Board Review

A 25-year-old woman is evaluated after a recent diagnosis of polycystic ovary syndrome. She is concerned about hirsutism and irregular menses. She has no desire to be pregnant at this time. She takes no medications.

On physical examination, she is afebrile. Blood pressure is 110/60 mm Hg, pulse rate is 68/min, and respiration rate is 16/min; BMI is 37. Coarse hair is noted on the chin, jawline, and periumbilical area. The remainder of her physical examination, including pelvic examination, is normal.

Which of the following is the most appropriate treatment?

A) Combined oral contraceptive pills

B) Intermittent progestin withdrawal

C) Levonorgestrel intrauterine system

D) Spironolactone therapy

Answer: A - Combined oral contraceptive pills

Objective: Treat irregular menses and hirsutism in a patient with polycystic ovary syndrome.

Key Point

The combined oral contraceptive pill is the optimal treatment to address both irregular menses and hirsutism in patients with polycystic ovary syndrome.

The most appropriate treatment is combined oral contraceptive pills. Hirsutism is present in approximately 70% of women with polycystic ovary syndrome (PCOS). The combined oral contraceptive pill is the optimal treatment to address both this patient's concerns of menstrual irregularity and hirsutism. The estrogen component increases hepatic production of sex hormone–binding globulin, decreasing the patient's circulating free testosterone level. For women in whom hirsutism is a major concern, treatment is focused on reducing androgen production, decreasing the fraction of circulating free testosterone, and limiting androgen bioactivity to hair follicles. Coarse, thick hairs that are already noted on examination will need to be removed with a depilatory method; however, terminal hair growth will be slowed with combined oral contraceptive use. Oral contraceptives that contain 30 to 35 µg of ethinyl estradiol appear to be more effective in managing hirsutism than formulations containing less ethinyl estradiol. Six months of treatment is considered the minimal interval in which to determine the level of response. Adherence to an oral contraceptive regimen will provide this patient with predictable menses as well as contraceptive benefit. In addition, the risk of endometrial hyperplasia is diminished.

Intermittent progesterone withdrawal, although effective for decreasing the risk of endometrial hyperplasia, would have no effect on this patient's concern regarding hirsutism.

The levonorgestrel intrauterine system is a long-acting, reversible contraceptive device that diminishes long-term risk of endometrial hyperplasia in patients with PCOS; however, it provides no benefit for hirsutism and has no effect on androgen production.

Spironolactone is a potent antiandrogen and is very effective against male-pattern hirsutism in patients with PCOS. However, it offers no benefit for control of the menstrual cycle. When spironolactone is prescribed, patients should be counseled regarding the potential teratogenicity in male fetuses, and a concurrent reliable contraceptive method should be established to prevent fetal exposure. Pregnancy can still occur in patients with oligo-ovulatory PCOS, and reliance on menstrual irregularity is not a substitute for a more proven contraceptive plan.

Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Consensus on women's health aspects of polycystic ovary syndrome (PCOS). Hum Reprod. 2012 Jan;27(1):14-24. Link Out