DISORDERS OF MENSTRUATION.
Menstruation, or the regular periodical discharge of blood from the
uterus, is a phenomenon that occurs only in the human race and in
some monkeys. The anatomical changes that accompany menstruation
have not yet been definitely determined. In some species of
monkey--_Semnopithecus entellus_ and _Macacus rhesus_[2]--the following
changes appear to take place at the menstrual periods: The endometrium
first becomes swollen and congested as a result of the growth of the
stroma, and increase in the number and size of the blood-vessels. The
vessels in the superficial part of the stroma degenerate and break
down, and blood is extravasated into the meshes of the stroma network.
The extravasated blood collects into lacunæ which lie close beneath the
uterine epithelium. Finally the lacunæ rupture and the blood escapes
into the cavity of the uterus, forming the menstrual clot. Then a fresh
epithelium grows over the torn surfaces, new blood-vessels are formed,
the stroma shrinks, and the endometrium of the intermenstrual period is
restored.
Nothing is known with any degree of certainty regarding the cause and
significance of menstruation. There is much diversity of opinion in
regard to the coincidence of ovulation and menstruation. Heape has
shown that for monkeys ovulation and menstruation are not necessarily
coincident; in forty-two menstruating specimens of _S. entellus_ not
one had a recently discharged follicle in either ovary. In monkeys,
therefore, menstruation may take place without ovulation, and it is
probable that the same is true for the human female. Ovulation and
conception may occur in the human female when menstruation is absent;
pregnancy not infrequently occurs during the amenorrhea associated with
lactation, and in India, where the girls are married at a very young
age, pregnancy and child-birth occur before menstruation has begun.
Leopold (quoted by Hirst) in an examination of twenty-nine pairs of
ovaries removed on successive days up to the thirty-fifth after a
menstrual period, found a Graafian follicle bursting on the eighth,
twelfth, fifteenth, sixteenth, eighteenth, twentieth, and thirty-fifth
days after the menstrual period. Thus ovulation frequently occurred
without menstruation during the intermenstrual interval. In five
cases there was no ovulation at the menstrual period, or menstruation
occurred without ovulation.
It seems probable, therefore, that the ripening of the ovum in the
ovary is independent of the process of menstruation, though the
increased blood-supply to the generative organs during menstruation
may, to a certain extent, determine the time of ovulation when a
sufficiently ripe ovum is present.
Though menstruation in women is analogous to the rut or “heat” of
other animals, yet there are some points of difference: The lower
mammals breed only at times of “heat,” and these times of “heat” occur
in the wild state only at certain periods of the year, which are
dependent upon climatic conditions, the young being born at the season
of the year best suited for their survival. Some domestic animals,
like the cow, probably as a result of domestication, have no regular
breeding time. In the lower mammals “heat” and ovulation appear to be
coincident, and these are the only periods during which the female
seems normally to have any sexual desire.
The monkeys examined by Heape menstruated throughout the year and yet
seemed in the free state to have definite breeding times.
The human female, with but few exceptions, menstruates throughout the
year and may breed at any time. The exceptions in the case of the human
female are of interest. Dr. Frederick A. Cook,[3] ethnologist to the
first Peary North Greenland Expedition, says of the Esquimaux living
in the extreme north, from the seventy-sixth to the seventy-ninth
parallels of latitude: “The passions of these people are periodical,
and their courtship is usually carried on soon after the return of the
sun; in fact, at this time they almost tremble from the intensity of
their passions, and for several weeks most of their time is taken up in
gratifying them. Naturally enough, then, the children are usually born
at the beginning of the Arctic night.” In Queensland the natives are
also said to have a special breeding season.
Menstruation usually begins in this country at the fourteenth year.
The time of the first appearance of the process is influenced by race,
climate, and environment. As a rule, it begins earlier in warm climates
and later in cold climates. It is earlier in girls who lead luxurious,
indolent lives than in girls of the working classes.
During the first year or two of menstrual life menstruation is often
very irregular. It may be absent for several months after its first
appearance, or recur at varying intervals before it becomes regularly
established. Irregularity at this time calls for no treatment.
_Precocious menstruation_ rarely occurs at a very early age. It has
been known to begin, and to recur with regularity, from the time of
birth. In such cases there is a corresponding premature development of
the sexual organs.
The _menstrual discharge_ consists of blood, mucous secretion from the
uterus and vagina, and epithelial cells from the endometrium.
The normal duration of the flow is from two days to a week. The amount
of fluid discharged is from 2 to 9 ounces. Menstruation occurs every
twenty-eight days, counting from the beginning of one period to the
beginning of another. The menstrual interval is subject to considerable
individual variations, which appear to be within the limits of health.
It sometimes occurs with regularity every two, three, or five weeks.
When it occurs every two weeks, the alternate flows are often but small
in amount. The occurrence of, or the attempt at, menstruation every two
weeks, in a woman who had previously menstruated monthly, is sometimes
a symptom of beginning uterine disease.
Menstruation commonly ceases at about the forty-fifth year, when the
menopause appears.
Most of the disorders of menstruation have already been considered as
symptoms of the various lesions of the genital organs that have been
described in the previous pages.
There are some disorders of menstruation, however, often unaccompanied
by discoverable lesions, which now demand consideration.
=Amenorrhea.=--Amenorrhea is the absence of menstruation. Failure of
the menstrual blood to be discharged from the vagina, such as occurs in
cases of atresia, is not necessarily amenorrhea; menstruation may have
taken place, though the most marked phenomenon of this process, the
discharge of blood, is concealed.
