Asrgdhara uvasti-psr


Published on


1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Asrgdhara uvasti-psr

  1. 1. “ A CLINICAL EVALUATION OF THE EFFECT OF UTTARA BASTI IN ASRGDARA W.S.R.TO DYSFUNCTIONAL UTERINE BLEEDING ” BY DR. DEEPASHREE B.A.M.S Dissertation submitted to theRajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of MASTER OF SURGERY (Ayu) in Prasooti tantra and Stree roga Guide Co-guide DR. RAMADEVI G, M.D. (Ayu) DR. JONAH, M.D (Ayu) Professor, Professor Dept of prasooti tantra & Dept. of Kaya Chikitsa streeroga S.D.M.C.A. Udupi S.D.M.C.A. Udupi Department of post graduate studies in Prasooti Tantra & Stree roga S. D. M. COLLEGE OF AYURVEDA, UDUPI 2010-2011
  2. 2. Department of Post graduate Studies in Prasooti Tantra & Stree roga S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118 DECLARATION I hereby declare that this dissertation entitled “ A CLINICAL EVALUATIONOF THE EFFECT OF UTTARA BASTI IN ASRGDARA W.S.R.TODYSFUNCTIONAL UTERINE BLEEDING ” is a bonafide and genuineresearch work carried by me under the guidance of Dr.Ramadevi G., M.D. (Ayu)and co guidance of Dr. Jonah M.D. (Ayu). Date: Signature of Candidate Place: Udupi Dr. Deepashree
  3. 3. Department of Post graduate Studies in Prasooti Tantra & Stree roga S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118 CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A CLINICAL EVALUATION OF THE EFFECT OF UTTARA BASTI IN ASRGDARA W.S.R. TO DYSFUNCTIONAL UTERINE BLEEDING” is a bonafide research work done by Dr. Deepashree in partial fulfillment of the requirement for the degree of M.S. (Ayu).. Date: Signature of Guide Place: Udupi Dr.G.Ramadevi., MD. (Ayu) Professor. Dept of prasooti tantra and streeroga S.D.M.C.A Udupi
  4. 4. Department of Post graduate Studies in Prasooti Tantra & Streeroga S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118 CERTIFICATE BY THE CO GUIDEThis is to certify that the dissertation entitled “ A CLINICAL EVALUATIONOF THE EFFECT OF UTTARA BASTI IN ASRGDARA W.S.R.TODYSFUNCTIONAL UTERINE BLEEDING” is a bonafide research work done byDr. Deepashree in partial fulfillment of the requirement for the degree of M.S. (Ayu). Signature of Co-Guide . Date: Dr. Jonah M.D. (Ayu). Place: Udupi Professor, Dept of Kaya Chikitsa S. D. M. C. A., Udupi.
  5. 5. Department of Post graduate Studies in Prasooti Tantra & Stree roga S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118 ENDORSEMENT BY THE PRINCIPAL/ HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A CLINICAL EVALUATION OF THE EFFECT OF UTTARA BASTI IN ASRGDARA W.S.R.TO DYSFUNCTIONAL UTERINE BLEEDING” is a bonafide research work done by Dr. Deepashree under the guidance of Dr.G.Ramadevi., M.D. (Ayu) and co guidance of Dr. Jonah., M.D. (Ayu) . H.O.D PRINCIPALDr.V.N.K Usha M.D.(Ayu.) Dr. U.N.PrasadDept. Of Prasuthi Tantra M.D. (Ayu.)and StreeRoga SDM College of AyurvedaS.D.M.C.A Udupi Udupi.Date:Place: Udupi
  6. 6. Department of Post graduate Studies in Prasooti Tantra & Stree roga S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118 COPYRIGHTI hereby declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis inprint or electronic format for academic / research purpose. .Date: Signature of CandidatePlace: Udupi Dr .Deepashree
  7. 7.     Dedicated to My Beloved  Parents  SHRI. RAGHUNATH SHEETY & SMT. KANTHI R. SHETTY
  8. 8. ACKNOWLEDGEMENTI humbly seek this opportunity to bow my head on the feet of the Lord Ganapathi & my Guruji forshowering their blessings and empowering me to this eventful outcome without any impediments.In deed it is my fortune to have carried out this dissertation work in SDMCA Udupi. In this regard i wouldlike to express my heart felt gratitude to Honourable Dr. D Veerendra Heggade, President of ShreeDharmasthala Manjunatheshwara Educational Society, for his courtesy, grace and blessings to carry outthis work.I express my heartfelt thanks to my esteemed and respected guide Dr. G. Ramadevi., Professor of PrasutiTantra and Streeroga Department, SDM College of Ayurveda for feeding me with precious andconstructive ideas & inspired me to achieve this goal. Her guidance is imperishable, something which timeor distance can not destroy.I wish to express my gratitude to my co-guide Dr. Jonah., Prof., Kayachikitsa Department, SDM College ofAyurveda for his valuable support and guidance during this whole work.I find words are inadequate to express my sense of gratitude towards my esteemed and respected teacherProfessor & H.O.D Dr. V.N.K.Usha, for her fruitful suggestions, optimistic view & motherly affectionshowered on me throughout my study period.Iam deeply indebted to my respected teacher Dr. Mamatha K. V. Prof. Department of Prasuti Tantra andStreeroga for her precious training, concern & generosity throughout my study period.I sincerely express my deep sense of gratitude to Dr.Sucheta, Dr.Vidhya, Dr.Veena, Dr Krishna bai fortheir help during this study.I am grateful to Dr. U.N. Prasad, Principal SDM college of Ayurveda, Udupi and Dr. Y.N.Shetty, Medicalsuperident of SDM Hospital Udupi for providing all the facilities in the college & hospital for carryingout my study.My sincere gratitude to the Dean Dr. Govinda raju & Assosiate Dean Dr. Prabhakar Renjal for theirinvaluable support, encouragement & guidance.My hearfelt gratitude to Dr.A.R Acharya, Prof of Shalya Department, SDM college of Ayurveda, Udupifor his timely help and support.
