Menstruation and Its Disorders

Kai Tiaki : the journal of the nurses of New Zealand, Volume VIII, Issue 4, 1 October 1915, Page 184

Menstruation and Its Disorders

A Lecture given by Dr. J. McNaughton Christie at the Nurses' Club, Wellington

I have chosen this subject for two reasons. Firstly, ' because there are so many ci old wives'" tales related about it, and, secondly, because nurses are frequently asked for advice on the subject, and ought to know something definite. The great difficulty, is studying the subject experimentally m that it only occurs m women and some of the higher apes. Menstruation is a complex process whose most obvious sign is a periodic discharge of blood from the uterus. It only occurs during the reproductive period, and its onset and cessation mark the beginning and end of this part of a woman's life. There are two opposing theories of menstruation; one is that menstruation is dependent upon ovulation and coincident with it. Ovulation is the escape and discharge of the ripe ovum from the ovary. In this view the graafian follicle, by its swelling during its development excites nerve impulses, which; being reflected on the vaso-motor system, give vise to local congestion. This view has, however, been collected by modern operative work, which has proved that ovulation occurs . at times which . are quite independent of menstruation. Ripe or ruptured follicles are found at all times of the menstrual cycle. The other theory is that menstruation is governed by the corpus luteum, i.e., the yellow substance which fills up the cavity m the ovary from which a ripe ovum has escaped. It has been proved that destruction, of the corpus luteum with the cautery delayed the appearance of the next menstrual period, and m some cases suppressed it altogether. This rather tends to prove that the corpus luteum is the part of the ovary which directly excites the menstrual period, probably through the medium of an internal secretion which is absorbed from it into the blood. The age of puberty is influenced by climate, race, social position, and mode of life. It used to be believed that it started very early m the tropics and vay late m the far north. Such is not the case. Its onset is really as early among the Esquimaux as it is amongst the inhabitants of tropical countries. The negro girl develops at sixteen, just as late as the Laplander or the 'Samoyed ; "and" Esquimaux women may

become mothers at twelve, just as early as the Hindu, women. While high temperatures favour early menstruation and lower temperatures tend to retard it, this is more seen m different parts of the same zone, than m the extreme zones like the tropical and the Arctic. Thus it starts somewhat earlier m the South of Europe than m the North. Engelmann, who has made a very exhaustive study of the subject m America, states that the age of first menstruation m America is 14.3 for the labouring classes, and 14.2 for the educated classes. He concludes by saying/ ''Climate has practically no influence ; race very little ; mentality, surroundings, education, and nerve stimulation stand out piominently as the factors which determine precocity." An important predisposing factor m fixing the age m any given case, however, is the customary time for the family. Anything b:low ten or above twenty must be considered abnormal. Cases of precocious menstruation are constantly being reported. Strausmann has collected fifteen cases where it appears during the first year of life. Frequently cases of precocious menstruation are ;a manifestation of some morbid condition of the uterus and appendages, such as ovarian tumours, myomata, and affections of the endometvium. The length of the period varies considerably m different persons. When once the individual standard has been established it should remain fixed, and any marked or prolonged variation from it is generally associated with a failure of general health, although it does not necessarily imply the presence of a local lesion. It may last from two to eight days, four or five being the average, and anything over a week being usually regarded as abnormal. The amount of blood lost .is very difficult to estimate. Different authorities give it as Varying from two to eight ounces. The amount which is normal for one woman may be excess for another. Most of the blood is lost during the first two days of menstruation, whatever may be the length of the period. Fov the first few menstrual periods, before the function is well established, the amount often varies

considerably, being excessive one period and scanty at another. As a rule a standard will be fixed m a few months, and this should remain fixed during the remainder of menstrual life. Any increase or diminution from what is normal m any individual is of more importance than the actual quantity lost. Should this deviation last for a short time it ought to be carefully enquired into and the cause found and rectified. It is not infrequent for menstruation to become suspended for twenty-four hours or more, after which the flow returns and pursues its normal course. The interval between the periods averages twenty -eight days ; but here again variation is encountered. In many healthy women it may be twenty-one days only; m others it may be five Weeks. Twenty -eight days bsing usual, one is not surprised to find that among uncivilised people the belief is held that the periodicity of menstruation depends upon the phases of the moon. The Menopatjse is the term used to denote the end of the period of reproductive activity and the cessation of menstruation. It generally ceases between 45 and 50. It may be delayed to 55 and occur earlier — ■ even at 40. There are three modes m which it may come to an end : — (a) It may terminate suddenly and finally without any preceding changes being observed ; (b) the period may occur at irregular and increasing intervals with gradual reduction m the amount of bleeding, for some time, until it finally disappears ; (c) during the period of irregularity occasional profuse or prolonged losses of blood may occur. The duration, of the period of irregularity is variable, and may extend over several years. Accompanying these changes m the menstrual function, certain general disturbances connected chiefly with the nervous system are commonly met with. These are occasionally absent, but to the majority of women the climacteric is a time- of more or less prolonged ill-health. The most characteristic and at the same time most troublesome symptom consists m attacks of "flushing." The patient has waves of heat passing over the body, accompanied by visible congestion of the neck and - face, and followed m severe cases With profuse sweating. They vary greatly m duration, sometimes only momentarily, m; others lasting 10 to 30 minutes, Head-

