CHAPTER IV

THE MENOPAUSE--CHANGE OF LIFE

The menopause, or “change of life,” also called the climacteric period, represents the end of the reproductive life of woman. It does not imply, however, that this is the end of a woman’s sexual life--that is, the loss of sexual feeling and the capacity for sexual gratification. A further word will be said upon this subject later in the present chapter.

The change is usually not a sudden one, the symptoms gradually making their appearance, and the decline of the reproductive processes taking place slowly but continuously. The resultant disturbances, of course, involve the whole organism, affecting the functions of many of the organs, and causing other distressing reactions.

This epochal series of events is started in the first place by changes that occur in the ovaries. The tissue changes that take place in these organs produce a powerful ovarian stimulus. The normal internal secretion of the ovaries, characteristic of the female, which is responsible for the typical physiological attributes of the sex, is no longer contributed to the blood stream.

The specific manifestations of the menopause are, first, as the very name implies, the permanent termination of the menstrual flow; the occurrence of a number of nervous disturbances, disorders of circulation, tension of the blood vessels, and of the metabolism.

These manifestations are so striking that they have, from very remote times, led to the belief that they involved great danger to woman’s life at the climacteric period.

Available statistics, however, do not seem to lend much credence to this assumption. While it is a more or less trying period and the far-reaching changes in the woman’s organism are attended by certain grave possibilities, they are certainly not so dangerous as those involved in the high-tide of woman’s sexual life, due to pregnancy, parturition, and the after effects of childbirth, not to mention the hazards of venereal infection in the early years of woman’s active sexual life.

In this connection Kisch states: “It is often asserted that in this ‘critical period’ of the menopause, the mortality of the female sex is notably increased. The data available are somewhat conflicting, but a careful examination leads us to believe that, if due allowance is made for the natural increase in the mortality with advancing years, no important increase in the mortality of woman can be traced as due to the troubles and disturbances of the climacteric period.”

This authoritative observation is very important, and should do much to reassure women approaching or undergoing the trials of the climacteric age.

AGE AT WHICH MENOPAUSE OCCURS

Like the onset of puberty and other factors that enter into the sexual life of woman, there is a wide range of variation in the appearance of the menopause. The usual time, in the temperate zone, is between the ages of 45 and 50, although it may occur before or after these ages. The normal limits have been mentioned as from 44 to 52; anything before or subsequent to those ages being considered exceptional.

The principal circumstances that seem to influence the occurrence of the menopause are the following:

1. The climate.

2. The race of the woman.

3. The age at which puberty occurred.

4. The sexual activity of the woman’s life, including the number of pregnancies, and the use or non-use of the function of lactation.

5. The social and economic conditions of the woman’s life.

6. General constitutional and pathological conditions, particularly from the standpoint of heredity.

Inasmuch as it had been noted that under climatic influences puberty and the menopause have a chronological relationship, it was once accepted as a fact that when puberty began early, the menopause would take place early; and when puberty occurred late, the menopause was correspondingly retarded.

A more careful analysis of all the circumstances involved, however, indicates that this is true only in regard to the influence of climate upon sexual development. It is true that in a cold climate a woman begins to menstruate late and ceases to menstruate late, and that in a hot climate the opposite situation prevails.

However, if a comparison is made between women =living under similar conditions= with respect to latitude and climate, there is a very different result. On this basis, it is observed that the earlier in life a woman begins to menstruate, the later will be the age at which this function will cease.

The chief exception to this rule seems to be where menstruation has occurred at an =abnormally= early age, as, for instance, before the age of 12. Extremes either way, precocious menstruation, or when greatly retarded, usually work toward the same end--a premature menopause.

In women who enjoy good health, whose menstrual flow has always been regular and sufficient in quantity, whose sexual functions and reproductive powers have been adequately exercised, who have given birth to several children, and have suckled these children, the menopause generally takes place considerably later than in women whose sexual life has been comparatively inactive, or in whom the opposite conditions have prevailed than those previously mentioned.

The more regular menstruation has been, the more normal the deliveries, the later does the climacteric take place.

Women who have given birth to a number of children, as a rule menstruate for several years later than sterile women, and somewhat later than those who have had one or two children. The menopause also appears to be postponed, other things being equal, when a woman has nursed her children.

If there has been an excessive number of pregnancies, the menopause is likely to appear early. The same result occurs when sexual intercourse has taken place at too early an age.

Constitutional factors also are important in influencing the time of the menopause. Women who have inherited a weak or delicate constitution, in whom the menstrual flow has always been pale or scanty, and the intermenstrual intervals unduly long, experience the climacteric earlier than strong, healthy women.