  9. 9. Iam thankful to Dr. Muralidhar, Technical adviser, SDM Pharmacy, Udupi for preparing & providing themedicines in time, required for my study.My sincere thanks to Nursing staff & Nursing assistants for their immense association & help during myclinical work.This dissertation will be no value if I don’t refer the unmatched inspiration and support of family.I am ever grateful to my beloved parents, Shri. Raghunath shetty and Smt. Kanthi R shetty for showeringtheir blessings and giving me moral support and guidance throughout my path.Even though more words can never replace the emotions one feels, still I crave to convey a cordial thanksto my brothers, sister & all my family members for constantly providing me valuable support andencouragement.I am deeply indebted to my special & close friends Mr. Viraj Rao & Jyothi Rao for their whole heartedsupport, encouragement, co-operation, inspiration and helpful suggestions.I wish to offer my sincere thanks to my friends Dr.Sunita, Dr.Rekha, Dr. Rachana, Dr.Padmasarita,Dr. Seetharam and especially my close friend Dr. Prathima, for their immense help & making my PGstudy memorable, unforgettable & colourful by adding different colours and all my juniors & friends fortheir timely co-opreation & inspiration. Dr. Deepashree
  10. 10. Abstract ABSTRACT Title: “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”The word “Stree” relates to her capacity of fertilization. The health of a woman to alarge extent depends on the normalcy of her menstrual cycle. In the present era beingemployed outside in a stressful atmosphere, the episodes of heavy menstrual bleedingare less tolerable, which disturbs her daily routine. The condition ends up withdebility and psychological upsets, which hinders the achievement of conception.As heavy menstrual bleeding (Asrgdara) is a debilitating disorder, the womanrequires rapid, safe and effective treatment. Ayurvedic texts have described a varietyof treatment options in the management of “Asrgdara”. Out of them the efficacy of“Uttara basti” is given much more importance by all the acharyas. Uttara basti thougha widely narrated therapeutic option is seldom in practice today. So the study is undertaken to evaluate the efficacy of this treatment modality scientifically.“Kashmarya Kutaja Grita” being the Raktashodhaka, Rakta stambaka, Raktasthapaka& Rasayana has been selected for the present study. Objectives: This study is undertaken with following Aim & Objectives: To carry out a comprehensive literary study of Asrgdara and DUB. To evaluate the therapeutic efficacy of “Pushyanuga choorna” in Asrgdara. To evaluate the therapeutic efficacy of “Uttara basti” in Asrgdara. To evaluate the therapeutic efficacy of “Uttara basti” after Yoga basthi in Asrgdara. To compare the above 3 groups. Setting: SDM Ayurveda hospital, Udupi A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r. to DUB
  11. 11. Abstract Study design: 30 patients suffering from Asrgdara were selected and randomly devided in to 3 groups Group 1 – of 10 patients were administered “Pushyanuga choorna” about 12g with Madhu in three divided doses, with 100ml of Tandulodaka in empty stomach for a period of one month. Group 2 – of 10 patients were administered “Kashmarya kutaja grita uttara basti ” for 3 days after cessation of bleeding. Group 3 – of 10 patients were administered “Kashmarya kutaja grita uttara vasti” for 3days, after a course of “yoga basthi” for 5 days with “Bala taila anuvasana” and “Dashamoola kashaya niruha vasthi”. Main outcome measures: Percentage changes in the severity of Pratyatma Lakshana of Asrgdara for 2 months. Results: • Statistically Significant improvement is seen in all the criteria of assessment in treating Asrgdara. (P=<0.001) • Reoccurence of the symptoms not seen in the trial groups. • Significant change is seen in pain, associated symptoms like weakness, low backache & Hb% in trial groups. • 05% of group I, 10% group II, 30% of group III showed complete cure. • 75% of group I, 80% of group II, 70% of group IІI showed improvement in signs & symptoms. • No change was observed in 20% of group I, 10% of group II. • On comparison between the groups clinically & statistically, Group 3 showed better response in comparison to Group 2 & 1. The variation seen in the groups statistically was significant for most of the parameters, which means the differences in the mean values among the treatment groups are greater than would be expected by chance. Conclusion: “Kashmarys Kutaja Gritha Uttara basti” has shown successful outcome in treating the Asrgdara.Key words: Asrgdara, DUB, Uttara basti, Kashmarya Kutaja Grita, Yoga basti,Dashamoola Kashaya niruha basti, Bala taila Anuvasana basti, Pushyanuga choorna,Madhu, Tandulodaka. A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r. to DUB
  12. 12. ABBREVIATIONS LIST OF ABBREVIATIONS• A.T After treatment• B.T Before treatment• Charaka samhita• Su.sam Sushruta samhita• Ash.Hru Ashatanga Hridaya• Ash.san Ashatanga sangraha• Bh.praka Bhavaprakasha• Bai.Rat Baishajya Ratnavali• Ka.Sam Kashyapa samhita• Sha.sam Sharangadhara samhita• Ya.Rat Yogaratanakara• Su Sutra sthana• Ni Nidana sthana• Chi Chikitsa sthana• COX Cyclo oxygenase enzymes• COCs Combined oral contraceptives• LTs Leukotrienes• NSAIDs Non-steroidal anti-inflammatory drugs• PG Prostaglandins• PGE2 Prostaglandins E2• PG F2α Prostaglandins F2α• PLseA2 Phospholipase A2• Cx Cervix• P/A Per abdomen• P/S Per speculum• P/V Per vagina
  13. 13. CONTENTSCHAPTER CONTENTS PAGE NO. INTRODUCTION 1-2 OBJECTIVES OF THE STUDY 3Part I CONCEPTUAL STUDY 4-71 1.1 Historical Review 4-6 1.2 Physiology of Arthava 7-11 1.3 Physiology of Menstruation 12-19 1.4 Review of Asrgdara 20-34 1.5 Modern disease review 35-43 1.6 Review of Uttara basti 44-47 1.7 Review of Basti 48-56 1.8 Drug review 57-71Part II CLINICAL STUDY 72-120 2.1 Materials and Methods 72-78 2.2 Observations 79-95 2.3 Results 96-120 Part III DISCUSSION 121-139 Part IV SUMMARY & CONCLUSION 140-143 BIBILOGRAPHY 144-154 ANNEXURE 155-163
  14. 14. LIST OF TABLESSl. No Description Page No.1 Formation of Arthava 82 Shuddha arthava lakshana 113 Different effects of Prostaglandins on 16 haemostatic mechanism4 Terminologies to describe AUB patterns 195 Nidana according to Caraka 216 Samprapti of Asrgdara 227 Types of Asrgdara 238 Lakshanas of Vataja Asrgdara 259 Lakshanas of Pittaja Asrgdara 2510 Lakshanas of Kaphaja Asrgdara 2611 Lakshanas of Sannipataja Asrgdara 2612 Differential diagnosis of Asrgdara 3313 Anovulatory DUB 3814 Endometrial abnormalities with endometrial 39 histology & typical bleeding patterns in DUB15 Medical treatment of DUB 4216 Uttara Basti dravya pramana 4617 Indication 4618 Yoga basti format 5019 Bala taila ingredients 5320 Shatapushpa descpition 5321 Dashamoola kashaya ingredients 54
  15. 15. 22 Kashmari description 5923 Kutaja description 6124 Pushyanuga choorna ingradients 64-6625 Incidence of Age 7926 Incidence of Socio economic status 7927 Incidence of Domicile 8028 Incidence of Religion 8029 Incidence of Occupation 8130 Incidence of Education 8131 Marital status 8232 Dietary Habit 8233 Rasapradhanya 8334 Mental stress 8335 Incidence of Prakriti 8436 Incidence of built 8437 Ahara shakti 8538 Abhyasa 8539 Vyayama Shakti 8640 Vyavaya 8641 Bowel habits 8742 Past history 8743 Of Parity 8844 Abortion 8845 Contraception 89
  16. 16. 46 Duration of illness 8947 Bleeding pattern 9048 Incidence of Pain 9049 Duration of flow 9150 Amount of bleeding 9151 Interval between 2 cycles 9252 Consistency 9253 Colour 9354 Odour 9355  Staining 9456 Hb% 9457 Assosiated symptoms 9558-59 Effect on duration of blood loss 9660 Comparison between the groups 9861-62 Effect on amount of blood loss 9963 Comparison between the groups 10164-65 Effect of interval 10266 Comparison between the groups 10467-68 Effect on consistency 10569 Comparison between the groups 10770-71 Effect on odour 10872 Comparison between the groups 11073-74 Effect on staining 11175 Comparison between the groups 113
  17. 17. 76-77 Effect on pain 114 78 Comparison between the groups 116 79-80 Effect on assosiated symptoms 117 81 Comparison between the groups 119 82 Overall effect of treatment 120          
