Use of Oral Gonadotropin Releasing Hormone Antagonist Combinations for Preoperative Management of Refractory Leiomyoma-Related Heavy Menstrual Bleeding

Uterine leiomyomas are noncancerous smooth muscle neoplasms that occur in up to 70% of women and the single most common cause of hysterectomy. There is a variety of treatments available for uterine leiomyomas, including medications, uterine artery embolization, myomectomy, and hysterectomy but surgical treatments predominate. Medical optimization of anemia is often required prior to surgical treatment secondary to heavy menstrual bleeding and resultant iron deficiency anemia from chronic blood loss. While iron and multivitamins are critical to increase hemoglobin, pharmacologic therapy to suppress menstrual bleeding is often needed. First line therapy is typically a trial of combined oral contraceptive pills (OCPs); however, this may not be effective in all patients. Parenteral administration of long-acting GnRH agonists is often used as a second line treatment; however, these agents can lead to an initial "flare" effect precipitating a heavy bleed during the agonist phase which can be problematic in such patients. An alternative course of action is the use of oral GnRH antagonist combination therapy (OGAC) with estradiol and norethindrone, an option approved in both the United States and the European Union for long-term treatment of leiomyoma-related heavy menstrual bleeding. To demonstrate the clinical utility of OGAC therapy in the preoperative setting, we report a successful patient outcome and review relevant literature.