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Menorrhagia





While the influence of the mind in producing painful menstruation and
a much diminished menstrual flow is well recognized, the connection
between the mind and an increased menstrual flow is not so generally
appreciated. Usually profuse menstruation (especially when it reaches
a height where it would properly be called menorrhagia) is considered
to be due to some serious pathological condition. Its most frequent
cause is undoubtedly subinvolution of the uterus after pregnancy, or
an overgrowth of the uterine mucosa because of some pathological
condition--usually an infection. While menorrhagia is often attributed
to colds or to getting the feet wet (and undoubtedly the disturbance
of the circulation consequent upon wet feet is an active factor in the
production of an increased menstrual flow) there is no doubt that in
most cases there is some more distinctly local cause at work. Another
important cause of profuse menstruation is the presence of a fibroid
tumor or other neoplasm which brings an increased blood supply to the
uterus and a consequent greater elimination at the menstrual epoch.

In most cases of subinvolution a curettage, at least, will have to be
done. Often the use of extremely hot douches, that is, just as hot as
can be borne, may accomplish much. Such quantities as a quart or two
are useless; several gallons should be taken, and that not in the
awkward cramped postures in which douching is sometimes done and in
which it cannot be expected to accomplish its purpose, but in the
reclining position and to be followed by an hour or two of rest with
the hips elevated. This treatment will be more effective if women do
not get the idea that an operation will surely have to be done on
them. Operations are now so much spoken about that some women
apparently do not feel that they have had quite all the experience
that is coming to them in life unless they have at least one to their
credit. If they can be made to realize that, in the past before the
days of operative gynecology, most such cases recovered of themselves
and that now if courage is resumed, appetite strengthened
through the will, constipation relieved, an abundance of outdoor air
secured (exercise is not so necessary), recovery will probably be more
complete than after an operation, there would be much less need of
operations than at present.

The material conditions based upon pathological changes which usually
produce menorrhagia hardly seem amenable to influence by the patient's
state of mind, yet experience demonstrates that much can be done for
these patients by setting their minds at rest, by improving their
general condition, by soothing their worry as to what the profuse flow
means. Many nervous patients have quite normal menstruation, as
regards the length and quantity of flow, until some serious
disturbance occurs in their mental state. I have had patients who for
months would have a perfectly normal menstrual flow of three to five
days to whom a serious mental disturbance always brings a profuse
menstruation. The arrest of a woman by mistake just before or at the
beginning of her menstrual period will often cause a greatly increased
flow and great weakness will follow. Women approaching the menopause
already have a tendency to an increased flow though not beyond the
bounds of what might be considered normal, and at this time almost any
shock will produce profuse menstruation and lead to prostration. If
the secondary anemia from this is not overcome during the interval
profuse menstruations may succeed each other for many months.

The necessity for reassuring these women, therefore, becomes evident.
Most of us have seen women who were worried at having a slightly
increased menstruation, and who had been told that they had a fibroid
tumor which was producing the increased menstruation, and which would
have to be removed if it continued to bring on this serious condition.
Such a suggestion inevitably leads to a series of more profuse
menstruations during the following months. Such women worry over their
state and dread an operation. They do not eat well and, even though
they do not lose much in weight, they often become distinctly anemic.
This anemia adds to the tendency to a freer flow and as a consequence
the menstrual period is lengthened in time and increased in amount.
This soon brings them to operation, though very often there has been
no increase in size of the fibroid tumor and there is no more reason
for operation than there was when they were first examined.

I have had under observation during the last two years a patient in
whom the diagnosis of a fibroid brought this unfortunate result. Her
menstruation had been profuse and prolonged before but now it became
still longer and lasted nearly fifteen days each month. As she lost
much in weight, was run down in strength, became self-centered, stayed
more at home, and took less exercise, the resultant depression in her
general condition emphasized the menorrhagia. As soon as it was made
clear to her that her case had but one indication for operation--the
loss of blood and that the fibroid was so small that it might well be
allowed to remain until after her menopause, when involution would
probably prevent further unfavorable action, she took heart, began to
exercise, ate more heartily, her marked constipation was relieved, she
slept better and in three months her menstruation was almost normal.
For many months she had no menorrhagia.

