Keywords: Blood transfusion; Genital bleeding; Hysterectomy, Uterine fibroids; Yaoundé

Introduction

A fibroid is a benign tumour formed by the over proliferation of connective tissue and smooth muscle fibers, to which collagene a complex protein is adjoined. Of all the possible localisations, its organ of predilection is the uterus. It evolves gradually during the reproductive years of the woman’s life and its pathogenesis is not clear. Epidemiologically, uterine fibroids occur in 25-30% of women aged more than 35years, in 40% of women above 40 years and in 50 % of women older than 50 years [1]. Recent cross sectional studies have shown that the risk of a woman aged above 45 years of developing fibroids is 60%. [2]. The incidence is higher in black than in Caucasian women. The etiology of fibroids is still very bleak and molecular biology is yet to explain many aspects about them. Their growth is strongly influenced by the female ovarian steroid hormones oestrogen and progesterone, growth factors, angiogenetic factors and the process of apoptosis. Black race, heredity, obesity, diabetes and hypertension are all associated with an increased risk of developing fibroids [2].

Clinically, symptoms are apparent in only about 50% of cases [1]. There is proof that specific clinical pictures are present in patients with a strong familial predisposition compared to other patients [2]. Menomettrorragia is the commonest symptom associated to fibroids. Fibroids could also present clinically with pelvic discomfort, dysmenorrhoea or even mechanical compressive symptoms in the urinary and digestive tracts. In some cases, fibroids have also been found to be at the origin of infertility [3]. Concerning their management, fibroids represent the first cause of hysterectomy for benign lesions in women of reproductive age and around perimenopause [4].

It is given its high frequency in our local setting that we sought out to carry out this study on the sociodemographic characteristics of uterine factors; more specifically, their ethnic factors, their clinical presentation as well as the therapeutic aspects concerning uterine fibroids in the gynaecology unit of the Yaounde Central Hospital

• Objectives
• General Objective :

To describe the epidemiological, clinical and therapeutic aspects of uterine fibroids in the Obstetrics and Gynaecology Unit of the Yaounde Central Hospial (YCH).

• Specific Objectives:
• Determine the frequency of uterine fibroids in the YCH
• Study the sociodemographic, obstetrical and anthropometric characteristics of patients presenting with uterine fibroids in the YCH;
• Describe the clinical characteristics of patients presenting with fibroids;
• Describe management options of uterine fibroids in the YCH.

Materials and Methods

Study Design : We carried out a cross sectional descriptive study with a retrospective collection of data.

Setting : Our study was carried out in the gynaecology service of the YCH. This service has 58 beds, a general delivery ward, a private individual ward, a surgical theatre, a unit for follow up of pregnant HIV infected women and an external consultation unit (obstetrics and gynaecology, antenatal, post natal and family planning unit).

Study Period : Our study covered a period of 5 years from the 1st of January 2013 to the 31st of December 2018.

Study Population : The target population were all the women who came consulting in the gynaecology unit of the YCH during the study period. We included the files of women presenting with uterine fibroids and then excluded all incomplete and unexploitable files.

Data Collection and analysis : Data collection was done using a pretested questionnaire that was formulated for the study. The data was analysed using Epi info version 3.5.3 and SPSS version 20 softwares. Tables were generated using Excel 2007 software.

Results

Frequency : During our study period from 2013 to 2018, we registered 3512 hospitalisation cases in the gynaecology service; 250 of which were cases of uterine fibroids giving a frequency of 14%.

Sociodemographic, Obstetrical and anthropometric characterisctics : The median age of the patients was 37.47 and the most represented age group was the 30-40 years age group with a frequency of 47.6%. Most of the women were housewives 36%. Majority were nullipara (51%) and the obese represented 28.8% (Table 1).

Clinical Characteristics

Symptoms : Menorragia was the most frequent type of genital bleeding. Pelvic pain was present in 40% of cases. Signs of local compression like constipation and pollakiuria were present in 34.4% and 31.6% of cases respectively (Table 2).

Diagnosis : From the histological point of view, there were multiple fibroids in most of the cases (Table 3). Fibroids which developped in the abdomino pelvic cavity were found in half of the cases (Table 4,5). Concerning the layer of the uterus involved as shown by ultrasound, majority of the fibroids were interstitial.

Complications : Anaemia was the most frequent complication with a frequency of 72.7%. Necrobiosis was observed in 22.4% of cases (Table 6).

Treatment

Therapeutic Means : Surgical treatment was the main treatment modality (69.2%) and 85% of cases received a blood transfusion (Table 7). Radical surgical means (total hysterectomy) was the most commonly practised (Table 8).

Post operatory complications : 32 cases (12.8%) of cases had post-operative complications with the majority of them being hemorrage. We had 02 cases of death (Table 9).

Discussion

Frequency : In our study we registered 250 cases of uterine fibroids out of 3512 hospitalisation cases during the study period giving a prevalence of 14% [5] reported lower frequencies of 6.7%. Cramer et al [6] described a serial histological study of 100 hysterectomy samples and discovered that the incidence of uterine fibroids moved from 33% diagnosed before surgery to 77% after pathology results. The real incidence of uterine fibroids is thud either under estimated or it tends to only report the symptomatic fibroids.

