Shweta pradara psr

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Clinical evaluation of patrangasava & amalaki beeja choorna in shweta pradara w.s.r leucorrhoea, Rekha G N, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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Shweta pradara psr

  1. 1. ‘‘A CLINICAL EVALUATION OF PATRANGASAVA &AMALAKI BEEJA CHOORNA IN SHWETA PRADARA w.s.r LEUCORRHOEA ” By Dr. REKHA.G.N, B. A. M. S. Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of MASTER OF SURGERY (Ayu) In PRASOOTI TANTRA AND STREE ROGA Under the guidance of DR. RAMADEVI G., M.D. (Ayu) Professor, S. D. M. C. A., Udupi DEPARTMENT OF POST GRADUATE STUDIES IN PRASOOTI TANTRA & STREE ROGA S. D. M. COLLEGE OF AYURVEDA, UDUPI 2010-2011
  2. 2. R G U H S DECLARATIONI hereby declare that this dissertation entitled “A CLINICALEVALUATION OF PATRANGASAVA & AMALAKIBEEJA CHOORNA IN SHWETA PRADARA w.s..rLEUCORRHOEA ” is a bonafide and genuine research workcarried by me under the guidance of Dr. RAMADEVI G., M.D. (Ayu). Signature of the candidate REKHA.G.N. B. A. M. S. Date: Place: Udupi
  3. 3. R G U H S CERTIFICATE BY THE GUIDEThis is to certify that the dissertation entitled “A CLINICALEVALUATION OF PATRANGASAVA & AMALIKI BEEJACHOORNA IN SHWETA PRADARA w.s..r TOLEUCORRHOEA” is a bonafide research work done by REKHA.G.N. inpartial fulfillment of the requirement for the degree of M.S.(Ayu). Signature of the Guide Dr.RAMADEVI.G., . M.D. (AYU) Professor Dept. of Prasooti tantra & Stree roga, UdupiDate:Place: Udupi
  4. 4. R G U H SENDORSEMENT BY THE HOD, PRINCIPAL/ HEAD OF THE INSTITUTIONThis is to certify that the dissertation entitled “A CLINICALEVALUATION OF PATRANGASAVA & AMALAKI BEEJACHOORNA IN SHWETA PRADARA w.s..r LEUCORRHOEA”is a bonafide research work done by REKHA.G.N. under the guidance ofDr.RAMADEVI. G., M.D. (Ayu), Professor, Department of Prasooti tantra andStree roga. Dr. V.N.K. Usha Dr.U.N. Prasad HOD & Professor PRINCIPALSDM College of Ayurveda SDM College of Ayurveda Udupi UDUPI. . Date: Place: Udupi
  5. 5. COPYRIGHT DECLARATION BY THE CANDIDATEI hereby declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate thisdissertation/ thesis in print or electronic format for academic / researchpurpose. Signature of the candidate REKHA.G.N. B. A. M. S. Date: Place: Udupi © Rajiv Gandhi University of Health Sciences, Karnataka .
  6. 6. ACKNOWLEDGEMENT xÉWûxÉëɤÉÇ aÉhÉÉkÉÏvÉÇ xuÉaÉÑÂÇ cÉ xÉUxuÉiÉÏqÉç | eÉlÉMüÇ eÉlÉÌrɧÉÏÇ cÉ vÉÉx§ÉÉSÉæ mÉëhÉqÉÉqrÉWûqÉç || ‘‘First and foremost in bow head at the feet of Lord and my Parents. No wordscan express my gratitude for their love and encouragement, with warm heart to myloving two brothers and my better half.’’ It is indeed a pleasure to have carried out this dissertation work at SriDharmasthala Manjunatheshwara College of Ayurveda, Udupi. In this regard, I wouldlike to express my heart felt gratitude to Honorable Dr. D. Veerendra HeggdeDharmadhikari Sri kshetra Dharmasthala, president of Sri DharmasthalaManjunatheshwara Educational Society (regd) for his courtesy, grace and blessing tocarry out this work. My hearty thanks to my respected guide, Dr. Ramadevi G. Professor Departmentof Prasuti tantra & Streeroga, SDM of College of Ayurveda, who inspired me in each andevery aspects of my study, who filled knowledge & courage throughout my study. My hearty thanks to my respected madam, Dr. Usha V.N.K.Prof. & HOD,Department of Prasuti tantra and Streeroga, of SDM College of Ayurveda, whoencouraged me in each and every aspect of my study provided valuable guidelines. I am grateful to Dr.U.N.Prasad Principal and Dr. U. Govind Raju, Prof. and Deanof PG Faculty, SDM of College of Ayurveda, for his invaluable support and guidance forthe completion of this thesis.
  7. 7. Also my sincere thanks to my respected Dr. Mamatha K.V. Professor Department ofPrasuti tantra & Streeroga for providing me valuable knowledge and gave exposure topractical aspects of the subject. I honestly thank Dr. Suchetha, Dr. Vidya ballal, and Dr. Veena Mayya for theirvaluable help in my study.My heartly thanks go to Dr. Krishna Bai who gave me opportunity for gaining practicalknowledge, carrier guidelines. I also extend my thanka to Dr.Y.N.Shetty, Medical superdent, SDM of College ofAyurveda for providing all the facilities in hospital to carry out the work successfully. I would like to thank all my friends and colleagues Dr.Prathima, Dr.Rachana ,Dr.Padma saritha, Dr.Deepashree, Dr.Sunitha, Dr.Radhika for their help in differentaspects. Last but not the least I owe my indebtedness to all my patients whose totalsupport made me to complete this work successfully.My thanks to them in ‘fine print’ Without the support of Sampark Xerox, UDUPI, my work would not have cometo ‘life’. I acknowledge my sincere thanks to all those who helped me during this study. DR. REKHA.G.N.
  8. 8. ABSTRACT ABSTRACT Shweta pradara is one of the most common & burning problem faced by the  women at all ages all around the globe no women is an exception for this illness, becauseof moist and sweaty gentiles. Many of the gynecological disorders present shweta pradaraas the major complaint. If it is neglected, it may lead to ascending infections harming thegeneral health & disturbing the women psychologically. Shweta pradara is not a disease, but a symptom of so many diseases. However,sometimes this symptom is so severe that it overshadows symptoms of actual disease andwomen come for the treatment of only this symptom.    The white discharge with foul smell makes it embracing to get into the socialgatherings and even engaging in to her personal affairs. The white discharge may start asa simple problem and end in severity up to infertility if not treated at right time. There aremany treatment prescribed for this problem but not free from side effects and reoccurrence. Hence selection of an appropriate treatment without disturbing the othersystems is very much essential. Considering the above factors this study is being selected with a hope to providebetter results through the time tested Ayurvedic formulations. This research work is a single blind clinical study with pretest and post testdesign. 20 patients aged between 18 to 40 yrs suffering from shweta pradara(Leucorrhoea) were taken for the study. The selected patients were categorized in twogroups Group A & Group B. These patients in group A were treated with Patrangasava30ml TID and A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA COORNA IN SHWETA PRADARA w,s.r. LEUCORRHOEA
  9. 9. ABSTRACTgroup B were treated with Amalaki beeja choorna 12gm TID. The signs and symptomswere observed before and after the treatment and these were compared. As outcome of study conducted as above, the result obtained is positive i.e. thedrug has vital action in remission of the symptom like yoni srava and kandu.Paired‘t’ test proved statistically highly significant in kandu, srava, and also inexcoriation of vulval region and signs of discharge. Thus the study gave the curative effect of Patrangasava than that of Amalakibeeja choorna.KEY WORDS- Shweta pradara Leucorrhoea Patrangasava Amalalaki beeja choorna A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA COORNA IN SHWETA PRADARA w,s.r. LEUCORRHOEA
