Definition. Dysmenorrhoea is a painful menstruation, the pain usually occurring just before or during the flow, but it may also be present after the flow has ceased.
Pathology. Dysmenorrhoea being but a symptom of various pathological states, it cannot be said to have any pathology which is distinctively its own. If all the organs of generation and their surrounding tissues are in perfect form and vigour, and sustain their normal relations to one another, and at the same time the blood and nervous systems are unimpaired, menstruation will take place without creating distinct pain, it being accompanied by only a sense of fullness and discomfort in the parts, and slight bearing-down sensations in the back and loins. As to its severity, dysmenorrhoea may vary in degree from this normal condition, to one in which the patient suffers for a few hours or for many days the most excruciating and agonizing pains, may induce other complications which together eventually destroy life. This condition may be brought about by any pathological state which causes a change in the shape or position of the uterus, congestion of the uterus, ovaries or surrounding cellular or serous tissues; or, a depreciated condition of the blood and nervous system creating a tendency to neuralgia, the uterine nerves, as a consequence, being in a state of hyperaesthesia. If neither of these conditions are present, dysmenorrhoea is not likely to occur, though our knowledge of pathology is not yet so perfect that we can say that such a thing would be impossible.
Varieties. For study and clinical convenience we may classify dysmenorrhoea as follows: (i) Congestive; (2) Neuralgic; (3) Membranous; (4) Obstructive. Some authors include also the spasmodic and ovarian varieties, but, as a rule, cases included in the former belong rather to the obstructive variety, while those dependent, supposedly at least, upon ovarian disturbance, may properly be classified as either congestive or neuralgic. It must be remembered, however, that any classification is more or less arbitrary, and cannot be rigidly followed. Nature does not always follow the lines thus established, to say nothing of those cases which present the characteristic of more than one variety, being dependent upon more than one pathological condition.
1. Congestive Dysmenorrhoea
At the menstrual period, as has already been noted, a certain amount of congestion is normal, which involves the mucous lining of the uterus and tubes, sometimes also including the ovaries, the cellular tissue and the peritoneum. Whenever from any cause this normal congestion increases beyond physiological limits, the condition is known as congestive dysmenorrhoea.
Aetiology. As may be readily inferred, but slight causes are sometimes necessary to induce an aggravation of the already existing normal congestion. These are most apt to operate in full-blooded, plethoric girls, who sometimes suffer more or less from this form of dysmenorrhoea through life, the least exciting cause serving to intensify their sufferings. Yet at the same time congestive dysmenorrhoea may occur in weak and anaemic girls who are subject to any of the following causes. General plethora; sedentary or luxurious mode of life; exposure to cold or wet; displacements; fibroid tumors; chronic metritis; endometritis; salpingitis; ovaritis; pelvic cellulitis; pelvic peritonitis.
Symptoms. The patient usually complains for a few days before the period of a feeling of fullness. Weight and heat in the back and pelvis, the flow being ushered in with more or less violent symptoms of a congestive or inflammatory nature, flushed face, hot skin and increased temperature. The pain varied in severity and character, but it is usually a steady, dull pelvic pain. The hypogastrium is usually more of less distended, hot and sensitive to the touch, the latter being often more noticeable over the left ovarian region. If the flow comes on freely the patient is ordinarily relieved, but this is not always the case, the suffering sometimes continuing to greater or lesser extent for several days.
Prognosis. As a rule the prognosis is favourable, though cases resulting from irremediable pathological states are sometimes found. There are cases, too, occurring usually in plethoric women, where more or less aggravation of the normal menstrual congestion seems to become a habit of the individual, and relief comes only with the menopause.
Treatment: Ordinary this from of dysmenorrhoea is amenable to the indicated remedy. The remedies most often required are, Aconite, Apis, Belladonna. Bryonia, Cimicifuga, Ferrum phos., Lachesis, Nux vomica, or Viburnum op.
