VALUE OF HERBAL DRUGS
IN FUNCTIONAL UTERINE BLEEDING

INTRODUCTION

UTERINE bleeding other than normal menstrual flow or an increased and or prolonged menstrual flow with or without a change in the cycle is a commonly encountered entity in general as well as consulting practice and hospital out-doors.

The mechanism causing it is not known precisely except that it is caused by disturbances of the physiological mechanism that controls menstrual cycle.

As such, treatment still remains empirical and rather unsatisfactory. Treatment is aimed at the control of excessive bleeding and restoration of the normal menstrual cycle in pre-menopausal age groups.

In some cases, the cause may be apparent but there are cases where exhaustive investigations are necessary to detect the cause of bleeding e.g. in suspected uterine and ovarian malignancy.

However, even with careful examination of the pelvis and diagnostic curettage in a number of cases, no definite cause is found.

And it is a common clinical experience that in the same cases routine hormone treatment and surgical measures like D & C do not help and hysterectomy has to be resorted to as a last measure.

PRESENT STUDY

Any treatment that can help to avoid drastic drug or surgical measures in established cases of functional uterine bleeding is therefore welcome and

this study was undertaken to assess the value of a combination of herbal drugs reputed in Ayurveda in the management of uterine bleeding.

PHARMACOLOGY AND THERAPEUTICS OF THE DRUG

Tablet Ayapon (Alarsin) was tried in this study.

Each tablet of Ayapon contains:

Ayapan:

Contains non-toxic haemostatics ayapin and ayapanin. It is used in uterine bleeding and other haemorrhages.

Nagkeshar:

Is astringent and haemostatic. It decreases actual bleeding and is therefore useful during active bleeding.

Ashoka:

Is astringent and uterine sedative. It has a direct action on uterine mucosa and is used in menorrhagia and postpartum haemorrhages.

Godanti:

Is astringent and cooling and haemostatic. Supplies calcium in an assimilable form.

MATERIALS AND METHOD

Only established cases of functional uterine bleeding where no pathological or other cause could be detected, were selected from our consulting practice and hospital patients.

All of them had been previously treated on usual lines: hormones, ergot preparations, and surgical measures like D & C but either had not benefited or had a recurrence of bleeding.

Most of these consisted of cases of uterine bleeding persisting after abortion, myomectomy, manual removal of placenta and evacuation of retained products of conception and uterine bleeding during puerperium.

And a few resistant cases of menorrhagia, metrorrhagia polymenorrhoea, and cases of persisting bleeding after I.U.C.D.

Dose:

2 tablets Ayapon 3 times a day for 2 to 12 weeks. In those cases which benefited, 1-2 tab. b.d. or t.d.s. for one week starting 3 days prior to expected menses, were given for next three cycles.

As a supportive treatment, haematinics and multivitamins were given where found necessary.

Bed rest was advised during bleeding episodes.

Superficial psychotherapy – explanations and reassurance was given in all cases and particularly their fear of cancer was allayed.

RESULTS

Results were evaluated according to decrease in duration and quantity of bleeding and were classified as good, moderate, slight and nil when there was no improvement.

In this group of cases usual drugs were used without any benefit. In most of these cases bleeding was controlled within 7-10 days and Ayapon was continued t.d.s. for one month.

CASE REPORTS

1. 16 old unmarried girl. MH – 6-8/20-25 days. LMP: 8 days back; profuse bleeding at short intervals for 6 months. Ayapon: 2 tds/1 mth., 1 tds/1 mth. Result: good, Periods regular.
2. 32 old 4 FTND, 3 living. MH/Irregular 6-8/15-30 days. LMP: 10 days back. Profuse irregular bleeding for one year following normal delivery. Pelvic findings: normal. Ayapon: 2 tds/2 months. 1 tds/1 month. Result: Good, period regular, bleeding controlled.
3. 35 old; 7 para, 1st abortion, 4 FTND, last two abortions at 4th and 3rd months. MH: 8-10/28-30 days. Regular but profuse period following last abortion 1 year back. D & C done 6 months back. Pelvic finding: normal. Ayapon 2 tds/2 months, 1 tds/1 mth. Results: Flow normal.
4. 18 old unmarried girl: MH: 6-8/15-20 days. Profuse period at short intervals for past 8 months. Ayapon: 2 tds/1 mth; 1 tds/2 mths. Result: Good, periods regular.
5. 30 Ys. Primary sterility. MH: 6-8/20-30 days. LMP: 4 days back. Pessary for R. V. Ut and D & C for sterility done. Profuse, irregular periods & dysmenorrhoea since pessary treatment 8 mths back. Pelvic findings: normal. Ayapon: 2 tds/2 mths.; 1 tds/1 mth. Result: Good, periods regular.
6. 31 Ys. Secondary sterility: 1 FTND, 8 yrs. back, living. MH: 8-10/15-30 days, previous history of menorrhagia. Treated with hormones, and D & C was done. Irregular, profuse periods following D & C. Pelvic findings: normal. Ayapon: 2 tds/1 mth; 1 tds/2 months. Result: Good.
7. 22 old. 1 FTND. 1 yr. back, living, MH: 6-8/15-30 days; irregular period for past 6 months. Pelvic findings: normal. Ayapon: 2 tds/2 months; 1 tds/1 mth. Result: Good.
8. 16 old, unmarried. MH: FMP-1 yr. back; 8-10/15-20 days; LMP-15 days back. Continuous bleeding for 2 months. Treated with hormones with temporary benefit. Ayapon 2 tds/2 mths; 1 tds/1 mth. Result: Good, periods regular.

