Effectiveness of Siddha treatment in the clinical condition of adnexal cyst - A case report

Adnexal masses are a spectrum of conditions from gynaecologic and non-gynaecologic sources which may be benign or malignant. The early detection and evaluation of an adnexal mass requires a high index of suspicion, a systematic history and physical examination. A 50 years old postmenopausal woman had complaints of severe lower abdominal pain especially in the right iliac region for the past 2 months. She had a history of large adnexal mass in right ovary which was later evaluated and diagnosed as a benign adnexal cyst. Due to age factor and family history surgical intervention was advised to the patient. In avoidance of surgery, patients preferred Siddha management and approached SRRI OPD. Treatment was started to the patient as per Siddha diagnostics. During the treatment the patient was relieved from symptoms gradually. Ultra-sonogram was done at the end of 12 weeks of treatment. The result showed bilaterally normal ovaries without any cyst. Follow up scans at the end of 3 rd and 6 th month revealed the same. Further research has to be done to prove the clinical efficacy of the prescribed Siddha medicines.


INTRODUCTION
dnexal masses are a spectrum of conditions from gynaecologic and non-gynaecologic sources which may be benign or malignant. The initial detection and evaluation of an adnexal mass requires a high index of suspicion with systematic history and physical examination. Currently, CA 125 should be evaluated and the patient must be in observation with ultrasonography for every four to six weeks, irrespective of the patient's age (1). There are some guidelines for the management of adnexal masses for postmenopausal women. Out of that, some suggest surgical removal of cysts > 5 cm in diameter, some recommend observation of patients with cyst < 7 cm in diameter and surgical removal for cysts > 7 cm in size. Recent studies reported that unnecessary surgical interventions were recommended for a unilocular cyst (< 5 cm in diameter) which is very low risk of malignancy in postmenopausal women (2,3). Therefore, the management of adnexal cyst remains controversial.
In Siddha medicine remarkable management are available for female reproductive diseases like polycystic ovarian disease (4), menorrhagia (5), leucorrhea, fibroid uterus, infertility etc. (6). In recent days, people are approaching traditional system of medicine to avoid or due to anxiety of surgical intervention. The present case study is reported in order to explain the safety and efficacy of siddha medicines for the clinical condition of adnexal cyst in postmenopausal women, without any surgical intervention.

Patient information
A 50 years old postmenopausal woman, a homemaker, had lower abdominal pain and abdominal discomfort for the past 2 months. She had a family history of CA uterus to her mother. She was diagnosed with an adnexal cyst in the right ovary and surgical intervention was advised for the same. Shortly she approached the OPD of Siddha Regional Research Institute, Puducherry due to fear of surgical procedures.

Clinical findings
The patient was clinically examined. On examination, the abdomen was soft and no palpable mass was found. The patient felt pain only in the right lumbar region. The patient's vital signs were normal.

Diagnostic assessment
Pelvic ultrasonography showed large adnexal mass on the right ovarian region, measuring 9.5*8 cm with no solid areas. Histopathological findings were evaluated that showed acellular smear negative for malignant cells and cyst fluid CA 125 was found to be within normal range. Considering the patient's age and family history, doctors advised to do a cystectomy. Meanwhile, the patient was not willing to do the surgery; she preferred Siddha treatment, so she approached SRRI, OPD. The patient was examined based on Siddha diagnostic procedures and treatment was started with regular OPD medicines on Aug, 2020 and the patient was advised to visit OPD once in 7 days.

Therapeutic intervention
The patient was prescribed with OPD medicines that are tabulated in Table 1 during the course of treatment. The patient was completely relieved from lower abdomen pain and abdominal discomfort within 2 weeks of treatment. A review scan was done after 4 weeks of treatment which showed cystic changes, cyst volume collapsed, cyst size -2.3×3.4 cm. She was advised to continue the medications. After 16 weeks of treatment, USG revealed bilateral normal ovaries without cyst.

Follow-up and outcome
The patient was observed up to 6 months after therapeutic intervention. No possible adverse reaction is noted throughout the course of treatment. Follow up scan was done on the 3 rd and 6 th month which shows a normal uterus and ovaries without any cysts (Table 2). Written consent had been obtained from the patient for publication of the case report.

DISCUSSION
The present case report details about the large adnexal mass (>10 cm) in a post-menopausal woman which was diagnosed as benign adnexal cyst. Due to her age surgical intervention was advised after 12 weeks of review. Patient approached OPD of SRRI during the review period for further managements. So Siddha treatment was started to the patient on the basis of Naadi, Mukkutram (Vatham, Pitham, Kabam) and Suvai (7). The prescribed medicines to that patient are Rasaganthi mezhugu, Amukkara chooranam, Thiripala chooranam, Annabedhi chenduram, Silasathu parpam with proper dosage and drug interval. Rasagandhi Mezhugu is a drug that is prescribed for diseases caused by all 3 humors (Vatham, Pitham, Kabam). Also, the drug Rasaganthi Mezhugu is scientifically proven for its anti-oxidant (8) and anti-cancer activities (9). Silasathu, Annabethi and Thiripala chooranam possess thuvarppu (Astringent) taste that helps to alleviate the altered Kabam. Thiripala has anti-oxidant activity (10) and it is commonly used as an adjuvant for better absorption of medicines (11). Amukkara has kaarppu and kaippu taste that helps to balance Kabam and Amukkara chooranam has a neuroprotective effect, and immunomodulatory activity (12) which may be useful for reducing psychological stress and improves patients sleep and quality of life. As per Siddha literature, cyst is caused by altered Kabam which in turn affects Udalthathu (body constituents). Usually, aggravated Kabam is balanced by kaippu (Bitter), kaarppu (Pungent) and thuvarppu (Astringent) taste drugs (7).
Hence, the prescribed Siddha drugs may have significant effect on balancing the altered Kabam and Udalthathu which in turn reduce the adnexal cyst. Further research is needed for the possible mechanism of action of the drugs toward the adnexal cyst.

CONCLUSION
The current case study about the therapeutic intervention for adnexal cyst helps to prove the efficacy of Siddha medicine in the treatment of adnexal cyst. Also, it improves the patient's mental health and provides a better quality of life.