aches and neuralgia are not uncommon ; tingling and numbness m hands and feet or other parts are often complained of. Increased excitability or depression and distaste for mental ov bodily exercise are often met with. Many women show a wellmarked tendency to ob3sity at that time. The artificial menopause which follows removal of both ovaries during the sexually active period of life, closely resembles the natural process, and the attendant symptoms are often unusually severe. Arrest of menstruation by the removal of the uterus, if one or both ovaries are retained, is usually almost entirely free from the attendant symptoms just described ; but when both ovaries have also been removed these symptoms, as a rule, are unusually severe. These clinical facts seem to indicate that these symptoms are induced by loss of the internal ovarian secretion rather than by arrest of the monthly haemorrhage from the uterus. Sometimes a premature menopause occurs apart altogether from operatic interference, and a recent case has been recorded m which menstruation ceased naturally at the age of 23, having begun at the age of eleven. A severe illness or mental shock seems m some cases to have bsen the exciting cause m others it has been due to lactational atrophy of the uterus ; m others no cause can be discovered. It is accompanied by the usual symptoms, but does not lead to premature senility, or to atrophic changes m the genital organs. We will now consider some of the disorders of menstruation. Amenorrhoea, absence of the menstrual function, is a natural condition o* puberty, after the menopause, during pregnancy, and also frequently during lactation. This may be called physiological amenorrhoea. Under all other circumstances amenorrhoea is abnormal, and the causes which produce it are various. Pathological amenorrhoea may be divided into two classes, namely : Primary and Secondary : the former class consists of cases m which the menstrual function has never been established, the latter includes all cas:s m which it is suppressed under abnormal conditions. Amenorrhoea is said to be complete when several months, or perhaps years, elapse without the occurence of a menstrual period ; it is incomplete when the intervals are prolonged, it may

be to ■ 8 or 10 weeks, and the amount of the bleeding is scanty. Amenorrhoea may be brought about by a variety of different conditions, -which can be classified most conveniently as causes of primary and sec ondary amenorr h oea re spe cti vely . Causes of Primary amenorrhoea are :— 1. Anaemia and other general disorders, e.g., advanced tuberculosis. 2. Delayed puberty. 3. Developmental faults : (a) Of the uterus — -Rudimentary uterus — Infantile uterus. (b) Of the cervix and vagina — Atresia, imperforate hymen. (c) Of the ovaries — Imperfect formation or complete absence of the ovaries. Causes of secondary amenorrhoea : — ■ 1. General debility from :■ (a) Acute illness. (b) During convalescence from illness, or surgical operation. (c) In the late stages of chronic disease, e.g., diabetes, chronic nephritis, tuberculosis, malaria, ■cancer. 2. Severe forms of anaemia. 3. Certain forms of chronic poisoning, e.g., alcohol, lead, morphine, other varie- : ties of the drug habit. 4; Disorders of the nervous system, e.g., nervous shock, overwork, hysteria, 1 certain forms of insanity. 5. General conditions such as change of climate, imprisonment. 6. Obesity. 7. Local pelvic conditions : — ■ (a) Obliteration of the uterine cavity from sloughing. (b) Atrophy of the uterus, e.g., lactational atrophy. (c) Acquired stenosis of the cervix or . : , vagina. (d) Bilateral ovarian tumours, especially when solid or malignant . (c) Surgical removal of the uterus, or of both ovaries. Dysmenorrhoea, or painful menstruation, is. very hard to define. The great majority of. women experience pain, more or less severe, when they menstruate. Pain is m all cases i an imponderable symptom, and some women tolerate pain better than others ; it is therefore impossible to define the boundary between what- is normal and what constitutes a; departure from the. normal,

