Impacts of Uterine Leiomyomata on Women’s Quality of Life

Background: Most women with Uterine Leiomyomata (UL) attribute various negative experiences in their lifetime to symptoms related to UL such as: abnormal uterine bleeding, various pressure symptoms and pelvic pain. Most of the research on UL examined the efficacy of treatment modalities, but only few researchers have addressed the impact of the disease on the women’s HealthRelated Quality of Life (HRQL). Methods: This is a descriptive, prospective, hospital-based qualitative study. The data was collected by: Focus Group (FG) interviews and by structured questionnaire. 200 women with symptomatic UL were recruited over a period of 6 months. The data was analyzed using the Statistical Package for Social Sciences (SPSS) data analysis tool, Version 20. Results: The majority of women (98%) graded their symptoms as moderate or severe. The mostly affected group are those in the reproductive age (20 to 39 years). 69% of the employed women claimed that the disease has affected their work and 55% of them reported UL as a reason for their absence from work. 27.2% of all women think that the disease has moderately restricted their social and physical activities, whereas 66.4% think the impact on their work is severe. 28.3% of all women think that their sexual life was moderately dysfunctional because of the disease and 52.2% think the effect was severe. 36.8% and 61.6% of all women reported moderate to severe psychological concerns respectively, such as: the sensation of fear, feeling of unfairness, and discouragement. Conclusions: Uterine leiomyomata are a common health concern for women in the child-bearing age. Symptomatic UL has apparently a negative impact on: women HRQL, sexual and social lives and it appears to affect their work performance. There is no significant correlation between the women symptoms and type of employment; however, the study is suggestive of a possible positive correlation between the women severity of symptoms and: social activities, energy, mood, sense of control, and sexual function. UPINE PUBLISHERS Open Access L Interventions in Gynecology and Women’s Healthcare Research Article ISSN: 2637-4544 DOI: 10.32474/IGWHC.2018.02.000139 Int Gyn & Women’s Health Copyrights@ Amir Ehadi Elzein Elnahas, et al. Citation: Marwa M A A, Faisal M S B, Amir E, Ameer O A. Impacts of Uterine Leiomyomata on Women’s Quality of Life. Int Gyn & Women’s Health 2(3)2018. IGWHC.MS.ID.000139. DOI: 10.32474/IGWHC.2018.02.000139. 161 Many women with UL may have symptoms like: a) Heavy and/or prolonged menses


Introduction
Uterine Leiomyoma (UL) is the most prevalent benigngynecological tumor in the female population. The tumor originates from the smooth muscle of the myometrium [1][2][3]. As many as 1 in 5 women in child-bearing age may have UL, and between 20 to 80% of all women may have the tumor by the age of 50 [4]. It seems that UL is more common in black than white Caucasian women [5,6].
The exact a etiology of UL is unknown, but there is considerable evidence that it might be due to a combination of factors, such as: hormonal, environmental, chromosomal, genetic drivers, cellular modulation, and phenotypical changes [7][8][9]2,10,11]. The UL have different sizes, locations and growth pattern and it may attain enough volume to significantly distort the uterine cavity and endometrial surface and affect the menstrual flow [12,13]. It may also affect reproductive outcomes and may be associated with pregnancy loss, preterm birth, dystocia and fetal malpresentation [14][15][16][17] Many women with UL may have symptoms like: The impact and the severity of the symptoms depend on: the size, the number and the site of the tumor, and black women are more likely to have severe or very severe symptoms [18].
Huge leiomyomata may be mistaken for pregnancy and in some conservative societies this can cause significant social embarrassment, especially to the single woman leading to lower self-esteem and negative impact on the quality of life. Although UL have no apparent effect on: libido, arousal, lubrication or, orgasm [19]. however, some women with UL reported pain during sexual intercourse [20][21][22], and this could possibly lead to anxiety, apprehension and sexual dysfunction and understandably sexual dissatisfaction and fear of pain during sex may dissuade the woman from sexual activity and can potentially lead to marital disharmony [18]. The association between UL and subfertility is controversial and lacks convincing evidence; however, a systemic review by Pritts and coworkers (2009) showed that UL, regardless of location, were associated with: reduction in pregnancy rates, live birth rates, and increase in miscarriage. These effects vary according to the type of fibroid itself, but the effect is more prominent with sub-mucous UL perhaps by distorting the implantation site [16]. UL are the leading cause of hysterectomy in the USA [23] and hysterectomy is considered a definitive treatment; however, recurrence and loss of reproductive potential could have psychosocial impacts on these women. Nonetheless, there are several alternative medical and less radical surgical modalities for the treatment of UL and the choice of treatment is dictated by many factors such as: the patient's desire to become pregnant in the future, the importance of uterine preservation, the severity of symptoms, and the tumor characteristics.

