Oral Contraceptives

Oral contraceptives (OC’s) are a mainstay of treatment of PCOS in women who do not want to become pregnant. The estrogen component of OC’s increases sex steroid binding globulin (SHBG) which bind androgens in the bloodstream and prevent their effects. Increases in SHBG reduce the amount of circulating free testosterone. The progestational component of OC’s reduce the amount of LH released from the pituitary gland, and therefore testosterone production form the ovary. The first generation progestin, norethindrone, is the standard by which other agents are measured. The second generation progestin, levonorgestrel, is the most potent progestin and has the greatest androgenic capacity, but it also may have the greatest capacity to reduce LH. The third generation progestational agents, such as desogestrel, are the least androgenic and most estrogenic of the progestational agents. Unfortunately, there has been a recent controversy as to whether the newer progestational agents are associated with an increased risk of stroke and myocardial infarction. The literature is so controversial, biased and conflicting that meaningful conclusions cannot be made. This is unfortunate because the individuals that would best be served by the third generation progestins are also at highest risk for complications. This bias in prescribing is also where the controversy may have arisen.

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