Common Treatments for PCOS

Combined Oral Contraceptives

Hormonal Birth Control

Contains synthetic estrogen and progestin. The first-line pharmacological treatment for menstrual irregularity and hyperandrogenism in women with PCOS who are not trying to conceive. Regulates cycles, reduces androgen production, treats acne and hirsutism, and protects the uterine lining from abnormal thickening.

Does not treat the underlying metabolic dysfunction of PCOS. Symptoms typically return when stopped.

Metformin

Insulin Sensitizer (Biguanide)

Improves the body's sensitivity to insulin, lowers circulating insulin levels, and can reduce androgen production driven by insulin resistance. Particularly effective for women with insulin resistance, metabolic syndrome, or prediabetes. May restore menstrual regularity, reduce androgen levels, support weight management, and lower long-term diabetes risk.

Off-label for PCOS (not FDA-approved for this indication). Well-tolerated — GI side effects minimized by taking with food or using extended-release.

Spironolactone

Anti-Androgen (Aldosterone Antagonist)

Blocks androgen receptors throughout the body, reducing the effects of elevated testosterone on hair follicles and sebaceous glands. The anti-androgen with the strongest evidence base for PCOS, used to treat excess hair growth, androgenic hair loss, and persistent acne.

Always prescribed alongside contraception — must not be used during pregnancy. Can cause elevated potassium levels.

Letrozole

Aromatase Inhibitor (Fertility)

Temporarily reduces estrogen, triggering the pituitary gland to release FSH, which stimulates ovulation. The current first-line pharmacological treatment for PCOS-related infertility per the 2023 International Evidence-Based PCOS Guidelines. Produces higher ovulation and live birth rates than clomiphene in women with PCOS.

Typically used in 5-day cycles at the start of the menstrual cycle. Often combined with metformin.

Clomiphene Citrate

SERM — Selective Estrogen Receptor Modulator

Blocks estrogen receptors in the brain, prompting the pituitary gland to release more FSH and LH to stimulate ovulation. Historically the most commonly prescribed ovulation agent for PCOS — now second-line behind letrozole per current guidelines, but still used, particularly in combination with metformin.

Can cause multiple ovulation (twins risk), hot flashes, mood changes, and thinning of the uterine lining.

GLP-1 Receptor Agonists

e.g. Semaglutide, Liraglutide, Tirzepatide

Mimics the GLP-1 hormone to stimulate insulin secretion, suppress glucagon, slow gastric emptying, and significantly reduce appetite. Emerging evidence shows GLP-1 agonists significantly decrease BMI and testosterone levels and improve ovulation rates in women with PCOS — with weight loss and insulin sensitization superior to metformin in some studies.

Rapidly growing evidence base as of 2024–2025. Not yet FDA-approved for PCOS specifically, but widely prescribed off-label. Contraindicated in pregnancy.

Progesterone / Progestins

Progestogen

Used cyclically to trigger withdrawal bleeds and shed the uterine lining in women with infrequent periods. Protects the endometrium from hyperplasia caused by prolonged estrogen exposure without regular ovulation — reducing the long-term risk of endometrial cancer.

Does not treat the underlying PCOS hormonal imbalance, but addresses a critical long-term complication.