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��ࡱ�>��	gi����f�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������[�	��&Lbjbj����4�ΐΐ&D���������������,^",�p````OOO"""""""�$�,'^"OOOOO"``�"���O�``"�O"��� !`�����Q�����)� �!."0^"� ,�';��'!�'!�OO�OOOOO""�OOO^"OOOO���������������������������������������������������������������������'OOOOOOOOO��:Therapeutic itinerary of women with uterine fibroids in Abidjan: about 170 cases at the Cocody university hospital (UH-C).

KAKOU Charles 1, KOFFI Soh Victor 2, KASSE Raoul 2, EFFOH Denis 1, GONDO Diomand� 1, ABAULETH Rapha�l3, BONI Serge 4.

Assistant professor 
Residential student 
Professor de gynecologyand obstetrics, UH-C 
Professor de gynecology et obstetrics, UH-C, Head of department 

Author correspondant�: Dr KAKOU Charles, gynecology and obstetrics department, Cocody university hospital, University Felix Houphouet Boigny.  06 Po Box 296 Abidjan 06. Phone number: 00 (225) 22 48�10 50, Fax: 00 (225) 22 44 23 79. Ivory Coast.  HYPERLINK "mailto:kakoucharles@yahoo.fr" kakoucharles@yahoo.fr
















SUMMARY
Introduction: The uterine fibroid is responsible for serious complications in African black women and represents the leading cause of hysterectomy.  
Material and method: we did a prospective descriptive case-control study over 3 years, from October 1, 2012 to September 30, 2015. We had 170 patients with uterine fibroid operable whose 129 had an itinerary of alternative care, called case group; and 41 who only visited the hospital which constituted the control group. We performed surgery for 82 patients in the case group and 41 patients in the control group. We compared the two groups including management and prognosis.
Results: In the case group, patients had an age between 30 and 40 years in 45.2% and were zero gravidity in 39.2%; against 63.4% and 19.5% respectively in the control group; with a statistically significant difference (alpha =5%). The reasons for consultation of the patients in the case group were genital hemorrhage in 75.6%; pelvic pain in 29.3% or pelvic mass in 49.9%. While in the control group, these same reasons of consultation respectively accounted for 70.7%; 7.3% and 21.2% with a statistically significant difference. Most of the patients consulted in first intention a traditional healer (43.9%) and saw their condition worsen (RR = 4, 5). A hysterectomy was performed in 22% among cases compared to 7.3% in the controls.
Discussion: The trend of the first consultations made to the traditional healers. The condition worsens with the appearance of a larger number of pelvic mass and pelvic pains. There is more realized hysterectomy among cases than controls.  
Conclusion: Patients have unconventional therapeutic itinerary which expose them to a hysterectomy.  
Keywords: Uterine fibroid, therapy, Africa.








