[Illustration:
FIG. 84.—Sagittal section through the ovary of a girl aged 16.
]
In considering the changes that take place in the female reproductive
organs at this period of life, we must distinguish between the proper
period of the _climacteric_, with its various manifestations antecedent
to and associated with the irregularity and ultimate cessation of
menstruation, from the condition of _old age_ in which menstruation has
actually and completely ceased, in which the menopause has been fully
accomplished, and in which the changes of senescence have set in at once
in the organs of the reproductive system and in the organism as a whole.
The most important and most significant changes of this sexual epoch are
unquestionably the anatomical alterations in the ovaries. A good many
years ago I undertook an investigation whose purpose was to follow the
natural involution of the graafian follicles from the time of the climax
on into old age, and for this purpose I examined a very large number of
ovaries of women at ages varying from 42 to 75 years (Archiv. für
Gynecologie, Bd, XII., Heft 3).
Throughout these years a slow but continuously progressive atrophy
proceeds in the ovaries; they become smaller and denser, diminishing
especially in height and width; their surface becomes extremely uneven;
and in extreme old age they wither away until no more is left in the
region formerly occupied by the ovaries than a flattened fibro-vascular
thickening (Figs. 84–88). The histological characteristic of the changes
in the ovary which proceed gradually from the commencement of the
menopause to extreme old age, may be summed up as consisting in a
continual increase and new formation of the connective tissue stroma at
the expense of the cellular layer, accompanied by retrogressive
metamorphosis of the graafian follicles.
[Illustration:
FIG. 85.—Sagittal section through the ovary of a woman aged 72 years.
]
The connective tissue ground substance of the ovary increases from the
periphery towards the centre, and progressively compresses the
epithelial structures of the organ. In the outermost layer of the
ovarian stroma, the so-called tunica albuginea, the strata of short,
dense connective tissue fibres increase notably in number, so that
whereas at first three layers at most could be distinguished, the tunic
ultimately comes to consist of from six to eight layers; at the same
time also the interior ovarian stroma becomes exceedingly dense, so that
numerous well-defined interlacing bundles of fibres can be made out in
its substance.
The first retrogressive metamorphosis which can be observed in the
graafian follicles is fatty degeneration, the formation of granule
spheres. Whilst the membrana propria (the theca folliculi) of the
follicle remains quite unaltered, we observe in the membrana granulosa,
in addition to the ovum, and the ordinary cells of this layer, spherical
aggregates of fat droplets, the granule spheres, which continually
increase in size, until ultimately of the cellular contents of the
follicle nothing whatever remains, and it now appears full of granule
spheres and fluid. The theca folliculi has now lost its spherical shape,
and assumes an ovid form (Fig. 89).
In a later stage of the degeneration of the graafian follicle, it
appears as a vesicular body with a relaxed wall, thrown into numerous
folds, this folded wall being formed by the theca folliculi. The cavity
of the follicle is reduced to a mere cleft, filled with a transparent
substance, and the space between this cleft and the inner surface of the
theca folliculi is occupied by round cells and a fibrous intercellular
substance, and is traversed by a vascular network. This second stage of
the retrogression of the follicle may therefore be designated the stage
of vesicular degeneration (Fig. 90).
[Illustration:
FIG. 86.—Diagrammatic representation of the Graafian Follicle.
]
[Illustration:
FIG. 87.—Ovary of a girl aged 19 years. (Normal size.)
]
[Illustration:
FIG. 88.—Ovary of a woman 72 years of age. (Normal size.)
]
In the last stage of this retrogressive metamorphosis, we find the
follicle completely transformed to a fibrous mass. It appears as an
elongated oval body, much lobulated, connected with the surrounding
stroma by thick strands of fibres; a trace of the original cavity can
still be distinguished in the form of a narrow cleft, without
distinguishable contents. The tissue of this body consists of connective
tissue fibres, with interspersed nuclei and nuclear fibres (Fig. 91).
The three stages I have observed in the retrogression of the follicle,
of which I have given a summary account above, may, I think, be
explained in the following manner: When the woman’s reproductive
activity ceases, the graafian follicles become subject to a
retrogressive metamorphosis, a fatty degeneration setting in in the
cells of the membrana granulosa and in the ovum, until ultimately the
whole of the granular epithelium has undergone atrophy. The follicle now
undergoes a vesicular transformation with shrinkage of its cavity, and
with the formation of a new tissue which appears to be young connective
tissue. As time goes on, this new connective tissue is formed in
increasing quantities, until finally the entire follicle is transformed
into a firm fibrous mass.
