What is the best approach to manage a 35-year-old female patient with acne, hyperpigmentation, painful periods, hair loss, graying of hair, painful scalp bumps, obesity (body fat 33%), hirsutism, and a history of simple uterine polyp (post polypectomy)?

Management of Suspected PCOS with Hyperandrogenism and Metabolic Features

Primary Diagnosis and Initial Evaluation

This patient's presentation—acne, hirsutism, painful periods, obesity, and history of uterine polyp—strongly suggests polycystic ovary syndrome (PCOS), which accounts for 70-80% of hirsutism cases and requires immediate hormonal and metabolic evaluation. 1

Essential Diagnostic Workup

The following laboratory tests must be obtained in the morning to confirm hyperandrogenism and exclude alternative diagnoses:

• Total and free testosterone measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) as first-line tests (sensitivity 74-89%, specificity 83-86%) 2
• DHEAS to assess adrenal androgen production and screen for non-classical congenital adrenal hyperplasia 1, 2
• 17-hydroxyprogesterone to exclude non-classical congenital adrenal hyperplasia, particularly given the severity of symptoms 1, 3
• LH and FSH to calculate LH/FSH ratio (>2 suggests PCOS) 1, 2
• TSH and prolactin to exclude thyroid disease and hyperprolactinemia 1, 2
• Fasting glucose, 2-hour oral glucose tolerance test, and fasting lipid panel to screen for insulin resistance, diabetes, and cardiovascular risk 2

Imaging Studies

• Pelvic ultrasound to assess for polycystic ovarian morphology (>10 peripheral cysts, 2-8 mm diameter, with thickened ovarian stroma) 1

First-Line Treatment: Combined Oral Contraceptives

Combined oral contraceptives (COCs) are the recommended first-line therapy for this patient, as they address multiple manifestations: acne, hirsutism, painful periods, and reduce ovarian androgen production. 4, 1

COC Selection and Mechanism

COCs work by decreasing ovarian androgen production, increasing sex hormone-binding globulin (which binds free testosterone), reducing 5-alpha-reductase activity, and blocking androgen receptors 4. Four COCs are FDA-approved specifically for acne treatment: ethinyl estradiol/norgestimate, ethinyl estradiol/norethindrone acetate/ferrous fumarate, ethinyl estradiol/drospirenone, and ethinyl estradiol/drospirenone/levomefolate 4.

Critical: Avoid COCs containing androgenic progestins (norethisterone derivatives or levonorgestrel), as these can worsen hirsutism. 1

Contraindications to Assess

Before prescribing COCs, verify this 35-year-old patient does not have:

• Smoking history (≥15 cigarettes/day is absolute contraindication at age ≥35) 4
• Hypertension (systolic ≥160 or diastolic ≥100 is absolute contraindication) 4
• History of deep vein thrombosis, pulmonary embolism, or ischemic heart disease 4
• Migraine with focal neurologic symptoms 4
• Active liver disease or history of breast cancer 4

Adjunctive Anti-Androgen Therapy

If hirsutism is moderate to severe (modified Ferriman-Gallwey score assessment needed), add spironolactone 50-200 mg daily to the COC regimen after 3-6 months if COC alone provides insufficient improvement. 1, 5, 6

Spironolactone acts as a peripheral androgen receptor blocker and has demonstrated effectiveness in reducing hirsutism to 53.5% of baseline at 1 year when combined with ethinyl estradiol 6. Treatment must continue for at least 6-12 months to see clinical benefit, as hair growth cycles are slow 7.

Important caveat: Spironolactone is teratogenic; ensure reliable contraception (the COC serves this purpose) 8. Monitor potassium levels, particularly if the patient has renal impairment 8.

Metabolic Management

Given obesity (body fat 33%) and likely insulin resistance (common in PCOS), initiate metformin 500-2000 mg daily in divided doses alongside lifestyle modification. 1, 7

Weight Loss and Lifestyle Intervention

A 5% weight reduction through diet and exercise improves metabolic and reproductive abnormalities in obese women with PCOS. 1 This is not optional—it directly impacts androgen levels, insulin sensitivity, and menstrual regularity 9, 10.

Specific recommendations:

• Structured dietary counseling focusing on caloric restriction and low glycemic index foods 10
• Regular aerobic exercise (150 minutes weekly minimum) 10
• Behavioral strategies to ensure adherence 10

Management of Specific Symptoms

Acne Treatment

Combine the COC with topical retinoid (adapalene or tretinoin) and benzoyl peroxide for active acne. 4 Topical retinoids address comedonal acne and are recommended as first-line for acne maintenance 4. Benzoyl peroxide prevents bacterial resistance and should be used with any antibiotic therapy 4.

For post-inflammatory hyperpigmentation, add azelaic acid 15-20% cream or gel. 4

Hair Loss Management

The scalp symptoms (painful bumps, hair loss, graying) require clarification:

• Painful scalp bumps without redness/drainage may represent folliculitis decalvans or dissecting cellulitis—refer to dermatology if persistent 4
• Androgenic alopecia should improve with androgen suppression from COCs and spironolactone over 12-24 months 5, 6
• Premature graying is not typically androgen-related; evaluate thyroid function and nutritional deficiencies (B12, folate) 2

Dysmenorrhea

The COC will address painful periods by suppressing ovulation and reducing endometrial prostaglandin production. 4 If breakthrough dysmenorrhea persists, add NSAIDs during menses 4.

Monitoring and Follow-Up

Timeline for Clinical Response

• Acne improvement: 3-6 months 4
• Hirsutism reduction: 6-12 months minimum (hair growth cycles are 6 months) 6, 7
• Menstrual regularity: 1-3 cycles 4
• Metabolic parameters: Reassess glucose, lipids, and weight at 3-6 months 2

Long-Term Considerations

Treatment duration should be at least 2 years for hirsutism and alopecia. 5 PCOS is a chronic condition requiring ongoing management 9, 10.

Screen annually for metabolic complications: type 2 diabetes, dyslipidemia, hypertension, and non-alcoholic fatty liver disease, as PCOS significantly increases these risks 9, 10.

Common Pitfalls to Avoid

• Do not assume PCOS without measuring 17-hydroxyprogesterone—non-classical congenital adrenal hyperplasia presents identically and requires different management 1, 3
• Do not use topical antibiotics as monotherapy for acne—this promotes bacterial resistance; always combine with benzoyl peroxide 4
• Do not expect rapid improvement in hirsutism—counsel patients that visible reduction takes 6-12 months, and premature discontinuation is common 7
• Do not neglect psychological impact—PCOS causes significant distress and poor quality of life; provide strong clinical support and consider mental health referral 9, 6
• Do not overlook the uterine polyp history—while simple polyps are common, ensure adequate surveillance given unopposed estrogen exposure from chronic anovulation 4

Alternative if COCs Contraindicated

If this patient has contraindications to COCs (smoking, hypertension, thrombotic risk):

Use metformin 1500-2000 mg daily plus spironolactone 100-200 mg daily, with mandatory reliable contraception (barrier method or progestin-only method). 1, 7 This combination addresses insulin resistance and provides anti-androgenic effects, though it is less effective than COCs for menstrual regulation 7.