Evaluation of the anatomical locations and sizes of uterine fibroids from ultrasound examination in Ghana Emmanuel Kobina Mesi Edzie1, Klenam Dzefi-Tettey2, Edmund Kwakye Brakohiapa3, Philip Narteh Gorleku1, Eric Aidoo4, Stephen Kwaku Amoah4, Samuel Asiamah2, Frank Quarshie5, Obed Nimo6, Amrit Raj7, Joshua Mensah Kpobi8, Evans Boadi8, Richard Ato Edzie1, Veronica Turkson1, Henry Kusodzi1, Abdul Raman Asemah1 1. Department of Medical Imaging, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana. 2. Department of Radiology, Korle Bu Teaching Hospital, 1 Guggisberg Avenue, Accra, Ghana. 3. Department of Radiology, University of Ghana Medical School, Accra, Ghana. 4. Department of Anatomy, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana. 5. African Institute for Mathematical Sciences (AIMS), Summerhill Estates, East Legon Hills, Santoe, Accra, Ghana. 6. Department of Imaging Technology and Sonography, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana. 7. Department of Paediatrics, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana. 8. Department of Radiology, Cape Coast Teaching Hospital, Cape Coast, Ghana. Abstract Background: Uterine fibroids locations and sizes, have significant influences on the quality of life of women especially preg- nant women and on live birth rate. Objectives: To determine the anatomical locations and sizes of uterine fibroids and assess any possible associations with age groups. Methods: This retrospective study reviewed the locations and sizes of a total of 3,542 patients who were ultrasonographically diagnosed with uterine fibroids from January 2019 to December 2021. The obtained data were analysed using GNU PSPP, and Python on Jupyter Notebook with statistical significance level set at p≤0.05. Results: The overall average diameter of uterine myoma was 5.50±2.60cm (95%CI=5.41–5.58, range=1.00cm–19.10cm) and the respective mean diameter of intramural, subserosal and submucosal fibroids were 5.53±2.60cm (95%CI=5.44–5.62), 5.50±2.27cm (95%CI=5.27–5.74) and 5.82±2.77cm (95%CI=5.49–6.14). Most of the fibroid nodules were small (48.36%, n=1713) and only 5.84% (n=207) were large (>10cm). Posterofundal fibroids and lower anterior myomas were mostly seen in the 35-44 years age class. Conclusion: The majority of the uterine fibroids were intramural and were mostly at the anterior uterine wall. The submucosal fibroids, even though the rarest, were averagely larger than the other types of uterine myomas. The diameter of uterine fibroids increased with age. Keywords: Uterine fibroids; Anatomical locations; Sizes; Ultrasound imaging; Ghana; Africa. DOI: https://dx.doi.org/10.4314/ahs.v23i4.48 Cite as: Edzie EKM, Dzefi-Tettey K, Brakohiapa EK, Gorleku NP , Aidoo E, Amoah SK, . . . Asemah AR. (2023). Evaluation of the anatomical locations and sizes of uterine fibroids from ultrasound examination in Ghana. Afri Health Sci, 23(4). 438-450. https://dx.doi. org/10.4314/ahs.v23i4.48 438 © 2023 Edzie EKM et al. Licensee African Health Sciences. This is an Open Access article distributed under the terms of the Creative commons Attribution License (https://creativecommons.org/licenses/BY/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. African Health Sciences African Health Sciences, Vol 23 Issue 4, December, 2023 Introduction Uterine myomata are the most common smooth muscle benign tumors of the uterus, comprising varying levels of fibrous tissues and smooth muscle cells.1 They compress the surrounding connective tissues and the myometrium, causing the progressive development of collagen rich pseudocapsules, blood vessels, and neurofibres. A recent study reported that, uterine fibroids have adverse effects on the reproductive system, due to significant gynaeco- logical morbidity. In Australia and the United States of America (USA) for instance, literature has reported that myomata are the most common indication for hysterec- tomy, in 40-60% of all cases.2 Studies have shown that, during the reproductive years of women, the majority of them will develop uterine fi- broids. In the USA, it is estimated that, about 26 million women between the ages of 15 and 50 years have uterine myomas, with records of high impacts, prevalence and in- cidence in the black community. African American wom- en, on average, are younger at first diagnoses of fibroids, with larger and more multiple tumours, and a higher like- lihood of myomectomy.3 The total annual fibroids hospi- tal admission cost in England, Germany and France were $86 million, $120 million, and $348 million respectively, and these especially impact the black community.1 Most patients with fibroids are asymptomatic as only 30% presents with symptoms like infertility, constipation, uri- nary frequency, anaemia, and