What is the preferred first‑line contraceptive for a reproductive‑age woman with polycystic ovary syndrome, including dosing, regimen, contraindications, and alternative options for symptom control?

Combined Oral Contraceptives for PCOS: First-Line Hormonal Therapy

For reproductive-age women with PCOS, prescribe a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with drospirenone as first-line therapy. 1

Specific Formulation and Dosing

• First-line choice: Monophasic COC with 30-35 μg ethinyl estradiol + drospirenone 1
• Alternative options: 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate if drospirenone is not tolerated or contraindicated 1
• Standard regimen: 28-day pack (21-24 active hormone pills followed by 4-7 placebo pills) 1
• Extended/continuous cycling: Consider for patients with severe menstrual symptoms or dysmenorrhea, as eliminating the hormone-free interval optimizes ovarian suppression 1

Clinical Benefits in PCOS

COCs provide multiple therapeutic benefits beyond contraception in PCOS patients:

• Menstrual regulation: Restores regular menstrual cycles and improves ovulatory dysfunction 1, 2, 3
• Androgen suppression: Reduces hirsutism and acne by suppressing ovarian androgen production 2, 4
• Cancer prevention: Long-term use (>3 years) provides significant protection against endometrial and ovarian cancers 1
• Endometrial protection: Prevents endometrial hyperplasia in women with chronic anovulation 3

Contraindications - Mandatory Pre-Treatment Assessment

Before prescribing, document these absolute contraindications:

• Age ≥35 years AND current smoking 1
• Blood pressure: Systolic ≥160 or diastolic ≥100 mm Hg 1
• Migraine with aura (stroke risk) 1
• History of venous thromboembolism (VTE) 2, 4
• Known thrombophilia 2, 4
• Active or history of arterial thrombosis 2

Important: Smoking in women <35 years is NOT a contraindication to COC use 1. A pelvic examination is not required before prescribing COCs 1.

Cardiometabolic Risk Assessment

While COCs are safe for most PCOS patients, individual risk stratification is essential:

Venous Thromboembolism Risk

• Baseline risk: 1 per 10,000 woman-years in reproductive-age women 1
• With COC use: Increases to 3-4 per 10,000 woman-years 1, 2
• Progestin variation: Drospirenone carries slightly higher VTE risk than levonorgestrel, though absolute risk remains low 1, 4
• No increased cardiovascular events in PCOS patients compared to general population with COC use 1

Metabolic Considerations

• Document at baseline: Age, smoking status, BMI, blood pressure, glucose tolerance status (including prediabetes), lipid profile, family history of VTE 2, 4
• Insulin resistance: COCs may decrease insulin sensitivity, particularly in obese patients, though this effect is reversible and diabetes incidence is not increased in past COC users 5
• Diabetes risk: Potential increased risk only in morbidly obese women with severe insulin resistance 2
• Monitor metabolic parameters at 3-6 months after initiation, especially in patients with pre-existing insulin resistance 1

Combination Therapy Approach

For PCOS patients with significant metabolic concerns:

• Combine COCs with weight reduction programs 1
• Add metformin as insulin-sensitizing agent for patients with hyperglycemia or significant metabolic dysfunction 1, 3
• Metformin is first-line for metabolic manifestations like hyperglycemia, while COCs are first-line for menstrual irregularity and dermatologic symptoms 3

Practical Management

Initiation and Follow-up

• Prescribe up to 1 year supply at a time to improve adherence 1
• Schedule follow-up at 1-3 months to address adverse effects or adherence issues 1
• Reassess at 3-6 months for metabolic parameters and clinical response 1
• Counsel patients that transient side effects (irregular bleeding, headache, nausea) are common in first 1-3 months 1
• Provide clear instructions on proper pill-taking and missed pill protocols 1

When to Adjust Therapy

• Consider changing formulation if side effects are problematic or clinical response is inadequate 1
• If metabolic parameters worsen significantly, reassess risk-benefit ratio 4

Common Pitfalls to Avoid

• Do not withhold COCs from adolescents or women <35 who smoke - smoking is not a contraindication in this age group 1
• Do not require pelvic examination before prescribing - it is unnecessary for determining COC eligibility 1
• Do not overlook baseline risk assessment - individual cardiometabolic risk stratification is key to avoiding unfavorable outcomes 4
• Do not ignore metabolic syndrome - PCOS patients have twice the prevalence of metabolic syndrome and are four times more likely to develop type 2 diabetes 3