Studies link ‘epidemic’ to delayed childbirth, beauty products, others

Recent estimates indicate that Nigeria loses more than N10.8 billion to treat about 12.77 million women of reproductive age that develop uterine fibroids, at a cost of about N850,000 per patient.

Uterine fibroids, also known as uterine leiomyomas or fibroids, are benign smooth muscle tumours of the uterus.
Latest World Bank figures show Nigeria’s female population amounted to approximately 105.57 million, while the male population is approximately 107.83 million.

Several studies have shown that the national prevalence of fibroids amongst Nigerian women is 12.1 per cent and the total cost of diagnosis, drugs and surgery for uterine fibroids is about N850,000 in Lagos.

Unpublished report shows, in Lagos for example, the Lagos University Teaching Hospital (LUTH) Idi-Araba, Lagos charges between N200,000 to N250,000 for abdominal myomectomy, while Lagos State University Teaching Hospital (LASUTH) Ikeja collects between N190,000 to N210,000 for open fibroid surgery.

A myomectomy is an operation to remove fibroids while preserving the uterus.
The University of Benin Teaching Hospital (UBTH) pricelist for abdominal fibroid surgery is around N180,000 to N250,000. Private hospitals in Nigeria do bill around N200,000 to N400,000 for fibroid surgery (it may be less depending on the hospital).

In UBTH, laparascopic myomectomy costs between N200,000 to N270,000 while many private hospitals in Lagos especially Cedacrest Hospital and Southern Shore Women clinics do laparoscopic myomectomy for around N800,000 to N1 million.

Laparoscopic myomectomy is the removal of uterine fibroids while leaving the uterus intact. It is the main treatment option for patients who would still like to conceive or prefer not to have a hysterectomy by minimally invasive procedure where small incisions are made in the abdomen over the area where the fibroid is. A camera and surgical instruments are inserted through these incisions to visualize the uterus and act.

Lily Hospital and Benin Medical Centre in Benin reportedly perform the procedure for around N800,000 or more. Some private practitioner in Nigeria charge as much as N3 million for fibroid surgery. Location matters too. Fibroid surgery in private hospitals in Lagos or Abuja will definitely be more expensive than private hospitals in Borno, Kebbi, Ekiti, Ebonyi, Nassarawa, Kogi or Jigawa.

Also, cost of diagnosis is high as abdominal scan for fibroids was around N4,000 to N6,000, diagnostic hysteroscopy was around N20,000 to N40,000, and complete blood count was around N3,000 to N5,000. Kidney function test is about N4000.

Some hospitals especially in Lagos will request the patient pays for admission, drugs and other consumables different from the cost of surgery. Because of the associated bleeding, most centres will request the patient pays for two to three pints of blood in case one needs transfusion during surgery. A pint of blood is between N8,000 to N10,000.

This analysis brings the cost of managing uterine fibroids from diagnosis to surgery to about N850,000. And with estimated 12.774 million women with the condition that undergo the procedure, it means that Nigeria spends at least N10.8 billion on managing uterine fibroids.

However, experts are unanimous that the rising cases and costs of uterine fibroids and tumour are because more women are now postponing marriage and childbirth in pursuit of their career as well hair/beauty products.

Bloating, constipation, cramping, painful sex and extreme fatigue are typical symptoms of uterine fibroids. “As crazy as it may sound, I thought these symptoms were happening to me simply because I was getting older,” said Unoma Onuorah.

The 40-year-old said: “Fibroids made it unbearable to plan a vacation, have a healthy sex life, and lose weight. They also caused me to have anaemia, which severely affected my energy level. I have also been trying to get pregnant after 13 years of marriage.”

Unoma experienced heavy and prolonged menstrual bleeding as a result of fibroids. “My periods were extremely heavy, and lasted nine to ten days,” she said. “It got worse and worse. Heavy bleeding through a super plus tampon and overnight pads within one hour, maybe two.”

Before treatment, Unoma also suffered from back pain, severe bloating, exhaustion, cramps, and pain during sex.
“You are basically uncomfortable going anywhere because you may leave a puddle behind,” shares one woman suffering from fibroid symptoms. “One time I was in a long board meeting and knew that I had bled through my outfit. I stayed sitting down after everyone got up and called the one other woman in the room over to tell her my situation. She went to go get a piece of cloth to cover my seat as I got up and handed me a brown paper bag with supplies to freshen myself up.”