abnormal uterine bleeding. Routine gynaecological screening, bleeding per vaginum, menorrhagia, amenorrhoea, dysmenorrhoea, and preg- nancy are common indications for pelvic ultrasonogra- phy that aid in the diagnosis of uterine fibroids.1,4 When uterine fibroids are suspected, ultrasound is the standard imaging examination owing to its high specific- ity and sensitivity in diagnosing this condition. The ultra- sound scans can be performed transabdominally (trans- abdominal scan – TAS) or transvaginally (transvaginal Corresponding author. Emmanuel Kobina Mesi Edzie, Department of Medical Imaging. School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast. PMB, Cape Coast, Ghana. Tel: +233244687946 Email: emmanuel.edzie@ucc.edu.gh scan – TVS). Despite both TAS and TVS can be used in most situations of pelvic diseases, the transvaginal sonog- raphy is preferable to transabdominal sonography.5 Mag- netic resonance imaging (MRI) is the gold standard for the diagnosis of uterine fibroids as it can more accurately localise and quantify the fibroid nodules. However, ultra- sonography is usually the main modality for diagnosis of uterine fibroids in most developing countries like Ghana because of its availability and affordability.6,7 The International Federation of Gynaecology and Ob- stetrics (FIGO) proposed the allocation of fibroids into seven types, from type 0 (where the submucosal fibroid is completely enclosed within the uterine cavity or pe- dunculated intracavitary fibroid) to type 7 (where inside the pelvis lies a pedunculated fibroid), aiming to arrive at a universal and detailed classification, but to date, there is no universally accepted way of classifying uterine fi- broids. Uterine myomas are mostly categorised accord- ing to their anatomical relationship to the endometrium, and myometrium. Thus, currently, the location is the only and basic feature for their classification resulting in three topographic categories: subserosal, intramural, and sub- mucosal fibroids.8,9 The locations and sizes of uterine leiomyomata help to determine their clinical behaviour, yet such studies are limited in our setting. Other studies have reported on the anatomical locations and sizes of fibroids with intramu- ral as the most common location for fibroid, but only few assessed possible associations between the locations, sizes and age groups.4,10,11 We sought to determine the an- atomical locations and sizes of fibroids, and assess any possible associations with age groups. The specific ob- jectives were; * To assess the anatomical locations of uterine fibroids. * To ascertain the associations between the anatomical locations of uterine myoma and the age groups. * To assess the sizes of uterine fibroids and possible as- sociations with age groups. Methods Study setting and design The ultrasound scan records and ages of all participants who visited the Cape Coast Teaching Hospital (CCTH) from January 2019 to December 2021 were evaluated in this retrospective cohort study. The CCTH is the only 439African Health Sciences, Vol 23 Issue 4, December, 2023 public tertiary facility serving the South-Central Ghana populace, and it is situated in Cape Coast, the regional capital. The facility is one of Ghana's top medical re- search institutions and a training site for the College of Health and Allied Sciences of the University of Cape Coast and the Nursing-Midwifery Training College of Cape Coast. It provides tertiary and subspecialty services (including radiology) to the region and beyond. The ages of the participants were categorised as follows; “15-24 years”, “25-34 years”, “35-44 years”, “45-54 years”, and “55-69 years”. The sizes (in diameter) of the fibroid nodules were also classified as follows; “small (<5 cm)”, “medium (5-10 cm)”, and “Large (>10 cm)”.12 The loca- tions were themed under, the types; intramural, submu- cosal and subserosal; and the positions; “anterior uterine fundus”, “anterior uterine body”, “anterior lower uterus/ cervix”, “posterior uterine fundus”, “posterior uterine body”, “posterior lower uterus/cervix” and “central uter- ine fundus”. Data collection Over the three-year period, we assessed the number of patients diagnosed with uterine fibroids by ultrasonog- raphy since ultrasonography is commonly used to diag- nose uterine myomas because of its radiation-free nature, affordability, availability, high specificity, and sensitivity.13 We employed the Lightwave Health Information Man- agement System (LHIMS), a computerised database sys- tem of the Cape Coast Teaching Hospital (CCTH), which has been used for many years and contains a detailed pa- tient’s information on height, weight, demographics, di- agnosis, laboratory results, procedures as well as the ra- diology