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. 

PSEUDOCYESIS - FALSE PREGNANCY

............... False pregnancy, phantom pregnancy, or hysterical pregnancy—commonly called pseudocyesis in humans and pseudopregnancy in other mammals—is the appearance of clinical or subclinical signs and symptoms associated with pregnancy when the organism is not actually pregnant. I have encountered this condition more than once and I found it very interesting. I had a case of a woman who came in for regular maternal health clinic. She looked around 8 months pregnant and she was looking forward to the birth of her child. She was very faithful in ANC clinics and had already started shopping for baby clothes. She had however come with a note from another clinician who was surprised with the 'pregnancy' because Pregnancy Determination Test was negative severally. He had referred her for further follow-up and ultrasound. I examined her and she looked pregnant. She had missed her monthly menstrual periods by 8 months, the abdomen was markedly distended( almost a term pregnancy), her breasts were discharging milk and she had Linear nigra ( the prominent black line down from the umbilicus seen in pregnancy), the 'baby' was also kicking and she excitedly grab my hand and place it on the abdomen to feel the movements. Her face was puffy like that of a pregnant woman. There were however several catches. Though the abdomen was distended, I couldn't feel the hard gravid uterus. There was no palpable fundus. The 'kicks' were actually peristaltic movements(bowel movements) confirmed on  auscultation with my stethoscope. I talked to her further and I realized that she was  desperate for a baby. I tried to counsel her on the possibility that there was no pregnancy but she reminded me that she even had morning sickness in the first trimester and the abdomen had been increasing in size slowly over the months. She believed that the previous laboratory that did her pregnancy test had fake strips.  I decided to send her for a repeat pregnancy test and an 'obstetric' ultrasound. The results came out promptly. Pregnancy test was negative and the ultrasound was a normal one with a normal non-gravid uterus. There was no baby. An abdominal ultrasound was also done just to make sure that it wasn't an abdominal pregnancy and it was also a normal scan. I took to the task of counseling her further and telling her about a medical condition called PSEUDOCYESIS. It's a false pregnancy caused by the effect of stress on the hypothalamo-pituitary-adrenal axis causing hormonal changes that stimulate pregnancy-like changes in the body. She was so stressed and desperate for a child and the brain triggered a pregnancy-mode in the body. We had a similar case of a woman who came in labour pains for a 'term pregnancy' but the midwife nurse was surprised that the cervix was  closed despite the woman having very strong visible contractions for many hours. She also wasn't so sure about the uterus fundus because she couldn't feel it well but certainly there were contractions. From the history we were prepared for the worst and probably a caesarean section. A quick but thorough routine ultrasound was done and there was no pregnancy even though the contractions were real. The woman ofcourse cursed and blamed it on witchcraft by her enemies who had taken her baby from the womb in the last minute to delivery. But there was no witchcraft, the diagnosis was PSEUDOCYESIS in a woman so desperate for a baby. Pregnancy test was negative.   Back to my first patient, I started treatment for her and she accepted her condition albeit half heartedly. I prescribed to her antidepressants for the psychological problem and bromocriptine to arrest the milk production. She has been faithful in her monthly follow-ups for the last 6 months and slowly we have been successful in 'reversing' the pregnancy. The abdomen has markedly decreased in size, her face is no longer puffy, her monthly periods are back and the milk production has stopped . The baby 'kicks' have also disappeared.  I hope from this post on PSEUDOCYESIS we get to acknowledge the power of the mind.  If the mind is so powerful as to simulate a false pregnancy then imagine what more it can do. This reminds me of a quote that says;  'The greatest force is derived from the power of thought. The finer the element, the more powerful it is. The silent power of thought influences people even at a distance, because mind is one as well as many. The universe is a cobweb; minds are spiders. - Swami Vivekananda' I hope you have a lovely week ahead and get to utilize the power of the mind to achieve great things in life. 

