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

Best Birth Control Options for PCOS

Combined oral contraceptive pills (COCs) are the first-line birth control option for women with PCOS as they provide multiple therapeutic benefits beyond contraception, including regulation of menstrual cycles, improvement of hyperandrogenism symptoms, and protection against endometrial cancer. 1

Why COCs are Recommended for PCOS

COCs offer several key benefits for women with PCOS:

1. Menstrual Regulation: COCs restore regular menstrual cycles, addressing a primary concern for many women with PCOS 1, 2
2. Androgen Suppression: They suppress ovarian androgen production, improving hirsutism and acne 1, 3
3. Endometrial Protection: COCs reduce the risk of endometrial cancer, which is elevated in women with PCOS due to irregular cycles 1, 4
4. Effective Contraception: They provide reliable birth control when needed 5

Individualized Risk Assessment Before Starting COCs

Before prescribing COCs, a thorough assessment of cardiometabolic risk factors is essential:

• Age (risk increases with age)
• Smoking status (contraindicated in smokers over 35)
• Obesity (BMI ≥30)
• Glucose tolerance (including prediabetes and diabetes)
• Blood pressure (hypertension increases risk)
• Lipid profile (dyslipidemia)
• Personal or family history of venous thromboembolism (VTE) 5, 4

Important Considerations and Potential Risks

Venous Thromboembolism Risk

• Different COC formulations carry varying VTE risks
• Risk is related to both estrogen dose and progestin type 4
• VTE risk is highest in the first year of use

Metabolic Considerations

• COCs may decrease insulin sensitivity in some women
• This effect is more pronounced in obese patients
• Glucose tolerance may be impaired, though this appears reversible 3
• COCs are generally not associated with increased diabetes risk in non-obese women without severe insulin resistance 5

Lipid Effects

• Effects on lipid profile depend on the type of progestin
• Values typically remain within reference ranges 3

Alternative Options

For women with contraindications to COCs:

1. Progestin-only methods (pills, injections, implants, or IUDs) - can provide cycle control with fewer metabolic effects
2. Medroxyprogesterone acetate (depot or intermittent oral therapy) - suppresses androgen and gonadotropin levels 1
3. Non-hormonal IUD - for contraception only, without hormonal effects

Combination Approaches

For optimal management of PCOS symptoms:

• COCs + weight reduction - can further improve metabolic parameters and androgen levels 3
• COCs + insulin sensitizers (e.g., metformin) - may be beneficial for women with insulin resistance, though this combination should be used selectively 3, 6

Common Pitfalls to Avoid

1. Assuming all COCs are equal - Despite guidelines suggesting similar efficacy, prescribing patterns show preferences for certain formulations like drospirenone-containing COCs in PCOS patients 6
2. Overlooking metabolic monitoring - Regular follow-up of glucose tolerance and lipid profiles is essential
3. Unnecessary combination therapy - Adding antiandrogens (like spironolactone) to COCs provides little additional benefit for most women 6
4. Using metformin without glucose intolerance - Metformin should primarily be used when glucose metabolism is impaired 1, 6

In summary, COCs remain the cornerstone of PCOS management for women not seeking pregnancy, offering multiple benefits beyond contraception. However, careful risk assessment and monitoring are essential to ensure safety and optimize outcomes.