If the hwmorrhage is excessive in amount or continues in spite of a faithful trial of the remedies indicated above, a local examination should be made. An anesthetic should always be given, both to spare the patient's feelings and because anything like a thorough pelvic examination is almost impossible in a virgin who is not anaesthetised. The practitioner should obtain permission and should be prepared to carry out at the time any minor operative treatment which the examination may show to be necessary. In most cases which have reached this stage it is advisable to dilate and curette the uterus (see under Endometritis: Curettage), and this may have to be repeated on one or two occasions before a permanent cure is attained. An erosion of the cervix may require to be shaved off, or a mucous polypus of the cervix may be grasped by the base and twisted off, the site of attachment being then thoroughly curetted. If cysts of the ovary or dermoids are present, the position must be explained to the relatives and suitable measures taken to deal with the condition. It may be well to warn the impetuous that because a slightly enlarged ovary is to be felt it is not always necessary to arrange for its immediate removal or mutilation, and that it is well first to try the effects of curetting and resuming general treatment for another three months or so.
2. Menorrhagia in Virgin Adults.—Most cases coming under this category arc caused by the presence of a tumour, either ovarian or uterine fibroid or a cervical erosion, with, as age advances, increasing probability of a malignant growth of the body of the uterus, though in a minority tuberculous or Inemorrhagic endometritis may be responsible for the bleeding. Such cases are not, therefore, likely to derive much benefit from general or drug therapy, and a local examination should not be too long delayed, otherwise permanent damage may be done to the system by the continued drain of blood. The treatment will depend on the finding at the examination (see Ovarian Tumours, Uterine Fibroids, Cancer of Uterus, Endometritis).
3. Menorrhagia in Married and Porous Women.—In this group of patients, which includes, of course, those who have the misfortune to be neither maid nor wife, a large number of causes may give rise to menor rhagia. These may be divided roughly into three main classes, and as no possible objection to an immediate vaginal examination can be urged, the practitioner should lose no time in deciding what is really the matter with his patient.
(i) Menorrhagia as the Result of Inflanunation.—Foremost in this group is gonorrhceal inflammation, and the hxmorrhage may be associated with acute or chronic endometritis, with salpingitis or pyosalpinx, or with ovarian abscess; indeed, its development may he the first sign which brings the patient under the notice of the physician in eases of involve ment of the uterus, tubes or ovaries in an attack of gonorrhea. The treatment of the menorrhagia is subordinate to that of the disease which is its cause; it consists in an endeavour to lessen congestion and to pro mote the elimination of the microbe by hot douches, swabbing the uterus with antiseptics such as phenol, and the use of glycerin and subitol tampons, to be followed by surgical measures if required, such as curetting, removal of pus tubes, &c. (see under Endometritis, Gonorrhoea,
Pyosalpinx). Puerperal inflammation is more acute, and clears up more completely than gonorrhoeal. It may leave sequelx in the shape of ovarian or tubal suppuration which sometimes give rise to menorrhagia and which should he treated by the drainage or complete removal of the suppurating foci. Finally, menorrhagia may he due to a tuberculous inflammation of the endometrium, which is practically always secondary to tubal tuberculosis, and should be treated as detailed under Endo metritis. Much benefit may be looked for from the administration of Tuberculin; u m il lig ramme should be injected and the result carefully watched. The initial rise of temperature should be allowed to subside, and a full fortnight should elapse after the first injection before a second is given. if the reaction is excessive, the patient being made extremely ill and her condition not improved after a few days, too large a dose has been given and half the quantity should be injected on the next occasion. On the other hand, if there is no rise of temperature and no reaction, the dose is probably too small and a larger one should he given, or a mistake in diagnosis has been made.
(2) Menorrhagia due to Puerperal Causes.—The uterine hmmorrhage may be due to abortion threatened or inevitable. As a rule this is recog nised by the patient herself, and the treatment should follow the lines laid down under Abortion. The presence of moderate loss lasting for a con siderable time, say to to 14 days, and appearing slightly before or after the usual time in a patient who is otherwise perfectly regular, should put the practitioner on his guard against a possible extra-uterine pregnancy. If examination shows that the fear is well grounded, the appropriate treat ment should at once be instituted (see Extra-uterine Pregnancy).
The incomplete expulsion of the ovum from the uterus, either before or at full term, is a fruitful source of both menorrhagia and metrorrhagia. A fragment of placenta left adherent to the uterine wall undergoes hyaline degeneration itself and induces in the neighbouring endometrium a condition of vascular dilatation which makes its presence felt both by increased flow at the normal period, and by anomalous and frequently profuse at other times. For such a condition there is only one remedy—the removal of the retained fragments by the curette. The use of ergot, iron and other drugs is unjustifiable, as it simply exposes the patient to the risk of developing a profound secondary without affording the slightest hope of removing the cause of the trouble. In curetting for retained fragments of placenta, considerable care is necessary, especially if the retention is of old standing, as the uterine wall at the site of the attachment is often much thinned, and may easily he perforated by injudicious use of force. After curetting, the uterus should be packed with iodoform gauze, to be removed next day, and douches should be given for a week. Sometimes the retained fragment is of considerable size and stands out from the uterine wall forming a placental polyp, which may be twisted off with forceps and the base curetted.