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Dysmenorrhea





Practically every woman of menstrual age has more or less discomfort
during menstruation. In most cases this does not rise beyond a heavy
depressed feeling shortly before menstruation begins, followed
by a sense of weight and discomfort in the back and then some
sensations more or less acutely uncomfortable due to congestion in the
pelvis, which begin to be relieved with the commencement of the flow
and then gradually disappear. Even in otherwise healthy women, various
achy feelings of distention are often felt in the neighborhood of the
ovaries, but these would scarcely be described as pain, unless the
patient is over-sensitive. The effect upon the disposition is more
marked and more universal. Some women are inclined to be irritable and
hard to get along with for a few days before their menstruation and
sometimes during the whole of its course. The frank recognition of
this fact by them and a consultation of the calendar when they find
that everything seems to be going against them and that everybody is
lacking in sympathy, usually leads to an appreciation of the fact that
the trouble is in themselves rather than in those around them, and
their condition becomes more bearable. It is curious, however, to note
how often this is forgotten, with consequent give-and-take of
irritation in their environment that makes the nervous and mental
condition worse and emphasizes the physical symptoms.

The term dysmenorrhea, from the Greek, means difficult menstruation
and is usually associated with painful conditions in connection with
the menstrual flow. It may be applied, however, to various
uncomfortable feelings, to superirritability, to fatigue, to lack of
energy, or even to more vague discomforts at this period. The
discomforts are usually spoken of as pains, especially after the
patient has been dwelling on them for some time and has been reading
patent medicine advertisements that tell of how women suffer in
silence, but analysis often shows that they are sensations of
pressure, of compression, of achy distress at most, and sometimes only
of unusual feelings--paresthesiae--that having got over the threshold
of consciousness, through concentration of attention upon them, are
occupying the center of the stage of mental activity to the exclusion
of all serious interests.

The serious difficulties of menstruation are due to definite
pathological conditions such as displacements of the uterus,
affections of the uterine mucosa and of the ovaries. There are,
however, many cases where the trouble is merely functional, dependent
on conditions that can be easily corrected without serious surgical or
even lengthy medical treatment, and where the patient's attitude of
mind towards the trouble is the most important factor in the medical
aspect of the case. As a matter of fact, many of the discomforts and
even serious pains complained of in connection with menstruation are
due rather to the patient's incapacity to bear even slight discomfort
with reasonable patience and without exaggerated reaction than to the
actual pain inflicted by whatever disturbance of function and tissue
may be present. People differ very much in their power to stand
discomfort and what seems quite trivial to one becomes unbearable
torture to another. With this in mind it is possible to relieve many
women who suffer from dysmenorrhea from their discomforts so that they
shall only have to bear what is every woman's heritage in the matter.
Successful management of these cases will save them from the supposed
necessity of being operated on, which is likely to be constantly
suggested to them in an age when women so often talk of their
operations.

The amount of pain suffered from any cause is dependent on two
factors, the pathological condition and the power of the individual to
withstand discomfort. When we are irritated, when we are very
tired, when we have fever, when we suffer from want of food or lack of
sleep or any other condition that exhausts vitality, even slight pains
become hard to bear. In relieving pain it is as important to remember
this lessened capacity to stand discomfort as it is to get at the
cause of the discomfort itself. This habit of standing discomfort with
reasonable patience is one of the best remedies for lessening
suffering, especially when it is known that the discomfort is only
temporary and the end of it is in sight.


Physical Condition.--In the treatment of suffering incident to the
menstrual period, then, the correction of all conditions that may
increase nervous irritability and make patients less capable of
standing pain should be the first care. Young women who are thin and
anemic, especially if they are more than ten per cent. under weight,
are likely to suffer much at their menstrual periods for two
reasons--through their lack of power to withstand discomfort and owing
to the fact that their ovaries and the uterus itself are especially
sensitive, probably through lack of nutrition consequent upon their
general condition. In these cases local treatment is not as necessary
as improvement of the patient's general condition and the raising of
her general bodily tone.

The bowels must, of course, be regulated, partly for the sake of the
general condition and the fact that it is very hard to have a regular
appetite unless there is a daily evacuation, and partly also because
the presence of an accumulation of fecal material in the lower bowel
is likely to produce congestion in the pelvic region. This added to
the normal congestion due to the menstrual function may cause undue
pressure upon sensitive nerves in the ovaries and uterus. Indeed a
regulation of the function of the bowels is immediately followed by a
lessening of the menstrual discomfort as well as by a general
improvement. Many women find that the taking of a gentle purge a day
or two before the menstrual period serves to make that period a source
of less discomfort than it would otherwise be, and undoubtedly the
suggestive value of such a remedy persuades many women that their
discomfort should be lessened.