ABORTIONS AMONG MARRIED WOMEN

ABORTIONS AMONG MARRIED WOMEN This past week, I witnessed a rising number of abortions among married women. I really couldn't understand what would make a married woman want to terminate a child born within the family unit. If it were a teenager or a single woman, or even a widow, I would understand.     Kenyan statistics indicate that there are about 310,000 abortions every year in Kenya. 21,000 women are admitted each year due to abortion related complications from having unsafe abortions – usually done in backstreet clinics. 2,600 of these eventually die. Of the women admitted, 12% were older than 34, 40% were between 25 and 34 while 16% were teenagers.  Clearly the more mature women above age 25 take the lead.  I usually break pregnancy news with a smile and a congratulatory note but this week I was faced with rude answers and tears among some of the women. Many cried uncontrollably and I had to probe further and ask what had triggered the sadness. They were after all married and with other children. They all complained of the rising cost of living and lack of happiness in the family. Some stated that their husbands were less concerned about taking care of the children and that the women had to hustle singlehandedly to raise the children.  A few begged for abortions but I was very frank with them that it's a crime in the Kenyan law and a big sin in the eyes of the Lord. I did counsel them and told them they should take it as a blessing and reminded them that there are many women who are desperate to have children. One lady told me that God should have taken what was in her womb and given it to a more deserving desperate woman.   We have had cases of women who come in with ruptured uteruses or sepsis only for us to find big rough sticks, metal rods, wooden objects etc that have gone through the uterus into the abdominal cavity. All these are usually among married women in their 30s and 40s. The teenagers are usually surprisingly less 'radical' in their methods of terminating pregnancies. I must say that older women have guts.  Most of the time when I get married women coming in with pre-term labour or abnormal bleeding in pregnancy, i'm usually very tough and demand to know what they used to illegally trigger labour. It's mostly strong concoctions taken or objects inserted into the uterus.  So what is causing so many abortions in family units? Are our husbands too busy at work to remember the family, is it alcohol and substance abuse, is it because of extramarital affairs and they end up neglecting their wives and children?  Or are women increasingly wanting an emotional and psychological readiness before carrying on with a pregnancy?   Those from the urban areas say it is more of a lifestyle choice than anything else because they would, for example, rather pursue a career than have a child. Increased westernization of the country has made traditionally large families to be frowned upon by many modern women in general. The average child per woman in Kenya in the 70s was eight, while today, the figure is just under three. How do we prevent this vice in marriage?  In my opinion, every woman after delivery should be advised on the different contraceptives before discharge from the maternity. The husbands should actively participate in the choice and use of contraceptives. Women nearing 40s can be advised on more permanent methods of family planning like tubal-ligation (Can our men agree to have vasectomies????). Men should be more dedicated in caring for their families. A law should be passed to arrest and charge any woman who attempted abortion; but this would mean that such women would be scared to come to hospitals and would die at home from life threatening complications. It's a very controversial topic. It's something that needs to be discussed and analyzed more deeply.  I will end my post today with a reminder of the Kenyan laws on abortion.  Abortion Laws in Kenya Article 26 in the new constitution was the bone of contention between the pro-life and pro-choice groups in the build up to the referendum. Article 26 of the Constitution contains 4 clauses on the rights to life which state that: 1). Every person has the right to life; 2). The life of a person begins at conception; 3). A person shall not be deprived of life intentionally, except to the extent authorized by this constitution or other written law; 4). Abortion is not permitted unless, in the opinion of a trained health professional, there is a need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law Have a happy valentines week!!!

D.V.T - THE SILENT KILLER

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This week I assigned myself the task to make a presentation about Deep Venous Thrombosis (DVT) to my colleagues in Chaaria. Its a silent killer that kills in seconds. It reminds me of the death of a popular TV personality who was found dead on her bathroom floor sometime in September. Rumors went round about the possibility of poisoning or bathroom accident because she was as fit as a fiddle but autopsy made a conclusion that she had succumbed to embolism from a DVT.

DVT is the formation of a clot in the deep veins of the limbs especially in the legs. If the clot dislodges( what we call embolism) and goes to the lungs, it causes death in seconds. I have atleast two DVT patients in the wards every month. A few succumb to embolism because they present to the hospital with breathlessness when it is too late. I have had to force some of the patients to be admitted in the hospital despite resistance. I confront them and tell them point blank that I do not want to be responsible for their deaths. It's one condition of which I put my foot down and refuse discharge against medical advice.

So how does it present? How do you know that you could be suffering from DVT? It classically starts as swelling of one leg which could be painful especially at the calf. The leg might get warm and reddened with time. Superficial veins sometimes get visible and in the extreme cases, the limb might get gangrenous or start turning blue. What are the risk factors for DVT? These are generally categorized into factors that cause Stasis of blood in the limbs, increased clotting of blood in the body and injury to major blood vessels. These include being immobile for long hours or days(especially in bedridden patients or long distance travellers), cancers which predipose to hypercoagulation of blood, trauma or fractures of limbs, recent abdomino-pelvic surgeries (e.g hysterectomy, prostatectomy, caesarean sections etc), recent bone surgeries(orthopedic surgeries), use of estrogen containing contraceptive pills, cannulation of major blood vessels of the body especially in dialysis patients,patients with diseases like nephrotic syndrome, pregnancy e.t.c. The list is endless.

Diagnosis requires color duplex ultrasound of the affected limb. This can be combined with other more complex investigations. Treatment requires compulsory hospitalization for anticoagulation and strict follow up in the months that follow. ( I will not bore you with the specific treatment modalities). So if you develop swelling of one leg no matter how innocent it looks, run to the hospital before death runs to you. It's not proper to ignore. We should also avoid sitting or lying down for long hours. This targets everybody including those who sit in offices for long hours, long distance travellers or frequent air-travellers. Those who are in hospital and having undergone surgeries should learn to ambulate early and walk around. How many times have we heard of stable patients collapsing on discharge or collapsing in the toilet just before discharge? (Why is the toilet the most common place for death in DVT patients? Food for thought!!!!). Or how many healthy people have we heard found dead after a perfectly normal daily activity.

