Management of Abnormal

Uterine Bleeding Associated

with Polycystic Ovary
Syndrome
(2009)

Philippine Society of Reproductive

Endocrinology and Infertility, Inc.
G/F POGS Bldg., 56 Malakas St., Diliman
Quezon City, Philippines
Telefax No.: 632 9209565
E-mail: psrei2001@yahoo.com
 PCOS
Philippine Society of Reproductive
Endocrinology and Infertility, Inc.
G/F POGS Bldg., 56 Malakas St., Diliman
Quezon City, Philippines
Telefax No.: (632) 920-9565
E-mail: psrei2001@yahoo.com

PSREI Board of Directors for the year 2012

President Marlyn T. Dee, MD

Vice President Joan Tan-Garcia, MD
Secretary Angela S. Aguilar, MD
Treasurer Eileen Co-Sy, MD
Auditor Danilo Jose C. Milla, MD
P.R.O. Gladys G. Tanangonan, MD
Board Member Madonna Victoria C. Domingo, MD

Technical Working Group

Chair Patria P. Punsalan, MD

Co-chair Marlyn T. Dee, MD

Members

Ma. Jesusa Banal-Silao, MD

Edwin E. Dimayuga, MD
Judith Galang-Perez, MD
Rudie Frederick B. Mendiola, MD
Vanesa Valentina I. Penolio, MD
Chiaoling Sua-Lao, MD

Editorial Staff

Editors Delfin A. Tan, MD

Maria Antonia E. Habana, MD
Associate Editors Angela S. Aguilar, MD
Regina Paz A. Tan-Espiritu, MD

