Female Dhat syndrome in primary care setting.

AIM: The study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome.
METHODOLOGY: Sixty-nine females considered to have nonpathological vaginal discharge after detailed gynecological evaluation, including required investigations, attending a rural community clinic were assessed for their belief about the vaginal discharge. The study subjects were also evaluated on the proposed criteria of female Dhat syndrome by using a semi-structured interview.
RESULTS: The mean age of onset of vaginal discharge was 36.1 (standard deviation - 8.5) years. Most of the females considered the loss of vaginal fluid as loss of a vital fluid from the body. Consumption of warm foods and drinks (75.8%) was the most common reason reported for vaginal discharge followed by eating unbalanced food/inappropriate food (73.5%). A majorty of the subjects considered vaginal discharge responsible for bodily weakness (87.0%), backache (71.0%) and stomache (66.7%). About two-third of the participants considered the taking energizing medications like vitamins/tonics/tablets and treatment from a gynecologist the treatment for vaginal discharge.
CONCLUSIONS: Significant proportion of females with non-pathological vaginal discharge have a belief that they are losing a vital fluid of the body. The subject attributes their symptoms to factors such as consumption of warm foods and drinks, and eating unbalanced food/inappropriate food. Accordingly, assessment and management of women with Dhat syndrome require addressing these important issues. Copyright:

Dhat syndrome as a disorder is usually reported in males. However, there are few reports of a female equivalent of Dhat syndrome.[123456789101112] The passage of vaginal discharge in females was equated with discharge of semen for the first time in 1988.[2] Chaturvedi[2] described this entity as “psychasthenic syndrome associated with leucorrhea.” In a clinic-based study, the authors found that a more than half of the female patients (majority presented with somatic symptoms) and 13% of the healthy female had a belief that passing nonpathological whitish discharge per vagina is harmful to their health.[3] In an ethnographic study from Uttaranchal, the authors evaluated females who presented with a concern of genital secretion and found an association of vague somatic symptoms such as burning head, dizziness, headache, backache, and progressive generalized weakness with genital secretions. The women labeled the genital secretion as “safedpaani,” “dhatu,” or “swedpradhar.” The women considered the “safedpaani” as the vital fluid of the body equivalent to Dhatu in males.[4] On evaluation, these females usually did not have evidence of infection and in terms of quantity, the quantity of discharge was similar to normal physiological discharge. Few other ethnographic studies have also reported similar profile.[56] Other studies from different parts of the country have reported the association of leucorrhoea with somatic manifestations.[789101112] In some of these studies, patients attributed their symptom of vaginal discharge to stress and emotional factors, excess heat in the body, infection, consumption of hot and spicy foods, and effect of warm weather.[789101112]

In view of lack of specific criteria for female Dhat Syndrome, recently authors tried to propose the criteria for female Dhat syndrome.[12] Till recently, although studies reported female equivalent of Dhat syndrome, no specific instrument was available to assess various dimensions of female Dhat Syndrome. Few years back, Dhat syndrome Questionnaire, developed for the assessment of Dhat syndrome in males was modified to assess the female equivalent of the disorder. This instrument was named as Scale for Assessment of Female Dhat syndrome (SAFeD).[13] However, this study was conducted in a tertiary care hospital in the psychiatric outpatient setting.

Only limited information is available for rural females, with respect to the nonpathological vaginal discharge. A study from north India, in a house to house survey reported vaginal discharge in 28.7% of females. Majority of these patients reported somatic symptoms and attributed the vaginal discharge to health, melting of bones, sexual promiscuity, poor hygiene, and diet.[6] However, this information was collected using open-ended questions rather than using a structured instrument. Accordingly, there is a need to understand nonpathological vaginal discharge in females from rural background, from the perspective of female Dhat syndrome. Accordingly, this study aimed to evaluate the females presenting with the complaint of nonpathological vaginal discharge to a general gynecology outpatient service in a rural community clinic from the perspective of female Dhat syndrome.

