Iron Status and Hematological Profile of Ghanaian Women with Fibroids

Uterine leiomyomas are the most common gynecologic tumors and though mostly asymptomatic, they may present with heavy or abnormal uterine bleeding, pelvic pain or pressure, subfertility, and recurrent pregnancy loss. Heavy bleeding is often a reason to prescribe iron supplements in a bid to maintain normal hemoglobin levels. These hematinics are also sometimes prescribed for several months prior to surgery even though menorrhagia may not be the complaint. These women tend to stay on these supplements for long periods of time often without any laboratory investigation follow ups. Therefore a possibility of them developing iron overload exists especially if bleeding is not the presenting complaint. The aim of the present study was to determine the hematological profile of women with fibroids in Ghana. Between May 2005 and March 2009, in a case-control study of premenopausal Ghanaian women aged 20–40 years at Anokye Hospital,(KATH) the hematologic profile of women with fibroid in Ghana was studied. Two hundred women with confirmed uterine fibroids and two hundred women with non-observable fibroids as controls were recruited for the study. Results of the study showed that women with fibroids had higher red cell counts and red cell indices compared to women who had no fibroids. The mean Hematocrit (HCT), Mean Cell Hemoglobin (MCH), Mean Cell Hemoglobin Concentration (MCHC), and Red Blood Cell Count (RBC) were all significantly higher among patients compared to controls. Mean Cell Volume (MCV), Platelet (PLT) and Total White Blood Cell (WBC) count did not differ significantly between the two groups. Total serum iron (FE) was significantly higher while total iron binding capacity was significantly lower among patients compared to the control group. The results of the study revealed that the number of the patients who were on hematinics was significantly higher than that of the control group. Findings of this study show that women with fibroids in Ghana had higher hemoglobin and serum iron levels compared to their compatriots who did not have the condition. Prescription of iron supplements should therefore be done with care and only after reviewing their hematology laboratory results so as to prevent the development of iron overload among these women.


INTRODUCTION
Uterine leiomyomas (fibroids) are the most common pelvic tumors in women and by far, are the most common of all benign gynecological neoplasms. Although the precise etiology of leiomyomas is unknown, they are generally hormone sensitive, with rates of growth semiquantitatively related to estrogen and progesterone receptor levels [1,2]. They are present in 20-30% of women over 30 years of age, rising to more than 40% in those over 40 years old. Uterine leiomyomas disproportionately affect black women with an estimated cumulative hysterectomy rate for fibroids of 20% by age 45 [2,3].
Generally, symptoms relate to the location of the lesion and its size. The most common pathological symptoms include abnormal uterine hemorrhage, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility [2][3][4]. Excessive menstrual bleeding occurs in about 30% of patients often the main reason to seek healthcare [3,5,6]. The blood loss can result in iron deficiency anemia. To help women maintain good blood iron and hemoglobin levels most women are often prescribed iron supplements, folic acid and vitamin B12 [2,7]. Sometimes these hematinics are also prescribed for several months prior to surgery even though menorrhagia may not be the complaint. Most of these prescriptions are made often without any prior laboratory investigation. These women tend to stay on these supplements for long periods of time and a possibility of them developing iron overload especially if bleeding is not the complaint is real.
Additionally, most pharmacies advertise blood tonics that contain iron supplements and these over the counter tonics are seen as an easier and less costly option for some women who do not see the need to go to a hospital to be properly assessed by a clinician. This can potentially lead to iron overload and other complications.

AIM
The aim of the present study was to determine the hematological profile of women with fibroids in Ghana.

Subject Selection
A case-control study was conducted among women who had been admitted for elective surgeries at the Gynecology Department of Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana between May 2005 and March 2009, to determine the hematologic profile of Ghanaian women with uterine fibroids. Two hundred (200) women with confirmed uterine fibroids and two hundred other women with no uterine fibroids as controls were recruited for the study a day or two before the planned surgical treatments for them. Both groups were premenopausal women between the ages of 20 and 40 years and had also been examined by gynecologists and had transabdominal ultrasound scan conducted to confirm their categorization before recruitment. Women with obvious hormonal imbalance, chronic hematological disorders, or malignant diseases were excluded. None of the study subjects had had blood transfusion prior to the day of the surgery. Details on the study protocol were approved by the Committee on human research and publication (CHRP) of the School of Medical Sciences/KATH.
All subjects consented to participate in the study and completed a structured questionnaire that elicited information on socio-demographic characteristics, economic background, physical activity, family and medical history, medication in use, previous obstetrics and gynecological histories. The presence or absence of menorrhagia in women was established using self-reported questionnaire and based on established guidelines on menorrhagia [8].

Sample Collection and Preparation
For the determination of hematological parameters, 3ml of blood was collected from each subject into ethylene diamine tetraacetic acid (EDTA) vacutainers and analyzed within three hours of collection. For the determination of total iron and iron binding capacity, 4ml of blood was collected into a plain vacutainer and allowed to clot to obtain serum. All blood samples were collected before surgery and before they were administered anesthesia.

