Dysmenorrheal psr


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Clinical study of dashamoola ksheera basthi in dysmenorrheal, Rachana H V, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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Dysmenorrheal psr

  1. 1. “A CLINICAL STUDY OF DASHAMOOLA KSHEERA BASTHI IN DYSMENORRHEA” By DR. RACHANA H.V, B. A. M. S. Dissertation submitted to the Rajiv 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 Streeroga GUIDE: CO-GUIDEDR. MAMATHA.K.V. M.D; Ph.D (Ayu) DR. VIDYA BALLAL., M.S (Ayu) Professor LecturerDept of Prasooti Tantra and Streeroga Dept of Prasooti Tantra and 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 DECLARATIONI hereby declare that this dissertation entitled “A CLINICAL STUDY OFDASHAMOOLA KSHEERA BASTHI IN DYSMENORRHEA” is a bona fide andgenuine research work carried by me under the guidance of Dr. Mamatha K.V.,M.D,Ph.D (Ayu) and co guidance of Dr. Vidya Ballal, M.S. (Ayu) Date: Signature of Candidate Place: Udupi Dr. Rachana H.V
  3. 3. Department of Post graduate Studies in Prasooti Tantra & Stree roga S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118 CERTIFICATE BY THE GUIDEThis is to certify that the dissertation entitled “A CLINICAL STUDY OFDASHAMOOLA KSHEERA BASTHI IN DYSMENORRHEA” is a bona fideresearch work done by Dr. Rachana .H.V in partial fulfillment of the requirement for thedegree of M.S. (Ayu) . Signature of Guide Date: Place: Udupi Dr. Mamatha.K.V., M.D, Ph.D (Ayu) Professor, Dept of Prasooti Tantra and Stree roga, 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 STUDY OFDASHAMOOLA KSHEERA BASTHI IN DYSMENORRHEA” is a bona fideresearch work done by Dr. Rachana H.V.in partial fulfillment of the requirement for thedegree of M.S. (Ayu). . Signature of Co-Guide Date: Place: Udupi Dr. Vidya Ballal, M.S. (Ayu) Lecturer, Dept of Prasooti Tantra and Stree roga 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 ENDORSEMENTThis is to certify that the dissertation entitled “A CLINICAL STUDY OFDASHAMOOLA KSHEERA BASTHI IN DYSMENORRHEA” is a bona fideresearch work done by Dr.Rachana.H.V under the guidance of Dr. Mamatha.K.V.,M.D. Ph.D(Ayu) and co guidance of Dr.Vidya ballal, M.S. (Ayu). . H.O.D. PRINCIPAL Dr. U.N.Prasad. M.D.(Ayu) Dr. V.N.K.Usha M.D.(Ayu) S.D.M.C.A. Udupi Dept of Prasooti Tantra & Stree Roga S.D.M.C.A. Udupi Date: Date: Place: Udupi 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 .Rachana.H.V
  7. 7. ACKNOWLEDGEMENTI humbly bow my head on the feet of almighty who have poured in me constant shore upfor the liberation of crossing this mile stone as well as all success, progress &achievements in my life. I am ever grateful to my beloved parents Shri Vasudeva Bhat and SmtSathyasheela for showering their blessings and giving me moral support and guidancethroughout the study. I would like to express my heartfelt gratitude to my dear sister Sahana and allother family members for constantly providing me valuable support and encouragement. I sincerely express my deep sense of gratitude to my beloved GuideDr. Mamatha K.V , Professor, Prasuti Tantra and Stree roga Department, SDM Collegeof Ayurveda for her support and guidance throughout the study. I wish to express my gratitude to my co-guide Dr. Vidya ballal, Lecturer, PrasutiTantra and Stree roga Department, SDM College of Ayurveda for her support andguidance. I sincerely express my deep sense of gratitude to my teacher Dr. Usha V. N. K.Prof. and HOD of Prasuti Tantra and Stree roga Department, SDM College of Ayurveda. I am thankful to my teachers Dr. Ramadevi Prof.,and Dr.Suchetha Asst. Prof.,Department of Prasuti Tantra and Stree roga, SDM College of Ayurveda for their supportduring this study.I wish to offer my sincere thanks to Prof. Dr. U. N. Prasad, Principal, S.D.M. College ofAyurveda, for his encouragement and support.I am thankful to Dr. B.V.Prasanna, Dr.Ravishankar for their suggestions during the work. I cannot move further before thanking to my friends Dr.Sunitha, Dr.Rekha,Dr.Deepashri, Dr.Prathima, Dr.Padma saritha, Dr.Vineeth, Dr.Prakash, Dr.AshwiniAmbalpady,Dr.Seetharam, Dr.Chaithra, Dr.Umayamma for being with me by providinghonest support to surmount each & every barrier successfully. And last but not least I want to thanks all my patients who cooperated methrough-out this work without whom it’s impossible & I thanks all those who havedirectly or indirectly contributed to the successful completion of this thesis work. Dr. Rachana .H.V
  9. 9.   ABSTRACTWith the advent of new millennium and the herald of high-tech era, women’s status wasexpected to reach new horizons both socially and physically. But some of the physiologicalthings trouble the lady to make her slow down the race. Menstruation is a normal physiological process, when it is accompanied with pain, is calledDysmenorrhoea. It is one of the commonest gynaecological complaints. In Āyurvedic text though, various conditions are described in which menstruation occurswith pain.In this especially there is derangement of Apana and Vyana Vayu. In classics, Bastiis considered as paramaushadha for the management of vata .It is the treatment modalityindicated in all types of yonivyapath. Dashamoola is best vatakaphahara and when it isprocessed with ksheera , it acts best on Tridosha.The drugs commonly used and sold over the country for dysmenorrhoea, though they areeffective in temporary relief but not permanent. Certain drugs have also caused various sideeffects on regular use.The present study is aimed at finding out a method of treatment for symptomatic relief aswell as permanent cure of underlying pathology of disease. On this basis,“A CLINICAL STUDY OF DASHAMOOLA KSHEERA BASTHI INDYSMENORRHEA” is taken.Key words- Dysmenorrhea, Dashamoola, Basthi, pain. 
