7) 대한한방부인과학회지 J Korean Obstet Gynecol. VOL.29 NO.1 : 092-101 (2016) http://dx.doi.org/10.15204/jkobgy.2016.29.1.092 위축성질염의좌훈치료연구에관한체계적문헌고찰 대전대학교한의과대학부인과교실백선은, 장새별, 최경희, 유정은 ABSTRACT Systematic Review of Fumigation Therapy for Atrophic Vaginitis Seon-Eun Baek, Sae-Byul Jang, Kyung-Hee Choi, Jeong-Eun Yoo Dept. of Oriental Gynecology, College of Oriental Medicine, Dae-Jeon University Objectives: The purpose of this systematic review was to overview and evaluate the effectiveness of fumigation treatment for women with atrophic vaginitis. Methods: We searched articles from Pubmed, Chinese Academic Journals (CAJ) and Oasis online databases. Searching keywords were fumigation, atrophic vaginitis, vaginitis, 阴道炎, 膣炎, 老年性阴道炎, 坐熏, 熏洗, 熏浴, 좌훈요법, 질염, 위축성질염. After searching the articles, we performed quality assessment using Cochrane risk of bias (RoB) tool. Results: Among the 142 articles were searched, 5 randomized controlled clinical trials (RCTs) were finally selected. All of 5 studies showed that fumigation treatment has significant effect on atrophic vaginitis in terms of the effectiveness rate, but 3 studies were not statistically significant. Conclusions: Our systematic review found encouraging but limited evidence of fumigation therapy for atrophic vaginitis. We recommend clinical trials which obtain stronger evidence without the demerits of trial design. Key Words: atrophic vaginitis, fumigation, systematic review, Phellodendri Cortex, Cnidii Fructus This study was supported by a grant of the Traditional Korean Medicine R&D Project, Ministry of Health & Welfare, Republic of Korea (HI15C0006)." Corresponding author(jeong-eun Yoo) : Dept. of Gynecology, Dunsan Korean Medicine Hospital of Daejeon Univ. 75 Daeduk-daero 176 beon-gil, Seo-gu, Daejeon, Korea Tel : 042-470-9139 E-mail : jeyoo@dju.kr 92
J Korean Obstet Gynecol Vol.29 No.1 February 2016 Ⅰ. 서론 위축성질염은폐경기여성에게국한하여주로발생하는질환으로모든연령대의여성을대상으로하는세균성, 칸디다성질염과달리에스트로겐호르몬부족으로질내벽상피세포와외음부피부가위축되고상처받기쉬운상태가되어발생하는질염이다 1). 위축성질염은일상생활의불편감과성기능장애를유발하여폐경이후에삶의질을저하시킬수있으며적극적인치료와관리가필요한질환이다. 위축성질염의진단은질의비정상적분비물, 성교통, 질의건조감, 통증및소양감, 재발성요로감염등의임상적인증상평가와질상피및외음부내진을통하여이루어지며, 질과자궁경부의내진시얇고반들거리며주름이소실된부드러운표면의붉은색질상피가관찰된다 2). 