Amenorrhea





No feature of menstrual difficulty shows so clearly the influence of

the mind over bodily function, and especially over those genital

functions that are supposed to be involuntary and spontaneous, as

amenorrhea. Almost any kind of mental trouble may produce a cessation

of the menstrual functions. Profound grief or a severe fright nearly

always does. Every physician of large experience has seen cases of

women who have missed their period because they were disturbed by a

fire, or a runaway, or an automobile or railroad accident within a

short time before their menstruation should normally occur. Even

slighter shocks may have a similar effect, and a profound shock of any

kind will seriously disturb menstruation. The most frequent effect is

to inhibit it, but it may be anticipated or delayed, and where there

is a tendency to too profuse a flow, it may produce menorrhagia.



Every physician knows that much less serious mental influences than a

profound shock or fright may somewhat disturb menstruation and, in

young women at least, this disturbance is nearly always in the

direction of lessened flow and amenorrhea. Home-sickness, for

instance, will often have this effect. Many of the foreign-born

domestics who come to this country have serious disturbances of their

menstrual flow, usually a diminution, during the first three or four

months after they arrive in America. This may, of course, be due in

part to change of climate, change of food and change of habits of

life. These girls while in their European homes have often been

accustomed to be much more out of doors and to have more exercise in

the open air than they have here.



That the mental state has much to do with menstruation may be

appreciated from the fact that serious changes of her state of life

may be accompanied by amenorrheal symptoms even when the patient stays

in the same climate and under conditions not different physically from

those under which she has lived. Country girls who come to the city

often suffer from such symptoms. Young women who enter convents

sometimes have these symptoms for some months, and this is so well

recognized as to be expected in a certain number of cases. Indeed,

there is danger that it should be attributed too much to the change of

mental state, and that other factors, such as incipient tuberculosis,

or disease of the ductless glands, or anemic states, which are

responsible for it, may fail to be appreciated because of the ready

explanation afforded by the mental factor. General experience shows

that the attitude of mind of a patient toward menstruation, the

expectancy of it at a particular time, and a good general physical

condition that predisposes to it, are quite as important for its

regularity as the specific physiological conditions which naturally

bring it about.





Fright and Amenorrhea.--Fright particularly may disturb menstruation

in many ways. Occasionally the disturbance of menstruation consequent

upon shock lasts for months or even years. At times when a woman

between thirty-five and forty is seriously frightened, especially by

terror that endures intensely for some hours, the sort that is

said to blanch the hair in a single night--and there are

well-authenticated instances--menstruation never recurs or if it does

recur it is vicariously from some other portion of the body than the

genital tract. Among my notes is a case of a woman frightened by a

revolver which a maniac had flourished for hours at her while she

dared not make a move nor a sign. Her menstruation stopped completely

for a time and then came back irregularly and usually from the ear.

The bleeding was from the pierce in the lobule which had been made for

earrings, and before it started a large swelling of this would come on

in the course of an hour, often not subsiding for days. In another

case a woman who was frightened during menstruation by an insane

person flourishing a knife near her had for several years after an

extremely irregular menstruation, and usually only the molimina in the

genital tract, while the bleeding was from the nose. Deep emotion can

very seriously affect menstruation.





Pseudocyesis.--The mind may bring about a cessation of menstruation in

another way without any other factor interfering and in spite of the

fact that physiological conditions would all seem to be favorable to

its regular occurrence. We have many cases in medical literature in

which married women anxious to have children have concluded that they

were pregnant, and have had complete cessation of their menstruation

for months with all the symptoms of beginning pregnancy, so as to

deceive even careful physicians. The best known historical instance is

that of Queen Mary, the eldest daughter of Henry VIII of England, who,

nearly forty when she married Philip II of Spain, was very anxious to

have children. Not long after her marriage menstruation stopped and

all the ordinary symptoms of beginning pregnancy developed. Her

condition was widely heralded throughout the kingdom; then, after a

time, to the intense disappointment of the Queen and her friends, it

proved that she was not pregnant but that her mental attitude had

produced the series of symptoms that proved so deceptive. These cases

of pseudocyesis are so likely to occur that a physician in dealing

with a woman, who being rather well on in years when she marries is

anxious to have children, must be on his guard and he must always take

into account the possibility of a pseudo-pregnancy and must be careful

not to be deceived by symptoms that would ordinarily indicate beyond

doubt the beginning of pregnancy. Even experts have been deceived in

such cases, and it is in them that accurate rules for the certain

detection of pregnancy are most needed.



These symptoms have reference not only to the uterus, but also at

times to other organs. They are not merely subjective, but sometimes

become so objective as almost to demonstrate the diagnosis of

pregnancy, and yet a mental condition is the only source of the

changes. For instance, cases of false pregnancy have been reported in

which, besides the gradual enlarging of the abdomen with many of the

signs of pregnancy accompanying that phenomenon, there has been an

enlargement of the breasts and even the secretion of milk. In a few

cases the enlargement of the abdomen has been accompanied by

pigmentation and the areola of the nipple has also become pigmented.

This is not surprising, since corresponding changes take place in

connection with fibroid tumors, and the deposit of pigment is not a

symptom of pregnancy, but only a result of the congestion which takes

place in these structures during their enlargement.