2. Neuralgic Dysmenorrhoea
In this class there is usually no structural lesion or organic disorder, the dysmenorrhoea depending upon the presence of a neurotic constitution, the nervous system in general and the uterine nerves in particular, being in a state of morbid sensibility, so that the causes which might in others produce neuralgia of the head or stomach or other parts, here concentrate their force upon the uterine nerves, giving rise to hyperaesthesia, which, under the influence of the menstrual congestion, causes pain. As one author says, the nerves play a part corresponding to that of the vessels in the congestive form.”
Aetiology. The predisposing causes are in general the same as those which tend to produce neuralgia in other parts: The neuralgic diathesis, either hereditary or acquired; hysteria, which is rather a result of the nervous condition, than a cause; chlorosis; plethora; malaria; gouty or rheumatic diathesis; mental onanism; excessive sexual indulgence, or ungratified sexual desire; ovaralgia.
Symptoms. In this variety of dysmenorrhoea the patient seldom at any time experiences an entire freedom from suffering During the inter-menstrual period she may feel only a sensation of weakness, weariness and weight, but oftener she suffers more or less with headache, neuralgia and other nervous affections, including hysteria, which become more pronounced as she approaches the menstrual nisus. At this time also she may show aberrations of temper, irritability and a tendency to melancholy. In some cases there is no considerable inconvenience until the menstrual period arrives, which is usually quite regular. At this time, whether prodromata have been present or not, the patient experiences excruciating pain in the uterine region, back and loins, which usually moderates or entirely disappears when the flow is established, but in some cases continues with more or less severity during the whole period. The neuralgic nature of the pain is recognized not only by its character, but also by the fact that in some women it occurs at some distant part of the body, as the eye or face, instead of the uterine region, while in others it may alternate in its location, or involve different localities at the same time. The feet and hands are almost invariably cold. After the attack she is usually greatly exhausted for several days.
Diagnosis. The presence of the above described symptoms and the absence of anatomical changes, are usually sufficient to establish the diagnosis. The pains are not expulsive, the blood is not clotted, and physical examination reveals no obstruction. From the congestive form it is chiefly differentiated by the absence of congestive symptoms. It is also, when once established, more regular in its occurrence, regardless of exciting causes.
Prognosis. As in other neuralgias the prognosis depends largely upon our ability to discover and remove and cause. If the patient inherit a neuralgic diathesis, the prospects for a cure are very discouraging. Otherwise, if she will consent to the adoption of such hygienic measures as are required to restore the tone of the nervous system, the prognosis is quite favourable.
Treatment. The first duty of the physician is to prescribe, such hygienic measures as will have a tendency to restore the tone of the nervous system. The patient should, if possible, be relieved of all mental worry and excitement and not be exposed to the influences to cold or damp, though in pleasant weather an abundance of fresh air and sunlight are indispensable. Flannels of proper weight should be worn next the skin during all seasons. She should take regular and systematic exercise, though never carrying it to the point of fatigue. A plain, nourishing diet is essential, and all the habits of life, especially as to sleeping, eating and defecation, should be regular. Often a change of climate and scenery will afford much benefit.
In cases in which the suffering is extreme, the temptation to give an opiate is very great, but we should remember that such relief is only temporary often no more than can be had with the properly indicated homoeopathic remedy, that it is obtained at the expense of the patient’s general health, and, being oft repeated, is almost sure to lead her to acquire the morphine habit.
The remedies most often required are: Asclepias, Belladonna. Caulophyllum, Chamomilla, Cimicifuga, Gelsemium, Hyoscyamus, Ignatia, Phosphorus, Platinum, Pulsatilla, Viburnum, Xanthoxylum.
3. Membranous Dysmenorrhoea.
Definition. Membranous dysmenorrhoea is painful menstruation accompanied by the discharge of larger or smaller pieces, tube- shaped portions, or pear-shaped sacs forming complete casts of the lining membrane of the uterus. Pathology and Aetiology. It must be understood at the onset, that the membrane cast off in this form of dysmenorrhoea is not a plastic exudation due to a croupy or diphtheritic endometritis, as was once supposed, but, that it consists of more or less of the lining membrane of the uterus. Various theories have been advanced to account for this process, but none of them have been fully established. Dr. Williams, London, contends, as do many others, that, “the whole, or a large amount of the mucous lining of the body of the uterus is cast off at every period. In health this is accompanied by a fine disintegration, giving rise to no pain or visible phenomena. Under certain as yet obscure conditions, however, disintegration of the mucous coat does not take place, though expulsion does.”
