THE FIBROIDS MENACE

FIBROIDS

Fibroids have become a real medical dilemma especially among us career women who get into the family way very late either in the mid 30s or early 40s. I have seen patients who have come in and narrated to me how fibroids have totally messed up their lives.


So what exactly is fibroids?? Fibroids or fibromyomas are the most common tumors of the human body. They arise from the muscular wall of the uterus(womb). Their Growth is due to action of the hormone estrogen. They arise during period of menstrual activity and are mostly found in nulliparous women( those who have never had children) or women who have not been pregnant for sometime. They are mostly found in black women and  tend to favor infertility and miscarriage due to distortion of uterus cavity.


There are 4 main types of fibroids. Interstitial,Subperitoneal,Subendometrial and Cervical. This categorization is based on their locations ; within the wall of the uterus, arising from the  outer layer of the uterus, arising from the inner layer of the uterus and from the Lower part respectively. The subendometrial ones are most notorious for causing miscarriages, the interstitial ones cause abnormally heavy menstrual bleeding and the cervical ones may cause obstruction of labour during normal delivery.


Fibroids tend to grow more during pregnancy and to shrink or atrophy during the post-menopausal period.

Patients present with a wide variety of symptoms depending on the size and type of fibroids. These include;  an abdominal mass, Increase in duration and amount of menses,Offensive discharge( if a subendometrial fibroid is undergoing necrosis), Late menopause, Abdominal pains which may be accompanied by vomiting( in case of degeneration of fibroids),Frequent urination and retention of urine (if the fibroids are too big), Infertility,Frequent abortions, Labour obstruction, Mass protruding from the vagina etc.


Fibroids are diagnosed by doing ultrasound scans.  Small fibroids that are not causing symptoms do not require treatment but big or symptomatic tumors require surgical removal.  Indications for surgery include heavy or prolonged bleeding, large tumors most likely to cause urinary symptoms, fibroids causing infertility or miscarriages, fibroids that are likely to obstruct labour and fibroids that tend to increase in size after menopause( these are most likely to get malignant change) e.t.c


Surgery can either be removal of the fibroids or total removal of the uterus depending on the patients need to conceive in the future. Sometimes a surgeon can go in with intention of removing the fibroids only to end up removing the entire uterus if bleeding is uncontrollable during the procedure.


Is there a way to avoid fibroids? Not really!! Remember fibroids also run in families. We can probably avoid them by getting children early ; this way, even if fibroids eventually come         , there will be no harm in removing the uterus.


I'm not against career progress among women, but a 2 year sacrifice to get babies can help a lot in avoiding the fibroid menace and consequences.( I can hear my mother saying AMEN to this). I however agree that other factors are to be considered too.  Let me know if this post was educative.

WHEN DOCTORS LIE

This morning, I woke up to read the Paul Kalanithi story. He was a top neurosurgeon at Stanford who succumbed to metastatic lung cancer at the age of 37 earlier this month. He had written numerous essays, “How Long Have I Got Left?” for The New York Times and “Before I Go” for Stanford Medicine, reflected his insights on grappling with mortality, his changing perception of time and the meaning he continued to experience despite his illness. He closed his Stanford Medicine essay with words for his infant daughter: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

 His story makes me reflect on how doctors, me included, deny patients the truth on the magnitude of their illness and the chance to prepare and face their last days appropriately. I remember the case of X who we had operated on and found that her cancer had spread everywhere in the abdomen and everything was matted together so we couldn't resect the tumor. When she came in to pick her biopsy results I told her the truth but not the whole truth. I did tell her that she had cancer but the look she gave me was so depressing and stressful that I decided to give her 'hope' and lie that we had removed the tumor and that all she would need was intervention in a cancer unit and the disease would go into remission if adequately handled. I figured out that if I broke the news as they are, depression would kill her faster than the illness. I basically left the task of disclosure to the oncologist.

 By reading the Kalanithi story, I realize that most of us deny our patients the chance to prepare for their last days. Some relatives even sneak in ahead of their patients and beg me to hide the truth and not to disclose to their patients that they have an end-stage illness. Others practically wink at me when they realize that I'm almost disclosing the disease to their sick relatives. We doctors lie in so many ways. I remember the case of 'Z' who was battling an unresectable brain tumor that was fast growing. Instead of the doctors in Kenyatta telling him the truth, they told him to go home and wait for their call on when to go for surgery. The family remained hopeful and kept on spending so much money taking him from hospital to hospital to make him 'stable for surgery' because they thought Kenyatta would call in anytime. Three months into the illness and they did not call making the patient hopeful only for him to succumb to the illness. I believe that had the truth been told, adequate preparation and coming to terms with the illness would have been made. Sometimes we even write palliative care referrals for the last-stage patients and lie to them that palliation is highly intensive treatment for metastatic cancer while in essence palliation is basically making the patient comfortable in the last days.