Generally speaking, women with a tendency to obesity cease to menstruate earlier than women of more normal build; blondes earlier than brunettes; women of phlegmatic temperament earlier than women of a sanguine and ardent temperament.

All those influences which have a weakening effect upon the feminine organism tend to hasten the advent of the menopause. Besides those mentioned in the preceding paragraph, factors such as severe labor, great sorrow, onerous occupations, abortions, local diseases of the reproductive organs, as well as distinctly pathological states, impel toward the same end.

VARIOUS MANIFESTATIONS OF APPROACH

The observations of gynecologists indicate that the duration of the climacteric manifestations varies largely between six months and three years. The mean duration, from the commencement of the symptoms until the cessation of menstruation, is about two years.

In a small proportion of cases the manifestations do not last over a month or two, while on the other extreme, cases are reported in which the duration has extended to four, six, eight, and even eighteen years (Kisch).

Tilt, a recognized English authority, has obtained some significant data about the various manifestations of approach of the menopause. Among a large number of women, sufficient to make a test of real value, he found the climacteric to occur as follows:

| | Percentage | | |of All Cases| |-----------------------------------------|------------| |By gradual diminution of the amount | | | of flow | 26.85 | |-----------------------------------------|------------| |By irregular recurrence of menstruation, | | | at intervals exceeding 21 days | 15.54 | |-----------------------------------------|------------| |By sudden interruption of the flow | 14.76 | |-----------------------------------------|------------| |By a terminal attack of metrorrhagia | | | (uterine hemorrhage between menstrual | | | period) | 12.87 | |-----------------------------------------|------------| |By a series of attacks of metrorrhagia | 8.79 | |-----------------------------------------|------------| |By sudden interruption and a terminal | | | attack of metrorrhagia | 6.75 | |-----------------------------------------|------------| |By alternations of very profuse and | | | very scanty menstruation | 5.65 | |-----------------------------------------|------------| |By irregular recurrence of menstruation, | | | at intervals of less than 21 days | 5.18 | |-----------------------------------------|------------| |By irregular recurrence of menstruation, | | | the intervals being sometimes | | | longer and sometimes shorter than | | | 21 days | 3.61 | |-----------------------------------------|------------| | | 100.00 |

An interesting physiological observation is made from the extensive researches of Andral and Gavarret, who have shown that in the female sex the quantity of carbonic acid eliminated by the lungs diminishes when menstruation first appears at puberty, but increases again at the climacteric age, with the cessation of the menstrual flow.

In the male, on the other hand, a gradual diminution in the elimination of carbonic acid begins in the 36th year of life.

In old age the quantity of carbonic acid eliminated is greatly reduced in both sexes.

Many authorities believe that too-early marriage, sexual excesses, and prostitution are chief factors in a premature climacteric. In some instances, at least, there seems to be a hereditary predisposition in this respect, since it has been observed that the mothers of women in whom it has occurred early have themselves been similarly affected. Of course, it is possible in some cases of this kind that the same external and environmental factors which caused the phenomenon in the mother also produced the similar result in the daughter--such, for instance, as sexual excesses, too-early marriage, or premature sexual experience.

The difficulties and disorders attending premature menopause are commonly more severe and more lasting than those that take place at the normal menopause. This is especially so if the premature menopause comes on quite suddenly, which, however, is comparatively rare.

The premature menopause usually approaches gradually. The flow becomes more scanty month by month, until finally it ceases altogether.

The premature climacteric may sometimes be delayed by expert gynecological treatment. Kisch refers to several cases in which the climacteric occurred at 35, 38, 39 and 42 years, respectively, when as a result of hydropathic treatment, regular menstruation recurred. In one case, a woman who had ceased to menstruate ten years before, gave birth to a child at the age of 45.

Retarded menopause presents some very interesting aspects, especially when late pregnancies have followed, many examples of which are on record. It sometimes happens that after the apparent termination of the menstrual periods, the flow recommences at an unusually late age.

Capwron quotes the case of a woman who became pregnant at the age of 65 years, with the recurrence of the menopause, which had ceased many years previously at the normal age. This woman aborted at three months, and the fetus was well formed.

Renaudin relates the case of a woman 60 years of age who gave birth to a child. Menstruation had ceased 12 years earlier.

A most remarkable instance is that reported by Meissner, of a woman who first began to menstruate at the age of 20. She had her first child when 47 years old, and gave birth to the last of her eight children in her sixtieth year.

