What is the recommended treatment course for a 27-year-old female with symptoms consistent with Polycystic Ovary Syndrome (PCOS) and Premenstrual Dysphoric Disorder (PMDD) who does not wish to conceive?

Treatment for 27-Year-Old Female with PCOS and PMDD Who Does Not Want Children

For a 27-year-old female with symptoms consistent with PCOS and PMDD who does not wish to conceive, the optimal treatment is a combined oral contraceptive containing drospirenone 3mg and ethinyl estradiol 20mcg in a 24/4 regimen, which effectively addresses both conditions simultaneously. 1, 2, 3

First-Line Treatment Approach

Combined Hormonal Contraception

• Drospirenone/ethinyl estradiol (24/4 regimen) is FDA-approved for PMDD treatment and provides significant benefits for PCOS symptoms 1, 3
  • Significantly improves emotional and physical symptoms of PMDD
  • Regulates menstrual cycles
  • Reduces hyperandrogenism (hirsutism, acne)
  • Provides endometrial protection
  • Offers effective contraception

Lifestyle Modifications (Essential Adjunctive Therapy)

• Should be implemented concurrently with pharmacological treatment 4
• Physical activity: 250 minutes/week of moderate-intensity exercise
• Dietary approach: 500-750 kcal/day energy deficit with low glycemic index diet rich in fiber and omega-3 fatty acids
• Goal of 10,000 steps/day

Second-Line or Adjunctive Treatments

For Metabolic Features of PCOS

• Metformin may be added for patients with documented insulin resistance 4
  • Modest benefits for weight loss when combined with lifestyle modifications
  • Improves menstrual regularity and reduces androgen levels
  • Common side effects: diarrhea, nausea, abdominal discomfort
  • Regular monitoring every 6 months for blood pressure, lipids, menstrual cyclicity

For Severe Hirsutism

• Spironolactone 100mg daily can be added to COCs 4
  • Visible improvement typically takes 6 months
  • Monitor potassium levels due to potential interactions with drospirenone

For Severe PMDD Symptoms

• Selective Serotonin Reuptake Inhibitors (SSRIs) may be considered if symptoms persist despite COC therapy 2
  • Effective for treating psychological symptoms of PMDD
  • Can be used continuously or only during luteal phase

Monitoring and Follow-up

Regular Assessment (Every 6 Months)

• Blood pressure monitoring
• Lipid profile
• Menstrual cyclicity
• Weight changes
• Metabolic parameters
• Assessment of symptom improvement

Red Flags Requiring Prompt Evaluation

• Persistent abnormal uterine bleeding despite treatment
• Signs of significant virilization
• Rapid development of symptoms
• Significant weight gain or worsening insulin resistance despite treatment

Important Considerations and Contraindications

Safety Considerations for COCs

• Contraindicated in women who smoke and are over 35 years old due to increased cardiovascular risk 1
• Increased risk of venous thromboembolism (3-4 per 10,000 woman-years) 4
• Caution in women with:
  • Kidney, liver, or adrenal disease (due to potential potassium elevation with drospirenone) 1
  • Concurrent use of medications that may increase potassium (NSAIDs, potassium-sparing diuretics, ACE inhibitors, etc.) 1

Contraceptive Options to Avoid

• Progestin-only methods (pills, implants, DMPA) may negatively affect mood symptoms in women with PMDD 2
• If hormonal contraception is contraindicated, copper IUD is recommended 2

Treatment Response Expectations

• COCs containing drospirenone show response rates of 39-58% compared to 36% with placebo 5
• Visible improvement in hirsutism typically takes 6 months 4
• Initial spotting or nausea may occur in the first 1-3 packs of pills but usually resolves 1

This comprehensive approach addresses both the reproductive/hormonal aspects of PCOS and the psychological/physical symptoms of PMDD while respecting the patient's desire to avoid pregnancy.