METHODOLOGY

The study was approved by the Institute ethic committee.

The study was carried out at the Gynecology outpatient service in a rural community clinician a Sub-District Hospital, which falls in the catchment area of Community Clinic of Department of Community Medicine of Postgraduate Institute of Medical Education and Research, Chandigarh. The town has a total population of approximately 23,000, with male literacy of 79.6% and female literacy of 73.4%. For this study, all the females (aged ≥18 years), free from any diagnosed psychiatric illness, able to understand colloquial/Hindi or Punjabi language, and those who provided the written informed consent for the participation in the study were recruited. In addition, participants were required to have vaginal discharge, which could be attributed to any infective pathology. For this, all the patients presenting with vaginal discharge were initially evaluated by a gynecologist and underwent investigations to rule out common bacterial, parasitic or fungal infections. Those who were found to have nonpathological vaginal discharge were approached for further evaluation for their belief about the vaginal discharge. Those who provided the consent were assessed at the rural health clinic by the trained Gynecologists well versed with the local language, dialect, traditions, and customs. The study sample comprised 69 patients. Patients were also evaluated on the proposed criteria of female Dhat syndrome using a semi-structured interview.[13]

These patients were evaluated on SAFED.[13] SAFED assesses the various aspects of Dhat syndrome. The elements covered by the questionnaire include frequency, consistency, color, and quantity of discharge; situations in which patient has the discharge, patients beliefs about the composition of discharge, reasons for passage of discharge; consequences of excessive discharge; accompanying somatic, anxiety, and depressive symptoms; comorbid sexual dysfunction and beliefs about help-seeking and treatment.

Statistical analysis

Statistical analysis was done using the Statistical Package for Social Sciences, Sixteenth version (SPSS-16) (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). For categorical variables, the frequencies with percentages were calculated. For the continuous variables, the mean and standard deviation (SD) were calculated.

RESULTS

The mean age of the study sample was 36.1 (SD - 8.5) years and the mean number of years of education was 8.6 (4.1). Majority of the participants hailed from extended/joint family (60.9%) and lower/middle socio-economic status (88.4%) and were Hindu (88.4%) by religion.

Participants started having the vaginal discharge at the mean age of 30.4 (SD −8.9) years, and the participants were symptomatic for a mean duration of 5.4 (SD - 4.5) years at the time of assessment.

The details of the passage of Dhat are shown in Tables 1-3.

Table 1

Characteristics of Dhat syndrome

Variables	Frequency (%)/mean (SD)
Age of onset of the passage of vaginal discharge/Dhat (years)	30.4 (8.9)
Duration of the passage of vaginal discharge/Dhat (years)	5.4 (4.5)
Frequency of passage of vaginal discharge/Dhat
Once in every 1 month	12 (17.4)
Once in every 2–3 weeks	13 (18.8)
2–3 times per week	17 (24.6)
Once or more per day	27 (39.1)
Quantity of vaginal discharge/Dhat passed every time?
Light wetness in vagina/2–4 drops	11 (15.9)
Wet feeling outside vagina/about a spoon full	10 (14.5)
Wetting of undergarments/more than a spoon full	30 (43.5)
Need to change undergarments due to wetness	18 (26.1)
Consistency of vaginal discharge/Dhat
Like water	15 (21.7)
Thin (like milk)	23 (33.3)
Thick (like oil)	31 (44.9)
Colour of the vaginal discharge/Dhat like water
Transparent like water	12 (17.4)
Like milk	43 (62.1)
Like pus	11 (15.9)
Different than the above	3 (4.3)
Belief about what is vaginal discharge/Dhat
Vaginal discharge/oil/pus	10 (14.5)
Vital fluid for body/semen	48 (69.6)
Other explanations/do not know	11 (15.9)
Belief about the major component of vaginal discharge/Dhat
Vital fluid for body/semen/blood/semen	62 (89.9)
Do not know/others	31 (10.1)

