What is the best treatment for a patient with Polycystic Ovary Syndrome (PCOS) and adenomyosis?

Treatment of PCOS with Coexisting Adenomyosis

For patients with both PCOS and adenomyosis, combined oral contraceptive pills (OCPs) represent the optimal first-line treatment, as they simultaneously address menstrual irregularity and endometrial protection in PCOS while providing hormonal suppression for adenomyosis symptoms. 1, 2, 3

Initial Management Strategy

Lifestyle Modifications (Foundation for All Patients)

• Target 5-10% weight loss through a 500-750 kcal/day energy deficit (total intake 1,200-1,500 kcal/day), which improves both PCOS metabolic/reproductive abnormalities and may reduce adenomyosis-related inflammation. 1, 2
• Implement at least 150 minutes/week of moderate-intensity exercise, which benefits PCOS symptoms even without weight loss. 1, 2
• No specific diet type is superior; follow general healthy eating principles tailored to individual preferences. 1

Hormonal Management: The Dual-Purpose Approach

Combined oral contraceptives serve multiple critical functions:

• Suppress ovarian androgen secretion and increase sex hormone-binding globulin for PCOS. 4, 1, 2
• Regulate menstrual cycles and prevent endometrial hyperplasia (crucial given PCOS-related unopposed estrogen exposure). 4, 1
• Provide hormonal suppression to control adenomyosis-related pain and abnormal uterine bleeding. 5, 3
• Reduce hirsutism and acne through androgen level reduction. 1, 2

Alternative Hormonal Options When OCPs Are Contraindicated

Levonorgestrel-releasing intrauterine system (LNG-IUS) is highly effective for adenomyosis management:

• Extremely effective in resolving abnormal uterine bleeding associated with adenomyosis. 5, 3
• Reduces uterine volume in long-term management. 5
• Provides endometrial protection for PCOS patients. 3
• This is the preferred option for patients who cannot take OCPs or have completed childbearing. 3

Progestin-only therapy (medroxyprogesterone acetate):

• Suppresses circulating androgen levels and pituitary gonadotropins in PCOS. 4
• Controls adenomyosis-related pain through antiproliferative and anti-inflammatory effects. 5
• Can be given as depot or intermittent oral therapy. 4
• Note: Optimal progestin type, duration, and frequency for endometrial cancer prevention in PCOS remains unknown. 4

Management of Specific Symptoms

For Hirsutism and Acne (Common in PCOS)

Combination therapy is most effective:

• Add spironolactone (50-200 mg daily) to OCPs for severe hirsutism, as it competitively inhibits androgen receptors. 1
• Spironolactone must be combined with OCPs in sexually active women due to pregnancy category C status (risk of feminization of male fetuses). 1
• Monitor potassium in older patients or those with comorbidities (hypertension, diabetes, chronic kidney disease). 1
• Topical eflornithine hydrochloride cream is the only FDA-approved topical treatment for hirsutism. 1

For Heavy Menstrual Bleeding (Overlapping Symptom)

The LNG-IUS is superior to OCPs specifically for heavy bleeding:

• Heavy menstrual bleeding is the most common adenomyosis symptom. 3
• LNG-IUS shows extreme effectiveness in resolving this symptom. 5, 3

For Pelvic Pain (Primarily from Adenomyosis)

• OCPs or progestins (dienogest, norethindrone acetate) provide pain control through hormonal suppression. 5, 3
• NSAIDs can be used adjunctively for pain management. 5
• GnRH analogues are effective but reserved for short-term use due to hypoestrogenic side effects. 5

Metabolic Screening and Management (Critical in PCOS)

All patients require metabolic surveillance regardless of weight:

• Screen for type 2 diabetes with fasting glucose followed by 2-hour glucose tolerance test (75-gram glucose load). 4, 2
• Obtain fasting lipid profile including total cholesterol, LDL, HDL, and triglycerides. 4, 2
• Calculate BMI and waist-hip ratio. 4, 2
• Do not neglect metabolic screening even in normal-weight PCOS patients, as insulin resistance occurs independent of obesity. 6

Metformin (500-2000 mg daily) should be added when:

• Insulin resistance or glucose intolerance is documented. 4, 2, 6
• Lifestyle modifications alone are insufficient for metabolic control. 2
• Patient has obesity or elevated cardiovascular risk factors. 2, 6

Special Considerations for Fertility Planning

If pregnancy is desired in the future:

• Continue lifestyle modifications and metabolic management. 1, 6
• Discontinue OCPs when ready to conceive. 1
• Use clomiphene citrate as first-line ovulation induction (80% ovulation rate, 50% conception rate). 2, 6
• If clomiphene fails, use low-dose gonadotropin therapy to minimize ovarian hyperstimulation risk. 1, 2
• Consider GnRH analogues before fertility treatments to improve pregnancy chances in women with adenomyosis. 5
• Metformin appears safe during pregnancy and may reduce miscarriage risk in PCOS. 6

Long-Term Monitoring

• Reassess metabolic parameters (glucose, lipids) annually. 4, 2
• Screen for depression, anxiety, and eating disorders, which occur at higher rates in PCOS. 2
• Monitor adenomyosis symptom control with chosen hormonal therapy. 3
• If medical management fails to control adenomyosis symptoms, hysterectomy may ultimately be required. 3

Critical Pitfalls to Avoid

• Do not use spironolactone as monotherapy in patients attempting to conceive; use clomiphene citrate instead. 1
• Do not use thiazolidinediones in pregnancy; their effects on early pregnancy are poorly documented compared to metformin. 6
• Do not exceed recommended clomiphene dosage and duration. 6
• Do not delay lifestyle intervention—it must be the foundation, not an afterthought. 6
• Do not assume normal weight excludes metabolic dysfunction in PCOS. 6