A A M J Anveshana Ayurveda Medical Journal

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1 A A M J Anveshana Ayurveda Medical Journal ISSN: Review Article Understanding Female Genital Malignancy in Ayurveda Mrudula K. S 1 Mamatha K. V 2 Vishwanatha 3 A b s t r a c t India is amongst the few innovators in the development and practice of well documented indigenous systems of medicine, the more important being Ayurveda, Unani and Siddha. Ayurveda in specific has incorporated a number of natural products in the treatment of a variety of cancers. Though there is a considerable decline in the rate of incidence of various types of cancer throughout the world, certain types of cancer still prevail in different countries. Cancer continues to be the second most common cause of death in women. Cancer of the breast is the most common followed by cancer of the cervix. In classics neither we find direct references regarding genital malignancies being dealt under Arubda (malignant lesion) Granthi (benign lesion) etc. nor we find any references about Symptoms like Yoni Srāva (discharge per vagina) being mentioned under Arbuda. Symptoms of Genital Carcinoma can be correlated with few of the conditions explained in our classics including Sannipātaja Ārtava duṣṭhi, Tridoṣaja pradara, Tridoṣaja yonivyāpat and to a certain Kuṇapagandhi Ārtava duṣṭhi also. Key words: Genital carcinoma, Arbuda, Granthi, Sannipātaja conditions. 1 PG Scholar, 2 Professor, Department of Prasuti Tantra and Streeroga, Shri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Kuthpady, 3 Research Officer, Department of Biotechnology and Microbiology, Shri Dharmasthala Manjunatheshwara Centre for Research in Ayurveda and Allied Sciences, Kuthpady, Udupi. CORRESPONDING AUTHOR Dr. Mrudula K. S PG Scholar, Department of Prasuti Tantra and Streeroga, Shri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Udupi, Karnataka, (India). mrudulakshanbhogue@gmail.com sue3/aamj_1302_1307.pdf AAMJ / Vol. 3 / Issue 3 / May June 2017

2 INTRODUCTION Amongst the female genital tract malignancies, cancer of the cervix holds the prime position in India followed by that of uterine endometrium, ovary, vulva, vagina and fallopian tube in that order of frequency. There is not only wide variation in the incidence but also in the distribution and life time risk of the major genital malignancies [i]. In India, a woman dies every two seconds due to cervical cancer. Every fourth women in world suffering from cervical cancer is an Indian [ii]. In the classics of Ayurveda malignant disorders are correlated closely with the descriptions of Arbuda. But, signs and symptoms of Granthi and Arbuda are not mentioned particularly to a system. The descriptions are vague and in general. Hence, if we search under Granthi and Arbuda, probably we do not find any link between these two. Instead, since Arbuda is Asādhya(incurable) or Kaṣṭhasādhya vyādhi (difficult to cure) at the same time Genital malignancies are difficult to cure or incurable with high mortality and morbidity, if we extend our search of references about the signs and symptoms of genital malignancy, the conditions narrated under Tridoṣaja origin in our classics do have some similarities with that of genital malignancies. To include a few, Tridoṣaja ārtavaduṣṭhi, Tridoṣaja Pradara, Tridoṣaja yonivyāpat and Kuṇapagandhi ārtavaduṣṭhi as well. Hence, an attempt is made to understand the descriptions of genital malignancies in terms of Ayurveda. Aims and Objectives To make comprehensive literary study on Genital carcinoma of females. To make a critical analysis of Genital carcinoma with related gynaecological conditions in Ayurveda. Materials and Methods Information of Genital carcinoma and its related conditions was collected from relevant modern and Ayurvedic text and research literature respectively. Evaluation was done to find out evidences related to Genital carcinoma and related conditions in Ayurveda from the materials stated above. Female Genital Carcinoma The origin of the word cancer is credited to the Greek physician Hippocrates ( BC), who is considered