What are the prescribed medications for Polycystic Ovary Syndrome (PCOS) treatment?

Medication Treatment for Polycystic Ovary Syndrome (PCOS)

The first-line medications for PCOS treatment should be selected based on the patient's primary symptoms, with metformin recommended for patients with metabolic features, combined oral contraceptives for menstrual irregularities and hyperandrogenism, and clomiphene citrate for women seeking fertility. 1

Treatment Based on Primary Symptoms

For Metabolic Features and Insulin Resistance

1. Metformin

   • Indicated for PCOS patients with documented insulin resistance or who have failed lifestyle modifications alone 1
   • Provides modest weight loss benefits (mean difference -0.73 kg/m²) when combined with lifestyle modifications 1
   • May improve menstrual regularity and reduce androgen levels 1
   • Common side effects: diarrhea, nausea, abdominal discomfort 1
   • Should be monitored with regular follow-up every 6 months 1

2. Newer Options

   • GLP-1 receptor agonists (liraglutide, semaglutide) may be more effective for weight loss than metformin 1
   • Liraglutide can lead to 0.3-3.38 kg weight reduction 1
   • Semaglutide shows even greater weight loss (3.47-6.5 kg) 1

For Menstrual Irregularities and Hyperandrogenism

1. Combined Oral Contraceptives (COCs)

   • First-line therapy for menstrual regulation and reducing hyperandrogenism 1, 2
   • Provides essential endometrial protection 1
   • Note: Increases venous thromboembolism risk (up to 4 per 10,000 woman-years) 1, 3
   • Requires careful evaluation of cardiometabolic risk factors before initiation 3

2. Progesterone Options

   • Oral micronized progesterone (200-300 mg daily for 12-14 days monthly) 1
   • Provides endometrial protection and improves menstrual regularity 1
   • Better safety profile compared to synthetic progestins 1

For Hirsutism and Dermatologic Manifestations

1. Anti-androgens (used with contraception in women not seeking pregnancy)
   • Spironolactone 100 mg daily 1, 2
   • Visible improvement typically takes 6 months 1
   • Other options: cyproterone acetate, flutamide, finasteride 4
   • Topical eflornithine for facial hirsutism 5

For Fertility and Ovulation Induction

1. Clomiphene Citrate

   • First-line medication for ovulation induction 1, 5
   • Dosage starting on day 5 of the cycle 1
   • 80% ovulation rate and 50% conception rate 1

2. Letrozole

   • Now considered first-line therapy for ovulation induction in women seeking pregnancy 2

3. Gonadotropin Therapy

   • For clomiphene-resistant patients 4
   • Low-dose step-up protocol preferred 4
   • May be combined with GnRH-agonist to reduce premature luteinization 4

Important Considerations and Monitoring

Foundation of All Treatment

• Lifestyle modifications should be the foundation of all PCOS treatment 1, 6, 2
• Include 250 minutes/week of moderate-intensity physical activity 1
• Energy deficit of 500-750 kcal/day 1
• Low glycemic index diet rich in fiber and omega-3 fatty acids 1

Monitoring Requirements

• Regular follow-up every 6 months 1
• Monitor blood pressure, lipid levels, menstrual cyclicity, weight changes 1
• Periodic assessment of endometrial thickness by transvaginal ultrasound 1
• Screen for depression and obstructive sleep apnea 2

Red Flags Requiring Prompt Evaluation

• Persistent abnormal uterine bleeding despite treatment 1
• Signs of significant virilization 1
• Rapid development of symptoms 1
• Significant weight gain or worsening insulin resistance despite treatment 1

Emerging Treatments

• Inositol supplements show efficacy similar to metformin with fewer side effects 6
• Statins and natural statins (monakolin) may help reduce hyperandrogenism 6

Remember that PCOS treatment should target the specific manifestations that are most bothersome to the patient, while also addressing the underlying metabolic abnormalities to reduce long-term health risks.