E-ISSN:2456-3110

Review Article

Cervical Ectropion

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 3 March
Publisherwww.maharshicharaka.in

Review of management of Cervical Ectropion using Traditional Ayurvedic Interventions

Mishra M.1*, Bagade T.2
DOI: http://dx.doi.org/10.21760/jaims.8.3.10

1* Mahi Mishra, Reader, Department of Prasuti Tantra and Stri Roga, Government Autonomous Ayurveda College and Hospital, F-1, Govt. Ayurveda College Campus, Near Mandre Mata Mandir, Kampoo, Lashkar, Gwalior, Madhya Pradesh, India.

2 Tanmay Bagade, Lecturer (Medical education, Global Health), Department of Prasuti Tantra and Stri Roga, Centre of Women’s Health Research, the University of Newcastle, School of Medicine and Public health, Callaghan Drive, New South Wales, Australia.

Cervical ectropion or cervical erosion is a highly prevalent condition among females of reproductive age. Although self-limiting and benign this disease can progress to chronic condition and or cause unpleasant and distressing symptoms that significantly impacting women’s quality of life. Modern therapies are limited to local ablative therapies and can temporarily relieve mild symptoms. However, there is a need to have a tailored approach to this condition based on the range of symptoms and stages of the disease. Also, this approach should depend on the understanding of the body temperament, daily dietary habits, routine occupational hazards, and the climacteric changes where the patient is residing. Ayurveda’s holistic healing approach holds an answer to the issue of chronicity and recurrent occurrence of cervical ectropion. Ayurveda’s disease management focuses on assessment of the history, signs and symptoms and its correlation with Prakriti and the vitiated Doshas. The treatment modality and the drug of choice are selected according to these assessments. Therefore, our study aims to review the current literature and clinical procedures mentioned in Ayurveda and synthesize the evidence associated with the medicinal drugs and combinations used to treat cervical ectropion.

Keywords: Cervical Ectropion, Cervical Erosion, Ayurveda

Corresponding Author How to Cite this Article To Browse
Mahi Mishra, Reader, Department of Prasuti Tantra and Stri Roga, Government Autonomous Ayurveda College and Hospital, F-1, Govt. Ayurveda College Campus, Near Mandre Mata Mandir, Kampoo, Lashkar, Gwalior, Madhya Pradesh, India.
Email: 		Mahi Mishra, Tanmay Bagade, Review of management of Cervical Ectropion using Traditional Ayurvedic Interventions. J Ayu Int Med Sci. 2023;8(3):55-62.
Available From
https://jaims.in/jaims/article/view/2336

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-01-24 2023-01-27 2023-02-03 2023-02-10 2023-02-17
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 18%

© 2023by Mahi Mishra, Tanmay Bagadeand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Cervical ectropion (also known as cervical erosion) is a common, but benign condition in women of reproductive age. Usually diagnosed during routine pelvic examination or pap screening, the prevalence of cervical ectropion is estimated to be between 17 to 50 percent globally.[1] In adolescents, the prevalence of cervical ectropion can be as high as 80%.[1] Swaminathan et al. in a multi-centric cross-sectional study in southern India, indicated a prevalence of 33%.[2] It occurs when cervical epithelium is exposed to increased levels of oestrogen causing eversion of squamous, columnar junction, as well as the columnar epithelium of the endocervix onto the ectocervix.[1] The eversion of squamocolumnar junction exposes the immunologically weaker cells to the acidic pH of the vagina.[1,3] Although benign, cervical ectropion can cause a range of symptoms including excessive vaginal discharge, intermenstrual and post-coital bleeding, pelvic pain, dyspareunia, and severe symptoms such as recurrent cervicitis and susceptibility to sexually transmitted infections, especially Human Papilloma Virus (HPV), Neisseria gonorrheae, and Chlamydia trachomatis.[1,3-7] Both, HPV and Chlamydia trachomatis are known to cause cervical cancers,[8] while chronic cervicitis is attributed to pelvic inflammatory diseases and infertility.[6] Therefore, it is crucial to treat symptomatic cervical ectropion earlier to prevent future complications.

