What is the best course of treatment for a 19-year-old female with Polycystic Ovary Syndrome (PCOS), amenorrhea, vitamin D and iron deficiency, hyperandrogenism (elevated testosterone levels), hirsutism, and hair loss, who is hesitant to take birth control due to concerns about worsening hair loss and mood swings, and has sharp right hip pain?

Management of PCOS with Amenorrhea, Hyperandrogenism, and Hair Loss in a 19-Year-Old

For this 19-year-old with PCOS, amenorrhea, and hyperandrogenism, combined oral contraceptives (COCs) remain the first-line treatment for menstrual regulation and endometrial protection despite her concerns, as they effectively suppress ovarian androgen production and regulate cycles, while spironolactone should be added specifically for hair loss and hirsutism. 1, 2, 3

Primary Hormonal Management

Combined Oral Contraceptives (Addressing Her Concerns)

• COCs are the guideline-recommended first-line treatment for women with PCOS not seeking pregnancy to regulate menstrual cycles, provide endometrial protection, and suppress ovarian androgen secretion. 2, 3
• Her concern about hair loss worsening with OCPs is not supported by evidence—OCPs actually reduce androgens and should improve androgenic alopecia over time by suppressing ovarian testosterone production. 1, 3
• Regarding mood concerns: while individual responses vary, OCPs do not systematically worsen mood in most women, and her current mood symptoms (fatigue, decreased motivation, mood swings) are likely related to untreated PCOS, vitamin D deficiency, iron deficiency, and prolonged amenorrhea rather than potential OCP use. 2, 3
• The one-year amenorrhea with only occasional spotting creates significant endometrial cancer risk that requires urgent intervention—either with COCs or cyclic progestin (Provera) to induce withdrawal bleeding and prevent endometrial hyperplasia. 2, 3

Spironolactone for Hyperandrogenism

• Add spironolactone 50-200 mg daily specifically for androgenic alopecia and facial hirsutism, as recommended by dermatology guidelines for hyperandrogenic symptoms. 1, 4
• Spironolactone works synergistically with OCPs by blocking androgen receptors while OCPs reduce androgen production. 1, 4, 3
• Potassium monitoring is unnecessary in young healthy patients without risk factors for hyperkalemia (older age, renal disease, or medications affecting potassium). 1
• Hair regrowth takes 6-12 months; set realistic expectations about timeline. 1

Nutritional Deficiency Correction

Vitamin D Supplementation (Critical Priority)

• Vitamin D deficiency is strongly associated with PCOS symptoms including insulin resistance, hirsutism, and menstrual irregularity, and supplementation improves these outcomes. 5, 6, 7
• Prescribe vitamin D3 50,000 IU weekly for 12 weeks based on evidence showing this dose significantly decreased androgens, hirsutism scores, and improved menstrual regularity in overweight PCOS patients. 8
• After 12 weeks, transition to maintenance dosing (typically 1,000-2,000 IU daily) and recheck 25(OH)D levels. 8
• Vitamin D supplementation combined with metformin produces superior outcomes for menstrual regularity compared to either alone. 9

Iron Replacement

• Replete iron deficiency with oral iron supplementation (ferrous sulfate 325 mg daily or as tolerated). [@General Medicine Knowledge@]
• Iron deficiency contributes to fatigue and may worsen hair loss independent of PCOS. [@General Medicine Knowledge@]
• Recheck complete blood count and ferritin in 8-12 weeks. [@General Medicine Knowledge@]

Metabolic Management

Lifestyle Modification (Foundation)

• Target just 5% weight loss through multicomponent lifestyle intervention—this modest reduction improves metabolic parameters, ovulation rates, and pregnancy outcomes in PCOS. 2, 3
• Prescribe at least 150 minutes per week of moderate-intensity activity plus muscle-strengthening exercises on 2 non-consecutive days per week. 3
• Reduce sugar-sweetened beverages, emphasize low glycemic index foods, high fiber, and anti-inflammatory dietary patterns. 3

Metformin Consideration

• Add metformin 500-2,000 mg daily (titrate gradually) as the preferred insulin-sensitizing agent, which decreases circulating androgens including those of adrenal origin, improves glucose tolerance, and tends to decrease weight. 2, 3
• Metformin combined with vitamin D and calcium produces better menstrual regularity outcomes than either intervention alone. 9
• Metformin has a favorable safety profile and appears safe in pregnancy if conception occurs. 2

Metabolic Screening (Mandatory)

Baseline Laboratory Evaluation

• Perform 2-hour oral glucose tolerance test with 75-gram glucose load to detect type 2 diabetes and glucose intolerance, as PCOS patients have high rates of insulin resistance. 3
• Obtain fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) as insulin resistance drives atherogenic dyslipidemia. 4, 3
• Check TSH to exclude thyroid disease. 3
• Measure prolactin to exclude hyperprolactinemia. 3
• Examine for acanthosis nigricans indicating underlying insulin resistance. 3
• Recheck vitamin D (25(OH)D) and iron studies/ferritin. 8

Hip Pain Evaluation (Separate Issue)

Orthopedic Assessment Required

• The 3-week history of sharp right hip pain with walking/running that feels like "something is out of place" requires dedicated orthopedic or sports medicine evaluation. [@General Medicine Knowledge@]
• Consider hip labral tear, femoroacetabular impingement, iliopsoas tendinitis, or stress fracture—particularly concerning given her vitamin D deficiency which increases fracture risk. [@General Medicine Knowledge@]
• Plain radiographs of the hip are the initial imaging study; MRI may be needed if plain films are unrevealing. [@General Medicine Knowledge@]
• Do not attribute musculoskeletal pain to PCOS—this requires separate diagnostic workup. [@General Medicine Knowledge@]

Critical Pitfalls to Avoid

• Do not delay endometrial protection—one year of amenorrhea creates substantial endometrial hyperplasia and cancer risk that requires immediate intervention with either COCs or cyclic progestin. 2, 3
• Do not accept her refusal of OCPs without thorough education—her concerns about hair loss and mood are not evidence-based contraindications, and the benefits clearly outweigh theoretical risks in her case. 1, 2, 3
• If she absolutely refuses OCPs, she must receive cyclic progestin (medroxyprogesterone acetate 10 mg for 10-14 days every 1-3 months) to induce withdrawal bleeding and protect the endometrium. 2, 3
• Minoxidil discontinuation was premature—topical minoxidil 5% is effective for androgenic alopecia but requires consistent daily use for 6-12 months before judging efficacy; inconsistent use guarantees failure. 1
• Thiazolidinediones are inferior to metformin as they increase weight and have less favorable risk-benefit profiles. 3
• Do not overlook the hip pain—vitamin D deficiency increases stress fracture risk, and this symptom requires dedicated evaluation. [@General Medicine Knowledge@]

Follow-Up Timeline

• Return in 4-6 weeks to assess tolerance of OCPs, spironolactone, metformin, and vitamin D supplementation. [@General Medicine Knowledge@]
• Recheck labs (glucose tolerance test, lipids, vitamin D, iron studies) at 3 months. 3, 8
• Reassess hair loss and hirsutism at 6 months—earlier assessment is premature as hormonal treatments require this duration for visible improvement. 1
• Schedule overdue annual wellness exam including cervical cancer screening given recent colposcopy for abnormalities. [@General Medicine Knowledge@]