What is the comparative efficacy of Oral Contraceptive Pills (OCP) for Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

Oral contraceptive pills (OCPs) are the most effective treatment for managing Polycystic Ovary Syndrome (PCOS), with combination OCPs containing both estrogen and progestin being the most effective formulation. The use of OCPs in PCOS has been supported by guidelines from the American College of Obstetricians and Gynecologists (ACOG) 1. For optimal results, a formulation containing 20-35 mcg of ethinyl estradiol combined with a progestin with low androgenic activity (such as drospirenone, norgestimate, or desogestrel) is recommended. Common regimens include Yaz (3 mg drospirenone/20 mcg ethinyl estradiol), Yasmin (3 mg drospirenone/30 mcg ethinyl estradiol), or Ortho Tri-Cyclen (norgestimate/35 mcg ethinyl estradiol) 1.

Key Considerations

• OCPs work by suppressing ovarian androgen production, increasing sex hormone-binding globulin (which reduces free testosterone), and regulating menstrual cycles.
• This addresses multiple PCOS symptoms including irregular periods, acne, and hirsutism.
• Patients should be monitored for side effects including venous thromboembolism risk, particularly in those with additional risk factors such as obesity, smoking, or hypertension 1.
• The development of newer progestins, such as drospirenone and dienogest, has improved the safety profile of OCPs by reducing off-target effects on androgen and glucocorticoid receptors.

Treatment Duration and Monitoring

• Treatment should continue for at least 6-12 months to evaluate efficacy, with many patients requiring longer-term therapy.
• Patients should be monitored regularly for side effects and efficacy, with adjustments to the treatment regimen as needed.
• The use of OCPs in PCOS has been shown to reduce the risk of endometrial cancer, although the extent of this effect is unknown 1.

Alternative Treatments

• Other treatments, such as antiandrogen drugs and insulin-sensitizing agents, may be used in combination with OCPs to manage PCOS symptoms.
• Mechanical removal of hair, electrolysis, and laser vaporization may also be used to manage hirsutism, although these methods may require repeated treatments and may not address the underlying hormonal imbalance 1.

From the Research

Comparative Efficacy of Oral Contraceptive Pills (OCP) for Polycystic Ovary Syndrome (PCOS)

• The efficacy of OCPs in treating PCOS has been evaluated in several studies, with a focus on their effects on clinical and biochemical parameters 2, 3, 4, 5, 6.
• Combined oral contraceptive (COC) pills are considered the first-line medical therapy for the long-term management of PCOS, as they restore regular menses, improve androgen excess, and provide effective contraception and protection from endometrial cancer 2.
• Studies have shown that COCs can improve hirsutism, acne, and menstrual dysfunction in women with PCOS, with some formulations being more effective than others 3, 4, 5, 6.
• For example, a study comparing COC plus spironolactone with metformin found that the COC plus spironolactone combination was more effective in reducing hirsutism and androgen excess, with similar safety and neutral effects on cardiometabolic risk factors 4.
• Another study found that a drospirenone-containing COC was more effective than a desogestrel-containing COC in improving clinical and biochemical parameters in women with PCOS, including persistent regular cycles, antiandrogenic effect, and favorable lipid and glycemic profiles 6.

Cardiometabolic Risk Factors

• While OCPs are generally considered safe and effective for women with PCOS, there are concerns about potential adverse cardiovascular and metabolic effects, particularly with regards to venous thrombosis and diabetes 2, 3.
• Studies have shown that COCs can increase the risk of venous thrombosis, although the risk is generally considered to be low in young, non-smoking women 2.
• Additionally, some studies have found that COCs may be associated with an increased risk of diabetes in morbidly obese women with PCOS and severe insulin resistance 2.
• However, other studies have found that COCs can have neutral or even beneficial effects on cardiometabolic risk factors, such as improving lipid profiles and reducing blood pressure 4, 6.

Individualized Risk Stratification and Management

• Given the potential risks and benefits of OCPs in women with PCOS, individualized risk stratification and management are essential to ensure safe and effective treatment 2.
• Clinicians should document individual risk factors, including age, smoking, obesity, glucose intolerance, hypertension, dyslipidemia, and personal or family history of thromboembolic events, before prescribing an OCP 2.
• By taking a tailored approach to oral contraception in women with PCOS, clinicians can minimize risks and maximize benefits, ultimately improving outcomes for these patients 2, 3, 4, 5, 6.