I have seen other cases in which amelioration of symptoms came just as
soon as the patient learned that, by improvement in the general
health, there was a possibility of lessening the tendency to
hemorrhage and thus of putting off the necessity for operation for a
time at least, if not until such natural changes occurred in the
system as to lessen the danger from the growing tumor. I have in mind
the wife of a physician whose menopause was delayed for some ten years
as a consequence of a good-sized fibroid growth. She had it when she
first came to me, and I watched the case for some seven years, and she
absolutely refused to entertain the idea of operation. I set her mind
at rest as to the seriousness of the growth provided the bleeding was
not injurious and no infective conditions occurred through the
intestinal walls to complicate the condition and cause adhesions.
Whenever she worked hard, or whenever she was much worried, she would
have alarming flooding. Under ordinary circumstances, however, when
things did not go awry, she had a menstruation somewhat more profuse
than normal and of five or six days in length. This continued from her
fiftieth to her fifty-fifth year, and then gradually subsided. She is
still alive at the age of sixty and, though she has had many trials
and hardships at the end of her life, she is healthy and considers
herself much better off than if she had had an operation. I doubt
whether this is true, that is, if the operation had been done twenty
years ago. But, after watching such a case and realizing that
operations on fibroids are more often fatal than any other of the
gynecologic operations that do not involve serious conditions, a
physician is justified in tiding women over the time to their
menopause and then letting nature dispose. Infective incidents
pointing to the formation of adhesions are a contraindication to this
policy, however.

The sufferer in this case was one of the most patient of women. She
had had to suffer much in mind and in body as the result of being left
almost destitute after a life of luxury, yet she seldom complained.
One might almost think her indifferent to hardship if one did not know
her well. She was not at all a stoic but she never allowed her
imagination to run away with her, she bore the ills of the day without
thinking of what was going to come next week and she worried as little
as possible under the circumstances. The ordinary woman, nervous and
excitable, would have broken down under the strain that was placed
upon her but she promises to live to a good age and her trials have
not hurt her vitality nor spoiled her disposition and she looks the
world in the face with surprising cheerfulness. This state of mind
modifies even fibroid menorrhagia favorably.

Fibroids have been reported "cured" by so many different
remedies--local applications, acupuncture, hot needles, electricity in
various forms, even internal treatment, which afterwards proved quite
unavailing--that it is manifest that the mind plays a large role in
controlling the symptoms.

Before operation it is important to put the minds of these patients
into an attitude of confidence, for operators who make it a point to
secure the confidence of their patients, or who for some reason have
their full faith, have better results in these cases than others of
equal surgical skill.

In unmarried women the development of a small fibroid with its reflex
disturbances is sure to be followed by excessive reaction in many
ways. Nervous symptoms are likely to be marked and the increase in
menstruation is usually much more profuse as a consequence of the
solicitude than because of the fibroid. Some of these tumors which,
though of small size, are so situated with regard to the nervous and
circulatory systems of the uterus as to produce profuse
menstruation even in women of phlegmatic disposition. In these
patients operations will be necessary whenever the loss of blood makes
it clear that the drain on the system is producing serious effects.
There are cases, however, in which the menorrhagia is not due directly
to the fibroid, but rather to its effect upon the general system and
this may be lessened very much by reassurance, by regulation of the
general health, by resumption of exercise and toning up of appetite
and, above all, by relief of the constipation which so often
complicates these cases. Fibroids may or may not continue to grow. The
removal of one is no guarantee that others will not form, nor that
others are not present in very small form which will develop later. As
a rule, there can be no question of the removal of the uterus unless
conditions are serious.

If in spite of general treatment and the calming of the patient as far
as possible profuse menstruation continues, it is an indication for
surgical intervention. Psychotherapy may readily be abused in these
cases, but it has a distinct use, and its application is more
frequently successful than has been thought; but it must be
deliberately employed. When, however, menorrhagia is a symptom of some
serious progressive condition, psychotherapy will do harm rather than
good. I have known women whose menstruation was stopped and then
recurred and even became profuse reassured that this was only a
symptom of the menopause when it was the first symptom of a cancer. In
such cases there must be no temporizing or reassurance, but a careful
determination of the actual condition must be made and immediate
operation done if it seems necessary. Psychotherapy may have a place
in incurable cancer, but in other cases it has none at all except to
calm the patient for operation where surgery may be of service.





Next: The Menopause

Previous: Dysmenorrhea



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