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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

I hereby declare that this dissertation entitled “clinical evaluation of

efficacy of Avachoornana with certain indigenous drugs(Kaseesa,

Tuttha, Gairika, Lodhra) in Gabhashaya Mukha Shotha W.S.R to

Primitive cervical cell pathology ” is a bonafide research work carried

out by me under the guidance of Dr.VNK Usha. M.D. (Ayu),

Professor&HOD, Department of Prasooti tantra & Stri-roga and co-

guidance of Dr. Sucheta, Assistant Professor, Department of Prasooti

tantra & Stri-roga.

Date: Signature of the candidate Place: Udupi Dr. Padmasaritha

DECLARATION


This is to certify that the dissertation entitled “clinical evaluation of

efficacy of Avachoornana with certain indigenous drugs(Kaseesa,

Tuttha, Gairika, Lodhra) in Gabhashaya Mukha Shotha W.S.R to

Primitive cervical cell pathology” is a bonafide research work done by

Padmasaritha in partial fulfilment of the requirement for the degree of

Master of surgery (M.S)

Date: Signature of the Guide

Place: Udupi Dr. VNK Usha. M.D. (Ayu)

Professor&HOD

Dept.Of Prasooti tantra & Stri-roga

CERTIFICATE


This is to certify that the dissertation entitled “A clinical study on the

effect of Upanaha Sveda in Pakshaghatha” is a bonafide research work

carried out by me under the guidance of Dr. VNK Usha. M.D. (Ayu),

Professor&HOD, Department of Prasooti tantra & Stri-roga and co-

guidance of Dr. Sucheta, M.D. (Ayu), Assistant Professor, Department

of Prasooti tantra & Stri-roga.

Signature of the H.O.D Signature of the Principal Dr. VNK Uska. M.D. (Ayu) Dr. U.N. Prasad M.D. (Ayu)

Date: Date:

Place: Udupi Place: Udupi

ENDORSEMENT

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation in print or Electronic format for academic / research purpose.

Date: Dr. Padmasaritha Place: Udupi © Rajiv Gandhi University of Health Sciences, Karnataka

COPYRIGHT

ACKNOWLEDGEMENT

In the beginning of the treatise, I bow to the almighty;

At this happiest juncture of successful completion of this research work, I prostrate to the feet of

“My Mother”, whose blessings and pain brought me up to this position.

I am greatly indebted to my revered teacher and guide Dr. VNK Usha, Professor and

HOD, Department of Prasooti tantra & Stri-roga, SDM College of Ayurveda and Hospital. It is

my fortune to have her as my guide whose excellent guidance, assistance and support in every

step during my course of study gave me a way to success for the dissertation and in future

profession also.

I express my sincere gratitude to my Co-Guide Dr. Sucheta kumari, Asst. Professor,

Department of Prasooti tantra & Stri-roga, for her timely guidance in carrying out this project.

It’s my great pleasure to express my deep gratitude to Prof. Muralidhara Sharma,

Department of Shalya tantra, my preceptor and role model whose erudite expositions and

benevolent ideas had given me a propitious direction in all stages of my life and I am ever

thankful for his support and guidance.

I express my heartfelt thanks to Dr. Mamatha K.V, Professor, for her immense inspiration,

valuable training and constructive ideas, throughout my study period.

I am thankful to my teachers, Dr.Ramadevi.G, Dr. Veena Mayya, Dr.Vidya Ballal,

Dr.Krishna Bai, for their support thought out these 3years.

It will not be out of the way to express my whole hearted thanks to my most lovable

persons on earth my Sister Dr.Abhilasha & Brother Prathap for their encouragement in all

aspects of my life.

I thank my batchmates, Dr.Prathima, Dr.Rekha, Dr. Rachana, Dr. Sunitha,

Dr.Deerashree, for their presence & support throughout the my work.

I would like to put on record the affection with which my friends Dr.Ravikanth,

Dr.Chaitra, Dr.Yashaswini, Dr.Radhika, Dr.Prakash, Dr.Seetharam for their support.

I thank all my patients for their co-operation, which was crucial for the successful

completion of this work.

I acknowledge my sincere thanks to all those who helped me during this study.

Dr.Padmasaritha

Abstract

“Clinical evaluation of efficacy of Avachoornana with certain indigenous drugs (Kaseesa, Tuttha, Gairika, Lodhra) in Garbhashaya mukha shotha w.s.r to Primitive cervical cell pathology”

ABSTRACT

Reproductive age of women is crucial involving complications of labour, infections during purperium, hormonal imbalance, etc predisposing to different kinds of pathology, where Cervical pathology being common, disturbes the lifestyle of women and her family.

Primitive cervical cell pathology, which includes the main clinical conditions – Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis, Cervical erosion, which can be considered as Garbhashaya Mukha Shotha, has been given importance in the present study, as these pre-clinical conditions carry the risk of carcinogenesis.

Under the guidelines and treatment modalities of Sushruta, from the time tested Ayurvedic formulations, Avochoornana of shodhana dravyas, mentioned for ‘Shotha-Samutthana’ has been planned to cut the root cause of the disease.

The Drugs Kaseesa, Tuttha, Gairika, Lodhra, having Shothahara, Granthihara, Ropana, Lekhana and Krimighna properties are selected for the present study.

Materials and Methods:

20 patients diagnosed as ‘Garbhashaya – mukha shotha’(Cervical Hypertrophy, Cervical Hyperplasia, Chronic Cervicitis and Cervical Erosion ) were taken for study from OPD and IPD sections of SDM Ayurveda Hospital , Kuthpady , Udupi.

The diagnosed patients of Garbhashaya Mukha Shotha were subjected to Tutthadi Avachoornana karma.

Duration of treatment: 7 days

Follow Up period : Follow up after 15 days of completion of the treatment.

Results: Statistically significant results were seen in Subjective parameters of Vaginal discharge(86%), Dysmenorrhoea(84%), Backache(82%), Burning micturition. In Objective parameters, satisfactory results were seen on Nabothian cysts(60%) and Pap-smear changes(71%), where as significant results were obtained on Area of Erosion(80%), Cervical Hypertrophy(67%) and Irregularity of Os(90%).

Key words: Garbhashaya mukha shotha, Cervical hypertrophy, Cervical hyperplasia, Cervical erosion, Chronic cervicitis, Tutthadi-Avachoornana.

Dedicated to

MY BELOVED

MOTHER

Surekha surya

CONTENTS Acknowledgement

Abstract

List of Tables

List of Graphs

List of Abbreviations

Page No PART - I: Introduction 1

PART - II: Objectives of the Study 2

PART – III: Conceptual Study

Chapter I Historical Review 3

Chapter II Garbhashaya- mukha shareer 5

Shotha 8

Ekadeshothita Shotha 18

Chapter III Anatomy of Cervix 25

Cervical Hypertrophy 30

Cervical Hyperplasia 30

Chronic Cervicitis 31

Cervical erosion 31

Chapter IV Drug Review 32

PART -V: CLINICAL STUDY

Materials and Methods 41

Observations 46

Results 67

PART –V1: DISCUSSION 76

PART –V11: SUMMARY AND CONCLUSION 84

BIBLIOGRAPHY 88

APPENDIX-CASE SHEET

Abbreviations

“Clinical evaluation of efficacy of Avachoornana with certain indigenous drugs (Kaseesa, Tuttha, Gairika, Lodhra) in Garbhashaya mukha shotha w.s.r to Primitive cervical cell pathology”

ABBREVIATIONS

1. A.H. - Astang hridaya

2. A.S. - Astang Samgraha

3. A.T - After Treatment

4. B.T - Before Treatment

5. C. S - Charak Samhita

6. M.N - Madhava Nidana

7. S.S. - Sushrut Samhita

8. S.K.D – Shabda Kalpa druma

Introduction

“Clinical evaluation of efficacy of Avachoornana with certain indigenous drugs (Kaseesa, Tuttha, Gairika, Lodhra) in Garbhashaya mukha shotha w.s.r to Primitive cervical cell pathology” Page 1

INTRODUCTION

The active reproductive years of female are quite interesting to observe, as it includes different physiological changes. The peak levels of estrogen which are inevitable for feminine orientation, sometimes lead to certain pathological problems, the Cervical Pathology being one of that.

Injuries during parturition, infections result in inflammation of cervix and conditions like pregnancy, lactation, unopposed estrogen action, inevitable estrogen therapy lead to histological changes with increase in cell size, multiplication of cells, destruction of epithelial tissue and lastly atypical cell formation.

These changes clinically give rise to many pathological conditions. Among them, Cervical Hypertrophy, Cervical Hyperplasia, Chronic Cervicitis, Cervical Erosion, which can be considered as Garbhashaya Mukha Shotha, should be treated promptly, if not may lead to malignancy. The Primitive Cervical cell pathology has the advantage, that it has a prognosis much better than the rest of Stage-1 tumours and also it is not possible to define the pre-clinical pathological conditions by the point of histology. Hence in suspected cases, the improved Cytologic screening like Pap-Smear has been adopted to diagnose the abnormal smears, interpreting High Grade Cervical Intra-epithelial Neoplasia, to rule out from the study.

Eventhough modern science has effective treatment methods like Cryotherapy, Laser resection, Electro-cautery etc are not out of side effects like secondary bleeding, cervical stenosis, etc. As the primitive cervical cell pathology provides ample time for correction, a proper therapeutic measure to combat the pathology, has been planned with Avachoornana, one of Shashti-Upakramas mentioned by Acharya Sushruta with the drugs Kaseesa, Tuttha, Gairika, Lodhra, which are having Ropana, Lekhana, Shodhana, Shothahara and Granthihara properties. These drugs had been the choice of selection as kshara dravyas are indicated for shodhana to breakdown the further invasion of pathologic process.

Objectives

“Clinical evaluation of efficacy of Avachoornana with certain indegenous drugs (Kaseesa, Tuttha, Gairika, Lodhra) in Garbhashaya mukha shotha w.s.r to Primitive cervical cell pathology” Page 2

OBJECTIVE OF THE STUDY

Conceptual Study Of Garbhashaya – Mukha Shotha (Cervical Hypertrophy, Cervical Hyperplasia, Chronic Cervicitis & Cervical Erosion).

Clinical study to evaluate the efficacy of Avachoornana with Kaseesa, Tuttha, Gairika, Lodhra in Garbhashaya-Mukha Shotha (Cervical Hypertrophy, Cervical Hyperplasia, Chronic Cervicitis & Cervical Erosion).

LIST OF TABLES

Tb

No.

List Of Tables Pg

No.

01 Types of Shotha according to nidana 12

02 Samanya Nidana of Nija-Shotha 13

03 Agantuja Nidana Of Shotha 14

04 Pathya-Apathya in Shotha Chikitsa 17

05 Measurements of Uterus 25

06 Observations 46

07 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Age:

46

08 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Religion:

47

09 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Marital Status:

47

10 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According to Education

48

11 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According to Habitat

48

12 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Socio-Eco Status

49

13 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Socio-Economic Status:

49

14 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Dietary Habit:

50

15 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Prakriti:

50

16 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Sara:

51

17 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Samhanan:

51

18 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Satva:

52

19 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Satmya:

52

20 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Agni:

53

21 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Ahara Shakthi:

53

22 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Vyayama Shakthi:

54

23

Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Desha:

54

24 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Bowel & Bladder

55

25 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Vaya:

55

26 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Duration of Illness:

56

27 Distribution Of 20 Patients According To Onset: 56

28 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Pradhana Nidana Present:

58

29 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To History Of Menstrual Cycle Interval:

58

30 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To History of Duration of Menstrual Flow:

59

31 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Clots Present:

59

32 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Menstrual Blood Loss:

60

33 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Abortion:

60

34 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Contraceptive Methods:

67

35 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Parity:

61

36 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Delivery Type:

61

37 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Vaginal Discharge:

62

38 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Dysmenorrhoea:

62

39 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Bckache:

63

40 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Dyspareunia:

63

41 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Area Of Erosion:

64

42 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Nabothian Cysts:

64

43 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Cervical Hypertrophy:

65

44 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Irregularity Of Os:

65

45 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Pap-Smear Reports

66

46 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Burning Micturition:

66

47 Effect Of Avachoornana on Vaginal Discharge 67

48 Effect Of Avachoornana on Dysmenorrhoea 68

49 Effect Of Avachoornana on Backache 69

50 Effect Of Avachoornana on Area Of Erosion 70

51 Effect Of Avachoornana on Nabothian Cysts 71

52 Effect Of Avachoornana on Cervical Enlargement 72

53 Effect Of Avachoornana on Irregularity Of Os 73

54 Effect Of Avachoornana on Pap-Smear Changes 74

Chapter 2 Conceptual study


CONCEPTUAL STUDY

RACHANA SHAREERA OF GARBHASHAYA MUKHA

GARBHASHAYA:

The words – Garbha and Ashaya forms Garbhashaya

Ashaya denotes “Avasthana visesha”28.

