adho srothas respectively. Hence both the measures must be adopted considering thedosage of drugs used for shodhana & the bala of the woman undergoing the procedure. Acharya Sushruta explains few of the agneya dravyas74 which increases artavaiÉ§É qÉixrÉMÑüijÉÉqsÉÌiÉsÉqÉÉwÉxÉÑUÉ ÌWûiÉÉ: |mÉÉlÉã qÉÔ§ÉqÉÑS¶ÉÑccÉ SÍkÉ vÉÑ£üÇ cÉ pÉÉãeÉlÉã || xÉÑ.vÉÉ.1/22 Matsya, kulattha, amla(kanji), tila, masha, sura, gomutra, udashevta, dadhi, sukta,all these are agneya dravyas which helps to improve the quality & quantity of artava74.As mentioned in Astanga SamgharaÌmɨÉsÉæÂmÉÉcÉÉUæxiÉimÉëuÉiÉïqÉÉlÉqÉç | A.xÉÇ vÉÉ. 1/13 Acharya Vagbhata explains that the use of pittavardhaka dravyas also helps inincreasing the artava49. Acharya Bhava Prakasha & Yogaratnakara have given the list of dravyas that can beused in artava kshaya. (Bp.N. Chi. 70/22-24, Y.R. Yonivyapad Chi.) o Matsya, kanji, tila, masha, udashveta, dadhi, are given orally. o Ishvakubeeja, danti, Chapala, guda, madana phala, yava, sukta, snuhi ksheera, varti is prepared from this & is kept in yoni. This helps to remove out the obstructed artava. o Jyotishmati, swarji kshara, rajika, lasuna all these drugs are mixed & given with cold water to drink for three days. Acharya Kashyapa explains in kalpastana, drugs like Lasuna,88 shatapuspa &satavari89 are beneficial in treating artava kshaya. The disease artava kshaya has vitiation of vata pitta & obstruction of vata kaphain artava vaha srothas. Acharya Caraka describes in all yoni vyapad as vata is the prime factor.lÉ ÌWû uÉÉiÉÉSØiÉã rÉÉãÌlÉlÉÉïUÏhÉÉÇ xÉÇmÉëSÒwrÉÌiÉ | cÉ.ÍcÉ. 30/115 “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   32 
  45. 45. Disease Review So he has advised to treat vata dosha first which normalizes other all doshas90.As explained by Acharya VagbhataoÉÎxiÉËUwrÉiÉã……UeÉÉãlÉvÉÉlÉç | A.WØû.xÉÔ 19/1-3Artava kshaya is basti sadhya vyadhi91This is further supported by Acharya KashyapaAsmÉmÉÑwmÉÇ AlÉÑuÉÉxrÉ CÌiÉ | MüÉ. xÉÇ ÍxÉ. 7/11In alpa pushpa i:e artava kshaya anuvasana basti is beneficial92.Hence the above can be summarized as follows o Shodhana & shaman both line of treatment can be adopted. o The use of agneya dravya is strongly recommended. o The drugs capable of increasing pitta which helps in increasing artava must be used.Sadhyasadhyata –Prognosis  As seen in the classics there is no description about the prognosis of the disease.The dosha involvement & the lakshanas of ksheena artava are one & the same. Hence thesadhyasaadhyata mentioned for ksheena artava can be considered. As explained by Acharya Sushruta, it is asadhya vyadhi.93 In A.S. Acharya Vagbhata has not clearly mentioned about it. But commentatorIndu has quoted vÉãwÉ xÉuÉï xÉÉkrÉÇ | A.xÉÇ vÉÉ. 1/25 ClSÒ OûÏMüÉ. Thisprobably indicates it to be sadhya82. Acharya Vagbhata in A.H. explains it to bekastasadhya vyadhi94Sapeeksha Nidana - Differential DiagnosisArtava kshaya can be noted in the followingVatala YonivypadTãüÌlÉsÉÉÂhÉM×üwhÉÉsmÉiÉlÉѤÉÉiÉïuÉxÉëÑÌiÉqÉç | A.xÉÇ.E 38/33 As there is alpa artava darshana, it can be considered as artava kshaya. Butpresence of ayama, suptata in vatala yonivyapad which is absent in artava kshaya95. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   33 
