DISORDERS OF MENSTRUATION A.C. Cowperthwaite, M.D.
Definition Amenorrhoea is an absence of the menstrual flow occurring at any time between puberty and the menopause, except during pregnancy and lactation, when such a condition is physiological.
Varieties Amenorrhoea occurs in tow forms: 1. Those cases where menstruation has never occurred, emansio mensium; 2. those in which it has ceases after having been established, suppressio mensium. In addition, the term partial amenorrhoea has been used to designate a condition of scanty, tardy or irregular menstruation. The term vicarious menstruation is used to designate a condition in which, in the absence of a discharge of blood from the uterus, there are periodic haemorrhages from other parts, such as the nose, lungs etc.
Pathology Amenorrhoea is but a symptom of various existing pathological states of the generative organs. It may arise also from grave constitutional diseases, such as phthisis, etc. It is evident, therefore, that the condition itself can have no established pathology, nor is it probable that amenorrhoea ever gives rise to pathological states, it being itself a result rather than a cause of the many constitutional diseases with which it is associated, and the existence of which has been erroneously attributed to the failure of the menstrual function. An exception should apparently be made in those cases where acute suppression of the means occurs from exposure to wet or cold, the flow not resuming, and phthisis rapidly following. Yet, in such instances, there is no reason to suppose that the exposure might not have produced phthisis, even had there been no disturbance of the menstrual flow. Such cases are not uncommon.
The wide range go pathological conditions liable to give rise to amenorrhoea may be inferred from the following quotation from Dr. Thomas, who says that “for the proper performance of the menstrual function three elements must exist in a perfect state of integrity: 1st, the uterus, ovaries, and vagina must be perfect in form and vigour; 2d, the blood must be in its normal state: and 3d, the nervous system governing the relations between the uterus and ovaries must be unimpaired in tone. Any influence disordering one or more of these may check ovulation, the great moving cause of the function, preventing the degree of sympathetic congestion necessary for rupture of uterine; vessels; or oppose the discharge of blood which has been effused.”
Aetiology. In accordance with the above views, Dr. Thomas tabulates the causes of amenorrhoea as follows:
Abnormal states of organs of generation:
Absence of uterus of ovaries:
Rudimentary uterus or ovaries;
Occlusion of uterus or vagina;
Atrophy of both ovaries;
Cystic degeneration of both ovaries.
Abnormal states of the blood:
Blood states of phthisis;
Blood states of cirrhosis:
Blood states of Bright’s disease, etc.
Abnormal state of ganglionic nervous system:
Atony from mental depression;
Atony from indolence and luxury;
Atony from want of fresh air and exercise; Atony from constitutional diseases, as phthisis, etc.
Exciting Causes-These operate only in cases of acute suppression, which may result from exposure to cold or wet just before or during the exposure to cold or wet just before or during the discharge, or from fright, grief, mental distress, or any profound disturbing influence.
Symptoms. In chronic amenorrhoea the symptoms are often only such as are characteristic of the pathological condition of which the amenorrhoea itself is but a symptom.
Acute suppression may give rise to symptoms which, in character and intensity, will vary from those of ordinary menstruation- backache, heaviness and weight, pelvic pains, etc. to symptoms of profound disorder, leading sometimes to severe and dangerous diseases.
Diagnosis.- The diagnosis of amenorrhoea is self-evident, but the diagnosis of the pathological conditions which produces it is often a matter of difficulty, and can only be accomplished by a thorough understanding of these respective states. Often the most important consideration is to determine whether or not the menses are absent from physiological causes-pregnancy or the menopause. Should the menses have ceased suddenly in an otherwise healthy subject the usual signs of pregnancy-morning sickness, etc., should be considered. It should not be forgotten that the menopause may occur at an early age, as also may puberty be delayed much beyond the usual time, which facts should enter into consideration in those cases in which menstruation has ceased without apparent cause, or, where it has not appeared at the usual age, and where, in either instance, abnormal symptoms have not developed.
Prognosis. This depends upon our ability to remove the existing cause, and is usually favourable. Aside from cases resulting from an absence or rudimentary condition of these organs, those which result from blood states or constitutional diseases are the most serious in their character.
Treatment. In the first place it is a safe and proper rule to follow that no case of amenorrhoea requires treatment so long as it presents no positively morbid symptoms. Very frequently emansio mensium requires no treatment, but suppressio mensium and partial amenorrhoea usually demand medical aid.
The treatment invariably consists in ascertaining and removing the cause, whether mechanical or constitutional.