Dr. Oldham claims “that at some time during the intermenstrual period, the entire lining membrane of the uterus is lifted from its base and separated, so as to be ready for extrusion at one of the next menstrual crises.” How this is accomplished, and why it occurs in only a small number of women and not in others, is still unknown, but it is generally supposed to result from inflammation or congestion. Scanzoni attributes it to “a considerable hyperaemia of the wall of the uterus, which is followed by an excess in the development of the mucous membrane.” Simpson attributes it “to an exaggeration of a normal condition, or to an exalted degree of a physiological action.” It has also been claimed that the membrane was deciduous in its character, the product of an abnormal conception, but as it occurs in women who have never had sexual intercourse, this theory has been discarded. Winckel, who is one of our reliable authorities, says that, “the membrane shows the changes characteristic of endometritis; therefore, the term endometritis dissecans is not inappropriate.” Dr. Winterburn says that, “it should be noted that the membrane thus thrown off is not the product of the present catamenial epoch, but of the preceding one.”
Winckel thus describes the anatomical appearance of the membrane: “These membranes show a smooth reddish inner surface upon which the orifice of the utricular glands maybe seen by the naked eye, and an external rough uneven surface, which appears as though torn from its connections, and it occasionally contains small blood clots. It is of unequal thickness, is usually very thin and almost transparent at the points where the walls join each other, and somewhat thicker at those portions where the mucous membrane has not been uniformly exfoliated. In many cases the discharged membrane is a complete sac containing three openings corresponding to the os uteri and the orifices of the tubes. Sometimes this exfoliative endometritis is associated with an exfoliative colpitis; large pieces of membrane, consisting of ulcerated pavement epithelium, are discharged, nd these are followed by tenacious fibrinous portions like those thrown off after the application of a concentrated solution of alum; yet I have seen such a colpitis dissecans occur in a virgin who had not used injections.”
The microscope shows an excess of round small cells and fibrillated tissues, the former being easily differentiated from the large irregular cells of a decidual membrane.
Symptoms. The symptoms vary much in intensity in different individuals, in some the membrane being discharged regularly with but little pain. Ordinarily the period is introduced by slight pains which gradually increase in intensity, until they become violent and expulsive, like the pains or abortion, and cease only when the membrane has been expelled, which is usually on the second or third, or more rarely, on the fourth day. The flow is not always profuse, being sometimes quite scanty, and not infrequently the membrane plugs up the cervix so that the blood is retained, and is discharged in clots after the expulsion of the membrane. The time between the periods is usually free from pain, but the patient usually feels weak and miserable, and may complain of various symptoms which are the result of existing complications.
Diagnosis. The nature of the pains and their regularity with each menstrual membrane expelled, are usually sufficient for diagnosis, but it may be necessary to submit the latter to a microscopical examination in order to differentiate either from an early abortion, or, less often, blood-casts or fibrinous moulds of the uterus, or exfoliations of the vaginal mucous membrane, or the exudation of diphtheritic endometritis.
Prognosis. This is usually considered unfavorable, though if treatment be commenced at an early stage a cure may be effected. The disease is not dangerous to life, though it may become associated with complications that are sometimes fatal. Sterility is a usual consequence of membranous dysmenorrhoea, but cases are reported where conception has occurred in advanced stages of the disease.
Treatment. The hygienic measures already suggested for neuralgic dysmenorrhoea should, to some extent at least, be applied in this variety. From our present knowledge of the pathology of this disease it is impossible to deny that some dyscrasia is at its foundation, which may be partially overcome by a proper attention to the diet and habits of the patient. By some it is claimed that the disease occur only in persons of a rheumatic diathesis, and if so, it is especially necessary that the patient be protected from atmospheric changes. She should wear flannel next the skin continually, and so far as possible enjoy the benefits of a mild, dry and even climate.
Relief is sometimes obtained by having the patient anticipate the period a few hours by going to bed and applying heat to the abdomen, sacrum and extremities.
