PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
DISSERTATION PROPOSAL
“A STUDY TO ASSESS THE KNOWLEDGE REGARDING MANAGEMENT OF FIBROID UTERUS AMONG III YEAR BSC NURSING STUDENTS IN SELECTED NURSING COLLEGES OF TUMKUR WITH A VIEW TO DEVELOP INFORMATION BOOKLET.”
SUBMITTED BY:
Mrs. AMRINA PASHA
IST YEAR M.Sc. NURSING,
OBSTETRICS AND GYNAECOLOGY NURSING
ARUNA COLLEGE OF NURSING
RING ROAD, MARLUR, TUMKUR.
(2012-2013).
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA
ANNEXURE-II
SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / NAME OF THE CANDIDATE AND ADDRESS / MRS. AMRINA PASHAARUNA COLLEGE OF NURSING
RING ROAD, MARLUR
TUMKUR
2. / NAME OF THE INSTITUTE / ARUNA COLLEGE OF NURSING
3. / COURSE OF STUDY AND SUBJECT / 1ST YEAR M.SC NURSING
OBSTETRICS AND GYNAECOLOGY NURSING
4. / DATE OF ADMISSION TO THE COURSE / 26-06-2012
5. / TITLE OF THE TOPIC / “A STUDY TO ASSESS THE KNOWLEDGE REGARDING MANAGEMENT OF FIBROID UTERUS AMONG III YEAR B.SC NURSING STUDENTS IN SELECTED NURSING COLLEGES OF TUMKUR WITH A VIEW TO DEVELOP INFORMATION BOOKLET”
6. BRIEF RESUME OF THE INTENDED WORK
6.1 INTRODUCTION
‘‘A woman's health is her capital’’
“Harriet Beecher”
Fibroids are the most common benign tumours in females and typically found during the middle and later reproductive years. Uterine fibroids are extremely common. As per a study done by Obstetrics and Gynecology clinic in the year 2000, Worldwide about 20-40% women will be diagnosed with fibroid and the incidence is twice more common in black women than white. Prevalence Rate for Uterine fibroid is approximately 1 in 20 or 5.00% or 13.6 million people globally. It appears that African American women are much more likely to develop uterine fibroids. If a prevalence of 50% by 50 years of age is accepted, a large number of women have asymptomatic fibroids.1
As per a study conducted by the National Institute of Health in India about 25% of women in their reproductive years have noticeable fibroids. There are probably many more women who have tiny fibroids that are undetected. Fibroids develop in women between the ages of 30–50years. As per the Country/Region Extrapolated Prevalence Population Estimated to have uterine fibroid in India is 53,253,530 in a total population of 1, 065,070,6072. And also it was observed that in 1000 of the fibroid uterus progresses into malignant lesions in the later stage.2
A study examined the incidence of uterine fibroids and factors that affect the women. The study is a prospective, ongoing cohort study of women in Karnataka done during the year 2004- 2007. The sample for this study was limited to premenopausal women with intact uteri and no reported diagnosis of fibroids before 2004. The study found uterine fibroids in 2,279 women in 76,711 documented person-years (2.97 percent). Factors that affected the prevalence of uterine fibroids included age at first birth, years since last birth, and younger age at menarche. Women who were parous had an incidence risk ratio of 0.7 relative to nulliparous women. Women who had a child less than 5 years of age were less likely to have uterine fibroids than those who had had a child 5 to 9 years previously. Finally, women who were older at menarche were less likely to have uterine fibroids than women who experienced onset of menses at 12 to 13 years. The current use of progestin-only injectables as birth control was associated with a 40 percent reduction in risk. Studies reported high levels of satisfaction on the part of the women assessed, measured at various points in time and along varied scales. They reported a range from 87 percent to 97 percent satisfaction with outcomes.3
Fibroids can also cause a number of symptoms depending on their size, location within the uterus, and how close they are to adjacent pelvic organs. Large fibroids can cause: pressure, pelvic pain, pressure on the bladder with frequent or even obstructed urination, and pressure on the rectum with pain during defecation.4
Abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are near the uterine lining, or interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods or spotting between menses. Women with excessive bleeding due to fibroids may develop iron deficiency anemia. Uterine fibroids that are deteriorating can sometimes cause severe, localized pain.4
Some women with uterine fibroids never have any symptoms. When symptoms do occur, however, ask the client to undergo a pelvic examination and an abdominal ultrasound to determine the size and location of the fibroid. If it is deemed medically necessary, such as when the fibroid continues to grow and experience pain or abnormal bleeding, The health care provider will determine the most appropriate treatment for you based on the age of the client, symptoms and the characteristics of the uterine fibroids.4
Treatment for uterine fibroid depends upon the severity of symptoms, as well as a woman’s age and desire for pregnancy. Options include: Hormones to regulate the menstrual cycle or to reduce symptoms such as oral contraceptive pills, Hysterectomy (removal of the uterus), Hysteroscopic removal of the uterine fibroids using a hysteroscope (instrument to visualize the endometrial cavity),Intrauterine device to release progestin within uterus to stop bleeding and pain, Myomectomy (surgical removal of the fibroids),Pain control medications, such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol)Uterine artery embolization (procedure that interrupts the blood supply to fibroids).4
6.2 NEED FOR THE STUDY
A randomly selected sample of 35-49 year-old women members of the George Washington University Health Plan were invited to participate in the study. Nearly 1,500 women participated in the initial enrollment and screening during 1996-1999. Postmenopausal women were interviewed about prior diagnoses of fibroids, and premenopausal women were screened for fibroids with pelvic ultrasound (transvaginal and transabdominal). Extensive information was collected by telephone interview and self-administered questionnaires. Premenopausal women were asked to maintain a seven-week prospective menstrual diary and to make a clinic visit at which time blood was drawn. Weight, waist and hip circumference, and blood pressure were measured.