  10. 10. LIST OF ABBREVIATIONS1. AT - AFTER TREATMENT2. BT - BEFORE TREATMENT3. C.S - CARAKA SAMHITHA4. Su.S. - SUSHRUTA SAMHITA5. Dh.N - DHANWANTARI NIGHANTU6. Kai.N - KAIYADEVA NIGHANTU7. Ma.N - MADANAPALA NIGHANTU8. Pr.N - PRIYA NIGHANTU9. Rj.N - RAJA NIGHANTU10. Bh Pr. - BHAVA PRAKASH NIGHANTU
  11. 11. CONTENTS1. INTRODUCTION 1-22. OBJECTIVES 33. REVIEW OF LITERATURE a. HISTORICAL REVIEW 4-6 b. CONCEPTUAL STUDY 7-48 c. DRUG REVIEW 49-564. MATERIALS AND METHODS 57-615. OBSERVATIONS 62-876. RESULTS 94-997. DISCUSSION 100-1108. CONCLUSION 1119. SUMMARY 112-11310. BIBLIOGRAPHY 114-12011. ANNEXURE 121-128
  12. 12. LIST OF TABLESTable No. List of Tables Page No. DRUGS 1 PATRANGASAVA 52-53 2 AMALAKI BEEJA CHOORNA 49-50 3 MADHU 51 4 SHARKARA 51 OBSERVATION TABLES 1 Incidence According To Age 62 2 Incidence According To Religion 63 3 Incidence According To Occupation 64 4 Incidence According To Education 65 5 Incidence According To Economic Status 66 6 Incidence According To Diet 67 7 Incidence According To Duration of Illness 68 8 Incidence According To Parity 69 9 Incidence According To Contraceptive Methods 70 10 Incidence according to prakruti 71 11 Incidence according to sara 72 12 Incidence according to samhanana 73 13 Incidence according to satmya 74 14 Incidence according to pramana 75 15 Incidence according to satva 76 16 Incidence according to ahara sakti 77 17 Incidence according to vyayama 78 18 Incidence According To Chief Complaint And Associated Symptoms 79 19 Incidence According To Signs 80 20 Incidence According To Severity Of Srava 81 21 Incidence According To Severity Of Kandu 82 22 Incidence According To Severity Of Kati Shoola 83 23 Incidence According To Severity Of Mutrakruchra 84
  13. 13. 24 Incidence According To Severity Of Maituna Asahishnuta 8525 Incidence According To Severity Of Per Vaginal Discharge 8626 Incidence According To Severity Of Evidence Of Pruritus 87 RESULTSR1 Effect On srava1.1 Effect of srava in group-A 881.2 Effect of srava in groups-B 881.3 Comparison between the groups 89R2 Effect On kandu2.1 Effect of kandu in group-A 902.2 Effect of kandu in group-B 902.3 Comparison between the groups 91R3 Effect On Mutrakruchra3.1 Effect on mutrakruchra in group-A 923.2 Effect on mutrakruchra in group-B 923.3 Comparison between the groups 93R4 Effect On Maituna Asahishnuta4.1 Effect on maituna asahishnuta in group-A 944.2 Effect on maituna asahishnuta in group-B 944.3 Comparison between the groups 95R5 Effect On evidence Of Per-Vaginal Discharge5.1 Effect On evidence Of Per-Vaginal Discharge in group-A 965.2 Effect On evidence Of Per Vaginal Discharge in group-B 965.3 Comparison between the groups 97R6 Effect On Kandu6.1 Effect on Kandu in group-A 986.2 Effect on Kandu in group-B 986.3 Comparison between the groups 99
  14. 14. LIST OF GRAPHSGraph List of Graphs Page No. No. 1 Incidence According To Age 62 2 Incidence According To Religion 63 3 Incidence According To Occupation 64 4 Incidence According To Education 65 5 Incidence According To Economic Status 66 6 Incidence According To Diet 67 7 Incidence According To Duration of Illness 68 8 Incidence According To Parity 69 9 Incidence According To Contraceptive Methods 70 10 Incidence according to prakruti 71 11 Incidence according to sara 72 12 Incidence according to samhanana 73 13 Incidence according to satmya 74 14 Incidence according to pramana 75 15 Incidence according to satva 76 16 Incidence according to ahara sakti 77 17 Incidence according to vyayama 78 18 Incidence According To Chief Complaint And Associated Symptoms 79 19 Incidence According To Signs 80 20 Incidence According To Severity Of Srava 81 21 Incidence According To Severity Of Kandu 82 22 Incidence According To Severity Of Kati Shoola 83 23 Incidence According To Severity Of Mutrakruchra 84 24 Incidence According To Severity Of Maituna Asahishnuta 85 25 Incidence According To Severity Of Per Vaginal Discharge 86 26 Incidence According To Severity Of Evidence Of Pruritus 87 RESULTS 1 Effect On srava 88 2 Effect On Kandu 90
  15. 15. 3 Effect On Mutrkruchra 924 Effect On Maituna Asahishnuta 945 Effect On evidence Of Per-Vaginal Discharge 966 Effect On Kandu 98
  16. 16. INTRODUCTION INTRODUCTIONAyurveda is the world’s existing health care system and scientific discipline believing in‘Swastasya swastya rakshanam aturasya vikara prasamanam’. It is a record of experiencejustified by all new studies and proved by repeated administration by generations.As a part of natural protection, estrogen accumulates “Doderlein’s Bacilli” in the vagina,converts the glycogen into lactic acid, thus maintain the vaginal pH acidic, rendering theascending organisms to some extent. The healthy status of yoni is the factor of paramountimportance in life of woman as it is playing a dual role, i.e. wife for sexual satisfaction ofpartner as well as mother for procuring good progeny.Any deviation from this natural process leads to complications like irritation in vaginadue to excessive discharges, which in turn causes devastating effect on marital harmony.This irritation can be caused due to infection or pathological manifestation in the vagina.The excessive discharge from the vagina can be considered as Shweta Pradara which isthe commonest of all gynecological disorders like vaginitis and no women is anexception from this illness.Today’s stressful modern life styles, food habits, social status and occupation affects thelocal environment which leads to higher incidences of Leucorrhoea.Recent surveys on this regard, shows a clear picture that about 50% of women aresuffering from vaginitis.Optimal management of vaginitis is of considerable importance as it is a cause ofconsiderable discomfort and poses a problem as it is difficult to eradicate, frequentlyrecurrent and can lead to complications. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 1 SWETHAPRADARA w.s.r.t TO LEUCORRHOEA
  17. 17. INTRODUCTIONThere are many treatment protocols advocate the use of metronidazole or synthetichormone preparations. Though curative, they are not free from side effects.Since ancient times, medicines from nature are in use, many efforts have been made toassess their efficacy particularly in cases of vaginitis, many local and oral treatments havebeen explained and have shown good results.Here one such attempt was made using a formulation and to rule its efficiency in swethaPradara has been chosen for the study. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 2 SWETHAPRADARA w.s.r.t TO LEUCORRHOEA
  18. 18. OBJECTIVES OBJECTIVES This study is undertaken with following Aim and Objective 1) To carry out comprehensive literary study on swetha pradara 2) To evaluate the efficacy of Amalaki beeja choorna in swetha pradara 3) To evaluate the efficacy of Patrangasava in swetha pradara 4) To compare the effect of Patrangasava and Amalaki beeja Choorna in Shweta pradara.A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 3 SHWETA PRADARA W.S.R. LEUCORRHOEA.