Purusha shareera is comprised of sapta ashayas, where stri possess Garbhashaya as one extra ashaya29.

Sushruta denoted “Shukra shonitam Garbhashayastham”30, which means the place where fertilized ovum gets implanted after shukra-shonita samyoga.

Garbhashaya Sthana:

In between ‘vipula kundala’ or Pitta-Pakwashaya Madhya, behind the vasti, Garbhashaya is situated, which clearly states that uterus is a pelvic organ, located in between the rectum and bladder in pelvic cavity 31,32,33.

The term ‘Jarayuna parivitam’34 has been explained as the covering of uterus by Kashyapa, which is denoting the peritoneum.

Garbhashaya Akriti:

‘Rohita matsya akriti’ denotes the pyriform shape of the uterus.

Alpamukham and Mahasushira mentioned by Dalhanacharya can be considered as cervix and cavity of body of the organ 35,36.

GARBHASHAYA:

Shabda kalpa dhruma states - vasasthanna of garbha as Garbhashaya.

“Yatra garbha thishtati”, the place where garbha resides is termed as Garbhashaya by Dalhana.

Kriya-vignana of Garbhashaya:

“Sukshma kesha pratikasha beeja raktavaha sira garbhashayam tarpayati maasadbeejaya kalpate”37- has been explained by Vishwamitra, which describes the functional aspect of endometrium, where rich supply of blood to it, in every month is meant to nourish the awaiting fertilized ovum. Where this is explained in the contemporary science, as secretory phase under the influence of oestrogen and progesterone hormones.



“masena upachitam raktam dhamanibhyam rutau punah”- describes the blood collection in the uterus for whole month, through endometrial capillaries.

‘ishatakrishnam vigandham cha vayuryonimukhanudeta’ – the word ‘yonimukha’ here is reffering to vagina, through which the blackish red menstrual blood escapes, under the influence of vata38,39,40.

GARBHASHAYA-MUKHA

Yoni:

Derivation of the term yoni is from – “Yu Mishrane”, meaning ‘UNION’, which can be taken as vagina in this context, reffering to organ of copulation.

Yoni refers to female reproductive tract-

In ayurvedic classiscs, yoni is a general term ascribed to all the female genital organs, in the context of gynaecological disorders.

- ‘Vimshatiryoni vyapadani’41,42

- ‘Yoni dosha’43

Yoni reffering to Garbhashaya-Mukha-

- Antarmukhi yonivyapat : Charaka described the word ‘vakrayatyananam’, meaning crooking of the mouth of the yoni, which refers to Garbhashaya-Mukha ( cervix ) 44

- Suchimukhi yonivyapat : ‘Anudwaram kuryat’ is the feature, meaning excessive narrowing of the orifice, which refers to Garbhashaya-Mukha45,46.

Garbhashaya- mukha :

Karnini yonivyapat – Indu commentary says, “Yonau garbhashya dwaramukhe”47, reffering to Garbhashaya-Mukha and due to formation of karnika, there is obstruction to menstrual flow

(‘rajomarga nirodhini), semen cannot enter the uterine cavity ( ‘shukrasya apratigrahat’), resulting in female infertility.



Garbhashaya-Mukha paryaya :

Apara mukha48

Artava vaha sroto mukha49

Garbha – chidra50

Yoni – mukha51

Kriya-shareera of Garbhashaya-Mukha :

Garbhashaya-Mukha, is the gateway to the upper uterine cavity, having wide range of functions like, endometrial shedding, protection against infections, facilitation of sperm entry, helping in the process of reproduction.

The cervical changes has been explained at different phases of menstrual cycle :

Niyatam diwase atite sankuchatyambujam yatha |

Rutau vyatite naryastu yonih samvriyate tatha ||52,53

After sunset, as the lotus gets closes, in the same way the yoni of a woman gets contricted, after

completion of rutukala and hence does not allow the entry of shukra.

The hormones oestrogen & progesterone maintains the physical, chemical & cellular

environment of the cervix.

Oestrogen decreases the protein, but increases the content of water and electrolytes. Hence in the

proliferative phase, the mucus is copious, thin & clear, with higher viscosity and stretching

capacity of upto 10cm (Spinnbarkeit phenomenon) 54, facilitating the sperm entry.

Progesterone increases the protein, but decreases water and electrolyte content. Hence the mucus

will be tenacious, thick & scanty, with lesser viscosity & stretching ability, leading to fracture

when put under tension ( tack property)55. Progesterone dominant mucus, restricts sperm entry.

Hence these hormones give clinical guidelines for clinical practice in the detection of ovulation.



SHOTHA

1. Utpatti –

Shotha - Shwayati iti shotha56

From the word “Shu Gatau” by adding suffix “Thana” shotha is derived.

Sh.ka.dru - Shu Gatau + Bahulakata Thana

Nirukti:

• Utseda is the Pratyatma lakshana of shotha “Utsedham lingam shwayathu karoti”57

• Utsedham samhatam Shopham tamahu nichayadatah58,59

• According to Vagbhatta utsedha means samhat i.e. stable and ‘ Samhatam ’refers to

‘Nischalatva’

Shopha includes different kinds of diseases, like granthi, alaji, arbuda, etc which are

having utseda as cardinal feature. Shopha are the swellings caused by the localized

doshas, residing in between twak & mamsa, which will have various manifestations like

pruthu or grathita, sama or vishama60.

Paryayas:

“Shotha roga vishesha . Tat paryayah shopha shwayathu ityamarah shothakah .”

Vyutpatti of shopha & shwayathu

Shopha – ‘ Shu Gatau’ Dhatu + ‘Pha’ pratyaya

Shwayathu - ‘Tu O Shvi Gati vriddhoh’

The word Gati means to move ( S.k.d. ) 61



Dosha-sambandha of Shotha:

In ‘Shotha chikitsa adhayaya’, Kashyapa described that, Vata is responsible for shotha , as Pitta

& Kapha are causative factors for daha & shaitya 62.

SHOTHA PRAKARA:

Utseda is the samanya lakshana of shotha, where ever its manifestation may be. Hence it

has been classified depending on different entities, as follows:63

- Cause

- Dosha involved

- Part involved

- Shape

1. Karana bhedena:64,65

i. Nija Shotha

ii. Aganthu Shotha

2. Avayava bhedena:66

i. Sarvangaja

ii. Ekangaja

3. Anga-bhedena:67

i. Sarvangaja - Sarva shareera gata shotha

ii. Ardhangaja - Ardha shareera gata shotha

iii. Ekangaja - Shotha in particular anga



4. Dosha vikruti bhedena:68

i) Vatika

ii) Paittika

iii) Slaismika

5. Akaara bhedena:69

(i) Pruthu

(ii) Unnatha

(iii) Grathita

6. Dosha bhedena - Ekangaja shotha and Sarvangaja Shotha are again classified

5 types of Sarvangaja Shotha70

(i) Vata

(ii) Pitta

(iii) Kapha

(iv) Sannipataja

(v) Visha

7. 6 types of Ekangaja Shotha71

(i) Vata

(ii) Pitta

(iii) Kapha

(iv) Shonita

(v) Sannipataja

(vi) Aganthu



8. Nine types of Shotha72

(i) Vataja

(ii) Pittaja

(iii) Kaphaja

(iv) Vata Pitta

(v) Vata Kapha

(vi) Pitta Kapha

(vii) Vata Pitta Kaphaja

(viii) Abhighataja

(ix) Vishaja



GENERAL CONCEPTS OF SHOTHA

Nidana :

Charaka has enumerated many karanas for manifestation of Nija as well as Agantuja Shotha.

- “Shuddhyamayabhakthakrushabalanam ksharamlatikshnoshnagurupaseva |

Dadhyamamrut shaaka virodhidushtagaropasrushtaanna nishevanam cha ||”73

Agantuja shotha manifests due to aghata on bahya twacha,

- “Bahyastwacho dushayitaabhighata: kashtashmashastragnivishayasadhyai: |”74

Identification of nidana and nidana-parivarjana has been given prime importance in ayurvedic classiscs on the basis of chikitsa, as Charaka stated in “Shwayathuchikitsadhyaya”-

- “Nidanadoshaviparyayakramairupacharet baladoshakaalavit” 75

Different kinds of Shotha nidanas explained by Acharyas :

TABLE NO - 1

Nidanas C.S S.S A.H M.N B.P K.S H.S

Nija Shotha + + + + + + +

Agantuja + + - - - + +

Abhighataja - - + + - - -

Vishajanya - + + + - - -

Raktaja - + - - + - -



Various shotha nidanas according to different Acharyas :

TABLE NO - 2

Shotha Samanya Nidana:76,77,78,79

Nidanas CS SS AH MN

Mithyayoga of vamanadi karma + + + +

Apathya prayoga after Panchakarma + + + +

Ati Krusha with alasaka, jwara, shwasa, atisara,bhagandara + + + +

Kushta, kandu peedita + + - +

Udgara, mala, mutra, apana vayu vega dharana + + + +

Amla , Lavana atisevana + + + +

Pishtanna atisevana + + - +

Phala, shaaka atisevana + + + +

Dadhi , Madhya, mandaka atisevana + + + +

Shooka, Shami dhanya atisevana + + + +

Ati sevana of aanupa and audaka mamsa + + + +

Garbha sampeedana + + - -

Garbha prapatana + + - -

Prajatanaam mithyopachara + + - +

Ati upavaasa + + + +

Ratri jagarana - - + -

Mrudbhakshana + + + +

Ati maithuna - + + -

Ati chankramana - + + -

Ati yaana - + + -



TABLE NO - 3

Agantuja nidana: 80,81,82

Nidanas CS SS AS AH MN

Chedana + + + + +

Bhedana + + + + +

Kshanana + + + + +

Bhanjana + + + + +

Utpeshana + + - - +

Prahara + + + + +

Bhandana + + - - +

Veshtana + + - - +

Vyadhana + + + + +

Peedana + + - - +

Bhallataka pushpa, phala, rasa samsparsha + + + + +

Shooka, krimi shookahita + + + + +

Visha patra, lata, gulma samsparsha + + + + +

Savisha prani damshtra + + + + +

Garbha sampeedana + + - - -

Ama garbha prapatana + + - - -



Poorva rupa of shotha:83,84

Anga-gauravam

Dhawathu

Sira-ayama

Ushma

SAMANYA LAKSHANAS: 85,86

Anga-vivarnata

Anavasthitatwa

Gauravam

Sira-tanutwam

Vataja shotha: 87 , 88, 89,90-vaata varna vedana

Lakshanas – Krishna/Aruna varna, Todavata, chhedanavat, bhedanavat, pidanvat,

pippilikasarpanavat, Shigra unnatatwa, Shigra shamanatwa, sarshapa kalkavalipta

chimichimayate, etc

Pittaja shotha: 91,92,93,94-pitta varna-vedana

Lakshanas – Krishna/pita/nila/pingala varna, Bhrama, jwara, sweda, trishna,mada, akshiraga.

Ushyate, dhuyate, ushmayate, sparshaasahatwa Utsedha, Ushma, etc

Kaphaja shotha:95,96,97,98-kapha varna-vedana

Lakshanas – Pandu varna, Kruchroothanaprashamobhavati, guru, shtira, shlakshna, atyana, shitala,

nipidito na cha unnamed, ratribali, ghana, Kandu.



