A woman with PCOS and BMI 32 kg/m² undergoes ovulation induction with letrozole. She fails to ovulate after 5 days letrozole 2.5 mg. The next step in management per current guidelines is:
- A Increase letrozole to 5 mg for the next cycle before considering other options ✓
- B Switch to clomiphene citrate as first-line therapy per WHO criteria
- C Add metformin to the next letrozole cycle to improve ovulation rates
- D Proceed directly to gonadotropin injection therapy
Correct answer: A. Increase letrozole to 5 mg for the next cycle before considering other options
Explanation
Per ASRM/ESHRE 2018 PCOS guidelines, letrozole (aromatase inhibitor) is first-line ovulation induction for PCOS (superior live birth rates over clomiphene per PCOSACT trial, NEJM 2014). The starting dose is 2.5 mg days 3–7; if no ovulation, the dose is incrementally increased to 5 mg, then 7.5 mg in subsequent cycles before switching agents. Clomiphene is an alternative first-line (not superior), and gonadotropins are second-line. Metformin improves insulin resistance but has limited ovulation induction efficacy as monotherapy in PCOS.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.