  19. 19. HISTORICAL REVIEW HISTORICAL REVIEWVEDIC PERIOD1 :The Vedas which are being considered as the first written record of IndianLiterature contains innumerable references in relation to streeroga. This was theperiod where amongst various conditions of streeroga, infection of thereproductive system and infertility received greater attention.Among various conditions of streeroga, infections of reproductive system andinfertility received greater attentionYoni has to be prepared before deposition of virya to make it capable of achievingconception i.e. fertilization, maintenance and nourishment of embryo is described.. The yoni is actual place of progeny where the man sows the seeds in the yoni,especially healthy yoni.Eradication of krimis, rakshasa is adviced which enter the garbhashaya and causeinfertility or destruct the yoni or reach the reproductive organs and cause trouble.Pinga (yellow mustard) is prescribed for the treatment of these krimis.The duruama (krimi/ organism) causes even ascending or descending infections.A reference for infertility which is due to unhealthy genital tract is explained inour classics, as due to influence of krimi.The word bhamsas, bhasad, upastha and yoni refer to the female genital tractspecially vulva, vagina and uterus and the word gavini to fallopian tubes.A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 4 SHWETA PRADARA w.s.r. LEUCORRHOEA
  20. 20. HISTORICAL REVIEWIn Atharvaveda there is description regarding many medicines used ingynecological diseases. o BRAHMANAS –The word yoni or upastha are used to denote internal and external female genitaltract. Yoni is situated in the mid part of the body below udara and is attached tothe abdomen by mamsa peshis.Negligence in following oblations/rituals leading to various diseases orabnormalities in yoni & also infertility has been described. o UPANISHADS –The word upastha and mushka are used to denote vagina and labia majorarespectively. The female was considered as kshetra and man is the seed.Specific oblations where prescribed for purification of upastha.KALPA SUTRAS –General health of the couple is being given greater importance i.e. physical andpsychological normalcy as it is said that parents can only provide body to theprogeny.Explanation of healthy yoni is described and is considered as kshetra because seedof any plant sowed in properly harvested field yields good crops.A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 5 SHWETA PRADARA w.s.r. LEUCORRHOEA
  21. 21. HISTORICAL REVIEWSAMHITA PERIOD [1000BC – 500 AD]The word Shweta pradara has not appeared in bruhtrayis i.e. Caraka, Susruta andVagbhata samithas.Commentator Cakrapani, Sharangadhara samita, Bhavaprakasha andYogaratnakara have used the word Shweta pradara for white vaginal discharges inchikitsa sthana of yonirogadhikara.BUDDHIST LITERATURE2 –Prohibition for women having gynecological disorders for ordainment –The cullavagga & parajika of vinayapitaka furnish a list of various gynecologicaldisorders attributed to women desirous to obtain ordainment (upasampada) &coincidently they were examined & in case they were found with the followingdisorders, might not join sangha.Paggharanti – is identical with pradara where an abnormal vaginal dischargeoccurs & leucorrhoea may be included in it.Sikharani- is that where the deformity of conical shape in vaginal canal is found.A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 6 SHWETA PRADARA w.s.r. LEUCORRHOEA
  22. 22. CONCEPTUAL STUDY AYURVEDIC REVIEW YONIShweta pradara is one of the symptoms in many yoni vyapads. So before describing thedisease, it is very much necessary to know something about the term yoni.In Ayurveda the term yoni is used in very broad sense and it indicates whole femalereproductive system, the exact meaning should be interpreted according to the otherdescription given as external genital organ or Vagina or Cervix in cases of yoni dhupana,yoni spurana and suchimuki yoni vyapat respectively.The word yoni is derived from the root ‘YU’ and suffix ‘Ni’ forming yoni with meaning‘youthi’ or sanyojayathe iti. That means join or unite.Acharya Dalhana while commenting over the description of Sushruta regardingmeasurement of bhaga (vulva). He says, “bhagoh yonih….” This can be taken for thedescription of entire vulva instead of introitus or vagina.Though the word yoni is used in a very comprehensive sense, in the present context isconsidered as “Vagina”.Description of yoni: 3,41. Bahirmukha srotasFemales have three extra external orifices, two in breasts (one in each breast ) and onedownwards to excrete artava, which is situated below the smaratapatra (clitoris) A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 7 SHWETA PRADARA w.s.r. LEUCORRHOEA
  23. 23. CONCEPTUAL STUDYDue to its inclusion among external orifices and situation below clitoris, it appears to bedescription of vagina or introitus.2. Shape of yoni.Yoni resembles shankha nabhi (hollow portion of conch shell) it is having three avartas;Garbhasaya is attached in the third avarta.Nadis of yoni and their specification7In manobhavagara, mukha (vaginal canal) of females there are three nadis, samirana,candramukhi and gauri.At Madanatapatra (clitoris) is mainly Samirana, sukra (semen) fallingover it becomesfruitle. The woman having mainly chandramuki in kandarpageha (mid vaginal canal) iseasily satisfied with coitus and delivers female child.Sexual satisfaction to women possessing gauri nadi in upasthagarbha (depth of vaginalcanal) is attained with difficulty and delivers usually male child. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 8 SHWETA PRADARA w.s.r. LEUCORRHOEA
  24. 24. CONCEPTUAL STUDY ANATOMY OF FEMALE REPRODUCTIVE ORGANThe anatomical knowledge of the female genital organs and their relation to theNeighboring structures helps in diagnosing various gynecological diseases. NothingSeems to be more fundamental to the knowledge base of the practicing gynecologiststhanThe knowledge of understanding of the anatomy of female pelvis.The female reproductive organs are 6,7: 1) External 2) Internal- a) The Vagina b) The uterus c) The fallopian tubes d) Ovaries 3) Breast or mammary glands, the accessory organ of female reproductive system.Here in my dissertation as I have taken the disease Leucorrhea which is consent mainlywith excessive or abnormal vaginal secretions, the same has been explained here. Vagina is one of the internal genital organs. • It is hallow fibromusculo-membranous tube communicating the uterine cavity with the exterior. The canal is directed upwards & backwards forming an angle of 450 with the horizontal in the erect posture. • It is the organ of copulation & forms the birth canal of parturition. • The upper part of the vagina is more spacious. It has got enough power of dispensability as evident during child birth and the lower vagina is constricted as it passes through the urogenital hiatus in the pelvic diaphragm. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 9 SHWETA PRADARA w.s.r. LEUCORRHOEA
  25. 25. CONCEPTUAL STUDYWalls of the Vagina:Vagina has got anterior, posterior & 2 lateral walls.The anterior and posterior walls opposed together but the lateral walls are comparativelystiffer especially at its middle, as such it looks ‘H’ shaped on transverse section. Thelength of the anterior wall is about 7 cm & that of the posterior wall is about 9 cm.FORNICES OF VAGINA 8 The fornices are the clefts formed at top of vagina (vault) due to projection of the uterine cervix through the anterior vaginal wall, where it is blended inseparably with its wall. There are 4 fornices – anterior (shallow), posterior (deeper) & 2 lateral. The posterior one being deeper and the anterior, most shallow one.RELATIONS OF VAGINA –The relations are described from below upwards –Anterior – The upper one-third is related with base of bladder. The lower two-third is closely related to the urethra. The urethra is embedded in the thickened pubocervical fascia & muscular wall of the vagina. Skene’s cells are in close connection with , which open in to the urether. .Posterior – The upper one-third is related with the pouch of Douglars. The middle-third with the anterior rectal wall separated by rectovaginal septum. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 10 SHWETA PRADARA w.s.r. LEUCORRHOEA
  26. 26. CONCEPTUAL STUDY The lower-third is separated from the anal canal by the perineal body.Peritoneum – The posterior fornix is lined by peritoneum which covers posteriorly the middle part of the rectum & anteriorly the supravaginal part of the cervix uteri & the body of the uterus. The peritoneal pouch so formed is known as pouch of Douglas. It contains loops of intestines. Due to close attachment of the peritoneum to the posterior fornix. This route is utilized for drainage of pelvic abscess, culdocentesis,culdoscopy & vaginal legation of fallopian tubes.Lateral – The introitus is related to bulbospongiosus muscle,vestibular bulbs & bartholin’s glands. The vestibular bulb lie deep to the bulbospongiosus muscle. The vaginal tube pierces the two layers of the triangular ligament approximately 1.5 cm from the introitus . within the two layers of triangular ligament lie the deep transverse perineal muscles 7 the compressor urethrae muscle. A few medial fibres of the levator ani muscles are attached to the lower part of the vagina . below the levator ani is the ischiorectal fossa containing loose fatty tissue.STRUCTURE –The vaginal walls consist of three layers – 1. Stratified squamous epithelium 2. Fibromuscular layer 3. Fibro fatty layer. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 11 SHWETA PRADARA w.s.r. LEUCORRHOEA