Professor Goodell's reminder that women have many organs outside of
their pelvis is important in dysmenorrhea. Almost any ailment that
drains a woman's strength and brings a series of irritations to bear
upon her nervous system will be reflected in her genito-urinary system
and will cause discomfort during the menstrual period. Over and over
again the physician finds that the true source of the menstrual
discomfort is not in the essentially feminine organs, but in the
digestive organs or occasionally even in such distant organs as the
lungs, and that proper attention to these brings relief during the
menstrual period. Just as soon as they realize that this is not a new
affection but only a reflex from their other ailment, whatever it may
be, they stand it with much better spirit and their complaints
diminish.

Anyone who has seen the difference between the reaction to menstrual
moliminia when patients are in good condition and when they are
otherwise run down will realize how much a matter of over-reaction to
symptoms dysmenorrhea may be. Teachers who begin the school year,
invigorated by their vacations, scarcely notice their periods, but at
the end of the course, when run down by months of hard teaching work
and especially by the confinement of the winter, they find the strain
extremely hard to bear. In many of these cases an examination by a
specialist seems to reveal something that might be benefited by
operation. There may be various uterine displacements, sensitive
ovaries, perhaps slightly enlarged yet often not distinctly
pathological, but just as soon as the physical condition is made
normal, the symptoms given by these conditions completely disappear.
Women who have nothing particular to do, who talk much about
themselves and their ills, who have had friends operated on and heard
much talk about the subject, are soon convinced that only an operation
will do them good. Once that suggestion is implanted in their minds,
the hypnotic dread of the operation and the morbid attraction of being
a center of interest and commiseration will make them exaggerate their
symptoms to such a degree that operation becomes almost inevitable.


Moral Fiber.--It is often said that modern women, as the result of
civilization, refinement, and city life, are of laxer physical fiber
and therefore cannot stand the ills that their grandmothers bore with
equanimity and considered as nothing more than what was to be expected
in this imperfect existence. Most physicians must feel, however, that
the increased laxity is not so much of the physical as of the moral
fiber. We have not weaker bodies than our forefathers, but weaker
wills. This is especially so with those who have much time to think
about themselves, and, therefore, is more true, of women than of men,
though in our generation men also have become very introspective. I
have seen--and I am sure that my experience is a common one among
physicians--delicate women who seemed unable to stand any trial or
hardship successfully, placed by unfortunate conditions--such as the
sudden death of a husband, or his failure in business--in
circumstances that were extremely hard to stand up bravely against.
Not only did they stand it, but they had better health, they had less
complaint of pains of all kinds, particularly in this matter of
dysmenorrhea, than they had before.


Pain and Occupation of Mind.--The more claims a woman has on her
attention the less likely is she to be bothered at her monthly
periods. If she does not have to get up in the morning because there
are no insistent obligations upon her, she is likely to lie in bed and
worry about herself and by concentrating her attention on her ills
will make them worse than they are. But if she has to be up and doing,
if household cares cannot be put off, if she has to earn her living by
working every day, she not only succeeds in doing it, but often also
forgets her ills to a great extent in her occupation. Of course, there
are pathological conditions that cannot be put off in this way, and if
there are serious uterine changes, or if an infection has spread along
the tubes to the ovaries, there will be symptoms that cannot be
distracted away. Even where there are minor pathological conditions,
however, occupation of mind will make pain less annoying and even make
it quite negligible. We know our own experience with toothache. This
is a real pain and with a real pathological condition of the most
material kind. The congestion of the sensitive dentine or the
irritation of an exposed nerve filament causes about as severe pain as
it is given to mortals to bear. Even with toothache, however, we can
by occupying ourselves with friends, or with a pleasant book, or a
game of cards, or the theater, so diminish the annoyance consequent
upon the pain as to be comparatively comfortable. If anything
completely occupies our attention as, for instance, a fire or an
accident, or bad news from a friend, then it may be hours afterwards
before we realize that we were suffering from a toothache. Since this
will happen with a dental nerve, why should it not happen to
branches of the genital nerve? There is no reason why one should be
more sensitive than the other, and whatever reason there is is rather
in favor of the dental nerve giving more bother, since it is nearer
the center of the nervous system and these nerves are usually said to
be more sensitive.