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PCOS
Management of abnormal uterine
bleeding associated with polycystic
ovary syndrome*
Authors: Lilia P. Luna, Enrico Gil C. Oblepias, Anna Lynn Alvarado-Magtinas,
Deane C. Campo-Cruz, Lyra Ruth C. Chua, Sonia E. Desquitado, Marinella
Agnes S. Garcia-Abat, Judith G. Perez, Claudette Ricero-Cabingue, Ma.
Victoria R. Tan
*An excerpt; taken from Chapter 4 (pages 30-40) of the book Consensus
Statements on POLYCYSTIC OVARY SYNDROME 2009, 262 pages, by the Philippine
Society of Reproductive Endocrinology and Infertility
Menstrual dysfunction
Statement 1: Menstrual dysfunction is commonly the
reason for consultation of women who are eventually
diagnosed with polycystic ovary syndrome. B
Overall between 60 and 85% of patients with PCOS ex-
hibit overt menstrual dysfunction.1 Among 273 Chinese
women diagnosed as having PCOS, some menstrual
irregularity was reported by 94.1% of the women.2
Even in this subset of patients, an abnormality in the
expected cyclical pattern of menstruation may not be
urgently interpreted as a cause for concern. In the
spectrum of menstrual disorders associated with PCOS,
women tend to be more tolerant of oligomenorrhea and
amenorrhea than experiencing episodic heavy menstrual
bleeding.1
Evaluation of abnormal uterine bleeding
Statement 2: PCOS is suspected to be a risk factor
for endometrial cancer and endometrial surveillance
is reasonable. GPP
It is widely assumed that in anovulatory states such
as PCOS, the hormonal milieu of unopposed estrogen
activity which favors endometrial growth and irregular en-
dometrial shedding predisposes the woman to abnormal
uterine bleeding (AUB), endometrial hyperplasia (EH) and
even endometrial carcinoma (EC). Several studies have
been published to support this association.3
In addition to the elevated estrogen (without the oppos-
ing effects of progesterone in the absence of ovulation),
hyperinsulinemia, elevated free insulin-like growth factor-I
and androgens, and obesity are all proposed to contribute
to endometrial dysfunction in women with PCOS, leading
to endometrial hyperplasia and endometrial cancer.4
However, epidemiological evidence to support the
hypothesis that PCOS predisposes to endometrial
cancer is limited.3 Still it is common practice among
gynecologists and physicians to apply strategies to
detect and/or prevent endometrial cancer in PCOS
women.5
Statement 3 : Endometrial biopsy need not be done in
PCOS women if the sonographic endometrial thick-
ness is less than 7 mm or the intermenstrual interval
is less than 3 months. B
In a prospective study of 56 PCOS women6 to determine
the predictive value of sonographic endometrial thick-
ness and the menstrual history, 36 women (64.3%) had
168
proliferative endometrium and 20 (35.7%) had endome-
trial hyperplasia. Five of the latter (25%) had cytologic
atypia. The endometrial thickness correlated positively
with endometrial hyperplasia (P =.018) and, together with
the average intermenstrual interval, were significant pre-
dictors of endometrial hyperplasia (P <.001). However,
endometrial thickness less than 7mm or intermenstrual
interval less than 3 months (corresponding to more than
four menstrual periods yearly) was associated with prolif-
erative endometrium only. Thus, endometrial hyperplasia
is effectively excluded when the endometrial thickness in
PCOS women is less than 7 mm.6
hese findings point to the usefulness of obtaining a
T
detailed menstrual history in women with PCOS by iden-
tifying those at increased risk of endometrial hyperplasia
and who require an endometrial biopsy.6
Statement 4: Endometrial biopsy should be done
in PCOS women if the endometrial lining is more
than 10 mm thick on transvaginal ultrasound done
between days 6-10 and if there is hyperinsulinemia.
GPP
he mean thickness of the endometrium was found to
T
be statistically higher (P<0.001) in women with PCOS
(11.1 mm) and in women with insulin resistance (9.6
mm) compared with women without PCOS and insulin
resistance (6.2 mm). It was concluded that both in women
with PCOS without insulin resistance and in women with
insulin resistance without PCOS, the ultrasonographically
estimated thickness of the endometrium is relatively high
and a closer follow-up of these women is required in or-
der to detect those in risk to develop hyperplasia and/or
atypia.7
targeted endometrial biopsy can identify those patients
A
with increased risk for endometrial hyperplasia. The risk
of endometrial carcinoma may be reduced by facilitating
the normalization of ovulation and insulin metabolism.8
Statement 5: Any PCOS patient with prolonged oligo-
or amenorrhea or who is older than 35 years and has
irregular bleeding should have an endometrial biopsy
to rule out carcinoma. GPP
n important point to remember is that advancing age
A
per se is not a factor in deciding to obtain endometrial
aspiration in patients with PCOS as it is in non-PCOS
patients.9
Management of abnormal uterine bleeding
Statement 6: The use of oral contraceptive pills for
a 21- day period followed by a 7-day pill free interval
improves menstrual regularity among women with
PCOS, regardless of body mass index. B
I mproved menstrual cyclicity, in both obese and non-
obese patients, was reported with the use of ethinyl
estradiol 35 g combined with cyproterone acetate 2 mg
over a period of 3-6 months. This benefit of OCPs was
superior to the use of metformin alone.10,11 In a Cochrane
review of four clinical trials, metformin was less effective
than the OCP in improving menstrual pattern (Peto OR
0.08, 95% CI 0.01 to 0.45).12
There are no trials assessing whether this more favorable