as the Father of Medicine. Hippocrates used the terms carcinos and carcinoma to describe non ulcer forming and ulcer forming tumours. Human beings and other animals had cancer throughout recorded history. Some of the earliest evidence of cancer is found among fossilized bone tumours, human mummies in ancient Egypt, and ancient manuscripts [iii]. Risk and Etiological Factors [iv] The most consistent risk factors for the development of genital malignancies includes Low socio economic status. Early age at first intercourse. Early age of first pregnancy. Multiple sexual partners. Marital instability. Exposure to high risk males. Women who are married to men with penile cancer. Smoking and Tobacco chewing. Prolonged OCP users. Immunosuppressive conditions like HIV, other viral infections like HSV, HPV and STDs. Infrequent or absent cancer screening or pap test. Obesity. Systemic illness including DM, HTN. Personal or family history of Carcinoma. Cervical Intraepithelial Neoplasia (CIN) and Carcinoma Cervix [v]. Invasive cervical cancers are usually preceded by a long phase of pre cancerous phase called CIN phase. Cervical intraepithelial neoplasia as the name suggests, is a neoplasia within the epithelial cells of cervix. This precancerous pre invasive phase is characterised microscopically as a spectrum of events progressing from cellular atypia to CIN further progressing to cervical cancer. Classification of CIN [vi] Mild dysplasia (CIN 1) The undifferentiated cells are confined to the lower one third of the epithelium. Moderate dysplasia (CIN 2) Undifferentiated cells occupy the lower 50 75% of the epithelial thickness. Severe Dysplasia and carcinoma in situ (CIN 3) In this grade of dysplasia, the entire thickness is replaced by abnormal cells. The basement membrane, however, is intact and there is no stromal infiltration. Squamous cell carcinoma/ Invasive carcinoma Tumour cells penetrate throughout the basement membrane to form isolated cells and small aggregates in the stroma, which undergo chronic inflammation and fibrosis. AAMJ / Vol. 3 / Issue 3 / May June

3 Signs and Symptoms [vii] Symptomless in very early stage. Early stage or Pre Invasive Stage presenting symptoms are coital bleeding, post-menopausal bleeding, metrorrhagia, white discharge watery or blood stained. Late stage continuous bleeding, foul vaginal discharge, back pain radiating to thighs, cachexia, Dysuria etc. Endometrial carcinoma [viii] Endometrial cancer has emerged as the most frequently encountered gynaecologic cancer in West. It accounts for 7% of all cancers in women. Endometrial cancer may be asymptomatic to begin with, it commonly manifests as menometrorrhagia in perimenopausal women, or as postmenopausal bleeding. White discharge. In early case, the discharge is watery or serosanguinous. Foul smelling discharge is a late symptom. Colicky lower abdomen pain. Carcinoma of Ovary [ix] This comprises 4% of cancers in women in India and 15 20% of genital malignancy. Abdominal discomfort and pain. Abnormal or postmenopausal bleeding. Abdominal lump. Weight loss, cachexia and anaemia in advanced stage. Carcinoma of Vulva [x,xi] Cancer of the vulva accounts for 1 to 4 % of all genital cancers. Pruritis vulvae is the most common complaint, occurring in 50% of symptomatic women. Swelling with or without offensive discharge. Difficulty in urination. Vulval ulceration and Bleeding. Pain. Inguinal lymph node involvement. Carcinoma of Vagina [xii] The incidence of primary vaginal carcinoma is very rare. It constitutes about 1% of genital malignancies. Secondary vaginal malignancy follows carcinoma vulva, cervix or urethra by direct spread. May be asymptomatic, being accidentally discovered during routine screening procedures. Abnormal vaginal bleeding including post coital bleeding is conspicuously present as an early symptom. Foul smelling discharge per vaginum Speculum examination reveals an ulcerative, nodular or exophytic growth. Carcinoma of Fallopian Tube [xiii] Carcinoma of the fallopian tube are uncommon and account for 0.3% of all cancers of the female genital tract. Signs