위축성질염의치료는국소적에스트로겐크림도포혹은여성호르몬제경구투여가일반적이며, 호르몬치료외에도위축성질염의주요증상인질건조감을개선시키기위한보습제와윤활제가널리활용되고있으나 3), 경질에스트로겐을장기간다량사용시에는자궁내막증식증이나자궁내막암의위험성을증가시킬수있는것으로알려져있다 4). 한의학에서위축성질염은 帶下 ' 의범주에서접근할수있으며, 발생시기와원인및증상을종합하여볼때폐경후腎陰虛로인한갱년기증상의하나로생각해볼수있다 5). 갱년기여성의腎陰虛證에서는衝任脈虛衰로인하여陰戶와陰道가마르므로질이건조하고, 작열감 등의증상이나타나는데이는에스트로겐호르몬저하로발생하는위축성질염의기전과유사하다 5). 위축성질염의한방치료에관한기존국내연구로는위축성질염을호소하는여성들의 HRV 특성연구 6), 노인여성의위축성질염실태및한방치료에대한인식조사연구 7) 등이있다. 좌훈은外治法의일종으로약물을전탕하여그증기를환부에쏘이는것과약물을태워서연기를쏘이는방법을말한다 8). 좌훈은하부생식기를주요치료부위로하여, 연기나증기에의한온열작용외에도선택한약재에따라다양한증상을직접적으로치료할수있는장점이있어 7), 한의학문헌에서는여성의생식기종창, 음부소양증등의부인과질환에많이응용하였다 9,10). 좌훈치료는실제임상에서질염을포함한다양한부인과질환에활용되고있으나 11), 유효성및안전성에대한근거는부족한실정이다. 기존에국내에서좌훈치료의질환별연구로는월경전증후군, 월경곤란증 12,13) 이있었으나, 위축성질염등다른질환에관한임상연구는찾아보기어려웠다. 이에저자들은위축성질염의한방치료중좌훈요법에대해기존에발표된무작위대조임상연구를체계적으로고찰하여그효과를알아보고임상적근거자료를제시하고자본연구를시행하였다. 또한좌훈요법의방법, 사용약재등연구동향을고찰하여향후에시행될연구의기초자료로삼고자하였다. 93
위축성질염의좌훈치료연구에관한체계적문헌고찰 Ⅱ. 대상및방법 1. 데이터베이스선택및검색 2015년 12월까지국내외에발표된모든논문을대상으로, Pubmed(www.pubmed. com), Chinese Academic Journals(CAJ, www.cnki.net), 오아시스 (oasis.kiom.re.kr) 의 3가지온라인데이터베이스를활용하여좌훈요법을위축성질염에활용한연구를검색하였으며언어제한은두지않았다. 검색어는 Pubmed 에서 [(fumigation) AND (atrophic vaginitis OR vaginitis)] 를사용하였고, CAJ에서는 阴道炎, 膣炎, 老年性阴道炎 와 坐熏, 熏洗, 熏浴 을조합하여사용했고, 오아시스에서는 좌훈요법, 질염, 위축성질염 을사용하였다. 2. 선정기준문헌선정기준은위축성질염이있는환자를대상으로, 좌훈요법을중재시술 (intervention treatment) 로하고, 중재시술을제외한일반적인치료시행을비교시술 (control treatment) 로한무작위대조임상연구 (randomized controlled clinical trial, RCT) 들을선정하였다. 문헌선정의제외기준은 1 원저가아닌문헌, 2 중복출판된연구, 3 임상시험이진행중인연구, 4 좌훈요법외기타치료를병용한연구등은제외하였다. 3. 포함연구자료분석본연구는위축성질염에대한좌훈요법의연구현황에대한체계적고찰로서최종선정된각논문들의원문을검토한뒤핵심정보를추출하였다. 선정 된논문들의연구디자인, 대상질환, 적용된중재, 대조군, 평가지표, 주요결과, 저자의결론등을각논문별로정리하여서술적인분석을하고, 이를표로정리해나타내었다. 1) 내용분석두명의독립된연구자 (JE Yoo, SE Baek) 가선택된임상연구를대상으로하여인구학적정보, 좌훈요법의약재, 치료기간, 대조군의중재방법, 주평가지표등에대한자료를조사하였다. 내용에대한의견이일치되지않을경우합의를통하여결론을도출하였다. 2) 논문의질평가본연구에서질평가는무작위대조임상연구 (randomized controlled clinical trial, RCT) 를대상으로 Cochrane risk of bias(rob) criteria에따른 6개의세부항목에대하여평가하였다 14). 모든항목의평가는본문중내용이명시된경우만을인정하는것으로하였다. 두명의연구자 (JE Yoo, SE Baek) 가내용에대한의견이일치되지않을경우합의를통하여결론을도출하였다. Ⅲ. 결과 1. 자료선별 2015년 12월까지발표된논문들중에서 Pubmed, CAJ, 오아시스 3가지데이터베이스를이용한검색을통해총 142 개의논문을발견하였다. 이논문들의제목과초록, 원문을검토하여문헌연구이거나, 위축성질염을대상으로한연구가아니거나, 좌훈요법이아닌연구인것, 무작위대조임상연구가아닌것 94
