Cyclical progesterone: endometrial protection
For women who cannot take estrogen-containing pills (or prefer not to), cyclical progesterone provides essential endometrial protection. Without regular withdrawal bleeds, unopposed estrogen from chronic anovulation increases endometrial hyperplasia and cancer risk (3 times baseline in PCOS).
Regimen: Medroxyprogesterone acetate 10 mg daily for 10-14 days every 1-3 months to induce a withdrawal bleed. Micronized progesterone 200-400 mg on a similar schedule. Or a levonorgestrel-releasing IUD (Mirena) for continuous protection with minimal bleeding.
Best for: Estrogen-contraindicated women, breastfeeding, older women who do not need contraception, or those preferring lower hormone exposure. It does NOT address androgen excess or insulin resistance; those need separate treatment.
Isotretinoin: severe refractory acne
For severe cystic acne unresponsive to COCPs + spironolactone + topical treatment, oral isotretinoin (Roaccutane, Sotret) is highly effective. A typical course is 4-6 months at 0.5-1 mg/kg/day.
Critical precautions: Absolutely teratogenic, so contraception is mandatory 1 month before, during and 1 month after treatment. Regular pregnancy tests. Baseline and monthly LFT + lipids. Common effects: dry lips and skin. Mood changes are rare but serious, so depression screening is important, especially in PCOS with elevated baseline depression.
Isotretinoin is managed by a dermatologist, coordinated with your gynecologist. It is not for mild or moderate acne; that is the COCP + spironolactone tier.
Evidence-based supplements for PCOS
Strong evidence: Myo-inositol + D-chiro-inositol (40:1 ratio, 2 g + 50 mg twice daily) improves ovulation, insulin resistance and androgens. Vitamin D (target above 30 ng/mL): deficiency is common in PCOS and may worsen insulin resistance.
Moderate evidence: Omega-3 fatty acids (1-2 g EPA+DHA daily) for lipid improvement and mild anti-androgen effect. N-acetylcysteine (600 mg twice to three times daily), an antioxidant that may improve ovulation.
Weak evidence: Chromium picolinate, cinnamon and berberine have a modest insulin sensitivity effect. Spearmint tea: small studies show a mild anti-androgen effect.
Little evidence: Most commercial "PCOS supplements" have minimal evidence beyond marketing. Discuss with your doctor before adding supplements, as some interact with medications.
Currently on medications you are unsure about?
A gynecologist can review your regimen against the 2023 guidelines in a single 15-minute consultation.