  27. 27. CONCEPTUAL STUDYStratified squamous epithelium – (five teachers) The lining of the vagina is a thick stratified squamous epithelium; it is under the action of sex hormones. The epithelium is thrown into folds which run transversely & are known as rugae. These rugae allow the stretching of the vagina. In addition to the rugae, there are two longitudinal folds, one each in the anterior & posterior wall. The epithelial layer consists of three layers of cells – deep, intermediate & superficial zones. This division is according to the degree of stratification. It’s similar to the epithelium of skin, but devoid of keratin, hair follicles, sweat & sebaceous glands. Stratification increases from the deep to the superficial zone. The presence of estrogen in the body is responsible for it. The superficial & intermediate zones have a rich content of glycogen . these layers stain with iodine due presence of the glycogen. At birth & upto 10-12 days, the epithelium is stratified squamous under the influence of maternal estrogen circulating in the new born. Thereafter upto prepuberty & in postmenopause,the epithelium becomes thin,consisting of few layers only. From puberty till menopause, the vaginal epithelium is stratified squamous & devoid of any gland.Fibromuscular layer – A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 12 SHWETA PRADARA w.s.r. LEUCORRHOEA
  28. 28. CONCEPTUAL STUDY This layer consists of smooth muscle fibre which form a thin muscular coating in a criss cross form. A few voluntary muscle fibres are contributed by the levator ani muscles.Fibrofatty layer – The muscular coat is covered on the outside by fibrofatty tissue, which is thickened anteriorly & posteriorly. The anterior thickening is known as pubocervical fascia & posterior thickening is known as rectovaginal fascia. The fibrofatty layer is continuous with the paravaginal tissue.SUPPORT OF VAGINA9 – The vagina is supported in its upper part by the lower components of the transverse cervical ligaments which fuse with its fascial sheath. Below this, it is held by the fibres of the levator ani which are inserted into its side walls, by the urogenital diaphragm & by the perineal muscles. The anterior vaginal wall, urethra & bladder base are supported by the pubocervical fascia. The posterior vaginal wall rests on the rectovaginal fascia & perineal body.CYTOLOGY OF THE VAGINA10Cornification is well marked in the vagina of the newborn infant because of the highoestrogen level which has been transmitted from the mother. After about 10 days thevaginal epithelium becomes thinner and remains in this state until the approach ofpuberty. At puberty the functional layer increases in thickness. In the first half of anormal pregnancy the cornification index is low and should not exceed 10%. A A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 13 SHWETA PRADARA w.s.r. LEUCORRHOEA
  29. 29. CONCEPTUAL STUDYprogesterone deficiency is shown by a rise in the cornification index and if the index risesover 25% the patient is liable to abort. In late pregnancy the cornification index falls evenlower and at term may fall below 10%. After the menopause, although the ovaries haveceased to function, some degree of cornification is usually present, the oestrogensprobably being derived from the adrenal cortex, and from conversion of androstenedioneinto oestrone in the peripheral fat.In post-menopausal phase, the vaginal epithelium atrophies with withdrawal of oestrogensupport. The epithelium becomes thin and parchment like and is prone to infection. Thevaginal smear shows mainly the basal basophilic rounded cells with large nuclei. Thebackground shows leucocytic infiltration. The superficial squames are absent andintermediate cells are few and far between.NATURAL DEFENSE MECHANISM OF THE VAGINA AGAINSTINFECTION– The skin of the vagina is tough stratified squamous epithelium devoid of glands. Itpresents a smooth unbroken surface to the attack of pathogenic organisms. The pH is low & high acidity mitigates against bacterial growth. The thickness of armous-the epithelium & hostile pH depends upon estrogen & therefore it is only in extreme youth before puberty & in after menopause, that bacterial inroads are likely. During the era of sexual acidity & maximum estrogen production. There are certain times in which the pH is raised – 1. During menstruation when the cervix & endometrial discharge which is alkaline,tends to neutralize the vaginal acidity. A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 14 SHWETA PRADARA w.s.r. LEUCORRHOEA
  30. 30. CONCEPTUAL STUDY 2. After abortion or labour when alkaline lochia has a similar effect. 3. Endocervicitis where excessive cervical discharge is present also has some effect. Apart from these exceptions, the vagina is naturally self sterilizing .pH OF VAGINA AT DIFFERENT STAGES – New born infant – 4.5 – 7 6 wks old child – 7 Puberty – alkaline to acid Sexual maturity – 4.0 – 5.5 Pregnancy – 3.5 – 4.5 Late post-menopausal – 6 – 8Blood supply11 1. The main artery supplying it is the vaginal branch of the internal iliac artery. 2. Upper part by cervicovaginal branch of the uterine artery, lowerpart –middle rectal and internal pudendal arteries.Venous drainageThe rich venous plexus drains the internal iliac veins through the vaginal veins whichaccompany the vaginal arteries.Lymphatic drainageUpper one third –external iliac nodesMiddle one third –internal iliac nodesLower one third –superficial inguinal nodes A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 15 SHWETA PRADARA w.s.r. LEUCORRHOEA
  31. 31. CONCEPTUAL STUDYNerve supply 1. lower one third –pudendal nerves 2. upper two third –sympathetic L1, L2 -parasympathetic S2, S3 nerves A CLINICAL EVALUATION OF PATRANGASAVA & AMALAKI BEEJA CHOORNA IN 16 SHWETA PRADARA w.s.r. LEUCORRHOEA
  32. 32. CONCEPTUAL STUDY SHWETA PRADARAÌlÉÂÌ£ü μÉåiÉ CÌiÉ vÉÑYsÉuÉhÉï:|| ( vÉoSMüsmÉSìÓqÉ )Shweta means white or anything of white colour. mÉëMüwÉåïhÉ S¨ÉqÉç CÌiÉ mÉëSU:|| ( vÉoSMüsmÉSìÓqÉ )Pradara means excess or increased degree (which indicates excessive flow). mÉëSÏrÉïiÉå CÌiÉ mÉëSU : | mÉëSUÉå ÌuÉxiÉÉËUiÉÉå pÉuÉÌiÉ || (cÉ. xÉÇ. ÍcÉ. 30/209 cÉ¢ü.OûÏMüÉ.)The term pradara means pradeerana or excessive flow13.Hence the combined term shweta pradara means excess white discharge per vagina. mÉÉhQÒûUå mÉëSUå CÌiÉ μÉåiÉmÉëSUå || cÉ.xÉÇ.ÍcÉ.30/116.cÉ¢üû.OûÏMüÉCakrapani has explained pandura pradara as shwetapradara 12……………ÍxÉiÉå vÉÑYsÉå ÅxÉÚaSUå……| A.xÉÇ.E. 39/73. ClSÒ.OûÏMüÉ. A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 17 SHWETA PRADARA W.S.R. LEUCORRHOEA
  33. 33. CONCEPTUAL STUDYIndu explains it as shukla asrugdara.Asrugdara indicates discharge of blood which can never be white, thus Indu’sexplanation becomes doubtful.Leucorrhoea (Shweta pradara) is a universal problem of all women as female genitals arevery much prone to infections since they are moist, more sweaty, coverd & can looselyspoken as shweta pradara, which means an excess amount of white discharge pv. whichmay be due to different pathological conditions of the genitalia. Hence it is notconsidered as a disease, but a symptom of so many diseases. Sometimes this symptom isso severe that it overshadows symptoms of actual disease.On the basis of consistency, color & smell etc, these vaginal discharges can be classifiedas follows –Tanu :Here the discharge is thin or watery if kapha prakopa is accompanied with pitta prakopa,of it’s drava guna specially.Styana :Here the discharge is thick & curdy. It denotes kapha prakopa in a stage of saamavastha.Avila tantula :Here the discharge is mucopurulent one. If kapha prakopa of saamavastha isaccompanied with vata prakopa.Picchhila :Here discharge is mucoid one. When kapha prakopa specially of its picchhila & snigdhaguna accompanied with vata prakopa. A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 18 SHWETA PRADARA W.S.R. LEUCORRHOEA
  34. 34. CONCEPTUAL STUDYDurgandhi peeta ;Here the discharge is a purulent one. Kapha prakopa of samavastha is accompanied withpitta prakopa is always present in this type of discharge.Shweta pradara is a symptom of so many gynecological disorders developing due tovitiation of kapha & vata kapha.Different conditions manifesting sweta pradara :There are various conditions in which different types of vaginal discharges occur. Theseare as follows –Yoni vyapats Lakshanas TreatmentKaphaja yonivyapat15,16 Picchila yoni, kandu yukta, 1)Basti with gomutra mixed atishitala and alpavedana with katu pradana dravya, 2)Varti – prepared with yava powdermasha mixed with, saindhava pesteled with arka dugdha. Pathya- taila, sidhu,yavanna & pathyarista. -Prepared with pippali, maricha, masha, sathava & saindava lavana A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 19 SHWETA PRADARA W.S.R. LEUCORRHOEA
