Cambridge University Press 978-0-521-72183-7 - Abnormal Uterine Bleeding Malcolm G. Munro Excerpt More information Section 1 Chapter Background 1 Historical context Chapter summary Historically, our culture has traditionally viewed even normal menstruation as an aberration, ostracizing reproductive-aged women; this legacy impacts contemporary societal perceptions. Many contemporary religions specify behavior for individuals and couples during menstruation. A given woman’s perception of her own symptoms may be impacted by her cultural and religious context; she may be embarrassed to present her symptoms, or may not know that they are indeed abnormal. Contemporary understanding of the pathogenesis of AUB is based on relatively new observations and evidence. Surgical and pharmacological therapy of AUB are currently in a state of relatively rapid evolution after changing little for a century. Introduction For the majority of those who have chosen to read this book, it is obvious that menstru- ation is a normal component of female reproductive physiology. However, perceptions of menstruation by our society at large may vary substantially by age, by culture, and by religious belief. Indeed, even in Western cultures, societal perceptions of normal men- struation may be impacted more than we’d like to think by our cultural legacies which, until relatively recently, were steeped in a context of medical naiveté. Indeed, as recently as the late nineteenth century, menstruation was described by the academic H. Beckwith Whitehouse as, “one of the sacrifices which women must offer at the altar of evolution and civilisation.” [1] Despite the acquisition of vast amounts of knowledge about the female reproductive system in general and an increasing capability to control menstruation and treat its dis- orders, many of these concepts continue to suffuse our culture, contributing to the plight of women affected by AUB. Understanding the historical and social underpinnings of menstrual mysticism is an important part of the education of any medical practitioner who deals with women in the reproductive years, or of any age, with both normal and abnormal uterine bleeding. Similarly, it is useful for the practitioner to understand something of the historical evolution of the therapeutic agents and procedures in contemporary use. Such knowledge provides a context for understanding the continuous evolution of knowledge about the pathogenesis, investigation, and medical and surgical treatment of women with AUB. © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-0-521-72183-7 - Abnormal Uterine Bleeding Malcolm G. Munro Excerpt More information Section 1: Background Normal menstruation The process of menstruation, itself unique to the female of the species, is associated with a range of symptoms and perceptions have been the subject of documents and publications that date to the beginning of recorded history [1–3]. Not surprisingly, this legacy has been influenced by a number of myths and societal taboos. In the first century AD, largely negative societal attitudes were depicted and perhaps influenced by a Roman historian named Pliny the Elder [4]. His Historia Naturalis includes a description of his perception of the menstruating woman, a vision that perhaps sets the stage for the perceptions of menstruation for the centuries that followed: “wine sours if they pass, vines wither, grass dies, and buds are blasted. Should a menstruating woman sit under a tree, the fruit will fall. A looking-glass will discolour at her glance, and a knife turn blunt. Bees will die, and dogs tasting her blood run mad.” Indeed, over 1500 years later, seventeenth-century descriptions of menstruation con- tinued to reflect the perception of normal menstruation as a disorder and included terms such as “the monthly disease, the monthly infirmity, the sickness, monthly evacuations, natural purgations,” or even, the “time of your unwonted grief,” or, perhaps even worse, “the monthly flux of excrementitious and unprofitable blood.” [2] One of the more poetic terms, “the flowers,” was actually a pejorative term likening menstruation to the fermen- tation of malt liquors whereby the liquid flings up to the surface a sort of scum bounding with air, which is called “the flowers.” [5] These seventeenth-century English perceptions of normal menstruation were captured by the Jacobean dramatist Barnabe Barnes who wrote, “thy soule foule beast is like a menstruous cloath, polluted with unpardonable sinnes.”