A lot of doctors claim that fibroid surgery is easy and that any doctor can handle it, that is not true —Professor Christopher Aimakhu

Professor Christopher Aimakhu, a consultant obstetrician and gynaecologist at the University College Hospital (UCH), Ibadan, says in this interview by Sade Oguntola that it is a misconception that fibroids alone cause infertility and excessive bleeding in all cases. He also suggests ways the condition can be best managed.

How common are uterine fibroids in your practice, and what symptoms bring women in for care?

Uterine fibroids are the most common benign tumours of the female reproductive tract. They are mostly benign, meaning that they›re not malignantcancers. Malignant cancers are the tumours that the spread can be fast and dangerous, so fibroids are not dangerous tumours.Generally, 25% to 50% of Black (negroid)women will have uterine fibroids. And if you do a post-mortem of these women, you’ll find out that at least 50% have it.  So, you’re talking about one in two women having fibroids.

Now, how common is it in my practice? I run a gynaecological clinic, and infertility is the most common complaint among women at the clinic. In fact, in those infertile women, about 20% of infertile women also have uterine fibroids. However, generally about 30% of my gynaecological patients in my practice would complain to me about uterine fibroids.

Now, what are the most common symptoms they bring? Many times, I must admit to you, most women, yes, apart from the history of infertility, which is the inability to conceive, and then, along the way, you find out they have fibroids. The other thing that is the most common symptom for them is having no symptoms at all. So, maybe they go for a routine ultrasound, maybe for job placement or something, and then it’s discovered that they have uterine fibroids.

So, the majority of women don’t have any symptoms. Now, in those women, the symptoms of the fibroids are based on the location of the tumour in the uterus. When the fibroids are located in the uterus, which is the womb, the most common symptom, of course, that is, if they have symptoms, is heavy flow. What we call menorrhagia. So, women will complain of heavy menstrual flow during their menses.

So, those are the most common symptoms that you see in women who have symptoms present.

Other things are abdominal swelling and abdominal pain if the tumour extends to the abdomen. Of course, the uterus is in front of the bladder, so they can complain of urinary symptoms.  Behind the uterus is the rectum and the anal canal, so they may complain of things like difficulty in passing faeces due to constipation. Of course, those that grow laterally, that is, towards this side, where you have the ureters that bring urine from the kidneys down to the bladder, they complain about pain when passing urine.

Is a fibroid the same as endometriosis? What do you think makes uterine fibroids so neglected or overlooked in medical discourse and funding?

Well, fibroids are not the same as endometriosis. In endometriosis, the woman menstruates from other organs in the body other than the endometrial lining (the inner lining of the uterus)/ So, endometriosis is an abnormality, and it could be in the ovaries, even in the chest, the lungs and other places in the abdomen. As such, the women menstruate from those areas.

Now, why is a fibroid neglected? I think fibroids are neglected; I would say, one, because it’s a female thing. If it weren’t a female thing, I think more attention or awareness would be made about it. Two, it’s not cancer. So, you find a lot of women who carry them around with them. Third, it is just about 5 to 15 per cent of women who have fibroids who have infertility. So, it’s not as if you have fibroids; you cannot get pregnant. No, fibroids are just one of the very many causes of infertility; people don’t bother too much about it because it does not account most of the causes of infertility. Ovulation and damage or blockage to the fallopian tubes are the most common causes of female infertility.

How has your understanding of the genetic basis of fibroids, such as the MED-12 mutation, changed treatment possibilities?

I think one of the things that has changed the dimensions of fibroids is that there is no doubt now that it is hereditary. If you have a woman who has fibroids, there’s likelihood that her female children may have fibroids. Although we know that genetic studies are being done, there’s no doubt that the causes of fibroids are unknown. What we know are the things that are common to women who have fibroidsor aetiological or risk factors. Of course, these includes that fibroid are found in women during their reproductive life. Women who are menstruating are in their reproductive life. Women between the ages of 25 and 45 are in the category of women who are of reproductive age. Those are the women that are having fibroids because fibroids are oestrogen-dependent tumours. When women get to like menopause or around the time of menopause, it has been shown that no new fibroids will be formed, and old fibroids tend to shrink. That is why we talk about age as a risk factor for fibroids.

