Another cause of climacteric menorrhagia is to be found in the frequent occurrence at this epoch of advanced arteriosclerotic changes in the uterine blood vessels, the disease being in some cases limited to the uterine arteries, and in others part of a general arterial degeneration. The blood may be derived from ruptured sclerotic capillaries of the mucous membrane; but in other cases it exudes in consequence of passive hyperaemia, without actual rupture of the bloodvessels. To such haemorrhages from atheromatous vessels we must refer many of the attacks of uterine haemorrhage that occur in elderly women, such as were formerly, before their true nature was understood, commonly regarded as instances of a very late return of menstruation. By careful examination the exact source of the blood can often be detected in such cases.

According to Theilhaber, one cause of the haemorrhages occurring at the climacteric is to be found in the atrophy of the uterine muscle which takes place at this period of life. Except during pregnancy and the puerperium, the uterus is usually in a state of moderate contraction; during the height of the menstrual flux, however, the uterus is relaxed. Then, as contraction of the muscle sets in, the menstrual hyperaemia and consequent haemorrhage are gradually brought to an end. When this contraction is insufficient, the hyperaemia and swelling of the uterus are more enduring. In association with the atrophy of the uterine muscle at the climacteric, there usually occurs a notable diminution in the size of the uterine vessels, so that, notwithstanding the diminished strength of the muscular contractions, any excessive loss of blood is prevented. But if this diminution in the calibre of the vessels fails to take place, the atony of the uterine muscle leads to hyperaemia, to haemorrhage, and often, in addition, to oedema of the organ, with elongation and thickening of its walls—hyperplasia uteri preclimacterica.

Among diseases of the uterus which during the climacteric may give rise to severe haemorrhage, and may lead to the mistaken opinion that menstruation still continues, we must in the first place mention carcinomatous disease of the cervix and of the body of the uterus; next in importance come myoma and fibrous polypi; less frequent causes of such haemorrhages are fungous endometritis, erosions, mucous polypi, prolapse of the uterus, and ovarian cystoma.

The climacteric age gives rise to a predisposition, not only to bleeding, but also to other pathological changes in the reproductive organs. We can by no means endorse the opinion of Currier—one long ago expressed also by Brierre de Boismont—that women during the sexual epoch of the menopause are less disposed to diseases of all kinds, and among them to diseases of the genital organs, than younger women, for the reason that their tissues are endowed with less vitality, and are, therefore, more resistent to all the causes of disease. On the contrary, the number of pathological disorders liable to affect the reproductive organs precisely at this period of life, is strikingly large. Among my 500 cases of women at the climacteric age, there were 440 who complained of such symptoms, the diseases from which they suffered being, in order of frequency:

Profuse haemorrhages in286 cases
Chronic metritis in79 cases
Leucorrhoea in327 cases
Displacements of the uterus117 cases
viz., prolapsus in65 cases
anteflexion and retroflexion in52 cases
Genital pruritus in46 cases
Vaginismus in12 cases
Carcinoma uteri in3 cases
Myoma uteri in5 cases
Tumor mammae in8 cases

I need hardly point out that in many individuals more than one of these diseases were present at the same time.

The most obvious feature of these statistics is the extraordinary frequency of uterine haemorrhage and of leucorrhoea in climacteric women. The former condition was present in more than half my cases; the latter actually in three-fourths.

The same two pathological states were also those most frequently recorded in Tilt’s statistics. This author, in 446 women at the climacteric, found the following diseases of the reproductive apparatus:

Haemorrhages in138 cases
Leucorrhoea recurring at irregular intervals in146 cases
Leucorrhoea recurring monthly in12 cases
Remittent menstruation in33 cases
Vaginitis in4 cases
Follicular inflammation of the vulva in10 cases
Inflammation of the labia in4 cases
Ulceration of the cervix uteri in9 cases
Prolapsus uteri in5 cases
Uterine polypi in4 cases
Fibrous tumours of the uterus in4 cases
Cancer of the uterus in4 cases
Chronic ovarian tumours in3 cases
Irritation and swelling of the breasts in14 cases
Lacteal or gelatinous secretion in breasts in2 cases
Hard, non-malignant tumour of the breast in2 cases
Chancre of the breast in1 case
Frequent sedimentation in the urine in49 cases
Difficult and painful micturition in9 cases
Incontinence of urine in4 cases
Haematuria in2 cases
Perineal abscess in2 cases

Chronic metritis and endometritis come under observation with considerable frequency during the climacteric age, but as a rule these diseases have originated during the period of sexual maturity, and in exceptional instances only does the cessation of the menses appear to be the etiological starting point of these disorders. In fact, this occurs only when the menopause is premature, or when it is quite sudden in onset, whether this be due to noxious influences or to constitutional disorder. For the menstrual process quite normally gives rise to a certain congestion of the genital organs; and should menstruation be suddenly suppressed, the blood-stasis in the uterus becomes so extreme that morbid tissue changes are very likely to ensue. And when chronic metritis has occurred before, the congestion and stasis in the uterus at the climacteric will usually suffice to light up the inflammatory process afresh. This is the explanation of the fact that symptoms of slight metritis make their appearance at the very beginning of the climax, manifested by thickening of the corpus uteri and of the portio vaginalis of the cervix, by swelling and softening of the mucous membrane, and by abundant secretion. In those who, either after full-term delivery or after abortion, have suffered formerly from chronic metritis or endometritis, but who have been quite free from any symptoms of these troubles for many years prior to the climacteric, it often happens that the change of life is ushered in by symptoms of congestion of the uterus with associated leucorrhoea. With the completion of the menopause, however, the resulting involution of the uterus exerts a favourable influence upon all such chronic inflammatory processes in the genital organs; as the atrophy progresses, the periodic attacks of congestion cease to recur. Thus it happens that women who for years have suffered from haemorrhages, from inflammatory disorders of the genital organs, and from various other troubles of a similar nature, will, once the menopause is fully over, feel quite well up to an advanced period of life—they seem as it were to begin life afresh.