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CONCEPT OF UDAVARTA (PRIMARY/SPASMODIC DYSMENORRHOEA) – AN AYURVEDIC PERSPECTIVE

Many women are familiar with the experience of spasmodic dysmenorrhoea, one of the commonest gynaecological conditions that affects the quality of life of many in their reproductive years.This condition manifested as painful menstruation, is the most frequently encountered gynaecological complaint and it can be included under Udavartha yonivyapat , caused by Apana vata vaigunya described in Ayurvedic classics. Nidana samprapthi and Rupa of Udavartha yonivyapat can well explain the etiopathogenesis and clinical features of Spasmodic dysmenorrhoea. “ Arthave sa vimukthe tu tat kshanam labhate sukham ” mentioned by Acharya Charaka substantiate the close similarity of Udavarta with Spasmodic dysmenorrhoea. Vegodavarthana leading to Pratiloma gati of Apana vata and rajas is the pathology behind Udavartha yonivyapath . So treatment should aim at the relief of pain by normalising the direction of menstrual flow which in turn is by normalising the vitiated Apana vayu . The present paper is aimed at incorporating all the references regarding Udavartha including Nidana panchakas from Ayurvedic classics and tried to give an Ayurvedic view to the concept and postulated theories on spasmodic dysmenorrhoea.


INTRODUCTION
As reproduction is the fundamental requirement for the maintenance of human life, Ayurveda elucidate due importance for the care of mother at every phase of her life. As a woman bears a child and is the foundation of a society, her health should be given utmost importance and care.  According to Sabdakalpadruma, sthree is said to be the root cause of progeny. "sthrayathi garbho yasyamithi sthree".  According to Raja nighantu sthree is stated as 'one who discharges arthava'. "Sthree cha arthava bhavathi sravathy ithi sthree". From the above statements we can conclude that, Acharyas have denoted the single term 'Arthava' in our classics to cover the entire female reproductive physiology. Menstruation is considered as a land mark of homeostatic condition of reproductive system. The same menstruation can create hell situation, if it is associated with unbearable pain as we are observing in cases of dysmenorrhoea. Though dysmenorrhoea literally means painful menstruation, a more realistic and practical definition includes painful menstruation of sufficient magnitude so as to incapacitate day to day activities.
Spasmodic dysmenorrhoea is one where there is no identifiable pelvic pathology. Pathogenesis of pain is attributed to a biochemical derangement. It is one of the most common gynaecological complaints affecting more than 70% of teenagers and out of this 30-50% of menstruating women suffers from varying degrees of discomfort. This situation not only has a significant effect on quality of life and personal health but also resulting in loss of work hours and depression. Absenteeism from work and school as a result of dysmenorrhoea is common.
In the classics of Ayurveda painful menstruation find its role as a sole symptom in Udavartha yoni vyapath. Udavartha is one among the twenty Yoni vyapath, described by various authors. Charaka while describing the features of Udavartha says that "Arthave sa vimukthe tu tat kshanam labhate sukham" which implies an immediate relief of pain following the discharge of menstrual blood, which clearly denotes spasmodic type of dysmenorrhoea. Normal menstruation is the function of Apana vayu, therefore painful menstruation is considered as Apana vata dushti.
According to modern medicine, there is no permanent cure for spasmodic dysmenorrhoea. Most of the medical therapies like analgesics, antispasmodics, NSAID, and anti prostaglandins are having many side effects. In the present scenario rather than the hormonal treatment belonging to contemporary science Ayurvedic preparations are proved effective in primary dysmenorrhoea. This study is particular about the description regarding Udavartha along with their treatment aspect and tried to give an Ayurvedic view to the concept and postulated theories of primary dysmenorrhoea on the basis of scattered classical references.

AIM AND OBJECTIVE
The present paper is aimed at incorporating all the references regarding Udavarta including Nidana panchakas from Ayurvedic classics and tried to give an Ayurvedic view to the concept and postulated theories on spasmodic dysmenorrhoea

MATERIALS AND METHODS
A thorough literary survey of Udavartha was done in the Ayurvedic classics with their commentaries and interpretation by masters in the field of Prasuti and Sthree roga.