Indeed, some women with uterine fibroids do not have symptoms. Consultant Obstetricians and Gynaecologists who spoke to The Guardian said abdominal pain; anaemia and increased bleeding can indicate the presence of fibroids. They said there might also be pain during intercourse (penetration), depending on the location of the fibroid. “During pregnancy, they may also be the cause of miscarriage, bleeding, premature labour, or interference with the position of the foetus. A uterine fibroid can cause rectal pressure. The abdomen can grow larger mimicking the appearance of pregnancy. Some large fibroids can extend out through the cervix and vagina.

“While fibroids are common, they are not a typical cause for infertility, accounting for about three per cent of reasons why a woman may not be able to have a child. The majority of women with uterine fibroids will have normal pregnancy outcomes. In cases of inter-current uterine fibroids in infertility, a fibroid is typically located in a submucosal position and it is thought that this location may interfere with the function of the lining and the ability of the embryo to implant,” they said.

The medical experts include: Consultant Obstetrician and Gynaecologist/Fertility Specialist and Medical Director of NISA Premier Hospital, Jabi, Abuja, Dr. Monday Nenfa Solomon; Medical Director, Optimal Specialist Hospitals Limited, Surulere, Lagos State, Dr. Chukwunenye Celestine; Medical Director, May Fair Specialist Hospital Onitsha, Anambra State, Dr. Raphael Nosike Omaliko; and Consultant Obstetrician and Gynaecologist, College of Medicine University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), Associate Prof. Ayodeji Ayotunde Oluwole.
Reasons for rise in cases

Solomon said some risk factors associated with the development of uterine fibroids are modifiable and fibroids are more common in obese women. He said fibroids are dependent on estrogen and progesterone to grow and therefore relevant only during the reproductive years.

Solomon said cases of uterine fibroids are rising in Nigeria because women tend to give birth later than they used to. He said it should be noted that nulliparity is a risk factor for uterine fibroids.

Nulliparity is a medical term used to refer to a condition or state in which a woman has never given birth to a child, or has never carried a pregnancy.

“More women are now postponing marriage and childbirth in pursuit of their carrier while others are unmarried. Another reason is because people are becoming more enlightened and tend to seek medical help unlike before. Race has also been implicated as it is generally common in black women than in their Caucasian counterparts,” the gynaecologist said.

He said the peak age of incidence of uterine fibroids is between 30 and 40 years. “Generally, it occurs more commonly in women of reproductive age group,” Solomon said.

Chukwunenye said there might not be an absolute increase in the number or percentage of Nigerian women with uterine fibroids. He said there is an obvious increase in the number of cases diagnosed and treated in recent years because of various factors.
Chukwunenye said these factors include increased awareness, increased demand for hospital services, and increased availability of ultrasound scanning units in the country among others.

The medical expert said the burden of uterine fibroids is much. “One study estimated that about 25 percent of women at the age of 30 has uterine fibroids, and about two thirds at the age of 60 years have it. The reproductive age group between 25 and 45 years,” Chukwunenye said.
Omaliko said the rise in the incidence might be ascribed to increase in the use and availability of investigative tools such as ultrasound.

On why the rise in uterine fibroids in Nigeria, Oluwole said there is a higher incidence of fibroids in black people, and this has been linked to genetic makeup, intake of diet deficient in certain vitamins example, vitamin D, or reduced intake of fruits and vegetables etc. He said the rise might be a result of increase diagnosis, delayed childbearing and many other reasons have been postulated.
Uterine fibroids and infertility

Solomon said cases of uterine fibroids contribute to the increasing cases of infertility. “If the fibroid is large or is located close to the inner lining of the uterus called the endometrium, it can distort this inner lining and make it difficult for the embryo to implant. Even when they implant and pregnancy occur, fibroids can lead to miscarriages. Fibroids sometimes can be located in some positions that make them block the tube making it difficult for the woman to conceive,” Solomon said.

