Unnatural Uterine Haemorrhage a Sign of Disease

Kai Tiaki : the journal of the nurses of New Zealand, Volume IV, Issue 3, 1 July 1911, Page 111

Unnatural Uterine Haemorrhage a Sign of Disease

The subject I have chosen for discussion this evening is one that ought to be of special interest to all nurses, and it is important that each one of you, whether devoting special attention to midwifery, to medical nursing, to sugical nursing, or to any other branch of your profession, should have a very definite knowledge of the significance of unnatural uterine haemorrhage, as indeed also of patients who have gynaecological symptoms, for your friends and your patients who have gynaecological symptoms causing them anxiety, will probably mention the fact to you, and will be guided by you m determining whether or not to consult their medical adviser. To very many women their nurse friend is their first line of defence m matters gynaecological, and it is indifferent to them what branch of medicine the nurse has chosen as her special department. The fact that she is a nurse, gives her opinion on gynaecological symptoms considerable weight.

The symptom that forms the subject of this lecture is one of the? commonest, if not the commonest, to helmet with m the treatment of diseases of the female genital system. Sir Alexander Russell Simpson at one time classified the patients admitted to his wards m the R. 1.8., according to the leading symptom., and the largest number were classified under the heading of Unnatural Uterine Haemorrhage.

Before considering unnatural haemorrhage let us determine what is included under natural haemorrhages. Menstruation occurs naturally at regular intervals of 21, 28 or 32 days or according to the habits of the individual. The menstrual discharge should be at first clear, unstained with blood, then blood stained and finally clear again for a short time before ceasing. The length of time during which the discharge lasts varies considerably m different people and m different climates and average about four to five days.

The menstrual discharge should never contain clots ; the secretion from the glands of the endometriuic (the membrane lining the interior of the uterus), dilutes the blood escaping from the vessels of the endometrium, and prevents it clotting.

Should the loss be excessive m amount, and contain clots, this symptom is known as Menorrhagia.

Should the uterine haemorrhage occiir during an inter menstrual period, the symptom is known as Metrorrhagia.

There is always some abnormal condition to account for either Menorrhagia or Metrorrhagia. They may both be present m the same patient at the same time, due to the same cause.

There is normally a certain amount of pelvic discomfort, a sensation of congestion, and a feeling of down bearing, accompanying menstruation, but actual pain is unnatural and is a symptom known as dysmenorrhoea, and is due to the existence of some pathological state m the genital system or to the influence of an improper environment. Uterine haemorrhage then may be unnatural m four different ways, firstly, by reason of the amount lost ; secondly, by reason of the nature of the discharge ; thirdly, by reason of the time of its occurrence ; and fourthly, by reason of the accompanying pain.

I^et us first consider the amount of the haemorrhage ; with regard to this no absolute statement can be made. The amount that is normal for one person would be excessive for another. The significance is not so much m the amount lost, as m any change that has taken place m the amount. If a woman who has usually menstruated for four days finds that she is menstruating for eight days or nine, that haemorrhage for that woman is excessive, and indicates some pathological condition or the influence of an improper environment as a cause.

In young girls who are only just developing a menstrual habit there is sometimes very irregular menstruation and occasional heavy losses. This does not indicate any diseased condition and will probably not last for many months. The condition can be helped by taking rest from severe exercises as hockey, tennis, cycling etc., fov two or three days before the menstrual period, by rest m bed during the period and by hot baths which relieve the congested pelvis

by inducing the blood to circulate m the superficial circulation.

Excessive loss means that there is an excessive amount of blood m the genital organs, or an unusually free supply to the genital system. In some women the blood has a poor coagulability and abrasions m any part of the body bleed very freely, these women may suffer from menorrhagia. A diseased condition of the walls of the bloodvessels such as the atheroma (i.e., thickening and hardening of the vessel walls), of syphilitics or of kidney diseases will allow of unnaturally free haemorrhage during menstruation. Heart disease and liver diseases m which there is an obstruction to the" flow of venous blood and a resulting back pressure with a tendency to the heaping up of blood m the veins m the interior of the abdomen are common causes of menorrhagia.

Over indulgence m alcohol causes a very extreme variety of menorrhagia, a symptom that has more than once led to the discovery of the secret drinker. The presence of cancer or of a fibroid tumour m the walls of the uterus will cause an increase m the blood supply to the uterus and an increase m the blood loss during m.enstruation. The presence of a mucous or fibroid polypus may be the cause of severe menorrhagia. The uterus contracts on the mass attempting to expel it. In these cases the menorrhagia develops gradually.

