GNRH1 and leiomyoma: GnRH agonists are often used as a second line choice; however, these agents can lead to an initial “flare” effect due to its initial gonadotropin release, precipitating a heavy withdrawal bleed and significant side effects.3 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 (EU) for treatment of leiomyoma-related heavy menstrual bleeding.