Cases arising from abnormal states of the blood, or nervous system, require chiefly the indicated remedy, but the great importance of proper hygienic and dietary influences must not be overlooked. Frequently the primary cause lies in malnutrition brought about by improper food and irregular habits of life. Girls those are sedentary in their habits, or are being reared under the pernicious influences of an artificial life, are quite prone to amenorrhoea, and in such we can only hope to secure a restoration to health by a systematic and strict observance of hygienic rules. The feet should be kept warm and dry; flannel should be worn next the skin at all times; regular habits should be enjoyed as to early retiring and early rising, bathing, regular meals of plain nourishing food, and regular defecation; systematic exercise, but not to over-fatigue; plenty of fresh air and sunlight, cheerful surroundings and agreeable and should be persistently observed.
In acute suppression, the hot sitz-or foot-baths, are valuable adjuvants, and indeed they may often prove of equal value in chronic cases.
The remedies most often called for are as follows:
Amenorrhoea from chlorosis: Aletris, Apis, Calcarea carb., Arsenicum, Chininum Chininum Arsenicum, Ferrum, Ferrum iod., Ferrum phos., Helonias, Ignatia, Lilium, Nux vomica, Phosphorus, Pulsatilla, Sepia, Senecio, Zincum met.
Amenorrhoea from plethora: Aconite, Belladonna, Gelsemium, Nux vomica, Sulphur.
Amenorrhoea from constitutional diseases: Aletris, Arsenicum, Calcarea carb., Chininum, Chininum, ars., Cimicifuga, Conium, Ferrum, Ferrum phos., Graphites, Iodine, Phosphorus, Pulsatilla, Sepia, Sulphur, Zincum met.
Acute suppression from cold : Aconite, Belladonna, Pulsatilla, Causticum, Cimicifuga, Gelsemium.
Acute suppression from fright or sudden emotions: Aconite, Belladonna, Cimicifuga, Ignatia, Opium, Platinum, Pulsatilla.
First menses delayed: Aletris, Calcarea carb., Cimicifuga Graphites, Pulsatilla, Silicea, Sulphur.
Partial amenorrhoea: Calcarea carb., Cimicifuga, Graphites, Phosphorus, Pulsatilla, Senecio, Sepia, Silicea, Sulphur.
Vicarious menstruation: Bryonia, Hamamelis, Millefolium, Phosphorus, Pulsatilla, Ustilago.
Only the chief indications for a few of the most important remedies can be given.
Aletris. From atony of the ovaries and uterus; anaemia; defective nutrition; indigestion; constipation; fainting; especially when weak from protracted illness.
Apis. Chlorosis; face oedematous, puffy, waxy; stinging pains especially in right ovary; menses scanty and irregular.
Calcarea Carb. Especially useful in scrofulous or tuberculous subject; fair, plumb girls, of a leuco-phlegmatic temperament; mal-nutrition; disturbances of ingestion; weary, languid want of vitality; anaemia.
Cimicifuga. In rheumatic, neuralgic, choreic or hysterical subjects; menses irregular, delayed or suppressed; ovarian irritation; uterine cramps; bearing down in uterine region and small of back, limbs heavy and torpid; suppression from cold or emotions; more generally useful in all classes of amenorrhoea than any other remedy.
Ferrum. In weakly, chlorotic persons, with fiery redness of the face; great nervousness and debility; emaciation; rush of blood to the head, veins of head swollen; flushes of heat in face.
Graphites. First menses delayed, or disturbances at the menopause. “Graphites is in climax what Pulsatilla is in youth” (Lilienthal). Menses late, scanty and pale; pain in epigastrium as if everything would be torn to pieces; patient inclined to obesity; induration of ovaries.
Helonias. From atony; anaemia; chlorosis; disordered digestion; general weariness and languor; depressed mood; censorious fault-finding; prolapsus from muscular atony; loss of sexual desire.
Ignatia. Menses suppressed from grief or suppressed mental suffering; frequent sighing; brooding over her troubles; sensation of weakness; and sinking at pit of stomach; hysteria.
Lilium Tigr. Partial amenorrhoea accompanied by nervous affection of the heart and ovarian irritation or uterine displacements and leucorrhoea.
Phosphorus. Amenorrhoea with blood spitting, or haemorrhage from the nose, anus or urethra; especially in tall, slender phthisical patients; dry cough and tight feeling in the chest.
Pulsatilla. Anaemia without chlorosis. First menses delayed; menses late, scanty, and of short duration; suppressed fro getting the feet wet; heavy pressive pain in abdomen and small of back, as from a stone; leucorrhoea like cream or milk; pains shift from part or part; constant chilliness; especially adapted to patients with light hair and blue eyes, and who are of a gentle, submissive, tearful disposition.
Senecio. Menses suppressed from cold; irregular, tardy or scanty; great debility; nervousness; sleeplessness; gastric derangements; pulmonary disease.
Sepia. Menses late and scanty, leucorrhoea before the menses, like milk, excoriating; uterine displacement; face sallow, with yellow spots; bearing-down pains; weakness and tired pain in small of back.