reports. Keywords like uterine myomas, fibroids, leiomyomas, hysterectomy, and myomectomy were used to find all the patients who had been diagnosed with uter- ine fibroids. After that, their unique electronic identifi- cation numbers were obtained to avoid duplication. All linked automated data sources of the patients were re- trieved using the unique electronic identification number generated. We conducted a detailed review of the medical records to extract the ultrasound scan fibroid reports for the anatomical locations and sizes based on the catego- rised themes, as well as the age groups of the patients. For analyses, a total of 3,542 patients diagnosed with uterine fibroids were consecutively selected and included. Image acquisition The ultrasound scans were performed by three radiolo- gists with over 10 years of cumulative experience in gy- naecological sonography, using Mindray Diagnostic Dig- ital Ultrasound System, Model DCN3, with a 3.5MHz convex probe and a 7.5MHz transvaginal probe, manu- factured in 2014 by Shenzhen Mindray Bio-Medical Elec- tronics Company Limited (Nanshan, Shenzhen, China). The examinations were done in transverse and sagittal planes to locate the uterine fibroids and measure their sizes (in centimeters). Statistical analysis GNU PSPP (Category: Education, Science & Math), pspp version 1.2.0-3, developed by the Free Software Foundation, was used for collating, grouping, inputting, and analysing the data to obtain the tables, frequencies and percentages. The charts were created using Python on Jupyter Notebook (Version 3.0) and LibreOffice Calc (version 1:6.1.5-3+deb10u6), developed by The Docu- ment Foundation. A Chi-square test was used to examine for possible associations between age and anatomical lo- cations and sizes of the uterine fibroids. P-values ≤ 0.05 were chosen to be statistically significant. Results The overall mean size (in diameter) of the fibroid masses was 5.50±2.60cm ranging from 1.00cm to 19.10cm and the average age of the patients was 35.58±9.04 years, also spanning from 17-68 years. The age group with the high- est prevalence was the 25-34 years (40.49%) and the least was 55-69 years (3.53%). The majority of the patients had small fibroid sizes (48.36%, n=1713), followed by medi- um sizes (45.79%, n=1622). Only 5.84% (n=207) had large fibroid sizes as shown in (Table 1). 440 African Health Sciences, Vol 23 Issue 4, December, 2023 Table 1: Age distribution and sizes of the fibroid nodules of the patients. Variable Count Percentage (%) Age; Minimum Maximum Mean (SD) 17 years 68 years 35.58 (9.04) years Age Group; 15-24 years 25-34 years 35-44 years 45-54 years 55-69 years 318 1434 1193 472 125 8.98% 40.49% 33.68% 13.33% 3.53% Fibroid Size; Minimum Maximum Mean (SD) 1.00cm 19.10cm 5.50 (2.60) cm Fibroid Size Categories; Small (<5cm) Medium (5-10cm) Large (>10cm) 1713 1622 207 48.36% 45.79% 5.84% Abbreviation: SD, Standard Deviation. The mean ages of the patients who had small, medium and large fibroid sizes were 32.52 years (CI=32.12–32.91), 36.99 years (CI=36.61–37.37) and 49.84 years (CI=48.90– 50.78) respectively. The mean ages for those who had in- tramural, subserosal and submucosal fibroids were 35.30 years (CI=35.00– 35.60), 35.55 years (CI=34.62–36.47) and 38.55 years (CI=37.48–39.63) respectively. The aver- age and diameters/sizes of the intramural, subserosal and submucosal uterine fibroids are shown in (Table 2). Table 2: Mean ages and fibroid sizes of patients in the various size and location categories. Variable Mean Age (SD) 95% CI for Mean F-value P-value Small (<5cm) 32.52 (8.37) years 32.12 – 32.91 476.93 <0.001* Medium (5-10cm) 36.99 (7.77) years 36.61 – 37.37 Large (>10cm) 49.84 (7.12) years 48.90 – 50.78 Overall 35.58 (9.04) years 35.28 – 35.88 Intramural 35.30 (8.68) years 35.00 – 35.60 6.01 0.014* Subserosal 35.55 (8.93) years 34.62 – 36.47 0.08 0.771 Submucosal 38.55 (9.16) years 37.48 – 39.63 38.79 <0.001* Mean Size (SD) Small (<5cm) 3.42 (0.98) cm 3.37 – 3.47 6640.69 <0.001* Medium (5-10cm) 6.87 (1.33) cm 6.81 – 6.94 Large (>10cm) 11.87 (1.58) cm 11.66 – 12.09 Overall 5.50 (2.60) cm 5.41 – 5.58 Intramural 5.53 (2.60) cm 5.44 – 5.62 7.50 0.006* Subserosal 5.50 (2.27) cm 5.27 – 5.74 0.00 0.965 Submucosal 5.82 (2.77) cm 5.49 – 6.14 4.67 0.031* Abbreviation: SD, Standard Deviation; CI, Confidence Interval; *Statistically Significant Table 2: Mean ages, fibroid sizes and fibroid location catagories of patients. 441African Health Sciences, Vol 23 Issue 4, December, 2023 Figure 1 depicts a direct relationship between fibroid siz- es and mean ages. Hence, the sizes of fibroid nodules, on the average, increased with age. The most frequent type of uterine fibroids was the intra- mural (83.34%, n=3306) followed by subserosal (9.38%, n=361) and submucosal (7.28%, n=280) (Figure 2). Figure 1: Fibroid sizes and the respective mean ages of the patients. Figure 2: The proportions of the various types of uterine fibroids. 