  35. 35. CONCEPTUAL STUDYYoni vyapat Lakshanas TreatmentSannipatika yonivyapat According to charaka when Mixed treatment prescribed the condition is kapha under individual dosha &or Tridoshaja or Sarvaja pradanya white mucoid general & simple treatmentyonivyapat 17, 18 discharge will be a should be done. prominent symptom. Susruta and vagbhata etc.. have mentioned prescence of features of all the three dosas . aggravated kapha can produce mucoid vaginal dischargesKarniniyonivyapat19,20,21,22 According to Susruta it Uttara vasti with jivaniya caused due to visiation of gana sadhita dravyas. kapha. Susruta says that Varti dharana with kapha & rakta produce kusta,pippali, arkagra & karnika in yoni. Karnini of saindhava pestled with yoni may give rise to blood ajamutra. stained or mucoid vaginal Kaphanashak chikitsa. discharges. Presence of pichilata kandu etc features refers to mucoid vaginal discharge A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 20 SHWETA PRADARA W.S.R. LEUCORRHOEA
  36. 36. CONCEPTUAL STUDYYoni vyapat Lakshanas Treatment As per charaka it Pichu dharana & anuvasana vasti is the condition with dhatakyadi taila.Upaplutayonivyapat 19,20 seen only in Pichu dharana with oil prepared pregnant women, of panchavalkala kashaya & but vagbhatta sallaki, jambu & dhava. describes that it Sneha & sweda. may occur in any Vatahara ahara. woman Adhamalla, states that this condition is nothing but the udavrutta yoni described by others authors. . sushruta states Local treatment of kalka- yava, about the features ,kinva,kusta,shatapushpa,priyanguAticharanayonivyapat18,19,20,21 like kandu & & bala. picchhila etc Vataghna dravya sadhita taila – lakshanas of shatapaki. kapha.While Swedana & asthapana vasti. Charaka & vagbhatta emphasize edema, pain & loss of sensation occurring in this condition. A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 21 SHWETA PRADARA W.S.R. LEUCORRHOEA
  37. 37. CONCEPTUAL STUDYYoni vyapat Lakshanas TreatmentAcharana yonivyapat 18,19,20,21 According to Uttaravasti with taila caraka, susruta, Pichu dharana with sneha vagbhata & other medicated with decoction of authors this shallaki,jingini,stem bark of condition is jambu, & dhava along with characterized panchavalkala is beneficial. itching . Snehana & swedana – application Susrutha describes of tempons soaked in sneha along vitiation of kapha with vatahara drugs diet. along with itching & he also specifies the development of krimi which may be due to the infective disorders of reproductive system.NIDANA AND SAMPRAPTIShweta pradara is a symptom not a disease thus etiopathogenisis of principal diseasewould be the etiopathogenisis of this condition also.However, on the basis of clinical features it appears to be a vitiation of kapha andvatakapha , thus its etiopathogenisis may be considered in the following way – A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 22 SHWETA PRADARA W.S.R. LEUCORRHOEA
  38. 38. CONCEPTUAL STUDYNidana –Kapha prakopaka nidana 25 –Aharajanya –Atimadhura, atyamla, atilavana, atisheeta, snigdha, guru , picchhila abhishyandi ahara.Excess intake of ayanaka, yavaka, naisadha, itkata, masa, mahamasha, godhuma, tila,pista, vikrti , dadhi, dugdha, payasa etc..Samashana & adhyashana.Viharajanya –Divaswapna , aalasya,avyayama, etc.Kaalajanya –Atisnigdha, sheetadi dravya sevana in sheeta kaala specially in vasanta rutu, poorvahnaetc.Vata prakopa nidana 26 –Aharajanya –Excess intake of ati katu, kashaya, atiruksha, sheeta, laghu ahara.Shuska shaka, varaka, koddalaka, mudga, masooraharenu,nishpava, kalayaAnashana, vishamashana etc.Viharajanya –Ativyayama, ativyavaya, ati adhyayana, pradhavana, prapatana,etc.Ratrijagarana, bharaharana , atichankramana etc.Vata mootra purisha chhardi kshavathu udgara ashru vega vighata.Kaalajanya –Excess intake of sheetadi dravyas in aparahna, sheeta kaala & varsha rutu. A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 23 SHWETA PRADARA W.S.R. LEUCORRHOEA
  39. 39. CONCEPTUAL STUDYSAMPRAPTI OF SHWETA PRADARA :Swahetu prakupita kapha Ati maithuna, garbhasrava/garbhapta Asamyak paricharya in rtukala , yoni adhavanaRasa dhatu dooshana in yoni Vata prakopa Disturbes the local echosystemDravaguna pradhanyatha Vitiates kapha Susceptable to invasion Of organisnsPicchilata & kandu in yoni Increases the kledata of yon Various degree of Vaginal discharge & Pruritis Shweta pradara VaginitisSAMPRAPTI GHATAKA:Dosha : Kapha, vata.Dhatu: RasaSrotas: artava vaha srotas.Udbhava Stana : AmashayaRogamarga : Abhyantara.Adhistana : YoniSroto Dusti : AtipravrittiVyaktha stana : Yoni A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 24 SHWETA PRADARA W.S.R. LEUCORRHOEA
  40. 40. CONCEPTUAL STUDY CHIKITSA Abhyantara Bahya1. Choorna 1. YoniprakshalanaAmalaki choorna with madhu Lodhra & vata twak kashaya Nyagrodha twak kashaya Triphala kwatha & takra2. Kalka 2. Varti dharanaRohitaka mula kalka with water Lodhra, priyangu & madhukaAmalaki beeja kalka mixed with honey and sugar varti in snehakta yoniNagakeshara with takraLodhra kalka with nyagrodhatwak kashayaChakramarda moola with tandulodaka3. Kwatha 3. AvachurnanaDarvyadi kwatha Khadira, pathya, jatiphala,Nyagrodhadi kashaya & nimba churna Panchavalkala churna 4. Pichu dharana A cloth soaked in nygrodha or Vata & lodhra twak kashaya is Placed in yoni. A CLINICAL EVALUATION PATRANGASAVA & AMALIKI BEEJA CHOORNA IN 25 SHWETA PRADARA W.S.R. LEUCORRHOEA
  41. 41. CONCEPTUAL STUDY  LEUCORRHOEALeuco (Gr) - To flow. The whites.A discharge is symptom where white, yellowish, or greenish, viscid mucus is present prevagina resulting from inflammation or irritation of the membrane lining the genital tractof the female.Leucorrhoea is a common manifestation of genital tract disorders. It means a ‘flow ofwhite substance’ & the amount of vaginal discharge ordinarily present in the adult, buthere the term is restricted to mean a excess amount of the normal discharge, which isalthough white or cream when fresh, it dries to leave a brownish yellow stain on clothing.When the discharge visualized microscopically it contains mucus, epithelial debris,organisms of various kinds & in second half of cycle, some leucocytes.Leucorrhoea is more irritable to women, in which it stains clothing & if the patient failsto bathe & maintain personal hygiene, causes excoriation & soreness of the vulva. Itincreases physiologically prior to menustration, midcyclically & during pregnancy & cangive rise to fears of cancer & of STD’s.Nonpathogenic leucorrhoea can be classified into two – a. Cervical & b. VaginalExcessive cervical secretion (Cervical leucorrhoea) –Cervical discharge is distinguished by being mucoid in type, causing the patients tocomplain of mucus discharge at the vulva. When the mucous secretion of the cervix isproduced in excess it undergoes little change in the vagina. The amount of mucusnormally secreted by the cervix is small. Probably the small quantity of cervical secretionwhich is normally discharged into the vagina is broken down so that the carbohydrate A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    26 SHWETA PRADARA W.S.R. LEUCORRHOEA
  42. 42. CONCEPTUAL STUDY radicle of the glycoprotein mucin is split off & fermented into lactic acid. It seems,however, that the number of doderlein’s bacilli found in the vagina is capable of dealingwith only the small amount of mucous normally secreted by the cervix. If the mucousdischarged from the cervix is excessive, it causes a mucus discharge at vulva.Excessive vaginal secretion (Vaginal leucorrhoea ) –This form of leucorrhoea is seen when the discharge originates in the vagina itself as atransudation through the vaginal walls. It is now established that almost all the lactic acidof the healthy vagina is formed from the glycogen present in the keratinized cells of thevagina & vaginal portion of the cervix. These cells are constantly being desquamated,when their glycogen is liberated to be fermented by doderlein’s bacilli, a process whichresults in the production of lactic acid. This process is under the control of estrogen, thelevel of which determines the pH of the vagina & it is likely that estrogen also influencesthe amount of vaginal transudation.Causes of leucorrhoea 33 –Causes of leucorrhoea can be categorized into two – 1. Physiological 2. PathologicalPhysiological Causes At birth –Mucoid vaginal discharge is present in new born babies for 1 – 12 days. This is due tostimulation of the uterus and vagina by the placental estrogen. Puberty –Leucorrhoea is commonly seen in young girls few years before and after the menarche.This is probably caused by the increased vascularity of the uterus, cervix & vagina at thattime. It is of temporary duration & needs no treatment. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    27 SHWETA PRADARA W.S.R. LEUCORRHOEA
  43. 43. CONCEPTUAL STUDY  Before menses –During the later part of menstrual cycle, the hypertrophied premenstrual glands of theendometrium secrete mucus which is discharged through the cervix into vagina. Before ovulation –Odorless clear mucoid discharge is seen usually during this period. During pregnancy –Normal discharge is increased in amount because of the vascularity of the female genitaltract. During lactation –Increase in normal discharge occurs when the genital tract comes under hormonalinfluence. During sexual excitement –During sexual excitement when there is an outpouring of bartholin’s secretion onto thevagina.Pathological Causes General health –Ill health –The chronic illness like diabetes, anemia etc causes leucorrhoea.Psychological – A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    28 SHWETA PRADARA W.S.R. LEUCORRHOEA