  18. 18. List of GraphsSl. No Description Page No.1 Incidence of Age 792 Incidence of Socio economic status 793 Incidence of Domicile 804 Incidence of Religion 805 Incidence of Occupation 816 Incidence of Education 817 Marital status 828 Dietary Habit 829 Rasa pradhanya 8310 Mental stress 8311 Incidence of Prakriti 8412 Incidence of built 8413 Ahara shakti 8514 Abhyasa 8515 Vyayama Shakti 8616 Vyavaya 8617 Bowel habits 8718 Past history 8719 Of Parity 8820 Abortion 8821 Contraception 8922 Duration of illness 89
  19. 19. 23 Bleeding pattern 9024 Incidence of Pain 9025 Duration of flow 9126 Amount of bleeding 9127 Interval between 2 cycles 9228 Consistency 9229 Colour 9330 Odour 9331 Staining 9432 Hb% 9433 Assosiated symptoms 9534 Effect on duration of blood loss 9635 Effect on amount of blood loss 9936 Effect of interval 10237 Effect on consistency 10538 Effect on odour 10839 Effect on staining 11140 Effect on pain 11441 Effect on assosiated symptoms 11742 Overall effect of treatment 120
  20. 20. LIST OF PICTURESPicture No Description Page No1 Drugs in Bala taila & Dashamoola 55-56 kashaya2 Drugs in Kashmarya Kutaja gritha 633 Drugs in Pushyanuga choorna 69-714 Reguirements for Uttara basti 78
  21. 21. INTRODUCTIONStree has been given prime or special status in India from time immemorial. Manusmriti theoldest anthroposophic treatise quotes: Yatra naryastu poojyante ramante tatra devatah .ie the societies in which women are respected are as good as heavenly abode.Women is endowed with energy of procreation for which menarche is the first step. Menstrualcycle commences with this & ends with menopause & having normal menstruation depicts thewell being of female.A slight deviation in the menstrual cycle which may be excessive or low is leading to the fear ofsome serious pathology of internal genital organs.Woman of today commonly experiencing heavy menstrual bleeding due to small family size,early menarche, later onset of menopause& increased responsibilities due to changing role ofwoman in society.Asrgdara characterized by excessive prolonged menstrual or intermenstrual bleeding & it isdescribed at around 1400BC, which has been described in ancient literature. Hippocrates alsowrote on this subject. Though such vast explanation is given yet efforts are required to identifythem clinically & establish their occurrence.This condition is distressing & potentially disabling, with this social & work commitments beingcancelled. Asrgdara is the common cause of Iron deficiency anaemia & general debility. It alsocauses psychological uposetslike lack of concentration, discomfort in work place, uneasinessetcGeographical conditions, racial factors, nutritional standards, environmental influences &indulgence in strenuous physical & mental activity can defect hormonal & menstrual status ofwomen. Even on completing her family, having irregular & excessive bleeding is a continousstress denoting hormonal aberrations. There is sharp increase in the incidence in women inmodern era hence require solution.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 1
  22. 22. This condition depends upon hormonal treatment. But hormonal therapy has its own adverseeffects like nausea, vomiting, G.I.T disturbances, obesity, sterility, hypertension, liver diseaseetc.Hysterectomy being the ultimate cure for DUB. Though the safe operation with minimummorbidity & mortality, the possible long term complications like ovarian failure, intestinal &urinary dysfunction & vault prolapse is quite disturbing.Therefore despite a wide treatment options for its management which have multiplied over therecent years. Yet considering the factors such as age, parity & wishes of the patient with regardto contraception, future pregnancy etc, the drug which is non-hormonal, non surgical, effective &without any adverse effects is the need of the home .Ayurvedic texts have described a variety of treatment options in the management of Asrigdara.Out of them the efficacy of “UTTARA BASTI” is given much more importance by all theacharyas. Uttara basti though a widely narrated therapeutic option is seldom in practice today.So now it is the need to evaluate the efficacy of this treatment modality scientifically. KashmaryaKutaja Grita being the Rakta stambaka, Raktasthapaka & Rasayana has been selected for thepresent study.  “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 2
  23. 23. OBJECTIVES This study is undertaken with following Aim & Objectives: To carry out a comprehensive literary study of ASRGDARA and DUB To evaluate the therapeutic efficacy of “PUSHYANUGA CHOORNA” in Asrgdara. To evaluate the therapeutic efficacy of “UTTARA BASTI” in Asrgdara. To evaluate the comparative efficacy of “UTTARA BASTI” after “YOGA BASTHI” in Asrgdara. To compare the above 3 groups. “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 3  
  24. 24.  History                                                                                                                       CONCEPTUAL STUDY  HISTORICAL REVIEW The subject of prasuti tantra and stree roga is dealt under Kaumar-bhrtya, one of the eightbranches of Ayurveda. All the measures pertaining to Bharana of Kumara constituteKaumarabrtya. The word Bharana means procuring, carrying, bearing, protecting, bringing,maintaining & nourishing etc. The child being pivot, entire physiopathology of woman hasrevolved around it..“Yonishu shuddhasu garbham vindati Yoshitaha” (Charaka). Normal healthy status of yoni is thekey factor for achieving the conception.Various gynaecological disorders i.e Yoni rogas & Artava doshas hamper the achievement ofconception. Hence both the Prasooti tantra & stree roga are included under Kaumara Bhrtya. Vedic Period1: The Vedas the first written record of Indian literature contain innumerablereferences in relation to stree roga. The word bhamsas, bhasad, upastha & yoni refer to femalereproductive tract especially vulva, vagina & uterus, and gavini to fallopian tubes. Thereferences of rtukala are also available.The word artava is used for joining period for 2 rutus. Probably due to presence of rtukala inwomen, the word artava is used to denote various physiological substances of menstrual cycle. Adirect reference of atiraja pravartana is available in kaushika sutra, where in arma kapalika orsushka panka mrittika, suggested as internal remedy.Brahmanas: The word “yoni2” or “upastha3” is used for internal & external female generativetract. Site of yoni is mentioned in the middle part of the body below the udara & is attached toabdomen by mamsa4. The reference of importance of rutumati5 woman for conception areavailable.Upanishad: The word upastha & muska are used to denote the vagina & labia majorarespectively6. Related to stree roga, the specific mode of life to be followed by the woman during3 days of menstruation, importance of rutukala, reproduction along with contraception has beendealt elaborately. “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ” Page 4
  25. 25.  History                                                                                                                       CONCEPTUAL STUDY Kalpa Sutras: In Dharmasutra the woman during menstrual period is considered as untouchableand the students were advised not to talk with her. To achieve the conception by an infertilewoman, instillation of the juice of the root of white flowered bruhati described.Data from the Epics: In Ramayana & Mahabharata vayu was given the highest position ofimmense power & movement and because of this it was called Deva, Bhagvan.Puranas : In all the Puranas vayu is regarded as Bhagvan & is glorified.Samhita period: Charaka Samhita7, Sushruta samhita8, Astanga Sangraha9 & Astanga Hrudaya10: Detailed classification of asrigdara with their nidana, lakshana, chikitsa & upadrava are explained elaborately. Kahyapa Samhita11: Explained the use of shatapushpa & Shatavari kalpam for menstrual disorder . Harita samhita12: Rajas vitiated by vata etc doshas produces symptoms not only related to menstrual blood but other symptoms also. Madhava Nidana13, Bhava prakasha, & yogaratnakara: Description of clinical features & complication etc of Asrigdara & Pradara are almost as in Sushruta. Vranda Madhava14: Explained the treatment of Pradara, Yoni vyapad & soothika roga. Chikitsa kalika: Pradara is said to be due to evil deeds (karmaja) & is such not cured with medicines. Yet certain recipes described for the treatment of Pradara. Bhela samhita: Explained, when Shonita does moves in dusta marga results in Asrgdara. Commentators Chakradatta, Gangadara made elaborate description of pathophysiology of Asrgdara. Vangasena considered Asrgdara as pranahara & every measures to cure it has to be done.Adhunika kala The term menstruation is derived from Latin “Menstrens” meaning monthly.Following are the advances to the contribution on Asrigdara by modern researchers. • In 1846, French surgeons,seen first clinical observation of Endometrial hyperplasia. • In 1850, Recamies, advised curettage as a method of treatment of DUB. “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ” Page 5