  10. 10. CONTENTSCHAPTER NO. CONTENTS PAGE NO. PART 1 INTRODUCTION 1-2 PART 2 OBJECTIVES OF THE STUDY 3 PART 3 REVIEW OF LITERATURE Historical Review 4-7 Ayurvedic Disease Review 8-29 Modern Disease Review 30-44 Basthi Review 45-53 Drug Review 54-67 PART 4 METHODOLOGY 68-71 PART 5 OBSERVATIONS 72-98 PART 6 RESULTS 99-114 PART 7 DISCUSSION 115-127 PART 8 CONCLUSION 128-129 SUMMARY 130 SHLOKA REFERENCES 131-133 Bibliography 134-147 Annexure 148-156
  11. 11. LIST OF TABLESTABLE LIST OF TABLES PAGE NO. NO. 1. Different terminologies used to describe pain in classics. 11 2. Synonyms of Pain 12 3. Lakshanas of Udavarthini according to different authors 13 4. Nidanas of yonivyapath causing Dysmenorrhoea 20 5. samanya chikitsa of yonivyapath 28 6. Vishista chikitsa of yonivyapath 29 7. Difference between primary and secondary dysmenorrhoea 41 8 Pharmocological action of tila taila 63 9 Ingredients of chandraprabhavati 64 10 Course of yogabasthi 69 11 Assessment criteria 70 12 Incidence of Age 72 13 Incidence of Marital Status 73 14 Incidence of Religion 74 15 Incidence of Socio-economic Status 75 16 Incidence of Education 76 17 Incidence of Dietary Habit 77 18 Incidence of Occupation 78 19 Incidence of Family history 79 20 Incidence of Mental stress 80 21 Incidence of Bowel Habit 81 22 Incidence of breast tenderness 82 23 Incidence based on location of pain 83 24 Incidence based on shoola during arthavakala 84 25 Incidence based on arthava associated with daha 85 26 Incidence based on consistency of arthava 86
  12. 12. 27 Incidence based on intermenstrual period 8728 Incidence based on Duration of arthava 8829 Incidence based on arthava associated diurbalya etc 8930. Incidence based on tandra, alasya 9031 Incidence based on kunapagandhi 9132 Incidence based on shronivankshanaprustarhi 9233 Distribution of patient based on Prakriti 9334 Distribution of patient based on Samhanan 9435. Distribution of patient based on pramana 9536 Distribution of patient based on satwa 9637 Distribution of patient based on Ahara Shakti 9738 Distribution of patient based on Vyayama Shakti 9839 Effect of treatment on shoola during arthavakala in group A 9940 Effect of treatment on shoola during arthavakala in group B 9941 Comparison of shoola in between the groups 10042 Effect of treatment on picchilatha of arthava in group A 10143 Effect of treatment on picchilatha of arthava in group B 10144 Comparison of picchilatha in between the groups 10245 Effect of treatment on Intermenstrual period in group A 10346 Effect of treatment on Intermenstrual period in group B 10347 Comparison of Intermenstrual period in between the groups 10448 Effect of treatment on duration of arthava in group A 10549 Effect of treatment on duration of arthava in group B 10550 Comparison of duration in between the groups 10651 Effect of treatment onDourbalya,shrama,murcha in group A 10752 Effect of treatment onDourbalya,shrama,murcha in group B 10753 Comparison of Dourbalya etc in between the groups 10854 Effect of treatment on Tandra, alasya in group A 10955 Effect of treatment on tandra, alasya in group B 10956 Comparison of Tandra, alasya in between the groups 110
  13. 13. 57 Effect of treatment on Kunapagandhi in group A 11158 Effect of treatment on kunapagandhi in group B 11159 Comparison of kunapagandhi in between the groups 11260 Effectof treatmenton Shronivankshanaprustarthi in group A 11361 Effectof treatmenton Shronivankshanaprustarthi in group B 11362 Comparison of shronivankshanaprustarhi in between the 114 groups
  14. 14. LIST OF GRAPHSSl. No. Description Page No. 1 Incidence of Age 72 2 Incidence of Marital Status 73 3 Incidence of Religion 74 4 Incidence of Socio-economic Status 75 5 Incidence of Education 76 6 Incidence of Dietary Habit 77 7 Incidence of Occupation 78 8 Incidence of Family history 79 9 Incidence of Mental stress 80 10 Incidence of Bowel Habit 81 11 Incidence of breast tenderness 82 12 Incidence based on location of pain 83 13 Incidence based on shoola during arthavakala 84 14 Incidence based on arthava associated with daha 85 15 Incidence based on consistency of arthava 86 16 Incidence based on intermenstrual period 87 17 Incidence based on Duration of arthava 88 18 Incidence based on arthava associated diurbalya etc 89 19 Incidence based on tandra, alasya 90 20 Incidence based on kunapagandhi 91 21 Incidence based on shronivankshanaprustarhi 92 22. Incidence of Prakriti 93 23 Incidence of Samhanan 94 24 Incidence of pramana 95 25. Incidence of satwa 96 26 Incidence of Ahara Shakti 97 27. Incidence of Vyayama Shakti 98
  15. 15. 28 Effect of treatment on shoola during arthavakala in group A 9928 Effect of treatment on shoola during arthavakala in group B 9929. Comparison of shoola in between the groups 10030 Effect of treatment on picchilatha of arthava in group A 10230 Effect of treatment on picchilatha of arthava in group B 10231 Comparison of picchilatha in between the groups 10232 Effect of treatment on Intermenstrual period in group A 10432 Effect of treatment on Intermenstrual period in group B 10433 Comparison of Intermenstrual period in between the groups 10434 Effect of treatment on duration of arthava in group A 10634 Effect of treatment on duration of arthava in group B 10635 Comparison of duration in between the groups 10636 Effect of treatment onDourbalya,shrama,murcha in group A 10736 Effect of treatment onDourbalya,shrama,murcha in group B 10737 Comparison of Dourbalya etc in between the groups 10838 Effect of treatment on Tandra, alasya in group A 11038 Effect of treatment on tandra, alasya in group B 11039 Comparison of Tandra, alasya in between the groups 11040 Effect of treatment on Kunapagandhi in group A 11240 Effect of treatment on kunapagandhi in group B 11241 Comparison of kunapagandhi in between the groups 11242 Effect of treatmenton Shronivankshanaprustarthi in group A 11442 Effect of treatmenton Shronivankshanaprustarthi in group B 11443 Comparison of shronivankshanaprustarhi in between the groups 114
  16. 16. LIST OF FLOW CHARTS Chart No.1 Samprapthi of udavarthini yonivyapath 14 Chart No2 Lakshanas of vataja yonivyapath 15 Chart No.3 Mechanism of pain in endometriosis 16 Chart No.4 Lakshanas of pariplutha yonivyapath 17 Chart No.5 Mechanism of pain in PID 18 Chart No.6 Lakshanas of vataja Arthava dushti 18 Chart No.7 Samprapthi of vataja Arthava dushti 19 Chart No.8 Propagating factors for vata prakopa 21 Chart No.9 Samprapthi of Dysmenorrhoea 25 Chart No.10 Synthesis of prostaglandins 32 Chart No.11 Management of primary dysmenorrhoea 36 Chart No.12 Mechanism of pain production in 44 Dysmenorrhoea Chart No.13 Role of basthi in the management of shoola 51 List of Pictures SI.NO NAMES Page No 1. Prakrutha varna of Arthava 9 2. Mechanism of pain production by prostaglandin 43 3. Preparation of Basthi 50 4. Dashamoola - Ingredients 60,61 5. Chandraprabhavati -Ingredients 66,67 
  17. 17. Introduction   INTRODUCTIONPain is body’s most important alarm system because it draws attention to the fact thatsomething is at fault. Total absence of pain sensation is also as disastrous as uncontrolledsevere pain. However, uncontrolled pain is the single most common reason for people to seekmedical advice.Pain is an unpleasant phenomenon that is uniquely experienced by each individual; it cannotbe adequately defined, identified, or measured by an observer.The word pain is derived from the Latin counterpart “Poena”, meaning penalty, punishmentor torment-rightly so, as pain is the single most important symptom that brings the patient tothe emergency.Pain is the biggest problem since the beginning of mankind. All the system of philosophy hastaken origin in search of the method to relieve the pain. The word ‘Disease’ itself denotespainful situation. Health is happiness & disease is pain. ‘Sarveshveteshu shuleshu prayena pavanah prabhuh’.Vata is responsible for pain. It is evident by the saying that no yonivyapath occurs withoutmorbid vata dosha. Vyana vata has contol over the muscles which brings about actions suchas contraction, relaxation, extension, flexion etc. When deranged all its functions in the entirebody gets affected. Vyana regulates blood circulation, vasomotor system. It exercises aninfluence by its nervous mechanism over sweat and other secretions and convey them to therespective destinations including endocrinal. Apana vayu has been given prime importance in Gynaecological disorders. Normalmenstruation is the function of Apanavayu, therefore painful menstruation is considered asapanavata dushti. According to ayurvedic view, normal arthava or menstruation should notbe associated with any sort of discomforts as pain, burning sensation etc. Hence painfulmenstruation is a variation from normalcy, which needs medical attention.For production of Ārtava ,Vyāna and Apāna work in coordination with each other.Contraction and relaxation of the uterus and its related organ are done by Vyāna Vāyu afterthat Ārtava is expelled out by Anulomana Kriyā of Apāna Vāyu.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 1    