[Illustration:
FIG. 89.
]
Thus we are led to infer that the gradual but extensive thickening of
the tunica albuginea (i. e., the outer, condensed layer of the ovarian
stroma), which, as we have seen, always occurs at the climacteric
period, offers a hindrance to the bursting of the follicles as they
mature, and in this we find the explanation of the irregularity of
menstruation and of the various troubles which attend the performance of
that function at the time of the menopause. It is reasonable to assume
that the resistance of this thickened tunica albuginea is responsible
for the fact that the interval between the bursting of the successive
follicles is now greater than normal, as much as six or eight weeks—this
retardation of menstruation being one of the commonest ways in which the
onset of the menopause is first manifested. Another phenomenon connected
with the onset of the menopause also finds a plausible explanation in
the anatomical grounds just mentioned. As already pointed out, in parous
women the menopause sets in later than in nulliparae. At every
pregnancy, the ovaries share in the more abundant nutrition of all the
reproductive organs, due to the general dilatation of the intrapelvic
vessels which accompanies this process; hence the ovaries become larger,
richer in lymph, and therefore softer, the cellular elements increase in
size, and perhaps also in number, and it is readily conceivable that in
such ovaries the cellular elements are able for a longer time to resist
the induration and the new formation of connective tissue which occur at
the climacteric.
The numerous nervous disturbances of the climacteric epoch would appear
also to depend upon the hyperplasia of the ovarian stroma which we have
observed to be the characteristic anatomical change in the ovaries at
this period of life.
[Illustration:
FIG. 90.
]
Associated with the fibrous transformation of the graafian follicles
there is, however, a failure of the so-called internal secretion of the
ovaries, a matter to which much attention has recently been paid.
_Brown-Séquard_ has especially maintained that the ovaries secrete a
substance which enters the blood, a substance which, notwithstanding the
fact that its presence cannot be proved either by chemical or any other
means known to us, yet is of considerable importance for the maintenance
of the equilibrium of mental and physical well-being. It is supposed
that the various profound disturbances of the general system occurring
at the menopause[52] are dependent upon the cessation of this internal
secretion of the ovary—disturbances which rise to a maximum as the
atrophy of the ovary proceeds, and which only gradually pass away after
a considerable lapse of time.
After the menopause is completely over, in the ovaries, as in other
parts of the female reproductive organs, the signs of senile
degeneration make their appearance.
In old women, we find the ovaries either shrunken to the form of small
fibrous cords, or else degenerated to form cysts of smaller or larger
size, the stroma surrounding these cysts being extremely hard, dense,
and tough.
[Illustration:
FIG. 91.
]
[Illustration:
FIG. 92.—Sagittal section through the Cervix of a woman 26 years of
age. Dendriform branched Glands.
]
[Illustration:
FIG. 93.—Sagittal section through the Cervix of a woman 65 years of
age. Glands which have undergone Cystic Degeneration.
]
[Illustration:
FIG. 94.—Cervix of a woman 70 years of age. The Cervical glands have
undergone Cystic Degeneration.
]
Whereas at the commencement of the climacteric period, the uterus
commonly exhibits a slight increase in size, owing to the condition of
passive hyperaemia already described, subsequently a gradual diminution
in the size of the organ may be observed. This atrophy begins with the
portio vaginalis and proceeds upwards. Whilst the body still appears
undiminished in size, the vaginal portion will be found already shorter,
more slender, and more flaccid. Gradually, however, the entire organ is
involved in the atrophic process. The uterus is then smaller than
formerly, its walls are thinner, its cavity reduced in size. Its
vascularity and its sensibility are alike diminished. The external os is
smaller, and the internal os is sometimes entirely obliterated. There is
a tendency at the climacteric period for the tubulo-racemose glands of
the cervical mucous membrane (Fig. 92) to undergo a cystic degeneration
(Fig. 93), and hence arise the cysts which are so commonly met with on
the portio vaginalis of women at this time of life, cysts varying in
size from that of a millet seed to that of a pea. In advanced life, the
formation of such cysts may be regarded as normal, and sometimes in the
form of grape-like clusters they almost completely occupy the lumen of
the cervical canal. (Figs. 94, 95, 96, and 97).