  44. 44. CONCEPTUAL STUDY Anxiety states & neurosis etc conditions increase the activite or passive congestion of thepelvic organs resulting into increased secretory activity by the glands causingleucorrhoea. Dysfunctional state of genital tract –Cervical causes –Discharge from the endocervical glands increases in the conditions like –CervicitisCervical erosionMucus polypEctropion &Cervical carcinoma etc.Vaginal causes –Vagina affected due to many infectious condition, resulting in the conditions likevaginitis etc.Different conditions associated with leucorrhoea –Colour consistency Amount odour Probable CausesClear Mucoid + to ++ none Normal ovulation, Emotional tensionMilky Viscid + to ++ None to Cervicitis,corynobacterium acrid vaginitis A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    29 SHWETA PRADARA W.S.R. LEUCORRHOEA
  45. 45. CONCEPTUAL STUDY White Thin with flakes + to ++ fusty Vaginal mycosisYellow green Frothy + to ++++ fetid Trichomonas vaginitisPink Serous + to ++ none Hypoestrogenism, non-specific infectionBrown Watery + to ++++ musty Vaginitis,cervicitis, endometriosis, cervical neoplasmGray, blood Thin + to ++++ foul Vaginal ulcer, pyogenic vaginitis, neoplasm ofStreaked vagina,cervix & endometrium VAGINITISVaginitis is the term referring to inflammation of the vaginal mucosa.Vaginal pain, itching and burning sensation are a triad of symptoms in vaginitis for whichwomen frequently seek health care. Excessive vaginal discharge and dysuria oftenaccompany these symptoms.The vaginal mucosa normally contains no gland & is not truly secretory. Estrogenmaintains slightly moist, the vaginal epithelium in healthy adult women undergoesconstant desquamation and the discharge of vaginal origin are characteristics chiefly bythe presence of epithelial cells.Progesterone stimulation after estrogen activation increases the glycogen content ofexfoliated cells. Maintenance of vaginal acidity is largely dependent upon levels of A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    30 SHWETA PRADARA W.S.R. LEUCORRHOEA
  46. 46. CONCEPTUAL STUDY estrogen & the presence of lactobacilli ( doderlein’s bacilli) which utilizes glycogen intheir metabolism. Any marked alteration of these relationships encourages the growth ofpathogens which may cause vaginitis.Between puberty & the menopause, the presence of lactobacilli maintains a vaginal pHbetween 3.8 – 4.2. This protects against infection. Before puberty & after menopause thehigher pH increases the risk of infection. Normal physiological vaginal discharge consistsof transudate from vaginal wall, squamous containing glycogen, polymorphs, lactobacilli,cervical mucus, residual menstrual fluid & a contribution from the greater & lesservestibular glands.When estrogen and progesterone levels are high, the genital tract resists infection.Classification of vaginitis –It can be typically classified into 3 –1. Infectious Vaginitis –Represents approximately 90 percent of all cases of vaginitis in women who are ofreproductive age. Infectious vaginitis is typically caused by bacterial overgrowth, yeastovergrowth, an infection by a protozoan called Trichmonas vaginalis, or various sexuallytransmitted organisms.2. Irritant Vaginitis –Caused by allergic-type reactions to condoms, spermicides, topical medications, tampons,soaps, perfumes, douches, or semen.3. Hormonal Vaginitis –Most often occurs in postpartum or postmenopausal women in the form of atrophic(thinning) vaginitis. Hormonal vaginitis can also occur in prepubescent girls due toendocrine system imbalance. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    31 SHWETA PRADARA W.S.R. LEUCORRHOEA
  47. 47. CONCEPTUAL STUDY Vaginitis : at different stages of woman’s life –The most common causes of vaginitis vary by patient’s age –Children:In children, vaginitis usually involves infection with GI tract flora (nonspecificvulvovaginitis). A common contributing factor in girls aged 2 to 6 yr is poor perinealhygiene (eg, wiping from back to front after bowel movements; not washing hands afterbowel movements; particularly in response to pruritus). Chemicals in bubble baths orsoaps may cause inflammation. Sometimes childhood vulvovaginitis is due to infectionwith a specific pathogen (eg, streptococci, staphylococci, Candida etc).Women of reproductive age:In these women, vaginitis is usually infectious. The most common types are bacterial,candidal vaginitis, and trichomonal vaginitis, which is sexually transmitted. Normally inwomen of reproductive age, Lactobacillus is the predominant constituent of normalvaginal flora. Colonization by these bacteria keeps vaginal pH in the normal range (3.8 to4.2), thereby preventing overgrowth of pathogenic bacteria. Also, high estrogen levelsmaintain vaginal thickness, bolstering local defenses. Factors that predispose toovergrowth of bacterial vaginal pathogens may include the following: • An alkaline vaginal pH due to menstrual blood, semen, or a decrease in lactobacilli • Poor hygiene • Frequent douchingPostmenopausal women:Usually, a marked decrease in estrogen causes vaginal thinning, increasing vulnerabilityto infection and inflammation. Some treatments (eg, oophorectomy, pelvic radiation,certain chemotherapy drugs) also result in loss of estrogen. Decreased estrogenpredisposes to atrophic vaginitis. Poor hygiene (eg, in patients who are incontinent or A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    32 SHWETA PRADARA W.S.R. LEUCORRHOEA
  48. 48. CONCEPTUAL STUDY bedridden) can lead to chronic vulvar inflammation due to chemical irritation from urineor feces or due to nonspecific infection. Bacterial vaginosis, candidal vaginitis, andtrichomonal vaginitis are uncommon among postmenopausal women but may occur inthose with risk factors.Women of all ages:At any age, conditions that predispose to vaginal infection may result fromhypersensitivity or irritant reactions to hygiene sprays or perfumes, menstrual pads,laundry soaps, fabric dyes, synthetic fibers, bathwater additives, toilet tissue, or,occasionally, spermicides, vaginal lubricants or creams, latex condoms, vaginalcontraceptive rings, or diaphragms.Various types of vaginitisVulvovaginitis –The premenarchal girls are specially vulnerable to vaginal infection because of – Lack of or very low level of circulatory estrogen lack of stratification of vaginal epithelium lack of glycogen & absence of doerlein’s bacilli no acid formation vaginal pH remains high around 7. Inadequate care of local hygiene Lack of protective pubic hair & fatty pads of labia majora.As the vaginal infection is almost always associated with vuvlvitis, the terminology ofvulvovaginitis is appropriate. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    33 SHWETA PRADARA W.S.R. LEUCORRHOEA
  49. 49. CONCEPTUAL STUDY Causes –The infection may be due to non-specific or specific organisms – Non-specific organisms (common) –The infection is polymicrobial in nature & it is difficult to pinpoint any particular oneresponsible for infection. The organisms are however of low virulence. Specific –Non-gonococcal, streptococcus, staphylococcus, candida albicans, e-coli etc. Foreign body Thread worm Following systemic illness-Viral infection like chicken pox, measles, scarlet fever. Following antibiotic therapy.Sources of infection – Direct contact from infected person. Indirect from foreign body,infected towel or bath tub & intestinal manifestation. Associated juvenile diabetes or antibiotic therapy favours monilial infection.Symptoms – Vaginal discharge which may be purulent or even blood stained in presence of foreign body. Pruritus or soreness in external genitalia. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    34 SHWETA PRADARA W.S.R. LEUCORRHOEA
  50. 50. CONCEPTUAL STUDY  Painful urination.Signs – Vulva becomes edematous & ulcerated. The offending foeign body may be dected. The examination may be done under anaesthesia. Vaginal epithelium in young girls looks red. Rectal examination is often helpful to detect the foreign body.Investigation – Examination under anaesthesia.Bacteriological examination of the discharge either by gram stain or hanging droppreparation or culture, to identify the causative organisms. Smear from the anal area for detection of pin or thread worm. Stool examinationmay reveal the thread worm. Blood examionation for estimation of sugar in suspected of juvenile diabetes. Urine for protein,sugar & culture.Treatment –As the causes remain obscure in majority, the principles to be followed are – General cleanliness To bathe in plain water without using any soap. To keep the local area dry. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    35 SHWETA PRADARA W.S.R. LEUCORRHOEA
  51. 51. CONCEPTUAL STUDY  Avoidance of nylon panties & to wear cotton, day & night.Medication –Non-specific – Local application of lotion calamine. Or 1% hydrocortisone cream is smoothening, with these simple measures , majority will be cured within 2 wks. In refrectory cases, estrogen either intravaginally as cream twice daily or tab ethinyl estradiol0.01 mg daily for 3 wks is effective to improve the vaginal defence. There is however, chance of withdrawal bleeding in girls nearer to menarche.Specific therapy – Trichomoniasis is treated by metronidazole ( 100 mg thrice daily for 10 days) Monilial infection is treated by local application of 1% gentian violet. Associated systemic illness should be treated by intramuscular antibiotic therapy. Foreign body is to be removed followed by use of estrogen therapy. Helminth is eradicated by oral use of albendazole.Candida vaginitis (Moniliasis) 34,35,36Etiology: Candida vaginitis is caused by candida albicans is gram positive yeast likefungus.Risk Factors:For the development of candidiasis are, o Pregnancy o Diabetes mellitus A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    36 SHWETA PRADARA W.S.R. LEUCORRHOEA