An inflamed condition or catarrhal condition of the membrane lining the uterus may cause haemorrhage m excess and such a condition may be set up by infection that gains access during labour or m cases of abortion and sometimes germs will gain access even though there has been no pregnancy. The exanthemata such as measles, and scarlet fever are not infrequently followed by inflammation of the endometrium and by menorrhagia.

A displaced uterus by kinking its blood vessels and becoming congested may be a cause of severe menorrhagia. The uterus ma3 T be congested out of sympathy with some inflammatory condition m the pelvis such as an inflamed appendix.

A large number of women who suffer from menorrhagia have really no disease to account for it and no pathological condition beyond a general lack of tone by which the blood vessels of the genital system are allowed to become and remain

distended and congested. This condition is common m hot and enervating climates, and during convalescence from long and weakening illnesses. It with great frequency follows severe attacks of influenza. Any of these conditions which will cause a congested condition of the uterus if kept up for a sufficient length of time will cause an overgrowth of the endometrium which may even become a surface with numerous polypoid masses on it and these may almost choke the uterine cavity. This overgrowth of endometrium is accompanied by an increase m the menstrual flow and a diminished intermenstrual rest ; and m severe cas.es there may be a white discharge during the short intermenstrual interval or even a continuous haemorrhage diminishing and increasing at intervals.

The treatment is easy and simple and most satisfactory m its result. It consists m removing the overgrown membrane ,and allowing a new ,and healthy membrane to grow i.e., the operation of curettage. A physical disturbance such as excessive sorrow, excessive joy, or even fear may be a cause of excessive menstrual loss.

For many years an idea has prevailed not only among the laity but with physicians rs well, that a tendency to menorrhagia or ir.etrorrhagia occuring ,at the menopause is to be regarded as ( a necessary evil which may safely be left alone. *

Nothing can be more erroneous or more productive of harm than this point of view. The period of life m which the menopause occurs is that m which cancer is most frequent and fibroid tumours attain their largest size, and the experience of gynaecologists during the last twenty years shows plainjy that the profuse ,and frequent menstruation often observed during this period, is m ,a large number of cases caused by either cancer or fibroid tumour.

The change m the amount may he unrmtur t al m another respect, it may show ,a decrease. A woman m the habit of menstruating for six or seven days may, after child birth, find the duration gradually decreasing until m th,e course of five or six ye,ars she may be menstruating for two or three days only, and losing relatively little Ovarian disease, Utero sacral eellulites, or too great diminution m the size of the uterus after labour, are the three conditions either of which mjght be responsible for this decrease.

Dealing with the nature of the discharge I would like to coll your attention to the fact that there should never be clots present m a menstrual hsemorrhagic discharge. Their pies.ence indicates that there is not sufficient secretion from the uterine mucous membrane to prevent the blood that escapes from it from clotting i.e., that for that mucous membrane the haemorrhage is m excess. The pathological conditions that ma)' be responsible for the appearance of clots are just exactly those that give rise to increase m the amount and have already been referred to. I know that this symptom is so common here m Auckland as m all sub-tropical climates as to be regarded by many as a normal condition. But it is not normal. It means that the pelvic vessels are more congested than they should be, even though it be nothing but the climatic influence that causes such congestion. The congestion causes an overgrowth of the endometrium and the overgrown endometriuih will bleed more freely than it should normally do.

Other solid particles that ma)' appear m the menstrual discharge are, (1) Uterine casts, (2) shreds of endometrium, (3) An early ovum, (4) Fragments of tumour or of a hydatid mole. It is important for nurses to know something of the significance of uterine casts.

The uterine cast is a mould of the interior of the uterus. It is triangular m shape, and its blunted angles correspond with the points at which the fallopian tubes open into the uterus, and at which the internal os opens from the uterus. Casts vary m their consistence. In some forms of endometritis they are passed at every menstrual period, and m these cases they consist of the shed mucous membrane, blood clot, and fibrin ; their passage is always accompanied by intermittent pain, the pain is usually the first sign of oncoming menstruation, and is so severe that the patient may faint., or cry out as if m labour. Immediately the cast is past the pain, which is caused" by the contractions of the uterus, ceases and menstruation continues painlessly. I have sometimes seen a blood clot, passed with pains of uterine contractions, show, a perfect moulding of the interior of the uterus when floated m water.

In cases of ectopic gestation {i.e., where conception has taken place and pregnancy

is proceeding m some situation other than the interior of the uterus), a uterine cast is sometimes passed, usually at or about the end of the third month and quite frequently at the time of rupture of the gestation sac. In these cases it is of extreme importance that the nurse should recognise and keep the uterine cast, which consists of the mucous membrane lining the uterus shed as a whole and its microscopical examination will show definitely whether or not there is an ectopic gestation, and may determine operative procedure. Instead of the casts coming away m tcto they may first break up, and then they appear m the discharge as shreds, and it is important that these shreds should be kept for the surgeon's inspection m cases of possible ectopic gestation.