  46. 46. Disease ReviewLohitakshaya YonivyapaduÉÉiÉÌmɨÉÉprÉÉÇ ¤ÉÏrÉiÉã UeÉ: |xÉ SÉWû MüÉvrÉïuÉæuÉhrÉï rÉxrÉÉÇ xÉÉ sÉÉãÌWûiɤÉrÉÉ || A.WØû.E.33/45 It is different from artava kshaya because of its other features like daha, karshya,vaivarnya95.Arajaska YonivyapadrÉÉãÌlÉaÉpÉÉïvÉrÉxjÉÇ cÉãiÉç ÌmɨÉÇ xÉÇSÕwÉrÉãSxÉ×Mç |xÉÉÅUeÉxMüÉ qÉiÉÉ MüÉvrÉïuÉæuÉhrÉïeÉlÉlÉÏ pÉ×vÉqÉç ||cÉ.ÍcÉ.30/17 In this yonivypad the pitta is the vitiated dosha. But Acharya Caraka has notexplained any symptom of anartava. Commentator Chakrapani explains anartava assymptom. But it cannot be considered as artava kshaya because it includes othersymptoms like karshya, vaivarnya which are not seen in artava kshaya75.Vandhya YonivyapaduÉlkrÉÉ lɹÉiÉïuÉÉÇ ÌuɱÉiÉç | xÉÑ.E. 38/10 Nastarva is a symptom in vandhya yoni vypad i:e absence of menstruation. But itis also associated with other symptoms96.Shandhi YonivyapadAlÉÉiÉïuÉÉxiÉlÉÉ wÉhQûÏ ZÉUxmÉvÉÉï cÉ qÉæjÉÑlÉã | xÉÑ E. 38/18 Here anartava & astana features are seen which is congenitally present. Butartava kshaya as explained in classics is not a congenital disease96. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”   34 
  47. 47. Disease review Oligomenorrhoea 97,98,99 It can be defined arbitrarily as one in which the cycle lasts longer than 35dayswith only 4-9 cycles in a year.Menstruation may be both infrequent & irregular or may be regularly infrequent. Infrequent menstruation & amenorrhea are essentially similar symptoms withidentical causes the difference is only one degree.Aetiology 100,101,102 Oligomenorrhoea can be caused by a hormonal imbalance. Menarche tomenopause the length, regularity & menstrual flow is under the hormonal control ofhypothalamus –pituitary-ovarian–uterine axis. Adrenal gland also takes part in productionof steroid hormones. Thus the causes & be divided into • Physiological • PathologyPhysiological factors It is quite common for women at the beginning & end of their reproductive livesto miss or have irregular cycles. This is normal & is usually the result of imperfect co-ordination between the hypothalamus –pituitary-ovarian axis. o Pregnancy o LactationPathological Uterine factor Tubercular endometrisis- There is destruction of the endometrium or inhibition of ovarian function by tubercular toxins Post radiation- There will be destruction of endometrium. Synechiae- Intra uterine adhesions viscero-cortical reflex leads to amenorrhoea “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     35    
  48. 48. Disease review  Surgical removal of endometrium i:e Ablation of endometrium by laser, resectoscope. Due to absence of FSH receptors. Ovarian factors Autoimmune disease PCOD – Tonically elevated LH increased androgen production from theca cell & stroma of the ovaries decrease SHBG increased unbound estrogens & androgens pituitary sensitivity to GnRH is increased preferential increased production of LH, decreased production of FSH due to inhibin. Disturbed adrenal function is also implicated in androgen excess. Resistance ovarian syndrome (savage syndrome)- defect in FSH receptors, follicles are present but are resistant to gonadotropins. Hypoestrogenic state Radiotherapy- Makes the ovaries unresponsive to gonadotropins Surgical extirpation- Removal of site of production of estrogen. Pituitary factors Tumors like Prolactinoma, Chromophobe adenoma, Cushing disease. In all the above conditions there is microadenoma associated with hyperprolactinaemia. This inhibits steriodogenesis of ovary directly & inhibits pituitary release of LH & FSH. Simmond’s disease Sheehan’s syndrome In above 2 conditions there is partial or complete destruction of pituitary by ischemia caused by venous thrombosis. The principle hormones affected are growth hormone, LH, FSH, TSH, adreno-corticotrophins & prolactin. Hyperprolactinaema “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     36    