442 African Health Sciences, Vol 23 Issue 4, December, 2023 Most of the fibroid masses were anatomically positioned at the anterior part of the uterine body (28.49%, n=1220) (Figure 3), and posterior part of the uterine body (22.07%, n=945) (Figure 3), followed by the centrally fundal part (21.28%, n=911) (Figure 4) and anterior uterine fundus (8.43%, n=361) (Figure 5). Only 5.98% (n=255) of the fibroid masses were at the posterior lower part of the uterus (Figure 4). The rest are shown in (Figure 6). Figure 3: Sonograms showing anterior intramural uterine body myoma indenting into the posterior wall of the urinary bladder (red arrows), posterior uterine body myoma (green arrow), and a posterior uterine fundus (yellow arrow). Figure 4: A longitudinal ultrasound image of the uterus showing a centrally fundal myoma (yellow arrow) and a posterior lower uterine myoma (red arrow). 443African Health Sciences, Vol 23 Issue 4, December, 2023 Figure 5: Ultrasound images of the uterus showing a myoma at the anterior uterine fundus (green arrows). Figure 6: The proportions of the anatomical positions of uterine fibroids. Most of the intramural fibroids were located at the an- terior part of the uterine body (29.29%, n=1150) and only 5.86% (n=230) were at the posterior lower part of the uterus. The subserosal and submucosal fibroids were both more common at the fundal part of the uterus con- stituting 32.53% (n=176) and 29.11% (n=115) respective- ly. Most of the small fibroids were at the anterior regions (45.31%) with the following specific constituents: body 35.75%; lower 0.54%; and fundus 9.02%. The remaining distributions of the types and sizes of uterine fibroids at the various anatomical locations or positions are showed in (Table 3). 444 African Health Sciences, Vol 23 Issue 4, December, 2023 Table 3: Distribution of the uterine fibroids types and sizes at the various locations. Location Intramural Subserosal Submucosal <5cm 5-10cm >10cm Posterior Uterine body 885 (22.54%) 95 (17.56%) 60 (15.19%) 466 (25.01%) 402 (19.55%) 77 (28.84%) Posterior lower uterus 230 (5.86%) 25 (4.62%) 50 (12.66%) 89 (4.78%) 135 (6.57%) 31 (11.61%) Posterior uterine fundus 305 (7.88%) 20 (3.70%) 20 (5.06%) 122 (6.55%) 168 (8.17%) 25 (9.36%) Total posterior 1420 (36.28%) 140 (25.88%) 130 (32.91%) 677 (36.34%) 706 (34.29%) 133 (49.81%) Anterior uterine body 1150 (29.29%) 165 (30.50%) 55 (13.92%) 666 (35.75%) 528 (25.68%) 26 (9.74%) Anterior lower uterus 250 (6.37%) 30 (5.54%) 60 (15.19%) 10 (0.54%) 153 (7.44%) 16 (5.99%) Anterior uterine fundus 326 (8.30%) 30 (5.54%) 35 (8.86%) 168 (9.02%) 166 (8.07%) 27 (10.11%) Total anterior 1726 (43.96%) 225 (41.48%) 150 (37.97%) 844 (45.31%) 847 (41.19%) 69 (25.84%) Central uterine fundus 780 (19.87%) 176 (32.53%) 115 (29.11%) 342 (18.36%) 504 (24.51%) 65 (24.34%) The majority of the patients with intramural fibroids were in the 25-34 years (40.36%, n=1294) and 35-44 years (35.09%, n=1125) age categories (p=0.001). Similar distribution across the age groups was seen in the patients with subserosal fibroids with p-value=0.003. The submu- cosal fibroids (Figure 7) were more frequent in the 35-44 years (39.29%, n=110) and 25-34 years (32.14%, n=90) age groups (p<0.001). The remaining distribution of the anatomical positions of the uterine fibroids across the various age classes are shown in (Table 4). The fibroids with small sizes were more common (62.87%) in the rel- atively younger population (≤34 years) whilst the large ones were more frequent (60.68%) in the older patients (≥45 years). The rest are shown in (Table 4). Figure 7: An ultrasound scan of the uterus showing a submucosal predominantly hypoechoic anterior myoma. 445African Health Sciences, Vol 23 Issue 4, December, 2023 Table 4: Association between the anatomical locations, sizes and age groups of uterine fibroids Fibroid Type 15-24years 25-34years 35-44years 45-54years 55-69years P-value Intramural 293 (9.14%) 1294 (40.36%) 1125 (35.09%) 420 (13.10%) 74 (2.31%) 0.001* Subserosal 15 (4.16%) 165 (45.71%) 125 (34.63%) 42 (11.63%) 14 (3.88%) 0.003* Submucosal 10 (3.57%) 90 (32.14%) 110 (39.29%) 55 (19.64%) 15 (5.36%) <0.001* Position; Posterior uterine body 65 (6.88%) 356 (37.67%) 352 (37.25%) 144 (15.24%) 28 (2.96%) 0.004* Posterior lower uterus 25 (9.80%) 100 (39.22%) 70 (27.45%) 55 (21.57%) 5 (1.96%) 0.001* Posterior uterine fundus 45 (14.29%) 110 (34.92%) 115 (36.51%) 40 (12.70%) 5 (1.59%) 0.004* Total posterior 135 (9.09%) 566 (38.12%) 537 (36.16%) 209 (14.07%) 38 (2.56%) Anterior uterine body 83 (6.80%) 567 (46.48%) 445 (36.48%) 95 (7.79%) 30 (2.46%) <0.001* Anterior lower uterus 25 (9.09%) 85 (30.91%) 110 (40.00%) 45 (16.36%) 10 (3.64%) 0.014* Anterior uterine fundus 75 (20.78%) 160 (44.32%) 90 (24.93%) 31 (8.59%) 5 (1.39%) <0.001* Total anterior 183 (9.86%) 812 (43.75%) 645 (34.75%) 171 (9.21%) 45 (2.42%) Central uterine fundus 40 (4.39%) 351 (38.53%) 313 (34.36%) 172 (18.88%) 35 (3.84%) <0.001* Size; Small (<5cm) 291 (16.99%) 786 (45.88%) 487 (28.43%) 125 (7.30%) 24 (1.40%) <0.001* Medium (5-10cm) 25 (1.54%) 644 (39.70%) 672 (41.43%) 235 (14.49%) 46 (2.84%) Large (>10cm) 2 (0.97%) 4 (1.93%) 34 (16.43%) 112 (54.11%) 55 (26.57%) *Statistically Significant Discussion The locations and sizes of uterine fibroids according to literature, have significant influences on the quality of life of women especially pregnant women and on live birth rate (proportion of babies that are born alive). Studies have reported that fertility may be impaired by fibroids (submucosal and intramural myomas extending towards the endometrial lining).14,15 Even though intramural fi- broids, the commonest type of uterine fibroids (83.34%) in this current study, are generally not dangerous, they can cause unpleasant symptoms and may contribute to subfertility (Figure 2) as also corroborated by several other studies.8,16 The subserosal (9.38%) and submucosal (7.28%) fibroids were the second and the least common types of fibroids respectively in this study. A similar pic- ture of finding of intramural, subserosal, and submucosal in their respective order of frequencies has been reported by other studies.17,18 A study by Moshesh et al., in Michi- gan, USA recorded a margin of 79.0% for the intramural fibroids and a comparatively low proportion of 4.0% for the submucosal fibroids.17 In a rural population of North India, Dayal et al., also reported intramual myomas as the commonest (66.7%), followed by subserosal (22.2%) and submucosal (8.9%).18 Padubidri et al., also found intra- 446 African Health Sciences, Vol 23 Issue 4, December, 2023 mural fibroids to be the most predominant (75.0%) but contrary to what we found, submucosal (15.0%) was the second most frequent type of uterine leiomyomata, fol- lowed by subserosal (10.0%) in their study.19 The themes of uterine fibroids locations vary across studies. In this current study, the anterior and posterior locations of uterine fibroids were further categorised as body, lower and fundal but generally, the majority of the uterine fibroids were anatomically positioned in the an- terior wall (43.34%), and posterior uterine wall (35.39%) (Figure 6). Zhang et al., broadly categorised the positions as posterior (44.2%), anterior (34.0%) and others (21.8%) thereby recording most of the fibroids at the posterior uterine wall, which is contrary to our findings.14 This may give some advantages in terms of treatment to women with fibroids in our setting as literature has reported that fibroids located at the anterior wall of the uterus are less difficult to treat especially with ultrasound-guided high intensity focused ultrasound (HIFU) ablation than those located at the posterior wall.20 Another study by Adesi- na et al., also reported that, fibroids at the anterior wall mostly require anterior uterine incisions which are as- sociated with least amount of blood loss as compared to those at the posterior wall mostly requiring posterior uterine incisions, which are significantly associated with increased blood loss.21 Most of the uterine fibroid nodules in this study were of relatively smaller sizes thus less than 5cm (48.36%), followed by medium sizes (5-10cm, 45.79%) and large sizes (>10cm, 5.84%) (Table 1). Similar results have been reported by Sarkodie et al., but with a comparatively high- er proportion of 64.4% of the fibroid masses less than 5cm.22 In another study by Lee et al., divergent results were observed. The authors recorded the majority of the uterine myoma nodules being medium (5-10cm, 48.11%), followed by small (<5cm, 42.45%) and large (>10cm, 9.44%).12 The mean diameter of uterine fibroids differ across studies and jurisdictions even though generally lit- erature posits that leiomyomas are larger in Africans or African American women.3,23 The overall mean diameter of uterine fibroids in our study was 5.50±2.60cm (range: 1.00-19.10cm), which may pose some threats on the quality of life of women in our set- ting particularly pregnant women (Table 1). According to literature, pregnant women with fibroid size s>3cm have high risk of developing complications even though they may deliver at a significantly earlier gestational age as compared to women without fibroids.24,25 Similar average diameter of 5.4cm (range: 1.6-18.2 cm) was reported by Deipolyi Amy.26 A comparatively higher mean diameter of 8.3cm