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 [{440}] 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.
CHAPTER IV
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 [{441}] 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.