J Korean Obstet Gynecol Vol.29 No.1 February 2016 등을배제하여 9편을선정하였고, 이중중재가복합적이어서좌훈요법의효과를판단하기어려운것을제외하여최종적으로 5편의논문이선정되었다. 선정 된 5편의논문은모두 CAJ 검색을통해발견된논문이었으며, Pubmed 와오아시스에서는본연구의선정기준에맞는논문을찾을수없었다 (Fig. 1). Fig. 1. Flow chart of clinical study search. 2. 선정논문의분석 1) 연구개요최종선정된 5편의연구들은각각 2003년 15,16), 2007년 17,18), 2014년 19) 발표된논문들로, 5편 15-9) 모두무작위대조임상연구였다. 좌훈치료에사용한약재구성및용량은각연구별로차이가있었으며, 세부적인좌훈방법및치료기간에서도각연구마다차이를보였다. 5 편 15-9) 의무작위대조임상연구모두좌훈치료와약물치료의효과를비교하는연구였으며, 5편 15-9) 모두양약을대조군으로사용하였다 (Table 1). 2) 평가지표총 5개의무작위대조임상연구에서 690명의여성이평가되었고, 결과측정은모두증상경감을토대로한치료율 15-9) 이사용되었다 (Table 1). 3) 중재방법 포함된연구 5편 15-9) 에서는각각좌훈치료에사용된약재의구성및용량과구체적인좌훈시행방법에대해상세하게설명하였다. 4) 치료효과및부작용각논문들에서는좌훈치료가위축성질염에대해서임상적으로모두유의한효과를보이는것으로나타났으나, 통계적인유의성이없는연구들도있었다. 5편 15-9) 의무작위대조임상연구중 Li 등 15) 의 2003 년도연구와 Gao 등 18) 의 2007년도연구에서는좌훈치료를시행한그룹에서통계적으로유의한치료효과를나타냈으나 (p<0.01), 나머지 3편 16,17,19) 의연구에서는통계적으로유의한결과를나타내지않았다. 또한 Li 등 15) 의연구에서는좌훈치료의부작용이없었으며, 나머지 4편 16-9) 의연구에서는부작용에대한언급이없었다. 95
위축성질염의좌훈치료연구에관한체계적문헌고찰 Table 1. Data of Randomized Controlled Clinical Trials of Fumigation for Atrophic Vaginitis First author (Year) Li 15) (2003) Xu 16) (2003) Feng 17) Gao 18) Chen 19) (2014) Intervention Fumigation, 30 minutes, twice a day, 10 continuous days (n=143) Fumigation, 30 minutes, twice a day, (n=71, age=58.13) Fumigation, 20 minutes, once a day, (n=57, age=62.3) Fumigation, 30 minutes, once a day, (n=70, age=57.8) Fumigation, 30 minutes, once a day, (n=30, age=54.39±4.50) Control Diethylstilbestrol 0.25 mg Metronidazole 200 mg 10 continuous days (n=143) 1% lactic acid (external use), Metronidazole 200 mg (vaginal tablet) Premarin 0.625 mg (per os), (n=26, age=56.24) 1 potassium permanganate (external use), Premarin soft cream (external use), Metronidazole 200 mg (n=50, age=65.7) Diethylstilbestrol 0.5 mg Metronidazole 200 mg (n=70, age=60.6) Diethylstilbestrol 0.5 mg Metronidazole 200 mg (vaginal tablet) once a day, (n=30, age=53.50±4.82) Primary outcome Effectiveness rate Effectiveness rate Effectiveness rate Effectiveness rate Effectiveness rate Main result Treatment group: 93.7%, Control group: 58.04% (p<0.01) Treatment group: 92.96%, Control group: 92.31% Treatment group: 