  18. 18. Introduction  Dysmenorrhea is a medical condition characterized by severe uterine pain duringmenstruation. While most women experience minor pain during menstruation,dysmenorrhoea is diagnosed when the pain is so severe as to limit normal activities, orrequire medication.Dysmenorrhea shows features of different kinds of pain, including sharp, throbbing, dull,nauseating, burning, or shooting pain. And it usually subsides as menstruation tapers off.Dysmenorrhea is a common symptom in various yonivyapads that affects approximately 50%of menstruating women, affecting their daily routines. In the first year after menarche 38% ofgirls develop dysmenorrhoeal pain. In the 2nd and 3rd year after menarche 20% experiencepains related to menstruation. About 80% of women who develop dysmenorrhoea do sowithin 3 years of menarche.So to maintain their health, utmost care and effective treatment is needed. So the treatmentwhich is effective for longer duration with minimal or no side effects is needed.In Ayurveda, Basti is considered as paramaushadha for the management of vaata .It is thetreatment modality indicated in all types of yonivyapath.  Dashamoola is best vatakaphaharaand when it is processed with ksheera , it acts best on Tridosha. Considering above factorsthis study is being selected.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 2    
  19. 19. Objectives  OBJECTIVES To study the concept of Dysmenorrhea and Basthi. To assess the efficacy of Dashamoola ksheera basthi in Dysmenorrhoea.                    “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 3 
  20. 20. Historical review   HISTORICAL REVIEW1,2VEDIC PERIODIn these texts, references related to Prasuthi tantra and streeroga are scattered. The wordarthava is used for joining period of two seasons and probably due to the presence of rutukalain women, the word arthava is used in classics to denote various physiologic substances ofmenstrual cycle. Where they indicate, healthy yoni as an actual place of progeny.There is no direct reference about the basti in Vedas. In Kaushika sutra of Atharva veda,“Ishika”word is used for shalaka which was used in treatment of mootravrodha this maysymbolize basti netra3BRAHMANASThe yoni or upastha are used for internal or external female genital tract. The reference of a girl nothaving her menarche, having normal growth of pubic hair, importance of rutumathi women forconception. KALPA SUTRAS:The woman during menstrual period was considered as untouchable. Dharma Sutras heregreater importance to general health of couple. Physical and psychological normalcy wasgiven importance as it is said that healthy parents can only provide healthy body and mind tothe progeny.UPANISHADReproduction along with contraception has been dealt elaborately. The female was considered asKshetra and man is the Seed.Ramayana: The pathological effects caused by aggravated vayu are described as deformitiesin body, obstruction in passage of urine, respiratory distress, pain and immobility of joints.Mahabharatha: Vayu has been dealt with more details. 5 types of vata are mentioned.                     “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 4  
  21. 21. Historical review  SAMHITHA KALACaraka samhita :-Almost all gynaecological clinical entities described by Charaka come under twenty yoni-vyapads.Charaka mentioned this in chikitsa stana-30 th chapter.4Dashamula ksheera basthi is mentioned in Charaka samhitha chikitsa stana, 30 chapters 5.Has given importance to basti by considering it as Ardha cikitsaa.6 Basti is explained in detail in Sidhi sthaana 1st, 2nd, 3rd, 5th, 7th, 8th, 10th, 11th, 12th, chaptersand in kalpa sthaana.Sushruta samhita :-Sushruta7 explained yonivyapath in a summarized way and with little difference in causativefactors as he has classified five under each dosa i.e., Udavarta, vandya, vipluta, paripluta andvatala due to vata.Sushruta has also considered basti as Ardha chikitsaa.Explained about the basti in detail in chikitsaa sthaana 35th, 36th, 37th, 38th, chapter.Sushruta has explained basti vyaapads, its causes, symptoms, treatments in detail.8Sushruta has contributed many new principles about the basti like explanations about theUtkleshana, shodhana, shamana bastis, names of different bastis based on the drugs used,etc.9Ashtaanga sangraha and hridaya :-Vagabhata10 have explained Udavarta yonivyapad in vataja yonivyapad.Both these samhitaas explained about the basti in different chapters of Sutra and kalpasthaanas.Kaashyapa , Haritha and Bela samhita :-Kashyapa11 Harita and Bhela12- though the subject related to prasuti tantra is given inconsiderable details but not to that much depth as seen in Charaka and Sushruta Samhita.                     “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 5  
  22. 22. Historical review  However, the stri roga is dealt in much concise way except the description of some menstrualdisorders and recipes for infertility.Gave different opinion about the basti in different contexts starting from basti netra, course ofbasti, etc.Basti has been explained in Khila sthaana and siddhi sthaana in detail.Some alterations in rules and regulations regarding the basti in baala are explained.Bhela samhita:- Bhela has explained basti in Siddhi sthaana 5th, 6th, 7th, 8th, chapters.Haareeta samhita :-Explained about the basti in Sutra sthaana 3rd chapter.Chakradatta :-In most of the explanations, he followed Charaka’s opinion.Ardhamaatrika basti is explained in 73 (Niruhaadhikaara)/23-26.13Explained Niruha in Anuvaasana basti in detail in 71st and 72nd chapter.Gheranda samhita :- Various yogic procedures are discussed in this samhita, where in after explainingmoolashodhana, description of basti is given and two types of basti namely jalabasti andsthala basti( shuska basti ) and their benefits are explained.14 MEDIEVAL PERIOD Even yogarathnakara15 , Bhavaprakasha16 , Sharangadara samhita17 and Madava nidana18mentioned 20 yonivyapath with treatment explained in detail.Shaaranghadhara samhita :-Detailed description of basti is available in uttara khanda 5th, 6th,7th, chapter.Some of the contributions are like paribhaasha of basti, Aasthapana etc.19Some variations in rules are noted.Bhaava prakaaasha:- Acharya Bhava mishra has highlighted the concept of basti in one of thechapter of Poorvakhanda, dealing with panchakarma vidhi prakarna.Aananda kanda:-He has not included basti among the Panchakarma.                     “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 6  
  23. 23. Historical review  Kalyanakaaraka :- Detailed description of basti is available in Vaatavyaadhi adhyaaya, andin Bheshajakarmopadrava chikitsa.Gada nigraha :-Even though he has included Niruha and Anuvaasana in Panchakarma,description about the basti is not available.20MODERN HISTORICAL ASPECTSDysmenorrhoea has a long history and a great deal of our present day knowledge dates backover many centuries. Hippocrates practiced dilatation of the cervix with pine rods, leaden pipes, or thefinger but this indication seems to have been for uterine displacements and puerperalcomplications.21Robert Batley first performed Oopherectomy for painful menstruation in 1872. It was apopular operation until the beginning of this century.In the 19th century Dysmenorrhoea was believed to be always due to some mechanicalobstruction to the flow of menstrual blood .Mackintosh in 1832 reported 27 cases in which hehas dilated the cervix and of these 24 were relieved.Pliny (A.D. 23 to 79) recommended asparagus root for pain in the uterus.                     “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 7  
  24. 24. Review of literature   AYURVEDIC CONCEPTDysmenorrhoea, which means painful menstruation, is frankly not a disease. It is a symptomassociated with much gynaecological pathologies. But when it present solely as a complaintwithout association of any other symptom, it may be considered as a primary dysmenorrhoea.In the classics of Ayurveda , painful menstruation finds its role as a sole symptom inUdavartha yonivyapath as well as an associated complaint with many other symptoms in thecases of vataja yoni vyapath, vataja arthava dushti, pariplutha yoni vyapath.In all these contexts the ‘Arthava’ is found to be associated with the laxanas which suggestsits abnormality or in other words Arthava does not exhibit the Shuddarthava laxanas,suggesting a diseased condition.According to classics, Shuddarthava is explained as one which is depended upon Varna,matra, Gandha of Artava and where associated with picchila, arthi, is considered asvikruthavastha, which can be seen in many gynaecological disorder. The Shuddhartava is anindicator of "Svasthavastha" and the Ashuddhartava is indicative of "Rogavastha".The following are the shudda arthava lakshanas:Shuddha Ārtava Lakshana22,23,241) Varna (Colour): We get different references for the prakrutha varna of arthava. They arenormal colour of menstrual blood.Like, Gunjaphala Rakta Kamal Alaktaka Indragopa Sashasrika Laksha Rasa Ishat Krishna It is also said that the colour of arthava depends on the prakruthi of a person by Bhavaprakasha25. Yogaratnakara and madava nidana have followed Charaka and Sushruta.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 8  
  25. 25. Review of literature   But in patients, it is very difficult to identify the colour of menstrual blood. Prakrutha varna of arthava mentioned in classics like Gunjaphala ,Rakta Kamal , Alaktaka ,Sashasrika ,Laksha Rasa. Prakrutha varna of Arthava mentioned in classics   Gunja Laksharasa Shashasruk Padma Shashasruk Alakthaka Shashasruk AlakthakaGandha (Odour) Madhugandhi26 Visrata Āmagandhitva27 Ācharya Sushruta says that the Rakta has Visragandha due to Prithivi Mahābhoota, same can be considered for Ārtava Dalhana explains that this foul smell in menstrual blood is due to the fact that Ārtava has same properties as of Pitta28. The menstrual blood has a characteristic odour caused by bacterial action and degeneration partly by the accompanying secretions of sebaceous and apocrine gland of vulva. One of the reasons for bad smell of menstrual blood is E. coli infection. These bacteria are present in stool and can travel from anus to vagina as both organs are present very close to each other. These bacteria can change the pH of vagina which encourages bacterial growth leading to bad smell. Normal pH of vagina is acidic. This acidity can protect from bacterial infection.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 9  