Current treatment approach
Current treatment approaches to symptomatic cervical ectropion include ablative treatments such as cryotherapy, electrocautery, laser therapy, focused ultrasonography, and local application of boric acid and other drugs.[1,4] Although these treatments are effective, there is a high rate of recurrence due to various causes such as change in vaginal micro-biota, pregnancy or hormonal imbalances in women.[9] Godha et al. have highlighted that the vaginal pH and microbiota has significant relation to women’s reproductive health.[10] In a review, Garcia-Velasco explained that disturbed vaginal microbiota is associated with risk of infertility, spontaneous abortions and preterm births.[11] Therefore, treatment of cervical ectropion should be holistically approached to alleviate symptoms, as well as protect the patients from future adverse reproductive health outcomes.

However, the current treatment approach to cervical ectropion is restrictedly focused on local ablative therapies, rather than enhancing efforts to improve vaginal pH and micro-biota for a sustainable relief of symptoms. Alternate therapies exist but have not been studied in detail. Therefore, there is a need to review the current literature to identify alternate therapies, especially the Indian system of medicine, i.e., approach of Ayurveda towards management of cervical ectropion.

Ayurveda’s approach: Ayurveda’s approach is to holistically eliminate the root causes of diseases, rather than treating the symptoms. Ayurveda's exclusive concept of ‘Prakriti’ believes that the human body is made up of five elements known as the Panchtatva, which include Sky (Aakash), Wind (Vayu), Fire (Agni), Water (Jal), and Earth (Prithvi). These components further form the three principal energies (Doshas) of our body, known as the Vata, Pitta, and the Kapha. The variation in the levels of Vata, Pitta, and Kapha, results in a variety of body types. There are seven combinations of these Doshas that result in seven principal temperaments, known as the seven Prakriti. Due to these variations the same diseases are presented with different signs and symptoms and severity. Hence understanding the temperament and understanding the dominant vitiated Dosha depending on the clinical presentation is of prime importance and treating the subject accordingly becomes the necessity. The seven Prakritis are: Vata, Pitta, Kapha, Vata-Pitta, Vata-Kapha, Pitta-Kapha, and Vata-Pitta-Kapha (Samdoshaj). Each of these Prakritis results in different psychosomatic characteristics in a person. Hence, for an Ayurvedic practitioner, the clinical assessment has a different approach. It begins as soon as a patient walks through the door. For example, if two people of the same age, sex, from the same place, and with the same disease, have a high possibility of being prescribed different medications.

An Ayurvedic practitioner shall ask them both, a series of questions related to their lifestyle habits, food and digestion, temperament, assessment of psychological state to understand their Prakriti, and then the management is decided. This approach of history taking ensures that medications are tailored according to the person’s Prakriti and not according to the clinical diagnosis. Chatterjee et al. have reiterated that Prakriti-based medicine provides personalised treatment to chronic diseases


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and has potential to offer solutions to challenges in modern medicine such as adverse drug reactions, drug withdrawals, and economic disparities.[57]

Localised treatment in Ayurveda
In Ayurveda, local treatment is known as Sthanik Chikitsa. It is derived from various references of Bruhatrayis or the three 3 main books of Ayurveda; namely Charak Samhita, Sushrut Samhita and Vagbhatt Samhita. The local treatment depends on the signs and symptoms given and presented by the patients. The various permutations and combinations are practically applied depending upon the Prakruti of the patient, the dietetics and the seasonal changes. In this rapid review, we aim to identify Ayurvedic procedures, therapies and medications that are currently used to treat cervical ectropion.