SD – Standard deviation

Table 3

Consequences of vaginal discharge/Dhat syndrome

Variables	Frequency (%)/mean (SD)
Weakness in sexual ability	25 (36.2)
Loss of sexual desire	22 (31.9)
Excessive sexual desire	17 (24.6)
Early death	5 (7.2)
Malformation of children	9 (13.0)
Birth of more female children	7 (10.1)
Loss of beauty of face and body	25 (36.2)
Reduction in size of vagina/uterus (penis in male)	14 (20.3)
Pain in genitals	47 (68.1)
Pain in genitals during sex	34 (49.3)
Repeated vaginal infection	32 (46.4)
Irritability before or after menstruation	46 (66.7)
Menstrual disturbances	41 (59.4)
Mental illness	33 (47.8)
Weakness in body, weakness in stamina and thinness of physique	47 (68.1)
Others	3 (4.3)

SD – Standard deviation

Associated psychological and somatic symptoms

The presence of vaginal discharge was associated with various psychological and somatic symptoms [Table 4].

Table 4

Psychological symptoms accompanying white discharge/Dhat syndrome (present in last 2 weeks)

Variables	Frequency (%)/mean (SD)
Bodily weakness	60 (87.0)
Mental weakness	35 (50.7)
Stomach ache	46 (66.7)
Back pain	49 (71.0)
Pain in your arms, legs, or joints (knees, hips, etc.,)	45 (65.2)
Pain or problems during sexual intercourse	34 (49.3)
Headaches	21 (30.4)
Chest pain	13 (18.8)
Dizziness	25 (36.2)
Fainting spells	14 (20.3)
Feeling your heart pound or race	31 (44.9)
Shortness of breath	15 (21.7)
Constipation, loose bowels, or diarrhea	42 (60.9)
Nausea, gas, or indigestion	37 (53.6)
Feeling tired or having low energy	16 (23.2)
Little interest or pleasure in doing things	20 (29.0)
Feeling down, depressed, or hopeless	23 (33.3)
Trouble sleeping	42 (60.9)
Poor appetite or overeating	25 (36.2)
Feeling bad about yourself, or that you are a failure, or have let yourself or your family down	21 (30.4)
Trouble concentrating on things, such as reading the newspaper or watching television	17 (24.6)
Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual	13 (18.8)
Thoughts that you would be better off dead, or of hurting yourself in some want	16 (23.2)
Burning micturition	39 (56.5)
Excessive straining while micturition	12 (17.4)
Itching on/around the genitals	41 (59.4)
Development of lesions on/around the genitals	14 (20.3)
Difficulty in gaining weight or losing weight	15 (21.7)
Excessive worry	27 (39.1)
Restlessness to the extent that you have difficulty in sitting still	18 (26.1)
Anger, irritability, getting annoyed easily	36 (52.2)

SD – Standard deviation

Help-seeking and treatment-related beliefs

Majority of the participants believed that there is a need for an investigation to understand the cause of vaginal discharge [Table 5].

