





































CAJGH_Template


 

 

New articles in this journal are licensed under a Creative Commons Attribution 4.0 United States License. 

 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

 

 

 

 

 

 

 

 

Comparing the Use of Uterine 

Artery Embolization to 

Gonadotropin-Releasing Hormone 

Agonists in Shrinking Fibroid Size: 

A Pilot Study in Kazakhstan 

 

Balkenzhe Imankulova1, Alibek 

Mereke2, Nazira Kamzaeva1, 

Talshyn Ukybassova1 
 
1Department of Obstetrics and 
Gynecology, National Research Center 
for Maternal and Child Health, National 
Medical Holding, Astana, Kazakhstan; 
2Department of Epidemiology, Graduate 
School of Public Health, University of 
Pittsburgh, Pittsburgh, PA 

 

Vol. 4, No. 1 (2015)   |   ISSN 2166-7403 (online)  

DOI 10.5195/cajgh.2015.232 |   http://cajgh.pitt.edu 

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx
http://creativecommons.org/licenses/by/3.0/us/


 

 

IMANKULOVA 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

Abstract 

Introduction: Uterine fibroids are the most common benign tumor in women in Kazakhstan. In the past two decades, endoscopic 

surgery has played an important role in the development of gynecologic surgery, particularly in the treatment of uterine fibroids. 

The goal of this paper is to evaluate whether uterine artery embolization (UAE) or gonadotropin-releasing hormone agonists 

(GnRHa) prior to myomectomy was more effective in decreasing fibroid size and improving surgical outcomes in a pilot study of 

women in Kazakhstan. 

Methods: This pilot investigation included 24 patients separated into 2 groups: medication group (pre-treatment with GnRHa – 13 

patients) and embolization group (pre-treatment with UAE – 11 patients). All patients had uterine fibroids, 3-10 cm in diameter, 

and were treated with myomectomy at the National Research Center for Maternal and Child Health, Astana, Kazakhstan. All patient 

data were obtained by a retrospective medical records review. Descriptive statistics were utilized to characterize participant 

demographics data. Independent t-tests were used to analyze continuous variables, and Chi-square and Fisher’s exact tests were 

used where appropriate for count data. 

Results: The group treated with GnRHa had an operating time of 40±10 minutes longer than the group treated with UAE, due to 

the peri-operative difficulties encountered by surgeons in detecting the layer between the myometrium and fibroid capsule. The 

group treated with UAE experienced better patient outcomes (less blood loss, less surgical time, and reduced use of anesthesia) and 

was a technically easier surgery due to visible differences in uterine layers. 

Conclusions: Despite the fact that both treatments (GnRHa and UAE) were effective for fibroid shrinking, embolization resulted 

in more optimal surgical time and improved patient outcomes. Results of this pilot study need to be confirmed in a randomized 

clinical trial, specifically focused on Kazakhstan and the Central Asian Region.  

Keywords: fibroids, Kazakhstan, GnRHa, uterine artery embolization 

Comparing the Use of Uterine Artery 

Embolization to Gonadotropin-

Releasing Hormone Agonists in 

Shrinking Fibroid Size:  

A Pilot Study in Kazakhstan 

 

Balkenzhe Imankulova1, Alibek 

Mereke2, Nazira Kamzaeva1, Talshyn 

Ukybassova1 
 
1Department of Obstetrics and Gynecology, 
National Research Center for Maternal and 
Child Health, National Medical Holding, 
Astana, Kazakhstan; 2Department of 
Epidemiology, Graduate School of Public 
Health, University of Pittsburgh, Pittsburgh, 
PA 

Research 

Approximately 20-30% of women worldwide 

over the age of 30 are diagnosed with uterine fibroids.1,2 

Uterine fibroids are the most common benign tumor 

diagnosed in women in Kazakhstan; however, treatment 

of this problem remains a complex and difficult 

challenge. The true prevalence of fibroids is likely to be 

underestimated in Kazakhstan, as access to medical 

facilities, and medical care in general, varies across the 

country. 