 Also, other risk factors are obesity, choosing not to have children and race. It is more common in Black people than in whites and, of course, some Asian populations. Women, who choose not to have children, stand a higher risk of having fibroids. It is said that the uterus tries to occupy itself with fibroids when there’s no baby to occupy itself with. And then, of course, it’s been shown that women who eat a lot of red meat tend to have fibroids.

Now, there have been genetic studies to see if fibroids could be due to genetic mutations. It’s not just the MED-12 mutation; other things are being studied to see if that can help in predicting the women who tend to have fibroids.

Historically, hysterectomy (womb removal) has been a default treatment. What are the limitations of that particular approach, especially for young women?

Hysterectomy is one of the many ways to treat fibroids. If women of reproductive age want to have surgery, the surgery that’s of choice is myomectomy, meaning removal of fibroids. But for women who don’t want to have children, or who have had enough children and want to have surgical removal of fibroids, we tend to offer them hysterectomy. Hysterectomy is the total removal of the uterus.

But surgery is not the only form of treatment for fibroids. The treatment for fibroids depends on what i can summarise as five things: the age of the woman, the location of the fibroids, the size of the fibroids, the symptoms she has, and the woman’s reproductive expectations i.e. does she want to have children or not. If you are having a woman who has very large fibroids, of course, you want to treat her compared to a woman who has small fibroids.

The location will tell you what the symptoms are going to be. For example, fibroids located in the inner lining of the uterus, which is the endometrial layer, are called submucous fibroids and tend to give heavy menstrual flows. This is unlike the ones that are inside the muscle of the uterus (intramural fibroids) or those on the surface of the uterus (subserous fibroids), which do not tend to give heavy menstrual flows but rather give more abdominal pain and abdominal swelling.

Of course, the reproductive expectation of the woman is considered, too. Does the woman want to have children or not? If a young 35-year-old woman, a movie star or somebody who doesn’t want to have children wants a hysterectomy, even at 35, she can be offered a hysterectomy since she doesn’t want it to recur.

Also, the treatment offered could be in terms of symptoms. Maybe she’s having pain; you may just give analgesics. Some women will complain of heavy menstrual flows. You can give drugs or medications.

In women, with an aversion to surgeries, medications that can shrink the tumours are given. However, those fibroids shrink in size for only about six months. Afterwards, there’s a rebound effect. The fibroids get bigger than they were before. 

With a lot of herbal and traditional medications that many women use, the fibroids break out from their encasement, like when you open a walnut. Fibroids are tumours that are like stones, and they can break out from their shell.  That is what happens to many who take a lot of herbal products claimed to treat fibroids. They tend to melt these fibroids, making them more difficult to treat and causing more symptoms. Some of them even make the fibroids drop out of the vagina and then cause a lot of wounds.  Also, the vaginas are tightened because of the way those things have come out.

 There are other ways to treat fibroids. Radiation can be used to shrink the fibroids. Called uterine artery embolisation, the radiation involves on the blood vessels that supply the fibroids to reduce the blood flow to the tumours.

A new technique of treatment called High Intensity Focal Ultrasound, HIFU, can also help to shrink the size of the tumour. They localise the tumours with a CT scan, and with radiation concentrated on the fibroids, the fibroids will shrink in size.

 But with surgical methods for fibroids, we can have myomectomy and hysterectomy. Myomectomy and hysterectomy can be performed by open surgery, where the woman is cut. You see, the woman has a scar. Or it can be through laparoscopy, which is a keyhole surgery. So, there can be hysterectomy via the vagina, which is called ‘laparoscopy-assisted vagina hysterectomy’ or ‘vagina hysterectomy’.

There are calls for personalised, less invasive therapies. What are the most promising developments in this space today?

