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.





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