INTRODUCTION
The uterine fibroid is the most common benign tumor of the genital tract in women of childbearing age [1, 2] affecting 20 to 25% of them. It is 3 to 9 times more common in black women than in white women [3, 4], and appeared generally after the age of 30 years [3, 5]. Although it�s a benign tumor, it�s the main indication for hysterectomy in women in perimenopause [6]. Uterine fibroids are operated only in case of complications. In our context of developing countries, there is a multiplicity of unorthodox therapy used: traditional medicine, Chinese medicine, prayer in church meetings. Patients have very little recourse to hospitals faced to this often misunderstood disease.  Our objectives were to specify the different types of care carried out by patients before surgical treatment and to clarify the impact on prognosis of this affection.
MATERIAL AND METHODS
It�s a prospective descriptive case-control study referred to 03 years, from October 1, 2012 to September 30, 2015, conducted in gynaecology and obstetrics department of the University Hospital of Cocody. It focused on patients who underwent surgery for uterine fibroid. We included all women, regardless of age, carriers of uterine fibroid who underwent care in the service. Have not been included women with uterine fibroid operated in our service and who have refused to participate in the study. The information was collected during an interrogation from a card of collection of information. The informed consent of patients was a prior test. The interrogation took place in  gynaecology and obstetrics department of the University Hospital of Cocody during the hospital stay of patients. We had 170 patients including 129 had a itinerary of alternative care, called case group; and 41 who only visited the hospital which constituted the control group. We performed surgery for 82 patients of the case group and 41 patients in the control group. We compared the two groups in order to appreciate the prognosis. The parameters studied were age; a professional activity remunerated; obstetric history; the reason for consultation; the time between the recognition of early signs and the first consultation to the hospital; the type and the number of "healthcare facilities" traveled by patients before surgery; the chronology of passage in different "healthcare facilities"; the type of surgery; the feeling of the patient cope with the disease. Data analysis was performed with the software Epi Info 3.5.1, 2008. 
RESULTS
Frequency
On 129 patients of case group, 82 were operated either 63.5% of the indications. 36.5% could not be made at the time of recruitment for a various reasons. The surgery consisted of myomectomy for 64 cases (78%) and total hysterectomy for 18 cases (22%). In the control group (41 cases), there was a myomectomy for 38 cases (92.7%) and a total hysterectomy for 03 cases (7.3%).
Clinical aspects
They are presented in the tables 1 to 3.
Surgical care 
They are presented in the tables 4 and 5.
DISCUSSION
Frequency 
We performed a surgery in 63.5% of the patients of case group. We performed myomectomy in 78% (64 cases) and of total hysterectomy in 22% (18 cases). A third (36.5%) of patients with uterine fibroid has not had surgery. Almost all surgeries have not been possible for uterine fibroid for reasons essentially related to depletion of financial resources of patients as a result of other types of care and treatments unconventional. Another reason was the non operating room availability in blood products [7]. In our country, there is still no social insurance fund. So, patients pay before receiving care [8].
Socio-demographic characteristics
In the case group, patients had an age between 30 and 40 years in 45.2% and were zero gravidity in 39.2%; against 63.4% and 19.5% respectively in the control group; with a statistically significant difference (alpha=5%). It is a condition that remains predominant in women genital activity. In the literature [9, 10], we found a peak frequency in the age range of 35-45 years. Other writers like Mahjoub [11] in Tunisia, the average age was 41.7 years. This may be due to long therapeutic itinerary made of unconventional and ineffective care exposing finally to a surgical result. Moreover, another finding emerges from our study: 15.8% patients were less than 30 years old. It is according with the concept of "rejuvenation" found in the literature, i.e. the appearance of uterine fibroid in more and more young patients.  The youngest patient in our series was 23 years old.
Reasons for consultation 
In the case group, type of cycle disorders such bleeding complications were the main reason for consultation with 75.6% of the cases followed by pelvic mass 49.9% and pelvic pains in 29.3%. For the control group, the symptoms consisted of genital bleeding (70.7%), pelvic mass (21.2%) or pelvic pains (7.3%). In fact, in our context of developing country preventive medicine is undeveloped. Women have recourse to hospital only when health becomes disturbing. This is the case of bleeding, considered a sign of gravity, as well as the pain. All these findings were already highlighted by several authors. Thus, genital bleeding represented the first reason for consultation with 35% of the cases according to a study in Algeria in 2013 of Nelson [1]; and 50.8% of cases according to Berroho and coll [13]. Most of patients consulting in first intention outside the hospital saw their condition worsen with the appearance of a larger number of pelvic mass 49.9% and a larger number of pelvic pains 29.3%  against respectively 21.2% and  7.3% in controls.
Site of first consultations
Most patients of the case group patients had consulted in the first outside hospitals in 63.4%. In the first, they consulted the traditional healers in 43.9%. The trend of the first consultations made to traditional medicine, then to any other "healthcare facilities" (Chinese medicine, prayer in churches). Patients resorted to the hospital only after those attempts failed. Reasons were mentioned by patients to explain the use of unconventional care: the mystical interpretation of uterine fibroid by patients and or their family (40.2%); lack of financial resources for healing (65%); traditional cares considered as effective and at low cost; the haunting of surgery (12.2%). The mystical interpretation of uterine fibroid by patients and or their family, leads them into places of prayer such churches. Indeed, traditional healers are often close to populations on the communicative level, making them promises of permanent cure of the disease at lower costs.  In addition, cares of the traditional healers are regarded by the population as effective and at little cost. These reasons help to understand the overall trend of Africans in favor of traditional medicine with regard to the place of the initial consultations. This seems to us relate to the absence of a system of universal health coverage that would directly lead patients to hospital structures and avoid a course.
Itinerary of patients 
Our study shows that before surgery, patients had first travelled several structures, where they had tried therapeutic methods. So, most of them (69.5%) had tried to seek treatment in more than three different places (traditional medicine, Chinese medicine or the Church). Furthermore, by studying the pass sequence patients care in these different sites, it appears that the most represented sequence was the traditional healer and then hospital (43.9%). Some patients were already spent in hospitals, are returned to these structures (36.6%), before returning to the hospital when they had no solution. It allows us to tell that medical staff can't always convince patients consulting conventional hospitals. The essential reasons were the anguish of surgery and the notion of recurrence of fibroids after surgery. It should be noted the importance of the traditional healers that must appear in the African health system. That's why the surgical management of patients was late. After the unorthodox care and have not recovered healing, patients accept faced with the evidence, to have surgery. They finally accept the fact that the actual treatment of the pathology involves the care.
Surgical care
Overall, hysterectomy was 22% in the case group compared to 7.3% in the control group. The myomectomie was 78% in the case group against 92.7% in the control group. The observed differences were significant (alpha=5%; X�=4, 14). It can be concluded that the patients visiting the hospital only benefit more often to conservative treatment. While patients who had an unconventional course benefit more than a hysterectomy. More by intra-group at the case comparisons, we recorded more cases of hysterectomy (33.3%) in the subgroup of patients who initially visited the hospital then returned to other structures of unconventional care. While, the rate of hysterectomy was to 17.3% (see table 4) in the subgroup having initially consulted out of hospital with a however no statistically significant difference.
But more importantly, we recorded 7.3% of hysterectomy in the control group versus 33.3% of hysterectomy in the Sub group of patients who initially visited the hospital then returned to other structures of non-conventional care (see table 5). The difference was significant at 5% with a X� equal to 7.84 and a RR equal to 4.5 . It can be concluded that they saw their condition worsen as a result of the delay in their care due to their itinerary. In african literature, hysterectomies for uterine fibroid under-recording figures vary between 25 and 40% the authors [6, 13, 14]. These figures are close to that of our patients of the group (22%). Less frequent use of unconventional care facilities would significantly reduce these rates of hysterectomy for conservative treatment. High rates of hysterectomy train a psychological impact of uterine fibroids on African patients.  In part, that would explain the delay in consultation for women. 


