The question of whether or not to treat PCOS with conventional prescription medications is a highly personal choice. If you are diagnosed with PCOS and find yourself in the position of making that choice, ask yourself: 

  • What are the main concerns that are affecting my quality of life? 
  • What are my goals of therapy? 

Treating female hormone imbalances is a bespoke approach and needs to be customized for each individual person. 

Before we discuss the prescription medication options, consider the two physiological aspects of PCOS that need to be treated:

Some women may be affected by predominantly one aspect and others may have symptoms of both to varying extents. 

Hyperandrogenism (excess male hormone): 

Typically this may present as skipped periods, excess hair growth over face and body, hormonal acne or hair loss on the scalp. There aren’t many over-the-counter supplements that can reliably block or suppress high testosterone levels. 

Oral contraceptive pills (OCPs): good old-fashioned birth control is often the first and most common approach to treating PCOS. By no means is it the only option though many women at the time of their diagnosis are suggested to start with this. It works well for some women particularly those who are looking for a reliable form of contraception and whose main issues are irregular periods or high testosterone levels. It may also be recommended for women who are taking another prescription medication, Spironolactone (more on that later). 

However, OCPs are best avoided in women who have a history of migraines, blood clots or are heavy smokers. Some women feel their OCPs cause water retention, weight gain and mood swings- talk to your doctor about this. Sometimes a simple switch to a different brand or a lower dose contraceptive pill may be a better fit. 

Hormonal IUDs: These include brands such as Mirena, Skyla, Liletta etc. They secrete progesterone only, not estrogen and suppress ovulation. They are not my top choice because of the lack of estrogen for a more balanced suppression, but they can be a good option for women with PCOS who are looking for contraception and a way of reducing menstrual flow. It may also be a better fit for a woman who is unable to take regular OCPs due to the estrogen content in the pill. 

Spironolactone (brand name, Aldactone): This a diuretic medication and has been used for decades to treat high blood pressure in men and women. It also happens to have an anti-androgenic effect by blocking testosterone receptors- not great for a man but helpful for a woman dealing with an imbalance of male hormones!

It does not suppress ovulation like OCPs and does not provide contraception- this is very important to note as Spironolactone could be harmful to a fetus and precautions must be taken to avoid pregnancy while on this medication. It is often used in tandem with OCPs for that reason. However, it is equally efficient on its own to treat the cosmetic effects of excess testosterone in a woman, specifically acne, hirsutism and hair loss. Acne is noticeably improved within 1-2 months but hair may take 4-6 months to respond. 

Because it is a diuretic medication, it can cause dehydration and electrolyte imbalances so it is important to take it under a doctor’s supervision and with monitoring. 

Insulin Resistance/Metabolic syndrome: 

This aspect of PCOS is often overlooked initially, perhaps because it is not as evident in younger women at the time of their PCOS diagnosis but it has important implications, especially as we age. Changes in diet and lifestyle are very important in addressing this but there are also medication options. 

Metformin: underrated and underappreciated for its long term benefits, Metformin is an excellent option to treat PCOS. Most common side effects are indigestion, bloating and diarrhea but overall, it is usually well tolerated. It makes your body more sensitive to its own insulin, thus lowering insulin resistance. By doing so, it helps PCOS in multiple ways- reducing the risk of prediabetes or gestational diabetes, reducing the risk of metabolic syndrome, and helping to maintain steady blood sugar levels. Many women notice their sugar cravings are lessened and energy levels fluctuate less while on this medication as it lowers the episodes of sugar crashes during the day. It may also help support weight loss in tandem with a low carb diet and regular exercise. For many women with PCOS who are trying to become pregnant, Metformin alone may help regulate periods and ovulation. 

Statin medications: Although this is not often used as a first choice medication for PCOS, cholesterol-lowering statin drugs such as Crestor or Lipitor may be beneficial for women with PCOS. They appear to help with their antioxidant properties as well as by lowering cholesterol and ovarian androgen hormone production. Since women PCOS have a higher risk for metabolic syndrome and cardiovascular disease, a statin drug would lower these risks particularly in women that have high cholesterol or a family history of heart disease and strokes. 

Fertility planning: 

If having trouble conceiving on your own, talk to your OB/GYN about the next steps. Typically, medication options are tried prior to considering IVF.

Clomid and Letrozole both medications help stimulate ovulation. This treatment is given in cycles on a short term basis. Up to 80% of women with PCOS will ovulate using these medications. Main side effects are bloating or mood changes, as well as a small risk of multiple pregnancy (twins).

There are so many treatment options for PCOS besides birth control pills (though diet and lifestyle changes remain the most powerful tool!). Feel free to explore these options with your doctor based on what your main goals of therapy are. And remember, your PCOS treatment plans may change over time as your life situation changes, for example, pregnancy planning, menopause etc. 

If you've missed my older posts on PCOS, you can check them out below!

Yours in good health, 

Ashita Gupta, MD