Following are the common Sthanik Chikitsa used to treat cervical ectropion and their descriptions:

1. Yoni Pichu: Yoni means vagina and Pichu means a tampon made up of sterile cotton and gauze as per the size of the vaginal opening and parity of the patient. This tampon is soaked in any one of the following depending upon the symptoms and the involvement of the Doshas example medicated oil (Jatyadi Tail), decoction (Kashaya), Churna mixed with oil (Gairik Churna mixed with Jatyadi oil). The drug administered through Pichu stays for a longer time on the affected area facilitating better absorption. It moistens and softens dry vagina. The medications restore the pH of vaginal flora thereby reducing vaginal infections. Taila or Sneha alleviates Vata Dosha. Pichu can be round shaped or elongated for shallow and deep insertion inside vagina respectively.[43]

2. Yoni Dhavana: Yoni means vagina and Dhavana or Prakshalana means cleansing of vagina.[44] It includes the douching of the vaginal canal. It is one among sixty types of Vrana Chikitsa. It is used in various conditions where the discharge is sticky, mucoid, unctuous, curdy, watery and offensive. Decoctions (Kwatha) of various plants can be used in different patients depending on the Lakshana (signs) Poorvaroop and Roop (symptoms) example: Triphala Kwatha, Panchavalkala Kwath.[45]

Various Kashaya used for this purpose in accordance to Doshas or characteristics of discharge are as follows: in Vata Dosha involvement - Triphala, Guduchi Kashaya or Mudgaparni Kashaya

can be used; in Pitta Dosha involvement - Panchvalkala or Panchtikta Kashaya can be used; in Kapha Dosha involvement - Aragwadhadi or Nimbadi Kashaya can be used; in thin, slimy discharge - Triphala Kashaya In thick, unctuous white discharge - Dashmula or Triphala Kashaya, and in offensive, mucopurulent discharge - Chandana or Lodhradi Kashaya.

3. Yoni Dhoopan: Yoni Dhoopan means vaginal fumigation.[46] It is done by strewing Dravyas in Dhoopana Yantra on Nirdhuma Agni after Yoni Dhavana. Dhoopan causes medicinal smoke which might act minutely on the mucosal lining of the introitus causing Srotoshodhana. Dhoom causes Swedana of Yoni which opens up minute or tiny pores thereby cleansing the yoni. Dhoopana Karma reduces the sticky discharge from the vagina and keeps the vulva and introitus dry. Dhoopana is also considered as Rakshoghna (bacterial and antiseptic). Commonly used drugs in Dhoopana karma are Guggulu, Dhatura Patra, Kushta, Agaru, Haridra, Shatapushpa. Care has to be taken about the temperature and the distance of the patient from the Dhoopana Patra (container). Allergies to smoke if any is also to be considered.

4. Yoni Varti: Varti means vaginal suppository. A medicated suppository which can be kept in the vagina depending on the intensity of vaginitis.[47] A vaginal suppository is a drug delivery system where it dissolves and gets absorbed in deeper tissues.[48] It is made using Shodhana Dravyas like Triphala,Ashoka Twak, Udumbar Lodhra, Jiraka, Kanjika, Kshara, Saindhava, Lavana. These drugs are astringent, hygroscopic, and possess wound healing properties. The size or thickness of this Varti should be like that of the thumb or forefinger. Just like selection of drugs in Prakshalana (douche) various types of Varti’s can be prepared and used. If the cervical erosion is along with the involvement of vaginitis and its congestion then this Varti can be used.

5. Yoni Purana: Yoni Purana means filling the Yoni or retaining Dravyas in the vaginal canal.[49] The Dravyas may be in the form of oil, Churna, Kalka, Veshvara, Pinda, bolus etc. made into compact mass and inserted into the Yoni. The active principles are absorbed through vaginal or cervical epithelium thereby producing the necessary action. Oils and poured in vagina and sealed with tampon. Symptomatic relief in dyspareunia


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and dryness of vagina due to oestrogen deficiency is obtained by this procedure.

