MANAGEMENT OF RESISTANT CASES OF LEUCORRHOEA *
(Usefulness of an Oral Adjuvant)
Dr. (Miss) MANI KHUDABUX, M.D., F.R.C.S.,
Consulting Obstetrician and Gynaecological Surgeon,
Northcote Nursing Home, Bombay 1.
The management of ‘leucorrhoea’ is a challenge in clinical practice. Its incidence is high, text-book diagnosis is not always possible. the treatment is tedious to the patient and annoying to the physician, the cure is uncertain and recurrences not uncommon.
RECENT RESURGENCE OF INTEREST:
In recent years there is an increasing interest in this subject all the world over mainly due to sudden changes in the relative incidence of trichomonas and fungas infestation. The availability of more and easy laboratory facilities has also contributed to this interest. The wide use of antibiotic-particularly ‘the broad spectrum’ ones may be responsible for the increase in this incidence.
Recent studies in India mainly undertaken in this regard with a view to evaluating the aetiological data of vaginal discharges deserve special attention. Among others, those of Satyavati et al (1957), Pandya (1958), Amonkar (1959), Dhabadego (1959), Narvekar et al (1959), should be mentioned, as the various points discussed by them may prove helpful in understanding the aetiology in clinical practice and choosing the correct line of treatment. The following points emerge from these reports and from the other recent publications on the subject :
- It is unusual to see in practice, the clinical text-book picture of the various types of vaginitis.
- No definite conclusions on the aetiological aspect of leucorrhoea can be drawn from vaginal-smear examinations alone.
- Even in established cases of fungus infection the practical difficulty of identification of isolated fungus suggests the empirical use of fungistatic agents.
- Trichomonas vaginitis and ‘non-specific’ leucorrhoea are the major groups.
- Cervical lesions are common in most of the cases.
- Two newly recognized (1955) entities of Haemophilus vaginitis without any specific symptoms or characteristic local appearances have added further to the clinical confusion.
- There must be other factors besides the known ones or probable ones which we have yet to know, because there are cases we are unable to diagnose or manage. In such cases we satisfy our scientific conscience by taking shelter behind terminology like ‘non-specific’: psychological’, ‘allergic’, ‘idiopathic’.
The position as regards treatment is not however, so hopeless as it may seem at first sight. Many of these patients can be successfully treated in general practice if a complete examination is patiently and carefully carried out. For cure depends on the understanding of casual factors. Normal physiological vaginal secretion at puberty, during pregnancy and in some women during the pre-menstrual days calls for no particular treatment. Vaginal over-medication or over-douching by extra particular women for personal hygiene may also cause vaginal discharge. A suitable explanation will help. Systemic diseases like tuberculosis amoebiasis etc. of course should be given specific treatment. Any local cause like the presence of a foreign body e.g., a retained pessary, must be removed.
Normal vaginal discharge comes mainly from the glands of the cervix with the addition of a transudate through the vaginal epithelium and probably also of some thin, watery alkaline and scanty discharge, from the body of the uterus, not exceeding 0.5 cc; it is of a semi-fluid consistency, is whitish or greyish in colour has little or no smell and should not cause any vulva irritation or itching. It contains glycogen, and the pH is 4 to 4.5. Doderlein’s bacilli and epithelial cells are numerous, but pyogenic organisms are absent.
The personal reaction of the patient will also have to be considered. What seems to be normal discharge to some may on examination turn out to be abnormal and vice versa.
Deviations from this pattern require investigation. It is advisable to refer the following conditions to a specialist:
(1) Pre-pubertal, menopausal and postmenopausal cases; (2) blood-stained, or serious discharges, particularly those following coitus or vaginal examination; (3) all except the simplest erosions; (4) cases not responding to treatment or cases suffering recurrences; (5) suspected gonococcal cases and (6) offensive discharges other than those due to simple foreign bodies.
The management of leucorrhoea at present is based on the following four principles: viz..
- The destruction of the abnormal organism;
- the elimination of any pathological lesions;
- the restoration of the normal flora and (4) the consideration of the psychological side of the patient.
Barring simple cases, it is necessary to adopt the strategy of local, surgical, systemic and even psychiatric lines of treatment either alone or in combination, to suit the needs of each individual case. However, in all cases, fear must be removed by reassurance and explanations and also the patient must be warned against over-treating herself.