Symptomatic fibroids are associated with 

significant morbidity and are typically associated with 

prolonged and heavy periods, pelvic pain, and in some 

cases, reproductive problems.3 Surgical interventions, 

such as hysterectomy or laparotomic myomectomy, used 

to be the primary surgical interventions for uterine 

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx


 

 

CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

fibroids. Other methodologies have been emerging in the 

past several years, such as laparoscopic myomectomy 

and uterine artery embolization (UAE), as well as 

medicinal interventions to reduce the fibroid volume. 

Hysterectomy is a curative approach for fibroid 

management; however, patients of reproductive age are 

in need of interventions that preserve reproductive 

function. With access to proper laparoscopic equipment 

and availability of well trained surgeons, laparoscopic 

surgery is the treatment of choice for symptomatic 

fibroids. Progesterone and its receptors increase the 

proliferation of fibroid cells in the uterus; therefore, 

antiprogestins and progesterone receptor modulators are 

considered reasonable medicinal treatments.2   

Gonadotropin-releasing hormone agonists 

(GnRHa) are commonly used before hysteroscopic 

myomectomy to make surgery easier and safer, but they 

are expensive, have potential side effects, and lack 

evidence based data to support this practice.4 Therapy 

using GnRHa appears to result in a decrease in estrogen 

and progesterone levels, which decrease the size of the 

fibroid While GnRHa do cause fibroid regression, they   .

measures  temporarycan only be used in the short term, as 

to operatively -in the perimenopausal women, or pre

reduce fibroid size before myomectomy.5 The 

disadvantages of using GnRHa reported in the literature 

are the rebound growth of the fibroids upon cessation of 

therapy and major side effects associated with their use.5 

In a previously published systematic review of the 

ues operative GnRH analog-literature on the use of pre

for symptom relief, GnRHa may improve some 

outcomes, but there is insufficient evidence to support 

their routine use prior to hysteroscopic resection of 

submucous fibroids.4 

While GnRHa are typically believed to be 

useful in fibroid reduction,2 our experience (unpublished 

data) suggests that fibroids exposed to agonists have 

deeper myometrium invasion that significantly impairs 

their enucleation during surgery. A previously published 

study suggested that pre-surgical treatment with 

embolization prior to myomectomy has the benefits of 

lowering intra-operative blood loss and increasing 

efficacy of conservative myomectomy.6 Additional 

benefits of UAE include reduction in the volume of 

fibroids and their vascularization, thus reducing surgical 

time. Furthermore, patients undergoing UAE appear to 

have shorter recovery times and fewer clinical symptoms, 

such as pain and fever due to resorption, as well as a 

decrease in uterine size.6,7     

Despite the fact that multiple papers and 

reviews have been published on the efficacy of GnRHa 

and UAE on fibroid reduction, many unanswered 

questions still exist in this area. Also, no studies have 

been conducted in Kazakhstan or Central Asia to 

compare the use of GnRHa to UAE. Thus, our study fills 

a significant gap in the research by comparing the pre-

treatment with uterine artery embolization (UAE) to 

gonadotropin releasing hormone agonists (GnRHa) prior 

to myomectomy in their effectiveness in improving 

surgical outcomes, specifically focusing on women in 

Kazakhstan. 

 

Methods 

This is a retrospective review of 24 clinical 

cases treated at the National Research Center for 

Maternal and Child Health in Astana, Kazakhstan from 

2013-2014. In 2012, this center became one of the first 

clinics in the Commonwealth of Independent States, 

which was accredited by the Joint Commission 

International. This study was limited to women of 

reproductive age with symptomatic fibroids undergoing 

laparoscopic myomectomy. Before myomectomy, all 

women were pre-treated for fibroid volume reduction.  

These 24 cases were divided into two groups, 

medication group and embolization group, which were 

based on the pre-surgical treatment of the fibroids. The 

medication group included 13 women who underwent 

laparoscopic myomectomy after pre-treatment with 

GnRHa on an outpatient basis in domiciliary clinics. 

