Continue OCPs in PCOS Patient with Suppressed Gonadotropins
Yes, continue the OCPs—the suppressed FSH, LH, and low estradiol levels you're seeing are the expected and desired pharmacologic effect of combined oral contraceptives, not a pathologic finding requiring discontinuation. 1, 2
Understanding the Laboratory Findings
The hormonal profile you describe is exactly what OCPs are designed to achieve in PCOS management:
- Suppressed FSH and LH (both 0): OCPs work by suppressing the hypothalamic-pituitary-gonadal (HPG) axis through negative feedback, which is their primary mechanism of action 3
- Low estradiol (18 pg/mL): This reflects ovarian suppression from the exogenous estrogen in the OCP, which downregulates endogenous ovarian estrogen production 3
- This is therapeutic, not problematic: The suppression of gonadotropins leads to decreased ovarian androgen production, which is precisely why OCPs are first-line therapy for PCOS 1, 2
Why OCPs Should Be Continued
Combined oral contraceptives remain first-line therapy for PCOS patients not attempting conception, as recommended by the American College of Obstetricians and Gynecologists and American Academy of Family Physicians 1, 2. The benefits include:
- Androgen suppression: OCPs suppress ovarian androgen secretion and increase sex hormone binding globulin (SHBG), addressing the hyperandrogenism central to PCOS 1, 2
- Menstrual regulation: OCPs regulate menstrual cycles and reduce endometrial cancer risk, which is elevated in PCOS patients with chronic anovulation 1, 2
- Metabolic considerations: OCPs are not contraindicated in PCOS patients, even those with metabolic concerns 2
Products Containing Cyproterone Acetate Are Most Effective
If optimizing therapy, COCs containing cyproterone acetate demonstrate the most robust gonadotropin and androgen suppression in PCOS patients 3. These products show:
- Significant FSH reduction at 3,6, and 12 months (WMD ranging from -0.48 to -4.70) 3
- Significant LH reduction at 3,6, and 12 months (WMD ranging from -3.57 to -11.60) 3
- Maximum effect on gonadotropin suppression compared to other progestin formulations 3
Common Pitfall to Avoid
Do not mistake physiologic OCP-induced suppression for pathologic ovarian failure. The key distinction:
- On OCPs: Suppressed FSH/LH with low estradiol is expected and therapeutic 3
- Primary ovarian insufficiency: Would show elevated FSH (>25-40 IU/L) with low estradiol in the absence of exogenous hormones 4
Cessation of menses alone while on OCPs is not an adequate indicator of ovarian suppression requiring intervention 4. The laboratory findings you describe confirm appropriate HPG axis suppression.
When to Monitor Ovarian Function
You would only need to assess true ovarian reserve if:
- The patient discontinues OCPs and wishes to attempt conception 4
- She remains amenorrheic for >12 months after OCP discontinuation (if under age 60) 4
- She develops concerning symptoms suggesting premature ovarian insufficiency after stopping OCPs 4
While she remains on OCPs, routine monitoring of FSH, LH, and estradiol is not recommended as these values will remain suppressed by design 4.