was found by Katsumori et al., in Japan and 4.1±0.8cm (range: 0.7-10.7cm) by Ciavattini et al., in their study which assessed the numbers and sizes of uterine fibroids and obstetric outcomes in Italy.24,27 Another study by Oliveira et al., in Brazil recorded an overall mean di- ameter of 1.9±1.3cm (range: 0.4- 6.9cm), but the reason for the significantly low average diameter could be due to the total exclusion of fibroids > 7cm from their study.28 The corresponding mean diameters of the intramural, subserosal and submucosal uterine fibroids in this current study were 5.53cm, 5.50cm and 5.82cm respectively, pur- porting that comparatively, the submucosal fibroids were larger, followed by intramural fibroids (Table 2). Similar results have been documented by Verma et al., who also recorded larger submucosal fibroids with a comparative- ly higher mean diameter of 8.2cm, but contrary to ours, their subserosal fibroids were the next largest.29 This could be due to the tendency of submusosal fibroids to grow bigger and even invade further into the uterine lay- ers. A study by Bettocchi et al., reported that submuco- sal myomas can grow larger and infiltrate deeper into the uterine tissues, thereby posing a greater threat to fertility and making removal more difficult.30 Hence, from this present study, the relatively smaller submucosal fibroids is a good finding with regards to fertility outcomes and ease of surgical intervention. The two top anatomical positions of intramural fibroids were at the anterior part of the uterine body (29.29%), and posterior part of the uterine body (22.54%), whilst the subserosal fibroids were most commonly positioned at the fundal region of the uterus (32.53%) and anterior part of the body (30.50%). In the study by Oliveira et al., the authors recorded the majority of intramural and sub- serosal fibroids at the fundus with comparatively higher proportions of 68.0% and 66.0% respectively.28 The oc- currence of the anatomical locations of fibroid nodules in our setting may not have dramatic implications on fer- tility outcomes and make surgical intervention like HIFU ablation easier. 447African Health Sciences, Vol 23 Issue 4, December, 2023 Unlike the intramural and subserosal fibroids which were more common in the comparatively younger age catego- ry (25-34 years) constituting 40.36% and 45.71% respec- tively, the submucosal fibroids recorded high prevalence in the late reproductive age group (35-44 years, 39.29%). This also reflected in the comparatively higher mean age for the submucosal fibroids as against the subserosal and intramural fibroids. The average age for submucosal fi- broids was 38.55±9.16 years in this paper. Verma et al., reported a higher submucosal fibroid mean age of 42 years.29 We found that posterofundal fibroids (Figure 3) and my- omas at the lower part of the anterior wall were more frequent in the 35-44 years age class, whilst the rest were predominantly in the 25-34 years group, both within the active reproductive age of women (15-49 years), which is in agreement with the pertinent literature.31 Small fibroids (<5cm) were comparatively more common in the young- er age group (<35 years), also corroborated by Sarkodie et al.22 Generally, the sizes of fibroids (in diameter) increased with age (Figure 1), as reported in literature.31 The ma- jority of the fibroids ≥5cm were at the anterior wall of the uterus, also corroborated by Shavell et al., in Detroit, USA. The authors further reported that such myomas (≥5cm) are commonly and significantly associated with preterm delivery, premature rupture of membranes, and short cervix coupled with high blood loss with requi- site postpartum blood transfusion and attention.32 Even though numerous treatment options for fibroids are available based on the symptomatologies, locations, num- bers, and sizes, they are limited for pregnant women, as some treatment alternatives may not be appropriate. For instance, prophylactic myomectomy is not recommended for pregnant women with fibroid size >5cm owing to its conferment of worse outcomes at delivery.33 Also, bio- chemical evidence generally suggests that the differences in oestrogen receptor densities in the different types of fibroids and the endometrium determines the frequen- cy and distribution of the various types. Oestrogens up- regulate oestrogen dependent growth of uterine fibroids while progesterone down regulates these actions after the cell mutations underlying their tendencies to over prolif- erate, have been established. The future holds promise for using hormonal manipulations for controlling the growth of uterine fibroids especially as the incidence rate is in- creasing in our setting as reported in a current study.34,35 Limitation The sample size