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx
http://www.jointcommissioninternational.org/
http://www.jointcommissioninternational.org/


 

 

IMANKULOVA 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

GnRHa was injected intramuscularly every 4 weeks for a 

period of 8 weeks (3 doses) prior to surgical intervention. 

Conservative myomectomy was carried out 4 weeks after 

the last injection. The embolization group included 11 

patients who underwent laparoscopic myomectomy 6-12 

months after UAE. UAE was carried out at the National 

Research Center for Maternal and Child Health on an 

inpatient basis. The National Research Center for 

Maternal and Child is a tertiary treatment facility 

specializing in gynecologic and obstetrical conditions. 

UAE procedures have been carried out at the center since 

2008. Because this study was limited to the review of 

medical records, it was exempt from human subject IRB 

review.  Prophylactic antibiotic therapy (cefazolin, 2000 

mg intravenously, 30 minutes before the surgery) was 

administered to all patients, based on standard treatment 

protocol. Patients came for follow-up assessment 6 to 12 

months after the surgery, where vaginal examinations 

and transvaginal uterine ultrasounds were conducted to 

assess fibroid symptoms and reduction. 

Data Analysis  

Descriptive statistics were utilized to 

characterize participant demographics data. Independent 

t-tests were used to analyze continuous variables, and 

Chi-square and Fisher’s exact tests were used where 

appropriate for count data. All analyses were conducted 

in Microsoft Excel.  

 

Results 

Patients treated with GnRHa (medication 

group) had a mean age of 34.2±2.2 years, and patients 

undergoing pre-operative UAE (embolization group) had 

a mean age of 38.6±1.2 years. Twenty-three percent of 

the patients in the medication group complained of 

infertility during the last 4-5 years, where infertility was 

defined as the inability to conceive after at least one year 

of unprotected, regular sexual intercourse. Pelvic pain 

was reported in 38.5% of patients in the medication 

group, and in 54.5% of patients in the embolization group 

(p<0.05) Algomenorrhea was reported in 15.4% of 

patients in the medication group, and in 9.0% of patients 

in the embolization group. Hyperpolymenorrhea was 

reported in 23% of patients in the medication group and 

36.4% of patients the embolization group (p<0.05) 

(Figure 1). 

 

Figure 1. Breakdown of patients’ complaints stratified by 

intervention group 

 

The most common complaints reported by 

patients in the embolization group included pelvic pain 

(54.5%) and hyperpolymenorrhea (i.e. dysfunctional 

uterine bleeding – 36.4%), possibly associated with 

larger fibroids than observed in the medication group. 

Uterine fibroids ranged in size from 3 to 10 cm 

in diameter and were located in the sub-serous and 

intramural layers of the uterus. Based on transvaginal 

ultrasound examinations, the medication group had 

single fibroid nodes located in the fundus of the uterus in 

38.5% of patients, in the anterior wall in 38.5% of 

patients, and in combination of the anterior wall with the 

transition to the fundus (fundal anterior fibroids) 

overlapping fallopian tubes in 23.0% of patients. The size 

of fundal fibroids averaged 5.1x4.3x2.0 cm, anterior wall 

fibroids averaged 5.1x5.0x2.3 cm, and fundal anterior 

fibroids averaged 6.0x5.8x3.0 cm. In the embolization 

group, the single fibroid nodes were located at the fundus 

of the uterus in 18.2% of patients, in the anterior wall in 

36.4% of patients, and in the fundal anterior location in 

45.5% of patients. The size of the fundal fibroids 

averaged 6.5x4.2x3.5 cm, the anterior fibroid nodes 

averaged 10.0x4.0x3.2 cm, and the fundal anterior 

fibroids averaged 5.7x5.4x3.5 cm. Transvaginal 

ultrasound demonstrated that 69.2% of patients treated 

with GnRHa had fibroid shrinkage with the uterine 

volume decreasing by 25%. The group undergoing UAE 

treatment had fibroid shrinkage up to 32% among 81.9% 

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx


 

 

CENTRAL ASIAN JOURNAL OF GLOBAL HEALTH 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

of patients (Figure 2). Both treatment groups were 

comparable in terms of gynecologic and obstetric history. 

