•Says They’re Benign Tumours, Not Cancers
Dr. Edmond Edi-Osagie, Consultant Gynaecologist, Fertility Specialist and Advanced Laparoscopic Surgeon based in Manchester, UK, in this interview with CHIOMA UMEHA, speaks on why he is setting up a fertility and endoscopic surgery service in Lekki, Lagos.
Fibroid is an issue that is of interest to many women of reproductive age especially here in Nigeria. What are fibroids?
Thank you for that very pertinent question in our contest. Fibroids are probably the most common benign condition that women, particularly African women, experience. Fibroids are actually benign tumors or masses of the womb that occur in women and the way to think about fibroids is to think about benign breast lumps. This is because fibroids are the womb’s equivalent of benign lumps that occur in the breasts. They are benign, originate from muscle and fibrous tissue and are particularly common in African women. We do not know how many African women have fibroids, but estimates tell us that at the time of death, fibroids have been found in up to 80 per cent of African women.
The vast majority of women do not appear to suffer from any significant symptoms or have any bad effect from the fibroids, and quite a few do not even know that they have fibroids. But in a substantial proportion, fibroids cause significant problems including menstrual problems, pelvic pain, and infertility, and so can blight many women’s lives. It is therefore a really important condition and one that every African woman needs to be aware of.
You said something that is particularly striking: that fibroids are the womb’s equivalent of benign breast lumps. Can you explain further?
Yes, the two conditions are very similar. In the breast, women develop benign lumps from the same type of tissue that gives rise to fibroids in the womb. So, they are very similar benign conditions, the only difference is that fibroids grow in the womb and so fibroids are benign tumours that grow from muscle and fibrous tissue in the womb.
So, why is it that the tumour in the breast often leads to cancer more than the tumour in the womb?
This is a myth; benign tumours in the breast do not lead to cancer. Cancer forms in a totally different way in the breast. Benign breast lumps remain benign lumps in the breasts: they do not transform into cancer.
Are breast lumps and fibroids in the womb cancerous?
I think the best way to look at fibroids is that they are benign; they are benign womb tumours not cancers. But, we know that in life anything can change from one condition into another. So there are fibroids that may transform if they remain in place for too long, if they get too big and if they occur in much older women. This very small risk of “malignant transformation” is of the magnitude of about one in 1,000 fibroids in women over the age of 50 years. But generally, fibroids are benign tumours and that is the best way to consider them.
What causes fibroid?
That is a million dollar question because we still do not know. What we know is that they develop from smooth muscle and fibrous tissue, but the exact cause is unknown. We also know that they are obviously a lot commoner in women of African origin, so we think there is a genetic linkage to their causation. But the genes that might be directly implicated have not been identified and we just do not know for certain how they influence fibroid formation.
Why and how do fibroids cause heavy periods?
Two main reasons: one relates to the bulk of fibroids. When fibroids grow, they increase the size of the womb and so the surface area of the lining of the womb, thereby increasing the area from which a woman bleeds and in consequence the amount of blood that the woman loses. A second reason is that fibroids contain what we call ‘Estrogen receptors.’ Estrogens are the female reproductive hormones produced by the ovaries and estrogen receptors are found in the womb but are even more concentrated within fibroids. Wherever you have a high concentration of Estrogen receptors, the development of the lining of the womb is affect increasing blood local flow and so the thickness of the lining of the womb, ultimately resulting in heavier periods.
What are the other dangers of fibroids?
From my perspective, the other big problem with fibroids is infertility; difficulty getting pregnant. The bigger the fibroids, the more numerous the fibroids, and the closer they are to the lining of the womb, the greater the impact they have on fertility. Although we do not consider fibroids to be a direct cause of infertility, the presence of fibroids can delay a woman’s ability to get pregnant and when they do get pregnant fibroids can increase the risk of losing the pregnancy by way of miscarriage. So, whenever we find fibroids in women who have delays in getting pregnant or who have suffered miscarriages we counsel them to remove the fibroids to try and optimise their fertility.
Do you think fibroid’s can be avoided if a woman gets married early?
No, that is a myth; not true at all. People used to assume that fibroids are a consequence of delay in childbearing, but we know that is not true. Anybody who is predisposed to developing fibroids will develop them, whether they start having babies early or late. The reason fibroids tend to be commoner as women get older is that women simply mature into the age when fibroids are common and if they do not have children, they can then start developing fibroids making it even more difficult for them to have children and perpetuating the problem. But, it is not true that fibroids are a consequence of not having children. Fibroids are a genetic predisposition and any woman who is genetically predisposed will develop them at some point.
But, can getting married early prevent fibroids?
