What are the common medications used to treat Polycystic Ovary Disorder (PCOD)?

Common Medications for Polycystic Ovary Syndrome (PCOD/PCOS)

First-Line Pharmacological Treatments

Metformin is the cornerstone medication for PCOS, improving insulin sensitivity, reducing testosterone levels, and addressing metabolic abnormalities, though lifestyle modification with even 5% weight loss should precede or accompany pharmacotherapy. 1

Metformin (Insulin Sensitizer)

• Mechanism: Improves insulin sensitivity, which reduces insulin levels and subsequently decreases ovarian androgen production, lowering testosterone levels 1
• Metabolic benefits: Interventions improving insulin sensitivity may positively impact risk factors for diabetes and cardiovascular disease in women with PCOS 1
• Weight effects: Tends to decrease weight in PCOS patients, unlike thiazolidinediones which cause weight gain 1
• Optimal candidates: Consider particularly in women with cardiometabolic features such as abdominal obesity and insulin resistance 1
• Dosing: Typical doses range from 1-1.5g daily, often given twice daily 2

Critical safety considerations for metformin:

• Readily crosses the placenta with umbilical cord blood levels equal to or higher than maternal levels 3
• Follow-up studies at 4-10 years show offspring exposed to metformin have higher BMI, increased obesity, and increased waist circumferences 3
• No evidence-based need to continue metformin in PCOS patients attempting conception 3
• Does not reduce risk of gestational diabetes in high-risk PCOS patients 3

Combined Oral Contraceptive Pills (COCPs)

• Primary indication: Menstrual regulation and androgen suppression 2
• Common formulation: Diane-35 (ethinylestradiol 0.035mg and cyproterone acetate 2mg) frequently used in studies 2
• Duration: Typically prescribed for 12 weeks initially, often combined with other agents 2

Anti-Androgen Medications

• Spironolactone: Addresses hirsutism, acne, and androgenic symptoms 4
• Critical monitoring: Monitor serum potassium within 1 week of initiation or titration and regularly thereafter due to hyperkalemia risk 4
• Contraindications: Avoid with potassium supplementation, ACE inhibitors, or angiotensin receptor blockers due to increased hyperkalemia risk 4
• Common side effect: Gynecomastia can occur in a dose-dependent manner, usually reversible 4

Fertility-Specific Medications

For Ovulation Induction

• Clomiphene citrate: First-line pharmacological treatment with strong evidence - approximately 80% of PCOS patients ovulate, and half who ovulate will conceive 3
• Clomiphene is significantly more effective than metformin for ovulation induction and should be tried first 3
• If clomiphene fails: Use low-dose gonadotropin therapy rather than high-dose protocols to reduce ovarian hyperstimulation risk 3

Anti-Obesity Agents (Emerging Evidence)

GLP-1 Receptor Agonists

• Semaglutide: 1mg weekly for 16 weeks showed improvements in metabolic parameters (fasting glucose, insulin, HOMA-IR) and anthropometric measures (weight, BMI, waist circumference, visceral body fat) 2
• Liraglutide: 1.8mg daily for 26 weeks demonstrated benefits in hormonal profiles, metabolic parameters, lipids, and body composition 2
• Exenatide: 5-10μg twice daily or 2mg weekly combined with metformin and lifestyle interventions showed hormonal and metabolic improvements 2

Orlistat

• Dosing: 120mg three times daily for 12 weeks 2
• Benefits: May help achieve weight loss and improve lipid and glucose metabolism 5
• Combination therapy: Often used with COCPs and lifestyle interventions 2
• Lifestyle co-intervention: Patients encouraged to walk 30 minutes daily 2

Essential Treatment Algorithm

1. Begin with lifestyle modification: Diet and exercise with target of 5% weight loss improves both metabolic and reproductive abnormalities 1
2. For metabolic/androgenic symptoms: Metformin ± COCPs ± spironolactone based on specific symptoms 1, 2
3. For fertility: Clomiphene citrate first-line, NOT metformin 3
4. For obesity: Consider GLP-1 agonists or orlistat as adjuncts to lifestyle modification 2, 5

Critical Drug Interactions and Monitoring

Metformin-Specific Interactions

• Cimetidine: Increases metformin exposure by 40% (AUC) and 61% (Cmax) - may increase lactic acidosis risk 6
• Topiramate: Increases metformin exposure by 25% (AUC) - both cause metabolic acidosis risk 6
• Alcohol: Potentiates metformin's effect on lactate metabolism - warn against excessive intake 6
• Renal function: Monitor closely as metformin clearance depends on kidney function 6

Spironolactone-Specific Monitoring

• Electrolytes: Monitor for hyperkalemia, hyponatremia, hypomagnesemia, hypocalcemia, and hypochloremic alkalosis 4
• Renal function: Monitor periodically as excessive diuresis can worsen renal function 4
• Blood pressure: Risk of symptomatic dehydration and hypotension 4
• Metabolic: Monitor uric acid and blood glucose periodically 4

Common Pitfalls to Avoid

• Do NOT use metformin as first-line for ovulation induction - clomiphene citrate is significantly more effective 3
• Do NOT continue metformin throughout pregnancy without clear indication, as it does not prevent spontaneous abortion or gestational diabetes 3
• Do NOT combine spironolactone with ACE inhibitors or potassium supplements without careful monitoring due to severe hyperkalemia risk 4
• Do NOT ignore the offspring metabolic consequences of metformin use during pregnancy - higher childhood BMI and obesity rates documented 3
• Always combine pharmacotherapy with lifestyle interventions - even modest 5% weight loss enhances medication effects 1