Again the solid particle may be an ovum, and m this case also it is important that everything solid should be kept for the surgeon to examine for if the ovum is not complete, he will have to curette the uterus to empty it completely.

Finally the solid particle may be a fragment of a tumour, or a polypus ; m which case it should also be kept for the surgeon to see. In fact it is a good maxim for a nurse to always keep for the surgeon's inspection any solid particle that appears m a uterine haemorrhage. In cases of hydatid mole there are things like grape skins shed with the haemorrhage, and these are quite diagnostic. The haemorrhage of a hydatid mole is quite characteristic. It comes on at irregular intervals and without warning ; it is exceedingly severe and is so alarming that a nurse would send for a doctor but the haemorrhage will have ceased before the doctor arrives. A haemorrhage such as this m a woman who is pregnant three to six months should always make one suspicious of hydatid mole.

We now come to treat haemorrhages unnatural by Teason of the time of their occurence.

It is not common for a patient with diseased ovaries to complain that whereas at one time she was quite regular she has become irregular, and can never foretell what her state will be one week ahead. The tendency is for her to change her type for a more frequent one, probably from 28 day type to 21 day type, and then to become irregular, perhaps two weeks,

then three weeks, then perhaps four weeks, then only a few days may intervene, and the amount lost at the periods will vary.

Such symptoms might be caused by ovaries that are inflamed as the result of organismal activity, germ activit} r , or by ovaries that are merely congested or cystic as part of a general pelvic congestion that might result from lack of tone m the vascular system as the result of an enervating climate a run-down condition, or a convalescence after an illness.

The commonest of all causes of such a congested condition of the ovaries is probably constipation, and often when this is corrected the menorrhagia and metrorrhagia will disappear without further treatment ; for m constipated women a large decomposing fceca! mass may be separated from an ova^ merely by the thin wall of the intestine.

The presence of a fibroid tumour of the uterus will also cause metorrhagia, as also will cancer of the uterus. Above all, I would have you remember that haemorrhage after the menopause or during an intermenstrual period, is the most constant symptom of carcinoma of the uterus, and may be the only symptom.

Never allow a woman who is past the menopause, even if only three or four months past it, to think that a haemorrhage is only a return of a disappearing menstruation. These cases are very often those of uterine cancer, and ever} r woman who has experienced such a haemorrhage should be examined with a view to determining the condition of the uterus.

It is unnatural for a woman to menstruate during lactation, i.e., while nursing a baby at the breast. The red discharge of a puerperal patient should cease about ten days after labour. If menstruation begins, or if the red discharge continues for more than two weeks m a woman who is nursing a baby at the breast, that woman has either a backward displacement of the uterus, or the uterus is not completely emptied of the products of conception.

I once heard a very famous gynaecologist say, that m all his experience he had never seen a case of menstruation during lactation as a single symptom, except m cases with backward displacement of the uterus.

If nurses would realise this fact, and when their patients show this symptom insist on them having medical advice, the uterus might be put into a good position by

the wearing of a pessary for a few months and the patient would avoid the chronic invalidism that results from a displaced uterus, and the operative measures that become necessary for its rectification .

Now we come to the last variety of cases, those m which the haemorrhage is unnatural BY KEASON OF THE PAIN that accompanies it : Dysirenorrhcea is the name given to painful menstruation.

In the perfectly healthy, menstruation is accompanied by a certain amount of discomfort, and down-bearing sensation m the pelvis, but not by actual pain. When pain is present there must be some pathological state to account for it, and it is often possible to diagnose what state is present by considering the time of the pain m relation to the haemorrhage and the place where it is most felt. It sometimes is present for three or four days before menstruation begins, and gradually subsides when the haemorrhage sets m. In these cases the pain is generally felt most severely m the iliac fossae ; one or other, or both, and is due to an inflamed condition of the tubes or ovaries. These inflamed parts become intensely congested just before menstruation, and this congestion is relieved when haemorrhage occurs and pain accompanies congestion, analogous to the relief that follows the leeching of an inflamed area. In another variety the pain is present only one day, or part of a day before haemorrhage, and is suddenly relieved by its onset. This type has already been referred to, and includes membranous dysmenorrhsea, and cases with acute anteflexion of the uterus, when the kink m the cervix offers obstruction to the escape of the menses. The site of this pain is the hypogastrium. You must remember that the uterus is for the most part a muscle ; its walls are half an inch thick, and this half-inch of muscle can contract powerfully, and it is stimulated to contraction by the presence of any foreign body m its interior, and a clot of blood or piece of cast off endometrium will cause irritation enough to provoke contractions which are painful, just as contractions of intestinal muscles produce colicky pains. A third variety m which pain begins before menstruation and continues undiminished during it, and is situated diffusely over the lower abdomen, is due to neuralgia ; it occurs m nervous, thin, weak women, and is often associated with some other condition, though frequently present m women whose

organs are perfectly healthy. This neuralgic variety is exceedingly difficult to treat, and often matrimony and child bearing prove the natural cure, after failure of the physician's best efforts.