  26. 26. Review of literature  3) Mātrā (Quantity)29According to Vagbhatta, it is four Anjali. Due to Variation of Desha, Kāla, Āhara, Vihāra,Prakriti etc. quantity of menstrual blood also changes. Thus the quantity of blood, which isnormal for one lady, may be abnormal for the other lady.Each soaked normal-sized tampon or pad holds a 5ml of blood. That means it is normal tosoak eight to sixteen normal-sized pads or tampons (“sanitary products”) in a whole period.Flow of more than 80 ml ( 16 soaked sanitary products) per menstrual period is consideredmenorrhagia.4) Guna :30Acharya has mentioned that arthava should be nishpiccha and when it is coming through thevagina women should not feel burning sensation.5) Arthava srava kala:It means duration of menstrual bleeding which varies according to the individuals.In classics we find different opinions regarding Arthava srava kala, it ranges from 5 days31,3days32 and rarely upto 7 days33.However, if slight flow without any other symptom of abnormality persists even for 16 days,it may be considered as normal.6) Arti :34Charaka says that “ Masath nishpicchadaharthi panchararathranubandhi cha”. Acharyaspecifies that normal menstruation also occurs without pain.In Ayurvedic texts various conditions are described in which menstruation associated withpain. The following table shows different terminologies used to describe pain associated indifferent Yonivyapaths.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 10  
  27. 27. Review of literature   TABLE NO : 1 Different terminologies used to describe pain in classics. CHARAKA SYMPTOMS REFERENCES SAMHITHA  Rajah Krichchha Udāvarta Yoniyāpada35 Saruk, yonitoda, Vātala Yoniyāpada36 Savedana Sashoola Sannipatika Yoniyāpada37 Saarti Paripluta Vyapada38 Saruja Vataja Asrigdara39   Manda Ruja Kaphaja Asrigdara40 SUSHRUTHA Rajah Krichchha, Udāvarta Yoniyāpada41 SAMHITHA Shoola, nistoda peeditha Vataja yonivyapath42   Vedanā Ārtava Dushti43 ASHTANGA Rajah Krichchha Udāvarta Yoniyāpath44 SANGRAHA AND ASHTANGA HRIDAYA  Toda Vataja yonivyapath45 Sarujam Vataja Ārtava Dushti46 MADHAVA Rajah Krichchha Udāvarta Yoniyāpada47 NIDANA,BHAVAPRAKASHA,YOGARATNAKARA                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 11  
  28. 28. Review of literature   TABLE NO-2Synonyms of Pain Shabda kalpa druma Monier williams AìÌiÉï – mÉÏQûÉ | Pain   ÂeÉÉ – mÉÏQûÉ | To break ÂMç –UéãaÉÈ | Pain urÉjÉÉ – SÒÈZÉqÉç | Uneasiness, pain, fear uÉãSlÉÉ - SÒÈZÉqÉç | Sensation, pain, feeling rÉÉiÉlÉÉ- aÉÉRûuÉãSlÉÉ | Acute pain AérÉÉxÉ – YsÉãvÉÈ, ´ÉqÉÈ | Pain, distance                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 12  
  29. 29. Review of literature   Udavarthini Yoni Vyapad:Nirukti: E¨Éç + AÉXè + uÉרÉç + bÉgÉç – ESÉuÉiÉï (vÉoS MüsmÉSìÓqÉ) The act of going up.Udavartha word refers to upward movement.”Vikarena rajasa urdhavagamanat udavartini ettyuchate.”.48 Urdhavagamana of rajasa is udavartini. Normal downward movement of rajas is obstructedand it moves in reverse direction. Udavartha yoni means painful menstruation in which yonidischarges frothy menstrual blood with difficulty. Relief of pain is obtained immediately afterproper discharge of menstrual flow. This is described by Charaka. Sushrutha49 says that besides painful, frothy menstruation, there are other pains of vata(Body ache, general malice etc)Indu50 has mentioned Discharge of clotted blood along with painful menstruation.In madhukosha51 commentary all around movement of vayu is said to be the cause of pain.Yogarathnakara52 added the discharge of frothy menstrual blood associated with kapha withdifficulty. TABLE NO : 3Lakshanas of udavarthini according to differnt authorsLakshana Ch SU AS AH Mn Yo1 Krichartava + + + + + +2 Vimukhta sukha + - - - - -3 Fhenilatwa - + + + + +4 Ruk + + - - + +5 Yoniprapeedana - - + + - -6 Kaphanivam Artava - - - - - +                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 13  
  30. 30. Review of literature   Chart no :1- Samprapthi of Udavarthini yonivyapath Apana vata vaigunya Viloma gathi of Rajas (Inappropriate law of polarity, Inadequate expulsive force, Narrowing of the cervical canal ) Krucchrarthava (Discharges menstrual bood with great difficulty) Shoola ( Pain)Among various theories of pain likeDeficient polarity: There is some co-ordination between fundal contraction and cervicaldilatation called polarity of uterus, which is probably controlled by a local nervousmechanism. The cervix fails to dilate when the uterus contracts to expel the menstrual blood.Uterine hypoxia: Inadequate expulsive force.Narrowing of the cervical canal: Difficult for the menstrual blood to escape--- Stronguterine contractions.- pain.In all these conditions there may be urdhva gamana of rajas, which causes pain.In coordinate muscle action of uterus as a whole, more likely due to imbalance in theautonomic nervous control of muscles is given maximum importance.Irregular contractions of all the myometrial muscle fibers have been explained as all aroundmovement of vayu i.e. ‘Samantadvartana’ in madhukosha commentary.Discharge of clotted blood mentioned by Indu may be the description of MembranousDysmenorrhoea. There is shedding of big endometrial casts during period. It is probably dueto the deficiency in the tryptic ferment normally secreted in the endometrium.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 14  
  31. 31. Review of literature  Vataja yonivyapad Chart no :2 – Lakshanas of vataja yonivyapath  These are the symptoms accompanying painful menstruation.Charaka53 mentioned that women of vata prakruthi, when consumes diet and indulges onother vata aggravating factors, then there will be vata prakopa. Increased vata reaching toYoni produces pricking and other types of pain, stiffness, roughness etc. Due to vata, themenstruation appears with sound, is painful, frothy, thin and dry.Sushrutha54 also mentiones pricking pain, acute pain, roughness and stiffness.Vagbhatas55,56 have added feeling of stretching ,stiffness, roughness and scanty, blackish orblackish red menstruation along with severe pain in groin region and flanks.Madava nidana57, Bhavaprakasha and yogarathnakara have followed sushrutha.The lakshanas of vataja yonivyapath like yonitoda, savedana, stamba,karkashata suggeststhe features of endometriosis.In endometriosis, they have explained the symptoms which are having similar explanations asthat of vataja yoni like pricking pain starts few days prior to menstruation get worsenedduring menstruation. In classics yoni toda is mentioned for pricking type of pain.Toda -- “Suchivyadaneneva Shooleneva vaa vyathayaam” |Savedana- Pain along with menstruation.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 15  
  32. 32. Review of literature  Vagbhata has included stiffness, roughness etc and displacement, a symptom often seen inlax perineum, specially associated with estrogen deficiency. All above symptoms are evidentin marked estrogen deficiency. Hypo-oestrogenism results in a decrease in size and volume ofuterine and cervical canal. This narrowness in the cervical canal may produce menstruationwith difficulty, leads to pain. Chart no :3- Mechanism of pain in endometriosisHere Dysmenorrhoea may be due to endometriosis or estrogen deficiency.Paripluta yonivyapad Paripluta means all around pain. Charaka58 says when a woman having pitta predominance withholds her natural urge of sneezing at the time of coitus vitiated pitta getting mixed with yoni causing abnormalities. The yoni become inflamed and tender and she gets painful menstruation. She also suffers from pain in lumbosacral and groin region, backache and fever. Sushrutha59 says that condition is characterized with severe dyspareunia. Both the vagbhatas60,61 have followed Charaka,they have included diarrhoea and anorexia etc.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 16  
  33. 33. Review of literature   Chart no :4 – Lakshanas of pariplutha yonivyapath The above mentioned lakshanas of pariplutha yonivyapath suggests signs and symptoms ofPID. In this there will be congestion of uterine wall with mild inflammatory changes. Thesame features can be seen even in the pelvic congestion syndrome. There is disturbance in theANS which leads to gross vascular congestion with pelvic varicosities. In both the conditions,pain aggravates prior to menstruation due to congestion. Increased vascularity is one of thecauses of congestive dysmenorrhoea.The symptom ‘Athisara’ mentioned by vagbhata can be seen in excessive production ofprostaglandins, which results dysmenorrhoea.The ushna, teekshna properties of vitiated pitta plays an important role in the stanikarakthavruddi with the help of vyana and apana vata. The yoni becomes inflamed and tenderand she gets painful menstruation.Madava nidana and yogaratnakara mentiones, “Pripluthayam bhavathi gramyadharmena rujabrusham” |62Dyspareunia is also another symptom present in PID.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 17  
