The menopause is the final cessation of menstruation. The age at which it occurs is dependent upon a great variety of conditions—nationality, climate, mode of life, constitutional and local diseases. In the northern countries of Europe the menopause is said to appear later than in the southern; in England, later than in America. It has been observed that country women menstruate to a later age than city women. The woman who bears a number of children in rapid succession and suckles them not infrequently has a premature menopause. The menopause may appear early in very fat women and in women who are the victims of tuberculosis, nephritis, and diabetes. Disease of the uterus, tubes, and ovaries may retard the menopause. In fibroid tumor of the uterus the menopause may be delayed for several years.

In this country the menopause occurs between the fortieth and fiftieth years—usually about the age of forty-five.

The menstrual bleeding may gradually diminish in amount until it disappears; or it may stop abruptly and permanently; or there may occur one or more intervals of amenorrhea of one, two, or three months’ duration, followed by normal menstrual bleedings, perhaps of diminished amount, before the flow finally ceases.

Profuse bleeding at the time of the menopause and slight bleeding occurring more often than monthly are, unfortunately, viewed by most women as of no moment, and as part of the normal phenomena of the change through which they are passing. The same may be said of the apparent reappearance of menstruation, or of slight irregular hemorrhages occurring after the menopause had been established and menstruation had been absent perhaps for many months. These phenomena are not normal. They should always excite the alarm of the woman, and they demand immediate examination on the part of her physician. As a rule, the bleeding is caused by some pathological condition of the uterus—fungous growths, polypi, fibroids, or cancer. The benign lesions may disappear spontaneously with the progressing atrophy of the womb, and the hemorrhages may cease. Many women undoubtedly recover without treatment, and are thus confirmed in the belief that such irregular hemorrhages are a normal part of the menopause; and the unfortunate women with cancer are thus encouraged to delay seeking medical advice until the disease has progressed too far for cure.

The normal changes of the genital organs that begin at the menopause are those of atrophy slowly progressing to the senile condition. The ovaries atrophy; the epithelial elements gradually give place to connective tissue; the Graafian follicles and corpora lutea are destroyed; the tunica albuginea becomes thick and shriveled. The uterus diminishes in size; the vaginal cervix may disappear; the utricular glands diminish in size and number; the endometrium atrophies. The Fallopian tubes shrink and become shortened, and the fimbriÆ disappear. Similar atrophic changes affect the vagina, the external genitals, and the mammary glands.

If the woman is in good general health, and has no disease of the uterus, the tubes, or the ovaries, the menopause may become established without any marked general disturbance.

In many cases, however, very annoying general symptoms appear, and last for one or two years before the woman becomes adapted to the altered conditions.

There may be headache, flushes of heat, nervous depression, derangement of the digestive apparatus, and other functional disturbance. The woman often becomes very fat at this period. The nervous derangement may be so severe as to result in insanity.

The vaso-motor disturbances are often the most annoying. The phenomena of the “flushes” consist of a feeling of heat over the whole or a part of the body, followed by sweating and the sensation of cold or a slight chill. The flushes may occur frequently during the day, sometimes several times during an hour.

The treatment of the menopause should be directed to the maintenance of the general bodily and mental health. The diet should be carefully regulated. Too much nutritious food should be forbidden. Purgatives should be administered whenever necessary. The woman should have plenty of fresh air and the proper amount of exercise. Mental depression demands a change of locality and surroundings.