Socio-démographic, obstetrical and anthropometric characteristics: The median age of the particicpants was 37.74 with extremes of 20 years and 55years. The 30-40years age group was the most represented in our sample; 47.6%. This result corroborates that of [7] whose most represented age range was 31-37 years although they reported a higher frequency of 30.55%. For Kountan, [8], the peak age at which fibroids occur was between 34-44 years. Butram [9] revealed that 20% of women had fibroids before 30 years and 40 % of them had fibroids after 50 years. In our study, most of the women were housewives (36%) and public service workers (25.6%). Toure [10] had 76% housewives and 23% public service workers. We also found that, nulliparas were the most dominant group amomg our cases representing 51%. This value is higher than that of Koutouan [8] who reported 36,3%. Primiparas represented 25,6% and multiparas 23,4% of the study population. This finding emphasizes the fact that pregnancy is probably a protective factor.

Clinical characteristics

Symptoms : Genital bleeding was the most frequent symptom occurring in 61% of cases. The bleeding was classified as menorragia (56.5%), menometrorragia (32.8%) and metrorragia ( 10.7%). These results are similar to those of Ouattara [7] and Huguier [11] who found genital bleeding in 62.96% and 50% of cases respectively. Thiero [12] on the contrary had a lower frequency of 32.3% Pelvic pain as a symptom was represented in our sample by 40% whereas other authors had 15% for Ouattara [7] and 10,9% for Thiero [12]. These pains are due to an extrinsic compression of the uterus given the increase in size of the uterus as reported by all authors. Urinary symptoms such as pollakiuria was found in 31,1% contrary to only 2.7% reported by Ouattara [7] and 4% by Bayo [13]. Dysmenorrhoea was present in 32% of cases. It is usually due to the association of uterine fibroids and adenomyosis. Ouattara, Abolo et Koutouan [7, 14, 8] reported frequencies of adenomyosis of 4,41 %; 1,25% et 1,81% in women with fibroids In 8% of the cases, the patients came consulting for a sensation of pelvic mass, This is similar to findings by Ouattara [7] who had 8,33%. Lamorte [15] in his series found that 21% of patients presented with pelvic heaviness. This sensation of pelvic mass and heaviness is related to the size of the fibroids.

Diagnosis : In our series, all the patients carried out an ultrasound. The ultrasound aided in ascertaining the number of fibroids which for the most of them were multiple (86.8%) as well as the localisation on the uterine walls which were mostly interstitial (47%). Prior research by Thiero [12], revealed that 90,9% of cases had underwent a caesarean section (451/496). Sangaret [16] in Abidjan had a coporeal localisation of the fibroids in 76% of cases. Heyler [16,17] observed a 7% isthmic localisation. Koné [5] had 112 cases of corporeal fibroids (93,3%) ; 18 cases of isthmic fibroids (15,0%) and 4,2% interstitial fibroids. In our study we found that 19 % of fibroids were submucous, 47 % intramural and 34% subserous. This result is comparable to that of Thiero [12] who found 37.3% subserous and 7.4% intracavity. Our study also showed that 86.8% of women had multiple fibroids. These results are comparable to those of Ouattara [7] who had 9,25% de solitary fibroids and 90,74% polymyomatous uteri. Bayo [12] found 89% polymyomatous uteri and 11% solitary fibroids.

Treatment

Concerning the treatment options, 10% received medical treatment while 8% had medical treatment followed by surgical treatment. Medical treatment with Progesterone is aimed at stopping bleeding while GnRH analogues help reduce the size of the fibroids prior to surgery. This result is largely less than those reported by Ouattara [7] who administered GnRH analogues in 60.32% of cases and Toure [10] who did so in 52% of cases. This could be explained by the expensive nature of the drug in our setting [18,19] did a metaanalysis which came up with the conclusion that tranexamic acid reduces per operatory bleeding during myomectomies and menorragia secondary to fibroids.

Conservative surgical means like myomectomy which have the advantage of preserving the fertility of women was done in our series in 49.2% of cases. This is similar to results of Thiero [12] who reported 37.9% in their study. Kountan [8] found 17,05% of myomectomies and Keita reported 78,9% (30cases) of myomectomies/polymyomectomies.

We carried out conservative surgery in patients with a solitary fibroid or in patients who desired to maintain fertility. For the other patients radical surgery was indicated. Thus, we carried out total hysterectomies in 50.8% of cases [20] in Dakar in 2003 found 27,86% of total hysterectomies while Thiero [12] reported 26% of total hysterectomies, 4.6% with annexectomies

In all our patients open surgery by laparotomy was the surgical method [21] in their study found that of the 436 women who underwent a myomectomy, 88 of the surgical interventions (20.2%) were carried out by laparoscopy, 342 (78.4%) by abdominal route and 6 (1.38%) were started by laparoscopy and then converted to laparotomy. They concluded that compared to abdominal myomectomies, those done by laparoscopy in adequately preselected patients was associated with comparable surgical outcomes but with shorter stay in hospital.

In our setting, we do not dispose of laparoscopy machines which explains why all our patients were operated by laparotomy. Majority of our patients (85%) received a blood transfusion. Post operatory complications were registered in 32 cases (12.8%) two of which were cases of death. The two cases of death occurred due to non-availability of blood products after myomectomies in Rhesus negative patients who had severe anaemia. Toure [10] registered 1 case of death 1 case of anaemia and 1 case of hemorrage while Traore [22] in 1992 working on 192 patients registered 1 case of peritonitis, 1 case of death secondary to septic shock and 1 case of wound infection

Conclusion

Uterine fibroids are a very common in our local setting. They are common in young women. Ultrasound is the most essential para clinical imaging test needed for diagnosis. The management is mostly surgical and is at times marred by complications or even death. Emphasis should be laid on the fight against risk factors especially obesity by sensitising women on the advantages of regular physical activity and healthy lifestyle.