Management of pcos after metformin

1. Objectives
Outline the next step of management in this case

2. • Needs individualization of the patient
• Depends on presenting symptoms like
• Menstrual disorder
• Infertility
• Obesity
• Hirsutism
• Patient counselling is important

3. • Treatment primarily targeted to correct
biochemical abnormalities like
Hyperandrogenemia Hyperprolactinemia
Hperinsulinemia Insulin resistance
Hyperlipidemia Hypersecretion of LH
High serum estrogens Low serum SHBG
Androgenic ovarian follicular
microenvironment
Low FSH & progesterone

4. Weight reduction in obese person
• First priority
• BMI < 25 kg/m2
• Improves:
• menstrual disorders
• Infertility
• Insulin resistance
• Hyperandrogenemia
• Reproductive function

5. Patients not desiring pregnancy
• Management of hyperandrogenemia
Combined OCP – Progestin, Estrogen
• Hirsutism
Antiandrogens(only in severe cases)
-Cyproterone acetate
-Flutamide
-Finasteride
• Hyperinsulinemia: Metformin
• Endometrial hyperplasia and abnormal bleeding:
Combined OCPs

6. Patients desiring pregnancy
• Ovulation induction – Clomiphene citrate
• Unresponsive cases – Pure FSH or Human
menopausal gonadotropin (HMG) along with human
chorionic gonadotropin (hCG)
• Metabolic syndrome – Metformin
In case of resistant to metformin, pioglitazone
and rosiglitazone can be used.
• Surgery – If resistant to medical therapy
Laproscopic ovarian drilling

7. References
• DC Dutta’s Textbook of Gynecology, 6th edition,
2013, page no: 572- 574
• Shaw’s Textbook of Gynecology, 16th edition, 2011,
page no: 430-434