Various local treatments are resorted to for the destruction of the abnormal organisms. If there is only increase in the amount of discharge but no alteration in the nature of the cervical secretion or vaginal discharge, local treatment is not necessary. Only the external genitals should be kept clean. General systemic treatment may be given for physical and mental tone-up.
Vaginal applications are available in various forms : e.g., tablets, pessaries, powders, creams, paints, and jellies. Most of them contain an agent to destroy the invading organism plus an acid buffer to restore the vaginal pH, sometimes glycogen or a sugar and also some anaesthetic agent. The action of the various agents, as pointed out at the Rheins Symposium (1957), are promising in laboratory investigations but fall short of expectations in clinical practice. This is because the local applications available at present are effective only locally. The recurrence of infestation of the vagina, even after microscopic and cultural clearance suggests that the sources of infestation exist extra-vaginally and the residual foci infestation are inaccessible to the drugs locally applied.
Vaginal irrigations and douches are useful, if, as already stated, the patient does not over-treat herself and if the proper solution is selected and provided, also the patient understands the correct use for self-application. Vaginal powders have the advantages of drying up the secretion by its physical state but are likely to be expelled prematurely by a very copious discharge. Vaginal tablets depend partly on the vaginal discharges to break them down and help in their dispersal. Pessaries are usually of a coca butter, gelatine or glycerine base and depend on the body-warmth to liberate the medication they contain. Tablets or pessaries are to be inserted by the patient herself high up in the vagina and many do not find them convenient for self-application. Creams or jellies are also to be self administered and may be more acceptable to the patient. Paints cannot be self-administered. Silver, mercurial and arsenical compounds are cautiously used for the destruction of abnormal organisms. Ichthyol pessaries are used for intense vaginitis. Oestogens in pessaries are used in senile cases for stratification of the vaginal mucosa. Local anaesthetic creams are used for pruritus with vaginal discharge and calamine lotion in itching, pruritus, due to secondary vulvar infections of the intertriginous type.
Resistant cases : — Resistant or recurrent cases usually result from a faulty diagnosis; inadequate or wrong treatment: reinfection from a site in-accessible to local treatment; resistant strains of the organism. The male partner is often responsible for the infection. In the male the infection may be in the prepuce, urethra, prostate, vesicles or bladder and may be entirely asymptomatic.
AN ORAL DRUG:
In addition to the treatment of the vagina as mentioned above, there is a growing interest now in the use of oral drugs in view of the shortcomings of the present methods, and the obvious advantages of an effective and safe oral treatment, if one such can be had. Such an oral treatment will be particularly of great use and value in general practice, and also as an adjuvant or a follow-up treatment after suitable local and surgical treatments.
Encouraging results have been reported regarding the usefulness of a composite Indian indigenous drug (Myron-Alarsin) in a number of cases of leucorrhoea met within general practice. (Desai-1952; Choudhary-1954; Sheth-1956; Vijayakar-Parker-1960). My experience with this drug in the first few cases was encouraging. This encouraged me to try it in resistant and recurrent cases of leucorrhoea, where local and surgical treatments did not avail.
Composition — This drug is composed of Balsa Myrrh (Bol), Balsa mukul (Guggal), Iron (loha bhasma), Mica (abhraka bhasma). The action and use of these ingredients as mentioned in books on indigenous drugs, satisfy some of the important needs of leucorrhoea cases like facilitating bowel-motion and relieving constipation, the toning of the uterus and its epithelium, regulating the functions of the ovary, correcting cervical activity, having antiseptic properties and helping the elimination of infective organisms. In India myrrh is used during and after puerpeium traditionally as an uterine restorative. It is excreted by the genito urinary and respiratory tracts and through its passage from the mucous membrane tones up, disinfects and regulates the functions of these organs. It is also said to be an emmenagogue, carminative, stomachic and urinary antiseptic. Guggal is also an oleo — resin with similar properties and is used in anaemia and debility in chronic cases. It is used alone or in combination with other drugs for gridlepains, joint aches and in rheumatic pains. Myrrh and guggal probably act as uterine tonics, giving strength to the genitals helping in the elimination of infective organism and in the involution of the uterus. Iron bhasma is haematinic and (abhraka bhasma) mica is a standard alterative having stomachic and urinary antiseptic properties. It is used in diseases of a consumptive nature like tuberculosis.