 Kalanithi talked about the importance of proper communication and disclosure of the whole truth in a gentle manner. His ‘dual citizenship’ as a doctor and as a seriously ill patient had taught him that respectful communication is the bedrock of all medicine. I now know and appreciate the importance of proper disclosure. It might stress the patient but with time they do come into terms with it and prepare for their illness and impending mortality adequately and with bravery.Had Paul Kalanithi not known the truth about his illness, he would have probably not planned for the conception and birth of his daughter into his illness.

You would be surprised at how strong some patients are.

The truth hurts but it is better than giving colorful lies

KCSE RESULTS AND HYPERTENSION

 Two weeks of silence. I'm back! I have been extremely busy during the weekdays and a tourist by the weekends. No excuse, I have been lazy!!!! This week, KCSE results were released. It's also on Monday that my boss and I were anxiously going through our 'KCSE' results ; our weekly histopathological reports from Agakhan University Hospital. Each batch comes in large numbers of around 20-30.  We are always so anxious to know the diagnosis of strange conditions we encounter and mostly crossing our fingers and hoping that we have less cancers. It's painful learning that certain patients indeed have cancer. My boss is  usually very anxious to know if the margins of tissues he removed are cancer-free and beaming when he learns that he did a thorough excision. You should see us seriously scruffling through the pages and commenting. For instance you would hear things like ' Oh, this is the lady teacher who came in with abnormal bleeds' or ' This is the mzee I admitted from Kangeta and I was too curios to know his progress making me pop-in in the weekends' or 'this is the father of the adamant three sons' or 'I knew it, it had to be lymphoproliferative disorder with that abnormal hemogram' etc. We quickly discuss the conditions briefly and decide on the way forward when the patients come to pick the results. The patients are usually always very anxious about the results to the extent that others literally lose weight in the days awaiting the arrival of the reports. I remember one lady was seriously shaking outside my office and I actually thought that she had urinary retention but later learned that she was too curious to know the meaning of the jargon that was written on her report. I could see a sigh of relief when I informed her that what she had was a totally benign condition; non-cancerous.  Away from 'KCSE,' today I want to talk about Hypertension. It's a condition that is becoming so common. I actually diagnosed my parents with it a few weeks back. Each day I diagnose 5- 10 people with hypertension. Of these, 8 are usually at the exact age of 55 years old. I don't know the relation between the  number 55 and hypertension.   Most of the times, Hypertension doesn't have any specific symptoms unless the blood pressure is too high. Patients present with any of the following symptoms;  persistent headaches, neck pains, blurring of vision, nausea, malaise, dizziness,palpitations, some even come in convulsing,with stroke or in a coma.  Hypertension is a paradox of an illness. Very easy to diagnose, very easy to treat and manage yet thousands of people go undiagnosed, others get sub-optimal treatment, some develop life-changing complications and others die.  Hypertension is defined as blood-pressure above 140/90mmHg in both variables or in one as in isolated systolic hypertension.  I will not go into details about how to grade it but it's graded differently depending on the values  How can we avoid hypertension? By  lifestyle modification. This involves eating low salt and low fat diet, exercising( atleast 30 minutes of brisk walking daily), cessation of smoking, reducing on alcohol use, reducing stress, managing well any comorbid illness one may have and most importantly weight reduction.Sedentary lifestyle should be avoided. We should all strive to have atleast a monthly Blood Pressure check irregardless of our age. This mostly applies to people with a family history of hypertension.  Hypertension can also be secondary to another illness. Patients with Diabetes, Renal Conditions, Heart Problems, Hyperthyroidism  etc are more at risk of developing secondary hypertension.  Medication for hypertension depend  on the grade of the hypertension. Some patients are only counseled of lifestyle modifications, others are put on one type of drug, others a combination of 2,3 or more drugs. The bitter truth about hypertension is that it's medication has to be taken for life. Its very frustrating to hear of patients who have been misguided by clinicians that their hypertension is healed and that they stop treatment only for them to come in with stroke or in coma. The doctor may reduce the number or dosage of drugs but at no given time can medication be stopped. I don't believe that herbal treatments heal hypertension, I will  leave this for further discussion.  There's no shortcut in the treatment. If not treated well, hypertension can cause complications like Congestive Cardiac Failure, Renal Failure, Stroke e.t.c One of my parents was frustrated when I told them that the medication has to be taken for life but I joked to them that probably God was passing them a signal to get grandchildren to remind them of daily drug use. That joke has become  a reality and today I celebrate the birth of AbdulRahim Mutula, my first nephew. As he grows older, may he the one to remind his grandparents to take their daily hypertension drugs.  Have a great referendum anniversary week.