Pain m the back is caused by inflammatory conditions of the utero-sacral ligaments, by inflammatory state of the cervix and of the endometrium. Dsplacements of the uterus cause congestion of the endometrium, and endometritis, and then pain follows. It is well to remember that pain m the back m women is not always a symptom of gynaecological significance. Many women feel muscular weariness m the back before they feel it m any other part of the body, and m these it is simply an evidence of the general condition.

Fibroid tumours of the uterus may set up irregular contractions of the uterus, and these evidence themselves by pains m the front or lower parts of the abdomen, the pain being intermittent and irregular.

Cancer m the body of the uterus may set up pains m the same way as fibroids and polypi, and this may be a very early symptom. It is caused by the attempts of the uterus to expell the malignant mass of endometrium m its cavity. When the cancer is m the cervix — -and this includes the great majority of the cases — -there is no pain until the cancerous process has spread to the bladder, rectum, pelvic glands, or pelvic nerves, by which time it is beyond surgical treatment. These facts that I have brought before you are just those that you can find m a text-book, and to many of you they have long been familiar and perhaps you feel that I have been wasting time ; for when you invite a person to lecture you, you have a right to expect something with a personality m it.

I cannot pretend that any of the information I have given you is new, though I do not know any one book m which you will find it all ; m feet, on reviewing it, I rather think that some of it has never appeared m print, for many of these facts I have absorbed from some of the great authorities I have been privileged to work for : such men as Sir Halliday Croom, Sir A. R. Simpson, Brewis, and Haig Ferguson. But be they old or new they are strong facts, and the only special claim I can make is that they are here before you picked out from

among those facts that put m an order and method that m my experience has been most useful for general gynaecolgical work and diagnosis ; therein you have the individuality and originality.

I trust I have not thrust too many details upon you m so short a time. If so my excuse must be my anxiety that you nurses should know as much as possible of gynaecological symptoms, than which there are none m the realm of symptomatology that are of greater importance to you.

The importance to you is threefold : Firstly, the importance to you as women. ' If we take fourteen as the average age for the first menstruation and forty-eight as that for the menopause, we find that the menstrual function extends over a period of 34 years m a woman's life ; and if we take 4J days as the average duration of menstruation and allow thirteen periods to each year, we find that 1989 days, or five years five and a-half months m a woman's life are, or rather may be, passed m menstruating. If she marries, it is closely associated with her capacity for bearing healthy children without detriment to her own health. And if on the other hand she remains single, so much of her time must be spent under the shadow of it that her usefulness and wellbeing are largely dependent upon a normal condition as regards it."

Secondly, because you are members of a community or state that is at present much concerned m the decrease m the birth rate ; and thirdly, because you are members of the nursing profession.

I am surprised to find that m most, if not all, of the New Zealand hospitals g3 r naecology is considered a part of surgery of too little significance and importance to be regarded as a speciality, and the nurses do not have any course of lectures m gynaecolog}^ as a separate subject. I certainly think you ought to have a special course of lectures m gynaecology at all the larger hospitals of the Dominion ; and you should have at least one definitely gynaecological question to answer m your written examination for State registration. In fact, it seems to me that it is more important for a nurse to have accurate knowledge of the details of gynaecological symptoms than of the symptoms of eye or ear diseases on which you have all had a course oi instruction, both m special wards and by special lectures. Gynaecology

is surely the most important to nurses, of all special subjects.

The position that the nurse occupies — intermediate between patient and physician m things gynaecological — is generally recognised, and has recently been acknowledged b}' the British Medical Association by its action m calling upon the nurses of Great Britain for their help m the crusade against cancer of the' uterus, the prevalence and high mortality of which must have shocked all of you.

New Zealand's statistics show that about one female of every ten that are born dies of cancer, and of these a quarter of them die of cr.ncer of the uterus.

