Table 2:

Management options for polycystic ovarian syndrome according to symptoms (1)^, (20)

Symptom	Treatment	Dosing or recommendation	Clinical considerations
Menstrual irregularity, heavy bleeding	First-line
	Lifestyle interventions	Diet and exercise aimed at weight reduction by 5%–10% or prevention of excess weight gain	Be aware of weight stigma and increased risk for disordered eating
	CHCs	Any form
	Progestins
	Oral medroxyprogesterone	5–10 mg for 5–10 d every 30–90 d
	Oral norethindrone acetate	5 mg daily for 7 d every 30–90 d or 5 mg daily for 3 wk on, 1 wk off
	Oral drospirenone	4 mg 24 d, 4 d placebo
	Oral dienogest	2 mg daily	May cause breakthrough bleeding
	Levonorgestrel intrauterine device	52 mg released over 5 yr	Patients may continue to have irregular, although lighter, bleeding
	Etonogestrel subdermal implant	68 mg released over 3 yr	Patients may continue to have irregular, although lighter, bleeding
	Intramuscular medroxyprogesterone acetate	150 mg intramuscularly every 3 mo
	Alternative options
	Metformin	1500–2000 mg daily in divided doses	Start at 500 mg and increase by 500 mg every 1–2 wk Cannot be used for endometrial protection in the event of amenorrhea but may help induce regular ovulation
	Inositol	Dosing varies 4 g of myo-inositol with a 40:1 ratio between myo-inositol and D-chiro-inositol daily (21)	Cannot be used for endometrial protection in the event of amenorrhea but may help induce regular ovulation
Acne, hirsutism or alopecia	First-line
	CHCs	Any form
	Topical hirsutism treatment	13.0% eflornithine	Can be used during or before external hair removal methods
	Minoxidil (for alopecia)	2% twice daily
	Topical or oral acne treatments	According to general guidelines
	External hair removal methods	Mechanical laser and light therapy
	Alternative options
	Spironolactone	50–100 mg twice daily	Must be used with effective contraception given teratogenicity (i.e., CHCs or progestin-based contraception if CHCs are contraindicated) Do not use in combination with CHC containing dropirenone Requires monitoring with electrolytes 3 mo after starting and then annually and with dose adjustments
	Finasteride	5 mg daily	Must be used with effective contraceptiongiven teratogenicity (i.e., CHCs or progestin-based contraception if CHCs contraindicated)
Overweight or obesity	First-line
	Lifestyle interventions	Diet and exercise aimed at weight reduction by 5%–10% or prevention of excess weight gain	Be aware of weight stigma and increased risk for disordered eating
	Metformin	1500–2000 mg daily in divided doses	Start at 500 mg and increase by 500 mg every 1–2 wk
	Alternative options
	Inositol	Dosing varies 4 g of MI with a 40:1 ratio between myo-inositol and D-chiro-inositol daily (21)
	Anti-obesity medications or surgery		According to general guidelines
Ovulation induction	First-line
	Lifestyle interventions	Diet and exercise aimed at weight reduction by 5%–10% or prevention of excess weight gain	Be aware of weight stigma and increased risk for disordered eating
	Metformin	1500–2000 mg daily in divided doses	Start at 500 mg and increase by 500 mg every 1–2 wk
	Letrozole	2.5 mg–7.5 mg for 5 d	Although considered first-line by many guidelines, still considered as off-label use in Canada If cycling regularly, start on day 2–5 If irregular cycles, can start randomly after negative home pregnancy test or medroxyprogesterone-induced withdrawal bleed Consider measuring serum progesterone level 3 wk after starting letrozole to confirm ovulation
	Alternative options
	Inositol	Dosing varies; 4 g of myo-inositol with a 40:1 ratio between myo-inositol and D-chiro-inositol daily (21)
	Referral to gynecologist or reproductive endocrinologist and infertility specialist

Note: CHC = combined hormonal contraceptive.