Various methods of treatment, such as dilatation of the uterine cavity, discission of the cervical canal, cauterization of the uterine mucous membrane, have been resorted to by old- school authorities with negative results. Dilatation of the cervix with tents often affords relief. On this point Dr. Ludlum says: “Very decided benefit may sometimes be derived from the employment of the spong tent, with a view to dilate and remove any obstruction of the cervix which prevents the free escape of the menstrual blood. This would cause the womb to disgorge, unload its capillaries, relieve the hyperaemia, avert an excessive hypertrophy of the mucous membrane, and possibly prevent its exfoliation. Moreover and it is by no means an inconsiderable thing this dilation greatly mitigates the sufferings of the patient.”
The remedies most often used are: Borax, Bromine, Bryonia, Calcarea carb., Cantharis, Caulophyllum, Iodium, Rhus tox., Colchicum, Collinsonia, Kali iod. Phosphorus, Gelsemium, Secale, Ustilago For the nervous and other concomitant symptoms that may arise, many other remedies may be indicated. See indications at the end of this chapter.
4. Obstructive Dysmenorrhoea.
Definition. A variety of a dysmenorrhoea dependent upon a partial or complete closure or obstruction of the genital canal, causing an impediment to the free escape of the menstrual discharge which collects above the obstruction and is only expelled by violent spasmodic pain. The obstruction most often exists in the cervical canal or at t he os, but it may be in the vagina or at the vulva.
Aetiology. The causes of obstructive dysmenorrhoea are: Atresia of the cervix of vagina, congenital or acquired; atresia of the hymen; stenosis of the cervix, congenital or acquired; flexion or version of the uterus, the former creating an angle in the canal, the latter less often causing in the canal, the letter less often causing obstruction by firm pressure of the os against the vaginal wall; forbid tumors in the cervix, causing distortion of the canal; uterine polypus obstructing the cavity or neck, often acting as a ball valve at the os internum, preventing the egress of fluids, but allowing the passage of a probe.
Symptoms. No symptoms are manifest until a sufficient amount of blood has accumulated within the uterus to cause distension, when spasmodic contractive pains are excited for the purpose of over-coming the obstruction. The pains gradually become more and more severe, the expulsive efforts resembling those of abortion, thought more painful. Finally a discharge, of more or less blood results and the pains are relieved until the accumulation has again taken place, when the process is repeated. The flow sometimes comes drop by drop, but more often the uterine contractions are followed by gushes, the blood being frequently clotted, the clots sometimes corresponding in size and shape of the uterine cavity.
In many cases, especially if they have existed for a length of time, more or less reflex symptoms are present. Vomiting is quite a common symptom, which is often obstinate and painful in character. There may also be indigestion, rectal and vesical tenesmus, and nervous, disorders, such as insomnia, chorea, hysteria, cramps, and even convulsions.
Diagnosis. Ordinarily the character of the pain and the regularity of its occurrence at each menstrual period will establish the nature of the case, but a positive diagnosis rests alone on a physical examination. The presence of an obstruction must be demonstrated beyond a doubt. This is accomplished chiefly by the touch and the sound, though a bi-manual or rectal examination, or even the speculum, may be necessary.
Prognosis. This depends chiefly upon our ability to overcome the mechanical obstruction. In some cases, however, the general state of the health resulting from persistent menstrual derangement is such that the prospects for an ultimate radical cure as less hopeful.
Treatment. The administration of remedies which accomplish so much in other varieties of dysmenorrhoea, is of little use here. The obstruction which gives rise to the trouble being purely mechanical in its nature, the treatment is necessarily surgical in character, though the pain may sometimes be temporarily relieved, or the constitutional or concomitant symptoms ameliorated by the use of the indicated remedy, or, by proper hygienic measures. In some instances the patient finds by experience that she obtains some relief by assuming and maintaining a certain position. This usually occurs when the trouble arises arises either from flexion or uterine distortion from a fibroid tumour.
Therapeutics of Dysmenorrhoea.
Aconite. Congestive dysmenorrhoea; high fever; abdomen swollen, hot and sensitive to the tough; vomiting; great restlessness and anxiety; pelvic inflammations.