Dwandwaja - Mixed lakshanas of the dosha involved 99

Sannipataja – Tridoshaja lakshanas are seen 100

Abhighataja Shotha 101,102

This type of Shotha is characterized by following features Visarpavana, bhrushoshma,

Lohitabhasa, Pitta lakshana

Vishaja Shotha 103 , 104

This type of Shotha is characterized by following features Mrudu, Chala, Adhogamanshil, Daha

and Ruja.

UPADRAVAS OF SHOTHA: 105

Aruchi

Atisara

chardhi

Daurbalya

Jwara

Swasa

Trishna

CHIKITSA: 106

Chikitsa-sutra includes 3 basic principles:

Antahparimarjana

Bahirparimarjana

Shastra-pranidhana



SAMANYA CHIKITSA: 107

“Nidanadoshaviparyayakramairupacharetm baladoshakaalavit”

APATHYA: 108,109,110

TABLE NO – 4

Ahara Navadhanya,shushkshaka,

krushara,dadhi,madhya,

guda,amla-guru-vidahi

dravyas,gramya-mamsa,

lavana, pishtanna.

Vihara Maithuna,diwaswapna

PATHYA: 111

Gomutra

Jangala mamsa rasa

Mahishi mutra

Takra

Ushtra mutra

Yavanna

Yusha



EKADESHOTHITA SHOTHA

Brihatrayi has explained about shotha in general and Ekadeshothita-shotha112 briefely at different context.

Sushruta described ‘shareera ekedeshothite’, reffering to localized swellings, seated in between twak & mamsa.

Vagbhata says ‘pratyangeshu tadaashraya113’, meaning shotha manifested at different organ should be named accordingly.

charaka too explained Ekadeshothita shotha in ‘Ashtodareeya adhyaya’, reffering to regional swellings, on which Chakrapani comments that – “Sampratyutseda samanyat pradeshikan shotha”114 which refers to general manifestation of shotha at different tissues or organs.

Charaka in the context of Ekadeshothita shotha says-

“ Rogasch utsedha samanyad adhimamsa arbudadayah |

Vishishta naamrupabhyam nirdeshyah shotha samgrahe ||”115

Even though Arbuda, Adhimamsadi are having their own nidana, samprapti, etc, the pratyatma lakshana is utseda, hence these must be considered under shotha.

Hence the heading Ekadeshothita shotha involves Arbuda, Adhimamsa too.

Shothastu Anekasankhyaha:

“Shophastu gaatraavayavaashrita ye te sthanadushyakrutinaamabhedat |

Anekasankhya: katiciccha teshaam nidarshanartham gadato nibodha ||” 116

shareera is comprised of numerous anga-pratyangas and hence diseases are innumerable117 depending upon the Sthana, Samsthana, Samuthana etc & also on the lakshanas of vitiated dosha like ruja, varna etc. To mention every disease in one text is quite lengthy, hence only broad classifications are described in our classics and one has to use yukti in understanding and naming the disease entity.



Hence, in the same way shotha can afflict any tissue or organ, as charaka has clearly classified according to aakriti, dushya, naama & sthana bhedena. Certain shothas were described by charaka with their lakshanas & chikitsa sutras like-

‐ Gala ganda ‐ Upakusha ‐ Talu vidradhi ‐ Shaaluka

And Granthi, Arbuda has also been explained in the same context.

GRANTHI SHOTHA: 118

Charaka has mentioned - Granthi shotha can manifest in any part or organ in the body, depending upon the dosha-vitiation, along with utseda as pratyatma lakshana.

Garbhashaya mukha shotha :

“Angaekadeseshwaniladibhi: syat swarupadhari sphurana: sirabhi: |

Granthirmahanmamsabhavastvanartirmedhobhava: snigdhatamaschalashcha ||”

Granthi shotha can manifest anywhere in the body, by the vitiation of siras and mamsa.

Even though there is no direct reference, all the explinations above clearly says shotha pertaining to Garbhashaya-Mukha can be considered under the category of Pradeshika shotha & hence general shotha nidana, samprapti, lakshanas & chikitsa are applicable to Garbhashaya-Mukha shotha also.



GARBHSHAYA - MUKHA SHOTHA

The refernce for shotha of female genital tract is available in kashyapa samhita, in the chapter named “Dushprajata chikitsa adhyaya” 119, where he explained ‘YONI-SHOTHA’ as one of the sootika rogas.

‘Karnikaakara Granthi’ formation has been explained by charaka in ‘Karnini yonivyapat’120. Where as Granthi can also manifest as shotha.

Hence, under the guidelines of samanya shotha nidana, samprapthi, lakshanas & chikitsa, shotha manifesting in Garbhashaya-mukha can be taken as Garbhashaya-mukha shotha.

Nidana:

A. Depending on the aetiopathology, it is of 2 types:

1. Nija – due to dosha-dushya vaishamya 2. Agantuja – abhigaatadi bahya karanas

Even though agantuja shotha is having different aetiology, after 7 days of affliction, it shows the features of nija shotha itself. As charaka said,

“ Aganturanveti nijam vikaram”121

Nidanas for general shotha are applicable to Garbhashaya-mukha shotha too.

B. Gabhashaya-mukha shotha nidanas can also be categorized into 2 types:

1. Samanya:

2. Visesha:

Samanya nidana:

Mithya ahara-vihara

Chikitsa upadrava

Nidanarthakara roga

Dhatu-kshaya



Mithya ahara:

Prakruti virudha ahara, irregular food habits, ati katwamlalavana rasa sevana, abhishyandhi ahara, virudha bhojana, adhyashana, amatrashana, vishamashana, etc leading to dosha utklesha, dislodging at different parts of the body manifests shotha.

Present day colouring, sweetening, flavouring, additives & preservatives are harmful to the biological system in the body leading to pathology.

Addctions like tobacco chewing, smoking, fast foods with rich fat & low nutritive value.

Mithya vihara: Ati vayu-atapa sevana

Ati vyayama & vyavaya

Diwasvapna, ratri jagarana

Altered Dina & Rutu charya in present era, with excess work, stress, multiple partners.

Chikitsa upadrava:

‐ Iatrogenic causes like, instrumentation during D&C, MTP, Forceps & Vacuum delivery leads to tears & lacerations of the genital tract, inviting pathogens if left untreated.

‐ Sootika will be deprived of agni & bala due to ati raka-nisruti & dhatu-shaithilyata, if proper care & nourishment is not given, leads to various diseases.

‐ Contraceptive methods like, Cu-T, Vaginal creams, Diaphragms irritates the local mucosal tissue & alters the normal vaginal flora manifesting infections.

‐ Other systemic disorders if not treated properly, lowers immunity, resulting in predisposition of various diseases.

Nidanarthakara roga:

Shotha may manifest as secondary to other disorders due to established dosha-dathu vaishamya & altered defence mechanism.

Dhatu-kshaya :

Sootikavastha and external trauma(abhighata), leads to excessive blood loss leading to vaata vruddhi, which is the prime factor for causation of shotha.



Visesha nidana:

‐ Garbha sampeedana ‐ Ama-garbha prapatana ‐ Vishama prasuti ‐ Dushprajata ‐ Prajatanam mityopachara

Garbha sampeedana:

It refers to faults in passenger.

Garbha means fetus;

Sampeedana - sam means constant/continuous;

Peeadana – pressure of fetus on Garbhashaya-mukha.

Nidanas for Garbha sampeedana might be taken as:

‐ Oversized fetus/Macrosomia : Vivrudha garbha ‐ Malpresentations : Asamyak agata,

Which are considered as nidanas for Mudagarbha122.

Ama-garbha prapatana:123

One of the main reason behind Ama-Garbha prapatana is hormonal imbalance/estrogen excess.

Incomplete abortion : Excess blood loss – Anemia – Infections

Incomplete abortion : Instrumentation / Surgical intervention – Lacerations over cervix – Infections.

Vishama-prasuti :

Abnormal / difficulty / prolonged labour may over strain the cervix with constant pressure on the organ,which will lead to cervical oedema, injury & predispose to infections.



Dushprajata:

Refers to Difficult labour.

“Garbha nishkramana kriya” – is the function of normal Apana vayu.

“Viguna apana vata” causes inco-ordinate uterine contractions & cervical dystocia

Mithyopachara in Sootikavastha:

Achiraprajatanam- just delivered woman, if indulges in Mithyopachara124.

If sootika paricharya is not followed – agni vaishamya & dhatu shithilata – dhatu kshaya & vata vrudhi – shotha

Mithyahara sevana – dosha prakopa – shotha

Poor hygiene, unrepaired cervical tears & lacerations – infections.

Samprapti of Gabhashaya-mukha shotha:

1. Nidana sevana

Dosha-prakopaka ahara-vihara

Dosha vikruti

Dhatwagni dushti

Khavaigunyata in the Garbhashaya-Mukha

Garbhashaya-Mukha Shotha

Yoni-srava, Yoni-kandu, Kashtartava, Kati-shoola, etc



2. Abhighata (Instrumentation on cervix), Cervical tears

Rakta-nisruti

Vaata-vruddhi

Dosha-vikruti

Shotha

Samprapti ghatakas:

1. Dosha – Vata pradhana tridosha 2. Dushya – Rasa, Rakta, Mamsa 3. Srotas – Rasavaha, Artavavaha 4. Vyadhi vyaktasthana – Garbhashaya-mukha

Chikitsa:

After explanation of broad classification and treatment modalities of shotha, Charaka clearly mentioned that every shotha lakshanas depends on the involved doshas and hence treatment should be directed towards the vitiated dosha, with the utility of chedana, bhedana, lepana, dahana adi kriyas in unexplained shothas.

“Parikshaya shothaprakaran anila adilinge |

Shanti nayedoshaharae yathaswam alepana chedana bhed dahae ||”125

According to Vagbhata, in any disease, where Mamsa vruddhi is present, Shastra, Kshara, Agni

karmas should be employed.

Mamsa vridhibhawan rogan shastra kshara agni karmabhi | 126

Chapter 1 Historical review


HISTORICAL REVIEW

Vedic period:

Vedas are said to be the primitive scripts of Indian literature. To denote the female genital organs, different words has been mentioned like upastha, bhasad, bhamsas, yoni, etc., specially reffering to vulva, vagina and uterus.

It is mentioned that rakshasa’s or krimi’s if enters garbhasaya cause infertility and yoni-dushti and hence has to be eradicated.1

In Rigveda:

Pralepa with ushna veerya dravyas like shigru and parna patra is mentioned as one of the treatment modality in shotha.2

In Atharvaveda:

Shothahara drugs like- varuna, pushkaramula, plaksha, latex of ashwatha are explained under shotha chikitsa.3

Brahmanas:

The external and internal female reproductive organs are reffered as yoni and upastha. The location of yoni is shareera Madhya and below udara, attached to mamsa.4

Samhita kala:

Charaka samhita:

In sutrasthana trishothiyadhyaya, charaka mentioned garbha sampeedana and amagarbha prapatana as the nidana’s of shotha. Depending upon the site affected, pradeshika shotha’s also has been enumerated. In chikitsasthana, mithya achara and vishama prasuti are described as the causative factors of nija shotha, where Shastradi abhighata will lead to agantuja shotha. Alepanadi chikitsa krama’s also are mentioned for anukta shotha’s.5,6,7,8

Sushruta samhita:

In shareerashana, sushruta described sthana and rachana-shareera of garbhashaya, representing “Rohitamatsya akriti”9,10 as simili, along with which tri-avarta’s are compared to “shankhanabhi akriti”. In sutrasthana, Amapakwaishaniyam adhyaya explains about “Ekadeshothita shotha”11,12. Similar treatment modalities has been mentioned for shotha and granthi13.

Chapter 1 Historical review


Ashtanga hridaya / Ashtanga sangraha:

Both the texts has given explaination about garbhashaya14,15. Uttara tantra of Ashtanga sangraha described the word garbhashaya dwara16. Both the Vagbhata’s has given similar descriptions of shotha, its nidana, purvaroopa, roopa etc, along with the explination of sthanika shotha17,18.

Kashyapa samhita:

Garbhashaya sthana is explained in shareera sthana19. Shotha adhyaya20 describes about samprapti lakshanas etc. In “Dushprajata chikitsa adhyaya” kashyapa explained “Yoni shopha” as one of the sootika roga21.

