Assessing Uterine Fibroid Symptoms and Health-related Quality of Life among women at Korle Bu Teaching Hospital, Ghana: an analytical cross-sectional study using the UFS-QoL questionnaire

We conducted a hospital-based analytical cross-sectional study among gynaecology patients diagnosed with uterine fibroids and receiving care at the KBTH. The hospital runs a specialist gynaecology clinic five days a week with an average daily attendance of 50 patients and performs approximately 40 to 60 fibroid-related surgeries monthly. Structured questionnaires were administered to participants who consented to participate in the study after study protocol was explained to them. The study population was those who were diagnosed with uterine fibroids and receiving clinical care in the KBTH between January 9 and April 8, 2023. Recruitment was based on ultrasound diagnosis of uterine fibroids. Participants were selected from the Gynaecology Clinic using a systematic random sampling approach, enrolling every alternate patient with uterine fibroids receiving care during the study period. This method was chosen to reduce selection bias while ensuring feasibility, as enrolling all eligible patients was not logistically practical given time and resource constraints. The selected participants were women 18 years and above who consented to take part in the study. Patients with uterine fibroids who had other major concurrent gynaecological disorders such as endometriosis, ovarian cysts, cancers were excluded. Participants’ basic sociodemographic data were collected from the hospital charts, followed by the administration of the validated tool - Uterine Fibroid Symptom & Health-Related Quality of Life Questionnaire (UFS-QoL). Trained research assistants administered the questionnaires in English or interpreted them into one of the two commonly spoken local languages (Twi and Ga) for participants who could not speak English. The questionnaires had been translated and back-translated into Ga and Twi following the initial pilot study. The UFS-QOL was developed to ascertain the impact of uterine fibroids in the lives of women who were diagnosed with uterine fibroids. The Uterine Fibroid Symptom and Health-Related Quality of Life (UFS-QoL) questionnaire developed by Spies et al. [ 9 ], is a validated tool specifically designed to assess the impact of uterine fibroids on symptom burden and QoL. Studies have demonstrated its reliability, validity, and responsiveness across various languages, including English, Chinese, and Brazilian Portuguese [ 10 , 11 ]. The questionnaire exhibits high internal consistency, test-retest reliability, and convergent validity when compared to other HR-QoL measures [ 10 , 11 ]. It effectively discriminates between women with and without uterine fibroids and is sensitive to treatment-related changes [ 12 ]. The questionnaire is made up of 8 questions on uterine fibroid-related symptoms and 29 questions on HR-QoL which is divided into 6 main groups: concern, activities, energy/mood, control, self-consciousness and sexual function [ 9 ]. The scores for both the symptom scale and the HR-QoL can be summed and transformed into a point scale ranging from 0 to 100 with a higher score on the symptom severity scale indicating greater severity of the symptoms and a higher score on the HR-QoL indicate a better quality of life [ 9 ]. The items and subscales assessed in this study were: symptoms severity, patients concerns, activity, energy/mood, control, self-consciousness, sexual function and their global health-related quality of life (HRQoL Global). Data were analyzed using SPSS Statistical Software version 25. Descriptive statistics were used to summarize participants’ sociodemographic and clinical characteristics. Associations between sociodemographic variables and UFS-QoL scores were assessed using the Student t-test, with statistical significance set at a p -value of less than 0.05. In addition, Pearson correlation analysis was conducted to examine the relationships between symptom severity scores and the various subscales of the UFS-QoL. Linear regression analysis was performed to determine the predictive value of age and symptom severity on overall HR-QoL scores. This study was approved by the Community Health Department Dissertation Ethical Review Committee, University of Ghana Medical School (CHDRC 07/2022).

