Clinical recommendation	Evidence rating	References	Comments
First-line agents for the treatment of hirsutism in patients with PCOS include spironolactone (Aldactone) and metformin (Glucophage), as well as eflornithine (Vaniqa) for facial hirsutism.	A	9, 13, 16, 20, 22, 23, 28–33	Eflornithine is the only one of these agents that is approved by the U.S. Food and Drug Administration for facial hirsutism; however, it has not been studied Specifically in women with PCOS.
First-line agents for ovulation induction and treatment of infertility in patients with PCOS include metformin and clomiphene (Clomid), alone or in combination, as well as rosiglitazone (Avandia).	A	6–8, 11, 15, 19, 20, 32, 35, 36	—
Metformin improves insulin resistance (diagnosed by elevated fasting glucose or fasting glucose/insulin ratios) in patients with PCOS; other useful agents include rosiglitazone and pioglitazone (Actos).	C	10–21, 33, 37, 46, 47	There are ample studies supporting the effectiveness of metformin for improving insulin resistance; however, physicians should be aware that there are few patient-oriented outcomes regarding the importance of improving insulin resistance.
Metformin is probably the first-line agent for obesity or weight reduction in patients with PCOS.	B	10, 46, 49	—
Metformin can improve menstrual irregularities (e.g., oligomenorrhea) in patients with PCOS.	A	10, 11, 47, 51	—