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Clinical evaluation of the effect of uttara basti in asrgdara w.s.r.to dysfunctional uterine bleeding, Deepashree, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE …

Clinical evaluation of the effect of uttara basti in asrgdara w.s.r.to dysfunctional uterine bleeding, Deepashree, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI, 2010-2011


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  • 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. 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. 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. 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. 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. 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.     Dedicated to My Beloved  Parents  SHRI. RAGHUNATH SHEETY & SMT. KANTHI R. SHETTY
  • 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. 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. Abstract ABSTRACT Title: “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to 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. 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. ABBREVIATIONS LIST OF ABBREVIATIONS• A.T After treatment• B.T Before treatment• Ch.sa 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 w.s.r.to dysfunctional uterine bleeding ”Page 1
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 2
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 3  
  • 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 w.s.r.to dysfunctional uterine bleeding ” Page 4
  • 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 w.s.r.to dysfunctional uterine bleeding ” Page 5
  • 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 w.s.r.to dysfunctional uterine bleeding ” Page 6
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 7
  • 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, Su.su.14/6) 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 w.s.r.to dysfunctional uterine bleeding ”Page 8
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 9
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 10
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 11
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 12
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 13
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 14
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 15
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 16
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 17
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 18
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 19
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 20 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 21 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 22 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 23 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 24 
  • 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 Ass.td 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 w.s.r.to dysfunctional uterine bleeding ”Page 25 
  • 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 Ass.td 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 w.s.r.to dysfunctional uterine bleeding ”Page 26 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 27 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 28 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 29 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 30 
  • 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 (Ca.si.3/A.H.ka.4) Kushadi Asthapana (Su.ci.37) Lodradi Asthapana (su.ci.38 ) Mustadi yapana basthi (A.sa.ka.5) For Anuvasana basthi: Madhukoshikadi (Su.ci.37 ) Shatapushpa taila (Ka.sa.ka.24,25) 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 (Ca.ci.30/90) 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 w.s.r.to dysfunctional uterine bleeding ”Page 31 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 32 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 33 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 34 
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 35
  • 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 w.s.r.to dysfunctional uterine bleeding ”Page 36
  • 57. Disease review                                                                                                        CONCEPTUAL STUDY  2. Irregular ripening of Endometrium90: In this there is poor formation & inadequate function of corpus luteum. Endometrium receives inadequate support of progesterone & break through bleeding occurs before the actual bleeding occurs in a form of spotting & it is brownish discharge. Corpus luteum insufficiency Inadequate secretion progesterone & estrogen Inadequate support to endometrial growth BleedingAnovulatory DUB91: It is the commonest cause of DUB. It is usually excessive. In the absence of growthlimiting progesterone due to an ovulation the endometrial growth is under the influence ofestrogen throughout the cycle. There is inadequate structural stromal support & the endometriumremains fragile.Two varieties are found: 1. Puberty menorrhagia92: This is a threshold bleeding of adolescence caused by excessive or unopposed estrogen & absence of progesterone in the anovulatory cycle. Anovulation Absence of progesterone & unopposed estrogen Excessive proliferation of endometrium without any secretory changes Menorrhagia 2. Metropathy haemorrhagica93: This type of DUB is usually met in premenopausal women. The basic pathology may lie at the level of the ovaries or due to disturbance of Rhythmic gonadotrophin secretion. There is slow & steady increase in estrogen levels with no inhibiting feed back“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 37
  • 58. Disease review                                                                                                        CONCEPTUAL STUDY  effect of FSH. As there is no ovulation, the endometrium is under the effect of estrogen & there is absence of growth limiting progesterone for prolonged period. Persistent ovarian follicle No corpus luteum Continued proliferation Estrogen level falls Menstruation. Table 13: Anovulatory DUB Insufficient follicular development Persistant ovarian follicle Inadequate production of E & P Adequate production of E, but no ovulation, corpus luteum fails to develop. Inadequate proliferation of No progesterone reaction endometrium without any secretory changes. Continuous unopposed Estrogen secretion. Atropic Endometrium Continuous proliferation of Endometrium. Benign hyperplasia/ adenomatous hyperplasia Assosiated with large dilated sub- endothelial vennules. When endometrium out-grows, its blood supply ↑ or there is ↓ in E secretion Menorrhagia Menstruation.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 38
  • 59. Disease review                                                                                                        CONCEPTUAL STUDY Table 14: Endometrial abnormalities associated endometrial histology & typical bleedingpatterns in DUB. TYPE Endocrine abnormality & E. Hystology Typical bleeding pattern Normal Short cycle ---short proliferative phase, Polymenorrhoea, bleeding normal endometrium. Menorrhagia Long cycle --- long proliferative phase, Oligomenorrhoea,m normal endometrium. enorrhagia Corpus Insuffficiency --- short luteal phase, Menstrual spotting , luteum irregular or deficient secretory Menorrhagia abnormality endometrium. Prolonged Irregular Endometrial shedding Menstruation Anovulatory Insufficient follicles --- short cycle, Polymenorrhagia inadequate proliferative or Atropic endometrim Oligomenorrhoea, Persistant follicles/ PCOD --- prolonged Metropathica cycles, proliferative or hyperplastic Haemorrhagica endometrium.    INVESTIGATIONS: 1. Blood investigation94: Hb%, platelet, BT,CT, PT, TSH, T3, T4 2. Endometrial biopsy 95: It is most commonly used diagnostic test for DUB. It provides an adequate endometrial sample in 90-100% of cases, but may fail to detect polyps & leiomyomas.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 39
  • 60. Disease review                                                                                                        CONCEPTUAL STUDY  3. Dilatation & curettage96: It allows more sampling of the uterine cavity & has the advantage of being both diagnostic & therapeutic. It indicated in DUB, To exclude the organic lesions in the endometrium To determine the functional state of the endometrium To have incidental therapeutic gain. 4. Ultrasound97: it can be used to examine the status of the endometrium, endometrial Hyperplasia, endometrial polyps & uterine fibroids. TVS is also very sensitive. 98 5. Hysteroscopy : it is done for better evaluation of endometrial lesion & to take biopsy from the offending site under direct vision. 6. Laparoscopy99: To exclude unsuspected pelvic pathology, such as endometriosis, PID & ovarian tumour. 7. Historiography: To exclude fibroid, polyp or congenital mal-formation of uterus. Because of reduced specificity HSG is mostly replaced by hysteroscopy.DIFFERENTIAL DIAGNOSIS OF DUB: Harmonal: PCOD, Thyroid dysfunction, Harmonal contraception, Levonorgesterol implant Pregnancy: Threatened/ spontaneous Abortion, Ectopic pregnancy, Post abortal endometritis Local pathology: STD, Polyp, trauma, malignancy Bleeding Diathesis: Platelet disorder, Thrombocytopenia, Vit.K deficiency“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 40
  • 61. Disease review                                                                                                        CONCEPTUAL STUDY  MANAGEMENT100: Exclusion of organic disease of the genital tract. Diagnosis of underlying dysfunction if possible. Assessment of the nature & severity of DUB and the age, parity & wishes to the patient with regard to contraception, future pregnancies & surgery. Management of DUB can be studied under 3 headings101: Reassurance Medical SurgicalReassurance: Women will be satisfied with the knowledge that there is no underlying cause for their menorrhagia. Non anaemic women with primary menorrhagia should understand that Treatment offerred are symptomatic control.Medical102: Hormonal : • Progesterone • Combined OCPs • GnRH analogues, etc Nonhormonal: • Prostaglandin synthetase inhibitors, • Anti fibrinolytic agent“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 41
  • 62. Disease review                                                                                                        CONCEPTUAL STUDY  Table 15: Medical treatment of DUB DRUG Mode of action Success Side effect Advantage rate NSAID Decrease prostaglandin 20-30% Headache, GIT Taken only during level by cyclic oxigenase disturbance menses Mefenamic acid Anti Prevent activation of 50% GIT disturbance, -do- fibrinolytic plasminogen intra cranial drugs thrombosi s Progestero Maturation of 15% Wt. gain, nausea, Appropiate ne endometrium, healing of bloating odema, treatment only for superficial breaks, headache, Anovulatory DUB increased structural depression stability & cessation of bleeding Combined Atrophy of the 53% Wt. gain, Contraception OCPs endometrium bec. The abdominal chronic oestrogen & discomforts, progesterone exposure break through suppress pituitary bleeding, CV gonadotrophins & inhibit risk endogenous steroidogenesis Levenegest Local release of 82-96% Difficulty during Beneficial effect in erol IU progesterone – insertion, intial dysmenorrhoea, device endometrial atrophy irregular endometrial bleeding, hyperplasia, PMS, prolonged contraception amenorrhoea, progesterone side effects Danazol Inhibits binding of sex 60% Adrogenic side Carry over effect“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 42
  • 63. Disease review                                                                                                        CONCEPTUAL STUDY  steroid to androgen & effects till 4m of cessation progesterone receptors --- of therapy Endometrial atrophy GnRH Inhibits FSH & LH 85-90% Post menopausal Carry over effect analogue amenorrhoea within 4-6 side effects, till 2m of cessation weeks costly of therapy Surgical103, 104: D & C --- It is done more for diagnostic than therapeutic. It is the urgent one, if the bleeding is acyclic & where endometrial biopsy is suspected. Endometrial ablation: is done when child bearing is over. The main complication being producing the therapeutic Asherman’s syndrome. Hysteroscopic : Laser ablation, Electro-surgery Non-hysteroscopic: Thermal ballon, Cryosurgery etc • Hysterectomy: is done for women at peri-menopausal age. It is justified where conservative treatment fails & blood loss impairs general health of the patient. Benefits: Complete cure of the condition, avoidance of continued long term medical therapy & removal of any missed pathology including unsuspected malignancy. The overall mortality rate: 1 & 2/ 1000 Morbidity as high as 59% Febrile illness in 15 – 32% Requires blood transfusion in 8-15% Hysterectomy has been associated with psychosexual dysfunction , early onset of ovarian failure & increased risk of CV disease.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 43
  • 64. Uttara basti CONCEPTUAL STUDY Review of Uttara bastiUttara basti is one of the best treatment modalities adopted in Stree roga. Uttara basti isexplained in the chikitsa sootra of almost all the yoni vyapaths & Arthava vyapaths. Basti isnothing but administration of medicaments through the anal route. Where as the uttara basti isgiven through uttara marga. Here uttara marga refers to the varinal route. The word Uttara is derived from,        “iÉÑ msÉuÉlÉiÉUlÉrÉÉå:” - EmÉrÉÑïSÏcrÉ ´Éå¹wuÉmrÉѨÉU: xrÉÉiÉç || (AqÉU MüÉåzÉ)  Upari - above, Udeechya - North direction, Shreshta-Superior The word Basti is derived from the word,  “Vasa nivase” or “Vasa Acchadane” - to stay or to cover.Definitions of Uttara basti: 1. E¨ÉU qÉÉaÉï SÏrÉqÉÉlÉiÉrÉÉ, ÌMÇüuÉÉ ´Éå¸ aÉÑhÉiÉrÉÉ E¨ÉU oÉÎxiÉ:| 105 2. ÌlÉÂWûÉSÒ¨ÉUÉæ rÉxqÉÉSÒ¨ÉU xÉÇ¥ÉMü: || 106  By the definitions, it is evident that Uttara basti is administration of medicaments after niruha basti & also it is given either through urethral passage or “Apathyapathaa”. Here Apathyapatha refers to intra-vaginal & intra-uterine. 3. E¨ÉUoÉÎxiÉUÌmÉ xlÉåWûÉålÉÑuÉÉxÉlÉuÉcNûÉåkÉlÉÇ ÌlÉÂWûuÉSÌmÉ MåüÍcÉSÉWÒû: .....| 107 Depending on the action of the drugs used, Vagbhata considered Uttara basti as Shodhana like Asthapana & Snehana like Anuvasana.Basti Putaka: Is the container in which basti dravya is filled & administered. Previously it was made up of bladder of Ourabhra, Shoukara, Aja or galacharma of birds108.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 44
  • 65. Uttara basti CONCEPTUAL STUDYPushpa netra:109 Is the nozzle used for the administration of Uttara basti. In olden days the material used for preparation of this was of Hema or Roupya. It must be smooth & shape must be tapering like Gopuccha. Its tip should be the size of the stalk of Ashvahana or Jatipushpa. In stree, the length should be 10 angula according to caraka110 & vagbhata111, 14 angula according to Sushruta112 It should have a width to allow a Mudga to pass through.Karnika: Are the rings to be fitted to Netra, so as to tie the Basti putaka. According to Caraka, there should be 2 Karnikas 113 - one at the base & one at 6 angula distance from the tip. Sushruta 114 has told to keep the Karnikas at 4 angula distance.Insertion115: • In stree, while inserting the Pushpa netra it must be 4 angula for Garbhashaya, 2 angula for Mootrashaya. But in young girls it should not exceed 1 angula for Mootrashaya.Time of administration: • In stree, Rutu kala120 is appropiate time for administration of the Uttara basti.Because yoni will remains open during this period & easily absorbs the sneha dravya (Sukham sneham tadaad atte). • But according to Astanga sangraha in emergencies (atyayika avastha) the procedure can be carried out even other than the Rutu kala121.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 45
  • 66. Uttara basti CONCEPTUAL STUDYBasti dravya pramana:- 116, 117, 118 Table: 16 Charaka Sushruta Vagbhata Sharangadara/Vangasena Sneha ½ Pala 1 Prasruta 1 Prakuncha(stree) 1 pala (yoni) pramana Shodhana: 1 Shukti (bala) 2 karsha (mootramarga) 2Prasruta Kwatha - Stree- 2 Prasruta - - pramana Kanya- 1 Prasruta (mootra marga)Indication119: Table: 17 Basti vikara Asrgdara Yoni bramsha Mootrasanga Yoni shoola Bindu bindu mootrasrava Yoni vyapathPROCEDURE: Poorva karma: As poorva karma to Uttara basti it is said to give 2 or 3 Asthapana basthis for Shodhana122. Acc. to Sushruta123 & Vangasena124, after proper snehana, swedana & Shodhana of body, the pt. should be given yavagoo with grita & ksheera as according to the strength.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 46