Let's be careful. Let's spread the information and learn to take any swelling of one limb seriously. Let us also get active. That simple standing from your chair and going to the dispenser in the office could save you from death. The frequent air travellers should learn to walk to and fro the aeroplane isles at-least 3 times in the flight (DVT is also called the 'pilots disease'). I hope that this week's post will help someone out there. Have a great start to February!!!! BEWARE!!!!! Let's be alert.

CANCER 2

Following the previous week's post on cancers, I did get many responses, comments, suggestions, cancer stories that made me cry  e.t.c. Of note was a message from 'Brian'(not his real name), one of my cancer patients aged 21. He messaged to ask why I had not included his story in the post. I had actually written about him but deleted the paragraph the last minute because I needed his consent first. I met Brian in April-May 2014. By that time I was working at Meru Hospital and would only come to Chaaria during my free time. He came for his histopathology report for stony hard masses that had developed in his abdomen. The report read  'Desmoplastic Small Round Cell Tumor'. What was that? I had never heard of such a name. There is a chance that it was somewhere underlined or highlighted in my pathology textbooks and notebooks during medical school but I couldn't remember what it was. Are these not things we read just to pass exams and quickly forget about them because they are rare? Was it malignant or benign? What was it's nature? I dashed to my boss's office where we have a mini-library. I couldn't get it in the first book I checked and almost immediately my boss and our most senior surgeon Dr. Pietro walked in and I informed them of my dilemma. They informed me that it's a rare type of soft tissue sarcoma that mostly affects males at the adolescent age or early 20s. It mostly presents as abdominal masses of no known origin. The sarcoma responds very well to chemotherapy. Armed with this information, I dashed back to my office and explained what I had just learned to him. He had not come with his parents so i counseled him the best I could like a younger brother. Brian was surprised but he had the motivation to seek specialist help without delay. I wrote his referral letter and took down his number because I wanted to follow up. He was very brave and I could see determination on his face  to conquer this illness. I naturally expected review in KNH after a few months but because of his drive and enthusiasm, Brian was able to get booked for chemotherapy without delay. We keep in touch at least once a week and he is well, almost done with Chemotherapy. He is responding very well to treatment but he tells me that sometimes he gets very weak after Chemo sessions. The journey he says, has not been easy. There are times he messages me that his white blood cells get down and he has to boost them with Neupogen, there are times his Chemo drugs run out of stock in KNH and he has to wait longer for his sessions, during the KNH doctor's strike he had problems getting doctors to administer his chemo,he has lost weight etc. Brian gives me the motivation to face life positively. He is doing very well and responding well to Chemo.  He tells me that he is the first person in his family to have cancer but he has taken it positively. He tells that the KNH oncology clinic is always flooded with patients and he only gets seen in the afternoon despite coming in very early due to the long queues.  Brian's is a success story,he says his life has not changed. He refused to let cancer change his life.  I'm praying hard he becomes cancer-free and becomes a motivation to other cancer patients.  I hope we all learn from him. I'm so glad our paths crossed and he is truly a source of inspiration.


   The next person who messaged me about her story validated something that a surgeon had asked me in theatre one day. We were doing a thyroid lumpectomy and the  surgeon asked me if we had done cytology or needle-biopsy of the thyroid lump. I had not thought about it because we were going to send the removed lump for histopathology anyway and thyroid cancer is extremely rare in our setting. I have never seen any case of thyroid cancer since i graduated. All our histopathology reports gladly come back negative for malignancy.  The incidence in Africa is  1 case out of 200,000 population per year. This friend messaged me that she was touched after reading my post. She had lost a close relation to Thyroid Cancer in the age-gap of early 30s last year. It was a thyroid lump that was never investigated properly and in the end the lady lost the battle to metastatic thyroid cancer. It's a mistake that all of us in the society and us doctors make by presuming that any thyroid swelling or Goitre is benign. The message made me think deeply and conclude that all thyroid swelling must be biopsied before surgery and still sent for histopathology after surgery . The cancer might be very rare in Africa but that one life lost is a lost generation, a lost parent, child, sibling, friend e.t.c.  We should not take chances with thyroid swellings no matter how rare the cancer is.


 This week, we had a class by Fr. Gaido about Esophageal cancers. He mentioned to us that it was so common among men from the North to the extent that any male patient from the North presenting with painful or difficulty in swallowing is almost always esophageal cancer . I have had arguments with some of them when I recommend OGD, they insist it's not necessary only for most of them to turn out to be cancer.  We discussed why it was a common disease in that area of the country and especially on men. Is it because of taking very hot burning tea? Does the resulting corrosive injury lead to cancer? Women only get to take the tea after the men have had their share so their tea is usually cold by then. Is this why the cancer hardly occurs among women of the same region? Think about it and tell me. 'Tafakari hayo.'  I'm considering doing a research on this.  Similarly, Liver Cancers are so common among Kambas especially those from drier parts of the region. Is it because of aflatoxins from poorly stored maize? Have a good week ahead. I pray that the blog-posts impact positively on each reader's life.