6. Yoni Lepana: Fresh paste or dry powder mixed with various oils are used as an ointment or lepa in yoni, and is termed Yoni Lepana. Acharya Sushruta mentions that just as water extinguishes fire instantly likewise Lepana cures Vrana Shula, cleanses wound or infection, reduces swelling or inflammation and quickens suppuration.[50] The drug gets absorbed through glands and capillaries and vessels. Pralepa-thin paste is applied.[51,52]

7. Kshara Karma: Ksharana means destruction of vitiated unhealthy tissues hence it is termed as Kshara the diseased tissue is scrapped out or removed by this Kshara.[53] It is both Soumya (action) and Tikshna (Prabhava) and can be used even on Marma Sthana. Kshara is made from several drugs depending on its potency. The potency here refers to the Ph value hence it alleviates Tridoshas. It is white in colour and though Soumya in nature it performs Dahana, Pachana, Darana due to its Agneya Guna. Kshara is Katurasa, Ushna Virya, Tikshna Guna, Vrana Sthotha Pachaka, cures Dushta Vrana, suppurated Shuddha Vrana, dries up an oozing Vrana, arrests Rakta Srava, Lekhana of firm muscular growth.[54] Kshara when used externally works on the concept of coagulative necrosis causes coagulation of proteins, disintegration of blackish brown discharge, sloughing and re-epithelization. The selection of Kshara depends on the site where it has to be used hence on the cervical tissue the Kshara of lower Ph is required. Kshara can be prepared in 5-10 days depending on the climacteric changes. Kshara must be applied for 60-90 seconds on the cervix and later washed off carefully with diluted lemon juice or Kanji. After which a medicated tampon is kept which helps in the healing process. Kshara Karma can be done once in three days.

8. Agnikarma: The literal meaning of Dahana is to burn or cauterize.[55] According to Ayurveda, Agnikarma is Anushastra Karma. The diseased tissue is treated by inflicting burns on the tissue surface directly by using different materials called Dahana Upkarana. Various Dravyas used in Agnikarma are Jamboshtha, Needle, Ghee, Guda, Madhu Taila, Shalaka prepared by gold, copper, iron, silver can be used.[56] Nowadays electric thermal cautery machine has taken the place of Shalaka. The heat transferred acts

by removing the obstruction in the Srotas and increases the blood circulation to the affected site thereby increasing the cellular activity and metabolism. However, it is postulated by some authors that afferent nerves stimulated by heat has an analgesic effect.

Table 1: Medications used in Ayurvedic procedures and their evidence-based effects specific to cervical ectropion

SN Latin Name/Mineral name Sanskrit Name Procedure/s where drug is used Drug formulation mentioned in Ayurvedic texts Effects
1. Azadirachta indica Neemb Prakshalan Dhoopan Nimbadichurna Anti-inflammatory, inhibitor of abnormal cell growth[12]
2. Jasminum officinale Jatipushpam Prakshalan Jatyadi Tail Anti-inflammatory[13]
3. Trichosanthes dioca Patol Prakshalan, Pichu, Lepa Patoladi Kwatha Anti-inflammatory, Antinociceptive, immunomodulatory, wound healing[14]
4. Pongamia pinnata Karanj Dhoopana Karanjadi Tail Anti-inflammatory, anti-ulcerative, antisecretary[15]
5. Glycerrhiza glabra Yashtimadhu Lepa, Prakshalan, Dhoopan Mulethi Churna Antibacterial, anti-ulcerative, antiviral, anticarcinogenic, antimutagenic, estrogenic, neuroprotective, immunomodulatory[16,17]
6. Saussurea lappa Kushta Lepa, Prakshalan, Pichu Chyawanprash Anti-inflammatory, anticarcinogenic, anti-ulcerative, antimicrobial, antiviral[18]
7. Curcuma longa Haridra Lepa, Prakshalan Pichu, Haridra Khand Anti-inflammatory, antimicrobial[19-21]
8. Berberis aristata Daruharidra Lepa, Prakshalan Pichu, Chyawanprash Antimicrobial, antioxidant, anticarcinogenic[22-24]
9. Picrorhiza kurroa Kutki Pichu, Prakshalan, Dhoopan Arogyavardhini Vati Anticarcinogenic, antioxidant, antimicrobial[25-27]
10. Rubia cordifolia Manjistha Prakshalan, Lepan, Pichu Mahamanjishtadi Kwatha Analgesic, anti-inflammatory, antimicrobial, antithrombitic[27,28]
11. Symplocos racemosa Lodhra Post Angnikarma Lodhrasav Anti-inflammatory, antimicrobial, antiproliferative[29-31]
12. Terminalia chebula Haritaki Lepan, Prakshalan, Pichu, Post Ksharakarma Triphala Churna,Shiva Gutika Antioxidant, antimicrobial, antiviral, anti-inflammatory, cytoprotective, immunomodulatory, inhibits bacterial triggers,[32-34]
13. Nymphoea stellata Neel Kamal Pichu,Lepa Arvindasav Antimicrobial, antioxidant,[35,36]
14. Copper sulphate Tutha Agnikarma, Pichu Jatyadi Tail Wound-healing (local effect), chelating effect (locally)[37,38]
15. Hemedesmus indicus Sariva Prakshalan, Lepa, Post Agnikarma Sarivadyasav Antimicrobial, anti-inflammatory, antioxidant, anti-boifilm[39,40]
16. Prunus cerasoides Padhmakhya Lepa, Pichu Kalyanak Ghrita Estrogenic, antibacterial, antioxidant[41,42]