  • 67. Uttara basti CONCEPTUAL STUDY Pradhana karma: 125 Uttara basti is administered to a woman when she is lying in the bed on her back with thighs lifted up & flexed. The nozzle should be inserted comfortably in the direction of her spinal column. 2 , 3 & 4 therapies should be administered. Its done for 3 nights by gradually increasing the dosage of sneha. After a gap of 3 days, it is to be repeated. Pashchath karma 126: The diet & regimen to be followed as Anuvasana basthi127 like drava, ushna & laghu. ie the patient should be given payasa, yoosha or mamsarasa. One should avoid Astamahadoshakara bhavas. Rest for sometime is advisable.Uttara basti, thus has given prime importance in treatment of almost all gynaecological disorders.Due to the apt site of its administration, acharyas have highlighted the efficacy of Uttara bastiover all other drugs administered orally, in the management of gynaecological disorders.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 47
  • 68. Vasti CONCEPTUAL STUDY Review of VastiDerivation of the word Vasti:Basthi has been used as the best therapy since time immemorial, to provide different benefits.Texts of Ayurveda talk high about basthi, considering it as Ardha as well as Poorna chikitsaa &after screening various texts & dictionaries, it is observed that word “Basthi” has been defined in3 ways; 1. As a karma & therapy 2. As an apparatus or material or instrument used for the administration of medicine. 3. Anatomically as an organ proper.Etiomological derivation: “Vasti” word is derived from “Vas dhatu” by adding “Ticch prathyaya” i.e Vasi --- Vas + ticch (vachaspatya) 128Derivation suggesting it as “Karma” or “Therapy” a) “Vas nivase” ---- To reside or to lie 129 “Vas Acchadane” ----- To cover (Vachaspathya) b)  uÉÉiÉÉåsoÉhÉåwÉÑ SÉåwÉåwÉÑ uÉÉiÉå uÉÉ uÉÎxiÉËUwrÉiÉå” | (A.WØû.xÉÔ.19/1)  i.e Vasti therapy is desirable in dosholbana condition & vata vitiated condition106 c) lÉÉÍpÉmÉëSåwÉå MüÌOûmÉÉμÉïMÑüͤÉaÉiuÉÉ zÉM×üiÉç SÉåwÉcÉrÉ ÌuÉsÉÉåŽ xÉxlÉåWû MüÉrÉÇ xÉÑmÉÑUÏwÉ SÉåwÉÈ xÉqrÉMçü xÉÑZÉælÉåÌiÉ cÉ rÉÈ xÉ uÉÎxiÉ || (cÉ.ÍxÉ.1/40)  i.e The therapy which while moving in the nabhi pradesha, kati, paarshva & kukshi, does the churning of shakrut & morbid doshas located there & then evacuate them in proper manner & provides nourishment to the body is called as Vasthi130. “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 48 
  • 69. Vasti CONCEPTUAL STUDYVasti Bheda: 1. According to Adhistana: Pakwashayagata, Garbhashayagata, Mootrashayagata,Vranagata 2. According to Dravya bheda: Niruha basti: Kashaya pradhana basti Anuvasana basti: Sneha basti, Matrabasti, Anuvasana basti.                                                         3. Acoording to Karma: Shodhana basti,Shamana basti, Sneha basti, Brahmana basti 4. According to Basti sankya: Karma basti: 30 bastis--- A+ 12N &12A alternatively + 5A Kala basti: 16 bastis--- A+ 6N & 6A alternatively + 3A Yoga basti: 8 bastis— A+N+A+N+A+N+A+AEtymiological Derivations ofNiruha vasti: 1. zÉUÏUUÉåWûhÉÉSÉåwÉÉÌlÉWïûUhÉÉSè AÍcÉlirÉuÉÏrÉïmÉëpÉÉuÉiÉrÉÉ cÉÉÎxiɳÉÔWûrÉxÉqpÉuÉͳÉÂWû CÌiÉ: | (A.xÉ.xÉÔ.28/7)  2. ..............SÉåwÉÌlÉWïûUhÉÉcNûUÏU lÉÏUÉåWûhÉÉ²É ÌlÉÂWû .......... | (xÉÑ.ÍcÉ.35/18)  Above etymology reveals that the vasti which by virtue of its achintya veerya& prabhava results in “Dosha nirharana” (expelling the doshas out of the body) & Shareera rohana (growth ie Dhatu poshana) is called as niruha basti. Its benefits are beyond explanation. In this study the Dashamoola niruha basti is used.Anuvasana vasti:1.   AlÉÑuÉÉxÉlÉ — lÉ.AlÉÑ+uÉÉxÉ----- xÉÉæUpÉåwrÉÑiÉ | AlÉÑuÉÉxÉÌiÉ AlÉÑuÉÉxÉlÉÇ SÏrÉiÉå uÉÉ || (Vachaspatyam)2.  AÌlÉuÉxɳÉÌmÉ lÉ SÒwrÉirÉlÉÑÌSuÉxÉÇ uÉÉ SÏrÉiÉ CirÉlÉÑuÉÉxÉlÉ.... | (xÉÑ.ÍcÉ.35/18) Which means the basti which can be given daily is called as Anuvasana.                                                            3.  ÌlÉzÉÉlÉÑuÉÉxÉlÉÉiÉç xlÉåWûÉåÅluÉÉxÉlɶÉÉlÉÑuÉÉxÉlÉ: ........ | (uÉ…ûxÉålÉ/uÉÎxiÉ MüqÉÉïÍkÉMüÉU:/7-8)“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 49 
  • 70. Vasti CONCEPTUAL STUDY It is named Anuvasana because the sneha (oil or grita) used in it anoints the body byresiding for whole night. In the present study bala taila 50ml was used for Anuvasana basti. According to Vagbhata, use of 2 or 3 Asthapana bastis followed by uttarabasti isbeneficial in case of Asrgdara. Here in this study instead of Asthapana basti only, a course ofYoga basti is given to Group III patients before the Uttara basti, ie in the following pattern. In the format of yoga Vasti ( 8 Vastis) 1. Anuvasana Vasti – 5 with Bala taila 2. Niruha Vasti – 3 wiyh Dashamoola kashaya Table No :18 Vasti A A N A N A N A Days 1 2 3 3 4 4 5 5 Evening Evening Morning Evening Morning Evening Morning EveningMethod of Basti karmaANUVASANA BASTI: Bala tailam ----- 50 ml Poorva karma: the patient was instructed to attened natural urges & was asked to take laghu bhojana. Pradhana karma: 50ml of Bala taila heated to luke warm was taken in basti syringe to which rubber catheter No.11 was connected. The patient was asked to lie down in the left lateral position with the left knee extended & right leg flexed resting on the left knee. The head was supported by left hand of the patient. The anal region & the inserting tip of the rubber catheter was lubricated with taila. The catheter was introduced in to the rectum gradually till small quantity of it remains inside the syringe to prevent the entry of air in to the rectum & colon. While introducing the taila , patient was asked to take deep breath“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 50 
  • 71. Vasti CONCEPTUAL STUDY and to be relaxed. The catheter was removed and the patient was asked to lie in same position. Pashchat karma: Patient’s buttocks were gently patted & her palms & soles are rubbed. Patient was given a pillow under her kati pradesha & was asked to remain in the supine position for about 10minutes. After an half an hour patient was asked to take luke warm bath & to avoid Astamahadoshakara bhavas. Anuvasans bastis were given as shown in the table, ie 1st & 2nd day morning, 3rd, 4th & 5th day evening after food. ie totally of 5 Anuvasanas.NIRUHA BASTI:Quantity : Madhyama matra according to sarangadhara i.e 1 prasta = 16 pala = 768 ml Madhu – 192 gms Lavana – 12 gms Sneha – 192 ml (Bala taila ) Kalka – 48 gms ( Shatapushpa) Kwatha – 384 ml (Dashamoola kashaya )Ingradients of Niruha basti: Bala taila, Dashamooola kashaya, Shatapushpa, lavana, madhu a) Kalka dravya: Shatapushpa choorna 48gms mixed with warm water & made in to a kalka. b) Sneha dravya: Bala taila was taken in 192ml quantity. c) Kwatha dravya: Freshly prepared Dashamoola kashaya is taken in 384ml in quantity. d) Madhu: Marketed by SDM pharm was taken in 192ml for basti sammilana. e) Basti yantra: Enema container was used from the panchakarma section of SDM hospital. Poorva karma: Method of preparation of Niruha basti dravya:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 51 
  • 72. Vasti CONCEPTUAL STUDY The niruha basti dravya was prepared freshly at the time of administration. The madyama matra description of Sharangadara was followed . ie the total quantity of 16 palas ie about 768ml approximately. The drugs were added as described in the classics ie madhu 192g was taken & added with 12g of Saindava lavana. They were mixed well to which 192ml of Bala taila was added & mardhana was continued. To this 48g of Shatapushpa kalka was added & mixed. Lastly the freshly prepared Dashamoola kashaya in 384ml quantity was added & stirred well. The contents were filtered & taken in plastic enema container in luke warm condition. The patient in Rista kosta ie in empty stomach was asked to attend natural urges. Pradhana karma: The patient was asked to lie in the left lateral position as explained earlier. The anal region & catheter being lubricated with taila & the patient was asked to breath deeply, the  basti dravya was administered through the enema can & the catheter. The mixture being luke warm & kept stirring during administration.  Pashchath karma: Similar to that of Anuvasana basti. Prathyagamana of basti dravya was observed within 10 minutes. Snana & bhojana were advised after evacuation of the basti dravya. Niruha basti was given on 3rd, 4th & 5th day early morning in empty stomach. Yoga basti Sneha Dravya: Bala Taila (Ra.Ni.Tai) Bala taila is prepared as the reference explained in Raja nighantu tailadhikara.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 52 
  • 73. Vasti CONCEPTUAL STUDY Table No : 19 Drav Family B.N Rasa Guna Veer Vipak Karma Chl. Costituents ya ya a Bala Malva Sida Madhura Laghu Shee Madh Vatapittahara, Eqhedrine, ceae cordifoli snigdha ta ura balya, Rakta steroid, phyto a picchila pittahara(D.ni) estrol, potassium nitrate Tila Pedali Sesamu Madhura Guru Ush Madh Vataghna, Glycolipids, aceae m anurasaK snigdha na ura balya phospholipids, indicum ashaya (C.soo,27) sesamolin, tikta sesamol Yoga basti kalka dravya: Shatapushpa Table No : 20 Dravya Family B.N Rasa Guna Veer Vipaka Karma Ch.l ya constituent Shata Anthum Apia Katu Laghu Ush Katu Vata kapha Β-sitosterol, β- sowa ceae tikta teekshna na shamaka, caryophyllene, pushpa deepana carvone“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 53 
  • 74. Vasti CONCEPTUAL STUDY “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 54 
  • 75. Vasti CONCEPTUAL STUDY   Table No: 21 Yoga basti Kashaya dravya: Dashamoola kashaya (pÉæ.U)Dasha Family B.N Rasa Guna Veerya Vipaka Karma Chl.ConstmoolaAgnimant Verbenace Premma Tikta,katu, Ruksha, ushna Katu Vatakapha hara, β- sitosterol, cerolic acidha ae Mucronata Kashaya, laghu deepana madhuraBilva Rutaceae Aegele Kashaya, tikta Laghu, Ushna Katu Kaphavatahara Xanthotoxin, marmin, Marmelos ruksha umbelliferoneShonaka Bignoniac Oroxylum Madhura, Laghu, Ushna Katu Kapha vatahara β- sitosterol, eae indicum tikta, kashaya ruksha tetulinbaicaleinPatala Bignoniac Stereospermu Tikta, kashaya Laghu, Ushna Katu Kaphavatahara Crystalline bitter substance eae m suaveolens rukshaGambhari Verbenace Gmeliana Tikta,kashaya, guru ushna Katu Kapha vatahara Β- sitosterol, butyric acid a arborea madhura premnazolearboroneKantakari Solanacea S. surattense Tikta, katu Laghu, Ushna Katu Vata pitta hara Β- carotene, β- e teekshna solamarginecarpesterolBrahati Solanacea S. Indicum Katu, tikta Laghu, Ushna Katu Vata pittahara Β- sitosterol, Ascorbic acid, e teekshna alaninemonnerinGokshura Zygophlll Tribulus Madhura Guru, Sheeta Madhura Vata pittahara Β- sitosterol, campesterol, acee terrestris snigdha stigmasterolPrshnapar Legumino Desmodium Madhura, tikta Laghu, Ushna Madhura Vata pitta hara Flavonoidsni sae Gangeticum snigdhaShalaparn Legumino Uraria picta Madhura, tikta Guru, Ushna Madhura Vata pitta hara Dimethyl tryptamine,i sae snigdha caudicine, desmodin  “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 54 
  • 76. Drugs used in Anuvasana basti & Niruha bastiPicture No.1 : Drugs in Bala taila, Shatapushpa kalka & Dashamoola kashaya Bala Tila Tila taila ShatapushpaAgnimantha Bilva Shyonaka 55
  • 77. Drugs used in Anuvasana basti & Niruha basti Patala Gambhari KantakariBrahati Gokshura Shalaparni Prshnaparni 56
  • 78. Pictures No. 3: Pushyanuga choorna Pata Jambu AmraPashanabheda Ambashtas (Pata) Shalmali Samanga(Manjista) Vatsaka (kutaja) Bahleeka (Hingu) 69
  • 79. Ativisha Bilva Musta Lodra Katvanga (Aralu) Maricha Mrdveeka Rakta chandana Shunti 70
  • 80. Katphala Dhataki Anantha Madhuka Arjuna GairikaRasasnjana Madhu Tandulodaka 71
  • 81. Drug Review CONCEPTUAL STUDY                                                                                       Table No.22 : Description of KashmariAuthor Rasa Guna Veerya Vipaka Doshaghna Karma Roga Tikta, Guru Ushna Katu Vatapittahar Deepana, Pachana, Brama,shotha,Shoola, Arsha, Visha,Bhava Kashaya, a Anulomana, daha, jwara,Prakasha Madhura medhya, bhedana Fruit: Snighdh Sheeta Madhur Rakta Bramhana, Vrshya, Vatapitta, Trusha, Rakta kshaya, Kashayamla a a pittahara Keshya, Rasayana Mootra vibandha,Rakta pitta, kshayaCharaka Tikta Guru Ushna Katu Pitta Rakta sangrahaka Rakta pitta(C.Su.25) Phala:Sh prashamanaSushruta Phala:Madh Guru Sheeta - - Keshya, Rasayana Raktapitta, Vatarakta,(S.Su.45, ura Medhya, Hrudhya Mootravibandha46) Taila:Madh - - - Kaphapitta Kapha pittahara - ura kashaya prashamanaDhanvantar Tikta Guru - - Tridhoshaha - Raktapitta, Shrama, Daha, Arti,i Nighantu ra jwara, trushna, vishaShodhala Phala: Guru, Sheeta Madhur Vata hara Brahmana. Kapha Raktapitta, Krimi, shopha, meha,Ni. Madhura Snigdha a shukrakara, daha, kshata, kshaya, ShakrutKaiyadeva Madhura, Guru Ushna - - Deepana, Pachana, brhama, shosha, trushna, ama shoola,Ni tikta, Medhya, bhedani visha, daha , jwara Pushpa: Grahi Sheeta Madhur Kaphapittah Rakta sangrahaka Pittasra, Asrgdara Madhura a ara Phala: Snighda, Sheeta Madhur Hrudhya, Piita rakta, Mootra vibandha, trusha, Kashayamla guru a Rasayana, daha, , kshata, kshayaRaja Ni. Katu, tikta Guru Ushna Kapha hara - Tridhoshaja Visha, Shopha, daha,arti, jwara, trushna, Rakta     “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 59   
  • 82. Drugs CONCEPTUAL STUDY                                                                                             Table No. 23: Description of KutajaAuthor Rasa Guna Veerya Vipaka Karma Doshaghnata RogaghnaCharaka Twak:Tikta Laghu Sheeta Katu Rakta stambaka, Kapha Raktatisara, Raktarsha,C.su.25 kashaya Ruksha sangrahaka, Grahi Raktasrava, visarpaSushruta Tikta,kasha Laghu ruksha Sheeta Katu - - Raktatisara,, Arshas, Kushta yaA. sangraha Tikta Laghu ruksha Sheeta Katu - - Raktapitta, yoni dourgandhaharaA. Hrudhaya Tikta Laghu ruksha Sheeta Katu - - Shonita shoola, RaktatisaraBhava Pra. Beeja:Katu Laghu,ruksha Sheeta Katu Sangrahideepana Tridosha Raktapitta, Raktarsha, Pradara,Sharangadh - - - - - - Rakta pitta, Raktarsha,ara Shoolahara, RajodoshaharaChakradatta - - - - - - Raktatisara, AsrgdaraDhanvantari Katu tikta Ruksha Sheeta Kusta, atisara, piitasraNi. Phala: Katu Ushna Deepana Tridhosha Raktarsha, shoola, atisaraShodhala N. - - Sheeta - - - Arsha, atisara, raktapitta,Kaiyadeva Kashaya Ruksha Sheeta Katu Deepana Kapha pitta Pittasra, trushna, arsha, atisara,Ni Pushpa:Tik Laghu Sheeta - Deepana Kapha pitta Kushta, atisara ta, Kashaya Phala: tikta - Ushna Katu Deepana, pachana Tridosha Kushta, atisara, visarpa, shoola,Raja Ni Katu, tikta, - Ushna - - - Atisara, twagdosha, arshas “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 61  
  • 83. Dugs CONCEPTUAL STUDY GRITHA • Obtained from Mammalia of Animal kingdom. • Contains vit. A, D, E & K. vitamin A and E are anti oxidants and are helpful in preventing oxidative injury to the body.vitamin A keeps epithelial tissue of the body intact. • Its digestability or rate of absorption is 96%, which is the highest of all oils & fats. Digestion, absorption and delivery to a target organ is crucial in obtaining the maximum benefit from any formulation. This is facilitated by ghee. Since active ingredients are mixed with ghee, they are easily digested and absorbed. Lipophilic action of ghee facilitates transportation to a target organ and final delivery inside the cell, because cell membrane also contains lipid. This lipophilic nature of ghee facilitates the entry of the formulation in to the cell and its delivery to the mitochondria, microsome and nuclear membrane. • Gritha alleviates th Pitta & vata.It is beneficial for rasa dhatu, shukra dhatu & ojas. It is sheeta veerya in property & is Mrdukaram, swara varna pradhanam. • Gritha is yogavahi in nature. ie. gritha when treated or impregnated with other drugs has a specific property of accepting the attributes of those drugs without loosing its own characters. “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 62 
  • 84. Pictures No. 2: Drugs in Kashmarya Kutaja Gritha Kashmari Kutaja Gritha 63