Cases are fairly frequent m which menstruation is accompanied by pain so intense as to interfere with the occupation or pursuits of . the patient, or even to compel her to stay m bed. Such as these must be accepted as casts of dysmenorrhoea . Two varieties occur, one being due mostly to the general pelvic congestion and the other to the contractions of the uterine muscle which dilate the cervix and expel the menstrual fluid. We may have both factors acting m the one case. These are named Congestive and Spasmodic Dysmenorrhoea respectively. Other varieties have been described. Thus certain writers classify dysmenorrhoea as uterine and ovarian. There is no such thing as ovarian dysmenorrhoea, as we have seen that menstruation and ovulation do not coincide. Many writers have described an obstructive form of dysmenorrhoea, said to be due to a flexion of the uterus, or a small external os (pinhole os). No flexion, however acute, can obstruct the uterine canal, as the walls are so thick. Further, narrowness of the os externum or os internum will not prevent the passage of menstrual blood through it m more or less rapid drops ; also a certain amount of dilatation of the cervix always occurs during menstruation and this facilitates the flow. Another variety of dysmenorrhoea frequently desscribed is Membranous Dysmenorrhoea. This condition is characterized by the discharge during menstruation of pieces of membrane, usually m strips, more rarely as a complete cast of the uterine cavity. This is not a disturbance of the menstrual process but a disease of the endometrium or. lining membrane of the uterus. Spasmodic dysmenorrhoea usually occurs m young women, and the greater number of cases- are cured by child-bearing. It may begin with the first onset of menstruation ; but often it does not appear until some years later. Women "who suffer from this disease may be otherwise m good health. More frequently they are either overworked or of a pronounced neurotic temperament. It has, however, no definite association with disease m any other part of the body. The pain begins either some hours before or at about the same time as the haemorrhage. It is m the- hypogastric abdominal zone that the pain is chiefly felt, and often it radiates into the back and down the thighs,

The pain may be most intense and agonising, and after some hours may lead to fainting and collapse. It is often attended by severe headache and vomiting. It is usually spasmodic m character ; but sometimes it continues without any remission for several hours. While the severity of the pain is great the haemorrhage is scanty; when the pain eases down the flow becomes freer. Women of gouty tendencies are said to be more liable than others to this disease. Clinical experience has shown that it is usually associate d with a low degree of fertility, or with sterility. Congestive Dysmenorrhoea generaUy speaking is a symptom of some other morbid condition and not a disease of itself, like Spasmodic Dysmenorrhoea. It is met with m cases of chronic pelvic inflammation affecting the tubes and ovaries, and the pelvic peritoneum and oellular tissue ; m cases of interstitial and submucous fibvoid tumours ; m some cases of backward displacement of the uterus, especially when complicated by adhesions or by subinvolutions. All these conditions lead to chronic local congestion, so that when the premenstrual congestion occurs the already congested pelvic vessels become overdistended and cause pain. After the menstrual flow has been m progress for some time, varying with its amount, relief occurs by depletion of the congested vessels, and diminution m tension. In congestive dysmenorrhoea the pain is never of that acute or agonising character often met with m the spasmodic form. It is continuous and open, 'relieved by rest m bed, the horizontal position helping the pelvic chculation. This form seldom, if ever, begins with the first onset of menstruation. Often one gets a history of some preceding pelvic trouble, with which the onset of the dysmenorrhoea is connected. The amount of the bleeding is as a rule profuse, scanty bleeding is very rarely met with. Often the period is prolonged. The pain is usually referred to the back, thighs, and both iliac regions. Headache and vomiting are usually absent. Menorrhagia is the name given to an excessive loss of blood at the menstrual periods, Metrorrhagia to an excessive loss at irregular intervals. They are not really dis as'is per se } but only symptoms of some of the following, and may be class :d under Local, Constitutional, and Vascular,

Local causes, due to condition present within the pelvis are : — Abortion, polypi, submucous myomata, malignant disease, retro-displacements of the uterus, subinvolution of the uterus, inversion of uterus, endometritis acute and chronic, tuberculosis of the endometrium, cystic disease of the ovaries, inflammation of the tubes and ovaries, ectopic gestation, scleroma or atheroma of the uterine blood-vessels, calcification of the uterine blood-vessels. Constitutional causes are : Anaemia, especially pernicious anaemia, rheumatic diathesis, scurvy, phthisis, infectious diseases. Vascular Causes : Cardiac disease with a vascular stasis, especially mitral regurgitation, hepatic diseases with a portal stasis, as m cirrhosis. I might say a word or two about the hygiene of menstruation. The periods of menstrual flow m the healthy girl require no marked deviation from her normal hygienic habits. Great cleanliness of person and of clothing should be enjoined, m opposition to a prevalent idea that bathing and changing underclothing must be avoided. The daily bath must not be intermitted ; a cold sponge bath may be substituted for a cold plunge ; but there is no necessity for changing the habit of daily bathing. Girls should not be taught to use a vaginal douche after each menstrual period. Diet such as is suitable at any time should be taken. There is no evidence that, m the normal girl, the function is affected by using any particular article of diet. Excessive exercise should be avoided. Many Women take the same amount of exercise as usual. Unless there is marked dysmenorrhoea it is not necessary to rest. There is only one word move I would like to say, and it is with regard to haemorrhage after the menopause. If, after the menopause, a woman has any haemorrhage she ought to seek medical advice at once. Thousands of women lose their lives by neglecting this. A careful systematic examination ought to be made, as this is one of the earliest and often the only symptom of malignant disease of the uterus. She should not wait until she gets pain or an offensive discharge. Often that is too late. Here you, as nurses, can be of great service to the community, and may be the means of saving many lives and much suffering.