DESCRIPTION Definition
Though dysmenorrhoea literally means painful menstruation, a more realistic and practical definition includes painful menstruation of sufficient magnitude so as to incapacitate day to day activities. Spasmodic dysmenorrhoea is one where there is no identifiable pelvic pathology [1]

Causes of Pain
The pain is related to dysrhythmic uterine contractions and uterine hypoxia.

Psychosomatic factors
Tension and anxiety during adolescence; lower the pain threshold.

Abnormal anatomical and functional aspect of myometrium
Uterine myometrial hyperactivity has been observed in cases with primary dysmenorrhea. The subendometrial layer of myometrium is known as Junctional Zone (JZ). In women with dysmenorrhea significant changes in JZ-include irregular thickening, hyperplasia of smooth muscle and less vascularity are seen. Dysperistalsis and hyperactivity of the uterine Junctional zone are the important mechanisms of primary dysmenorrhea.

Imbalance in the autonomic nervous control of uterine muscle
There is over activity of the sympathetic nerves leads to hypertonicity of the circular fibers of the isthmus and internal os.

Role of prostaglandins
In ovulatory cycles, under the action of progesterone, prostaglandins (PGF2α, PGE2) are synthesized from the secretory endometrium. PGF2α is a strong vasoconstrictor, which causes ischemia of the myometrium. Either due to increased production of the prostaglandins or increased sensitivity of the myometrium to the normal production of prostaglandins, there is increased myometrial contraction with or without dysrhythmia.

Role of vasopressin
There is increased vasopressin release during menstruation in women with primary dysmenorrhea. Vasopressin increases prostaglandin synthesis and also increases myometrial activity directly.

Endothelins
Endothelins in endometrium can induce PGF2α. Local myometrial ischemia caused by endothelins and PGF2α aggravate uterine dysperistalsis and hyperactivity.

Platelet activating factor (PAF)
Leukotrienes and PAFs are vasoconstrictors and stimulate myometrial contractions. Clinical features:  The pain begins a few hours before or just with the onset of menstruation. The severity of pain usually lasts for few hours, may extend to 24 hours but seldom persists beyond 48 hours.  The pain is spasmodic and confined to lower abdomen; may radiate to the back and medial aspect of thighs.  Systemic discomforts like nausea, vomiting, fatigue, diarrhoea, headache and tachycardia may be associated. It may be accompanied by vasomotor changes causing pallor, cold sweats and occasional fainting. Rarely, syncope and collapse in severe cases may be associated.  Abdominal or pelvic examination does not reveal any abnormal findings. Treatment General measures  Assurance  Analgesics and antispasmodic drugs  To empty the bowel  Encourage normal activities Severe cases: Drugs, Surgery Drugs  Prostaglandin synthetase inhibitors (3-6 cycles)  Oral contraceptives (combined estrogen and progestogen) (3-6 cycles). Surgery  Laproscopic uterine nerve ablation(LUNA)  Laproscopic presacral neurectomy -rare AYURVEDIC VIEW Udavartha is one among the twenty Yoni vyapath, described by various authors. The condition where Artava is shed with great difficulty and the pain is termed as 'Kashtartava' in classics. With the help of etiological factors and the clinical features given for most of the diseases, Kashtartava (painful menstruation) can be classified into primary and secondary dysmenorrhoea. Charaka while describing the features of the Udavartha says that "Arthave sa vimukthe tu tat kshanam labhate sukham" which implies an immediate relief of pain following the discharge of menstrual blood, this inturn is the characteristic feature seen in spasmodic dysmenorrhoea. Also the following descriptions by various authors substantiate the similarity between Udavartha and spasmodic dysmenorrhoea.  Krchrarthava: Painful menstruation [2]  Rajaso gamanadurdhwam: Obstruction leading to upward movement of menstrual blood [3]  Badha raja: Presence of clots [4]  Samanthath varthanam vayo: Irregular uterine contractions [5]

Nirukthi
The word udavartha is derived from the root, Uth+ange+vruth+khange pratyaya (sabdakalpa drumam) -meaning -'The act of going up' Udavarta word refers to upward movement ('Udavartha iti urdhwam nitam') [6] Urdhwa gamana of rajas is Udavartini. Here normal downward movement of rajas is obstructed and it moves in reverse direction Nidana (Aetiology) All Acharyas have unanimously described Udavarta as a Vataja yonivyapath. Raja pravrutti is regulated by Apana vayu since it plays a vital role in Dharana and Nishkramana of Raja, vitiation of Apana vayu therefore leads to Udavarta yonivyapath.
Acharya Vagbhata had clearly mentioned that without involvement of Vata dosha vitiation of yoni does not happen in females. [7] The main two reason of disorder of Vata are Margavarodha and Dhathukshaya.

