Racism is finally being recognized as a public health emergency. Racism has a direct impact on public health. We know that racism affects mental health, causes psychological distress, increases stress levels, increases anger and feelings of rage, exacerbates chronic diseases, increases inflammation, increases  maternal and infant mortality rates, and reduces overall health outcomes and life expectancy.  We know that 7.6 percent of black women have heart disease, compared to 5.8 percent of white women. Black women have a 1 in 9 chance of developing breast cancer while white women have a 1 in 8 chance. However, a white woman’s chance of dying from breast cancer is 1 in 37, whereas black women have a 1 in 31 chance of dying from breast cancer. Black women are 77% more likely to die from cervical cancer than white woman. Cervical cancer is completely preventable with regular PAP smears and HPV testing. Premature birth, miscarriages, and infant mortality are all more prevalent in black women. And, fibroids are 3x more common in black women. I learned all of this in medical school and, while I always knew these statistics, I never dug too deep in trying to understand why. This article is going to focus specifically on fibroids and my own research in trying to understand why black women are more likely develop fibroids compared to other races.

What are fibroids?

Fibroids are noncancerous tumors that develop within the muscle tissue of the uterus. For many women, they never cause a problem. For other women, depending on the size and location of the fibroids, they can cause pain, heavy bleeding, and miscarriages. They can also grow out from the uterus and affect the bladder and/or GI tract leading to urinary and gastrointestinal issues. Fibroids are generally stimulated to grow in the presence of estrogen so are most prevalent during the reproductive years and often shrink in menopause, however they are less likely to regress in menopause for black women.

Racial Discrepancies of Fibroids

• Black women are 3x more likely to develop fibroids than white women.
• Black women are more likely to develop them at a younger age.
• Black women are more likely to have bigger fibroids.
• Black women are more likely to have more significant symptoms from the fibroids (this is likely secondary to having larger fibroids).
• The rate of hospitalization for fibroids is 3x higher for black women than white women.
• Black women are 3x more likely to undergo hysterectomy (removal of the uterus) for fibroids, despite less invasive options.
• Black women are 7x more likely to have a myomectomy (surgical removal of a fibroid) than white women.
• Black women needing surgeries are less likely to have laparoscopic surgeries which is less invasive process of removing the uterus.
• Blood transfusions related to fibroid surgery are higher in black women than white women.

How Fibroids Affect Women

• Heavy or prolonged periods leading to anemia which contribute to fatigue, brain fog, and shortness of breath.
• Painful menstrual cramps
• Painful ovulation
• Passage of clots during menses
• Interference with daily and social activities
• Missed days of work
• Painful intercourse

Why are Fibroids More Common in Black Women?

There is not a clear answer nor is there a lot of research to date looking at understanding why black women develop fibroids more than white women. But there is data that does suggest certain triggers:

• Genetics: There is a genetics contribution to the development of fibroids in black women. But genetics alone do not explain everything. We know through epigenetics that the expression of genes is dictated by our environment.
• Vitamin D: Data suggests that low levels of Vitamin D increase the likelihood of developing fibroids. Black women tend to have lower levels of Vitamin D due to the increased melanin in their skin which reduces the body’s ability to produce Vitamin D.  I would also argue that due to health care disparities between black and white women, black women may be less likely to be screened for vitamin D deficiency.
• Stress: Stress can lead to fibroid growth due to changes in estrogen and progesterone levels caused by the stress activation of the hypothalamic pituitary adrenal axis (HPA Axis) and the subsequent release of the stress hormone cortisol. There have been studies that showed that the stress from racial discrimination increases risk of developing fibroids.
• Inflammation: Inflammation contributes to fibroid growth. Prolonged stress alters the effectiveness of cortisol to regulate the inflammatory process, leading to more inflammation, more inflammatory cytokines, and greater likelihood of fibroid growth development.
• Environmental triggers: Chemicals in plastics and personal care products mimic estrogen in the body and can contribute to greater estrogen stimulation and the growth of fibroids. Hair products are a controversial one but worth mentioning. Many black women and men have been encouraged to look as European as possible with “neat” and straight hair. The chemicals in most of these products are endocrine disruptors and can promote fibroid growth. There has been numerous accounts of black men and women being discriminated against because of their natural hair.  This has led to the CROWN Act being first passed in California in 2019  which protects against discrimination against braids, twists, and locks. 
• Black women are also more likely to experience symptoms longer before seeking treatment. The larger fibroids grow,  the more challenging they can be to treat with natural methods.

It is time to acknowledge the role of racism in medicine and how, while many physicians and health care providers do not consider themselves racist, we do operate in an inherently racist system. Despite our best efforts, our medical system is faced with the reality that there is worse health outcome in black women in nearly all areas of health. Those of us in the medical field are responsible for shattering structural racism in health care. It is not enough to just be respectful; we need to research and appreciate the differences in health care to black women. We need to support more black women in the medical field, and we need to continue to do what is right, not just what is easy