A 38-year-old woman with symptomatic fibroids (heavy menstrual bleeding, bulk symptoms) desires uterine preservation. Uterine size is 18 weeks. She has a 7 cm intramural fibroid and two 3 cm submucosal fibroids. She is perimenopausal. The non-surgical medical option that reduces fibroid volume by 50% and controls bleeding via GnRH receptor antagonism for preoperative use is:

• A Ulipristal acetate
• B Leuprolide acetate (GnRH agonist)
• C Relugolix combined with estradiol and norethindrone acetate ✓
• D Mifepristone

Explanation

Relugolix (a non-peptide oral GnRH antagonist) combined with low-dose estradiol and norethindrone acetate (add-back therapy) — marketed as Myfembree — is FDA/regulatory approved for uterine fibroid heavy menstrual bleeding. Unlike GnRH agonists, it acts immediately without an initial flare, reduces fibroid volume, and add-back therapy prevents the vasomotor and bone density effects of estrogen deprivation. Ulipristal acetate (SPRM) has been suspended in many markets due to hepatotoxicity concerns. Leuprolide is a GnRH agonist (not antagonist) with an initial flare.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.