Sangraha kala:

Madhava nidana:

Vishama prasuti and aamagarbha patana are included as the causative factors of shotha22. Madhava explained nidana, samprapti, lakshanas of shotha in a separate chapter.

Bhava Prakasha:

Shothadhikara adhyaya also explained vishamaprasuti as one of the shotha nidana23.

Bhela Samhita:

Shwayathu chikitsa adhyaya explaines about shotha in detail24.

Yoga Ratnakara:

An indivisual chapter on shotha is available with all its nidana, samprapti and chikitsa, where he too has described vishamaprasuta as tha causative factor. Prishniparnyadi drugs mentioned for tha treatment of shotha25.

Harita Smhita:

Short description of shotha is available26.

Vangasena:

Detailed explination regarding shotha nidana, samprapti, chikitsa are mentioned, including vishamaprasuti as one of the nidana of shotha27.

Chapter 4 Drug review


DRUG REVIEW

KASEESA :138,139 Ferrous sulphate – FeSO4H2O

Group –Uparasa group

Utpatti :

‐ Sahaja : Naturally available as a decomposition product of Iron sulphide ‐ Krutrima : Artificially prepared by the action of SO4 on iron.

Occurrence :

It occurs in crystalline and massive forms, which is greenish and obtained by the name ‘Hirakasa’.

Localities:

Germany, Boveria, Swedan, Spain, and USA.

Prakara :

Rasarnava : -1.Shukla

2.Krishna

3.Peeta

Rasajala nidhi: - 1.Baluka kaseesa (swetha)

2.Pushpa kaseesa (peeta)

3.Kritrima kaseesa (harita)

4.Dhatu kaseesa (shyama)



Rasendra chudamani & Rsa ratna samuchaya: According to form

1. Baluka kaseesa 2. Pushpa kaseesa

Ayurveda prakasha: - 1. Dhatu kaseesa (pamshu kaseesa)

2.Pushpa kaseesa (kinchitpeeta)

Gunakarma :

Rasa : Tikta, amla, kashaya, kshareeya

Guna : Snigdha, ushna, guru, nirmala, dhumabha

Veerya : Ushna

Karma : Ropana, amasamsoshana, vishapaha, vranaghna, ragakara, jantughna, etc

Dosha prabhava : Sleshma nashana, vatakaphahara.

Method of shodhana:

‐ Dolayantra shodhana : Bhringaraja swarasa, Kanji, Rajakoshataki rasa, etc ‐ Bhavana : Nimbu rasa, Kanji, Ksheera

Marana : Laghuputa 2-3 times.

TUTTHA140,141: Copper sulphate (Sasyaka)

Group – Maharasa varga, Upadhatu



Mythological origin: Sasyaka is a solidified vomited material of Garuda pakshi. The vomitus was on Marakata mountain, after drinking amrita first and then halahala poison. Hence it is a mixture of both Amrita & Visha, possessing the properties of both.

According to ‘Ayurveda prakasha’ – Tuttha is an upadhatu of tamra and hence have the properties of tamra & sasyaka both. Sasyaka is the mineral form of copper sulphate, where as tuttha is now artificially prepared copper sulphate.

Paryaya nama:

‐ Amrutasanga ‐ Shikhi-griva ‐ Tamra grabha ‐ Vitunnaka ‐ Shikhi tuthaka ‐ Sasyaka ‐ Mayura tuthaka

Prakara :

As per Source : - 1. Swabhavaja (sasyaka)

2. Kritrima (tuttha)

As per Colour : -1. Rakta (sreshta)

2.Kalika / Blackish (adhama)

Gunakarma :

Rasa : Katu, kashaya, madhura, kshara

Guna : Laghu, ruksha

Doshakarma : Kaphapitta hara, tridosha shamana

Karma : Lekhana, bhedana, krimighna, twak doshahara

Method of shodhana :

‐ 1. Swedana in dolayantra for 2 yama ‐ 2. Bhavana with raktavarga dravya rasa or qwatha ‐ 3. Tapana and nimajjana



Marana : Kukkuta puta

Modern description:

Tuttha is the hydrous sulphate of copper combined with water. Its mineral is copper ore known as ‘chalcenthite’

Hardness – 2.5

Specific gravity – 2.1 to 2.3

Appearance : Lustre vitrious to dull

Colour : Deep blue, sky blue, greenish blue

Streak : White to light blue, translucent

Taste : Disagreeable, metallic

Composition :

CuSO4 5H2O : - Cu : 31.6%

- SO4 : 32.1%

-H2O : 36.1%

Readily soluble in water, yielding blue solution.

GAIRIKA142,143: Red ochre-Hematite [ Fe2O3]

Group – Uparasa group



Nirukti: Due to its golden red colour, it is called as ‘Swarna gairika’

Paryaya nama:

‐ Rakta dhatu ‐ Girija ‐ Girimrut ‐ Rakta pashana

Prakara:

‐ Swarna gairika ‐ Pashana gairika ‐ Samanya gairika

Gunakarma :

Rasa : Mdhura, tiktha, kashaya

Guna:

‐ Snigdha ‐ Katina ‐ Ruksha ‐ Himam

Veerya : Sheeta

Vipaka : Madhura

Karma : Vranaropana, Dahahara, Kandughna, Alakshmihara, Vishapaha, etc

Dosha prabhava : Pitta shaman, Kaphapaha, Vatajit

Physical properties :

Swarna gairika is raktatara, where as pashana gairika will be in tamra varna and hard in touch.

Method of shodhana :

‐ Bhavana with Godugdha ‐ Bharjana in Gritha.



Modern description:

The mineral of Iron sulphate is ‘Malatite’, belonging to monoclinic and prismatic class. Crystal form is rarely available, where earthy, fibrous or capillary crusts or efflorescences are commonly obtained.

Its crystals have perfect basal or distinct prismatic cleavages.

Hardness – 2

Specific gravity – 1.8 to 1.9

Various green shades can be seen, which on exposure looks yellowish, luster vitrious to dull, transparent to translucent.

Contains – FeO : 25.9%

SO3 : 29.8%

H2O : 45.3%

Manganes, Magnessium, Copper, Zinc

It is decomposition productof Iron sulphide mineral, especially Pyrite, Marcasite, Chalcopyrite and Pyrrhotite.

LODHRA144:

Botanical name – Symplocos racemosa

Family – Symplocaceae



Synonyms:

‐ Akshibhaishajya ‐ Rodhra ‐ Sthoolavalkala ‐ Tirita ‐ Tilva ‐ Galava

Gunakarma:

Rasa – Kashaya

Guna – Laghu, Ruksha

Veerya – sheeta

Vipaka – Katu

Dosha karma – Kapha pitta hara

Actions and uses:

‐ Astingent ‐ Refrigerant ‐ Anti-inflammatory ‐ Depurative ‐ Febrifuge ‐ Haemostatic ‐ Alterant ‐ Ophthalmic ‐ Expectorant

It is useful in eye diseases, spongy and bleeding gums, asthma, bronchitis, skin diseases, menorrhagia, leucorrhoea, haemorrhages, gonorrhea, etc

Physical constants:

‐ Total ash : Not more than 12% ‐ Acid-insoluble ash : Not more than 1% ‐ Alcohol-soluble extractive : Not less than 9% ‐ Water-soluble extractive : Not less than 15%



Chemical constituents:

‐ Monomethyl pelargonidin glucosides ‐ Loturine ‐ Colloturine ‐ Loturudine ‐ Reducing sugars ‐ Oxalic acid ‐ Phytosterol ‐ 3-monoglucofuranoside of 7-O-methyl leucopelargonidin ‐ Pelargonodin-3-O-glucoside ‐ Betulinic ‐ Acetyloleanolic ‐ Olealonic ‐ Ellagic acids

Pharmacological activities:

‐ Antimicrobial ‐ Antidiarrhoeal ‐ Spasmogenic ‐ Heart depressant ‐ Blood pressure depressant

Formulations and preparations:

‐ Rodhrasava ‐ Pushyanuga churna ‐ Brihat gangadhara churna ‐ Kutajashtaka churna ‐ Asthisandhanaka lepa ‐ Laghugangadhara churna ‐ Nagarjunanjana ‐ Vajrakapata rasa ‐ Lodhradi qwatha



AVACHOORNANA 145

Avachoornitam – tri, ava+choorna+karmani i.e dusting of the powder.

Choornikruta dravyam |

Gudaa karaa iti bhashaatatparyayaha | [ s.k.d ]

Sushruta has explained “AVACHOORNANA” as one of the ‘Shashti upakramas’.

‐ Medojushtanagambheeran durgandhamscha choornashodhanai : |146

Which states that – in medayukta, utthana, durgandhita vranas shodhana dravya Avachoornana is advised.

Avachoornana dravyas are also explained :

Triphala dhatakipushpa rodhra sarjarasan samaan |

Krutwa sukshmani choornani vranam tairavachoornayet ||147

In utsanna mamsa associated with katinyata, kandu and existing since long time, shodhana with Kshara karma is advised.

‐ Utsannamamsan katinaan kanduyuktam chirotthitan | Tathaiva khalu du:sadhyan shodhayet kshara karmana ||148

Sushruta in sutrasthana – “Mishrakadhyaya”, included kaseesa as “shodhana choorna”.

1. Kaseesa saindhava kinve….|

Shodhanangeshu chanyeshu choornam kurveeta shodhanam || 149

In other context, lodhra & kaseesa are explained under “Ropana choorna”.

2. Kangukaa triphalaa rodhram kaseesam shravanaahwayaa |

Dhavaashwakarnayostwak cha ropanam choorna mishyate || 150

Sushruta in chikitsasthana 19th chapter151, included the drugs - Kaseesa, Tuttha, Gairika & Lodhra, for their Granthihara properties.

- Kaseesa tutthe tato atra deye choornikrute…|

Chapter 5 Clinical study


CLINICAL STUDY

Garbhashaya Mukha Shotha considered under Ekadeshotthita shotha, can manifest in different

forms, with various clinical features along with Utseda. Acharya Sushruta has mentioned

Avachoornana for shodhana of affected dhatu, where he included Kshara dravyas for

Ropanartha, Lekhanartha, ksharana & Kshanana of vitiated dhatu.

Objectives of the study:

1) To accomplish a comprehensive literary study to understand Garbhashaya- Mukha Shotha

(Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis and Cervical erosion).

2) To evaluate the efficacy of Avachoornana on Garbhashaya- Mukha Shotha (Cervical

hypertrophy, Cervical hyperplasia, Chronic cervicitis and Cervical erosion).

MATERIALS & METHODS

Source of the data:

Minimum 20 patients diagnosed as ‘Garbhashaya – mukha shotha’(Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis & Cervical erosion ) will be taken for the study from OPD and IPD sections of SDM Ayurveda Hospital , Kuthpady , Udupi .

STUDY DESIGN:

It is a single blind clinical study with a pre-test and post-test design where in a minimum of 20

patients suffering from Garbhashaya Mukha Shotha were selected. Selected 20 patients will be

subjected to Avachoornana with Kaseesa, Tuttha, Gairika, Lodhra.

A special format was prepared considering all the points pertaining to the history in our classics and allied sciences. Patient were analyzed and selected accordingly. The parameters of signs and symptoms were scored on the basis of standard method of statistical analysis.



Inclusion criteria:

Age – 18 to 40 yrs.

Married women

Clinically diagonosed cases of Chronic Cervicites & Cervical Erosion.

Patients diagnosed with PAP SMEAR test as Cervical Hypertrophy &Cervical Hyperplasia

Exclusion criteria:

Unmarried & pregnant women.

Cervical polyps.

Carcinoma of cervix.