Surgical times in the medication group were 

roughly 40 minutes longer than in the embolization 

group. This is due to the peri-operative difficulties in 

detecting the layer between myometrium and fibroid 

capsule. Furthermore, blood loss was much higher in the 

medication group (130.0±20 ml) compared to the 

embolization group (80.0±10.0 ml). All patients were 

encouraged to resume physical activity 8 hours 

postoperatively, and sutures were removed 3 days after 

the surgery. Patients were discharged from the hospital 

4.0±1.0 days post-surgery. Histological results also 

confirmed uterine fibroid diagnosis in both groups. 

Furthermore, both groups had transvaginal uterine 

ultrasound examinations as follow-up assessments 

between 6 and 12 months. However, during the 12 month 

post-surgical follow-up, three patients in the medication 

group reported uterine fibroid recurrence, whereas the 

embolization group reported only one case of fibroid 

recurrence. Pregnancy during the 12 months after surgery 

was reported in 53.8% of patients in the medication group 

(p<0.01), where 28.6% of women became pregnant at 6 

months and 72.4% of women at 9 months after onset of 

normal menstrual function. Only one patient in the 

embolization group became pregnant 12 months after 

recovery, and which previously had anatomical 

localization of the fibroid nodes at the fundus of the 

uterus and fundal anterior wall. Overall, this group did 

not complain of infertility as the primary reason for the 

decision to undergo embolization. The embolization 

group only had 2 patients who did not experience fibroid 

reduction.  

 

Figure 2. Reduction of fibroid size after pretreatment 

with GnRHa or UAE  

 

 

Discussion 

This study concluded that despite the fact that 

both treatments (GnRHa and UAE) were effective for 

fibroid reduction, embolization resulted in more optimal 

surgical time, and improved patient outcomes. This is one 

of the first studies of this nature conducted in Central 

Asia, as previously published studies from the Asian 

continent primarily focused on Chinese8,9 and 

Japanese10,11 women.  

Limitations of this study included a very small 

sample size and the retrospective nature of this 

investigation. An additional limitation of this study is the 

varying time period between pretreatment with 

medication or embolization and fibroid surgery. Several 

women wanted to have surgery at 6 months after pre-

treatment, while others waited up to 12 months. Also, this 

study did not allow for a more detailed evaluation of 

infertility, since the authors did not have access to 

women’s reproductive hormone test results and their 

sexual partners’ spermiogram results.  

To date, there is a paucity of published evidence 

to confirm the safety of uterine artery embolization for 

the future of reproductive function and fertility. 

Therefore, we discourage UAE for patients planning to 

have children. UAE is an acceptable method for surgical 

preparation, leading to fibroid shrinkage, lower 

intraoperative blood loss, shorter anesthesia, and surgical 

times. Based on our experience, the laparoscopic 

myomectomy after UAE has been advantageous in the 

identification of fibroid nodules and normal myometrium 

by fibroid color, consistency, and its borders. Thus, 

future studies are needed to confirm these findings. 

Overall, we would like to recommend implementation of 

a randomized clinical trial for comparison of uterine 

artery embolization and gonadotropin-releasing hormone 

agonists in shrinking fibroid size and improving surgical 

outcomes, specifically in the Central Asian region.   

  

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx


 

 

IMANKULOVA 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

References  

1. Mahmoud MS, Desai K, Nezhat FR. Leiomyomas beyond 

the uterus; benign metastasizing leiomyomatosis with paraaortic 

metastasizing endometriosis and intravenous leiomyomatosis: a 

case series and review of the literature. Arch Gynecol Obstet. 

2015;291(1):223-230. 