94.74%, Control group: 96.00% Treatment group: 98.6% Control group: 77.1% (p<0.01) Treatment group: 63.3%, Control group: 66.7% Adverse effect None Not reported Not reported Not reported Not reported Table 2. Herbal Medicine for Fumigation Treatment First author Composition of herbal medicine (Year) Li 15) 蛇床子, 黃柏, 白鮮皮, 赤芍藥, 鷄血藤, 蟬蛻, 威靈仙, 白殭蠶, 防風, 半枝蓮, (2003) 淫羊藿 15 g, 紫蘇, 薄荷, 甘草 10 g, 荊芥穗 9 g Xu 16) (2003) Feng 17) Gao 18) Chen 19) (2014) 鮮桃樹葉 120 g, 苦蔘 30 g, 蛇床子, 黃柏 20 g, 虎杖 10 g, 仙鶴草, 枯帆 6 g 蛇床子, 地膚子 30 g, 黃柏 20 g, 桂枝, 白芍藥 15 g 黃柏 25 g, 桂枝, 白芍藥 15 g, 蛇床子, 地膚子 10 g 苦蔘, 黃柏 20 g, 人蔘葉, 野菊花, 淫羊藿, 補骨脂, 银花藤, 蒲公英, 七葉一枝花 15 g, 薄荷, 甘草 10 g 96
J Korean Obstet Gynecol Vol.29 No.1 February 2016 3. 선정논문의질평가본연구에서는다섯편의무작위대조임상연구에대하여 RoB를사용하여질평가를시행하였다. 포함된연구들의질은대체적으로낮았다. 무작위대조임상연구들중에서무작위배정방법에대해언급한연구는 Li 등 5편 15-9) 이었으며, 난수표를이용했다고기록되어있었다. 배정순서은폐에대해 서는모두언급이없었다. Li 등 5편 15-9) 의연구는중재의특성상연구참여자의맹검이불가능하여비뚤림의위험이높았고, 평가자맹검에대해서는언급되어있지않았다. 포함된다섯편의연구모두대상자의중도탈락이없었다. 선택적보고에대한비뚤림은평가할만한근거가부족했다 (Table 3). Table 3. Quality Assessment of Each Included Randomized Controlled Clinical Trials First author (Year) Li 15) (2003) Xu 16) (2003) Feng 17) Gao 18) Adequate sequence generation Allocation concealment Risk of bias Incomplete outcome Blinding data addressed Free of selective reporting Free of other bias L U H L U U L U H L U U L U H L U U L U H L U U Chen 19) (2014) L U H L U U Risk of bias : low risk of bias (L), high risk of bias (H), unclear (U) Ⅳ. 고찰 본연구는국내외온라인데이터베이스검색을통해위축성질염에좌훈치료를활용한임상연구들을조사하여그연구현황을분석하였다. 무작위대조임상연구 15-9) 의분석결과좌훈치료가위축성질염에대해서임상적으로치료율면에서모두유의한효과를보이는것으로나타났으나, 통계적인유의성이없는연구 16,17,19) 들도있었다. 본연구는적절한근거자료로서의가치를가지기위해전체적으로는체계적문헌고찰의방법론을따랐으나, 체계적문헌고찰에서처럼모든필수적인데이터베이스를대상으로검색하지않고 3개의제한된데이터베이스에서만기존연구를검색했다는한계를가지고있다. 그러나위축성질염의좌훈치료에대한연구자체가아직많이이루어지지않았기때문에검색방법의간소화로인한제한점은크지않다고생각된다. 97
위축성질염의좌훈치료연구에관한체계적문헌고찰 본연구에포함된무작위대조임상연구 5편 15-9) 에서는각각좌훈치료에사용된약재의구성및용량과구체적인좌훈시행방법에대해상세하게설명하였는데, 5편 15-9) 의연구중 1편 17) 의경우 1 회에 20분씩, 나머지 4편 15,16,18,19) 의연구에서는 1회에 30분씩좌훈요법을시행하였으며, 2편 15,16) 의경우하루 2회, 나머지 3편의연구 17-9) 에서는하루 1회좌훈요법을시행하였다. 또한 5편 15-9) 의연구중 3편 15,17,18) 에서는좌훈치료시행후좌훈을시행한약액으로질과외음부를세척하였고, 1편 16) 의연구에서는좌훈치료후질에약액이충분히흡수되도록질내에코튼볼을일정시간삽입하여치료효과의증대를도모하였다. 