Treatment of Heavy Menstrual Bleeding in PCOS Patients

First-Line Treatment Options

The American Academy of Pediatrics recommends monophasic pills with 30-35 μg of ethinyl estradiol as initial therapy for heavy menstrual bleeding in PCOS patients 2
Extended or continuous cycle regimens of combined oral contraceptives (COCs) may be beneficial for patients with severe menstrual bleeding to minimize blood loss 2
COCs are the mainstay of long-term management for PCOS patients with heavy menstrual bleeding, providing both contraception and therapeutic benefits, and suppressing androgen secretion by the ovaries and increasing sex hormone binding globulin levels, improving hyperandrogenism symptoms 1

Depot Medroxyprogesterone Acetate (DMPA) suppresses circulating androgen levels and pituitary gonadotropin levels in women with PCOS, and can be used as a second-line treatment for heavy menstrual bleeding 1
For heavy or prolonged bleeding with DMPA, treatment options include NSAIDs for 5-7 days 3, 5 or hormonal treatment with COCs or estrogen for 10-20 days (if medically eligible) 3, 5

The Centers for Disease Control and Prevention (CDC) recommends that for patients without cardiovascular risk factors, COCs with 30-35 μg ethinyl estradiol can be used as first-line treatment 2
For patients with cardiovascular risk factors or contraindications to COCs, the CDC recommends the use of the Levonorgestrel-Releasing Intrauterine System (LNG-IUD) as a first-line treatment 4
If bleeding irregularities persist and are unacceptable to the patient, alternative contraceptive methods should be considered 3, 4

The American Academy of Pediatrics notes that COCs increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years) 2
Long-term COC use reduces the risk of endometrial cancer, which is particularly important for PCOS patients who are at increased risk due to chronic anovulation 1, 2