  34. 34. Review of literature   Chart no :5- Mechanism of pain in PIDVataja Artava dushti 63,64,65 The artava (menstrual blood) vitiated by vata is red, black or blackish red in colour , is thin, frothy and excreted slowly with pain. Chart no :6 – Lakshanas of vataja arthava dushti  These are the symptoms seen in the vataja artava dushti.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 18  
  35. 35. Review of literature   Chart no :7 – Samprapthi of vataja arthava dushti  Vataprakopaka ahara,vihara Dhatukshya and margavarodha Vitiation of Vyana and Apana vata Akunchana and prasarana(Ischemia) Blood flow ( Prana vata Dusti) SHOOLA(PAIN) Due to consumption of vataprakopaka ahara,vata gets aggrevated and vitiates rasa and then Upadathu nirmana i..e Arthava. This is produced in less quantity. Due to vitiation of vyana and apana vata,the akunchana and prasarana kriya of garbhashaya does not takes place properly. There may be also prana vata dushti, so proper oxygen supply will not be there, leading to hypoxia. Due to this uterine muscle will struggle to expel the menstrual blood out, leading to pain. Even myometrial ischemic theory says that lack of blood supply causes myometrial ischemia thus producing painful stimuli.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 19  
  36. 36. Review of literature   Nidanas of Yonivyapath causing Dysmenorrhoea TABLE NO: 4 Yonivyapad samanya hetu mentioned by different acharyas Mithyachara ,Pradustartava ,Beeja dosha ,Daiva CHARAKA66 SUSHRUTHA67 Mithyachara ,Pradustartava ,Beeja dosha ,Daiva Pravruddha linga purusha atisevana by ruksha durbhala stree/bala VAGBHATA68 Dusta bhojana ,Vishamanga shayana ,Brisha maithuna sevana,Dustartava Apadravya Sevana into yoni ,Bheeja dosha ,DarivatahMadhavakara, Bhavaprakasha, and Yogarathnakara have followed Caraka in this aspect.MITHYACHARA It includes both mithya Ahara, mithya vihara Mithyahara- Anashana, alpashana, atyashana are included under this. Among this alpamatrashana and anashana leads to dhatukshya and illhealth which may result in anemia, increased chances of infection, decreased pain threshold and increased chances of diseases. Atyadhika Ahara, dushta Bhojana leads to amothpatti. This infact can lead to various pathologies. Certain other factors along with virudha ahara can potentially cause the utklesha doshas to localise (Stana samsraya) in Yoni.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 20  
  37. 37. Review of literature   Over intake of Ruksha and Kshareeya substances and Katu, Tiktha, Kashaya rasa. These rasas are believed to be a propagating factor of vata dosha. Chart No:8 Propagating factors of vataprakopa Ruksha,kshara Karshana Dhatu kshaya Vata Dosha In general, any kind of mithya ahara will affect the production of Rasa Dhatu and रज being the upadhatu of Rasa is also bound to get affected leading to Yoni Vyapad or Arthava Vyapad. High fat diet encourages growth of the bacteria in the colon that produce enzymes that promote the absorption of uncoupled estrogen complexes formed in the liver. The uncoupled free estrogen is absorbed back into the blood stream resulting in higher total levels of estrogen in women’s body. Excessive intake of animal fat of the saturated type causes blood to clot more readily. Passage of large clots through the neck of the uterus during menstrual flow can cause pain; hence consumption of animal fat can potentially contribute to Dysmenorrhoea. VIHARAMithyavihara- Abnormal mode of life like suppression of natural urges , excessive coitusand exercise, fear, sadness etc will vitiate vata. Sedentary life styles, stress and strain in dailylife are risk factors for dysmenorrhoea.Career has become a major priority in a woman’s life in the present era, adding to more  stress. There is significant change in the sleeping pattern due to shift duties. .Ratri jagaranacauses Vata prakopa while Divaswapna causes Kapha prakopa, hence depending upon thepredominant habit of today’s women, Vataja/ Kaphaja/ Vatakaphaja Yoni Vyapad’s canmanifest.These days, the amount of travel encountered by women has also increased for both Workingwomen and Housewives. Travel leads to Vata prakopa and travel on uneven roads can becompared to Gaja Ustra Yana which can lead to greater vata prakopa specifically Apanavayu. Too much riding on vehicles, there will be increase in the blood flow to adhoshareera,                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 21  
  38. 38. Review of literature  even the atyaasana is one of the nidaana and due to this there will be an increased congestionin the pelvic blood vessels and stagnation of blood for longer time. As vata stana is said to bepakvashaya, Kati etc, due to these nidanas there will be vata prakopa.Vegadharana can disrupt the HPO axis leading to hypoestrinism. Oestrogen deficiency leadsto dryness of vagina by affecting its mucous secretions and also leads to lack of menstruationwith difficulty leads to pain.In some persons IUCD causes pain during menstruation which can be included underapadravya sevana as told in our classics. It has been suggested that this could be due touterine contraction in order to expel the foreign body outside.Pradushta Artava : The word arthava refers to menstrual blood, ovum and ovarianhormones. mÉçëSÒ¹ãlÉãuÉ AÉiÉïuÉãlÉãÌiÉ uÉÉiÉÉÌSSÒ¹UeÉxÉ CirÉjÉïÈ |69The normal menstruation which is not having intermenstrual period of one month ,isassociated with pain and burning sensation, excreted blood is unctuous, very scanty orexcessive in amount, colour is not resembling with gunja, laksha, padma, alakthaka orshashasruk can be consider as pradushta arthava.Ovarian hormones are causative factors for good number of gynecological disorder.Beeja dosha- Hereditary factors of dysmenorrhoea can be consider under this. Congenitaldefects like pin hole os, atresia of vagina; imperforated hymen etc also can be included.Stenosis at the internal Os or narrowing of the cervical canal → difficult for the menstrualblood to escape → strong uterine contractions → pain70.Daiva- It is unknown or idiopathic factor. In the absence of apparent cause, the diseasesdevelop by purvajanmakrita papa due to curse of God.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 22  
  39. 39. Review of literature   IMPORTANCE OF VATA IN ARTHAVA NISHKRAMANA Among Tridosas, Vata Dosa has more importance for the physiological and pathological state of the body due to its Gunas and Karmas. Regarding the different predominant functions of the Vata going to happen in different cells of the different systems of body, it is subdivided into five types i.e. Prana, Udana, Samana, Vyana and Apana. Vata is responsible for pain. For production of Ārtava, Vyāna and Apāna have coordinate relation with each other. Vyāna Vāyu is responsible for Contraction and relaxation of whole body organs and Anulomana or munchana of artava is done by Apāna Vāyu.Function of Apana Vayu : Apana vayu has been given prime importance in Gynaecological disorders. Normal menstruation is the function of Apanavayu, therefore painful menstruation is considered as apanavata dushti. According to ayurvedic view, arthava or menstruation should not be associated with any sort of discomforts as pain, burning sensation etc., there by with association like painful menstruation is not a normalcy and it needs medical attention. Niskramana karma of the Apana Vata means the proper retention and expulsion of its subjects in proper direction. Hetus for the Apana Vaigunyata acts on the basis of Samanyam Vrddhikaranam and are Aharaja, Viharaja, Vegadharana and Manas on the basis of Swasthacatuska.Function of Vyana Vayu : Vyana vata has contol over the muscles which brings about actions such as contraction, relaxation, extension, flexion etc. When deranged all its functions in the entire body gets affected. M×üixlÉSãWû cÉUÉã urÉÉlÉÉã UxÉxÉÇuÉWûlÉÉã±iÉÈ | xuÉãSÉxÉ×Mç xÉëÉuÉhɶÉÉÌmÉ mÉÇcÉkÉÉ cÉã¹rÉirÉÌmÉ | ¢Ñü¬¶É MÑçÂiÉã UÉãéãaÉÉlÉç mÉëÉrÉvÉÈ xÉuÉïSãWûaÉÉlÉç ||71                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 23  
  40. 40. Review of literature   Vyaana vaata has access all over the body, helps circulation of rasa, secretion of sweat and circulation of blood. It has control over the muscle which brings about 5 types of actions such as contraction, relaxation, extension, flexion, holding articles. Vyana regulates blood circulation, vasomotor system. It exercises an influence by its nervous mechanism over sweat and other secretions and conveys them to the respective destinations including endocrinal. It is stated that all the body functions are under the control of Vyana Vayu72. Prakrit functions of Yoni and Garbhashaya are also done by Vyana Vayu. These functions of Vyan Vayu are due to its Chalaguna, sukshma guna and laghu guna. which makes the Vyan Vayu mobile and suggests it to others. Based on anyonya avarana prakarana, in some conditions, Apana vata is innocent and vyana vata is agressive and vice versa. “uÉqrÉÉkqÉÉlÉÇ ESÉuÉiÉï aÉÑsqÉÉÌiÉï mÉËUMüÌiÉïMüÉÈ” |73 When apana vata is encircled by vyana , produces vomiting, distension,retrograde course of vata, gulma and cutting pain in abdomen. “AmÉÉlÉãlÉ AÉuÉ×iÉã urÉÉlÉã pÉuÉãiÉç ÌuÉhqÉ賈 UãiÉxÉÉÇ” | 74 çAÌiÉmÉëuÉ×iÉiÉã...............................................|| The vyana vata covered by apanavata, produces excessive urine and stools. These are the symptoms even mentioned in the modern perspective of Dysmenorrhoea. Usually uterine cramp is accompanied by one or more systemic symptoms that include ----Nausea and vomiting (89%), Fatigue (85%), Diarrhoea (60%), Low backache (60%),Headache (45%), Nervousness, dizziness and in some severe cases even syncope and collapse can be associated with Dysmenorrhoea.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 24  