  • 85. Drugs CONCEPTUAL STUDY  KUTAJA 135, 136,137 euÉUÉÌiÉxÉÉU U£üÉzÉÉåï M×üÍqÉ ÌuÉxÉmÉï MÑü¹lÉÑiÉç || (pÉÉ.mÉë)“Kutaja twak shleshma raktasangrahikopashoshaananm”|| (C.Su.25/40)B.N : Holarrhena AntidysentricaFamily: ApocynaceaeSynonym: Girimallika, vatsaka, kalinga, indrayava, indravrukshaSwaroopa: Small tree, 30-40 ft in ht., seeds – yavasadrasha, grayish ½ inch long, 25-30 seeds in1 fruit. Flowering from April to July and fruits from August to OctoberDestribution: Common in tropical parts of parts of India and in Sub-Himalayan tract. RasaPrayojya Anga: Twak, BeejaChemical constituents: Alkaloids – Conessine, fats, tannins 1.4%, resinPharmacological action: Anti bacterial, Anti spasmodic activity, Immuno-modulation activity,Anti diarrhoeal activity, anti mico-bacterial activity.Research studies:It is reputed drug for chronic dysentery & diarrhea & specific for haemorrhoidal flux.Seeds of H.antidysentrica & tubers of C.rotundus are ingredients in preparation for dysentery,bilious affections & piles.Reference: Selected medical plants of India, a monograph of identity, safety, clinical use,compiled by Bharatiya vidya bhavan, Chemexil 1992, Bombay.Clinical report:Preparation containing solid extract from H.antidysentrica bark & seeds showed complete curerate of 80% in 25 pt.s of diarrhoea & dysentery with an average of 3 days treatment & slowed noside effects. (Reference: India, J pharm, Sci 1982,44,25)   “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 60  
  • 86. Drugs CONCEPTUAL STUDY  PUSHYANUGA CHOORNA 138,139 (Ca.chi.30/90, A.H.u.34/45) Method of preparation: All the drugs are collected in Pushya nakshatra & taken in equal quantities. Made in to fine powder separately. Mixed well, sieved & preserved. As the crude drugs are collected and choorna is prepared on Pushya nakshatra, the formulation gained the name Pushyanuga choorna. Anupana: Madhu & Tandulodaka Matra: Samanya matra (1 karsha) Indications: • Arsha roga, • Raktatisara • All types of Doshaja & Agantuja rakta vikaras in Bala, • Yonidosha • Rajodosha • All types of Yoni sravas (sweta,neela,sapeetaka,shyavaruna) “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 64  
  • 87. Drugs                                                                                                                                                                                             CONCEPTUAL STUDY                                                                                              Table No. 24: Pushyanuga choornaSN Dravya Family B.N Rasa Guna Veerya Vipa Doshag Rogag hnata Prayojy Chl. Const ka hnata ¬è a Anga1 Pata Minisper Cissampelo Tikta Laghu Ushna Katu Kapha Atisara, Moola Hayatinin, maceae s pareira Teekshna pittahara Yoniroga cissamine2 Jambu Myrtacea Syzygion Kashaya Laghu Sheeta Katu Kapha Raktapitta, Daha Phala Kaemferol, e cumini madhura ruksha pittahara, Myricetin,quercetin amla grahi3 Amra Anacarda Mangifera Kashaya Laghu Sheeta Katu Vatahara Rakta pradara Phala Mangiferin, ceae indica mangiferolic acid4 Pashan Saxifraga Berginia Kashaya Laghu Sheeta Katu Tridosha Yoniroga, Moola Berginin, β- sitosterol abheda ceae lingulata tikta snighda hara Mootrakrucchra5 Rasanj - - Tikta Teekshna Ushna Katu Kaphahar Visha, netraroga - - ana katu a6 Ambas Minisper Cissampelo Tikta Laghu Ushna Katu Kapha Yoniroga Moola Hayatin, menismine, htas maceae s pareira rushna pittahara cissamine, queritol7 Shalma Bombace Salmalia Kashaya Laghu Sheeta Mad Pitta vata Raktapitta, Moola Gallic & tannic acid, li ae melabarica snigdha hura hara Rakta pradara D-galacto pyranose,8 Saman Rubiacea Rubia Madhura, Guru Ushna Katu Kapha Raktaatisara Moola Antitumour cyclic ga(man e cordifolia tikta ruksha pittahara hexa peptides, jista) rubifolic acid “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 65  
  • 88. Drugs                                                                                                                                                                                             CONCEPTUAL STUDY   9 Vatsak Apocyna Holarrhena Tikta Laghu Sheeta Katu Kapha Pradara Twak Conessidine, a(kutaj ceae Antidysentr kashaya ruksha pittahara Asrgdara holadiene, kurchine a) ica10 Bahlee Umbellif Ferula Katu Laghu Ushna Katu Kapha Vibanda, shoola Niryasa Phellandrene, butyl ka erae narthex teekshna vatahara propenyl, polyanthin11 Ativish Ranuncul Aconitum Katu Laghu Ushna Katu Visha Tridoshahara Moola Atisine, heteratisine, a aceae rephyllum tikta ruksha hara hetisin12 Bilva Rutaceae Aegel Kashaya Laghu Ushna Katu VataKap Atisara Moola Umbelliferone, marmelos tikta ruksha hahara marmin, marmesin13 Musta Cyperace Cyperus Tiktakatu Laghu Sheet a Katu Kapha Rakta vikara Moola Cinol, copadiene, ae Rotandus kashaya ruksha pittahara Atisara copaene, β- silenene14 Lodra Styraceae Symplocos Kashaya Laghu Sheeta Katu Kapha Pradara Twak Symposide, loturine, Racemosa tikta ruksha pittahara Raktapitta loturidine15 Gairika - - Madhura Snigdha Sheeta Katu Pittahara Rakta vikara - -16 Katvan Simaroub Ailanthus Tikta Ruksha Sheeta Katu Kapha Yoni vyapath Twak Nimbin, β-sitosterol, ga aceae Excels kashaya pittahara kulinone (Aralu)17 Marich Piperacea Piper Katu Laghu Ushna Katu Kapha Swasa Shoola Phala Piperene, α & a e nigrum teekshna vatahara βpinene, piperonal, β alanine “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 66  
  • 89. Drugs                                                                                                                                                                                             CONCEPTUAL STUDY   18 Shunti Scitamin Zingiber Katu Guru,ruk Ushna Mad VataKap Shoola Rhizom α-curcumene, citral, aceae officinale sha,teeks hura ha hara Raktapitta e citronellol, hna19 Mrdve Vitaceae Vitis Madhura Snigdha Sheeta Mad Vata Raktapitta Phala Β- sitosterol, eka vinefera hura pittahara Kamala jasmonic acid,20 Rakta Legumin Ptero Tikta Guru Sheeta Katu Kapha Raktapitta, Kanda Pterocarpol, santalin, chanda aceae carpus madhura ruksha pittahara Trushna sara lupenediol na santalenus21 Katpha Myricace Myrica Kashaya Laghu Ushna Katu Kapha Klaibya Twak Myriconol, β- la ae escultena tikta katu teekshna vatahara Shukradosha sitosterol, myricadiol22 Ananth Zygophyl Fagonia Kashaya Laghu Ushna Mad Vata Vishama jwara, Panchan - a aceae cretica tikta katu snigdha hura pittahara Trushna ga madhura23 Dhatak Lytherac Woodfordi Kashaya Laghu Sheeta Katu Kapha Yoniroga, Pushpa Inositol, tannins, i eae a fruticosa ruksha pittahara Pittasra woodferidin24 Madhu Legumin Glycirrhiza Madhura Guru Sheeta Mad Vata Vrunaroga, Moola Glycyrrhizin, ka aceae glabra snigdha hura pittahara Visha glycyrrhizic acid, (yastim liquirtin. adhu)25 Arjuna Combrat Terminalia Kashaya Laghu Sheeta Katu Kapha Raktapitta, Twak Arachidic stearate, aceae Arjuna ruksha pittahara Hrudroga cerasidin, arjunic   “A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ” Page 67  
  • 90. Drugs CONCEPTUAL STUDY Madhu (Ref: bha. Pra. ni) Synonyms: Makshika, Madhvika Rasa: Madhura, Kashaya anurasa Guna: Laghu, ruksha, sookshma Veerya: Sheeta Doshaghna: Kaphaghna, Pittaghna, , Raktadoshahara Karma: grahi, vilekhana, chakshushya, deepana, svarya, vrana shodhana, vrana ropana, soukumaryam, sroto vishodhanam, hrudya, prasada janakam, varnya, medhakara, vrushya, yogavahi. Rogaghnata: Kusta, kasa, pittsra, kaphameha klama krimihara, medohara. Tandulodaka kÉÉuÉÌrÉiuÉÉ iÉiÉÉå SårÉÇ iÉhQÒûsÉÉåSMü MüqÉÉïÍhÉ || ( zÉÉ.xÉÇ) 1 pala of tandula is washed with 8 gunas of water. The fitrate is referred to as Tandulodaka. Matra : 2 palas Uses: 1. Vagasena says Bhoomyamalaki taken with Tandulodaka cures Pradara 2. Yogarathnakara in Streeroga adhyaya mentioned it is given with Bhoomyamalaki in Raktapradara. 3. According to modern it is known to be good demulsant.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 68  
  • 91. Methodology CLINICAL STUDY MATERIALS AND METHODSCurrent study “A clinical evaluation of the effect of Uttara basti in Asrigdara w.s.r. toDysfunctional uterine bleeding ” was carried out in department of prasuti tantra and stree rogaSDM Ayurveda hospital, Udupi.Aims and objectives of the study: 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.Source of data: Minimum 30 patients suffering from Asrigdara were selected for the study from the OPD and IPD of S.D.M Ayurveda Hospital Kuthpady, Udupi.Method of data collection: Patient presenting with complaints of excessive menstrual bleeding and irregular bleeding as that of menorrhagia, metrorrhagia, polymenorrhoea were selected. A detailed proforma was prepared considering all the patients pertaining to history, signs, symptoms and examination as mentioned in our classics and allied sciences to confirm the diagnosis. The parameters of signs and symptoms were scored on the basis of standard method of statistical analysis.Inclusion criteria: Patient with age group of 20 to 45 years. Patient with pratyatma lakshana of Asrigdara. Patient diagnosed as DUB“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 72
  • 92. Methodology CLINICAL STUDYExclusion criteria: Patient with thyroid dysfunction, DM, HTN etc. Threatened or spontaneous or incomplete abortion. Bleeding disorders like thrombocytopenia etc. STD, Patient with IUCD, polyp, benign and malignant tumours of uterus. Study design: Patient fulfilling above criteria were selected and assigned 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 from the next day following the stoppage of menstrual bleeding. GROUP 3 – of 10 patients were administered Kashmarya kutaja uttara vasti” for 3 days, after a course of “Yoga basthi” for 5 days with “Bala taila anuvasana” and “Dashamoola kashaya niruha vasthi” from the next day following the stoppage of menstrual bleeding. In the format of yoga Vasti ( 8 Vastis) 1. Anuvasana Vasti – 5 with Dashamoola kashaya 2. Niruha Vasti – 3 with Bala taila Vasti A A N A N A N A Days 1 2 3 3 4 4 5 5 Even- Even- Morn- Even- Morn- Even- Morn- Even- ing ing ing ing ing ing ing Ing“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 73
  • 93. Methodology CLINICAL STUDY Niruha vasti: Quantity : Madhyama matra according to sarangadhara i.e 1 prasta = 16 pala = 768 ml o Madhu – 192 gms o Lavana – 12 gms o Sneha – 192 ml (Bala taila ) o Kalka – 48 gms ( Shatapushpa) o Kwatha – 384 ml (Dashamoola kashaya ) Anuvasana Vasti – Bala tailam ----- 50 mlMethod of Administration of Uttara basti:The following instruments are used in sterile condition: Cusco’s speculum, Uterine sound, 10ml syringe, IUID (Intrauterine insemination device) Uttara basti was administered from the next day following the cessation of bleeding. After giving local snehana & swedana, Patient was placed in lithotomy position. External genitalia (initially prepared) , vagina and cervix were swabbed with savlon. After P/V examination Cusco’s speculum was introduced,uterine sound was passed to note the size & direction of the uterus. 5ml of autoclaved Kashmarya Kutaja gritha was kept readily drawn in 10ml syringe, to which the cannula of IUID was connected. The narrow cannula is introduced into the uterus and the gritha pushed inside slowly. Patient was kept in supine position for half an hour by keeping the pillow on her back and advised bed rest. This procedure of Uttara basti was repeated for 3 consecutive days & the dosage of gritha was fixed ie 5ml on each day.Follow up : Patient were asked to follow-up for the next 2 cycles.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 74
  • 94. Methodology CLINICAL STUDYAssessment criteria:The patient’s responses were assessed on the basis of subjective parameter 1. Duration of menstrual flow: 1-5 days 1 6-9 days 2 10-14 days 3 >15 days 4 2. Interval between 2 menstrual cycles: Normal: 28-32 days 0 Frequent: Menses at 21 days cycle 1 Intermittent: Menses at 15days cycle 2 Delayed: Menses at >35 days 3 3. Amount of menstrual blood loss: 1-3 pads/day 0 4-5 pads/day 1 6-7 pads/ day 2 >7 pads /day 3 4. Consistancy of bleeding: Watery 0 Watery + clots(small) 1 Clots(moderate) 2 Clots(severe) 3“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 75
  • 95. Methodology CLINICAL STUDY 5. Staining : Present 1 Absent 0 6. Odour : Present 1 Absent 0 7. Intensity of pain during menstruation: Absent O Mild (Pt able to tolerate) 1 Moderate (subsides with use of analgesics) 2 Severe (does not subsides even with the use of analgesics) 3 8. Assosiated symptoms: Assosiated symptoms Nil Mild Moderate Severe (Grade 0) (Grade 1) (Grade 2) (Grade 3) Low backache Bodyache Weakness Pain in calf mm Breast tendernes Headche Vomitting Loose motion Giddiness Lack of concentration Depression Rise in temperature Excessive sweating“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 76
  • 96. Methodology CLINICAL STUDY 9. Uterine size:- P/V examination or USG if neededFinal Assessment: Cured: Regularization of menstruation, ie 3-5 days / 28-30 days. Regularization in amount of bleeding, using 1-2 pads per day. Reduction in associated symptoms like pain. Improved: Mild improvement in amount of bleeding, length of the cycle & pain. No relief – No changeInvestigations: Hb% CT, BT USG Harmonal essay Endometrial biopsy (if necessary).“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 77
  • 97. Observations CLINICAL STUDY OBSERVATIONS 1. Incidence according to age: Table No. 25 Graph No.1 Age GI GII GIII Total % 20-28 5 0 0 5 16.7 29-37 3 7 6 16 53.3 38-45 2 3 4 9 30 In the study of 30 patients, 16.7% belonged to the age group between 20-28 years, 53.3% between 29-37 years, 30% were between 38-45 years of age. 2. Incidence according to Socio Economic status: Table No. 26 Graph No.2 S.E. status GI GII GIII Total % Lower class 2 1 2 5 16.7 Middle class 6 8 7 21 70 Upper class 2 1 1 4 13.33 In the study, 16.7% belonged to lower class, 70% to middle class & 13.3% to upper class.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 79
  • 98. Observations CLINICAL STUDY 3. Incidence according to domicile: Table No.27 Graph No.3 Domicile GI GII GIII Total % Urban 3 8 4 15 50 Rural 7 2 6 15 50 There are equal distribution of patients as per the incidence according to domicile. 4. Incidence according to religion: Table No. 28 Graph No.4 Religion GI G G Total % II III Hindu 4 6 8 18 60 Muslim 3 2 2 7 23.33 Christian 3 2 0 5 16.67 In the study 60% patients were belonged to Hindu community, 23.33% were muslims & 16.67% were Christians.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 80
  • 99. Observations CLINICAL STUDY 5. Incidence according to Occupation: Table No: 29 Graph No. 5 Occupation G I GII GIII Total % House wife 4 7 8 19 63.33 Working 3 3 2 8 26.67 Labour 2 - - 2 6.67 Student 1 - - 1 3.33 Among the patients taken for the study, 63.33% were housewives, 26.67% were working (teacher, clerk etc.), 6.67% were labourers & 3.33% of them were studying. 6. Incidence according to Educational status: Table No: 30 Graph No : 6 Educatinal G I GII G III Total % stautus Primary 0 2 3 5 16.67 High 3 2 5 10 33.33 school Pre-degree 4 2 1 7 23.33 Degree 3 4 1 8 26.67 In the present study, 16.67% patients had studied till primary, 33.3% till high school, 23.3% till pre degree & 26.67% were educated till degree.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 81
  • 100. Observations CLINICAL STUDY 7. Incidence according to marital status: Table no : 31 Graph No : 7 Marital G G G Tota % Status I II III l Married 6 10 10 26 86.67 Un- 4 0 0 4 13.33 married In the present study, 86.67% of patients were married & 13.33% were unmarried. 8. Incidence according to dietary status: Table No :32 Graph No : 8 Diet G I GII GIII Total % Vegitarian 3 2 1 6 20 Non 7 8 9 24 80 vegitarian 20% of patients were vegitarians & 80% were taking mixed type of diet.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 82
  • 101. Observations CLINICAL STUDY 9. Incidence according to rasa: Table No :33 Graph No : 9 Rasa GI GII GIII Total % Madhura 2 3 6 11 36.67 Amla 3 3 4 10 33.33 Lavana 8 9 8 25 83.33 Katu 8 9 9 26 86.67 Tikta 7 5 4 16 53.33 Kashaya 0 0 2 2 6.67 In the present study, 36.67% of pt.s were habituated to madhura rasa, 33.33% to amla rasa, 83.3% to lavana rasa, 86.67% to katu rasa, 53.3% to tikta ras & 6.67% to kashaya rasa. 10. Incidence according to mental stress: Table No : 34 Graph No :10 Mental stress GI GII GIII Total % Present 6 7 8 21 70 Absent 4 3 2 9 30 In present study, 70% patients were suffering from mental stress & 30% had no such incidence.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 83
  • 102. Observations CLINICAL STUDY 11. Incidence according to body built: Table No: 35 Graph No : 11 Built G I GII G III Total % Lean 3 4 6 13 43.33 Moderate 6 4 3 13 43.33 Obese 1 2 1 4 13.33 In the present study, 43.33% were having lean built, 43.33% were moderate & remaining 13.33 were obese. 12. Incidence according to Prakruti: Table No : 36 Graph No : 12 Prakriti G I GII GIII Total % Vata pitta 4 4 3 11 36.67 Pitta kapha 6 4 4 14 46.67 Vata kapha 0 2 3 5 16.67 In the present study, 36.67% patients were of pittakapha prakriti, 46.67% were of vatapitta prakriti & remaining 16.67% of vata kapha prakriti. 13. Incidence according to Aharashakti:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 84