[6] It is of interest that primitive societies quite independently usually have negative terms for menstruation, such as the “sik bilong mun” of the Pidgin language of Papua New Guinea. The phrase, “at those monthly periods”, was used for the first time in the early seventeenth century [2]. Even in current times, certain religious and cultural beliefs sur- round the process of normal menstruation. For example, even for Modern-Orthodox Jews, the term Niddah refers to the ritually unclean period that comprises the days of men- struation and a week thereafter, when any physical contact between spouses is strictly forbidden [7]. Indeed, even mainstream women, and, in particular, adolescents, are often saddled with the notion that menstruation is an unhealthy time and one that shouldn’t be the topic of open conversation [8]. Consequently, even contemporary practitioners must render care knowing that normal menstruation, for many, is rooted in a cultural context of shame. Abnormal menstruation It is likely that the first mention of heavy uterine bleeding (HUB) in the ancient literature was from Hippocrates, who was born in approximately 460 BC and wrote the first com- prehensive medical textbooks. The English translations of Hippocrates’ work date from the early nineteenth century and are, no doubt, influenced by the English language as it was used at the time. Consequently, interpretation of these translations should be undertaken in this context. Aristotle quoted Hippocrates in describing the process of HUB in the fol- lowing fashion: “In quantity, bleeding is excessive, saith Hippocrates, when they flow about eighteen ounces.”“In time when they flow about three days.”“But it is inordinate flowing when the faculties of the body are thereby weakened.” Aristotle also used a number of terms to describe abnormal menstruation and included variable, irregular, and often light bleeding in his descriptions, including the notation that such bleeding is often accompanied 2 © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-0-521-72183-7 - Abnormal Uterine Bleeding Malcolm G. Munro Excerpt More information Chapter 1: Historical context by pain [9]. It is worth noting that the 18 ounces is equivalent to about 540 mL of blood, a volume almost seven times what is considered the upper limit of normal today. Thomas Sydenham, writing in 1666 [10], describes “immoderate menstrual flow” and considered that “the natural flow of the menses would fill a vessel the size of a goose’s egg,” a volume more in keeping with contemporary understanding. William Heberden, a very successful general physician and astute observer, practising in London in the mid 1700s, was also a capable gynecologist. He perhaps provided one of the earliest descriptions of acute anovulatory AUB: Sometimes, without any apparent cause the menses have exceeded the healthy limits … and have appeared in too great abundance. But these cases have been usually more alarming than dan- gerous, for among the many instances of excessive floodings which I have known, I have remarked only two, who, without being pregnant, have bled till they were exhausted and died. [11] The word menorrhagia, which is derived from the Greek word “mene” meaning moon and the verb “regnumi” meaningtoburstforth,appearstohavecomeintouseforthefirst time in the late 1700s in the lectures of Professor William Cullen, Professor of the Practice of Physic at the University of Edinburgh. Cullen wrote extensively about “menorrhagia,” using the term “menorrhagia rubra” to describe immoderate bleeding in nongravid and nonpuerperal women, and “menorrhagia abortus” todescribeheavybleedinginpregnantorlying-inwomen[12]. The English physician Fleetwood Churchill, one of the first true specialists in obstetrics and gynecology, authored a textbook on the Principal Diseases of Women in which he devoted a full chapter to “menorrhagia,” which he indicates “signifies an increase in the catamenia.” He specifically states that the term “uterine haemorrhage should be applied exclusively to floodings connected with pregnancy and parturition.” [13] It seems probable that the term “metrorrhagia,” used to describe irregular bleeding, came into usage at about the same time as “menorrhagia,” since Cullen certainly used the term “maetrorrhagia” in his lectures [12]. However, “metrorrhagia” seems to have been less popular than “menorrhagia,” and Churchill does not use this term at all – he uses “irregularity of bleeding”–although he does use other Latin-based terms like amenorrhea and dysmenorrhea [13]. The causes of abnormal uterine bleeding Until the 1800s only Aristotle can be found to have opined on the causes of AUB, sug- gesting that one or a combination of “breaking of the veins, heating of the blood, and trauma” were at fault [9]. However, by the mid 1800s a number of authors began to suggest interesting hypotheses. Dewees penned the following perspective on the pathogenesis of heavy menstrual bleeding (HMB): Women are most