The majority of fibroids are managed conservatively, meaning you don›t do anything. If there are no symptoms, just advise the patients. But if the symptoms are not too severe, you can watch and see. I›ve seen young women who want to go for very good jobs and routine examinations say they have fibroids, and they become very worried. And they say they want to take them out? There is no point in treatment or removal if she is not having symptoms. One in two women has fibroids. So, counselling is very key. In Nigeria, we don’t have a health system where everybody goes to the general practitioner. So, when you get to that age where a woman develops fibroids, then she can be counselled. And then they won’t panic, and they will be less assured that things are fine.

If you have a young woman who even has symptoms and she’s not ready to get pregnant, she can be left alone. There are drugs now that, if a woman has heavy flows, can reduce the amount of bleeding.

Given fibroids’ complexity, how can diagnostic tools evolve to better classify and guide treatment?

The singular way to diagnose a fibroid is by ultrasound. Ultrasound is one of those techniques that any woman can walk into any diagnostic facility to have a scan done. That is the cheapest, most effective way of diagnosing uterine fibroids. If a fibroid is picked, she can also seek medical help. Of course, other methods like the CT scan can be used to diagnose fibroids. But all women can have easy access to an ultrasound.

How can researchers and clinicians work together to shift the treatment paradigm from surgical to more conservative, patient-centred care?

Currently, in the developed world, the number of surgical interventions for fibroids has reduced because there are lots of other ways of treatment, including different medical approaches that many of these developed countries now embrace. One, medical management speaks well for insurance. Insurance coverage for medical treatment is more easily available than insurance coverage for surgery.

Two, in the developed world, the surgeons are not conservative when it comes to the surgical management of fibroids. In the developed world, when a woman has fibroids, no matter how many children she has or the symptoms she presents with, they would rather go for the removal of the uterus (hysterectomy) because fibroids can recur in most women many years later. So it’s only in societies like ours that put a high premium on having children that we choose to have conservative surgeries like myomectomies when women have fibroids.

So, which method or which treatment will you go for, given the fact that when you do a hysterectomy, the woman becomes menopausal immediately?

No, I disagree with you. You can remove the uterus without removing the ovaries. Hysterectomy is the removal of the uterus. If you conserve the ovaries, the woman won’t menstruate, but those menopausal symptoms will not reduce drastically. You will still have those menopausal symptoms, but it won’t be severe because they are still producing oestrogen and progesterone. The female hormones are produced by the ovaries. So, if a woman is less than 45 years of age, we tend to leave the ovaries behind following hysterectomy.  But when a woman is more than 45, we tend to remove the ovaries at surgery because we don’t want the woman to come back later with a history of ovarian cancer. So, if you have to take out the uterus, you don’t always have to take out the ovaries.

Do you find that most patients are aware of alternatives to hysterectomy when they come in? Why or why not?

Now in my practice, there are very few women who come in who have not tried alternative treatment for fibroids. There are lots of herbal products and methods claimed to treat fibroids.  So many things sold on the internet claim to take care of fibroids. I won’t use this interview to judge if they’re effective or not.

What challenges do you therefore face when trying to offer uterus-sparing options to your African patients?

In most developed countries, doctors tend to offer patients methods that will take out the uterus completely. In our case, women prefer myomectomy (surgical removal of fibroids) because they still want to have children. Also, another difference is that fibroids in our women tend to be very large , and complications have started to occur. Many times, because of the way our system is, patients do not seek help until the fibroids are very big (large) or are causing severe symptoms.

A woman can have a daughter who has a heavy menstrual flow and just say, Oh, it’s part of it. And use all sorts of things during the heavy periods. So, in the conservative approach, the challenges we face are that our fibroids are bigger. Two, even women who qualify for hysterectomy won’t want to undergo hysterectomy because they still believe they want to have children. A few weeks ago, I had a 44-year-old woman who’s had four children, has huge fibroids and still wants a conservative measure because she thinks; she may still want to have children, even though her last child is like 12 or 14 years old.