  • 103. Observations CLINICAL STUDY Table No : 37 Graph No : 13 Aharashakti GI GII GIII Total % Heena 2 1 1 4 13.33 Madhyama 6 7 9 22 73.33 Pravara 2 2 0 4 13.33 In the study 13.33% of patient were of heena aharashakti, 73.33% were having madhyama Aharashakti & remaining 13.33% were of Pravara aharashakti. 14. Incidence according to Abhyasa: Table No : 38 Graph No : 14 Addiction GI GII GIII Total % Tea 6 7 4 17 56.67 Coffee 4 3 6 13 43.33 Tobacco 1 - 1 2 6.67 Pan 2 1 1 4 13.33 In the present study 56.67% were having habit of tea, 43.33% to coffee, 6.67% to Tobacco &13.33% to pan. 15. Incidence according to Vyayama:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 85
  • 104. Observations CLINICAL STUDY Table No : 39 Graph No : 15 Vyayama G I GII GIII Total % Avara 0 1 2 3 10 Madyama 8 7 6 21 70 Pravara 2 2 2 6 20 In the present study, 10% patients were of avara vyayama shakti, 70% were of Madyama vyayama shakti & remaining 20% of Pravara vyayama shakti . 16. Incidence according to vyavaya: Table No : 40 Graph No : 16 Vyavaya G I G II G III Total % Daily 0 2 0 2 7.69 Once in 0 4 2 6 23.07 2 days Once in 3 3 4 10 38.46 a week Rare 3 1 3 7 26.92 None 0 0 1 1 3.85 In the study, 4 patients were unmarried & out of 26 married patients, 7.69% patients going for coitus daily, 23.07% once in 2days, 38.46% were once in a week, 26.92% rare, & 3.85% were not doing. 17. Incidence according to bowel habits:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 86
  • 105. Observations CLINICAL STUDY Table No: 41 Table No : 17 Bowel GI GII GIII Total % Regular 8 7 6 21 70 Constipated 2 3 4 9 30 70% patients had regular bowel habits & 30% were constipated. 18. Incidence of past history: Table No : 42 Graph No : 18 Past history GI GII GIII Total % Present 1 2 3 6 20 Absent 9 8 7 24 80 20% patients had past history & 80% were not. 19. Incidence according to parity:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 87
  • 106. Observations CLINICAL STUDY Table No : 43 Graph No : 19 Parity GI GII GIII Total % One 2 3 1 6 23.07 Two 3 5 5 13 50 Three 1 2 2 5 19.23 >Three 0 0 1 1 3.85 None 0 0 1 1 3.85 In the present study, 4 patient were unmarried & out of 26 married patients, 23.07% patients had single parity, 50% had 2 parity, 19.23% were of 3 parity, 3.85% had more than 3 parity & remaining 3.85% had no issues. 20. Incidence according to abortion: Table No: 44 Graph No : 20 Abortion GI GII GII Total % None 4 5 3 12 46.15 One 2 5 6 13 50 Two 0 0 1 1 3.85 >two 0 0 0 0 0 In the present study, 50% of patients had h/o one abortion, 3.85% of them had h/o 2 abortions & remaining 46.15% were had no such history. 21. Incidence according to contraception:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 88
  • 107. Observations CLINICAL STUDY Table No : 45 Table No : 21 Contraception GI GII GIII Total % Ligation 1 6 5 12 46.15 IUCD 2 0 0 2 7.69 Pills 1 2 2 5 19.23 Safe method 2 2 3 7 26.92 In the present study, 4 patients were unmarried & out of 26 married patients, 46.15% were had ligation, 7.69% were having IUCD, 19.23% were using contraceptive pills & remaing 26.92% were following safe method. 22. Incidence according to duration of illness: Table No : 46 Table No : 22 Duration of GI GII GIII Total % iillness 3 – 6 months 8 4 3 15 50 7- 12 months 2 3 4 9 30 1-5 years 0 2 2 4 13.33 >5 years 0 1 1 2 6.67 In the present study, 50% were having duration of illness 3-6m, 30% of 7-12m, 13.33% of 1-5 years, 6.67% of >5 years. 23. Incidence according to bleeding pattern:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 89
  • 108. Observations CLINICAL STUDY Table No : 47 Table No : 23 Bleeding GI GII GIII Total % pattern Excessive 5 4 3 12 40 Prolonged 3 3 2 8 26.67 Intermenstrual 1 2 3 6 20 Frequent 1 1 2 4 13.33 In the present study, 40% patients had excessive amount of bleeding, 26.67% had prolonged bleeding, 20% had intermenstrual bleeding, 13.33% had frequent bleeding. 24. Incidence according to Pain: Table No : 48 Table N: 24 Pain GI GII GIII Total % Absent 2 2 0 4 46.67 Mild 5 6 3 14 36.67 Moderate 3 2 6 11 13.33 Severe 0 0 1 1 3.33 Out of 3o patients, 46.67% had no pain, 36.67% patients had mild degree of pain, 13.33% had moderateb pain & 3.33% were had severe degree of pain. 25. Incidence according to pradhana vedhana:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 90
  • 109. Observations CLINICAL STUDY i. Duration of bleeding (in days): Table No : 49 Graph No : 25 Duration GI GII GIII Total % 3-5 days 1 1 0 2 6.67 6- 9 days 6 4 3 13 43.33 10 –15days 3 3 5 11 36.67 >15 days 0 2 2 4 13.33 Out of 30 patients, 6.67% of patients had 3 to 5 days bleeding, 43.33% had 6- 10days bleeding, 36.67% had 10-15days bleeding & 13.33% had >15 days. ii. Amount of bleeding: Table No : 50 Table No : 26 Amount GI GII GIII Total % Mild 5 3 2 10 33.33 Moderate 5 5 7 17 56.67 Severe 0 2 1 3 10 In the present study, 33.33% had mild amount of bleeding, 56.67% had moderate & remaining 10% had severe degree of bleeding. iii. Interval of bleeding (in days):“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 91
  • 110. Observations CLINICAL STUDY Table No : 51 Graph No : 27 Interval GI GII GIII Total % 28-35 days 6 5 7 18 60 Once in 20 3 4 3 10 33.33 days Once in 15 1 1 0 2 6.67 days 60% patients had 28 to 35 days interval of bleeding, 33.33% were having menses once in 20 days & remaining 6.67% once in 15days. iv. Consistency: Table No : 52 Graph No : 28 Consistency GI GII GIII Total % Watery 4 3 2 9 30 Watery + 6 5 5 16 53.3 clots Clots 0 2 3 5 16.67 30% patients had watery consistency, 53.33% had watery +clots in consistency, 16.67% had clots in the menstrual bleeding. v. Colour:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 92
  • 111. Observations CLINICAL STUDY Table No : 53 Graph No : 29 Colour GI GII GIII Total % Pale 1 2 1 4 13.33 Bright 3 1 3 7 23.33 red Dark red 4 5 5 14 46.67 Brown 2 2 1 5 16.67 13.33% patients had pale colour bleeding, 23.33% had bright red bleeding, 46.67% had dark red colour bleeding & 16.67% had brown colour bleeding. vi. Odour: Table No : 54 Graph No : 30 Odour GI GII GIII Total % Present 6 7 8 21 70 Absent 4 3 2 9 30 70% patient had complained bad odour in their menstrual bleeding & 30% not.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 93
  • 112. Observations CLINICAL STUDY vii. Staining: Table No : 55 Graph No : 31 Staining GI GII GIII Total % Present 5 7 9 21 70 Absent 5 3 1 9 30 70% patients had complained staining of cloths & 30% had not. 26. Incidence according to Hb%: Table No : 56 Gragh No : 32 Hb% GI GII GIII Total % 6-8 0 1 2 3 10 8-10 4 3 5 12 40 10-12 6 6 3 15 50 10% patients were having their Hb% in between 6 to 8, 50% in between 10 to 12 & 40% in between 8 to 10.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 94
  • 113. Observations CLINICAL STUDY 27. Incidence according to Assosiated symptoms: Table No : 57 Assosiated symptoms GI GII GIII Total % 1.Body ache 3 4 3 10 33.33 2.Weakness 5 7 6 17 56.67 3.Giddiness 1 2 3 6 20 4.Low backache 2 4 3 9 30 5.Vomiting 0 1 0 1 3.33 6. diaarhea 0 0 1 1 3.33 7.Breast tenderness 1 2 3 6 20 8.Lack of concentration 0 1 2 3 10 9.Depression 0 2 3 5 16.67 In the study, 33.33% had bodyache, 56.67% pt.s complained weakness, 20% had giddiness & breast tenderness, 30% had lowbackache, 3.33% had vomitting & diarrhoea during their menses, 10% had lack of concentration & 16.67% had depression. Graph No : 33“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 95
  • 114. Picture No.4 Requirements in Uttara basti 1.Savlon 2.Cotton 3.Artery forceps 4. Cusco’s speculum 5. Uterine sound 6. Cannula of IUID 7. 10ml syringe 8. Kasmarya Kutaja Gritha 9. Pair of sterile gloves 78
  • 115. Results CLINICAL STUDY RESULTS 1. Effect on Duration of bleeding: 1.1 Comparision within groups: First follow up Table No : 58 Group N Mean d Paired t test BT AT1 % S.D S.EM t P I 10 1.5 0.7 0.8 53.33 0.422 0.133 6.00 =<0.001 II 10 2.3 0.9 1.4 60.86 0.516 0.163 8.573 =<0.001 III 10 2.6 0.7 1.9 73.07 0.316 0.100 19.00 =<0.001 1.2 Comparision within Groups: Second follow up Table No : 59 Group N Mean d Paired t Test BT AT2 % S.D S.EM t P I 10 1.5 0.8 0.7 46.66 0.483 0.153 4.583 =0.001 II 10 2.3 0.9 1.4 60.86 0.516 0.163 8.573 =<0.001 III 10 2.6 0.7 1.9 73.07 0.316 0.100 19.00 =<0.001 Graph No: 34Effect within groups:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 96
  • 116. Results CLINICAL STUDYGroup I:The mean score of the duration of the bleeding which was 1.5 before treatment reduced to 0.7after treatment in the first follow up & was 0.8 in the second followup. When these values wereanalysed statistically by adapting the Paired t test, the difference was significant at the level ofP =<0.001 & P=0.001 respectively.Group II:The mean score of the duration of the bleeding which was 2.3 before treatment reduced to 0.9after treatment in the first follow up & was remained same in the second follow up. When thesevalues were analysed statistically by adapting the Paired t test, the difference was significant atthe level of P =<0.001.t = 8.573 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.031 to 1.769The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001)Group III:The mean score of the duration of the bleeding which was 2.6 before treatment reduced to 0.7after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically by adapting paired t test, the difference was significant at thelevel of P =<0.001.t = 19.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.674 to 2.126The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001) 1.3 Comparision between groups:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 97
  • 117. Results CLINICAL STUDY Table No : 60 Group N BT-AT1 S.D ANOVA TEST F P I 10 0.8 0.422 II 10 1.4 0.516 16.722 <0.001 III 10 1.9 0.316 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of duration of blood loss and analysed statistically. (Table 1.3) The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = <0.001). Overall significance level = 0.05 Comparisons for factor: Comparison Diff of t Unadjusted P Critical Significant Means Level GrIII vs.Gr I 1.100 5.775 <0.001 0.017 Yes Gr II vs. GrI 0.600 3.150 0.004 0.025 Yes Gr III vs. Gr II 0.500 2.625 0.014 0.050 Yes 2. Effect on Amount of blood loss:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 98
  • 118. Results CLINICAL STUDY 2.1 Comparision within groups: First follow up Table No : 61 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 1.6 0.8 0.8 50.00 0.422 0.133 6.00 <0.001 II 10 2.5 0.8 1.7 68.00 0.483 0.153 11.129 =<0.001 III 10 2.7 0.6 2.1 77.77 0.316 0.100 21.00 =<0.001 2.2 Comparision within groups: Second follow up Table No : 62 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 1.6 0.9 0.7 43.75 0.483 0.153 4.583 =0.001 II 10 2.5 0.8 1.7 68.00 0.483 0.153 11.129 =<0.001 III 10 2.7 0.6 2.1 77.77 0.316 0.100 21.00 =<0.001 Graph No : 35“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 99
  • 119. Results CLINICAL STUDYEffect within groups:Group I:The mean score of the amount of the bleeding which was 1.6 before treatment reduced to 0.8after treatment in the first follow up & was increased to 0.9 in the second followup. When thesevalues were analysed statistically by adopting paired t test, the differences were significant at thelevel of P <0.001 & P =0.001Group II:The mean score of the amount of the bleeding which was 2.5 before treatment reduced to 0.8after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 11.129 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.354 to 2.046The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001)Group III:The mean score of the amount of the bleeding which was 2.7 before treatment reduced to 0.6after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 21.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.874 to 2.326The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001)“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 100
  • 120. Results CLINICAL STUDY 2.3 Comparision between groups: Table No : 63 Group N BT-AT1 S.D ANOVA TEST F P I 10 0.8 0.422 II 10 1.7 0.483 26.016 <0.001 III 10 2.1 0.316 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of amount of blood loss and analysed statistically. (Table 2.3) The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = <0.001) Comparisons for factor: Comparison Diff of t Unadjusted P Critical Significant Means Level Gr III vs. Gr I 1.300 7.042 <0.001 0.017 Yes Gr IIvs. Gr I 0.900 4.875 <0.001 0.025 Yes Gr IIIs. Gr II 0.400 2.167 0.039 0.050 Yes“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 101
  • 121. Results CLINICAL STUDY 3. Effect on interval: 3.1 Comparision within groups: First follow up Table No : 64 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 1.2 0.5 0.7 58.33 0.483 0.153 4.583 =0.001 II 10 1.2 0.4 0.8 66.66 0.422 0.133 6.00 =<0.001 III 10 1.5 0.3 1.2 80.00 0.422 0.133 9.00 =<0.001 3.2 Comparision within groups: Second follow up Table No : 65 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 1.2 0.6 0.6 50.00 0.516 0.163 3.673 =0.005 II 10 1.2 0.4 0.8 66.66 0.422 0.133 6.00 =<0.001 III 10 1.5 0.3 1.2 80.00 0.422 0.133 9.00 =<0.001 Graph No : 36Effect within groups:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 102
  • 122. Results CLINICAL STUDYGroup I:The mean score of the interval of the bleeding which was 1.2 before treatment reduced to 0.5after treatment in the first follow up & was increased to 0.6 in the second followup. When thesevalues were analysed statistically, the differences were significant at the level of P=0.001 &P=0.005Group II:The mean score of the interval of the bleeding which was 1.2 before treatment reduced to 0.4after treatment in the first follow up & was remained same in the second followup. When thesevalues were analysed statistically, the differences were significant at the level of P =<0.001t = 6.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 0.498 to 1.102The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001)Group III:The mean score of the interval of the bleeding which was 1.5 before treatment reduced to 0.3after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 9.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 0.898 to 1.502The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001) 3.3 Comparision between groups: Table No : 66“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 103
  • 123. Results CLINICAL STUDY Group N BT-AT1 S.D ANOVA TEST F P I 10 0.7 0.483 II 10 0.8 0.422 3.563 0.042 III 10 1.2 0.422 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of interval of bleeding and analysed statistically. (Table 3.3) The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = 0.042). Comparisons for factor: Comparison Diff of t Unadjusted P Critical Means Level Significant Gr III vs. Gr I 0.500 2.522 0.018 0.017 No Gr III vs. Gr II 0.400 2.018 0.054 0.025 No Gr II vs. Gr I 0.100 0.504 0.618 0.050 No 4. Effect on consistency:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 104
  • 124. Results CLINICAL STUDY 4.1 Comparision within groups: First follow up Table No : 67 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 1.6 0.7 0.9 56.25 0.316 0.100 9.000 =<0.001 II 10 1.7 0.6 1.1 64.70 0.316 0.100 11.00 =<0.001 III 10 1.7 0.3 1.4 82.35 0.516 0.163 8.573 <0.001 4.2 Comparision within groups: Second follow up Table No : 68 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 1.6 0.8 0.8 50.00 0.422 0.133 6.000 =<0.001 II 10 1.7 0.6 1.1 64.70 0.316 0.100 11.00 =<0.001 III 10 1.7 0.3 1.4 82.35 0.516 0.163 8.573 <0.001 Graph No : 37Effect within groups:Group I:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 105
  • 125. Results CLINICAL STUDYThe mean score of the Consistancy of the bleeding which was 1.6 before treatment reduced to0.7 after treatment in the first follow up & was increased to 0.8 in the second followup. Whenthese values were analysed statistically, the difference was significant at the level of P=<0.001& P=<0.001 respectively.Group II:The mean score of the Consistency of the bleeding which was 1.7 before treatment reduced to0.6 after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 11.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 0.874 to 1.326The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001)Group III:The mean score of the Consistency of the bleeding which was 1.7 before treatment reduced to0.3 after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 8.573 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.031 to 1.769The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001 4.3 Comparision between groups: Table No : 69 ANOVA TEST“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 106
