Title: An attempt to understand the concept of PCOS w.s.r to Artavavaha Sroto Dusti

: Polycystic ovarian syndrome (PCOS) is the most common endocrine ovarian disorder affecting 5 to 10% women of reproductive age. It is also known as stein- laventhal syndrome or hyper androgenic Anovulation. The main primary character of PCOS is irregular menstrual cycle which leads to improper ovulation. Exact pathogenesis of PCOS is not understood clearly, it may be discussed under following headings: Abnormality of Hypothalamic-pituitary compartment (Hormonal imbalance), androgen excess, anovulation, obesity and insulin resistance etc. tubes. Abnormality of Artavavahasrotas causes Vandhyatva , MaithunaAsahishnuta and Artavanasha.Vandhyatva caused due to abnormality in chaturvidhagarbhottpadaka(rutu, kshetra, ambu and beeja)samagri . MaithunaAsahishnuta related to vatala, paripluta, vipluta and shandiyoniyapada , while Artavanasha related to Vandhya, Arajaska and shushkayonivyapada . All these symptoms like Vandhyatva, MaithunaAsahishnuta and Artavanasha are correlated with common symptoms of PCOS which include Infertility, Dyspareunia &Amenorrhoea respectively. As there is no curative treatment available in modern medicine, understanding of PCOS with reference to Artavavahasrotodusti may be a ray of hope to treat PCOS with Ayurvedic remedies.


Introduction:
The term Polycystic Ovarian Syndrome (PCOS) was first described by Irving Stein and Michael Leventhal as a Triad of 'Amenorrhoea', 'Obesity' and 'Hirsutism' in 1935 when they observed the relation between obesity and reproductive disorders. It is hence also known as the 'Stein-Leventhal Syndrome' or 'Hyperandrogenic Anovulation' (HA) and is the most common endocrine ovarian disorder affecting approximately 5-10% women of reproductive age worldwide. PCOS is currently considered as a lifestyle disorder affecting 22-26% of young girls in their reproductive age in India. It is one of the leading causes of infertility in women. It is primarily characterized by extremely irregular menstrual cycles, in which even ovulation may not occur. 1 The main features of PCOS are anovulation, hyperandrogenismand insulin resistance. Anovulation results in irregular menstruation,amenorrhea, ovulationrelated infertility and polycystic ovaries.Hyperandrogenism results in acne and hirsutism. Insulin resistanceis often associated with obesity, Type 2 diabetes, and high cholesterollevels. 2 Exact pathogenesis of PCOS is not understood clearly, it may be discussed under following headings: Abnormality of Hypothalamic-pituitary compartment (Hormonal imbalance), androgen excess, anovulation, obesity and insulin resistance etc. 3 If pcos is not managed in early stage it may leads to cardiovascular disorders, obesity, infertility and may cause complications like depression, complications in pregnancy, sleep apnea and endometrial cancer. 4 Srotas are the circulatory channels through which Dosha's, Dhatu's and Mala's moves from one part to another part of the body. Each srotas has srotomoola, srotomarga and srotomukha.

AETIOLOGY OF PCOS:
The exact cause of PCOS is unknown or heterogeneous in nature. However it has certainly been linked to a variety of aetiological factors.

 INSULIN RESISTANCE:
PCOS is not just a reproductive disorder but a multifaceted metabolic disorder that shows a high association with insulin resistance leading to hyperinsulinaemia, wherein 10% show Type II Diabetes.Besides, 30%-35% have Impaired Glucose Tolerance (IGT).Such a condition results in the increased production of testosterone thus leading to abnormal or non-existent ovulation.
Scientists at the Medical College of Georgia at Georgia Regents University reported that high activity levels of a micro RNA named miR-93 in fat cells hinders the use of glucose by insulin contributing to PCOS and also to insulin resistance.

 HORMONAL IMBALANCE:
The imbalance of certain hormones is common in women suffering from PCOS.
i) High testosterone levels leading to signs of hyperandrogenism.
ii)High Luteinizing hormone (LH) whose excessively increased levels disrupt proper ovarian functions.
iii)Low Sex Hormone Binding Globulin (SHBG) hormone that allowstheexpression of hyperandrogenism. iv)High Prolactin levels which stimulates the production of milk in pregnancy and is found to be raised in comparatively few patients. The exact reason of these hormonal imbalances is unknown but researchers are trying to establish their link with the ovary itself, the part of the brain that governs the hormonal secretions or the other endocrine glands. The possibility whether insulin resistance triggers such changes too needs to be assessed.