  41. 41. Review of literature   Chart no :9 -SAMPRAPTHI OF DYSMENORRHOEA NIDANA  SEVANA                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 25  
  42. 42. Review of literature   Vata prakopaka karanas like over intake of ruksha, ksareeya substances, over indulgence of katu rasa, Athiyanavarohana etc can lead to dhatukshaya. Due to dhatukshaya , expulsive force for normal flow will be insufficient. This results in stagnation and increased expulsive efforts on the part of muscular wall. This may produce ischemia and pain. By the suppression of ‘Adhovatadhi vegas’75 the vata dosha moves in reverse direction i.e. upward instead of going downward. The aggravated vayu (apana vayu) moving in reverse direction fills yoni (uterus). This causes prapeedana of yoni, initially pushes the raja upwards then discharges vedanayukta Safhenila Srava with great difficulty. (Su, As, AH). The lady feels relief immediately following discharge of menstrual blood (Ch). Margavarodha like pin hole os, polyp, septate uterus, etc may lead to hypertonicity and hyperactivity of the muscle fibers resulting in dysmenorrhoea.Samprapti GhatakaDosha – Apana vata,Vyana vata. Dushya- artava,rasa,RakthaVyaktnasthana- garbhashaya.Srotas –artava vaha srotas.Strotodushti prakaara- Sanga, Vimarga gamana.Roga marga –abhyantara.Udbhava stana – Pakvashaya.Patyapatya:Pathyas: The diet employed is common to all types of yoni vyapadas. - Sura, Arista ,Asava ,lashuna Swarasa76 in early morning in avarana conditions. ksheera ,mamsayukta bhojana in Dhatukshayaja condtions. - Yavanna bhojana, abhayarista ,seedu ,taila, pippali churna, loha bhasma ,pathya churna along with madhu.77 - Bala taila, mishraka sneha ,sukumara sneha pana78 - Lashuna prayoga79Apathyas: Manda prayoga is contraindicated.80                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 26  
  43. 43. Review of literature  Updravas: 81, 82, 83The samanya updravas of yonivyapad are considered here. Infertility Pradhara Arsha Gulma Vatadi peedaSadhysadhyata84,85,86,87 According to Acharya Sushruta Yonivyapad occurs due to vitiation of single dosha issadhya.CHIKITSĀThe procedure beneficial to exterminate the causative factors and help in reinstating theDoshic equilibrium is Chikitsā. The Chikitsā done should be such as to eradicate successfullythe disease. Dysmenorrhoea is found as a symptom of various Yonivyapadas like Vātala,Udāvarta, Pariplutha,and vataja arthava dushti . So, the general principles of treatment givenby all Ācharyas can be drawn as follows – As Vāta is main causative factor of all Yonivyapadas, so it should be treated first. For Ārtava Shuddhi, after applying oleation and sudation, vamana and virechana, five Shodhana measures should be used, after this Uttarbasti should be given repeatedly88 . Achārya Charaka has explained the same but in mild form. Virechana is beneficial for Yoni Rogas and Ārtava Rogas. In menstrual disorders caused by Vāta Doshā, the specific treatment prescribed for suppressing that particular Doshā should be used. Recipes prescribed for Yoni Rogas and Uttarbasti etc. should also be used after giving due consideration to the vitiated Doshā.89 Unctuous, hot, sour and salty articles should be used for the relief frommenstrual disorders due to Vāta. Sweet, cold and astringent substances for the purification ofPitta and hot, dry and astringent for Kapha 90 For Avrita Apāna Vāyu, treatment should be Agnideepaka, Grahi,Vātanulomana and Pakvashaya Shuddhikara.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 27  
  44. 44. Review of literature   TABLE NO ;5- SAMANYA CHIKITSA OF YONIVYAPATH Shodhana chikitsa Mridu shodhan karma is employed for all types of yonivyapad.91 Mridu snehana, swedana as a preoperative procedure followed by shodhana therapy, samsarjana krama is then carried out as follow up procedure.92,93,94,95 Virecana is considered as best among all shodhana chikitsa.96,97,98,99,100 Shamana Chikitsa: Bhrihat Shatavari grita 101 Phala grita102 Triphaladi grita103 Maharasnadi Kwatha104 Jeerakadi modaka105,106 Nyagrodadi kwatha107 Various types of basti 108 Palasa niruha basti Shatavaryadi anuvasana basti109 Guduchyadi rasayana basti110 Baladi yamaka anuvasana basti111 Shatavaryadi rasayana basti112 Vishista Chikitsa113 Abhayanga Parisheka Pralepa Dharana Picchu Uttara basti by ( Vagbhata) These are adopted depending upon the requirement.                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 28  
  45. 45. Review of literature   TABLE NO : 6 ---VISHISTA CHIKITSA Udavarthini yonivyapath • Dashamoola ksheera basthi114 • Anuvasana and uttare basthi with traivruth sneha115 • Use of gramya, audaka ,anupa mamsa rasa116 • All other measures capable of suppressing vata Vataja yonivyapath117 • Guduchyadi taila pichu dharana • Guduchyadi taila or amla dravya yukta taila uttarabasti • Sukhoshna taila abhyanga & Himsra kalka dharana • Kashmaryadi ghrita, Shatavaryadi ghrita--- pana Pariplutha yonivyapath118 • Shallaki, jingini,jambu,dhava and panchavalkala sadhitha sneha pichu Vataja arthava dushti119 • Gritha medicated with bharangi, madhuka and badradaru • Priyangu and Tila kalka should be applied in vagina. • Niruha basthi is like nector                        “A Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”  Page 29  
  46. 46. Review of Literature  MODERN CONCEPT 120.121,122,123.124,125,126,127The word Dysmenorrhea is derived from Greek, means painful menstruation, is a symptomrather than a disease. Dysmenorrhea (Dys-difficult, men-month) is a condition in which themenstruation is painful. It is one of the common menstrual disorders and the type of painassociated with menstruation varies with the cause.While most women experience minor pain during menstruation, dysmenorrhoea is diagnosedwhen the pain is so severe as to limit normal activities, or require medication.Classification:1. Primary Dysmenorrhea2. Secondary Dysmenorrhea3. Membranous.Primary Dysmenorrhea:Cause: 1) Prostaglandins. 2) Vasopressin. 3) Pychosomatic factor 4) Deficient polarity. 5) Uterine hypoxia 6) Uterine hypoplasia. 7) Imbalance in Autonomic nervous control of uterine muscle. 8) Unequal development of Mullerian ducts. 9) Narrowing of the cervical canal. 10) Endometrial factors. 11) Inadequate liquefaction of menstrual clot 1) PROSTAGLANDINS Prostaglandins are C20 hydrocarbon lipids with hydrophilic and hydrophobic properties. C20 polyunsaturated fatty acids, such as archidonic acid are the biosynthetic precursors of several families of compounds that exert diverse biological actions, which include prostaglandins, the thromboxanes, certain hydroperoxy and hydroxy fatty acid derivatives and the leukotriens. There are 2 main sets of prostaglandins, the E&F series, each having 3 members, E1, E2, E3 and( F1,F2,F3 ) alfa .These are primary prostaglandins. In addition to the above 6 primary prostaglandins, there are several secondary ones.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 30 
  47. 47. Review of Literature  The cause of primary dysmenorrhoea is increased endometrial prostaglandin production. These compounds are increased in secretory as opposed to proliferative endometrium. The biosynthesis and metabolism of prostaglandins and thromboxane derived from arachidonic acid are depicted. The decline of progesterone levels in the late luteal phase triggers lytic enzymatic action, resulting in a release of phospholipids with the generation of arachidonic acid and activation of the cyclo oxygenase pathway. Prostaglandins released from the endometrium in the late luteal and early follicular phases of the menstrual cycle cause uterine muscles to contract, sloughing the superficial and intermediate layers of the endometrium. Excessive production of prostaglandins is thought to cause abnormal uterine activity and result in uterine hypoxia and ischemia . In fact, women with primary dysmenorrhea have been shown to have higher levels of prostaglandins in the endometrium compared with those who do not have dysmenorrhoea. In primary dysmenorrhoea, the greatest amount of Prostaglandins is released during the first 48 hours of menstrual flow, which coincides with the duration of the clinical symptoms. In addition to FSH,LH and Prolactin receptors , granulosa cells also contain specific receptor sites for prostaglandins (PGE2 and PGF2 alfa). It appears that Prostaglandin regulate human granulosa cell function and the possibility exists that such hormones are involved in abnormal ovarian states. The LH surge appears responsible for stimulating the local synthesis of prostaglandins. Prostaglandins increase markedly in the pre ovulatory follicle are highest at ovulation,there by suggesting a role in the ovulatory process. The mechanism through which prostaglandins may induce follicle rupture is unknown. Smooth muscle cells have been identified in the ovary & prostaglandin stimulates ovarian contractions located in the theca externa. Menstruation involves prostaglandin-induced arterial vasospasm and uterine contractions to raise intrauterine pressure and expel uterine contents.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 31 