  26. 26.  History                                                                                                                       CONCEPTUAL STUDY  • In 1919, Robert, named the clinical syndrome as “Metropathica Haemorrhagica” • In 1924, Norale coined the term “Swiss Cheese”since then widely used in literature. • In 1947, Mekely, Stated that irregular shedding of the endometrium is a specific form of the functional uterine bleeding. • In 1976, William & co-workers, Reported that the concentration of PGE2 (Vasodilator) was more than PGF2α (vaso-constrictor) in the endometrium of DUB • In1981, ehrlich, conducted study on cytoplasmic progesterone & estradiol receptors(ER) in normal & hyperplastic endometrium concluded prolonged oestrogen stimulation increased endometrial hyperplasia . • In1982, Grima showed the therapeutic effect of D&C is temporary. • In1982, Devore, studied the use of IV premarin in DUB,where in 72% stopped bleeding . • In 1983, Dockerary, conducted an ultra structural study of menstrual blood in DUB proved that the presence of fibrin & platelet plus fibrinolytic activity was much more. • In In 1990 Lewis, Stated that hysteroscopy for AUB was a valid alternative to the traditional D &C and therefore should more widely used in clinical practice. • In 1994, Bullete & co-workers, Studied the therapeutic effect of GnRH agonist in the treatment of DUB & this is a preventive measure for endometrial carcinoma. • In 1997, Nagpal & Co-workers, conducted study on patients with DUB who had undergone endometrial eblation therapy & some of them were required hysterectomy. • In 2000, Wren BG, Reported DUB affects 5% of menstruating women & harmone is not a viable option to control the problem; the prostaglandin inhibits or use of tranexemic acid may allow short term relief from excessive bleeding. • In 2003, Seidman & co-workers, conducted a study to determine the outcome of hysteroscopic endometrial resection. The results were higher rate of amenorrhoea & complete relief of dysmenorrhoea which were achieved in older age group than younger. “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ” Page 6
  27. 27. Physiology CONCEPTUAL STUDY Physiology of menstruation (Ayurvedic view)Arthava: “Rutou bhavam arthavam15 • It is one, which happens periodically. So it can be correlated with the menstruation which takes place in a cyclic manner. • In the clssiccs, Arthava is also denoted for ovarian harmone16 & ovum17 in different context.Utpatti: There are different opinions about the utpatti of Arthava. Arthava is formed from the essence of rasa18 Raja is formed from Ahara rasa19 Raja is the upadhatu of Rakta20 The hormones of hypothalamus to pituitary to ovary & then to endometrium are carriedthrough Rasa. In endometrium the blood is accumulated for whole month & then dischargedduring menstruation. This process has been explained by Chakrapani with the words ofAvirbhava (formation) & tirobhava (discharge)21Periodicity of menstruation: 22,23 The Intermenstual period has been given as of one “Masa” by all the Acharyas. Masa means alunar month – Chandra Masa ie 28 days.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 7
  28. 28. Physiology CONCEPTUAL STUDY Table 1 : Formation of Arthava Ahara Pachaka pitta Samana vayu Ahara rasa Rasa Dhatu Rasa dhatvagni Artava (cha.chi.15/17, Arthavavaha dhamani Reaches garbhashaya Apana vata Tryaham pravartanamam Artava or Raja pravartate Artava a upadhatu of rasa is soumya in nature during avirbhava, assumes agneya nature by Karmavashat & kalavisheshe during tirobhava.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 8
  29. 29. Physiology CONCEPTUAL STUDYPhases of Menstruation:According to the physiological changes taking place in the body , the menstruation period isdevided in to 3 phases,. The phases are Raja srava kala Rutu kala Rutu vyateeta kala1.Raja srava kala: The phases of menstruation is raja srava kalsa.The duration of this is, 3 days: According to Sushruta, Vagbhata & Bhavamishra24,25 5 days: According Charaka26 7 days: According to Hareeta & Bhela27,28 Thus this phase is present for 3-7days about 5 days in average.But Bhavamishra further said that, If the flow is excessive, it lasts for 3 days If flow is average, it lasts for 5 days If flow is slight & without any abnormality, then it lasts for 16 days & it may be considered normal.Collection of blood in uterine vessels for excretion: As previously collected raja has been discharged, new collection of raja starts. The blood collected for whole month by 2 dhamanis assuming slight black colour &specific odour is brought downwards to vaginal orifice for excretion by Vayu, is the explanationgiven by Sushruta29. Vishvamitra has clarified that hair thin vessels (sookshma kesha pratikasha)fill the uterus for whole month to receive beeja30.These changes are correlated to the vascular & secretory changes occurring in the endometriumfor whole month to prepare it for conception, when there is no fertilization it sheds off.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 9
  30. 30. Physiology CONCEPTUAL STUDYDosha dominance in Raja srava kala: In the Raja srava kala Arthava is excreted out. It is the normal function of Apana vata31.So this phase is dominated by vata.2. Rutu kala: This is termed as period most suitable for achievement of conception. Accordingto Indu, the sperms are deposited during this period are likely to result in conception32.Duration: About the duration of Rutukala, there are 2 opinions, It is of 12 days after menstruation33,34 It is of 16 days after menstruation35. Though it appears that the first 2 opinions are different, but are not. Dalhana has clarifiedthis controversy, by saying that among 16 days, first 3 days & last 1 day where there is yonisankocha, should not be counted36. Remaining 12 days are considered under Rutukala.Dosha dominance in Rutu kala: Rutu kala is a period resembling proliferative phase. According to Ayurveda forregeneration & growth of tissues, Prithvi & Jala mahabhootas are essential, which are thebhautika components of Kapha. Considering these it can be considered that this phase isdominated by kapha dosha.3. Rutu vyateeta kala: This phase has been described in very short way. The period which follow Rutu kala isRutu vyateeta kala. In this period regressive changes takes place in yoni leading to Yonisankocha37. As lotus flower closes after sun-set, similarly after rutukala the yoni gets constrictedand it does not allow the entry of Shukra inside..Dosha dominance in Rutu vyateeta kala: This phase resembles the secretory phase, where there is secretion from stromal glands.For any bodily secretions Pitta is essential factor. Also this secretory phase is dominated byProgesterone which is having thermogenic effect. Thus it can be consider that this phase isgoverned by Pitta.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 10
  31. 31. Physiology CONCEPTUAL STUDYArthava pramana : It is 4 anjali--- according to Sushruta & Vagbhata38Shuddha Arthava lakshana:The menstruation is considered as normal, which has Intermenstrual period of 1 month &following features. Table 2: Shuddha Arthava Lakshana No Author Dura Colour Amount Staining Assosiated sympts Tion 1 Charaka 5 Gunjaphala Naiva ati - Nishpicch savanarm34 bahu, a- daharti Padmalaktaka Naaty sannibha alpam Indragopa sankasha 2 Sushruta 3 Laksharasopam - Vaso na - viranjayet Shashasruk pratimam Eeshat Krishna varna 3 Vagbhata 3 Shasharudhira Dautam cha 1&2 virajyamanam Laksharasopam 4 Harita 7 - - - - 5 Bhela 7 - - - - 6 Bhava 16 Eeshat Krishna varna - - Nishpicch prakasha a- daharti Physiology of menstruation (Modern view)Mensruation:“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 11