Premenopausal women were followed by telephone interview for new diagnoses of fibroids, symptom change and treatment decisions. The first follow up was conducted in 2001-02 and the final follow-up, in 2004-05.
Uterine leiomyomata, also known as fibroids, are the leading indication for hysterectomy in the United States. Despite the morbidity and high medical costs associated with fibroids, there has been little epidemiologic study of this condition. These benign tumors are hormone-dependent, develop after puberty and regress after menopause. Both estrogen and progesterone are considered important stimulants, or at least permissive factors for tumor growth. To address the need to understand this condition in order to develop nonsurgical treatments and eventually to prevent the condition, collaborators designed the Uterine Fibroid Study.5
As common as it is, it may remain silent. Majority of women with fibroids are asymptomatic. Sometimes they may only been found by accidental finding. Most of the women especially rural women are unaware about the symptoms of fibroid uterus. Abnormal uterine bleeding is the most common symptom of a fibroid. If the tumors are near the uterine ling or interfere with the blood flow to the lining, they can cause heavy periods, prolonged periods or spotting between menses. Women with excessive bleeding due to fibroids may develop iron deficiency anemia. Uterine fibroids that are deteriorating can cause severe localized pain.
Fibroids can also cause a number of symptoms depending on their size, location within the uterus and how close they are to adjacent pelvic organs. Large fibroids can cause pressure, pelvic pain, and pressure on the bladder with frequent or even obstructed urination, pressure on the rectum with pain during defecation, pain during intercourse.6
Due to the alarming number of women that are affected by fibroids, The Fibroid Treatment Collective offers “Top Ten Things women should know about fibroids”.
1. Uterine fibroids can affect women of all ages, but are most common in women ages 40 -50
2. Depending on size ,location and number of fibroids symptoms will develop.
3. No one is sure why women develop fibroids which affect 40% of women over 35 years in America and have a high rate of incidence among African Americans. There is a possible link between uterine fibroid tumors and oestrogen production.
4. Fibroids are diagnosed with an ultrasound in their Gynecologist’s office. Magnetic Resonance Imaging is also used to determine how fibroids can be treated and provide information about any underlying disease.
5. Uterine fibroids can be treated with surgery including hysterectomy and myomectomy.
6. Approximately 600,000 hysterectomies are performed annually in the United States, about 300,000 due to uterine fibroids.