Uterine Leiomyomata and the Quality of Life
Heavy menstrual periods, prolonged bleeding, frequent periods, inter-menstrual bleeding, irregular and unpredicted periods, abdominal discomfort, pain, pressure symptoms, anemia and fatigue are among the commonly reported symptoms [12,13]. The severity and the unpredictability of such symptoms are more than likely to affect the quality of life of women negatively, making them feel not in control, irritable and anxious and limit and interfered with physical activities and make them worry about their health, relationships, work performance and progression [24][25][26]. Despite that many women with UL: delayed treatment, sought more than two physicians for consultation and some waited an average of 3.6 years before seeking treatment [22]. There were few studies examining the effect of UL on women 's sexual satisfaction, and even fewer on the effects of different treatment options on sexual satisfaction [22]. The effect of the location of UL on the causation of dyspareunia is controversial; however, women with very large tumor recorded the worst sexual satisfaction and most pain [21,19]. The number and size of the tumor do not appear to influence the incidence or intensity of dyspareunia; however, fundal and anteriorly-placed leiomyomata seem to cause higher-intensity dyspareunia and it is more distressing if the tumor is near the cervix [19]. UL seems to interfere with sexual satisfaction probably from the dyspareunia, but the tumor seems to have no effect on libido, arousal, lubrication or orgasm [19]. The prevalence of UL in pregnancy is 3 to 10%.

The Site
Omdurman Maternity Teaching Hospital is the largest specialized maternity hospital in Sudan with average number of deliveries of more than 25000 per annum.

The Study Period
The study spanned over 7 months period; starting on the first of August 2014 and the last of day of recruitment was the 28th of February 2015.

The Study Population
The study population was all women who were diagnosed with UL during the time of the study at Omdurman Maternity Teaching Hospital. The women were presenting with various gynecological problems and some of them were pregnant.

The Study Sample Size
The sample size was 200 and was calculated according to the equation: Where N is the population size, r is the fraction of responses of interest, and Z(c/100) is the critical value for the confidence level c.

Data Collection
The data was collected by; detailed and structured questionnaires and by direct interview conducted by Dr Marwa Mohamed Awad Allah aided by trained colleagues.

Inclusion Criteria
The study included women attending the obstetrical or the gynecological clinics with symptoms related to UL, or diagnosed with UL, or underwent surgery for UL at Omdurman Maternity Hospital during the study period.

The Exclusion Criteria
Women who had pelvic masses proved to be not UL and women who are not willing to participate in the study were excluded.

Data Analysis
The data was analyzed using the Statistical Package for Social Sciences (SPSS) data analysis tool, Version 20.

Ethical Approval
The study was approved by the Ethics Committee of the Sudan  Table 2). Four (2%) women described their menstrual loss and duration as mild, 80 (40%) claimed moderately heavy and/or prolonged periods and in 116 of the women (58%) the bleeding was described as severe and/or prolonged ( Table 2).
21 women (10.5%) thought that they were mildly affected by the pressure symptoms of the leiomyomata, the effect was moderate in 78 (39%) and severe in 101(50.5%), see table (2). The impact of the leiomyomata on the psychological wellbeing of the women was rated as mild by 3 women (1.5%), moderate by 74 (37%) and severe by 123 (61.5%), see Table 2. 13 women (6.5%) think that the symptoms caused by the leiomyomata have mildly affected their physical activity, the effect was moderate in 54 (27%) and severe in 133 (66.5%), see Table 2. 8 women (4%) thought that the leiomyomata had mild negative impact on their mode and energy, the impact was moderate in 49 (24.5%) and severe in 143 (72.5%), see table (2). 18 women (9%) thought that the symptoms have made them loose control, in 37 women (18.5%) the effect was moderate, and it was severe in 145 (72.5%), see Table 2 Table 3 The association was strong and significant between the intensity of the symptoms and the followings:   Chi-Square Tests a. 2 cells (33.3%) have expected count less than 5. The minimum expected count is 1.16.