Two, she may believe that if she comes into the world the next time, she won’t have her uterus. Three, they may believe that you have taken out my uterus; that means my daughter, who will not have children. There are a lot of mystical things in it. So the tendency is for women not to have a hysterectomy even when they qualify for it. So, you will have to educate the patient and understand the facts about hysterectomy.

I have seen a patient who has previously had two myomectomies because the fibroids have grown back or re-occurred, coming to me for a third one. You have to convince that woman not to have a myomectomy or a hysterectomy.

Do systemic issues, such as access to healthcare or insurance policies, affect what kind of treatment women receive for fibroids?

First, surgical methods are expensive, be it in public or private hospitals. It is specialised care. A lot of medical doctors claim to know how to do these methods very well. However, the majority of complications from fibroid surgeries are caused by people who are not trained enough to do them. Then, surgeries are also not very accessible. It is not every facility that can offer surgeries for fibroids.

The health insurance policy does not consider infertility a disease. So, if a woman complains of infertility because she has fibroids, she may not be offered insurance coverage because infertility is not a disease. The only way to get insurance coverage will be if her initial complaints were symptoms like heavy menstrual flow or abdominal pain of uterine origin. If the initial complaint is that you want to get insurance for treatment of infertility, you’re unlikely to get it.

Are there some other common myths and misconceptions regarding fibroids in the community that women or men talk about?

Well, firstly, some women who have big fibroids assume that they have been pregnant for years, and the pregnancy has refused to be delivered. You have women who assumes that it is part of being fat or that they are naturally big, who don’t accept that they have fibroids. Then you have those who have heavy flows, for example, who say it runs in their family. I’ve seen a woman with fibroids who is anaemic from bleeding, and she keeps on saying that it runs in her family. So those are the things I tend to see most of the time.

What can patients do to help reduce or prevent deaths during and after fibroid surgery?

They should seek appropriate medical help. Their choice of facility shouldn’t be based on how big the health facility is, but rather on the expertise of the person offering the treatment. A lot of doctors claim that fibroid surgery is easy and that any doctor can handle it. That is not true.  The single thing that helps most is referral. If a woman has experienced a particular treatment before, she tends to tell people the facility where the surgery took place. Patients die from fibroid surgeries, whether being done by a good doctor in a bad facility or by an incompetent doctor in a good facility. If you do not assess your patients well and know what to do, then there could be a problem if there are complications following surgery, with death resulting.

Also, there should be a way of regulating hospitals and practitioners who offer not just fibroid surgeries but generally all surgeries. A lot of people escape by doing the wrong things, and they don’t get punished for that.

So, in identifying the right place to go, start with the basic way of looking at things first, with your general practitioner or your family doctor. Not all fibroids should end up with a gynaecologist. If there is a need to go to a secondary facility, an appropriate referral will be given. This way, the higher centres don’t get overwhelmed by cases they don’t need to see. So, a patient who has a very tiny fibroid and thinks she needs surgery can be properly counselled. She may not need this surgery.   

ALSO READ FROM NIGERIAN TRIBUNE: Online reports linking Shettima’s remarks to Rivers crisis false — Presidency

The deaths you mentioned were they deaths on the theatre table, deaths from complications after the surgery or both?

You can have deaths in three ways. You can have deaths even before surgery from fibroids? A woman who has heavy flows can have drops in blood level and bleed herself to death. Some religious bodies reject blood transfusions. Two, we have women who die during surgery. During a myomectomy, which is a surgical removal of fibroids, many things are done for patients to reduce the blood loss at surgery.  It’s not just cutting and removing fibroids. You must be able to reduce the blood loss at surgery and give the appropriate antibiotics and other drugs.  And of course, the kind of anaesthesia given is important. Some doctors will not even have started operating on the patient when they give the patient something to sleep, and she dies. So you have to do a lot to make sure that the woman is alive and recovers after surgery. Fibroids, if not handled well, can kill.