Indian Journal of Community Medicine

Abstract

Background: Reproductive health is closely associated with culture of a country. Its sign and symptoms can be best understood within the ethnomedical contest rather then biomedical theories.
Objective: To ascertain the views of the respondents regarding vaginal discharge.
Methods: Three roadside villages of Panchkula, Haryana was purposively selected. A house to house survey was done and a total of 236 married women 15-45 years were interviewed by a female social worker on various aspect on vaginal discharge. Six FGDs and five case studies were also done.
Results: Prevalence of vaginal discharge was 28.7%. Weakness, backache and poor vision were told as the main health effects of vaginal discharge. Heat, melting of bones, sexual promiscuity, poor hygiene and diet were told as the major causes of vaginal discharge. Consultation rate for vaginal discharge was 59%.
Conclusion: The views of the rural north Indian women regarding vaginal discharge reflected the Ayurvedic system of thinking of the Indian masses.

Keywords: Vaginal Discharge, Reproductive Health, Women’s Health

Every society has its own set of beliefs regarding etiology and other aspects of various diseases. The area of reproductive health is also replete with a wide range of beliefs pertaining to etiology and remedy of related diseases. For example, in South Asia, genital secretions (semen/vaginal discharge) are considered to represent body’s vital essence. Experience in India also reveals that genital secretions have complex cultural meanings for the people and that their loss is a matter of grave concern for them¹. The complaint of vaginal discharge is accompanied by a host of somatic symptoms, which do not fit a particular biomedical diagnostic category. It can best be understood within the ethnomedical context of Ayurveda. This forms a part of the overall cultural orientation of men and women in India, who view most of the maladies of body and mind through the cultural prism of Ayurveda². However, from a biomedical perspective vaginal discharge is associated with physiology or pathology of female reproductive tract. Thus, at the interface of culturally shaped illness and biomedical disease, there is a significant potential for mistranslation². Whereas the biomedical perspective is more or less universally similar, the cultural perspective varies in different areas. Present study was conducted to estimate the prevalence of vaginal discharge and also to explore the ethnomedical context of vaginal discharge in rural north India.

Material and Methods

A female social worker enlisted 15-45 years old married women from three roadside villages from Panchkula district, Haryana, North India (population=9554). The villages were selected purposively as these constituted the rural field practice area of the parent department of the principal investigator. Systematic random sampling of the houses was done in the villages to select the respondents. A sample size of 236 was calculated at 95% level of confidence with an error margin of 5%. A house-to-house survey was done by the social worker to enlist the eligible respondents. They were contacted and interviewed individually. During the enlisting process, general socio-demographic data was sought from the respondents. They were also asked if they had vaginal discharge or not. Those who had the problem were interviewed about it with the help of another interview schedule. This included questions about the type of vaginal discharge, discomfort experienced and treatment seeking behaviour. The interview also included open-ended questions through which verbatim responses of the women were noted. In addition. 5 case studies were also done on women who were willing to spare time for indepth interview and were vocal about their symptoms. Two focus group discussions each were conducted by the principal investigator with the help of the social worker in all the three villages. Content analysis and textual analysis was done. Consent of the respondents was taken before the interview. The study was approved by institute ethics committee.

Results

Overall, 230 married women aged 15-45 years were registered out of a total population of 9554 in three villages selected for the study. Literacy rate (at least five years of schooling) of women and their husbands was 69% and 84% respectively. Most of them were Hindus (91%) and were housewives (96%). Majority belonged to middle (50%) or lower (30%) socio-economic class. When asked about various types of vaginal discharge, most of the women told that it was watery (218; 94.8%). Some (65; 28%) told that it was yellow. Many women said that it could be with (164; 71.3%) or without pain (154; 64%) and with (108; 47%) or without foul smell (104; 45%). Many women told that when itching started the color of discharge turned yellow. Majority (51; 77%) of the cases told that vaginal discharge affected their daily routine (some discomfort- 45; much discomfort-6). Majority of respondents (150; 65%) said that generally every woman had vaginal discharge sometime or other in her life. Causes and effects of vaginal discharge as perceived by women are listed in table 1. Almost all of them said that vaginal discharge led to weakness (228; 99%) and backache (226; 98.2%). Some told that discharge was the result of evil shadow cast by someone. More than one third of the respondents (82; 35.6%) told that an effective cure for vaginal discharge was available. Most of the respondents (212; 92.1%) said that a woman with vaginal discharge could spread illness to men during sex and 204 (88.6%) said that having vaginal discharge affected sexual relations and that such women should not have sexual relations with their husbands. All except two of them (228; 99.1%) said that vaginal discharge could be prevented if husbands avoided visit to other women. More than half (128; 55.6%) of them told that observance of good personal hygiene could prevent vaginal discharge. More than half of the women (120;52,2%) said that husband should also be treated if wife has vaginal discharge.