Conclusion:
We didn't observe association between the Employment and Symptom Intensity, χ2 = 5.86, p > 0.05 Chi-Square Tests a. 5 cells (55.6%) have expected count less than 5. The minimum expected count is .08.

Conclusion:
We observed a strong association between Physical Activity and Symptom Intensity, χ2 = 317.03, p < 0.001 c) The mode and energy, χ2 = 149.69, p < 0.001 (Table 7)    Chi-Square Tests a. 5 cells (55.6%) have expected count less than 5. The minimum expected count is .08.

Conclusion:
We observed a strong association between Concern and Symptom Intensity, χ2 = 130.17, p < 0.001 There was no observed association between the employment and the symptoms' intensity, χ2 = 5.86, p > 0.05 (Table 5).

Discussion
The study has shown that the incidence of Uterine Leiomyomata (UL) is more common (93.6%) among women of child-bearing age (20-39 years), this is in accordance with the observation that UL is prevalent in the third and fourth decade of life and one of the most common benign tumors in this age group and is more common among black women [5,4,6,33,34,35]. All the participants attained some level of education and 70% had secondary-school or higher education and this might have allowed them to have a better in depth understanding of the disease and its related problems. 66 (33%) the women in the study had complications that could be attributed to the UL such as; infertility, miscarriage and anemia. The miscarriage rate in this study is 19.8%. The association between UL and adverse reproductive outcomes was observed in several studies [28,29,14,3,30,27,17,36], and it has been hypothesized that the compressed endometrial vascular supply by the leiomyomata may affect the fetus adversely resulting in miscarriage [36,37].
Many studies attributed heavy menstrual loss to UL [38,12,13,39]; however, a case study by Bachmann and coworkers [40] did not find a clinical support to explain anemia in women with submucosal UL, and in our study, we observed a lower rate of anemia of 5%, compared to reported rates by Noor and coworkers (2009). The possible explanation for this discrepancy is that perhaps our study population is probably better nurtured as inferred from their: level of education, possible higher income and enhanced social status. The most commonly reported symptom in relation to UL is severe prolonged heavy menstrual loss followed by pressure symptoms [12]. The figures from our study have strongly shown the association between the problems-related to the leiomyomata and different aspects of the women activities and wellbeing and are consistent with other the findings [13]. Zimmermann  regarding the effect of UL on their fertility, which could probably explain their stress and anxiety and its effect on marital and social lives and work with potential loss of revenue and income. Some women were worried about their body image, especially single and younger women, and some of them felt embarrassed by the symptoms and many of the latter group feared that UL may lessen their chance of getting married. In our study we observed that 76.7% of the parous women are of low parity, but we do not have robust evidence to associate this with UL, but conversely, we could not associate it with any other factors. On the other hand, a metaanalysis of 23 studies on the effect of uterine UL on women fertility found that UL in general, regardless of location, were associated with a 15% reduction in pregnancy rates and 30% reduction in live birth rates [16] and another study by Ben-Nagi, coworkers [41] reported an association between UL and subfertility; however, this association might be not fully understood and controversial [42]. fears that the UL may grow (79%), there is something inside of them that does not belong there (69%), they would experience future health complications (63%), they will need a hysterectomy (55%), and that UL would turn into cancer (54%). Few studies addressed the QOL with regard to UL and there is a lack of psychometrically sound disease-specific HRQOL instrumentation. Furthermore, many of the available studies were uncontrolled or retrospective in nature. In many cases, a number of different benign gynecological conditions were studied along with UL, leading to an inability to make explicit inferences regarding HRQOL related to UL alone. It remains a challenge for future studies to address these issues and have a better in depth understanding of the QOL consequences of UL. The management of UL has financial consequences on the: healthcare system, work productivity, women' mental wellbeing, and family life. For these reasons more research is needed. Research on the impact of UL on the wider family is required.

Conclusion
We think a prospective randomized case-control study, which is community based including a wider population is more likely to shed more light on the impact of UL on the women's QOL and on her surrounding community. Furthermore, there is an urgent need to evaluate and or develop support for the women with UL and their families, because this chronic disease could be debilitating to the whole family both socially and economically.