A 29-year-old woman comes to your gynecology office for the evaluation of ‘bad blood clots’. She underwent menarche at age 15 but, since menarche, has always had irregular periods, varying 1 to 4 months between menstrual periods. When they do occur, she says that they last for 3 to 4 weeks and that the bleeding often has ‘a lot of clots’. This excessive bleeding requires her to wear adult diapers. Her last period was three months ago. Upon further questioning, she has also noticed an increasing hair growth along her chin, chest, abdomen and thighs. She lost some scalp hair. Review of systems is significant for snoring in sleep, weight gain, and thoughts of depression. She denies any history of medical problems. Family history is significant for diabetes in her dad and obesity in her mother. Her temperature is 99.9 °F , heart rate is 108 beats/min, blood pressure is 168/98 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 99% on room air. On physical exam, you notice she is obese with a body mass index of 35. You discover velvety, mossy, hyperpigmented skin and skin tags along her neck, and coarse hair growth along the chin, chest, and upper abdomen. Her pelvic examination is normal. Laboratory tests revealed elevated luteinizing hormone (LH), elevated testosterone, elevated cholesterol, elevated glucose, and normal FSH and TSH. Urine pregnancy test is negative. An ultrasound of the ovaries reveals multiple immature follicles. She has been sexually active with her husband for the past 4 years, using condoms sporadically. She has never been pregnant. She would like to conceive in the near future because she feels ‘things are going out of control’. Q.Which of the following is the first-line therapy for ovulation induction in this patient attempting to conceive?
