A CLINICAL STUDY TO EVALUATE THE EFFICACY OF MADHUKA CHURNA IN THE MANAGEMENT OF RAKTAPRADARA

INTRODUCTION :

In Ayurveda (Ancient Vedic Medicine System), the woman is considered to be the ‘Mother’ and the ‘Source of Creation’. The reproductive life of women starts with puberty and ends with menopause. In-between these two ends, there is a progenitive life having Rutuchakra (menstrual cycle). Menstrual bleeding is termed as Rajasrava. Woman having regular menstruation, possessing Shuddha Aartava (healthy menstrual blood), Shuddha Yoni (healthy female genital tract) and Garbhashaya (healthy uterus) can bestow a Sreshta Praja (healthy progeny) [1]. Hence women’s menstrual problems acquire a lot of significance. Artava (menstrual blood) is expelled from the uterus through vagina in biological rhythm of women during her reproductive period i.e. from menarche to menopause. Length of Rutuchakra (menstrual cycle) is usually twenty-eight to thirty days. A deviation of two to three days from the monthly rhythm is also quite common. The duration of bleeding is about five days and estimated blood loss is 20 to 80 ml [2]. The menstrual rhythm (length of the cycle) depends upon the hypothalamo-pituitary-ovarian function. If there is any variation from the normal menstrual cycle it leads to menstrual disorders which not only hampers the day-to-day activities of a woman but also affects the physical and emotional state of mind. Different gynecological disorders are discussed in Ayurvedic classics in Yonivyapad (Gynecological disorders) and Artavavyapad (Menstrual disorders). Raktapradara, a disease manifesting as excessive bleeding per vagina, is one of the most commonly occurring gynecological disorder among the women of reproductive age. It varies in both amount and duration. About 10 to 30% of reproductive aged women are affected by Raktapradara (excessive menstrual bleeding). Acharya Charaka mentioned due to Pradirana (excessive excretion) of raja (menstrual blood) it is named as Pradara [3]. Charaka describes its pathophysiology stating that the vitiated vayu along with rakta, reaches the rajovaha sira and further increases the rajas and causes Raktapradara [4]. Improper life style, isolated families, Emotional influence such as changes in environment, nervous tension, anxiety states, unsatisfied sex urge, marital upset, mental stress, increased use of drugs in the form of hormonal pills are the main causes leading to the disease. The disease is characterized by excess flow of blood out of the body and Rakta (blood) is known to be a vital substance of the body (Jivana karma), women thus require a rapid, safe and effective treatment. Despite of advances in modern science, management of gynecological disorders is not yet satisfactory, as various treatments prescribed in modern medicine like hormonal and surgical therapy, antiprostaglandins, antifibrinolytic agents etc have not proved their definite efficacy despite of high price and side effects. Due to limitations of medical therapy and surgical therapy, there is a necessity to have an integrated and comprehensive therapeutic intervention in Ayurveda which not only cures Raktapradara (Dysfunctional Uterine Bleeding) and prevents its recurrence but also helps in improving the general health of women. Raktapradara (Dysfunctional Uterine Bleeding) is mainly due to vata-pitta dosha in association with rakta, hence raktasthambaka (haemostatic) and vatashaman chikitsa may be adopted. Ayurveda, describes a wide range of medicines/drugs which are vata-pitta shamaka, balya (strength), brmhana (nourishment), vrshya (aphrodisiac) and rasayana (rejuvenative) in the management of Raktapradara (excessive menstrual bleeding). Madhuka Churna (Licorice) and Sharkara (Rock sugar) along with Tandulodaka (Rice water) as Anupana (Adjuvant) mentioned in the context of Raktapradara (Dysfunctional Uterine Bleeding) in Bhavaprakasha [5] is one such formulation. Hence the present study was undertaken to analyze it clinically and statistically.

AIMS AND OBJECTIVES

To evaluate the efficacy of Madhuka Churna in the management of Raktapradara.

MATERIALS AND METHODS:

For the clinical study 30 Patients were selected from OPD of Prasuti Tantra & Stree Roga Department of Sri Siddharoodha Charitable Hospital, attached to N. K. Jabshetty Ayurvedic Medical College & P. G. Research Centre, Bidar. The drugs required for the study were procured from a GMP certified pharmacy under the supervision of Department of Dravya Guna specialist and the drug was prepared in the Rasashala of N. K. Jabshetty Ayurvedic Medical College & P. G. Research Center, Bidar under the supervision of Rasashastra Bhaishajya Kalpana specialist.

