( Originally Published 1918 )
NORMAL menstruation in a healthy woman should not occasion any symptoms of illness whatever, except perhaps a slight malaise and a sense of fullness in the pelvic region due to the congestion. There should be no weakness or physical disability. Any deviation from the normal, however slight, should be classed as a menstrual disorder.
Although usually considered as functional disorders, disturbances of menstruation are most often based on some underlying constitutional difficulty or organic condition, and local treatment without considering the body as a whole is not to be considered good treatment.
PREMATURE MENSTRUATION.—Menstruation in some cases has occurred before puberty—in fact, in infants. In the latter it usually lasts only a few days and is of no consequence, except it be profuse, when it may cause weakness. When it occurs at a later age, but before the time expected in that individual, it is usually due to precocious development, or to the child's having had its attention drawn to the sex functions by its nurse or playmates—perhaps being taught the habit of masturbation. In such cases the genitals develop prematurely, the breasts enlarge, and other signs of puberty appear. Unless proper care is taken and the child restrained, the foundation for future weakness and nervous disorders may be laid.
Treatment.--The child should be removed from the influence of vicious companions. Rest and sleep and proper feeding are needed to build up the nervous system. Cleanliness, fresh air and sunshine, and active outdoor exercise should be encouraged. The mental development must not be pushed at the expense of the physical.
LATE OR DELAYED MENSTRUATION.—A mother is often worried because her daughter has passed the age of puberty and the menses have not as yet appeared. Or the girl herself, if she has been informed upon the subject, will wonder what is the matter, and worry because the expected event does not occur.
This may be an hereditary condition, and ordinarily need cause no alarm, as the flow will be established in good time. In some cases it is due to a sedentary life, with its lack of exercise and fresh air. It may be due to poor food or insufficient food. The delay often occurs in the case of those girls who habitually overeat and who grow excessively fat. If the menses are delayed very long after the normal time of puberty, it should be considered as an amenorrhea, and the treatment of the condition will be taken up under that head. In simple delayed menstruation, no treatment is necessary apart from general health improvement.
VICARIOUS MENSTRUATION.—This is a rare condition and occurs when, in the absence of normal menstruation, there is a flow of blood from some other organ at the time when menstruation should take place. This may happen every twenty-eight days for some months. Hemorrhages from the nose, stomach, lungs, nipples, ear, gums, bladder, or even from an unhealed ulcer or open sore, may occur. There may be bleeding hemorrhoids. In some cases there is no blood, but an excessive leucorrhea, a diarrhea, or an unusual flow of saliva. No treatment is needed beyond that for the re-establishment of the normal menstruation.
AMENORRHEA.—This is a condition in which there is an absence of menstruation for one or more periods. Physiologically it occurs during pregnancy and lactation. It may be due to the absence of uterus or ovaries, either congenital or through surgical removal. It may also be due to undevelopment or malformation of uterus, ovaries, or vagina, or to an imperforate hymen.
The ovary, besides its function of secreting the ova, also has another function, that of secreting a substance which is thrown into the lymphatic stream, and is called an internal secretion. Other glands in the body also have such a function, as the thyroid, pituitary and adrenals. There seems to be somewhat of an equilibrium between the secretions of all of these glands, so that when the function of one is disturbed that of one of the others may be changed. Hence in disturbances of the thyroid there may be an amenorrhea.
The most common causes of the condition, however, are those due to a change in the health and well-being of the woman. Amenorrhea in itself very seldom produces ill-health, but vice versa. Anemia, either primary, as chlorosis and pernicious anemia, or secondary to a wasting disease, is a common cause. Tuberculosis and malaria are very often to blame. It may be due to organic disease of the heart, liver, kidney, or spleen. Digestive disturbances, diabetes, and nervous disorders conduce to the disorder. It may follow an attack of an acute disease, as pneumonia, diphtheria, typhoid, etc.
We have observed amenorrhea in several cases in which the women were actively engaged in athletic and gymnasium work. This is also a case of conservation on the part of the body, all available vitality apparently being expended in the vigorous muscular effort.
Treatment.: We generally have to consider whether the girl or woman ever has menstruated, or whether the flow has been established at puberty, but for some reason has missed one or more periods at a subsequent time.
In the first case, puberty arrives with all its signs except the menses; periodically the girl is seen to be dull, to lose her appetite, to suffer with malaise, and often headache. This lasts for a few days and then she is all right. This may go on for months before the general health shows signs of failing.
In the second class we must always rule out pregnancy and lactation.
The treatment of both classes is practically the same. In the first place, if the cause can be found, it must be removed before anything else is done. If there is a constitutional or acute disease, it must be treated by appropriate measures.
If the patient is inclined to stay indoors, and reads and studies incessantly, a complete change should be made in the manner of living. She must go outdoors every day, practice deep breathing, get as much sunshine as possible, and engage in outdoor games and other exercises. Walking and hill climbing are extremely beneficial. If active exercises are too severe and seem to tire the patient, massage or mild calisthenics may be substituted.
The exclusive milk diet should next be thought of. This is the best means we have of quickly building up the quality as well as the quantity of blood.
A proper amount of rest and sleep must be secured. If the patient is obliged to be confined indoors during the day, outdoor sleeping, or a well-ventilated room is obligatory. During cold weather warm clothing must be worn.
A cool sponge bath may be taken daily, and a hot tub bath twice a week. The hot sitz bath is a most valuable measure in amenorrhea. To get the best effects from the sitz bath, it should be taken daily for several days just before the expected menstrual period. If the menses appear, it must be discontinued. The bath should last from five to fifteen minutes. Between the menstrual periods the cold or cool sitz is of value, but this must be stopped several days before the time for the menses. It may be alternated with the hot sitz. If the baths seem to weaken the patient, or take too much energy, they had better be discontinued, or only the hot sitz used.
