From the Guidelines
For women with PCOS experiencing amenorrhea, combined oral contraceptive pills (COCPs) are the preferred treatment over progesterone-only options. This recommendation is based on the benefits of COCPs in suppressing androgen secretion by the ovaries, increasing the level of circulating sex hormone binding globulin, and reducing the risk of endometrial cancer, as noted by the American College of Obstetricians and Gynecologists (ACOG) 1. The use of COCPs addresses multiple aspects of PCOS, including regulating menstrual cycles, reducing androgen levels, and protecting the endometrium from unopposed estrogen.
Key benefits of COCPs in PCOS management include:
- Regulation of menstrual cycles
- Reduction of androgen levels
- Protection of the endometrium from unopposed estrogen
- Provision of contraception In contrast, progesterone-only options, such as medroxyprogesterone acetate, may induce withdrawal bleeding but do not offer the same hormonal balance benefits as COCPs. Progesterone-only options may be considered for women with contraindications to estrogen, such as a history of thromboembolism, uncontrolled hypertension, migraines with aura, or those over 35 who smoke. However, for most women with PCOS and amenorrhea, COCPs are the first-line treatment due to their comprehensive benefits, as supported by the ACOG guidelines 1.
From the Research
Treatment Options for PCOS with Amenorrhea
- Combined oral contraceptives (COCs) are considered a first-line treatment for regulating menstrual cycles in women with PCOS who are not seeking fertility 2, 3.
- COCs have the added benefit of reducing the risk of endometrial hyperplasia and cancer 2, 3.
- Progestin-only options are also available for women with PCOS, and can help regulate menstrual cycles and reduce the risk of endometrial hyperplasia and cancer 2.
- Metformin is an alternative medical option for improving ovulation rates in women with PCOS who cannot take combined hormone contraception or are attempting conception 2.
Comparison of COCs and Progestin-Only Options
- COCs have been shown to improve menstrual cyclicity, hyperandrogenism, and reduce the risk of endometrial cancer in women with PCOS 3, 4.
- However, COCs may increase the risk of venous thromboembolism (VTE) and cardiometabolic risk factors, such as obesity, glucose intolerance, and dyslipidemia 3, 4.
- Progestin-only options, such as medroxyprogesterone acetate (MPA), have been shown to provide good menstrual cycle control and beneficial changes in hormonal values associated with hyperandrogenism, without significant changes in lipid or carbohydrate metabolism 5.
Considerations for Treatment
- Individual risk assessment is key to avoiding unfavorable outcomes related to COC use in women with PCOS 3.
- Patients should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC, and re-assessed at consecutive visits 3.
- The choice of treatment should be based on the individual patient's needs and medical history, and may involve a combination of lifestyle modifications, hormonal contraception, and other medical therapies 2, 3, 6.