  52. 52. CONCEPTUAL STUDY  o Oral Contraceptive use o Broad spectrum antibiotics , Disease of thyroid parathyroid o HIV infection.Transmission of infection:Coitus with the infected male partnerPathology:Candida albicans is present in vagina in about 20% of women without any symptom. Itthrives in acid media especially with abundance of carbohydrate.The important host factor is depressed cell mediated immunity.The recurrence is from the bowel. There may be temprorary relief during or soonfollowing menstruation because of diminished acidity of vaginal flora.Clinical features:Vaginal discharge with intense vulvovaginal pruritusThe pruritis is out of proportion to the discharge .There may be dyspareunia due to local soreness.On examination: The discharge is thick, curdy white and is in flakes. Often adherent to the vaginal wall. Red swollen vulva with the evidence of pruritus Vaginal tenderness on examination Removal of the white flakes reveals multiple oozing spots.Diagnosis: Pruritus with discharge Wet mount test A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    37 SHWETA PRADARA W.S.R. LEUCORRHOEA
  53. 53. CONCEPTUAL STUDY  pH less than 4.5 Whiff test – negative Micro – fungus as refractile long thread like fibres with bamboo shoot like buds.Treatment:Elimination of causative factors Treatment of those disorders Fungicidal treatment orally and locally that is Nystatin / Imidazole groups in the form of either vaginal cream or pessary, once in a day at bed time for 2 consecutive weeks. Single dose of oral therapy with Fluconazole or Itraconazole should be given. Use of condom and application of hystatin ointment for few days following each act of coitus, for male partners. Age old practice of local application of 1% gentian violet.Trichomonas vaginitis :37, 38Incidence:Trichomonas vaginitis infects approximately 3 million American women annually. Infections areoften sub clinical.The third world countries have reported rates of T.V. that vary from 19% to 47%.This is the most common form of vaginitis and is found an approximately 50% of womencomplaining of vaginal discharge.Co-infection with trichomonas has been reported in 60% of patient with gonorrhoea. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    38 SHWETA PRADARA W.S.R. LEUCORRHOEA
  54. 54. CONCEPTUAL STUDY Etiology:T.V. is caused by the “trichomonas vaginalis” protozoan, is an ovoid motile flagellatedparasite. It measures 15-20 u in length and 8-10 u in width. It has got 4 anterior flagellaa spear like protrusion at the other end with an undulating membrane surrounding itsanterior 2/3 and is actively motile.Mode of transmission:Media for the transfer of disease are Coitus with infected male partner. Contaminated domestic towels, bed linen and personal clothing. Improperly sterilized surgical instruments such as specula. Bathtub, swimming pools.Other causes are:Debilitating illness, that lowers local resistance.Antibiotics, douching etc are altering the vaginal flora, which harbor the manifestation ofdisease.Incubation period:It is about 3-28 days.Pathology:Organisms usually lie in between the rugae and produce surface inflammatory reaction.When the local defense is impaired such as during and after menstruation, after sexualstimulation, etc, and when the vaginal pH is raised to 5.5. – 6.5, these organisms thrive inthose conditions.Clinical Features: About 25% of patients harboring trichomonas are asymptomatic. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    39 SHWETA PRADARA W.S.R. LEUCORRHOEA
  55. 55. CONCEPTUAL STUDY  There is sudden onset of profuse vaginal discharge after dating from the last menstruation associated with backache, occasionally lower abdominal discomfort. Varying degree of irritation and itching within and around the introitus. Presence of dysuria and frequency of micturation and history of previous similar attack.On examination: There is a thin, greenish, yellow and froathy offensive vaginal discharge. Erythematic and edema of the vulva and vagina are the evidence of pruritis. Vaginal examination may be painful. The vaginal walls become red and inflamed with multiple punctate hemorrhagic spots are found over the portio vaginalis part of the cervix, that giving the appearance of ‘Strawberry”Diagnosis:The diagnosis should be suspected in all cases, where discharge cause pruritus, but ismade certain by the identifying the organism in a wet mount smear preparation.By immunofluroscent staining technique.Identification of organism in slide 38The material is dropped over a slide and then mixed with one drop of normal saline. It isthen covered with a coverslip. Actively motile trichomonads can be seen undermicroscope easily. It can be effectively visualized after staining with 1% brilliant cresylviolet; leucocytes and other bacteria will not take up the dye.Management: Prevention of causative factors. Care in the disposal of undergarments and cleanliness of bath towels. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    40 SHWETA PRADARA W.S.R. LEUCORRHOEA
  56. 56. CONCEPTUAL STUDY  Treatment of tricomonas is optimized by the use of systemic therapy with one of the 5 nitroinidazole, in the form of metronidazole either 2g in a single dose or 200mg thrice daily for 7 days. The same treatment schedule should be given to the husband for 1 week. During these time intercourse should be post poned until both partner become asymptomatic And also abstain from the use of alcohol, which can cause disulfiram like reaction, consisting of severe nausea and vomiting.Chlamydial vaginitis –Causative organism - Chlamydia trachomatis.Sexually transmitted disease (STD) and causes urethritis.Incidence:25 – 40 % of female partner of men suffering from non-gonococcal urethritis.Clinical Features: Often no symptoms Dysuria & frequency of micturation. Irritant mucopurulent vaginal discharge. At times cervicitis. Sometimes it may cause reiter syndrome with arthritis, skin lesion,conjunctivitis & genital infection. During pregnancy – abortion, preterm labour & IUGR may occur. New born suffers from conjunctivitis, nasopharyngitis & pneumonia. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    41 SHWETA PRADARA W.S.R. LEUCORRHOEA
  57. 57. CONCEPTUAL STUDY Investigation – Immunofllorescence test – smear prepared from urethral & cervical secretion. IGM can be detected in 30% cases of recent infection. Cervical smear shows leucocytes . Elisa test.Treatment – Tetracycline 500mg & clindamycin 500mg 6th hrly for 14 days. Combination of cefoxitin 7 ceftriaxone with doxycycline 100 mg bd for 14 days Other drugs are amoxicillin 500 mg tid for 7 days. Erythromycin 500 mg tid for 7 days.Bacterial Vaginosis: 39,40It is another sexual transmitted non-specific vaginitis or gardnerella vaginitis. It is due toalteration of normal vaginal bacterial flora that results in the loss of hydrogen peroxide –producing lactobacilli and an overgrowth of predominantly anaerobic bacteria.Incidence&PrevalenceBacterial vaginosis accounts for 60% of vulvovaginal infections. Young adult women,particularly those who are sexually active, are most commonly affected.Pathology – A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    42 SHWETA PRADARA W.S.R. LEUCORRHOEA
  58. 58. CONCEPTUAL STUDY Gardnerella vaginitis is the organism most commonly associated with bacterialvaginosis. It is a small pleomorphic coccobacillus that may be gram variable whenstained & is found attached to epithelial ‘clue cells” in smears of vaginal exudates ordischarge.It is considered to be sexually transmitted.Other micro-organisms isolated from vaginal culture in bacterial vaginosis include genitalmycoplasma & anaerobic bacteria such as peptostreptococci, bacteroides & moboluncus.Lactobacilli are decreased or absent. The microbial ecosystem of the vagina is thusaltered.Clinical feature – A fishy , vaginal odor particularly noticeable during intercourse. Smooth sticky white or gray discharge for days to weeks. Elevated vaginal pH more than 4.5 Minimal or no vulvar irritation.Diagnosis: It is diagnosed on the basis of following findings. 1) A fishy vaginal odour, which is particularly noticeable following coitus. 2) Vaginal discharge is gray and thin coats the vaginal walls. 3) The PH of these discharge is higher than 4.5 4) Minimal/no vulvar irritation. 5) Microscopy of the vaginal secretions reveals an increased number of clue cells, and leucocytes are conspicuously absent. In advanced cases of bacterial vaginosis, more then 20% of epithelial cells are clue cells. 6) Releases of fishy, amine like order, when vaginal discharge mixed with KOH. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    43 SHWETA PRADARA W.S.R. LEUCORRHOEA