  48. 48. Review of Literature Synthesis of prostaglandins When there is damage to the cell membrane, which is basically made up of phospholipids, the enzyme phospholipase A2, which is present in leukocytes and platelets, is activated by proinflammatory cytokines, such as interleukin . This enzyme leads to the degradation of phospholipids, resulting in production of arachidonic acid . This, when metabolized, forms leukotrienes through the action of the enzyme lipoxygenase, and prostaglandins, prostacyclins and thromboxanes, through the action of the cyclooxygenase enzyme (COX). COX is the first enzyme involved in producing prostaglandins from arachidonic acid. It converts, by oxygenation, the arachidonic acid into two unstable components: prostaglandin G2 and prostaglandin H2. These prostaglandins are later transformed by isomerases into prostacyclin, thromboxane A2, and prostaglandins D2, E2 and F2. Prostaglandin E2 is important because of its pyrogenic action and in increasing sensitivity to pain. Arachidonic acid also leads to production of leukotrienes, via lipoxygenase enzyme. Blocking of the cyclooxygenase enzyme results in a reduction in the formation of prostaglandins. The prostaglandins in fact are both physiologically important and potentially pathologically harmful. PGE2 is the principal eicosanoid formed from arachidonic acid. It is a crucial mediator of inflammatory changes. Chart no;10 –Synthesis of prostaglandins                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 32 
  49. 49. Review of Literature Gastrointestinal effects:The prostaglandins inhibit gastric secretion but stimulate pancreatic secretion and mucussecretion in the intestine and markedly increase intestinal motility. By stimulation ofintestinal adenylate cyclase, the prostaglandin can inhibit sodium entry into mucosal cellswith an apparent increase in chloride secretion. These effects, coupled with resultingincreased water secretion and intestinal motility are the basis of the diarrhoea produced by theprostaglandins, that frequently precedes the onset of menstruation.2) Vasopressin:There is increased vasopressin release during menstruation. Women who have primarydysmenorrhoea have higher level of circulating vasopressin. Vasopressin increasesprostaglandin synthesis and also increases myometrial contractility directly. It causes uterinehyperactivity and dysrthythmic contractions, which causes ischemia and hypoxia and leads topainful menstruation.3)Psychosomatic factor:Due to tension and anxiety during adolescence, lower abdominal pain threshold is oftenattributed as an aggravating factor in pain perception. This may explain in part, thedisappearance of pain with advancing age.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 33 
  50. 50. Review of Literature 4) Deficient polarity:There is some co-ordination between fundal contraction and cervical dilatation called polarityof uterus, which is probably controlled by a local nervous mechanism. The cervix fails todilate when the uterus contracts to expel the menstrual blood.5)Uterine hypoxia:Inadequate expulsive force.6)Uterine hypoplasia :128It is said that the myometrium contains an excessive amount of fibrous tissue, which disturbsthe normal contraction power.7)Imbalance in the autonomic nervous control of uterine muscle:There is over activity of the sympathetic Hyper tonicity of the circular fibers of the isthmusand internal os. The relief of pain following dilatation of the cervix or following vaginaldelivery may be explained by the damage of the adrenergic neurons which fails to regenerate.8)Unequal development of Mullerian ducts.:The pain is due to unequal muscular contractions in conditions like septate or bicornuateuterus.9)Narrowing of the cervical canal:Difficult for the menstrual blood to escape--- Strong uterine contractions.- pain.10)Endometrial factors129They are increased uterine ischemia and elevated PGF2 production at the time ofmenstruation that causes abnormal uterine activity. The basal tone is elevated (10mm hg)during contractions and are dysrhythmic with the increased and abnormal uterine actionblood flow is reduced giving rise to uterine ischemia and pain.11)Inadequate liquefication of menstrual clotIt was suggested that deficiency of thrombolysin causes failure of menstrual clots to becomeliquefied. So the endometrium is discharged into the cavity of uterus in the form of shreads or                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 34 
  51. 51. Review of Literature as membranes or even as casts as in membranous dysmenorrhoea. The pain is caused by theuterine distension either with menstrual blood or by large hemorrhages into the endometrium.Symptoms: The pain of primary dysmenorrhoea usually begins a few hours prior or just after the onset of a menstrual period and may last as long as 48-72 hrs. The pain is labor like with suprapubic cramping and may be accompanied by lumbosacral backache, pain radiating down the anterior thigh , nausea, vomiting ,diarrhea and rarely syncopal episodes. The pain of dysmenorrhoea is colicky in nature and unlike abdominal pain due to chemical or infectious peritonitis is improved with abdominal massage, counter pressure.Signs : On examination, the vital signs are normal. The suprapubic region may be tender to palpation. Bowel sounds are normal and there is no upper abdominal tenderness and no abdominal rebound tenderness. Bimanual examination at at the time of dysmenorrhoeic episode often reveals uterine tenderness , however , severe pain with movement of the cervix or palpation of the adnexal structures is absent. The pelvic organs are normal in primary dysmenorrhoea.Diagnosis: To diagnose primary dysmenorrhoea, it is necessary to rule out underlying pelvic pathology and confirm the cyclic nature of the pain. Pelvic examination should be performed to assess the size and tenderness of adnexal structures and nodularity or fibrosis of uterosacral ligaments or recto vaginal septum. Cervical studies for gonorrhoea and chlamydia and if relevant a complete blood count with ESR are helpful to rule out subacute salpingo-oophoritis. If no abnormalities are found, primary dysmenorrhoea tentatively can be diagnosed.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 35 
  52. 52. Review of Literature MANAGEMENT OF PRIMARY DYSMENORRHOEA Assurance Analgesics and anti spasmodic To empty the bowel Encourage normal activities FAILS • No contraindication for • Wanting contraception. prostaglandin synthetase • No contraindication of inhibitor. pills. • Patient wanting pregnancy.Prostaglandin synthetase inhibitors Oral contraceptive pills FAILS Laparoscopy To exclude pelvic pathology Dilatation of the cervix Recur Pre sacral neurectomyPatient assessment: In assessing the adolescent with Dysmenorrhea the physician need to know hermenstrual history and the timing of her cramps, pain and/or premenstrual symptoms as wellas her response to them. The key questions are these Is she missing school/college/work if so how many days? Does she miss other activities? Social events? Does she have nausea & vomiting, diarrhea or dizziness? What medication has she used to treat the symptoms?                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 36 
  53. 53. Review of Literature  What makes the pain better? Worse? What is the nature of the mother daughter interaction? Does or did her mother or sister have cramps? Is there family history of endometriosis? Young women whose cramps are disabling out of proportion to the apparent severity may have confounding factors contributing to their symptoms. Such as a reluctance to attend, school a history of physical or sexual abuse, or significant psychosocial problems. How long have periods been painful? Has there been any change? When does the pain occur? Is there pelvic pain at other times or dyspareunia? Is there flooding or passage of clots? How long do periods last and how often do they occur? Is there any intermenstrual bleeding or post-coital bleeding? Is there a history of infertility or pelvic inflammatory disease? What contraception is being used? SECONDARY DYSMENORRHOEA: Secondary dysmenorrhoea usually occurs years after the onset of menarche. However, by definition, secondary dysmenorrhoea does not reflect age of onset but is cyclic menstrual pain association with underlying pathology. The pain of secondary dysmenorrhoea often begins 1-2 weeks prior to menses and persists until a few days after the cessation of bleeding. The mechanisms underlying secondary dysmenorrhoea are diverse and not fully elucidated, although most involve either excess prostaglandin production or hypertonic uterine contractions secondary to cervical obstruction, intrauterine mass or a foreign body. Non steroidal anti inflammatory agents and oral contraceptives are less likely to provide pain relief in secondary dysmenorrhoea than in primary dysmenorrhoea.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 37 
