If the patient has not menstruated by day 35 and she is not pregnant, a progestogen-induced withdrawal bleed should be initiated.
To induce a withdrawal bleed, a short course of a progestogen, such as medroxyprogesterone acetate 20 mg/day for 5–10 days can be given.
The starting dose of CC is 50 mg/day.
The dose of CC may be increased to 100 mg if there is no response. Doses of 150 mg/day or more do not appear to be of benefit. If there is an exuberant response to 50 mg/day, as in some women with PCOS, the dose can be decreased to 25 mg/day.
Hypersecretion of LH is found in 40% of women with PCOS and is associated with a reduced chance of conception and an increased risk of miscarriage, possibly through an adverse effect of LH on oocyte maturation. Elevated LH concentrations are more often found in slim women with PCOS.
Clomifene citrate may cause an exaggeration in the hypersecretion of LH and have anti-estrogenic effects on the endometrium and cervical mucus. It is suggested that LH be measured on day 8 of the cycle and if persistently elevated then move on to alternative therapy as the chance of
conception is reduced and the risk of miscarriage increased.
All women who are prescribed CC should be carefully monitored with ultrasonographic assessment of follicular growth because of the risk of multiple pregnancy, which is approximately 10%.
If pregnancy has not occurred after 6–9 normal ovulatory cycles, it is then reasonable to offer the couple assisted conception (that is in vitro fertilisation [IVF]).