Working Women.--With regard to painful menstruation, the habits of
many country people, and of the European peasantry generally, furnish
valuable indications of the power of work to dissipate discomfort.
During my medical student days in Vienna I had the opportunity to know
rather well a group of women who were engaged in working on a
building. They carried up the bricks and mortar for the men and worked
the windlasses by which heavy materials were carried to the different
stories, and they mixed the mortar and prepared the building materials
generally. These women, living constantly in the air and working very
hard, had almost no symptoms of menstrual difficulty. They never laid
off at this time except in a few cases in which subinvolution after
pregnancies and genital infections had left conditions that made it
hard to understand how they worked at all.

I learned in addition from them, for most of them came from the
country, that the women who work so commonly in the fields in central
Europe have little difficulty with menstruation and practically do not
know that it is coming on them until the show indicates its presence.
I had known before how true this was for the Irish peasant women. This
seems to be the normal healthy condition, and the state of mind of
these women aids this satisfactory state of affairs. They rather look
down upon women who complain at this time as being of such inferior
health as to be despised. Doubtless if they were persuaded, as so many
seem to be, that a woman must expect to have a serious time, or at
least a great deal of discomfort about this period, they would have
it, too. Of course, they have some difference of feeling at this time.
They feel more tired in the evenings, and they awake in the morning
less rested, but that is no more than the changes in the weather bring
to men.

On the coast of Brittany and Normandy many of the women rake for
shellfish. Their custom is to wade into the water and, standing with
the water often above the knee and waves sometimes washing as high as
the waist, to rake all day for the shellfish that they are seeking.
They do not lay off from this occupation, as a rule, when their
menstruation is on them, but continue as if nothing were the matter,
and there are very few complaints of menstrual troubles among them.
Such occupation would seem to be positively counter-indicated, but
long years of experience have shown them that there is no need of
interruptions in their work and as they need every centime that they
can obtain in this way for the support of their families, they
continue even in very cold weather, when it would seem inevitable that
this must produce serious results.

It is not uncommon for a young woman, who, while her family was in
good circumstances, was a severe trial to everyone for a week more or
less, every month, to become quite free from trouble for herself and
others when, owing to a change in the family circumstances, she has
had to take up some occupation for a living. I have notes of cases of
this kind in which the pain was so severe that, after several years of
medication and external applications, it was decided to dilate the
cervix uteri in the hope of affording relief. The relief thus
afforded, however, was only temporary. A little later in life,
however, the necessity of earning a living has in some cases quite
freed these young women from the torments that sent them so frequently
to their physicians.


We need the report of many more of such gynecological conditions which
get better as a consequence of occupation of mind without any other
treatment. We have any number of reports of benefits derived from
operation, but not infrequently these reports refer only to a few
months after the operation, when the strong mental suggestion of the
performance of the operation and the general betterment of health
consequent upon care during convalescence are still acting upon the
patient, and she has the benefit of the gain in weight and strength
that usually follows because of hope, appetite, exercise in the air,
etc. Not infrequently in these cases there are, later on, sad relapses
into painful conditions quite as severe as before, while, on the other
hand, some change in the circumstances of the individual, or some
intense preoccupation of mind a few years after, brings lasting cure,
thus showing that it was the mental state which was at the root of the
condition rather than any bodily affection.


Spasmodic Dysmenorrhea.--There are two forms of dysmenorrhea that have
been the subject of much study. One of them consists of cramp-like
pains which occur some time before menstruation, are relieved if the
flow is copious, but continue if it is scanty. This affection has
often been attributed to mechanical obstruction. Nearly twenty years
ago Dr. Champneys in his Harveian Lectures on Painful Menstruation
discussed this subject, and showed that the mechanical explanation
while very simple and popular was probably not correct. His conclusion
was that the dysmenorrhea was more frequently due to conditions
outside of the uterus than in that organ. He recommended plenty of
healthy exercise between the periods and especially riding if the
patient were not a working woman, regular activity of the bowels with
epsom salts as probably the most valuable single remedy, and then a
number of drugs such as guiacum and sulphur that are not specifics but
have a general effect. In his experience castoreum, a strongly
suggestive remedy, gave more relief than anything else. He advised
against local treatment unless there was a very definite reason for it
and frankly expressed the opinion that the complaints were often due
more to an incapacity to stand the slight discomfort that is more or
less inevitably associated with the congestive state that precedes
menstruation than to any pathological lesion.