  49. 49. Disease review  Hypothalamus causes GnRH deficiency Vigorous exercise Pseudocyesis Brain tumors Psychogenic shock stress Anorexia nervosa- Release of GnRH is inhibited. There is low level of esterogen & LH, but FSH level remains normal. There may be hyerprolactinemia due to altered dopamine inhibition. Tumours of hypothalamus & pituitary need surgical excision. Adrenal causes Cushing syndrome Suprarenal tumours or hyperplasia The effect of estrogen on the endometrium is opposed by excess androgen. Thyroid factors Hypothyroidism Graves disease Raised TSH & hyperprolactinaemia by direct action of TRH on galactophere cells in the pituitary. Drugs Contraceptive pills- This leads to ‘post pill syndrome’ due to suppression of GnRH release Anti depressants, Dopamine blockers- These agents raises the prolactin levels Anti hypertensive- These are dopamine depleting agents & raises the prolactin levels. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     37    
  50. 50. Disease review  Nutritional factors Extreme obesity Excessive weight loss in the athletes & ballet dancer Severe anemia Malnutrition Chromosomal factors An underlying sex chromosome abnormality such as an XXX arrangement. Other factors Diabetes Renal disease Probably all these factors will be affecting the hypothalamus –pituitary- ovarian – uterine axis Many women are obese, hirsuite with poorly developed secondary sexual characters, genital hypoplasia, ovarian subfunction.Hypomenorrhoea 103,104,105 Uterine bleeding may be slight in amount, short in duration or both. Bleedingwhich lasts 2 days or less is unusual & this pathology is termed as Hypomenorrhoea.Causes Constitutional causes Constitutional scanty menstruation is perhaps best explained by assuming the presence of an unusual arrangement, or relative insensitivity of endometrial vascular apparatus. Uterine causes Scanty loss sometimes means that the bleeding surface is smaller than the normal. The endometrial cavity will be reduced to much- During myomectomy, “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     38    
  51. 51. Disease review  Due to intra uterine adhesions Due to chronic endometritis Hormonal causes Disturbances in endocrine system do not ordinarily lead to scanty menstruation without altering the cycle at the same time. Scanty menstruation is however occasionally seen as forerunner to amenorrhoea & oligomenorrhoea & thus has the same causes. Use of low dose oral contraceptives results in endometrial atrophy that causes hypomenorrhoea. Nervous & Emotional causes Ovarian –Uterine axis are sometimes suppressed by the psychological factor & sometimes succeed only in reducing the amount of flow. E.g.-Pseudocysis which is frequently characterized by scanty period rather than amenorrhoea.Approach towards both hypomenorrhoea & oligomenorrhoea 106,107,108 There is altered co-ordinate function of Hypothalamus-pituitary-ovarian-uterineaxis by some pathology. Hence a thorough history taking has a prime importance & all clinicalexamination is mandatory. Laboratory investigation are required either for the diagnosis or to confirm theclinical diagnosis. Detail history taking also plays an important role which further helps to decideline of treatment. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     39    