A total of 163 out of the 178 eligible participants diagnosed with fibroids agreed to participate in the study giving a response rate of 91.6%. Participants were aged between 21 and 70 with a mean age of 39.2 years (SD ± 3.9), while almost half (46%) were 31 to 40 years old. In terms of parity, 95 (58.3%) of the respondents were nulliparous with 27%, 19%, 15%, and 7% of them giving birth once, twice, three times and four times, respectively (Table 1 ). Table 1 Sociodemographic characteristics of participants and parity Characteristic Frequency ( n ) Percentage (%) Age (years)  21–30 26 15.9  31–40 75 46.0  41–50 49 30.1  51–70 12 7.4  Mean ± SD 39.2 ± 3.9 Marital Status  Single 68 41.7  Married 80 49.1  Widowed 8 4.9  Divorced 4 2.5  Separated 3 1.8 Religion  Christian 152 93.3  Muslim 8 4.9  Traditionalist 3 1.8 Parity  0 95 58.3  1 27 16.6  2 19 11.7  3 15 9.2  4 7 4.3 Sociodemographic characteristics of participants and parity Regarding the duration of diagnosis, 23.3% participants ( n  = 38) had been diagnosed with uterine fibroids for more than 5 years. The rest of the participants had been diagnosed for less than 5 years. There was no significant association between the duration since the diagnosis of uterine fibroids and the symptoms score or the HR-QoL scores. Instructively, about one-third (32.5%) of women with fibroids had undergone a previous myomectomy. 42% of participants reported trying to conceive or having a diagnosis of infertility, with an average duration of 5.6 years based on self-reported data (Table 2 ). Table 2 Clinical and reproductive history of participants Characteristic Frequency ( n ) Percentage (%) Duration since fibroid diagnosis  Less than 5 years 125 76.7  5 to 9 years 30 18.4  10 to 14 years 8 4.9 Previous Myomectomy  Yes 53 32.5  No 110 67.5 Trying to Conceive  Yes 68 41.7  No 95 58.3 Clinical and reproductive history of participants In a significant majority, 155 (95.1%) of participants’ family members, including either parents or siblings, knew about their diagnosis of uterine fibroids and were supportive. Similarly, all 80 (100%) of the married women indicated their husbands were aware of their diagnosis, and 76 (95.0%) of whom were supportive. The remaining 4 (5.0%) of them were neutral. The average symptom severity subscale score was 34.6 ± 13.6 (mild). Overall, 57 (35%) participants reported moderate to severe uterine fibroid-related symptoms. (Table 3 ) The most worrisome symptom from the women surveyed appeared to be heavy menstrual bleeding with an average score of 3.12 out of 5. This was followed closely by the feeling of tightness or pressure in their pelvic area (score of 3.09) and then feeling fatigued (score of 2.72). In terms of participants’ HR-QoL, 136 women (83.4%) reported adverse impact of the fibroids on their overall quality of life comprising moderate impact (65.0%), important impact (17.8%) and very important impact (0.6%), with the total overall UF-QoL (global HR-QoL scores averaging 61.3 ± 14.9) (Table 3 ). Table 3 Symptom severity, global HRQoL and HRQoL subscale Scores Mean (+/-SD) Severity Number of women ( n ) Percentage (%) Symptom Severity Score 34.6 ± 13.6 Mild (0 – < 40) 106 65.0 Moderate (40 – < 80) 56 34.4 Severe (80–100) 1 0.6 Concern Score 63.2 ± 18.3 Mild (75–100) 45 27.6 Moderate (50 – <75) 87 53.4 Important (25 – <50) 29 17.8 Very important (0 – <25) 2 1.2 Activity Score 62.9 ± 17.4 Mild (75–100) 38 23.3 Moderate (50 – <75) 97 59.5 Important (25 – <50) 24 14.7 Very important (0 – <25) 4 2.5 Energy/Mood Score 61.5 ± 15.5 Mild (75–100) 32 19.6 Moderate (50 – <75) 101 62.0 Important (25 – <50) 27 16.6 Very important (0 – <25) 3 1.8 Control Score 58.7 ± 17.9 Mild (75–100) 31 19.0 Moderate (50 – <75) 82 50.3 Important (25 – <50) 47 28.8 Very important (0 – <25) 3 1.8 Self-Conscious Score 58.3 ± 20.1 Mild (75–100) 39 23.9 Moderate (50 – <75) 80 49.1 Important (25 – <50) 36 22.1 Very important (0 – <25) 8 4.9 Sexual Function Score 61.4 ± 23.5 Mild (75–100) 58 35.6 Moderate (50 – <75) 74 45.4 Important (25 – <50) 21 12.9 Very important (0 – <25) 10 6.1 HRQoL Global Score 61.3 ± 14.9 Mild (75–100) 27 16.6 Moderate (50 – <75) 106 65.0 Important (25 – <50) 29 17.8 Very important (0 – <25) 1 0.6 Mean ± SD Symptom severity, global HRQoL and HRQoL subscale Regarding the QoL