OCP effect leads to a reduction in the long-term risk of
endometrial cancer compared with metformin.12
here has been no head to head comparison done to
T
compare the effectiveness of the continuous and cyclic
OCP regimens in the treatment of PCOS women with
abnormal uterine bleeding.
Statement 7: The most important parameter in the
choice of OCPs for the treatment of PCOS is the type
of progestin. GPP
he most important parameter in the selection of OCP
T o randomized trials of progestogens for anovulatory
for the treatment of women with PCOS is the type of
progestin, since most progestins also possess variable
androgenic effects The androgenic property of a progestin
determines the changes in sex hormone binding globulin
production. SHBG production is the critical factor which
determines the level of circulating free fraction of andro-
gens.13
ith increasing androgenic activity, the stimulatory ef-
W cycle (paired t test, t = 4.638, P < 0.005 in the first cycle
fect of combined OCP on SHBG synthesis is decreased.
Differences observed in SHBG level can be attributed to
the intrinsic androgenic (or anti-androgenic) properties of
the progestogens.14 In healthy users after six cycles the
mean changes in SHBG reached +270% versus +80%
if combined OCP contained low or higher androgenic
progestins.13
The first choice of combined OCP for the treatment of
women with PCOS should be progestins with low andro-
genic activity, which do not decrease estrogen-stimulated
production of SHBG.13 Norgestimate and desogestrel are
virtually nonandrogenic progestins.15
rospirenone, an analogue of spironolactone with unique
D heavy menstrual bleeding. B
antimineralocorticoid and antiandrogenic activities, has
been approved for use in combination with ethinyl estra-
diol; thus, it is potentially ideal for the treatment of women
with the polycystic ovary syndrome.17
Statement 8: Treatment protocols for OCP use in
PCOS patients with abnormal uterine bleeding rec-
ommend a minimum duration of 3-6 months. B
reatment protocols for OCP use in PCOS patients rec-
T
ommend a minimum duration of 3-6 months wherein most
studies report improved menstrual cyclicity measured in
terms of days in between menses. The suppression of
androgenic production by OCPs underlies the improve-
ment of the menstrual dysfunction observed in women
with PCOS.
here is no current recommendation on how long OCP
T lower among LNG-IUS users. Hemoglobin increased
can be used. It would seem that prolonged use would
be influenced by considerations such as risk for diabetes
mellitus, coronary artery disease, and endometrial cancer.
However, there are no prospective studies confirming the
effect of long-term use of OCP on the risk of these condi-
tions. On the other hand, it is generally accepted that OCP
does not modify the absolute risk of coronary heart dis-
ease in healthy users <35 years of age with no cardiovas-
cular risk factors, who do not smoke, and who have had
their blood pressure checked before starting OCP use.
I n PCOS, there are only a few short-term studies with
contradictory results evaluating potential adverse effects
Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users.
PCOS
of OCPs on cardiovascular risk factors and glucose
homeostasis. Nevertheless, limited available data support
the benefits of long-term OCP use in PCOS.18
Prospective data about the influence of OCPs on the
risk of diabetes mellitus, coronary artery disease and
endometrial cancer in PCOS women are lacking.19
Statement 9: Cyclical oral progestogens may be
effective in regulating and reducing bleeding in ano-
vulatory dysfunctional uterine bleeding. C
N
dysfunctional bleeding, particularly PCOS, have been
identified.20 A small, non-randomized study in 6 women
treated with either norethisterone (NET) 5 mg three times
daily or medroxyprogesterone acetate (MPA) 10 mg three
times daily for 14 days from day 12 to 25. There was
a significant reduction in menstrual blood loss from a
pretreatment mean of 131 40 mL to 80 31 mL during
the first treatment cycle, and 64 14 mL in the second
and t = 4.025, P =< 0.01 in the second). The duration
