Uterine fibroids are common and an incapacitating problem for many women across the world including those in Uganda.

Shannon K. Laughlin Tommaso, a health science expert, in his publication in the US Clinical Trial.gov, states that nearly 60% of women with fibroids across the globe report that symptoms affect their quality of life and impede physical activity.

While 24% report that fibroid symptoms prevent them from reaching their true potential at work, heavy menstrual bleeding, the most common symptom of uterine fibroids, affects approximately 1.4 million women per year.

Medical therapy is the first line treatment for heavy menstrual bleeding but further studies need to be done to prove the effectiveness of these treatments.

In his study to determine the effectiveness of non-estrogenic medical therapy in women with a range of fibroid sizes, locations and number, it was discovered that two effective medical treatments for heavy menstrual bleeding have limited data on women with fibroids.

The Levonorgestrel intrauterine system (a process where plastic device is placed in the uterus where it slowly releases the hormone to prevent pregnancy for 3 to 5 years) was approved for the treatment of heavy menstrual bleeding in 2009 and is highly effective in decreasing menstrual bleeding, treating anemia and improving quality of life. Moreover, it can be used continuously for 6 years.

Others, according to him, are Tranexamic Acid which is widely used outside the U.S. and was approved for treatment of heavy menstrual bleeding in 2009. Tranexamic Acid reduces menstrual blood loss in 40% of women and improves quality of life in women with fibroids.

However for the case of Uganda there are various options of treatment depending on the gravity of the fibroids and this is after diagnostics is done. Below are the explanation by the scientists.

How are fibroids diagnosed?

Doctor Moses Tiri, an obstetrician at International Hospital Kampala (IHK) explains that the primary way to diagnose a fibroid is through healthcare provider’s routine health examination. In most cases women come for general checkup when they are not feeling well.

The doctor in the process of routine checkup may feel a firm, irregular pelvic mass. The scientist may also use imaging tests such as X-ray, ultrasound or magnetic resonance imaging (MRI) to check for fibroids.

Transvaginal ultrasound (also called ultrasonography)

In this method the scientist uses high frequency sound waves to produce images of the uterus on a screen. This will allow him or her to see the internal structures and any fibroids present. Transvaginal ultrasound is administered by inserting the ultrasound wand into the vagina and may provide clearer pictures since its closer to the uterus during this procedure.

Magnetic resonance imaging (MRI)

This in-depth test produces pictures of your uterus, ovaries, and other pelvic organs. This way doctors will get to know if a woman has fibroids.

Other methods are the normal X-ray, Hysteroscopy which is a visual exam of the cervix and the uterus using a viewing instrument and endometrial biopsy where scientists insert a tube into the uterus to take a tissue sample for examination in the laboratory.

Symptoms of fibroids

Dr Peter Ssebaddukaa, a senior pediatrician and gynecologist at Mulago Specialized Women and Neonatal Hospital (MSNH), says in most cases women come to the hospital with various health complaints which doctors can’t tell how long they have occurred.

Usually some women complain of heavy painful, prolonged periods, others complain of failure to conceive, some complain of a swelling in the abdomen, failure to pass urine normally, dizziness due to over bleeding during menstrual periods and others come when they are anemic due to too much bleeding.

Others feel constipation meaning one’s bowel movements are tough and the woman will find difficulties in passing stool. 

Dr Ssebadduka contends that usually some of these health problems lead to social challenges such as marriage breakages especially if the woman fails to conceive. Both husband and wife will begin seeing other partners and may end up contracting HIV/Aids.

“Others resort to going to see traditional doctors who will deceive them with all sorts of things such as displaying goat intestine which they will claim is medicine. Some will say they can administer the medicine directly by having sexual intercourse with the woman and will infect her with HIV/Aids,” he noted.

Patient experience

Irene Ngambe aged 30, a resident of Mpererwe, a Kampala suburb, has been seeking fibroid medication since January 2021. She holds a diploma in business administration.

While narrating her story at Mulago Specialized Women and Neonatal Hospital, she said she is not married but has a boyfriend and she is yearning to bear a child.

“I have been having painful and prolonged periods for over 12 years and I thought it was normal. On January 3^rd 2021 I over-bled during my menstrual period that lasted 10 days. Later I began feeling dizzy. I could feel tired when I have not done any work and I was discharging a lot of white stuff.  I sought medical care in a nearby clinic next to my residence. The doctor suspected I had fibroids, he gave me pain killers and iron boosters to restore the blood lost,” she recalls.

The doctor referred her to ABI Clinic in Wandegeya where an ultrasound was administered and she was diagnosed with fibroids. However to remove them would cost her Shs3m which she did not have.

After swallowing the drugs she purchased from the clinic, the bleeding and whitish discharge have since reduced but she wants the fibroids removed.

