Assessment of Health-care Professional’s Knowledge Regarding the Comorbidities of Vitamin D Deficiency and its Relationship with Uterine Fibroids

1. INTRODUCTION

Vitamin D is crucial for calcium balance, metabolic functions, and immune system modulation. Its deficiency is associated with an elevated risk of non-skeletal chronic diseases such as autoimmune conditions, cardiovascular issues, and certain cancers, emphasizing its pivotal role in overall health [1].

Results of a study indicated that elevated serum vitamin D levels are strongly linked to a reduced risk of uterine fibroids (UFs), offering a promising new option for clinical treatment [2].

Vitamin D is generated in the human skin by the photochemical conversion of 7-dehydrocholesterol to cholecalciferol (vitamin D3). Subsequently, vitamin D3 undergoes metabolism to form 25-hydroxyvitamin D (25(OH)D), the primary storage and circulating form. Further transformation to the hormonal form, 1,25-dihydroxyvitamin D, occurs through hepatic and renal enzymes [3].

The worldwide prevalence of vitamin D deficiency is currently characterized as an epidemic and a significant public health concern in numerous regions. Despite the sunny conditions in the Middle East, the region continues to grapple with a high incidence of hypovitaminosis D [4].

Dietary sources of vitamin D, like fatty fish and fortified dairy products, are limited. However, the human body can synthesize vitamin D through direct exposure to sunlight’s ultraviolet B radiation on the skin [5].

The role of vitamin D in the biology and therapy of uterine fibroids has been well investigated [6].

A selective progesterone modulator has received approval for short-term therapy for addressing symptomatic fibroids [7].

The common symptoms associated with leiomyomas include menorrhagia, pelvic pain or pressure, and subfertility. These symptoms vary from one patient to another and do not necessarily correlate to the size of the fibroids. Abdominal-pelvic examination may be normal if the fibroids are small, but most patients with uterine fibroids are asymptomatic and require no treatment [8].

The purpose of this study was directed at:

2. PATIENTS AND METHODS

3. RESULTS

Table 1 revealed that all participants (100%) were female; their mean age was 32 ± 65.3. Nearly most of the participants in the current study were nurses (88.5%), and the remaining (11.5%) were gynecologists. More than three-quarters of them worked in the Maternity Teaching Hospital (77%) while 11.9% and 7.1% worked in Smart Hospital and Faroq Medical City, respectively. 56.7% of them had more than 5 years of experience at the hospital, and 93% and 94.7% of them did not train regarding uterine fibroid and vitamin D deficiency, respectively.

TABLE 1: Socio-demographic data

Table 2 demonstrated that more than half of the participants chose the correct answer in items 1, 7, and 8, while less than half chose the false answer in all other items, but more than half did not know the answer in items 4, 5, and 6.

TABLE 2: Some items regarding age, gender, obesity and uterine fibroid

Table 3 showed that more than half answered correctly in item 1, while only 15.9% (11%) answered correctly in items 4 and 6, which are negative questions. Only 58.4% (69.9%) of them chose the correct answer in items 2 and 9, respectively.

TABLE 3: Some items regarding reproductive factors and uterine fibroid

Table 4 indicated that more than half of the participants chose the correct answer in items (1, 2, 3, 5.a., 5.b., 5.d., 5.e., 5.f.).

TABLE 4: Some items regarding the relation between lifestyle, diet and vitamin D

Table 5 demonstrated that more than half of the participants answered correctly on all items except item 8, which dealt with the fact that uterine fibroids do not interfere with ovulation but impair fertility.

TABLE 5: Some statements regarding signs and symptoms of uterine fibroid

Table 6 revealed that more than half of the participants chose the correct answer only in items 1.a., 1.I., and 4.a., and nearly a quarter of them chose the false answer in items 1.b., 1.m., 1.n., and 2.

TABLE 6: Some facts regarding deficiency, signs and symptoms and interaction of vitamin D with some medications

Figure 1 showed that nearly a quarter of the health-care professionals (74.3%) had a medium level of knowledge about uterine fibroid and vitamin D deficiency, while only 24.8% of them had a high level of knowledge.

Fig. 1. Level of knowledge of the participants regarding uterine fibroid and vitamin D deficiency.

Table 7 explores that the level of knowledge was significantly associated only with the position of participants and level of education, at P < 0.05.