Total Iron and Total Iron Binding Capacity (TIBC)
Determination of total serum iron and iron binding capacity was done with a kit obtained from Atlas Medical TM (ATLAS Medical, Cambridge, UK) which is designed for the simultaneous determination of iron and iron binding capacity in human serum. Total serum iron test principle involves the removal of iron from transferrin, reducing it to the ferrous state, binding it to a chromophore, and quantifying it by measuring the amount of color developed at 560 nm.
The unsaturated iron binding capacity (UIBC) is determined by adding Fe (II) ion to serum so that they bind to the unsaturated iron binding sites on transferrin. The excess Fe (II) ions are reacted with Ferrozine to form the color complex, which is measured photometrically. The difference between the amount of Fe (II) added and the amount of Fe (II) measured represents the unsaturated iron binding. The total iron binding capacity (TIBC) is determined by adding the serum iron value to the UIBC value.

Tumor Extraction
The operations were undertaken by obstetrician/gynecologists of the K. A. T. H. At laparotomy for myomectomy or hysterectomy, the uterine size was estimated in comparison to a gravid uterus. The number of myoma nodules removed were counted and recorded. The locations of the tumors within the uterus were also stated. The total weight of the tumor was taken using a weighing scale.

STATISTICAL ANALYSIS
Descriptive statistics for all variables were computed. Continuous variables were expressed as means ± standard error of mean (SEM) and compared using the t-test for independent groups. Univariate logistic regressions were used to evaluate parameters that were independently related to fibroids. All analyses were two-tailed and P-value <0.05 was considered statistically significant. All statistical analysis were done using GraphPad Prism version 5.00 for Windows (GraphPad Software, San Diego California USA, www.grphpad.com). Table 1 compares the socio-demographic and obstetric/gynecologic features between the patients and the control group. The results showed a significant difference between the patients and the control subjects when analyzed based on income, gynecological and familial history of fibroids. Table  2 describes the hematological characteristics of the study population.

RESULTS
Analysis of data obtained on hemoglobin revealed a significant difference (t=8.276, p <0.0001) between the blood hemoglobin levels of the patients and the control patients. The mean blood hemoglobin level of the patients was 12.83±0.2548 gdl -1 and that of the control group was 10.12±0.2045 gdl -1 . Correlation analysis revealed there was a significant (r 2 = 0.8264, p<0.0001) between the blood hemoglobin level and tumor weight as shown in Fig. 1A. The analysis of data on hematocrit showed a significant difference (t=4.334, p<0.0001) between the blood hematocrit level of the patients and the control subjects. The mean blood hematocrit level of the patients was 41.46 ± 1.088% and that of the control group was 36.44 ± 0.5012% as shown in Table 2. There was a significant correlation (r 2 = 0.8105, p= 0.0407) between the blood hematocrit of the patients and tumor weight as shown in Fig. 1B.

White Blood Cell (WBC) Count
Analysis of data revealed an insignificant difference (t=0.4241, p= 0.6721) between the WBC count of the patients and the control group. The mean WBC count of the patients was 5.359±0.2504 x 10 9 L -1 and that of the control was 5.209±0.2476 x 10 9 L -1 as shown in Table 2. The correlation analysis showed no significant correlation (r 2 = 0.0794, p= 0.0823) between the WBC counts of the patients and their tumor weight as shown in Fig. 1C.