Ammonium Carb. Cholera-like symptoms at the commencement of the menses; blood black and clotted; acrid, making the thighs sore; especially in nervous delicate women.
Ammonium Mur. Discharge of a quantity of blood from the bowels at every catamenial period; during the flow the discharge at night is more profuse.
Apis. Congestive or neuralgic dysmenorrhoea from ovarian influences; enlargement of the right ovary, which is sensitive and painful; also with pain in the left pectoral region, with cough; sharp plunging or stabbing pains in the uterus, or in the head, sometimes followed by convulsions, at every menstrual period, the patient feeling tolerably well during the interval scanty, dark urine; waxy skin.
Asclepias Cor. Dysmenorrhoea associated with dropsy; or catarrhal conditions, intermittent, bearing-down, labor-like pains.
Belladonna. Congestive dysmenorrhoea in plethoric women, especially girls, of when associated with local pelvic inflammations; rush of blood to the head; throbbing headache; full bounding pulse; abdomen hot, painfully distended and sensitive to the touch or jarring; great pressing downward in the genitals, as if they would protrude through the vulva.
Borax. Membranous Dysmenorrhoea. Menses too early, too profuse, and attended with colic and nausea.
Bromium. Membranous dysmenorrhoea; violent contractive spasms during the menses, lasting for hours, leaving the abdomen sore; loud emissions of flatus from the vagina.
Bryonia. Membranous dysmenorrhoea, or, when associated with rheumatic symptoms; distention of the abdomen, and colic; profuse flow; stitching pains, worse from the slightest motion.
Cactus. Excruciating, agonizing pain in the lumbar region during the menses, sensation of painful constriction in the groins, extending around the pelvis; flow scanty, ceasing when lying down; acute pains and sensations of constriction about the heart.
Cantharis. Membranous dysmenorrhoea; burning in the vulva and ovarian region; itching in the vagina; vesical tenesmus and painful urination.
Caulophyllum. Congestive or neuralgic varieties; also obstructive from retroflexion or retroversion; spasmodic pains in the uterus and various portions of the hypogastric region, congestion and irritability of the uterus; fullness, heaviness and tension in the hypogastric region; scanty flow.
Chamomilla. Drawing from the sacral region forward; griping, pinching, or labor-like pain in the uterus, followed by discharge of large clots of blood; tearing pain in the legs; very sensitive to pain; nervous and irritable.
Cimicifuga: All things considered, this is our most valuable remedy in all varieties of dysmenorrhoea. It is especially useful in congestive or neuralgic forms, when occurring in nervous, hysterical or rheumatic women; lancinating shooting pains in the uterine and ovarian regions; bearing-down in the uterine region and small of the back; excruciating pain in the abdomen, small of the hysterical spasms; scanty flow; between the periods debility, nervous erethism, neuralgic pains.
Cocculus. Neuralgic dysmenorrhoea in nervous, hysterical women; cramps in the abdomen; colic pains; faintness and debility; nausea; convulsions.
Collinsonia. Obstructive or other forms of dysmenorrhoea resulting from haemorrhoids or constipation; pruritus; displacements.
Gelsemium. Neuralgic, congestive, and what has been termed by some authors, spasmodic dysmenorrhoea; severe, sharp, labor- like pains in the uterine region, extending to the back and hips, dull aching in the lumbar and sacral regions; neuralgia of distant parts; cramps in the abdomen and legs; convulsions.
Hyoscyamus. Extreme nervousness, even to mania, or hysterical spasms; during the menses convulsive trembling of the hands and feet; headache, nausea and profuse sweat; labor-like pains in the uterus, with pulling in the loins and small of the back; involuntary loud laughter and silly actions; lascivious, uncovers and exposes herself.
Ignatia. In nervous, hysterical women who sigh and brood over imaginary troubles; violent labor-like pains, followed by discharge of black clotted blood of a putrid odor.
Kali brom. Very nervous, restless and sleepless; neuralgic form from ovarian or uterine irritation; obstructive form from sub-involution or fibroids.
