PCOS treatment based on symptoms

Letrozole (Femara) is first-line for infertility in patients with PCOS. It’s more effective at improving pregnancy rates than clomiphene (Clomid)....

As a community pharmacist, you will get questions abouttreatm ent of polycystic ovary syndrome (PCOS), since it affects about 1.4 million Canadian women. They often need help managing irregular periods, excess androgen (acne, hirsutism, etc) and CV risks (obesity, diabetes, etc). Plus PCOS is one of the most common causes of infertility...

Continue to evaluate and treat CV risk factors. Emphasize that a 5% to 10% weight loss may improve irregular periods, hirsutism, metabolic effects and pregnancy rates. Ask patients how they’re coping, PCOS symptoms can trigger anxiety, depression, or eating disorders. If symptoms affect daily function, ensure patients are connected to a primary care provider, counsellor, etc.

Tailor medication options based on patient goals, symptoms, etc. COMBINED hormonal contraceptives are still first-line for irregular menses, acne, and hirsutism. Suggest a low-dose combo OC based on comorbidities, risks (age, weight, etc), and preferences. Advise that progestin-only contraceptives are not as effective as combined hormonal contraceptives for PCOS symptoms.

Letrozole (Femara) is first-line for infertility in patients with PCOS. It’s more effective at improving pregnancy rates than clomiphene (Clomid) and clomiphene is no longer on the market.
Metformin (Glucophage) is NOT first-line for irregular periods, hirsutism, or infertility.

There’s not much evidence it’s better than lifestyle changes. But continue to recommend metformin for patients with PCOS and diabetes or prediabetes.
Also suggest it second-line for irregular periods, if patients can’t use a combined hormonal contraceptive.

Spironolactone can help with hirsutism or acne. Suggest it as an add-on to hormonal contraceptives.

But avoid spironolactone in pregnancy, due to possible birth defects.

References

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. Obstet Gynecol. 2018 Jun;131(6):e157-e171.
Al Wattar BH, Fisher M, et al. Clinical Practice Guidelines on the Diagnosis and Management of Polycystic Ovary Syndrome: A Systematic Review and Quality Assessment Study. J Clin Endocrinol Metab. 2021 Jul 13;106(8):2436-2446.
Franik S, Le QK, et al. Aromatase inhibitors (letrozole) for ovulation induction in infertile women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2022 Sep 27;9(9):CD010287.