What is the most effective oral contraceptive pill (OCP) for treating Polycystic Ovary Syndrome (PCOS) in Canada?

From the Guidelines

Combination oral contraceptive pills (OCPs) containing both estrogen and progestin are the most effective treatment for Polycystic Ovary Syndrome (PCOS) in Canada, with Diane-35 (cyproterone acetate 2mg/ethinyl estradiol 35mcg) being a preferred option for patients with significant hirsutism or acne due to its strong anti-androgenic properties. The use of OCPs in PCOS treatment is supported by the American College of Obstetricians and Gynecologists (ACOG) guidelines, which highlight the benefits of combination OCPs in suppressing androgen secretion, increasing sex hormone-binding globulin, and reducing the risk of endometrial cancer 1.

Key Considerations for OCP Selection

• For patients without severe hyperandrogenism, low-dose OCPs such as Alesse or Marvelon (containing 20-30mcg ethinyl estradiol) are good options.
• Treatment typically continues for at least 6-12 months before reassessing, with many patients requiring longer therapy.
• OCPs work by suppressing ovarian androgen production, increasing sex hormone-binding globulin (which reduces free testosterone), and regulating menstrual cycles.
• Before starting treatment, patients should undergo baseline blood pressure measurement and screening for contraindications including history of venous thromboembolism, migraine with aura, or certain cardiovascular conditions, as highlighted in a recent review of oral contraceptive pills and hypertension 1.

Alternative Treatment Options

• For patients who cannot tolerate OCPs, alternatives include metformin or spironolactone depending on specific PCOS symptoms.
• Metformin, an insulin-sensitizing agent, can improve insulin sensitivity, decrease circulating androgens, and improve metabolic outcomes 1.
• Spironolactone, an anti-androgen medication, can help alleviate symptoms of hirsutism and acne in PCOS patients.

Recent Developments in OCPs

• Newer generations of progestins, such as drospirenone and dienogest, have been designed to promote anti-androgenic and/or anti-mineralocorticoid activity, which may be beneficial for PCOS patients 1.
• OCPs containing estradiol valerate or estetrol, naturally occurring estrogens, may have fewer associated adverse effects, but further research is needed to determine their efficacy and safety in PCOS treatment 1.

From the Research

Oral Contraceptive Pills for PCOS Treatment

The most effective oral contraceptive pill (OCP) for treating Polycystic Ovary Syndrome (PCOS) in Canada is not explicitly stated in the provided studies. However, the following points can be considered:

• Combined oral contraceptive (OC) pills are 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.
• The benefits of hormonal contraception outweigh the risks in the vast majority of women with PCOS, but concerns have been raised about potential adverse cardiovascular and metabolic effects of OCs 2, 3.
• A tailored clinical approach to oral contraception in women with PCOS requires individualized risk stratification and management by determination of each PCOS patient's personal cardiometabolic risk profile at baseline and during follow-up 2.

Specific Oral Contraceptives for PCOS

Some studies have evaluated the effectiveness and safety of specific oral contraceptives for PCOS treatment:

• Drospirone ethinyl estradiol and ethinyl estradiol cyproterone are two commonly used drugs in the clinical treatment of PCOS, but there is a lack of evidence-based medicine to support their use 4.
• A low-dose estrogen-antiandrogen combination (Diane-35) has been shown to reduce hormonal disturbances and improve clinical signs of androgenization, hormone profile, and ovarian size in patients with PCOS 5.
• Combined oral contraceptives (COC) can suppress androgen production, ameliorate skin androgenic symptoms, and improve menstrual dysfunction in PCOS patients, but their metabolic effects are still unresolved 6.

Key Considerations

When selecting an oral contraceptive for PCOS treatment, the following factors should be considered:

• Individual risk factors, including age, smoking, obesity, glucose intolerance, hypertension, dyslipidemia, thrombophilia, and personal or family history of a venous thromboembolic event 2.
• The type and dose of estrogen and progestin components in the oral contraceptive, as they can affect cardiometabolic effects 2, 3.
• The potential benefits and risks of oral contraceptive use in PCOS patients, including the impact on insulin sensitivity, glucose tolerance, and lipid levels 6.