Table 1: Vaginal Discharge: Its perceived causes and effects on women’s health

Causes and effects of vaginal discharge		No.	(%)
Causes	Weakness	223	(97.0)
	Melting of bones	219	(95.2)
	Heat	205	(89.1)
	Visit to other women by husband	224	(97.4)
	Poor personal hygiene of husband	221	(96.0)
	Internal gynecological problem	207	(90.0)
	Poor personal hygiene of women	164	(71.3)
	Diet	140	(60.9)
	Backache	168	(73.0)
	Family planning operation	90	(39.1)
	Having too many children	121	(52.6)
	Use of Copper T	114	(49.6)
Effects	Weakness	228	(99.1)
	Backache	226	(98.2)
	Pallor	177	(77.0)
	Poor Vision	164	(71.3)
	Bodyache	111	(48.4)
	Giddiness	118	(51.4)
	Urinary Problems	73	(31.8)
	Pain Lower abdomen	129	(56.0)
	Other (Swelling,headache irritability, weight loss, fever etc.	80	(35.0)
	Infertility	45	(19.5)

*There were multiple responses also.

Prevalence of vaginal discharge was estimated to be 28.7% (66 cases). Majority of these cases (49; 74.2%) had the discharge for more than one year. Except for 8 (12%) women who had yellow or brown discharge, all of them told that it was white or colorless. All the cases reported wetting of undergarments. Foul smelling discharge was reported by 43 (65.1%) women. Consistency of discharge was told to be thick (23; 34.8%), thin ((27; 40.9%) or mixed (16;24.2%).

Twenty women (51.3%) consulted a government doctor for vaginal discharge, while 8 (20.5%) each consulted private doctors or Ayurvedic doctors. Eight women consulted TBAs, (traditional birth attendants), health workers or local unqualified practitioners (RMPs). Many home remedies for vaginal discharge were also used by one-third women (12; 30.8%). Consultation rate was 59%. Twenty seven (41%) women did not consult anyone.

Money spent on treatment of vaginal discharge was Rs.100- 500 (18; 46.2%) or more than Rs.500/- (9; 23%). In 12 cases (30.8%) no money was spent.

Reasons for non-consultation were – took it as normal (12), shyness (2), cost (2), no cure (2) or others (11- no escort, can tolerate, do not know where to go etc). In two women it was the first episode of vaginal discharge. In 12 cases husbands were also advised treatment but only 7 complied with the advice. In 19 (29%) women there had been more episodes earlier. More than half of the affected women (36; 55%) said that they had continuous vaginal discharge throughout the year while nine (14%) of them told that they had vaginal discharge only before or after the menses. Majority (56; 84.8%) of women who had vaginal discharge told that they used underwear only during menses while 9 (13.6%) of them used it regularly. One woman told that she had never used any underwear. Most of the affected women (60; 91%) used washed rags as menstrual pads while one of them used just cotton packs. Five (7.6%) women used pads available in the market.

Of the 66 women who complained of vaginal discharge, 24(36%) had undergone tubectomy, 4 were using Copper-T, 2 were using oral pills and 18 (27%) reported condom use. Seventeen (26%) were not using any contraceptives. The conceptual framework of the respondents regarding causes and effects of vaginal discharge is shown in figure-1 and figure 2. Fig 3 shows the treatment pathways adopted by the affected cases. (Some of the verbatim responses given by the respondents during the interviews and FGDs have been directly incorporated in following discussion).