  54. 54. Review of Literature Etiology – Adenomyosis. Uterine myoma. Intra-uterine contraceptive device. Large endometrial polyp. Endometriosis . Pelvic inflammatory disease. ADENOMYOSIS Dysmenorrhoea accompanied by adenomyosis (ingrowths of endometrium into the uterine musculature) often begins upto 1 week prior to menses and may not resolve until after the cessation of menses. Associated dyspareunia and metrorrhagia increase the probability of the diagnosis of adenomyosis. Whereas endometriosis is characterized by ectopic endometrium with in the peritoneal cavity, adenomyosis is defined as the presence of endometrial glands with in the myometrium, at least one high power field from the basis of the endometrium. Although occasionally noted in women in the younger reproductive years, the average age of symptomatic women is usually 40 years or older. Symptoms: Adenomyosis is often asymptomatic. Symptoms typically associated with adenomyosis include excessively heavy or prolonged menstrual bleeding and dysmenorrhoea, often beginning upto 1 week prior to the onset of a menstrual flow. Management: Relief of secondary dysmenorrhoea caused by adenomyosis can be assured after hysterectomy but less invasive approaches can be tried initially. Non steroidal anti inflammatory agents, oral contraceptives and menstrual suppression with progestins or continuous oral contraceptive pills have been found to be useful.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 38 
  55. 55. Review of Literature  ENDOMETRIOSIS Dysmenorrhoea varies in severity and duration and from cycle to cycle. Symptoms are often initially mild. Women with only a few scattered implants of endometriosis may have the most severe complaints of pelvic pain compared with those with dense adhesions and large amounts of active disease, including endometriomas, who may be totally asymptomatic, i.e. there is poor correlation between the extent of disease and the severity of the symptoms. Often the pain occurs before the onset of menstrual flow and worsens with flow. Peritoneal irritation and pain is caused through leaking implants and production of prostaglandins in the menstrual fluid. Prostaglandin (PGE and F2alfa) production from small petechial implants that are present in mild, low stage disease was found to be much greater than from the powder burn or black implants, which are more common in patients with higher stage endometriosis. Therefore, prostaglandin production may account for severe pain in some patients who have mild disease. Dysmenorrhoea is the result of pressure developing within the endometrial cavity which depends on the magnitude of the contractions, and the pressure within the cervical canal and the fallopian tube ostia. Endometriosis is detected in 15-40% of patients who undergo laparoscopy for the assessment of chronic pelvic pain. Endometriosis produces a low grade inflammatory reaction. The dysmenorrhoea may be especially suggestive of endometriosis if it begins after years of pain free menses. The dysmenorrhoea often starts before the onset of menstrual bleeding and continues throughout the menstrual period. The distribution of pain is variable but most often is bilateral.Treatment Medical treatments’ including oral contraceptives, danazol, progestogens, gonadotrophin-releasing hormone (GnRH) agonists and gestrinone, produce temporary relief of symptoms. No drug eradicates endometriosis or produces long-term cure, particularly in those women with deeply invasive disease. Discontinuation of medication usually results in a recurrence of pain within 12 months.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 39 
  56. 56. Review of Literature  FIBROID In fibroid there is increased surface area of endometrium and endometrial hyperplasia which may result in increased uterine contractions for the expulsion of menstrual blood. Again there is interference with normal uterine contractility due to the interposition of fibroid. Both these increases the myometrial contractility and dysrrythmia which results in severe dysmenorrhoea. It may also be due to pressure from the fibroid on venous drainage increasing blood flow. A disturbance of the balance of E and F prostaglandins noted within the menstrual effluent raises the question of whether a disturbance in the metabolism of prostaglandins is a contributory factor or possibly even an etiological factor. Large fibroids can present with pressure symptoms on adjacent organs. Treatment Prostaglandin synthetase inhibitor is used to relieve pain which is caused by degeneration of fibroid. PELVIC INFLAMMATORY DISEASE PID often followed a delayed or inadequately treated acute pelvic infection with low grade pyrexia and minor abdominal pain. Infection increases the production of inflammatory mediators which results in increased production of prostaglandins. Increased prostaglandins cause irregular contractions and dysrrythmia which may lead to hypoxia and pain.Presentation and diagnosis Pelvic pain may be associated with menstruation (secondary dysmenorrhoea), deep dyspareunia, or be present constantly with disruption of lifestyle. Heavier menstrual loss is seen which may be due to increased blood flow to the uterusassociated with infection or may result from interference with the function of the spiralarterioles which normally control volume of blood loss. Vaginal discharge is usually minimal in chronic cases but may be increased and offensive.TreatmentAnalgesia in increasing strengths may be necessary to control pain. Antidepressantmedication may potentiate the effect of analgesics, and short-wave diathermy may have arole. If a desire for fertility is not a consideration then removal of infected tissue may be theonly way to get pain relief. This may involve total abdominal hysterectomy with bilateral                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 40 
  57. 57. Review of Literature salpingo-oophorectomy as leaving the ovaries behind at hysterectomy results in continuingpain in a number of patients. IUCD Intra uterine contraceptive devices are known to provoke leucocytic infiltration whichcan activate the production of PG. Furthermore, capsular distension or accident to an ovariancyst, mechanical stimuli or tissue trauma may alter cell membrane stability causing PGproduction and pain.TABLE NO :7DIFFERENCE BETWEEN PRIMARY AND SECONDARY DYSMENORRHOEA PRIMARY SECONDARY Between 18-35 years >35 years 1-2 years after menarche, Many years after menarchy. confined to ovulatory cycles. Present in first day, get 3-5 days before the onset of menses reduced after 12-24 hours when and relieved at intiation of the flow is properly established. menstruation. Coliky and cramp like pain Dullache as a result of increasing related to dysrrythmic uterine tension in pelvic tissues. contraction and hypoxia Associated with nausea , Associated with menorrhagia, anorexia, vomiting, headache, whitish discharge, infertility, fatigue, diarrhea, low backache , dysparenia dysuria and frequency of micturation. Reveals abnormal lesions like P/A no abnormalities. myoma etc. P/V uterus and adnexa are Pathology reveled by P/V normal.MEMBRANOUS DYSMENORRHOEA This is one variety of primary dysmenorrhoea but is rare. There is shedding of big endometrial casts during period. It is probably due to the deficiency in the tryptic ferment normally secreted in the endometrium. It is not relieved even following pregnancy. This is said to run in family.                “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhea”   Page 41 
  58. 58. Pathways  of  Uterine  Pain   PATHWAYS OF UTERINE PAIN130,131,132,133Any stimulus that excites pain nerve endings in diffuse areas of the viscera can cause visceralpain. Such stimuli include ischemia of visceral tissue, chemical damage to the surface ofviscera, spasm of the smooth muscle of a hollow viscus, excess distention of hollow viscusand streching of connective tissue surrounding or within the viscus.Pain from the body of the uterus is conveyed by the sympathetic (T12 and L1) via thepresacral nerves, where as pain from the cervix uteri is conveyed by the parasympathetic viathe pelvic splanchnic nerves (S2, S3,S4).Therefore, in intractable spasmodic dysmenorrhoea section of the presacral nerves givesrelief from the symptoms.UTERUS:T12 and L1: Sympathetics are vasoconstrictors and stimulate the contraction of uterinemuscle. The afferent sympathetic fibers convey essentially visceral pain sensations. Thevisceral pain may be caused by the streching of solid viscera, distension of hollow viscera,irregular spasm of the smooth muscle or by the ischemia.Parasympathetic preganaglionic fibers leave the spinal cord at the level S2, S3, S4 andsynapse with ganglion cells in the sympathetic trunk or possibly in the hypogastric plexus.The postganglionic fibers supply the smooth muscle of uterus.Afferent pain fibers from the fundus and the body of the uterus ascend to the spinal cordthough the hypogastric plexus, entering it through the posterior roots of the 10,11,12 thoracicspinal nerves. Fibers from the cervix run in the pelvic splanchnic nerves and enter the spinalcord through the posterior roots of the 2nd ,3rd and 4th sacral nerves.Although it is recognized that the uterine muscle is largely under hormonal control,sympathetic innervations may cause uterine contraction and vasoconstriction, where asparasympathetic fibers have the opposite effect.Conditions, where pain sensation can arise from the viscera are:Ischemia: Causes visceral pain in the same way that it does in other tissues, presumablybecause of the formation of acidic metabolic end products or tissue degenerative productssuch as bradykinin, proteolytic enzymes or others that stimulate pain nerve endings.                        “Clinical study of Dashamoola Ksheera Basthi in Dysmenorrhoea”  Page 42