  32. 32. Physiology CONCEPTUAL STUDYDefinition39: Mensruation is the periodic uterine bleeding owing to shedding of endometriumdue to invisible interplay of harmones mainly through Hypothalamus-Pituitory-Ovarian axis. Ittakes place approximately at 28 days interval between menarche to menopause. The principalevents of menstrual cycle corresponds to those of ovarian cycle leading in to changes ofendometrium.Menstrual cycle is devided in to 2 segments: • Ovarian cycle: In this it has 2 stages; i. Follicular phase ii. Luteal phase • Endometrial cycle: It has been traditionally classified in to 4 stages; i. Regenerative phase ii. Proliferative phase iii. Secretory phase iv. Menstrual phase1. Ovarian cycle40: Follicular phase:. This phase constitutes the first half of the menstrual cycle. It includes development & maturation of follicles & ovulation. Ovarian follicles are the glandular structures occupying the stroma of cortex. Each follicle consists of the ovum surrounded by epithelial cells namely granulose cell. These follicles gradually grows in to a matured follicle through various stages. Follicular cells Premordial follicle Primary follicle Vesicular follicle Graffian follicle              Ovulation: The shedding of the ovary is called ovulation. The ovarian follicle as it enlarges becomes so big that it is not only reaches the surface of the ovary but also form a bulging in this situation. Ultimately the follicle ruptures & the ovum is shed from the ovary.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 12
  33. 33. Physiology CONCEPTUAL STUDY Luteal phase: This phase extends between 15th & 28th day of menstrual cycle. This phase includes formation of corpus luteum & its degeneration. When the follicle rupture, its wall collapse & becomes folded & forms glandular yellow body called corpus luteum. The development of corpus luteum completed in 5 days. Degenerative changes commence 4-6 days prior to the next menstrual cycle. In the absence of pregnancy luteolysis occurs.Endocrine control41: The hypothalamus secretes GnRH which acts on anterior pituitary gland & causes release of FSH & LH. FSH causes many follicles to grow, with maturation of one of them having high estrogen receptor concentration & high intrafollicular estrogen level. 2 cell system of theca & granulose cell is responsible for the production of steroids. As the follicle grows it secretes inhibin & causes suppression of FSH. Antral follicle with highest estrogen & lowest androgen content houses the healthy oocyte. High oestrogen exerts oppositive feed back on LH release responsible for LH surge at mid cycle. Ovum is released as a result of break in the capsular wall by proteolytic enzyme-collagen After ovulation, follicle collapses to form a yellow colloid body - Corpus luteum. Withdrawal of hormone essentially progesterone leads to loss of endometrial tissue called menstruation.2. Endometrial cycle42: Regenerative phase: Regeneration of endometium starts before the stoppage of menstruation & ceased within 2 or 3 days. Events: • Regeneration of glands & stromal cells • Growth of new blood vessels • Thickness is 2mm“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 13
  34. 34. Physiology CONCEPTUAL STUDY Proliferative phase: Stage of proliferation extends from 5th or 6th to 14th day. Changes occurs due to rise of ovarian estrogen. Events: • Glands become tubular • Epithelium become columnar • The spiral vessels extend unbranched • Endometrial thickness 3-4mm Secretory phase: It begins on 15th day & ceased 5 or 6 days prior to menstruation. Events: • Surface epithelium become more columnar & ciliate. • Glands increase in size with appearance of secretion containing glycogen between basement membrane & nuclei. This is called as subnuclear vasculation, the earliest evidence of ovulation. • Glands become cork screw shaped. • The fluid has nutritive value for fertilized ovum • Blood vessels show marked spiraling of capillaries. • Thickness of endometrium reaches its highest 5-6mm Menstrual phase: It is essentially degeneration & expulsion of endometrium as a result of withdrawal of hormonal support. In the absence of pregnancy, uterus could be producing some luteolytic factor Prostaglandins, which reach ovary by retrograde venous flow causing regression of corpus luteum with fall in the level of estrogen & progesterone. In response, regressive changes in endometrium like dehydration of glands, intense spasm of arterioles leading to stasis & tissue anoxaemia. These vascular changes are brought about by prostaglandins.Role of Prostaglandins in menstruation43: Prostaglandins have been important in the patho-physiology of menstruation disordersever since. It was discovered that menstrual blood contains an agent that stimulate smoothmuscles & they were later identified as prostaglandin F2α & PGE2.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 14
  35. 35. Physiology CONCEPTUAL STUDY Physiology of prostaglandins44 Prostaglandins are products of archidonic acid metabolism through the cyclo-oxygenasepath way. This path way also yields from Tromboxanes & together the products are termedprostanoids. The cyclo-oxygenase (cox) enzyme exits in 2 isoforms. COX-1 is constituently expressedthrough out the body & COX-2 is induced locally only at sites of inflammation. Theendometrium mostly exhibits COX-1 activity in the physiological state. Phosphonoids in the cells Phospholipase A2 Cyclo-corticoide mepacrine Arachidonic acid (Cyclooxygenase path way) (Lipo-oxygenase path way) Cyclo endo-peroxidase Hydro-cicosatetraenoic acid Prostaglandin (PGG2, PGH2) Hydro-oxycicotetranic acid Prostacycline (PGI2) Leukotrine Tromboxane (TXA2) The endometrium & to some extent myometrium synthesise prostaglandins from arachidonic acid. The vascular changes in the endometroium & the amount, duration of menstrual bleeding controlled by the interaction of different prostaglandins Table 3: Different effects of Prostaglandins on haemostatic mechanism. Prostaglandin Vessel caliber Platelet aggregation Myometrial contractility PGE2 Vasodilatation Inhibitor Inhibits during menses Stimulator at other times“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 15
  36. 36. Physiology CONCEPTUAL STUDY PGI2 Vasodilatation Inhibitor --- PGF2α Vasoconstrictor --- --- TAX2 Vasoconstrictor Strong activator Stimulant                                                                                      Control of menstrual blood loss The endometrial surface area is large (10 to 45 mm2) indicating that haemostasis duringmenstruation is usually very efficient. Possible factors in the blood loss are; 1. Platelet plug formation 2. Vaso-constriction 3. Endometrial repair1. Platelet plug (Haemostasis) formation:One of the fascinating aspects of menstruation is that menstrual blood does not clot & theendometrium has a high fibrinolytic activity.Menstrual blood contains platelets which fail to aggragate in response to pro-aggregatory agentssuch as ADP & collagen • Contains no fibrinogen & • Contains reduced amounts of coagulation factors compared to peripheral blood. • It does contain fibrin & fibrin degradation products confirming the potent fibrinolytic activity within the uterus. This fibrinolytic activity is enhanced in women with dysfunctional uterine bleeding.The endometrium also generates factors that inhibits platelet aggregation & adhesion. They are prostacyclin (PGI2), nitric oxide (NO), & platelet activity factors (PAF).2. Vasoconstriction:At the onset of menstruation, damaged blood vessels are seated by intravascular thrombi ofplatelets & fibrin. However as menstruation progresses, the functional endometrium is shed, thus“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 16
