# Polycystic ovary syndrome (PCOS primary management) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Endocrine System 2024 · International Evidence-based Guideline for PCOS 2023 - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Endocrine System 2024 - International Evidence-based Guideline for PCOS 2023 ## Treatment metadata - Ethinyl estradiol + Cyproterone — oral.solid - Metformin — 500 mg — oral.solid ## Complete treatment card ```text POLYCYSTIC OVARY SYNDROME (PCOS PRIMARY MANAGEMENT) Sources: Egyptian National Drug Formulary - Endocrine System 2024 · International Evidence-based Guideline for PCOS 2023 Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (11) - Irregular cycles are normal in the first year after menarche; from 1 to 3 years afterwards, intervals outside 21 to 45 days count as irregular - From 3 years after menarche until the perimenopause, count intervals outside 21 to 35 days, or fewer than 8 cycles a year, as irregular - A year or more after menarche, any single interval of 90 days or longer is abnormal - Primary amenorrhoea means no periods by the age of 15, or 3 years after breast development begins [absent periods] - Adolescents with severe acne that resists oral or topical antibiotics carry about a 40% chance of developing PCOS [acne] - Acne that persists or worsens in a woman in her mid-20s to 30s should raise the question of androgen excess [acne] - Weigh the risk factors: a family history of polycystic ovary syndrome or of metabolic syndrome, and androgen exposure before birth - Regular periods do not exclude it, because some women with the syndrome ovulate only occasionally - Red flag for an androgen-secreting tumour: sudden onset and fast progression, since such tumours may raise androgen levels only mildly - Obesity, impaired glucose tolerance and type 2 diabetes travel with it, and so do infertility, metabolic syndrome, cardiovascular disease, low mood, obstructive sleep apnoea, endometrial cancer and fatty liver disease [apnoea · infertility · low mood · obesity] - Red flag: a delayed diagnosis lets the comorbidities progress, and the lifestyle changes that matter most become harder to put in place SIGNS - what you find (10) - Scalp hair loss varies: at the vertex, the crown, or diffuse; severe androgen excess adds bitemporal loss with a receding frontal hairline [hair loss] - Hirsutism means coarse dark terminal hair in a distribution normally seen in men [excess hair] - Grade hirsutism objectively at examination using the modified Ferriman-Gallwey system rather than by eye [excess hair] - The threshold for hirsutism falls between 4 and 6 depending on ethnic background, and hair removal at home is common enough to hide it [excess hair] - Virilisation is not the usual picture: more muscle bulk, smaller breasts, a deeper voice, an enlarged clitoris [virilisation] - Red flag for an androgen-producing tumour of the ovary or adrenal gland: virilisation means androgens are high enough to investigate [virilisation] - Between 38% and 88% are overweight or obese, and abdominal fat is greater than in women matched for body mass index [obesity · overweight] - A normal body mass index does not rule the diagnosis out - The commonest form shows all four features at once: androgen excess, hirsutism, infrequent or absent ovulation, and polycystic ovaries [excess hair] - The picture often eases with age, with less androgen excess and a rise in FSH TESTS (12) - PCOS is diagnosed under the Rotterdam criteria when 2 of 3 are present: chronic oligo- anovulation, clinical or biochemical androgen excess, and polycystic ovarian morphology with no other cause - The 2023 international guideline requires 2 of 3 in an adult, with mimics excluded: androgen excess clinically or on bloods, ovulatory dysfunction, and polycystic ovaries on scan or a raised AMH - When irregular cycles and androgen excess are both present in an adult, neither ultrasound nor AMH is needed - In adolescents, ovulatory dysfunction and androgen excess must both be present, and ultrasound and AMH are unhelpful because their specificity is low - Ovulation can fail even when cycles look regular, so measure serum progesterone when