The term menorrhagia signifies excessive menstrual flow. The excess may be by increased rate of discharge during the usual time, by lengthened duration, or by too frequent returns of the periods.

There are wide physiological limits to the amount of discharge and the duration of a menstrual period. While the average time is from three to five days, and the average amount from three to five fluidounces, both these terms may be doubled, or, on the other hand, they may be diminished to a single day and a single ounce, without detriment to the health. Menorrhagia may be said to exist when the flow is in excess as compared with what is usual with the individual, or when the loss is so great as to affect her general health.

The periodical return of the flow is of prime importance in establishing the existence of menorrhagia. Repetition at periods approximating the menstrual is the keynote of diagnosis. By this menorrhagia is distinguished from the hemorrhage of a miscarriage and from metrorrhagia. A profuse flow of blood after an absence of menstruation for one or two months is held by patients, in perfect good faith, to be the effect of taking cold: with almost absolute certainty such a train of events indicates an abortion. Metrorrhagia is uterine hemorrhage occurring independently of the menstrual periods. More surely indicative of organic disease than menorrhagia, it is often most closely allied to it; many cases which in the early stages present an increased menstrual flow as a symptom are at a more advanced period accompanied by metrorrhagia.

Thus far the diagnosis of menorrhagia is easy. Not so that differential diagnosis upon which alone can therapeutic measures be based.

This derangement depends upon as many and as widely diverse causes as the others. It is often one expression of affections of the general system, is sometimes caused by disease of organs neither pelvic nor generative, is a common symptom of a number of organic diseases of the uterus, or it may be simply functional. The necessity for a thorough physical examination is apparent. By touch, single and bimanual, by the speculum, and by the uterine sound the condition of all the pelvic organs should be investigated. These means failing to reveal the cause of the menorrhagia, the examination should be pushed farther. The cervix should be dilated by tents and the cavity of the uterus explored. Very frequently this measure, and this alone, will reveal the cause of the derangement. Such an examination is often as valuable for its negative as for its positive results. No practitioner fulfils his duty to his patient or is just to himself who treats a menorrhagia for any length of time without making a physical examination. It may seem unnecessary to emphasize so plain a duty, yet consultants very frequently find cases in which palpable causes of the disease exist and where a direct examination has not even been proposed.

The following schedule will indicate the widely diverse conditions which may give rise to menorrhagia, and will serve as a guide to the study of the subject:

CAUSES OF MENORRHAGIA.—
I. Diseases of the General System:
Plethora;
Chlorosis and anæmia;
Debility, as from excessive lactation;
The exanthemata and typhoid fever;
Hæmophilia;
Scorbutic, uræmic, and malarial cachexiæ.
II. Local Affections, not Uterine:
Cerebral, as psychical influences;
Cardiac and pulmonary affections, as valvular disease, emphysema, and phthisis;
Hepatic diseases, as cirrhosis and the changes produced by residence in tropical climates;
Splenic and renal disease;
Abdominal tumors and loaded bowels;
Peri-uterine inflammations;
Ovarian influences.
III. Uterine Causes:
Subinvolution;
Areolar hyperplasia;
Endometritis, with fungous growths;
Laceration of the cervix, with eversion;
Ulceration of the cervix;
Displacement of the uterus;
Polypi and fibroid tumors;
Retention of products of conception;
Malignant disease;
Congestion.

I. Menorrhagia, the result of the first class of causes, but rarely occupies more than a subordinate position. The acute affections, as the exanthemata, do not afford time for more than a single flow, and this has been well termed uterine epistaxis. The condition of plethora is manifest. The cachexiæ are generally well marked and evident. An exception may be made in this regard as to the effect of prolonged residence in malarious locations. There can be no question that menorrhagia is frequently of malarial origin, and even when the patient does not present a cachectic appearance. The disease may be produced by hepatic and splenic derangement, by deteriorated sanguinification, or by depression of nervous force. Menorrhagia is not infrequently a result of Bright's disease; an examination of the urine would determine this point. That the opposite conditions of plethora and anæmia should both cause menorrhagia is not difficult of explanation; in the one there is excess of blood with increased vascular pressure; in the other, a changed condition of the blood favoring transudation, with loss of tone of the vessels.

II. That menorrhagia, as well as amenorrhoea, may have a purely emotional origin there can be no question, although this cause is not generally recognized. The following case is an illustration: A healthy young married woman, while menstruating, saw a neighbor's son thrown from his horse; his foot became entangled in the stirrup, and he was trampled to death before her eyes. She was immediately taken with flooding, and profuse menstruation occurred for several succeeding periods. Siredey expresses doubts as to cardiac and pulmonary diseases so frequently causing menorrhagia as they are generally believed to do. In a considerable experience during several years, and paying special attention to this point, he found but one case thus caused. The mechanical effect of disease of the abdominal organs in producing passive congestion in distal parts is more direct and the influence in producing menorrhagia more apparent. The same may be said of accumulations in the bowels and the pressure of abdominal tumors. Peri-uterine inflammations rank very high in the list of causes: their presence and results, direct and indirect, as abscesses, displacements of the uterus, etc., should never be overlooked. Ovarian influence is naturally a potent etiological factor; menorrhagia is a frequent result of sexual excesses, and is often seen in prostitutes and where there is great disparity of age between the husband and wife.

III. Affections of the uterus itself are by far the most frequent cause of menorrhagia. The necessity of investigating accurately the condition of the great central organ of menstruation, and of ascertaining to what particular disease the derangement of the flow is to be attributed, will bear repetition. That an anatomical or pathological diagnosis can always be made is not maintained, but when examination has failed to reveal a basis for such a diagnosis, the practitioner should distrust his position and consider his diagnosis provisional only, awaiting more information from renewed examination or from further progress of the case. The cases are few in which such a diagnosis cannot be made. They are recognized by the term congestion as a cause in the schedule given above. Congestion is of course the prominent factor in many cases of menorrhagia, as in those from polypi and fibroids, those produced by ovarian influences, and others which are evident. But the class here recognized consists of those cases in which no anatomical or other cause can be found, excess of the congestive element of menstruation alone affording a rational explanation. Such cases occur most frequently at the two extremes of life—at puberty and at the menopause. During both these periods menorrhagia often occurs unexpectedly and inexplicably.