  • 126. Results CLINICAL STUDY Group N BT-AT1 S.D F P I 10 1.6 0.316 II 10 1.1 0.316 4.078 0.028 III 10 1.4 0.516 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of interval of bleeding and analysed statistically. (Table 4.3) The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = 0.028). Comparisons for factor: Comparison Diff of t Unadjusted P Critical Significant Means Level Gr III vs. Gr I 0.500 2.837 0.009 0.017 Yes Gr III vs. Gr II 0.300 1.702 0.100 0.025 No Gr II vs. Gr I 0.200 1.135 0.266 0.050 No 5. Effect on odour: 5.1 Comparision within groups: First follow up Table No : 70“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 107
  • 127. Results CLINICAL STUDY Group N BT AT1 d Paired t test % S.D S.EM t P I 10 0.9 0.3 0.6 66.66 0.516 0.163 3.674 =0.005 II 10 0.8 0.2 0.6 75.00 0.516 0.163 3.674 =0.005 III 10 1.0 0.1 0.9 90.00 0.316 0.100 9.00 =<0.001 5.2 Comparision within groups: Second follow up Table No : 71 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 0.9 0.4 0.5 55.55 0.527 0.167 3.00 =0.015 II 10 0.8 0.2 0.6 75.00 0.516 0.163 3.674 =0.005 III 10 1.0 0.1 0.9 90.00 0.316 0.100 9.00 =<0.001 Graph No : 38Effect within groups:Group I:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 108
  • 128. Results CLINICAL STUDYThe mean score of the odour of the menstrual blood which was 0.9 before treatment reduced to0.3 after treatment in the first follow up & was 0.4 in the second followup. When these valueswere analysed statistically, the difference was significant at the level of P=0.005 & P=0.015Group II:The mean score of the odour of the menstrual blood which was 0.8 before treatment reduced to0.2 after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=0.005t = 3.674 with 9 degrees of freedom. (P = 0.005)95 percent confidence interval for difference of means: 0.231 to 0.969The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = 0.005)Group III:The mean score of the odour of the menstrual blood which was 1.0 before treatment reduced to0.1 after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 9.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 0.674 to 1.126The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001) 5.3 Comparision between groups: Table No : 72“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 109
  • 129. Results CLINICAL STUDY Group N BT-AT1 S.D ANOVA TEST F P I 10 0.6 0.516 II 10 0.6 0.516 1.423 0.502 III 10 0.9 0.316 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of odour and analysed statistically. (Table 5.3) The differences in the mean values among the treatment groups are not great enough to exclude the possibility that the difference is due to random sampling variability; there is not a statistically significant difference (P = 0.258). 6. Effect on staining: 6.1 Comparision within groups: First follow up“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 110
  • 130. Results CLINICAL STUDY Table No : 73 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 0.8 0.3 0.5 62.50 0.527 0.167 3.000 =0.015 II 10 0.9 0.2 0.7 77.77 0.483 0.153 4.583 =0.005 III 10 1.0 0.1 0.9 90.00 0.316 0.100 9.000 =<0.001 6.2 Comparision within groups: Second follow up Table No : 74 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 0.8 0.4 0.4 50.00 0.516 0.163 2.499 =0.037 II 10 0.9 0.2 0.7 77.77 0.483 0.153 4.583 =0.005 III 10 1.0 0.1 0.9 90.00 0.316 0.100 9.000 =<0.001 Gpaph No : 39Effect within groups:Group I:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 111
  • 131. Results CLINICAL STUDYThe mean score of the staining of the menstrual blood which was 0.8 before treatment reducedto 0.3 after treatment in the first follow up & was increased to 0.4 in the second followup.When these values were analysed statistically, the difference was significant at the level ofP=0.015 & P=0.037Group II:The mean score of the staining of the menstrual blood which was 0.9±0.100 before treatmentreduced to 0.2±0.133 after treatment in the first follow up & remained same in the secondfollowup. When these values were analysed statistically, the difference was significant at thelevel of P=0.001Group III:The mean score of the staining of the menstrual blood which was 1.0±0.000 before treatmentreduced to 0.1±0.100 after treatment in the first follow up & remained same in the secondfollowup. When these values were analysed statistically, the difference was significant at thelevel of P=<0.001 6.3 Comparision between groups: Table No : 75“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 112
  • 132. Results CLINICAL STUDY Group N BT-AT1 S.D ANOVA TEST F P I 10 0.5 0.527 II 10 0.7 0.483 1.423 0.258 III 10 0.9 0.316 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of staining and analysed statistically. (Table 6.3) The differences in the mean values among the treatment groups are not great enough to exclude the possibility that the difference is due to random sampling variability; there is not a statistically significant difference (P = 0.258). 7. Effect on pain: 7.1 Comparision within groups: First follow up“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 113
  • 133. Results CLINICAL STUDY Table No : 76 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 1.2 1.0 0.2 16.66 0.422 0.133 1.500 =0.168 II 10 1.3 0.8 0.5 38.46 0.527 0.167 3.000 =0.015 III 10 2.3 0.4 1.9 82.60 0.316 0.100 19.00 =<0.001 7.2 Comparision within groups: Second follow up Table No : 77 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 1.2 1.0 0.2 16.66 0.422 0.133 9.000 =0.168 II 10 1.3 0.8 0.5 38.46 0.527 0.167 3.00 =0.015 III 10 2.3 0.4 1.9 82.60 0.316 0.100 19.00 =<0.001 Graph No : 40Effect within groups:Group I:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 114
  • 134. Results CLINICAL STUDYThe mean score of the pain during menstruation which was 1.2 before treatment reduced to 1.0after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was insignificant at the level of P=0.168.t = 1.500 with 9 degrees of freedom. (P = 0.168)95 percent confidence interval for difference of means: -0.102 to 0.502The change that occurred with the treatment is not great enough to exclude the possibility thatthe difference is due to chance (P = 0.168)Group II:The mean score of the pain during menstruation which was 1.3 before treatment reduced to 0.8after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically,t = 3.000 with 9 degrees of freedom. (P = 0.015)95 percent confidence interval for difference of means: 0.123 to 0.877The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = 0.015)Group III:The mean score of the pain during menstruation which was 2.3 before treatment reduced to0.4 after treatment in the first follow up & remained same in the second followup. When thesevalues were analysed statistically, the difference was significant at the level of P=<0.001t = 19.000 with 9 degrees of freedom. (P = <0.001)95 percent confidence interval for difference of means: 1.674 to 2.126The change that occurred with the treatment is greater than would be expected by chance; thereis a statistically significant change (P = <0.001) 7.3 Comparision between groups: Table No : 78“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 115
  • 135. Results CLINICAL STUDY Group N BT-AT1 S.D ANOVA TEST F P I 10 0.2 0.422 II 10 0.3 0.483 22.783 <0.001 III 10 1.5 0.527 The effect between groups: The 3 groups when compared before & after treatment by Anova Test (F test) for the symptom of pain during menstruation and analysed statistically was found to be significant with P=0<0.001 The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = <0.001). Comparisons for factor: Comparison Diff of T Unadjusted P Critical Significant Means Level Gr III vs. Gr I 1.700 8.833 <0.001 0.017 Yes Gr III vs. Gr II 1.400 7.274 <0.001 0.025 Yes Gr II vs. Gr I 0.300 1.559 0.131 0.050 No 8. Effect on associated complaints: 8.1 Comparision within groups: First follow up“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 116
  • 136. Results CLINICAL STUDY Table No: 79 Group N BT AT1 d Paired t test % S.D S.EM t P I 10 1.6 0.7 0.900 56.25 0.316 0.100 9.00 =<0.001 II 10 1.3 0.4 0.900 69.25 0.316 0.100 9.00 =<0.001 III 10 1.9 0.6 1.300 73.68 0.483 0.153 8.510 =<0.001 8.2 Comparision within groups: Second follow up Table No : 80 Group N BT AT2 d Paired t test % S.D S.EM t P I 10 1.6 0.9 0.700 43.75 0.483 0.153 4.583 =0.001 II 10 1.3 0.4 0.900 69.25 0.316 0.100 9.00 =<0.001 III 10 1.9 0.6 1.300 73.68 0.483 0.153 8.510 =<0.001 Graph No : 41  Effect within groups:Group I:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 117
  • 137. Results CLINICAL STUDYThe mean score of the Assosiated symptoms which was 1.6 before treatment reduced to 0.7after treatment in the first follow up & was 0.9 in the second followup. When these values wereanalysed statistically, the difference was significant at the level of P=<0.001 & P=0.001Group II:The mean score of the associated symptoms which was 1.3±0.213 before treatment reduced to0.4±0.163 after treatment in the first follow up & remained same in the second followup. Whenthese values were analysed statistically, the difference was significant at the level of P=<0.001Group III:The mean score of the associated symptoms which was 1.9±0.180 before treatment reduced to0.6±0.163 after treatment in the first follow up & remained same in the second followup. Whenthese values were analysed statistically, the difference was significant at the level of P=<0.001 8.3 Comparision between groups: Table No : 81“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 118
  • 138. Results CLINICAL STUDY Group N BT-AT1 S.D ANOVA TEST F P I 10 0.9 0.316 II 10 0.9 0.316 3.695 0.038 III 10 1.3 0.483 The effect between groups: The differences in the mean values among the treatment groups are greater than would be expected by chance; there is a statistically significant difference (P = 0.038). Comparisons for factor: Comparison Diff of t Unadjusted P Critical Significant Means Level Gr III vs. Gr II 0.400 2.354 0.026 0.017 No Gr III vs. Gr I 0.400 2.354 0.026 0.025 No Gr I vs. Gr II 0.000 0.000 1.000 0.050 No Overall effect of therapies Table No : 82“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 119
  • 139. Results CLINICAL STUDY Group Cured in % Improved in % No change in % I 05 75 20 II 10 80 10 III 30 70 0 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. Graph No : 42“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 120
  • 140. DISCUSSION  DISCUSSIONAsrgdara manifesting as excessive bleeding per vaginum is seem to be an age old disease knownto man kind since the era of Vedas & puranas. Its description is widely narrated in almost all theclassical texts.Asrgdara characterized by excessive or prolonged flow of blood occurring in menstrual &intermenstrual period. This can be compared with dysfunctional uterine bleeding by itsaetiopathological consideration, presentation and features. DUB is defined as abnormal uterinebleeding without any clinically detectable organic pathology.Dysfunctional uterine bleeding is common menstrual disorder. It is more prevalent in modernwomen because of small family, early menarche, late menopause, nutritional deficiency andstress & strain of double folded responsibilities of modern women creates an ideal nidana formenstrual disorders.Arthava is 3 folded according to its description. It represents ovum, hormones and menstrualblood. Even though the word with reference to Asrgdara denotes menstrual blood, the hormonesshould be considered on the basis of aetiopathogenesis. Though the menstrual blood is amanifestation of the changes initiated and triggered by female sex hormones, which beingexplicit, it is this substance which is said to be diseased or vitiated.The artava formed by rasa dhatu is brought about to the fine vessels of garbhashaya by the actionof normal functioning of vayu which is responsible for its timely excretion through vaginalpassage.Artava which is formed from Rasa is soumya which has prithvi & jala as its major components.Arthava attains agneyatva by the kala parinama. Abnormality of agneya or tejas component canaffect its amount to be excreted. So any vikriti in arthava indicates dhatu vikriti .The causes for dhatu vikriti includes,Rasa dhatu vikriti: Certain food products like guru, Amla, Lavana, vidahi, Viruddhahara, sura,sukti etc causes agni vaishamyata that in turn causes rasa dusti and rakta dusti results in toAsrgdara.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 121
  • 141. DISCUSSION Dietic abnormalities lead to nutritional abnormality. Iron deficiency is suspected of having anaffect on contractility of spiral endometrial vessels and myometrium due to deficient cytochromeoxidase. (as quoted by Dawn). It is possible that it works either through hepatic dysfunction orH-P-O axis or directly on the uterine vasomotor apparatus. This concept of Apathya ahara sevanawith relation to Iron deficiency anaemia can be correlated to rasa dhatu vimanatah.Garbhashayagata vikriti: As a result of atimaituna , atiyana, garbhasrava, garbhapatha etccauses vata vitiation, which affects the garbhashaya the moola sthana of arthavavaha srotas andwill also affects the sukshma rajovaha dhamanis leads to Asrgdara.Garbha prapataat has been considered as nidana according to Madhava. Homlsrome &Melennon (1947) have mentioned the association of post-abortal sub-involution & irregularshedding of endometrium. . Abortion can produce chronic inflammation of reproductive systemthis leads to polymenorrhagia.Excessive coitus, heavy weight lifting, excessive walking etc may cause passive or activecongestion & it causes hypertrophy of myometrium & endometrium. So that uterus enlarges 2-6times from its normal size. A similar vascular upset which involves the ovaries may make themcystic causing polymenorrhoea. This aspect can correlated to the nidana of Bhela ie shonita goesin to dushta marga pratipadyate.Manasik vikriti: Shoka, krodha etc causes Rajoguna bhahulyata, this leads to vyana vata vikritithat leads to Dhatvagni and pitta vikriti and causes Asrgdara.Emotional influences such as changes in enviornment, grief , tension, anxiety, marital upset,stress situation etc affects women’s pshychology , which in turn may influence production ofovarian hormones via H-P-O axis pathway or else produce vasomotor disturbances, both thesecauses DUB.These factors operate through the endocrine system which is influenced by the hypothalamus,more probably through the autonomic nervous system which controls the blood vesselssupplying the pelvic organs. This can be correlated to the nidana ie “chintanam ca ati chintanaat”“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 122
  • 142. DISCUSSION In vandhya, vatapurita ksheera nadi causes vimarga gamana of vata and leads to Asrgdara.Most of the infertile women suffer from some menstrual abnormalities. Milk is formed by theaction of prolactin hormone of adenohypophysis , to which hypothalamus sends an inhibitoryfactor. Abberations of prolactin leads to irregular gonadotrophin production which influences theovary thus formation of estrogen and progesterone may increase, which in turn may produceDUB.Abhighata: Madhava while explaining the nidana, considers Abhighata as one of the causativefactor. This can be analysed as to dosha abhighata or Mano abhighata or any iatrogenic cause astubal sterilization. After tubal ligation, disruption of vascular network between ovary & uterusresults in hormonal imbalance & prolonged oestrogen stimulation of uterus & subsequentprolonged & heavy shedding of endometrium.As asrgdara is characterised by excessive bleeding it leads to complications like balahani, Dhatuksheenata, Dourbalya, pandu, bhrama, angamarda etc. so any disturbances in the H-P-O axiswill alter the ovarian function and there by the menstrual cycle. Menstrual disorders even thoughseem to be a simple disease, can affect her physical and emotional activities. The conventionaltreatments like hormonal therapy, NSAIDS, surgical treatments like D & C, uterine ablations andhysterectomy are not free from complications.Now the treatment needed is pure, synthetic, non hormonal, practical, safe, gentle to improvethe menstrual and ovulatory cycle with no re-occurrence of symptoms and without any adverseeffect on long term usage.In our classics we get various forms of treatments in the management of Asrgdara like oraladministration of Kashaya, choorna, Ghrita, Kalka & Uttara basthi etc.As the disease is characterized by excess flow of blood out of the body & Rakta is known to be avital substance of the body (Jeevana) hence Rakta sthambhaka chikitsa is benificial. Charakaexplains the treatment to be as Rakta yoni ie rakta sthapana after giving due consideration to theassociation of the doshas. He says it to be treated on the lines of Raktaatisara, Shonita pitta &Raktarshas.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 123