Discussion

The prevalence rate of vaginal discharge reported in the present study (29%) implies that every fourth woman suffers from vaginal discharge in the study area. More than half of the affected respondents in our study said that as a problem, vaginal discharge continuously nagged them. This way, it emerged as one of the commonest reproductive health problem of women. It is even accepted as an essential feature of womanhood as indicated by the statement made by 65% of our respondents that ’ everyone has vaginal discharge’. Some of the respondents remarked, ‘little vaginal discharge is there in every woman, so there is no need to worry much about it’. Such statements tend to give an impression of existence of a concept of normality regarding vaginal discharge among rural Indian women. Some of the women, in fact, said that it occurred normally in many women prior to menstrual bleeding indicating the onset of menses. In addition, many of the women, who did not consult anyone for vaginal discharge, told that they did so because they considered it normal.

Other authors have also documented that vaginal discharge was one of the commonest symptom reported by women in India^1,3,4 Palai et al had also reported a prevalence rate of 21.6 % for vaginal discharge from this part of India⁵. Patel et al also reported that their respondents said that vaginal discharge was the ‘fate of every woman’ and that there was no need of treating it⁶. Even male respondents of another study from rural Haryana by the authors reported that vaginal discharge was the main health problem of women⁷. In India, ‘diet’, ‘weakness’ and ‘heat’ are the dominant themes in context of women’s illnesses. As per the Ayurvedic concepts, vaginal discharge in women has been equated with semen discharge (dhat) in men. People have even been reported to say that vaginal discharge contained jaraseem (micro-organisms…just like sperms in semen⁸. And in the Indian system of medicine, ‘semen’ is a potent and all powerful, precious fluid in the body. This is also supported by dietary theory of Ayurveda , where it has been documented that semen is formed as the seventh stage product after a high degree successive refinement/assimilation of food, passing through six stages of formation of vital elements (dhatus) viz., chyle, blood, flesh, fat, bone and marrow (Fig.1).

As per the Vedic concept, the food we eat gets sequentially converted into seven parts, of which our body is made.

1. First Rasa (Chyle) is made from food and remains in body. The remnant is excreted as feces. Thus, Rasa is the essence of food. Then blood (rakta) is made from Rasa.
2. Thus, rakta (blood) is the essence of Rasa
3. Similarly, maans (flesh)is the essence of blood (rakta)
4. Fat (meda) is the essence of flesh (maans)
5. Bone (asthi) is the essence of fat (meda)
6. Marrow (majja) is the essence of bone (asthi) and
7. Semen (Veerya) is the essence of marrow (majja)

The most/macro part is Rasa and the most micro is Veerya i.e. sperm (semen).

It has also been said that from 100 drops of blood only one drop of semen is formed and that formation of one drop of blood requires consumption of sackfulls of nutritious food items. Hence, the loss of even a few drops of semen is equated with ebbing away (seepage) of vital power/strength from the body leading to weakness¹. Similarly, vaginal discharge among women has also been said to be a major cause of weakness. Bang and Bang⁶ and Patel et al⁹ also reported similar findings from western India.

The eighth stage product in this process is ‘radiance’ (oja) and the ninth one is our inner mind (mana). Such concepts are responsible for the thinking among Indian women that vaginal discharge leads to a loss of radiance of the faces of the affected persons. Similar concept exists for the menfolk suffering from ‘night emission’ (spermatorrhea) or those indulging in excessive masturbation. In Indian settings, it has often been commented that ‘more the semen is conserved more is the radiance of the face’. Thus, emphasis is on the conservation of semen. It has also been reported that traditional birth attendants (dais) in north India often boasted of spot diagnosis of vaginal discharge just by looking at the lustrelessness of the faces of the women¹⁰. Majority of the respondents in our study also told that it led to pallor (pale faces). Some women remarked that deficiency of blood was involved in the etiology of the vaginal discharge, since, in the affected women, a blood product got lost i.e. vaginal secretions. Consequently, faces of such women were discolored (drainage of blood) and were pale / white. Such women become too weak to walk.