Margavarodha
Apana vayu is said to be the governing force of the menstrual flow. If there is any sort of obstruction to this Apana pain is produced. Apana can be obstructed from blocking the passage itself (anatomical) or due to certain things which hamper the working capacity of

Pradushtarthava
The word Artava refers to menstrual blood, ovum and ovarian hormones. Pradushtartava refers to the menstruation which is not having intermenstrual period of one month, and is associated with pain and burning sensation. Excreted blood is unctuous, very scanty, or excessive in amount, and the color does not resemble with that of Gunja, Laksha, Padma, or Shashaasrk.

Beejadosha
Hereditory factors of dysmenorrhoea can be considered under this. Depending on the degree of the defect in the abnormalities of Beeja, Beeja bhaga (chromosome or gene) can lead to abnormalities like absence or the defective formation of genital organs such as pinhole os (Suchimukhi), atresia of vagina, uterine hypoplasia, imperforated hymen etc.

Daiva
In the absence of apparent cause the disease developed by Purva janmakritha papa due to the curse of God.

Poorva roopa
The pain may start few hours prior to menstruation, as slight low back ache or lower abdominal pain. Roopa  Yonim udawarthayathe [10] -Specifies dysperistals is and retrograde flow of menstruation which may result in pain.
 Raja krichrat [2] -Indicates difficult discharge of menstrual blood.  Phenilata [11] -indicates frothy menstruation.  Vimukthe tu tat kshanam labhate sukham [12] -Cessation of pain after establishment of menstrual flow.  Samanthatvarthanam vayo [5] -In coordinate or irregular contractions of all the myometrial muscle fibres have been explained as all around movement of Vayu.  Badha raja [4] -Indicates special form of spasmodic dysmenorrhoea characterised with expulsion of big clots of blood due to decreased fibrinolytic activity.  Kapha samsrishta artavam [13] -It explains difficult discharge of menstrual blood with Kapha. It is taken as association of mucous membrane or endometrium, then it can be equated with another form of spasmodic dysmenorrhoea i.e membraneous dysmenorrhoea.  Anya vata vedana [14]   Vata kopa karanas like intake of Ruksha substances, over intake of Katu rasa, Alpasana, Atiyanaavarohana etc can lead to Dhathukshaya (uterine hypoplasia) and vitiation of Vata. Due to Dhatukshaya the myometrium became insufficient to produce effective expulsive force for normal flow, which results in stagnation and increased expulsive effort on the part of muscular walls. This may produce ischemia and pain.
By the suppression of Adho vatadi vegas, Apana vayu gets obstructed moves upwards in the reverse direction and fills the yoni (retrograde menstruation). This Yoni seized with pain initially throws or pushes the Raja upwards, then discharges it with great difficulty. The lady feels relief immediately following discharge of menstrual blood. Here the type of Srotodushti occurred is Vimarga gamana.

. Vataja arthava dushti
The Artava vitiated by Vata is red, black or dark violet in color, thin, dry, frothy and scattered. It is excreted slowly and with pain. Among various causes responsible to aggravate Vayu, use of dry and hot articles, excessive exercise and grief etc are important. These factors produce some physical weakness and slight decrease in the amount of Dhatus especially Rasa and Raktha, and naturally leading decrease in the amount of menstrual blood discharged. On the basis of the above facts Vataja arthava dushti appears to be oligomenorrhoic condition associated with dysmenorrhoea caused by general weakness.

Vatala yonivyapath/ Vatiki
Because of Vatakara diet and activities, the disordered Vata causes Toda type of pain. The genital tract becomes rough due to loss of moisture. Tingling sensation, rough and dry vagina, anaesthesia of vagina are the symptoms accompanying painful menstruation. Discharge is black in color, watery and with foam. It gives rise to Gulma as its complication. Pain is present in the groin and the flanks. Back ache is also a common complaint. All these Lakshanas are suggestive of some pelvic pathology associated.