5편 15-9) 의연구에서시행된좌훈치료의약재구성을빈도순으로분석하였을때, 가장많이사용된약재는黃柏과蛇床子였고, 黃柏은 5편 15-9), 蛇床子는 4편 15-8) 의연구에서사용되었다. 그외로는祛風燥濕, 殺蟲止痒하는白鮮皮, 威靈仙, 苦蔘, 地膚子, 淸熱解毒, 疏風淸熱止痒하는薄荷, 荊芥穗, 紫蘇, 防風, 蟬蛻, 白殭蠶, 野菊花, 蒲公英, 養血活血하는赤芍藥, 鷄血藤, 淸熱生津하는人蔘葉, 補腎壯陽하는淫羊藿, 補骨脂등의다양한약재가사용되어, 淸熱燥濕, 去風止痒, 滋陰降火, 補腎瀉火등의작용 15-9) 으로위축성질염에적용하였다. 黃柏은항진균 20), 항염증 21) 효과가있다고알려져있는약재로, 淸熱燥濕, 瀉火解毒, 退虛熱하는효능이있어帶下, 熱淋, 濕疹瘙痒, 瘡瘍腫毒등을치료하며, 특히下焦의濕熱을除하여, 陰虛陽亢과濕熱이下注하여발생한병증에다용하게된다 22). 蛇床子는溫腎助陽, 祛風燥濕하고殺蟲하는효능이있어 女子帶下陰痒, 子宮寒冷不孕를치료하며, 특히外用하면燥濕殺蟲하는작용이있어, 여성의陰痒帶下에적용하는대표적인약재이다 22). 한의학에서위축성질염은帶下의범주에서접근할수있으며, 발생시기와원인및증상을종합하여볼때에스트로겐호르몬저하로발생하는위축성질염과유사하며, 폐경후腎陰虛로인한갱년기증상의하나로생각할수있다 5). 5편 15-9) 의연구에포함된위축성질염환자들의연령을살펴보면, Li 15) 의연구에포함된대상자는모두 55세이상이었으며, 이는다른 4편 16-9) 의연구에서도확인할수있었다 (Table 1). 갱년기여성의腎陰虛證에서는衝任脈虛衰로인하여陰戶와陰道가마르므로질이건조하고, 작열감등의증상이나타나는데 5), 이러한증상에는滋陽肝腎, 育陰潛陽의치법을적용해볼수있다 5). 중의학에서는위축성질염을 老年性阴道炎 이라고명명하며, 세균성질염등과비교했을때감염의소인보다는질점막이얇아지고자극에민감해져서쉽게출혈이발생하는등조직학적변화의특징이있기때문에국소병변부위의외치요법을병행하는것이환자의증상을경감시키는데효과적인것으로보고있다 23). 老年性阴道炎 은肝腎不足症과脾虛濕盛症으로대별하여변증론치할수있으며특히전자의경우知柏地黃丸이경구약으로많이활용되고있다 24). 黃柏은瀉火燥濕하면서도陰을손상하지않는성질이있 어 22) 본연구에서도좌훈약재로사용된 것을확인할수있었다. 老年性阴道炎 에있어서外陰熏洗療法은止痒, 止痛, 止帶, 消腫의효과가있으며, 훈증시에 98
J Korean Obstet Gynecol Vol.29 No.1 February 2016 는약액의증기와환부의적당한거리와온도를유지하여화상을입히지않도록주의해야한다 25). 분석대상이된 5편 15-9) 의무작위대조임상연구에서결과측정은모두위축성질염의증상경감을평가한치료율이사용되었는데, 치료율평가기준은 5편의연구가각각차이가있었다. 4편 16-9) 의연구에서는음도청결도 (vaginal cleanliness classification) 지표를사용하여위축성질염의호전도를평가하였는데, 음도청결도는질분비물도말표본을고배율렌즈로관찰하여균주의정도에따라 Ⅰ도, Ⅱ도, Ⅲ도로평가하는지표 26) 이며, 그외임상증상의호전, 내진소견, 질산도검사등의지표를종합하여치료율을산정하였다. 무작위대조임상연구 15-9) 의분석결과좌훈치료가위축성질염에대해서임상적으로치료율면에서모두효과를보이는것으로나타났으나, 통계적인유의성이있는연구는 2편 15,18) 이었다. 본연구에포함된연구들의질은대체적으로낮았는데, 그원인을고찰해보면, 5편 15-9) 의연구모두중재의특성상연구참여자의맹검이불가능하여비뚤림의위험이높을수밖에없다는것을고려해볼수있다. 또한평가지표가단일화되어있지않아, 효과추정치를산정하는데어려움이있었으며, 4편 16-9) 의연구에서사용된음도청결도외에도, Nugent Score 27), Maturation Value 28) 등위축성질염의증상정도를객관적으로평가할수있는공통적인지표에대한논의가필요할것으로사료된다. 본연구는위축성질염의한방치료중좌훈요법에대해기존에발표된임상연구를고찰하여그효과를알아보고임상적근거자료를제시하고자시행되 었다. 연구결과, 임상적으로위축성질염의치료율면에서효과가있고부작용이없어, 위축성질염이있는폐경기여성에게적용될수있으며, 특히, 유방암환자등호르몬치료가적용되기어려운위축성질염 2) 환자들의보완대체요법으로도고려될수있다고판단된다. Ⅴ. 결론 본연구의결과로보아임상적으로좌훈치료가위축성질염의치료법으로고려될수있으나, 포함된연구의수가부족하고방법론적으로질이낮은논문이대부분이기때문에향후체계적인연구가더필요할것으로사료된다. 비록검색방법에서한계가있었으나, 본연구의결과를차후위축성질염에대한좌훈치료의임상연구를계획함에있어기초자료로활용할수있을것으로예상된다. Received : Jan 25, 2016 Revised : Jan 29, 2016 Accepted : Feb 06, 2016 감사의글 본연구는보건복지부한의약선도개발사업 (HI15C0006) 의지원에의해서이루어진것임. 참고문헌 1. Tami P. Atrophic vaginitis : signs, symptoms, and better outcomes. The 99
