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.





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