for this study could have been under-es- timated because patients whose information were not found on the LHIMS were not included. Conclusion The majority of the uterine fibroids were intramural and mostly at the anterior uterine wall. Even though the sub- mucosal fibroids were less common, they were averagely larger than the other types of uterine myomas and mostly seen at the central uterine fundus. The diameters of uter- ine fibroids increased with age. Fibroid nodules less than 5cm were mostly at the anterior uterine body whilst those greater than 10cm were common at the posterior uterine body. Ethical consideration The committee for ethical review of our hospital gave ap- proval for this research to be carried out, with clearance number, CCTHERC/EC/2020/097. Confidentiality and anonymity were maintained throughout the study. This study conformed to the revised 2013 Declaration of Hel- sinki. Competing interests The authors have no competing interests to declare. Data availability statement Access to the data used for this paper could be made available upon a formal request to the director of re- search, CCTH through the email address: ccthresearch@ gmail.com. Funding information No external funding was secured for this research Acknowledgment We are thankful to the management and staff of the re- cords and Ultrasound scan units of CCTH for their sup- port in making this study successful. 448 African Health Sciences, Vol 23 Issue 4, December, 2023 References 1. Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynecol Obstet. 2020; 149(1):3-9. https://doi.org/10.1002/ijgo.13102 2. Sparic R, Mirkovic L, Malvasi A, Tinelli A. Epidemiol- ogy of uterine myomas: a review. Int J Fertil Steril. 2016; 9(4):424. https://doi.org/10.22074/ijfs.2015.4599 3. Hartmann KE, Fonnesbeck C, Surawicz T, et al. Evi- dence Summary. InManagement of Uterine Fibroids [In- ternet] 2017 Dec. Agency for Healthcare Research and Quality (US). Available from: https://www.ncbi.nlm.nih. gov/books/NBK537747/ 4. Edzie EKM, Dzefi-Tettey K, Brakohiapa EK, Abdulai AB, Kekessie KK, Aidoo E, et al. Assessment of the clin- ical presentations and ultrasonographic features of uter- ine fibroids in adult Africans: A retrospective study. Oman Med J. 2023 Jan 1;38(1):1-0. https://doi.org/10.5001/ omj.2023.36 5. Woźniak A, Woźniak S. Ultrasonography of uterine leiomyomas. Menopause Review. 2017; 16(4):113. https:// doi.org/10.5114/pm.2017.72754 6. Edzie EKM, Dzefi-Tettey K, Gorleku PN, et al. Evalu- ation of the clinical and imaging findings of breast exam- inations in a tertiary facility in Ghana. Int J Breast Cancer. 2021; 2021. https://doi.org/10.1155/2021/5541230 7. Testa AC, Di Legge A, Bonatti M, Manfredi R, Scambia G. Imaging techniques for evaluation of uterine myomas. Best Pract Res Clin Obstet Gynaecol. 2016 Jul 1; 34:37-53. https://doi.org/10.1016/j.bpobgyn.2015.11.014 8. Zepiridis LI, Grimbizis GF, Tarlatzis BC. Infertili- ty and uterine fibroids. Best Pract Res Clin Obstet Gynae- col. 2016; 34:66-73. https://doi.org/10.1016/j.bpo- bgyn.2015.12.001 9. McLucas B. Diagnosis, imaging and anatomical clas- sification of uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2008; 22(4):627-42. https://doi.org/10.1016/j. bpobgyn.2008.01.006 10. Abdelmtalab MA, Tahir O, Hussein K, Badawi K. An- atomical locations of uterine fibroids in Sudanese women. Anat J Afr. 2020; 9(1):1701-6. https://doi.org/10.4314/ aja.v9i1.6 11. Abdelmotalab MA. Anatomical Locations & Types of Uterine Fibroids and their Impact on the Clinical Presentation. Clin Obstet Gynecol. 2017. Available from: http://repository.ribat.edu.sd/public/uploads/upload/ repository/anatomical%20locations%20&%20types%20 of%20uterine%20fibroids_269444817.pdf 12. Lee HJ, Norwitz ER, Shaw J. Contemporary manage- ment of fibroids in pregnancy. Rev Obstet Gynecol. 2010; 3(1):20. https://doi.org/10.3909/riog0101 13. Cortellaro F, Perani C, Guarnieri L, et al. Point-of- care ultrasound in the diagnosis of acute abdominal pain. Oper Techniques and Recent Adv Acute Care and Emerg Surg. 2019 (pp. 383-401). Springer, Cham. https://doi. org/10.1007/978-3-319-95114-0_27 14. Zhang Y, Hua KQ. Patients' age, myoma size, myoma location, and interval between myomectomy and preg- nancy may influence the pregnancy rate and live birth rate after myomectomy. J Laparoendosc Adv Surg Techn. 2014; 24(2):95-9. https://doi.org/10.1089/lap.2013.0490 15. Brady PC, Stanic AK, Styer AK. Uterine fibroids and subfertility: an update on the role of myomectomy. Curr Opin Obstet Gynecol. 2013; 25(3):255-9. https://doi. org/10.1097/GCO.0b013e3283612188 16. Kelly Burch. What Is an Intramural Fibroid? 2022. Verywell Health. Available from: https://www.verywell- health.com/intramural-fibroid-5189297 Cited April 7, 2022. 