Treatment of menstrual disturbance in individuals with polycystic ovary syndrome
Combined oral contraceptives (COCs) provide the most effective menstrual regulation in PCOS; they also provide effective contraception. They have the added benefit of suppressing ovarian androgen production, which can be beneficial for hirsutism, acne and androgenetic alopecia. Although some small studies of COCs have shown an adverse effect on glucose metabolism, a meta-analysis did not find that they worsen insulin resistance in individuals with PCOS1.
Although COCs containing antiandrogenic progestogens (eg cyproterone dienogest, drospirenone) may have added benefit compared to formulations with other progestogens, there are limited head-to-head comparisons and insufficient data to recommend specific formulations.
Use the lowest dose of estrogen that effectively controls the menstrual cycle. Use:
If COCs are contraindicated, the 52 mg levonorgestrel-releasing intrauterine contraceptive device (LNG-IUD) can be used to provide endometrial protection and contraception. Use:
levonorgestrel-releasing IUD 52 mg inserted into the uterus. Replace every 5 years. polycystic ovary syndrome levonorgestrel-releasing iud
An oral cyclical progestogen can be considered for individuals who have a contraindication or preference to avoid COCs or the LNG-IUD. Oral cyclical progestogens induce endometrial shedding and provide endometrial protection; however, they should not be used long term because they:
- are less effective than the LNG-IUD for regulating menstruation
- do not address other aspects of PCOS such as hyperandrogenism
- are poorly tolerated (adverse effects include breast tenderness and headaches)
- confer a risk of hypoestrogenism (which affects bone health and possibly cardiovascular health).
If an oral cyclical progestogen is indicated, see Heavy menstrual bleeding for dosages.
Metformin may increase menstrual frequency in individuals with PCOS by inducing ovulation. However, metformin is not recommended for management of menstrual disturbance in individuals with PCOS (except to treat impaired fertility); it provides poor control of heavy bleeding and inadequate protection against endometrial hyperplasia and cancer.