What Is the Best Birth Control for PCOS?

A combined hormonal contraceptive treats irregular periods and acne

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Taking a hormonal contraceptive for PCOS is very common, not only to protect against unwanted pregnancy but to serve other purposes as well, like regulating menstruation and treating acne.

With that, you may wonder which hormonal contraceptive your doctor will recommend for treating your PCOS. Unfortunately, the answer is not as cut and dry as most would like.

PCOS is a complex condition, so managing it requires a thoughtful discussion with your doctor.

Combined Hormonal Contraceptive for Treating PCOS

All in all, in PCOS, a combined hormonal contraceptive—one that contains estrogen and progestin—is the first-line therapy for women with irregular periods and symptoms of androgen excess.

The good news is that when it comes to combined hormonal contraception, there are a few options to choose from:

How do these forms of contraception work to combat PCOS? Well, they perform three main functions: 

Protect a Woman's Uterus

Women with PCOS do not ovulate regularly, meaning they do not release an egg every month from one of their two ovaries. This phenomenon is unfortunately linked to a buildup of the uterine lining (called  endometrial hyperplasia) and potentially uterine cancer.

In a combined hormonal contraceptive, the progestin works against estrogen (which normally thickens the endometrium in preparation for pregnancy), and this protects against endometrial hyperplasia.

Provide Contraception

Combined hormonal contraception protects a woman from an unwanted pregnancy by maintaining a steady level of hormones in her body. This can be especially important in women with PCOS, who ovulate and menstruate irregularly.

Reduce Testosterone Levels

A combined hormonal contraceptive helps lower androgen levels in the body, most notably testosterone production in the ovaries.

This can help ease undesirable symptoms like acne, scalp hair loss, or facial hair.

Taking the "Pill" for PCOS

Let's say that you decide to take the "pill" for your PCOS. Is one birth control pill better than another? You may be surprised to learn that there are in fact no studies examining one birth control pill versus another in treating PCOS. So, this is where your doctor will take into account your concerns and expectations when prescribing your birth control pill.

In essence, an oral contraceptive can be differentiated on whether the dose of estrogen-progestin stays the same throughout the pill pack (monophasic), if progestin increases once about halfway through the pill pack while the estrogen stays the same (biphasic) or if the levels of estrogen and progestin are different each week of the pill pack.

Keep in mind that in each of these types of pills, the last week is only a sugar pill, which contains no active hormone. This allows for normal shedding of the uterine lining which is called withdrawal bleeding.

Monophasic pills can be classified further based on the dosage of estrogen, known as ethinyl estradiol, in the pill. Low dose oral contraceptives contain 20mcg of estrogen plus the progestin.

Regular dose contraceptives contain 30mcg to 35mcg of estrogen plus progestin and high dose contains 50mcg of estrogen plus the progestin.

Finally, there are different types of progestin, and they have different levels of androgenic activity. Those with high androgenic activity may aggravate acne or facial hair growth so may not be the ideal option for a woman who is concerned about these PCOS-related symptoms. 

In the end, it's important to talk with your doctor about your hopes and preferences when it comes to taking a combined hormonal contraceptive. This way, your doctor can help you decide what the best option is for you.

Progestin-Only Therapy for Treating PCOS

Sometimes a woman cannot or chooses to not take a combined hormonal contraceptive. In this instance, a doctor may recommend a progestin-only therapy, of which there are two main types: 

Continuous Progestin-Only

A continuous progestin-only oral contraceptive (called the "minipill") can provide contraception and protect against uterine lining thickening, but it will not treat symptoms of testosterone excess. 

Likewise, a hormonal IUD (for example, Mirena) provides both contraception and uterine protection, but will also not help with testosterone excess.

Intermittent Progestin-Only 

Another medication a doctor may prescribe for PCOS is called Provera or medroxyprogesterone. Provera is a form of progesterone that mimics the second half of your menstrual cycle and can bring on a period.

Provera is a pill that you take every day for 10 to 14 days every month or every other month. Provera protects the uterine lining from becoming too thick, but it does not provide contraception or lower testosterone levels.

A Word From Verywell

Managing your PCOS can be a tricky process, especially since it's linked to a number of other symptoms besides menstrual irregularities and androgen excess like obesity and high glucose levels. In fact, you may be surprised to learn that weight loss, if you are overweight or obese, may help with regulating your menstrual cycles.

Remain committed to your care and be open and ​honest when talking with your doctor about your questions or worries.

Sources:

Barbieri RL, Ehrmann DA. (2016). Treatment of polycystic ovary syndrome in adults. In: UpToDate, Crowley WF, Martin KA (Eds), UpToDate, Waltham, MA.

Williams T, Mortada R, Porter S. Diagnosis and treatment of polycystic ovary syndrome. Am Fam Physician. 2016 Jul 15;94(2):106-13.

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