  • 143. DISCUSSION As it is known, no disease can occur without the influence of vata, hence such measures whichcan control vata is equally important . Vasti chikitsa forms the apt line of treatment for vatawhich is also mainly indicated in the treatment of Asrgdara.For the treatment of disease, principally 2 types of therapy are employed ie Shodhana &Shamana. It is emphasized by authors that the disease eradicated by means of Shodhana hasnegligible chance of recurrence because vitiated doshas are totally expelled from the body, whereas the disease treated by shamana chikitsa are vulnerable for recurrence because subtle amount ofvitiated Doshas left over in the body may get aggravated with the slightest opportunity.For shodhana chikitsa applied in Arthava vyapath, normally entire Poorva karma &Paschatkarma need to be done. At times it becomes practically difficult to apply due to the timeconsuming, drastic shodhana especially to the women who are already shattered psychologicallydue to their illness and also can not afford prolonged period of treatment.Secondly, Women’s lives are more often have to revolve around a menstrual calendar, withsocial obligations & work commitments being cancelled during the menses. They thus require arapid safe & effective treatment for their menstrual problem.The aim of the treatment of Asrgdara should be • To cease the excessive bleeding • To correct or regularize the Rutu chakra. • To maintain the general health of the body ie ojovriddhi & bala vriddhi • To correct the disease caused by altered & vitiated doshas . • To prevent the complications.Considering this aspect, only such a treatment which can fulfill the basic criterias ieRaktastambaka, Raktapittahara and Bhrumhana effects are disired in the treatment.Thus Kashmari & Kutaja are one such combination, Kashmari phala has tikkta kashaya madhurarasa, guru guna, sheeta veerya, katu vipaka, vatapittahara action & Kutaja has tikta kashaya rasa,laghu ruksha guna, sheeta veerya, katu vipaka, Kapha pitta shamaka property. Gritha is sheetaveerya & pitta vata shamaka property. Both the Kashmari & Kutaja are having Stambhaka &“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 124
  • 144. DISCUSSION Rakta shodhaka qualities thus selected for the study. To evaluate the efficacy of this herbalpreparation it is given in 2 groups in patients of Asrgdara.Whereas, Pushyanuga choorna is well known drug for Asrgdara, wherin majority of the drugs arepossessing tikta kashaya rasa, laghu ruksha guna, sheeta veerya, katu vipaka, Kapha pittahara,Rakta shodhaka & Raktastambaka property.PLAN OF SELECTION OF DRUGS:The innate properties of the drugs have been enlisted in the drug review. Looking in to thesequalities, the probable mode of action is assessed. An attempt is made to analyze the mode ofaction based on rasa panchakas. Majority of the drugs selected for the study possess, Tiktakashaya rasa, Laghu ruksha guna, Sheeta veerya & Katu vipaka. Rasa: Tikta Rasa: Agni vardhaka, there by does Ama pachana. The sanga caused due to Ama is resolved by tikta rasa. Tikta rasa which is known to possess akasha & vayu mahabhoota helps in srotoshodhana. It has a special affinity towards Rakta vaha srotas, does rakta shodhana. Kashaya rasa: Which predominantly possess prithvi & vayu mahabhoota has sthambhana action. Asrgdara characterized by excessive flow of blood (increase in drava pitta & rakta) is benefited by this sthambhana property. Guna: Majority of the drugs possess laghu ruksha guna. As known in the pathogenesis of Asrgdara, there is increase in drava pitta (teja + jala mahabhoota), laghu rukshaguna does the shoshana of the increased jala mahabhoota. Veerya: Majority of the drugs are known to possess sheeta veerya.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 125
  • 145. DISCUSSION  Sheeta veerya Arthava (pitta) Agneya Pitta shamaka Teja mahabhoota Hime sthambhane Jala mahabhoota All the drugs have well established Raktapittahara qualities which acts well against the pathogenesis of Asrgdara . Vyadhi pratyaneeka chikitsa: Due to above said qualities, it acts as sthambhana, raktapittahara, Rakta shodhaka & grahi. Hence its action on the diseases like Ratkapitta, Raktarshas, Pradara etc can be well understood. Some other special actions like, • Kashmarya: It is useful in daha, arti, shotha, jwara, Rakta vikaras. • Kutaja: Is very effective drug in Shoola, Rajodoshas,Yoni dourgandhya Thus it proves its efficacy in improving most of the parameters of symptoms of Asrgdara.As an affirmative to the mode of action explained so far, available research data shows,Kashmarya 1. The alcoholic extracts of stem bark has showed hypoglycaemic activity & anti viral activity. 2. Premnazole showed anti-inflammatory activity comparable to that of phenylbutazone . it probably acts by regulating activity ACTH.Kutaja: 1. Is a reputed drug for chronic dysentery & diarrhoea & specific haemorrhoidal flux. 2. Clinical work on dysentry & diarrhoea showed remarkable improvement. 3. It has Anti bacterial, Anti spasmodic activity, Immuno-modulation activity, Anti diarrhoeal activity, anti micro-bacterial activity.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 126
  • 146. DISCUSSION Comprehensive study of Pushyanuga choorna shows that it contains dravyas of different actions. Musta: Mustaka possess garbhashaya sankochaka property. This proves the uterine muscular activity & helps in endometrial shedding out & does vasoconstriction. Vatsaka (kutaja), Dhataki, Yastimadhu, Arjuna contain tannins which is Anti spasmodic activity. Maricha, shunti possess deepana & pachana properties, which help in proper function of agni. There by does ama pachana and helps in sroto shodhana & raktashodhana. Pata, Bilva,Jambu, Amra,Shalmali, Samanga(manjista), Rakta chandana, Lodra, Gairika, & Kutaja possess Rakta Stambhaka properties owing to kashaya, tikta rasa. Drugs like Mustaka, Chandana, Pashanabheda, Mrdveeka, Katvanga (Aralu), Katphala, contain β-sitosterol as a main chemical component. It is a remarkable plant nutrient. They are proved to be major safe nontoxic nutrients for maintenance of health & protection against many serious disorders. (April 25, 1994, issue of news week.) Plant sterols are believed to be the only natural non-toxic substances having anti- bacterial, anti-microbial & anti fungal activities scientifically prove to have positive effects on female reproductive system especially on uterus. It also contains phyto-estrogen sustances like musta, chandana.In keeping with theories proposed so far, we can safely concluded that all the drugs taken in thepresent study have the capability to act at all levels of the samprapti, thus satisfying “SampraptiVighatanam eva chikitsa”. It also justifies that Asrgdara is to be treated on the lines ofRaktapitta, Raktarshas & Raktaatisara.UTTARA BASTI:From the above discussion, it is clear that Vata is the Anubandhya Dosha in the causation ofAsrgdara. Hence to counteract the disease at the gross root level it is mandatory to treat VataDosha & basti is the main line of treatment.As quoted by Acharya, rÉå xÉÇÌiÉiÉåwÉÉÇ lÉÌWû MüͶÉSlrÉÉå uÉÉrÉÉå: mÉUÇ eÉlqÉÌlÉ WåûiÉÑUÎxiÉ|“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 127
  • 147. DISCUSSION  iÉxrÉÌiÉ uÉ×®¶rÉ zÉqÉÉrÉ lÉÉlrÉSè oÉÎxiÉ ÌuÉlÉÉ pÉåwÉeÉqÉÉÎxiÉ ÌMÇüÍcÉiÉç || iÉxqÉÉΊÌMüixÉÉkÉïÍqÉÌiÉ oÉëÑoÉÎliÉ xÉuÉÉï ÍcÉÌMüixÉÉqÉÌmÉ oÉÎxiÉqÉåMü | (cÉ.ÍxÉ.1/40, 41)In relation to Apaana vayu & its association in the pathogenesis of Asrgdara, Uttara basthi is aprocedure targeted at the apt side of manifestation of the disease, ie Garbhashaya which is theApana vayu kshetra.As per the definition of Uttara basthi it is administered after Niruha Basthi for the purpose ofShodhana. Considering this vital aspect, in the present study in Group ІІІ, Uttara basti isadministered after a course of Yoga basti.As seen in the modern texts, the estrogen metabolized (conjugated) in the liver reaches theintestines where they are broken down by micro organisms & are reabsorbed as active hormone(Entero-hepatic circulation). The disturbance of liver function or intestinal flora can thus alterthis mechanism with subsequent disturbances of menstrual cycle.Analysing this we can state that yoga basti promotes the integrity of intestinal flora. Howeverthis is a point for further analysis.Regarding the time of Administration : x§ÉÏhÉÉqÉiÉïuÉMüÉsÉå iÉÑ mÉëÌiÉMüqÉï iÉSÉcÉUåiÉç | aÉpÉÉïxÉlÉÉ xÉÑZÉÇ xlÉåWÇû iÉSÉÅÅSiÉå ÌWû AmÉÉuÉ×iÉÉ || (cÉ.ÍxÉ.9) ÌlÉrÉiÉÇ ÌSuÉxÉåÅiÉÏiÉå xɃÓûcÉirÉqoÉÑeÉÇ rÉjÉÉ | GiÉÉæ urÉiÉÏiÉå lÉÉrÉÉïxiÉÑ rÉÉåÌlÉ: xÉÇÌoÉërÉiÉå iÉjÉÉ || (xÉÑ.zÉÉ.3/7) ie it is to be administered during Ruru kala, after stoppage of menses. Because during Rutu kala,yoini is Apavruta and during Rutuvyateeta kala yoni becomes sankuchita.Practically after the stoppage of menstruation & up to the day of ovulation, the cervical os isslightly dilated & also free from any obstruction or mechanical barrier. After ovulation the osconstricts a bit & cervical mucous plug is formed with a consistency which does not permit anypenetration. This correlates rightly to the above explanation.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 128
  • 148. DISCUSSION Also during this Rutu kala, sneha is absorbed easily (Sukham sneham tadaadate). Howeveraccording to Astanga sangraha the procedure can be carried out (in atyayika avastha) even otherthan the Rutu kala. ÌuÉkÉiÉÏiÉ iÉSÉ iÉxqÉÉSè AlÉ×iÉÉuÉÌmÉ cÉÉirÉiÉå || (A.xÉÇ.xÉÔ. 28)Probable mode of action in Uttara basti:Intravasation first appears in the uterine wall with rapid dispersion in to the lymphatic andvenous structures. Opacification of the ovarian & iliac veins is often seen.Oily preparation have been more theoretical actions due to their delayed absorption.The Gritha administrated may be thought to have both local & systemic action. ........ AxÉ×aSUå | ÌuÉSkrÉÉSè E¨ÉU oÉÎxiÉ rÉjÉÉxuÉÉæwÉkÉ xÉÇxM×üiÉqÉç || (cÉ. ÍxÉ. 9)The probable mode of action of the selected drugs have already been discussed. Gritha alleviatesPitta & Vata, the basic Doshas involved in the pathogenesis. Gritha impregnated by the otherdrugs facilitates absorption & delivery of the active principles to the target organ & facilitatestransportation to the target organ & final delivery inside the cell.The uterine veins communicate with the vaginal plexuses, which is known for vaginalmetastasis. It is known that vaginal epithelium not only secretes but also absorbs to causesystemic reaction.Thus the local & systemic actions can be analysed as: Local actions like: action on small blood vessels, haemostatic & coagulant action, uterine stimulant activity, potentiation of myometrial & endometrial activity like prostaglandins & the role of Eicosinoids. Systemic actions like anti-oestrogenic activity, conversion of abnormal phospholipid & cholesterol to normal in the liver can be thought of.PLAN OF THE STUDY:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 129
  • 149. DISCUSSION  In the present study, a total of 30 patients suffering from Asrgdara (DUB) were takenfrom OPD & IPD of SDMCA & hospital Udupi. The signs & symptoms of Asrgdara,utrasonography & Endometrial Biopsy were considered for the diagnosis. These 30 patientsbetween age groups of 20-45 years of age were categorized in to 3 groups: GROUP І – 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 ІІ – of 10 patients were administered “Kashmarya kutaja grita uttara basti ” for 3 days after cessation of menstrual bleeding, for one cycle GROUP ІІІ– of 10 patients were administered “Kashmarya kutaja uttara vasti” for 3 days, after a course of “Yoga basthi” for 5 days with “Bala taila anuvasana” and “Dashamoola kashaya niruha vasti” after cessation of bleeding.OBSERVATIONS SEEN IN THE PATIENTS:1. Age : In the present sample taken for the study, patients belonged to the age group of 29-37 years in 53.3%, between 38-45years in 30% and 16.7% were between 20-28 years of age. DUB can occur at any age group, but in present study the incidence was comparatively more during reproductive age. As Asrgdara is a vata pittaja disorder its incidence during the reproductive age group ie when pitta is dominant can be acceptable.2. Socio-Economic status & educational status: With respect to socio-economic status, incidence showed that 70% of patient belonged to middle class, 16.7% to lower class, 13.3% to upper class, where as with respect to educational status, incidence showed that none of the patients were reported to be illiterate. i.e 33.3% patients were studied till high school, 26.67% were educated till degree, 23.33% till pre-degree & 16.67% till primary school. Analyzing the above 2 incidences, it can be noted that there is a correlation between the upper class & well educated, middle class & moderately educated and lower class & less educated groups.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 130
  • 150. DISCUSSION  It can be inferred that the disease is bound to occur in all women irrespective of their socio-economic status & standards of living. Education contributes to better understanding & response of patients towards the treatment.3. Domicile: There was equal distribution of patient according to the incidence of domicile. The abnormal diets, changed life style, increased responsibilities in both urban & rural area women, leading to menstrual abnormalities. Thus shows the equal distribution.4. Religion: Incidence in this showed that majorities were Hindus, represents the dominance of Hindu population in & around udupi.5. Occupation: Occupation has a important role to play in the manifestation of various diseases. Most of the times, it is the root cause of all the unwholesome regimens assumed by a person. In the present study maximum were house wives (63.33%). House hold work, day sleep etc may contribute to vitiation of Doshas. Sexual & psycho-sexual problems can influence the hormonal functions leading to manifestation of the disease.6. Diet: 80% of patients were found to consuming mixed type of diet. Rice & fish forms the major part of the diet in & around Udupi. Most of them are habituated to consume excess amount of katu, amla, lavana rasa. Consumption of fermented food items like dosa, idly etc which contain mainly Masha being arthava janaka, it contributes to the etiology. As described earlier, it should be noted that excess intake of all these food items lead to vitiation of vata, pitta & rakta mainly, thereby substantiating the classical theory of its pathogenesis.7. Ahara shakti & abhyasa: Incidence according to ahara shakti showed that in the present study 73.33% madhyama jarana shakti, 43.33% had heena jarana shakti & 13.33% had pravara jarana shakti. Incidence of abhyasa (habituation) showed that 56.67% were addicted to intake of Tea, 43.33% to coffee & 13.33% to pan chewing. As these are not only ushna veerya dravyas but“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 131
  • 151. DISCUSSION  the chemicals present in that alters the H-P-O axis leads to menstrual abnormalities like DUB.8. Prakruti: Incidence according to prakruti showed majority of patients ie 46.67% to be of pitta kapha prakruti & 36.67% of vatapitta prakruti .This observation does not support the theory of tendency of vata pitta prakruti in Asrgdara. The small number of sample taken for the study is inadequate either to justify or reject this principle.9. Past history: Incidence showed that 80% patients had no relevant past history & 20% had h/o previous illness like malaria, enteric fever etc. however nothing much can be drawn from this incidence.10. Marital status: Incidence according to the marital status showed that 86.67% were married & 13.33% were unmarried. As the treatment involved the procedure of Uttara basti, more number of married patients were selected. Even, In the Group I also 60% were married. This shows that married women are more susceptible for disease because of their increased responsibilities & mental stress.11. Parity: Distribution of patients according to the parity of women showed that 50% were para2, 23% were para1, 19.23% were para3, 3.85% were more than para3 & another 3.85% were nulliparous. Although definite concept regarding the influence of parity can not be drawn. It is believed that due to increased parity there is increased surface area of uterine cavity, resulting in excessive menstrual bleeding. In the study of 30 patients, it was observed that 1 patient had primary infertility.12. Contraception: Majority of patients ie 46.15% had undergone permanent sterilization with tubectomy, 26.92% were had no history of use of any contraception, 19.23% were on pills. It was observed that the problems started years after tubectomy & had not influenced the incidence of Asrgdara.13. Mental stress:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 132