  37. 37. Physiology CONCEPTUAL STUDYthese haemostatic thrombi are lost. By 20 hours after the start of the menstruation, blood loss iscontrolled by intense vasoconstriction of spiral arteries.The role of prostaglandins in menstruation is well established. Prostaglandins synthesized fromarachidonic acid are present both in endometrium & menstrual fluid in high concentrations.Their synthesis in endometrium is influenced by steroid harmones & highest levels are foundduring menses. This is particularly true for prostaglandin F2α is a potent vasoconstrictor whereas others, prostaglandin E2 & prostacyclin (PGI2) leads vasodilatation.Inhibitors of the prostaglandins synthesis decreases menstrual blood loss & myometrialcontractility. Exogegenous prostaglandins affect uterine contractility & can induce menstrualtype bleeding . Other vasoconstrictors which have attracted recent interest are Endothelin &platelet activating factor (PAF).Lysosomal enzymes liberated at the time of menstruation as lysosomal phospholipase A2increases the availability of the prostaglandin precursor, arachidonic acid.The endometrial tissuein DUB has higher concentrations of PGE2 & PGF2 α3. Endometrial Repair:Menstruation is finally curtailed by endometrial repair. This process is stimulated physiologicallyby increasing levels of oestrogen released in to circulation by the developing ovarian follicles.The oesrogen induced endometrial proliferation is mediated by epidermal growth factot (EGF). Itseems likely that endometrial EGF contributes to repair of both glandular & stromal tissue.Angiogenesis is an important part of endometrial repair as the developing tissues need adequateblood supply. Vascular endothelial growth factor (VGEF) is a highly potent endothelial nitrogenproduced by the endometrium. Its production is stimulated both by oestrogen & by hypoxia.These data suggest a rule VGEF in endometrial repair at the start of the menstrual cycle.Understanding the mechanism of the control of menstrual loss is steadily increasing. Furtherinformation about these mechanisms & their abnormalities during menstruation will enableeffective medical treatments to be developed and reduce the need for surgical treatment.Factors determing the amount of blood loss:“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 17
  38. 38. Physiology CONCEPTUAL STUDYThe amount of blood loss during episodes of dysfunctional uterine bleeding is probablydetermined by a no of factors. These include, 1. The total area of the endometrial cavity 2. The vascularity of the uterus, the number & caliber of the endometrium vessels & the presence of any structural changes in the vessel walls. 3. The amount of haemorrhage in to the endometrium & necrosis of the endometrial tissue. 4. The nature, potency & amount of vaso-constrictors & the responsiveness & the functional state of the spiral arterioles. 5. The potency & balance of effects of the various coagulation & the lytic factors liberated from the endometrium & the coagulability of the blood in the spiral arterioles. 6. The rate of regeneration of the endometrium.Criteria for normal menstrual cycle45 The menstrual cycle is said to be within normal limits of Cycle length is in the range of 21-35 days with mean of 28 days Duration of Menstrual bleeding is in range of 3-7 days with mean of 5 days. Amount of Menstrual bleeding is up to 80ml with average around 40ml Any deviation from this either in length, duration or amount of bleeding is considered as AUB.Following are the terminologies used to describe AUB patterns46: Table 4: Terminologies to describe AUB patterns“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 18
  39. 39. Physiology CONCEPTUAL STUDY Polymenorrhoea Uterine bleeding occur at regular interval less than 21 days apart. Oligomenorrhoea Infrequent uterine bleeding that occurs at interval more than 35 days. Menorrhagia Is prolonged (>7days) & or excessive (>80ml) uterine bleeding occurs at regular interval. Metrorrhagia Uterine bleeding occur at irregular but frequent interval, amount of bleeding is variable & duration of flow is often prolonged. Menometrorrhagia Prolonged uterine bleeding that occur at irregular interval Intermenstrual Uterine bleeding with variable amount that occur between regular bleeding intervals.  “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 19
  40. 40. Disease review                                                                                                        CONCEPTUAL STUDY  Ayurvedic review of Asrgdara Asrgdara is a disease manifesting as excessive bleeding per vaginum. Acharyasexplained it as one of the rakta pradoshaja vikara & Raktayoni as its symptom. And alsomentioned Pradara as its synonym.Nirukti/ Derivation47: mÉëSÏrÉïiÉå CÌiÉ mÉëSU: ÌuÉxiÉÉËUiÉÉå pÉuÉÌiÉ AxÉ×Mçü SÏrÉïiÉå rÉÎxqÉͳÉÌiÉ AxÉ×aSUqÉç || (cÉ.ÍcÉ.30/cÉ¢ü) Asrk = Rakta/ Raja Dara= Continuous/Excessive flow Continuous/ Excessive flow of raja is called AsrgdaraParibhasha: 1. AÌiÉmÉëxÉ…¡åûlÉ AlÉ×iÉÉæGiÉÉæ uÉÉ iÉSåuÉ AxÉ×aSUqÉç || (A.xÉÇ.zÉÉ.1/11) 48 2. AxÉ×aÉç SÏrÉïiÉå crÉuÉiÉå rÉÉÎxqÉͳÉirÉxÉ×aSUqÉç || (qÉÉ.ÌlÉ.61/2 qÉkÉÑMüÉåzÉ)49 3. mÉëSÏrÉïiÉå CÌiÉ mÉëSU: ÌuÉxiÉÉËUiÉÉå pÉuÉÌiÉ AxÉ×Mçü SÏrÉïiÉå rÉÎxqÉͳÉÌiÉ AxÉ×aSUqÉç || (cÉ.ÍcÉ.30/cÉ¢ü)51 4. iÉSåuÉÉÌiÉmÉëxÉ…åûlÉ mÉëuÉרÉqÉlÉ×iÉÉuÉÌmÉ| AxÉ×aSUÇ ÌuÉeÉÉlÉÏrÉÉSè..| (xÉÑ.zÉÉ.2/18) 50 By the above definitions it is clear that, Excessive or prolonged flow of blood occurring in menstrual or intermenstrual period is called Asrgdara & Pradara is synonym of Asrgdara.Nidana52, 53, 54, 55: 1. Acc to Charaka rÉÉÅirÉjÉï xÉåuÉiÉå lÉÉUÏ sÉuÉhÉÉqsÉ aÉÑÃÍhÉ cÉ| MüOÕûlrÉjÉ ÌuÉSÉWûÏÌlÉ ÎxlÉakÉÉÌlÉ ÌmÉÍzÉiÉÉÌlÉ cÉ || aÉëÉqrÉÉæSMüÉÌlÉ qÉå±ÉÌlÉ M×üzÉUÉÇ mÉÉrÉxÉÇ SÍkÉ | zÉÑ£üqÉxiÉÑxÉÑUÉSÏÌlÉ. . . . . . . . . . . . || (cÉ.ÍcÉ.30/205-6) Table 5: Nidana according to caraka“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 20 
  41. 41. Disease review                                                                                                        CONCEPTUAL STUDY  Lavana rasa (jala + agni) Pitta prakopa, Raktavardhana, dhatukshaya Amla rasa (Prthvi + agni) Pitta vruddhi, Rakta dusti, mamsa vidaha Katu rasa (Agni + vayu) Rakta sravaka, Shonita samghata bhedana Vidahi annpana (Agni + vayu) Pitta prakopa Snigdha annapana (Prthvi + jala) Kleda Guru Annapana (Prthvi + jala) Kleda Pistanna (Abhishandhi) Kaphabhishandi Krshara Kapha pitta Pasaya (guru vistambi), Dadhi Kapha medas Mastu, sura, gramyodaka Kapha, pitta Nidana AÉ´ÉrÉ AÉ´ÉrÉÏ pÉÉuÉ xÉÇoÉlkÉ Vata+ Rakta prakopa (Drava pitta Rakta) Rakta pramana upakramya Garbhashayagata sira aÉpÉÉïzÉrÉaÉiÉ ÍxÉUÉ: (Vruddhena raktena yojayitva rajo vivardhayati-Chakrapani) 2. Madhava nidhana: ÌuÉÂkS qɱ AkrÉzÉlÉÉiÉç AeÉÏhÉïiÉç aÉpÉïmÉëmÉÉiÉÉiÉç AÌiÉqÉæjÉÑlÉÉŠ | rÉÉlÉ AkuÉ zÉÉåMü AÌiÉMüwÉïhÉÉŠ pÉÉUÉÍpÉbÉÉiÉcNûrÉlÉ̬uÉÉ cÉ|  (qÉÉ.ÌlÉ.61/1) Apathya---Viruddha, adhyashana, ajeernaat. Vihara-----Yana, adhva, bhara, abhigaata, atimaithuna, divaswapna Manasika-- Shoka—rajoguna vruddhi---vata-pitta prakopa--Asrgdara Anya ---Garbha prapatat--vata prakopa---Asrgdara“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 21 
  42. 42. Disease review                                                                                                        CONCEPTUAL STUDY  3. Hareeta: Vandhya---ksheera naadi(vatena paripoorita)---kshire cha na bhavet + Arthavam cha adhikam yatah 4. Bhela samhita: Shonita--- dusta marga pratipadyate---Pradara Samprapti: 56,57,58,59  Table 6: Samprapti of Asrgdara Nidana   Factors vitiating Vata Factors vitiating Pitta & Kapha (Chinta,shoka,yana,bhara, (Guru,lavana,amla,vidaha,adhyashana, Atimaithuna) viruddhahara, sura, sukta) Increase in Drava Pitta Increase in volume of Rakta Reaches Garbhashayagata Rajovaha sira                Formation of increased Raja  (AÉzÉÑ ÌuÉuÉkÉïrÉÌiÉ, UxÉ pÉÉuÉÉiÉç ÌuÉqÉÉlÉiÉ:)                                                                               Apana vayu expels the increased Raja Asrgdara“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 22 
  43. 43. Disease review                                                                                                        CONCEPTUAL STUDY  Bheda Table 7: Types of Asrgdara Author Vataja Pittaja Kaphaja Dwandwaja Sannipathaja Charaka + + + - + Sushruta + + + + + Vagbhata + + + + + Madhava + + + - +         “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 23 
  44. 44. Disease review                                                                                                        CONCEPTUAL STUDY                                                                    Roopa:  Samanya Lakshanas: UeÉ: mÉëSÏrÉïiÉå rÉxqÉÉiÉç mÉëSUxiÉålÉ xÉ xqÉ×iÉ: | (cÉ.ÍcÉ.30/209) 60  ie Menstrual bleeding is excessive in amount iÉSåuÉÉÌiÉ mÉëxÉ…¡åûlÉ mÉëuÉרÉqÉlÉ×iÉÉuÉÌmÉ | AxÉ×aSUÇ ÌuÉeÉÉlÉÏrÉÉSiÉÉåÅlrÉSè U£ü sɤÉhÉqÉç || (xÉÑ.zÉÉ.2/18) According to Dalhana AÌiÉ mÉëxÉ…¡åûlÉåÌiÉ - AÌiÉmÉëÉcÉÑrÉåïhÉ SÏbÉïMüÉsÉÉlÉÑoÉlkÉålÉ uÉÉ mÉëuÉרÉÇ xÉëÑiÉqÉç | AlÉ×iÉÉuÉÌmÉ – AsmÉqÉmrÉSÏbÉïMüÉsÉqÉÌmÉ mÉëuÉרÉÇ – AxÉ×aSUÇ ÌuÉeÉÉlÉÏrÉÉiÉç | AlrÉSì£ü sɤÉhÉÉiÉç– AlrÉSè AlrÉÉSØMçüsɤÉhÉÇ ‘TåüÌlÉsÉÇ zÉÏbÉëqÉcNûqÉç’-SÉåwÉÉlÉÑoÉlkÉM×üiÉÇ sɤÉhÉÇ  ie Excess amount of bleeding during menstruation for prolonged duration and scanty flow in intermenstrual period for short duration with specific features according to the association of specific doshas. AxÉ×aSUÇ pÉuÉåiÉç xÉuÉï: xÉÉ…ÉqÉSïÇ xÉuÉåSlÉqÉç ||(xÉÑ.zÉÉ.2/19) 61, 62 MåüÍcÉS§ÉæuÉÉxÉ×aSUsɤÉhÉÇ mÉPûÎliÉ| iɱjÉÉ – SWåûSkÉÉå uÉǤÉhÉSåzÉqÉxrÉÉÈ ´ÉÉåÍhÉ cÉ mÉ×¸Ç cÉ iÉjÉæuÉ uÉ×MçMüÉæ || AxÉ×aSUÇ cÉÉÌmÉ MüUÉåÌiÉ lÉÉrÉÉï aÉpÉÉïzÉrÉÉÌiÉï iuÉÍcÉUåhÉ bÉÉåUÉqÉç - CÌiÉ|| (xÉÑ.E.45/44-QûsWûhÉ) ie Assosiated symptoms like angamarda, vedana, daha in adhovankshana, shroni, prushta, kukshi, vrukka & shoola in garbhashaya.  “A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 24 
