Which medication is first line for ovulation induction in women with PCOS, regardless of BMI?

Letrozole is recognized as the first-line medication for ovulation induction in women with polycystic ovary syndrome (PCOS), irrespective of their body mass index (BMI). Letrozole, an aromatase inhibitor, works by decreasing estrogen levels, which subsequently stimulates the hypothalamus to increase gonadotropin-releasing hormone (GnRH) release. This process promotes follicular development and ovulation.

Current guidelines indicate that Letrozole is often more effective than clomiphene citrate for inducing ovulation in PCOS patients, especially considering its better ovulation and pregnancy rates. Moreover, it is associated with fewer adverse effects, particularly in terms of reduced risk of multiple gestations compared to other interventions.

In the management of PCOS, other options like clomiphene citrate, gonadotropins, and metformin may be utilized, but they are not regarded as the frontline treatments for ovulation induction. For instance, clomiphene citrate has traditionally been used but the evidence suggests that Letrozole has surpassed it in efficacy and safety for the population of women with PCOS. Gonadotropins are more invasive and are typically reserved for cases where other treatments fail. Metformin, while beneficial for insulin sensitivity