7. Over 50% of women who get hysterectomies have their ovaries removed, rendering them infertile.
8. Embolization has emerged as the safest, simplest , cost effective way to treat fibroids.
9. Uterine Fibroid Embolization has an overall success rate of 94%.
10. Recurrence after embolization has not occurred. This is one of the major advantages over Myomectomy, where fibroids which have been surgically removed often grow back.7
Treatment’s becomes more challenging, especially in young women who may desire fertility at a later stage, and in view of the fact that many women are starting their families in their mid-thirties when they have a 30% chance of having a fibroid(s). As per a study conducted in India in 2006, 600,00 hysterectomies performed annually in India due to Fibroid uterus and Myomectomy is performed less than 40,000 times. Over 25,000 Uterine artery embolisation have been performed in the country since 1996. The systematic evidence review updated the 2001 Agency for Healthcare Research and Quality's systematic review on the management of uterine fibroids. The research examined 107 research studies conducted on the topic between 2000 and 2006. The report says that there has been woefully little research comparing the risks and benefits of different treatment options and few pharmaceutical options for symptom relief have been studied for long-term effectiveness.8
A retrospective longitudinal study was conducted regarding natural history of fibroids and identify factors that may influence their growth. The study was done on a 122 premenopausal women.72 were nulliparous and 74 had multiple fibroids. The median interval between the initial and final examination was 21.5 months. The mean fibroid volume increased by 35.2% per year. Small fibroids (< 20mm mean diameter) grew significantly faster than larger fibroids (P=0.007).The median increase in size was significantly higher in cases of intramural fibroids (53.2 (interquartile range (IQR), 11.2-217)%than in subserous fibroids (25.1 (IQR, 1.1-87.1)%) and submucous fibroids (22.8(IQR, -11.7 to 48.3)%). The study concluded that fibroids in premenopausal women is influenced by the tumor’s size at presentation.9
A retrospective study regarding evaluating the preference sensitive care decisions. The study was done on a 260 women with fibroid uterus. Correlations tested associations among their preferences, knowledge and treatment decisions by using mailed surveys and interviews. The adjusted response rate was 82%, but only 100 respondents fit all criteria for analysis. 86% felt informed, satisfied and that the decision was consistent with their values. However only 55% of patient could answer at least five of seven fibroid questions correctly. The study concluded that there were knowledge gap between knowledge and decision – preference relationship for this condition.10
The above study shows the prevalence of fibroid uterus in the State and also that a prompt treatment can help faster recovery for which adequate knowledge imparting is necessary. During clinical posting Investigator had seen many patients with fibroid uterus. And they didn’t have adequate knowledge regarding management and complications of uterine fibroid. And further study showed that a very little study has been conducted on this topic. This made aware of the fact that there is a need for providing knowledge regarding management of fibroid uterus, among the III year B.Sc Nursing students of selected Colleges, Tumkur.
6.3 REVIEW OF LITERATURE
Review of literature is a key step in research process. Review of Literature refers to an extensive, exhaustive and systematic examination of publications relevant to the research project it refers to both the activities involved in searching the information on a topic, as well as the actual written report that summarizes the state of the existing knowledge of various abstracting and indexing services.
A study was conducted among 32 patients aged 25- 49 years to determine the effectiveness of uterine artery embolization (UAE) as a primary treatment method in treatment of symptomatic fibroids using ultrasound and MRI. The study concluded that the uterine artery embolization (UAE) is effective for the reduction of fluid volume.11
A study was conducted to assess the management of fibroids based on immunohistochemical studies of their pseudocapsules. Twenty non-pregnant patients underwent laparoscopic intracapsular myomectomies. Samples of the removed fibroids pseudocapsules were analyzed by immunochemical staining for collagen IV, immunohistochemical location of the vascular membrane-bound laminin and quantitative analysis of their images. Based on immunohistochemical findings, the study concluded that the pseudocapsules are essential for optimal muscular healing and myometrial function in future pregnancies.12
Scheurig – Muenkler et al ( 2010) conducted a study to evaluate the safety and outcome of ovarian artery embolization in patients with collateral supply to symptomatic uterine leiomyomata. The study was done on 13 patients with relevant leiomyoma. Perfusion by way of enlarged ovarian arteries underwent additional ovarian artery embolization during the same (N=10) or a second procedure (n=3). Symptoms before therapy and clinical outcome were assessed using a standardized questionnaire. The results showed that median clinical follow –up time was 16 months.10 of 13 patients showed improvement or complete resolution of clinical symptoms.7 patients showed complete and 4 showed >90% fibroid infarction after embolization therapy. The study concluded that ovarian artery embolization is technically safe and effective in patients with ovarian artery collateral supply to symptomatic uterine leiomyomata.13
Gupta JK et al (2010) conducted a study to review the benefits and/or harms from randomized controlled trials of Uterine artery embolization versus other intervention for symptomatic uterine fibroids. Three trials were included in this review. Two randomized control trials compared uterine artery embolization with abdominal hysterectomy in 234 women. The second trial included 63 women comparing uterine artery embolization with myomectomy. The minimum follow-up reported was 6 months with a mean of 17 (+/-9.3) months. The results showed that there is improvement in fibroid related symptoms such as menstrual loss was atleast 85% in the uterine fibroid group from both trials. The mean dominant fibroid volume decreased by 30-40% in two trials. Women undergoing uterine artery embolization resumed routine activities sooner than those undergoing surgery. The study concluded that uterine artery embolization offer an advantage over hysterectomy with regards to a shorter hospital stay and a quicker returns to routine activities.14