Table no. 1: Madhuka churna (Licorice powder)

Drug Name

Family

Botanical

Name

Parts used

Guna

Dosha karma

Madhuka[6] (Licorice powder)

Fabaceae

Glycyrrhiza glabra

Roots

Rasa: Madhura

Guna: Guru, Snigdha

Virya: Sheeta

Vipaka: Madhura

Vata-pitta hara

Khanda-sharkara (Rock Sugar) – Vata, Raktapitta nashaka [7]

Tandulodaka (Rice water) – Pittashamaka, Mutrala, used as an Anupana (Adjuvant) [8]

Method of preparation of Madhuka churna (Licorice powder)

Ingredients:

Madhuka - Glycyrrhiza glabra Linn. – 1 part

Khandasharkara - 1 part

The drugs Madhuka Churna (Licorice) and Sharkara (Rock sugar) were cut into pieces and powdered separately by by grinding and pounding in khalva yantra (mortar and pestle). When reduced to fine particle then sieved through fine cloth. Vastragalita churna (cloth-sieved powder) was then homogenously mixed by triturating it in a clean khalva yantra (mortar and pestle) to maintain the uniformity of the particle. Dosage – As mentioned in Bhavaprakasha, 1 karsha matra (12 grams) is the dosage of Madhuka Churna (Licorice) and Sharkara (Rock sugar) [5] which was administered in divided doses 4gm TID.

Method of preparation of Tandulodaka (Rice water) [8]

Ingredients:

1. Tandula (de-husked rice grains): 1 pala (48 gms)

2. Water: 8 parts (384 ml)

1 part of Tandula (de-husked broken rice grains) were taken in a clean vessel and soaked in 8 parts of water and kept overnight. Then it was macerated with hand and watery portion was decanted and collected as Tandulodaka (Rice water). Dosage – General dosage of Tandulodaka (Rice water) is 2 pala (96ml) [8]. The quantity of Anupana (adjuvant) with churna (powder) in pittaja roga is said to be 2 pala - 96ml. (Sa. M. Kh. 6/4). Thus the dosage of Tandulodaka (Rice water) administered was 2 pala.

Method of Collection of Data: In this clinical study, patients suffering from Raktapradara (Dysfunctional Uterine Bleeding) were thoroughly examined and diagnosed before selection. Only those patients fulfilling the inclusion criteria were selected.

Research Study Design: The study being a Single-Arm Open Clinical Trial, the patients were selected on the basis of Simple Randomized Sampling Method as per inclusion criteria.

Selection Criteria

Inclusion Criteria

1) From Menarche to Menopause

2) Prolonged and Excessive Menstrual Bleeding

3) Irregular and Intermenstrual Bleeding

Exclusion Criteria

1. On Hormone Replacement Therapy

2. With Intra-Uterine Contraceptive Device

3. Previously Diagnosed Bleeding Disorder

4. Severe Anemia of Unknown Etiology

5. History of Pelvic Pathology

6. History of Systemic and Metabolic Disorders

Consent – Obtained (attached)

Ethical Clearance – Obtained (attached)

Diagnostic Criteria

Diagnosis was made on the basis of lakshanas (symptoms) of Raktapradara (DUB)

§ Heavy Menstrual Bleeding

§ Irregular Menstrual Bleeding

§ Prolonged Menstruation

§ Intermenstrual Bleeding

§ Pain and ache all over the body

Investigations: The following investigations were carried out in the patients to rule out any organic or systemic disease.

§ CBP

§ RBS

§ Blood Group with Rh factor

§ Urine Routine

§ Bleeding Time

§ Clotting Time

§ HIV, HBsAg

§ USG Abdomen and Pelvis

After diagnosis as Raktapradara (Dysfunctional uterine bleeding), the consent of patients was taken and they were administered Madhuka churna (Licorice) and Sharkara (Rock sugar) 4grams TID daily after food for 3 consecutive menstrual cycles with Tandulodaka 96ml (Rice water) as anupana (adjuvant). Follow-up was done every month after menstruation. 35 patients were registered out of which 5 patients were drop-outs and the study was carried out on 30 patients.

