A 30-year-old woman with PCOS and BMI 35 kg/m² is started on metformin 1500 mg/day. What is the EVIDENCE-BASED indication for metformin in PCOS management per the ESHRE 2023 international guideline?

• A First-line ovulation induction agent superior to letrozole
• B Prevention of OHSS in IVF cycles
• C First-line treatment for hirsutism in PCOS
• D Metabolic management (weight, insulin resistance, lipids); improved ovulation induction response as adjunct ✓

Explanation

The 2023 International PCOS Guideline (ESHRE/ASRM endorsed) positions metformin for: metabolic management (reducing insulin resistance, improving lipid profiles, weight management) and as an adjunct to improve ovulation induction efficacy when combined with clomiphene or letrozole. It is not first-line for ovulation induction (letrozole is), not recommended for OHSS prevention in IVF, and not first-line for hirsutism (which is treated with anti-androgens like spironolactone or OCP).

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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