Professor Christopher Aimakhu, a consultant obstetrician and gynaecologist at the University College Hospital (UCH), Ibadan, says in this interview with Sade Oguntola that it is a misconception that fibroid causes infertility and excessive bleeding in all cases, but its effect is subject to its size and location in and around the womb.
What are fibroids, and why is it important that we raise awareness about them?
Fibroids are almost always benign tumours of the female reproductive tract. They are the most common tumours of the female reproductive tract. Women who typically have fibroids are those who are between the ages of 20 and 45 years. This is the reproductive age of women. Nowadays, it appears that more women are undergoing normal medical examinations, such as ultrasound scans, which has led to a rise in the frequency of diagnosing fibroids. In actuality, it affects more black women globally as a whole. Thus, fibroids affect roughly 25% of women in the reproductive age range. Post-mortem reports for women, however, indicate that up to 50% of them have it.
What puts women at risk for fibroid in general, and does every woman experience the symptoms of fibroid?
Women in the reproductive age range, with a familial history of fibroids, obesity, black women, and women experiencing infertility or childlessness are among the groups of women who are more likely to develop fibroid. Additionally, fibroids have a genetic propensity. Nowadays, being asymptomatic, or without symptoms, is the most typical sign of fibroids. It was only unintentionally discovered, perhaps as a result of the woman getting tested medically, experiencing infertility, or having repeated miscarriages. The most common symptom of this condition is menorrhagia, or heavy menstrual flow. However, the size and location of fibroids affect their symptoms.
For example, there will be a significant menstrual flow if they are in the inner lining of the womb, which is the submucous region from which the lady menstruates. Should it be developing inside the womb, the mother will experience enlargement in her abdomen.
It can also cause abdominal pain. If its growth on the outer body of the womb is towards the bladder, it can cause urinary symptoms like pain during urination and increased frequency of urination.
When the womb’s outer body grows towards the rectum, it may result in unpleasant stools or make defecation difficult. Constipation may arise in areas where the growth is encroaching on the intestines. Urinating more frequently means that you may have to go to the toilet more frequently. If it grows in the direction of the rectum, you can then have it. Stools can hurt if you have them. Defecating can be tough for you. Some women additionally report having swelling limbs and loinaches. Basically, not every woman with fibroid has all of these symptoms. It varies depending on the size and location.
In some cases, the lady with fibroid may experience different symptoms depending on its size. It’s possible that some of the women you encounter have extremely noticeable big fibroids, yet they claim not to feel anything. They never stop getting asked if they were pregnant, though. For this reason, some individuals simply assume that it comes with being large and overweight.
Why the differences in sizes of fibroids removed during surgeries?
Indeed, it primarily relies on the individual’s inclination towards fibroids. It’s comparable to some women experiencing fibroid recurrence following surgery. Some women have the operation, and because their wombs are predisposed to it, it recurs after some months or years. Some people are genetically predisposed to fibroids.
Also, a woman may have a combination of different types and sizes of fibroids. There might also be an abundance of them. It goes without saying that you have to remove them during surgery when you see them.
Can birth control pills and non-steroidal anti-inflammatory drugs cause or exacerbate fibroids?
Because contraception—especially birth control pills—is used to manage the menstrual cycle, it often reduces fibroids in women. Birth control tablets regulate the endometrium, the lining that lines the inside of the womb, to stop bleeding and prevent conception. Uterine fibroids are generally less common in women who use oral contraceptives. Non-steroidal anti-inflammatory drug use also has no effect on the development of fibroid. In fact, non-steroidal anti-inflammatory drugs are one of the drugs used to treat pain in women with fibroids.
What are the reproductive symptoms associated with fibroids?
The most common reproductive complication is infertility. You discover that infertility or inability to get pregnant is often the first complaint made by women with fibroids to their doctors. It’s only upon further investigation that you learn the woman has fibroids in addition to infertility. Nonetheless, fibroids only account for roughly 25% of infertility cases. Not all women with fibroids are unable to conceive. In actuality, infertility is caused by 10–25% of fibroids. And the reason for that is where they are situated. The lady may not be able to conceive if they are situated where implantation takes place.
Because these tumours are oestrogen-dependent, they continue to grow during pregnancy even after they become pregnant. Because of oestrogen in women, this is the reason they are common in women who are of reproductive age. When they get to menopause, there’s a reduction in oestrogen levels.
Thus, fibroids may cause women to lose their pregnancies after becoming pregnant. In addition, it may result in pain, bleeding, or even an adjustment in the baby’s position during pregnancy. The infant might lie transversely or in other abnormal positions. Furthermore, because of the fibroids, the womb may not be able to contract properly after delivery, which may result in heavy bleeding after delivery.