Solomon said myomectomy, the surgery for the treatment of uterine fibroids, can be complicated by either damage to the tubes and endometrium or scar tissues (called adhesions) both of which are important for pregnancy to occur.

The NISA Premier boss said women with fibroids can still have children depending on where the fibroids are located and how large they are. “Even after treatment of uterine fibroids, they can still have some children,” he said.

To Chukwunenye, the link between uterine fibroids and infertility is weak. He said many women with uterine fibroids conceive easily and deliver their babies without significant complications. The medical expert, however, said those with very large uterine fibroids or smaller nodules that are compressing or blocking the fallopian tubes may suffer infertility. He said uterine fibroids contribute little to rising cases of infertility in Nigeria.

Chukwunenye said women with uterine fibroids could still have children.
Omaliko said uterine fibroid is really not an established cause of infertility except in cases where it occludes the Fallopian tubes. Omaliko also said women with uterine fibroids can have their babies while the fibroids are in situ, especially when the tumour has not grown to giant size.

On the contribution of uterine fibroids to rising cases of infertility in Nigeria, Oluwole said a direct relationship is usually not the case, but several other factors are important for this association. He said it has been observed that fibroids are associated with infertility but not necessarily a cause of infertility.

Can women with fibroids still have several children? “Yes, as some black women have coexisting pregnancies with uterine fibroids and can successfully carry the pregnancy to term,” Oluwole said.

A study by researchers at Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, noted that being a predominantly reproductive age disease, concurrent infertility and symptomatic uterine fibroids pose management challenges.

The study was published in Tropical Journal of Obstetrics and Gynaecology.
The researchers concluded: “Symptomatic fibroid was significantly prevalent among women with infertility. Myomectomy improves fertility potential and success rate of In Vitro Fertilisation (IVF). Uterine fibroid has both direct and indirect effect on infertility and pregnancy rate in this group of the patient can be improved through routine screening for uterine fibroids and early removal of the fibroids before they grow into giants size.”

Uterine fibroids and cancer
Solomon said uterine fibroids are entirely benign and arise from smooth muscles within the uterus and do not become cancerous. He said very rarely (not more than one per cent), they may transform to cancer and the implicated factors include anaemia, fibroid size, increasing age (above 50 years), and suspicion based on imaging.

Solomon said the cure for uterine fibroids is just as clearly discussed earlier. “Treatment for uterine cancer depends on the stage it was discovered. In the early stages, surgery (hysterectomy) is the mainstay. Chemotherapy and radiotherapy are also done,” he said.

The obstetrician and gynaecologist said uterine fibroids are the commonest gynaecological tumour worldwide. He said compared with their white counterparts, Nigerian women have a two-to-three fold higher incidence of uterine fibroids. He said fibroids among blacks is usually larger and more numerous than in whites. Solomon said at 35 years, about 40-60 per cent of Nigerian women have fibroids, and at 50 years, about 70-80 per cent have fibroids. “Uterine cancer arising from uterine fibroid is very rare but note that there are other causes of uterine cancers (like endometrial cancers, choriocarcinoma), which are managed appropriately,” he said.

On what causes uterine fibroids to become cancerous, Chukwunenye said: “The cause is unknown.”
Omaliko said fibroid could undergo many changes such as: red degeneration during pregnancy, calcification, myxomatous, hyaline, cystic, fatty, necrotic degenerations etc. Omaliko said the mass could occlude the ureters and cause renal problems; they can also sit on the bowels and cause constipation.

What causes uterine fibroids to become cancerous? Oluwole said this occurs rarely and cannot be predicted as a very small percentage can progress to a sarcoma, which is the cancer associated with uterine fibroids.

Link with hair straightening chemicals
On the link with hair straightening products, Chukwunenye said this may be true but the link is weak. “There is a need for further studies in other countries, other than the United States of America where the link was first described,” he said.

Solomon said some hair straightening products contain hazardous chemicals and hormone-like substances, which disturb the functions of body hormones, are linked to certain cancers. He said among cancers that have been associated to these products are uterine cancer, breast cancer and ovarian cancer. Solomon, however, more studies are ongoing to verify if this is true or not.

Omaliko said nobody is certain about the cause of cancer, the use of that product has not been fully confirmed as an associated factor. Omaliko said the female hormone, estrogen are the underlying factor.