The bowels must be kept free and active by proper diet, the enema being used in emergencies, cathartics never.
Systematic abdominal massage and bending exercises are of benefit.
MENORRHAGIA.-This is a condition characterized by an excessive flow of blood at the menstrual periods, or a prolongation of the normal menstrual period. It is sometimes called "flooding."
It may be due to local or constitutional causes. The most important local causes are: Infective and simple inflammation of the uterus ; displacements of the uterus ; fibroid tumor and cancer ; polypi ; disease of the ovaries. Any condition producing a congestion of the pelvic viscera is a cause, as uncompensated heart disease, tumors of the abdomen, congestion of the liver, the wearing of tight bands, or corsets. Straining because of constipation, excessive work or exercise, heavy lifting, running sewing machines, standing all day at ironing, or clerking, are sometimes potent causes. Constitutionally, the woman may be anemic, or there may be a tendency to bleed.
There may also be weakness following acute disease, or resulting from a constitutional disease. The condition may be due to excessive use of alcoholic liquors, overeating, or the use of stimulating foods. If pregnancy is present or suspected, it may indicate a threatened abortion.
Treatment.—The woman should rest, prefer-ably in bed, during the time of the period. This alone will sometimes shorten the time, or reduce the quantity of the flow. Liquids should be restricted. The diet should contain foods which are known to be laxative.
A careful examination should be made to rule out the presence of local disease. If present this must be treated.
A regime should be adopted that will build up the general health. The quality of the blood must be improved, and for this purpose there is nothing better than the milk diet. This should be taken up to within a few days of the period, and then discontinued while it lasts. In some cases a fast during the first few days of the period is advisable. This very often shortens the time. Between the periods, mild exercise, such as calisthenics, walking, bending, and floor exercises should be taken. These will reduce the pelvic congestion and tend to equalize the circulation.
Between periods the cold sitz bath is beneficial. This should last for one minute, and is best taken just before retiring. It may be taken every evening, but must be discontinued upon the appearance of the flow. The cold sitz is used sometimes to check the flow, but it may prove to be a dangerous procedure, and should not be used unless the flow has continued for a normal length of time and there seem to be no signs of cessation. Instead of the sitz bath a cold compress over the pelvic region may be used. Massage over this region is often beneficial. The hot vaginal douche may be tried.
METRORRHAGIA.-This is a condition in which there is bleeding from the uterus between the normal menstrual periods. It must always be distinguished from menorrhagia because it usually means that there is a serious local condition. It may indicate an impending abortion, the presence of cancer or fibroid, or a severe inflammatory condition of uterus or ovary. The treatment is that of the underlying cause.
DYSMENORRHEA.-This is the most dreaded menstrual disturbance, causing in some cases in-tense suffering for a few days at every menstrual period, and often leading to serious impairment of health, because of the pain and mental and physical depression.
The causes are many. One type is neuralgic in character. It is probably due to congestion of the pelvic viscera, and is often associated with neuralgia in other parts of the body. The pain is sharp, and seems to radiate from the region of the ovaries, to the uterus and back, and down the legs.
This type of menorrhea may be due and indeed the ovaries to the uterus and back, and down the as neurasthenia and hysteria. There may be digestive disturbances and anemia.
A second type is congestive or inflammatory in character, and is due to inflammation of the uterus, or of the tissues in the vicinity of the ovaries and uterus. Or it may be due to displacements, or pressure from tumors. The pain is not present before the flow, but comes on a few hours after it has been established and lasts during the period. The pain is throbbing in character, and radiates to and up the spine, down the thighs and to the back.
A third class is due to obstruction in the lumen of the uterus. It may result from imperfect development, or an infantile uterus. There may be a stricture of the cervical canal, due to the contraction of scar tissue, or swelling because of inflammation. There may be a flextion (doubling over) of the uterus, tumor, polypus, or clots of blood. The pains are paroxysmal and intense in character and disappear as soon as the flow is established.
A fourth type is the membraneous form, in which the superficial layers of the uterine lining are cast off.
Treatment.— When the patient is seized with the pains she should go to bed immediately. The bowels should be emptied by means of a hot enema. This alone often relieves. A hot compress should be placed over the lower abdomen and pelvic region, covered with a hot-water bottle. Instead of these, bags filled with oats or bran can be heated and applied. They may also be placed under the buttocks. Hot drinks may now be given. No food should be taken. The patient must be kept warm, by placing hot-water bottles to the feet and limbs, if necessary. If the pain is severe and the above measures fail, the patient should be put into a hot sitz bath, the water being as hot as can be borne. She should stay in this until the pain is relieved, or at least for a half hour, returning immediately to bed.
It is between periods, however, that the real cure must be made. Every measure that will tend to build up the health must be taken. Fresh air, outdoor exercise, games, walking, and hill-climbing, etc., are all good. Sufficient sleep and rest must be secured. The diet should be wholesome, practically along the lines mentioned before. If there is a local condition, such as displacement, obstruction, or inflammation, it must be taken care of by appropriate treatment. In most cases the one remedy that has been most effective is a fast of from seven to fourteen days followed by the exclusive milk diet. If desired, a series of fasts of three to five days may be taken, using the milk diet between.
Between periods the cold sitz bath, or the alternate hot and cold sitz bath, may be taken, with the idea of toning up the uterus.
A woman is tempted to take drugs to ease her pain, but this is not advisable, as the drug only deadens sensation and in no way removes the cause, or helps the condition.