In all probability there will be about 100 deaths from cancer of the uterus m New Zealand during the present year. German statistics show that about 25 per cent, of the cases operated on are still free of the infection at the end of five years, so that we can look forward to saving about 25 lives annually here m New Zealand when the housewife of New Zealand begins to realise that Unnatural Uterine Haemorrhage is a serious symptom, and this is a very low estimate. The question that faces us is 11 How are we to teach women the importance of this symptom ? J The same question has faced gynecologists all the world over. In Germany for the last six or seven years there has from time to time appeared m the daily newspapers a notice calling the attention of all women to the fact that Unnatural Uterine Haemorrhage is a sign never to be treated lightly, and all women evidencing it should consult their physicians at once. They have also stuck posters on the doors of public places, theatres, etc., to disseminate the same information.

For the last three years all the best American newspapers have occasionally published articles asking, or rather begging women who had any unnatural haemorrhage to seek advice without delay. The result has been that cases of inoperable cancer presenting themselves at American hospitals have been brought down from 70 per cent, to 40 per cent.

In England the problem is being treated differently. It was thought that to advertise m the newspapers would be offensive to the feelings of British women, so the British Medical Association decided to send appeals to all doctors, midwives and nurses informing them of the importance of the

symptoms that lead one to suspect uterine cancer. I will read you the appeal that was last year sent to all nurses : —

" Cancer of the womb is a very common and fatal disease m women, but it can be cured by operation when it is recognised early.

"A woman sometimes tells a nurse or a midwife her ailments before she speaks to a doctor, and the nurse or midwife has then an opportunity of aiding our crusade against this terrible disease.

" Cancer may occur at any age and m a woman who looks quite well and who may have no pain, no wasting, no foul discharges and no profuse bleeding. To wait for pain, wasting, foul discharge, and profuse bleeding is to throw away the chance of successful treatment. The early signs of cancer of the womb are ; 1. Bleeding which occurs citer the change of life. 2. Bleeding after sexual intercourse, and after a vaginal douche. 3. Bleeding, slight or abundant even m a young woman if occurring between the usual monthly periods, and especially when accompanied by a bad smelling or watery bloodtinged discharge. 4. Thin watery discharge occurring at any age. ( ( The nurse or midwife who is told by a patient that she has any of these symptoms should insist upon her seeing a medical practitioner m order that an examination may be made without delay. By doing so she will often help to save a valuable life, and will bring credit to herself and to her calling/

Furnished with the knowledge that this appeal gives it becomes the nurse's duty to her sex to forewarn her patients. The effect of the publication m German newspapers is already definite. It has revolutionised German statistics and German gynecologists can now show more creditable statistics for the treatment of uterine cancer than can the surgeons of any other country, simply because they are getting their cases early.

Why should not we m New Zealand revolutionise our statistics ? It can be done, but only by the help of the nurses. We medical men can teach you, but you have better opportunity than we of ;ma king

the information that we give you popular knowledge. Remember then that Unnatural Uterine Haemorrhage is the commonest symptom of cancer of the uterus, and regard every case m whichfthis symptom shows itself with suspicion until it is shown beyond doubt that cancer is not the cause. And finally, I wish to refer to those cases of cancer of the uterus that when first seen by the doctor are already too far advanced to receive benefit from operative treatment. The patient is generally losing weight, and if she is not suffering pain already she is certain to do so before this terrible disease has terminated. She has a constant vaginal discharge, probably blood-stained, and its odour is powerful and very offensive. As the bladder and rectum become invaded their functions are disturbed and the patient thereby distressed. Her condition becomes a mental as well as a physical burden to her. She rapidly loses strength and becomes bed-ridden. Her friends become less friendly as her disease progresses. I could tell you of cases that are not pleasant to recall to memory ; details that you would not care to hear, of how these poor women have been neglected by their friends and relatives, who have allowed their loathing for the disease to affect their attitude towards its

victim. I know of no sadder cases than these. The physician and surgeon are helpless, and the patient prays constantly that the end may not be long postponed.

Iyittle wonder that nurses sometimes decline to engage themselves for such cases. But who is to help such a patient if not a nurse ? Such cases will come to all of you, and if you have the instinct of a nurse and a true woman, it is your opportunity, and you will rise to the occasion and be found not wanting, for here is a test of your powers of endurance. You will require all the fortitude and delicacy you can command. You will have to treat not the patient only, but the relatives too. You can tell them that their fears of infection from the discharge are without foundation, and you can take mental control of them and change their attitude towards the patient.

The doctor knows when he asks r you to nurse such a case that he is calling upon you to make a sacrifice, but he is also giving you as fine an opportunity as you will have of showing your strength as a woman and your value as a nurse. You will be rewarded by your patient's deepest gratitude, and by the rewards that inevitably follow all such works of devotion and self-sacrifice