The sudden and permanent cessation of menstruation, whether at the normal climacteric age, or earlier in life, is always a pathological occurrence. As compared with the normal, gradual disappearance of menstruation, associated with the usual climacteric symptoms, such a sudden extinction of menstrual activity is, moreover, quite rare. When it does occur, the cause is to be found in one of various pathological general states, such as one of the acute infectious disorders, or some other exhausting disease, or sometimes in some local disease of the reproductive organs; occasionally, however, it may occur in perfect health, in consequence of some powerful physical or mental stimulus, such as a severe blow or intense fright.
This sudden menopause has been observed after severe labour or abortion with profuse haemorrhage, or after cholera or typhoid; we must assume that in such cases the anæmia of the genital organs has disturbed the function of ovulation; whilst in cases due to mental shock, the interference with ovulation must be through the intermediation of the nervous system. Frequently, of course, in these cases, the sudden menopause is also a premature one.
Tilt reports a case in which a sudden menopause ensued upon phlebotomy during menstruation; several cases also in which women at ages varying from 30 to 34, or 39 years, ceased to menstruate suddenly and permanently in consequence of grief at the unexpected death of the husband; and another case of sudden menopause due to a fall down stairs. Courty reports three cases of sudden menopause at the age of 30, consequent upon an attack of cholera. Dusourd has seen three cases in which, in women aged 40 to 43 years, severe haemorrhoidal bleeding was followed by sudden and permanent cessation of menstruation. Mayer reports the case of a delicate middle-class woman 34 years of age, who had begun to menstruate at the age of 14, had married at the age of 20, and at the age of 21 after a normal delivery, ceased for ever to menstruate; and another case of a working-class woman 34 years of age who first menstruated at the age of 13 years, married at the age of 20, had two children in rapid succession, and finally ceased to menstruate, in consequence of a fright, at the age of 30 years. Krieger reports the case of a very nervous woman who first menstruated at the age of thirteen, and in whom at the age of 23 a sudden menopause ensued upon a nervous attack; in another case reported by the same observer, a sudden menopause occurred in a delicate woman 41 years of age owing to her husband’s death—this woman had previously experienced six months amenorrhœa in consequence of sorrow at the death of one of her children. The following remarkable case is reported by Brierre de Boismont: A sempstress began to menstruate at the age of 13 years; she married very soon after this, and gave birth to four children, the last when 21 years of age. In the course of the following year there was a fire in the house, and owing to this fright a sudden menopause occurred. Similar cases have been reported quite recently by Bossi and Walter.
The harmful influence which the occurrence of a sudden menopause exercises upon the general condition of the woman who experiences it, is manifested chiefly by violent circulatory disturbances, hyperaemia and congestion of the brain, lungs, and abdominal organs, and by states of excitement and depression of the nervous system. Of the vicarious haemorrhages which are apt to ensue upon such a sudden menopause, we have already spoken.
Generally speaking, women in middle life, in whom the whole organism is accustomed to the onset and decline of the menstrual hyperaemia, endure the functional disturbances induced by a sudden and complete cessation of menstruation much more easily than women who have already entered upon the climacteric age, or have nearly attained that age. The climacteric age is one in which women are already predisposed to circulatory disturbances in the pelvic organs, and it will readily be understood that in them the sudden interruption of the menstrual haemorrhages will have more serious consequences than in women in the prime of their sexual life, and therefore endowed with a greater power of resisting disturbances of the normal functions.
Pathology of the Menopause.
Diseases of the Genital Organs.
Among the commonest of the symptoms of the sexual epoch of the menopause is menorrhagia. It occurs especially in plethoric women, in those who during the prime of their sexual life have been accustomed to menstruate abundantly, and in those who have given birth to many children or had many miscarriages; but it is seen also in weakly and delicate individuals, in whom the tissues of the genital organs have become extremely flaccid and loose in texture. A luxurious mode of life, more especially a free consumption of alcoholic beverages, and also frequent sexual intercourse during the climacteric period, appear to favour the occurrence of menorrhagia at this epoch.
Not infrequently, menorrhagia is the first sign of the commencement of the climacteric, menstruation having been hitherto regular, and not excessive in amount. Generally, when this climacteric menorrhagia begins, the intervals also become shorter, the menstrual period being reduced to three or even two weeks. At times, however, the more profuse menstruation recurs at longer intervals, six weeks, two months, or even longer. In any case, the occurrence at the climacteric age of a severe or atypical haemorrhage, renders it the imperative duty of the physician to undertake a local examination of the genital organs; for it is necessary to ascertain without delay whether such a haemorrhage is a true climacteric phenomenon, or whether it is due to some actual disease of the reproductive organs—a neoplasm, or the like.
If the haemorrhage is due solely to the change of life, the vaginal portion of the cervix will usually be found soft and flaccid, bleeding readily on slight injury, and sometimes eroded; there is generally associated leucorrhoea. This relaxation and loss of firmness in the uterine tissues at the time of the menopause is the cause of the predisposition to excessive haemorrhage. An additional cause exists in the circulatory disturbances in the pelvic organs. We presume that women affected with menorrhagia at this time of life suffer from some persistent disturbance in the region of the inferior vena cava, whereby the outflow of blood from the veins of the pelvis is hindered, and a chronic condition of stasis in the uterus is conditioned. Hence arises distension of the vessels of the uterine mucous membrane, and this rhexis is relieved by the excessive haemorrhages. In these considerations lies the explanation of the fact that women who have had many children or many miscarriages, are especially prone to suffer from climacteric menorrhagia; and also women who for any reason are predisposed to intra-abdominal stasis.