TABLE 7: Association between the level of knowledge and some socio-demographic data

4. DISCUSSION

The purpose of the present study is to analyze the health-care professionals about the association between uterine fibroid and vitamin D insufficiency in one government and two private hospitals in Sulaimani city. The great thing is that the current study is the first to analyze the health-care providers relating about uterine fibroid and vitamin D deficiency among Kurdish employees’ women in the Kurdistan area of Iraq. A study by Guo et al. [2] demonstrated that a significant correlation has been established between a deficiency in vitamin D and the development of leiomyomas.

Therefore, administration of vitamin D3 may decrease the size of fibroids [9]. It seems that vitamin D supplementation is an effective strategy to treat it.

Regarding socio-demographic data, the current study showed that all participants were female. More than half of them were government employees, married, nearly half of them had (1-3) children, less than a quarter of them were gynecologists, and the majority of them were nurses’ staff. Among this, nearly half of the nurses graduated from the Institute of Nursing, and more than half of them had more than five years of experience at the hospital. Nearly all of them lived in urban regions. Nearly all of them did not participate in training courses regarding uterine fibroid and vitamin D deficiency and their comorbidities.

However, knowledge is indispensable for health-care professionals, as underscored in the influential study by Sharif et al. [10]. This research highlights the crucial role of knowledge, especially for nurses, who, being closest to patients, play a vital part in reducing stress and anxiety through education.

However, the importance of knowledge is described in many studies; one of them is the study of Sharif et al. [10], which mentioned that knowledge plays a crucial role for health-care professionals in general, especially for nurses, because the nurses are the nearest person for the patients to teach them and decrease their stress and anxiety from their diseases.

Table 2 in the current findings revealed that more than half of the participants selected the correct answer (true) in items that deal with (genetic predisposition to leiomyomas, weight loss is associated with a decreased risk of uterine fibroids in women, and uterine fibroids are linked to visceral fat, but there’s no significant association with subcutaneous fat thickness. On the other hand, the same table in the present study indicated that more than half of the participants did not know the answer to the items that were explained (fibroid risk is lower for white women compared to black women, black women are diagnosed with fibroids earlier, they often experience multiple, larger fibroids with more severe symptoms than other ethnic groups, and black women are over twice as likely to have a hysterectomy). Less than half of them chose the correct answer in the variables: myomas occur rarely before puberty, their frequency decreases with menopause, and the rate of hospitalization for uterine leiomyomas increases with age. Actually, women of reproductive age have a considerably higher prevalence of uterine fibroids. This is owing to hormonal changes in females that lead to the tumor’s origin. Estrogen and progesterone contribute to the progression and promotion of uterine fibroids [11]. It has increased with age during the reproductive years, reducing after menopause [12]. Especially, as noted, occur in black females [13]. Obesity is responsible for an increase in the conversion of adrenal androgens to estrogen and a lower hepatic synthesis of sex hormone-binding globulin, resulting in more unbound active estrogen. Thickness, or the expression of visceral fat, was connected with the existence of fibroids, but subcutaneous fat thickness was not substantially associated with the disease [14].

Regarding the items it deals with (there is a strong relationship between late age at menopause and risk for fibroids, and at the fibroid level, the number of progesterone receptors is elevated), less than a quarter replied properly, which is the (false) answer. More than half of them pick the correct answer in the items that are discussed (breastfeeding has been found to have little to no influence on fibroid incidence, and the use of oral contraceptives is the risk factor for the incidence of uterine leiomyoma). During the menopause stage, the levels of key hormones are altered. For instance, follicle-stimulating hormone levels start to climb gradually, marking the end of reproductive years, whereas estrogen and progesterone gradually decrease [15]. According to a Chinese study by Ying et al. [16], which revealed that women of childbearing age with more than an equal body mass index and use of oral contraceptives are at risk of uterine leiomyoma.

Table 3 in the present study showed that less than half of the participants answered correctly regarding the items of polycystic ovary syndrome [PCOS] which is associated with a higher incidence of fibroids, both in women receiving estrogens only and in those receiving combined therapy. A correlation with the growth of fibroids is shown, but more than half of them answered correctly about the use of oral contraceptives as a risk factor for the incidence of uterine leiomyoma.

Low 25-hydroxyl vitamin D (25(OH)D) levels have been connected with endocrine disturbances in PCOS women. Moreover, vitamin D might alter the steroidogenesis of both estradiol and progesterone in healthy women, where low levels of 25(OH)D might be associated with infertility [17]. The usage of oral contraceptives and a body mass index >25 kg/m² were the risk factors for the occurrence of uterine leiomyoma in Chinese women of reproductive age [16].

