Big shout out to Andrey Dolinko, MD, who suggested today’s topic!
ACOG PB 194 is an excellent resource for your studying on PCOS (membership required).
PCOS is a syndrome, diagnosed clinically by at least 2/3 of the Rotterdam criteria:
1. Hyperandrogenism - hirsutism, male pattern baldness.
2. Oligo- or amenorrhea - 3+ months without menses.
3. Polycystic ovaries on ultrasound - 12+ follicles or increased ovarian volume.
In terms of treatment, the big take home message is to understand whether your patient is planning on pregnancy or not. CHCs are the mainstay therapy of patients not desiring pregnancy due to their multimodal method of action - regulation of HPO axis, increased SHBG, and endometrial protection. Also remember metformin (insulin sensitization) and spironolactone, finasteride, or flutamide (anti-androgens) as other adjuncts in patients not desiring pregnancy.
In those desiring pregnancy, oftentimes the complaint will be infertility. While letrozole is now preferred for ovulation induction over clomiphene due to a higher live-birth rate, letrozole does not yet enjoy FDA approval. For the other symptoms of PCOS in patients desiring pregnancy, the first line therapy is lifestyle modification! The literature doesn’t support metformin for ovulation induction, but some may use it for its other benefits prior to pregnancy.
We didn’t discuss laparoscopic ovarian drilling in this episode, but that would be another surgical treatment for PCOS-related infertility.