What is the best course of treatment for a female patient with a history of Polycystic Ovary Syndrome (PCOS) and hypothyroidism, who is experiencing heavy menstrual bleeding, has a hemoglobin (Hgb) level indicating mild anemia, and has a history of irregular oral contraceptive use?

Management of Recurrent Heavy Menstrual Bleeding in PCOS with Hypothyroidism and Poor Contraceptive Adherence

Start combined oral contraceptives containing 30-35 μg ethinyl estradiol (with levonorgestrel or norgestimate) as first-line treatment, ensure thyroid function is optimized, check hemoglobin and iron studies, and strongly counsel on adherence strategies given the history of missed pills. 1, 2, 3

Immediate Assessment Required

Before initiating treatment, you must rule out:

• Pregnancy (despite irregular pill use, this remains possible) 1, 2
• Sexually transmitted infections (particularly in reproductive-aged women with breakthrough bleeding) 1, 2
• Structural lesions (polyps, fibroids) given the recurrent nature of bleeding 1, 2
• Thyroid function optimization - hypothyroidism itself causes menorrhagia and can contribute to anemia through multiple mechanisms including iron malabsorption 4, 5

Check current TSH level, as uncontrolled hypothyroidism is a direct cause of heavy menstrual bleeding and can cause microcytic anemia through menorrhagia and iron malabsorption 4, 5.

First-Line Medical Management

Monophasic combined oral contraceptives are the definitive first-line treatment:

• Use formulations with 30-35 μg ethinyl estradiol combined with levonorgestrel or norgestimate 2, 3
• These reduce menstrual blood loss by inducing regular shedding of a thinner endometrium 2, 3
• Additional benefits include reduced risk of endometrial cancer (critical in PCOS patients who have chronic anovulation) 4, 3

Addressing the Adherence Problem

Given the history of regularly missing pills, implement specific adherence strategies:

• Set up cell phone alarms for daily pill reminders 3
• Involve a family member for support and accountability 3
• Consider extended/continuous regimens (taking active pills for 3-4 months continuously) to reduce the complexity of cycling on/off 3
• Counsel explicitly that 7 consecutive hormone pills are needed to prevent ovulation, and provide clear instructions on what to do if pills are missed 3

If adherence remains problematic despite counseling, consider alternative methods:

• Contraceptive vaginal ring (NuvaRing) - simpler once-monthly insertion regimen 3
• Depot medroxyprogesterone acetate (DMPA) - injectable every 12 weeks, though may cause initial irregular bleeding 3
• Levonorgestrel IUD - provides 71-95% reduction in menstrual blood loss and requires no daily adherence 3

Management of Current Anemia

With hemoglobin of 11.9 g/dL (mild anemia):

• Start iron supplementation immediately 6
• Recheck hemoglobin in 4-6 weeks to assess response 7
• The combination of hypothyroidism and heavy menstrual bleeding creates a dual mechanism for iron deficiency 5

Acute Bleeding Management

For the current 9-day bleeding episode:

• NSAIDs for 5-7 days (mefenamic acid 500 mg three times daily or celecoxib 200 mg daily) to reduce blood flow acutely 1, 2
• If using extended-regimen COCs and heavy bleeding occurs, consider a 3-4 day hormone-free interval (but not during the first 21 days of use and not more than once per month) 1, 3

PCOS-Specific Considerations

Women with PCOS require additional management beyond bleeding control:

• Screen for type 2 diabetes with fasting glucose followed by 2-hour glucose tolerance test (75-gram glucose load) 4
• Check fasting lipid panel (PCOS patients have increased cardiovascular risk with dyslipidemia) 4
• Calculate BMI and waist-hip ratio 4
• Monitor blood pressure at follow-up visits (COCs can increase BP) 2, 3
• Consider metformin if cardiometabolic features present (abdominal obesity, insulin resistance), though this is primarily for metabolic management rather than bleeding control 4

Critical Safety Screening

Before prescribing COCs, assess for:

• Thrombotic risk factors (COCs increase VTE risk 3-4 fold) 2, 3
• Smoking status (though not contraindicated in women <35 years) 3
• Cardiovascular disease risk factors 2

Follow-Up Strategy

• No routine follow-up visit required for contraceptive management alone 1, 2
• Patient should return for side effects or concerns 1, 2
• Reassure that breakthrough bleeding is common in first 3-6 months and generally not harmful 1, 2
• Re-evaluate for underlying gynecological problems if bleeding persists beyond initial months despite treatment 1, 2
• Monitor blood pressure at any follow-up visits 2, 3

Common Pitfalls to Avoid

• Do not dismiss bleeding without ruling out pregnancy, infection, or structural pathology 1
• Do not start empiric iron therapy alone without addressing the underlying bleeding disorder 7
• Do not ignore thyroid optimization - uncontrolled hypothyroidism will perpetuate both bleeding and anemia 4, 5
• Do not recommend hormone-free intervals during the first 21 days of extended/continuous CHC regimens 1
• Do not overlook the endometrial cancer risk in PCOS patients with chronic anovulation - COCs provide protective benefit 4, 3