subscales, the mean scores for the subscales are as follows: Symptom Severity Score − 34.6 ± 13.6, Concern – 63.2 ± 18.3, Activities – 62.9 ± 17.4, Energy/Mood – 61.5 ± 15.5, Control – 58.7 ± 17.9, Self-conscious − 58.3 ± 20.1 and Sexual function score – 61.4 ± 23.5 (Fig. 1 ). Fig. 1 Distribution of symptom severity and HR-QoL scores Distribution of symptom severity and HR-QoL scores From the regression analysis, the correlation coefficient of – 0.612 between the symptom severity and HRQoL scores with an increasing symptom severity score indicates a decreasing HRQoL score with symptom severity. Additionally, there was a significant correlation between the HRQoL subscale scores and the global HRQoL score with ‘Activities’ having the highest correlation of 0.913, and ‘Sexual Function’ having the lowest of 0.615. This indicates increases in each of the subscales can contribute to increases in the overall global HRQoL (Table 4 ). Table 4 Correlation and regression analysis of HRQoL and symptom severity Variable Symptom severity Concern Activities Energy/Mood Control Sexual function Self-conscious Pearson correlation coefficients  Pearson correlation −0.612** 0.845** 0.913** 0.873** 0.844** 0.615** 0.716**  Significance level 0.01 0.01 0.01 0.01 0.01 0.01 0.01 Variable R² F p -value Beta Coefficient Regression analysis  Age 0.044 1.905 0.175 57.122  Symptom severity score 0.374 96.238 0.000 84.494 **Correlation is significant at 0.05 significant level Correlation and regression analysis of HRQoL and symptom severity **Correlation is significant at 0.05 significant level In terms of participants’ age versus symptom severity and HRQoL scores, there was no significant correlation as the correlation between the age and the symptom severity and the QoL scores were − 0.211 ( p  = 0.175) and 0.242 ( p  = 0.118) respectively (Table 4 ).

Uterine fibroids are benign tumours of the uterus affecting up to 80% of women in their reproductive age [ 1 ]. Recent studies highlight the significant global burden of uterine fibroids, with both incidence and prevalence rising over the past few decades. In 2019 alone, approximately 9.64 million new cases were diagnosed worldwide [ 2 ]. Specific to Korle Bu Teaching Hospital (KBTH), the largest referral hospital in Ghana, uterine fibroids constituted the cause of approximately 26.7% of admissions to the Gynaecological ward and about 40% of major gynaecological surgeries [ 3 , 4 ]. Beyond their physical health implications, uterine fibroids significantly impact mental and social well-being, dimensions that are critical to overall health and QoL. Studies from high income countries (HIC) have highlighted the far-reaching consequences of fibroids on QoL. For instance, 25% of women with uterine fibroids reported that the condition prevented them from achieving their full career potential, while many experienced decreased productivity due to absenteeism [ 5 ]. In another study, African American women were also 77% more likely to miss work than their Caucasian counterparts due to uterine fibroids and related complications [ 6 ]. In addition to diminished work performance, women with uterine fibroids frequently report negative effects on self-image and sexuality, which adversely impact their social relationships [ 7 ]. Emotional well-being is also significantly affected, with many women expressing persistent fear due to the unpredictability of the symptoms. These fears often include concerns about soiling clothing, future health complications, fibroid growth, and the potential need for hysterectomy [ 7 ]. Approximately 69% of affected women have expressed distress about harbouring a foreign entity within their body [ 7 ]. These multifaceted burdens underscore the profound impact of uterine fibroids on QoL [ 7 ]. Common fibroid-related symptoms assessed by the UFS-QoL include lower back pain, fatigue, bloating, pelvic pain, and heavy menstrual bleeding [ 8 ]. Studies further reveal that the presence, severity, and number of symptoms are strongly correlated with poorer UFS-QoL scores, underscoring the significant impact of fibroids on HR-QoL [ 8 ]. Despite the availability of tools such as the UFS-QoL to measure symptom-related QoL, there is limited research on the subject from sub-Saharan Africa, a region with the highest global prevalence of uterine fibroids. This gap is particularly concerning given the unique sociocultural and healthcare contexts of this region. We aimed to assess the Symptoms-Related QoL of women with uterine fibroids receiving care at the KBTH, Ghana’s largest tertiary referral centre. The primary strength of this study lies in its emphasis on investigating the impact of compromised physical health in women with uterine fibroids on their overall well-being and QoL in our setting, where uterine fibroids are highly prevalent but lack any such previous research. This work appears to be the first study in our setting to investigate the subject.