Other systemic disorders like diabetes mellitus, HTN etc

Assessment criteria:

Subjective parameters

Vaginal discharge:

Purulent Discharge 3

Mucopurulent discharge 2

Slight discharge 1

No discharge 0

Dysmenorrhoea :

Severe 3

(Not able to do routine work, forced to take rest)

Moderate 2

(Pain during work)

Mild 1



(Pain able to tolerate, routine work will not affect)

Absent 0

Backache:

Severe Pain 3

(Interfering daily routine, relief on medication not satisfactory)

Moderate pain 2

(Continuous, interfering daily routine, relief on taking medicine)

Mild pain 1

(Pain occasional , or only feeling of discomfort)

No pain 0

Objective parameters:

Cervical features

Area of Erosion

76% - 100% 3

51% - 75% 2

26%-50% 1

00%-25% 0

Nabothian cysts :

Multiple/congested 4

Multiple/non –congested 3

Single/congested 2

Single/non-congested 1

No cysts 0

Cervical enlargement :

Cervical Width > 3.5cm 3



Cervical width > 3 cm 2

Cervical width > 2.5cm 1

Cervical width – 2.5 cm 0

Irregularity :

All Round The Cervix 3

On either side of cervix 2

On one side of cervix 1

Regular 0

Changes in papsmear reports :

Presence of atypical cells 3

Changes in cellular patterns 2

With Infections/Inflammation 2

Changes in cellular pattern 1

Normal cells 0

Vaginal discharge :

Purulent discharge 3


Slight discharge 1

No discharge 0

INVESTIGATIONS:

Blood- Hb,TC, DC, ESR, RBS

Urine – Albumin



Sugar

Microscopic

PAP SMEAR

USG when indicated.

Interventions:

Drug : Avachoornana with Kaseesa, Tuttha, Gairika, Lodhra, once in the Morning.

Mode of administration of drug: local Dusting of the drugs in choorna form.

Dose : 3-5gm

Duration of treatment: 7 days

Follow Up period: Follow up after 15 days of completion of the treatment.

Method of Avachoornana:

Patients are advised to come early in the morning after finishing their menstrual period.

Procedure:

- Advised to empty the bladder

- Then taken in Lithotomy position

- Under aseptic measures, Vulva is cleansed with sterile cotton & antiseptic solution.

- Using Cusco’s speculum, Cervix was visualized, cervical discharges were cleaned with

cotton.

- With the help of sterile Wooden spatula, about 3-5gm of choorna was dusted over the

affected area of the cervix.

- Speculum was removed.

A total number of 20 patients of Primitive cervical pathology fulfilling the inclusion criteria were included for the study.

Observations and results of the study are analysed below. Observations were made before and after the treatment.

- Number of patients taken for the study : 20 - Number of patients completed the study : 20 - Number of drop outs : 0

TABLE NO – 7 & CHART NO - 1

Age in years No of patients % 20 – 30 08 40% 30 - 40 12 60%

Distribution of Garbhashaya Mukha Shotha patients according to Age:

Distribution of Garbhashaya Mukha Shotha patients according to Religion :

Religion No of patients %

Hindu 18 90%Muslim 1 5% Christian 1 5% others 0 0


Distribution of Garbhashaya Mukha Shotha patients according to marital status :

Married life in yrs

No of patients %

Married 20 100%Unmarried 0 0

Distribution of Garbhashaya Mukha Shotha patients according to Education :


Distribution of Garbhashaya Mukha Shotha patients according to Habitat :

Desha No of patients % Urban 4 20% Rural 16 80%

Education No of patients % Uneducated 2 10% Primary school

6 30%

High school 8 40% Graduates 4 20%

Distribution of Garbhashaya Mukha Shotha patients according to Socio-economic status :

Socio-economic status

No of patients %

Poor 4 20% Lower middle 10 50% Upper middle 6 30% Rich 0 0


Distribution of Garbhashaya Mukha Shotha patients according to Diet :

Diet No of patients % Vegetareans 2 10% Mixed 18 90%

Distribution of Garbhashaya Mukha Shotha patients according to Prakriti :

Prakriti No of patients % Vata-pitta 6 30 Vata-kapha 12 60 Pitta-kapha 2 10


Distribution of Garbhashaya Mukha Shotha patients according to Saara :

Saara No of patients % Pravara 2 10 Madhyama 16 80 Avara 2 10

Distribution of Garbhashaya Mukha Shotha patients according to Samhanana :

Samhanana No of patients % Pravara 2 10 Madhyama 14 70 Avara 4 20


Distribution of Garbhashaya Mukha Shotha patients according to Satwa :

Satwa No of patients % Pravara 0 0 Madhyama 16 80 Avara 4 20

Distribution of Garbhashaya Mukha Shotha patients according to Satmya :

Satmya No of patients % Madhura 8 40 Amla 0 0 Lavana 2 10 Katu 10 50 Tikta 0 0 Kashaya 0 0


Distribution of Garbhashaya Mukha Shotha patients according to Agni :

Agni No of patients % Samagni 4 20 Mandagni 10 50 Tikshnagni 2 10 Vishamagni 4 20

Distribution of Garbhashaya Mukha Shotha patients according to Ahara shakti :

Abhyavarana shakti

No of patients % Jarana shakti No of patients %

Pravara 2 10 Pravara 2 10Madhyama 12 60 Madhyama 12 60Avara 6 30 Avara 6 30


Distribution of Garbhashaya Mukha Shotha patients according to Vyayama shakti :

Vyayama shakti No of patients % Pravara 4 20 Madhyama 12 60 Avara 4 20


Desha No of patients % Anupa 20 100 Jangala 0 0 Sadharana 0 0


Distribution of Garbhashaya Mukha Shotha patients according to Bowel & Bladder habits:

Bowel No of patients % Bladder No of patients % Regular 8 40 Regular 10 50Irregular 12 60 Burning micturition 10 50


010203040506070

No.of Pt's %

Reg

Irreg

Vaya No of patients % Madhyama 20 100 Vruddha 0 0


Distribution of Garbhashaya Mukha Shotha patients according to Duration of illness :

Duration of illness

No of patients %

Weeks 3 15 Months 11 55 Years 6 30


Onset No of patients % Sudden 6 30% insidious 14 70%

TABLE NO – 27 & CHART NO – 21, 22 & 23

Distribution of Garbhashaya Mukha Shotha patients according to pradhana Nidana present in the patient :

Aharaja No of patients % Vishamashana 7 35 Adhyashana 6 30 Anashana 4 20 Viharaja No of patients % Diwaswapna 8 40 Ati-vyayama 0 0 Ati-vyavaya 6 30 Anya No of patients % Ama 16 80 Durbala / Krusha 4 20

30

40

Vi ashana


Distribution of Garbhashaya Mukha Shotha patients according to History of menstrual cycle interval :

Interval of cycle No of patients % 26-28(a) 4 20% 28-30(b) 12 60% 30-32(c) 3 15% 32-34(d) 1 5%


Distribution of Garbhashaya Mukha Shotha patients according to the History of duration of menstrual flow : Duration of menstrual flow

No of patients %

2-3(a) 6 30% 3-4(b) 8 40% 4-5(c) 2 10% 5-7(d) 4 20%


Distribution of Garbhashaya Mukha Shotha patients according to the History of clots present :

Clots No of patients % Present 5 25% Absent 15 75%


Distribution of Garbhashaya Mukha Shotha patients according to the History of amount of menstrual blood loss:

Amount of Men. bl. loss No of patients % Mild (a) 4 20% Moderate(b) 12 60% Severe (c) 4 20%


Distribution of Garbhashaya Mukha Shotha patients according to the History of Abortion:

Abortion No of patients % Present 4 20% Absent 16 80%


Distribution of Garbhashaya Mukha Shotha patients according to Contraceptive History :

Contraceptive method

No of patients %

Barrier method 9 45% Oral pills 4 20% Cu-T 2 10% Tubectomy 5 25%


Distribution of Garbhashaya Mukha Shotha patients according to History of Parity :

Parity No of patients % P1 8 40% P2 8 40% P3 4 20%


Distribution of Garbhashaya Mukha Shotha patients according to History of the Delivery type :

Type of delivery No of patients % FTND 18 90% Ass.Vag.Delivery 0 0% LSCS 2 10%

SUBJECTIVE PARAMETERS:


Distribution of Garbhashaya Mukha Shotha patients according to vaginal discharge:

Vaginal discharge

No.of Pt’s %

Mild 3 15 Moderate 16 80


Distribution of Garbhashaya Mukha Shotha patients according to Dysmenorrhoea:

Dysmenorrhoea No.of Pt’s % Mild 8 40 Moderate 4 20 Severe 1 5 Absent 7 35


Distribution of Garbhashaya Mukha Shotha patients according to Backache:

Backache No.of Pt’s % Mild 8 40 Moderate 6 30 Severe 1 5 Absent 5 25


Distribution of Garbhashaya Mukha Shotha patients according to Dyspareunia:

Dyspareunia No.of Pt’s % P 4 20 A 16 80

OBJCTIVE PPARAMETERS:


Distribution of Garbhashaya Mukha Shotha patients according to Area of Erosion:

Area of Erosion No.of Pt’s % 76%-100%(A) 8 40 51%-75%(B) 10 50 26%-50%(C) 2 10


Distribution of Garbhashaya Mukha Shotha patients according to Nabothian Cysts:

Nabothian cysts No.of Pt’s % Present 8 40 Absent 12 60


Distribution of Garbhashaya Mukha Shotha patients according to Cervical Hypertrophy:

Cx hypertrophy

No.of Pt’s

>3.5cm 3 15 >3cm 6 30 >2.5cm 9 45 =2.5cm 2 10


Distribution of Garbhashaya Mukha Shotha patients according to Irregularity of Cx Os:

Irregularity No.of Pt’s % All around Cx(A) 9 45 On either side(B) 6 30 On one side(C) 5 25


Distribution of Garbhashaya Mukha Shotha patients according to the changes in Pap-smear reports:

Changes in Pap-smear reports No.of Pt’s % Presence of Atypical cells(A) 0 0 Changes in cellular pattern with infection(B)

6 30

Changes in cellular pattern(C) 2 10


Distribution of Garbhashaya Mukha Shotha patients according to the associated C/O Burning micturition :

Burning micturition No of patients % Absent 2 10% Mild 8 40% Moderate 9 45% Severe 1 5%

Chapter Results


EFFECT OF AVACHOORNANA ON PRIMITIVE CERVICAL PATHOLOGY

- The analysis was done statistically using Sigma plot 11.0 - Paired t-test was used for comparing the results

TABLE NO - 46

Effect on Vaginal discharge :

No of patients

Mean

Diff in mean

% Paired t-test

BT AT S.D S.E T P Df 20 1.900 0.250 1.650 86.84 0.489 0.109 15.079 <0.001 19

CHART NO - 41

Statistical analysis revealed that, the mean value of Cervical discharge which was 1.900 before treatment has reduced to the value 0.250 after treatment and remained same after follow-up , which is statistically significant (P=<0.001)

TABLE NO - 47

Chapter Results


Effect on Dysmennorhoea :

No of patients Mean

Diff in mean %

Paired t-test

BT AT S.D S.E t P Df20 0.950 0.150 0.800 84.21 0.696 0.156 5.141 <0.001 19

CHART NO - 42

Statistical analysis revealed that, the mean value of Dysmenorrhoea which was 0.950 before treatment has reduced to the value 0.150 after treatment, has further reduced to 0.005, which is statistically significant (P=<0.001)

TABLE NO - 48

Effect on Backache :

Chapter Results


No of patients Mean

Diff in mean % Paired t-test

BT AT S.D S.E t P Df

20 1.150 0.200 0.950 82.60 0.686 0.153 6.190 <0.001 19

CHART NO - 43

Statistical analysis revealed that, the mean value of Backache which was 1.150 before treatment has reduced to the value 0.200 after treatment and after follow-up it has further reduced to 0.150, which is statistically significant (P=<0.001)

Objective parameters :

Cervical features :

Chapter Results


1.Area of erosion :

TABLE NO - 49

No of patients Mean



20 2.300 0.450 1.850 80.43 0.587 0.131 14.091 <0.001 19

CHART NO - 44

Statistical analysis revealed that, the mean value of Area of Erosion which was 2.300 before treatment has reduced to the value 0.450 after treatment and after follow-up further reduced to 0.200, which is statistically significant (P=<0.001)

2.Nabothian cysts :

TABLE NO - 50

Chapter Results


No of patients Mean



20 0.750 0.300 0.450 60 0.686 0.153 2.932 0.009 19

CHART NO - 45

Statistical analysis revealed that, the mean value of Nabothian cysts which was 0.750 before treatment has reduced to the value 0.300 after treatment and after follow-up has still reduced to 0.150, which is statistically significant (P=0.009)

TABLE NO - 51

3.Cervical enlargement :