Table 5

Help-seeking and treatment-related belief

Variables	Frequency (%)/mean (SD)
Need for investigations of blood and urine
Very essential	59 (85.5)
Less essential	8 (11.6)
Not at all essential	2 (2.9)
Ever undergone any investigations of blood and urine	40 (58.0)
Received treatment prior to current assessment
General physician	34 (49.3)
Unani/Ayurvedic/homeopathy	25 (36.2)
“Sex specialist”	--
MBBS (medical officer)	37 (53.6)
Gynecologist	21 (30.4)
Surgeon	7 (10.1)
Dermatologist	--
Psychiatrist	16 (23.2)
Others like quake	27 (39.1)
Belief about treatment for white discharge
Change in food	38 (55.1)
By taking energizing medications like vitamins/tonics/tablets	46 (66.7)
By taking energizing injections	36 (52.2)
By taking medications which can increase the sexual desire	19 (27.5)
By taking medications to reduce infection	31 (44.9)
By taking medications which are used for the treatment of mental problems	22 (31.9)
By taking treatment from gynecologist	41 (59.4)
Consultation and discussion with a doctor	39 (56.5)
There is no treatment	9 (13.0)
Medications to reduce sexual desire	12 (17.4)
By talking to doctors, i.e., counseling	11 (15.4)
Others	4 (5.8)
Feeling about the questionnaire of Dhat syndrome
Considered questionnaire
Very good	38 (55.1)
Good	13 (18.8)
Neither good nor bad	14 (20.3)
Bad	4 (5.8)
Length of the questionnaire
Very lengthy	36 (52.2)
Lengthy	23 (33.3)
Neither lengthy nor small	4 (5.8)
Small	6 (8.7)
Time taken to fill the questionnaire (min)	35.8 (10.8)
How much can you tell about your problem?
Completely	15 (21.7)
To a large extent	38 (55.1)
To some extent	10 (14.5)
Not at all	6 (8.7)

SD – Standard deviation

DISCUSSION

The current study aimed to evaluate symptoms and causation of passing nonpathological vaginal discharge among female patients to examine the existence of female Dhat syndrome. Nonpathological vaginal discharge has been referred to as a medium of communication about health issues, particularly sexuality, social distress or psychological problems.[3414] Hence, it can be considered that reporting of vaginal discharge in females may have deep cultural meaning.

In the present study, about three-fourth reported the wetness in the vagina along with need to undergarments or change clothes. This finding is almost similar to the previous study conducted among the patient with psychiatric illness evaluated vaginal discharge.[15] In terms of consistency, majority of the participants reported it to be like milky discharge, which is also reported in the earlier studies too.[4691011] Majority of the patients in the present study reported that vaginal discharge is made up of vital fluid of the body. Existing studies have also reported similar findings.[1215] Ayurvedic beliefs consider “Dhatu” as the most refined element of the body, which is considered to “tone” and “energize” the body. As per the anthropologist, Dhatu leaves the woman's body as a whitish, odourless discharge which is often associated with “heaty” symptoms such as burning hands and feet, dizziness, and joint pain.[16] Findings of the present study are also in consonance with these beliefs.

In the present study, most of the participants reported vaginal discharge occurred irrespective of any specified situation. A significant proportion of patients also experienced vaginal discharge in other situations, too, such as, while passing urine, while feeling pressure or strain on the abdomen, during menstruation, just before and after menstruation, and at the experience of sex-related dreams. These findings are in similar lines, with the previous study based on the same instrument[15] or those studies which have evaluated the concept by using different methods.[617] These findings suggest the existence of the concept across different treatment setting and hence, the nosological system should recognise the existence of the same. This can help in further research on the topic.

In terms of the reasons for passage of vaginal discharge, the participants reported the reasons such as consumption of warm foods and drinks, high energy food, eating unbalanced food/inappropriate food, urinary/vaginal infection or problems of the urinary tract. The previous studies which have evaluated the causes have also documented factors like consumption of food items which produce heat or which are warm, stress and emotional factors, excess heat in the body, infection, hot and spicy foods and hot weather, backache, the operation for family planning, having too many children, physical and sexual violence etc.[6911] Ayurvedic textbook reports that nonpathological discharge occurred because of excess humoral heat in the body and advocate the avoidance of “heaty” foods such as ghee, eggs, or meat.[4] The cultural explanation for these symptoms might be the reason for these responses.

The most frequent consequences of passage of vaginal discharge are in similar lines with the existing literature[4791011] and suggest that females who present with symptoms of weakness in the body, weakness in stamina, pain in genitals, and irritability before and after menstruation, menstrual disturbances, pain in genitals during sex, mental illness, weakness in sexual ability, loss of beauty of face and body and loss of sexual desire, should be evaluated for nonpathological causes and associated psychological and mental symptoms, which can have a bidirectional relationship with each other.[89101114]

The associated psychological and somatic symptoms profile in the index study is almost similar as seen in the previous studies in females with vaginal discharge.[45781415] These findings suggest that unexplained gynecological symptoms may represent a somatic idiom of psychological distress.

