Part 86

3. The Woman’s Sexual Activity.

An important influence upon the early or late onset of the menopause is exerted by the degree to which a woman’s reproductive functions have been exercised during the menarche. My personal observations have shown me that in women who are in good health and of a powerful build, whose menstrual flow has always been regular and sufficient in quantity, whose reproductive organs have been adequately and properly exercised, who have had a physiological amount of sexual intercourse, have given birth to several children, and have suckled these children, the cessation of the menstrual flow generally occurs much later than in women in whom the conditions of the sexual life have been the opposite of those just mentioned. The more regular menstruation has been, and the more normal the deliveries, the later does the menopause ensue.

Especially striking is the influence of the number of deliveries upon the time of occurrence of the menopause. In women who have given birth to a number of children, menstruation as a rule continues for several years later than in sterile women, or in those who have had one or two children only. If a woman suckles her children, the date of the menopause appears also to be postponed. Deliveries late in life seem likewise to delay the onset of the menopause, whereas abortions accelerate its occurrence. If, however, pregnancy succeeds pregnancy at extremely short intervals, the menopause is likely to occur early; the same result is brought about by sexual intercourse at too early an age. The menopause occurs latest in women who have begun to menstruate early, who have married, have given birth to more than three children, and have been delivered of their last child at full term when 38 to 42 years of age.

As regards the 500 women previously mentioned, in whom I made personal observation as to the age at which the menopause occurred and the circumstances by which its onset was influenced, the effect of marriage and the number of children born is shown by the following details:

Of the 48 women in whom the menopause occurred between the ages of 35 and 40, 16 were unmarried, 6 married and childless, 18 married with one or two children, 8 married with more than two children.

Of the 141 women in whom the menopause occurred between the ages of 40 and 45, 3 were unmarried, 4 married and childless, 46 married with one or two children, 88 married with more than two children.

Of the 177 women in whom the menopause occurred between the ages of 45 and 50, 1 was unmarried, 2 were married and childless, 32 married with one or two children, 142 married with more than two children.

Of the 89 in whom the menopause occurred between the ages of 50 and 55, none were unmarried, none were childless, 19 were married with one or two children, 70 were married with more than two children.

Of the 17 women in whom the menopause occurred at an age above 55 years, there were two only who had not had more than two children, whilst there were 10 who had had six to eight children.

The influence of lactation is shown by the fact that in the case of 40 women who had not suckled their children, the mean duration of menstrual activity was four years less than the established mean duration of 27 years.

4. The Social Circumstances of the Woman’s Life.

The conditions in which a woman passes her life are not without influence upon the time of onset of the menopause. In general it may be said that among the women of the labouring classes, whose livelihood is so often precarious, and who are apt to suffer from habitual physical overwork, menstruation ceases at an earlier age than among the women of the well-to-do classes and those who lead an easier life. But though the climacteric thus occurs earlier among the lower than among the upper classes, the difference is not a considerable one.

According to Mayer’s calculation, the mean age at which menstruation ceases is, in upper class women, 47.13 years, in lower class women, 46.97 years. Small as this difference appears, amounting on the average to no more than two months, it must not be forgotten that among the upper classes, menstruation begins earlier than among the lower classes, by an amount which averages 1.31 years. Thus the total duration of sexual activity is almost one and a half years longer in the upper than in the lower classes.

5. General Constitutional and Pathological Conditions.

An important influence upon the time of occurrence of the menopause is exerted by the individual and hereditary predisposition of the woman, by her constitutional state, and by certain illnesses from which she has suffered. Women who by inheritance are constitutionally weakly and delicate, in whom the menstrual flow has always been pale and scanty, in whom the intermenstrual intervals have been excessive, and who have a slender habit of body, attain the climacteric age earlier than women with vigorous bodily development and powerful muscles, with large breasts, and in whom menstruation has always been regular and abundant. Women with a great tendency to obesity cease to menstruate earlier than women of more normal proportions; blondes earlier than brunettes; women of phlegmatic temperament earlier than women of a sanguine and ardent temperament.

In general it may be said, that all influences which have a weakening effect upon the feminine organism, tend also to accelerate the onset of the menopause: such are, severe labour, great sorrow, wearisome occupations, severe menstrual losses, rapidly succeeding pregnancies, and abortions; also a number of pathological general states shortly to be discussed, as well as local diseases of the reproductive organs.

Fritsch points out that menstruation continues to a later age in proportion as the woman’s state of general nutrition is a good one. He also asserts that women with a very large uterus, who have always had an abundant menstrual flow, those with retroflexion, with hypertrophy of the portio vaginalis, or chronic endocervicitis and endometritis, and those with small myomata which have given rise to no marked symptoms, often continue to menstruate far beyond the usual age.

The mean duration of the climacteric phenomena, from the commencement of these until the final cessation of menstruation, is about two years. This mean is made up of extremely wide individual variations; in a small proportion of the cases the climacteric manifestations may last no more than a month or two, whilst at the other end of the scale we meet with cases in which the duration extends to 4, 6, 8, and even 18 years.

In considerably more than half of all the cases, however, the duration of the climacteric manifestations varies between six months and three years. Thus, in Tilt’s series of cases, the duration of the “change of life” was

6 months in 12.07 of all cases 1 year in 22.64 of all cases 2 years in 18.62 of all cases 3 years in 9.43 of all cases

6. Premature, Delayed and Sudden Onset of the Menopause.

In exceptional cases, the menopause, instead of taking place between the fortieth and the fiftieth year of life, occurs at an abnormally early or an abnormally late age.

Premature cessation of menstrual activity, in the third or the fourth decennium of life—very rarely indeed before the third decade—depends in part upon disturbances of metabolism and of haematopoiesis, and in part upon diseases of the female reproductive organs; in some cases, however, it may be due to some hereditary constitutional peculiarity; or it may occur suddenly, in consequence of some violent shock to the nervous system.

Among the disorders of metabolism which may lead to a premature menopause, excessive adiposity, lipomatosis universalis, occupies the first place. Next in order of importance come a chloro-anæmic condition of the blood, pernicious anæmia, splenic leukaemia, certain of the acute infectious disorders—typhoid, cholera, scarlatina, acute articular rheumatism,—further pulmonary tuberculosis, diabetes mellitus, Graves’ disease, Addison’s disease, and myxoedema. These various conditions may give rise, in part by infective processes, and in part in consequence of the general cachectic condition, to atrophy of the ovaries with destruction of the graafian follicles, and to atrophic processes in the uterus, and these changes lead to the premature cessation of menstrual activity.

Excessive obesity has a restrictive influence upon ovarian activity, manifested in part, as already mentioned, by the occurrence of sterility, but in part also, in very obese women, by the onset of a premature menopause. Among 215 cases of extreme obesity in women, I found 49 in which the menopause occurred at a remarkably early age. In these cases the menopause occurred at the following age:

In 1 woman at the age of 17 years In 14 women at the age of 20 to 25 years In 11 women at the age of 25 to 30 years In 9 women at the age of 30 to 35 years In 14 women at the age of 35 to 40 years

In none of these cases did the local examination of the reproductive organs disclose the existence of any noteworthy disease.

Of the diseases of the genital organs which are competent to give rise to a premature cessation of menstrual activity, the most important are the puerperal infective processes and other inflammatory states of the reproductive organs, with their results—chronic metritis, perimetritic and parametritic exudations, chronic oophoritis, atrophy of the uterus and the ovaries.