Chapter Results


No of patients Mean


BT AT S.D S.E t P df

20 1.400 0.450 0.950 67.85 0.605 0.135 7.025 <0.001 19

CHART NO - 46

Statistical analysis revealed that, the mean value of Cervical Hypertrophy which was 1.400 before treatment has reduced to the value 0.450 after treatment has further reduced to 0.300, which is statistically significant (P=<0.001)

TABLE NO - 52

4. Irregularity :

Chapter Results


No of patients Mean


BT AT S.D S.E t P df 20 2.200 0.200 2.000 90 0.858 0.192 10.420 <0.001 19

CHART NO - 47

Statistical analysis revealed that, the mean value of Irregularity which was 2.200 before treatment has reduced to the value 0.200 after treatment has remained same, which is statistically significant (P=<0.001)

TABLE NO - 53

5. Changes in Pap smear reports :

Chapter Results


No of patients Mean


BT AT S.D S.E T P df

08 1.750 0.500 1.250 71.42 0.463 0.164 7.638 <0.001 7

CHART NO - 48

Statistical analysis revealed that, the mean value of Pap-Smear changes which was 1.750 before treatment has reduced to the value 0.500 after treatment, which is statistically significant (P=<0.001)

TABLE NO - 54

6. Vaginal discharge :

Chapter Results


No of patients Mean


BT AT S.D S.E T P df

20 0.950 0.350 0.600 63.15 0.598 0.134 4.485 <0.001 19

CHART NO - 49

Statistical analysis revealed that, the mean value of Vaginal discharge which was 0.950 before treatment has reduced to the value 0.350 after treatment has further reduced to 0.150, which is statistically significant (P=<0.001)

Chapter 6 Discussion


DISCUSSION

Garbhashaya Mukha is the access for yoni, as Indu has mentioned –

“Yonau garbhashaya dwara”

This term has been explained in the context of ‘Karnini yonivyapat’, while eloberating the description of ‘Karnika’ formation at Garbhashaya mukha dwara.

The terms ‘Vakrati aananam’ & ‘Anudwaram kuryat’ in Antarmukhi & Suchimukhi yonivyapat signifies Garbhashaya Mukha.

‘Shotha’ is manifested by the local amalgamation of doshas with twak & mamsa, presenting ‘Utsedha’ as the pratyatma lakshana.

Tri-shothiya adhyaya of Charaka, has forwarded the description of” Avayava-pradhana shotha”(Oragan specific),on which Chakrapani, comments and hints about Pradeshika shotha, which includes both neoplastic & non-neoplastic tissue proliferations.

Sushruta described - “Shopha samutthana granthividhradyalaji prabhrutaya:”, which states that all the granthi, vidhradhi, alaji, arbuda, adi conditions are having Utsedha as common feature, eventhough they are having different akruti, lakshanas and dhatu involvement, representing both benign and malignant neoplastic conditions.

Charaka states that Shotha are innumerable and hence depending upon the factors involved, they should be named and treated - ‘sthanadushyakrutinaamabhedat’ and he made classifications in the view of ‘ruja varna samutthana samsthanaam’.

Sushruta’s description of ‘Ekadeshotthita Shotha’, Chakrapani eloberation of ‘Pradeshika Shotha’ refers to regional swellings.

Vagbhata’s description of ‘Pratyangeshu tadashraya’ refers to Shotha pertaining to particular organ.

The present study on Primitive cervical cell pathology, involving the conditions – Cervical Hypertrophy, Cervical Hyperplasia, Cervical Erosion, Chronic Cervicitis are based on ‘Ekadeshotthita shotha’, which involves both the neoplastic and non-neoplastic cell proliferations.

The cervical canal is the lower part of the uterus, with S-C junction as histological hallmark, which is present in between columnar epithelium of endocervix and squamous epithelium of the ectocervix.Depending on age, hormones, parity, it varies in its location in regard to the anatomical external os.



S-C Junction has given the prime importance, as it is the prey for CIN, which is a single and continuous disease with dysplasia & carcinoma in situ. CIN1(mild dysplasia), can genuinely regress to normal, with diagnostic procedures and treatment. It is seen that CIN1 & 2 progress to more severe lesions if untreated and half of CIN3 cases left without treatment eventually ended up in invasive carcinoma.

In the present study on Primitive cervical cell pathology, involving the above mentioned 4 pathologies, includes cellular changes, infection, inflammation, derangements in cellular pattern, which predispose the cervix to form atypical cells, leading to invasive carcinoma.

The drugs Kaseesa, Tuttha, Gairika and Lodhra selected for Avachoornana are having shodhana, ropana, lekhana and granthihara properties can check the pathology, destroying the root to progress further.

As the cervix is always a moist area, with its glandular secretions, needs medicaments which are quickly and readily absorbed. Avachoornana is one such effective Upakrama, hence has been selected, as other forms of medicine take much time for absorption.

Plan of the study :

The patients for the study were selected from the IPD & OPD sectionS of SDMAH, Udupi. 20 patients fulfilling the inclusion criteria of Garbhashaya mukha shotha were registered.

Total number of patients registered – 20

Completed – 20

Drop out – 0

Clinical Study:

A single blind clinical study was conducted on Patients suffering from Gabhashaya mukha shotha. Patients were randomly selected. For Avachoornana, the drugs – Kaseesa, Tuttha, Gairika, stem bark of Lodhra were made into Sukshma-churna and applied over the affected area over the cervix. Treatment was given for 7 days. Follow-up was taken after 15days of completion of treatment. The following observations were made.



OBSERVATIONS & RESULTS :

Age:

40% of patients were in the age group 20-30 years and 60% patients belonged to the age group of 30-40years.

Religion:

Most of the patients included in the study were Hindus (90%) followed by Christians (5%) and Muslims (5%). This may be due to Hindu dominant population in this area.

Marital status:

As the pathological conditions included in the study are common in married women, only married patients were included.

Education:

40% patients had their education till high school, followed by 30% , educated till primary school. Decreased literacy may be the result of ignorance towards health & hygiene, predisposing to the illness, thus increasing the incidence of disease.

Habitat:

80% of patients belonged to rural area, which hints that less literacy and lack of knowledge about the disease, increases the incidence.

Socio economic status:

Most of patients were from lower middle class (50%), 6 patients belonged to upper middle class (30%) and 4 patients belonged to poor class (20%).

Diet:

90% of patients were consuming mixed diet while 10% of them were vegetarians. Non-vegetarian food takes longer time for the digestion (Guru Paki) and food also have tikshna, ushna properties, causing dosha-prakopa. This is one of the important causes for Sroto dushti, manifesting the disease.

Prakruti:

60% were of Vata- Kapha Prakruti, 30% were of Vata-Pitta Prakruti, while 10% were of Pitta- Kapha Prakruti Dominance of Vata Kapha Prakruti can be seen.



Saara:

80% patients belonged to Madhyama saara, followed by 10% each to Pravara & Avara saara.

Satwa:

80% of patients had Madhyama Satwa and 40% had Avara Satwa.

Samhanana:

70% had Madhyama Samhanana, 20% belonged to Avara, followed by 10% of Pravara Samhanana.

Satmya:

50% of patients gave a history of consuming Katu Rasa Pradhanya where as 40% patients gave history of consuming Madhura rasa pradhanya dravyas & 10% of the patients gave the history of consuming Lavana Rasa Pradhana food.

Agni:

50% of patients had Mandagni and 20% each of Vishamagni & Samagni, followed by 10% of patients who had Tikshnagni. Mandagni inturn may cause dhatwagni mandhya and dhatu-kshaya, leading to vaata prakopa, resulting in shotha.

Abhyavarana & Jarana shakti:

60% of patients belonged to Madhyama, 30% of Avara, followed by 10% of Pravara Abhyavarana and Jarana shakti.

Vyayama shakti:

60% belonged to Madhyama Vyayama shakti and 20% each to Pravara and Avara Vyayama shakti.

Desha:

100% of patients were from Anupa Desha. Due to kapha predominance, kaphadi doshas vitiate with minimum nidana sevana, leading to disease.

Bowel habit:

60% patients had Irregular Bowel habit and 40% had Regular Bowel habit.



Vaya:

100% of patients belonged to Madhyama vaya, as the disease is common in reproductive period only middle aged females were taken for the study.

Duration of illness:

55% patients had the disease since Months, 30% since years and 15% had since Weeks.

Onset:

70% of patients gave the history of gradual onset while 30% gave history of sudden onset.

Nidana:

35% patients gave the history of Vishamashana, 30% were indulging in Adhyashana and 10% had Anashana history. Vishamashana is characteristic feature of vaata predominance, which is the main dosha involved in shotha manifestation.

40% were involved in Diwaswapna, 30% had Ati-vyavaya. These both act as nidanas for vaata prakopa, which may predispose the disease.

80% had Ama lakshanas and 20% were Durbala with Dhatu-kshaya. Both these kshaya & ama lakshanas are prime factors for disease entity.

Menstrual history:

Maximum no. of patients (60%) had normal menstrual flow, with normal duration & interval of bleeding. Though metrorrhagia & menorrhagia are frequently associated with the disease , it was present only in 4 patients in the present sample . So it can be said sample is small to see the effect of disease on menstruation .

Abortion:

In the present sample 20% of patients had h/o abortion followed by D&C. Hence, by this

history it can be said that Abortion may be due to infection or it may predispose to infection.



Contraception:

25% had Cu-T insertion, 20% patients were on OCP’s, followed by 45% of patients who were practicing Barrier methods. Cu-T may cause constant irritation, while OCP’s directly affects the cervical mucosa.

Parity:

40% patients were P1 & P2 each , followed by 20% with parity P3. Mutiparous women are

more prown to disease, due to exposure to birth trauma & infections during purperium.

Type of Delivery:

90% of Patients had Normal vaginal delivery, which is the main predisposing factor along with multi-parity, which will affect the cervix to manifest the disease.

Incidence on associated symptoms:

Dysmenorrhoea:

40% had Mild, 20% had Moderate pain during menstruation. It may be due to hypertrophy of the cervix with obstructed glands, constricting the way of menstrual flow.

Backache:

40% had Mild and 30% had Moderate Backache.

Dyspareunia:

20% patients had Dyspareunia and was absent in 80% of patients. Hence it can be stated that dyspareunia is not always associated in Primitive cervical pathology.

Burning micturition:

45% had moderate, whole 40% patients had mild burning micturition. This is due to secondary infectio to urethra, causing urinary distress.



Discussion on effect of therapy:

Vaginal discharge:

The change observed on Vaginal discharge was 86.84%, at the end of the therapy it was seen that statistically significant results were obtained (P=<0.001)

Dysmenorrhoea:

The change observed on Dysmenorrhoea was 84.21%, at the end of the therapy it was seen that statistically significant results were obtained (P=<0.001)

Backache:

The change observed on Backache was 82.60%, at the end of the therapy it was seen that statistically significant results were obtained (P=<0.001)

Objective parameters:

Area of erosion:

The change observed on Area of erosion was 80.43%, at the end of the therapy it was seen that statistically significant results were obtained (P=<0.001)

Nabothian cysts:

The change observed on Nabothian cysts was 60%, at the end of the therapy it was seen that statistically significant results were obtained (P=0.009)

Cervical hypertrophy:

The change observed on Enlargement of Cervix was 67.85%, at the end of the therapy it was seen that statistically significant results were obtained (P=<0.001)

Irregularity:

The change observed on Irregularity of Os was 90%, at the end of the therapy it was seen that statistically significant results were obtained (P=>0.001)

Changes in Pap-smear reports:

The change observed in Pap-smear reports was 71.42%, at the end of the therapy it was seen that statistically significant results were obtained (P=>0.001)



PROBABLE MODE OF ACTION OF DRUGS:

- Kaseesa with its kshara-amla gunas, ushna veerya and vishapaha, vaata-kaphahara properties, does shodhana of vitiated dhatu, lekhana of diseased tissue, ropana of raw surface.

- Tuttha posessess katu-tikta rasas, kshara-laghu-ruksha gunas. It is kapha-pitta hara and does lekhana of dead cells, along with bedhana till healthy tissue is reached. With its krimighna, shodhana & twak-doshahara properties cures infection and inflammation, which is the main step for healing.