Membranous Dysmenorrhea.--This affection like membranous colitis
remains one of the mysteries of pathology and etiology. There is no
doubt, however, that there are large nervous elements in its
production and that it is worse at times of worry, while mental
factors of many kinds influence its occurrence and also its relief. In
his Harveian Lectures Dr. Champneys discussed the questions connected
with it very well and his monograph is a classic on the subject. Many
drugs have seemed successful and then have failed. Castoreum has done
good in this as in spasmodic dysmenorrhea. A number of gynecological
methods of treatment have been successful when first applied, when
physician and patient were both confident of their value, and then
later has failed. Probably nothing does more good than getting the
patient's mind off her condition, securing such occupation as will not
permit of introspection to any extent, though of course treating
surgically whatever requires operation. It must not be forgotten that
while many of those suffering from the disease complain of pain,
not a few sufferers from it have no symptoms of this kind and their
condition is discovered more or less by accident. After this there is
likely to be much more discomfort from it. All this must be borne in
mind in its treatment.


Minor Ovarian Lesions.--In many cases there is vague discomfort in the
ovarian region about the time of menstruation, and the ovary is found
to be somewhat enlarged or perhaps dislocated. In these cases if there
is continued complaint of pain, operation will almost surely be
advised and frequently cysts are found. This is considered to be
justification enough for the removal of the ovaries or at least for
their resection. It is doubtful, however, whether ovarian cysts in the
majority of cases are really a pathological condition. Those who are
engaged in spaying cattle think it almost if not quite normal for
cysts to exist in the ovaries. Whether this is not also true of women
we have not the data to determine. In a number of the patients who are
operated upon for this condition there is a relapse of symptoms, and
there seems to be no doubt but that whatever good is accomplished
comes from the expectation of relief followed by the weeks of rest and
quiet in bed and very often the gain in weight which succeeds the
operation. Whether something of this kind would not follow from the
simpler procedure of improving the general health is an open question.

It is sometimes insisted that the general health will not improve in
gynecological cases unless the offending pathological condition is
removed. This is true if the patient is persuaded that there is some
pathological condition present which must be corrected or else she
will not be better, and if favorable suggestion cannot be used to
advantage. If, however, these patients understand from the beginning
that probably the local condition, which gives the symptoms, is due
rather to their general health than to a definite lesion, there is
more probability of improvement. It is surprising how many of these
cases are relieved by an improvement of the general health, by the
relief of constipation, by the decrease of congestion by laxatives,
and by the persuasion that there is nothing which will go on to
serious developments (this is the most disturbing of dreads) but only
a condition that will probably get no worse and the symptoms from
which may yield to general treatment.

The popularity of many so-called remedies for women's diseases is due
to their success in lifting the veil of discouragement and, by
alcoholic and other tonic stimulation, helping the women into a better
general condition and a more favorable frame of mind.


The Individual.--In all cases of dysmenorrhea, then, it is important
not to be influenced too much by the complaints (for here, as
Broadbent insists with regard to angina pectoris, the more complaint
we have the less serious the condition will often be), but to
investigate the patient's condition and, where there is not some
definite and serious pathological lesion, to analyze the beginning and
the development of the individual case and eliminate the neurotic
elements. Often the menstrual difficulty is due to suggestion, as the
patient has been in contact with others who were sufferers and caught
her complaint from them by psychic contagion. Special investigation is
needed as to her occupation of mind. This must be provided for her.
Nothing else will save her from herself. Travel may do it, exercise
may be helpful, but an occupation in which she is deeply interested,
especially if it involves association with other people, is the
best basis of psychic treatment. Improvement of the general health and
the relief of various symptoms are auxiliaries.


Unfavorable Suggestion.--After consulting with many women physicians,
with many women who have lived active lives, with many superiors of
religious orders in consultation about their religious women, I cannot
but conclude that painful menstruation is ever so much oftener a
result of mental and nervous states than of organic disturbances.
Unfortunately a tradition has now been established that women suffer
much at this time, so many of them give in to their feelings,
exaggerate their discomfort, dwell on their sensations, affect the
blood supply to the genital organs through the sympathetic nervous
system, actually produce functionally pathological hyperemia where
only physiological was present (the simile of the blush makes this
easy to understand), and finally set up a condition that is actually
painful, though there was only some discomforting sense of compression
and congestion before. We have been educating young girls in disease,
not in health. Plato pleaded for the opposite. After these 2,400 years
we might take it up seriously.





Next: Menorrhagia

Previous: Amenorrhea



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