Selection of cases: — Cases were selected from our consulting practice, which were treated by us before on the usual lines (local and surgical) but in which there was recurrence or resistance. This selection offered us a better scope for observation, patient co-operation and follow-up.
Dose adopted : — Two tablets thrice a day were given till improvement was noticed and then continued for 2 to 4 weeks. After that one b.d. or one t.d.s. for 6 more weeks. The patients were advised not to take the tablets on empty stomach and asked to avoid coitus or sexual excitement. This treatment was continued during menstrual periods. They were asked to come for a check-up after 14 days, again after 6 weeks. When improvement was noticed they were called after 8 weeks. When the case was considered cured they were requested to report after a year again.
In most of the cases there was definite improvement and in non-resistant cases the results were very encouraging. Even in some of the resistant cases the results were good. The noteworthy feature was a striking relief in the associated symptoms which made the patient confident of a cure and co-operative for complete treatment. No toxic side-effects were observed or reported.
REPORTS OF CASES TREATED WITH MYRON
Case 1 : Stenotypist aged 27 years had leucorrhoea, dragging pain in lower hypochondrium and frequency of micturition.
Previous treatment: — E.U.A.. D and C.; cautery to cervix and medical treatment for cystitis.
Diagnosis : — Large cervical erosion-Endocervicitis, mild cystitis.
Treatment: Two tablets of Myron t.d.s. for a fortnight followed by 1 t.d.s. for a month.
Result : — The dragging pain in the lower abdomen which persisted after cauterization and treatment for cystitis disappeared after a course of treatment with Myron tablets.
Case 2 : — Housewife, aged 33 years; had leucorrhoea; low backache and pruritus vulvae.
Previous treatment : —Ventro suspension operation done after medical treatment for vaginitis,
Diagnosis : — Fixed retroversion; Trichomonal vaginitis with a small cervical erosion.
Treatment : — 2 tablets of Myron t.d.s.. for a month postoperatively.
Result : — Persistent though markedly diminished vaginal discharge cleared up completely after a course of treatment with Myron tablets.
Case 3 : — School teacher, aged 27 years, had leucorrhoea and dysmenorrhoea and shooting pains in the lower extremities during inter-menstrual period.
Previous treatment : — E.U.A.,D and C ; cautery to cervix.
Diagnosis : — Latero-flexion of uterus; large cervical erosion.
Treatment: — 2 tablets of Myron t.d.s. for 6 weeks; treatment commencing 3 weeks after the operation.
Result: — P. S. Exam of cervix 3 weeks after the operation showed incomplete healing of the erosion. Treatment was with Myron tablets: examination 3 weeks after the tablets were given, showed the return of cervix to normal. But Myron was continued for a total period of 6 weeks.
Case 4 : — Housewife aged 22, had profuse leucorrhoea, dysmenorrhoea and pruritus vulvae; also low backache.
Previous treatment: — E.U.A.,D. and C., cautery to cervix.
Diagnosis : — Cervical erosion, cervicities.
Treatment : — Myron 2 tablets t.d.s for one week then reduced to 1 t.d.s for the next five weeks.
Results : — Approximately a month after operation, she had no complaints of pruritus: and —only negligible if any, leucorrhoea. But the complaints of dysuria and backache persisted, for which a course of Myron tablets was given. As the patient felt some improvement in her symptoms the treatment was continued with marked improvement after a month.
Case 5 : — Housewife, aged 53, had prolapse, leucorrhoea, frequency of micturition, backache, loss of appetite and a general feeling of being unwell.
Previous treatment : — P.F.R. done.
Diagnosis : — Cysto-urethrocele, first-degree prolapse.
Treatment: — Myron 1 tablet t.d.s. for six weeks postoperatively.
Results : — Post-operative complications nil, healing of operation wound was sound : 6 weeks after a course of Myron tablets the patient had specific and marked improvement in her appetite and a comparative feeling of wellbeing.
Case 6 : — Cook aged 42 years, had severe backache; meno-metrorrhagia, episodes of fleeting joint-pains and leucorrhoea.