  • 152. DISCUSSION  Incidence in the present study that showed 70% of patients were subjected to mental stress. The increased responsibilities of woman in & outside the family affects her pshychology, which in turn disturbs the H-P-O axis & causes DUB.14. Duration of illness & treatment history: Incidence in the present study showed that 50% were suffering from between 3-6 months, 30% were from between 7-12 months, 13.33% were from1-5 years & 6.67% were from >5 years . Patients who presented with complaints between 3-6 months had no past history of treatment. However those who were suffering from a longer duration undergone various measures of treatments. These findings illustrate the chronicity of illness.15. Pattern of bleeding: Incidence according to pattern of bleeding showed 40% of patients were suffering from excessive bleeding, 26.67% were had prolonged bleeding, 20% had intermenstrual bleeding & 13.33% were had frequent menstruation. Therefore it can be seen that excessive & prolonged bleeding (Asrk deeryate) was common manifestation of Asrgdara than frequent & intermenstrual bleeding (anrutavapi cha). It can be thus concluded that Asrgdara is a disease characterized by excessive & prolonged , frequent, intermenstrual acyclic bleeding.16. Pain: Incidence according to pain showed that 46.67% of patients had no pain, 36.67% had mild pain & 13.33% had moderate pain. . Painless bleeding is said to be due to anovulatory cycles is most common in DUB. It is shown by Aickles et.al (1964) as quoted by Deshpande that there is a lipoid substance present in the endometrium during menstruation & it appears after ovulation. This lipoid is obtained in 3 fractions and all the 3 fractions have a stimulatory effect on the myometrium to cause its contraction. Its absence in anovular menstruation is the cause of painless menstruation. It appears that mechanism of control of menstrual bleeding may have 2 components ie myometrial contraction & vasoconstrictions. Absence of contractile substance in the endometrium in DUB may be one of the cause for profuse bleeding. Though the disease is pitta predominant, incidence of pain shows association of vata.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 133
  • 153. DISCUSSION 17. Assosiated symptoms: Since the pathogenesis of Asrgdara involves the vitiation of vata & pitta doshas & kshaya of Rakta dhatu. Various associated symptoms are found in the patients like weakness, bodyache, low backache, headache, giddiness, depression, lack of concentration etc.18. Haemoglobin % Observations revealed the incidence of anaemia of various degrees ie mild to moderate. This may be due to the excessive blood loss during the menstruation. Other routine haemotological investigations like bleeding time, clotting time, total count & differential count were found to be in normal range.Effect of treatment:The assessment of the results were made by adopting the standard methods of scoring the signs& symptoms. Follow up of all the cases was carried out up to 2 consecutive menstrual periodsafter treatment.All the observations regarding the changes in the menstrual variables like the duration ofbleeding, amount of bleeding, consistency, pain during menstruation, reduction in the associatedsymptoms and the mean Hb% were assessed. 1. Effect on duration of bleeding: On the individual assessment of all cases, it was found that there was gradual reduction in the symptoms of duration of bleeding which was assessed on the number of days, the patient had bleeding during menstruation before treatment & after treatment. i.e during each monthly follow up. In group I, the mean score of duration of bleeding reduced from 1.5 to 0.7 during 1st follow up & which was increased to 0.8 during 2nd follow up. On statistical analysis P values were <0.001 & = 0.010 during 1st & 2nd month respectively, showing that the symptoms of duration of blood loss was statistically significant during both 1st month & 2nd month. In group II, the mean score reduced from 2.3 to 0.9 after treatment in 1st follow up & was remained same in 2nd follow up, which was statistically significant with P value =<0.001.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 134
  • 154. DISCUSSION  In group III, the mean score was reduced from 2.6 to 0.7 after treatment on 1st follow up & remained same on 2nd follow up, which was statistically significant with P value =<0.001, showing that symptoms of duration of blood loss was statistically significant throughout. Comparison between the groups were analyzed by applying Anova test which was significant with P value <0.001. This means group III is more effective in reducing the severity of duration of bleeding in comparison to group II & group I. Thus it proves the effectiveness of the shodhana chikitsa by expelling the doshas out from the body. 2. Effect on amount of blood loss: In group I, the mean score of amount of bleeding reduced from 1.6 to 0.8 during 1 follow up & was increased 0.9 during 2nd follow up. On statistical analysis P values st were =<0.001 & =0.001 during 1st & 2nd month respectively, showing that the symptoms of amount of blood loss was statistically significant during both 1st & 2nd month. In group II, the mean score of amount of bleeding reduced from 2.5 to 0.8 during 1st follow up & remained same during 2nd follow up, which was statistically significant with P value =<0.001 showing that symptoms of amount of blood loss was statistically significant throughout. In group III, the mean score of amount of bleeding reduced from 2.7 to 0.6 during 1st follow up & which remained the same during 2nd follow up, which was statistically significant with P value =<0.001, showing that the symptoms of amount of blood loss was statistically significant throughout. Comparison between the groups was analyzed by applying Anova test which was significant with P value <0.001. This means group III is more effective in reducing the severity of amount of bleeding in comparison to other 2 groups & group II showed moderate results. Thus shows the efficacy of both yoga basti & Uttarabasti in treating the heavy menstrual flow. 3. Effect on interval of bleeding:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 135
  • 155. DISCUSSION  In group I, the mean score of interval of bleeding reduced from 1.2 to 0.5 during 1 follow up & was increased 0.6 during 2nd follow up. On statistical analysis P values st were =0.001 & = 0.005 during 1st & 2nd month respectively, showing that the symptoms of amount of blood loss was statistically significant during both 1st & 2nd month. In group II, the mean score of interval of bleeding reduced from 1.2 to 0.4 during 1st follow up & was remained same during 2nd follow up. On statistical analysis P value was =<0.001, showing that the symptoms of amount of blood loss was statistically significant during both 1st & 2nd month. In group III, the mean score of interval of bleeding reduced from 1.5 to 0.3 during 1st follow up & which remained the same during 2nd follow up, which was statistically significant with P value =<0.001, showing that the symptoms of amount of blood loss was statistically significant throughout. Comparison between the groups was analyzed by applying Anova test which was significant with P value = 0.042. ie Group III showed better results, group II showed moderate effectiveness & group I was less effective. 4. Effect on consistency: In group I, the mean score of consistency before treatment which was 1.6 reduced to 0.7 during 1st follow up & which was increased to 0.8 in 2nd follow up. On statistical analysis P values were =<0.001 & = <0.001 during 1st & 2nd month respectively, showing that the symptoms of amount of blood loss was statistically significant during both 1st & 2nd month. In group II, the mean score of consistency was reduced from 1.7 to 0.6 after treatment & remained same on 2nd month. It is also significant statistically with P values <=0.001, showing that the symptoms of consistency of blood was statistically significant throughout., In group III, the mean score of consistency before treatment 1.5 reduced to 1.2 after treatment & remained same during 2nd month follow up . It is also significant statistically with P values <=0.001 Comparison between groups was done by applying Anova test which showed statistically significant difference (P = 0.028). ie Group III showed better results when“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 136
  • 156. DISCUSSION  compared to group I, but not to the group II. This means both the yoga basti with uttara basti & only uttara basti are showed same effect on consistency. 5. Effect on pain during menstruation: In group I, mean score of pain reduced from 1.2 to 1.0 during 1st month & which was remained same during 2nd month follow up. On Statistical analysis P values was =0.168, showing that the symptoms of pain during menses was statistically insignificant during both 1st & 2nd month. In group II, mean score of pain reduced from 1.3 to 0.8 after treatment & remained same during 2nd follow up. Statistical analysis was significant with P value 0.015. In group III, the pain after treatment was reduced from 2.3 to 0.4 & was remained same in the 2nd follow up. Statistical analysis was significant with P value =<0.001. Comparison between groups was analyzed by applying Anova test which was significant with P value <0.001. Overall, the effect on pain during menstruation in Group І & ІІ showed only mild improvement after the completion of treatment. Whereas Group IIІ is more effective in reducing the severity of pain during menstruation. As basti is the apt line of treatment for vata, which is the root cause for pain, Yoga basti revealed excellent results on treating it. 6. Effect on associated symptoms: In group I, the mean score improved from 1.6 before treatment to 0.7 after treatment & was 0.9 on 2nd follow up. Which was significant statistically with P value <0.001 & =<0.001 respectively. In group II, the mean score improved from 1.3 before treatment to 0.4 after treatment which was significant statistically with P value =<0.001. In group III, the mean score improved from 1.9 before treatment to 0.6 after treatment which was significant statistically with P value =<0.001“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 137
  • 157. DISCUSSION  Comparison between groups was analyzed by applying Anova test which was significant with P value 0.038. Group III showed better results on associated symptoms like low backache, body ache, pain in the calf muscles etc. whereas other 2 groups showed mild improvements.Overall effect of therapies:In the overall effect of therapies it was noted that, Group Cured (in %) Improved (in %) No change (in %) Group I 05 75 20 Group II 10 80 10 Group III 30 70 00 There was no deterioration noted in any of the 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.The medicines administered in all 3 groups of the study have shown reduction in almost allparameters of assessment. On comparison of the effect between the 3 groups, excellent response was observed ingroup III who were administered with Uttara basti followed by Yoga basti. Thus it stronglyproves the efficacy of shodhana chikitsa in treating the Asrgdara. Comparison between Group II & group III, Group II helped to bring about moderateimprovement in most of the parameters, yet clinically & statistically the improvement was better“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 138
  • 158. DISCUSSION seen in Group III. However it can not be concluded that only Utara basti is comparatively lesspotent as the sample size is small & treatment duration is less ie only for 3 days in one cycle. However group I also responded better & thus can be prescribed for longer duration withpromising results.Special observations: During the course of treatment, it was observed that in 2 patients who received oral treatment had recurrence of bleeding in 7days gap, but the planned treatment was continued. This episode of bleeding did not recur during the follow up period. In the present study 3 patients presented with continuous spotting of 2-3 months preceded by period of Amenorrhea. They were planned for Uttara basti followed by yoga basti treatment. There was remarkable improvement in all the 3 patients after the administration of treatment. In the present study out of 30 patients, 4 patients presented with foul smell in menstrual blood before treatment which was cured after Uttara basti treatment in all the patients. 3 patients presented with white discharge per vaginum along with the low backache, that was also showed remarkable reduction after the Uttaravasti with yoga basti treatment. It was observed that all the patients could tolerate the treatment quite well, except in some patients who developed mild pain in the lower abdomen after the uttara basti procedure, which was relieved by rest. Apart from this no other adverse reaction to the procedure was noted.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 139
  • 159. SUMMARY   SUMMARY“A clinical evaluation of the effect of the Uttara basti in Asrgdara w.s.r to Dysfunctional uterinebleeding” is the title of the present dissertation work. The whole study was elaborated in 4 parts • Conceptual study • Clinical study • Discussion • Conclusion The dissertation start with the literary review of the subject taken for the study, is the Ist section. Historical aspect discussed in the 1st chapter. Physiology of Arthava is dealt in in 2nd chapter. Physiology of menstruation in 3rd chapter. The general description of Asrgdara like nirukti, nidana, normal physiology, clinical manifestation, principles of treatment, prognosis & differential diagnosis all are dealt in 4nd chapter. Review of DUB dealt in 5rd chapter. Review of Uttara basti in 6th chapter Review of basti in 7th chapter The review of the drugs selected for study is dealt in detail in 8th chapter. Clinical part is the ІІnd section of the dissertation. The material & method including selection of patients for study, laboratory investigations, plan of study & citeria for assessment of results are explained in this part. All the results obtained in all the 3 groups were analysed by statistical methods & are methodically presented in the chapter of observations and results. The interpretation of the results obtained with the possible mode of action of the drugs selected is presented in the IIIrd section – Discussion. Conclusion: The conclusions are drawn from the present study are enlisted in IV section.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 140
  • 160. CONCLUSIONS  CONCLUSIONSObservations: In the present study patients between 20-45 years of age were selected for which maximum werebetween 30-37 years of age, belonging to middle socio-economic class, were of equaldistribution according to domicile, most of them were having mixed diet, maximum patientswere house wives & 70% were subjected to mental stress, 46.67% were of Pitta kapha prakriti,86.67% were married, 50% were para2, 3.85% were of nulliparous & maximum patients hadundergone ligation.Incidence according to pattern of bleeding showed 40% were having excessive bleeding , 26.7%had prolonged bleeding, 20% had intermenstrual bleeding, 13.3% had freqent menstruation.Incidence according to pain showed 36.67% had mild pain & 13.33% had moderate pain.Patients reported assosiated symptoms like bodyache, weakness, low backache, headache,giddiness etc. Incidence of anaemia was noted in maximum number of patients.Results:There was marked reduction in the mean score of all the parameters of assessment ie duration ofbleeding, amount of blood loss, consistancy, odour, staining, pain & assosiated symptoms in allthe 3 groups which was also statistically significant. • However on comparision between the groups clinically & statistically, Group III has shown excellent results, wherin Group II & I had less response in comparision to Group III. 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.Conclusions drawn from this study are enlisted below:“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 141  
