Lecture Note: Standard Operative Procedures for Yoni Varti and Case Study on Yoni Varti in Pre-Malignant Lesions of The Cervix

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Standard Operative Procedures
for Yoni Varti and Case Study on Yoni Varti
in Pre-Malignant Lesions of The Cervix

Dr. Asokan V
Professor and Head,
Department of PG Studies in Prasuti Tantra and Stri Roga,
Alva’s Ayurveda Medical College,
Moodubidire, Karnataka,RGUHS.

based on the lecture available at- Studies on Yoni-Varti

Introduction

Yoni Varti is one among the Sthanika Chikitsa and has been indicated as the first line of treatment in the context of Kaphaja Yoni Vyapada.

Definition: Vartis are therapeutic agents that are elongated with tapering ends, thick and broad at the centre, thin and tapering at both ends. They are used for local use in Sthanika Chikitsa, one of the Shashti Upakrama of Vrana Chikitsa, falling under Vati Kalpana. Commonly used to expel accumulated stool, urine, pus, blood, and Shleshma, it is named Phalavarti, which incorporates Gudavarti or Yonivarti. Thus, it expels the Sanchita Dosha and also controls local infections. Pippalyadi Yoni varti, Triphaladi varti, Nimba varti, Arkaadi Varti are some of the commonly used Varti.

Method of Preparation

The required fine powder of the drugs are mixed with adhesive agents like Masha, Dugdha and rolled into a big form. The Varti’s are prepared and kept for drying in the shade.

Size of the Varti

The size of the Varti should be rolled into the thickness of Pradeshini Anguli, i.e., that of the index finger according to the need of the patient, 2 to 6 Angula in length.

Purpose

The purpose is for Shodhana, Vrana Ropana, and Krimighna.

Duration

The duration is until the urge for micturition. The drug should be administered for Muhur Dharya or Kshanam Dharya, which means we can administer the Varti and keep it in position until the urge for micturition, which is around 2 to 3 hours in one sitting, whichever is the earliest.

Site

The site includes the external genitalia, that is the Prathama Avartha of the yoni. The interval is twice in a day or once in a day according to the need of the patient.

Indications

The indications for the application of Yoni Varti are Kaphaja Yoni Vyapada, Garbhashaya MukhaShodhana, Karnini Yoni Vyapada, Vrana in Yoni Mukha, Acharana Yoni Vyapada, Shweta Pradara, Yoni Shopha, Yoni Kleda (excessive discharge per Vagina), Yoni Kandu, Yoni Paichilyata (Slimy mucoid discharge), and Anarthava (secondary absence of menstruation). The indications also include the use of Yava churna, Saindhava, and Arkadugda for Bhavana in Kaphaja Yonivyapada.

Karnini Yoni Vyapada: Kushta, Pippali, Arkagra, Saindhava and bhavana with Basta Mutra.
Acharna Yoni Vyapada: Go pitta or Matsya pitta Sidhha Varti.
Yoni Kandu, Sopha, Kleda: Go pitta or Matsya pitta Sidhha Varti.

The Purva Karma for Yoni Varti Dharana:

This includes informed written consent of the patient, the parts to be prepared, evacuation of the bladder prior to the procedure, positioning of the patient, i.e., the dorsal position with legs flexed at knees, i.e., Utthana Shayana with Sankuchita Sakthi, monitoring the vitals like recording of the B.P., pulse, temperature of the patient, Yoni Prakshalana by Sukhoshna Jala. These are the prerequisites.

The Pradhana Karma:

 The main operative procedure of the Yoni Varti includes cleansing the vulva and the vagina with Sukoshana Jala. The vaginal canal should be lubricated, and the Varti should be anointed with either Tila, Ghrita, Madhu, Dugdha, or Sukhoshna Jala according to the need. The prepared Varti should be introduced slowly into the vagina to the posterior fornix and should be retained there until the urge for micturition.

Paschata Karma

Observe for irritation at the Sthanika region, i.e., the vaginal canal if any. Monitor for 2-3 hours for any abnormal vaginal discharges, burning sensation, hot feeling, etc. Vaginal irrigation to drain the residual Dravya’s after the specific period of time using Sukhoshna Jala and using a plastic syringe. Materials and methods for Yoni Varti incorporate setting up of the required materials like a pair of Sterile gloves, Sterile gauze pieces, Bowl for Varti, Sukhoshna jala, Cusco’s speculum, Sim’s speculum, Anterior vaginal wall retractor, Sponge holding forceps, Disposable syringe for Prakshalana, Stainless steel vessel with 500 ml capacity to up to 1-liter capacity for the Kwatha or Sukhoshna Jala as well we can use the enema pot.