Kali Carb. Cutting, stitching pain in the abdomen ; aching in the small of the back; uterine spasm; menses acrid, of a bad odor, excoriating the thighs; especially useful after loss of fluids or vitality, especially in anaemic persons.
Kali Iodium When occurring in mercurial, syphilitic or scrofulous subjects, or when associated with or arising from chronic rheumatism; frequent urging to urinate when the menses appear; tearing, darting pains in the limbs; painful bloating of the abdomen; subsultus tendinum; always worse at night.
Lachesis. Labor-like pains and sharp pains in the left ovarian region and in the uterus, relieved when the flow begins; the uterus will not bear the contact even of the clothes, which cause uneasiness, but not pain.
Lilium Tig. Neuralgic dysmenorrhoea, or dysmenorrhoea from displacement; bearing-down, with sensation of heavy weight and pressure in the uterine region, as if the whole contents of the pelvis would press out thorough the vagina; severe neuralgic pain in the uterus and ovaries; sub-acute uterine inflammations; sympathetic cardiac symptoms.
Nux Vomica. Contractive uterine spasms; colic pains followed by the discharge of coagula; pressure toward the genitals; pain in the back; nausea; faintness; constipation; irritable, oversensitive, choleric patients.
Platina. Painful sensitiveness and constant pressure in the region of the mons veneris and genital organs, with internal chills and external coldness, except of the face; bearing-down and drawing pains in the abdomen; spasm and screaming; flow dark and clotted; ovarian inflammation; pruritus; nymphomania; hysteria.
Pulsatilla. Heavy pressive pain in the abdomen and small of the back, as from a stone; the limbs tend to go to sleep; menstrual colic; flow thick and black; chilliness; symptoms ever changing; shifting pains; nausea, especially mornings; the patient peevish, fretful and inclined to weep.
Secale. The discharge black, fluid, every fetid, expulsive pains; colic; spasms, cold extremities; cold sweat; weak pulse and great prostration.
Senecio. Dysmenorrhoea with urinary sufferings, tenesmus, heat and urging; pain in the back and loins; pale, weak, nervous sleepless, hysterical; catarrhal subjects.
Sepia. Dysmenorrhoea from endometritis; weakness and tired pain in the small of the back; bearing-down and pressure in the uterine region; leucorrhoea before the menses, yellow, like milk; excoriating; like pus; of bad smelling fluids; displacements.
Sulphur. Long standing and obstinate cases in scrofulous subjects; headache before the menses; headache and nosebleed during the menses; blood thick, dark, acrid, corroding, sour- smelling; yellowish, corrosive leucorrhoea; burning in the vagina.
Thuja. The congestive from from ovarian inflammation; distressing burning pain when moving; she must lie down; much noisy flatus in the abdomen; vaginismus.
Ustilago Maidis: Membranous dysmenorrhoea; the blood dark and clotted; constant aching distress in the uterus; burning in the ovaries.
Veratrum Alb. Dysmenorrhoea, with vomiting and purging, or exhausting diarrhoea and cold sweat; nymphomania before the menses.
Veratrum Viride. The congestive variety; menstrual colic; intense cerebral congestion; strangury before the menses; convulsions.
Viburnum Opulus. This is one of our most promising remedies for dysmenorrhoea; it relieves all cases of the congestive or neuralgic type, and sometimes membranous and obstructive also, but its action seems to be exhausted in about three months. Before the menses, severe breaking-down, drawing in the anterior muscles of the thighs; heavy aching in the sacral region and over the pubes; occasions sharp, shooting pains in the ovaries; pains make her so nervous she cannot sit still; excruciating, cramping, colicky pains in the lower abdomen and through the womb; pains begin in the back and go around, ending in cramps in the uterus. During the menses, nausea; cramping pain and great nervous restlessness; the flow ceases for several hours, then returns in clots; the flow scanty, thin, light-coloured, with sensation of lightness of the head; faint when trying to sit up.
Xanthoxylum. Neuralgic dysmenorrhoea, especially in women of a spare habit and of a delicate, nervous temperament; ovarian pains extending down the genito-crural nerves. Dreadful distress and pain; headache; menses too early and too profuse; pains down their anterior part of the thighs.