anovulation needs confirming - It is a diagnosis of exclusion: rule out thyroid disease, a raised prolactin, and non- classical congenital adrenal hyperplasia from 21-hydroxylase deficiency - For congenital adrenal hyperplasia, measure serum 17-hydroxyprogesterone, followed if needed by an ACTH stimulation test - Confirm androgen excess biochemically by measuring total and free testosterone, the free fraction being estimated with the calculated free androgen index - If testosterone is normal, androstenedione and DHEAS can be added, though both are less specific and DHEA falls with age - Red flag: androgens well above the reference range point elsewhere - an ovarian or adrenal tumour, congenital adrenal hyperplasia, Cushing syndrome, hyperthecosis after the menopause, drugs, or severe insulin resistance - Transvaginal ultrasound assesses ovarian morphology most accurately, and counting the follicles in each ovary is the best marker in adults - 20 or more follicles in at least one ovary defines polycystic morphology in adults; follicle count per cross-section and ovarian volume are also reliable IF NOT THIS - what else fits (10) - Androgenic steroid use - Hypothyroidism - Late-onset congenital adrenal hyperplasia - Idiopathic or familial hirsutism - Ovarian malignancy - Hyperprolactinaemia - Cushing syndrome - Ovarian hyperthecosis, especially after the menopause - An androgen-producing tumour of the ovary or adrenal gland - Syndromes of severe insulin resistance Source StatPearls "Polyendocrine Metabolic Ovarian Syndrome" - disease-level clinical article Status traced to the source above 1. ETHINYL ESTRADIOL + CYPROTERONE [1st line] Adult 1 tablet daily for 21 days starting on day 1 of cycle, followed by 7 pill-free days - long-term (review after 3-4 cycles) Peds Not applicable in pediatric care; specialist adolescent gynecology referral Source International Evidence-based Guideline for PCOS 2023 Why Diane-35 is not registered by the Egyptian Drug Authority (imported only). Registered COC alternatives with alternative progestogens (e.g. Drospirenone) are widely available and may be preferred for VTE risk profile. Caution This is first-line for hyperandrogenism (hirsutism, acne) and menstrual irregularity. VTE risk is higher than standard COCs; contraindications include history of VTE, severe HTN, focal migraine, smoking >35yo. Continue long-term for symptom control; hyperandrogenism recurs upon discontinuation. Egypt DIANE 35 - 21 TABLETS (ILLEGAL IMPORT) BAYER HEALTHCARE > 43.00 EGP (2.05/unit) 2. METFORMIN [2nd line] Adult 500 mg orally once daily with meal, titrate weekly up to 500-850 mg twice daily - long- term Peds Specialist pediatric endocrine referral for adolescents Source Egyptian National Drug Formulary - Endocrine System 2024 (metformin monograph), Adult dosing, immediate release: "Initial: Oral: 500 mg once or twice daily", "may increase gradually by 500mg increments every 7 days", "Usual maintenance dosage: Oral: 1 g twice daily or 850 mg twice daily". Note: the only metformin indication in this formulary is type 2 diabetes, so these are its general adult titration figures, not a PCOS-specific regimen; the International Evidence-based Guideline for PCOS 2023 is not held in this corpus. Why Metformin improves insulin sensitivity and reduces hepatic glucose output; in PCOS it is used to address the underlying insulin resistance and cardiometabolic risk that drive the syndrome. Caution Metformin is first-line for cardiometabolic management and insulin resistance in PCOS. Monitor renal function before starting and annually. GI adverse effects are minimized by gradual titration with meals. Egypt METFORMIN-EL NASR 500MG 200 TAB. EL NASR 26.00 EGP (0.13/unit) DIAPHAGE 500MG 20 TAB. PHAROPHARMA 4.00 EGP (0.20/unit) AMOPHAGE 500MG 30 TAB. AMOUN 10.50 EGP (0.35/unit) CIDOPHAGE 500 MG 10 TAB. CID 11.00 EGP (1.10/unit) GLUCOPHAGE 500 MG 50 F.C.TABS. MINA PHARM > ... 60.00 EGP (1.20/unit) KELVAMET MR 500 MG 30 TABS. BIOMED 54.00 EGP (1.80/unit) ANDOGLYCEMIC XR 500MG 30 EXT. REL. TABS. ANDALOUS PHARMA 24.00 EGP METIANORMIN 500 MG 30 EXT. REL. F.C.TABS. WADI ELNEEL BENTA 54.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)