and Symptoms Is often nil. Rarely there may be colicky pain on the lower abdomen, thin intermittent profuse vaginal discharge followed by relief of pain and bleeding. Signs may be one of tender fixed mass on the lateral vaginal fornix. Ayurvedic understanding of the disease: Health of a women is well explained in terms of multiple indicators including normal menstrual cycle. In Ayurvedic treatise, menstrual flow is described in terms of ārtava (menstruation) Hence, Shudha ārtava laksha (normal characters of menstrual blood) plays a vital role in determining the normalcy of health of a woman. Any deviations from these shudha ārtava lakṣaṇa can be considered as a warning sign of underlying pathology of Genital Carcinoma. Kuṇapagandhi Ārtavaduṣṭhi [xiv] The Kuṇapagandhi Ārtavaduṣṭhi is caused by Rakta. In this condition, the amount of blood discharged during menstruation is more and the smell of ārtava is similar to that of dead body. Aacharya Dalhana in his commentary has further explained Śōṇita varṇa and Pitta vedana, which is nothing but, Ōṣa, Chōṣa (burning like pain) etc. and Analpam refers to excessive in amount. Similar explanation is given by Acharya Vagbhata. Hence Kuṇapagandhi Ārtavaduṣṭhi can also be considered as foul smell discharge per vagina. Mūtrapurīṣagandhi ārtavaduṣṭhi [xv] Mūtrapurīṣagandhi ārtava menstrual discharges smell like urine and faeces. Mūtra purīṣagandhi can be co related with Vesico vaginal fistula, vesico uterine or recto vaginal fistula. According to its description it can AAMJ / Vol. 3 / Issue 3 / May June

4 be considered as either cyclic or acyclic abnormal bleeding associated with vaginal drainage of urine or faeces or both. Sannipātaja Asṟagdhara [xvi] According to Acharya Charaka, Pradīraṇa (excessive excretion) of raja is termed as Asrgdhara. Lakṣaṇa In sannipātaja Asrgdhara, combined lakṣaṇas of all the three doṣas will be seen along with the following lakṣaṇas. Sl. No Author 1 Charaka 2 Sushruta 3 Vagbhata 4 Madhavak ara Amount / Duration Śāśvāta (continuous) Table 1 Features of Sannipātaja Asṟagdhara [xvii] Colour Smell Consistency Nature Sarpi, majja, vasopamam, Pītam (colour similar to ghee, marrow, fat) Kānjikābham (colour similar to sour gruel) Kāmsya nīla (bluish in colour) Kṣaudra, sarpi, Haritāla varṇa (colour similar to honey, ghee and arsenic) Durgandha (foul smelling) Durgandhi (bad odour) Pichila (unctuous) Vegavān (fast in nature) Kuṇapam (smell like dead body) Majja prakāśam (similar to marrow) Associated symptoms Tṟiṣṇā (thirst) Dāha (burning) Jvara (fever) Sannipātaja Yonivyāpat [xviii] Combined lakṣaṇas of vātaja, pittaja and kaphaja yonivyāpat will be present is the opinion given by different authors. However, Acharya Indu, commentator of Ashtanga sangraha explains the lakṣaṇa of sannipātaja yonivyāpat as follows Dāha(burning), Pāka(suppuration), Jvara(fever), Śaithya (coldness), Kandu(itching) Ruk, Toda (various kinds of pain) Miśra lakṣaṇa ārtava mixed symptomatic vaginal discharge Anṟitu srāva is the term given by Acharya Chakrapani. Can be considered as inter menstrual bleeding. Raktaja Granthi and Arbuda [xix] Due to the similarities in the etiology, clinical features, doṣa and dūṣya involved, granthi and arbuda are said to be identical according to Acharya Charaka. Further, Acharya Chakrapani explains that, the disease granthi has been named to denote its specific character ie., glandular or nodular swelling. Acharya Sushruta has mentioned 5 types of granthi, vātaja, pittaja, kaphaja, medoja and sirāja. Raktaja granthi is the additional type of granthi explained by Acharya Vagbhata. Lakṣaṇas Saswāpa loss of sense in that particular region. Pitta lakṣaṇa granthi associated with intense burning sensation, blazing type of pain, pita varṇa, uṣṇa srāva, gets suppurated very fast. Raktaja Arbuda Acharya Sushruta has mentioned 6 types of Arbuda ie., vātaja, pittaja, kaphaja, raktaja māmsaja and medaja. Lakṣaṇa Māmsa pinda or māmsa ankura muscular growth or mass Apāki does not suppurate Sasrāva associated with discharge Rakta srāva continuous bleeding Pāndu Anaemia due to continuous bleeding DISCUSSION Though there is a considerable decline in the rate of incidence of various types of cancer throughout the world, certain types of cancer still prevail in different countries, In the context of Kuṇapagandha ārtava duṣṭhi, the smell of ārtava is explained as Kuṇapagandhita or Śavagandhita. Offensive and foul smell are the terms used to describe the odour of the vaginal discharge in most of the conditions of Genital Malignancy which can be co related with kuṇapagandha and pūtīgandha mentioned in the classics. AAMJ / Vol. 3 / Issue 3 / May June