- Gairika with its Madhura-kashaya rasas, snigdha guna, sheeta veerya, vishaghna & raktasrava-hara properties, acts as an adjuvant and catalyst, enhancing the qualities of formulation, by soothening the tissue against the harsh effects of Kaseesa & Tuttha, which are known irritants. With its sandhaneeya guna, does ropana of the burnt epithelium, enhancing healthy healing of the tissue.

- Lodhra with its kashaya rasa & sheeta veerya, acts as febrifuge & hemostatic. It is kapha-pittahara, draining out all the glandular debris out of the obstructed gland and its vranaropaka property helps in proper healing. It also acts as astringent.

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Pp824: 162




Pp824: 162




Pp824: 164

Chapter 7 Summary & Conclusion


SUMMARY & CONCLUSION

The present study entitled “Clinical evaluation of efficacy of Avachoornana with certain indigenous drugs [Tuttha,Kaseesa,Gairika,Lodhra] in Garbhashaya Mukha Shotha w.s.r to Primitive Cervical cell pathology” is planned with the following aims and objectives.

1) To accomplish a comprehensive literary study to understand Garbhashaya- Mukha Shotha

(Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis and Cervical erosion).

2) To evaluate the efficacy of Avachoornana on Garbhashaya- Mukha Shotha (Cervical

hypertrophy, Cervical hyperplasia, Chronic cervicitis and Cervical erosion).

The whole study was elaborated in terms of :

1. Conceptual study

2. Drug review

3. Clinical study

4. Discussion

5. Summary and conclusion

Indu has mentioned the term Garbhashaya-Mukha, which refers to Cervix, the access for the uterine cavity.

Vagbhata has explained “Samhata rupa utsedha” of Shotha and manifests due to amalgamation of doshas in between twak and mamsa.

“Pratyangeshu tadashraya” & “Ekadeshotthita shotha”, refers to organ specific & regional swellings, having ‘utsedha’ as clinical feature, which involves both non-neoplastic and neoplastic cellular proliferations.

On the basis of Charaka’s version - ‘sthanadushyakrutinaamabhedat’, Shotha depending on its location is considered as Garbhashaya-Mukha Shotha, referring to Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis, Cervical erosion with or without Carcinogenesis.

“Shotha samutthana” of Sushruta states that eventhough the basic character is utsedha, Shopha-Vidhradhi-Granthi-Arbuda-Alaji, differs in their pathological evolution and severity. While explaining Akruti, Lakshana, consistency and severity, he has hinted about Benign and Malignant lesions.



Cervical pathology, which is not advanced to stage of operability, can be taken as Primitive cervical cell pathology. The selected cases were exposed for Pap-smear to check the pattern & arrangement and the first stage of Atypical cells also has been included in the study. As all the above mentioned conditions are not advanced, can be called as Primitive cervical cell pathology.

In Primitive cervical cell pathology, where the epithelium is the victim for all the changes in disease process, there will be a constant cell damage with change in cellular pattern & arrangement, due to chronic and continuous irritation. These changes forms the atypical cells with pleomorphism, leading to invasive carcinoma.

To correct these chronic infectious conditions, inflammatory processes & cell proliferative stages

of the disease, present Upakrama - Avachoornana with Kaseesa, Tuttha, Gairika, Lodhra, which

are proved to work on the pathology, has been planned. The formulation includes 2 Kshara

dravyas, having Ksharana, Kshanana, Lekhana, Bedhana Shodhana & Gratnthihara properties.

Gairika, have the properties of Vrana-Ropana, Sandhaneeya and Rakta-prasadana properties,

while Lodhra posessess Krimighna, Ropana, Shothahara & Rakta-skandana gunas.

A single blind clinical study, with 20 patients diagnosed as Garbhashaya – Mukha Shotha (Cervical hypertrophy, Cervical hyperplasia, Chronic cervicitis and Cervical erosion) have been treated with Avachoornana of Kaseesa, Tuttha, Gairika, Lodhra for 7 days.

Results were obtained as follows :

Statistically significant results were seen in Area of erosion, Cervical hypertrophy, vaginal

discharge, Dysmenorrhoea & backache.

Statistically satisfactory results were seen in Nabothian cysts, Pap-smear changes & Burning

micturition.

Hence, it can be planned as prevention for advanced cellular pathology at OPD level and may

prove best preventive method for Carcinoma of Cervix.



Suggestions:

Every woman with Primitive Cervical Cell Pathology, should be subjected to Kaseesa, Tuttha, Gairika, Lodhra – Avachoornana, in the view of prevention of Cervical cancer.

In the present Formulation, the dose of Kaseesa & Tuttha, can be decreased, to make it gentle and patient friendly, as these 2 drugs are known irritants.

This study can be conducted on larger group to achieve the beneficial effects of the formulation and to prove in wider sense statistically.

Avachoornana with Kaseesaadi can be well tried on Peri-menopausal women also, in whom the risk of carcinogenesis is more.

DEPARTMENT OF PRASOOTI TANTRA AND STREE ROGA S.D.M. COLLEGE OF AYURVEDA & HOSPITAL, UDUPI

RESEARCH PROFORMA FOR M.D. (AYURVEDA)

Title: Clinical Evaluation of efficacy of Avachoornana with certain indigenous drugs [Tuttha,Kaseesa,Gairika,Lodhra] in Garbhashaya Mukha Shotha w.s.r to Primitive Cervical cell

pathology

Scholar: Dr.K.Padma Saritha Year: 2009-2011 Guide: Dr.V.N.K.Usha Co – Guide : Dr.Sucheta 1.Patient Biodata 1.Name : 8.IPD No : 2. Age/Sex: yrs/M/F 9.OPD No : 3.Marital Status : M/UM/W/D 10.Ward No : 4.Religion: H/M/C/J/Si/other 11.Bed No: 5.Education Status: UE/PS/MS/HS/GR/PG 12.DOA: 6.Economic Status: VP/P/LM/M/UM/R 13.DOD: 7.Address: Result: Change/Marked change/ Unchanged Date of commencement: Date of completion: 2. Chief Complaint. Yoni Srava :

1. Onset: Sudden / Insidious

2. Duration : Days / Months / Yrs

3. Course : Continuous / Intermittant / Prior to MC

4. Quantity : Copious / Scanty

5. Colour : White / Yellow / Curdy white / Clear / Blood

stained

6. Odour : Non offensive / Offensive

7. Nature : Watery / Thin / Thick / Mucoid / Purulent

Yoni kandu :

1. Duration : Days / Months / Yrs

2. Site : Labia majora (Ext) / Labia minora ( Int )

3. Severity : Mild / Moderate / Severe

3.Anubandha vedana Dysmenorrhoea Pain: Onset & Subsidence

Severity : Mild – able to tolerate, routine work not affected

Moderate – pain during work

Severe – not able to do routine work, forced to take rest

Backache : Duration : days / months/ yrs

Onset : sudden / insidious

Character : severe / Dull Colicky / Constant / Intermittant / Radiating

Relation to menstruation : mild / moderate / severe

Dyspereunia : Present / Absent

Burning Micturition : Duration : days / months / yrs

Pain : Present / Absent

Severity : mild / moderate / severe

4.History of Present Illness: 5.History of Past Illness 6.Family History 7.Personal History Ahara Sambandhi :

1. Type of food : Veg / Mixed

2. Rasa Sambandhi : M / A / L / K / T / Ka

3. Diet habits :

4. Habits / Addictions :

Vihara Sambandhi : Vyayama : Vyavaya : Bowel Habits : Menstrual History / Rajo Vrittanta : Menarche________years M.C._________ days Reg / Irr / Painfull

Srava Kala : days / scanty / normal / heavy

Menopause_______years

Associated complaints : pain / clots / smell

History of contraception / Prasava Vrittanta : Vivaha kala :

P__G__L__D__A__

Particulars of baby : M / F

Type of Delivery :

Temporary: Mechanical/Chemical/Oral/Local/I.U.C.D

Permanent: Tubectomy/ Vasectomy/ Hysterectomy

8.Previous H/O : Cervical lacerations / PPH / cervical tear / Encirclage

9.Vital signs Pulse : per min B.P : mm of Hg Temperature: Heart rate : /min Respiratory rate: /min

10.General Physical examination. 1. Built : normosthenic / asthenic / Hyperasthenic

2. Nourishment: well / moderate / poor.

3. Height: cms.

4. Weight: kg

5. Pallor: P / A

6. Icterus: P / A

7. Cyanosis: P / A

8. Clubbing : P / A

9. Lymphadenopathy: P / A

10. Edema: P / A

11.Dashavidha pariksha 1. Prakrithi V / P / K / VP / PK / KV / KP / VK / Sama

2. Vikriti V / P / K

3. Satva P / M / A

4. Sara P / M / A

5. Samhanana P / M / A

6. Pramana Dairghya_____ cms Bhara____ Kg

7. Satmya P / M / A

8. Ahara shakthi Abhyavarna shakthi Purvakalina P / M / A Adyatana P / M / A

Jarana Shakthi Purvakalina P / M / A Adyatana P / M / A

9. Vaya Bala / Madhyayama / Vriddha

10. Vyayama shakthi Purvakalina P / M / A Adyatana P / M / A

12.Sroto pariksha 1. Pranavaha srotas

2. Udakavaha srotas

3. Annavaha srotas

4. Rasavaha srotas

5. Raktavaha srotas

6. Mamsavaha srotas

7. Medovaha srotas

8. Asthivaha srotas

9. Majjavaha srotas

10. Arthavavaha srotas

11. Mootravaha srotas

12. Purishavaha srotas

13.Systemic Examination

System Inspection Palpation Percussion Ascultation

Respiratory

Cardiovascular

Perabdomen

Urogenital

Musculo skeletal

14.Gynaecological Examination : 1. Local Examination :

Vulval Inspection : Discharge : Present / Absent

Discolouration :

Inflammation : Ulceration / redness / eruptions

2. P / S Examination : Cervix : Congestion : + / ++ / +++

Hypertrophy : Irregularity / Nodularity / Tear

Erosion : 1. UL / LL / around Os

2. Simple flat / papillary / follicular

Nabothian Cyst : No Cyst / Single / Multiple

Discharge : Slight / Moderate / Multiple

Vagina : Pink / Red / Ulcerated

3. P / V Examination : Vagina : Tenderness : Present / Absent

Cervix : Size : Normal / Atrophied / Hypertrophied

Os : Shape : Reg / Irreg / Nodular

Mobility : Mobile / Restricted mobility / Not mobile

Nabothian Cyst : No Cyst / Single / Multiple

Bleeding Type : Bleed on touch : Present / Absent

Uterus : Position : AV / RV

Consistency : Firm / Soft / Hard

Mobility : Mobile / Fixed

Size : Normal / Bulky / Atrophied / Mass present

15.Investigations. Routine Hematological Investigation.

Results Hb% T.C. D .C E.S.R R.B.S

B.T

A.T

Routine Urine Investigation.

Results Physical Chemical Microscopic

B.T

A.T

Pap Smear Test : Cervical Biopsy : USG :

16.Chikitsa

Days 1 2 3 4 5 6 7

Date

Varna

Daha

Srava

Shotha

Rakta srava

others

16.Assessment criteria

Criteria B.T A.T

Degree of erosion

Appearance

Yoni srava

Yoni kandu

Kati shoola

Udara shoola

Mutra daha

Subjective parameters

1. Vaginal discharge

Purulent Discharge 3


Slight discharge 1

No discharge 0

2. Dysmenorrhoea

Severe 3 (Not able to do routine work, forced to take rest)

Moderate 2 (Pain during work)

Mild 1 (Pain able to tolerate, routine work will not affect)

Absent 0

3. Back ache

Severe Pain 3 (Interfering daily routine, relief on medication not

satisfactory)

Moderate pain 2 (Continuous, interfering daily routine, relief on taking

medicine)

Mild pain 1 (Pain occasional , or only feeling of discomfort)

No pain 0

Objective Parameters Cervical features

1. Area of Erosion

76% - 100% 3

51% - 75% 2

26%-50% 1

00%-25% 0

2. Nabothian cysts :

Multiple/congested 4

Multiple/non –congested 3

Single/congested 2

Single/non-congested 1

No cysts 0

3. Cervical enlargement

Cervical Width > 3.5cm 3

Cervical width > 3 cm 2

Cervical width > 2.5cm 1

Cervical width – 2.5 cm 0

4. Irregularity

All Round The Cervix 3

On either side of cervix 2

On one side of cervix 1

Regular 0

5. Changes in papsmear reports

Presence of atypical cells 3

Changes in cellular patterns 2

With Infections/Inflammation

Changes in cellular pattern 1

Normal cells 0

6. Vaginal discharge :

Purulent discharge 3


Slight discharge 1

No discharge 0

Final Assessment : Cured : Normal Coloured Cervix with no Discharge & normalcy of clinical features

Improved : Moderate relief from the clinical features

No response : No relief



CERVIX - ANATOMY

UTERUS:127

Uterus is a hollow muscular & thick walled, pyriform organ, located in between bladder & rectum and is placed in the lesser pelvis.