Previous treatment : — E. U.A., D. and C; cautery to cervix correction of R.V. and maintenance pessary.
Diagnosis : — Cervical erosion— Mobile R. version.
Treatment: — Myron 2 tabs t.d.s. for 4 weeks and 1 tab. b.d. for the next 2 weeks.
Result : — Satisfactory; backache was persistent though less severe while the other symptoms had abated.
Case 7 : — Milliner, tailoress aged 30 years, came complaining of white discharge (P. V.) since she was 19 years old, she had indefinite H. 0. premenstrual and intermenstrual backache and leucorrhoea.
Previous treatment: — D. and C.
Diagnosis : — Nothing abnormal was detected.
Treatment: — Myron 2 tablets t.d.s. was given for 3 weeks and then reduced to 1 t.d.s. for another 3 weeks.
Results: — She had already undergone 2 operations of D. and C between the years of 19 and 30. She had vaginal treatment and extravaginal oral medicinal treatment. In view of no gross abnormal findings and considering all the previous treatment she had undergone with little or no benefit, a course of Myron tablets was given with remarkably encouraging results.
Case 8 : — Housemaid, aged 45 years had leucorrhoea, girdle pain and dysmenorrrhoea.
Previous treatment : — Cervical cauterization.
Diagnosis : — Cervical erosion with hypertrophic R V. uterus (large and flabby).
Treatment : — A course of antibiotics and Myron 2 tablets t.d.s. were given for 4 weeks, reduced later to 1 t.d.s. for 2 weeks.
Result : —The patient refused to undergo any operation, or take any form of local vaginal treatment. A month after treatment with Myron and antiobiotics she showed fairly good results i.e. rapidly healing cervix; leucorrhoea, was greatly diminished but the girdle pain still persisted though less severe.
Case 9 : — Housewife, aged 22 years, had leucorrhoea, low backache and a dragging pain in the lower abdomen which radiated to both the lower extremities.
Previous treatment : — Ventri-suspension appendicetomy.
Diagnosis : — R. V. uterus with bilaterally prolapsed ovaries.
Treatment : — Myron 2 tablets t.d.s. for 2 weeks and then 1 tablet t.d.s. for 4 weeks.
Result : —A long pelvic type of appendix presented itself at operation (Ventri-suspension). So an associated appendicectomy was performed. The only complaint the patient volunteered three months after operation and after finishing the course of Myron tablets was occasional mild attacks of lower abdominal drag.
(1) Recent interest in vaginal discharges is pointed out. (2) Recent Indian studies on the subject are mentioned. (3) Management of leucorrhoea is considered. (4) need for an oral drug is emphasized and (5) usefulness of a herbomineral drug as an adjuvant in resistant cases is recorded.
I am thankful to Alarsin Pharmaceuticals. Bombay 1, for published data on Myron and for the other references furnished.
- Amonkar, D. M. Jr. of Obst. Gynaec. of Ind. 2 p 168. 1959.
- Chopra, R., Indigenous Drugs of India, 2nd Edn. 1958.
- Choudhary, R. C., Ayurveda, Calcutta.
- Desai, L. M., The Antiseptic, Madras, Dec.
- Dhabadego, S. B., Paper read at the 10th All India Obst. and Gynaec. Congress, 1959.
- Dixit, S. S., Indian Medical Jr., Poona.
- Ghosh, R. Pharmacology, Materia Medica and Therapeutics 20th Edition. 1957.
- Narvekar, M. R., et al Paper read at 10th All India Obst. and Gynaec. Congress in Dec. Hyderabad (Dn.) 1959.
- Pandya, S. C.. et al – of Obst. and Gyanec., India 8: March. 1958.
- Satyavati, C., et al Jr. M. A. 28 : 5, 229, 232. 1957.
- Sheth, A. S., Indian Practitioner, Bombay, 1956.
- Shirodkar, V. N., Bombay Hospital Jr., 1: 18-19. 1959…
- Vijayakar (Parkar), Indu Indian Practitioner, Bombay, June. 1960.
- Wagh, K. V., Paper read at 36th All India Medical Conference Indore, in December.
- Watsa, M. C., Ind. Jr. of Med. Sciences. 13: 4, 335-345 April. 1959.
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