624 EMIL NOVAK 



$ 



etiology of excessive menstruation, which is to be sought in local pelvic 

 disease far more frequently than in constitutional causes, endocrine or 

 otherwise. In a small proportion of cases, amenorrhea is the result of 

 congenital or acquired disease or anomalies of the pelvic organs, such as 

 absence of the uterus or of the ovaries. In the latter case, the absence 

 of menstruation is clearly due to a total agenitalism or anoophorism. 

 Much more interesting, however, are the cases of amenorrhea which are 

 so frequently observed in the entire absence of any gross anatomic dis- 

 ease of the pelvic organs. Most of these are undoubtedly due to hypo- 

 genitalism, although, as already emphasized, it is not always easy to 

 determine whether this deficiency of ovarian function is primary or sec- 

 ondary in nature. 



One other distinction seems worthy of mention. In some cases, the 

 extreme type being represented by complete removal of the ovaries, the 

 amenorrhea is due to a genuine anoophorism, or hypo-oophorism, as the 

 case may be, i.e., the function of the entire ovary, with its probably several 

 hormones, is in abeyance. In this group the amenorrhea is practically 

 always associated with constitutional or developmental changes of one 

 form or another. This type is well illustrated by the well-known adi- 

 posogenital dystrophy, to which fuller reference will be made later. 



In a second group, on the other hand, the amenorrhea appears to be 

 due to a deficiency of only the menstruation-producing hormone of the 

 ovary that of the corpus luteum. Menstruation is absent, but no other 

 noteworthy changes are seen. This is well illustrated in the amenorrhea 

 of lactation (see below). In cases of this type the hormone of the 

 corpus luteum alone is either antagonized or inhibited, so that a condi- 

 tion of what may perhaps be called hypo-luteinism, or drluteinism is 

 produced. 



The principal causes of amenorrhea as they relate to the endocrine 

 system may be grouped as follows : 



Physiological Amenorrhea. At puberty and at the menopause it is 

 common to observe a so-called "dodging period," characterized by inter- 

 vals of amenorrhea of varying lengths. These are obviously to be ex- 

 plained by the gradual inauguration of ovarian secretion at the first- 

 iianied epoch, and by its gradual cessation at the other extreme of men- 

 strual life. 



Amenorrhea of Pregnancy. Amenorrhea is the normal status during 

 pregnancy. There are some who would explain this as due to a cessa- 

 tion of ovulation during pregnancy. There can be no doubt, however, 

 that the inhibiting influence of the living embryo is a factor of great 

 importance in the causation of the amenorrhea in either intra- or extra- 

 uterine pregnancy. In the latter, for example, the appearance of uterine 

 hemorrhage is usually indicative of the death of the embryo, as, indeed, 