  52. 52. Disease review This includes i. Mode of onset of menses ii. Sudden change in environment, emotional stress, or any mental upset. i. Sudden change in weight – may be loss or gain. ii. Intake of psychotropic or anti hypertensive drugs. iii. History of- a. Radiotherapy or chemotherapy b. Acne, hirsute, change in voice. c. Inappropriate galactorrhoea. d. Headache or visual disturbance. e. Hot flushes & vaginal dryness. f. Curettage leading to synechae, post partum or post abortal infection. iv. Labor and puperial events –PPH, shock, lactation. v. Medical history of tuberculosis, diabetes, chronic nephritis or overt hypothyroid state, duration of use of OCPs. vi. Family history- if anything to be enquired.vii. General examinations- a. Nutritional status b. Extreme emaciation or marked obesity. c. Presence of acne or hirsute. d. Breast discharges.viii. Pelvic examination a. Examination of external genitalia along with development of secondary sexual characters. b. Enlargement of clitoris c. Adnexal mass suggestive of tubercular T-O mass. d. Per-vaginal examination “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     40    
  53. 53. Disease review  ix. Special investigations a. Urine Pregnancy Test- To exclude pregnancy in woman with active reproductive period. b. Radiology- radiological of pituitary gland. CT scan to detect pituitary adenomas. c. Ophthalmology- Examination of retina & visual field should be done if pituitary tumor is suspected. d. Hormonal assays- FSH, LH, Serum Prolactin, Testosterone levels TSH, T3, T4 levels Increased in gonadotrophin indicates primary ovarian failure. Decrease in gonadotrophin indicates Hypothalamus- Pituitary defect. e. Ultrasound- to document status of uterus, ovaries. Thickness of endometrium. Endometrial thickness < 4mm indicates anorexia nervosa. f. Chromosomal studies for excluding Turner’s Syndrome (XO) Super female (Trisomy X or XXX) x. Laparoscopy- xi. Treatment 109,110,111 a. Reassurance plays a major role. b. Therapeutic tests o When investigations leave doubt as to with link of H-P-O-U axis is primarily at fault, therapeutic tests is of great value. o The first of these is to assess uterine sensitivity to ovarian hormones. o After excluding pregnancy, hpyerprolactinaemia & hypothyroidism, a Progesterone Challenge Test is administered. If the patient has withdrawal bleeding it indicates the presence of a functional outflow tract, & also presence of sufficient circulating “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     41    
  54. 54. Disease review  endogenous estrogens which has primed the endometrium & the diagnosis is anovulation. If on the other hand, the patient does not have withdrawal bleeding in response to the progesterone challenge, a combination of both estrogen & progesterone is given. If negative response indicates a defect in the outflow tract i:e uterine amenorrhea. If bleeding does occur it points to a defect in production of both estrogen & progesterone. Serum FSH & LH levels are measured. If these are raised, the cause is ovarian failure where as if they are low or normal, the cause is hypothalamic. o GnRH Dynamic Test- If with GnRH administration, there is rise of pituitary gonadotrophins, it is probably a cause of hypothalamic dysfunction. o Laparoscopy- - This is done to exclude the presence of streak gonads & small ovarian tumors, - To recognize PCOD in which ovarian drilling can be done. - Abnormal gonads may be removed at the same sitting.  “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA                       AND LASUNADI VATI IN ARTAVA KSHAYA”                                     42    
