Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Treatment Update for Polycystic Ovary Syndrome

Obstet Gynecol; ePub 2018 Jun; Legro, et al

The American College of Obstetricians and Gynecologists (ACOG) has issued clinical management guidelines that updated the use of letrozole for ovulation induction in women with polycystic ovary syndrome (PCOS). The document examined the best available evidence for both the diagnosis and clinical management of PCOS. Among the ACOG recommendations and conclusions, including the update on the use of letrozole, for the management of PCOS:

  • An increase in exercise combined with dietary change has consistently been shown to reduce diabetes risk comparable to or better than medication.
  • Improving insulin sensitivity with insulin-sensitizing agents is associated with a decrease in circulating androgen levels, improved ovulation rate, and improved glucose tolerance.
  • For women with PCOS, letrozole should be considered as first-line therapy for ovulation induction because of the increased live birth rate compared with clomiphene citrate.
  • The addition of eflornithine to laser treatment is superior in the treatment of hirsutism than laser alone.
  • Women with a diagnosis of PCOS should be screened for type 2 diabetes and impaired glucose tolerance with a fasting glucose level followed by a 2-hour glucose level after a 75-g glucose load.
  • Women with PCOS should be screened for cardiovascular risk by determination of BMI, fasting lipid and lipoprotein levels, and metabolic syndrome risk factors.
  • Reduction in body weight has been associated with improved pregnancy rates and decreased hirsutism, as well as improvements in glucose tolerance and lipid levels.
  • There may be an increase in pregnancy rates by adding clomiphene citrate to metformin, particularly in obese women with PCOS.
  • If clomiphene citrate or letrozole use fails to result in pregnancy, the recommended second-line intervention is either exogenous gonadotropins or laparoscopic ovarian surgery.


Polycystic ovary syndrome. ACOG Practice Bulletin No. 194. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;131:e157–71.