First principle: pick the goal, then the tool
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Not seeking pregnancy
- Lifestyle (nutrition, activity, weight): the foundation, improving insulin resistance, cycles and androgen symptoms.
- Combined hormonal contraception: regulates cycles, protects the endometrium (opposes estrogen), raises SHBG (helps hirsutism).
- Anti‑androgen (e.g. spironolactone) for refractory hirsutism — always with reliable contraception (teratogenic risk of feminising a male fetus). 🚩
- Endometrial protection is mandatory even outside contraception — chronic anovulation is an unopposed‑estrogen state.
Seeking pregnancy
- Optimise weight/metabolic status first.
- Letrozole is first‑line ovulation induction (higher live‑birth than clomiphene in PCOS); escalate to gonadotropins, laparoscopic ovarian surgery, or IVF.
- Beware OHSS with gonadotropins (PCOS ovaries are high responders). 🚩
Pitfalls
- Prescribing an anti‑androgen without contraception.
- Neglecting endometrial protection in an amenorrhoeic woman not on contraception.
- Treating PCOS as purely reproductive and ignoring cardiometabolic risk.
Pearls
- 🎯 No pregnancy → lifestyle + COC (± anti‑androgen with contraception). Pregnancy → lifestyle + letrozole.
- 🩺 "How long since your last period?" — long anovulatory gaps mandate a progestin challenge/endometrial protection.
Next → From ovulatory dysfunction to ectopic tissue and pain (Concept 19).