The term primary amenorrhea, or _emansio mensium_, is applied to
those cases in which menstruation has never appeared. Secondary
amenorrhea, or _suppressio mensium_, is applied to those cases in which
menstruation has ceased after having once been established.
Amenorrhea is due to defective development of the organs of generation;
to premature atrophy, such as occurs in superinvolution of the uterus;
to lesions, pathological and traumatic; to acute and chronic general
diseases; and to psychical disturbances.
Menstruation is often absent during the acute diseases, such as typhoid
fever, and it may remain suppressed until the general health is fully
restored.
Amenorrhea may also occur in any chronic debilitating condition. It is
common in chlorosis, anemia, phthisis, and malaria.
It frequently results from changes of climate and surroundings, and
continues until the person becomes adapted to the new environment. It
is seen in emigrants from other countries, and in women who move from
the country to large cities. It is often caused by overwork, physical
and mental, and by insufficient food. It is not uncommon in studious
school-girls.
Amenorrhea is sometimes due to the excessive general development of
fat, even in young woman who are apparently in good general health.
Amenorrhea is frequently associated with insanity. It may be caused by
fright, grief, or anxiety. The fear of pregnancy after illicit coitus
sometimes produces it.
In some unusual cases amenorrhea is present without any discoverable
cause. The woman may be in perfect general health, and the sexual
organs may be well developed, at least so far as can be determined by
physical examination.
In amenorrhea there is often a general periodical disturbance that
marks the times at which the menstrual bleeding should occur. There may
be headache, flashes of heat, nervousness, nausea and vomiting, and a
feeling of fulness and pain in the pelvis. Various cutaneous eruptions
may occur as the result of amenorrhea, as in other diseases of the
genital apparatus.
The poor health, mental and physical, that usually accompanies
amenorrhea is often thought by the patient and her friends to be
the result, rather than the cause--as it really is--of the arrested
bleeding.
_Treatment._--The treatment of amenorrhea depends upon the cause of
the condition. Little, if any, benefit is to be expected in those
cases due to defective development of the uterus or the ovaries. If an
attempt at menstruation is made, as shown by periodical local pain and
general disturbance, and the uterus is found to be small and sharply
anteflexed, benefit may sometimes result from thorough dilatation of
the cervix.
Most cases of amenorrhea demand general treatment. The mode of life
should be regulated according to strict hygienic principles. Fresh
air, sunshine, baths, and suitable exercise should be prescribed.
Studious girls should be made to lead more active lives. A change of
surroundings is beneficial. A visit to the seashore and salt-water
baths are of advantage.
The general health should be improved by the administration of iron,
strychnine, or some other tonic. Blaud’s pill and the hypophosphites
are useful. Obesity should be relieved by a regulated diet and
exercise. The regularity of the bowels should always be carefully
attended to. Most of the so-called emmenagogues are of but little, if
any, value. Benefit is sometimes derived from the use of potassium
permanganate (gr. j-ij three times a day) and the binoxide of manganese
(gr. j-ij three times a day). These medicines should be administered in
pill form for several weeks.
Oxalic acid in doses of from ⅒ to ¼ of a grain, given in lemon syrup
for a period of from one to four months, has been recommended, and is
sometimes very useful.
It seems probable that pelvic massage practised for a period of several
months may result in benefit.
=Acute suppression of menstruation= during a menstrual period is a
phenomenon to which the term amenorrhea is not properly applicable.
It may be caused by exposure to cold or by some sudden emotional
disturbance during the menstrual flow.
The condition may be unaccompanied by any subjective symptoms, or there
may be present ovarian and pelvic pain.
The _treatment_ consists in rest in bed, the application of warm
fomentations to the lower abdomen, and hot foot-baths. Especial care of
the general health should be observed at the following menstrual period.
=Scanty Menstruation.=--Scanty menstruation occurs when the menstrual
flow is much less than normal. It must be remembered that individual
peculiarities in this respect may be within the limits of health. When
one or more periods are missed, and the flow shows a continual tendency
to diminish in amount, treatment may be demanded.
The causes and the treatment of scanty menstruation are those which
have already been considered under Amenorrhea.
=Vicarious Menstruation.=--Vicarious menstruation is the discharge of
blood, at the menstrual periods, from some part of the body other than
the uterus. In some cases, instead of a discharge of blood, a secretion
of another character takes place.
The vicarious discharge may be the only phenomenon present, or it may
occur supplementary to the normal uterine bleeding.
The vicarious bleeding may take place from almost any part of the
mucous or cutaneous structures. It occurs from the nose, the throat,
the lungs, the stomach, the bladder, and the anus. It may occur from an
ulcer or other lesion of the external surface. Sometimes the cutaneous
hemorrhages appear in the form of ecchymoses.
Various secretions may take the place of the bleeding. A monthly flow
of milk from the breasts has been observed, and a periodical diarrhea
or leucorrhea has taken place.
Vicarious menstruation is a rare condition. It may occur in defective
development of the uterus and ovaries. It is usually found in
debilitated nervous women, and accompanies a deficient menstrual
discharge from the uterus.
_Treatment._--Direct local treatment should be applied to the vicarious
bleeding only when it becomes excessive. The general health of the
woman should receive attention. Treatment should be applied to any
local lesion of the genital apparatus that may be discovered. The
directions given for amenorrhea are also applicable here.