Figure 1: Dietary Theory of Vaginal Discharge as per Laywomen/ Ayurveda

Change in diet of the women with modernization has also been implicated as a causative factor for aggravation of the problem of vaginal discharge, as reflected by the statements of some of the respondents in a previous study by the principal author in a neighbouring area–’earlier women used to take milk/lassi (butter milk), i.e., the diet with cooling effect. Now they take tea and other heat producing diet leading to vaginal discharge⁸. (Fig.2).

Figure 2: Indian women’s conceptual framework regarding vaginal discharge

Figure 3: Treatment pathways for vaginal discharge cases

Most of the respondents in the present study ascribed vaginal discharge to weakness (kamjori), melting of bones (haad galna) and body heat (garmi). Simultaneously, most of the respondents said that vaginal discharge led to weakness and backache. This would appear confusing on superficial inspection, since, like the findings of other authors from different parts of India⁹. These symptoms are being told as both the cause as well as the effect of vaginal discharge in our study also. However, it can be explained as per the Ayurvedic theory of food assimilation, where bone formation is depicted as a precursor of semen formation and semen is considered to be equivalent to vaginal discharge. So, for laywomen, who have vaginal discharge, it is natural to comment that their bones (especially backbone) are melting leading to excessive semen (vaginal) discharge. And since backbone is melting (getting hollowed) there is backache also. Moreover, ‘heat’ (of stomach – Jatharagni) is an essential facilitating factor for various stages of food assimilation. So, any heat producing condition is considered to hasten the steps involved in the process of conversion of bones…..to marrow …to semen and hence to vaginal discharge. This is reflected in the responses of the respondents where they said that vaginal discharge resulted from consmption of ‘hot’ western medicines or of the food grown in the fields where western fertilizers3 based on powdered bones of animals, had been used. Such fertilizers are said to lead to heat, which in turn caused vaginal discharge. This ‘heat fixation’ in the thinking of the Indian women in context of their reproductive health problems has also been reported by other authors(6,9).

Some of the respondents expressed a concept of internal and external diseases and said that maintenance of personal hygiene could help in reducing vaginal discharge but total control was unlikely since it was an internal disease. They seemed to imply that vaginal discharge was a manifestation of some underlying internal defect which would not be rectified by superficial personal hygienic measures (which presumably meant external cleanliness only).

When the women were asked ‘Can vaginal discharge be due to poor hygiene’ many of them told…. “Maybe; but it can be there despite good hygiene’ ‘No; it is an internal disease’; ‘Good hygiene may reduce it a bit. But it is an internal disease’

‘No; nobody can clean internal filth. One can clean only the exterior’

Most of the women used washed rags as menstrual pads; only 7.6% used pads available in the market. Use of underwear was very low. Regular use of underwear was reported by only 14% women. Rest of them used it only during menses.

Role of husbands was also elaborated by many women. That husbands were equally involved in causation/remedy/ prevention of vaginal discharge was evident by the fact that almost all women said that it could be prevented if husbands avoided promiscuity. Some of the women said that if a man had sex with his wife after taking alcohol, the ‘heat’ of the husband is transmitted to the wife leading to vaginal discharge. Most of them (92%) agreed that it was sexually transmitted disease. This is also reflected in the statement made by many respondents ….’(Usually) bad (promiscuous) women get such disease. They do not go to doctor and continue to spread the infection.’ Bang and Bang and Patel et al also reported that people ascribed vaginal discharge to promiscuity^6,9.