Not infrequently, these cysts lead to the formation of polypi, by
enlarging until the mucous membrane projects so far that a stalk is
formed.
Examining the bodies of 47 women who died at ages varying from 42 to 80
years, I found in 28 ovula Nabothi in the cervical mucous membrane, for
the most part at the os uteri externum, but in some cases also extending
up to the os internum, sometimes between the plicae palmatae, sometimes
isolated, sometimes grouped.
Sometimes in old women no trace of a vaginal portion remains, and the
uterus is found to be transformed to a small, thin-walled, shrunken
body, no more than one-fourth of its original size; in such cases the
saying of Graaf appears to be justified, that after the menopause the
uterus returns to the size it has in the young girl. In the majority of
such cases, the cavity of the uterus is also contracted (concentric
atrophy). It sometimes happens, however, that in old age the os externum
and the os internum are the seat of atresia, whilst the intermediate
portion of the cervical canal remains unaffected. In this way,
especially when the cervical canal and the cavity of the body of the
uterus are distended with mucus or with fungous growths, is produced
what is known as the _uterus bicameratus vetularum_.
[Illustration:
FIG. 95.—Ovula Nabothi in the Portio Vaginalis.
]
In many cases, when the cervical canal has been obliterated, we find the
uterine cavity distended with mucous secretion (excentric atrophy). The
substance of the uterine wall is in old age commonly dense and tough,
but occasionally, in extreme old age, less firm than formerly, withered
and friable, and traversed by degenerated arteries, and in this state it
is predisposed to haemorrhages (apoplexia uteri). Such intramural
haemorrhages usually occur in the fundus; the friable uterine substance
has then a blackish-red appearance, infarcted with extravasated blood;
sometimes the uterine cavity is also filled with blood. In general it
may be said that when the menopause is completely over, when uterine
activity has entirely ceased, the uterus returns to the state in which
it was before the menarche—it is physiologically dead.
The tubes become flaccid, thinner, shorter, and are at times
obliterated. In the mucous membrane of the tubes in old women we no
longer find any trace of the glands described by Hennig; the epithelial
cells have also lost their cilia.
During the climacteric period, the vagina is usually relaxed and roomy,
the mucous membrane is smooth, injected and secretes freely;
subsequently, in old age, it becomes firm, tough and dry.
[Illustration:
FIG. 96.—Vesicle (Ovula Nabothi) from the Uterine Mucous Membrane.
]
_Wendeler_ found that the initial change of the climacteric in the ovary
is a chronic and progressive endarteritis obliterans; the result of this
process is, in addition to the obliteration of the follicles, a
continually increasing hyaline degeneration of the smallest arteries and
the arterioles, especially along the line of transition between the
cortical and the medullary substance of the organ; this degeneration
extends to the surrounding connective tissue, and thus leads to the
formation of peculiar, vitreous, translucent foci of sclerotic
connective tissue, containing few cells or none; these are the so-called
_corpora fibrosa_ or _corpora albicantia_. Only subsequently to the
formation of these bodies does the characteristic wrinkling of the
surface of the ovary occur, with general shrinkage of the organ, these
changes being due to the contraction that sets in in the numerous
scattered foci of connective tissue, which, as already mentioned, are
situated in close proximity to the cortex.
[Illustration:
FIG. 97.—Mucous glands undergoing Cystic Degeneration.
]
The gradual atrophy of the uterus after the extinction of its sexual
activity leads to a diminution in all the diameters of the organ, so
that in old women it becomes flattened as in childhood, all its curves
having disappeared; the muscular substance is replaced by connective
tissue; and the portio vaginalis dwindles and even entirely disappears.
As regards the bacterial flora of the genital organs of elderly women,
_Menge_ and _Koenig_ find that the vagina for the most part contains
bacteria which do not thrive when cultivated aërobically on alkaline
agar plates. In exceptional cases, however, such bacteria are found, and
may even be sufficiently vigorous to produce pyogenic infection.
According to _Strogamoff_, the vagina in all circumstances contains a
great variety of micro-organisms—cocci, diplococci and rod-forms.
Rod-forms are the prevailing types found in normal conditions in elderly
women, but they are much smaller than in women who are still in the
period of reproductive activity. Organisms liquefying gelatine were
found in one instance only, a case of vaginal prolapse. In one half of
the cases examined, there was no development of culture media inoculated
from the cervix uteri, whether on agar or gelatine.