Reacting to some studies linking hair-straightening chemicals with higher risk of uterine cancer, Oluwole said: “To generalise this, further research is needed. But some hormonal compounds have been found in them and this may be a possible link to the development of cancer.”

A study published in the Journal of the National Cancer Institute has associated hair-straightening chemicals with higher uterine cancer risk.

Women who used chemical hair straightening products were at higher risk for uterine cancer compared to women who did not report using these products, according to a new study from the National Institutes of Health. The researchers found no associations with uterine cancer for other hair products that the women reported using, including hair dyes, bleach, highlights, or perms.

The study data includes 33,497 United States (U.S.) women ages 35-74 participating in the Sister Study, a study led by the National Institute of Environmental Health Sciences (NIEHS), part of United States National Institute of Health (NIH) that seeks to identify risk factors for breast cancer and other health conditions. The women were followed for almost 11 years and during that time 378 uterine cancer cases were diagnosed.

The researchers found that women who reported frequent use of hair straightening products, defined as more than four times in the previous year, were more than twice as likely to go on to develop uterine cancer compared to those who did not use the products.

Approximately 60 per cent of the participants who reported using straighteners in the previous year were self-identified Black women, according to the study published in the Journal of the National Cancer Institute. Although, the study did not find that the relationship between straightener use and uterine cancer incidence was different by race, the adverse health effects may be greater for Black women due to higher prevalence of use.

The findings are consistent with prior studies showing straighteners can increase the risk of hormone-related cancers in women.
The researchers did not collect information on brands or ingredients in the hair products the women used. However, in the paper they note that several chemicals that have been found in straighteners (such as parabens, bisphenol A, metals, and formaldehyde) could be contributing to the increased uterine cancer risk observed. Chemical exposure from hair product use, especially straighteners, could be more concerning than other personal care products due to increased absorption through the scalp which may be exacerbated by burns and lesions caused by straighteners.

Burden/Implications
Solomon said implications or complications of uterine fibroids as aforementioned include infertility, menorrhagia, abdominal mass and distension, miscarriage, abdominal pain, dysmenorrhoea, dyspareunia, pressure symptoms, miscarriage, poor growth of babies in the womb, preterm labour, difficult labour, risk of caesarean section and heavy bleeding after delivery, delayed uterine involution after delivery.

What are other implications of uterine fibroids? Oluwole said majority of women with fibroids have no symptoms, but when they have symptoms, it is commonly grouped as bleeding, pain, or urinary or bowel pressure symptoms with varying presentation pattern, abdominal swelling, painful menses etc.

On the burden of uterine fibroids in Nigeria, Oluwole said, generally, data on this is poor, so an answer to this is difficult. He said one can conservatively say about 15-20 per cent of women have one form of uterine fibroids. He said women of reproductive age, when the female reproductive hormones are active are the most vulnerable.

Chukwunenye, however, said it could affect the general health of the sufferer, including heavy and painful menstruation which may lead to absenteeism, chronic anaemia leading to anaemic heart failure, chronic constipation, back pressure damage of the kidneys, and rarely it could transform to a malignant tumour of the uterus called Leiomyosarcoma.

Solutions
Solomon said solution to uterine fibroids is to treat it. He said the treatment depends on the symptoms and the size. He said most cases of fibroids cause no symptoms are should not be a source of worry. The fertility expert said possible symptoms that fibroids can cause includes heavy and prolonged menstruation (called menorrhagia), abdominal mass and distension, miscarriage, pelvic pain, painful menstruation (or dysmenorrhea), painful sexual intercourse (or dyspareunia), specific pressure symptoms depending on the affected structure, etc.

Solomon said when they cause symptoms or if the size is big, they should be treated. He said treatment could be non-surgical with drugs or surgical. He said other methods of treatment without operation include Uterine Artery Embolization (UAE) and the use of High Intensity Focused Ultrasound (HIFU). The obstetrician and gynaecologist said drugs can be used to control the symptoms, however, the mainstay of the treatment is surgery. “The surgery may involve the removal of the womb together with the fibroids (or hysterectomy) if clearly indicated or in women who have completed their family size. In women who still want to have children, the treatment is to remove the fibroids alone (or myomectomy). These surgeries can be done by the open method (laparotomy) or through a key-hole or minimal access approach (laparoscopy or hysteroscopy),” he said.

