A 28-year-old woman with irregular, heavy menstrual bleeding and clinical features of polycystic ovary syndrome (PCOS) presents for management. She desires contraception and has no contraindications to hormonal therapy. What is the drug of choice for her abnormal uterine bleeding?

Explanation

## Medical Management of AUB in PCOS **Key Point:** Combined oral contraceptive pills (COCPs) are the first-line hormonal therapy for anovulatory abnormal uterine bleeding in PCOS when contraception is desired. ### Why COCPs in PCOS-Related AUB 1. **Mechanism of action:** - Suppress ovarian androgen production (↓ LH pulse frequency) - Provide endometrial stability through progestin component - Regulate menstrual cycles - Reduce hyperandrogenism symptoms 2. **Dual benefit:** - Contraception + treatment of AUB + management of hyperandrogenism - Improves acne and hirsutism (anti-androgenic progestins preferred) ### Comparison of Hormonal Options for PCOS-AUB | Agent | Mechanism | Contraception | Androgenicity | First-Line? | |-------|-----------|---------------|---------------|-------------| | **COCP** | Ovarian suppression + endometrial stability | **Excellent** | ↓ (anti-androgenic progestins) | **Yes** | | LNG-IUD | Local progestin effect | Good | Minimal systemic | No — second-line | | Depo-Provera | Ovulation suppression | Good | Minimal | No — for contraception alone | | Mifepristone | Progesterone antagonist | None | None | No — not indicated for PCOS | **High-Yield:** COCPs are preferred in PCOS because they address multiple pathologies simultaneously: anovulation, hyperandrogenism, and provide contraception. **Mnemonic:** **PCOS-COCP** → **P**olycystic **O**vary **S**yndrome benefits from **C**ombined **O**ral **C**ontraceptive **P**ills (ovarian suppression + endometrial control + anti-androgen effect). **Clinical Pearl:** Use COCPs with anti-androgenic progestins (norgestimate, desogestrel, drospirenone) in PCOS to maximize benefit for hirsutism and acne alongside AUB control. ### When to Use Alternatives - **LNG-IUD:** If contraception not desired or COCP contraindicated; excellent for AUB but does not treat hyperandrogenism - **Depo-Provera:** Contraception-focused; less ideal for PCOS hyperandrogenism - **Mifepristone:** Not indicated in PCOS; used only for medical abortion [cite:ASRM Guidelines on PCOS, Park 26e Ch 17]