Not necessarily. If a woman is going to develop fibroids, nothing will stop her from doing so. What she can achieve by getting married and having children early is that she can avoid some of the consequences of having fibroids such as infertility. Women can go into a vicious cycle of fibroids and infertility; fibroids can develop as they get older if they do not get pregnant and the presence of fibroids may make it more difficult for them to get pregnant. Women therefore run the risk of going around that vicious cycle until they break the cycle by removing the fibroids.
Can fibroids be treated?
Yes, there are many treatments for fibroid. The main manifestation of fibroids is heavy periods and so women who suffer from heavy periods should not just assume that this is natural. They should seek advice from a health specialist and get checked out to know whether they have fibroids. What determines whether women with fibroids get treatment is what those fibroids are causing them. So, if they are perfectly well, coping with their periods and feel the fibroids are not causing any other problems, they do not necessarily need any treatment. Such women can simply monitor their fibroids with scans every year to ensure they do not get excessively large.
A substantial proportion of women with fibroids, particularly large fibroids, however suffer from symptoms including heavy and painful periods and/or abdominal swelling. Because fibroids are a tumour or mass, their ultimate treatment is to remove them surgically, and these days we have various safe methods of removing fibroids surgically.
Pertinent to African women especially is the fact that we can now remove fibroids through endoscopic surgery. We can remove fibroids through laparoscopic surgery making very small mini-cuts in the tummy; this affords women faster recovery, causes less scaring, and helps preserve their fertility. This is part of the expertise we are bringing to Nigerian women.
Another way we remove fibroids is through hysteroscopic surgery where we go through the neck of the womb with a camera and cut away the fibroids. There is only a particular type of fibroid we can remove in this way and it is the clinical assessment of the woman that gives us the accurate indication as to whether she is suitable for this kind of procedure. Ultimately for women who are not suitable for either laparoscopic or hysteroscopy surgery, we do traditional or open surgery where we make a large cut in the tummy to remove the fibroids.
Treatment of fibroids will generally enhance fertility and quality of life by reducing uterine bulk, menstrual/pelvic pains and the excessive bleeding that are associated with fibroids. In some women, perhaps women who are not within the reproductive age group, fibroids can be treated hormonally. We can suppress female hormones and, in that way, help to control the symptoms of fibroids whilst not removing the fibroids. Other forms of fibroid treatment include radiological blocking of the arteries that feed fibroids; this is generally available to women who have passed the reproductive age group. There is also the option of hysterectomy for older women to get rid of the womb.
Which treatment will be proper for the fibroids that are not in one particular area of the womb?
The truth of the matter is that different kinds of fibroids may be more amenable to different types of treatment including surgeries. What determines the best kind of treatment to offer a woman is the woman’s circumstances, her fertility desires, her age and the type of fibroid she has, and that is where the specialist comes in. Women need to see specialists who understand what fibroids are and can assess them by way of their history, pelvic examination, pelvic ultrasound scan and perhaps blood tests. The specialist should then be able to tell them exactly what is going on and how they can be managed. The treatment of fibroids aims to at least control heavy bleeding and menstrual pain, improve fertility, and ultimately improve quality of life.
In that case, do fibroids cause menstrual pain?
Yes, fibroids are one of the common causes of heavy and painful menstrual periods.
Is this also the case in younger girls?
The symptoms women get from fibroids are not dependent on their age, but more on the size and type of the fibroids. So, if fibroids are big enough in anybody they can cause heavy and painful menstrual periods at any age.
What is your advice for women who have reached the age of 50 years?
At the age of 50 years, there are several options for treating fibroids dependent on the woman’s interests and expectations. One of the things that we are very keen to emphasise is that women have a choice as to what form of treatment they undergo. So, there are some women who do not like surgery and so want to avoid surgery at any cost; these women have the option of hormonal or radiological treatment. Unfortunately, we cannot utilize these options for younger women in the reproductive age group because they have detrimental impacts on fertility.
What about adolescents?
There are many fibroid treatments suitable for adolescents and they also depend on the size and location of the fibroids. The best treatment for symptomatic fibroids for anybody within or before the reproductive age group is surgical removal of the fibroids. But, sometimes that may not be appropriate for maybe a 16-year-old girl who is going through school and doing exams. So, in such people, we may use hormonal manipulation to control the symptoms temporarily but ultimately they would require some form of Endoscopic surgery to remove the fibroids.
Is it really fibroids that cause pain for young girls?
There are many other conditions that cause pain in young women and one of these that we are really particular about is Endometriosis. Fibroids and Endometriosis are conditions we refer to as estrogen-dependent because it is the estrogens produced by women from their ovaries that cause these conditions to grow. Fibroids and Endometriosis will grow because they are fed by estrogens. My message to ladies is that periods are not supposed to be excessively heavy or excessively painful; anybody who is having excessively heavy or painful periods, or whose periods are stopping them from functioning normally including disrupting their attendance at school or work, needs to seek specialist advice. They need to be assessed to ascertain what is going on, so they can make an informed decision on how best to be treated for their condition.
