Women and Health; Uterine Fibroids

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(Edited)

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There are cases where ladies have vaginal bleeding other than during menstruation. A lady presented to the clinic with bleeding in between her period. She didn't present until about a year or so, when asked, she said she thought it was normal, and probably most girls experienced the same. There is nothing normal about it, in fact, such a case is termed "abnormal uterine bleeding".
Although, there are times when this is physiological, what I mean is, it is considered a normal occurrence, as in the case of an "implantation bleed" after conception. Other than this scenario, bleeding per vaginum is a cause of worry and should be investigated and treated promptly.
She was also asked if she had other complaints, she said no, but on examination, a mass was felt on her lower abdomen. She thought it was just her stomach getting bigger, which is understandable in the case of uterine fibroids as it takes years for the mass to get to the size of an orange. One of the most common causes of abnormal uterine bleeding in Nigeria is Uterine Fibroid, and that's what we're going to talk about.
Uterine fibroids are common benign tumors of the myometrum(muscles of the uterus). It may also originate from the cervix on rare occasions(5%). They are referred to as leiomyoma. These tumors rarely become malignant and may be asymptomatic for years, as in the case if the patient in question.
Uterine fibroids occur in women in their reproductive age, usually an age range of 30 to 35. It does not occur before menstruation and the incidence and size reduces after menopause. Incidence is more in women of African descent compared to caucasians. A positive family history, as well as parity have been implicated. Women who have bore no children are at higher risk. Obese women have also been shown to be implicated.
Its exact cause is unknown but it is thought to be as a result of a mutation leading to a loss in growth regulation. It is strongly thought that the growth is perpetuated by the ovarian hormones, estrogen and progesterone, especially estrogen, and this is supported by the fact that there are no cases before menstruation and a regression in fibroids sizes after menopause.
Ladies with a longer estrogen exposure period tend to present more, such as in the case of early menarche(first menstruation), use of exogenous estrogen, such as pills used in hormone replacement therapy. Interestingly, smoking has been documented to reduce the risk of developing uterine fibroids. Smoking has also been said to reduce the risk of developing uterine cancer as well. This is no reason to smoke though! There is an inverse relationship between uterine fibroids and increased parity, so with more child births, the chances of developing uterine fibroids reduce.
Fibroids are just overgrowths of uterine muscles and so, are generally identical. Having that said, fibroids are classified based on their location in the uterus.

Intramural fibroids, for simple understanding, this just means the tumor lies in the muscular layer of the uterus. The muscular layer is sandwiched between two other layers.


Subserosal fibroids, the tumor lies on the outer layer if the uterus and may grow into the peritoneum(where the gut is).


Submucus fibroids, think of this as the opposite of subserosal fibroids. Here, the tumor grows into the uterine cavity. It's the rarest form(5%), but it's the most important clinically because it presents with more bleeding and may also have adverse effects on pregnancy, may even lead to a miscarriage.


Cervical fibroids, very uncommon, but very difficult to respect surgically. Here, the tumor is located on the cervix. Already sounds like a headache! There may be more bleeding in this case as a result of exposure of the tumor to bruising.


The diagnosis of uterine fibroids is made clinically but some investigations aid in confirming the diagnosis. Clinical features that aid in the diagnosis are menstrual changes like irregular bleeding or change in cycle length, pain, usually at the lower abdomen. Pressure symptoms (incread frequency in urination as a result of the uterus on the bladder), abdominal enlargement with increasing tumor size, subfertility, which is a common reason for patient presentation.
Most asymptomatic patients present with complaints of difficulty conceiving and the diagnosis is made during physical examination and history taking. Investigations that could be confirmatory are ultrasound scan and hysterosalpingogram, amongst others.
The treatment approach are both medical and surgical, as well as palliative and definitive. Medical approach is considered in symptoms relief such as the pain using analgesics, well, depending on the degree of the pain, the big guns opioids may be indicated. Hematinics are used to compensate for the bleeding. GnRH agonists are used in reducing the tumor size to facilitate the surgery if a vaginal myomectomy is the preferred approach.
Surgical approach is the treatment of choice in symptomatic cases. Surgical options are vaginal or abdominal myomectomy(a myomectomy is the surgery extraction of the fibroid mass). Endoscopic procedures like hysteroscopic or laparoscopic resection, a myolysis and uterine artery embolization. But even after all of these options, there is no guarantee of cure and reoccurrence is a concern. The definitive treatment for uterine fibroids is a hysterectomy(removal of the uterus). This option is the last line and is not lightly considered.
Some herbal therapy have been proposed but efficacy is still under observation and not yet thought to be a treatment option. This includes aloe berry nectar, bee propolis, gacina pus. This is still yet to be a generally accepted treatment option.
The most important complication of fibroids is that associated with pregnancy, it could cause difficulty in conception by dislodging the embryo if the fibroid is located in the uterine cavity due to its irregular surfaces. Other complications are prolapse through the cervix, infections and the rare chance of malignancy. Uterine fibroids are a bother because of their symptomatology as well as the cosmetic implications and effect on the patient's esteem. A myomectomy is quite routine and not a cause to worry. There are several guidelines limiting morbidity or mortality to the bearest minimum. Performing a myomectomy immediately after a caesarean section is not recommended as it increases concerns on blood loss and regulation as well as complications but is currently under review.
Reference; https://goodherbalcure.name.ng/fibroid-removal/ https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288


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6 comments
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this is kinda muddled up and difficult to read. Feel free to edit and break it down into small blocks of text for easier reading.

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I edited the post, and I hope its okay now.

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References?

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Just inputted them. Thank you. For future reference, is this format okay or are headings preferred?

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