If a woman is diagnosed with fibroid cancer, should she go for help right away?
The thing that draws notice to them the most frequently is their excessive menstrual flow. It is possible for a woman to bleed to the point of anaemia (reduction in red blood cells), and she will require blood transfusion. A few weeks back, I recall hearing from a mom who said that when her daughter was bleeding, it seemed like they were pouring water into a bucket. And occasionally, it can be the soreness or oedema. It was recently mentioned that the stomach or abdomen is growing or getting bigger. So they are the typical reasons, besides not being able to conceive, why women seek medical care.
What are the treatment options?
Treatment options for fibroids can be conservative (that is, to observe and watch her for some time). The woman is most likely a young woman who has recently begun menstruation or an elderly woman who may be nearing menopause. Hopefully, the fibroids will disappear or cause no symptoms when the woman finishes menstruating. Not every fibroid needs treatment or surgery. If the symptoms are minor, they can be treated. In the event that there is minimal bleeding and minimal additional symptoms, such as soreness, I say fine, let’s wait and see. We give her some hormonal therapy if she has heavy periods or anti-inflammatory medications if she has abdominal pains.
Haematinics, or blood-forming drugs, are prescribed if she is anaemic and has heavy menstruation. But we generally don’t want her to take folic acid because it can increase the size of the tumours. One of the substances that promotes the growth of tumours is folic acid. This is especially crucial if they have large fibroids. Next, we treat patients with heavy menstruation with medications that help reduce the size of the fibroid. The woman’s symptoms return six months after taking those medications that cause the fibroid to shrink and then have rebound growth, which is the drawback.
Similarly, fibroids can be surgically removed, particularly if the fibroid is large, causing infertility, and there is a significant menstrual flow. Therefore, hysterectomy—the surgical removal of the womb—is the definitive procedure for fibroids in women who have finished having children or in elderly individuals. However, myomectomy, or the removal of the fibroids, is performed on those who still wish to become parents. However, there is a chance that a myomectomy won’t be able to remove every tumour or that they will reoccur.
Now, to remove the fibroids themselves by myomectomy, you can have the straightforward abdominal myomectomy, which is the one that cuts through the abdomen. There are now laparoscopic ones in which you just use a keyhole for the surgery. If you have the ones in the inner lining of the endometrium, you can go through the cervix, and then you can excise them (via hysteroscopy). We have non-invasive procedures too, where you can use lasers. The most recent technique is known as high-intensity focused ultrasound (HIFU), and it involves using high-intensity ultrasound to reduce tumour size. However, its availability is limited in Nigeria, and its cost is high.
Similar to this, you can actually inject contrast to reduce the blood supply to the tumours and then either remove the fibroid by laparoscopic surgery, a keyhole procedure, or open the woman up. Additionally, there are non-invasive methods that you can employ lasers to reduce their sizes.
Some medical treatments intended to reduce the flow may actually cause those women to experience a pseudomenopause. This is as a result of the medication’s ability to reduce the womb’s inner lining, which is where the menstrual flow originates. Women using these medications report no longer experiencing their menses. Of fact, some women lament the recurrence of their symptoms.
Furthermore, some women’s experience following fibroid surgery has been compared to what would happen if a resident of a high-rise building on the fifteenth floor closed all of the windows for a vacation for a few years, returned to find dust on the furniture, and wondered how the dust got inside. This is the nature of these fibroids.
There are situations when taking them out also takes everything the eyes can see. However, years after the fibroid is back, it reappears because the lady is already predisposed to fibroids. It’s not that the previous one has happened again; instead, new ones have emerged. Therefore, surgery to remove the womb is the only effective treatment for fibroid, especially if the tumour continues coming back.
Instead of going after eliminating every fibroids that creates symptoms, as is the case with open myomectomy, more recent approaches are actually directed towards employing other techniques to guide the removal of all fibroids that generate problems. For example, the high-intensity focused ultrasonography just shrinks the fibroids, which significantly reduces the symptoms.
What would be your advice to Nigerian women in coping with fibroids?
When I was talking about predisposing factors to fibroids, diet matters. Some studies have shown that red meat predisposes to fibroids. So, lifestyle changes can help. In terms of symptoms, one thing that can help is for women to be aware of their symptoms and any distortion in their menstrual patterns. Additionally, when they experience symptoms, get medical attention to determine whether fibroids are the cause. The woman’s age, expectations for her reproductive or having children, the size and location of the fibroid, and symptoms will all influence how the fibroids are treated.