The following are a few of the many authentic cases of protracted menstruation. Kisch reports no less than 106 cases in which the menopause did not occur until after fifty, of which five were as late as 57, two at 58, one at 59 and one at 60. Of Tilt’s many cases, two were at 57, four at 58, one at 59, one at 60, and two at 61. Courty instances a case in which menstruation persisted after the age of 65; Mayer, three cases at 64; Beigel, two cases, one at 65 and the other at 72.

To recur to the normal phase of the subject, as I have said, the actual dangers incident to the menopause have been much over-rated in the past. There are, however, two principal hazards which should be noted. First, there is the great tendency to profuse uterine hemorrhage, and, secondly, the liability to the occurrence of malignant tumors of the ovaries, uterus and mammary glands (breasts).

SEXUAL ACTIVITY AFTER THE CLIMACTERIC

Probably more distress and real suffering incident to the menopause is due to the mental attitude toward the phenomenon than is generally realized. A woman may have a feeling--as unquestionably many do--that her sexual life is over, that she is _passe_, and will no longer have the same attraction for her husband in particular, or the male sex in general.

The influence of a mental attitude of this kind is in itself quite pernicious. We know the relationship between ideas and physical states--autosuggestion--and how the former tend to realize themselves in the corporeal being. Not only that, but the mental and spiritual reactions are depressing, and conducive to morbidness and despondency.

Even the most philosophical woman, when under the influence of such negative ideas, has her outlook on life distorted. A woman with less mental control becomes embittered at her fate, which may lead to all sorts of nervous and psychological complications, with their unfavorable physical responses.

It would be interesting to know, if all the facts could be ascertained in a large number of cases of pathological menopause, what percentage of morbidity is really due to false notions and _unhealthy_ idea-complexes. Much misery could be eliminated by some rational insight into these problems.

Men, of course, in their ignorance of sexual matters, are to a large extent responsible for perpetuating this condition. Edgar Selwyn’s successful and somewhat sensational play, “_Dancing Mothers_,” uses this situation as its central idea. _Ethel Westcourt_, having reached her forties, supposed herself _passe_--in which supposition her philandering husband and flapper daughter fully concurred. Her husband had told her that the woman of forty is the dispassionate high-priestess of her sex. She decided to teach them a lesson by going out and pretending to live as lightly and loosely as they. In her first contact with the gay outside world, she discovered that she was not _passe_, that she still possessed charms that could successfully compete in the amorous marts, even with those of young girls of her daughter’s age. By the irony of fate, she not only eclipsed her daughter in the eyes of one _Naughton_, a man about-town, but also her husband’s promiscuous lady friend, an ex-mistress of _Naughton’s_. So this “dispassionate high priestess of her sex” proved herself a woman in whom the human passions burned as brightly as in the heyday of passionate womanhood.

As a matter of fact, the idea behind this theme is more authentic than perhaps even the author realized in his search for dramatic material.

The _restlessness_, physical, mental and spiritual, of woman at this age is proverbial. Our shortcoming has been in failing to recognize the trouble. A diagnosis of the actual conditions would have automatically supplied its own remedy. We can successfully cope with a situation only when we have an intelligent understanding of it, and not until then.

Dr. William J. Robinson has discussed this question with characteristic wisdom in the following words: “The generally prevalent opinion among women, and men for that matter, and not only the laity, but unfortunately of the medical profession as well, is that the menopause is the end of a woman’s sexual life. Nearly every woman labors under the erroneous impression that with the establishment of the menopause, with the cessation of the menses, she ceases to be a woman, and as she does not become a man, she becomes something of a neuter being, neither man nor woman. And she has the idea that after the menopause she can have no further attraction for her husband or for other men. Naturally, such an idea has a very depressing effect on any human being. A human being fights to the last to retain all its human functions, especially a function which is considered as important as the sexual function.

“Of course, with the permanent cessation of the menses, the woman’s _reproductive_ function is at an end. But the reproductive function is _not_ synonymous with the sexual function, as I must insist again and again, and naturally until this erroneous idea is dispelled much unnecessary misery will be the lot of our women. If women in general will learn that with the establishment of the menopause they do _not_ cease to be women; if they will learn that the sexual desire in women lasts long beyond the cessation of the menopause, many women being as passionate at sixty as at thirty; if they will learn that their attractiveness or non-attractiveness to the male sex does not depend upon the menopause, but upon their general condition, if they will learn that many women at fifty or sixty are much more attractive than some women half that age, they will not take the onset of the menopause so tragically and they will thereby avoid the greater part of this mental and emotional suffering.”