TABLE NO - 5

Measurements

S.No. Measurements 1 Total length 7.5 cm (3”) 2 Length of fundus and body 5 cm 3 Length of cervix 2.5 cm 4 Maximum breadth 5 cm 5 Thickness 2.5 cm 6 Weight 30 – 40 gms 7 Length of cervical canal and uterine cavity 6 cm

Divisions :

The uterus is subdivided into 3 parts

1. Fundus 2. Body 3. Cervix

Fundus :

Th fundus is formed by the free upper end of the uterus and lies above the openings of uterine tubes. It is convex like a dome.

Body :

Body extends from fundus to the isthmus corresponding with internal os of the cervical canal.

Cervix :

Cervix lies below the isthmus and is subdivided into supravaginal and vaginal parts by the vaginal wall.

Layers of the Uterus :



From within outwards the uterus is subdivided into 3 layers.

1. Endometrium 2. Myometrium 3. Parametrium

Endometrium :

Endometrium is mucous membrane of the body of uterus consists of surface epithelium and lamina propria. The surface epithelium is lined by ciliated columnar epithelium before pubety and during reproductive period it is lined by simple columnar epithelium. Lamina propria contains numerous tubular uterine glands, embryonic stroma cells blood vessels, lymphatics and nerves.these uterine glands dips into inner surface of myometrium.

Functionally endometrium consists of outer basal layer, inner functional layer. Functional layers undergoes cyclical changes while basal layer remains unaltered helping in regeneration of epithelial lining of denuded endometrium.

Myometrium :

Myometrium is muscular layer of the uterus consists of 3 layers of smooth muscles –

1. Outer Longitudinal 2. Middle Circular 3. Inner Reticular.

Parametrium :

Perimetrium is the serous layer derived from peritoneum covering entire organ except the lateral borders, anterior supravaginal cercical part and vaginal part of cervix.

Cervix 128



The cervix is cylindrical organ situated in the lower part of the uterus, measuring about 2.5cm long. It is wider at the centre and constricted in the ends. The lower cervical part pierces the anterior vaginal wall, dividing it into supravaginal & vaginal parts.

The fusiform cervical canal (cavity of the cervix), communicates with the cavity of the uterine body above through the internl os and below with the vaginal cavity through the external os.

The main function of cervix is to protect the upper genital tract against bacterial invasion and entry of spermatozoa at the time of ovulation, facilitating the fertilization. As it is a fibromuscular organ, it has a great capacity of dilatation during labour, under the influence of hormones.

Histology of cervix: 129

There will be 2 kinds of epithelium initially laid down during embryological development.

‐ Columnar epithelium ‐ Squamous epithelium

-Ectocervix or portio-vaginalisis the part of the cervix exposed to the vagina and is lined by stratified squamous epithelium.

-Endocervix is continuous with the endocervical canal and is lined by a single layer of tall columnar mucous secreting epithelium.

-The endocervical mucosa is thrown into folds resulting in formation of clefts and tunnels, commonly referred to as cervical glands.

-The junction between ectocervix & endocervix is the junctional mucosa, consisting of gradual transition between squmous and columnar epithelia i.e squamo-columnar junction, which is a clinically significant landmark clinically and pathologically.

-The cervical mucosa undergoes changes under the influence of hormones and during pregnancy.

Blood supply of Uterus & Cervix – 130



Arterial Supply –

Blood supply is from uterine artery one on each side, which arises directly from anterior division

of internal iliac or in common with superior vesicle artery. The other sources are ovarian &

vaginal arteries to which the uterine arteries anastomose .

Venous Supply –

The venous channels correspond to the arterial course & drain into internal iliac veins.

Lymphatic Drainage –

Lymphatics drain into following group of glands -

1) Body - a) Preaortic & lateral aortic groups of glands.

b) Superficial inguinal gland .

c) External iliac groups .

2) Cervix – a) External iliac, obturator lymph nodes either directly or

through para- cervical lymph nodes .

b) Internal iliac group

c) Sacral groups

Nerve Supply - The nerve supply is derived principally from the sympathetic & partly from the

parasympathetic system.

1. Sympathetic components are from T5 – T6 (M) & T10 to L1 spinal segments

(sensory).

2. The somatic distribution of uterine pain is that area of the abdomen supplied by T10 to

L8.



3. Parasympathetic system is represented on either side by the pelvic nerve which

consists of both motor & sensory fibres from S2,S3,S4 & ends in the ganglia of

Frankenhauser .

SQUAMOCOLUMNAR JUNCTION:131

The endocervical canal is composed of columnar epithelium and exocervix is covered by squamous epithelium, the meeting point of the two is termed as “Squamo-columnar junction”.

SCJ is located on the exocervix in neonates, but in later life,it is not usually restricted to the external os, as it is a dynamic point changing in response to puberty, pregnancy, menopause & hormonal stimulation. Estrogen does the filling of glycogen in the vaginal epithelium, on which lactobacilli act, maintaining the pH and stimulates subcolumnar reserve cells to undergo metaplasia.

TRANSFORMATION ZONE:132

The metaplasia establishes the original inward SCJ towards the external os, and over the columnar epithelial villi and this area is called as Transformation zone.

The transformation zone extends from the original SCJ to the physiologically active SCJ.

In the transformation zone, if the metaplastic epithelium matures, produces glycogen & resembles original squamous epithelium histologically & colposcopically.

The original squamous epithelium of the vagina and exocervix have 4 layers:

1. The basal layer is a single row of immature cells with large nuclei and a small amount of cytoplasm.

2. The parabasal layer includes 2-4 rows of immature cells that have normal mitotic figures and provide the replacement cells for the overlying epithelium.

3. The intermediate layer includes 4-6 rows of cells with larger amounts of cytoplasm in a polyhedral shape separated by an intercellular space. Intercellular bridges, where differentiation of glycogen production occurs, can be identified with light microscopy.

4. The superficial layer includes 5-8rowsof flattened cells with small uniform nuclei and a cytoplasm filled with glycogen. The nucleus becomes pyknotic and the cells detach from the surface ( exfoliation ). These cells form the basis for papanoolaou testing.

CERVICAL HYPERTROPHY 133



Enlargement of an organ is due to increase in the parenchymal cell mass, which may be due to:

‐ Increased size & functional capacity of the indivisual cells ‐ Increased number of cells ‐ Usually combination of both

Responsible stimuli are:

‐ Increased functional demand ‐ Increased trophic hormonal activity

Physiological enlargement is by the increase in the muscle bulk, where as pathological enlargrment is the result of disease processes.

The process of hypertrophy does not always involve proliferation, but often there will be co-existent hyperplasia.

CERVICAL HYPERPLASIA 134,135

Aetiology:

‐ Chronic irritation ‐ Infectious conditions ‐ Imbalance of hormonal activity

Metaplasia is a less well specialized change from one type of differentiated tissue to another, which is common in the lining epithelium and is frequently associated with hyperplasia and is not a pre-cancerous condition. This benign & orderly hyperplasia occurs in the squamous cell covering of the cervix.

Cervical hyperplasia is characterized by thickening of the epithelium, hyperkeatosis, parakeratosis and lengthening of the rete ridges.

CERVICAL INTRAEPITHELIAL NEOPLASIA 136



CIN is regarded as a single disease, beginning at the squamocolumnar junction, in the epithelium of the transformation zone.

CIN represents the intermediate stage in the production of cancer. Here all cytological features of malignancy are present, but there is no invasion to the surrounding tissue.

CIN is two-fold common in the anterior lip than at the posterior lip and rarely originates in the lateral angles. And it can progress to involve the entire transformation zone, often does not replace the original squamous epithelium.

CIN is more common during menarche or following pregnancy, as metaplsia is active.

Onchogenic factors like sperm, seminal fluid histones, trichomonas, Chlamydia, herpes simplex virus & human papilloma virus (HPV), plays important role in the denelopment of CIN.

CERVICAL EROSION137

Formation of ‘Transformation zone’ is the fundamental thing in the evolution of ‘Cervical epithelial abnormalities’, involving CIN and eventual invasive squamous cell carcinoma. Cervical erosion is the process by which the inner ecto-cervical epithelium roll over outwards of the cervical stroma with its crypts and overlying epithelium into the exocervix.

“Squamous metaplasia” occur in the Transformation zone, permitting much tougher and resistant squamous epithelium to replace the highly specialized, fragile columnar cells of the endocervical epithelium. The columnar cells do not transform into squamous cells, as mature epithelial cells of one type cannot change to differentiate and become another cell type.

The stimulus to squamous metaplasia in the cervix is acidic vaginal pH, compared to the cervical canal. There will be reserve cells [developing from the stromal cells and blood derived monocytes], beneath the columnar epithelium and plays instrumental role in the replenishment of columnar epithelium lost by exfoliation. Reserve cells first appear as a row of nondescript small, round cells beneath the columnar epithelium, following the contour of the villi and superficial crypts as well.

Hence with the continuous stimulus, the reserve cells proliferate, forming thick layer of several cells, obliterating the spaces between the villi, flattening the surface of the transformation zone. At this stage, the columnar cells remain as an intact layer on the surface, appearing as fragmented islands of mucinous epithelial cells. This metaplastic epithelium is often mistaken for CIN, however pleomorphism is the rule.

Graph

No

List Of Graphs Page No

01 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Age:

46

02 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Religion:

47

03 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Marital Status:

47

04 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According to Education

48

05 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According to Habitat

48

06 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Socio-Eco Status

49

07 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Dietary Habit:

49

08 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Prakriti:

50

09 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Sara:

50

10 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Samhanan:

51

11 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Satva:

51

12 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Satmya:

52

13 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Agni:

52

14 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Ahara Shakthi:

53

15 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Vyayama Shakthi:

53

16 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Desha:

54

17 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Bowel & Bladder

54

18 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Vaya:

55

19 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Duration of Illness:

55

20 Distribution Of 20 Patients According To Onset: 56

21 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Pradhana Nidana Present:

57

22 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To History Of Menstrual Cycle Interval:

57

23 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To History of Duration of Menstrual Flow:

58

24 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Clots Present:

58

25 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Menstrual Blood Loss:

59

26 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Abortion:

59

27 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Contraceptive Methods:

60

28 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Parity:

60

29 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Delivery Type:

61

30 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Vaginal Discharge:

61

31 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Dysmenorrhoea:

62

32 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Bckache:

62

33 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According History of Dyspareunia:

63

34 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Area Of Erosion:

63

35 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Nabothian Cysts:

64

36 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Cervical Hypertrophy:

64

37 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Irregularity Of Os:

65

38 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According To Pap-Smear Reports

65

39 Distribution Of 20 Patients Of Garbhashaya Mukha Shotha According Burning Micturition:

66

40 Effect Of Avachoornana on Vaginal Discharge (S) 67

41 Effect Of Avachoornana on Dysmenorrhoea 68

42 Effect Of Avachoornana on Backache 69

43 Effect Of Avachoornana on Area Of Erosion 70

44 Effect Of Avachoornana on Nabothian Cysts 71

45 Effect Of Avachoornana on Cervical Enlargement 72

46 Effect Of Avachoornana on Irregularity Of Os 73

47 Effect Of Avachoornana on Pap-Smear Changes 74

48 Effect Of Avachoornana on Vaginal Discharge (O) 75

Cxos

Drug Applied

4th Day 10th Day

On Follow‐up