위축성질염의좌훈치료연구에관한체계적문헌고찰 Journal for Nurse Practitioners. 2011; 7(6):502-12. 2. Stika CS. Atrophic vaginitis. Dermatol Ther. 2010;23(5):514-22. 3. Castelo-Branco C, et al. Management of post-menopausal vaginal atrophy and atrophic vaginitis. J. Maturitas. 2005;52:46-52. 4. Kim JG. Management of menopausal women. 3rd edition. Seoul:Kunja publisher. 2007:103-6. 5. The Society of Korean Medicine Obstetrics and Gynecology. Oriental obstetrics& gynecology Ha. 1st edition. Seoul: Euiseongdang. 2012:133, 139, 143-5, 277. 6. Kim MY, et al. A Study on Heart Rate Variability(HRV) of Women with Atrophic Vaginitis. The Journal of Oriental Obstetrics and Gynecology. 2015;28(3): 11-20. 7. Heo SJ, et al. A study on urinary incontinence, interstitial cystitis, atrophic viginitis of eldery women using senior welfere center and nursing home and the cognition of traditional korean medicine. The Journal of Oriental Obstetrics and Gynecology. 2010;23(3): 123-38. 8. Shin GH. Hanbangoeyongyak, Seoul: Yeollinchaekdeul. 1994:100. 9. Heo J. Donguibogam. Seoul:Hanmiuihak. 2001:493, 495, 626. 10. Jang GB. Gyeongakjeonseo. Seoul: Jeongdam. 1999:633, 647, 741, 743, 746, 776-7. 11. Chae MS, et al. Study on Satisfaction and Features of Patient Groups Treated with Korean Medicine ChaeSteam Therapy (KMST) at Korean Medicine Hospital. The Journal of Oriental Obstetrics and Gynecology. 2014;27(3):28-40. 12. Lee KO, et al. Effects of Artemisia A. Smoke(Ssukjahun) on Menstrual Distress, Dysmenorrhea, and Prostaglandin F2α. Korean J Women Health Nurs. 2009; 15(2):150-9. 13. Shon IS. The effect of the herb fumigation therapy on the relief of premenstrual syndrome and dysmenorrhea. Graduate School of Catholic University of Pusan. 2005. 14. Kim SY, et al. NECA s guidance for undertaking systematic reviews and meta-analyses for intervention. 1st edition. Seoul:National Evidence-based Healthcare Collaborating Agency. 2011: 65-91. 