What is the best birth‑control method for women with polycystic ovary syndrome?

Best Birth Control for PCOS

For women with PCOS who are not attempting to conceive, a monophasic combined oral contraceptive containing 30-35 μg ethinyl estradiol with drospirenone is the recommended first-line birth control method. 1

Specific COC Formulation Recommendations

The preferred formulation is a monophasic COC with 30-35 μg ethinyl estradiol combined with drospirenone, as this provides optimal cycle control, androgen suppression, and menstrual regulation in PCOS patients. 1

Alternative progestin options include:

• Levonorgestrel (30-35 μg ethinyl estradiol) 1
• Norgestimate (30-35 μg ethinyl estradiol), which has a favorable side effect profile 2

Administration Strategy

Use the standard 28-day pack containing 21-24 hormone pills followed by 4-7 placebo pills. 1

For patients with severe PCOS symptoms:

• Consider extended or continuous cycling (eliminating the hormone-free interval) to optimize ovarian suppression and potentially increase contraceptive effectiveness 1
• This approach is particularly beneficial for those with severe dysmenorrhea or menorrhagia 1

Why COCs Are First-Line for PCOS

Combined oral contraceptives provide multiple therapeutic benefits beyond contraception:

• Suppress ovarian androgen secretion and increase sex hormone-binding globulin, reducing hirsutism and acne 2, 3
• Regulate menstrual cycles and provide endometrial protection against hyperplasia and cancer 2, 4
• Long-term use (>3 years) significantly protects against endometrial and ovarian cancers 1
• Completely reversible with no negative effect on future fertility 2

Pre-Treatment Risk Assessment

Before prescribing, document the following absolute contraindications:

• Age ≥35 years AND current smoking 1
• Blood pressure ≥160/100 mm Hg 1
• Migraine with aura (stroke risk) 1
• History of venous thromboembolism 1

Obtain baseline metabolic screening:

• Fasting glucose and 2-hour oral glucose tolerance test 2, 3
• Fasting lipid profile 2, 3
• BMI and waist-hip ratio 2, 3
• Blood pressure 1

Important Nuances About VTE Risk

The absolute risk of venous thromboembolism remains low despite relative risk increases with COC use:

• Baseline risk in reproductive-age women: 1 per 10,000 woman-years 1, 2
• Risk with COC use: 3-4 per 10,000 woman-years 1, 2
• Drospirenone carries slightly higher VTE risk than levonorgestrel, though absolute risk remains low 1

No evidence suggests increased cardiovascular events in PCOS patients using COCs compared to the general population. 1

Metabolic Monitoring Strategy

For PCOS patients with pre-existing insulin resistance or metabolic concerns:

• Monitor metabolic parameters at 3-6 months after initiating therapy 1
• Repeat cardiovascular risk screening every 6-12 months (weight, blood pressure, lipids, glycemic control) 2
• Consider combining COCs with metformin (500-2000 mg daily) if insulin resistance or glucose intolerance is documented 1, 3
• Implement lifestyle modification targeting 5-10% weight loss through 500-750 kcal/day deficit 2, 3

Practical Prescribing Details

Initiation timing:

• If started within first 5 days of menstrual bleeding: no backup contraception needed 2
• If started >5 days since bleeding: use backup contraception for first 7 days 2
• For patients with infrequent menses: start anytime if reasonably certain not pregnant, with 7 days backup contraception 2

Follow-up schedule:

• 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
• Counsel that transient side effects (irregular bleeding, headache, nausea) are common in first 1-3 months 1

Common Pitfalls to Avoid

Do not require pelvic examination before prescribing COCs – it is unnecessary for determining eligibility. 1

Do not withhold COCs from adolescents or women <35 years who smoke – smoking is not a contraindication in this age group. 1

For metabolically healthy PCOS patients with regular cycles, recognize that long-term COC use masks the natural menstrual pattern, preventing monitoring of ovarian activity and PCOS status. 1 In these specific patients, COCs are most appropriate when treating specific symptoms like dysmenorrhea or menorrhagia, rather than as routine therapy. 1

Alternative: Progestin-Only Regimens

If COCs are contraindicated or not tolerated, use cyclic progestin therapy:

• Medroxyprogesterone acetate 10 mg daily for 12-14 days per month (most robust evidence for endometrial protection) 2
• Oral micronized progesterone 200 mg daily for 12-14 days per month (superior safety profile with lower cardiovascular and thrombotic risk) 2

However, progestin-only regimens do not provide contraception and do not suppress ovarian androgen production as effectively as COCs. 2