  45. 45. Disease review                                                                                                        CONCEPTUAL STUDY  Vishishta lakshana Table 8: Vataja AsrgdaraAuthor Amount Colour Smel Consist Natur Pain Ass.t Rasa Anya of flow l ency e symptomsCharak - Kimshukod - Phenila - Saruja/ Kati parshva - Sashaa aka tanu niruja vakshana bda ruksha Krisharuna hrutSushru - Aruna, - Tanu Aska - - -ta Krishna parusha ndi picchilaVagbh - Aruna Loha Phenila Aska - - Kashata srava ndi aya Gan dhiMadav Alpa Aruna - Phenila - Vatadi - -a pishitodaka ruksha lakshanas Table 9: Pittaja AsrgdaraAuthor Amoun Colour Smell Cons Nature Pain Ra Anya t of isten sympts sa flow cyCaraka Nitanta Neela peeta Arati Daha raga Anruta rakta asita trushna moha vapi - - - jwara brama -Sushru Neela peeta Visra - Askandi - Kata harita tu - shyava - -Vagbh Krushna Visra - Askandi - kat chandriata peeta harita uû kayukta - Mastya - gandhi“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 25 
  46. 46. Disease review                                                                                                        CONCEPTUAL STUDY Madha Brusha Neela peeta - - - Pittart daha - -va vegi rakta i Table 10 : Kaphaja AsrgdaraAuthor Amount Colour Smel Consist Nature Pain Asstd Rasa A of flow l sympts ny -ency aCaraka - Pandu - Guru picchila Ghana Alpa Arochaka - - vedana hrullasa Ghanam swasa kasaSushru Bahala Pandu - Picchila Skandhi - - - -ta cira snighda sraviVagbh - Pandu, Vasa Snighda Skandhi - - Lava -ata kovidara gand picchila na pushpa, i tantumat gairikopaka i sadrashaMadha - Pandu - Picchila - - - - -va Table 11: Sannipataja AsrgdaraAuthor Amount Colour Smell Consist Nature Pai sympt Rasa Any of flow n a -encyCaraka - Sarpi Durgand Picchil Bahu - Trushna daha - - majja ha a jwara vasopam vega dourbalya a peetaSushruta - Kanji - - - - - - Dourgan dhyaVagbhata - Kansya Durgand - - - - - -“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 26 
  47. 47. Disease review                                                                                                        CONCEPTUAL STUDY  neela haMadhava - Madhu kunapag - - - - - - sarpi andhi haratala Upadrava63: Dourbalya Brama Moorcha Tama Trushna Daha Pralapa Pandu Tandra ShophaSadhyasadhyata64, 65:All the clssics consider tridoshaja Asrigdara as Asadhya & following are the asaadhya lakshanas. Shashvat sravanti Trushna Daaha Jwara Ksheena rakta DurbalaHareeta under the description of arista lakshanas of Arthava says, when it is associated with Apoorne divase pushpamanuyaat, jwarartha, sarano bhavet – then that stree will not survive66.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 27 
  48. 48. Disease review                                                                                                        CONCEPTUAL STUDY                                                           CHIKITSAA SIDHDANTA Ayurvedic texts have described a variety of treatment options in the management ofAsrigdara, including Shodhana & Shamana chikitsa. Out of them, the efficacy of “Shodhanachikitsa” is having prime importance as it expels out the vitiated doshas from the body. Eventhough, the use of Uttara basthi has explained in the samanya chikitsa ofyonivyapaths & Arthava vyapaths, its efficacy in Asrgdara is given much more importance, byall the Acharyas.Chikitsaa sootra of Asrgdara: U£ürÉÉålrÉÉqÉxÉ×auÉhÉåïUlÉÑoÉlkÉÇ xÉqÉÏYzrÉ cÉ iÉiÉ: MÑürÉÉï±jÉÉSÉåwÉÇ U£üxjÉÉmÉlÉqÉÉæwÉkÉqÉç || (cÉ.ÍcÉ.30/86) rÉÉålÉÏlÉÉÇ uÉÉiÉsÉɱÉlÉÉÇ rÉSÒ£üÍqÉWû pÉåwÉeÉqÉç;cÉiÉÑhÉÉïÇ mÉëSUÉhÉÉÇ cÉ iÉiÉç MüÉUrÉåΰwÉMçü || U£üÉÌiÉxÉÉËUhÉÉÇ rÉŠ iÉjÉÉ zÉÉåÍhÉiÉÌmĘ́ÉlÉÉqÉç | U£üÉzÉïxÉÉÇ cÉ rÉiÉç mÉëÉå£Çü pÉåwÉeÉÇ iÉŠ MüÉUrÉåiÉç|(cÉ.ÍcÉ.30/227) Charaka explains the treatment to be just like rakta yoni ie raktasthapana oushadhas should be used after giving due consideration to the association of doshas67. o Should be treated on lines of adhogata raktapitta68. o Treatment prescribed for raktatisara, raktapitta, raktarsha should be used69. xÉuÉåïwÉÑaÉpÉïxÉëÉuÉÉå£Çü mÉëSUåwÉÑ mÉëzÉxrÉiÉå || (A.xÉ.E.39/62) Garbhasrava treatment should be used.The general principles of treatment of Asrgdara as follows70: Nidana parivarjana Dosha shodhana“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 28 
  49. 49. Disease review                                                                                                        CONCEPTUAL STUDY  Dosha shamana Rakta sthapana, ralktasagrahana Use of tikta rasa1.Nidana parivarjana:Nidana plays the prime role in the initiation of pathogenic process which proceeds towards thedevelopment of disease. Hence it is the chief principle of treatment in Ayurvedic texts.2.Dosha shodhana: Diseases treated with the Shodhana chikitsa, have negligible chance of recurrence becausevitiated doshas are totally expelled from the body. Those treated with Shamana chikitsa arevulnerable for recurrence because subtle amount of vitiated doshas left over in the body afterShamana chikitsa, can get aggravated with the slightest apportunity. Vamana: As mentioned earlier Asrgdara should be treated on lines of adhoga raktapitta. “mÉëÌiÉqÉÉaÉï WûUhÉÇ U£üÌmɨÉå ÌuÉkÉÏrÉiÉå”| So may help to normalize the gati of apana vata , thus helping to cure the desease. There is no direct reference either for its indication or contra- indication. Virechana: Virechana has been indicated. The predominant dosha being pitta, virechana serves as the best shodhana therapy. Charaka has suggested the use of mahatiktaka grita for virechana in Asrgdara. Basthi:    “lÉ WûÏ uÉÉiÉÉSØiÉå rÉÉåÌlÉuÉïÌlÉiÉÉlÉÉÇ xÉÇmÉëSÕwrÉiÉå” | It is well known fact that none of yoni roga is caused without the vitiation of vata dosha. Hence the pacification & regulation of the vitiated vata becomes necessary. Classics have mentioned the use of both Niruha & Anuvasana basthi in Asrgdara. Uttara basti: oÉÎxiÉeÉåwÉÑ ÌuÉMüÉUåwÉÑ rÉÉåÌlÉÌuÉpÉëÇzÉeÉåwÉÑ cÉ| rÉÉåÌlÉzÉÔsÉåwÉÑ iÉÏuÉëåwÉÑ rÉÉåÌlÉurÉÉmÉiSèxÉ×SUå ........ .....ÌuÉSkrÉÉSÒ¨ÉUçÇ oÉÎxiÉÇ rÉjÉÉxuÉÉæwÉkÉxÉÇxM×üiÉqÉç || (cÉ.ÍxÉ.9/63) oÉxiÉÉæ UÉåaÉåwÉÑ lÉÉUÏhÉÉÇ rÉÉåÌlÉaÉpÉÉïzÉrÉåwÉÑ cÉ | ̲§ÉÉxjÉÉmÉlÉzÉÑ®åprÉÉå ÌuÉSkrÉɯÎxiÉqÉѨÉUqÉç || (A.WØû.xÉÔ.19/70)“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 29 
  50. 50. Disease review                                                                                                        CONCEPTUAL STUDY  Acharyas have recommended the efficacy & importance of Uttara basti in the Treatment of Asrgdara. According to Vagbhata, use of 2 or 3 Asthapana bastis followed by Uttarabasti is beneficial.                                                                                       MüÉzqÉrÉï MÑüOûeÉ YuÉÉjÉ ÍxÉ®Ç E¨ÉU oÉÎxiÉlÉÉ | U£ürÉÉålrÉUeÉxMüÉlÉÉÇ mÉѧÉblrÉÉ¶É ÌWûiÉÇ bÉ×iÉqÉç || (cÉ.ÍcÉ.30/100)                                                                            In Charaka chikitsastana 30th chapter, he has explained the use of Kashmarya Kutaja kwatha siddha grita Uttara basti in the management of Raktayoni. Nasya: In brahtrayis, there is no reference of use of nasya in Asrgdara . But Kashyapa quotes that nasya should not be given during rajasrava kala.3.Dosha shamana: Doshas which are in vruddha avastha are brought down to normal by inducing different methods of shamana line of treatments.4.Rakta samgrahana & Rakta sthaapana dravya: This means the administration of drugs or other measures which causes rakta stambhana.5.Use of tikta rasa: Tikta rasa is advised with following purposes It pacifies the pitta dosha To improve metabolism As a coagulantThese 5 principles include almost all the measures of treatment of Asrgdara in ayurveda.Thus, the aim of treatment of Asrgdara should be, To cease the excessive bleeding To pacify the vitiated doshas & maintain their equilibrium“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 30 