of bleeding was also reduced following treatment, from
a mean of 8.5 2.4 days before treatment to 6.2 1.7
days in the first treatment cycle, and 5.5 1.1 days in
the second (t = 3.105, P = 0.027). No obvious difference
was observed between the two progestogens.20
arger randomized studies are needed to confirm the
L
role of progestogens in anovulatory DUB associated with
PCOS and to compare its types, dosages and routes of
administration.
Statement 10: Progestogen-releasing intrauterine
systems are more effective than no treatment for
rogesterone-releasing intrauterine systems that have
P
been used for menorrhagia include Mirena (levonorg-
estrel- intrauterine system) and Progestasert. Al-
though these devices have not been compared to either
placebo or no treatment control groups in randomized
controlled trials, there were significant reductions in wom-
en treated with both Mirena and Progestasert.21,22
Progestasertis not available in the Philippines.
n open randomized study compared 1821 women using
A
the LNG-IUS to 937 women using the copper-releasing
device Nova T during 5 years of use.21 The local effect
of levonorgestrel in the uterine cavity caused reduction of
menstrual blood loss and development of oligo-amenor-
rhea, and the termination rates because of heavy and/or
prolonged menstrual flow were significantly (P < 0.001)
during use of the LNG-IUS and decreased during Nova T
use, and the difference between the devices was statisti-
cally significant.
I n 12 women with menorrhagia (greater than or equal to
80 ml per menstrual period) Progestasert, the menstrual
blood loss was significantly reduced after 1 month but the
duration of bleeding was somewhat prolonged. Twelve
months after insertion the menstrual blood loss amounted
to 35% of the blood loss before the insertion.22
Statement 11: LNG-IUS was more effective than
cyclical progestogens and mefenamic acid but sig-
169
PCOS
nificantly less effective than endometrial ablation as
a treatment for heavy menstrual bleeding. A
randomized study compared the LNG-IUS and nore-
A additional benefit in terms of menstrual regulation.34 In
thisterone in 45 women with heavy regular periods and
a measured menstrual blood loss exceeding 80 ml. The
LNG-IUS was inserted within the first 7 days of menses
and norethisterone 5 mg was given 3 times daily from
day 5 to day 26 of the cycle for 3 cycles. Compared to
baseline, the LNG-IUS reduced menstrual blood loss by
94% (median reduction, 103 ml) and oral norethisterone
reduced it by 87% (median reduction, 95 ml).23
I n 51 women with menorrhagia randomized to receive the
LNG IUS or oral mefenamic acid for six cycles, LNG-IUS
produced greater reduction in menstrual blood loss, total
menstrual fluid loss, and pictorial blood loss assessment
chart score at the third and sixth cycle of treatment.24
he LNG-IUS was compared with endometrial resection
T here is no data comparing the other insulin sensitizing
in women with menorrhagia and demonstrated compara-
ble reduction in the menstrual bleeding in two studies,25,26
and somewhat less satisfactory results in another two
studies. 27,28 The advantage of the LNG-IUS was that it is
reversible and has no operative hazards.25 In one study,27
recurrent menorrhagia was observed at 12 months in four
women in the intrauterine device group (including two with
partial expulsion of the device) and in three women in
the resection group. Compared with baseline values, at
1 year, the pictorial blood loss assessment chart (PBAC)
score was reduced by 79% in the former group and by
89% in the latter.
hree trials,29,30,31 compared LNG-IUS with balloon abla-
T oderate weight loss during long-term calorie restriction
tion. In two randomized studies with a total of 129 women
with menorrhagia, respectively, the Thermochoice
endometrial ablation and the LNG-IUS were equally ef-
fective in the management of menorrhagia.29 In another
study of 36 women randomized to LNG-IUS or outpatient
thermal balloon ablation, the LNG-IUS was not as effec-
tive as thermal balloon ablation in reducing the menstrual