Solomon said there is no effective means of preventing uterine fibroids since the exact cause is not clearly understood. He said women who started giving birth to babies early are less likely to have fibroids. The fertility expert said it is advised that women should get married early and start giving birth. He said some studies have suggested several nutrients like Vitamin D as well as exercise as being helpful in preventing fibroids but these have not been proven beyond doubt. He, however, if a woman’s womb/uterus had previously been removed (hysterectomy) due to any reasons, she cannot develop uterine fibroid.

Solomon said the National Health Insurance Act (NHIA) covers the treatment for uterine fibroids and tumour and this has been a huge relief to the populace.

Chukwunenye said the solutions include increasing awareness, early diagnosis, appropriate follow-up, adequate medical treatment and gynaecologic surgical intervention when the need arises. He said it is important for women to know that it is best, easier and safer to remove uterine fibroids when it has not become too large.

Chukwunenye said the gynaecologist would be in a position to advise them the best time to remove them. He said some women abscond from care when they are advised surgical treatment, only to come back when the uterine fibroids have grown so large and is threatening their lives. “At this late stage, usually treatment outcomes are poor,” he said.

The obstetrician and gynaecologist said since there are no known causative factors, only associated factors; it is difficult to say what girls/women can do to prevent developing uterine fibroids. He said preventing the associated factors like pelvic infections and exposure to external sources of the female hormone estrogen, may be helpful.

Chukwunenye said depending on the plan type, there are various levels of coverage by health insurance schemes in Nigeria.
Omaliko said the solution is surgery to relieve the occlusion. Omaliko said fibroids are genetically determined tumours, they occur more in black people who tend to have more fibrous tissue.

On the solutions, the medical expert said a good health seeking behaviour would help with early diagnosis and optimal care in standard health facilities. He said women are encouraged to do regular medical check up and be open-minded to medical solutions.

On what can girls/women do to prevent developing uterine fibroids, Oluwole said it is important to note that there are some that have a genetic predisposition and majority of women have fibroid with no symptom of concern. He said this might have been picked during a routine scan. “Hence a healthy lifestyle, intake of balanced diet and early child bearing might be helpful,” Oluwole said.

Oluwole said some gynaecological conditions are covered and this may apply to some forms of treatment of fibroids. He, however, said there are more advanced treatment modalities that may not be covered by NHIA.

Several studies have shown that diets high in fruits and vegetables tend to lower the risk of developing fibroids. According to researches, fibres, vitamin A, C and E, phytoestrogens, carotenoids, meat, fish, and dairy products are of unclear effect. It has also been demonstrated that normal dietary levels of vitamin D may reduce the risk of developing fibroids.

Is there any cure for uterine fibroids/cancer?
Oluwole said there is no permanent cure for uterine fibroids as they can grow back even after surgical removal. He said some cancers could be cured when picked up early while certain cancers have no cure but its growth can be slowed down with surgery, chemotherapy and radiotherapy.

Chukwuneneye said temporary cure for uterine fibroids is myomectomy that is the removal of the fibroid nodules with preservation of the uterus. He said the permanent cure is hysterectomy, that is the total removal of the uterus. He said very early stages of uterine cancer can be cured by radical hysterectomy but advanced stages are incurable as of now.
Natural cures

Recent studies have validated more herbal remedies to provide permanent solution to the menace without adverse side effects.
Turmeric

Turmeric is a spice that comes from the root of Curcuma longa, a member of the ginger family, Zingaberaceae. It contains the active ingredient curcumin. Curcumin is a bright yellow chemical produced by some plants. It is the principal curcuminoid of turmeric. (It is sold as an herbal supplement, cosmetics ingredient, food flavouring, and food colouring.

In Nigeria, it is called atale pupa in Yoruba; gangamau in Hausa; nwandumo in Ebonyi; ohu boboch in Enugu (Nkanu East); gigir in Tiv; magina in Kaduna; turi in Niger State; onjonigho in Cross River (Meo tribe).