  51. 51. Disease review                                                                                                        CONCEPTUAL STUDY  To improve the general health of the bodyA brief review of the drugs & yogas indicated in asrgdara: For Asthapana basti: Chandanaadi/Rasnaadi niruha basti ( Kushadi Asthapana ( Lodradi Asthapana ( ) Mustadi yapana basthi ( For Anuvasana basthi: Madhukoshikadi ( ) Shatapushpa taila (,25) For virechana: Mahatiktaka grita especially in pittaja Asrgdara. For Uttara basthi: Kahmarya kutaja kwatha siddha grita.Internal medicines: Kashayas: Darvaadi kashaya, Dhataki & Pooga kusuma Kalka & Choorna: Tunduleeyaka moola with honey Rasanjana with Laksha choorna Bala moola kalka with milk Indrayava choorna Pushyanuga choorna with madhu & tandulodaka ( Ksheera prayoga: Ksheera prayoga with Ashoka valkala siddha ksheerapaka Modaka: Alabu phala modaka, Malaya phala modaka Avaleha: Kooshmandavaleha, Jeerakaavaleha Grita: Brahat Shatavari grita, Shalmali grita, Sheeta kalyanaka grita, Shatavari grita, Mahatiktaka grita Rasoushadhis: Pradararipu rasa, Bolaparpatee rasa Gutikas: Gokshura guggulu, Chandraprabha gutika“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 31 
  52. 52. Disease review                                                                                                        CONCEPTUAL STUDY Vishesha chikitsa according to predominance: Vataja Asrgdara: -Tila choorna with Dadhi or Phanita/Shookara/vasa/madhu. -Varahas medayukta mamsa with kulattha kwatha. -Sharkara, madhu, nagara, yastimadhu with guda. Pittaja Asrgdara: -Nimba, gudoochi with Madhya. -Madhuka, triphala, lodra, musta with honey. -Payasa, utpala, shalooka, bias, ambuda with milk, sugar & honey. Kaphaja Asrgdara: -Nimda/guduchi/lohitaka/Malaya with madhu, kakajangha moola with madhu & lodhra. Sannipatika: Although it is considered as different to treat, yet following medicines can be administered; Tanduleeyaka moola kalka + Rasanjana Pathya, amalaki, vibheetaki, dahuharidra kwatha with madhu & lodra choorna“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 32 
  53. 53. Disease review                                                                                                        CONCEPTUAL STUDY  Differential diagnosis of Asrgdara In ayurveda most of the gynaecological disorders like Yoni vyapaths & Arthava vyapathsare having excessive vaginal bleeding as their symptom. Eventhough excessive bleeding is themain clinical feature of Asrgdara, it has its own etiology & samprapti. So there is a need todifferentiate it from following disorders. Table no. 12: Differential diagnosis of Asrgdara Asrja yonivyapath Pittavruta apanavata Lohitakshara yonivyapath Raktarsha Pittaja yonivyapath Raktatisaara Astarthava dusti Adhogaraktapitta1. Asrja yoni vyapath71: Asrja is a condition where in due to raktapittahara nidana, the yonisthita rakta gets vitiated by pitt resulting in atipravartana of rakta even with garbhe api labde (with conception) Chakrapani commentary on this says, excessive bleeding leads to abortion, therefore the woman remains without Praja (Apraja) . Due to excessive bleeding per vaginum, it is referred to as Rakta yoni. 2. Lohitakshara vyonivyapat72,73: This condition is characterized by continuous or excessive bleeding or trickling of blood associated with other features of Pitta-osha, chosha, daha, jwara etc.the word kshara refers to oozing or trickling. The kind of bleeding pattern is seen in small cervical polyp or erosions which presents with intermittent scanty bleeding. Due to association of chronic inflammation with erosion, symptoms like burning sensation etc are present.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 33 
  54. 54. Disease review                                                                                                        CONCEPTUAL STUDY  Therefore this condition can be considered as irregular bleeding association with erosion or polyp.It can be ruledout by clinical examination, PAP smear &by D&C 3. Pittaja yoni vyaapath74,75,76: Lakshana Pittaja yonivyapath Pittaja Asrgdara Sthanika paka + - Sarvadaihika ushnata + - Anyadhika ushnakunapagandhiyonisrava + - Anrtavapi brhatartava + ++ Roga, trushna, moha, brama - + Raktasrava - + 4. Arthava dusti77,78 : Among the Astarthava dusti, kunapagandhi arthava dusti caused due to rakta, presents with excessive menstrual flow associated with other features like vedana & kunapagandhi (smell of dead body). This Asadhya vyadhi can be seen in condition of carcinomas with necrosis of tissue. 5. Pittavrta apanavata79: Rajashcha atisravanam is feature associated with other lakshanas – haridra mootra varcha, tapa guda medrayah. The concept of avarana is considerd as a pathological process towards the development of the vyadhi, but not the vyadhi itself. 6. Raktarsha, Raktaatisara80: These can be differentiated as the marga through which it present. 7. Adhoga raktapitta81,82: This can be differentiated from Asrgdara as adhoga raktapitta presents with bleeding through other adhogata margas like gudamarga, mootramarga apart from yoni marga.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 34 
  55. 55. Disease review                                                                                                        CONCEPTUAL STUDY  Disease Review of DUBDefinition of DUB83,84: DUB is defined as a state of abnormal bleeding without any clinically detectable organic pelvic pathology like tumour, inflammation or pregnancy. DUB is not one condition with one etiology, but it is a group of disorders characterized by dysfunction of the uterus, ovary, pituitary, hypothalamus or other parts of the reproductive system which results in abnormal or excessive uterine bleeding.                                                         The etiology is purely hormonal & that of the hypertrophy & hyperplasia of the endometrium are induced by a high titre of estrogen in the circulating blood. The bleeding may be abnormal in frequency or amount or duration or combination of any three. It is diagnosis of exclusion & one must proceed through a logical evaluation to rule out all other causes of the abnormal bleeding.Pathophysiology 85,86: The current concept concludes that the abnormal bleeding is most likely due to local causesin the endometrium. These are, Alteration in the prostaglandins due to, Excessive endometrial secretion of PGE2 causes failure of vasoconstriction. Excessive prostacyclin in endometrium & myometrium causing inhibition of platelet aggragation & endometrial vasodilatation. Increase in endometrial fibrinolysis: excessive fibrinolysis with failure of formation of secondary thrombi, this is due to lower level of TXA2 & PGF2 in menstrual endometrium of women with DUB. Defects in spiral vessels. Abnormal vascularity of the endometrium. Delayed degeneration of the endometrium Increase in endometrial lysosomal enzymes with excessive formation of prostonoids. Deficient formation & release of endometrial vasoconstrictor.“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 35
  56. 56. Disease review                                                                                                        CONCEPTUAL STUDY Classification87: Primary : --- Pathology in endometrium or H-P-O axis. It is of 2 types: Ovulatory Anovulatory Secondary: ---Pathology detected outside the H-P-O-Endometrial axis like endocrinopathies, haematological, vascular disease, liver disorders etc. Iatrogenic:This is caused due to drugs like irregular intake of hormonal drugs, IUCD etc.Ovulatory DUB88: The cycle is ovulatory but has inadequate luteal phase or poor & inadequate formation ofcorpus luteum.Two varities are found, 1. Irregular shedding of endometrium89: The abnormality is usually not in extreme of reproductive period. Normally regeneration of the endometrium is completed by the end of the 3rd day of menstruation, but in irregular shedding desquamation is continued for a variable period with simultaneous failure of regeneration of the endometrium. It is due to persistent corpus luteum. Incomplete withdrawal of LH Persistent corpus luteum Persistent secretion of progesterone Inadequate release of Phospholipids A2. Inadequate release of prostaglandins Irregular shedding“A clinical evaluation of the effect of Uttara basti in Asrgdara dysfunctional uterine bleeding ”Page 36