  55. 55. Drug Review  Lasuna –Botanical name- Allium sativumFamily – LILIACEAETable no: 5 Rasa Guna Viryaa Vipaka Doshakarma Caraka Katu Guru Ushna Katu Vataghna Snigdha Sushrut Madhura Snigdha Ushna Katu Kaphaghna a Teekshana Picchila Sara. Dh. Ni. Madhura Guru, Ushna Katu Kaphaghna Snigdha Teekshana Picchila Sh. Ni. Katu Snigdha Ushna Katu Kaphaghna Teekshana sara guru Kai. Ni. Katu, Snigdha Ushna Katu Vatakaphahara Madhura Teekshana Guru Sara. BP. Ni. Amla Snigdha Ushna Katu Pittakara, vargita Teekshana vatakaphahara pancharasa Guru, Sara. Ushna R. Ni. Amla Ushna Ushna Katu Kaphavatanut vargita pancharasa Ni. Ad. Madhura, Snigdha Ushna Katu Kaphavatanut Katu Ushna, Guru,Chemical constitution-Alliin; carbohydrate (arabinose, galactose etc); vitamins (folic acid, niacin, riboflavin,thiamine, vit.c); amino acids (arginine,asparagic acid, methionine etc.); enzymes(allinase); volatile compounds (allylalcohol, allylthiol, allylpropyl disulphide etc.);thioglycosides(scordine, scordinine A1, A2 & B etc,); prostaglandins A2, D2, E2 and F2;allylmethylselenide, ajoene, proteoruboside B. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”       43 
  56. 56. Drug Review  JeerakaBotanical name- Cuminum cyminumFamily – UMBELLIFERAETable no: 6 Rasa Guna Virya Vipaka Doshgnata Sushrut Katu Teekshna Ushna Katu Pittavardhaka, a Ushna Kaphavatahara Dh.Ni Katu Ruksha Ushna Katu Vataghna Sh. Ni. Katu Teekshna, Ushna Katu Kaphavatahara Ushna Pittakruta Kai. Ni. Katu, Laghu, Ushna Katu Pittala, Tikta Ruksha Kaphavatapaha BP. Ni Katu Laghu, Ushna Katu Kaphavatahara Ruksha Pittakara R. Ni. Katu Ushna Ushna Katu Vataghna Ni. Rt. Madhura Laghu, Ushna Katu Vataghna Ruksha, UshnaChemical constitution-Ciminin, diacyl glycerol, imperatorin, isoimperatorin, isoimpinellin, oxypeucedanin;apigenin & apiin; oxalic, cuminaldehyde, p-cymene etc. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”       44 
  57. 57. Drug Review  HinguBotanical name-– Ferula northaxFamily – UMBELLIFERAETable no: 7 Rasa Guna Virya Vipaka Doshgnata Caraka Ushna Katu Kaphavata shamaka Dh. Ni. Katu Sara Ushna Katu Vatakaphapham Sh. Ni. Katu Laghu, Ushna Katu Vatakaphagna Snidgha Pittakopaka Kai. Ni. Tikta,Katu Laghu Ushna Katu Vatakaphanashaka BP. Ni. Teekshna Ushna Katu Vataghna, Pittavardhaka R. Ni Katu Ushna Katu VatakaphapahaChemical constitution- Gum-a- pinene, phllandrene, see.butyl propenyldisulphide, atrisulfide, asaresinotanol, farnesiferol A, gummosin, kamolonol, mogoltadone,polyanthinin, polyanthin, undecylsulfonyl acetic acid; umbelliferone, root- foetidin,luteolin, Whole plant- assafoetidin, ferocolicin. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”       45 
  58. 58. Drug Review  PipalliBotanical name – Piper longumFamily – PIPERACEATable no: 8 Rasa Guna Virya Vipaka Dosakarma Caraka Madhura Guru, Ushna Madhura Kaphavataghna, Katu Snidgha, Pittakara Shuska, Yogavahi Susruta Swadu Guru, Ushna Katu Kaphavataghna Pittavishodhini Dh. Ni. Madhura Teekshna Ushna Katu Tridoshajeet , katu Hima, Snigdha Sh. Ni. Sushka- Katu Teekshna, Ushna Katu Vatakaphahara Snigdha, Laghu Adra Madhura Snigdha, Sheeta Kaphakara Guru Kai. Ni. Sushka- Hima Sheeta Madhura Kaphaprada Guru Snigdha Adra - Sara, Ushna Madhura Kaphavatahara Snigdha,T eekshna BP Laghu, Anush Madhura Vatakaphahara Snigdha na Pittaprakopaka R.N. Teekshna Ushna Madhura Kaphavatahara Laghu, Snigdha, UshnaChemical constitution-Essential oil, mono- and sesquiterpenes, caryophyllene(mainly), piperine,piplarine,piplartine, piperlongumine, piperlonguminine, pipernonaline, piperundecalidine,pipercide, sesamin, beta-sitosterol; four aristolactams (cepharonone B, aristolactum All,piperlactumA and piperolactam B); five 4,5-dioxoaporphines etc. “A COMPARATIVE CLINICAL STUDY OF KRISHNA TILA KASHAYA AND LASUNADI VATI IN ARTAVA KSHAYA”       46 

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