The feeling of the patient cope with the disease
It is true that for almost half of the patients in our study (47.6%), uterine fibroids were a disease like any other (ordinary). However, it should be noted that a significant proportion (40.2%) considered it as the mystical. All of these considerations may be partly related to ignorance of the uterine fibroid by these women. Black African women tend to consider mystical certain pathologies that they find difficult to explain. So ignorance and some considerations on uterine fibroids by African culture suggest that these populations accept hardly anyone a 'simple disease '. It is also one of the reasons why the traditional healers and the churches are most often sought by these patients, claiming that "the fibroid remains a mysterious disease".
CONCLUSION
The uterine fibroid is a frequent pathology in the breed population black. It requires adequate support. This study enabled us to clarify the therapeutic itinerary of african women in front of this pathology. He is a young, more often nulliparous woman posing for a complication of uterine fibroids in a hospital after completing different types of care outside hospitals.  These complications are bleeding, pelvic pain or infertility. Despite the disparity of the ways therapy used on a long itinerary with an exorbitant expenses, the only option as a last resort in these women is surgery. This surgery is most often a hysterectomy signing away the obstetrical future of patients. Our Government and Gynecologists should then focus awareness on the pathogenesis and effective treatment against the uterine fibroid.
Conflict of interest statement: the authors declare non conflict of interest.
REFERENCES�:
1. Nourelhouda C, Abbassia D. Epidemiological profile of uterine fibroids in the region of Sidi Bel Abbes, Algeria. Pan Afr Med J 2013; 15: 7. 
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