Thai researchers have successfully decreased the size of uterine fibroids after six months of daily oral administration of turmeric.
The study titled ‘Curcumin in Reduction Size of Myoma Uteri’ was published in Thai Journal of Obstetrics and Gynaecology.
The researchers at the Department of Obstetrics and Gynaecology, Bhumibol Adulyadeji Hospital, Directorate of Medical Services, Royal Thai Air Force, Bangkok, Thailand, determined effects of curcumin in decreasing size of leiomyoma (uterine fibroid) and to determine adverse effects of curcumin.

The study was a prospective on conducted in reproductive women with leiomyoma in Bhumibol Adulyadeji Hospital. 35 women with 81 leiomyoma lumps were recruited to participate by convenience sampling.

Ultrasound measurement of size of leiomyoma was done before treatment with curcumin was started. Main outcomes measure was size of leiomyoma. Size of leiomyoma was compared between before and after taking curcumin for six months.

The results showed the mean diameter of leiomyoma were statistically different at before and after three and six month’s curcumin intake. And both mean volume of leiomyoma was statistically different at before and after three and six month’s curcumin intake. Adverse effect of curcumin was not found.

Also, Egyptian researchers have successfully used turmeric, in clinical studies, to decrease the volume of uterine fibroids in women.
The study published in Journal of American Science is titled “Curcumin a New Modality for Treatment of Uterine Myoma.”

The researchers from Heliopolis Research Center, Cairo and Department of obstetrics and Gynaecology, Faculty of Medicine, Ain Shams University Cairo Egypt noted: “Curcumin, the active ingredient in turmeric, is known for its antitumor, anticancer, strong anti-inflammatory, antioxidative, antiangiogenic, proapoptotic, antiamyloid, antiarthritic, potent inhibitors of cytochrome p450, reduced cholesterol level. Uterine fibroid are the most common pelvic tumours and occur in 20 to 25 per cent of premenopausal women.

“Current pharmacological therapies include gonadotropin releasing hormone GnRH agonists/antagonists, oral contraceptive, progestin selective modulator of progesterone receptor (Aspprisnil) and mifepristone.

“The aim of this work is to use for the first time in the literature curcumin for treatment of uterine myoma. A total of 50 women had uterine myoma were enrolled in the study, the inclusion criteria were age between 20-35 years mean age 32±3.25, no more than (three) intramural myomas the main diameter at 3 D transvaginal ultrasound >5mm.

“Curcumin is used in the tablet form each tablet 450 mg one tablet after meal three times daily for 12 weeks, assessment of uterine bleeding by using daily bleeding diapers and haemoglobin (Hb)/main constituent of the red blood cell concentration, uterine dimensions and myoma dimensions are measured by 3D ultrasound.”

Haemoglobin is the main component of red blood cells and serves as the transporter for oxygen and carbon dioxide in the blood.
The results of the study found statistically significant decrease in the uterine volume and myoma volume (cm3). “Again we find statistically significant increases in Hb percentage after treatment the bleeding stop completely in
88 per cent after two weeks treatment and after four weeks in 12 per cent of the cases,” it noted.

The researchers concluded: “Curcumin is a new drug with multiple pharmacological actions, no reported side effects of significances for treatment of myoma.”

Also, another study published in Gynecological Endocrinology showed curcumin suppressing fibroid cell replication by interacting with Peroxisome Proliferator-Activated Receptor-Gamma (PPARg). PPARg is a cell receptor that plays a role in controlling the cell cycle and cell division. It also has been found to suppress inflammation.

In order for PPARg to be active, it needs to bind to other molecules. Once this happens, it can then influence cell behaviour. In laboratory trials, the authors of the study found curcumin activated PPARg by binding to it. Doing so inhibited replication and growth of uterine fibroid cells. Curcumin and PPARg interaction also induced apoptosis, or programmed cell death, of fibroid cells.
Lime concoction

A study on herbal preparations for uterine fibroids published in Journal of Medicinal Plants Studies recommended: “…Grind Secamone afzelii leaves inside a bottle of Citrus aurantifolia (lime) fruit juice. Add a cowrie with no hole and little potash. Soak it for one day. Take two spoons once a week to treat fibroid.”