The mode of action of Varti: As it is administered through the transvaginal route, it has better bioavailability as the drugs can bypass the liver metabolism because of the rich vascular vaginal mucosa enhancing the absorption of the drugs. Varti’s are also hygroscopic in nature, and they absorb cervical and vaginal discharges. The quicker absorption with the more bioavailability of the therapeutic agents is possible through Yoni Varti. The Varti show the action according to the drugs used like Shodhana, Ropana, Krimighna and Kandugna. So, it is indicated in vaginal infections like Trichomoniasis and Moniliasis. The safety measures to be taken during Varti application include preparing it under aseptic precautions, preserving it under aseptic precautions, and using it under aseptic precautions.

Case Study: Vulvovaginal Candidiasis and Cervical Erosion

Vulvovaginal candidiasis is the second most common cause of vulvovaginitis. Indulgence in Kapha Prakopaka Nidana, including Agnimandya, leads to Rasadhi Dhatu Dushti, manifesting in the Yoni as Kaphaja Yoni Vyapada. If left untreated, it may manifest as Karnini Yoni Vyapada (cervical erosion). Chronic cervical erosion, along with extrinsic factors like HPV infections, poor sexual hygiene, and immunodeficiency conditions, predisposes women to early pre-malignant lesions such as dysplastic changes, LSIL, HSIL and CIN.

Incidence and Screening Needs: The incidence and screening needs for patients with cervical erosion include around 1 to 2 lakh new cases, with a mortality rate of 70 to 80 thousand women per annum, as reported by the World Health Organization (WHO). Cervical malignancies account for 15% of all types of cancers in India, affecting women.

Case Presentation: This case study is based on the International Conference of Harmonization for Good Clinical Practice guidelines. The patient, a 29-year-old primiparous woman, presented with recurrent whitish vaginal discharge for the past 4 months, associated with vulvovaginal itching aggravated over the past month. She had regular menstrual cycles with itching and thick curdy discharges in the post-ovulatory phase. Family history revealed moderate psychological stress over the past month, and there was no significant medical or surgical history. The patient was a teacher with dietary habits including regular consumption of Abhishyandi Ahara like curds and Kapha-Prakopaka Nidana like Avyayama, Mootravegadharana during working hours. There was no history of Diva Swapna, and the patient engaged in brisk walking as the sole mode of exercise. She reported low oral fluid intake, approximately 1 litre per day, with a history of dysuria. Bowel habits were regular. Obstetrical history included a single parity (primipara) with a seven-year-old child, a full-term normal delivery, and a history of abortion after the first delivery. Coital history revealed once to twice in 30 days, with itching reported by the male partner after coitus. Contraceptive practices included coitus interruptus for the past 7 years.

Clinical Examination: General examination revealed a moderate built, non-coated tongue, regular pulse rate (72 beats per minute), normal blood pressure (110/70 mm Hg), regular respiratory rate (18 per minute) and afebrile temperature. Systemic examinations were within normal limits, and all Dashavidha Pariksha’s were normal. On examination, the patient had a soft, non-tender per-abdomen and soft, non-tender breasts. Per-speculum examination revealed thick, curdy, whitish discharge with quantitatively profuse, flaky appearance, and a moderately eroded cervix. Per vaginal, an antiverted and normal-sized uterus was observed, with free fornices.

Treatment Plan: The treatment plan included Yoni Prakshalana with Sukhoshna Jala followed by Triphaladi Yoni Varti Dharana per vagina, administered twice a day for 7 days. The patient was advised to follow a diet with plenty of water and fresh leafy vegetables, maintain hygiene, avoid coitus for 7 days, and refrain from excessive consumption of Madhura, Amla, Lavana Ahara, Dhadhi, and excessive Ksheera.

Outcome: The outcome of the study revealed a marked reduction in discharges, itching, and pain in the vulval region. Wet vagina and vaginal swab tests showed Candidiasis before the study and negative results after the study. Pap smear results indicated low-grade squamous epithelial lesions before the trial and negative results after the trial, with a follow-up period of 15 days. Vagina smear was positive for pseudo hyphae before the trial and negative after 7 days of treatment. Follow-up investigations and examinations were done at 3-month intervals. Visual evidence showed improved cervical health at the end of the trial.

Mode of Action: The probable mode of action of the drugs, including Triphala with Kaphaghna and Tridoshaghna action, Haridra with Kandughna action, Nimba with Krimighna properties, and Tankana with Shleshmahara and Lekhana properties. Triphaladi Yonivarti, with its Ruksha Guna and Ushna Veerya Dravya, was indicated in Kaphaja Yoni Vyapada. Yoni Prakshalana reduced the whitish discharge, and Yoni Varti imparted dryness, denaturing bacterial colonies of Candida, maintaining vaginal pH, and healing CIN1 lesions through healthy cervical re-epithelialisation.

Conclusion: In conclusion, early detection and screening can aid in adopting preventive measures for cervical carcinoma by identifying pre-malignant lesions. Morbidity due to cervical erosion can be substantially reduced. Abnormal vaginal discharge should not be neglected, and awareness regarding it is crucial in preventive care. Triphaladi Yoni Varti acted as Shodhana, Ropana and Vyadihara due to its Krimighna action in Kaphaja Yoni Vyapada associated with cervical cellular premalignant changes.

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