2. Szamatowicz M, Kotarski J. [Selective progesterone 

receptor modulator (ulipristal acetate--a new option in the 

pharmacological treatment of uterine fibroids in women]. Ginekol 

Pol. 2013;84(3):219-222. 

3. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery 

embolization for symptomatic uterine fibroids. Cochrane 

database of systematic reviews (Online). 2014;12:CD005073. 

4. Kamath MS, Kalampokas EE, Kalampokas TE. Use of GnRH 

analogues pre-operatively for hysteroscopic resection of 

submucous fibroids: a systematic review and meta-analysis. Eur 

J Obstet Gynecol Reprod Biol. 2014;177:11-18. 

5. Sankaran S, Manyonda IT. Medical management of 

fibroids. Best Pract Res Clin Obstet Gynaecol. 2008;22(4):655-

676. 

6. Nasser F, Affonso BB, de Jesus-Silva SG, et al. [Uterine 

fibroid embolization in women with giant fibroids]. Revista 

brasileira de ginecologia e obstetricia : revista da Federacao 

Brasileira das Sociedades de Ginecologia e Obstetricia. 

2010;32(11):530-535. 

7. Bernardo A, Gomes MT, Castro RA, Girao MJ, Bonduki CE, 

Yokoyama CA. [Impact of the myoma arterial embolization by 

uterine volume, diameter myoma greater and in the ovarian 

function]. Revista brasileira de ginecologia e obstetricia : revista 

da Federacao Brasileira das Sociedades de Ginecologia e 

Obstetricia. 2011;33(8):201-206. 

8. Zhang Y, Sun L, Guo Y, et al. The impact of preoperative 

gonadotropin-releasing hormone agonist treatment on women 

with uterine fibroids: a meta-analysis. Obstet Gynecol Surv. 

2014;69(2):100-108. 

9. Yu YH, Gong SP, Wan SM. [Clinical application of GnRHa 

before uterine myomectomy: report of 20 cases]. Di 1 jun yi da 

xue xue bao = Academic journal of the first medical college of 

PLA. 2004;24(3):317-319. 

10. Higashijima T, Kataoka A, Nishida T, Yakushiji M. 

Gonadotropin-releasing hormone agonist therapy induces 

apoptosis in uterine leiomyoma. Eur J Obstet Gynecol Reprod 

Biol. 1996;68(1-2):169-173. 

11. Uemura T, Mori J, Yoshimura Y, Minaguchi H. Treatment 

effects of GnRH agonist on the binding of estrogen and 

progesterone, and the histological findings of uterine 

leiomyomas. Asia-Oceania journal of obstetrics and gynaecology 

/ AOFOG. 1991;17(4):315-320.  

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx


 

 

IMANKULOVA 

 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

Figure 1. Breakdown of patients’ complaints stratified by intervention group 

 

  

23.0

38.5

15.4

23.0

0.0

54.5

9.0

36.4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Infertility Pain Algomenorrhea Hyperpolymenorrhea

P
er

ce
n

t

Complaints

GnRH UAE

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx


 

 

IMANKULOVA 

 

This work is licensed under a Creative Commons Attribution 4.0 United States License. 

 

This journal is published by theUniversity Library System of the University of Pittsburgh as part  

of its D-Scribe Digital Publishing Program and is cosponsored by the University of Pittsburgh Press. 

 

Central Asian Journal of Global Health 

Volume 4, No. 1 (2015) |  ISSN 2166-7403 (online) | DOI 10.5195/cajgh.2015.232|http://cajgh.pitt.edu 

 

 

Figure 2. Reduction of fibroid size after pre-treatment with GnRHa or UAE 

 

69.23
81.82

30.77
18.18

0

20

40

60

80

100

GnRH UAE

P
er

ce
n

t

Treatment

Shrinking No Change

http://www.library.pitt.edu/
http://www.pitt.edu/
http://www.library.pitt.edu/articles/digpubtype/index.html
http://www.upress.pitt.edu/upressIndex.aspx