15. Li FL. Clinical study of chinese traditional herbal medicine external treatment on 143 cases of senile vaginitis. Jiangsu Journal of Traditional Chinese Medicine. 2003;24(6):40. 16. Xu GQ, et al. Analysis of clinical effect of wash and steaming with Chinese traditional herbal medicine in treating 71 senile vaginitis patients. Journal of Henan University. 2003; 22(2):27-8. 17. Feng DN, Sun YM. Clinical study of chinese traditional herbal medicine fumigation treatment on 57 cases of senile vaginitis. Medical Journal of Communications. 2007;21(4):440-1. 18. Gao YL, Gao MJ. Clinical study of 100
J Korean Obstet Gynecol Vol.29 No.1 February 2016 traditional chinese herbal medicine fumigation treatment on 70 cases of senile vaginitis. Asia-Pacific Traditional Medicine. 2007;11(3):61-2. 19. Chen H, Yang Y. Analysis of clinical effect of fumigation treatment with ginseng leaf in treating senile vaginitis patients. Journal of Practical Traditional Chinese Medicine. 2014;30(8):756-7. 20. Han YM, Kim JH. Antifungal Effect of Obacunone on Candida albicans. Yakhakhoeji. 2013;57(6):383-7. 21. Jang JH. Anti-inflammatory Effect of Phellodendri Cortex Extract. Graduate School of Kyungwon University. 2010. 22. The compilation committee of Herbology. Herbology. Seoul:Younglim publisher. 2008:221-2, 627-8. 23. Si TY, Yang JL. Gynecology Medical Practice in Chinese Medicine Ha. 2nd edition. Beijing:Renminweishengchubanshe. 2007:281-320. 24. Li YY, et al. Diagnosis and Treatment of Gynecology in Chinese and Western Medicine Ha. 2nd edition. Beijing: Zhongguozhongyiyechubamshe. 2005: 248-9. 25. Liu MR, et al. Chinese obstetrics& gynecology. 2nd edition. Beijing: Renminweishengchubanshe. 2007:73-5. 26. Lyu HX, Lyu HL, Qi Y. Correlation between vaginal cleanliness classification and vaginal environment. China Prac Med. 2015;10(19):41-2. 27. Campos AA, et al. Comparative study between the ph test and of the KOH versus Nugent score for diagnosis of bacterial vaginosis in pregnant women. Rev Bras Ginecol Obstet. 2012;34(5): 209-14. 28. Lee DK, et al. The short-term effect of black cohosh on vaginal atrophy and safety in postmenopausal women. Korean Journal of obstetrics and gynecology. 2007;50(2):306-13. 101