The outcomes of the current study showed that more than half of the participants chose the correct response regarding vitamin D in items that talk about (vitamin D is a fat-soluble vitamin, physical inactivity is involved in fibroids development and growth, deprivation of some diets rich in vitamin D is involved in fibroids development and growth, and foods rich with vitamin D such as fish oil, liver, milk, and eggs, some fish such as salmon, sardine, and tuna, alcohol consumption, and caffeine consumption. Whereas, less than half answered correctly concerning the involvement of stress in fibroids development and childhood exposure to physical, sexual, and emotional abuse). However, the incidence of clinical fibroids among premenopausal women is increasing due to the chronicity and severity of child and teenager physical and sexual abuse [18]. Although fewer than nearly half of them answered erroneously regarding this subject (49.6%).

Age is a crucial non-modifiable risk factor for fibroid development, with diagnoses peaking at 50 years. Myomas do not occur before puberty and decrease with menopause. The development and growth of fibroids appear to be influenced by various modifiable risk factors, including physical inactivity, stress, and caffeine consumption. Regular exercise may protect against fibroids by lowering sex hormones, insulin, and circulating estrogen while increasing sex hormone-binding globulin levels. Women who exercise regularly have a lower risk of fibroids compared to those who don’t. Stress is a potential factor in fibroids risk. Childhood abuse, including physical, sexual, and emotional abuse, increases leiomyoma risk, while supportive relationships can mitigate this. Stressful experiences are also linked to a higher body mass index and obesity [14]. Women 35 years of age in the highest risk categories of caffeinated coffee (≥3 cups/day) and caffeine intake (≥500 mg/day) were both associated with higher fibroid risk [19]. As well, a study found a positive link between event frequency and fibroid prevalence, especially in white women. Socioeconomic adjustments slightly reduced the effect. Stress intensity was correlated with fibroids in white women across all stress levels, compared to those without such experiences [20].

Concerning uterine fibroid, more than half of the participants accurately responded to variables regarding (uterine fibroid is a benign tumor of the uterus, the symptoms and treatment of fibroids are depending on the location of the fibroid, the main causes of uterine fibroids are unknown, most women who have uterine fibroids do not have any symptoms, fibroids that occur near the uterine lining can cause heavy or painful periods, longer periods, or spotting at other times, and large fibroids may cause pelvic pain and pressure on the bladder (causing frequent urination or blocking urination) but less than half of them were answered correctly regarding the item of (fibroids do not interfere with ovulation but impair fertility). The researchers returned this result to the lack of participation of health-care workers in training courses regarding uterine fibroid and vitamin D deficiency. As the current study detected, almost all of the participants did not participate in the training courses regarding vitamin D deficiency and uterine fibroid.

The present study revealed some diseases that are due to deficiency of vitamin D, such as lack of absorption of calcium and phosphorus by the intestine, autoimmune diseases, multiple sclerosis, hypertension, cardiovascular diseases, cancer, diabetes mellitus (DM), bacterial vaginosis, increased risk of respiratory infection, asthma, and schizophrenia for maternal health, osteomalacia and osteoporosis, miscarriage, preeclampsia, and gestational DM.

A study by Andersen et al. [21] demonstrated that there is a relationship between 25(OH)D and first-trimester miscarriages, indicating vitamin D as a modifiable risk factor for abortion. A study indicated that vitamin D receptors are located in many different tissues, e.g., the brain, prostate, and immune system organs. Vitamin D is considered to lessen the risk of various chronic diseases, among them diabetes, cardiovascular diseases, and multiple sclerosis. Vitamin D has been proposed to reduce the incidence of breast, prostate, and colorectal cancers, presumably due to better regulation of cell differentiation, angiogenesis suppression, and apoptosis promotion [22].

