Is it safe for a 28-year-old female with endometriosis, adenomyosis, urethral stenosis, high myopia, PCOS, and a history of UTIs, kidney stones, and CNVM to start Dianne 35 (cyproterone acetate and ethinyl estradiol) for hirsutism while taking Primrose oil supplement and myoinositol?

Safety and Recommendation for Diane 35 in This Clinical Context

I recommend AGAINST starting Diane 35 (cyproterone acetate/ethinyl estradiol) in this patient due to the absolute contraindication of active choroidal neovascular membrane (CNVM) requiring ongoing anti-VEGF injections, which represents active vascular disease that significantly increases thrombotic risk when combined with combined oral contraceptives. 1

Critical Contraindications Present

Your patient has active vascular disease (CNVM with ongoing monthly injections), which creates an unacceptable risk profile for combined oral contraceptives:

• Vascular complications: Combined oral contraceptives containing ethinyl estradiol increase venous thromboembolism (VTE) risk from baseline 1 per 10,000 woman-years to 3-4 per 10,000 woman-years 2, 1
• Drospirenone-specific concerns: Diane 35 contains drospirenone, which carries a slightly higher VTE risk compared to levonorgestrel-containing pills 2
• Active neovascular disease: Your CNVM represents ongoing pathological angiogenesis and vascular instability, which combined with estrogen's prothrombotic effects creates compounded risk 1
• Low blood pressure (90/70): While not an absolute contraindication, this suggests potential cardiovascular instability that warrants caution with hormonal therapy 1

Alternative Management Strategy for Your Conditions

For Hirsutism and PCOS Management:

First-line approach without combined oral contraceptives:

• Lifestyle modification is mandatory: Target 5-10% weight loss through 500-750 kcal/day energy deficit, with at least 150 minutes/week moderate-intensity exercise 3, 4
• Metformin 500-2000 mg daily: Given your metabolic profile (elevated AST 75, ALT 44, borderline eGFR 87, low progesterone 0.58), metformin addresses insulin resistance without thrombotic risk 3, 4
• Spironolactone 100-200 mg daily: This is the first-line antiandrogen for moderate-to-severe hirsutism and can be used WITHOUT combined oral contraceptives if you use reliable non-hormonal contraception 5, 6, 7
• Continue myoinositol: This supports metabolic management in PCOS 3

For Endometriosis/Adenomyosis Pain:

Progestin-only options are safer:

• Medroxyprogesterone acetate (progestin-only): Suppresses androgens, controls adenomyosis-related pain, and avoids estrogen-related thrombotic risk 4
• This addresses both your severe PMS back pain and provides endometrial protection without the vascular risks of combined oral contraceptives 4

For Menstrual Regulation:

• Cyclic progestin therapy: Medroxyprogesterone acetate 10 mg for 10-14 days per month regulates cycles without estrogen exposure 4
• Metformin alone: Can improve menstrual regularity in PCOS through metabolic pathways 3, 4

Specific Concerns About Your Supplement Regimen

Evening primrose oil interaction: While not specifically contraindicated, primrose oil has antiplatelet effects that could theoretically interact with your anti-VEGF injections for CNVM. Discuss this with your ophthalmologist managing your injections 1

Mandatory Metabolic Surveillance

Given your laboratory abnormalities, you require comprehensive monitoring regardless of treatment choice:

• Elevated liver enzymes (AST 75, ALT 44): Require monitoring before starting any hormonal therapy; these levels make combined oral contraceptives relatively contraindicated 3, 4
• Borderline kidney function (eGFR 87): Important for spironolactone dosing and potassium monitoring 1
• Anemia (HB 11.5) and elevated ESR (32): Suggest chronic inflammation from endometriosis/adenomyosis requiring treatment 4
• Screen for diabetes: Fasting glucose followed by 2-hour glucose tolerance test given PCOS and family history 3, 4

Critical Pitfalls to Avoid

• Do NOT use Diane 35 with active vascular disease: The CNVM represents an absolute contraindication that supersedes hirsutism treatment 1
• Do NOT use spironolactone without reliable contraception: It causes fetal abnormalities; use barrier methods or progestin-only contraception 5, 7
• Do NOT delay lifestyle intervention: This must be the foundation, not an afterthought, for both PCOS and metabolic health 3, 4
• Do NOT ignore the elevated liver enzymes: These require investigation and monitoring before any hormonal therapy 3

Recommended Treatment Algorithm

Immediate (Month 1-3):

• Start metformin 500 mg daily, titrate to 1500-2000 mg over 4-6 weeks 3, 4
• Begin spironolactone 50 mg daily, increase to 100 mg after 2 weeks if tolerated 5, 7
• Implement lifestyle modifications: 500-750 kcal/day deficit, 150 min/week exercise 3, 4
• Start cyclic medroxyprogesterone acetate 10 mg days 14-25 of cycle for menstrual regulation and endometrial protection 4
• Use reliable barrier contraception (condoms) 5

Month 3-6:

• Reassess hirsutism score, menstrual regularity, and metabolic parameters 3, 4
• Consider increasing spironolactone to 150-200 mg if hirsutism persists 5, 7
• Repeat liver function tests, fasting glucose, lipid profile 3, 4

Month 6-12:

• Continue all therapies; hirsutism improvement requires minimum 6-12 months 5, 7
• Add topical eflornithine for facial hirsutism if needed 5
• Consider laser hair removal (alexandrite or diode) for permanent reduction 5

Coordinate with your ophthalmologist regarding the safety timeline for any future hormonal contraception after CNVM stabilizes, though current active disease absolutely contraindicates combined oral contraceptives 1