5 In the context of Mūtrapurīṣa gandhi ārtavaduṣṭhi, mūtra purīṣagandha refers to smell of urine and /or faeces. Hence vaginal discharge or menstrual blood which smells like that of urine or faeces can be considered under mūtrapurīṣagandhi ārtava duṣṭhi. The vaginal discharge when gets mixed with urine or faeces can smell like the same. This can happen only when an abnormal communication (fistula) is formed in between vagina and urinary tract/ rectum. Excluding the surgical causes here, the only appropriate condition where urine and stool will be mixed along with discharge / menstrual blood is the advanced stage of carcinoma cervix. There is different opinion regarding the colour of ārtava in Sannipātaja asṟagdhara according to different Acharya. According to Charaka the colour resembles to that of sarpi majja and vasa. The colour of ārtava is said to be as kanji varṇa as per Sushruta. According to Vagbhata the colour of Ārtava is said to be as kamsya neela and as per Madhavakara the colour is similar to that of sarpi and haratala. The rationality behind describing different colour of ārtava in sannipātaja Asrigdhara by different author could be due to the tridoṣa involvement and predominance of a single doṣa or in combination with each other. Menstural blood is bright to dark red in colour, the change in colour from brown to black could be due to degradation of blood cells either due to exposure to air (oxidation) over time, the action of bacterial enzymes or exposure of blood to certain chemicals that may cause rapid degradation and discolouration. Hence, one can suspect various underlying pathologies including malignancy whenever there is any deviation in the normal colour of menstrual blood or vaginal discharges. The definition of Asṟagdhara itself says that there will be pradīraṇa (excessive excretion) of ārtava. Further in Sannipātaja asṟagdhara, acharya Charka mentioned that there will be Śāśvata Srāva. Anrutu srāva is the term coined by Acharya Chakrapani while explaining sannipātaja Yonivyāpat. These symptoms can be correlated with the symptoms such as excessive bleeding which can be seen in almost all the genital carcinoma when tumour invades a blood vessel and anṟitu srāva may be considered as inter menstrual bleeding or post coital bleeding, as the bleeding occurs other than in ṟitukāla. Tṟiṣṇā and Jvara are the features explained under Sannipātaja asṟagdhara. In Sannipātaja yonivyāpat Jvara, Kandu, ruk, Toda are explained. Appearance of these signs and symptoms can be considered as an active stage of infection. Ruk, Toda can be seen in advanced stages of genital carcinoma wherein there is nerve invasion. In Sannipātaja asṟagdhara, Kṣīṇarakta and durbala are the features explained which can be co related as Anaemia and Cachexia in the terminal stages of Carcinoma. Two disease entities arising due to excessive, uncommon or peculiar and improper growth of cells have been described under Granthi and Arbuda in Ayurveda classics. Due to very short description of clinical features as well as treatment, this Granthi and Arbuda may be considered as an exophytic character of malignancy. Acharya Charaka has described these diseases in the chapter of Śōtha, due to similarity in basic clinical features of Śōtha, Granthi and Arbuda. With the descriptions available, Śōtha may be considered as an initial stage of infection and inflammation, Granthi as an early neoplastic/ benign changes in the cell and Arbuda as the advanced stage of malignancy. According to Acharya Vagbhata, Raktaja Granthi is