Is there anything a mother can do to prevent her child from experiencing all these before she reaches reproductive age?
Unfortunately not, and that is simply because we do not know exactly what causes these conditions. What we do know is that some people are predisposed to them and we know that nothing can stop such people from developing fibroids if they live long enough. So, the best thing a mother can actually do for her daughter is to chat with her daughter regularly to find out whether her daughter is suffering from very heavy and very painful periods and if those things are making her miss school or work, and generally jeopardizing her wellbeing. Mothers can help their daughters in such situations by taking them to see specialists who can assess and offer them appropriate treatment.
How has the removal of fibroids helped in facilitating fertility in women who desire it?
Fibroids are a known impediment to fertility and have negative impacts on fertility for various reasons. One is the physical effect of the size of the fibroids on the womb. We sometimes see women with large fibroids reaching up to their upper belly; when you think that the womb is just a small organ in the pelvis, it’s not hard to understand that such wombs will be completely distorted by those fibroids. A womb that is distorted by fibroids, particularly if the womb lining is affected, is not going to be a conducive place for pregnancy. If there are large fibroids in the tummy already, and women get pregnant, where is the baby going to grow into? These are some of the things that cause fibroids to be detrimental to fertility.
Another issue is that fibroids in different positions can block the passage of sperm through the womb, making it difficult for sperm and egg to meet and for pregnancy to take place. For these reasons, we are very clear that any woman who is trying to get pregnant or any woman who is experiencing miscarriages and has fibroids, should give consideration to having the fibroids removed.
These days we have loads of options in our tool kits to deal with fibroids. We can remove fibroids through laparoscopy, hysteroscopy and open surgery, and these techniques are now available to women in Nigeria. Women who suspect they might have fibroids need to see s specialist who has the expertise to assess and treat them. Modern surgery for fibroids, particularly laparoscopy and hysteroscopy surgery, is safe and many women can leave hospital on the same day; recovery is faster to enable them return to normal routines quicker, unlike traditional or open surgery where women might need to be off work for months. So, these endoscopic surgery options have really revolutionalised what we can do for women and once we remove the fibroids there is reasonably good evidence that women’s fertility is enhanced.
How affordable are these surgical procedures?
The one thing I would say is that, there are now many world-standard hospitals that have cropped up in Nigeria, in Lagos particularly, and those hospitals take cognisance of the local economic environment. So, my experience is that the way surgical fees are determined here, is responsible and reflects peoples’ ability to pay for the surgeries. I think generally, they are affordable for the vast majority of people who can access those services. But, I take the point that specialist health care and surgery particularly is not cheap as the specialist equipment that is required costs money.
There are indications from some people who have had surgical removal of fibroids that they grow back; is that really true?
The problem is that if a person is genetically predisposed to developing fibroids, removing the fibroids at any point in time does not eliminate the genetic predisposition to forming fibroids. So, removing fibroids needs to be seen as providing the women the opportunity to live their lives free of heavy periods and excessive pain, and enhancing their fertility. The advice we give to women after surgery to remove fibroids is that if they are considering pregnancy they need to maximise their chances by trying to conceive as soon as feasible. Studies tell us is that up to 25 per cent of women will regrow their fibroids within five years of removal; so we know fibroids can recur. We do not know who is more likely to regrow fibroids but there are some tell-tale signs that warn us that some women may be more predisposed; women who develop fibroids at a much younger age and women who develop multiple fibroids tend to have higher chances of recurrence of fibroids.
What about endometriosis? Seems to be a condition that women who are going through know little about.
There is a general lack of awareness of endometriosis, not just amongst the general public, but even amongst medical professionals. There are still lots of people who don’t know much about endometriosis. But, thankfully there is more enlightenment now, with more discussions about it, and people are starting to learn more about the condition.
Endometriosis is a condition that blights the lives of many women. Although, not as common as fibroids, we reckon maybe 1-in-10 women have endometriosis. That is quite a large proportion of women who suffer with endometriosis, and because of its symptoms which include very significant pelvic pain, painful sex and negative impacts on fertility, it can actually have a more detrimental effect on women’s quality of life compared to what they experience with fibroids. So, it is a very important condition for women to know about.
Again, the message is that any woman who is having very painful periods and especially if those periods are stopping her from functioning normally should seek medical advice to find out if they have endometriosis. There are many effective treatments for endometriosis including advanced endoscopic surgery options that are now available to women in Nigeria.