blood loss at one year. However, the LNG-IUS was found
to be as effective as thermal balloon ablation in increasing
the hemoglobin values.31
Statement 1 2: The LNG-IUS is associated with a
higher rate of progestogenic side effects such as
intermenstrual bleeding and breast tenderness than
endometrial ablation. A
hree trials comparing LNG-IUS with ablation reported
T conceived (five) or experienced a more regular menstrual
a higher rate of side effects within one year, most of
which were progestogenic, in the women with LNG-
IUS in situ. Higher rates of weight gain, bloating, acne
or greasy skin, nausea and breast pain were likewise
reported.27,28,31
Statement 1 3: Metformin should be used as an
adjunct to general lifestyle improvements but not
as a replacement for weight loss, improved diet
and increased exercise in treating abnormal uterine
bleeding in women with PCOS. A
lthough metformin is an effective treatment for anovula-
A Thirty-eight overweight or obese PCOS women were
tion in PCOS, many women will still experience menstrual
irregularities.32 Further studies are needed to elucidate
the risk-benefit ratio of long term metformin use in the
PCOS patient population not presenting with infertility.33
170
A double blind multicentre study compared addition of
metformin to a weight loss program and concluded that
addition of metformin to a weight loss program offered no
this study, only the percentage of weight loss correlated
with improvement in menses (regression coefficient =
0.199, P = 0.047, OR = 1.126, 95% CI 1.001, 1.266).
nother placebo-controlled crossover study of 56 PCOS
A
women aged 18-45 years demonstrated that metformin
did not affect menstrual frequency but significantly de-
creased weight, systolic blood pressure and increased
HDL-cholesterol in obese women with PCOS.35
Cochrane meta-analysis of 6 trials has proven that
A
metformin was less effective than OCP in improving
menstrual pattern (Peto OR 0.98, 95% CI 0.01-0.45) in
women with PCOS.12
T
drugs versus OCPs.12
Statement 14: Lifestyle modifications, targeting a
weight loss of 5-10 % of initial body weight, sig-
nificantly improve menstrual regularity and rate of
ovulation. A
In women with PCOS, menstrual cyclicity is negatively af-
fected by hyperinsulinemia, insulin resistance and obes-
ity.36 About 40% of women diagnosed with this condition
are overweight and may be more insulin resistant than
weight-matched individuals.
M
is associated with a marked clinical improvement which
reflects the reduction in insulin concentrations and recip-
rocal changes in sex hormone-binding globulin. Of 24
obese PCOS women (mean weight 91.5 kg) who were
treated for 6-7 months with a 1000 kcal, low fat diet, 13
subjects lost more than 5% of their starting weight (range
5.9-22%). In this group there was a marked increase in
concentrations of SHBG (pretreatment: 23.6; post-treat-
ment 36.3 nmol/l, P = 0.002) and a reciprocal change
in free testosterone levels (77 vs 53 pmol/l, P = 0.009).
These changes were accompanied by a reduction in fast-
ing serum insulin levels (median (range) 11.2 (5.2-32) vs
2.3 (0.1-13.8) mU/l, P = 0.018) and the insulin response to
75 g oral glucose. Of these 13 women, 11 had menstrual
dysfunction. Among these women, nine of 11 showed
an improvement in reproductive function, i.e. they either
pattern. There was a reduction in hirsutism in 40% of the
women in this group. By contrast, in the group who lost
less than 5% of their initial weight, only one of the eight
with menstrual disturbances noted an improvement in
reproductive function and none had a significant reduction
in hirsutism. The improvement in menstrual function and
fertility may therefore be consequent upon an increase
in insulin sensitivity which, directly or indirectly, affects
ovarian function.37
eight reduction might play the most significant role in
W
restoration of ovulation in obese women with PCOS.38
randomized to one of four 48-week interventions: met-
formin 850 mg two times per day, lifestyle modification
plus metformin 850 mg two times per day, lifestyle modi-
fication plus placebo, or placebo alone. Ovulation rates