Like the previous study, based on the same questionnaire,[15] with regards to the treatment expectations, about two-third believed that symptoms of vaginal discharge could be relieved by taking energizing medications like vitamins/tonics/tablets. Other measures considered the beneficial effect of change in food, by taking energising injections, treatment from a gynaecologist, and consultation and discussion with a doctor. These explanations could be understood in a way that woman with vaginal discharge would be treated with multivitamins, iron, and advice on a nutritious diet, personal hygiene, and rest.[7]

Limitation of the study

This was a cross-sectional study. The sample size although is larger than most of the earlier studies, which have evaluated the females with nonpathological vaginal discharge, the sample size can still be considered as small. The patients were not evaluated for comorbid psychiatric diagnosis. The confounding factors such as sexual violence, attitude, and knowledge toward the sex were not included.

CONCLUSIONS

The present study suggests that a significant proportion of females presenting with nonpathological vaginal discharge believe that they are losing a vital fluid of the body. These symptoms occur in the context of adverse psychosocial stressors and manifest with many somatic and psychological symptoms. These patients usually attribute their symptoms to cultural factors like consumption of warm foods and drinks, eating unbalanced food/inappropriate food, consumption of high energy foods, and urinary/vaginal infection or problems of urinary tract. The management requires addressing these issues. Accordingly, there is a need to develop intervention package or module to address females with nonpathological vaginal discharge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 2

Situations in which there is passage of Dhat and reason for passage of white discharge/Dhat

Variables	Frequency (%)/mean (SD)
Situation in which you experience discharge of vaginal discharge/Dhat
While straining for stools	39 (36.5)
As night falls/sex-related dreams	32 (46.4)
While masturbation	12 (17.4)
While having intercourse	24 (34.8)
Any time, with no associated specific situation	54 (78.2)
While passing urine	45 (65.2)
While having sexual excitement	26 (37.7)
While feeling pressure or strain on the abdomen	29 (42.0)
While watching/reading pornography	20 (29.0)
During menstruation	30 (43.5)
Just before and after menstruation	29 (42.0)
After not having sex for long period of time	13 (18.8)
Reason for passage of vaginal discharge/Dhat
Due to excessive masturbation	3 (4.3)
Due to excessive sexual intercourse	8 (11.6)
Due to less sexual intercourse	10 (14.5)
Due to not being satisfied during sexual intercourse	18 (26.1)
Due to having sexual intercourse while menstruation	16 (23.2)
Due to premarital sexual intercourse	6 (8.7)
Due to having sexual intercourse outside the wedlock	7 (10.1)
Due to homosexual relationship	7 (10.1)
Due to having sexual intercourse in unnatural way	9 (13.0)
Due to having sexual dreams	23 (33.3)
Due to low sexual desire	21 (30.4)
Due to excessive sexual desire	14 (20.3)
Due to lack of indulgence in masturbation	8 (11.6)
Due to eating unbalanced food/inappropriate food	51 (73.9)
Due to excessive eating	33 (47.8)
Due to wrong deeds of past life	16 (23.8)
Due to lack of sleep/improper sleep	17 (24.6)
Due to constipation	34 (49.3)
Due to worm infestation of gastrointestinal tract	29 (42.0)
Due to urinary infection or problems of urinary tract	44 (63.8)
Due to vaginal infection/disease	41 (59.4)
Due to uterine infection/disease	20 (29.0)
Due to use of birth control pills	18 (26.1)
Due to hereditary reasons (because others in family also suffer from the same problem)	13 (18.8)
Due to some mistake done in childhood	11 (15.9)
Due to consumption of high energy foods	48 (69.6)
Due to consumption of warm foods and drinks	52 (75.4)
Others	13 (18.8)

SD – Standard deviation