Table No. 2 – Drug Dose Design

Group	Drug	Dose	Anupana	Time of Adminis- -tration	Route of Adminis- -tration	Duration
Trial group (30 patients)	Madhuka Churna and Sharkara	4 gm	Tandulodaka	Thrice daily, after food	Orally	3 consecutive Menstrual Cycles

Assessment Criteria The patients undergone treatment were assessed for the efficacy of Madhuka Churna (Licorice) on the basis of grading criteria of Subjective & Objective Parameters depicted below for improvement in specific symptomatology of Raktapradara (Dysfunctional Uterine Bleeding). Assessment was made every month after the cessation of menses for 3 consecutive menstrual cycles. During the study, all the patients were regularly analyzed and the notable changes were duly recorded. Follow up was advised after the treatment.

Subjective Parameters

1. Duration of Menstrual flow

2. Interval of Menstrual cycle

3. Intermenstrual Bleeding

4. Pain in abdomen

Objective Parameters

1. Amount of Blood Loss in Number of pads used per day.

GRADINGS

Table No. 3 - Grading Criteria for Duration of Menstrual flow

Duration of Menstrual flow in no. of days	Grade
3 - 5 days	0
6 - 8 days	1
9 - 11 days	2
>11 days	3

Table no: 4 - Grading Criteria for Interval of Menstrual Cycle

Interval of Menstrual cycle in no. of days	Grade
28 - 35 days	0
20 - 27 days	1
<20 days	2
>35 days	3

Table no. 5 - Grading Criteria for Intermenstrual bleeding

Intermenstrual bleeding	Grade
Intermenstrual bleeding absent	0
Intermenstrual bleeding present	1

Table No. 6 - Grading Criteria for Pain in abdomen Grading

Pain in Abdomen	Grade
No pain	0
Mild	1
Moderate	2
Severe	3

Table No. 7 - Grading Criteria for Amount of blood loss in No. of pads / day

Amount of blood loss No. of pads / day	Grade
1 – 2 pads / day	0
3 – 4 pads / day	1
5 – 6 pads / day	2
> 6 pads / day	3

Mode of action: Na hi vatadrute vayum yoni sampradusyati [9] which tells without role of vata there is no stree roga (Gynecological disorder). In Raktapradara (Dysfunctional uterine bleeding) there is dusti of vatadosa. The treatment should be directed to the treatment of vata and eradication of the cause. Madhuka churna acts as vata-pitta hara [6] and asrahara. It possesses sheeta veerya (cold potency) and rasayana property that helps in stopping excessive bleeding and strengthens uterine lining. It is given known that the estrogen regenerates the endometrium and estrogenic like activity possessed by Madhuka (Licorice) aids in breaking down the pathogenesis of Raktapradara (Dysfunctional uterine bleeding).

RESULTS:

Table No. 8 - Effect of Treatment

Parameters	BT Mean SD	AT	AT Mean SD	Df	t-value	Effective ness %	p-value	Rem arks
Duration of Menstrual Flow	1.466	AT1	1.1330.8603	29	3.808	22.72%	<0.001	H.S.
		AT2	0.56670.626	29	9.000	61.36%	<0.0001	H.S.
		AT3	0.1660.379	29	10.933	88.63%	<0.0001	H.S.
Interval of Menstrual Cycles	1.166	AT1	0.9661.124	29	2.693	17.14%	=0.006	H.S.
		AT2	0.4330.935	29	3.958	62.85%	<0.001	H.S.
		AT3	0.1330.571	29	4.883	88.57%	<0.0001	H.S.
Inter Menstrual Bleeding	0.2	AT1	0.166	29	1.000	16.66%	0.163	N.S.
		AT2	0.133	29	1.439	33.33%	0.080	N.S.
		AT3	0.033	29	2.408	83.33%	<0.011	S.S.
Pain in Lower Abdomen	1.6	AT1	1.1330.628	29	5.037	29.16%	<0.001	H.S.
		AT2	0.50.731	29	11.000	68.75%	<0.0001	H.S.
		AT3	0.20.406	29	12.339	87.5%	<0.0001	H.S.
Amount of Menstrual Blood Loss	1.9	AT1	1.50.731	29	4.397	21.05%	<0.001	H.S.
		AT2	0.7660.678	29	14.297	59.64%	<0.0001	H.S.
		AT3	0.20.406	29	17.405	89.47%	<0.0001	H.S.

The table presents the mean ± standard deviation (SD) of Duration of Menstrual flow, Interval of Menstrual Cycle, Intermenstrual Bleeding, Pain in Lower Abdomen and Amount of Menstrual Blood Loss recorded four different time points: BT (baseline), AT1- after cessation of 1^stmenstrual cycle, AT2- after cessation of 2^nd menstrual cycle, AT3- after cessation of 3^rdmenstrual cycle. The sample size (n) for all time points is 30.