 GENETIC FACTORS:
PCOS is a genetically determined ovarian disorder and the genetic links to the disease have been researched in detail.
Research at the University of Oxford and the Imperial College London revealed that a gene implicated in the development of obesity is also linked to susceptibility to PCOS.
A study published in 2005 also showed that excessive exposure to androgens during intra-uterine life may have a permanent effect on gene expression leading to PCOS and later to insulin resistance. The familial clustering of PCOS is common. It has been noted that the first degree relatives of patients with PCOS may be at high risk for diabetes and glucose intolerance. Similarly, a study revealed that mothers and sisters of PCOS patients showed higher androgen levels than the control subjects. PCOS is a genetically determined ovarian disorder and the heterogeneity can be explained on the basis of interaction of the disorder with other genes and with the environment.

 STRESS AND OTHER PSYCHOLOGICAL FACTORS:
PCOS is often caused by psychological factors. Increased stress can upset the normal menstrual cycle and causes hormonal changessuch as raised levels of cortisol and prolactin which affect menstruation that normally resumes after the stress subsides.

 MISCELLANEOUS:
The sedentary lifestyle, dietary variations, lack of exercise or intensive physical exercise have also been contributory factors as also extreme weight loss, disorders of the endocrine system and various disorders of the ovaries. 8

PATHOPHYSIOLOGY:
Exact pathogenesis of PCOS is not understood clearly, it may be discussed under following headings: Abnormality of Hypothalamic-pituitary compartment (Hormonal imbalance), androgen excess, anovulation, obesity and insulin resistance etc. Associated high prolactin level.

C. SYSTEMIC METABOLIC ALTERATIONS:
I. HYPERINSULINEMIA CAUSES a) Stimulations of theca cells to produce more androgens. b) Insulin results in more IGF-1 by autocrineaction, IGF-1 stimulates theca cells to produce more androgens. c) Insulin inhibits hepatic synthesis of (SHBG) resulting in more free level of androgens.

II. HYPERPROLACTENEMIA:
a) In about 20% cases there may be mild elevation of prolactin level due to increased pulsitivity of GnRH or due to dopamine deficiency or due to both. b) The prolactin further stimulates adrenal androgen production. Whatever may be the aetiology the endocrinologic effect of PCOS produce vicious cycles of events.

 ANOVULATION:
Because of low FSH level, follicular growth is arrested at different phases of maturation. The net effect is diminished oestradiol and increased inhibin production due to elevated LH. There is hypertrophy of theca cells and more androgens are produced either from theca cells or stroma.
There is defective FSH induced aromatization of androgens and oestrogens. Follicular microenvironment is therefore more androgenic rather than oestrogenic. Unless there is follicular microenvironment, follicular growth, maturation and ovulation cannot occur.
There is huge number of atretic follicles that contribute to increased ovarian stroma (hyperthecosis) LH level is tonically elevated without any surge.

 OBESITY AND INSULIN RESISTANCE:
Obesity recognized as an important contributory factor. Apart from excess production of androgens, obesity is also associated with reduced (SHBG). It also includes insulin resistance and hyperinsulinemia which in turn increases the gonadal androgen production.
Aetiology of insulin resistance is unknown mutations of the insulin receptor gene in the peripheral target tissues or reduced tyrosine autophosphorylation of the insulin receptor is currently thought to be an important cause. 9

SROTAS:
The term "srotas" denotes a channel or path through which the nutrient materials to the various tissues are supplied for nourishment. It is derived from the root "स्त्र ु स्त्रवणे " meaning to flow, to ooze, to exude, to cause to flow etc. charakacharya has defined the srotas as "स्त्रवणात स्त्रोताां सि" meaning thereby the structure through whichstravanam(oozing, filtering or permeation) takes place.
Depending upon direction, aim and function srotasare explained in charakasamhita by following names:

यावन्तःप ु रुषे म ू र्ति मन्तोभावववशे षास्त्तावन्तए वास्स्त्मन्रोतिाां प्रकारववशे षाः|
The specific varieties of the channels of circulation in the human body are the same in number as the structural entities in it. 13 According to sushrutacharyasrotasa's are considered as pratyanga'sof body and classified into two types.

Bahirmukhasrotas:
"श्रवणनयनवदनघ्राणग ु दमे ढ्राणणनव रोताां सिनराणाां बहिम ु ि खार्न, Bahirmukhasrotasa's are also called navadwara's they are common for both sexes, seven are present in head region and two in the lower part of the body.
Two ears, two eyes, one mouth, two nasal passages, anus, the urethra.
Above these are common for both sexes.
But there are three extra bahyasrotasa's present in women, as two breasts acts as outlet for milk, one apatyamarga (yonidwara or opening for menstrual blood).

ARTAVA, ARTAVAVAHA SROTAS AND ITS DUSTI:
Artavarepresents the elements that are produced following a rhythm and events of cycles in female genital physiology.