Platelet Count
As shown in Table 2, analysis, revealed an insignificant difference (t=1.007, p= 0.3156) between the means of the platelet count of the patients and the control group. The mean platelet count of the patients was 181.9±8.440 x 10 9 L -1 compared to that of the control group which was 193.6±8.008 x 10 9 L -1 . Correlation analysis showed that there was no significant correlation (r 2 = 0.0001, p= 0.9230) between the platelet counts of the patients and their tumor weight as shown in Fig. 2A. Comparing data on patients and control subjects, revealed an insignificant difference (t=0.6567, P= 0.5123) between the MCV of the patients and that of the control group. The mean MCV of the patients was 80.88±0.8974 fL and that of the control group was 80.10±0.7866 fL as shown in Table 2. Further analysis of the data showed an insignificant correlation between the MCV and the weight of tumor (r2= 0.0013, p= 0.8263) as shown in Fig. 2B.
There was a significant difference (t=10.97, P<0.0001) between the MCH of the patients and that of the control group using unpaired t-test analysis. The mean MCH value of the patients was 30.72±0.3577 pg and that for the control group was 25.55±0.3090 pg as shown in Table 2.
Correlation studies showed a significant correlation between the tumor weight and the MCH obtained (r2= 0.76231, p= 0.0308) as shown in Fig. 2C.
A significant difference (t=18.99, P <0.0001) between the MCHC of the patients and the control group was observed. The mean MCHC value for the patients was 33.40±0.2989 gdL-1 and that for the control group was 24.06±0.3901 gdL-1 as shown in Table 2. Correlation analysis showed there was a significant correlation between the tumor weight and the MCHC obtained (r2= 0.7724, p<0.0001) as shown in Fig. 3A.
A significant difference (t=12.01, P<0.0001) was observed between the patients and the control group after analysis of the data obtained on RBC count using the unpaired t-test analysis. The mean RBC value for the patients was 6.018±0.1479 x 1012 L-1 and that of the control group was 3.876±0.0996 x 1012 L-1 as shown in Table 2. When the data was further analyzed there was a significant (r2= 0.9417, P<0.0001) correlation between the weight of the tumor and the RBC count as shown in Fig. 3B.
Significant differences were observed for both TI (t=2.747, p= 0.0133) and TIBC (t= 3.062, p= 0.0067) levels between the controls and the patients when the data was subjected to analysis. The mean TI levels for patients and controls were 20.66±0.8985 mmolL-1 and 16.92±1.023 mmolL-1 respectively as shown in Table 2. The TIBC levels between the two groups were also significantly different as shown in Table 2. The patients had a mean TIBC value of 55.10 ± 2.957 mmolL-1 while the controls had a mean value of 66.20±2.097 mmolL-1. Table 3 reveals that the risk of developing leiomyoma was higher for women who had more years off normal education. Women with tertiary (OR=3.28, 95% CI= 1.64-6.55) and secondary education (OR=2.35, 95% CI= 1.33-4.14) were at a higher risk of developing fibroids. Table 3 also shows that menorrhagia was strongly associated with fibroids (OR=3.31, 95% CI= 1.93 -5.66). Menorrhagia was the reason most of the patients first came to see a clinician. Most of the women with fibroids were on hematinics (64%) whereas most of the controls were not (45.5%).

DISCUSSION
Not much research data is available on the hematological profile of leiomyomata patients.
The results of the present study show a significant difference between the red cell indices of the patients and the controls. The patients had higher mean values of all red cell indices, except MCV, compared to the controls contrary to popular reasoning that because prolonged excessive bleeding is a common symptom in fibroid patients, the red cell indices of these patients should be reduced. Yet in many of the patients the hematologic profile did not correlate with the severity of menorrhagia. The results of this study showed that the patients had significantly higher total iron and lower total iron binding capacity compared to those of the controls. All the red cell indices correlated significantly with the weight of the tumor obtained except the MCV. The finding of this study indicated that leiomyoma mostly occurred in women who were generally more educated and earn higher income compared to their counterparts who do not have the tumor. Higher education correlates with better paying jobs and hence the income disparity between the two groups.
The relation between poverty and malnutrition has been proven by previous studies to have a significant inverse relationship with education [9]. Education improves health, and its effects are larger at lower levels of income [10]. Good nutrition is key to maintaining a good hemoglobin level. Thus women with fibroids therefore are in a better state of general health and are able to maintain a higher level of hemoglobin despite the excessive bleeding compared to those who do not have the condition.  There have been reported cases of women with fibroids presenting with erythrocytosis [11,12]. Three schools of thought have emerged as possible causes of the erythrocytosis, all based on the observation that there is complete resolution of the erythrocytosis after surgical extirpation of the leiomyomata although none of them has been firmly proven [12].
The present study, however, did not find any case of erythrocytosis. The high red cell indices of patients compared to the controls suggest that women with fibroids had a compensatory mechanism yet unknown to the authors, which enable them to produce enough red cells to compensate for the menorrhagia. The correlation between red cell indices and tumor mass suggest the release or production of more erythropoietin in a mechanism involving the tumor. Further studies to determine the involvement, if any, of the tumor mass in erythropoietin production in women with fibroids are recommended.
The higher levels of blood iron and low level of iron binding capacity may be attributed to the observation that most of the patients had been on blood tonics which contained iron supplements. In Ghana, additionally, most pharmacies advertise blood tonic that contain iron supplements and these over the counter tonics are seen as cheaper options for women who cannot afford to see a clinician. Thus self medication is common in Ghana especially among the more educated [13]. Long term use of iron supplements can lead to iron overload and other complications [14,15]. Even though none of the patients experienced iron overload, the results of the study reveal that most women with fibroids in Ghana do not need to be on iron supplements on the long term if not associated with menorrhagia.

CONCLUSION
Women in Ghana with fibroids have significantly higher hemoglobin and higher serum iron levels compared to those who do not have the condition. This may be due to the hematinic they often are on. Care should be taken when prescribing Iron supplements for women with fibroids especially those without menorrhagia and where possible this must be done based on evidence of the hematology results as most of these women do not need these supplements. Findings of this study may be typical to this population and further studies in regions with similar population dynamics are recommended to compare.

CONSENT
All authors declare that written informed consent was obtained from all subjects before they were enrolled for this study.