What are the best oral contraceptives (OCs) for Polycystic Ovary Syndrome (PCOS)?

Best Oral Contraceptives for PCOS

Combined oral contraceptives (COCs) containing ethinyl estradiol with either cyproterone acetate or drospirenone are the most effective oral contraceptives for PCOS management, with COCs containing cyproterone acetate showing superior results for hirsutism reduction. 1, 2

First-Line Therapy Selection

COCs are the first-line pharmacological therapy for PCOS management, offering multiple benefits:

• Menstrual cycle regulation
• Reduction of hyperandrogenism (hirsutism, acne)
• Endometrial protection
• Contraception

Recommended COC Formulations for PCOS

1. First Choice: Ethinyl estradiol (35μg) + Cyproterone acetate (2mg)

   • Superior for hirsutism reduction (35% reduction vs 18% with drospirenone) 2
   • Effectively normalizes hormone profiles 3
   • Reduces ovarian size to normal after 12 cycles 3

2. Alternative: Ethinyl estradiol (30μg) + Drospirenone (3mg)

   • Better for waist-to-hip ratio improvement 2
   • Effective for androgen reduction, especially DHEA-S 2

Benefits of COCs in PCOS

• Decrease LH/FSH ratio and testosterone levels significantly after 3 cycles 3
• Increase sex hormone-binding globulin (SHBG), which reduces free testosterone 3
• Improve clinical signs of androgenization (hirsutism, acne) 1, 3
• Regulate menstrual cycles 1
• Protect against endometrial hyperplasia and cancer 1
• Reduce ovarian size 3

Risk Assessment Before Prescribing

Before prescribing COCs for PCOS patients, assess for:

• Age (increased risk with age >35)
• Smoking status (contraindicated in smokers >35)
• Obesity (BMI >30)
• Hypertension
• Dyslipidemia
• Glucose intolerance or diabetes
• Personal or family history of venous thromboembolism 4

Important Risk Considerations

• COCs increase venous thromboembolism risk three to fourfold (up to 4 per 10,000 woman-years) 5
• PCOS itself is associated with increased cardiovascular risk 5
• COC use may increase hsCRP and homocysteine levels, potentially affecting cardiovascular risk 6
• Morbidly obese women with severe insulin resistance may have increased diabetes risk with COCs 4

Monitoring and Follow-up

• Regular follow-up every 6 months
• Monitor blood pressure
• Assess endometrial thickness by transvaginal ultrasound
• Monitor lipid levels and adjust treatment accordingly 1
• Evaluate improvement in clinical symptoms (hirsutism typically improves between 8-12 cycles) 3

Adjunctive Therapies

• Consider adding metformin for patients with insulin resistance or metabolic syndrome 1
• Spironolactone (100 mg daily) can be added for persistent hirsutism, with visible improvement typically taking 6 months 1
• Note: Recent evidence suggests no added benefit of low-dose metformin for hirsutism when combined with COCs 7

Common Side Effects and Management

• Weight gain
• Breast tenderness
• Mood changes
• Secondary amenorrhea (rare)
• Increased blood pressure (monitor regularly) 3

Treatment Duration and Fertility

• COCs are completely reversible with no negative effect on long-term fertility 5
• Some patients may conceive within 2-3 cycles after discontinuing therapy 3

For optimal PCOS management, COCs containing cyproterone acetate should be first-line therapy, with drospirenone-containing COCs as an effective alternative, particularly for patients concerned about waist-to-hip ratio.