Another study supported the idea that vitamin D is responsible for boosting intestinal absorption of calcium and phosphate, which is directly related to the preservation of the proper structure and function of the skeletal system. Vitamin D insufficiency is often linked to diabetes, cancer, and autoimmune illnesses [23]. Recently, vitamin D was suggested to prevent and treat autoimmune disorders such as rheumatoid arthritis, type 1 diabetes, and multiple sclerosis [24]. Vitamin D may inhibit uterine fibroid cells and reduce lesions, making it a potential anticancer agent. Vitamin D deficiency has been linked to uterine fibroids [25]. An observational British birth study found a linear connection between serum 25OHD content and a decreased risk of acute respiratory tract infection [26]. Many epidemiological studies link schizophrenia to vitamin D deficiency. In particular, two major studies linked infant vitamin D insufficiency to schizophrenia risk [27]. Vitamin D deficiency is linked to bacterial vaginosis and may explain its high racial inequality [28]. Preeclampsia women and their newborns had increased rates of 25(OH)D deficiency, while obesity did not affect levels. Obese pregnant women gave their fetuses less 25(OH)D [29]. The normal vitamin D range is 50–125 nmol/L [30]. The World Health Organization divided women into three groups based on 25-hydroxy vitamin D3 levels:

Regarding the signs and symptoms of vitamin D toxicity, which are nausea, vomiting, pancreatitis, and vascular calcinosis, more than half of the health-care professionals did not respond with the correct answers. Whereas hypercalcemia can cause acute pancreatitis if vitamin D levels are too high [33]. Vitamin D intoxication causes nausea and vomiting [34]. Concerning the interaction of some drugs with vitamin D supplements, such as cholesterol-lowering agents such as atorvastatin, thiazide diuretics, and steroids such as prednisone, nearly three-quarters of them did not answer correctly. A study demonstrated that thiazide diuretics are used to treat blood pressure, edema, and kidney stones in hypercalciuria patients, but vitamin D supplementation may cause or worsen hypercalcemia. Prednisone, hydrocortisone, and dexamethasone are used for adrenal replacement, immunological suppression, and chemotherapy. Osteoporosis is a common corticosteroid side effect. Vitamin D metabolism changes may be a mechanism [35]. Activated and complicated, vascular calcification causes arterial and pulse wave velocity stiffness by depositing calcium in artery walls. Finally, cardiovascular illness diminishes artery elasticity and changes cardiovascular hemodynamic parameters, causing morbidity and mortality. End-stage arterial hypertension, cardiac hypertrophy, ischemic heart disease, or peripheral arterial disease dramatically increases mortality in people over 55. Calcium deposits in vessel walls are a major risk factor for severe ischemia episodes [36].

Concerning the level of knowledge of the participants regarding uterine fibroid and vitamin D deficiency, the present study showed that nearly a quarter of them had a high level of knowledge, while nearly three-quarters of them had a medium level of knowledge.

The findings were communicated to health-care professionals who did not actively participate in training courses regarding uterine fibroid and vitamin D deficiency. It’s noteworthy that the predominant demographic in the data comprised nurses. However, around 25% of them had employment spans falling within the years 1998-2003, and over half had accumulated more than five years of experience in the department where they conducted vitamin D investigations.

Regarding the association between the level of knowledge and some socio-demographic data, there was no significant association between the level of knowledge and socio-demographic data except level of education and position of health-care professional (0.02, 0.02), respectively.

Nurses enhance medical teams by sharing information with patients, including discussions about expectations for quality of life. They must show understanding of patients’ needs, communicate effectively using understandable language, and maintain awareness of boundaries in patient interactions [37]. The researchers identified a problem where health-care professionals, lacking sufficient knowledge, faced challenges instructing and educating patients, resulting in complications for the patients. Therefore, this study suggests to the Ministry of Health in the Kurdistan Region of Iraq an increased focus on enhancing the scientific expertise of medical personnel. This can be achieved through their participation in training courses, seminars, workshops, and conferences, elevating their ability to provide practical and scientifically informed patient care.

5. CONCLUSION

In summary, the study showed that the risk of vitamin D deficiency leads to many comorbidities and diseases, including uterine fibroid. As well, the results of the current study indicated that nearly three-quarters of the participants had a medium level of knowledge and nearly a quarter of them had high-level knowledge, respectively, regarding the comorbidities of vitamin D deficiency and its relationship with uterine fibroids. And the level of their knowledge was only significantly associated with their position and level of education.

6. RECOMMENDATION

Health-care professionals need to participate in training courses, seminars, workshops, conferences, and booklets related to uterine fibroid and vitamin D deficiency in those hospitals that include obstetrics and gynecology departments. Collaboration is essential among health-care professionals, particularly gynecologists, who, due to their extensive knowledge and advanced studies, play a crucial role in partnering with other team members, including nurses.