did not differ significantly between groups. However,
when data were analyzed by presence or absence of
weight reduction in subjects, independent of treatment
group, the estimated odds ratio for weight loss was
9.0 (95% CI 1.2-64.7) with respect to regular ovula-
tion. If weight loss occurred during metformin therapy,
the odds ratio for regular ovulation was 16.2 (95%
CI 4.4-60.2).38
Statement 1 5: Maintenance of a hypocaloric diet
(1200-1400 kcal /day) and sustained exercise regimen
over a period of 6 months or more improve ovula-
tion rates and menstrual regularity independent of
metformin use. A
Studies have demonstrated that compliance with a
weight loss regimen achieved by an exercise schedule
combined with a hypocaloric diet over a 6 month period,
improved insulin sensitivity, endocrine parameters and
menstrual regularity.39
I n studies involving the use of metformin, after adjusting
for baseline BMI and age, only weight loss alone, but not
use of metformin alone, was associated with a significant
improvement in menstrual cyclicity.34
I n women with BMI > 39, patients taking metformin 850
mg twice a day and adhered to a lifestyle modification
regimen showed improved ovulation rates and menstrual
cyclicity after 12 months.38
aintaining a hypocaloric diet (1200-1400 kcal/day)
M Liangan Wang. Clinical and metabolic features of polycystic ovary
and targeting 150 minutes of exercise per week over
a 24 week period was necessary to observe improved
ovulatory rates. However investigations noted increased
dropout rate due to time commitment of subjects.38 Since
most studies involve women who are overweight, the op-
timal dietary strategies and exercise regimen and efficacy
of lifestyle changes in women stratified by weight need
to be addressed. The role of utilizing antiobesity phar-
macologic treatments and surgery are still being studied.
Statement 16: If hormonal treatments are not accept-
able to the woman, then either tranexamic acid or
nonsteroidal anti-inflammatory drugs can be used.
A Anagnostopoulou F, Parava M, Vouxinou A, Georgopoulos NA,
A review of the treatment modalities for dysfunctional
uterine bleeding showed that the antifibrinolytic tran-
examic acid (TXA) is the most effective medical therapy to
treat dysfunctional uterine bleeding.40 It causes a greater
reduction in objective measurements of heavy menstrual
bleeding when compared to placebo or other medical
therapies (NSAIDs, oral luteal phase progestagens and
ethamsylate).41 TXA in a dose of 2-4 gm/day is highly
effective and a safe option for menorrhagia. The lower
dose of 2 gm/day is an effective and safe option in DUB
when compared to cyclical medroxyprogesterone acetate
(MPA) 10 mg twice daily.42
s a group, NSAIDs were more effective than placebo
A 11 Morin-Papunen L, Vauhkonen I, Koivunen R, Ruokonen A, Martikainen
at reducing heavy menstrual bleeding, of comparable
efficacy with ethamsylate, but less effective than either
tranexamic acid or danazol.43 In 76 women with DUB,
ethamsylate 500 mg 6-hourly did not reduce mean
menstrual blood loss; mefenamic acid 500 mg 8-hourly
reduced MBL by 20%, and tranexamic acid 1 gm 6-hourly
reduced MBL by 54%.44
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PCOS
Danazol appears to be an effective treatment for heavy
menstrual bleeding compared to other medical treat-
ments, though it is uncertain whether it is acceptable to
women. The use of danazol may be limited by its side
effect profile, its acceptability to women and the need for
continuing treatment. Overall no strong recommendations
can be made due to the small number of trials, and the
small sample sizes of the included trials.45
Statement 17: Chinese herbal medicine seems to
show an encouraging comparative effectiveness with
conventional Western medicine. B
meta-analysis of four RCTs or quasi-RCTs involving
A
525 PCOS patients with dysfunctional uterine bleeding
treated with Chinese herbal medicine showed encourag-
ing results but the methodological quality was poor in all
trials except one.46
ith the lack of trials comparing CHM with no treatment
W
or placebo, it is impossible to accurately evaluate the
efficacy of CHM. More RCTs with a higher quality are
required.46
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intrauterine system (LNG IUS) and transcervical resection of the
endometrium (TCRE) in the treatment of menorrhagia: preliminary
results. Gynaecol Endosc 1998; 7: 61-65.
29 Barrington JW, Arunkalaivanan AS, Abdel-Fattah M. Comparison
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balloon ablation in the treatment of menorrhagia. Eur J Obstet Gynecol
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30 Busfield RA, Farquhar CM, Sowter MC, Lethaby A, Sprecher M, Yu
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Appendix
Levels of evidence for intervention studies
Level Type of Evidence
of evidence
1++ High-quality meta-analysis, systematic
reviews of RCTs, or RCTs with a very
low risk of bias
1+ Well-conducted meta-analyses, system-
atic reviews of RCTs, or RCTs with a low
risk of bias
1- Meta-analyses, systematic reviews of
RCTs, or RCTs with a high risk of bias*
2++ High-quality systematic reviews of case-
control or cohort studies
High-quality case-control or cohort studies
with a very low risk of confounding, bias
or chance and a high probability that the
relationship is causal
2+ Well-conducted case-control or cohort
studies with a low risk of confounding,
bias or chance and a moderate probability
that the relatuionship is causal
2- Case-control or cohort studies with a high
risk of confounding, bias, or chance and a
significant risk that the relationship is not
causal*
3 Non-analytic studies (for example, case
reports, case series)
4 Expert opinion, formal consensus
* Studies with a level of evidence ''-" should not be used as a basis for
making a recommendation
Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users.
PCOS
Grades of recommendation**
Grade Recommendation
A At least one meta-analysis, systematic
review or randomized control trial rated
as 1++ and directly applicable to the target
population OR a sytematic review or a
body of evidence consisting principally of
studies rated as 1+ directly applicable to
the target population and demonstrating
overall consitency of results
B A body of evidence including studies rated
as 2++ and directly applicable to the target
population and demonstrating overall
consistency of results OR extrapolated
evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated
as 2++ and directly applicable to the target
population and demonstrating overall
consistency of results OR extrapolated
evidence from studies rated as 2++
D Evidence level 3 or 4 OR extrapolated
evidence from studies rated as 2+
GPP Good practice point (GPP). Recom-
mended best practice based on the clini-
cal experience in this case of the expert
working group
** Royal College of Obstetricians and Gynecologists. GRADE working
group. Grading quality of evidence and strength of recommendations.
BMJ. 2004;328:1490-8.
173
PCOS
Index of Drugs Mentioned in the Guideline
This index lists the products and/or their therapeutic classifications mentioned in the guideline. For the doctor's
convenience, brands available in the PPD references are listed under each of the classes. For drug information, refer
to the PPD references (PPD, PPD Pocket Version, PPD Text, PPD Tabs, and www.TheFilipinoDoctor.com).