1. Effect of Drug on Duration of Menstrual Flow: At the baseline (BT), the mean score was 1.4660.819. At AT3, which decreased to 0.1660.379. It showed highly significant differences (HS) with p value <0.0001.

2. Effect of Drug on Interval of Menstrual Cycle: At the baseline (BT), the mean score was 1.166 which reduced to 0.1330.571. It showed highly significant differences (HS) with p value <0.0001.

3. Effect of Drug on Intermenstrual Bleeding: At the baseline (BT), the mean score was 0.2 which reduced to 0.0330.182. It showed statistically significant differences (SS) with p value <0.011.

4. Effect of Drug on Pain in Lower Abdomen: At the baseline (BT), the mean score of the symptoms was 1.6 which reduced to 0.20.406. It showed highly significant differences (HS) with p value <0.0001.

Effect of Drug on Amount of Menstrual Blood Loss: At the baseline (BT), the mean score was 1.9which reduced to 0.20.406. It showed highly significant differences (HS) with p value <0.0001.

Table No - 9: Overall Effect of Treatment

	BT Mean ± SD	AT	AT Mean ± SD	Df	t value	Effectiveness	P value	Remarks
Overall	6.33 ± 2.46	AT1	4.9 ± 2.68	29	7.319	22.63%	<0.001	H.S.
		AT2	2.4 ± 2.22	29	13.499	62.10%	<0.0001	H.S.
		AT3	0.73 ± 1.31	29	16.754	88.42%	<0.0001	H.S.

The table presents the mean ± standard deviation (SD) of Overall Effect of the Treatment. At the baseline (BT), the mean score of the symptoms was 6.33 where the mean reduced to 0.731.31. It showed highly significant differences (HS) with p value <0.0001.

Table No - 10: Total Effect of Treatment

	AT1		AT2		AT3
	No. of Pts	%	No. of Pts	%	No. of Pts	%
Cured (100%)	0	0	5	16.66%	18	60.00%
Marked Improvement (>75 To <100%)	0	0	6	20.00%	9	30.00%
Moderate Improvement (>50 To 75%)	3	10.00%	10	33.33%	2	06.66%
Mild Improvement (>25 To 50%)	11	36.66%	8	26.66%	1	03.33%
No Change <25%	16	53.33%	1	03.33%	0	0

In the present study total effect of the treatment was assessed on the basis of percentage of relief obtained. It showed that, in trial group at the end of treatment, 60% were cured, 30% had marked improvement, 06.66% were moderately improved and 03.33% had mild improvement.

DISCUSSION :