She was referred to Kawempe Referral Hospital which she found so congested with women facing the same challenge. She needed urgent attention, so she decided to go to Dr Ssebadduka at MSNH.

“I have discussed it with Dr Ssebadduka, he is willing to help me because I want the fibroids removed in order to conceive. I feel the years are running out and I will soon reach my menopause without a baby,” Ms Ngambe says,

It is her contention that the fibroids are many and one has blocked her tube which once removed will allow entrance of sperms to the uterus. She says she used to be fat but she has lost a lot of weight, which she needs to regain. As for the financial implications, she is optimistic her elder sister will meet half the cost.

She intends to obtain a loan to cover the rest of the costs. Currently she is engaged in voluntary research jobs where she is paid little money.

Options for treatment to fibroids

Dr Ssebadduka explains that treatments may include medical, surgical or radiological options. However if the fibroid is not causing any problem, usually the scientists counsel the patient not to disturb it.

“If it causing a problem, we shall find the cause and the symptoms in order to advance treatment. If fibroids grow to a significant size usually beyond 6cm or cause more serious symptoms, medical treatment may be necessary. The health care provider will recommend a treatment based on your health and medical history, the size of your fibroids, your plans for future pregnancy, how you may respond to treatment and one’s treatment preference,” he said.

Medical Treatments

Dr Tiri explains that not all fibroids grow and even large ones may not cause any symptoms, and most shrink after menopause.

However, still a patient is advised to see a doctor who will check on their growth, especially if one develops symptoms like bleeding or pain, and at least get pelvic exams every year.

Dr Tiri notes that most treatment options are categorized and the most common is open surgery. The surgery is administered on a fibroid size of between 4cm-6cm. Others he explains them as below.

There are different ways of doing surgery and they include, endometrial ablation which is a procedure in which doctors destroy the lining of the uterus to cut down on the bleeding linked to small fibroids.

Myomectomy:  It is a surgery to remove fibroids. If you plan to become pregnant, your doctor may recommend this over other procedures. But it may cause scarring that can lead to infertility. One will need to wait 4 to 6 months after surgery before they can try to conceive. In most women, symptoms go away following a myomectomy. But in others, the fibroids will reoccur.

Whether it works will partly depend on how many fibroids you have and whether the surgeon could remove them all.

Hysterectomy: It is surgery done to remove the uterus and this means the fibroid was at an acute stage. Many women don’t need treatment that is drastic. In private facilities the cost of administering this ranges from Shs4m – Shs6m.

Endometrial ablation: This is where the lining of the uterus is destroyed using a heated balloon or a tool that emits controlled microwave energy. Pregnancy is unlikely after ablation.

Laparoscopy method: Laparoscopic fibroid removal is where doctors use small, specialized surgical instruments inserted through one or more tiny incisions in the abdomen, eliminating the need for traditional open surgery. Patients benefit from shorter hospital admissions, if any, less pain, less scarring, fewer complications, faster recovery and faster return to normal activities.  This may cost from Shs6m-Shs8m.

Uterine Embolisation:  This method is still new in Uganda and other African countries. The services are already at IHK and other private hospitals. Dr Tiri explains that uterine fibroid embolisation (UFE) is a procedure done by scientists where they cut one of the veins in the woman either on the thigh or chest. This may cost from Shs8m-Shs10m in private facilities.

“Then under Fluoroscopy we are able to guide a wire through the vessel which supplies fibroids with food and block it. Since there is no more food supply, the fibroid will eventually shrink and die off,” the doctor says.

Once the wire is inserted through the veins to the position where the fibroid is placed, it blocks blood flow to fibroids in the uterus. This method is also called uterine artery embolisation. This method applies to all types of fibroids. Embolisation is administered on fibroid size of from 8-10cm.

In open surgery usually the doctors may decide to remove the uterus when the fibroid has grown abnormally and is causing too much pain to the woman including other symptoms like over-bleeding. Sometimes it is the muscles which are removed depending on the gravity of the problem.

Fibroid treatment using medicine

Dr Tiri explained that it is possible to treat a fibroid with medicine and studies are going on in UK where the scientists are developing the GnRH analogues to induce menopause that will take place for six months to allow fibroids to shrink off. This means the body will not produce estrogen for 6 months.

Doctors can administer pain relievers such as Panadol and Ibuprofen among others but this is temporary.

Hormone Therapy: This is where the doctors will recommend women to stop taking birth control pills.

GnRH agonists. Your doctor may prescribe one to shrink fibroids and reduce anemia. They carry the same precautions as GnRH antagonists.

SERMs.  Selective Estrogen Receptor Modulator are a type of medicine that works on your estrogen levels and may shrink fibroids without temporary menopause symptoms.

Nutritional remedy: The experts say usually it is important for women especially those who become anemic to take food items that contain calcium, vitamin C, iron and zinc among others. They could be vegetables, fruits and cereals such as millet and sorghum.