Hormones and Related Drugs Analcid

Arthran
Contraceptives and other Hormones Atmose
Cyproterone acetate Befidan
Androcur Dolfenal
Cyproterone acetate + Ethinyl Dolsten
estradiol Gardan
Althea Gisfen
Diane-35 Istan
Desogestrel Lanafen
Cerazette Mecid-A
Desogestrel + Ethynyl estradiol Medianon
Gracial Medianon Suspension
Marvelon 28 Mefenax
Mercilon Penomor
Drospirenone + Estradiol Pharex Mefenamic Acid
hemihydrate Ponsac Forte
Angeliq Ponser
Drospirenone + ethinyl estradiol Ponstan
Yasmin Ralgec
Yaz Revalan
Gestodene + Ethinyl estradiol Rritemed Mefenamic Acid
Gynera Stangesic
Meliane Winthrop Mefenamic Acid
Minulet
Sophia Oral Hypoglycemics
Levonorgestrel
Mirena Biguanides
Levonorgestrel + Ethinyl estradiol Metformin
Charlize Ansures ER
Lady Diafat
Nordette Fornidd
Nordiol 21 Galvusmet*
Trinordiol Glucophage/Glucophage Forte
Levonorgestrel + Ethinyl estradiol + Glucophage XR
Ferrous fumatare Gludin
Trust Pill Glumet/Glumet-XR
Famila 28 F Humamet
Levonorgestrel-Intrauterine System Metta SR
(LNG-IUS) Neoform 500
Medroxyprogesterone acetate Nidcor
Depotrust Panfor SR-500/Panfor SR-1000
Lyndavel Pharex Metformin
Provera Ritemed Metformin HCl
Medroxyprogesterone acetate + Winthrop Metformin HCl
Estrogen
Premelle Hemostatics
Norgestimate
Norgestrel + Ethinyl estradiol Tranexamic acid
Femenal Hemostan
Norethisterone Hemostop
Primolut N Hemotrex
Norethisterone + Estradiol Traxan
Micropil
Norifam Dietary Drugs and/or Supplements
Norethisterone + Estradiol + Chinese herbal medicines
Ferrous fumarate
Micropil Plus
Progesterone-Releasing IUD

Androgens
Danazol
Elle
Ladogal

Analgesics
NSAIDS
Mefenamic Acid

174