17. Moshesh M, Peddada SD, Cooper T, Baird D. In- traobserver variability in fibroid size measurements: es- timated effects on assessing fibroid growth. J Ultrasound Med. 2014; 33(7):1217-1224. https://doi.org/10.7863/ ultra.33.7.1217 18. Dayal S, Kumar A, Verma A. Clinicopathologic cor- relation of leiomyoma with clinical findings and second- ary changes in a rural population of north India. Am J Clin Pathol. 2014; 141(2):275-9. https://doi.org/10.1309/ AJCPSLMZ1TOC4JCF 19. Padubidri VG, Daftary SN. Fibromyomas of the uter- us. In: Howkins & Bourne Shaw’s Textbook of Gynae- cology. 12th ed., New Delhi, India: Churchill Livingstone; 1999; 275–285. Available from: https://books.google. com.gh/books?id=t8AVzCg05QYC 20. Liu Y, Wu X, Wu A, Gong C, Wang Z, Zhang L. Ul- trasound-guided high intensity focused ultrasound abla- tion for uterine fibroids: long-term outcomes and fac- tors affecting local recurrence. Int J Hyperthermia. 2021; 38(1):1341-8. https://doi.org/10.1080/02656736.2021.1 973585 21. Adesina KT, Owolabi BO, Raji HO, Olarinoye AO. Abdominal myomectomy: A retrospective review of de- terminants and outcomes of complications at the Univer- sity of Ilorin Teaching Hospital, Ilorin, Nigeria. Malawi Med J. 2017; 29(1):37-42. https://doi.org/10.4314/mmj. v29i1.8 449African Health Sciences, Vol 23 Issue 4, December, 2023 22. Sarkodie BD, Botwe BO, Ofori EK. Uterine fibroid characteristics and sonographic pattern among Ghana- ian females undergoing pelvic ultrasound scan: a study at 3-major centres. BMC Women’s Health. 2016; 16(1):1-6. https://doi.org/10.1186/s12905-016-0288-4 23. Baird DD, Saldana TM, Shore DL, Hill MC, Schect- man JM. A single baseline ultrasound assessment of fi- broid presence and size is strongly predictive of future uterine procedure: 8-year follow-up of randomly sampled premenopausal women aged 35–49 years. Hum Reprod. 2015; 30(12):2936-44. https://doi.org/10.1093/hum- rep/dev235 24. Ciavattini A, Clemente N, Delli Carpini G, Di Gi- useppe J, Giannubilo SR, Tranquilli AL. Number and size of uterine fibroids and obstetric outcomes. J Maternal-Fe- tal Neonatal Med. 2015; 28(4):484-8. https://doi.org/10.3 109/14767058.2014.921675 25. Guo XC, Segars JH. The impact and management of fibroids for fertility: an evidence-based approach. Obstet Gynecol Clin. 2012; 39(4):521-33. https://doi. org/10.1016/j.ogc.2012.09.005 26. Deipolyi A. MRI enhancement predicting fibroid volume reduction to uterine artery embolization. Front Womens Health. 2017; 2(2):1-3. https://doi.org/10.15761/ FWH.1000128 27. Katsumori T, Akazawa K, Mihara T. Uterine ar- tery embolization for pedunculated subserosal fibroids. Am J Roentgenol. 2005; 184(2):399-402. https://doi. org/10.2214/ajr.184.2.01840399 28. Oliveira FG, Abdelmassih VG, Diamond MP, Do- zortsev D, Melo NR, Abdelmassih R. Impact of subse- rosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fer- tilization–intracytoplasmic sperm injection. Fertil Ster- il. 2004; 81(3):582-7. https://doi.org/10.1016/j.fertn- stert.2003.08.034 29. Verma SK, Bergin D, Gonsalves CF, Mitchell DG, Lev-Toaff AS, Parker L. Submucosal fibroids becoming endocavitary following uterine artery embolization: risk assessment by MRI. Am J Roentgenol. 2008; 190(5):1220-6. https://doi.org/10.2214/AJR.07.3312 30. Bettocchi S, Siristatidis C, Pontrelli G, et al. The destiny of myomas: should we treat small submucous myomas in women of reproductive age? Fertil Steril. 2008; 90(4):905- 10. https://doi.org/10.1016/j.fertnstert.2007.09.015 31. Zimmermann A, Bernuit D, Gerlinger C, Schaefers M, Geppert K. Prevalence, symptoms and management of uterine fibroids: an international internet-based survey of 21,746 women. BMC Women's Health. 2012; 12(1):1-1. https://doi.org/10.1186/1472-6874-12-6 32. Shavell VI, Thakur M, Sawant A, et al. Adverse ob- stetric outcomes associated with sonographically identi- fied large uterine fibroids. Fertil Steril. 2012; 97(1):107-10. https://doi.org/10.1016/j.fertnstert.2011.10.009 33. Pritts EA, Olive DL. When should uterine fibroids be treated? Curr Obstet Gynecol Rep. 2012; 1(2):71-80. https:// doi.org/10.1007/s13669-012-0010-y 34. Englund K, Blanck A, Gustavsson I, et al. Sex steroid receptors in human myometrium and fibroids: chang- es during the menstrual cycle and gonadotropin-releas- ing hormone treatment. J. Clin. Endocrinol. Metab. 1998; 83(11):4092-6. https://doi.org/10.1210/jcem.83.11.5287 35. Edzie EKM, Dzefi-Tettey K, Brakohiapa EK, Quarshie F, Ken-Amoah S, Cudjoe O, et al. Age of first diagnosis and incidence rate of uterine fibroids in Gha- na. A retrospective cohort studies. Plos One. 2023 Mar 16;18(3): e0283201. https://doi.org/10.1371/journal. pone.0283201 450 African Health Sciences, Vol 23 Issue 4, December, 2023