Sannipatiki yoni vyapad
Due to consumption of congenial and noncongenial type of Rasas together, all the three Doshas situated in yoni and uterus get vitiated and produce their specific symptoms, such as burning sensation and pain in vagina, yellowish and white unctuous vaginal discharges. Her menstrual discharge is also whitish pale and unctuous. Since in this condition features of all the three Doshas are present specially general symptoms, hence it may be considered either as acute infective disorder of reproductive system or as gynaecological disorder developing due to diseases of other systems.

Vatika asrgdara
Here, the discharged menstrual blood is froathy, thin, rough, blackish or reddish, associated with or without pain. Vata produces severe pain in sacral, groin and cardiac region, flanks, back and pelvis. It can be equated with pelvic congestion syndrome or pelvic sympathetic syndrome.

Pariplutha
Charaka says that when a women having predominance of Pitta withholds her natural urge of sneezing and eructation at the time of coitus, then vitiated Pitta, getting mixed with Vayu reaches Yoni. The Yoni becomes inflamed and tender and she gets painful menstruation having yellowish or bluish color of menstrual blood. She also suffers from pain in lumbosacral and groin region, back ache and fever. Susrutha says that the condition is characterised with severe dyspareunia. On the basis of this description it can be inferred that Charaka has described acute inflammatory stage (of gonococcal infection), while Susrutha has described later stage of the same, i.e., chronic inflammatory stage.

Suchimukhi
Atisamvrtatwa i.e., excessive narrowing of orifice of yoni leads to pain in this condition.

Antharmukhi
Due to intercourse in an abnormal position or after heavy meals, there is abnormal pressure on uterus and hence its position becomes disordered, especially the abnormality is observed in relation to the cervix. There is severe pain in the bones and muscles i.e., in the pelvic region and uterus and the lady suffers from dyspareunia also. This is a condition of either acute antiflexion or acute retroflexion.

Viplutha
Viplutha is charecterised with Nitya vedanaconstant pain in vagina associated with other pains of vata. It can be considered as vaginal neuralgia or presacral neuralgia specially of psychogenic origin.

Diagnosis
Udavarta yoni vyapath can be easily diagnosed from other conditions mimicking it by its specific characters like  The pain strictly restricted to menstruation and usually patient feels relief following discharge of menstrual blood.  There will be no alterations in the amount of Artava, neither it will be excessive nor scanty.  There will be no local pathology like protuberance of mass, dryness, roughness or numbness of Yoni. Upadarava: Specific Upadravas are not mentioned for Udavartha and those mentioned in Yoni rogas such as Pradara, Gulma, Arsa, Vandhyatha, Artavadosha etc can be taken as its Upadrava. Sadhyasadhyatha (Prognosis)-Udavartha yoni vyapath is considered under Sadya category, as the disease is Ekadoshaja (Vataja).

Chikitsa
In case of Udavarta, Vataprakopa is the main reason and so the treatment should be directed to normalise the Vata. All Acharyas opine that, none of the Yonirogas occur without vitiation of Vata, and thus Vata is to be corrected first. Treatment modalities include Pancha karma, internal medications, external therapies like Parisheka, Lepa, Pichu dharana etc. Diet modifications, lifestyle changes and yogic practices can also be adopted as these are very important for maintaining a healthy menstrual cycle.

Basic principles of treatment of Vata
External and internal use of oil preparations, fomentations, use of Shodhana methods in mild form, massage, bandages, alcoholics, nourishing food, use of enema etc can be employed to normalise Vata. These can be summarized in a nut shell as;  To reduce pain -pain relieving measures  To reduce Rukshata and Kharata-oil preparations for external and internal use.  To bring Apana to its normal, thereby normalizing the direction of menstrual flowmild laxatives and enematas.  To remove obstruction-fomentations, oil preparations, Shodhana.  To remove Dhathukshaya -nourishing, general tonics and Dhathuvardhaka articles. The specific treatments for Udawartha mentioned in classics  Snehana karma with Trvrtha sneha, Swedana karma [15]  Use of meat soup of Gramya anupa and Oudaka animals [15]  Panam and Vasthi with Dasamoola ksheera [15]  Anuvasana vasthi and Uttaravasthi with Trivritha sneha [15]  Dasamoola trivrith kwatha kalka sidha sneha for Pana, Anuvasana and Uttaravasthi. [16]