Amenorrhea from Dread.--In some cases all the symptoms of pregnancy

develop, or at least there is complete cessation of menstruation, as a

consequence of nervousness and dread of the occurrence of pregnancy.

Unmarried women who fear that they may have become pregnant by

indiscretion, sometimes become so worried over their condition that,

without any physiological reason, they miss one or more periods and

thus add to their nervous state and further inhibit menstruation,

though usually two months is the limit of such amenorrhea and the

menstrual flow commonly makes its reappearance shortly before or after

the time of the third period. Occasionally, however, in the case of

anxiously expectant married women further symptoms of pregnancy may

appear and the case becomes more complicated. Every physician of

considerable experience has seen such patients, and doubtless much of

the harvest which advertisers reap from drugs that are supposed to

produce abortion comes from nervous young women who are not really

pregnant, but have inhibited their menstruation by worry, and who take

these medicines with confidence and have the menstrual flow restored

by trust in their efficacy.





Ductless Gland Disease.--Of course, in many cases of amenorrhea there

are serious underlying constitutional conditions which may or may not

be amenable to treatment, but the possibilities of which must always

be thought of. One case of amenorrhea I saw in recent years proved to

be due to a beginning acromegaly. There was no sign of enlargement of

the hands, though there had been a coarsening of the face which was

attributed to growth and to the fact that the girl was taking much

horseback exercise in all weathers. She had a headache for which no

remedy seemed to be of any avail, and when the amenorrhea developed it

was naturally thought that the headache must be due to gynecologic

conditions. Nothing was found on investigation, however, and

eventually the gradual development of the symptoms of acromegaly

showed what was really the basic cause. Occasionally diseases of other

ductless glands, as the thyroid, may have amenorrhea as one of the

first symptoms. It is seldom that any serious thyroid condition

develops without disturbance of menstruation, but this is less

frequently in the direction of diminution than toward profusion and

prolongation. In some cases, however, one or more periods is missed in

the early development of the disease. In this, however, others of the

characteristic tripod of symptoms--rapid heart, tremor,

exophthalmes--are sure to be present even though the enlargement of

the thyroid is not noticeable.





Tuberculosis.--But more important than these causes of amenorrhea is

the early development of tuberculosis. In some cases, even before

there is any cough that calls attention to the condition, or when the

cough has been considered to be one of those myths now fortunately

passing, "a cold that hangs on," the cessation of menstruation may

depend entirely on the weakness and anemia due to the growth of

tubercle bacilli in the lungs.





Inanition Amenorrhea.--Sometimes indigestion, or what is supposed to

be indigestion, may be at the root of the amenorrhea. In many cases it

really is not true indigestion that is present, but a disinclination

for food which has increased to such a degree as to bring about a

lowered state of nutrition. In nervous young women and, above all, in

nervous spinsters beyond forty, disturbances of menstruation

consequent upon lack of nutrition are not infrequent. Often their

indigestion is considered to be a reflex from their genital

organs, when, on the contrary, whatever disturbance of their genital

organs is present is due to the inanition which has developed because

they have not been eating enough. Many of these women literally starve

themselves, and they, must be persuaded to eat once more and taught

what to eat, and their weight must be watched until it gets up to what

is normal for their height.





Psychotherapy and Treatment.--The treatment of amenorrhea on

psychotherapeutic principles will be readily understood from the fact

that there is a distinct psychic element in practically all the cases

touched on in this chapter. This psychic element is generally

appreciated and admitted. If a woman is accustomed to connect certain

physical incidents with disturbances of menstruation, then those

disturbances are almost sure to recur. As a rule, many an incident

said to be disturbing to the function would probably have no influence

upon it but for the dread connected with it and the anticipation of

some interference. In all cases of amenorrhea, then, the patient's

mind must be put into a favorable state and suggestions must be made

that will lead to the expectancy of menstruation at the next regular

period. If the mind can cause menstruation to cease, as is clear from

experience, any inhibition from this source must be removed and its

power set to bring relief to these patients. Drugs should not be

neglected, and general physical conditions must be improved, but if

the patient's mind continues to be unfavorably affected towards her

menstruation, its satisfactory return will be delayed until somehow

mind as well as body are co-ordinates for the resumption of the

function.



The best testimony to the value of psychotherapy in amenorrhea is

found in the success of many of the remedies used for the condition,

which, in the successive phases of medical development, have included

all sorts of home treatments, many types of quack medicines, and

innumerable proprietary combinations. Many of these have acquired a

reputation for efficacy not justified by any direct pharmaceutic

effects which we now know them to possess. From the familiar gin and

hot water, through the various combinations of aloes and the tonic

remedies of a later time, only the most general and obvious effects

could have been produced by the medicines, yet apparently specific

reactions have followed them in the menstrual cycle. But this was

because the mind of the patient was prepared by the taking of the

remedies and unfavorable suggestions as to menstruation were removed.

Above all, with amelioration of the general health, constipation being

relieved, the appetite restored and the whole tone of the system

improved, nature became capable of taking up once more the menstrual

function. What was accomplished by indirect psychotherapy in the past

can now be done much better by direct mental suggestion, when at the

same time various remedial measures in other therapeutic departments

are employed as auxiliaries. But the physician must be sure that the

mind of the patient is properly disposed or remedies may fail and

symptoms continue.





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