The respondents told a wide spectrum of complications of vaginal discharge. By their responses it appeared that vaginal discharge was perceived to affect the total body system of women. Diminished acuity of vision (61%) was also told as an ill effect of vaginal discharge by majority. Bang and Bang also reported similar findings⁹. Now, loss of semen, as per Ayurvedic theory, is a direct cause of diminution of acuity of vision. In Vedic context, the procreative eye is considered as the organ of generation. In Vedic symbolism it is the tear, which is at the base of expansion of creation of the world11. Hence, a direct link between the process of reproduction and organ of vision is apparent. Hence, loss of semen / vaginal discharge, as a potent cause of weakness, is seen as a cause of diminished acuity of vision as well. It is pertinent to note here that in another study by the principal author (on menopause) diminished acuity of vision emerged as the most common menopausal symptom¹².

Some women told that if untreated the vaginal discharge might lead to infertility. As indicated above, vaginal discharge is equated to semen and implies loss of female sperms thus leading to infertility. In a previous study by the author some women from the study area had commented, “A woman with leucorrhea (vaginal discharge) will not develop any desire for a man. Such women are like mules who can not conceive”⁷.

Some women even enumerated cancer as the complication of untreated vaginal discharge. Some told that it could lead to AIDS, TB, or even death. Few told that it could lead to some internal bodily defects. Our respondents seem to be concerned about the discharge when its color was yellowish and or was associated with itching.

Most of the women told that vaginal discharge lead to formation of ulcers down below. In Ayurvedic system of medicine, boils/ulcers are considered as a manifestation of bursting out of the excess ‘body heat’. Thus, body heat is the cause of both the ulcers and vaginal discharge. So the linkage of vaginal discharge and ulcers is understandable. Apart from that, some women said that ulcer at vulva developed as the result of contact of the skin with filthy water - the discharge. They even evinced a morbid fear of the smell of the discharge, which could spread inside body …leading to internal ulcer or even cancer. They told that contact with filthy water might also lead to pus formation/sepsis in uterus, which might eventually decompose, putrefy and wither away. Some of the women told that it might also lead to formation of holes in the uterus and eventually uterine prolapse. Thus, for women, vaginal discharge was perceived to be even more serious illness than menstrual problems.

Many women told that untreated chronic vaginal discharge could lead to a situation where the bones turn hollow.. (and melt away). In such situation the condition becomes incurable the bones get weak and the women find it even difficult to walk. Some women told that the discharge lead to an overall loss of vitality… the body machinery goes haywire and the whole body may putrefy.

As far as treatment of vaginal discharge is concerned majority of the respondents had faith in government doctors. However, almost one fourth of them consulted Ayurvedic doctors also. Homeopathic doctors were consulted by almost one-third of the respondents. One fourth of the respondents resorted to various home remedies.

Some of them also ascribed supernatural causation to it e.g., effect of evil shadow. Bang and Bang also reported similar findings⁹. This is also a dominant theme in the minds of people as far as the laymen’s concept of aetiology of diseases is concerned. Some of the women ascribed vaginal discharge to use of family planning methods viz., copper – T, tubectomy. Patel et al and Trollope-Kumar also reported similar findings^1,6.

Thus, the problem of vaginal discharge in Indian settings need to be interpreted in context of Ayurveda, which percolates deeply in the daily routine of Indian people, particularly in matters pertaining to health. In particular, such knowledge needs to be imparted to doctors trained in allopathy in order to improve the quality of doctor-patient communication. It is important to remember here that these symptoms (weakness/backache) are the most common complaints of women in O.P.Ds. When they complain of ‘weakness’ or ‘backache’ they expect the doctor to understand its implications, pay special attention to them and probe further about their reproductive health problems. However, the doctors trained in western medicine often tend to ignore these bodily symptoms and often fail to understand their reproductive health implications. They send back women having such complaints with symptomatic treatment only e.g., analgesics and hematinics. Consequently, the women get a sense of receiving inadequate medical care. Trollope-Kumar also reported that in South Asia the complaint of loss of genital secretions in both men and women along with a constellation of symptoms may often represent a culturally shaped illness¹. So, proper interpretation of these symptoms by the treating gynecologists is essential.

Acknowledgements

The study was supported by Institute Research Scheme Fund, PGI, Chandigarh.

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Department of Community Medicine PGI, Chandigarh-160012
E-mail: amarminhas56@rediffmail.com
Received: 03.11.05