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Ayurvedic medications: The success of each procedure depends on patient selection according to their Prakruti, and the extent of the symptoms. Chronic or recurrent cervical ectropion needs multiple procedures that can usually include combination of local and vaginal applications along with oral medications over a period to improve clinical outcomes. The various combinations of procedures and medications have a cumulative effect on treating cervical ectropion, especially if it is associated with severe symptoms. The medications mentioned in the above procedures contain medicinal herbs and minerals described in the Ayurvedic texts.

Table 1 is a summary of the medications used in different procedures and their evidence.

Table 1: Medications used in Ayurvedic procedures and their evidence-based effects specific to cervical ectropion

Discussion

Table 1 highlights the different groups of medications and the current published literature on their effects. Although the exact mode of action of various formulations mentioned in Ayurvedic texts needs to be analysed in a separate study, the mode of action of different herbs and minerals mentioned in Table 1 can give a brief idea of their effect on cervical ectropion. As shown in the Table 1, Most of the drugs are anti-inflammatory, antimicrobial, and antioxidant, while Hemedesmus indicus has anti-biofilm effect. These properties together can reduce inflammation and infection associated with cervicitis, an important symptom of cervical ectropion. Rubia cordifolia has shown antithrombin effect and is mainly used to reduce symptoms such as post-coital bleeding in patients suffering from cervical ectropion. Several of the herbs described in Table 1 that have shown anticarcinogenic effect or inhibit abnormal cell growth, making them potentially useful to prevent further progression of disease and future dysplasia.

Vaginal wall being a mucosal layer has fast absorption. The vaginal wall is very well suited for the absorption of drugs since it contains a vast network of blood vessels. Moreover, the anatomically backward position of the vagina may help itself retain the drug thereby holding it in situ for a longer duration.

The drugs used for Sthanika Chikitsa acts by exerting its antiseptic, antimicrobial, antifungal, anti-inflammatory and analgesic actions. Hence proper Sthanika Chikitsa with proper drugs gives potentially good results in gynecological disorders.

Conclusion

The review highlights that there are several different treatment options available in Ayurveda and further clinical trials should be conducted to better understand their effects on different types of patients. Alternative therapies can address chronic ectropion and reduce associated symptoms. Ayurvedic is focused on a holistic approach to treatment by alleviating the root causes, rather than the disease. Praktiti and Dosha assessment is an ancient holistic approach that should be an important step towards personalised and tailored medicine that has potential to treat the root causes of chronic conditions.

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