Raktapradara (Dysfunctional uterine bleeding) is a disease manifesting as excessive bleeding per vagina. Charaka explained Pradara as a separate disease with its management in Yoni Vyapat Chikitsa (Gynecological disorders) [10]. It is characterized by Artava Ati Pravrutti (excessive menstrual flow) [3] Deerga Kala Pravrutti (prolonged menstrual bleeding) Anruta Kala Pravrutti (irregular menstrual bleeding), [11] Daha (burning sensation) in Adhovankshana pradesha (lower abdominal region), [12] Sroni (pelvis), Prushta (back) and Kukshi (abdomen), Shoola (pain) in Garbhashaya (Uterus) Angamardha (bodypain) [13] etc. It is a Pitta Pradhana Tridoshaja Vyadhi. By considering the above lakshanas (symptoms), Raktapradara can be correlated to Dysfunctional Uterine Bleeding. DUB is the state of abnormal uterine bleeding following anovulation due to dysfunction of hypothalamo–pituitary - ovarian axis. It is due to the imbalance in the estrogen and progesterone hormone which results in irregular shedding of endometrium and prolonged, heavy, irregular and intermenstrual bleeding. It varies in both amount and duration. Present study was planned to evaluate the clinical effect Madhuka Churna (Licorice) and Sharkara (Rock Sugar) along with Tandulodaka (Rice water) as Anupana (adjuvant) mentioned in the context of Raktapradara (Dysfunctional Uterine Bleeding) in Bhavaprakasha [5]. Madhuka churna (Licorice powder) is a drug having madhura rasa (sweet taste), guru snigdha guna (heavy unctuous nature), sheeta virya (cold potency) and madhura vipaka (sweet taste conversion after digestion). It is vata-pitta shamaka [6]. It is included in Shonithasthapana (hemostatic), Angamardaprasamana Varga (reduces body pain), Dourbhagyanashana (removes doshas) and Garbhabrmhana (nourishes the uterine cavity). Madhuka has pharmacological actions like antiulcer, antioxidant, anti-inflammatory [14]. It nourishes the rasa dhatu (nutrient plasma), artava (menstrual blood) and rakta dhatu (blood tissue) and manifesting menstrual cycles to normalcy. Glabridin and glabrene possess estrogen–like activity which helps to stabilize the endometrium and prevent irregular bleeding and spotting. Estrogen also increases the levels of clotting factors. Glycyrrhizin, an anti-inflammatory compound has also been found as the first plant-based inhibitor of thrombin suggesting its anti-coagulant activity which promotes vasoconstriction of blood vessels and eventually stopping the blood flow and inflammation. Sharkara (Rock Sugar) [7] is having madhura rasa (sweet taste), susheeta virya (cold potency), madhura vipaka (sweet taste conversion after digestion). It is asrahrut (reduces bleeding), dahahrut (reduces burning sensation) also indicated in pitta-asra vyadhi due to which it helps to stop bleeding. It reduces agnimandhya, promotes rasa dhatu vruddhi (nutrient plasma), artava (menstrual blood) and reduces Raktapradara (Dysfunctional uterine bleeding). Rich in various minerals, vitamins and amino acids, consumption of sharkara (Rock Sugar) mainly regenerates blood circulation and prevents other complications associated with anemia like dizziness, fatigue and weakness. Tandulodaka (Rice water) [15] strengthens body immunity and balance pitta, having madhura rasa, kashaya anurasa and vata pitta shamaka as well as rakta stambhaka karma (hemostatic property), apart from reducing menstrual flow, it also contributes to establishing hormonal balance. Madhuka Churna (Licorice powder) is statistically significant and thus controls the duration and amount of bleeding. Glabrene stabilizes the endometrium and prevents irregular bleeding and help in regularizing interval of menstrual cycles to normalcy. It also reduces pain and relaxes uterine muscles which helps to reduce the pain in lower abdomen in Raktapradara (Dysfunctional uterine bleeding). The present study shows that sheeta virya dravya upayoga helps in reducing the symptoms. The change seen in study was due to the properties of the drugs such as vata–pitta shamaka, balya, brmhana, vrshya and rasayana, it is hemostatic in action, analgesic & anti–inflammatory which may help in reducing the symptoms. Further studies in a new direction are awaited-for.

Limitations: This study was conducted for 30 patients at a particular region for a short duration. It was effective in reducing the symptoms of Dysfunctional uterine bleeding when given for 3 consecutive cycles. This cannot be generalized to a larger scale population.

Need for further study: To identify the in-depth mechanism of action of Madhuka churna and Sharkara with Tandulodaka in Raktapradara, this study can be conducted in larger sample for a longer duration for scientific validation.

CONCLUSION:

Raktapradara is mainly due to vata–pitta dosha in association with rakta (blood). Madhuka Churna (Licorice powder) is Rakta-sthapaka, Deepana–paachana and Vata–shamaka dravya having sheeta virya (cold potency), madhura rasa (sweet taste), madhura vipaka and sthambhaka (hemostatic) properties. After statistical analysis, the results showed that Madhuka Churna (Licorice powder) was effective in the management of Raktapradara (Dysfunctional uterine bleeding). 60% were completely cured, 30% had marked improvement, 06.66% had moderate improvement and the rest 03.33% were having mild improvement in the symptoms. Thus, the formulation Madhuka Churna (Licorice powder) effectively helps in breaking down the pathogenesis of Raktapradara (Dysfunctional uterine bleeding) and prevents its recurrence. It effectively reduced duration of menstrual flow, amount of menstrual blood loss, regularized the interval of menstrual cycle, reduced intermenstrual bleeding and reduced pain abdomen. Management of Raktapradara (Dysfunctional uterine bleeding) through an integrative Ayurvedic approach proved to be successful. Madhuka Churna (Licorice) not only regularizes the menstrual cycle to normalcy but also improves the overall health of the woman.

Financial support and sponsorship - Nil

Conflicts of interest - There are no Conflicts of interest

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A CLINICAL STUDY TO EVALUATE THE EFFICACY OF MADHUKA CHURNA IN THE MANAGEMENT OF RAKTAPRADARA – CASE SERIES

Article Information:

Abstract:

Keywords:

Article :

INTRODUCTION :

MATERIALS AND METHODS:

RESULTS:

DISCUSSION :

CONCLUSION:

REFERENCES:

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