  • 161. CONCLUSIONS  Asrgdara is well described gynaecological disorder by all the Acharyas, covering the etiopathology at every level of female physiology. It includes a spectrum of nidana like dietic causes to previous incidence of obstetrical complications like garbhapatha & ksheera vaha nadi vikriti. After critical analysis, it can be concluded that Asrgdara can be compared to DUB. The incidence of Asrgdara is high among the women of reproductive age & of perimenopausal age. The incidence is irrespective of the socio-economic status, domicile or education status. However dietary habits, mental status plays an important role in the etiology, hence the incidence is increasing day by day. It is the disease which deteriorates the health of the woman in due course of time. Though the disease in modern science is dealt with various therapeutic options ie medical (hormonal &/or non-hormonal) and surgical (D & C, endometrial ablation, hysterectomy) yet no treatment is free of side effects like headache, GIT disturbances, weight gain etc. Pushyanuga choorna possessing Rakta stambaka & Rakta shodhaka properties and proved the efficacy in treating the Asrgdara. Kashmarya & Kutaja possess rakta stambaka & rasayana properties and are Phyto estrogen drugs. Kashmari fruit is well known drug for ratapitta & which contain beta- sitosterol as its main chemical constituent. It acts directly on muscular fibres in the uterus. And has got stimulating effect on the endometrium and on the ovarian tissue. The classical preparation “Kashmarya Kutaja Grita” has proved to be quite effective in treatment of Asrgdara without involving any desirable side effects. Significant improvement is seen in all the criteria of assessment in treating Asrgdara. Reoccurence of the symptoms not seen in the trial groups. Significant change is seen in pain, associated symptoms & Hb% in trial group. Comparision between 3 groups showed significant result for most of the parameters. ie Group III showed excellent results on almost all the parameters of assessment on comparison to group II & group I. Thus shows the importance of shodhana chikitsa.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 142  
  • 162. CONCLUSIONS  Group II helped to bring about moderate improvement in most of the parameters. However it can not be concluded that only Utara basti is comparatively less potent as the sample size is small & treatment duration is less ie only for 3 days in one cycle. Thus we can conclude that Pushyanuga choorna & Kashmarya Kutaja Grita have marked good results in treating the Asrgdara, these are non hormonal inexpensive, easily available & applicable type of treatment in Asrgdara & as effective as progesterone hormone. Uttara basti done under complete aseptic precautions with modified simple method of administration has proved to be safe with encouraging results in the present study.Suggestions: Results of the treatment can be better analysed by noting changes in the thickness of the endometrium (by USG) before & after treatment (ie during follow up period), changes in the histological pattern of the endometrium before & after treatment and carrying out hormonal assays to note for any changes at the hormonal level. The current study was carried on a small sample for a partial time & it showed hopeful results. Working up upon larger samples & long duration of treatment with practical modifications as the disease runs a chronic course may help to bring about a better results. And hormonal effect of these drugs can be studied in menstrual and ovulatory cycles. Invitro and Invivo experiments may help for better confirmation of the action of drug & procedure. However, practically carrying out a course of “Uttara basti” in 3 consequent cycles after “yoga basti” can help to bring better results than observed in the present study.“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 143  
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  • 171. BIBILOGRAPHY  106. Vagsena, Vagasena samhita, Dr. Nirmal saxena, Choukamba samskruta series office, Vranasi, 1st edition, 2004 Pp1327, p1145 107. Vagbhata Ashtanga samgraha, indu teeka, choukamba samskruta samsthana, Varanasi Delhi, Pp967, p207 108. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p720 109. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p720 110. Sushruta, Sushruta samhita with nibandha samgraha commentary by Dalhanaacharya, edited by Vaidhya Jadavjee Trikambajee Achaarya, from the beginning of 4th adhyaya of chikitsa sthana, surabharathi prakashana, Varanasi, Reprint 2003, Pp824, p537 111. Vagbhata Ashtanga samgraha, indu teeka, choukamba samskruta samsthana, Varanasi Delhi, Pp967, p216 112. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p720 113. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p721 114. Sushruta, Sushruta samhita with nibandha samgraha commentary by Dalhanaacharya, edited by Vaidhya Jadavjee Trikambajee Achaarya, from the beginning of 4th adhyaya of chikitsa sthana, surabharathi prakashana, Varanasi, Reprint 2003, Pp824, p537 115. Sushruta, Sushruta samhita with nibandha samgraha commentary by Dalhanaacharya, edited by Vaidhya Jadavjee Trikambajee Achaarya, from the beginning of 4th adhyaya of chikitsa sthana, surabharathi prakashana, Varanasi, Reprint 2003, Pp824, p538 116. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p721 117. Sushruta, Sushruta samhita with nibandha samgraha commentary by Dalhanaacharya, edited by Vaidhya Jadavjee Trikambajee Achaarya, from the beginning“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 152
  • 172. BIBILOGRAPHY  of 4th adhyaya of chikitsa sthana, surabharathi prakashana, Varanasi, Reprint 2003, Pp824, p538 118. Vagbhata Ashtanga Sangraha, Indu teeka, choukamba samskruta samsthana, Varanasi Delhi, Pp967, p216. 119. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p721 120. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p720 121. Vagbhata Ashtanga Sangraha, Indu teeka, choukamba samskruta samsthana, Varanasi Delhi, Pp967, p216. 122. Vagbhata, Ashtanga Hrudaya, with commenteries of Arunadatta & Hemadri, edited by Bhishgaachaarya Hari shastri paradakara vaidhya, choukamba oriental, Varanasi, Reprint 9th edition, 2005, Pp956, p283 123. Sushruta, Sushruta samhita with nibandha samgraha commentary by Dalhanaacharya, edited by Vaidhya Jadavjee Trikambajee Achaarya, from the beginning of 4th adhyaya of chikitsa sthana, surabharathi prakashana, Varanasi, Reprint 2003, Pp824, p538 124. Vagsena, Vagasena samhita, Dr. Nirmal saxena, Choukamba samskruta series office, Vranasi, 1st edition, 2004 Pp1327, 125. Agnivesha charaka samhita with teeka of chakrapanidatta, edited by jadvjee trikambajee achaarya, choukamba samsthna, Varanasi, 5th edition 2001, Pp738, p721 126. Bhavamishra, Bhavaprakasha including nighantu, Sri Bramha shankara mishra, part 1st, choukamba Sanskrit samsthana, Varanaasi, 11th edition 2004, Pp929 127. Vagbhata, Ashtanga Hrudaya, with commenteries of Arunadatta & Hemadri, edited by Bhishgaachaarya Hari shastri paradakara vaidhya, choukamba oriental, Varanasi, Reprint 9th edition, 2005, Pp956, p283. 128. Vachaspatya-Shree Taranatharaka Vachaspathi Bhat, 3rd edition 1968, Choukamba Sanskrit serried, Varanasi, Pp-5442, P.no-4864 129. Vachaspatya-Shree Taranatharaka Vachaspathi Bhat, 3rd edition 1968, Choukamba Sanskrit serried, Varanasi,Pp-5442,P:4864“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 153
  • 173. BIBILOGRAPHY  130. Agnivesha, Caraka samhita siddisthana, Acharya Yadavji Trikambaji, Choukamba publications, reprint 2000, Varanasi Pp738, P.no-648 131. JLN Shastri, Dravya guna vigyana, vol-2, 2nd edition, 2004, choukambha orientalia, Varanasi, Pp 1134: 426 132. Sharma P.V., Dravya guna, Vigyana, vol-2, 1999, choukambha Bharati academy, Varanasi, Pp 873: 225 133. Bhavamishra, Bhavaprakasha, Edited with vidyotini Hindi commentary by Bhishagrathna Pandit Shri Brahma shankara Mishra, Vol II, 11th edition 2003, Chaukamba orientalia Varanasi, Pp:836 134. JLN Shastri, Dravya guna vigyana, vol-2, 2nd edition, 2004, choukambha orientalia, Varanasi, Pp 1134:428 135. Sharma P.V., Dravya guna, Vigyana, vol-2, 1999, choukambha Bharati academy, Varanasi, Pp 873: 463 136. Bhavamishra, Bhavaprakasha, Edited with vidyotini Hindi commentary by Bhishagrathna Pandit Shri Brahma shankara Mishra, Vol II, 11th edition 2003, Chaukamba orientalia Varanasi, Pp:836 137. JLN Shastri, Dravya guna vigyana, vol-2, 2nd edition, 2004, choukambha orientalia, Varanasi, Pp 1134: 328 138. Agnivesha: Charaka samhita, Varanasi, Chaukambha Sanskrit sansthana, reprint 2004, Pp 738:638 139. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and Ayurveda Rasayana of Hemadri Vaghbhata, 9th edition 2002, Chaukhambha orientalia, Varanasi, Pp: 946:900“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 154
  • 174. ANNEXURE DEPARTMENT OF PRASOOTI TANTRA & STREE ROGA, S.D.M.C.A UDUPI CASE PROFORMA OF CLINICAL STUDY IN ASRGDARA (DUB) Student: GUIDE: Dr. Deepashree Dr.G.Ramadevi M.D. (Ayu) PG Scholar Asst. Professor. Atura vivara Pt. name : Age : OPD No : Religion : IPD No : Education : D/O Admission: Occupation : D/O Discharge: Marital status : Address: Socio-economic status : Main complaint:H/O Present illness: 1. Artava sambandhi: Duration of illness : LMP : Onset : Duration of Blood loss : Interval of Blood loss : Amount of Blood loss : i) No. of pads per day : 155  
  • 175. ANNEXURE  Character: i) Colour : Brick red/Dark red/ Brown/Pale red ii) Consistancy : watery/watery+clots /clots iii) Staining : Present / Absent iv) Odour : Present / Absent 2. Vedana sambandhi : Pain : Present /Absent : Premenstrual/ During menses / Continuous Intensity : Mild / Moderate / Severe Aggravating Factors : Relieving factors: 3. Anya yoni srava: Vaginal Discharge : Present / Absent Amount : Mild /Moderate / Severe Character : i) Colour ii) Consistancy iii) Odour Relation with Menses : Before/ During / After 4. Anubandha vedana: Headache Rise of temperature Giddiness Low backache Excessive sweating Depression Bodyache Vomiting. Lack of concentration Weakness Loose stools Burning sensation Pain in calf muscles Hot flushes Breast tendernessPoorva vyaadhi vrattanta : H/O HTN, DM, UTI, Thyroid, Genital infectionKoutimbika Vrattanta: H/O DUB, LSCS, DM, HTN, TB, Thyroid 156  
  • 176. ANNEXURE Rajo vrattanta: Menarche : LMP : Previous Menstrual History : Other Relevant Factors :Obstretic History: Married life: G :P : L : D : A Last Delivary: Gravida Antenatal Events Mode of delivary Post partum Events 1 2 3Contraceptive History: Safe method Contraceptive pills IUCD LigationPersonal History: Diet : Appetite : Addictions : Sleep : Bowel : Micturition :General Examination: Built : Nourishment : 157  
  • 177. ANNEXURE  Height : Weight : Pallor : Odema : Nail changes : Conjunctiva : Icterus : Lymph odenopathy : Neck : Thyroid – Normal / Abnormal Any otherVital signs: Pulse : B.P : Tempt.: Heart Rate : Respiratory Rate :Dasha vidha pareeksha Prakruti : Vikruti : Sara : Samhanana : Pramaana : Satmya : Satva : Ahaara shakti : Vyayama shakti : Vaya : 158  
  • 178. ANNEXURE Ashta vidha pareeksha Nadi : Mootra : Mala : Jihva : Shabda : Sparsha : Druk : Aakruti :Systemic Examination Respiratory CVS GIT Nervous System OthersAbdominal Examination Inspection Palpation Percussion AuscultationBreast Examination Right – Lump / Tenderness Left – Lump/ TendernessExamination of Reproductive System Vulva :Per speculum : Vagina : Colour / Condition Cervix : Normal / Congested / Hyper-trophied P/V examination: Cervix : Size – Normal / Abnormal 159  
  • 179. ANNEXURE  Condition – Healthy / Unhealthy Consistancy –Soft / Firm / Hard OS –Nulliparous / Multi parous Uterus: Size – Normal / Abnormal Position – AV / RV Mobility –Mobile / Fixed Consistancy – Soft / Firm/ Hard Fornixes – Palpable: Normal / TenderInvestigations Blood group & Rh Typing : Hb% : CT, BT: Urine routine & Micro : USG : Endometrial Biopsy :Upashaya – Anupashaya :Vyaadhi :Upadrava :Sadyaasadhyata :Chikitsaa : 1. Oral medication: Drug : Dose : Anupana : Duration of Treatment : Follow-up : 160  
  • 180. ANNEXURE  2. Uttara basti: Poorva karma: Procedure 1st day 2nd day 3rd day 4th day 5th day Bala taila TOA Anuvasana Complications Basti Dashamoola TOA Kashaya Niruha Basti TOE Complications Pradhana karma: Procedure 1st day 2nd day 3rd day Snehana,swedana Uttara basti TOA Dosage Complications Pashchaat karma: 1st 2nd 3rd 4th 5th 6th 7th 8th Diet Regimen 161  
  • 181. ANNEXURE Follow-up assessment: Sl.No 1st follow-up 2nd follow-up 1 LMP 2 Duration of Bleeding Normal: 3-4 days – 0 Mild: 5-6 days – 1 Moderate: 6-10 days – 2 Severe: >10-15 days – 3 3 Amount Normal: 2-3pads – 0 Mild: 4-5 days – 1 Moderate: 6-7 days – 2 Severe: 7 or >7pads/day –3 4 Interval Normal: 28-35 days – 0 Frequent: once in 20 days – 1 Intermenstrual: once in 15days - 2 5 Colour Pale red/ Brick red/Dark red/ Brown 6 Consistancy Watery: 0 Watery + clots : 1 Clots: 2 7 Staining Absent: 0 Present: 1 7 Odour Absent: o Present: 1 8 Intensity of Pain No pain: 0 Mild pain: Tolerable – 1 Moderate: disturbs daily work- 2 Severe: needs medication – 3 9 Other vaginal Absent: 0 discharge Present: 1 10 Assosiated symptoms i) Headche Absent: 0 Present : 1 ii) Low backache No Pain: 0 Mild: 1 Moderate: 2 162  
  • 182. ANNEXURE  Severe: 3 iii) Bodyache & No: 0 Mild: 1 iv) Weakness Moderate: 2 Severe: 3 v) Giddiness Absent: 0 Present: 1 vi) Depression Absent: 0 Mild : 1 Moderate: 2 Severe: 3 vii) Lack of Absent: 0 concentration Present: 1 viii) Rise in Afebrile: 0 temperature Febrile : 1 ix) Excessive Absent: o sweating Present: 1 x) Vomitting Absent : 0 Present: 1 xi) Loose motion Absent: 0 Present: 1 xii) Pain in calf Absent: 0 mm Present: 1 xiii) Breast Absent: 0 tenderness Present: 1Result :Signature of the candidate Signature of Guide 163  
  • 183. Drugs CONCEPTUAL STUDY   DRUG REVIEWDravya is the instrument in the hands of the physician to combact the disease pathology in thebody. In charaka shareera emphasis is given about the knowledge of drug & clearly mentionedthat person who does not know about the drug is not a vaidya but is a killer because without theknowledge, the drug is poison. Any dravya becomes a Bheshaja when it is used in the right form& dose (ca.sha.1/135).In the present study Kashmarya Kutaja Grita & Pushyanuga choorna are the drugs of choice.The proposed drugs are described in ayurvedic classics in the treatment of Asrigdara.KASHMARYA KUTAJA GRITHA: MüÉzqÉrÉï MÑüOûeÉ YuÉÉjÉ ÍxÉ®Ç E¨ÉU oÉÎxiÉlÉÉ | U£ürÉÉålrÉUeÉxMüÉlÉÉÇ mÉѧÉblrÉÉ¶É ÌWûiÉÇ bÉ×iÉqÉç || (cÉ.ÍcÉ.30/100)Method of preparation: Kashmarya Kutaja grita is prepared in SDM pharmacy according to the general procedure explained in Grita Kalpana vidhi of Baishajya ratnavali. Kashmari 131, 132, 133:´ÉÏmÉhÉÏï qÉkÉÑUÉ ÌiÉ£üÉ uÉÏrÉÉåïwhÉ uÉUÉ aÉÑÂ:|SÏmÉlÉ mÉÉcÉlÉÉå qÉåkrÉ pÉåÌSlÉÉå pÉëqÉ zÉÉåwÉÎeÉiÉç |SÉåwÉ iÉ×whÉÉqÉzÉÔsÉÉzÉÉåï ÌuÉwÉSÉWû euÉUÉmÉWûÉ || (Mæü.ÌlÉ)  B. N : Gmelina arboreaFamily: VerbanaceaeSynonym: Shriparni, Gambhari, Peetarohini, Madhuparnika, MadhuparniGana: Shothahara, virechanopaga, daha prashamana (Charaka)“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 57 
  • 184. Drugs CONCEPTUAL STUDY   Bruhat panchamoola, Sarivadi (Sushruta)“Kashmarya phalam rakta sangrahika raktapitta prashamanaanam” || (C.Su.25/40)Features : A moderate sized tree reaching 18 ft., leaves are laarge cordate-ovate, flowers areyellow, tinged with brown, Fruits-drupes, yellow when ripe, seeds-oblong. Flowering inFebruary-April & Fruiting in April-July.Destribution : Found throughtout Deccan Peninsula.General description: According to Charaka its fruit as best among Rakta-Sangrahaka andRaktapittahara (C.S.Su.25). Its fruit is one among the ‘Madhura Triphala’ & is considered as asubstitute for Draksha. It is Brmhana, Vrshya & Rasayana in nature.Prayojya anga: Moola, twak, phala, pushpa, patraChemical constituents: β-sitosterol, Premanazole, Traces of alkaloid, traces of benzoic acid,resinous & saccharine substancesPharmacological action: Tonic, stomachic, laxative, glactogogue, as a nerve tonicReaserch studies of Kashmari136: 1. The alcoholic extracts of stem bark has showed hypoglycaemic activity & anti viral activity against Ranikhet disease virus (Dhar et al., 1968) 2. The rasayana effect of the fruits was studied in Rabbits, an increase in the % of α2 and γ- globulins, gain in body weight & alertness in physical behavior was observed after treatment. 3. Premnazole showed anti-inflammatory activity comparable to that of phenylbutazone . it probably acts by regulating activity ACTH 4. The study revealed that the liquid extract from its bark is strongly astringent & contain beta-sitosterol. It acts directly on muscular fibres in the uterus. And has got stimulating effect on the endometrium and on the ovarian tissue.(Reference: India, J pharm, Sci 1992)“A clinical evaluation of the effect of Uttara basti in Asrgdara w.s.r.to dysfunctional uterine bleeding ”Page 58