  59. 59. CONCEPTUAL STUDY Treatment:Metronidazole 500 mg twice daily – an antibiotic is a drug of choice.Other antibioties like Ampicilline 500mg, Cephalosporin 500mg, Tetracycline 500mg, inproper divided doses.Metronidazole gel 0.75%, 5g intravaginally twice daily for 5 days.Clindamycin cream 2%, 5g intravaginally at bed time for 7 days.Clindamycin 300g orally twice daily for 7 days.   Non-specific vaginitis :41During the reproductive period when the vaginal defense is lost, the local pathogens likestaphylococcus streptococcus E coli etc, produces acute symptoms, like varying amountof vaginal discharge with irritation of the vulva.Foreign bodies like pessary, tampon , IUCD or child birth trauma or vaginal operationpredispose to such infection.Clinical featuresThere is varying amount of vaginal discharge, sometimes offensive with irritation ofvulva.On examination The colour , consistency and the amount of discharge varies . Vulva may be congested and swollen with evidence of pruritis Vaginal mucosa is red, tender and swollenTreatment: A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    44 SHWETA PRADARA W.S.R. LEUCORRHOEA
  60. 60. CONCEPTUAL STUDY  Improvement of general health. Removal of the foreign body . Local application of bactericidal cream twice daily for 7 days or terramycine vaginal tablet 100mg inserted twice daily for 10 days is quite effective.On examinationP/S: Congested vaginal wall, orifice. Whitish discharge which is stick to wall or coming out from the orifice. Presence of healthy cervix.P/V: Normal sized uterus without any evidence of fibroid. Fornices are free. Bimanual examination reveals absence of tenderness on fornix and while moving the cervix. Free and mobile uterus.Investigations: Various investigations are carried out to exclude the other disorder which leads to signs and symptoms of vaginitis. Hb%: TC, DC, ESR: Cervical and high vaginal swab culture for aerobic and anaerobic organisms. Laparoscopic examination: to rule out the pyosalpinx etc. USG: to rule out the PID, fibroid uterus, pelvic endometritis.TESTS FOR VAGINITIS – wet mount & whiff test A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    45 SHWETA PRADARA W.S.R. LEUCORRHOEA
  61. 61. CONCEPTUAL STUDY Vaginal Wet MountVaginal wet mount helps in the diagnosis of vaginitis of variety of organisms. Theexamination of vaginal secretions leads to the recovery of organisms causing infectionand allows for more accurate treatment regimens.Proper specimen collection and handling of vaginal samples is must for proper results.The vaginal vault and walls should be swabbed using swabs. If any fluid has pooled inother areas, these areas should be swabbed as well. The swabs should then be placed in atube containing 0.5 ml saline and examined within two hours of collection. The sampleshould remain at room temperature.After obtaining the sample, the slide should be properly prepared for examination. Themethod of preparing the slide is as follows: 1. Vigorously mix the swab in and out of the saline making sure to collect all the material adhering to the side of the tube. 2. Remove the swab from the saline and depress onto a clean, dry microscope slide expressing a small amount of fluid. 3. Cover slip the sample and examine under a microscope.The KOH slide may be prepared by adding a drop of KOH to the sample after followingthe directions as noted above. The saline slide should be examined first to allow the KOHto properly digest other cellular elements in the sample such as epithelial and blood cells.Microscopic view of the slide should be started by examining the saline preparation. The10x objective is used for cellular distribution and obvious cellular and fungal elements.The 40x objective is used to identify the presence of white and red blood cells, quantityand type of bacteria present, clue cells, motile Trichomonas, yeasts, and fungal hyphae.The KOH slide should be examined with the 10x objective for any yeast and hyphaepresent and the 40x objective is used to distinguish smaller budding yeasts and hyphae. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    46 SHWETA PRADARA W.S.R. LEUCORRHOEA
  62. 62. CONCEPTUAL STUDY Common causes of bacterial vaginitis include Trichomonas vaginalis, Gardnerellavaginalis, and Candida albicans. All of these infections can be diagnosed by directexamination. The absence or presence of white blood cells and normal vaginal flora areclues that can be directly related to the causative agent of infection. The amine test andvaginal pH also can help to determine the cause of infection.Yeast infections, commonly caused by Candida albicans, & can be identified upon directexamination. The direct examination will yield budding yeasts and hyphae. The use ofKOH enhances the recovery of these fungal elements. Yeasts provoke a large white bloodcell response with a negative amine test. Normal vaginal flora will be present.Trichomonas vaginalis causes the Trichomoniasis . This is a single-celled parasite whichis transmitted sexually. Commonly, the parasite is motile with its flagella whipping backand forthNon-specific vaginitis is mainly due to Gardnerella vaginalis. Microscopically it ischaracterized by a lack of normal vaginal flora and a predominance of many smallcoccobacilli. The small bacteria adhere to the surface of the epithelial cells creating aspeckled appearance. These speckled cells are called clue cells and their presence isconsidered diagnostic for Gardnerella vaginitis.Use of vaginal lubricants, douches, tampons, contraceptive jelly, and medications mayinterfere with the examination. Patients should avoid using these items before samplecollection. In some cases, the Gram stain may be used to aid in the diagnosis of thesepatients.Procedure : A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    47 SHWETA PRADARA W.S.R. LEUCORRHOEA
  63. 63. CONCEPTUAL STUDY Patient is asked to lie on the back with her feet in the stirrups. A pelvic examination willbe done, and a speculum (an instrument used to keep the vagina open in order to examinethe interior) will be inserted into your vagina and opened slightly.A sterile, moist cotton swab is inserted, and a sample of the discharge is taken. The swab,and then the speculum, are removed . Slides from the discharge are prepared, then viewedunder a microscope.Special considerationsIf the infection is caused by trichomoniasis or a bacterium, the sexual partner should betreated also. This prevents the partners from being re-infected after the treatment.Whiff test :Vaginitis is diagnosed using clinical criteria and testing. First, vaginal secretions areobtained with a water-lubricated speculum, and pH paper is used to measure pH in 0.2intervals from 4.0 to 6.0. Then, secretions are placed on 2 slides with a cotton swab anddiluted with 0.9% NaCl on one slide (saline wet mount) and with 10% K hydroxide onthe other (KOH wet mount). The KOH wet mount is checked for a fishy odor (whiff test),which results from amines produced in trichomonal vaginitis or bacterial vaginosis. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN    48 SHWETA PRADARA W.S.R. LEUCORRHOEA
  64. 64. DRUG REVIEW DRUG REVIEW AMALAKI BEEJA Botanical Name: Emblica officinalis Family: euphorbiaceae Synonyms – abhaya, amrta, dhatri, vayastha, vayasya, vrshya, tisyaphala, sitaphala. Parimana – 12 karsha – 5 gms (approx) Distribution – cultivated throughout India. Morphology –64 It’s a large deciduous tree with greenish grey or red bark, peeling off in scales. Leaves – pinnate,distichously close – set, linear oblong, obtuse. Flowers – densely fascicled along the branchlets, yellowish; males on slender pedicles, females sub sessile. Fruits – berry, depressed globose, succulent, yellow or pink when ripe, obscurely 6- lobed. Seeds – trigonous. Flowering season : Feb-may & fruiting season – oct - April. Part used: fruit, Seed. Author Varga Rasa Guna Veerya Vipaka Doshagnata KarmaCharaka Jvaraghna, Madhura, Sheeta, - - Tridoshahara -Samhita Kasaghna, Amla, ruksha vayasthapana, kashaya, kushtaghna A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN SHWETA 49 PRADARA W.S.R. LEUCORRHOEA
  65. 65. DRUG REVIEWSushruta Amalakyadi, Madhura, Sheeta, - - Sarvadoshahara - parusakadi, Amla, ruksha triphala kashaya,Vagbhata Parusakadi Amla Sheeta - - Pittakaphashamaka -Bhava Haritakyadi Madhura, Ruksha, Ushana or - Tridosha nashaka Rasayana,Prakasha Amla, sheeta, sheeta(de raktapittaharnighantu kashaya, grahi pends on a, the fruit) mrudurecha kaDhanvantri Mishrakadi Kashaya, Sheeta, Sheeta - Tridosha shamaka RasayanaNighantu katu, sara anu lomana pitta, amla, madhuraNighantu Amla, - Sheeta Amla Tridoshahara -Adrasha kashaya, madhu shamaka madhura raRaja Mishrakadi Kashaya, Sheeta, - - - Shophahara,nighantu katu, laghu rasayana, amla, daha, madhura Pittahara A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN SHWETA 50 PRADARA W.S.R. LEUCORRHOEA
  66. 66. DRUG REVIEWMADHU(Ref: bha.pra. ni)Synonyms: Makshika, Madvika.RASA: Madhura, KashayaGUNA: Laghu, RukshaVEERYA: SheetaDOSHAGNATA: Kaphagna, Pitagna, Rakta dosharaKARMA: grahi.vilekhana, chakushya, deepana, swarya, vrana shodana, vrana ropana,Shotovishodana,hrudya, medhaya, vrushya, yogavahie.ROGAGNATA: kusta, kasa, pippasa, klama, krimi hara, Madhya.SARKARA (Dh.Ni.23207)SYNONYMS- Minandi, swetha, matsyandika, sita, shudha, shubra, sitophalaSarkara is sheeta veery & useful in all types of burning disorders, subsidesbleeding disorders, emesis, syncope and thirst. A CLINICAL EVALUATION OF PATRANGASAVA & AMALIKI BEEJA CHOORNA IN SHWETA 51 PRADARA W.S.R. LEUCORRHOEA

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