curable, whereas Raktaja Arbuda is incurable which further supports the above statement. CONCLUSION It is often claimed that the malignancy is new disorder produced due to current diet lifestyle modalities and the disease did not exist in ancient periods. Knowledge regarding malignancy was well known as we get plenty of details regarding malignancy in ancient Ayurvedic literature. It may be possible that the incidence might have been much lower than the present day situation. Signs and symptoms of the early phase of genital malignancy may be correlated with the symptoms explained in the context of Kuṇapagandhi ārtavaduṣṭhi, where foul smelling vaginal discharges will be seen. Intermittent phase of genital malignancy may be correlated with few of the symptoms explained in the context of Sannipātaja yonivyāpat as well as Sannipātaja asrgdhara where, daaha, kandu, and abnormal bleeding will be the dominant feature and Pandu and Durbala explained in Sannipātaja asrgdhara due to excess blood loss supports the complications explained in genital malignancy. Mūtrapurīṣa gandhi ārtava duṣṭhi may be considered as the terminal phase where genitourinary fistula will be formed. Perhaps Ayurveda can play major role in all the aspects of malignant disorders. The scope for Ayurveda in the area of oncology could be prevention, anti cancer therapy, adjuvant to chemotherapy and radiotherapy and improving the quality of life in advanced disease conditions. ΛΛΛΛ AAMJ / Vol. 3 / Issue 3 / May June

6 REFERENCES i. D.C Dutta: textbook of Gynaecology, 5 th Edition, New central book agency Publications (p)ltd,kolkata;2009, Pp-627, p.32. ii. Priya Ganesh kumar, Colposcopy In Practical Gynecology,, Ist Edition, CBS Publishers New Delhi; 2015, Pp 112, p -1. iii. The History of Cancer, American Cancer Society, Pp-16, p1-2. iv. Yao S.Fu, Pathologyy of the uterine cervix, vagina and vulva,2 nd Edition,The curtis center, independence square west, Philadelphia; 2002,Pp-565, p-275. v. Priya Ganesh kumar, Colposcopy In Practical Gynecology,, Ist Edition, CBS Publishers New Delhi; 2015, Pp 112, p -34. vi. Yao S.Fu, Pathologyy of the uterine cervix, vagina and vulva,2 nd Edition,The curtis center, independence square west, Philadelphia; 2002,Pp-565, p-300. vii. C.S Dawn, Textbook of gynaecology, contraception and dermography14 th edition, Dawn books, Kolkata; 2003, Pp- 256, p-166. viii. V.G.Padubidri, Shirish N Daftary, Shaw s Textbook of Gynaecology, 13 th edition, Reed Elsevier India Private Limited, New Delhi;2005, Pp -508, p ix. V.G.Padubidri, Shirish N Daftary, Shaw s Textbook of Gynaecology, 13 th edition, Reed Elsevier India Private Limited, New Delhi;2005, Pp -508, p-375,376. x. V.G.Padubidri, Shirish N Daftary, Shaw s Textbook of Gynaecology, 13 th edition, Reed Elsevier India Private Limited, New Delhi;2005, Pp -508, p-88. xi. D.C Dutta, Textbook of Gynaecology, 5 th Edition, New central book agency Publications (p)ltd,kolkata;2009, Pp-627, p-323. xii. D.C Dutta,Textbook of Gynaecology, 5 th Edition, New central book agency Publications (p)ltd,kolkata;2009, Pp-627, p-325,326. xiii. C.S Dawn, Textbook of gynaecology, contraception and dermography14 th edition, Dawn books, Kolkata; 2003, Pp- 256, p-173. xiv. Premavathi Tivari, Ayurvediya prasuti tantra evam stree Orientalia,Varanasi;2009, Pp-636 p-145. xv. Dr.V.N.K.Usha, A text book of Gynaecology Streerogavijnan,Reprint Edition, Chaukhamba Sanskrit Pratishthan,Delhi;2011, Pp-692, p-76. xvi. Premavathi Tivari, Ayurvediya prasuti tantra evam stree Orientalia,Varanasi;2009, Pp-636 p-172. xvii. Premavathi Tivari, Ayurvediya prasuti tantra evam stree Orientalia,Varanasi;2009, Pp-636 p-192. xviii. Dr.V.N.K.Usha, A text book of Gynaecology Streerogavijnan,Reprint Edition, Chaukhamba Sanskrit Pratishthan,Delhi;2011, Pp-692, p-246. xix. Premavathi Tivari, Ayurvediya prasuti tantra evam stree Orientalia,Varanasi;2009, Pp-636 p-371,397. Source of Support: Nil. Conflict of Interest: None declared How to cite this article: Mrudula et.al,. : Understanding Female Genital Malignancy in Ayurveda. AAMJ 2017; 3: ΛΛΛΛ AAMJ / Vol. 3 / Issue 3 / May June