The Rotterdam criteria (2003) for PCOS require 2 of 3 features. A woman has irregular periods (cycle length 45-60 days) and clinical hyperandrogenism (Ferriman-Gallwey score 12) but a polycystic ovarian morphology (PCOM) is absent on ultrasound. She has PCOS by Rotterdam criteria. She now presents with infertility. According to ACOG/ESHRE 2023 international evidence-based guidelines, what is the FIRST-LINE ovulation induction agent?
- A Letrozole (aromatase inhibitor) 2.5-7.5 mg days 3-7 ✓
- B Clomiphene citrate 50 mg days 2-6
- C Metformin alone as it treats the underlying insulin resistance
- D Recombinant FSH with LH-add-back for better response
Explanation
The 2023 International PCOS Guideline (ESHRE/ASRM co-sponsored) upgraded letrozole to the recommended FIRST-LINE ovulation induction agent for PCOS, based on PPCOS II trial and subsequent meta-analyses showing superior live birth rates and ovulation rates compared to clomiphene citrate. Letrozole acts by temporarily suppressing estrogen (aromatase inhibition), removing negative feedback on hypothalamus-pituitary to stimulate FSH, without the anti-estrogenic endometrial effects of clomiphene. Starting dose is 2.5 mg for 5 days, titrated to 5 or 7.5 mg. Clomiphene was previously first-line but is now second-line. Metformin alone has poor ovulation induction efficacy.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.