Managing Polycystic Ovary Syndrome (PCOS) symptoms with hormonal birth control

Birth control pills, transdermal patches, and the vaginal birth control ring are combined hormonal contraceptive (CHC) methods. They contain two hormones: oestrogen and progestogen. The pill (combined oral contraceptive, COC) is used by over 20%of women of reproductive age in 27 countries worldwide, with the highest prevalence in European countries.1 Combined oral contraceptives offer a variety of non-contraceptive health benefits and therapeutic effects. The hormones in the pill have also been used to treat other medical conditions, such as PCOS, endometriosis, adenomyosis, acne, hirsutism, amenorrhea, menstrual cramps, menstrual migraines, menorrhagia (excessive menstrual bleeding), menstruation-related or fibroid-related anaemia and dysmenorrhea (painful menstruation).2

Even for those with manageable periods, it is often the worst time of the month with cramping, bloating, nausea, or diarrhoea. For those with PCOS, periods can be severely painful. In honour of PCOS Awareness Month this September, we will explore how using hormonal birth control can help control the symptoms of PCOS.

In addition to CHCs, types of contraception that reduce the overall number of periods for months or even years at a time can reduce period-related symptoms of PCOS. Many women who use a hormonal intrauterine device (IUD) (159 million users worldwide1) stop getting periods after one year of use. Similarly, around half of all who use injectable contraceptives (74 million users worldwide1) stop getting their periods after one year. The pill, the patch, the ring, hormonal IUDs, the implant, and injectable contraceptives can all make periods lighter because these birth control methods make the lining of the uterus thinner. A thinner uterine lining has less tissue to shed, resulting in lighter periods.

However, PCOS is related to clinical and metabolic comorbidities that may limit the prescription of CHCs. Common risk factors for cardiovascular diseases (CVD), such as systemic arterial hypertension (SAH), obesity, dyslipidaemia, metabolic syndrome and type 2 diabetes mellitus can develop in women with PCOS by the fourth decade of life.9,10,11 Consequently, clinicians should still evaluate each patient individually and consider the presence of risk factors, such as age, smoking, obesity, diabetes, SAH, dyslipidaemia, and a personal or family history of venous thromboembolic events or thrombophilia.5 When the use of oestrogen is contraindicated for the patient or when multiple risk factors for CVD are present or oestrogen intolerance occurs, the use of progestogen-only contraceptives (POCs) or nonhormonal contraceptives is recommended. If these methods do not adequately control the symptoms of hyperandrogenism, an alternative is to combine a POC or a nonhormonal method with an antiandrogen medication, such as spironolactone, cyproterone or finasteride.3

Although guidelines do not suggest one formulation over another in terms of effectiveness, low-dose oral contraceptives containing neutral or antiandrogenic progestins may be the choice in the treatment of PCOS regarding the androgen excess and the metabolic disturbances associated with the disorder. Despite the potential adverse cardiovascular and metabolic effects of CHCs, current evidence suggests that the benefits of hormonal contraception outweigh the risks for its use in most women with PCOS.12

Because the characteristics and severity and risk factors of PCOS can vary from person to person, treatment plans are highly individual. It is very important to talk to a provider about all the potential treatment options. It is also possible to be on hormonal birth control and start investigating the drivers behind a patient’s hormone imbalance.