What is the best birth control for Polycystic Ovary Syndrome (PCOS)?

Best Birth Control for PCOS

Combined oral contraceptive pills (COCPs) are the first-line birth control option for women with PCOS who are not trying to conceive, as they effectively suppress androgen production, regulate menstrual cycles, and reduce the risk of endometrial cancer. 1

Mechanism and Benefits of COCPs in PCOS

COCPs provide multiple benefits for women with PCOS:

• Suppress ovarian androgen production
• Increase sex hormone binding globulin levels, reducing free testosterone
• Regulate menstrual cycles and prevent endometrial hyperplasia
• Improve androgenic skin symptoms (acne, hirsutism)
• Provide reliable contraception

Specific COCP Recommendations

When selecting a COCP for PCOS management, consider the following:

Best Options Based on Evidence:

1. COCPs containing anti-androgenic progestins:

   • Formulations with cyproterone acetate show superior efficacy in reducing hirsutism, biochemical hyperandrogenism, and BMI compared to conventional COCPs 2
   • However, these should not be first-line due to higher venous thromboembolism risk

2. Fourth-generation COCPs:

   • Result in lower BMI and testosterone levels compared to third-generation agents 2
   • Drospirenone-containing COCPs (like Yaz) have antimineralocorticoid and antiandrogenic properties that may be particularly beneficial 3

3. Extended or continuous regimens:

   • 24/4 day regimens (24 active pills, 4 placebo days) may provide better hormone stability 3

Important Considerations

Metabolic Effects

• COCPs may decrease insulin sensitivity, particularly in obese patients
• Consider combination therapy with weight reduction or insulin sensitizers to improve metabolic parameters 4
• Monitor for glucose intolerance, though evidence suggests any impairment is likely reversible 4

Alternative Options

For women who cannot take COCPs:

• Medroxyprogesterone acetate (depot or intermittent oral therapy) can suppress androgen levels and regulate cycles 1
• Insulin-sensitizing agents like metformin may improve menstrual irregularities but have limited benefit for hirsutism 5

Additional Management

For optimal PCOS management alongside contraception:

• Weight loss (even 5% of initial weight) can significantly improve metabolic and reproductive abnormalities 1
• Regular exercise program is beneficial even without weight loss 1
• For severe hirsutism, consider combination therapy with an antiandrogen (like spironolactone) alongside COCPs 1

Monitoring and Follow-up

Women with PCOS using COCPs should be monitored for:

• Lipid profiles (fasting total cholesterol, LDL, HDL, triglycerides)
• Glucose tolerance
• Blood pressure
• BMI and waist-hip ratio

Common Pitfalls to Avoid

1. Failing to screen for contraindications to COCPs (history of thromboembolism, migraine with aura, etc.)
2. Not addressing metabolic aspects of PCOS alongside contraception
3. Overlooking the need for endometrial protection in women with irregular cycles
4. Using progestin-only methods that may not adequately address the hormonal imbalances in PCOS

Remember that while COCPs are effective for symptom management, they do not cure PCOS, and symptoms typically return when discontinued.