There was a moderate to severe impairment in the QoL in 83.4% of women with uterine fibroids at the Korle Bu Teaching Hospital. This QoL impairment significantly correlates with the severity of the symptoms of the women. Better health-related QoL scores was associated with lower symptom severity scores, while lower QoL scores were associated with higher symptom severity scores. These findings underscore the significant burden that uterine fibroids impose on women’s well-being and highlight the urgent need for targeted interventions to alleviate symptom severity and improve the overall QoL in affected individuals. Specifically, routinely assessing the symptom-related quality of life scores in women seeking treatment for fibroids as part of standard care, and subsequently offering those with impaired QoL some tailored professional clinical counselling, and psychological therapy can help enhance the overall patient experience of fibroid-related clinical care.

We examined the symptom-related QoL among women with uterine fibroids at the Korle Bu Teaching Hospital. Participants ranged in age from 23 to 71years, with a mean age of 39.2 ± 3.9 years. By age 50, 92.1% had uterine fibroids, aligning with previous studies [ 13 – 15 ]. A significant proportion (83.4%) reported a moderate to severe impact on their QoL, with a total UFS-QoL HRQoL score averaging 61.3 ± 14.9, consistent with findings from other studies [ 8 , 16 , 17 ]. Consistent with previous findings, including those by Herve F. et al. [ 16 ] our study identified heavy menstrual bleeding as the most distressing symptom among women with uterine fibroids, with an average score of 3.12 out of 5. This aligns with prior research highlighting heavy bleeding and passage of clots as the most impactful symptoms on QoL in this population [ 8 ] Our data also showed that this was followed closely by sensations of pelvic tightness or pressure (3.09) and fatigue—likely reflecting anaemia due to excessive menstrual loss [ 3 ]. The majority of respondents (65%) indicated experiencing mild symptoms, while only 35% reported experiencing moderate to severe symptoms. This observation contrasts the findings reported by Herve F. et al. from their national survey in France, where 64% of patients with uterine fibroids reported moderate to severe symptoms, and 36% reported mild symptoms [ 16 ]. Differences in the different patient populations and cultural characteristics might account for the reported symptom severities across the two studies. Despite this disparity in findings, the mean symptom severity score of 34.6 ± 13.6 from this current study aligns with the findings reported by other researchers from Europe and the United States of America [ 8 , 17 ]. There was no significant association between the duration since the diagnosis of uterine fibroids and the symptoms score or the HR-QoL. Although majority (83.4%) of the women reported moderate, important and very important impact of uterine fibroids on their QoL, the duration of the diagnosis was not found to have a significant impact. This was contrary to expectations reported by Shofany C. et al., that there would be improvement of the QoL of women affected with such chronic diseases over time [ 18 ]. This lack of improvement in patients with uterine fibroids in our study could be attributed to increasing symptom severity in the absence of definitive treatment as well as the relatively larger sizes of fibroids often diagnosed in our setting, which may contribute to the worsening symptoms as they grow [ 19 ]. Although a study by Fortin C. et al. [ 5 ] suggested a significant improvement in the QoL in women who had undergone a