OBSERVATIONS

1. In those cases which benefited, bleeding was controlled within 3-7
2. In metrorrhagia, there was remarkable improvement in the regularity of
3. Even in resistant cases where previous extensive hormone treatment and D & C were done there was remarkable improvement. In such cases the drug was continued for 3 months (2 tab. t.d.s.).
4. Where local pathology such as congestion was treated surgically but bleeding persisted, Ayapon proved
5. Toxicity or side-effects were not observed. There was no withdrawal bleeding after Ayapon treatment was discontinued.
6. For full benefit, Ayapon treatment should be continued for 2-3 months even after bleeding is
7. Its simple and safe dosage is helpful for prolonged treatment which is necessary in resistant cases of functional uterine bleedings.

DISCUSSION AND CONCLUSIONS

In cases where the family and the patient allow, the family physician should not hesitate to examine the case per vaginum rather than treat the case blindly for a considerable time.

The only things necessary for examination are bi-vulva speculum and a pair of gloves. The examination should be in the presence of an attendant or a relative.

The aim should be to rule out organic disease especially carcinoma. This helps the family physician to direct many an early case of genital malignancy.

Cancer is curable provided it is diagnosed and treated in the early stages. Speculum examination will reveal any obvious cause of bleeding from vulva, vagina and vaginal part of the cervix.

The urethra should also be examined as a possible site of bleeding.

In a considerable number of cases, it is probable that psychological disturbances are the principal causes of functional uterine bleeding, particularly during the prime reproductive years.

Most of these factors are related to sexual or reproductive functions, fear of pregnancy etc.

In most of such cases superficial psychotherapy – explanations, reassurance, ventilation of grievances – is a must. But in refractory cases, deep psychotherapy is necessary and such cases should be referred to a psychiatrist.

In reproductive age group before 40 years hysterectomy and other drastic surgical measures and drastic drug therapy should be avoided if there is no specific use for them.

Indiscriminate use of hormones should be controlled. Oestrogens can be employed only as short term therapy. They arrest the metropathic bleeding but the subsequent withdrawal bleeding is sometimes profuse. There are also toxic effects as nausea and vomiting.

Malignancy and organic diseases should be ruled out in older group of patients by physical examination, vaginal smears, and endometrial and cervical biopsies before embarking on surgical and or drug treatment.

Surgery can now be reserved for refractory cases and for those nearing or past their reproductive period.

Very profuse bleeding may require an emergency D & C both to establish the exact diagnosis and to control the bleeding.

Ergot preparations are useless. Injections of calcium, vitamins C., K. and P. as also specific haemostatics such as carbazochrome, spinal cord extracts, etc., all of which are very widely used, have their usefulness in bleedings from tumours, infections and trauma as supplementary measures.

But in functional uterine bleeding, in some cases hormones or D & C help to some extent but not always. Once bleeding is controlled either by a surgical and or medical curettage cyclical hormone therapy is adopted.

Against this background of unsatisfactory treatment, the value of this herbal combination deserves attention.

Phadnis (1964) had observed its usefulness in menorrhagia of long-standing treated with hormones, etc. and where D & C was done. And in some of these cases Ayapon helped to avoid hysterectomy.

In a controlled series, Mehta (1964) found it efficacious in menorrhagia and metrorrhagia.

Pandya et al (1963) have reported comparatively better results with a combination of Ashoka and Nagkeshar – two ingredients of Ayapon – in menorrhagia.

Javeri (1965) had tried Ayapon from puberty to menopausal age groups with encouraging results. Her cases included functional uterine bleedings after surgical measures like D & C, Caesarean sections and G.B. ring, etc.

Our observations tend to show the usefulness of Ayapon in functional uterine bleedings persisting after abortion, myomectomy, manual removal of placenta and evacuation of retained products of conception and uterine bleeding during puerperium.

And in a few resistant cases of menorrhagia, it helped in avoiding drastic surgical measures like hysterectomy.

With the introduction of Loop on a mass scale, Loop bleeding cases are being reported and in these cases drastic drug or surgical treatment is out of the question.

Ayapon seems to be a drug of choice in these cases because it is safe and economical.

It is likely to be useful as a supportive therapy where surgical measures have to be adopted.

In resistant cases this drug has to be continued for about 3 months for complete relief.

No close observation for adjustment of dosage are necessary and it has no toxicity or side-effects.

These are advantages for a family physician who has to treat a number of these cases in daily practice.

ACKNOWLEDGEMENT

We are thankful for M/s. Alarsin Pharmaceuticals, Bombay-1, for the liberal supply of Ayapon tablets.

REFERENCES

1. Ghosh R.: Pharmacology, Materia Medica and Therapeutics, 20th Edition, Hilton, Calcutta, 1957.
2. Javeri Veenaben: Treatment of Functional Uterine Bleeding (A Clinical study with Ayapon), Indian Practitioner, 18:2, 783, 1965.
3. Mehta A. M.: Use of a Eupatorium Ayapon Combination in Functional Uterine Bleeding, paper before the Scientific Session of 40th All India Medical Conference at Kakinada, 1964.
4. Pandya S. C. et al: Value of Indigenous Drugs in Menorrhagia; Current Medical Practice 7:8, 543, 1963.
5. Phadnis H. N.: Use of Ayapon Compound in Functional Uterine Haemorrhages; Antiseptic, 61:10, 683, 1964.