Pharmacologic management of PCOS: Menstrual irregularities

Females with less than 8 menstrual cycles in a year need further evaluation in view of the Rotterdam criteria. The most common presentation of polycystic ovary syndrome (PCOS) is menstrual irregularities in 60% to 85% of females. The high blood androgen level, increase in luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, raised insulin, with high number of follicular counts leads to anovulation and menstrual disorders. Chronic anovulation because of unopposed estrogen dominancy and failure to produce progesterone proceeds to endometrial cell proliferation and endometrial hyperplasia with the probability of ending in endometrial cancers. The mainstay of treatment is weight reduction with lifestyle modification. The combined oral contraceptive pills (COCPs) should be added to regularize the menstrual cycle. The estrogen component of COCPs should be near to natural estradiol with the lowest possible dose. The estradiol valerate is preferable because of fewer metabolic side effects. The antiandrogenic property of the progesterone in COCPS is desirable. Both drospirenone and cyproterone are considered the progesterones of choice in patients with menstrual irregularities along with features of hyperandrogenism. The second-line management depends on the phenotype of PCOS. Insulin sensitizers, like metformin and inositol, can be used either alone or in combination with COCPs for females with insulin resistance. Similarly, those with hyperandrogenism get benefit by adding an antiandrogen to COCPs.