previous myomectomy, irrespective of the procedure used, this current study found no such association between previous myomectomies and improvements in the symptom severity or HR-QoL score of women with recurrent myomas. The possibility of other potential socio-cultural differences in the two study contexts may account for this observation. Notably, the participants in this current study were women presently with fibroids for which they were seeking treatment, and not those with history of fibroids who had been treated with myomectomy, as in the case of Fortin C et al. Additionally, it is likely that participants in this category represented only a proportion of women seeking care for their recurrent symptomatic fibroids. Despite previous studies suggesting that increased parity was associated with a reduced risk of developing uterine fibroids [ 6 ], there was no significant association between parity and the severity of the symptoms or the uterine fibroid-related QoL in this current study ( p = 0.272). This lack of association could be attributed to the diverse presentations of uterine fibroids and other determinants of symptom severity, such as the location of the fibroid within the uterus which may in turn contribute to the HR-QoL. Also, it is likely that the nulliparous women with symptomatic fibroids might be more focused on their nulliparity (or childlessness) and so not making much premium on the physical symptoms of their fibroids, seeing over 40% of participants have been trying to conceive in a setting where infertility is associated with significant psychological and emotional distress in affected women [ 20 ]. In order of impact severity, evaluating the QoL across the various domains, the women’s ‘self-consciousness’ was impaired the most, followed by ‘control’ , ‘sexual function’ , ‘energy/mood’ , ‘activity’ and then ‘concern’ . Most women were more troubled by the feelings of weight gain, the size and appearance of their abdomen, and the size of clothing they had to wear during their menstrual periods. This was followed by a good proportion of them being bothered by the feeling of a lack of control over their health and life. These agreed with findings in previous studies that reported feelings of being less productive, worrying about their general health, and uncertainty about the future for “control” [ 7 , 9 , 21 ]. Most women also reported diminished sexual desire with a correlation of 0.872 ( p  = 0.01) between the reported diminished sexual desire and associated abstinence from sex. All of these had a positive correlation with the symptoms score, indicating that a rise in symptom severity corresponded to a decreased QoL in women with uterine fibroids. There was no significant correlation between the age and the symptom severity and the QoL scores as the correlation between the age and the symptom severity and the QoL scores were − 0.211 ( p = 0.175) and 0.242 ( p = 0.118), respectively. This is similar to findings reported by Ford, among African American women [ 12 ]. These underscore the need for clinicians to include a broadened routine of patients with uterine fibroids particularly those symptomatic, so that their QoL impairments can be diagnosed and managed to mitigate its adverse impact on their wellbeing. The main limitation of this study may relate to the relatively small sample size of the patients studied. Based on this, a larger multi-centre survey would be recommended to obtain a greater power study that should inform policy, especially for full medical insurance coverage for the treatment costs of uterine fibroids in Ghana. Also, the cross-sectional design of this study limits its ability to establish causality and track changes in the symptoms and quality of life over time, which could otherwise have been an important scientific exercise. Another limitation relates to the fact that participants were already wanting treatment, which would indicate they are having symptoms or are bothered by the fibroids. Recruitment was also based solely on ultrasound findings, which cannot always distinguish fibroids from conditions such as adenomyosis or endometriosis. Finally, the potential contribution of comorbidities to symptom severity was not investigated in this study but would be an important area for future research.“.